People of Irish Heritage of Italian Heritage and of Puerto Rican Heritage.

2780_BC_Ch34_001-014 03/07/12 9:58 AM Page 1 Chapter 34 People of Italian Heritage Sandra M. Hillman Overview,

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Inhabited Localities, and Topography Overview Italian Americans, bound by the commonalities of language, home country, heredity, religion, and history, have found a permanent home in North America. There is a paucity of new research on Italian Americans. Whereas much was written about Italian Americans in the 1970s and 1980s, little has been written since then. Italian American immigrant groups include 1. First-generation, traditional, older Italians primarily living in enclaves 2. Second-generation, less-traditional Italians living in suburban and urban neighborhoods with ethnic enclaves 3. Third-generation, more-educated Italians living primarily in the suburbs 4. A relatively small group of newer immigrants with strong ties to their homeland (Ragucci, 1981) The first group reflects a somewhat despairing immigrant experience, whereas the remaining groups exemplify a happier, more-resilient, and more-contented experience. Because of age, length of time in the United States, socioeconomic status, diverse ethnic background, and other variant cultural characteristics (see Chapter 1 in the fourth edition of this book), Italian Americans are not a homogeneous group. This chapter describes the beliefs and practices of Italian Americans from the mainland of Italy, although some of these characteristics may be shared by Italian Americans with a heritage from Sicily or Sardinia. Italy, which includes Sicily and Sardinia, has a landmass of 116,318 square miles, an area slightly larger than the state of Arizona. With a population of over 61 million, Italy is divided into 20 regions with 109 provinces. In the north, the Alps separate Italy from France, Switzerland, Austria, and Slovenia; on the west are the Ligurian and Tyrrhenian seas; on the east is the Adriatic Sea; and to the south are the Ionian and Mediterranean seas (CIA World Factbook: Italy, 2011). The climate of Italy varies significantly according to its diverse topography. Northern Italy consists of the great plain and the valley of the river Po and the surrounding Alps. Central Italy contains the Apennine Mountains, whereas Mezzogiorno in the south consists of lower mountains and stony hills, with large areas bereft of trees, resulting in soil erosion and, in turn, deterioration of the soil into clay. Heritage and Residence A country rich in history, Italy is famous for the marvels of ancient Rome, such as the Coliseum, libraries, museums, and St. Peter’s Square; the Leaning Tower of Pisa; the canals and Piazza San Marco in Venice; the Ravenna opera; the ruins of Pompeii; the Portofino lace makers, wineries, and marble workers; and artists such as Michelangelo and Leonardo da Vinci. An Italian, Christopher Columbus, is credited with discovering North America, which is named after the Italian explorer Amerigo Vespucci. Nearly 5 centuries before modern Italy became a nation, Italians began migrating to the Americas in large numbers. Early Italians, under the sponsorship of French, English, Portuguese, and Spanish governments, sought adventures as explorers, warriors, sailors, soldiers, and missionaries. The 12,000 or more Italians who came to America between the founding of the American Republic in 1783 and the establishment of modern Italy as a nation in 1871 were scattered throughout North America, with large concentrations in the Northeast and the lower Mississippi Valley. Early Italian immigrants came from an agricultural background and differed in several respects from later immigrants who began arriving at the close of the 19th century. Many of the later immigrants were political refugees who had a variety of skills and occupations, such as tradesmen, artists, musicians, and teachers. These Italian immigrants exerted a civilizing influence on a society largely dependent on Europe for cultural guidance (Mangione & Morreale, 1993). 1 2780_BC_Ch34_001-014 03/07/12 9:58 AM Page 2 2 Aggregate Data for Cultural-Specific Groups Between 1810 and 1820, when immigration statistics were first compiled, 439 Italian immigrants came to the United States. By 1860, only 14,000 Italians immigrants had been recorded, the majority of whom came from northern Italy. After 1880, large numbers of Italian men came from the Mezzogiorno, and by 1901, southern Italians composed 83 percent of the Italian immigrants in the United States. Of all Europeans who immigrated during those years, Italians had the smallest proportion of women and children. Italian men were described as birds of passage, whose goal was to stay for a few years, save their money, and return to their villages. Fleeing poverty in southern Italy in particular, many men left their families behind with the hope of returning to Italy once they had earned enough money (Chick-Gravel, 1999). Over 3.8 million Italians immigrated between 1899 and 1924, with the peak in migration between 1901 and 1910. Many in this group were women and children. However, 2.1 million Italians returned to their homeland during these same years, with only 1.7 million immigrants remaining. During the peak years of immigration, 97 percent of the Italians entered the United States through New York City, giving it the largest Italian population of any city in the country (Mangione & Morreale, 1993). Between 1965 and 1973, Italian immigration stabilized around 25,000 people per year. Between 1974 and 1986, a steady decline occurred in Italian immigration, with less than 5000 new immigrants entering the United States annually (Mangione & Morreale, 1993). Most Italian Americans live in the states of New York, New Jersey, Massachusetts, Pennsylvania, and California. Major cities inhabited by Italian Americans include Chicago; New Orleans; New York; Philadelphia; Boston; Newark, New Jersey; and San Francisco (Mangione & Morreale, 1993). Italian enclaves, or Little Italies as they are called, can be found in New York City, Boston, Cleveland, and other major cities throughout the United States. The great Italian migration to North America that began in the 19th century has ended. The current Italian American population of almost 18 million ranks fifth in the United States, preceded by German, Irish, English, and African Americans (American Factfinder: U.S. Census Bureau, 2006). In Canada over 1.3 million residents claim Italian ancestry (Statistics Canada, 2006). Factors such as time in their new country, new experiences, and a new social environment are changing the offspring of these early immigrants. The Italian culture with its values and cuisine has had an impact on the cultural landscape of North America. It would be a mistake to conclude that Italian culture in America is disappearing. Beyond pasta and pizza, Italian immigrants and their children have made and continue to make an impact on the arts, architecture, and commerce. Reasons for Migration and Associated Economic Factors In the early 1800s, Italy had an archaic, corrupt government and lacked an industrial base, and the mercantile system heavily taxed the population to raise capital for commerce. After unification, the national government imposed a legal system favoring the moreindustrialized north over the agricultural Mezzogiorno regions to the south. To meet impossible tax burdens, peasant farmers, contadini, mortgaged their lands. By 1900, a minority had most of the wealth, whereas the destitute majority paid almost all the taxes. Because of these economic hardships, many Italians massmigrated to North America where they often confronted equally severe economic hardships due, in part, to language barriers. Many had to live in poverty until becoming established. Italians who immigrate today are less likely to live in poverty because most have relatives to assist them in getting established in their new environment. Educational Status and Occupations Contrary to expectations of early American teachers, first-generation Italian immigrant parents insisted that their children conduct themselves according to the code of behavior and value system that kept Italian families intact for centuries. Under parental influence, most children did not stay in school long. Some completed high school and occasionally went to college, despite an Italian proverb that cautioned fathers against making their sons “better” than themselves. Although children usually paid their own way through college, their education often generated a sense of alienation between the educated offspring and the rest of the family. Although the majority of early Italian immigrants were from the farmlands of Italy, lack of capital for land and equipment limited their ability to continue farming in the United States. The great majority became contract laborers in urban areas. A few were lured to the southern part of the United States, where they obtained employment in agriculture and, as soon as they could, bought land. These farmers created the small Italian farm communities that dot Louisiana, Texas, Mississippi, Alabama, Tennessee, Virginia, and Maryland today (Mangione & Morreale, 1993). In work as in all dimensions of life, the sense of pride among Italian Americans is more visceral and passionate than subliminal and abstract. Italian Americans seek to do something that can demonstrate their success to their families. Because of their general distaste for abstract values, ambivalent attitude toward formal schooling, and desire to remain close to family, a disproportionate number of second- and third-generation Italian Americans seek employment in blue-collar jobs. 2780_BC_Ch34_001-014 03/07/12 9:58 AM Page 3 People of Italian Heritage In recent years, Italian Americans not only have caught up but also have, on average, slightly more schooling and higher incomes than non-Italians. Today, Italian Americans are well represented in law, politics, research, technology, big business, and finance. By the late 1980s and early 1990s, Italian Americans gained prominence in the top ranks of the establishment (Matusow, 1999). Communication Dominant Languages and Dialects The official language of Italy is Italian, a Romance language derived from Latin. However, all socioeconomic REFLECTIVE EXERCISE 34.1 Giorgio, an Italian American high school senior, is expected after he graduates to work in his father’s pasticceria (Italian Pastry Shop) where he has worked after school since he was 14. His father told him that upon graduation, he could earn a real salary in the business and soon start doing some of the buying. His father is very proud to be the owner of a store that started as his immigrant great-grandfather’s pushcart and has been passed down from generation to generation. It is obvious that his father intends for him to own the business in the future. The problem is that he is not interested in doing so and does not know how to tell him. Ever since Mr. Mateo, his English teacher, praised him for his latest written assignment, Giorgio has toyed with his real love: to be an English teacher. He has always secretly enjoyed writing stories and poetry, which he keeps hidden in his room. He never expected to go to college, but when Mr. Mateo told him that he should consider attending the state university and that he might even qualify for a scholarship, the thought of college became a possible reality. The problem is that he could only imagine how disappointed his father would be. His father considers college impractical. What seems really strange to him is that his sister, Guilia, has a real head for business and his father does not even see it. She could run the store; however, if his father has his way that will never happen. Giorgio feels stuck. Mr. Mateo thinks he should begin to apply to colleges. Dad thinks he should go to work. When he told his teacher that he will have to go into the family business even though he does not want to, he suggested that he talk to his school counselor. No one in his family has ever talked to a counselor, as far as he knows. Every now and then, his mother goes to talk to Father Marco, the local parish priest, but Giorgio does not know what she talks about. If his dad had problems, he would never let anyone know them. He does not know what to do. You are Giorgio’s school nurse and counselor. 1. How would you counsel Giorgio? 2. What do you see as the important issues for him? 3. What do you need to know about the Italian American culture and history to work effectively with Giorgio? 3 groups in the 20 regions of Italy speak different dialects (CIA World Factbook: Italy, 2011). The dialects of northern Italy contain numerous German words. Spanish, French, and German languages influence Neapolitan Italy. Piedmontese is strongly affected by the French and Spanish languages, whereas the dialects of Sicily have been strongly influenced by French, Spanish, Greek, Albanian, and Arabic languages. Sardinia has its own language, Sardinian. So numerous are the dialects that they are mutually incomprehensible to some extent. When an interpreter with knowledge of the patient’s specific dialect is unavailable, the interpreter should select words that have pure meanings from Tuscany Italian, which is used for formal writing. First-generation Italians who immigrated to America brought the dialects of their regions with them. Today, in some second- and third-generation Italian homes, these dialects are still spoken. However, many secondgeneration Italian Americans do not speak Italian well or at all. Either their parents encouraged them to learn English or, more often, the children refused to speak the mother tongue. Often, though, the next generation becomes curious about its background and tries to recover parts of its heritage. A number of third-generation Italian Americans are studying Italian in an effort to reconnect with their Italian heritage. Many would like to teach their children to speak Italian. Grammatically correct Italian is musical and romantic because vowels predominate over consonants, expressing the many subtleties of thought and feeling in a delicate manner. In many Italian households, discussions can become quite passionate, with voice volumes raised and many people speaking at once. The health-care provider must understand this cultural characteristic when presenting health information for decision-making purposes. Cultural Communication Patterns The willingness to share thoughts and feelings among family members is a major distinguishing characteristic of the Italian American family. Positive and negative emotions and sentiments are permissible and encouraged and color their daily lives. Many times, a fluctuating emotional climate exists within the family, with expressions of affection erupting briefly into what appears to an outsider as anger or hostility. Conflict is generally confined to periodic outbursts and does not usually cause resentment or open and permanent ruptures. In fact, emotional neutrality to Italians denotes noninvolvement or the absence of affection. Italians are sentimental and not afraid to express their feelings. Traditional Italian Americans value close family ties, express warmth freely, and have heart and feeling for one another (Johnson, 1985). The emotional bond among Italian Americans is reaffirmed by frequent 2780_BC_Ch34_001-014 03/07/12 9:58 AM Page 4 4 Aggregate Data for Cultural-Specific Groups kissing. The “typical” kiss is Eastern European style, with a kiss on each cheek. They frequently touch and embrace family and friends. Touching between men and women, between men, and between women is frequently seen during verbal communication. Whereas nonverbal methods of communicating are common to all societies, Italians have elaborated, refined, and stylized gestures into an art form. It is said that the Italians from southern Italy are capable of carrying out a conversation without saying a single word. Gestures convey a range of feelings from poetic eloquence to intense anger. These messages, however, are best conveyed in an economical, subtle, flowing, and almost-imperceptible manner. For example, a slowly raised chin means “I don’t know.” Health-care providers need to observe Italian American patients for nonverbal cues to obtain the full meaning of verbal communication. Temporal Relationships The literature provides different views of temporal relationships among Italian Americans; thus, one can posit that Italians are past, present, and future oriented. Past orientation is evidenced by the pride they take in their home country’s rich Roman heritage. Within the context of fatalism and their present orientation, they do not allow their imagination to stray too far, do occupy themselves with concrete problems and situations, and do accept things. Finally, they are future oriented, as evidenced by the importance given to planning ahead and saving financially for the future. Time orientation varies by immigrant group. Whereas first-generation and newer immigrants view time as an approximation rather than categorically imperative (Migliore, 1989), second- and third-generation Italian Americans adhere to clock time at least in the work situation and for appointments. For this group, deadlines and commitments are considered important and adhered to firmly. In Italy, punctuality is not valued as much as it is in the United States. For example, a conference that is supposed to start at 9:00 a.m., may actually begin 30 or more minutes later. Format for Names Before the Napoleonic era, last names were not commonly used in southern Italy. After the Napoleonic era ended in 1814, the French often assigned to a family or sometimes an entire village, the name of that village. The contadini peasant custom was to name first children for their grandparents and later children for their godparents. To avoid confusion, they instituted a practice of assigning nicknames according to some physical characteristic or their occupation. For example, Giovanni Pelo is translated as “Johnny one hair.” This nickname was given because his body was covered with dark hair (Gambino, 1975). This practice of assigning nicknames continues with many Italian American families. Otherwise, a person is called by the first or given name in social situations and by a title such as Miss, Ms., Mr., Mrs., or Dr., and his or her last or family surname in the health-care environment. Family Roles and Organization Head of Household and Gender Roles First-generation and newer-immigrant traditional Italian American families recognize the father’s authority as absolute; nothing is purchased and decisions are not made without his approval. The father’s decision may be accepted as law even among his married children. To criticize one’s father is considered a sacrilege. In many traditional Italian American families today, the father continues to dominate family decisions as long as he remains in good health and is the chief breadwinner. He is known as the Padrone or capo di famiglia, the “head of the family.” In old age and illness, the eldest son supersedes him, but even then, the father retains much of his prestige. The “typical” traditional Italian father frequently demonstrates public and private affection for his children, but such demonstrations are less frequent in public for his wife (Mangione & Morreale, 1993). In the past in Italy and consistent with most Italians practicing Catholicism, families were large. However, within the last 20 years, family size is rapidly declining. Currently in Italy, the birth rate is 1.39 per woman (CIA World Factbook: Italy, 2011). Italian Americans discuss marriage largely in terms of power; thus, the divergence between the cultural ideal and the reality of marriage becomes obscure when one analyzes power issues between husbands and wives. Many husbands turn over their paychecks to their wives to run the home, and thus, Italian women tend to have more power in economic decisions. Women also dominate decision making on childbearing issues and family social events. The Italian American husband believes that, as the man, he has the power as head of the family regardless of the wife’s influence. Even though traditional roles remain strong in Italian American second- and thirdgeneration families, a trend toward more egalitarian relationships is evolving. Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents Italian American children who grow up in a home in which the parents speak an Italian dialect are able to more readily absorb their culture. Although this creates closer family ties, it can produce a conflicting sense of identity when these children speak another language outside the home. Italian American children are taught to have good manners and respect for their elders. Both male and 2780_BC_Ch34_001-014 03/07/12 9:58 AM Page 5 People of Italian Heritage female children are encouraged to be independent and expected to contribute to the family’s support as soon as they are old enough to work. This work ethic continues in second- and third-generation families. Adolescent girls are expected to remain virgins until marriage. In decades past, among first-generation Italians, an aunt or the teenage girl’s mother acted as a chaperone when the girl went on a date (Moluzzi & Bertolo, 1977). Today, second- and third-generation Italian American teenage girls have greater latitude and freedom in dating behavior, although the expectation of maintaining virginity remains high. Family Goals and Priorities L’ordine della famiglia, “family order,” a system of social attitudes, values, and customs, has proved to be impenetrable to the exploitation of strangers and is the main tie that holds the Italian American household together. The rules governing family membership are simple and explicit: Fear God and respect the saints. The father is the father, and he is experienced. Always honor and obey your parents. Work hard, work honestly, work always, and you will never know hunger. Trust family first, relatives second. The foundations of a good family life inherent in the traditional way are home ownership, good food, respect, and display of affection (Wells, New, & Richman, 1994). Italian American families maintain close relationships. Love and warmth, security, and the expression of emotions are the most common characteristics of the Italian American family. Daughters have close ties with both parents, particularly as they approach old age. Among first-generation Italians, the welfare of the family was considered the primary responsibility of each of its members. Although many second- and third-generation Italian Americans no longer live in an immediate Italian enclave, they return home frequently to maintain family, community, and ethnic ties. While parents are alive, their home is most often the focus of kinship gatherings. Sons and daughters visit frequently during the week and after church on Sundays to share a large meal at the parents’ house. Frequent contact with parents generally means contact with siblings and, often, aunts and uncles. Italian Americans are almost twice as likely as other ethnic groups to see a parent daily or at least several times a week. If personal contact is not possible, frequent telephone contacts are made, sometimes several times a day. Love, respect, self-sacrifice, and mutual responsibility essentially summarize the diffuse sentiments most respondents express in regard to their parents. The status of Italian Americans in old age is one of continuity. Although they are more dependent in terms of their social and psychological needs and more disengaged from work and roles connected with formal and informal associations, they are firmly entrenched in the extended family system. Even though they may 5 have major worries about maintaining traditional family values, changes have not resulted in their exclusion from the lives of their children. Continuity in parental roles is an important factor in maintaining the high status of older people. For older women, motherhood and domestic roles change in intensity but do not lose their centrality. As grandmothers, their nurturing functions continue. For men, the loss of the work role does not noticeably affect their central role in the family. Instead, the absence of the work role permits greater family involvement. To many older Italians, the ideal living situation is to maintain one’s own home near one’s children because many believe they do not feel the same when they are not in their own homes. Parents receive respect, gratitude, and love in return for their many sacrifices. With little variation, the prevailing view is that older people should reap rewards in old age for having had a single-minded dedication to parenthood during difficult times (Johnson, 1985). Pesenti’s (1990) study on family values and psychological adjustment among female Italian Americans and Jewish American immigrants in nursing homes suggested that older Italian women have greater filial expectations, are more traditional in family ideology, and have a poorer adjustment to nursing-home life than Jewish women. Italian Americans have an actively functioning kinship and extended family system that is the primary focus of solidarity for the nuclear family. Relationships are not allowed to wither through lack of contact, because through force of habit and the ritualization of occasions for high sociability, rarely a week passes that relatives do not play a central part in the average family’s activities. Within this extended family network, Italian Americans are much more likely to associate with cousins, aunts and uncles, and nieces and nephews than are non-Italians. Even if one tries to distance oneself from such an all-embracing family system, it is easier said than done (Johnson, 1985). Primary relationships are usually lifelong. For example, many Italians of today’s generation recall their childhoods in an extended family system in which grandparents lived in the household and aunts and uncles lived on the same block. As young children, cousins become well acquainted because their parents visit frequently. Because they live in close proximity, friendships form in their early years and continue throughout their lives. The elaboration of collateral relationships is one reason many Italian families are able to maintain a higher level of kinship solidarity than is evident for society at large. Because the extended family is close and frequent visitations are important, the health-care provider may need to make special arrangements for visitation when Italian Americans patients are in acuteor long-term-care facilities. Social status for most Italian American families comes from family lineage. They cultivate power, 2780_BC_Ch34_001-014 03/07/12 9:58 AM Page 6 6 Aggregate Data for Cultural-Specific Groups wealth, and possessions when they can afford them. Titles are more important than names, which can be an asset in the health-care environment. If the health-care worker has a title of importance, using it may increase compliance with health treatments and regimens. Alternative Lifestyles Despite values clearly defined around family obligations, Italian Americans generally do not reject another family member because of an infraction or alternative lifestyle. They may complain and argue with the deviant member, hoping for a change, but if their complaining and arguing fail to bring about the desired change, they still accept the individual and live with the consequences. When health-care providers need to make socialsupport referrals for Catholic gays or lesbians, they can assist patients in contacting Dignity through the Catholic Church in large cities. With divisions in many major U.S. cities, Dignity is an alternative lifestyle REFLECTIVE EXERCISE 34.2 Raffaele, age 47 years, is the only child of Romano and Anna. He is a police officer and has lived with his parents in the family home since birth. Over the past few years he has become increasingly more aware of the fact that his parents are aging and that if he remains single he will have to face their loss alone. He has never been married or been seriously involved with a woman until recently when he met Sondra online who lives a great distance from his hometown. Raffaele and Sondra have been seeing each other for the past 2 years and have become very connected. Raffaele’s parents, especially his father, are not happy with his involvement with a woman such a distance away and have spoken very clearly against the relationship. As an only son Raffaele is extremely dedicated to his parents and for whom he has great respect. Even though he is in his late 40s, he is torn between continuing the relationship with Sondra or honoring his parents and looking for another woman closer to home. He is quite confused about the right choice to make and has become anxious and is now smoking a pack of cigarettes a day. Given the role of authority and decision making that Italian parents play into old age over their children, how might you advise Raffaele with his difficultly choosing to continue his long-distance relationship or finding someone closer to home who meets his parents’ expectations. 1. What do you see as the important issues for Raffaele? 2. What counseling approach would you use? 3. What do you need to know about the Italian American culture and history to work effectively with Raffaele? 4. How would you counsel him on the relationship between the choice he makes and its effects on his well-being and physical health? support group that follows the doctrine of the Catholic Church. Workforce Issues Culture in the Workplace For most Italian Americans, the acquisition of education, title, and money is of great importance. Italians believe strongly in the work ethic, are punctual, and rarely miss work commitments owing to a cold, headache, or minor illnesses. If completing their work requires staying later, they do so. Although the family is of utmost importance to Italians, work takes priority over family unless serious family situations arise. This cultural predisposition parallels the North American work ethic. The one thing Italian Americans have in common is a sense of pride in their culture and in the achievements of their forebears (Matusow, 1999). Issues Related to Autonomy Italian immigrants and their descendants regard work as moral training for the young. Among Italian Americans, work is viewed as a matter of pride, demonstrating that one has become a man or a woman and is a fully functioning member of the family. So strong is this ethic that it governs behavior apart from monetary gain derived from employment. To Italian Americans, it is morally wrong not to be productively occupied. Poveri si, ma perche pigro? (Poor yes, but why lazy?). Even though Italian Americans have the utmost respect for their employer, they are emotional and passionate people, and when a confrontation arises, Italians are likely to get involved. For example, the first Italian immigrants working in New York City defended themselves against deplorable working conditions by banding together to form one of the city’s largest unions (Mangione & Morreale, 1993). Because of language barriers, first-generation Italians and newer immigrants are more likely to accept assigned tasks without expecting any decision-making authority. Second- and third-generation immigrants, having a command of the English language, are more apt to seek positions of authority, take responsibility, and become managers or business proprietors. Italians born and educated in the United States usually have little difficulty communicating with others in the workforce. Newer immigrants and those with limited English language skills have the most difficulty assimilating into the workforce, a problem that is common to all non-English-speaking immigrants. Biocultural Ecology Skin Color and Other Biological Variations Because of Italy’s proximity to Switzerland, Austria, and Germany in the north and to North Africa in the south, Italians as a group have varied physical characteristics. Those from a predominantly northern 2780_BC_Ch34_001-014 03/07/12 9:58 AM Page 7 People of Italian Heritage background have lighter skin, lighter hair, and blue eyes, whereas those from the south of Rome, particularly from Sicily, have dark, often curly hair, dark eyes, and olive-colored skin. Health-care providers should be aware of skin variations among Italian Americans, especially when assessing for anemia, cyanosis, lowered oxygenation levels, and jaundice in those who are darker skinned. In dark-skinned patients, the skin turns ashen instead of blue in the presence of cyanosis and decreased hemoglobin levels. To observe for these conditions, the practitioner must examine the sclera, conjunctiva, buccal mucosa, tongue, lips, nailbeds, and palms and soles of the feet. To assess for jaundice, the practitioner needs to look at the conjunctiva and in the buccal mucosa for patches of bilirubin pigment. Diseases and Health Conditions In the 1800s, malaria ran rampant in the swamps of southern Italy. Sicily experienced outbreaks of cholera in 1837. Rickets, caused by a lack of calcium in children’s diets, was also prevalent. The incidence of infectious diseases, such as malaria, typhus, and cholera in the south and pellagra in Lombardy and Venetia in the north, have been reduced by advances in medicine, but they continue to contribute to high mortality, particularly infant mortality, from inadequate living conditions (Johnson, 1985). Early Italian immigrants to America lived and worked in poor, crowded conditions that made Italian families susceptible to anemia, bad teeth, pneumonia, meningitis, diphtheria, tuberculosis, and industrial accidents. Some first-generation Italians suffered from somatic complaints and physical ailments, which the immigrants sometimes attributed to il mal occhio “evil eye” (see Folk and Traditional Practices). Second-generation immigrants tend to develop neurological and psychotic symptoms attributable to guilt toward the parents from whose culture they have broken (Bryant, 1976). People of Italian ancestry have some notable genetic diseases, such as familial Mediterranean fever, Mediterranean-type glucose-6-phosphate dehydrogenase (G-6-PD) deficiency, and beta-thalassemia. Familial Mediterranean fever, recurrent polyserositis, was originally common only in the Middle East but is now seen in various parts of the world. This familial disease is characterized by short attacks of fever, peritonitis, pleuritis, and arthritis, with death due to amyloidosis if the disease progresses. No specific diagnostic test is available; treatment is symptomatic (Porth, 2009). Mediterranean-type G-6-PD deficiency is an inherited, X-linked, recessive disorder most fully expressed in homozygous males, with a carrier state found in heterozygous females. Red blood cell damage begins after intense or prolonged administration of sulfonamides, antimalarial agents, salicylates, or 7 naphthaquinolones; after ingestion of fava beans; or in the presence of hypoxemia or acidosis. Supportive therapy includes withdrawing the causative agent and administering blood transfusions and oral iron therapy, which usually results in spontaneous recovery (Porth, 2009). Beta-thalassemia, of which there are two types, is prevalent in Greeks, Italians, Sephardic Jews, and Arabs. Both are caused by genetic defects affecting the synthesis of the hemoglobin A or B chain. Beta-chain production is depressed moderately in the heterozygous form, beta-thalassemia minor, and severely depressed in the homozygous form, thalassemia major, which is also called Cooley’s anemia, after the American physician who described it. Beta-thalassemia minor causes mild to moderate anemia, splenomegaly, bronze coloring of the skin, and hyperplasia of the bone marrow. Affected persons are usually asymptomatic. Persons with betathalassemia major may experience severe anemia; death owing to high-output cardiac failure can occur in early childhood if this condition is left untreated. No cure exists, but palliative therapy includes repeated transfusions of packed red blood cells (Porth, 2009). In addition to these genetic diseases, Italian Americans have a high incidence of hypertension and coronary artery disease related to smoking and their type A behavior (Mangione & Morreale, 1993). Bernstein, Flannery, and Reynolds (1993) reported that Italian Americans have significantly higher risks of nasopharyngeal, stomach, liver, and gallbladder tumors. Females exhibit a low risk for cancer of the oral cavity, esophagus, colon, rectum, and pancreas. Males exhibit a low risk for cancer of the larynx, lung, breast, prostate, and bladder, melanoma, and non-Hodgkin’s lymphoma. Kidd, Lancaster, and McCredie (1993) reported an increased incidence of ventricular septal defects in children of Italian heritage and that congenital heart disease in infants is associated with older maternal age at conception. Italian Americans are also at an increased risk for multiple sclerosis (MS). This finding provides evidence that ancestry, genetics, and environment are a part of the complicated picture of MS (Page, Kurtzke, Murphy, & Norman, 1993). Variations in Drug Metabolism The medical literature does not report any variations in drug metabolism or interactions specific to Italians or Italian Americans in general. However, health conditions such as Mediterranean-type G-6-PD deficiency and thalassemia have a profound effect on drug metabolism. Because conditions such as hypoxemia and acidosis, ingestion of fava beans, and the administration of sulfonamides, antimalarial agents, salicylates, and naphthaquinolones can exacerbate these conditions (Levy, 1993), health-care professionals must take extra precaution when prescribing these drug therapies for Italian Americans. 2780_BC_Ch34_001-014 03/07/12 9:58 AM Page 8 8 Aggregate Data for Cultural-Specific Groups High-Risk Behaviors Older Italian Americans may have significant health problems related to dental caries. Many first-generation Italians believe that it is useless to provide dental care to first teeth because they are temporary and are likely to impute caries in permanent teeth owing to poor North American air. Although the general population has access to much education regarding the risks of smoking, many Italian Americans immigrants continue to smoke. Alcoholism also presents a risk in this group. Muhlin’s (1985) comparison of alcohol-related and non-alcohol-related diagnoses among immigrants in New York State reported that 40 percent of Italian men compared with 50 percent of Irish men are hospitalized for alcohol-related diagnoses. No current studies on alcohol use among Italians could be found. However, in Italy and among some Italian Americans, children are introduced to alcohol as part of their regular family life and learn to drink moderate amounts while still young. In both countries, alcohol is commonly drunk with meals and is considered a natural and normal food. Health-care providers need to assess Italian Americans for dental problems due to poor dental hygiene, cardiorespiratory diseases due to smoking, and possible alcohol misuse and alcohol-related diseases. Health-Care Practices The beliefs of first-generation and newer Italian immigrants toward biomedical care are much the same as they are in Italy. Most of these immigrants believe that they come to North America equipped with the best medical knowledge and ideas on the preservation of family health. Although many second- and thirdgeneration Italian Americans are less traditional in health-care practices, many practice some of the traditional methods for staying well. Several distinct patterns for making a decision to seek health care are reported among a sample of Catholic Italian Americans. These patterns include the occurrence of an interpersonal crisis, a perceived interference with social or personal relations, sanctioning, or a perceived interference with vocational or physical activity. The health-care provider must provide health counseling within these health-seeking and decisionmaking patterns. Providing culturally congruent care among Italian Americans is essential to compliance. Nutrition Meaning of Food To Italian Americans, food is symbolic of life and the principal medium of life, particularly family life. Respect for food as the medium of life is upheld even among the poor. The ceremony of eating is honored by Italian Americans, who convey to their children that the waste or abuse of food is a sin. In an emotional sense, food is a connection between an Italian child and the parents, representing the product of the father’s labor and prepared with care by the mother. In a symbolic sense, meals are a communion of the family, and food is sacred because it is the tangible medium of that communion. Italian American mothers’ “preoccupation with food” has a kernel of truth in it. There is something incredibly generous in the Italian nature, particularly when it comes to the preparation and sharing of food. An Italian mother may demonstrate her affection by feeding her family and anyone else she likes. To the average Italian mom, love is a four-letter word: food (Giordano, 1986). The close association between food and mothering results in some predictable problems. Many Italians and traditional Italian Americans believe that bigger babies are healthier. The size of the baby is perceived as an index of the successful maintenance of maternal and wifely responsibilities. The expression mange, mange, or “eat, eat,” on the lips of many immigrant mothers is still heard today. Common Foods and Food Rituals The Italian diet, rich in vegetables, pasta, fruit, fish, and cheese, varies according to the region of Italy from which the individual originated. Northern Italian foods are rich in cream and cheese, resulting in a potentially high intake of fat. Southern Italian foods are prepared in red sauces, spices, and added salt. Because of regional variations in food selections and preparation practices, health-care professionals must specifically inquire about the diet of their Italian American patients, preferably during intake assessments. The staples of the Italian Americans diet are spaghetti, lasagna, ravioli, pasta with pesto, and manicotti. Vegetables, fresh fruit, and beans are common. Popular Italian foods include lentils, sausage, eggplant parmigiana, salami, olive oil, espresso and cappuccino coffee, wine, ice cream (gelato), pastries such as cannoli and biscotti, and cheeses such as provolone, ricotta, romano, and parmigiana. Other common dishes include escarole, Caesar salad, calzone, and pizza. Table 34-1 lists the Italian names of popular foods with their descriptions and ingredients. One important concept to understand about many Italians and their relationship with food is that an outsider cannot enter an Italian home and discuss anything of consequence until at least some token meal is shared. Entering into the family communion is a prerequisite to partaking in any of its affairs. In the Italian tradition, each meal is significant. The noontime meal is traditionally taken whenever possible by the entire family. Dinner is a gathering of the family. Italian wine is part of almost every meal, and a mixture of water and wine is given to children. Breakfast has never been an important meal for southern Italians. Time and circumstances permitting, 2780_BC_Ch34_001-014 03/07/12 9:58 AM Page 9 People of Italian Heritage ❙❙◗ Table 34-1 Italian Foods Common Name Calamari Frittata Minestrone Melanzane alla parmigiana Pasta con pesto Pasta e fagioli Pasta marinara Pizza fritta Prosciutto Spaghetti aglio olio Tortellini Veal scaloppini Description Squid, fried or on pasta Ingredients Floured squid fried in olive oil or in red sauce Italian omelet Eggs, peppers, and onions cooked in olive oil Soup with Escarole and beans greens with garlic and other herbs Eggplant Eggplant, tomato Parmesan sauce, bread crumbs, Parmesan cheese, and mozzarella cheese Sauce served Sauce of basil, nuts, over linguine olive oil, and garlic Fresh-made Shell-shaped pasta, pasta and beans kidney beans, and tomato sauce Pasta in tomato Pasta sauce fried in sauce garlic and olive oil Fried dough Bread dough fried in with sugar and oil and sprinkled with cinnamon sugar and cinnamon Thinly sliced Delicate, thin ham ham served with melon Spaghetti with Spaghetti, olive oil, olive oil garlic, and red pepper Little rounds of Pasta dough stuffed pasta in white with meat and or red sauce cheese Medallions Veal sautéed with of veal wine, butter, and lemon the major meal of the week is the most leisurely and is shared with the largest gathering of la famiglia. The Sunday dinner, which begins in mid afternoon and lasts until early or even late evening, is a relaxed social gathering featuring tasty cheeses, fish, and salamis. Although the routine of North American life has altered this schedule, especially for daytime weekday meals, many Italian Americans still adhere to the ceremonies of the evening and Sunday dinners. Italians love ceremonies and feasts. The Italian historian Arrigo Petacco recalls that every day was a feast day to some patron saint, during which time the streets rang with shouts in every Italian dialect. Each feast day became an assertion of the southern Italian peasants’ Old World belief that magic rather than the religious sacraments was their way of dealing with the supernatural. Sorcerers rather than priests were sought by those afflicted in mind and body. Few Italians could resist the music, dancing, eating, drinking, and firework festivities associated with Italian feasts (Giordano, 1986). In many parts of North American Italian communities, an annual religious festival 9 honors some favorite patron saint or the Madonna. The saint with the largest constituency is San Gennaro, the patron saint of Naples. Dietary Practices for Health Promotion Italian immigrants brought many dietary practices to North America for keeping their families healthy. One of the most common practices for health promotion is eating a clove of garlic every night before going to bed to prevent upper respiratory infections. Garlic may also be worn around the neck when there is an epidemic of influenza or other upper respiratory ailments to prevent the wearer from getting the infection. Another healthpromotion practice, eating a fresh raw egg every morning, keeps the person strong. Fresh dandelions are used to make a salad or are boiled to make soup to give the person strength. Red wine mixed with water is given to children with meals to maintain healthy blood. Nutritional Deficiencies and Food Limitations Because the Italian diet is rich in fruits, vegetables, garlic, pasta, and olive oil, nutritional deficiencies are rare. First-generation Italians who lived in tenement housing initially suffered from nutritional deficiencies owing to lack of money and dislike for American food. Native food practices have not changed much for Italian immigrants or second- and third-generation Italian Americans. Italian food is one of the most popular choices for North Americans of all nationalities, making it easily accessible. In addition, because of the Italian propensity to cook with olive oil and garlic and serve pasta and a variety of vegetables, nutritionists have endorsed most Italian food as healthy. Pregnancy and Childbearing Practices Fertility Practices and Views Toward Pregnancy Most first-generation Italian Americans did not practice birth control and rarely discussed matters related to sex. Premarital sex and adultery were absolutely forbidden. Second-generation Italian women often introduced birth control years after the marriage. Sex was rarely discussed in the family, premarital sex was greatly restricted, and adultery was a strict taboo. However, many third-generation Italian Americans use birth control from the beginning of the marriage, and sex is commonly discussed in the family. External restrictions on premarital sex have weakened, but internal inhibitions remain strong. In the past, adultery was often seen as unacceptable but sometimes excusable. The proportion of Italian Americans women aged 35 to 44 years with five or more children is second lowest in comparison with women of other ethnic groups in the same age range. A strong sense of modesty and embarrassment among Italian Americans results in the avoidance of discussions related to sex 2780_BC_Ch34_001-014 03/07/12 9:58 AM Page 10 10 Aggregate Data for Cultural-Specific Groups and menstruation (Spector, 2009), hindering early diagnosis and primary prevention interventions. Traditional ideas among Italian Americans regarding pregnancy have undergone slight but significant variations in the United States. The belief that a mother does not conceive while nursing continues to be held by many Italian women. Women who do not conceive at regular intervals during their childbearing years are believed to be more likely to develop tumors. An American obstetrician suggests that the tumor theory may be related to the belief that conditions against conception are unhealthy, contributing to a malignant nature. Sprinkling salt under and around the bed of a newly married couple is believed to make them fertile. Prescriptive, Restrictive, and Taboo Practices in the Childbearing Family Traditional beliefs related to pregnancy include coffee spills may result in the baby being born with a birthmark where the coffee was spilled; the women must abstain from sexual relationships while pregnant; and if the expectant mother’s cravings for a particular food are not satisfied, a congenital anomaly may occur or the baby will be marked. In addition, if a pregnant woman is not given the food she smells, the fetus moves and a miscarriage results; if she turns or moves in a certain way, the fetus does not develop normally; and she should not reach over her head because harm may come to the baby. Many traditional Italians fear hospital care in North America, except in the case of childbirth. Although many women still prefer the family physician or a midwife and home confinement, many Italian women deliver their babies in hospitals. A hospital delivery provides a means of avoiding the traditional sexual intercourse rites at the onset of labor—a tradition sometimes seen today. In the via vecchia (old way), if labor does not progress rapidly enough, a neighbor has to spit out of the window. This ritualistic spitting has the power to break any magic spell that might have brought the ill fortune of a slow labor. People who believe in the via nuova (new way) do not practice this ritual spitting. Among traditional Italian Americans, a postpartum woman is not allowed to wash her hair, take a shower, or resume her domestic chores for at least 2 or 3 weeks after birth so she can rest. The woman’s mother and other female family members tend to the chores and assist with the care of the new baby. New mothers are expected to breastfeed, restoring the health of the reproductive organs and keeping the mother and baby free of infections (Lasker, Egolf, & Wolf, 1994). Death Rituals Death Rituals and Expectations In the Italian American family, death is a great social loss and brings an immediate response from the community. Sending food and flowers (chrysanthemums), giving money, and congregating at the home of the deceased are expected. As for other life events, among the first responses to death is food, which is brought by friends and distant relatives. Italian Americans believe food is a source of comfort during troubled times. Italian death rituals can be very demonstrative. The funeral procession to the cemetery is a symbol of family status. There is great pride in the size of the event, determined by the number of cars in the procession. Although there is a tendency today to decrease the elaborateness of the funeral, it remains very much a family and community event. Its ritual recognition deemphasizes death. Grief over the deceased is eased if a biomedical explanation for the cause of death is given and if it is explained that the death was inevitable. Within the context of fatalism in Catholicism, many Italian Americans view death as “God’s will”; thus, a fatal diagnosis may not be discussed with the ill family member. More-traditional families hold anniversary masses for the deceased and wear black for months or years. This is not as common among younger generations. Responses to Death and Grief Emotional outpourings can be profuse, and the activities around a funeral provide distinct examples of the Italian American way of ritualizing life events. Women may mourn dramatically, even histrionically, for the whole family. They do not merely weep; they may rage against death for the harm it has done to the family. Family members may moan and scream for the deceased throughout the church. Screaming is an effort to ensure that Jesus, Mary, and the saints hear what the bereaved are thinking and feeling. Family members get up constantly to touch and talk to the deceased loved one. Children are taught to let the female kin express their feelings for them. The real time of sorrow comes at the end of the ceremony when the priest and nonfamily congregation say good-bye to the deceased. At this time, the family is left alone for a time with their loved one. Older women may throw themselves onto the casket, trying to prevent it from leaving the church. Then, the priest intones the farewell: “May the angels take you into paradise, may the martyrs welcome you on your way.” Whereas men mourn, they do so in the fashion of pazienza (patience). Their constant, silent, and expressionless presence may be their only act of public mourning. Today, second- and third-generation Italian Americans families still acknowledge the need for the mourning procession and the company of family and friends to grieve the loss of a loved one. Abundant tears and moaning are still recognized as the proper expression of grief. To many, giving up these 2780_BC_Ch34_001-014 03/07/12 9:58 AM Page 11 People of Italian Heritage customs means an improper expression of respect for the deceased. When the loss is great, such as in the death of a child, the expression of grief continues for years. Health-care providers working in hospice must be familiar with the Italian American’s response to death and grieving to effectively offer positive support. Spirituality Dominant Religion and Use of Prayer Rome is the world seat for the central administration of the Roman Catholic Church, the largest Christian denomination in the world. The predominant religion of Italians and Italian Americans is traditional Roman Catholicism, which includes folk religious practices that have changed little since the birth of Christ. Moreover, an amalgam of beliefs has evolved from diverse cultures that took up residence in Italy through the centuries, Thus, Italian Americans’ spiritual and religious beliefs have their roots in pagan customs, magical beliefs, Mohammedan practices, Christian doctrines, and Italian pragmatism. The center of Roman Catholic worship is the celebration of Mass, the Eucharist, which is the commemoration of Christ’s sacrificial death and of His Resurrection. Other sacraments are Baptism, confirmation, confession, matrimony, ordination, and Anointing of the Sick. The workings of nature and the benefits and calamities caused by nature are attributed to (1) saints resembling pagan gods such as witches, ghosts, and demons; (2) the Christian God; (3) Satan; and (4) any and all possible combinations and alliances of these factors. Most Italians pray to the Virgin Mary, the Madonna, and a number of saints. Many traditional first-generation and newer Italian Americans families display shrines to the Blessed Virgin in their backyards. Italian Americans view God as an all-understanding, compassionate, and forgiving being. Prayer and having faith in God and saints help Italian Americans through illnesses. Italian men bypass praying to the Madonna because women are perceived to have a closer relationship with the Madonna. Niceties of Catholic orthodoxy and enlightened learning are employed together with pagan practices. The lessons of common sense and science are freely mingled with those of magicoreligious beliefs. Healthcare providers must respect and acknowledge such beliefs to gain the trust of their patients. Meaning of Life and Individual Sources of Strength Family and religious beliefs give strength to Italian Americans, who see themselves first as family members and then as individuals. Family, whose primary focus is concern and a sense of pride in the home onore della famiglia (the symbol of family), helps 11 individuals cope with the surrounding world and provides a sense of continuity. Work and physical activity are considered essential for a full life. Italian Americans love the arts and have made great contributions over the centuries in music, opera, and painting. They believe that life is to be experienced with pazienza; they are happy and pride themselves as being clean, conscientious, and passionate people. Italian Americans prevail through their unbreakable amalgam of determination sustained by the solidarity of la famiglia. The hearts of the Italian people throb with warm blood and are as tough as the most annealed steel (Mangione & Morreale, 1993). Spiritual Beliefs and Health-Care Practices Because most Italian Americans have strong beliefs in Catholicism, when a loved one becomes ill, they pray at home and in church for the person’s health. In times of illness, the health-care provider may need to help the patient obtain the basic rites of the Sacrament of the Sick, which includes anointing, communion, and if possible, a blessing by the priest. A small wafer, the Eucharist, is considered a food for healing and of health. Even though Catholics are obligated to fast or abstain from meat and meat products on certain days of the year, the sick are not bound by this practice. Despite the church’s exception for the sick, many first-generation immigrants and older people choose to fast. Health-Care Practices Health-Seeking Beliefs and Behaviors The beliefs of first-generation and newer immigrants about health and health care are similar to the beliefs in their homeland. In traditional terms, illnesses are attributable to (1) wind currents that carry disease, (2) contamination, (3) heredity, (4) supernatural (God’s will) or human causes, and (5) psychosomatic interactions (Spector, 2009). First-generation and, to a lesser degree, second- and third-generation Italian Americans may not accept institutional care either in sickness or in old age. An example of a condition attributable to wind currents is leaving a body cavity, such as the abdomen, open too long during surgery, which exposes it to excess air and leads to a quicker death. Within the context of fatalism, diseases largely run their own course; thus, it is better to leave the investigation into health problems until a condition becomes so obvious that it cannot be neglected. The condition, evil eye, caused by supernatural human agents is discussed under Folk and Traditional Practices. Nervousness, hysteria, and many other mental illnesses are attributed to an evil spirit entering the body and remaining there until it is cast out by making its abiding place so unpleasant that it is forced to leave. A study by Van der Stuyft and colleagues (1989) looked at migration, acculturation, and utilization of 2780_BC_Ch34_001-014 03/07/12 9:58 AM Page 12 12 Aggregate Data for Cultural-Specific Groups primary health-care services by Italians, Moroccans, and Turks. Data suggested that with increasing acculturation among participants, vague complaints become more prevalent, the delay before seeking a solution is shortened, and the prognosis improves. Gilford’s (1994) study of Italian Australian working women found that these women discuss health and illness concerns as a way to express feelings of loss over the fertility of their youth and of grief over a life left behind in Italy. These losses are experienced physically and expressed metaphorically through conditions of “bad blood” and “nerves” and contribute to their increased vulnerability to a range of diseases, including cancer. For these women, the change of life is experienced as the end of life, and their fear of cancer is representative of their fear of social and physical death. Responsibility for Health Care The family, the most dominant influence on the individual, is viewed as the most credible source of healthcare practices. Italians believe that the most significant moments of life should take place under their own roofs. Research completed in Italian neighborhoods in Baltimore suggested that the extended family is the front-line resource for intensive advice on emotional problems. Mental-health specialists are frequently perceived as inappropriate agents for meeting problems that are beyond the expertise of the family and local community. Most second- and third-generation Italians take responsibility for their own health care and engage in health promotion more than those of the first generation. Most also have health insurance coverage. From the family perspective, the mother assumes responsibility for the health of the children. Folk and Traditional Practices Earlier immigrants from southern Italy had many folk practices for organic and mental disorders. For difficult cases, they summoned a witch, barber, midwife, or herbalist. Because life was precarious and evils abounded, the contadini attempted to make sense of a dangerous world. Events were caused by forces and powers that were, in turn, controlled by agents. One had to find which agent was behind a certain force and then marshal a counterforce by soliciting a more powerful agent to oppose it. These agents are given one generic name, il mal occhio (the evil eye), which is also called occhio captive (bad eye), occhio morto (eye of death), and occhio tristo (wicked eye). Individuals can protect themselves from the evil eye by using magical symbols and by learning the rituals of the maghi (witch). Amulets, miniature representations of natural or manmade weapons that fight off the evil eye, include teeth, claws, and replicas of animal horns worn on necklaces or bracelets, held in a pocket, or sewn into clothing. Cornetti (little red horns) can still be purchased in little Italy communities as good luck charms. First-generation and many second- and third-generation Italian Americans believe in obtaining as much protection from the evil eye as possible. These red horns, hung over a door, are supplemented by an array of pictures and statues of Madonnas and saints liberally distributed throughout their homes. Many are still seen today. When Italian American patients bring these amulets with them into the health-care settings, the health-care provider should not remove them because they provide great solace to the patient. All life-sustaining things of the earth are given special respect, and particular plants are believed to have particular magical attributes. Common plant items used in folk healing are olive oil, lemon juice, wine, vinegar, garlic, onion, lettuce, and tobacco. A crown of lemon leaves cures a headache. Wild fennel, deadly nightshade, and sorrel are also used. The leaves and flowers of the wild mallow herb, Malva, are used to make tea, providing cool energy and positive effects on the lungs and stomach. When suffering from a fever, a person is given hot rather than cooling drinks. For indigestion, a mixture of coffee grounds and sugar is taken. Grain sprouts, especially those grown in the dark, in consecrated ground, in the churchyard, or in a crypt, protect against Satan and the forces of chaos. The principal animals in folk prescriptions are the wolf, chicken, viper, lizard, frog, pig, dog, mouse, and seahorse. Body secretions such as saliva, urine, mother’s milk, blood, and earwax are commonly used as folk medicines. Some Italian mothers use earlymorning saliva to bathe the eyes of children with conjunctivitis. Baldness is treated with an application of warm cow’s urine. Sulfur and lemon juice are mixed as an ointment for scabies, and potato or lemon slices are bound to the wrists to reduce fever. Barriers to Health Care Most Italian Americans have few barriers to health services. However, many, especially the first generation, tend to underuse their resources because they have little faith in medical providers. Newer immigrants who have difficulty with the English language and are unfamiliar with the health-care system can benefit from a cultural broker or primary case manager to help bridge these barriers. Cultural Responses to Health and Illness Both age and gender mediate ethnic differences in the expression of pain for Italian Americans. Older Italian Americans, especially women, are more likely to report pain experiences (Koopman, Eisenthal, & Stoeckle, 1984), express symptoms to the fullest extent, and expect immediate treatment. Italians tend to be more verbally expressive with chronic pain than do some other ethnic groups (Lipton & Marbach, 1984). Neill’s (1993) study on pain in acute myocardial infarction indicates that patients of Jewish and Italian 2780_BC_Ch34_001-014 03/07/12 9:58 AM Page 13 People of Italian Heritage ancestry exhibit more-expressive pain behaviors than patients of Irish or English ancestry. Vincente’s (1993) study examined Italian Americans’ attitudes and beliefs about mental-health services and mental-health workers. The results suggested that Italian American professionals have the highest level of satisfaction with their work, show the most tolerance for deviant behavior in the community, and hold a nontraditional view of psychiatry. Because Italian Americans tend to report more symptoms and report them more dramatically, physicians tend to diagnose emotional problems in Italian patients more frequently than in other ethnic groups (Rotunno & McGoldrick, 1982). Most Italian Americans believe that people who have disabilities should be cared for at home by the family; thus, very few are placed in long-term-care facilities. Germans followed by Italians have the greatest acceptance for people with disabilities. Persons with physiological or physical disabilities such as asthma, diabetes, heart disease, and arthritis are the most accepted, whereas persons with disabilities such as AIDS, mental retardation, psychiatric illness, and cerebral palsy are the least accepted (Westbrook, Legge, & Pennay, 1993). A person with a physical or mental disability is not stigmatized in the Italian culture because the condition is believed to be due to God’s will. Illness can be caused by suppressing emotions and stress from fear, guilt, and anxiety. If a person does not vent these feelings, the person may burst (Rotunno & McGoldrick, 1982). The sick role for many Italian Americans is one not entered into without personal feelings of guilt; thus, they may keep sickness a secret from family and friends and are not inclined to describe the details because they blame themselves for the health problem. Families may be ashamed to let neighbors know of an incident that may impair the social status of a family member. This applies especially to afflicted daughters. A reputation of poor health unfavorably affects the value of a young woman’s potential as a wife. This concept applies only somewhat to males. When a family member is sick, other women in the family take over and assist the sick person until they are well. Blood Transfusions and Organ Donation Judicious use of medications and blood transfusions is permissible and morally acceptable as long as the benefits outweigh the risks to the individual; thus, Italian Americans have little objection to accepting a blood transfusion when needed. First-generation immigrants are, in general, not prone to donating their organs. Second- and third-generation Italian Americans may also reflect this perspective. Organ donation is morally permissible when the benefits to the recipient are proportionate to the loss of the organ to the donor and when the organ does not deprive the 13 REFLECTIVE EXERCISE 34.3 Sergio is a 32-year-old single male who lives with his mother and younger brother in New York City. His mother and father emigrated from Naples, Italy, before Sergio was born. He grew up speaking an Italian dialect and learning traditional beliefs about health from his mother, as his father died when he was very young. Sergio’s mother often told him how life was precarious at best, there were many evils in the world, and he must protect himself from these agents, called the malocchio. She told Sergio he can protect himself from the evil eye by using magical symbols and by learning the rituals of the maghi. Sergio still wears the red horn his mother had given him as a symbol of protection when he was a child. Although Sergio was raised in America and uses the health-care system when he is sick, he still believes that evil agents exist and can have a negative impact on his health. 1. What is malocchio and maghi? 2. What are some of the symptoms of malocchio? 3. What are some of the traditional treatments for malocchio? 4. What might allopathic providers prescribe to treat malocchio? 5. How common is it for second- or third-generation Italian Americans to have malocchio? donor of life or the functional integrity of the body. Otherwise, organ transplant is an individual decision. Health-Care Providers Traditional Versus Biomedical Providers The powers of the occult are not limited to saints. For traditional Italian Americans, certain humans are believed to have immediate and potent access to magical powers. These are the maghi (male witch) and the maghe (female witch) who are granted various degrees of black-magic power at birth. A man or woman with more limited powers is often called un’uomo di fuori (a different man). A powerful sorcerer is called lupo mannaro (werewolf). These extraordinary people are believed to possess or influence the evil eye. They have power to cast spells, cause or cure ailments, and change events by using their own force—even their gaze is believed to be potent. These traditional beliefs may be practiced by first-generation and newer Italian immigrants but hold little value for second- and thirdgeneration Italian Americans. Health-care providers should accept and incorporate these practices into their treatment plans, along with providing written instructions for biomedical treatments. The barber’s role in bloodletting was firmly established among first-generation Italian Americans. Native Italians, who readily went to the barber for bloodletting, strenuously object to blood tests. The belief is that 2780_BC_Ch34_001-014 03/07/12 9:58 AM Page 14 14 Aggregate Data for Cultural-Specific Groups the barber draws off unhealthy blood, in contrast to blood taken for testing in which the needle is inserted into a healthy arm. Italians believe in the connection between soul and blood found in Leviticus: “For the life of all flesh is the blood there of.” The shaman (usually a male) has an advantage over the family physician. He is more than a physician; he is a practical student of human relations. Status of Health-Care Providers Some health-care providers find themselves practicing on one side of an invisible border, which separates them from their Italian patients such that differences of culture can lead to misunderstanding and impede gaining cooperation with prescribed therapy. Today, some physicians collaborate with shamans and herbalists to accommodate patients’ cultural preferences. 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Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage Italian American immigrant groups include ▪ First-generation, traditional older Italians primarily living in enclaves ▪ Second-generation, less traditional Italians living in suburban and urban neighborhoods with ethnic enclaves ▪ Third-generation, more educated Italians primarily living in the suburbs ▪ A relatively small group of newer immigrants with strong ties to their homeland Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage ▪ This presentation describes the beliefs and practices of Italian Americans from the mainland of Italy, although some of these characteristics may be shared by Italian Americans with a heritage from Sicily and Sardinia. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview ▪ Italy is famous for the marvels of ancient Rome, such as the Coliseum, Parthenon, museums. Also famous for St. Peter’s Square, the Leaning Tower of Pisa, the canals and Piazza in Venice, the ruins of Pompeii, artists, and the Portofino lace makers, wineries, and marble. ▪ New York City has the largest Italian population of any city in the country. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage ▪ In addition to New York, other states with high Italian populations are New Jersey, Massachusetts, Pennsylvania, and California. ▪ Major cities in addition to NYC hosting large Italian Americans populations include Chicago, New Orleans, Philadelphia, Boston, Newark, New Jersey, and San Francisco. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage ▪ Italian enclaves, or “Little Italy’s” as they are called, can be found in New York City, Boston, Cleveland, and other major cities in the US. ▪ The current Italian American population of almost 16 million ranks fifth in the United States, preceded by German, Irish, English, and African Americans. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ The official language of Italy is Italian, a Romance language derived from Latin. ▪ All socioeconomic groups in the 19 regions of Italy speak different dialects. ▪ The dialects of northern Italy contain numerous German words. Spanish, French, and German languages influence Neapolitan Italy. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Piedmontese is strongly affected by the French and Spanish languages, whereas the dialects of Sicily have been strongly influenced by French, Spanish, Greek, Albanian, and Arabic languages. ▪ Sardinia has its own language, Sardinian. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ First-generation Italians who immigrated to America bring the dialects of their region with them. ▪ Today, in some second-generation and thirdgeneration Italian homes, these dialects are still spoken. ▪ Many second-generation Italian Americans do not speak Italian well or at all. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Either their parents encouraged them to learn English, or more often, the children refused to speak the mother tongue. ▪ Often the next generation becomes curious about its background and tries to recover parts of its heritage. ▪ A number of third-generation Italian Americans are studying Italian in an effort to reconnect with their Italian heritage. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Grammatically correct Italian is musical and romantic because vowels predominate over consonants, expressing the many subtleties of thought and feeling in a delicate manner. ▪ In many Italian households, discussions can become quite passionate with vocal volume raised and many people speaking at once. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ The willingness to share thoughts and feelings among family members is a major distinguishing characteristic of the Italian American family. ▪ Positive and negative emotions and sentiments are permissible, encouraged, and color their daily lives. ▪ Many times a fluctuating emotional climate exists within the family with expressions of affection erupting briefly into what may appear to an outsider as anger or hostility. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Conflict is usually confined to periodic outbursts and does not usually cause resentment or open and permanent ruptures. ▪ In fact, emotional neutrality to Italians denotes noninvolvement or the absence of affection. ▪ Italians are sentimental and not afraid to express their feelings. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Traditional Italian Americans value close family ties, express warmth freely, and have heart and feeling for each other. ▪ The emotional bond among Italian Americans is reaffirmed by frequent kissing. ▪ The “typical” kiss is eastern European style, with a kiss on each cheek. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ They frequently touch and embrace family and friends. Touching between men and women, between men, and between women is frequently seen during verbal communication. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ It is said that the Italians from southern Italy are capable of carrying out a conversation without saying a single word. ▪ Gestures convey a range of feelings from poetic eloquence to intense anger. ▪ Italians are past, present, and future oriented. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Past orientation is evidenced by the pride they take in their rich Roman heritage. ▪ Within the context of fatalism, they do not allow their imagination to stray too far, occupy themselves with concrete problems and situations, and accept things. ▪ They are future oriented as evidenced by the importance given to planning ahead and saving financially for the future. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Time orientation varies by immigrant group. ▪ First-generation and newer immigrants view time as an approximation rather than categorically imperative. ▪ Second-generation and third-generation Italian Americans adhere to clock time at least in the work situation and for appointments. For this group, deadlines and commitments are considered important and adhered to firmly. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Before the Napoleonic era, last names were not commonly used in southern Italy. ▪ After the Napoleonic era ended in 1814, the French often assigned to a family, or sometimes an entire village, the name of that village. ▪ The contadini peasant custom was to name first children for their grandparents and later children for their godparents. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ To avoid confusion, they instituted a practice of assigning nicknames according to some physical characteristic or their occupation. ▪ For example, Giovanni Pelo is translated as “Johnny one hair”. This nickname was given because his body was covered with dark hair. ▪ This practice of assigning nicknames continues with many Italian American families. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ In the past, an Italian father’s decision may have been accepted as law even among his married children. ▪ To criticize one’s father is considered a sacrilege. ▪ In many traditional Italian American families today, the father continues to dominate family decisions as long as he remains in good health and is the chief breadwinner. ▪ He is known as the Padrone or capo di famiglia, the “head of the family.” Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ In old age and illness, the eldest son supersedes the father, but even then, the father retains much of his prestige. ▪ The “typical” traditional Italian father frequently demonstrates public and private affection for his children, but such demonstrations are less frequent in public for his wife. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ Many husbands turn over their paychecks to their wives to run the home, and thus Italian women tend to have more power in economic decisions. ▪ Women also dominate decision making on childbearing issues and family social events. ▪ A trend toward more egalitarian relationships is evolving. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ Italian American children are taught to have good manners and respect for their elders. ▪ Both male and female children are encouraged to be independent and expected to contribute to the family’s support as soon as they are old enough to work. ▪ This work ethic continues in second-generation and third-generation families. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ L’ordine della famiglia, “family order,” a system of social attitudes, values, and customs, has proven to be impenetrable to the exploitation of strangers and is the main tie that holds the Italian American household together. ▪ The rules governing family membership are simple and explicit: Fear God and respect the saints. The father is the father, and he is experienced. Always honor and obey your parents. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ Italian American families maintain close relationships. ▪ Love and warmth, security, and the expression of emotions are the most common characteristics of the Italian American family. ▪ Daughters have close ties with both parents, particularly as they approach old age. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ Although many second-generation and thirdgeneration Italian Americans no longer live in an immediate Italian enclave, they return home frequently to maintain family, community, and ethnic ties. ▪ While parents are alive, their home is most often the focus of kinship gatherings. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ Italian Americans are almost twice as likely as other ethnic groups to see a parent daily or at least several times a week. ▪ If personal contact is not possible, frequent telephone contacts are made, sometimes several times a day. ▪ Continuity in parental roles is an important factor in maintaining the high status of older people. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ The loss of the work role does not noticeably affect their central role in the family. Instead, the absence of the work role permits greater family involvement. ▪ Italian Americans have an actively functioning kinship and extended family system that is the primary focus of solidarity for the nuclear family. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ Social status for most Italian Americans families comes from family lineage. ▪ Titles are more important than names. ▪ Despite values clearly defined around family obligations, Italian Americans generally do not reject another family member because of an infraction or alternative lifestyle. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ Italians believe strongly in the work ethic, are punctual, and rarely miss work commitments owing to a cold, headache, or minor illnesses. ▪ If completing their work requires staying later, they do so. ▪ Although the family is of utmost importance to Italians, work takes priority over family unless serious family situations arise. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ Among Italian Americans, work is viewed as a matter of pride, demonstrating that one has become a man or woman and is a full functioning member of the family. ▪ So strong is this ethic that it governs behavior apart from monetary gain derived from employment. ▪ To Italian Americans, it is morally wrong not to be productively occupied. Poveri si, ma perche lognisi? (Poor yes, but why lazy?) Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ Even though Italian Americans have the utmost respect for their employer, they are emotional and passionate people, and when a confrontation arises, Italians are likely to get involved. ▪ Italians born and educated in the United States usually have little difficulty communicating with others in the workforce. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Italians as a group have varied physical characteristics. ▪ Those from a predominantly northern background have lighter skin, lighter hair, and blue eyes, whereas those from the south of Rome, particularly from Sicily, have dark, often curly hair, dark eyes, and olive-colored skin. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ People of Italian ancestry have some notable genetic diseases, such as familial Mediterranean fever, Mediterranean-type glucose-6-phosphate dehydrogenase deficiency (G-6-PD), thalassemia, and recurrent polyserositis. ▪ Italian Americans have a high incidence of hypertension and coronary artery disease related to smoking and perhaps their type A behavior. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Italian Americans have significantly higher risks of nasopharyngeal, stomach, liver, and gallbladder tumors. ▪ Females exhibit a low risk for cancer of the oral cavity, esophagus, colon, rectum, and pancreas. ▪ Males exhibit a low risk for cancer of the larynx, lung, melanoma, breast, prostate, bladder, and non-Hodgkin’s lymphoma. Transcultural Health Care: A Culturally Competent Approach, 4th Edition High-risk Behavior ▪ Although there is much education in the general population regarding the risks of smoking, many Italian Americans immigrants continue to smoke. ▪ Alcohol misuse also presents a risk in this group. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ To the Italian Americans, food is symbolic of life and the principal medium of life, particularly family life. ▪ Respect for food as the medium of life is upheld even among the poor. ▪ The ceremony of eating is honored by Italian Americans who convey to their children that the waste or abuse of food is a sin. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ In an emotional sense, food is a connection between an Italian child and the parents, representing the product of the father’s labor and prepared with care by the mother. ▪ In a symbolic sense, meals are a communion of the family, and food is sacred because it is the tangible medium of that communion. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ An Italian mother may demonstrate her affection by feeding her family and anyone else she likes. ▪ To the average Italian mom, love is a four letter word. ▪ The Italian diet, rich in vegetables, pasta, fruit, fish, and cheese, varies according to the region of Italy from which the individual originated. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Northern Italian foods are rich in cream and cheese, resulting in a potential high intake of fat. ▪ Southern Italian foods are prepared in red sauces, spices, and added salt. ▪ The staples of the Italian Americans diet are spaghetti, lasagna, ravioli, pasta with pesto, and manicotti. ▪ Vegetables, fresh fruit, and beans are common. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Popular Italian foods include lentils, sausage, eggplant parmigiana, salami, olive oil, espresso and cappuccino coffee, wine, ice cream (gelato), pastries such as cannoli and bisciotti, and cheeses such as provolone, ricotta, romano, and parmigiana. ▪ Other common dishes include escarole, Caesar salad, calzone, and pizza. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Dinner is a gathering of the family. Italian wine is taken at almost every meal, and a mixture of water and wine is given to children. ▪ Breakfast has never been an important meal for southern Italians. ▪ Eating a fresh raw egg every morning, keeps the person strong. ▪ Fresh dandelions are used to make a salad or are boiled to make soup to give the person strength. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ One of the most common practices for health promotion is eating a clove of garlic every night before going to bed to prevent upper respiratory infections. ▪ Garlic may also be worn around the neck when there is an epidemic of influenza or other upper respiratory ailments to prevent the wearer from getting the infection. Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck Genetic conditions common Italians and Italian Americans is a. Hemophilia b. Polydactylism c. Bi-polar disorders d. Thalassemia Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: D Thalassemia is a common genetic disorder among Italians and Italian Americans. The other conditions are not. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ Many third-generation Italian Americans use birth control from the beginning of the marriage, and sex is commonly discussed in the family. ▪ There continues to be a weakened external restriction on premarital sex, but internal inhibitions remain strong. ▪ In the past, adultery was often seen as unacceptable but sometimes excusable. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ Italy has some of the lowest birth rates in the world, which is surprising for a predominantly Catholic country. ▪ Traditional ideas among Italian Americans regarding pregnancy have undergone slight but significant variations in the United States. ▪ The belief that a mother does not conceive while nursing continues to be held by many Italian women. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ Traditional beliefs related to pregnancy include the following: coffee spills may result in the baby being born with a birthmark where the coffee was spilled; the women must abstain from sexual relationships while pregnant; and if the expectant mother’s cravings for a particular food are not satisfied, a congenital anomaly may occur or the baby will be marked. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ If a pregnant woman is not given the food she smells, the fetus moves and a miscarriage results. ▪ If she turns or moves in a certain way, the fetus does not develop normally ▪ She should not reach over her head because harm may come to the baby. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ Among traditional Italian Americans, a postpartum woman is not allowed to wash her hair, take a shower, or resume her domestic chores for at least 2 or 3 weeks after birth so she can rest. ▪ The woman’s mother and other female family members tend to the chores and assist with the care of the new baby. ▪ New mothers are expected to breastfeed, restoring the health of the reproductive organs and keeping the mother and baby free of infections. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ In the Italian Americans family, death is a great social loss and brings an immediate response from the community. ▪ Sending food and flowers (chrysanthemums), giving money, and congregating at the home of the deceased is expected. ▪ As for other life events, among the first responses to death is food, which is brought by friends and distant relatives. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Italian death rituals can be very demonstrative. ▪ The funeral procession to the cemetery is a symbol of family status. ▪ There is great pride in the size of the event, which is determined by the number of cars in the procession. ▪ Although there is a tendency today to decrease the elaborateness of the funeral, it remains very much a family and community event. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Grief over the deceased is eased if a biomedical explanation for the cause of death is given and if it is explained that the death was inevitable. ▪ Within the context of …
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