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Iraqis in Minnesota

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Common medical issues and cultural concerns of Iraqi patients

Social structure

The majority of Iraq’s population of 24 million are Shiite Muslims, a population with strict religious practices, food prohibitions, and treatment of women. Iraqi immigrants in the U.S. may be either Sunni or Shiite Muslims, or Christians. Sunni Muslims have fewer religious and cultural restrictions than Shiite Muslims. Sunni Muslims and Christians tend to represent the urban political elite, the merchant classes, and the military. They tend to be more educated than Shiite Muslims and often have professional careers—especially women.

Shiite households are private and segregated according to gender. Allegiance to the family and tribe takes precedence, with fear of bringing shame to the extended family an ongoing concern. Men are head of the household and control the finances. Women are responsible for taking care of the children and the elderly. When a woman marries, she lives with her husband’s family. Marriage is consideredsacred and serves as a bond between families in Iraqi culture. In Iraq, arranged marriages at 12 and 13 are not uncommon, with preference given to first cousin marriages. Traditional Shiite women dress in black with a full hijab or purdah covering the body and face.

Arabic is the universal language of Iraq with more than 15 dialects spoken, presenting difficulties for U.S. immigrants and health care providers seeking translators.

Diet

Staple Iraqi foods include sheep, goat, chicken, beef, or fish, and barley, rice, and wheat for bread. In the U.S., Iraqis prefer to buy meat fresh from a farm or from a trusted halal market. Meals may include meat cooked with onion and garlic, soup, salad, eggs, and beans, with a yogurt drink, apricot juice, sweet coffee or tea. Almonds, dates, pancakes, or cinnamon pudding are favored desserts. Traditional Muslims do not use ice in drinks or drink cold beverages in the morning. Hot and cold foods are not eaten simultaneously.

Two major Muslim feasts are Eid al-Fitr, celebrated at the end of Ramadan, and Eid al-Adha, celebrated during an annual pilgrimage to Islam’s holiest site, Mecca, in Saudi Arabia. During Ramadan, Muslims fast from sun up to sun down, eating their main meals before dawn and at sunset. Health care providers are advised that medication schedules may need to be adjusted during Ramadan.

Religion

The core beliefs of Muslims are based on the religion of Islam, rooted in the Islamic holy book, the Qur’an, and the teachings of the Prophet Muhammad. Most Iraqi Muslims are very religious and pray at dawn, noon, mid-afternoon, sunset, and in the evening. Religious differences between Sunni and Shiite Muslims are rooted in belief of the rightful successor to Muhammad.

Both Shiite and Sunni Muslims adhere to halal laws regarding food. Meat must be slaughtered by another Muslim, a process that involves asking God for forgiveness for taking the life of the animal. Islam forbids consumption and handling of pork and alcohol.

Medical care

Language, cross-cultural communication, unique cultural barriers, and variations in health beliefs can impact clinical outcomes and patient satisfaction. Establishing a relationship with the Iraqi patientand family before care begins and being receptive to family suggestions are important for building respect and providing effective care. Respect for the patient’s religious beliefs is essential.

In the Arab world, smiling and sustained direct eye contact conveys trust, although women avoid eye contact with men. Iraqi patients may nod and smile, but still may not understand medical information. Ask patients to repeat instructions. Iraqis tend to prefer a gradual, prolonged disclosure of information, rather than a brief explanation of diagnosis and prognosis. Health care providers are advised to compare the treatment they recommend with the way they would treat a member of their own family.

Use trained medical interpreters. Although the presence of family during visits is important, family members, especially children, should not to be used as interpreters.

Women must be fully clothed when in the presence of a man and may not want to be touched by a man—not even a handshake. If possible, provide a same sex provider and interpreter for intimate exams and sensitive issues. Iraqi women may be reluctant to see clinicians who are not of Arab descent or do not speak their language. They may fear a non-Arab will lack sensitivity to their unique cultural and religious needs.

In addition to adopting Western medical practices, Iraqis often use home remedies and read the Qur’an for guidance. To stay healthy, they believe in staying warm, being well-fed, resting well, and avoiding hot/cold and dry/moist shifts, such as wind and drafts. Good health is perceived as a gift from God—being free from pain, being strong, and feeling good. In this culture, being overweight is associated with health and strength.

Health issues specific to Iraqi immigrants include nutritional deficits, typhus, cholera, tuberculosis, and especially post-traumatic stress. Many Iraqi refugees are torture victims and have lost family members. They have unique treatment needs. Often the mental and emotional torture they received was so severe they are still struggling to cope with it after many years.

Since 1990, people living in Iraq have been restricted to monthly rations of chicken, flour, sugar, and yeast, limiting their intake of nutrients and vitamins.

Although Iraqi immigrants respect Western medicine, providers, and health education, preventive health is not a priority. They may resist diet change, exercise, regular screenings, and follow-ups.

Death and dying

In the Arab world, death is feared and never discussed. Iraqis expect care to be discussed within the context of hope for life. The family may not allow the do-not-resucitate practice, autopsy, or organ donation. At death, the family summons an Imam, an Islamic spiritual guide. The body is wrapped in layers of white cotton and taken to a mosque for final prayers, followed by immediate burial.6,7

Iraqi in Minnesota

The United Nations reports more than five million Iraqis have been exiled because of war since the 1950s. Iraqis have been immigrating to the U.S. at the rate of several thousand per year since the 1990 Gulf War. In 2009, the U.S. began increasing the number of Iraqi refugees it accepts each year, up from 202 per year in 2006 to 17,000 per year in 2009.1,2,3

According to the American Community Survey, as of 2007, more than 100,000 Iraqi immigrants resided in the U.S., with nearly 60,000 of those residents receiving refugee-status citizenship.4

The 2009 Minnesota State Demographic Report shows nearly 600 Iraqis living in Minnesota, primarily in Fridley, Coon Rapids, and Brooklyn Park. Michigan, California, and Illinois have the largest Iraqi populations in the U.S.5

Culture in context

Culture is essential in assessing a person’s health and well-being. Understanding a patient’s practice of cultural norms can allow providers to quickly build rapport and ensure effective patient-provider communication. Efforts to reduce health disparities must be holistic, addressing the physical, emotional, and spiritual health of individuals and families. Also important is making connections with community members and recognizing conditions in the community.

Get to know your patients on an individual level. Not all patients from diverse populations conform to commonly known culture-specific behaviors, beliefs, and actions. Generalizations in this material may not apply to your patients.

In order to provide equitable and effective health care, clinicians need to be able to function effectively within the context of the cultural beliefs, behaviors, and needs of consumers and their communities. According to the 2002 Institute of Medicine report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, racial and ethnic minorities tend to receive lower quality health care than non-minorities even when access to insurance and income is accounted for. Failing to support and foster culturally competent health care for racial and ethnic minorities can increase costs for individuals and society through increased hospitalizations and complications.

Additional Resource

YouTube Video: Do I need an interpreter? Video vignette in Arabic created by the Minnesota Multilingual Resource Exchange (The Exchange) through the Building Healthier Communities award to inform limited English speaking patients on their right to an interpreter at no cost.

Sources:
1. U.S. Citizenship and Immigration Services, viewed July 20, 2011
2. Migration Information Source, viewed July 22, 2011
3. Newsweek, Iraqis in America, How the newest wave of U.S. immigrants is faring in their adopted homeland, July 3, 2009
4. 2007 American Community Survey, viewed July 22, 2011
5. Minnesota State Demographic Center, viewed July 22, 2011
6. Iraq in Minnesota, viewed June 1, 2009
7. Migration Policy Institute, viewed June 1, 2009