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Common health equity issues for Iraqis
Cultural competence is the ability to recognize and understand the role culture plays in health care and to adapt care strategies to meet patient needs.
Get to know patients on an individual level. Each person’s preferences, practices, and health outcomes are shaped by many factors. Generalizations in this material may not apply to your patients.
Minnesota is home to an estimated 2,000 Iraqi refugees.
Iraqis in Minnesota
Minnesota is home to an estimated 2,000 Iraqi refugees, with many Iraqis living in Fridley, Coon Rapids, and Brooklyn Park. The long years of war in Iraqi—Gulf War, Iraq War, and war against ISIS—have resulted in millions of Iraqi refugees. More than 2.6 million people have been forced from their homes and remain inside Iraq, while 220,000 are refugees in other countries.
A 2014 study of Iraqi refugees in the U.S. found that compared to most other refugee groups, Iraqis tend to be older.
Most Iraqis speak Arabic. Many Iraqis in Minnesota speak English, although it is not their native language.
Little information is available about the disparities Iraqi Minnesotans face in health outcomes and care delivery compared to the overall population.
Social determinant disparities
Social determinants of health are economic and social conditions that influence the health of people and communities. Many Iraqi refugees in Minnesota are well-educated professionals. They may not be able to practice their professions due to training and certification requirements.
Many aspects of Iraqi-Minnesotan culture reflect the culture of the general U.S. population and generational differences impact social practices. In traditional Iraqi culture, family is the most important institution. The status, reputation, and well-being of the family is more important than the well-being or happiness of any individual. Family members are expected to support one another, andfamilies are large and multi-generational. Children live at home until they are married. In traditional society, a woman moves into her husband’s home when she marries, and her actions are controlled by her in-laws. Traditional Iraqi culture is patriarchal. Misbehavior by women is thought to be more serious than if the same behavior was done by a man.
About 97 percent of people in Iraq are Muslims. Christianity is the second most common religion.
Rules of etiquette for Iraqis are similar to those of many Islamic cultures:
Traditional Iraqi food is similar to the food of many Middle Eastern countries. Kebabs (cooked meats), mezza (first course salads and appetizers), rice, barley, vegetables, and fruits are featured in Iraqi cuisine. Since most Iraqis are Muslims, pork is avoided. Because Iraq is the world’s largest producer of dates, the fruit plays a role in many Iraqi dishes.
Many Muslims don’t eat pork or drink alcohol. For observant Muslims, all meat must be halal, or slaughtered according to Islamic laws. Most Iraqis observe Ramadan (the Muslim holy month) by fasting from sunrise until sunset. For the observant, even a sip of water during daylight would be a break in the fast. Pregnant, breastfeeding, and menstruating women, in addition to children, the elderly, and people with illnesses, are exempt from fasting during this holy month.
As immigrants acculturate, they replace traditional meals with fast food, contributing to an increase in obesity, diabetes, and hypertension.
Unlike most other refugee groups, Iraqi refugees in the U.S. are more likely to suffer from chronic diseases of older people (cardiovascular disease, diabetes, hyperlipidemia) than communicable diseases or diseases associated with poverty, like malnutrition.
Among many traditional Iraqis, modesty dictates that, whenever possible, a patient is seen by a clinician of the same sex. If a male clinician is treating a woman, it is desirable to have a woman present in the exam room. Clinicians should limit requests for disrobing and should proceed with greater caution and asking permission than may be normal with a patient of a European background. Women may avoid eye contact out of a sense of modesty, and not because they don’t respect or aren’t listening to the provider.
Antibiotics are available in Iraq without a prescription. One result of this is that many Iraqis use antibiotics to treat a variety of illnesses, whether or not antibiotics are medically appropriate. This practice may result in Iraqi patients requesting antibiotics from health care providers in the U.S., despite current guidelines that counter-indicate antibiotic use.
People of Muslim faith can be reassured that vaccines which contain porcine gelatin, derived from pork products, have been approved as Halal, allowed according to Islamic teaching.
War and ongoing violence in Iraq have exposed many Iraqis to trauma, including torture, imprisonment, and loss of family members to violence. As a result, post-traumatic stress disorder (PTSD), depression, and anxiety are common in the Iraqi refugee population. A 2014 study of Iraqis refugees in the U.S. found:
Many Iraqis have a very different concept of mental health than Americans. In Iraq the term mental illness is used for severe, incurable diseases like schizophrenia. As a result, providers in the U.S. may want to discuss symptoms and therapies rather than diagnoses.
End of life
When discussing end of life issues with any patient, health care providers need to understand preferences based on personal and family views. Islam is clear that suicide or active euthanasia (even to alleviate suffering) is not permitted. Palliative care is permitted and encouraged. Life sustaining technology may be withdrawn for brain death and persistent vegetative state. Advanced directives are encouraged (if they do not violate the ban on suicide/euthanasia), since they can play a valuable role in helping the family of a terminally ill person make decisions about care.
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