Table of Contents
Iranian people have their own religion, traditions and perceptions, which considerably influence their behavior, health problems and solutions. Notwithstanding the fact that currently these behaviors are considered as less orthodox, they are still widely used. Hence, health care providers should thoroughly study and analyze the behavioral patterns for ethical communication, grounded diagnosis and relevant treatment Persian culture representatives. The current work provides the description and assessment of four domains of the Purnell Model for Cultural Competence, which have a direct connection with health care offered to the representatives of this culture. These domains are nutrition, high-risk behaviors, pregnancy and upbringing, and death rituals. Recommendations for the further research address each of these four domains. Study of the distinct features of this cultural group forms the understanding of how they can be used in health care to improve its quality.
According to the Purnell Model for Cultural Competence, one of the 12 domains, which determine variations of values, practices and beliefs of personal cultural heritage and can influence life and health of an individual, is nutrition (Purnell, 2002). This domain is concerned with such matters as having adequate food, food choices and rituals, and the use of diet to solve health problems.
The traditional Iranian diet is based on wheat and a great variety of unrefined, unleavened, and whole-wheat breads. Rice is also rather popular dietary option. However, it is more popular among the representatives of upper class due to established cultural norms and high prices (Ghassemi, Harrison, & Mahammad, 2002). The similar situation concerns the consumption of fish. It is highly valued, but rather expensive. People also consume dairy products (represented by fresh cheese and yoghurt), a great variety of vegetables and fruits. The regular consumption of nuts and fresh greens in small quantities also plays an important role in the nutrition. The main beverage is tea.
The nutrition patterns of Iranian people depend greatly on demographic changes, absence of steady economic growth, urbanization and social development that take place in the country. Iranian people suffer from malnutrition and micronutrient deficiencies. At the same time, the obesity is considered the new emerging problem. These challenges are a result of relationship between food consumption and income.
According to official statistics, the per capita dietary energy increased from 2000 kcal person -1 to 3000 kcal person -1 in the last 40 years (Ghassemi, Harrison, & Mahammad, 2002). At the same time, about 20 % of population is food insecure (as they have access to less than 90 % of dietary energy needs) and 11 % of population is severely food-insecure (have access to less than 80 % of food needs) (Ghassemi, Harrison, & Mahammad, 2002). Due to the sharp interdependence between the income and nutrition, 30 % of population cannot afford high quality dietary food and, thus, consume insufficient amount of vitamins and microelements (like, calcium, riboflavin and vitamin A).
Rapid urbanization led to a considerable reduction of activity and shift in the food baskets of urban families. People in big cities prefer inexpensive dietary energy products instead of diverse and high quality food. They started to consume more bread, sugar, fats and oils. At the same time, the consumption of fruits, vegetables, meat and dairy products has considerably lowered. These trends in rural areas are less dramatic. Nutrition behaviors of Iranians are characterized by the imbalances between under- and over-consumption: more than 30% of citizens overconsume by 120% of the recommended nutrients (except riboflavin) and 30% of citizens consumes less than 90% for these nutrients (Ghassemi, Harrison, & Mahammad, 2002).
The additional attention should be paid to the fact that obesity and related chronic diseases (like cerebrovascular and cardiovascular) are considered the leading mortality causes (Ghassemi, Harrison, & Mahammad, 2002). These health issues are common for adult females between the age of 40 and 69 in both rural and urban areas with 28% in big cities and about 15% in rural areas (Ghassemi, Harrison, & Mahammad, 2002). Males suffer less from this disease with 11% being sick in urban areas and6 % in rural areas (Ghassemi, Harrison, & Mahammad, 2002). However, these figures are expected to grow in the nearest years because of the growing child obesity. It is notable that this trend is negatively associated with income level (i.e. representatives of lower, middle and upper classes suffer from this disease). At the same time, it is positively associated with age. However, education differently influences the prevalence of obesity, since better-educated men and lower-educated women tend to suffer from excess weight.
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Another dimension of the above-mentioned concept is high-risk behaviors, which are represented by alcohol, drug, and tobacco use, lack of physical activity, and high-risk sexual practices (Purnell, 2002).
The use of alcohol is associated with such disorders as dependency, overdose, and related medical and psychological issues. In the Islamic countries (including Iran), religion confides this problem and, therefore, producing, selling, and consuming alcohol is prohibited. However, it still smuggled into the country and distributed in the black market. According to official statistics, the alcohol use nationwide is lower than 10% and the prevalence of alcohol dependency is less than 0-2 % (Lankarani and Afshari, 2014).
The authorities of the country have successfully developed and realized the special programs aimed “to tackle drug addiction and HIV/AIDS, despite these issues having similar stigmas to those of alcohol use” (Lankarani and Afshari, 2014, p.1927). At the same time, this country has one of the highest drug use rates in the world (Lankarani and Afshari, 2014). The governmental program obliged more than 500000 individuals to take an active part in the buprenorphine and methadone treatment programs (Lankarani and Afshari, 2014). The effective implementation of these programs in the combination with free access to new syringes and condoms led to the significant reduction of the hepatitis B and C, and HIV.
The smoking of cigarettes in Iran started and rapidly spread through the country during the Kingship of the Shah Abbas Safavi from 1571 to 1629 (Meysamie, Ghaletakim, Zhand, & Abbasi, 2012). The first tobacco factory that produced more than 600 million cigarettes annually was built in 1937 (Meysamie et al., 2012). Currently, the government controls Iranian Tobacco Company that has more than 10 manufacturing facilities in different locations of the country and produces more than 12 billion cigarettes every year for about 6 million smokers (12 % of the whole population of the country) (Meysamie et al., 2012). This high-risk behavior is more popular among men (23.4 %) than among women (1.4 %) (Meysamie et al., 2012). The average number of smoked sticks per day is 13.7 (Meysamie et al., 2012). The initiation and continuation of smoking behaviors in this country are associated with young smokers and inadequate education. Moreover, it is connected to economic status of male gender, insufficient knowledge about smoking and associated side effects, disintegration and familial conflicts, ability of friends, relatives and peers who suffer from this high-risk behavior to live alone and far from the family, and etc (Ebrahimi, Sahebihagh, Ghofranipour, & Tabrizi, 2014). This high-risk behavior has a considerable negative influence on the cardiovascular, respiratory, digestive, sexuality and reproductive systems of Iranians. Hence, the government of the country developed and adopted the set of procedures, which aim to decrease the amount of smokers. It has “banned the tobacco advertising and smoking in public buildings in October 2003” (“Smoking curbs,” 2011). Moreover, smokers were banned from the ability to take the high-ranking positions in the government since July 2010 (“Smoking curbs,” 2011).
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Currently, there is no systematic information concerning changes of the physical activity of Iranians. However, the great variety of factors typical for modern Iran can lead to the decrease in physical activity. The factors include considerable urbanization (more than 60 % of population lives in big cities); insufficient development of the transportation system that forces people to purchase automobiles and use taxis; development of education that leads to the increase of white-color professionals and decrease of manual workers; and the existing tendency of organizing social events at homes (Ghassemi, Harrison, & Mahammad, 2002).
The sexual behaviors of adults and youth differ greatly in Iran. Young people “tend to be more vanguard to new ideas and are more likely to be liberal in sexual attitudes and behaviors” (Khalajabadi-Farahani, 2014, p. 171). One distinct characteristic of the sexual life of young Iranian women is that they do not practice standard vaginal intercourse due to the importance of virginity in the Muslim religion and due to the strict social norms concerning marriage and sex (Khalajabadi-Farahani, 2014). The premarital sex is supported only by 39% of female and 41% of young males (Khalajabadi-Farahani, 2014). Hence, it is replaced by non-vaginal intercourse.
Pregnancy and Upbringing
This dimension of the Purnell Model for Cultural Competence incorporates the fertility practices, methods of births, established views and prescriptive, and taboos (Purnell, 2002).
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The history of Iranian family planning programs dates back to 1970s, when the policy “Two children are enough” was developed by the public health sector (Karamouzian, Sharifi, & Haghdoost, 2014). Later it was suspended due to change of the ruling regime (replacement of the monarchy and cancellation of all regulations produced by it) and reversed by the new governments, which promoted large family sizes. This policy was extremely popular during the war against Iraq, when a large population was considered as the advantage (Karamouzian, Sharifi, & Haghdoost, 2014). During the post-war period, the officials developed the policy to reduce the population through providing free contraceptives and low cost vasectomies. The population also used other methods to limit fertility, like natural contraceptive methods (withdrawal) and delayed marriages (Karamouzian, Sharifi, & Haghdoost, 2014). All these policies caused the decline of the Total Fertility Rate “from 6.5 in 1976 to 1.6 births per woman in 2012” (Karamouzian, Sharifi, & Haghdoost, 2014, p. 231) in both urban and rural areas and increase of maternal and child health. However, such tendency sparked concerns among the officials (the former president Mahmoud Ahmadinejad and the supreme leader of the country Ayatollah Sayed Ali Khamenei) and raised the concern that such tendency could lead to a Total Fertility Rate become below the replacement rate. This caused the development of “at least two children is ideal” policy, encouraging women to have at least three children at the age of 30 (Karamouzian, Sharifi, & Haghdoost, 2014). The government outlawed vasectomies and tubectomies (except the cases when they are necessary for saving human life) and made these practices illegal and severely punished (up to 5 years of imprisonment to providers) (Karamouzian, Sharifi, & Haghdoost, 2014).
According to official statistics, about 1,170,000 of Iranian women give birth to children (Zahrani, 2008). More than 95 % of births take place in health care providing institutions. “The men do not attend labor and birth as father or doctor” because this event is considered to be the women’s task (Zahrani, 2008, p. 52). Young Iranian mothers usually confined to their hospitals bed and have no freedom to move and walk. According to the local regulations, “applying intravenous lines and restricting oral intake are mandatory rules in almost all hospital settings” (Zahrani, 2008, p. 52). The most common birth position is supine. Episiotomy is widely used for a first birth. The cesarean section rate is rather high (about 40 % in public hospitals and more than 90 % in private health care providing institutions), because local doctors prefer to follow the principle that “obstetricians routinely end every pregnancy on the due date rather than allow labor to begin on its own” (Zahrani, 2008, p. 52). Nowadays, home births are illegal in Iran because of the absence of a referral system.
Termination of pregnancy is allowed only if three physicians confirm major malformation of fetus and availability of factor that can endanger the mother’s health (Samadiras, Khamnian, Hosseini, & Dastgiri, 2012). The additional attention should be paid to the fact that according to the religious norms, the fetus becomes viable after the 20th week (Samadiras et al., 2012). Hence, a woman cannot obtain the pass for abortion after this period. Nowadays, the major reason of abortion is congenital anomalies.
As it was noted above, the premarital sex is considered as taboo. Hence, single pregnant women can face considerable harassment, especially in rural areas (Waxler–Morrison, Anderson, Richardson, & Chambers, 2005). At the same time, pregnancy in the marriage is considered to be blessing, during and after which women obtain much more attention, care and gifts. According to established Iranian views, pregnant woman “must abstain from heavy physical work, rest frequently, and eat rich and healthy foods” (Waxler–Morrison et al., 2005, p. 154). They often receive expensive gifts as the compensation for the sufferings during the childbirth (the greater the suffering (especially if the child is a male), the greater is the gift) (Nazir, n. d.).
The bottle-feeding is more preferred than breastfeeding. Instead of pre-packaged baby formulas, Iranian women prefer to mix breast milk and solid food when feeding the infant at the age of 4-6 months (Nazir, n. d.). They consider the physical rest, proper diet, emotional ease and hygiene to be essential. Male infants are always circumcised at the hospital or at homes (Nazir, n. d.).
Iranian people consider family as the most important social institution, and their children are the focal part of this establishment. They are loved, adorned and even spoiled. The child rearing is the responsibility of women, while men are engaged in money earning. However, in recent decades such believes have changed due to the fact that women faced necessity to find the job and obtain education because of the worsened economic situation. Hence, currently children are often raised by grandparents.
The last domain of the Purnell Model for Cultural Competence that is discussed in the current work is death rituals. It contains personal and public views on death, preparations to death and burial practices.
The religion of the Iranians (Islam) considers the life preservation as one of the paramount matters. At the same time, death is recognized as inevitable and predestined by God. Hence, the treatment that merely prolongs the final stage of a terminal illness is not obligatory and “it is permitted to disconnect life supporting systems even though some organs continue to function automatically (e.g. the heart) under the effect of supporting devices” (Queensland Health, 2010, p.13). At the same time, suicide and euthanasia are prohibited because Islam considers human life as sacred. The recovery can be only stopped if a patient suffers from the treatment that terminates his life and has been considered as a person that does not have any hope for recovery. The treatment before the death should be thoroughly discussed with the family of the patient.
During the imminent death, family members may be willing to perform certain rituals. Nowadays, the usual practice is represented by sitting near the bed of the patient, reading Qur’an, and praying for the peaceful departure of the patient’s soul. If the patient is conscious, the family members “may wish to recite the Shahadah (declaration of faith) and pass away while reciting these words” (Queensland Health, 2010, p. 13).
After the death of the patient, the body should be washed, dressed in white clothes and buried within one day. The public grievance lasts for 3 days. People are dressed in black. Close relatives are obliged to follow this dress code for 40 days. During this time period, family members visit and offer condolences. Then, the family grieves privately.
Iranians believe that after the death the human soul remains in the interworld until resurrection. The final judgment will be performed at the end of the world. At the time of the death, Iranians pray for Allah’s forgiveness, fast and pay the religious taxes for the smooth transition into the next world. All these actions also aim to compensate the shortcomings, which were made during the live.
Recommendations for Research
Numerous matters concerning the treatment of Iranians remained uncovered. Under the domain of nutrition, there is a growing trend of obesity and overweight people of different ages and genders. In order to discuss this topic, as well as determine causations and consequences, the qualitative research has to be performed. The application of the grounded theory will aid in analyzing the available data. The researchers will collect the information concerning the overweight Iranians and identify the major factors and trends.
Under the domain of high-risk behavior, the additional attention has to be paid to the increasing trend of smoking among Iranians. The number of active and passive smokers is constantly growing despite the laws developed and adopted by the government. The study of this trend is rather important because smoking is considered one of the major preventable issues, which have the negative influence on health and can cause death. The research has to use quantitative method to collect and analyze data. It will be collected through special surveys and engage Iranians of different ages, genders, from various locations and smoking experience as target sample.
As for pregnancy and upbringing, the main idea is related to finding and analyzing the information regarding the epidemiological features of termination of pregnancy because of the birth defects. This idea can be realized through the quantitative analysis, i.e. collection of the data concerning pregnant females who have been diagnosed and recommended to terminate their pregnancy because of the assumption that fetus has some defects and disorders. The data will be analyzed by using descriptive statistics and such instruments as proportions, standard deviations and means. This will help understand the features of pregnancy termination and provide necessary recommendations to health care providers, authorities and young couples.
The additional attention needs to be paid to such domain as death ritual, especially to studying of the actions that have to be performed and avoided by health care providers when treating patients who have been considered as hopeless for recovery and will die. The medical providers have to consider Iranian culture and traditions when treating patients.
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