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Cultural issues

Vol. 4 •Issue 2 • Page 37
Cultural issues

Using a transcultural assessment model to understand Afghanis and Islamic culture and religion

Many of the 4 million people of Arab descent living in the United States trace their ancestry and traditions to the nomadic desert tribes of the Arabian peninsula. Most Arabs share a common language and the majority are united by Islam, a major world religion that originated in 7th century Arabia, with 1 billion believers worldwide.1 Some 8 million Americans are among the world's fastest growing faith.

Since the Sept. 11 attacks in New York and Washington, DC, increased racial and religious animosity have left Arabs, other Middle Easterners, Muslims, and those who bear a physical resemblance to members of these groups, fearful.2

An understanding of the people of Afghanistan, Afghan-Americans and the Islamic culture and religion can greatly assist the nurse who cares for patients from diverse cultures.

Culturally Competent Care

Culture is a patterned behavioral response that develops over time as a result of imprinting of the mind through social and religious structures, and intellectual and artistic manifestations. Culture is also the result of acquired mechanisms that may have innate influences but are primarily affected by internal and external stimuli.

Cultural competence is a dynamic, fluid, continuous process where an individual, system or health care agency finds meaningful and useful care delivery strategies based on knowledge of the cultural heritage, beliefs, attitudes and behaviors of those they care for.3 To provide culturally appropriate and competent care, it is important to remember that each individual is culturally unique and as such a product of past experiences, cultural beliefs and cultural norms. Although there is as much diversity within cultural and racial groups as there is across and among cultural and racial groups, knowledge of general baseline data relative to the specific cultural group is an excellent starting point to provide culturally appropriate care.

Transcultural Assessment

The Giger and Davidhizar Transcultural Model postulates that each individual is culturally unique and should be assessed according to six cultural phenomena: communication, space, social organization, time, environmental control and biological variations (see Figure).


The model can be used in understanding the people of Afghanistan and for assessing individual differences.

Communication — Communication embraces the entire world of human interaction and behavior, and is the means by which culture is shared, transmitted and preserved. Both verbal and nonverbal communication are learned in one's culture. Communication often presents the most significant problem in working with clients from diverse cultural backgrounds.

Arabic is a very flowery language with elaborate metaphors; therefore, attempts to translate from Arabic to English often result in redundancy. When translators are used, it is essential to stress to the translator that elaborate metaphors be minimized in order to capture the essence of what the client is trying to convey. It is also important to remember that if an interpreter is needed, it is necessary to use an interpreter of the same sex. If a family member interprets, a relative of the same sex must be used for translation of sensitive topics related to sex, reproduction, marital problems, cancer, HIV/ AIDS, etc.

There are a number of reasons why translators should be the same sex. First, women were forbidden to interact with members of the opposite sex when power was seized by the Taliban, a group with its origins in a group of Islamic students who instituted an Islamic fundamentalist regime in 1996. Male-to-male communication was permitted, but not female to male unless with the husband, son or father of the woman involved. Islam requires that the man be head of the household and women are expected to respect this, thus the ban on discussing sensitive matters with men other than immediate family members.

Nonverbal communication is generally expressive, warm, other-oriented, shy and in most instances modest. For many Afghans, respect for one's elders is paramount and this extends to professionals. When interacting with professionals or elders, many Afghans are concerned about wasting the professional's time.

Touch is prohibited between members of the opposite sex, especially if the person is not the husband. This is both for cultural reasons and because of Taliban edicts.

To prevent their true feelings from being discovered Afghans may have a flat affect (use little facial expression). They also may reserve louder volume for urgent messages. In fact, for some Afghans, anger is usually expressed in a high intense voice. Messages tend to be repeated for emphasis to increase understanding.1

Space — Space refers to the distance between individuals when they interact. All communication occurs in the context of space. There are four distinct zones of interpersonal space: intimate, personal, social and consultative, and public. Rules concerning personal distance vary from culture to culture.

Some Afghans prefer closeness in space with others and particularly with the same sex. When comfortable with others, these individuals prefer to be in close proximity to build trusting relationships, particularly with health care professionals.

Social Organization — Social organization is the way in which a cultural group organizes itself around the family group. Family structure and organization, religious values and beliefs, and role assignments may all relate to ethnicity and culture.

Family Organization — When a member of an Afghan-American family seeks health care the father, eldest son or an elderly uncle acts as the family spokesperson. However, caring for patients in or out of the hospital is usually delegated to women. Caring for patients may include preventing self-care and avoiding early ambulation, believing that energy needs to be preserved for healing. Fathers are not expected to participate in childbirth, whereas a mother, sister or other in-law is expected to be present and provide support.1

Children are considered sacred by most Afghanis. However, child-rearing is based more on negative than positive reinforcement and permissiveness. Children, especially males, are expected to be inquisitive and to seek and discover answers to their many questions. It is not unusual to see small children roaming freely or exploring a clinic or hospital without parental supervision. However, children are expected to be obedient to all adults including health professionals.

Women's rights have been severely restricted in Afghanistan. When the Taliban came into power in l996, strict edicts were issued forbidding women, except those working in health care, to work outside the home, attend school or leave their homes unless accompanied by a husband, father, brother or son.1 While under Taliban rule, women in public were expected to be covered from head to toe in a burqu (shroud), with only a mesh opening to see and breathe through. Women are not permitted to wear white socks or shoes, since white is the color of the Taliban flag. Some Afghan-American women retain these customs.

Strict Muslims pray five times a day and may have to wash before every prayer. When a Muslim becomes sick, families may want to pray for him/her.4 They may pray in silence or in another room for privacy. As directed by the last Prophet Muhammad, Muslims wash their hands many times and in connection with certain occasions such as waking from sleep or touching a dog.

Time — Time is an important aspect of interpersonal communication. Cultural groups can be past, present or future-oriented. Those who focus on the past attempt to maintain tradition and have little motivation for formulating future goals. Other individuals are present-time oriented and if the present task is viewed as most important, the people in present-time oriented cultures tend to be unappreciative of the past and do not plan for the future. Individuals with future-time orientation plan and organize present activities to achieve future goals. These individuals tend to be receptive to preventive health practices such as routine check-ups and screenings for early detection of disease.3

Most Afghans are more past and present than future-time oriented but generally tend to follow two different time concepts which include: "on time" for official business and "spontaneous time" for social and informal gatherings.1

Environmental Control — This is the ability of the person to control nature, and to plan and direct factors in the environment that affect them. If a person is from a cultural group where there is less belief in internal control and more in external control, there may be a fatalistic view, where seeking health care is viewed as useless.

Some Afghans believe that illnesses are caused by the evil eye, bad luck, loss of personal objects, germs, winds, drafts or an imbalance of hot and dry and cold and moist.

Biological Variations — Biological differences, especially genetic variations, exist between individuals in different racial groups. Glucose-6-phosphate dehydrogenase (G-6-PD) deficiency, sickle cell anemia and thalassemia are common among Afghanis.

About 30 percent of marriages in Afghanistan are between first cousins, contributing to genetically determined diseases.1 Diseases such as diabetes, hypertension and coronary heart disease have also emerged as major health problems in Afghanistan partly as a result of the multifactorial nature of these diseases (e.g., gene-environmental interaction). Genes such as apolipoprotein A, apolipoprotein B and nitrous oxidase synthase have all been genetically linked as contributing to the development of hypertension, diabetes and coronary heart disease in Afghanis. *


1. Meleis, A. (1996). Arab Americans. In J.G. Lipson, S.L. Dibble, P.A. Minarik (Eds.), Culture and nursing care. San Francisco: UCSF Nursing Press.

2. Sheler, J. (2001, Oct. 29). Muslims in America. U.S. News and World Report, 50-52.

3. Giger, J., & Davidhizar, R. (1999). Transcultural nursing: Assessment and intervention. St. Louis: Mosby-Year Book.

4. Eshleman, J. (1992, November). Death with dignity: Significance of religious beliefs and practices in Hinduism, Buddhism, and Islam. Today's OR Nurse, 14-19.

Ruth Davidhizar is dean of nursing at Bethel College, Mishawaka, IN, and Joyce Newman Giger is professor of graduate studies in the University of Alabama at Birmingham School of Nursing.


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