People of Haitian Heritage and People of Iranian Heritage

Transcultural Health Care: A Culturally Competent Approach, 4th Edition Iranian Larry Purnell, PhD, RN, FAAN

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Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage ▪ Over 400,000 in the United States with about ½ living in California ▪ Currently about 76 million in Iran with 75% under the age of 30 ▪ Much diversity in Iran (Persia) among its inhabitants and also much diversity among Iranians in the United States Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage Continued ▪ The reform institutions of current Iran are colored by religious traditions and ideology of Islam. ▪ Current industrialization of Iran has been from the outside, not from the inside and is due to the oil production industry. ▪ Political instability continues with clashes between conservatives and liberals. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage Continued ▪ First wave of immigration between 1950 and 1970 were mostly students and professionals from the social elite and many stayed in the United States. ▪ Second wave between 1970 and 1978 were varied in their background, but most were still affluent and urban and came for education and to be with family. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage Continued ▪ Not a major influence in the United States because they did not live in ethnic enclaves and assimilated into the United States culture easily ▪ The third wave of immigration began in 1979 at the time of the Islamic revolution and included voluntary and involuntary political exiles and others who come for economic and personal security Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage Continued ▪ The hostage crisis between 1979 and 1981 increased ethnic tension of Iranians in the United States ▪ Many are unable to find work in the United States that is compatible with their education in Iran ▪ Most highly educated immigrant group in the United States Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications ▪ Farsi (Persian) is the national language of Iran but half speak another language with the educated group speaking three or more languages, including English ▪ Invasions by numerous other nations have caused a mistrust and suspicion of foreigners resulting in not sharing one’s feeling with strangers Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications Continued ▪ Tell stories rather than being blunt and to the point in conversations leading to politeness and sometimes disguised as modesty ▪ Hierarchical relationships dictate politeness and social communication resulting in a public self and a personal self Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications Continued ▪ Family affairs remain within the family ▪ Self-control is valued and therefore do not show anger or emotions ▪ Men can show affection for men and women for women in public, but not men and women ▪ Stand close in conversations, regardless of social status between conversants Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications Continued ▪ Maintain intense eye contact between intimates, but avoid eye contact with superiors and elders ▪ Expressive gesturing ▪ Balance in temporality ▪ Clock time is meaningless, even with appointments unless well acculturated Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications Continued ▪ Formality in addressing each other unless close friends ▪ More traditional men do not mention their wives’ names in public ▪ Man should wait for woman to extend her hand for a greeting Transcultural Health Care: A Culturally Competent Approach, 4th Edition Name Format ▪ Order of the name is the same as the Western method with the given name followed by the surname. ▪ Traditional women do not take their husband’s last name although some in the United States and elsewhere may upon immigration. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles ▪ Society is patriarchal and hierarchical ▪ Oldest son takes over if father is not present or unable to carry out decision-making ▪ Male children are more desirable than female children—true in other cultures as well Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles Continued ▪ Men deal with finance and matters outside the home. ▪ Women care for the home and children. ▪ Before 1960s social reform, women were legally expected to be obedient and submissive to their husbands. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles Continued ▪ Marry early and have children. New law says women cannot marry until age 14—was 12 and marriages may still be arranged, but less so in the United States ▪ Respect elders and never speak rudely to them ▪ Children rarely left with babysitters Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles Continued ▪ Traditional do not allow dating; women are expected to remain virgins until married, but not men ▪ Strong intergenerational ties and family life together or nearby ▪ May dress conservatively outside the home but less so while at home Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles Continued ▪ Divorce uncommon in Iran and carries a stigma—if divorce, it is the woman’s fault, never the man’s—varies in the United States ▪ Pregnancy before marriage can have devastating outcomes and is not talked about, it does not happen—it is just taken care of ▪ Gay and lesbianism highly stigmatized and is a capital crime punishable by death in Iran Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Wide variations in skin color, hair color, and eye color and depends on heritage from previous domination by other countries and cultures ▪ Common illnesses in Iran include malaria, hypertension, meningitis, hookworms, and parasitosis Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology Continued ▪ Great numbers with genetic disorders brought on by close sanguinity marriages resulting in blindness, epilepsy, anemias, hemophilias ▪ Glucose-6-phosphate dehydrogenase deficiency —fava bean allergies can cause hemolytic crisis Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Food is a symbol of hospitality; serve the best food for guests who are expected to eat several servings. ▪ Polite to refuse snacks and beverages when first offered—accept it on the third offering ▪ Rarely eat fast food; fresh food is greatly preferred, and many hours are spent preparing meals Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition Continued ▪ Strict Muslims avoid pork and alcohol and meat must be prepared with ritual slaughter called halal. ▪ Food should be eaten with the right hand (clean hand) and food should be passed with the right hand or both hands. ▪ Traditional prefer family to bring food from home if hospitalized. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition Continued ▪ Balance food between garm (hot) and sard (cold) —if balance does not occur, one may become “chilled” or “overheated.” ▪ Women are more susceptible to these conditions than are men. ▪ Newer immigrants may have protein and vitamin deficiencies. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Family ▪ Menstruating women are not allowed to touch holy objects, have intercourse, exercise, or shower. ▪ Iran is changing from openly discouraging birth control to now cautiously and secretly encouraging birth control because of the population explosion. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Family Continued ▪ Cravings must be satisfied because the fetus needs the craved food ▪ Avoid fried foods or foods that cause gas ▪ Eat lots of fruits and vegetables ▪ Balance garm and sard foods ▪ Pregnant woman should not work after the sixth month Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Family Continued ▪ The father should not be present at birth in the traditional family ▪ 30- to 40-day postpartum period where other women are to care for the new mother ▪ Ritual bath after this period so religious obligations can continue ▪ Eat different foods if a boy baby versus girl baby ▪ Eat an herbal extract (taranjebin) to have a boy Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Okay to begin life support, but usually not okay to end life support ▪ Multiple family members come to bedside of the dying person and recite/read prayers ▪ Bed should be turned to face Mecca ▪ More traditional want to return to Iran to die Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals Continued ▪ Even though death is seen as a beginning, not an end, mourning and grief are displayed openly and even dramatically to encourage letting go ▪ After death, relatives and friends gather on days 3, 7, and 40 to pray and grieve with family and friends Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals Continued ▪ All wear black for mourning and women should not wear makeup ▪ On the anniversary of the death, family and friends again gather to express grief and pay respect to their loved one Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals Continued ▪ Ritual body washing by another Muslim after death and dressed in a white shroud; body orifices stuffed with cotton and ritual prayers said during the cleansing ▪ If non-Muslim, touch the body only with gloves ▪ No embalming in Iran nor is cremation practiced Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ Specific Muslim practices include praying 5 times each day and need privacy and ritual washing before prayer ▪ During Ramadan, fasting from sunup to sundown unless pregnant or ill ▪ Family relationships and friendships are primary sources of strength Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality Continued ▪ Sadness is valued and a sad person is considered to be deep, thoughtful, and sensitive ▪ God’s Will and power over one’s fate fosters passivity and dependence Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck A 76 year old Iranian, Muslim male is in the process of dying after a long debilitating illness. The nurse would a. Have his Imam visit. b. Make sure no one touches him with bare hands. c. Turn him to face Mecca. d. Place him in a supine position. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: C At the time of death, the dying person should be positioned to face Mecca. This can be accomplished by moving the bed or at a minimum of turning the patient’s face towards Mecca. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practices ▪ Combination of humoral medicine, Islam, and biomedical practices ▪ Humoral medicine—illness is caused from an imbalance in wet and dry and hot and cold forces ▪ Sacred men are able to heal ▪ Evil eye is alive and well Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practices Continued ▪ Good health is a daily way of life ▪ Seek care immediately and shop around for the right treatment ▪ Use traditional herbs and over-the-counter medicine to relieve symptoms and seek care provider to determine the cure ▪ Able to purchase a wide variety of drugs over-thecounter in Iran and bring them to the United States Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practices Continued ▪ Narahati—general term to express unpleasant emotional or physical illnesses and somatization is common and accepted and can be treated religiously or medically, depending on what the cause might be ▪ Ghalbam gerefteh—distress of the heart—is an expression of emotional turmoil or homesickness Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practices Continued ▪ Various remedies for the evil eye and dependent on the age and family of the person afflicted ▪ Language can be a barrier to care for some ▪ Descriptions of conditions may be different from the US description ▪ Many do not have health insurance Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practices Continued ▪ Concept of insurance may not be known to some ▪ Usually very expressive with pain and discomfort ▪ Mental illness is highly stigmatized and may hinder other family members from marriage ▪ Prefer drugs, the stronger the better, and prefer IV over IM, and IM over pills ▪ The more invasive, the better Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practitioners ▪ Organ donations and transplantations may be seen as a business transaction ▪ Folk or religious practitioner used for narahatis ▪ Most respected biomedical practitioner is a middle-aged male with a title and white hair ▪ Firm believers in high technology Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practitioners Continued ▪ Nurses are usually afforded little respect— partially because of training ▪ Physicians are on top—all other healthcare providers take a lesser position ▪ If self-care is encouraged, it may be seen as non-caring Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck Mrs. Said is brought to the nurse practitioner by her daughter because she has naharati. The nurse recognizes this condition as a. Equivalent to congestive heart failure. b. Generalized distress. c. Generalized weakness of aging. d. Abdominal pain. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: B Naharati is generalized distress that can be brought on by stress, anxiety, homesickness, or other things that can cause emotional turmoil. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Transcultural Health Care Haitian Americans Larry Purnell, PhD, RN, FAAN Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview ▪ Haiti shares the Island of Hispaniola with the Dominican Republic. ▪ Dominican Republic and Haiti have little in common culturally. ▪ Haiti is the poorest country in the Western hemisphere with a per capita income of less than $450. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview Continued ▪ Over 500,000 Haitians live in the United States, with more arriving after the Haitian earthquake in 2010. Their numbers may exceed 1.5 million. ▪ Most live in NYC, FL, Boston, Chicago, and CA ▪ Most come here for better economic opportunities and political freedom Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview Continued ▪ Haitians are a mix of Arawak Indian, Spanish, French, and African Black resulting in sharp class stratification and color consciousness ▪ 1791 ended slavery in Haiti Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications ▪ Languages are primarily Creole (for the poor) and French (wealthier) and English although many speak all three languages ▪ Black, mulatto, or white and colors in-between ▪ Most Blacks are poor and underprivileged Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview ▪ Early immigration to the United States was the wealthier groups for education, followed by general immigration after 1920 and the United States occupation of Haiti ▪ After 1964, Duvalier became president for life, mass exodus because of oppression politically and economically Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview Continued ▪ 1980 immigration with the Mariel Boat Lift from Cuba brought first legal and then the Boat People from Haiti. ▪ Many had left Haiti to Cuba in previous generations and this group joined in coming to the United States. ▪ Resulted in Cuban-Haitian entrant: status pending Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview Continued ▪ French model of education with liberal arts, philosophy, classics, and languages—Latin and Greek and de-emphasizes technical and vocational training and the social and physical sciences ▪ Educated Haitians are multilingual ▪ Only 15% to 20% receive an education—high illiteracy rates Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications ▪ French and Creole official languages ▪ 15% speak French, 100% speak Creole ▪ Oral communication patterns to pass on culture through proverbs and storytelling ▪ Smile timidly to hide lack of education and understanding ▪ Nod of the head does not mean “I understand” Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications Continued ▪ Most are private individuals who do not want friends or family to interpret for them ▪ Traditional Haitians do not usually maintain eye contact ▪ Touching is common ▪ Women may hold hands while walking in public Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications Continued ▪ Most are present oriented out of necessity, the past is cherished and the future is predetermined —many remain rather fatalistic ▪ Punctuality is not valued—flexible time is the norm Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications Continued ▪ First and middle name are usually hyphenated ▪ Woman takes her husband’s name upon marriage ▪ Last names are usually French or Arabic in origin ▪ Formality in name is the norm Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles ▪ Matriarchal or shared decision-making is the norm—although there are variations ▪ Male is the primary breadwinner ▪ Concept of machismo prevails ▪ Not uncommon to have more than one mistress or for women male partners Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles Continued ▪ Children are valued and expected to be well behaved—otherwise physical punishment may be used ▪ Most feel US society is too permissive ▪ Boys are given more freedom and permissive behavior ▪ Girls cannot go out alone until age 17+ Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles Continued ▪ Nuclear, consanguine, and affinal relatives are the norm ▪ Family lineage is what denotes respect, not money ▪ Children expected to care for parents when selfcare is a concern Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles Continued ▪ Single parenting is well accepted ▪ Homosexuality is taboo—if known, total denial from both sides ▪ Mistress supports her children with little to no financial help Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck The nurse is providing insulin injection instructions to Mrs. Paul, a 44-year-old Haitian. When the nurse asks her if she understands the instructions, she nods. To assure understanding, the nurse should a. Ask her to repeat the instructions. b. Give her written instruction to ensure. c. Have her demonstrate an injection. d. Give the instructions to a family member. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: C The best way to assure understanding is for the patient to demonstrate the injection. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health Conditions ▪ Cholera, parasitosis, and malaria without malaria control measures ▪ Hepatitis, tuberculosis, venereal disease have high rates ▪ Most test positive for TBC because of Bacille bilie de Calmette-Guerin vaccinations ▪ High rates of diabetes and hypertension Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ For many, food means survival ▪ Prefer eating at home and dislike fast food ▪ When hospitalized, many prefer to fast rather than eat hospital food ▪ Dislike yogurt, runny eggs, and cottage cheese ▪ Staples are rice and beans, plantains, salad Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition Continued ▪ Lists of foods are in the Haitian–American chapter ▪ Foods are classified as cold (fret) and hot (cho), acid and non-acid, and heavy and light ▪ Must balance fret and cho foods or illness occurs Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition Continued ▪ ▪ ▪ ▪ ▪ Cough medicines are hot, laxatives are cold Avoid citrus, causes acne After ironing do not open refrigerator door Do not shower when you are hot Do not put warm feet directly on the cold floor Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition Continued ▪ Diet high in carbohydrates and fat ▪ Being overweight is seen as positive ▪ Major portion of meat protein is given to men Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy ▪ Pregnancy is not an illness so why seek prenatal care ▪ Spicy foods will cause the fetus to be irritable ▪ Vegetables and red fruits build blood for the fetus ▪ Increased salivation—“use a spit cup” Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy Continued ▪ Prefer natural childbirth, although changing somewhat in the United States ▪ Men usually not present during labor—female family members are preferred ▪ Dress warmly and stay in bed 2 to 3 days after birth and use an abdominal binder to close the bones so cold air does not enter and cause illness Transcultural Health Care: A Culturally Competent Approach, 4th Edition Postpartum ▪ Three baths postpartum, more difficult in the United States ▪ Avoid food believed to increase vaginal discharge—lima beans, okra, mushrooms ▪ Other foods are strength foods ▪ Breastfeeding is encouraged ▪ All infants receive lok to help meconium pass Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck Most Haitians practice the hot and cold dichotomy of foods. This is know in Haitian Creole as a. Yin and yang. b. Calor y frio. c. Fret and cho. d. Am and duong. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: C Fret and cho are the Haitian Creole words for hot and cold. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Prefer to die at home ▪ Death watch by family who brings religious pictures and have bedside prayer ▪ Male kinsman responsible for funeral arrangements, notifying all family members, and coordinating the service ▪ Preburial veye to celebrate deceased’s life Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals Continued ▪ Seven consecutive days of prayer in the home to help the passage of the soul into the next life ▪ Believe in resurrection so no cremation ▪ Autopsy may relieve fear of deceased becoming a zombie Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ ▪ ▪ ▪ Family is the center of life Catholicism is the primary religion of Haiti Religious practices combined with voodooism Loa, the gods or spirits, believed to receive powers from God can provide protection and wealth Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practices ▪ Good health is balance between hot and cold, eat well, be plump, pray, be free of pain, eat and sleep right, and exercise ▪ Illness is seen as punishment and comes of two types—natural and supernatural ▪ Natural illnesses of two types—short duration caused by environmental factors Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practices Continued ▪ Natural longer term illness due to disequilibria between hot and cold and bone displacement ▪ Supernatural illnesses are caused by angry spirits, which are placated by ceremonial feasts ▪ Gas is a major cause of illness and can be in any part of the body Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practices Continued ▪ Certain foods can dispel gas ▪ Postpartum more susceptible to gas ▪ Traditional Haitians have a low pain (doule) threshold and is difficult to assess because of vague terms used to describe pain ▪ Injections are preferred to oral medications Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practices Continued ▪ Condition is deemed very serious if oxygen is needed ▪ Special diet for physical weakness—vitamins, liver, pigeon meat, leafy green vegetables, and cow’s feet ▪ Sezisman, similar to susto or magical fright, is caused by unexpected bad news and fright Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practices Continued ▪ Strong stigma with mental illness ▪ Self-treat and self-medicate or take friends medicine ▪ May bring medicines from Haiti ▪ Cultural bound illness—oppression Transcultural Health Care: A Culturally Competent Approach, 4th Edition Barriers ▪ Delay seeking care because of self-care ▪ No health insurance ▪ View that Western medicine does not understand voodooism ▪ Language difficulties ▪ Very reluctant to receive blood transfusions or engage in organ donation Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practitioners ▪ Use traditional and Western practices simultaneously ▪ Respectful of Western healthcare providers ▪ May have limited understanding of Western healthcare providers and their functions and capabilities 2780_BC_Ch32_001-013 03/07/12 9:56 AM Page 1 Chapter 32 People of Iranian Heritage Homeyra Hafizi and Hydeh Hafizi The author would like to recognize Juliene G. Lipson for her contributions to this chapter in previous editions. Overview Iran is a geographically and ethnically diverse, nonArabic-speaking, Muslim country. Iran’s 1979 Revolution generated a steady wave of immigration to North America, Europe, and Australia. Prior to the 1979 Revolution, the main reason for immigration was educational advancement. The few who immigrated had little impact on the host country’s social makeup and the health-care system. But with the marked increase in immigration, some Iranian communities, such as that in Los Angeles, have begun to influence the regional economy. Since the 1979 Revolution, Iran’s socioeconomic and political instability and the most recent power shifts in the Middle East have spurred emigration. Among immigrants, a deep generation gap within the family unit and with the larger population frequently occurs. Firstgeneration Iranian-born immigrants often live between the two worlds. Their age and reason for immigration are mitigating factors. The generational gap has widened as each subgroup adopts the new culture and garners new manners of self-expression. A study of Iranian immigrants in New South Wales, Australia, noted that women’s roles were changing slowly from the more traditional roles of home manager and nurturer to those of education and employment (Omeri, 1997). In another study conducted in Los Angeles, Iranian women who left Iran at a young age had more liberal attitudes toward sex and intimate relationships, and more conflicts between their Iranian and American identities (Hanassab, 1998). Evidence suggests that, in general, women acculturate at a faster rate than men and begin to undermine the patriarchal and sexist cultural values (Darvishpour, 2002). Many Iranian immigrants face considerable ethnic bias in the United States, with an intensity directly linked to the ongoing events in the Middle East. The sense of bias and confusion toward Iranians began in November 1979 with the 14-month occupation of the U.S. Embassy in Tehran. Some trilingual immigrants identified themselves by their ethnicity rather than their place of origin. For example, one would identify himself or herself as Turkish rather than as an Iranian Turk. The tragic events of 9/11, the ongoing instabilities in the Middle East, the current Iran’s nuclear ambitions, and the wars in Iraq and Afghanistan have collectively contributed to the marginalization of the Iranian immigrant. By virtue of its location and predominant religion, and the central government’s discourse with the neighboring countries, Iran is a figure in international politics. The host countries’ general public, such as the United States, erroneously views Middle Eastern immigrants as a homogenous population. In actuality, most Iranians are more secular and nationalistic in their beliefs than people from Sunni Arab nations, who may hold a more common Islamic identity (Sayyedi, 2004). The U.S. Census Bureau estimates the number of Iranians in the United States at 400,000. Unofficially, the estimate is over 1 million living in the United States and close to 5 million outside of Iran. The political climate discourages Iranian immigrants from disclosing their native origin; hence, they self-identify as “other” or “White.” During the 2010 Census the Iranian community took part in large-scale media outreach encouraging it citizens to accurately portray their heritage. The final results of this census are pending at this time. The 2000 Census described the California Iranian American population as largely concentrated in the Los Angeles area, which consequentially has the largest concentration of Iranians outside of Iran. With over 250,000 persons, this population is larger than the combined number of Iranians in 20 other states. The Los Angeles population is ethnically and religiously diverse. Although Muslims are still the majority, the Armenian, Jewish, and Baha’i communities have a strong presence (Bozorgmehr, Sabagh, & Der-Martirosian, 1993). Divided by political, religious, and social class differences, most live in small social networks. 1 2780_BC_Ch32_001-013 03/07/12 9:56 AM Page 2 2 Aggregate Data for Cultural-Specific Groups In this chapter, the terms Persian and Iranian are used interchangeably. In 1935, the country’s name was changed from Persia to Iran (from the word aryana) to present an image of progress and to unify the many ethnicities, tribes, and social classes. The original Persians were an Indo-European group, the Aryans of India. The Persian Empire, founded by Cyrus the Great in 559 BC, covered an area from the Hindu Kush (now in Afghanistan) to Egypt. Iranians are proud of their heritage, which includes ancient empires, the Zoroastrian religion, and some of the world’s greatest poets and leaders in philosophy, astronomy, and medicine. Even though the focus of this chapter is on cultural commonalities, health-care providers must recognize that Iranians are a highly diverse popluation. We encourage readers to carefully assess each client’s and each family’s beliefs and circumstances. Overemphasis on culture, religion, and ethnicity as the defining factors in the expression of health and illness, treatmentseeking behaviors, and health-maintenance practices can lead to stereotyping (Hollifield, 2002). Iran covers an area of about 636,000 square miles and is bordered by the Caspian Sea on the north and the Persian Gulf on the south. Neighboring countries are Turkmenistan, Azerbaijan, Armenia, Turkey, Iraq, Afghanistan, and Pakistan. Iran is home to many agricultural communities, nomadic tribes with livestock, and several highly industrial regions. Fertile agricultural lands are found in the southwest and on the Caspian Sea shore. The dry lakes of the interior regions are less conducive to farming. Both northern and southern shores are extremely humid. A large area of the country is mountainous. The climate varies with altitude, including hot, dry summers and extremely cold, snowy winters. Iran has a population of over 76 million; 61 percent of whom are under the age of 30 with a median age of 28 and the majority live in urban areas. Between 1996 and 2006 Iran estimated their population growth rate at 1.6 percent. At this time, the population growth rate is estimated at 1.25 percent (Iran Statistical Yearbook, 2007). Almost one-fifth of the inhabitants live in an impoverished state with no basic public-health infrastructure, including drinking water, electricity, and sewage. The overwhelming majority of the people practice Shiite Islam. Christianity, Judaism, and Zoroastrian, an ancient Persian faith, are recognized in Iran, and adherents enjoy a degree of pseudo-freedom. However, the Baha’i community has experienced discrimination since the religion was established in the 19th century (CIA World Factbook, 2011). Heritage and Residence In Iran, ethnic groups with differing dialects and strong heritage coexist in a somewhat conflict-free environment, and the many groups embrace and identify with the core of the Iranian culture and the Persian civilization. For example, regardless of ethnicity or religion, the country unifies around Eid Norouz as a symbol of national identity and as a significant cultural event. The practice of visiting during Eid Norouz is an important expression of care, both within the family structure and as a community activity (Omeri, 1997). As commonly practiced in Iran, immigrant families continue to gather for important occasions such as weddings, births, and funerals. Iran is divided into regions, each inhabited by people of differing ethnicities and traditions. For example, Iranian Turks live in the northwest, Kurds live along the western borders, and Arabic-speaking Iranians live in the south and southwest. Ethnic interdependence is not favored by the central government in Iran. The many years of occupation by the Greeks, Arabs, Mongols, and Turks have adapted Iranians to assimilate without a complete loss of their collective self or their national identity. For example, although most Persian Zoroastrian converted to Islam after the Arabs conquered the land in the 7th century, they continue as the only Muslim nation in the Middle East to use the solar calendar and to celebrate Eid Norouz. Eid Norouz is observed on the spring equinox in celebration of the New Year without any religious undertones. Centuries of occupation and the void of a central government committed to the country’s welfare have placed Iran at an economic and industrial disadvantage. The reality became painfully noticeable to the people of Iran in the early 1900s when trading expanded to Europe and the West. The awareness marked the very slow beginning of emigration. In the mid-1900s, several political parties—Nationalist, Communist, and religious in ideology—literally pushed Iran toward becoming a more independent nation. To this day, even though it was short-lived, the nationalistic movement of Dr. Mosadeq resonates fondly in people’s minds. The Pahlavi Dynasty (father and son) followed this movement, but it was mired in corruption and unethical alliances with foreign governments. Moreover, Mohammed Reza Shah reinstituted the secret police and did not tolerate political opposition. The 1979 Revolution and the establishment of the Islamic Republic of Iran were direct consequences of Pahlavi’s management of the country. However, some positive and powerful social and economic reforms were instituted during Pahlavi’s reign such as national public health, literacy programs, and the creation of a more secular society with decreased power for the religious clergy. Women’s rights advanced until they were fully enfranchised in 1963. The 1979 Revolution drove the social and secular gains underground. Today, Iranian society is facing one of its greatest challenges; this time the occupying force has originated from within and its people are trapped by friendly fire. To this day, a central tenet of the Iranian social life and personal development is the boundary between 2780_BC_Ch32_001-013 03/07/12 9:56 AM Page 3 People of Iranian Heritage inside/private (baten) and outside/public (zaher). Stimulated by the long history of occupation, the most private and true self is always kept for intimate spaces and trusted relations. “Inside” and “outside” define both individuals and families, in which honor and social shame play powerful roles. Reasons for Migration and Associated Economic Factors Three waves of immigration contribute to the diversity of Iranians in the United States and elsewhere. In addition, each wave of immigrants appears to respond differently to the stress of migration. The first two waves of immigrants, 1950s to 1970 and 1970 to 1979, are demographically more cohesive. The second wave included mostly young urban technocrats, scientists, professionals seeking advanced education, and adolescents of upper-middle class or privileged families who came to study at U.S. universities. Fluent in English, familiar with Western culture, and financially supported by government grants, scholarships, or family wealth, these individuals were able to adjust to life in the United States. For this population of immigrants, a primary source of stress was distance from family and friends (Jalali, 1996). The third wave immigrated from the early 1980s to the mid-1990s to escape the Iran–Iraq war and the Islamic government’s political persecution. They were forced migrants rather than voluntary; some sought refugee status and continue to consider themselves in exile. This wave is more varied in its makeup and includes older individuals, fewer professionals, a higher percentage of high-ranking members of the prerevolution Iranian armed forces, owners of midsize businesses, industry managers, and clerks. Challenges particular to this older population of Iranian immigrants have been learning the language, adapting to the new culture and lifestyle, and redefining the relationship between the parent and child (Emami, Benner, & Ekman, 2001). Older immigrants often express their ambivalence about being in the United States and may strongly believe they immigrated for the sake of their children for the provision of emotional and financial support, similar to that of older immigrants in Sweden (Emami, Torres, Lipson, & Ekman, 2000). Older people often feel isolated, and their desire to return home keeps them from making permanent commitments. They are concerned about how their children will fare as they adopt less appealing aspects of the new culture. Older people view lack of respect for age and experience, loose family ties, and insufficient social support as examples of an unfavorable Western culture (Omeri, 1997). At times, to avoid isolation and to emulate the past, some immigrants “befriended” other Iranians despite having little in common but their national heritage and language, and hence, creating a community weak in infrastructure and ties. 3 In summary, lack of fluency in the English language, education, and familiarity with Western cultures are characteristics that differentiate the last wave of immigrants from those who immigrated prior to the 1980s (Bozorgmehr, 1997). The third wave has experienced multiple losses and witnessed role reversals between parents and children. These families left Iran under duress and lost their financial assets and status. Many experienced a profound degree of hardship, such as fleeing Iran by relying on smugglers and other high-risk means only to seek refugee status (Koser, 1997). Educational Status and Occupations Iranians greatly value education and expect their children to do well. Individuals who immigrated before the 1979 Revolution have most often obtained college degrees and are professionally successful and active. Iranian immigrants strive to maintain a social façade of affluence and upper-class status because family judgment and social shame weigh heavy on their decision making. These issues have rarely been mentioned in studies addressing the health and mental health needs of immigrants in the United States (Sayyedi, 2004). Many middle-aged immigrants who held whitecollar positions in Iran were unable to find comparable work in the United States. As a result, they are selfemployed in businesses, using their business acumen to maintain a middle-class or better lifestyle. In Los Angeles, 61 percent of Iranian heads of household claimed to be self-employed in 1987 and 1988 (Dallalfar, 1994); 82 percent of Iranian Jews were selfemployed. Only 10 percent reported employment in blue-collar jobs (Bozorgmehr et al., 1993). Healthcare providers should not assume education and social class from occupation alone. Communication Dominant Languages and Dialects Farsi is the national language of Iran, and all schoolchildren are taught in Farsi. An indication of modern Iran’s Indo-European heritage is found in words similar to English words. As mentioned previously, nearly half the country’s population speaks different languages and dialects, such as Turkish, Kurdish, Armenian, or Baluchi. Well-educated and well-traveled immigrants and those who might have stayed in an intermediate country prior to entering another country may speak three or more languages. Cultural Communication Patterns The health-care provider should attempt to distinguish cultural patterns from individual personality characteristics. Communication among Iranians must be understood within the context of their history, the personality styles valued in the culture, and the structure of social 2780_BC_Ch32_001-013 03/07/12 9:56 AM Page 4 4 Aggregate Data for Cultural-Specific Groups relationships. Iranians are very cautious in their interactions with outsiders. Not verbalizing one’s thoughts is viewed as a customary and useful defensive behavior. This form of communication, also known as ta’arof, can effectively hinder open exchange of feelings with the health provider. Time to complete assessment, history taking, and therapeutic approaches must be planned accordingly. Clearly implemented in the practice of ta’arof is the road map to communication, whereby being other-centered, not self-centered, is expressed with distinct and respectful forms of speech and behavior. Whereas the constant offers of hospitality and compliments may sound insincere to non-Iranians, the dynamic is hard at work to set the boundaries of the relationship (Sayyedi, 2004). Bagheri (1992) described such highly valued personality characteristics in Iranians as indirectness, subdued assertiveness, modesty, and politeness. Iranians are very concerned with respectability, a good appearance of the home, and a good reputation. Social behavior is also influenced by a constant awareness of others’ judgment. Spontaneity is limited by rules that clearly define how and when to approach people of different ages and members of the opposite gender. Communication also occurs on a continuum anchored by baten (inner self) and zaher (public persona). Baten is personal feelings, and zaher is a collection of proper and controlled behaviors. What lies in between is a buffer zone. The Persian language and its nonverbal accompaniments have evolved to help the expression of this complexity. Ta’arof is an example of a tool in verbal communication. Health-care providers should be aware of the manner in which Iranians handle potentially disturbing information. Discussing serious diagnoses must be handled with respect to the family dynamics. Care is expressed in supportive gestures and by maintaining family relationships in times of health and need. Frequent visiting and keeping in contact by any available means are care practices (Omeri, 1997). More traditional married couples do not publicly display affection to each other; however, most are vocal in expression of love for their children. Greeting is often accompanied by a kiss on each cheek (maybe three kisses) and a handshake. Strangers and healthcare providers may be greeted with both arms held at the sides. A slight bow or nod while shaking hands shows respect. Iranians generally stand when another person enters or leaves the room for the first time. It is appropriate to offer something with both hands. Crossing one’s legs when sitting is acceptable, but slouching in a chair or stretching one’s legs toward another person is considered offensive. Nonverbal beckoning is done by waving the fingers with the palm mostly up. Tilting the head up quickly means no, and down means yes. Extending the thumb (like thumbs-up) is considered a vulgar sign. As in other Mediterranean cultures, personal distance is generally closer than that of Americans or Northern Europeans. The strength of the relationship affects how freely participants touch each other. Iranians maintain intense eye contact between intimates and equals of the same gender. This behavior may be observed less in traditional Iranians. Conversations are expressive, as body language is used and the tone is loud. Temporal Relationships Time orientation is a combination of emphasis on the present and on the future. The ideal is to maintain a balance between enjoying life to the fullest and ensuring a comfortable future. Iranians’ understanding of time as a contextual and directional phenomenon enhances the effectiveness of health promotion and education. At the same time, a fatalistic theme among many Iranians may hinder their understanding of health risk assessment and risk reduction. Continuity and balance in life is the definition of health and well-being. Obtaining the diagnosis of a chronic or terminal illness is tolerated as an expected outcome of aging. Such news is taken gravely when it involves someone of a younger age. Any disappointments in and derailments from the culturally accepted process of caring are reasons for ill health (Emami et al., 2001). Iranians are feeling oriented. Interestingly, in business, they portray a strong work ethic; they are time conscious and intensely competitive. Although social time is extremely flexible, Iranians respond to time requirements at work. Format for Names Iranians refrain from calling older people and those in higher status by their first names. One is expected to greet every member of the family. To begin an interaction, the younger person initiates the greeting process. Traditional and many nontraditional women do not take the surname of their husbands. Iranians give their name with the given name (first name) first followed by their surname (last name). Thus, the author of this chapter introduces herself as Homeyra Hafizi. However, when my husband accompanies me to a gathering and folks are introducing one person to another, I am referred to by my husband’s last name. No one will call me Mrs. Hafizi, they will refer to me as Mrs. Kashanian (husband’s surname). Legally I am Homeyra Hafizi and all my documents refer to me as such. There is social and legal differentiation and expression. When in doubt, the health-care provider needs to specifically ask and explain the necessity of the legal name for medical record keeping purposes. Family Roles and Organization Consistent with traditional collectivistic cultures, Iranian families value harmony within an established 2780_BC_Ch32_001-013 03/07/12 9:56 AM Page 5 People of Iranian Heritage patriarchal hierarchy. Also valued are avoidance of open conflict, unconditional respect for parents, and indirect and figurative communication to maintain social hierarchy and group harmony. As a norm, they tend to be fatalistic and have an external locus of control and destiny (Daneshpour, 1998). Head of Household and Gender Roles Readers should carefully assess each client’s and each family’s beliefs and circumstances. Overemphasis on any one factor as the defining factor in the expression of self, health and illness, treatment-seeking behaviors, and health maintenance practices can lead to stereotyping or overgeneralization. Gender roles in a mostly hierarchical and patriarchal culture are fairly understood. However, urban-dwelling Iranians and those belonging to a less traditional family structure are very loosely tied to the doctrine of patriarchal hierarchy and work hard in defining the relationship on equal terms. In traditional families, the father is the authority figure. In this mostly hierarchical culture, the father has authority and expects obedience and respect. In the father’s absence, the oldest son has authority. Today’s families have fewer children, and the authority figure may be a working female adult who is respected for her skills and competence. Most sibling relationships are deep, trusting, and lively. Healthcare providers should understand the decision-making dynamics of the family. The process is very collaborative as the family or the patient enlists trusted friends and relatives who are subject-matter experts. In the recent past, Iranians living in Iran have started to enlist professional experts in the form of “counselors” to discuss issues of child rearing or marriage counseling with a greater emphasis on relationships and personal development rather than on psychological and mental health issues. Young people are free to select their life (marriage) partners, but families prefer to have the voice to approve. Husbands are often a few years older than their wives. Male immigrants experience emotional stress when they lack social status, which is greatly tied to finances and occupation. Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents Most immigrant Iranian families are child oriented, sometimes to a fault, as they can become overly protective. Manners are considered important even outside the home. Children and teens are usually included in adult gatherings. Young children are rarely left with babysitters as families rely on each other and friends for support. Taboo behaviors for teens in Iran very much resemble their counterparts in other countries. In Iran, parents are concerned about education, smoking, drugs, alcohol, influence of bad peers, sex, and the uncertainty of the future especially in the backdrop of a 5 volatile Middle East. Young women are expected to remain sexually inactive until they marry, but sexual activity by men outside marriage is tolerated. Dating is not allowed in the most traditional Iranian families but is tolerated in more acculturated families. Education used to be the means to a financially stable future, but with the high unemployment rate in Iran, education remains sacred but as the means to the end. Many Iranian adolescents in the United States resemble their American counterparts in dress and outward behavior; they often behave more respectfully toward family members, particularly older people and other highly respected individuals and members of the family. The fear of shaming the family and losing face in public is a strong social constraint. Family Goals and Priorities The family is the most important institution in the Iranian culture. One might argue religion to be just as important. Members of a family often live in close proximity to minimize isolation, maintain strong intergenerational ties, and ensure support. The intensity of such strong relationships can be a double-edged sword; it brings comfort as it generates conflict. The key is to find a healthy balance. A strong family unit ensures the continuation of the family name and lineage. If parents are able, they support their children financially in education, home buying, or starting a business. The children’s academic or career achievement is considered that of the collective family unit. Parenting values and behaviors vary dramatically across immigrant Iranian families. Parents are conscientious in meeting their children’s needs for comfort, safety, and success. Similar to parents from other collectivistic and traditional cultures, they expect their children’s commitment to the ancestral lineage. Since the mid-1990s, immigrant parents have become interested in improving their parenting skills by challenging some of the more traditional views. They attend parenting classes taught by Iranian American psychologists, social workers, and marriage and family therapists, and learn to rely on such behavioral modification techniques as rewards or time-outs for discipline (Sayyedi, 2004). Some Iranians have clothing that is worn only inside the home. Often, they remove their shoes at the door and wear slippers inside. Outside the home, they tend to dress conservatively. Religious women living outside Iran may avoid bright colors, cover their arms and legs, and conceal their heads with head covers or scarves (hejab). In Iran, wearing the hejab is mandatory because of the ruling Islamic Republic. Age is a sign of experience, worldliness, and knowledge. Regardless of kinship or relationship, an older person is treated with respect. Older people are cared for at home. Skilled nursing facilities are viewed 2780_BC_Ch32_001-013 03/07/12 9:56 AM Page 6 6 Aggregate Data for Cultural-Specific Groups negatively and only as the very last resort. Despite their esteemed role within the Iranian family, older immigrants with minimal language skills feel isolated when their adult children work and the grandchildren are in school. Loneliness and isolation among older people are particularly common in neighborhoods where transportation is unavailable or walking is unsafe. In some enclaves of Southern California and Sweden, Iranians have established adult day-care centers in response to this issue (Emami et al., 2000). Iran does not have a formal caste system; however, social status is both inherited and gained. Some are born into the upper class, but one can also ascend the class hierarchy through higher education and attainment of professional status. Parents often try to arrange marriages with families of higher status. Alternative Lifestyles The religion of Islam has a conservative point of view about the male–female relationship, as is true of the Iranian society, maybe secondary to the Islamic influence over the many centuries. Most Iranians strongly disapprove of the practice of living together before marriage. Divorce is now viewed less negatively among the Iranians living in Iran and abroad. The rates have been increasing in both populations. Based on an official Iranian government’s report for 2000–2010, the rate of divorce has tripled and marriages are failing early, most within the first 5 years. The report stated that in Iran, every seven marriage ends in divorce; in Tehran, the rate is even higher—closer to one in every four marriages. Experts contribute this trend to the awareness of women toward their own human rights and equality and their ability to maneuver the Iranian legal system (Yong, 2010). This is not an easy task in a highly conservative country. Rezaian (1989) found that intraculturally married Iranians reported more marital satisfaction than Iranians married to Americans or other intraculturally married Americans. One reason may be that cultural mores advocate for ignoring minor marital discord to maintain family stability. Collectivist cultures place greater emphasis on one’s role in a kinship structure. In Iran, out-of-wedlock teen pregnancy is neither talked about nor prevalent, and it can have a devastating outcome. Although homosexuality undoubtedly occurs in Iranians as frequently as in any other group, it is highly stigmatized. Iranian gays and lesbians do not easily disclose their sexual orientation because they would be against both a religious and a cultural norm. Since 1979, when the judicial system became one with the religious doctrine, homosexuality, which is considered unnatural and sacrilegious, is a crime punishable by death (Clark, 1995). According to the 1991 Iranian Constitution, Articles 108–113, sodomy is a crime for which both partners are punished. The punishment is death if the participants are adults of sound mind and consenting (Arlandson, 2010). In contrast to the older generation, younger Iranians are increasingly tolerant of alternative lifestyles. Workforce Issues Culture in the Workplace Iranian immigrants face several difficulties, among them are acquiring legal residency and suitable employment opportunities. For example, an Iranian physician whose degree is not recognized abroad and has to work in a less than desirable position experiences continual bitterness that manifests itself outwardly as anger and discord or internally with serious outcomes to personal health and familial relations. Iranians may perceive and actually experience a degree of bias at work. Prejudice is less evident in multicultural and metropolitan areas. There is a general lack of understanding that the countries of the Middle East and their people are very different in ethnic identity and culture. For the most part, Iranians are secular and nationalistic and do not adhere to an Islamic identity common to the Arab nations (Biparva, 1994). More acculturated immigrant professionals respond flexibly in the workplace. For example, when one of the authors (Hafizi) perceives that a client is uncomfortable with her background or overtly expresses dislike, she uses ta’arof. Using formal speech, she addresses clinical tasks with minimal personal touch and interaction. Efficiency and efficacy supersede personal communication and human connection. Issues Related to Autonomy Most newcomers may not be familiar with American vernacular or slang. An ongoing stressor is the condescending attitudes directed at individuals with a strong accent. For example, a nurse with a master’s degree described her first year in the United States as follows: I was seen as an ignorant nurse’s aide who couldn’t even speak English. One nurse used to follow me around, checking everything I did. I resented being treated that way, and my own self-esteem suffered (Lipson, 1992, p. 16). Biocultural Ecology Skin Color and Other Biological Variations Iranians are white Indo-Europeans. Their skin tones and facial features resemble those of other Mediterranean and Southern European groups. Their coloring ranges from blue or green eyes, light brown hair, and fair skin to nearly black eyes, black hair, and brown skin. Diseases and Health Conditions In Iran, the estimated 2010 birth rate was 18.52 per 1000 people, and the infant mortality rate was 2780_BC_Ch32_001-013 03/07/12 9:56 AM Page 7 People of Iranian Heritage 43.5 deaths per 1000, slightly higher than in the recent past (CIA World Factbook, 2011). Heat and humidity in some provinces provide fertile ground for the spread of cholera, including new and mutant strains. Malaria is widespread in Baluchistan and Hormozgan (in the southeast), and south of Kermon (in the southeast), with serologic test results sometimes showing more than one strain in a single client. In rural areas that lack standardized sanitary systems, viral and bacterial meningitis, hookworm, and gastrointestinal dysenteries caused by parasites are prevalent. Hypertension is widespread in Tehran; 22 percent of adults are affected (Azizi, Ghanbarian, Madjid, & Rahmani, 2002). Ischemic heart disease is on the rise secondary to the stress of living under economic and social constraints. The most recent estimate from 2010 is that 18 percent of adults are affected by this condition, down from 22 percent in 2002. (Azizi et al., 2002). Health-care providers should screen newer immigrants for diseases and illnesses common in their home country. The most common health problems in Iran are linked to underdevelopment, the recent economic downturn, mental stress, and lack of coordination of scarce resources. Examples of common health conditions are malnutrition (caused by protein and vitamin deficiencies), hepatitis A and B (caused by poor sanitary conditions, such as poor aseptic technique, or public-health measures), rising rates of tuberculosis and syphilis, genetic problems (owing to interfamily marriages), and genetic blood dyscrasias. Interfamily marriage used to be common; however, increasing urbanization and scientific data have resulted in a decline. The head of Iran’s Institute of Mental Health estimates that 1.2 million people in Iran suffer from acute psychological illnesses. Forty to 60 percent of all Iranians suffer from an episode of mental illness that requires specialized medical intervention (Nyvzanlayn Mehr News Agency, 2007). In 2010, the chair of the Iranian Diabetes Association, and supported by the Iranian government statistics, reported the prevalence of diabetes to be at 8 percent, with an annual increase of 1 percent (http:// www.not.ir/news/70544.aspx) [site is inaccessible in the United States]. Thalassemias are prevalent in the northern and eastern provinces. Mediterranean glucose-6phosphate dehydrogenase (G-6-PD) deficiency is also common among people of Iranian heritage and can precipitate a hemolytic crisis when fava beans are eaten; it can also affect drug metabolism, such as increasing sensitivity to primaquine. In the United States, many Iranians experience stress-related health problems from cultural conflict and loss, homesickness, and the previous conditions of war. Although Northern California Iranians in Lipson’s study (1992) were generally healthy, many expressed their ongoing stress somatically, through 7 intermittent physical discomfort. Several articulated a direct connection between their worries and their illness; for example, three of the first seven people interviewed had suffered from ulcers and attributed their “stomach problems” to their “worries” and “troubles.” Others complained of headaches, backaches, a racing heart, or other manifestations of anxiety or depression. Iranians often focus their acute generalized stress on the alimentary system, attributing illness or its severity to something eaten (Emami et al., 2001). High-Risk Behaviors Iranians’ high-risk health behaviors are similar to those in the general population. Among both men and women, smoking is more prevalent in Iran than in the immigrant population residing in the United States. In general, health education, through the media and the influence of their children, encourages many to quit smoking. A degree of alcohol and recreational drug use occurs in the Iranian immigrant population, but the rate is no higher than that of the population at large. Alcohol is prohibited by the Qur’an, Holy Book of the Islamic faith. However, Iranians who are not devoutly religious drink socially but in private places, a few to excess. Because drinking is not socially and publically permitted there are no statistics on the prevalence of alcoholism in Iran. In Iran, the most popular street drug among the older generation is opium, traditionally used for medicinal purposes. However, years of opium use has created both a psychological and a physical addiction in this population. The prevalent drug in Iran is opium, used by young and old, employed and unemployed. Traditionally it was used for medicinal purposes, but now it knows no boundaries. Another prevalent drug in Iran is heroin. Family responses to drug use range from complete support of the family member to disownment. Drug use, as with any other issue that carries a heavy social burden, is generally concealed from others. So, more families support their children, if they can, as a parental and familial obligation to save them and to save face. Moderate alcohol use is openly accepted among immigrant Iranians. Substance abuse in this population is related to low levels of acculturation, a perception or experience of prejudice, a sense of helplessness and loneliness, as well as the presence of other mental health stressors enhanced with poor coping skills. Sometimes Iranian men demonstrate their “masculinity” by claiming to “hold” their liquor well. The need to assert masculinity combined with a poor selfesteem increase the risk of alcohol addiction and spousal abuse. Health-Care Practices Because of city planning and self-contained neighborhoods, walking is a great form of mobility in Iran. 2780_BC_Ch32_001-013 03/07/12 9:57 AM Page 8 8 Aggregate Data for Cultural-Specific Groups Soccer remains a passion, regardless of age and gender. Men continue to play soccer and encourage their children’s participation to promote family activity. Iranian women participate in a wide range of physical activities such as walking, swimming, or aerobics depending on finances and time availability. Mandatory seat belt use on intercity highways in Iran was instituted in the 1990s; compliance is periodically monitored and enforced. Radio and TV stations are state owned and at the state’s disposal for any form of campaign. In the United States, most Iranians comply with safety laws such as wearing seat belts and using child seats and restraints. Nutrition Meaning of Food Food is a symbol of hospitality and kinship. Iranians prepare their best dishes and insist on the consumption of several servings. More food than necessary is prepared and presented both as a sign of respect and to preserve public face. Tea is the hot beverage of choice and is offered with cubed sugar, dates, pastries, fruits, and nuts. Preparation and serving tea are an art. The same is true for certain traditional dishes. Common Foods and Food Rituals Iranian food is flavorful, with a lengthy preparation time. Working immigrants have created shortcuts and healthier versions of traditional recipes. Presentation is important. At any given table, a pleasing mixture of foods of different colors and ingredients, composed of a balance of garm (hot) and sard (cold) (see Dietary Practices for Health Promotion), are usually served. Tea, fruit, and pastries are served both before and after each meal. Iranians prefer fresh ingredients, although cost and availability are determining factors. Canned, frozen, hormone-injected, and fast foods are perceived to be less nutritious and contain preservatives harmful to health and well-being. Eating fast food is less common, especially among older immigrants, mainly owing to poor nutritional value, associated cost, and taste preference. The most common carbohydrates are rice and sheet breads (wheat and white). The art of preparing rice is the measuring stick of a good cook. Long-grained white rice is preferred. The bread of choice is flat like lavash or pita. Corn and potatoes are used but are less favored. Beans and legumes (e.g., pinto, mung, kidney, lima, and green beans; and split and black-eyed peas) make up a high proportion of the dietary intake and are commonly used in rice mixtures. Dairy products are dietary staples, particularly eggs, milk, yogurt, and feta cheese. Dairy by-products, such as doog (yogurt soda) and kashk (milk by-product) are other favorites. Meat and protein choices are beef, lamb, poultry, and fish. Shellfish is also consumed, but it is a regional favorite of south of Iran. Fresh fruit is always found in Iranian homes. Green, leafy vegetables are used in cooking, and herbs such as parsley, cilantro (coriander), dill, fenugreek, tarragon, mint, savory, and green onions are served fresh at a meal or included in stews served over rice. Similar to Judaism, Islam has a strict set of dietary prescriptions, halal, and proscriptions, haram. Slaughter of poultry, beef, and lamb must be done in a ritual manner to make the meat halal. Strict Muslims avoid pork and alcoholic beverages; a few avoid shellfish. Historically, pork was prohibited for hygienic reasons. Compliance with proscriptive food and beverage items is seen less frequently among the younger generations. Health-care providers can make simple adjustments to accommodate traditional food practices of Iranians by making provisions for home-cooked meals or identifying more appealing foods on the hospital menu. One of the authors (Hafizi) noted by experience that hospitalized Iranian older people would identify and select one or two food items for the duration of their stay and greatly appreciated any form of spice to add flavor to their hospital meal. A simple slice of lemon or a cup of hot tea would be pleasing items. Dietary Practices for Health Promotion Based on humoral theory, Iranians classify foods into one of two categories, garm (hot) and sard (cold). The categories sometimes correspond to high- and lowcaloric foods. The key to humoral theory is balance and moderation. The belief is that too much of any one category can cause symptoms of being “overheated” or “chilled.” In accordance, symptoms are treated by eating foods from the opposing food group. Becoming overheated is manifested by sweating, itching, and rashes as a result of overeating hot, garm, food items such as walnuts, onions, garlic, spices, honey, or candy. Conversely, the stomach may become chilled, causing dizziness, weakness, and vomiting after overeating cold, sard, food items such as grapes, rhubarb, plums, cucumbers, or yogurt. Susceptibility is believed to be gender dependent. Women are more susceptible to sardie, caused by eating too much cold food, than to garmie, a digestive problem from eating too much hot food. Health-care providers may need to incorporate Iranian foods and dietary practices into health teachings in order to improve compliance with special dietary restrictions. Nutritional Deficiencies and Food Limitations Economic problems and unemployment in Iran have made certain foods unavailable, resulting in an increased incidence of protein and vitamin deficiencies. Although influenced by food marketing campaigns, imports, and the globalized economy, the older generation’s basic food beliefs remain mostly unchanged. Almost all ingredients used in Iranian 2780_BC_Ch32_001-013 03/07/12 9:57 AM Page 9 People of Iranian Heritage cooking are available in Middle Eastern markets or via the Internet. The same is true for medicinal herbs. Health food stores stock some of the items but at a higher price. Pregnancy and Childbearing Practices Fertility Practices and Views Toward Pregnancy Iran adopted a national family planning program in 1967 at a time when traditional values and low literacy prevented people from clearly understanding the impact of rapid population growth. High fertility was valued for religious and economic reasons and as insurance against potential loss of children and poverty in old age. In 1989, the plan was revitalized by the Islamic Republic; however, this time the populace was markedly educated and urbanized, and the plan was fully supported by the religious and political leaders. As a result of this plan’s evolution over the years and a combination of modern and traditional contraceptive use, the fertility rate is on the decline (Mehryar, Roudi, Aghajanian, & Tajdini, 1997). Vasectomies are slowly beginning to gain acceptance. Traditional Iranian beliefs and practices are influenced by Galenic or humoral medicine, particularly with regard to hot and cold temperament and the conditions of pregnancy and birth. Menstrual blood is believed to be unclean; therefore, menstruating women refrain from participating in religious activities and intimacy. Historically, infertility was blamed on the woman. Baluch, Al-Shawaf, and Craft (1992) found that reasons for seeking infertility treatment differed for men and women: Men wanted children to ensure future support, and women wanted to fulfill social expectations of having babies, especially early in the marriage. Prescriptive, Restrictive, and Taboo Practices in the Childbearing Family Food cravings during pregnancy are believed to result from the needs of the fetus; thus, cravings must be satisfied. Special attention is given to the balance of hot and cold food items. Heavy work is believed to cause miscarriage. Sexual intercourse is allowed until the last months. The pregnant woman receives considerable support from female kin both during the pregnancy and postpartum. During the birthing process, in the more traditional families, the father is usually not present. The choice for delivery is mainly based on the medical status of the mother and child. The postpartum period can be as long as 30 to 40 days. Some families believe in keeping an infant home for the first 10 to 15 days, after which time the infant is strong enough to handle environmental pathogens. The more-acculturated 9 families utilize mother and child education classes to prepare for delivery. Death Rituals Death Rituals and Expectations Family members and friends gather to support the dying person and each other. Among devoted Muslims, the deathbed, or at least the patient’s face, is turned to face Mecca. In the 1980s and early 1990s, Muslim burial services were few and scattered. In some instances, family members assisted in preparing the body for burial. This is less common now because more facilities have been established to handle these rituals such as the process and sequence in washing the body and wrapping in a white cotton shroud while prayers are read. The process of dying and death itself are expected phases in the continuum of life (Emami et al., 2001). In a fatalistic culture and Islam, the locus of control is outside the person. This is commonly referred to as the will of God. Withdrawal of life support may be considered as “playing God.” This is not to say that Iranians absolutely defy withdrawal of life support. It is only natural to expect that as immigrant Iranians acculturate into their host countries’ practices, their own perceptions of health and illness might also change, making it essential to assess the their beliefs within the context of the event (Emami et al., 2001). There may be no objection to beginning life support, viewing it as a gift of medical technology (Klessig, 1992). No specific religious rules against autopsy exist. However, the reason to proceed must be clear and legitimate; some families may still refuse. In Iran, embalming is not practiced, and coffins are not used. The body is buried directly in the earth to facilitate the transition from “dust to dust.” Cremation is not practiced in Iran. It is unlikely for Iranians to practice cremation, but cases of personal choice have been documented. Responses to Death and Grief Loss of a loved one is met with strong and expressive grieving among family and friends. Death is perceived as a beginning in which the mortal life gives way to the spiritual existence and unification with God. After burial, relatives, friends, and acquaintances gather on the 3rd, 7th, and 40th days. Recently, many families are forfeiting the tradition of observing the 7th and 40th days by donating associated monies to the needy or charities. This is becoming an accepted practice. Special foods are served, and grieving may be expressed outwardly and loud. Attendance at funerals is a sign of caring as well as a socially expected way of paying respect to the dead and the family. Black is the customary color for clothing. On the anniversary of the death, the family gathers again. Some families donate money to charity in lieu of a ceremony. In either 2780_BC_Ch32_001-013 03/07/12 9:57 AM Page 10 10 Aggregate Data for Cultural-Specific Groups case, relatives observe the date by visiting the grave site, especially on the first anniversary. Spouses or parents regularly visit the grave site in subsequent years. Spirituality Dominant Religion and Use of Prayer Islam exerted its influence on Iran and its culture in terms of temporality, fate, and dietary practices (Pliskin, 1987). However, certain culturally embedded norms, such as family loyalty and respect for older people, transcend religious and ethnic boundaries. During the month of Ramadan, individuals fast from sunrise to sundown, although certain individuals are exempt from fasting such as those whose health is in jeopardy. The time for prayer is observed five times per day by those who have a strong faith in this practice. The beliefs of non-Muslim Iranians may be significantly different and must be specifically addressed. Meaning of Life and Individual Sources of Strength Family, friendship, and social support are sources of strength and comfort, particularly in times of illness or crisis (Omeri, 1997). Iranians are highly affiliative and thrive on social relationships. Given the importance of such contact, health-care providers may need to adjust visiting policies. Spiritual Beliefs and Health-Care Practices Tagdir means God has power over one’s fate in life and death. The belief is more characteristic of older immigrants than younger ones. Hafizi’s research (1990) illustrated this concept and the integration of religion and health. In the words of a highly educated and devout Muslim man: To ask me what health means is to ask me how I see myself in relation to God, my family, the society as a whole, and my relation to my material body. Man is the embodiment of an unworldly being. To excel through this journey, the body and spirit work as a unit. The mortal life represents only one stage of this voyage, while death another. Death is not the end, death signifies one’s “graduation” to a higher level. I believe in God and His plan for the future. Simply said, being sick is not having a cold; rather it is not having the vision and the ability to deal with the cold (Hafizi, 1990). Health-Care Practices Health-Seeking Beliefs and Behaviors Traditional Iranian health beliefs and therapeutic practices are a combination of three schools of medicine: Galenic (humoral), Islamic (sacred), and modern biomedicine. In classic humoral theory, illness arises from an imbalance, an excess or deficiency in the basic four qualities of hot and cold or wet and dry. Treatment restores homeostasis. Every individual has a distinctive balance of four humors (mezaj) resulting in a unique temperament (tabi’at). An emotional upset can cause physical illness, and vice versa. Climate and weather are believed to significantly affect health. For example, people protect against wetness and wind. Ears might be covered on a windy day because wind is believed to cause earache or infection. Sacred medicine is from the Qur’an and hadith, in which holy men are considered healers. The sacred tradition includes beliefs in the evil eye and jinns as evil spirits. Healing is reached through manipulating impurities or by prayers. Galenic medicine is a way of life, a daily practice in health promotion and wellness, illness, disease, and injury prevention; and health promotion and wellness. Modern medicine is viewed more curative in nature. Biomedicine and humoral medicine complete one another. Among Iranians, narahati is a general term used to express a wide range of undifferentiated, unpleasant emotional or physical feelings such as feeling depressed, uneasy, nervous, disappointed, or, generally speaking, not well. Iranians may use somatization to communicate emotional distress in a way that is culturally sanctioned and socially understood. The stressor can be personal, social, spiritual, or psychological. Narahati allows individuals to distance themselves from the actual problem while putting the responsibility and focus on the metaphoric body. Because Iranians generally shy away from overt expressions of “personal self,” the “somatic self ” becomes a focal point in the health-care encounter. The concepts of zaher (and baten) once again manifest themselves in the health arena, creating a safe communication tool. The ritual of ta’arof creates the same safety zone in social, nonmedical interactions. A widespread belief among Iranians is that fright or being startled by bad news negatively affects health outcomes. Symptoms caused by fright range from mild to extreme fatigue accompanied by chills and fever. When appropriate, identify the family spokesperson for communicating matters of grave concern, because losing hope is the most grave illness. In some instances, a sudden ailment may be attributed to the evil eye, cheshm-i-bad, the belief that negative thoughts and jealousy can cause illness. Cheshm-i-bad can be the result of an intentional or unintentional projection of a thought. Acculturated immigrants use the terminology in everyday speech and encounters; however, most do not fully believe in the concept. Cheshm-i-bad and other folk syndromes are better understood by viewing the body in the context of its social and supernatural environment. Similar to somatizing, which distances an individual from the actual problem, cheshm-i-bad attributes illness to an outside person or force. In reality, the evil eye gives meaning to an occurrence of puzzling origin and puts the blame on something other than the affected person. 2780_BC_Ch32_001-013 03/07/12 9:57 AM Page 11 People of Iranian Heritage Hafizi’s research (1990) found that Iranians’ concepts of health represented two of Smith’s (1983) four domains: the clinical view (health as absence of disease) and the adaptive view (health as the ability to cope successfully). Healthy people are able to cope successfully with the changing world and address issues of resources scarcity with a more balanced and, at times, innovative approach. Health is a lifestyle marked by demands and adaptations (Hafizi, 1990). Similar health concepts were found among older Iranian people in Sweden (Emami et al., 2000). Iranians accept both biomedical diagnoses and culturally based illness categories. Body is viewed in relation to its total environment: personal, familial, society, God, and the supernatural. At symptom onset, oftentimes the first question is “Did you eat something that did not agree with you (your mezaj)?” Responsibility for Health Care Iranians seek treatment relatively soon after the onset of symptoms. If within their ability, they will “shop around” until they find a provider of choice. They seek advice from acquaintances or family, particularly those who are medically inclined, and use home remedies for symptom management. Self-medication occurs with use of prescription, over-the-counter, and homemade herbal remedies that are commonly used and used simultaneously. Some antibiotics, codeine-based analgesics, mood-altering drugs in the benzodiazepine family, and intramuscular vitamins are available over the counter in Iran. Immigrants commonly bring these medications for personal use because they are known to them and serve as a cost-saving measure for both the insured and the uninsured. Medication self-adjustment is also a common practice, especially when finances are an issue or symptoms are not resolved. Health-care providers should carefully consider dosage and medication type. In some instances, because of previous inappropriate use, a first-generation antibiotic may not affect the microorganism. When ill, Iranians rely heavily on family members for support and assistance. The patient may behave passively, while the family appears persuasive in medical encounters. This unceasing and, at times, overbearing attention is an expected behavior of caring. If a patient is hospitalized, visiting is frequent, sometimes excessive according to U.S. standards. Dealing with the patient’s right to privacy and the good intentions of the visiting relatives is a balancing act. Two cultural traits among the more-traditional and less-acculturated immigrants can complicate help-seeking behaviors. Ta’arof may keep patients from sharing their personal feelings. Zaher, a social façade of decorum and composure to hide one’s unwanted negative feelings or attitudes, may further preclude the communication necessary for a meaningful 11 assessment. More-acculturated immigrants tend to be more open and direct. Folk and Traditional Practices Herbal remedies are used in a complementary manner to prevent illness, to maintain health, and to manage symptoms. Iranians believe strongly in combination therapy. Herbal remedies became increasingly popular in post-Revolutionary Iran because of the economic embargo and scarcity of biomedical supplies. The popularity of herbal remedies in Iran is met with the same cyclical attention they receive elsewhere in the world which is economical and belief driven. Some common herbal medications include gol-i-gov zabon, Borago officinalis Borage, starflower, for management of the common cold, relief of anxiety, or cleansing of the kidneys and the urinary tract. Khakshir (flat, brown rocket seed) is used to regulate the digestive system, skin disorders, fever reduction, and kidney stones. In other words it treats symptoms of being “overheated” after eating too much garm food items. Razianeh is said to have a variety of uses. It contains precursors of estrogen and progesterone. It is reported to increase milk production in a nursing mother and can also reduce blood pressure in men and women. Quince seeds are sucked or used to create a thick syrup which with hot water is used for sore throats; sedr is used to prevent or treat dandruff if used in place of shampoo and body soap. Sedr is believed to contain antiseptic and antifungal agents and strengthen hair follicles. Barriers to Health Care Lack of adequate language skills, inadequate financial resources, lack of insurance, immigration status (unlawful residence), and lack of transportation are the top five barriers for access to health care. Family members and friends serve as interpreters, which is unadvisable but within the patient’s right if they choose to do so. When young adolescents are used for this purpose the dynamics of discussing highly technical, medical, and at times private issues with the care providers while involving a minor creates ethical dilemmas. To mitigate financial and immigration status barriers, immigrants resort to the use of home remedies or self-diagnosis or selfmedication with the supplies they brought with them. In recent years, establishment of a more robust Iranian network with a focus on community outreach and assistance is slowly addressing these issues, but they remain a definite concern. Cultural Responses to Health and Illness Iranians are expressive about their pain. Some justify suffering in the light of rewards in the afterlife. For example, the grandmother of a young woman with a slow-growing brain tumor consoled herself and her 2780_BC_Ch32_001-013 03/07/12 9:57 AM Page 12 12 Aggregate Data for Cultural-Specific Groups granddaughter with the statement that “Suffering in this world assures her a place in heaven.” Mental illness is stigmatized and is believed to be genetically predisposed. Mental illness is likely to be called a “neurological disorder” or narahati-e-asa’b. Bagheri (1992) found that Iranians consider psychopharmacological treatment to be most effective for somatic illness. Iranian immigrants experience numerous stressors related to resettlement in a foreign culture. As measured by the Health Opinion Survey, 44 percent of Lipson’s (1992) newer immigrant interviewees experienced medium or high stress compared with 14 percent of the long-term-resident group. With reference to mood, about 35 percent of the informants answered yes when asked if they considered themselves to be “nervous,” and about the same percentage stated that they did not have “peace of mind.” The reasons were adjusting to their new life in the United States, missing family members, and having concerns about relatives left behind. Despite these problems, most Iranian immigrants had no plans to seek counseling or treatment, preferring to rely on family support (Lipson & Meleis, 1983). In recent years, psychotherapy and counseling have become acceptable treatment modalities, particularly in dealing with children (Sayyedi, 2004). In Iran, use of counseling, both pre- and post-marriage, is also on the rise. Since the return of the injured soldiers from the Iran–Iraq war, physical disability has begun to receive attention. Before then, the handicapped and the mentally challenged were kept at home with few care and treatment options. The outcome of the war and the World Health Organization’s Year of the Disabled stimulated Iran to promulgate the civil rights of people with disabilities and to guarantee access to health care. Today, physical therapy and art and music therapy are used as adjunct treatments. Blood Transfusions and Organ Donation Blood transfusions, organ donations, and organ transplants are widely accepted among Iranians. In Iran, donation of organs has become a business transaction—if a kidney is needed, it can be purchased (Zargooshi, 2001). Health-Care Providers Traditional Versus Biomedical Providers Iranians appreciate state-of-the-art facilities, hightechnological equipment, and skilled professionals. At the same time, the expense of health care is a widespread concern. Immigrants are confused by differences in the mannerisms and attitudes of the health-care providers in Iran versus those abroad. According to one woman, “Doctors here don’t listen to you, they are always careful of malpractice; they don’t want to be specific” (Lipson, 1992). Many Iranian patients expect to receive a definitive diagnosis and a clear road map for treatment including prescriptions and therapies. They may not ask too many questions or inquire about different modalities thinking that the provider knows best. Status of Health-Care Providers Religious and folk providers are generally not sought by most Iranian immigrants. The most respected health-care provider is an educated and experienced physician. In Iran, medical imaging equipment, such as computed tomography scanners, is readily available. The government of Iran has supported medical school admissions based on influential kin rather than merit; therefore, graduates are of mixed quality. In Iran, nursing as a profession remains in its infancy. Nurses are accorded considerably less respect compared with physicians, and the profession receives mixed reviews in terms of patient satisfaction. Nursing education has evolved from an apprenticeship to a baccalaureate degree, and nurses are still striving for acceptance and recognition as professionals (Nasrabadi, Lipson, & Emami, 2004). Immigrants have repeatedly stated that nursing care in the United States is far more interactive, communicative, and people oriented. REFERENCES* Arlandson, J. (2010). Mohammad and the Homosexual. Retrieved from http://www.answering-islam.org/Authors/Arlandson/ homosexual.htm Azizi, F., Ghanbarian, A., Madjid, M., & Rahmani, M. (2002). Distribution of blood pressure and prevalence of hypertension in Tehran adult population: Tehran Lipid and Glucose Study (TLGS), 1999–2000. Journal of Human Hypertension, 16(5), 305–312. Bagheri, A. (1992). Psychiatric problems among Iranian immigrants in Canada. Canadian Journal of Psychiatry, 37, 7–11. Baluch, B., Al-Shawaf, T., & Craft, I. (1992). Prime factors for seeking infertility treatments amongst Iranian patients. Psychological Reports, 71, 265–266. Biparva, E. (1994). Ethnic organizations: Integration and assimilation vs. segregation and cultural preservation with specific reference to Iranians in the Washington, D.C. metropolitan area. Journal of Third World Studies, 11, 369–404. Bozorgmehr, M. (1997). Internal ethnicity: Iranians in LA. Sociological Perspective, 40(3), 387–409. Bozorgmehr, M., Sabagh, G., & Der-Martirosian, C. (1993). Beyond nationality: Religio-ethnic diversity. In R. Kelly (Ed.), Irangeles: Iranians in Los Angeles (pp. 59–79). Berkeley: University of California Press. CIA World Factbook. (2011). Iran. Retrieved from https://www. cia.gov/library/publications/the-world-factbook/geos/ir.html Clark, D. (1995, January 27). Small Iranian group maintains anonymity. The Washington Blade, p. 14. Dallalfar, A. (1994). Iranian women as immigrant entrepreneurs. Gender and Society, 8(4), 541–561. Daneshpour, M. (1998). Muslim families and family therapy. Journal of Marital and Family Therapy, 24(3), 355–390. Darvishpour, M. (2002), Immigrant women challenge the role of men: How the changing power relationship within Iranian 2780_BC_Ch32_001-013 03/07/12 9:57 AM Page 13 People of Iranian Heritage families in Sweden intensifies family conflicts after immigration. Journal of Comparative Family Studies, 33(2), 270–296. Emami, A., Benner, P., & Ekman, S. -L. (2001). A sociocultural health model for late-in-life immigrants. Journal of Transcultural Nursing, 12(1), 15–24. Emami, A., Torres, S., Lipson, J., & Ekman, S. -L. (2000). An ethnographic study of a day care center for Iranian immigrant seniors. Western Journal of Nursing Research, 22, 169–171. Hafizi, H. (1990). Health and wellness: An Iranian outlook. Unpublished master’s thesis, University of California, San Francisco. Hanassab, S. (1998). Sexuality, dating and double standards: Young Iranian immigrants in Los Angeles. Iranian Studies, 31, 65–76. Hollifield, M. (2002). Accurate measurements in cultural psychiatry: Will we pay the costs? Transcultural Psychiatry, 39(4), 419–420. Iran Statistical Yearbook. (2007). Statistical Center of Iran. Tehran, Iran. Azar. Jalali, B. (1996). Iranian families. In M. McGoldrick, J. Giordano, & J. K. Pearce (Eds.), Ethnicity & Family Therapy, 2 ed., (pp. 347–363). New York: Guilford Press. Klessig, J. (1992). The effect of values and culture on life-support decisions. Western Journal of Medicine, 157(3), 316–322. Koser, K. (1997). Social networks and the asylum cycle: The case of Iranians in the Netherlands. International Migration Review, 31(4), 591–612. Lipson, J. (1992). Iranian immigrants: Health and adjustment. Western Journal of Nursing Research, 14, 10–29. Lipson, J., & Meleis, A. (1983). Issues in health care of Middle Eastern patients. Western Journal of Medicine, 139, 854–861. Mehryar, A., Roudi, F., Aghajanian, A., & Tajdini, F. (1997). Repression and revival of the family planning program and its impact on fertility levels and demographic transition in the 13 Islamic Republic of Iran. Retrieved from http://faculty.uncfsu. edu/aaghajanian/papers/femalelaborforce%20participationfertility.pdf Nasrabadi, A., Lipson, J., & Emami, A. (2004). Professional nursing in Iran: An overview of its historical and sociocultural framework. Journal of Professional Nursing, 20, 396–402. Nyvzanlayn Mehr News Agency. (2007 [1389 in the Iranian calendar]). Retrieved from http://www.salamatnews.com/view News.aspx?ID=22380&cat=6 Omeri, A. (1997). Culture care of Iranian immigrants in New South Wales, Australia: Sharing transcultural nursing knowledge. Journal of Transcultural Nursing, 8(2), 5–17. Pliskin, K. (1987). Silent boundaries: Cultural constraints on sickness and diagnosis of Iranians in Israel. New Haven, CT: Yale University Press. Rezaian, F. (1989). A study of intra- and inter-cultural marriages between Iranians and Americans. Unpublished doctoral dissertation, California Institute of Integral Studies, San Francisco. Sayyedi, M. (2004). Psychotherapy with Iranian-Americans: The quintessential implementation of multiculturalism. The California Psychologist, 37, 12-13. Smith, J. A. (1983). The idea of health: Implications for the nursing profession. New York: Teachers College. Yong, W. (2010, December 7). Iran’s Divorce Tate Stirs Fear of Society in Crisis. New York Times. Retrieved from http://www. nytimes.com/2010/12/07/world/middleeast/07divorce.html Zargooshi, J. (2001). Iranian kidney donors: Motivations and relations with recipients. Journal of Urology, 165, 386–392. For case studies, review questions, and additional information, go to http://davisplus.fadavis.com Chapter 15 People of Haitian Heritage Jessie M. Colin and Ghislaine Paperwalla *The authors would like to thank Ingrid Parenteau and Sheran Kegerise, graduate students at Barry University, for their assistance in the literature review and preparation of the manuscript. Overview, Inhabited Localities, and Topography Overview Haiti, located on the island of Hispaniola between Cuba and Puerto Rico in the Caribbean, shares the island with the Dominican Republic. With a population of 9.7 million inhabitants, Haiti covers an area of 27,750 square kilometers (10,714 square miles), about the size of the state of Maryland (CIA World Factbook, 2011). In 1492, Christopher Columbus landed on the island and named it Hispaniola, which means “Little Spain.” Haiti, or Ayti, meaning “land of mountain,” was given its name by the first inhabitants, the Arawak and the Caribe Indians. Before 1492, there were five well-organized kingdoms: the Magua, the Marien, the Xaragua, the Managua, and the Higuey (Dorestant, 1998). Two-thirds of Haiti contains mountains, great valleys, and extensive plateaus; small plains mark the rest of the country. The capital and largest city, Port-au-Prince, has a population of over 800,000. Widespread unemployment and underemployment exist; more than twothirds of the labor force do not have formal jobs owing to the marked decrease in assembly sector jobs. In addition, Haiti’s economy suffered a severe setback when a magnitude 7.1 earthquake devastated its capital city, Port-au-Prince, in January 2010. About 80 percent of the population had already lived under the poverty line, with 57.4 percent living in abject poverty (CIA World Factbook, 2011). After the earthquake, the GDP per capita was $1200 (CIA World Factbook, 2011). Prior to the earthquake, two-thirds of Haitians depended on the agricultural sector, mainly small-scale subsistence farming, and are still vulnerable to damage from frequent natural disasters, exacerbated by the country’s widespread deforestation. U.S. economic engagement under the Haitian Hemispheric Opportunity through Partnership Encouragement (HOPE) Act, passed in 2006, has boosted apparel exports investment by providing tariff-free access to the United States (CIA World Factbook, 2011). The infant mortality rate is high, with 54.02 deaths per 1000 live births; the average life expectancy is 62.17 years (CIA World Factbook, 2011); and in 2008, only 70 percent of the urban population (50 percent in rural areas) had access to improved drinking water sources (WHO, 2010). The World Health Organization (WHO) estimated that prior to the disaster in 2010, diarrheal diseases accounted for 16 percent of deaths among children less than 3 years of age. In October 2010, an outbreak of cholera added to the devastation of the earthquake, killing an additional 3000 people and infecting approximately 130,000 more (BBC News, 2011). The Haitian population in the United States is not well documented; this may be because of the U.S. Census Bureau’s inability to track the …
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