Afghans & Afghan

Americans

Transcultural Nursing
 General Objectives

1. Apply creative and critical thinking with knowledge of transcultural

nursing in a given health care setting.

2. Practice nursing responsibilities in accordance with existing laws, legal,

ethical, professional, and moral principles and with cultural considerations.

3. God-centered evangelizer with service orientation to one’s profession

 Our Learning Goals

Learning Learning Learning

Outcome 1 Outcome 2 Outcome 3
After this lesson the
students will be able to Gain knowledge of the
develop a general complex variables that affects Apply appropriate cultural
understanding of the the achievement of health and guidelines in the delivery of
understanding of the well-being of the Afghans and nursing services in a given
perspectives, traditions, Afghan Americans. health care setting.
values, practices Afghans
and Afghan Americans.
 Our Learning Goals

Learning Learning Learning

Outcome 4 Outcome 5 Outcome 6
Engage in advocacy • Present the lesson using the • social organization,
activities for the inclusion • Giger and Davidhizar model of • environmental
of patient’s cultural beliefs • Transcultural Nursing control,
and practices in all
• the model includes six cultural • biological
phenomena: communication, variations.
dimensions of the health • time,
care. • space,
 "Nurses should explore new ways of providing
cultural care in multicultural societies, understand
how culture affects health-illness definitions and
build a bridge for the gap between the caring
process and the individuals in different cultures."

Değer (2017)
 What do we know
about Afghanistan?
 Overview
Afghanistan, a poor, underdeveloped,
and landlocked country of
approximately 251,825 square miles.
For almost two decades, Afghans were the
largest refugee population—at its peak, more
than 6 million people—in the world.
The 2010 U.S. census listed 95,453
persons of Afghan descent residing in the
United States ( ). This is likely an
undercount because many Afghans
reported their ethnicity to census takers
rather than their national origin.
The largest population, in the San
Francisco Bay Area, numbers 30,000 to
40,000 people, many of whom are second
generation. There are eight mosques and
many cultural organizations and Afghan-
owned businesses.
Afghan and Afghan-Americans
 Communication

• Afghanistan has two national languages: Dari, a dialect of Persian (50%), and Pashto (35%)
• most Afghans speak either Dari or Pashto with regional variations, or another local mother tongue,
and many speak two or three other languages in addition to English, such as Urdu, Hindi, or German.
Many educated Afghans also speak Russian.
• Afghans tend to speak in stories rich in context, rather than providing brief answers to specific
Add family
questions. Generally, people are reluctant to share personal and a text quote,
issuesphoto,
with or videoother than
people
family members, including health care professionals, but women may discuss
to support their
your ideaproblems with
friends, including non-Afghans. Men do not discuss their personal problems with others.
• women speak loudly, men, on the other hand, tend to speak in soft tones in private or public settings,
• generally call elderly persons by respectful terms, such as uncle, aunt, or mother
• Determinants of touch are family relationships and gender
• Islamic rules apply when it comes to touching others depending on your relation
• Greetings between people who are not family members or close friends may be a simple nod or a
handshake, but a man should wait for a woman to extend her hand first
 Afghan Americans

• youth do not look elders directly in the eyes, but stand turned slightly to the
side, with their heads slightly down to convey proper respect
• When an elderly person or the head of a family enters the room, people show
their respect by standing.
• People kiss the back of an elderly person’s hand as a sign of respect and
acknowledgment of his or her wisdom, which comes with age
• Sustained eye contact varies by acculturation and generation. More traditional
unrelated men and women do not sustain eye contact nor do they “insult”
someone they perceive to be of higher status by making direct eye contact. In
general, health providers should avoid winking at or touching a person of the
opposite gender. Winking is seen as flirting and should be avoided.
 Implications for Nursing Care

• An appropriate interpreter may be needed for patients who speak

little or no English

• A considerable number of Afghans who speak English may not

read or write it; thus, it is important to check for English literacy
before asking them to read forms or instructions.

• Ideally, the interpreter is trained, respected in the community, of

the same gender as the patient, and around the same age or older.

• It is important to translate health education and training materials

into both national languages, even though most Afghans read
Dari.
• Afghan refugee women can more successfully adjust to their new country if they develop
a trusting interpersonal relationship with one or more “point persons” as the primary
source of information for all their needs, learn to speak English fluently, gain
understanding of how they themselves can navigate the U.S. government and social
service information systems, and practice asking questions of strangers in public and
customer service so they can advocate for themselves and their families
 Space
• In Afghanistan, extended families live in large houses or compounds, and
women socialize as they cook and do household chores together
• Afghans in the United States miss the daily proximity of other family
members.
• As with other cultural characteristics, space varies with relationship, gender,
and acculturation.
• Physical space between close friends and family engaged in conversation is
closer than that between those of northern European heritage, often 1 to 1.5
feet.
• On the other hand, unrelated men and women who are more traditional keep
more distance from each other, often socializing in separate rooms or separate
areas of one room.
• Spatial comfort depends on the activity and relationship of the people involved
and on the setting, such as among all Afghans or with others
• Afghans are extremely modest people who are used to thick walls between
rooms.
• In strictly private activities, such as using the toilet and having sexual relations,
people may fear that other family members may “hear” such activities through
the thin walls of the typical U.S. apartment or house; a couple may avoid sexual
relations because a daughter’s or mother’s bedroom is next door.
 Implications for Nursing Care
• The topics of sexuality, birth control, and vaginal or breast examinations are
considered very private and extremely embarrassing for women;
• older women may have minimal knowledge of how their bodies work
• There is no formal education for these women in terms of sexuality, birth control,
and the like.
• Women prefer to be seen by female gynecologists.
• If only a male is available, the woman’s husband will accompany her to
appointments and stay in the room during the examination.
• Traditional women avoid being touched by male nurses or physicians
• The situation is somewhat different among young adults and teens educated in the
United States, although some parents forbid their middle school– and high
school–aged children to take sex education classes.
• It is uncommon to leave one’s children with babysitters because of language and
custom.
• When children cannot accompany their parents to appointments, they stay with
other family members who do not work. However, children usually accompany
their parents to most health appointments and all social activities. Expect children
and provide art materials or other diversions.
• Numerous family members and friends gather at the bedside of a patient who is
hospitalized and remain until asked to leave. Visiting a sick person is a very
important value, and the room will seem crowded. If an Afghan is crying, it is
important just to sit beside him or her, without touching or hugging or calling
further attention to him or her
 Time
• depending on the situation Afghans may have different
orientations to time
• Past orientation is evident in tradition and family lineage
• Present interaction is observable in present interaction
• Future interaction is observable in hardwork and commitment
to children's education
• Acculturation influences stricter use of time
• may be late to an appointment if with guests
• may compensate by coming early to an appointment
 Implications for Nursing Care

• Awareness of the importance of hospitality and

smooth social interactions may help nurses anticipate
for missed appointments
• Remind a day ahead by phone call for any need for
interpreter or transportation difficulties
• rarely future-oriented that may affect teaching
prevention and health risk reduction
 Social Organization
Family System and Role
• the core of the Afghan culture and psychological well-being is Family life
• close ties are maintained with the extended family
• free time is spent with family and old friends
• distrust is common to those outside the family circle so new friendships are slow to
develop
Afghan Americans
• a lack of social support especially for the women and the elderly due to limitations in
language and cultural norm
• severe isolation, depression and numerous physical symptoms are reported
• feelings of being a burden to their families are also reported
 Impact of Acculturation and Immigration

• Afghan culture in the US is in transition

• families range from traditional to cosmopolitan
• enmeshment- family obligations to (parents and older siblings) extended family supersedes
other responsibilities including to a spouse.
• traditional men expect their wives to be a stay at home wife
• husbands are the head of the family and the main provider
• Women still needs to be conservative but must marry before 26
• children are not allowed to socialize especially female children with the opposite sex for
majority of the Afghan Americans
• Women may have diffuculty pursuing a career or higher education
• strict obedience to the head of the family and other elders
 Implications for Nursing Care

• Assess for how long the family has been in the US , acculturation leve,
origin (rural or urban), cosmopolitan or traditional.
• Ask who makes the decisions
• Family obligations and traditional hierarchy may interfere with getting
appointments or compliance.
• Be aware of the strong aversion of the Afghans to interference in family
affairs which they see as private.
• perceive school and social service agency intervention as undermining
parental control
• physical discipline of children
 Environmental Control
• Afghans are very concerned about their health
• combine internal and external locus of control
• as well as natural and supernatural concepts of health and illness belief and behavior
• believes that health is maintained through regular exercise, eating fresh food and a
balanced diet, staying warm and getting enough rest
• natural illness are believed to be caused by the thingss that exist in nature such as the
germs, dirt, cold and wind.
• during the change of seasons people are more vulnerable to cold or flu
• if one is not taking care of one's body it will result to illness
• illness can also be interpreted as the "will of God" and should be borne with patience as it
cleanses one of individual sins
• illness is also perceived as a result of not adhering to the principles of Islam
 Environmental Control
• Islam strongly emphasizes personal hygiene
• washing bodies before praying (ablution)
• washing of feet, face, hand, nose and inside the throat
• if a person passes gas, urinates, bleeds etc. he must wash again because he is impure
• after sex a person must wash from head to to foot before he is fit to pray
• women are prohibited to pray and to fast during menstruation until they perform a
purification ritual in 7 days
• supernatural illness are caused by "jins", the evil eye (nazar) or punishment from God
• epilepsy, evil eye,
• traditional medicine and prayers
 Environmental Control
Illness and wellness behavior and access to healthcare
• barriers to care is lack of health insurance
• no culturally specific services
• Dari and Pashto health education materials are rarely available
• newly arrived Afghans have a lot of health issues like tuberculosis, parasitism,
nutritional deficiences
• Long staying Afghans in the US have diabetes, asthma and motor vehicle injuries
• birth control is a problem, pap smears, breast exams

Mental Health Issues

• depression and psychosomatic disorders
• PTSD
• psychiatric care is a last resort due to stigma that might shame family
 Death, belief and customs
• death is viewed as a beginning of a new
and better life, spiritual existence and a
cherised state in which one solidifies his
relationship with God
• praying five times a day helps them avoid
committing bad deeds
• believe that death is the power of God
over His creation
• life support viewed as a gift of medical
tech.
• the body of the dead is prepared ritualisticaly by aother
Muslim
• the body washing can be delayed but it is ideal to do the
body washing ritual right away by a mullah and a male
family member who prays during the washing
• the body is placed in a white shroud and placed in a coffin
• if the deceased is female only close female relatives are
allowed to view her face
• if the deceased is male close male relatives and his wife are
the only ones allowed to view his face
• embalming is not allowed
• 40 days mourning, no make up, wears chador
 Implications for Nursing Care

• the culturally competent nurse must be sensitive to values and beliefs

that may be held by the Afghans and the effects of such beliefs to the
health care practices
• for the nurse to appreciate that while the client believes that illness is
the "will of Allah" the client still seeks Western medical care.
 Religion
• Afghans are staunch Muslims with the majority following the Sunni
branch (84%) , Shi'a (15%) others (1%)
• Majority of the Afghans adhere to Islamic Principles of hygiene,
modest behavior and moral values even if they are modernly dressed
just like majority of the Arab Americans
• females shoud remain chaste until marriage, no man can touch a
female
• Eat only halal foods and avoid haram voids ( pork and blood
products)
• they may look American in the way they dress but remains
conservative and adhere to their Islamic outlook
Biological Variations
• Afghans are a mixture of original tribes who invaded the are throughout history
• Greeks, Kushan(Caucasian nomads) Indians from the South, Huns from the north , Arabs,
Turks and Mongols
• Indo- European genetics is evident in Pashtuns and Tajiks whose skin tones and facial features
resemble other Mediterranean groups with coloring ranging from blue or green eyes, light
brown hair and fair skin to nearly black eyes, black hair and brown skin
• some may have slanted eyes, high cheek bone, yellow toned skin (Mongolian Heritage)
• Assess for jaundice and anemia by examining the sclerae and oral mucosa
• Cross cousin marriages are common before so diseases like epilepsy, blindness and several
forms of anemia and hemophilia are prevalent
Diet
• the Afghan diet is generally healthy based mainly
with rice seasoned with herbs,vegrables and small
amount of poultry
• fresh fruits, raisins and nuts, cake
• cooking food with large amounts of oil, fattu meats
and over-cooking are some of unhealthy food
practices
• as a nurse, include in your health teaching the use of
less oil
1. The person most likely to be the head of the home for
Afghan Americans is:
A. oldest son
B. Father
C. oldest daughter
D. wife
 2. When communicating with a client who speaks a different language, which best practice
should the nurse implement?

A. Speak loudly and slowly.

B. Arrange for an interpreter to translate.
C. Speak to the client and family together.
D. Stand close to the client and speak loudly.
 3. A nurse is preparing to deliver a food tray to a Afghan-
American client whose religion is Islam.
The nurse checks the food on the tray and notes that the
client has received a roast pork dinner with iced tea as a
beverage. Which of the following actions should the nurse
take?
A. Give the food as is.
B. Call the dietary department and requests for a new set of
food.
C. Call the patient's AP to check for approval of the diet.
D. Check with the dietician if it addresses the nutritional needs
of the client.
4. An Afghan-American teenager goes to the ER with chief complaints of right lower quadrant pain.
The attending physician on duty is male. When the girls family refused to let him examine the girl,
what would be the next best action that you can make as his assisting nurse?

A. Reassure the family that the you are going to be their at the doctors side when he examines the
patient.
B. Offer to examine the girl on the doctor's behalf.
C. Talk to the father of the girl that the doctor needs to palpate the area to accurately diagnose the
girl and that you are going to be with the doctor when he examines her.
D. Tell the patient to convince her parents to allow the doctor to see her .
 Tashakor barakat

‫بسیار از شما متشکرم‬

References:
Giger, J. N., & Davidhizar, R. elaine. (2004). Transcultural Nursing. In
. Mosby Incorporated.
Purnell, L. D., & Paulanka, B. J. (2008). Transcultural Health Care.
In . F A Davis Company.