Maria Juarez
Maria Juarez, a 53-year-old Mexican American widow, was referred to a community health nursing agency by a clinic. Her married daughter reported that Mrs. Juarez was having severe and prolonged vaginal bleeding and needed medical attention. The daughter had made several appoint- ments for her mother at the clinic, but Mrs. Juarez had refused at the last minute to keep any of them.
After two broken home visit appointments, the community health nurse made a drop-in call and found Mrs. Juarez at home. The nurse was greeted courteously and invited to have a seat. After introductions, the nurse explained that she and the others were only trying to help. Mrs. Juarez had caused a lot of unnecessary concern to everyone by not cooperating, she scolded in a friendly tone.
Mrs. Juarez quickly apologized and explained that she had felt fine on the days of her broken appointments and saw no need “to bother” anyone. Questioned about her vaginal bleeding, Mrs.
Juarez was evasive. “It’s nothing,” she said. “It comes and goes like always, only maybe a little more.” She listened politely, nodding in agreement as the nurse explained the need for her to see a physician. Her promise to come to the clinic the next day, however, was not kept. The staff labeled Mrs. Juarez as unreliable and uncooperative.
Mrs. Juarez had been brought up in traditional Mexican American culture that taught her to be submissive and interested primarily in the welfare of her husband and children. She had learned long ago to ignore her own needs and found it difficult to identify any personal wants. Her major concern was to avoid causing trouble for others. To have a medical problem, then, was a difficult adjustment.
The pain and bleeding had caused her great apprehension. Many Mexican Americans have a partic- ular dread of sickness and especially hospitalization. Furthermore, Mrs. Juarez’s culture had taught her the value of modesty. “Female problems” were not discussed openly. This cultural orientation meant that the sickness threatened her modesty and created intense embarrassment. Conforming to Mexican American cultural values, she had first turned to her family for support. Often, only under dire circumstances do members of this cultural group seek help from others; to do so means sacri- ficing pride and dignity. Mrs. Juarez agreed to go to the clinic because refusal would have been dis- respectful, but her fear of physicians and her reluctance to discuss such a sensitive problem kept her from going. Mrs. Juarez was being asked to take action that violated several deeply felt cultural val- ues. Her behavior was far from unreliable and uncooperative. With no opportunity to discuss and resolve the conflicts, she had no other choice. Knowing this, how would you approach Mrs. Juarez?
of Mexican Americans, for example, are Catholic), but reli- gious beliefs often consist of a blend of Catholicism and pre- Columbian Indian beliefs and ideology, along with magi- coreligious practices. Hispanics believe in submission to the will of God and that illness may be a form of castigo, or punishment for sins. They cope with illness through prayers and faith that God will heal them. Their religion also deter- mines the rituals used in healing. For example, solito, a con- dition of depression in women similar to a midlife crisis in American culture, is treated by having the patient lie on the floor while her body is stroked by the curandero (native healer) until the depression passes. Latino culture includes beliefs that witchcraft (brujeria) and the evil eye (mal de ojo) are supernatural causes of illness that cannot be treated by “Anglo” or Western medicine. Empacho, a stomachache in children that occurs after a traumatic event, is treated by the curandero with herbal mixtures made into teas. After tender loving care and a bowel movement, the child is con- sidered healed (Table 5.5). As with Asians, Hispanics use
“hot” and “cold” categories of foods to influence their diet during illness. Many Hispanics tend to be present-oriented, and consequently are not as concerned as the mainstream culture about keeping to time schedules or preparing for the future (Giger & Davidhizar, 2004; Leininger, 2006; Eggen- berger, Grassley, & Restrep, 2006; Spector, 2009).
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own home, 42% work as professionals or managers, and the median income for Arab American families is 4.6% higher than other Americans (Naim, 2005). Many Arab immigrants have only arrived since the 1990s, fleeing war-torn countries or repressive regimes (Goodman, 2002; Naim, 2005).
A common language (Arabic) and background unite them, yet only 18% of Muslims (followers of Islam) reside in Middle Eastern countries. Arabs are largely Christian or Muslim, although some Arabs may be Jews or Druze (Elec- tronic Resource Center, 2007b). Christian Arabs first began emigrating to the U.S. in the late 19th and early 20th cen- turies (mostly from Syria and Lebanon), but during the mid- dle of the 20th century, Muslim Arabs began to emigrate in greater numbers (commonly from Palestine, Egypt, Iraq, and Yemen). Islam is the fastest-growing global religion, with more than 1 billion followers worldwide. Most Muslims live in Indonesia, the southern Philippines, and the United States (Electronic Resource Center, 2007c). The Council on Ameri- can–Islamic Relations (2008) reports that, in the U.S., 25% of Muslims are of Southeast Asian ancestry, while only 23% are of Arab descent. Approximately 8 million Americans are Muslim. In Britain, it is estimated that Muslim worshippers will outnumber Anglicans within a few years, and the Christ- ian Research Organization in England projected that, if current
trends continue, by 2039 Muslims will surpass all British Christians in worship attendance (Baqi-Aziz, 2001). The tenets of Islam are interpreted more liberally in some nations and more strictly in others, but all practicing Muslims adhere to the five tenets of Islam in some fashion (Table 5.6).
Population Characteristics and Culture
An Arab is defined as “an individual who was born in an Arab country, speaks the Arabic language, and shares the val- ues and beliefs of an Arab culture” (Kridli, 2002, p. 178).
Arab Americans can trace their ancestry to the North African countries of Morocco, Tunisia, Algeria, Libya, Sudan, and Egypt, as well as the western Asian countries of Lebanon, Palestine, Syria, Jordan, Bahrain, Qatar, Oman, Saudi Arabia, Kuwait, United Arab Emirates, and Yemen. Iran is some- times listed in this group, although Iraqis generally consider themselves to be Persian, not Arab (Arab American Institute Foundation, 2002). Assyrian/Chaldean/Syriac and Sub- Saharan (Somalian and Sudanese) groups are also noted as Arab. In general, the beliefs and practices of people from such disparate and distant countries cannot be encompassed into one culture. Despite the fact that some of these countries are highly Westernized, enjoy natural resources such as crude 110
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UNIT 1 Foundations of Community Health NursingTABLE 5.5
Hispanic Health Beliefs and Folk Diseases
Belief Name Explanation/Treatment
Ataque Severe expression of shock, anxiety, or sadness characterized by screaming, falling to the ground, thrashing about, hyperventilation, violence, mutism, and uncommunicative behavior. Is a culturally appropriate reaction to shocking or unexpected news, which ends spontaneously.
Bilis Vomiting, diarrhea, headaches, dizziness, nightmares, loss of appetite, and the inability to urinate brought on by livid rage and revenge fantasies. Believed to come from bile pouring into the bloodstream in response to strong emotions and the person “boiling over.”
Bilong (hex) Any illness may be caused by this; proper diagnosis and treatment requires consulting with a santero or santera (priest or priestess).
Caide de mollera A condition thought to cause a fallen or sunken anterior fontanel, crying, failure to nurse, sunken eyes, and vomiting in infants. Popular home remedies include holding the child upside down over a pan of water, applying a poultice to the depressed area of the head, or inserting a finger in the child's mouth and pushing up on the palate. (Note: According to Western medicine, these symptoms are indicative of dehydration and can be life-threatening. The community health nurse's role is imperative—to promoting hydration and definitive health care.)
Empacho Lack of appetite, stomach ache, diarrhea, and vomiting caused by poorly digested food. Food forms into a ball and clings to the stomach, causing pain and cramping. Treated by strongly massaging the stomach, gently pinching and rubbing the spine, drinking a purgative tea (estafiate), or by administering azarcon or greta, medicines that have been implicated, in some cases, in lead poisoning. (Note: The community health nurse must assess family for the use of these “medicines” and initiate appropriate follow-up).
Fatigue Asthma-like symptoms treated with Western health care practices, including oxygen and medications.
Mal de ojo A sudden and unexplained illness including vomiting, fever, crying, and restlessness in a usually well child (most vulnerable) or adult. Brought on by an admiring or covetous look from a person with an “evil eye.”
It can be prevented if the person with the "evil eye" touches the child when admiring him or her if the child wears a special charm. Treated by a spiritualistic sweeping of the body with eggs, lemons, and bay leaves accompanied by prayer.
Pasmo Paralysis-like symptoms in the face and limbs treated by massage.
Susto Anorexia, insomnia, weakness, hallucinations, and various painful sensations brought on by traumatic situations such as witnessing a death. Treatment includes relaxation, herb tea, and prayer.
Adapted from Spector, R. E. (2004). Cultural diversity in health and illness(6th ed.). Upper Saddle River, NJ: Pearson Education, Inc.
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oil and the riches that may follow, and are more liberal in fol- lowing traditional cultural practices, others do not. It must also be noted that the Middle East has one of the slowest growing levels of personal income in the world and the highest unem- ployment rates among developing nations (Naim, 2005).
Arabs are mostly divided into two distinct religious groups: Muslims and Christians. Arabs value Western medi- cine, trust American health care workers, and do not gener- ally postpone seeking medical care (Electronic Resource Center, 2007d). Several practices, however, are unfamiliar to most Americans. Many Arabic women stay at home and are not in the workforce. Families impose stricter rules for girls than for boys. After menarche, teenage girls may not social- ize with boys. The adolescent female also begins to cover her head and perhaps wears a hajab, which takes the form of a modest dress and veil designed to diminish attractiveness and appeal to the opposite sex. Some Arab groups take this mode of dress to extremes, not even allowing a woman’s eyes to show out of the hajab. Modesty is one of the core values for Arabs; it is expressed by both genders, although more evi- dently by females (Al-Shahri, 2002; Goodman, 2002).
Within the Arabic population, strict sexual taboos and social practices exist. All sexual contacts outside the marital bond are considered illegal. Those known to have been involved in such activities can be socially rejected, or in some countries even put to death. The stigma of lost honor can continue with their families for generations to come.
Another social practice, at times mistakenly related to the Islamic religion, is the practice of female genital mutilation.
This is practiced in a few of the Arabic countries on the African continent and has spread to southern Egypt, but it is rare or nonexistent in other Arabic countries. This horrific practice may include the removal of a young woman’s labia, clitoris, or both, and it sometimes includes closing the vagi- nal opening by suturing (Kridli, 2002).
Health Problems
Health problems among Middle Easterners are most fre- quently lifestyle related. These include poor nutritional prac- tices, resulting in obesity, especially among women; smoking among men; and lack of physical exercise (Al-Shahri, 2002).
In some rural areas, especially in Saudi Arabia, men and
women chew tobacco, and an increase of oral cancers is seen.
Major public health concerns for most Arabs are related to motor vehicle accidents, maternal–child health, TB, malaria, trachoma, typhus, hepatitis, typhoid fever, dysentery, and parasitic infections (Giger & Davidhizar, 2002).
Most social restrictions are directed toward women and can affect their health. Pregnancy can be complicated by gen- ital mutilation, which results in infections and difficult deliv- eries. Childbearing continues up until menopause, and 30% of marriages in some Arabic countries are between first cousins;
both factors can contribute to the prevalence of genetically determined diseases (Giger & Davidhizar, 2002). The desire to have more sons than daughters often results in very large families and closely spaced pregnancies—often without the benefit of family planning. It is often debated whether birth control methods are sanctioned by Islam or not, but Akbar (2007) states that Muslims can reason for themselves, and notes that family planning is not forbidden by the beliefs of Islam. Abortion and infanticide are not accepted, however.
Health Beliefs and Practices
Traditional medicine is practiced in spite of the growth of Western medical services in some of the richer Arab nations.
Traditional health care practices are much more common in the poorer Middle Eastern countries and in rural areas of all Arabic countries.
Muslims believe in predestination—that life is deter- mined beforehand—and they attribute the occurrence of dis- ease to the will of Allah. However, this does not prevent peo- ple from seeking medical treatment. Islamic law prohibits the use of illicit drugs, which include alcohol. Users of such substances are liable to trial, and those convicted of smug- gling substances into an Arab country can be sentenced to death in some cases. Sharaf, or honor, is an important con- cept in Arab American beliefs, and drug addiction, mental illness, or unwed pregnancy of a family member brings shame to the entire family (Electronic Resource Center, 2007e). Conversely, when a member does something good or is recognized for an achievement, that honor is reflected on the family as a whole.
Cleanliness is paramount and ritualistic, especially before prayers and after sexual intercourse. The bodies of CHAPTER 5 Transcultural Nursing in the Community
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111TABLE 5.6
The Five Pillars (Tenets) of Islam
1. Faith Declaration of faith (shahada) that there is no God but Allah and that Mohammad is the messenger of Allah.
2. Prayer Obligatory prayers five times a day at dawn, noon, mid-afternoon, sunset, and when night falls (called salat) link the worshipper to God. Prayers are led by a learned man who knows the Quran, as there is no hierarchical authority in Islam (such as a minister or priest).
3. Almsgiving This is like tithing and is a very important principle, as all wealth is thought to belong to God. It is called zakat, and each Muslim is expected to pay 2.5% of his or her wealth annually for the benefit of others in need.
4. Fast To abstain from food, drink, and sexual intercourse during daytime (from dawn to sunset) throughout the ninth lunar month (Ramadan). It is a means of self-purification and spirituality. The sick, elderly, or pregnant/nursing women may be permitted to break the fast.
5. Pilgrimage The pilgrimage to Makkah (the Hajj) once in a lifetime for those who are physically and financially able to do so.
About 2 million people go to Makkah every year (located in Saudi Arabia).
Adapted from The Five Pillars of Islam. Retrieved from: http://www.islamicity.com/mosque/pillars.shtml.
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both genders are kept free of axillary and pubic hair. The left hand is used for cleaning the genitals and the right one is reserved for eating, hand shaking, and other hygienic activ- ities. Muslims fast during Ramadan from sunrise to sunset, and this can include abstinence from all things (including medications or intravenous fluids). Illness can be an excep- tion to this rule, but public health nurses should consult with a family elder or Muslim leader to encourage the client to continue with any necessary treatments. Also, Muslims pray several times daily, facing toward Mecca. Home visits should be planned so that prayers are not interrupted (Elec- tronic Resource Center, 2007e).
When caring for Arabs in clinics or at home, a nurse of the same sex as the client should be assigned. Many topics (e.g., menstruation, family planning, pregnancy, and child- birth) must be discussed only with and by women; men are not included in these discussions.
Additional guidelines for nurses working with all immigrant groups include the following:
◆ Do not make assumptions about a client’s understanding of health care issues.
◆ Permit more time for interviewing; allow time to evaluate beliefs and provide appropriate interven- tions.
◆ Provide educational programs to correct any misconceptions about health issues; this can occur in clinics, mosques, schools, or homes.
◆ Provide an appropriate interpreter to improve com- munication with immigrants who do not speak English well.