Medifem Branding Magazine by Camila Fernandez Canales Tampa Florida

www.medifem.com

medi fem 1

CONTENTS 01

DOMESTIC ABUSE

HEALTH CARE FOR BLACK WOMEN

domestic violence and abuse

addressing domestic violence

disparities in healthcare for black women

what leads to domestic violence?

steps we can take immediately

problem statement

institutions working to address the issue

what is domestic violence?

policymakers, health care professionals and communities can improve Black women’s maternal health.

what to do in a domestic violent situation

domestic violence and its health implications

barriers for survivors of color

why do women stay?

psychological and emotional violence

role of public health personnel

03 ISSUES WITH RELIGION 32

issues in health care of middle eastern patients

health care issues

guidelines for health care professionals

01 DOMESTIC ABUSE

NATIONAL DOMESTIC VIOLENCE HOTLINE: https://www.thehotline.org/ 1.800.799.7233

Hispanic women were more likely than nonHispanic women to report that they were raped by a current or former intimate partner at one point in their lifetime.

DOMESTIC VIOLENCE AND ABUSE When people think of domestic abuse, they often focus on domestic violence. But domestic abuse includes any attempt by one person in an intimate relationship or marriage to dominate and control the other. Domestic violence and abuse are used for one purpose and one purpose only: to gain and maintain total control over you. An abuser doesn’t “play fair.” An abuser uses fear, guilt, shame, and intimidation to wear you down and keep you under their thumb.

48% of Latinas in one study reported that their partner’s violence had increased since they immigrated to the U.S

Domestic violence and abuse can happen to anyone; it does not discriminate. Abuse happens within heterosexual relationships and in same-sex partnerships. It occurs within all age ranges, ethnic backgrounds, and economic levels. And while women are more often victimized, men also experience abuse—especially verbal and emotional. The bottom line is that abusive behavior is never acceptable, whether from a man, woman, teenager, or an older adult. You deserve to feel valued, respected, and safe. Domestic abuse often escalates from threats and verbal assault to violence. And while physical injury may pose the most obvious danger, the emotional and psychological consequences of domestic abuse are also severe. Emotionally abusive relationships can destroy your self-worth, lead to anxiety and depression, and make you feel helpless and alone. No one should have to endure this kind of pain—and your first step to breaking free is recognizing that your relationship is abusive.

23.4% of Hispanic/Latino females are victimized by intimate partner violence

In a study conducted by the Asian Task Force Against Domestic Violence, 47% of Cambodians interviewed said they knew of a woman who experienced domestic abuse.

African American females experience intimate partner violence at a rate 35% higher than that of white females, and about 2.5 times the rate of women of other races

ADDRESSING DOMESTIC VIOLENCE An effective response to violence must be multi-sectoral; addressing the immediate practical needs of women experiencing abuse; providing long-term follow up and assistance; and focusing on changing those cultural norms, attitudes and legal provisions that promote the acceptance of and even encourage violence against women, and undermine women’s enjoyment of their full human rights and freedoms. The health sector has unique potential to deal with violence against women, particularly through reproductive health services, which most women will access at some point in their lives. However, this potential is far from being realized. Few doctors, nurses or other health personnel have the awareness and the training to identify violence as the underlying cause of women’s health problems. The health sector can play a vital role in preventing violence against women, helping to identify abuse early, providing victims with the necessary treatment and referring women to appropriate care. Health services must be places where women feel safe, are treated with respect, are not stigmatized, and where they can receive quality, informed support. A comprehensive health sector response to the problem is needed.

Domestic violence is a serious social and public health problem that occurs in all countries around the world. Domestic violence includes an array of physical and sexual violence, emotional abuse, and controlling behaviors by intimate partners. In 48 population-based studies from around the world, between 10% and 69% of women reported being physically assaulted by an intimate partner at some point in their lives, and for many of these women, physical assault was part of a continuing pattern of abusive behavior [2]. The World Health Organization recently conducted a study on domestic violence against women and women’s health in which 24,000 women were interviewed, at 15 different sites, in 10 geographically, culturally, and economically diverse countries. Even though the settings varied greatly, both among and within countries, the results indicate that violence against women by their male partners is common and has serious consequences.

WHAT LEADS TO DOMESTIC VIOLENCE? Domestic violence against women is an age old phenomenon. Women were always considered weak, vulnerable and in a position to be exploited. Violence has long been accepted as something that happens to women. Cultural mores, religious practices, economic and political conditions may set the precedence for initiating and perpetuating domestic violence, but ultimately committing an act of violence is a choice that the individual makes out of a range of options. Although one cannot underestimate the importance of macro system-level forces (such as cultural and social norms) in the etiology of gender-based violence within any country, including India, individual-level variables (such as observing violence between one’s parents while growing up, absent or rejecting father, delinquent peer associations) also play important roles in the development of such violence. The gender imbalance in domestic violence is partly related to differences in physical strength and size. Moreover, women are socialized into their gender roles in different societies throughout the world. In societies with a patriarchal power structure and with rigid gender roles, women are often poorly equipped to protect themselves if their partners become violent. However, much of the disparity relates to how men-dependence and fearfulness amount to a cultural disarmament. Husbands who batter wives typically feel that they are exercising a right, maintaining good order in the family and punishing their wives’ delinquency - especially the wives’ failure to keep their proper place.

PROBLEM STATEMENT Domestic violence is the most common form of violence against women. It affects women across the life span from sex selective abortion of female fetuses to forced suicide and abuse, and is evident, to some degree, in every society in the world. The World Health Organization reports that the proportion of women who had ever experienced physical or sexual violence or both by an intimate partner ranged from 15% to 71%. The trend of violence against women was recently highlighted by the India’s National Crime Records Bureau (NCRB) which stated that while in 2000, an average of 125 women faced domestic violence every day, the figure stood at 160 in 2005. A recent United Nation Population Fund report also revealed that around two-thirds of married women in India were victims of domestic violence. Violence in India kills and disables as many women between the ages of 15 and 44 years as cancer and its toll on women’s health surpasses that of traffic accidents and malaria combined.(8) Even these alarming figures are likely to be significantly under estimated given that violence within families continues to be a taboo subject in both industrialized and industrializing countries.

WHAT IS DOMESTIC VIOLENCE? Domestic violence can be described as the power misused by one adult in a relationship to control another. It is the establishment of control and fear in a relationship through violence and other forms of abuse. This violence can take the form of physical assault, psychological abuse, social abuse, financial abuse, or sexual assault. The frequency of the violence can be on and off, occasional or chronic. “Domestic violence is not simply an argument. It is a pattern of coercive control that one person exercises over another. Abusers use physical and sexual violence, threats, emotional insults and economic deprivation as a way to dominate their victims and get their way”. The Protection of Women from Domestic Violence Act, 2005 says that any act, conduct, omission or commission that harms or injures or has the potential to harm or injure will be considered domestic violence by the law. Even a single act of omission or commission may constitute domestic violence - in other words, women do not have to suffer a prolonged period of abuse before taking recourse to law. The law covers children also.(4) Domestic violence is perpetrated by, and on, both men and women. However, most commonly, the victims are women, especially in our country. Even in the United States, it has been reported that 85% of all violent crime experienced by women are cases of intimate partner violence, compared to 3% of violent crimes experienced by men.(5) Thus, domestic violence in Indian context mostly refers to domestic violence against women.

WHAT TO DO IN A DOMESTIC VIOLENT SITUATION Don’t alert your abuser if you are planning to leave. Create a safety plan. Is there a way you can put aside some money, clothing, documents and other necessities in case you need to leave? Can you find a place to stay in case of emergency and alert a few trusted friends and family members? Even if you are unsure as to how the situation might escalate, it is important to be prepared for your safety.

If you are in a domestic violence situation or know someone who is, you can call the 24-hour National Domestic Violence Hotline at: 1-800-799-7233. If you would like to make a donation to support East LA Women’s Center you can visit our website at elawc.org or call 323-526-5819.

Join a support group for survivors of domestic violence: even if you are not prepared to leave the relationship, you can discuss your situation with other survivors and receive group therapy with trained counselors. Get one-on-one help: many domestic violence centers offer free one-on-one counseling. A domestic violence counselor can help discuss your situation, offer therapy and connect you to resources in your area. Call the hotline if you need help. Take precautions while calling. If your abuser checks your phone logs, try calling from a pay phone or a friend’s phone. Don’t call while your abuser is within hearing. Always dial 911 in an emergency.

DOMESTIC VIOLENCE IS THE MOST COMMON FORM OF VIOLENCE AGAINST WOMEN

DOMESTIC VIOLENCE AND ITS HEALTH IMPLICATIONS Violence not only causes physical injury, it also undermines the social, economic, psychological, spiritual and emotional well being of the victim, the perpetrator and the society as a whole. Domestic violence is a major contributor to the ill health of women. It has serious consequences on women’s mental and physical health, including their reproductive and sexual health. These include injuries, gynecological problems, temporary or permanent disabilities, depression and suicide, amongst others. “Many forms of verbal and psychological abuse appear relatively harmless at first, but expand and grow more menacing over time, sometimes gradually and subtly. As victims adapt to abusive behavior, the verbal or psychological tactics can gain a strong ‘foothold’ in victims’ minds, making it difficult for them to recognize the severity of the abuse over time.” These physical and mental health outcomes have social and emotional sequelae for the individual, the family, the community and the society at large.

Over both the short term and long term, women’s physical injuries and mental trouble either interrupts, or ends, their educational and career paths leading to poverty and economic dependence. Family life gets disrupted which has a significant effect on children, including poverty (if divorce or separation occurs) and a loss of faith and trust in the institution of the family. These sequelae not only affect the quality of life of individuals and communities, but also have long-term effects on social order and cohesion.(9) In India, one incident of violence translates into the women losing seven working days. In the United States, total loss adds up to 12.6 billion dollars annually and Australia loses 6.3 billion dollars per year. The physical health consequences of domestic violence are often obscure, indirect and emerge over the long term. For example, women who were subject to violent attacks during childhood are bothered by menstrual problems and irritable bowel syndrome in later life.

WOMEN OF COLOR SEXUAL ASSAULT STATISTICS

A study of sexual abuse in the South Asian immigrant community conducted between 1991 & 1996 found that 60% of the women spoke of being forced to have sex with their husbands against their will.

About 40% of Black women report coercive contact of a sexual nature by age 18. About 9 in 10 American Indian victims of rape or sexual assault were estimated to have had assailants who were non-native.

90% of Indian women in chemical dependency treatment are victims of rape and childhood sexual abuse.

Most sexual assault done against African American women goes unreported. For every African- American woman that reports her rape, at least 15 African-American women do not report theirs.

BARRIERS FOR SURVIVORS OF COLOR Each community of color has challenges and circumstances that are unique to their community. However, there are common factors that account for many of the barriers survivors of color face as they seek help. Cultural and/or religious beliefs that restrain the survivor from leaving the abusive relationship or involving outsiders. Distrust of law enforcement, criminal justice system, and social services. Lack of service providers that look like the survivor or share common experiences, as well as lack of culturally and linguistically appropriate services and lack of trust based on history of racism and classism in the United States.

Assumptions of providers based on ethnicity. Attitudes and stereotypes about the prevalence of domestic violence and sexual assault in communities of color.

In a content analysis of 31 pornographic websites, of the sites depicting the rape or torture of women, nearly half used depictions of Asian women as the rape victim.

Legal status in the U.S. of the survivor and/or the batterer.

PSYCHOLOGICAL AND EMOTIONAL VIOLENCE Psychological and emotional violence covers “repeated verbal abuse, harassment, confinement and deprivation of physical, financial and personal resources”. Quantifying psychological abuse is extremely difficult, and very few studies have been conducted to establish prevalence rates of this type of violence. Qualitative studies that have been undertaken conclude that it is just as damaging to one’s health to be continuously psychologically abused as it is to be physically abused. Undermining an individual’s sense of self esteem can have serious mental and physical health consequences and has been identified as a major reason for suicide. For some women, the incessant insults and tyrannies which constitute emotional abuse may be more painful than the physical attacks because they undermine women’s security and self-confidence.

WHY DO WOMEN STAY? Economic dependence has been found to be the central reason. Without the ability to sustain themselves economically, women are forced to stay in abusive relationships and are not able to be free from violence. Due to deeprooted values and culture, women do not prefer to adopt the option of separation or divorce. They also fear the consequences of reporting violence and declare an unwillingness to subject themselves to the shame of being identified as battered women. Lack of information about alternatives also forces women to suffer silently within the four walls of their homes. Some women may believe that they deserve the beatings because of some wrong action on their part. Other women refrain from speaking about the abuse because they fear that their partner will further harm them in reprisal for revealing family secrets, or they may be ashamed of their situation. Violence against women is a violation of basic human rights. It is shameful for the states that fail to prevent it and societies that tolerate and in fact perpetuate it. It must be eliminated through political will, and by legal and civil action in all sectors of society.

Violence against women has a far deeper impact than the immediate harm caused. It has devastating consequences for the women who experience it and a traumatic effect on those who witness it, particularly children.

ROLE OF PUBLIC HEALTH PERSONNEL Domestic violence against women has been identified as a public health priority. Public health personnel can play a vital role in addressing this issue. Since violence against women is both a consequence and a cause of gender inequality, primary prevention programs that address gender inequality and tackle the root causes of violence are all essential. Public health workers have a responsibility to build awareness by creating and disseminating materials and innovative audio-visual messages, which project a positive image of girl child and women in the society. An integrated media campaign covering electronic, print and film media that portrays domestic violence as unacceptable is the need of the hour. The role of increasing male responsibility to end domestic violence needs to be emphasized. Programs are required which intend to address battered women’s needs, including those that focus on building self-efficacy and livelihood skills. The significance of informal and local community networks should be acknowledged in this regard. The survivors of domestic violence can be involved in program planning and implementation in order to ensure accessibility and effectiveness. Rather than spotlighting women as victims in non negotiable situations, they should be portrayed as agents capable of changing their own lives. The public health experts have a vital role to play in networking with NGOs and voluntary organizations and creation of social support networks. The public health experts have a potential to train personnel specialized to address the needs of victims of domestic violence. In the field of research, public health personnel can contribute by conducting studies on the ideological and cultural aspects which give rise to and perpetuate the phenomenon of domestic violence. Similarly, the execution and impact of programs must be assessed in order to provide the necessary background for policy-making and planning. However, the health sector must work with all other sectors including education, legal and judicial, and social services.

In January, India implemented its first law aimed at tackling domestic violence (The Protection of Women from Domestic Violence Act, 2005) to protect the rights of women who are victims of violence of any kind occurring within the family and to provide for matters connected therewith or incidental thereto. It also defines repeated insults, ridiculing or name-calling, and demonstrations of obsessive possessiveness and jealousy of a partner as domestic violence. The big challenge in front now is to enforce it in true sense. “A law is as good as its implementability, despite the lofty aspirations. The responses to the enactment are polarized, with one section fearing its misuse by an elite class in metro cities and another segment predicting its futility for the mass of rural women saddled with the yoke of patriarchy to which courts are as yet alien” (Flavia Agnes)(13) A bill alone will not help in preventing domestic abuse; what is needed is a change in mindsets. Concerted and co-ordinated multisectoral efforts are key methods of enacting change and responding to domestic violence at local and national levels. The Millennium Development Goal regarding girls’ education, gender equality and the empowerment of women reflects the international community’s recognition that health, development, and gender equality issues are closely interconnected. Hence the responses to the problem must be based on integrated approach. The effectiveness of measures and initiatives will depend on coherence and co ordination associated with their design and implementation. The issue of domestic violence must be brought into open and examined as any other preventable health problem, and best remedies available be applied.

DOMESTIC VIOLENCE AND REPRODUCTIVE HEALTH There is enough evidence to support that higher reproductive morbidity is seen among women experiencing domestic violence. Studies conducted in North India have shown elevated odd’s ratio of gynecological symptoms, while comparing women with husbands reporting no domestic violence and women who experienced physical and sexual violence. It may be attributed to the fact that abusive men were more likely to engage in extra marital sex and acquire STDs, there by placing their wives at risk of acquiring STDs. There was also lesser condom use reported among such men. These make women more susceptible to HIV infection, and the fear of violent male reactions, physical and psychological, prevents many women from trying to find out more about it, discourages them from getting tested and stops them from getting treatment.

Studies in the northern state of Uttar Pradesh have also shown that unplanned pregnancies are significantly more common among wives of abusive men. Besides this, research has shown that battered women are subject to twice the risk of miscarriage and four times the risk of having a baby that is below average weight. In some places, violence also accounts for a sizeable portion of maternal deaths. Reproductive health care that incorporates domestic violence support services is needed to meet the special needs of abused women.

BATTERED WOMEN ARE TWICE AT RISK OF MISCARRIAGE AND FOUR TIMES AT RISK OF HAVING A BABY BELOW AVERAGE WEIGHT

02 HEALTH CARE FOR BLACK WOMEN

THE DISPARITIES IN HEALTHCARE FOR BLACK WOMEN

BY: PIRAYE BEIM Endometriosis Foundation of America Jun 6, 2020

Inequality comes in many forms for People of Color, both here and abroad, but race-related health disparities are among the starkest and most resistant to progress. Being a Black female further amplifies these inequities, which is particularly troubling and ironic given the fact that Women of Color make up the majority of healthcare workers. Over the last few months, the COVID-19 pandemic has brought this unfortunate reality into even more clear focus. An often-cited quote in the business world is “you can’t manage what you can’t measure.” At Celmatix, we have been working for over a decade to address critical gaps in data collection for women’s health. This has included thinking outside of the bubble of traditional research metropolises like Boston and San Francisco, and expanding our research partnerships to reproductive health centers of excellence across the US and to biological repositories that allow us to reach women at community health centers and urban hospitals which serve women who may not have access to reproductive specialist care. In addition to investing in diversified data for our scientific and clinical research studies, we’ve also made significant investments in our “Next Gen Women’s Project,” an ambitious two-year consumer research effort that interviewed or surveyed more than 4K millennial women to understand how their healthcare needs differ from earlier generations of women and to discern their attitudes concerning their reproductive health and fertility. As part of this research, we had the privilege of collaborating with the Black Women’s Health Imperative, Women’s Health Magazine, and Oprah Magazine to better understand why Black women are facing higher infertility rates, greater stigma around reproductive challenges, and larger barriers to accessing fertility care.

Black women are underrepresented in clinical trials that require consent and are overrepresented in studies that do not. Black women only comprise 15 percent of participants in published clinical trials for the condition. Data from the FDA shows that in trials for 24 of the 31 cancer drugs approved since 2015, fewer than 5 percent of participants were Black. This diversity in study patients is needed to ensure that new drugs are both safe and effective for all patients. In contrast, Black participants are disproportionately over-represented in studies that do not require consent.

Maternal mortality and injury rates are higher for Black females, irrespective of income or education level. Black women are 3 to 4 times more likely to die from pregnancy complications than White women. They are also 3 to 4 times more likely to suffer from a severe disability resulting from childbirth than White women.

Health conditions that disproportionately impact Black women receive very little government research funding. Estimates reveal that nearly a quarter of Black women between the ages of 18 and 30 have fibroids — compared with 7 percent of white women. By age 35, that number increases to 60 percent. 23

Black women are significantly underrepresented in key biomedical research datasets, including genomic data repositories and related analyses: Nearly 80 percent of all individuals included in genomic studies are of European descent. While this may be a decrease from 20 years ago (when it was as high as 96 percent), this change is mostly driven by a higher number of studies being done in Asia on populations of Asian ancestry.

STEPS WE CAN TAKE IMMEDIATELY Anti-racism and implicit bias training needs to be incorporated into medical school education, but in the short term, state licensing boards and the American Board of Obstetrics and Gynecology (ABOG) should take the lead here to address disparities in maternal health. For maintenance of board certification, 35 hours of annual CME training is required for all OB/GYNs. The licensing bodies and ABOG should immediately require that a certain number of hours of CME training be mandated to include bias and anti-racism curriculum. This re-education needs to happen at every level of care, including for nurses and other healthcare professionals who interact with black women during labor and delivery. Recent initiatives are a good start, but we need to go further, faster. Relying on voluntary measures may mean we will have to wait a long time to see the impact of these recommendations.

African American females experience intimate partner violence at a rate 35% higher than that of white females, and about 2.5 times the rate of women of other races

The US NIH and FDA should update their policies to confront the underlying reasons for low clinical trial and voluntary research participation by Black women: The FDA should update its policies guiding clinical trial enrollment to better incentivize drug companies to increase enrollment of black clinical trial participants. The NIH should also revisit policies and incentives to expand research and address data disparities for People of Color. However, we also need to have a real open dialog about how Black people have been misused in clinical trials to date. The US has a long history of mistrust, with horrific examples such as American physician J. Marion Sims, who honed his techniques by performing surgery on enslaved Black women without the use of anesthesia. In the 1900s, poor Black women also endured forced sterilizations as birth control. And, for the last 70 years, some of the medical community’s largest findings and largest profits were made possible through a Black woman named Henrietta Lacks. Lacks’ cells have been cultured and used in experiments and commercialized without her, or her family’s consent. And as we mentioned, even today, Black Americans are overrepresented in studies that do not require their consent, nearly 30 percent compared to the making up just 13 percent of the US population. Importantly, in order to see real change, we must also correct the funding discrepancy for Black research investigators. An NIH study team found that taking into account factors including education, training, and experience, Black investigators are nearly 11 percent less likely to receive NIH funding compared to their White counterparts. As researchers from these Black communities are more likely to study underrepresented communities and engender their trust, this lack of diversity in funding can also directly impact the inclusion of Black study participants. Black women should not be left behind in the march toward precision and personalized medicine. All stakeholders (public and private) generating and leveraging genomic datasets for both basic research and commercial product development should pledge to increase diversity in their datasets, even if it comes at a cost to profitability. This includes investing in diversity for analysis as well. As an extension, scientific journals should reward research groups that publish results from non-Northern European cohorts, even if the population sizes and power of those studies are impacted as a result of focusing on underserved and understudied populations.

INSTITUTIONS WORKING TO ADDRESS THE ISSUE: It is important for us to remind you that you are not alone, you are cared for and loved so we celebrate and encourage you to visit the following institutions:

BLACK WOMEN’S HEALTH IMPERATIVE The country’s first nonprofit organization created by Black women to help protect and advance the health and wellness of Black women and girls BLACK MAMAS MATTER ALLIANCE The alliance helps advocate for better legislation to reduce black maternal mortality, highlights necessary areas of research and spreads information about the social determinants of health that influence outcomes like traumatic birth or maternal and infant mortality. SISTER SONG SisterSong is a Southern-based, national membership organization; its purpose is to build an effective network of individuals and organizations to improve institutional policies and systems that impact the reproductive lives of marginalized communities. FERTILITY FOR COLORED GIRLS Provides services for underserved Black women and couples. This includes educational programming about treatment options, resources to connect with counselors, financial grants, and monthly support group meetings hosted by seven different chapters across the country.

Data about health outcomes for Black mothers should be tracked and reported. Hospitals and birthing centers should be required to publicly disclose health outcomes for labor and delivery for different demographic groups, and individual physicians and staff members should be presented with their own statistics to review on an annual basis as part of their institutional performance reviews.

Congress and citizens should exert pressure on government funding bodies like the NIH to dedicate more research funding for conditions that disproportionately impact black women: Conditions such as uterine fibroids and sickle cell anemia are grossly under-funded relative to their impact on large numbers of American women. More NIH and private sector funding must be generated for medical conditions that impact the lives of Black women.

BLACK WOMEN ARE THREE TO FOUR TIMES MORE LIKELY TO EXPERIENCE A PREGNANCY RELATED DEATH THAN WHITE WOMEN

POLICYMAKERS, HEALTH CARE PROFESSIONALS AND COMMUNITIES CAN IMPROVE BLACK WOMEN’S MATERNAL HEALTH. EXPAND ACCESS TO HEALTH COVERAGE Only 87 percent of Black women of reproductive age have health insurance, and many more experience gaps in coverage during their lives. To improve Black women’s health outcomes, policies should focus on expanding and maintaining access to care and coverage. Women need health coverage throughout their lifespan including access to preventive health care, such as birth control, to maintain their health and to choose when and whether to become a parent. For women who choose to become a parent or expand their families, good prenatal and maternity care are critically important for healthy pregnancies and healthy children. Pregnant women who lack insurance coverage often delay or forgo prenatal care in the first trimester, and inadequate prenatal care is associated with higher rates of maternal mortality.

Black women are more likely to live in the South, where women generally experience poorer health outcomes and where many states have chosen not to expand Medicaid coverage, which leaves many Black women in the “coverage gap.” Women fall into the coverage gap because they earn too much to qualify for traditional Medicaid, but not enough to purchase insurance on the Affordable Care Act (ACA) marketplace; as a result, they lack access to health coverage. Expanding Medicaid coverage would improve maternal outcomes for Black women by providing better access to care and reducing financial instability.

03 ISSUES WITH RELIGION

THE WESTERN JOURNAL OF MEDICINE

In the process of migration, a family or a person loses a social network, the social, human resources on which they depend for both daily and long-term needs. An immigrant experiences a sense of disorganization and disorientation that manifests itself in a syndrome called cultural exhaustion or shock.

ISSUES IN HEALTH CARE OF MIDDLE EASTERN PATIENTS Relationships between Middle Eastern patients and Western health care professionals are often troubled by mutual misunderstanding of culturally influenced values and communication styles. Although Middle Easterners vary ethnically, they do share a core of common values and behavior that include the importance of affiliation and family, time and space orientations, interactional style and attitudes toward health and illness. Problems in providing health care involve obtaining adequate information, “demanding behavior” by a patient’s family, conflicting beliefs about planning ahead and differing patterns of communicating grave diagnoses or “bad news.” There are guidelines that will provide an understanding of the cultural characteristics of Middle Easterners and, therefore, will improve rather than impede their health care. A personal approach and continuity of care by the same health care professional help to bridge the gap between Middle Eastern cultures and Western medical culture. In addition, periodic use of cultural interpreters helps ameliorate the intensity of some cultural issues.

The need for affiliation is dominant among Middle Easterners. They thrive on a large repertoire of relationships and family relations fulfill many affiliation needs. During illness or crisis, Middle Easterners rely on other persons instead of trying to cope by other means.

Our suggestions are based on the premise that quality health care includes respect for the cultural values of patients and that it is a health professional’s responsibility to maintain a flexible approach to accommodate patients from varying backgrounds. We hope that health professionals will recognize the cultural characteristics of Middle Easterners to improve rather than to impede their care.

Several problems related to the cultural norms and values mentioned above were elicited through consultation requests we received from health professionals who work with Middle Eastern patients. The problems included difficulty in obtaining adequate information from patients, demanding behavior of patients’ families, patients’ disinclination to plan ahead and other communication obstacles.

HEALTH CARE ISSUES Several problems related to the cultural norms and values mentioned above were elicited through consultation requests we received from health professionals who work with Middle Eastern patients. The problems included difficulty in obtaining adequate information from patients, demanding behavior of patients’ families, patients’ disinclination to plan ahead and other communication obstacles. DEFINING THE PROBLEM Relevant information with which to understand a patient’s presenting complaint is indeed difficult to get from Middle Easterners. Obvious problems with the English language are shown by a recent immigrant’s statement that “A few hours before I go to doctor, I was thinking what I should say. I open dictionary to write the words, but the dictionary didn’t have.” Often Middle Easterners express vague symptoms, giving generalized and global descriptions of their health status. Vague physical symptoms substitute for anxiety or depression because Middle Easterners lack concepts that distinguish mental states from physical states, and their experience does not permit them to carefully describe signs and symptoms as they are associated with different parts of the body. Passivity in the presence of a physician also interferes with eliciting information. Because the authority of a physician is never questioned, a Middle Easterner is not likely to ask questions or give information that would contradict or “show disrespect.” This very respect for a health professional’s expertise prevents a Middle Easterner from understanding why a physician cannot diagnose and prescribe without resorting to tests and “irrelevant” questions. A third obstacle to communication is the Middle Easterners’ resistance to disclosing detailed personal information to strangers. Arabs value privacy and guard it vehemently, even though privacy within a family is virtually nonexistent. They view the comprehensive health assessment on admission with suspicion and as an intrusion until the relationship between medical problem and personal questions is made clear to them. Once trust with a caregiver is established, personal information is given more freely. We remind readers that political refugees, such as Iranians, Palestinians and other Middle Easterners who are here illegally, are likely to be highly suspicious of the questions of any “official.” They may assume that a health professional has direct and regular contact with the immigration office or other government officials.

Arabs value privacy and guard it, even though privacy within a family is virtually nonexistent. They view the comprehensive health assessment on admission with suspicion and as an intrusion until the relationship between medical problem and personal questions is made clear to them.

GUIDELINES FOR HEALTH CARE PROFESSIONALS Our suggestions are based on the premise that quality health care includes respect for the cultural values of patients and that it is a health professional’s responsibility to maintain a flexible approach to accommodate patients from varying backgrounds. We hope that health professionals will recognize the cultural characteristics of Middle Easterners to improve rather than to impede their care. INFORMATION DISCLOSURE In reference to important medical information, health professionals should include a family spokesperson rather than communicate solely with a patient. The spokesperson is usually the oldest man present, because older men are considered to be wiser and more able to cope with bad news with fatalistic reasoning. In some instances, the spokesperson may be a grandmother, though even she should be protected because women are believed to be more deleteriously affected by bad news. In the case of Mr Ali, the patient himself did not ask about his prognosis; Mrs Ali was consulted about hospital care and discharge planning and the oldest son was given the results of the pathology report. A health professional must be particularly careful about how negative information is presented. A common communication practice in the Middle East is to reveal the news of a tragedy or a poor prognosis in stages. For example, a colleague learned that her mother in Egypt was ill. The colleague prepared to visit but was unable to get concrete information from her family. Not until the family was bringing her home from the airport was she told that her mother had died. Potentially upsetting information should be given gradually, within the context of other information and events, and carefully modulated with hope. We should learn to control our so-called frankness in dealing with people of a culture that puts a high value on maintaining pleasant surface relations. Once a grave diagnosis or poor prognosis is communicated, it should not be discussed again. A health professional should be sensitive to the customary ways of handling such information, namely, by using the family’s choice of euphemisms. If death is anticipated, it is important not to suggest nor request a visit from a religious official until a spokesperson of the family clearly requests such a visit. To suggest or request a visit on behalf of the family violates the value of hope, “interferes in God’s plans” and conveys an image of a health care system that “gave up.” All that predisposes a mistrustful relationship between a patient and health professionals.

THE PERSONAL APPROACH Many difficulties with Middle Eastern patients dissolve when a health professional is accepted into the family system. An approach that combines expertise and authority with personal warmth more likely encourages trust than would a stiff professional facade. Gaining initial trust may not be totally under a health professional’s control. A young female physician may not be accorded the same respect automatically accorded an older male physician until she has proved her competence and patient and family get to know her well. In the contextual culture of Middle Easterners, individuals are seen as members of families, groups and even universities; they will naturally be more comfortable with a health professional about whom they know something beyond the specialty. It is useful to offer some personal information in the interest of gain ing trust and, if asked personal questions, one should not refuse to answer them. Withholding information may prompt patient and family to withhold important health state information. Volunteering personal information helps enhance a trusting relationship. Because immigrants value courtesy and hospitality, a health care professional is well advised to take a few minutes to “warm up” before delving into the business of the appointment or visit. Similarly, food is heavily laden with meaning in the Middle East. Offering or receiving food is a powerful symbolic gesture of acceptance of a person which can be different for others.

Middle Easterners are seen as members of families, groups and even universities; they will naturally be more comfortable with a health professional about whom they know something beyond the specialty.