Cultural Influences on Health Care in Palestine

The incidence of cancer is increasing in developing countries despite the advances in knowledge in these locations about prevention and treatment (World Health Organization [WHO], 2005b). The increase in cancer cases and deaths is part of a pronounced shift in the global disease burden (Huerta & Grey, 2007). Each country has a unique approach to cancer care in which culture plays a role. This holds true for the people of Palestine, who have steadfast traditions intertwined with cultural beliefs, values, and practices. This article offers a cultural perspective on various aspects of the Palestinian population according to the Culture Care Theory (Leininger & McFarland, 2002) and the challenges healthcare staff may encounter. With an increase in globalization, cultural values have become important in today's health care in regard to how a person seeks care and abides with treatment. In general, Palestinians have limited health awareness and exposure to technologies because of economic challenges and limited resources. A basic description of Palestinian life, as it relates to culture, will give nurses insight to better manage Palestinian patients seeking health care outside of Palestine and the Middle East. Culture and Health-Related Factors Why do some people engage in health-promoting behaviors, such as breast cancer screening, and others do not? Culture is the most significant factor that affects how the individual perceives health and determines whether to seek cancer screening. The implications of culture are dependent on its scope, such as the culture of an ethnic group or an individual (Suh, 2004), and is considered dynamic and defined in many ways. Helman (2000) defined culture as A set of guidelinesboth explicit and implicitwhich individuals inherit as members of a particular society, and which tells them how to view the world, how to experience it emotionally, and how to behave in it in relation to other people, to supernatural forces or gods, and to the natural environment (p. 85). Leininger and McFarland (2002) stated that culture is a learned behavior, not inherited, and they defined culture as Learned, shared and transmitted knowledge of values, beliefs and lifeways of a particular group that are generally transmitted intergenerationally and influence thinking, decisions, and actions in patterned or certain ways (p. 47). Culture affects way of life and well-being and provides beliefs and values that give life meaning and purpose (Kagawa-Singer & Wellisch, 2003). In addition, culture gives individuals a sense of identity, self-worth, and belonging, as well as the rules for behavior that enable members of a cultural group to physically survive and provide welfare and support (Kagawa-Singer & Chung, 1994). Saxena, Carlson, Billington, and Orley (2001) stated that culture and social factors affect a person's perception of quality of life (QOL) and are influenced by several variables, such as gender, race, ethnicity, socioeconomic status, and education. QOL is affected by the multifaceted outcomes experienced by the person, such as physical health, psychological state, level of independence, social relationships, and relationship to the environment (WHO QOL Group, 1995). QOL differs from culture to culture, where each culture assigns levels of importance to various aspects of life. For example, women in Palestine are concerned with how a cancer diagnosis will impact their role as mothers and their family obligations. They also try to maintain employment and activities of daily living as long as they can. Men in Palestine often do not seek health care unless they are very sick because they take pride in being healthy. Culture is a significant determinate in health care because it affects the way people communicate. Culture can affect health care indirectly by influencing physician-patient relationships (Fleming & Towey, 2008). Saxena et al. (2001) reported that cultural factors are considered fundamental in coping with disease and treatment and affect patients' attitudes toward illness and health practices. In the Culture Care Theory, culture is viewed as a framework people use to solve human problems (Leininger & McFarland, 2002). The Sunrise Model (see Figure 1) helps visualize the different dimensions of the Culture Care Theory (Leininger & McFarland, 2002). Elements of the model include technologic factors; religious and philosophical factors; kinship and social factors; cultural values, beliefs, and lifeways; political and legal factors; economic factors, and educational factors. These elements will be used to describe how culture affects Palestinians' access to and willingness to use healthcare services, enabling the nurse to better understand the impact culture has on patient care and how to be sensitive to this unique population. Technologic Factors Availability and use of technology vary widely from rural to urban areas. In 2009, televisions were in 92% of Palestinian households, and most Palestinians use television media and health awareness programs as their source of health information. Telephones also are available, with 92% of families having at least one mobile phone. Those who do have access to telephones can use them to call their doctors or nurses for advice or to follow-up on laboratory tests; however, computers (49%) and Internet access (29%) are limited (Palestinian Central Bureau of Statistics, 2011). The use of technology is limited in healthcare settings and, when used, is intended for diagnosis more often than for prevention. Mammography screening is available through religious and social welfare organizations and costs approximately $30 (U.S.) per mammography screening; government health insurance does not cover the test. This cost is considered very expensive for most Palestinians. Finally, treatments such as radiation therapy are only available at a limited number of sites (Rockoff, El Jabari, Avgar, Ziv, & Barnea, 2004). Religious and Philosophical Factors The primary religions in Palestine are Islam (98%) and Christianity (2%) (Looklex Encyclopedia, 2008). Religious beliefs are important when patients approach the healthcare system. Spiritual and religious beliefs influence health and illness practices. Some patients believe that illnesses, such as cancer, may be the result of misfortune or even a punishment from God (Fleming & Towey, 2008) and that an illness is a destiny that cannot be changed. Muslims, in particular, center all aspects in their daily life on religion (Halligan, 2006). Patients who are gravely ill often take comfort in their remembrance of God by reading the Muslim holy book, the Koran. The Christian community includes different denominations (e.g., Catholic, Orthodox) and is steadfast in faith. Many in the Christian community believe that health is a gift from God. Because women and men in Palestine have strong beliefs in God, their faith helps them to accept their sickness. Most feel that being a member of a religious group gives them strength to accept their illness with grace (Azaiza & Cohen, 2006). Both religious groups live in harmony, access the same hospitals, and are taken care of by members of both groups of faith. Religion does not play a role in patients' choice of physicians, and they seek specialists regardless of their faith. However, religion does play a role in the dietary regimen for Muslims and Christians. The Muslim religion forbids the consumption of pork and pork products as well as alcohol (Ahmad, 2004; Pennachio, 2005). This may prohibit Muslims from taking medication derived from pork, such as insulin. Palestinian Muslims prefer to eat food prepared at home so no doubt exists as to what it includes. They also try to fast during the holy month of Ramadan, with no food or drink consumed between sunrise and sunset. This has implications for the administration of oral Clinical Journal of Oncology Nursing Volume 15, Number 3 Cultural Influences on Health Care in Palestine 283 medication and injections. Palestinian Christians may fast or eat only a vegetarian diet prior to and during religious holidays. However, even if patients are very religious, many do attend doctors' appointments during holidays. Kinship and Social Factors For Palestinians, like many other Arab groups, family structure is comprised of two distinct families. The first is the extended family (aila), which is all of a person's blood relatives plus women who were brought into the kinship through marriage. The second family structure is the clan (hammula), and consists of all individuals who descend from the same great-grandparent (Hammad, Kysia, Rabah, Hassoun, & Connelly, 1999). The family is considered a significant social organization system in Palestinian culture. The concept of family is greatly valued; the traditional family is still the foundation of society. The extended family network plays a large role in supporting sick family members and is involved in patient care. For example, the family supports the patient's emotional, social, and psychological well-being (Halligan, 2006). The family, particularly the male head of the household, will take on the role of decision maker for family members. The Palestinian population does not rely on social workers and depends on the familyrelatives and friendsfor support (Ahmad, 2004; Management Sciences for Health, n.d.). The support of the family is essential to patients' well-being. Family members may act as caregivers when patients are hospitalized and typically provide around-theclock care. This extensive family support is a part of the healing process and usually is a source of comfort for patients. Mitchell (1998) noted that disclosure of information about the seriousness of an illness varies among countries and ethnic groups because of differing cultural, ethical, and legal concerns. Disclosure of information about cancer differs from person to person in Palestine. Family members may choose to withhold information about the actual diagnosis in an effort to "protect" the patient (Ozdogan et al., 2006). Ozdogan et al. (2006) showed that a family's request not to tell the patient all of the information influenced the physician's behavior (i.e., the physician adheres and does not tell the patient). In contrast, Mitchell (1998) noted that North American and Northern European populations expect more complete disclosure of information. In the Palestinian culture, in general, patients prefer to be directly informed of only a good prognosis. When a negative prognosis must be communicated, healthcare workers approach the head of the family to disclose health information, particularly when it concerns older adults or pediatric patients (Management Sciences for Health, n.d.). In Palestine, family cohesion and support are two of the greatest aspects in the life of patients. Worldview Cultural and Social Structure Dimensions Culture Care Technological Factors Religious and Philosophical Factors Kinship and Social Factors Cultural Values, Beliefs, and Lifeways Environmental Context, Language and Ethnohistory Political and Legal Factors Economic Factors Educational Factors Influences Care Expressions Patterns and Practices Holistic Health, Illness, and Death Focus: Individuals, Families, Groups, Communities, or Institutions in Diverse Health Context of: Professional Care-Cure Practices Nursing Care Practices General (Folk) Care Transcultural Care Decisions and Actions Culture Care Preservation and Maintenance Culture Care Accommodations and Negotiation Culture Care Repatterning and Restructuring Culturally Congruent Care for Health, Well-Being, or Dying Figure 1. Leininger's Sunrise Model to Depict the Theory of Culture Care Diversity and Universality Note. From Transcultural Nursing: Concepts, Theories, Research, and Practice (p. 80), by M. Leininger and M. McFarland, 2002, New York, NY: McGraw-Hill.

A focus-group study by Giacaman et al. (2007) found that participants who reported positive family and social networks were satisfied with their lives, even in economically deprived and rural areas in Palestine. This demonstrates the tremendous value of family. Research studies have pointed out the positive effects of emotional and social support on psychosocial adjustment and coping with cancer (Ashing-Giwa & Kagawa-Singer, 2006) and stress (Classen, Butler, & Koopman, 2001). The social organization of men and women plays an important role in the Palestinian culture. In Palestine, men are viewed as the authority in the family. The eldest male member of the family is the head of the household and has the traditional role of determining how healthcare decisions are made for all family members, particularly the women. Women do not like to discuss personal information or concerns about themselves or their families, so they rely on male family members to communicate for them (Management Sciences for Health, n.d.). Traditional Palestinian women prefer same-sex healthcare providers to care for them; however, modern women are more likely to have no preference (Halligan, 2006). In addition, the Palestinian community distinguishes between the doctor and the nurse: Nurses are perceived as subordinates, and this view may impact their effectiveness. Support groups can be important for patients with cancer, providing emotional support, material aid, advice and information, positive feedback, physical assistance, and social participation. Palestinians are not as familiar with this concept because support groups are very limited. Patients may be unaware of support groups, or the distance and cost to travel to the few hospitals that have support groups may be too great. Because cancer is believed to be a stigma, both men and women often try to conceal their diagnosis and avoid discussing it. If cancer is discussed, it often receives a label of "that disease." Cultural Values, Beliefs, and Lifeways Cultural values play a large role in seeking health care. In the author's experience, many Palestinian women tend to keep their condition secret and thus their cancer may remain undiagnosed. Meleis and Hattar-Pollara (1995) further explained how Middle Eastern Arab culture affects women's behavior by stating that Arab women have restricted access to health information outside their community because of traditional norms and the high value placed on the role of women as mother and homemaker. In addition, modesty and embarrassment in exposing one's body to strangers, religious practice, and gender preference are cultural barriers to seeking health care (Kulwicki, Miller, & Schim, 2000). Traditional beliefs such as fatalism (Azaiza & Cohen, 2008) are barriers to seeking health care and screening. Fleming and Towey (2008) found that attitudes and health beliefs differ among groups and vary significantly among groups with different racial, ethnic, socioeconomic, and educational backgrounds. Differences include beliefs about the causes of illness and treatment effectiveness, actions required to maintain health such as cancer screening or participating in cancer prevention, treatment of illnesses, nutritional practices, and the use of folk and traditional remedies. The Palestinian population, particularly women, have low rates of adherence to prevention recommendations, such as breast examinations, mammograms, and cervical cancer screening. They are reluctant to seek health care because of cultural values regarding modesty and premarital virginity (Matin & LeBaron, 2004). Women also are very reluctant to discuss their sexuality with healthcare providers because many women consider the topic to be shameful. In addition, many women fear the negative stigma associated with breast cancer because it may affect a woman's standing in the community or her daughters' chances of marrying (Rockoff et al., 2004). Kulwicki et al. (2000) noted that many Arab populations in the Middle East seek folk remedies or traditional medicine before seeking Western medicine. Folk remedies include herbal treatments such as mint tea, chamomile tea, and cinnamon. In many cases, medical care is accessed after the patient's health has deteriorated and cancer is at a later stage. Political and Legal Factors The legal aspect of health care is not well defined; living wills or advance directives are not available. The prevailing tendency is for the male head of the family to make decisions about treatment and do-not-resuscitate orders for family members. Likewise, offspring will make decisions for older parents. If parents are divorced, the parent who is the guardian of the children makes the health decisions regarding minors. Pennachio (2005) discussed several issues regarding the legal factors in an Arab country, such as Palestine, with the male head of the household making medical decisions even when the patient is conscious and competent. Also, in a conservative family, a woman of any age cannot sign consent forms. Instead, they typically have a father, older brother, husband, or son sign their forms. Economic Factors The economic situation in Palestine is considered very poor, and the majority of families rely on the male head of the household for income. The poor economic status of the population discourages cancer screening and preventive health care. Palestinian government insurance is affordable and easy to obtain, but coverage is not as comprehensive as insurance in other countries (i.e., Medicare or Medicaid in the United States) (Rockoff et al., 2004). Because 60% of the population is poor and unemployed (WHO, 2007), the majority of Palestinians do not carry health insurance and cannot afford to seek health care. Individuals with low economic status are less likely to receive cancer screening services and may be more likely to be diagnosed with late-stage cancers. These individuals do not seek health care routinely; the only opportunity for cancer diagnosis may be during an unrelated doctor appointment. For example, women might have cancer diagnosed during an antenatal screening. In general, the population does not seek medical care until signs and symptoms of illness are present (Rockoff et al., 2004). Diagnostic tests (e.g., computed tomography scans, magnetic resonance imaging) are Family members may choose to withhold information about the actual diagnosis in an effort to "protect" the patient. Clinical Journal of Oncology Nursing Volume 15, Number 3 Cultural Influences on Health Care in Palestine 285 only available in certain locations and patients may have to travel a great distance to reach those locations. In addition, treatments such as chemotherapy may not be readily available in all healthcare centers and, unless a patient has adequate personal finances, they may go without treatment. Reconstructive surgery is very limited within Palestinian hospitals, with many women seeking surgeries in neighboring countries such as Israel or Jordan at their own expense (Rockoff et al., 2004). Educational Factors and Literacy Rate The level of education, knowledge of disease, and availability of resources about cancer influence how an individual approaches health care. Educated people who are high school graduates or have completed higher levels of education have more control of their own healthcare decisions and seek health care earlier than people with lower education levels (Husseini et al., 2009). Although the literacy rate for younger Palestinians was 91% in 2002 (WHO, 2005a), older adults generally have limited education and do not seek health care as often. According to Rockoff et al. (2004), health-related resources such as educational material focus mainly on childhood diseases and breast cancer in many healthcare clinics; therefore, the health awareness pamphlets regarding other cancers and diseases are scarce in number. Because of society's lack of knowledge about the nature of the disease, cancer remains one of the greatest challenges in the Middle Eastern healthcare setting. Conclusion This article elaborates on the cultural values of the Palestinian population and provides an understanding of the aspects of the Palestinian culture that can influence health-seeking behaviors and healthcare delivery. Leininger's (1995) Sunrise Model is used to enlighten and empower healthcare professionals who may care for patients from Palestine or the Middle East. The model provides the nurse an outline of various cultural aspects, particularly the importance of the family in Arab countries regarding the care of loved ones (Luna, 2002) and to involve the family in the planning of care to the delivery of culturally competent care (Leininger, 1981). It helps the healthcare provider to focus on the issues that might affect individuals of Arab descent, particularly women. In conclusion, this article will help the healthcare professional interact with Palestinian and other Arab populations in a positive manner and facilitate a positive caring environment.

After Reading the article Cultural Influences on Health Care in Palestine provided above address the following:

• Describe the Leininger's Sunrise Model.
• Discuss in detail how the different factors of the sunrise model are applied to the population segment in this paper.

Remember to bring in any personal experience had with this specific segment of the population.