Nursing in Afghanistan: A cultural perspective

In any practice setting, nurses must strive to provide culturally competent care. For healthcare professionals working beyond America’s borders, incorporating cultural sensitivity into patient care is especially crucial.In Afghanistan, both military and civilian nurses face the challenge of providing culturally appropriate care in a country with a poor economy and minimal healthcare assets. As the Afghani government matures and the country stabilizes, greater efforts will be made to rebuild the healthcare infrastructure.
Like other healthcare providers deployed with the 14th Combat Support Hospital (CSH) to Afghan­istan in support of Operation Enduring Freedom VII, I discovered firsthand the importance of integrating a patient’s cultural preferences into the plan of care. From February 2006 to February 2007, medical personnel at the 14th CSH cared for a diverse population that included American soldiers, Afghani civilians, Afghan National Army soldiers, and other Coalition soldiers from around the world. Afghanis accounted for about 85% of the inpatient population and required the greatest level of cultural sensitivity. Many had severe, debilitating injuries that necessitated extensive medical care. During their lengthy hospital stays, the staff’s cultural savvy was critical to their recovery.
A vulnerable population
Most Afghanis who seek health care at American or Coalition hospitals in Afghanistan are extremely sick, severely injured, or near death. Many end up at these hospitals after being turned away from (or treated unsuccessfully at) Af­ghani hospitals—in most cases, due to lack of equipment or expertise to treat their conditions. Those who seek medical care at American facilities (whether in Afghanistan or the United States) are vulnerable to misdiagnosis, mistreatment, and misunderstanding because they’re unfamiliar with Western medical practices.Afghanistan’s healthcare infrastructure is one of the poorest in the world. In many rural areas, nearly two decades of war have rendered health care virtually nonexistent.
The environmental health situation is deplorable, too. Only about 7% of Afghanis in urban areas have safe sanitary disposal facilities. Access to high-quality health care is limited, and one in six children dies by age 1.
Barriers to improving Af­ghan­istan’s healthcare infrastructure include:
• lack of educated physicians and nurses to staff the few medical facilities that exist
• poor roads and transportation, which pose obstacles for Afghanis in rural areas who seek care
• an extremely weak economy and lack of money to initiate new healthcare programs
• too few universities to educate healthcare professionals.
Understanding Afghani culture
Whether Afghanis seek care in their native land or in the United States, cultural considerations for healthcare workers center on religion (Islam) and family. Afghanistan’s culture is deeply rooted in Islam. Even in times of sickness, prayer is an extremely important part of daily life. Inability to pray can cause much anxiety and stress.
To decrease stress and make Afghani patients and families feel comfortable and welcome, direct them to clean, appropriate prayer areas and tell them which direction faces Mecca. Afghanis place great importance on the Koran and other religious materials, so try to make these items available or find out how to access them.
Also recognize that Ramadan is the most significant time of year for those of the Islamic (Muslim) faith. Lasting 1 month, Ramadan starts on the first new moon of autumn. It’s a time for inner reflection, devotion to God, and self-control. During Ramadan, Muslims fast and avoid med­ications and sexual activity from sunrise to sunset. Although these restrictions usually don’t apply to extremely ill or hospitalized patients, they must be addressed with patients and their families.
Know that eating in front of someone who’s fasting is consid­ered disrespectful. During Rama­dan, make sure morning and midday meals aren’t delivered to Af­ghani patients’ rooms, and urge other staff members to avoid eating in front of patients and their families.
Family focus
When an Afghani patient seeks health care, the father, the eldest son, or an elderly uncle serves as family spokesperson. Traditionally, Afghani women are considered the primary caregivers outside the hospital environment—but this wasn’t always the case when patients were admitted to the 14th CSH. In Af­ghan­istan, males act
as primary caregivers for family mem­bers admitted to American hospitals. (In the United States, Af­ghani women may take on this role.)To properly recognize the family’s role in Afghan culture, allow one family member to stay with the patient to act as caregiver. If a female Afghani is admitted to the hospital, be aware that a male chaperone may need to stay with her as an escort throughout her hospitalization.
Other cultural considerations
Certain Afghani cultural beliefs may inhibit self-care and healing—and healthcare providers must consider these when formulating the patient’s plan of care. For instance, some patients may not want to ambulate, believing they need to preserve their energy for healing. In this case, encourage physical therapy exercises, but be sure to explain why they’re important to recovery.Also, try to arrange for the patient to go outdoors. Many Afghanis believe the sun has healing properties and enjoy sitting in the sun to absorb its energy.
Be aware that many Afghanis are relatively uneducated and may get confused when physicians and nurses explain medical information or treatment options. Many would rather defer medical decisions to the physician.
Avoiding bodily exposure
When caring for Afghani patients of either sex, keep their bodies cov­ered as much as possible. For Af­ghanis, bodily exposure is embarrassing and shameful. Although such exposure is necessary in an extreme emergency or trauma, be sensitive to the patient’s feelings about this and cover the patient to the extent possible.Also try to keep your own skin covered when caring for Afghanis so as not to offend them. Although this may be somewhat inconvenient for hospital personnel, it shows Af­ghani patients that the staff is dedicated to cultural sensitivity.
When I worked at the 14th CSH, Dr. Walayat Shah, an Afghani interpreter, recommended that only female nurses and physicians care for female patients. An Afghani wo­man, he explained, is uncomfortable being touched by a man other than her husband or father. In some circumstances, her husband might shun her if another man touches her.
Know that Afghanis consider children (especially boys) sacred, and many of the rules regarding invasion of privacy don’t apply to them. For example, Afghanis aren’t offended when a child’s clothing is removed during a healthcare procedure. Also, Afghani children are expected to respect and obey adults, regardless of their relation­ship to them. ­

After-death care
When an Afghani patient died in the 14th CSH, we went to great lengths to ensure culturally correct preparation of the body. First, we notified an interpreter and a chaplain, who recited an Islamic prayer and provided guidance for preparation of the body. We turned the patient’s head toward the direction of Mecca, tied the large toes together to prevent the legs from spreading, closed the mouth and eyes to prevent evil spirits from entering, and kept the body covered at all times. Family members then claimed the body and completed the remaining burial preparation. By taking the few extra moments to carry out these steps, caregivers can influence the family’s perception of the quality of care their loved one received.


Creating cultural committees and competency
Healthcare practitioners preparing to deploy to or work in countries outside the United States need to learn everything they can about local customs and cultures. One way to ensure they’re well informed and able to provide culturally correct care is to form cultural committees or focus groups that research the local culture and create appropriate policies. Another way is for those who’ve worked overseas to publish articles describing their experiences so other healthcare workers get the message.The concept of cultural competency applies to all aspects of nursing care, including inpatient and outpatient settings, research, home health, and even nursing management. As U.S. societies throughout the world become increasingly multicultural, all nurses should strive to gain cultural competence, regardless of their practice setting, role, or specialty.
Selected references
Giger J, Davidhizar R. Culturally competent care: emphasis on understanding the people of Afghanistan, Afghanistan Americans, and Islamic culture and religion. Int Nurs Rev. 2002;49:79-86.Leishman J. Perspectives of cultural competency in health care. Nurs Stand. 2004;19
(11):33-38.
Reece B. Afghanistan: from war to hope. Soldier Magazine. 2005;March:14-19. http://
findarticles.com/p/articles/mi_m0OXU/is_3_60/
ai_n15677625. Accessed December 20, 2007.
World Health Organization (2001). Country profiles: Afghanistan. www.emro.who.int/
mnh/whd/CountryProfile-AFG.htm. Accessed December 20, 2007.

Daniel J. Yourk, First Lieutenant in the U.S. Army, served as an Emergency Room Nurse at the 14th Combat Support Hospital in Bagram, Afghanistan. The views expressed in this article are the sole responsibility of the author and do not reflect the official views of the Army Medical Department, Department of the Army, or Department of Defense.

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