Cultural Beliefs and Healthcare
Healthcare’s purpose in general, and Nursing’s purpose in particular, is to provide care and nurture the health of each person with whom the healthcare system comes into contact. Perceptions, however, of what healthcare and nursing entail or should entail are not universal. Perceptions of the same are often derived from a person’s culture or socio-demographic background, and his awareness of and accessibility to healthcare services. Cultural values often dictate a person’s behavior to his health or reaction to any sickness.
In order to develop a health system that strives to fulfill any person’s best health potential, then culture must be considered such that any healthcare program or intervention must be culturally sensitive and include cultural mechanisms that better embrace the needs of each individual patient. The purpose of this paper is to describe one particular cultural group in the United States: Pakistani Americans, and offer recommendations how a healthcare system may better foster care for Pakistani Americans by learning about and incorporating certain culturally appropriate services to their healthcare system.
The results of an interview conducted in the home of Mustafa (who does not want his last name used due to privacy issues) are based on M. Leininger’s Sunrise Model. The recommendations at the end are based in most part on the interview data. Leininger’s Sunrise Model in Brief In Leininger’s Sunrise Model visualizes the different dimensions of Leininger’s Culture Care Theory. It illustrates a complete view of the different yet closely related dimensions of the theory. The Sunrise Model in this study is used as a cognitive map to orient one with Pakistani-American culture and to depict the different dimensions of the theory.
The central purpose of Leininger’s theory is culture care (Leininger, 1991, p. 35). The goal as established by the Culture Care Theory is to provide culturally congruent care to individuals, families, groups, communities and institutions. Culturally congruent care is defined as “those cognitively based assistive, supportive facilitative, or enabling acts or decisions that are mostly tailor made to fit with an individual’s, group’s, or institution’s cultural values, beliefs, and lifeways in order to provide meaningful, beneficial, satisfying care that leads to health and well-being. ” (Leininger, 1995, p. 75).
The theory helps a healthcare practitioner learn about the worldview of a group of people or an individual from that group. As briefly noted earlier, a person or group derives its cultural and social structure dimensions from that worldview, and it is the latter that defines their existence. These cultural and social dimensions influence care patterns and healthcare practices. The Culture Theory states that there are seven cultural and social structure dimensions:
- Technological factors,
- Religious and philosophical factors,
- Kinship and social factors,
- Cultural values and lifeways,
- Political and legal factors,
- Economic factors, and
- Educational factors.
Due to space limitations, not all dimensions of the Culture Care Theory, as depicted and represented by the Sunrise Mode, can be considered in this paper, and those considered are: Religion, Cultural Values, and Political Factors, but first an overview of Pakistani-Americans is provided so as to provide an additional means to context. Pakistani-Americans: An Overview In 1947, Pakistan received its independence from British India.
The new nation was created on the basis of Islam so that Muslims from British India would have a nation to of their own, as opposed to India, which remained largely Hindu. According to the CIA World Fact book, 95% of the population of Pakistan is Muslim, and of that percentage, 75% are Sunni Muslims and 20% are Shi’a Muslims. The other remaining 5% of the population are Christian and Hindu. Pakistan is not a secular state, and the state religion is indeed Islam. Religion enters many aspects of the Pakistani political and social life.
Since Pakistan came into existence relatively recently, in 1947, any record of the life of Pakistani Americans can really only begin since that year, but prior to that year, there were Muslim immigrants coming to the United States from British India, and the region that is now Pakistan. In the early 1900s, around 2,000 Indians, including both Muslims and Hindus, worked alongside immigrants from China, Italy and Japan to build the Western Pacific Railway in California. (Smith, 2008, and Jensen, 1988). Other Indians worked on other construction projects throughout the Western states, but particularly California.
Sometimes an Imam was brought to the fields with them, and the Imam would pray from the Koran several times a day when the Muslim men took their breaks. (Jensen, 1988). Some Indians returned to their country after they had saved considerable funds, but many more remained in the United States. While those who stayed faced racial prejudice, the Muslims also were subject to religious prejudice. The United States was and is mostly Christian, and difference, especially at that period of history, was not tolerated and embraced.
There were calls that those in the United States be expelled while further calls were made to deny Muslims entry to the United States. (Smith, 2008). The Asiatic Exclusion League (AEL) was organized in 1907 to encourage the expulsion of Asian workers, including Indian Hindus and Muslims. (Jensen, 1988). The years to follow were met with legislation introduced into the Congress to deny Muslim Indians visas, residency and citizenship rights. Most of these pieces of legislation were defeated, however, and in 1947, Congress passed a bill that would allow naturalization to those Indians in the United States.
(Smith, 2008). According to reports form the Immigration and Naturalization Service cited in Jansen (1988), from 1947 to the mid 1960s, there were only around 2,500 Pakistani immigrants in the United States. Since 1965, the Untied States has seen the largest migration of Pakistanis to the United States. Numbers of Pakistani immigrants swelled after 1970, with thousands of Pakistanis entering the United States each year since that time. Like their Asian Indian counterparts, they tended to be urban, well-educated, and professional.
Many of them had come from cities like Karachi and Lahore, and were familiar with Western culture and ways of living. However, the dependents and relatives that they have since sponsored for permanent residence in and citizenship to the United States in the years after 1965 have tended to be characterized by lower levels of education. The 1990 U. S. Census indicates that there were around 100,000 Pakistani-Americans in the United States. The largest percentage, 32% is in the Northeast, with 27% in the South, 21% in the West and 20% in the Midwest. The Highest concentrations of Pakistani Americans are in New York, California and Illinois.
It seems they tend to settle in large cities as a reflection possibly of their cities in Pakistan, i. e. Lahore, Karachi and Rawalpindi. It also is a reflection of course to move where the availability of employment is better. Due to their short history in the United States, and relatively small numbers of immigration as compared to others, there has been very little written about the Pakistani-American community. Scholars write about ethnic communities in the United States, but they tend to put the larger Asian Indian sub-continent community together as one community, rather that the many diverse communities it encompasses.
For instance in a study undertaken by Kananur Chandras in Arab, Armenian, Syrian, Lebanese, East Indian, Pakistani and Bangladeshi Americans: A Study and Source Book (San Francisco: E&R Research Associates, 1977), little is done to distinguish between Asian Indian, Pakistani Americans and Bangladeshi Americans. There is an assumption too that because Pakistanis are overwhelmingly Muslim, then they can be listed under the heading of America’s Arab Muslim community. There are also no comprehensive lists of Pakistani-American organizations or newspapers.
This study was undertaken with the help of one interviewee, Mustafa, allowing me to enter his home. Conclusions about the Cultural Phenomenon of Pakistani-Americans Culture is a word used as if an umbrella to encompasses various dimensions, as outlined by Leininger’s Sunrise Model. As mentioned, due to time and space constraints, only the topics that seemed most relevant and pertinent to my interview with Mustafa are included in this paper, and they are: (1) Religion, (2) Cultural Values, and (3) Economic and Education Factors. The following is a discussion of my data and literature review. Religion
Muslims are devout people who often visit a mosque once a week, usually on Friday afternoons. They are guided in prayer by an Imam at the mosque. Women and men sit separately, and in many mosques there is a separate room for women. Both men and women must keep their arms and legs covered while they are in the mosque; they should also cover their heads, but for men, the latter is not always followed. Children are also encouraged to attend education classes that are based on the Islam faith. Most Pakistani-Americans are devout Muslims. Religion has always played a prominent role in the lives of Pakistanis, and that includes Pakistani-Americans.
The Koran is their path in life and they greet each other with Salum Aleikum, which was how I was greeted at the door by Mustafa. When I first walked into Mustafa’s House, his grandfather was sitting in a chair in a corner, and his fingers rubbed over his prayer beads. Muslims pray five times a day towards their holy city Mecca, Egypt. In the corner of the room behind the grandfather’s chair was a mat rolled up. It was my impression that he, or they, used this mat when praying. One thing I noticed was that there were no pictures on the wall of family or friends or pieces of art.
The walls were rather plain apart from something that looked like calligraphy on velvet red paper, and framed nicely in a deep blue frame. In Islam, according to the Koran, idolatry is forbidden, and this is why I believe, or at least noted, that this family did not keep pictures of people, whether family or friends or movie stars, on their walls. Pakistani-Americans also remain very sensitive about the roles and place of the sexes. Islam has strict rules that apply to men and women, girls and boys. In general, Pakistani culture, as interpreted by Islam, is a very patriarchal culture. The man is head of the house.
So it seemed too in this house. When Mustafa’s wife and sister came into the living room to be a part of the discussion we were having, they sat on cushions on the floor, as opposed to sitting on the very couch that was behind them. However, when Mustafa’s son came in, he sat on the couch. It may have been personal preference, but it was a very visual representation of patriarchy that is in Pakistani culture. Further, the son spoke often. He is only 10 years old, but wanted to talk a lot and spoke in English. On the other hand, Mustafa’s wife never spoke, except for a few whispers to Mustafa’s sister, and that too was not in English.
Mustafa’s sister did speak, but it was only twice, and it was to ask where I was attending school. She did speak mostly in English, but oftentimes looked at the grandfather for approval, and even, it seemed, she looked at Mustafa and her nephew for their approval as well. Mustafa told her it was fine, speak up, but he never mentioned it to his wife, to say that it was fine to speak. Three quarters into the interview, both women left, to retreat to the kitchen, where they made more tea and placed some cookies on a plate for us to eat.
Once they had replenished our tea and gave us the cookies, they returned to the kitchen and I never saw them again until I said goodbye. Cultural Values Food is important to many cultures; it is both a symbol and a connector. Nowhere is food more important to a culture than the cultures of the Indian sub-continent. In Pakistan, as in India, there are regional variations that exist, but Pakistani cuisine in general tends to be highly spiced. These spices include cumin, turmeric, cloves, cinnamon, cardamom, and of course chili powder.
The first two and last are from the Indian sub-continent, while those in between are influences from their Arab neighbors. Unlike some Hindus, meat is an important part of their dish, and it includes lamb, goat and beef. For devout Muslims, the meat should be halaal, or kosher, such that the meat is cut in a way that ensures the slow draining of blood from the animal. The latter is for religious reasons, thus, exemplifying another area where religion plays an intricate role in the lives of Pakistanis. Keeping with the tradition of Islam, Pakistanis do not eat pork.
This is opposite to their neighbor India, where the large part of the population is Hindu, and they do not eat beef, but can eat pork. Considering above where scholars today tend to lump Asians together, this is a very important distinction between Muslim Pakistanis and Hindu Indians. It would be highly offensive to give any Muslim pork, and likewise, to give any Hindu Indian beef! Food is as important to culture as spiritual wellness is important to the health of the body. Many Americans believe that food factors in as one of the most important aspects to attaining and maintaining a healthy body and lifestyle.
That means eating fruits and vegetables and low fat foods that are not fried. Food for Pakistani-Americans is a means to keep their culture alive and their family together. The women, like Mustafa’s wife and sister, spend hours in the kitchen preparing dinner, then everyone gathers together to eat. Their foods are high in fat as many are fried and they tend to use a lot of oil and ghee. Thinking of food as a source of health does not equate to them as health for the body, but health for the mind and soul. Food combined with religion is good for the soul and the family. Islam does not believe in a mind/body dualism.
On the contrary, it is religion that is good for the body, making the body and mind one. Maintaining spiritual peace is thought to be essential to their health. (Athar, 1998). Those who keep to traditions may believe that disease can be a direct consequence or rather punishment from God for any sin that that person or someone close to that person has committed. (Athar, 1998). Therefore, it can be deduced that if one follows religious teachings and does not commit any sin which is outlined in the Koran or Islamic teachings, then one may remain healthy, both body and mind.
When I inquired into this aspect of their culture, Mustafa concurred. He left the room momentarily and returned with what he called a taawiz. It’s an amulet that contains verses from the Koran, and Muslims wear it when they are sick. Mustafa told me a story that when his son was five years old and had pneumonia, they made him wear this and within a couple of days, to the surprise of his physician, his son was feeling much better. He said that the taawizes are symbols of their faith, and that they are given by Imams and worm usually by adults to cure and prevent illness, which are often caused by the commission of sins.
Another cultural symbol and large aspect of not only a Muslim Pakistani-American’s life, but to all Muslims, is Ramadan. Mustafa said that this is a time to where Muslims can heal, and when he said that I felt again as though he was meaning both spiritually and physically. During Ramadan, Pakistani Muslims fast from the first day light until sunset. Ramadan is the ninth month of the Muslim lunar calendar. During the fast of Ramadan, Muslims are not allowed to eat or drink during the daylight hours. Smoking and sexual relations are also forbidden.
His grandfather went to Mecca once during Ramadan, and he believes that is why he has been able to live such a long and healthy life. It is Mustafa’s hope too that he will be able to visit Mecca, or Medina, in the future. Apart from the body and mind being one, and that following religious teachings, one may stay healthy, there is also traditional medicine which is a part of their culture. So if one does get sick, and nothing else seems to cure it, ayurveda medicine is sought along with conventional medicine.
Mustafa seemed very flexible on which medicine to use, and it seemed that this was symbolized in part by the arrangement of his home. It was decorated with beautiful rugs and calligraphy, something about the place made you feel you were in another world. It could have been the smells as well, as cumin and cinnamon were very potent. These things were mixed with a flat screen TV and an Xbox 360 station in the opposite end of the room. The mix of western and eastern culture in the room reflected his words when he said he is very much flexible if they use ayurvedic or western medicine.
In fact, they have both in the house for headaches, stomach pain, etc. Economic & Education Factors According to the U. S. Census report, the profile of the Pakistani American today is dramatically different from the earliest Muslims immigrants from the Indian subcontinent, who came to the United States as manual and agricultural workers with few skills and little or no education. Many Pakistani American males who entered the United States after 1965 were well educated, urban, and sophisticated. They found professions in law, medicine and academia.
In the post-1965 wave of immigration, many Pakistanis also came to America as students who earned graduate degrees, and once they received their degrees they pursued careers in their fields in the United States and eventually attained permanent resident status, and for many, citizenship. On the other hand, there are some Pakistanis who have immigrated to the United States, who failed to find positions within their specific fields because their qualifications and experience did not transfer readily to the American context.
Many unfortunately have taken jobs well below their qualifications, but there are others who have either retrained themselves in other professions or fields, or pursued continued education their respective fields. Again, according to the U. S. Census, most of the Pakistani community lives a comfortable, middle-class and upper-middle-class lifestyle. Although there are incidences of poverty among newer uneducated immigrants, but on the whole, they are doing very well. The latter immigrants, however, tend to take low-paying jobs involving manual or unskilled labor and tend to live in big cities where such jobs are readily available.
Many Pakistani-Americans also own their own businesses, including restaurants, groceries, and clothing and appliance stores. It is common to include members of the extended and immediate family in their business. Pakistani Americans tend to follow the residence pattern set by other Americans, in that they move to more affluent suburbs as their prosperity increases. Members of the community believe in the symbolic importance of owning homes; accordingly, Pakistani Americans tend to save and make other monetary sacrifices earlier on in order to purchase their own homes as soon as possible.
Members of the family and the larger community tend to take care of each other, and to assist in times of economic need. Hence, it would be more common to turn to a community member for economic assistance rather than to a government agency. Relatively low levels of the community are therefore on welfare and public assistance. All these things seem to resonate with Mustafa. Their home is in an upper middle class community. He owns three restaurants where his brothers and a few nephews work.
He was well educated before moving to the United States, but his field was in medicine, and he could not find a job with his education background and experience. He did not want to return to school so started one restaurant. Upon its success, he was able to open two other restaurants. As mentioned, he is well educated, and he wants his sister to finish college and his son to go to a very good school. He hopes his son will be a doctor as well, or maybe a lawyer. He believes in education and knows that it can bring you economic success.
He says that it was his education that gave him the skills to learn to manage a business, and though he was a trained doctor, it was education that made him see the world differently and gave him skills. Recommendations to Promote Culturally Congruent & Competent Care In order to provide culturally congruent care, there must a review of traditional and professional health care systems and a synthesis of these aspects put together. The care provided would be unique for each individual as a result of this synthesis. Overall, however, any existing behavior and lifestyles that are good for health should not be changed.
Furthermore, culture care accommodation “refers to those assistive, supporting, facilitative, or enabling professional actions and decisions that help people of a designated culture to adapt to, or to negotiate with, others for a beneficial or satisfying health outcome with professional care providers. ” (Leininger 1991, p. 48). The latter must be considered in any healthcare plan. A first step could be to elicit the persons’ perspective by asking such questions as: What do you call the problem? Why do you think this problem or illness has occurred?
What do you think the illness does? What do you think the natural course of the illness is? These types of questions will flush out any religious beliefs they may have about their illness. Then ask: How do you think the sickness should be treated? This question will clue you into if they want ayurvedic or other traditional medicine used in combination with western medicine. Then ask: Who do you turn to for help? Who should be included in the decision-making process? Pakistanis are very close and it is the family as one unit that often makes decisions.
There are other measures that can be taken, such that pork should not be served if the person must be hospitalized. The healthcare provider should be cognizant of Ramadan. Also, if there is a Muslim Pakistani-American who needs healthcare, if may be wise to ask if she prefers a female doctor. The same may be true for male Pakistani-Americans. Overall, it is wise to be alert and knowledgeable of other cultures. It will help promote goodwill as well as healthy relationships for everyone, and the society all together.
- Athar, S. Information for health care providers when dealing with a Muslim patient. Islamic Medical Association of North America, IL: The Library of Islam. Balagopal, Padmini, et al. Indian and Pakistani Food Practices, Customs, and Holidays. Chicago, IL: The American Dietetic Association, 1996.
- Jensen, Joan. Passage From India: Asian Indian Immigrants in North America. New Haven: Yale University Press, 1988.
- Leininger MM. (1997). Overview and Reflection of the Theory of Culture Care and the Ethnonursing Method. Journal of Transcultural Nursing, 8:2, 32–52.
- Leininger MM. Culture Care Diversity and Universality: A Theory of Nursing. National League for Nursing Press, New York, 1991.
- Smith, Jane I. Patterns of Muslim Immigrations. International Information Programs, retrieved on October 23, 2008 from ;http://usinfo. state. gov/products/pubs/muslimlife/immigrat. htm;.
- Williams, Raymond Brady. Religions of Immigrants from India and Pakistan: New Threads in the American Tapestry. New York: Cambridge University Press, 1988. U. S.
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