Cultural competency | Working with interpreters | Important note

Iran was known as Persia until 1935 when the Shah requested of the international community that it be called by its native name, Iran. It was subsequently referred to as both although most of its peoples will refer to themselves as Iranians rather than Persians. It is a country with a history (like most others) of invasions and occupations including by the Arabs, Turks, Mongols, British and Russians, and its traditions are ethnically and religiously diverse and rich. In 1979 Ayotollah Ruhollah Musavi Khomeini led the Islamic revolution, ousting the Shah and founding the Islamic Republic of Iran. His unpopularity with the U.S and the West provided Saddam Hussein of Iraq an opportunity to invade Iran and the bloody Iran-Iraq war ensued until 1988 when Khomeini finally accepted a truce mediated by the United Nations. Iran lost nearly a million civilians and military personnel and many people were displaced internally, fled or immigrated.

Iran was known as Persia until 1935 when the Shah requested of the international community that it be called by its native name, Iran. It was subsequently referred to as both although most of its peoples will refer to themselves as Iranians rather than Persians. It is a country with a history (like most others) of invasions and occupations including by the Arabs, Turks, Mongols, British and Russians, and its traditions are ethnically and religiously diverse and rich. In 1979 Ayotollah Ruhollah Musavi Khomeini led the Islamic revolution, ousting the Shah and founding the Islamic Republic of Iran. His unpopularity with the U.S and the West provided Saddam Hussein of Iraq an opportunity to invade Iran and the bloody Iran-Iraq war ensued until 1988 when Khomeini finally accepted a truce mediated by the United Nations. Iran lost nearly a million civilians and military personnel and many people were displaced internally, fled or immigrated.

Since education was highly valued during the time of the Shah, many students studied in the West and those who migrated there, before and after the revolution, remained abroad and have been able to enjoy good prospects. However since the new regime, there has been oppression of women, violence and violations against religious minorities (especially the Baha’is) and political dissidents are imprisoned, tortured or executed. Asylum seekers and refugees arriving in countries of resettlement, including New Zealand leave often without means, are separated from family and their heritage and may have suffered severe hardship before leaving. Some Iranians migrate out of choice to escape the current dictatorship and for freedom of lifestyle.

Iranian greetings

Speech bubble

Hello

Speech buble

Salaam

Speech bubble

Goodbye

Speech buble

Khoda hafez

  • Farsi

Farsi (Persian) is the national language of Iran. It is a non-Arabic language but is written in Arabic script and includes some extra characters not found in Arabic. Most Iranians will speak Farsi as it is the only language taught in schools, however some people may also speak Arabic, or one of the following: Turkish, Armenian, Kurdish, Luri and Baluchi. There are a number of minority ethnicities in Iran. 

Gestures and interaction

  • It is appropriate to shake hands with men and with many Iranian women
  • If a women is wearing a hijab (headdress) it is best to allow her to initiate the handshake. Otherwise use a verbal greeting
  • Use ‘Mr’. and ‘Mrs’. and surname
  • Eye contact may be shorter than usual for New Zealanders out of respect
  • Showing respect, especially for elders, is appreciated
  • Showing an interest in the culture and practices will enhance relationship with the practitioner and compliance
  • Out if respect, clients are unlikely to ask questions. Practitioners can offer information and invite questions

Gestures and interaction

  • It is appropriate to shake hands with men (using the right hand) and with many Iranian women however, if a women is wearing a hijab (headdress) it is best to allow her to initiate the handshake, otherwise a verbal greeting and smile will be best
  • ‘Mr’. and ‘Mrs’. and surname is appropriate
  • Eye contact may be shorter than usual for New Zealanders out of respect
  • Showing respect, especially for elders, is appreciated (e.g. greeting the elders first, the practitioner being on time for appointment, greeting them in their traditional way)
  • Showing an interest in the culture and practices will likely enhance relationship with the practitioner and compliance
  • Health practitioners are usually highly regarded and older or more traditional clients may not ask questions as it is considered disrespectful. It would be helpful to invite the client and their family to ask questions

Many Iranian immigrants in New Zealand are more westernized and secularized than some of the other immigrants presented in this resource, and adherence to traditional roles may vary considerably from one individual and family to another

  • Religion plays an important part in family life (95% of Iranians are Muslim)
  • Family ties are more important than political or social alignments
  • Filial duty is highly regarded
  • Traditionally fathers and sons manage outside relations for the family, while women usually manage the household (this is a changing value)
  • There is great respect for elders and those in authority
  • Marriage in Iran is more often by mutual choice. It is not unusual for marriage to be within the kin group (first or second cousins)
  • Mutual dependence is required over independence
  • Divorce is permitted in Iran although this is more difficult for woman than men to initiate and achieve

Many Iranian immigrants in New Zealand are more westernized and secularized than some of the other migrant groups (who are presented in this resource) and so adherence to traditional roles may vary considerably from one individual and family to another

  • Religion plays an important part in family life (95% of Iranians are Muslim)
  • Family ties are more important than political or social alignments
  • Filial duty is highly regarded
  • Traditionally fathers and sons manage outside relations for the family while women usually manage the household
  • There is great respect for elders and those in authority
  • Marriage in Iran is more often by mutual choice. It is not unusual for marriage to be within the kin group (first or second cousins)
  • Individuals are oriented towards the good of the whole family and mutual dependence is required over independence
  • Divorce is permitted in Iran although this is more difficult for the woman than the man to initiate and achieve
  • Western biomedical concept of disease causation
  • Balance
  • Spiritual/religious
  • Supernatural
    • Jinn
    • Evil eye
  • Cultural
  • ‘Wind’ as a possible cause for rheumatism is culturally accepted
  • ‘Lack of blood in the head’ is often seen as cause for headaches
  • Western biomedical concept of disease causation
    • This is commonly accepted and may co-exist along with any of the other attributions of illness
  • Balance
    • Similarly to many other cultures included in this resource, it is believed that health is based on keeping the body elements in ‘balance’ and that certain kinds of lifestyle, treatments and external factors can influence this, with diet having significant bearing on one’s state. Of particular importance is the notion of ‘hot’ and ‘cold’ which does not imply temperature, but is elemental in nature. Excess of either state can cause related illnesses, which can be treated through the use of the opposite foods to achieve balance. Individuals are hot, cold or neutral in nature.
  • Spiritual/religious
    • Punishment from God for sins committed
    • God’s will (tagdir)
  • Supernatural (these beliefs are less subscribed to by the younger generations, particularly in resettled countries)
    • Evil spirits known as ‘Jinn’ in Islam can cause some illnesses, (often associated with mental health problems), and ‘Zar’ spirit possession is seen as a cause for poor mental health (See Jackon, K. (2006) Ch. 2 for more information about supernatural beliefs in Islam)
    • The ‘evil eye’ (ayin harsha in Arabic) present in some individuals, can put a curse on others by looking at them. This mostly affects children and is associated with physical illness, in particular epilepsy (See Jackon, K. (2006 Ch. 2).
  • Cultural beliefs
    • ‘Wind’ as a possible cause for rheumatism is culturally accepted
    • ‘Lack of blood in the head’ is often seen as cause for headaches 
  • Western biomedical medicine (very well established)
  • Traditional medicine
  • Herbal medicine
  • Cupping
  • Magico-religious articles and religious rituals
  • Western medicine
    • This practice is very well established and practiced, sometimes in conjunction with traditional medicine.
  • Traditional medicine
    • The use of herbal and natural cures is a tradition extending over centuries in Iran, and is part of an holistic approach incorporating physical and psychological factors. Traditional specialists (‘hakim’) administer herbal potions, do bone-setting, cupping (badkesh), leech therapy as well as massage therapy with plant oils. Both physical and psychological symptoms may be treated. (See Kemp and Rasbridge, 2004, Ch. 20 for a list of common herbal treatments, and Jackson, 2006, Ch. 7 for detailed information on psychological descriptors and presentations).
  • Magico-religious articles and religious rituals may be used. Articles such as amulets and the blue-glazed faience eye is common in the Eastern Mediterranean. ‘Esfand’, is a seed burned to ward off the evil eye and possibly bad spirits. A do-aa-nevis (prayer-writer) will scribe verses of the Koran or prayers which clients attach to themselves as protections against spirits.
Important factors for Health Practitioners to know when treating Iranian clients
  1. There is great variance in adherence to traditional practices amongst resettled Iranians. Younger resettled Iranians are generally familiar with Western medicine and health systems and use traditional practices less frequently than the older generations
  2. In spite of considerable reform regarding women’s position in Iran, resettled men face intrafamilial stress with role changes and perceived loss of status in New Zealand
  3. Tentative diagnoses, reliance on diagnostic tests, and no provision of medicines can be interpreted as signs of incompetence as compared with the more aggressive practices in Iran. Explanations about treatment decisions, especially when no medications are advised, may deter clients from ‘doctor shopping’
  4. If medicine is prescribed, practitioners need to enquire about the use of herbal medicines to assess for potential drug interactions
  5. Compliance with prescriptions can be affected by language difficulties. Interpreters can assist with providing written instructions in the client’s own language
  6. Modesty is culturally prescribed, particularly during pregnancy
  7. It is traditional in many Iranian families that terminal illness diagnoses and prognoses are discussed with the male head of the family and concealed from the client. The process of Informed Consent may be new to many families and this process will need to be explained
  8. When doing HOME VISITS:
  • Give a clear introduction of roles and purpose of visit
  • Check whether it is appropriate to remove shoes before entering the home
  • If food or drink is offered, it is acceptable to either decline politely, or to accept
  • No food or drink will be consumed by the family from sunrise to sunset during Ramadan
  • Modest dress is appropriate, particularly during Ramadan
  • It is respectful to address the male family member first when visiting traditional families 
Important factors for Health Practitioners to know when treating Iranian clients
  1. There is great variance in adherence to traditional practices amongst resettled Iranians. Younger resettled Iranians are generally familiar with western medicine and health systems and use traditional practices less frequently than the older generations. However, it is crucial to assess the degree of acculturation on an individual basis. 
  2. In spite of considerable reform regarding women’s position in Iran, resettled men face intrafamilial stress with role changes and perceived loss of status in New Zealand.
  3. Tentative diagnoses, reliance on diagnostic tests and no provision of medicines can be interpreted as signs of incompetence as compared with the more aggressive practice in Iran. Explanations about treatment decisions, especially when no medications are advised, may deter clients from ‘doctor shopping’.
  4. If medicine is prescribed practitioners need to enquire about the use of herbal medicines to assess for potential drug interactions.
  5. Compliance with prescriptions can be affected by language difficulties. Interpreters can assist with providing written instructions in the client’s own language.
  6. Modesty is culturally prescribed, particularly during pregnancy.
  7. It is traditional in many Iranian families that terminal illness diagnoses and prognoses are discussed with the male head of the family and concealed from the client. The process of Informed Consent may be new to many families and this process will need to be explained. It is best to ask the client who they would like to be included in medical decisions. If the client does not want to make any decisions for themselves, they will need to have a Durable Power of Attorney signed.
  8. When doing HOME VISITS:
  • Give a clear introduction of roles and purpose of visit
  • Check whether it is appropriate to remove shoes before entering the home
  • If food or drink is offered, it is acceptable to either decline politely, or to accept (be aware that no food or drink will be consumed by the family in between sunrise to sunset during the Ramadan period)
  • Modest dress is appropriate, particularly during Ramadan
  • It is respectful to address the male family member first when visiting traditional families

Sue to add

Severe mental disturbance (distress or ‘craziness/madness’) is stigmatized. Suicide in a family would be highly stigmatized as this is forbidden by the Qu’ran for all Muslims.

Sue to add

The staples of Iranian diet are rice with meat, chicken or fish, fruits, vegetables and herbs. Hospitalized clients may not request different food and therefore may not eat much that is provided while in hospital. Families are usually happy to supplement foods for members (in fact feeding is seen as the responsibility of the family). ‘Halal’ meats needs to be provided for hospitalized Muslim clients.

For more traditional clients, factors and foods affecting the humoral balance (see Health Care Beliefs and Practices above) need to be considered. Clients will advise about this, but it would be appreciated if these needs are recognized and incorporated into treatment where possible.

Sue to add

Muslims

  • When death approaches, a Muslim will recite “There is no god but Allah, and Muhammad is His Messenger”
  • Do Not Resuscitate (DNR) orders are usually elected
  • In Iran, after death the body is taken to the morgue within a few hours. Prayers are continuously recited at home and relatives and friends will visit the family for up to 10 days after the burial
  • Burial in a cemetery is required, not cremation
  • After death the male body is washed by a male relative or professional, a morde shour' (dead body washer), and a female by a female relative or ‘morde shour’
  • The body is laid out in specific ways, clothed in a shroud (white cloth) and taken to be buried immediately thereafter
  • Public expression of grief is required by Shiite Muslims (especially from the women). This may be seen as dramatic compared with western standards

According to the Perumal (2010) report on MELAA people living in the Auckland Region, key health concerns for Middle Eastern people include:

  • Cardiovascular disease (higher prevalence, which increased with deprivation, and higher rates of hospitalization due to chest pain and angina as compared with Others, Maori and Pacific)
  • Diabetes (significantly higher prevalence than Europeans and possibly within MELAA group)
  • Cancer (mortality rate and cancer registration highest in Middle Eastern people compared with all other ethnicities.)
  • Respiratory diseases (asthma for females)
  • TB
  • Kidney and urinary infections (highest amongst all Other females)
  • Low vitamin D deficiency (particularly women and girls which may be due to avoidance of sun and because of dress code to cover up)
  • Lack of sufficient daily physical exercise (higher amongst females)

These are listed by Kemp and Rasbridge (2004) as health risks for new Iranian immigrants or refugees. However, local community members believe that many of these diseases are not prevalent in Iran and may be listed because of Iran’s inclusion under Middle Eastern groupings:

  • Amebiasis
  • Anthrax
  • Boutonneuse fever
  • Brucellosis or undulant fever
  • Cholera
  • Crimean-Congo hemorrhagic fever
  • Cysticercosis (tapeworm)
  • Dracumculiasis (Guinea worm disease)
  • Familial Mediterranean feer (Mediterranean area, primarily among persons of Sephardic Jewish, Armenian, and Arab ancestry)
  • Giardia
  • Helminthiasis (ascariasis,echinococcosis/hyatid disease, schistosomiasis)
  • Hepatitis
  • Hookworm
  • Leishmaniasis
  • Malaria
  • Plague
  • Sickle cell disease or sickle cell hemoglobulinopathies (occurs primarily in people of African lineage but also to a lesser degree among people from the Mediterranean area and amongst Arabs)
  • Thalassemias
  • Toxocariasis
  • Trachoma
  • Trematodes (liver-dwelling: clonorchiasis and opisthorchiasis; blood-dwelling: schistosomiasis or bilharzias; intestine-dwelling; and lung-dwelling: paragonimiasis)
  • Tuberculosis
  • Typhus

Sue to add

  • Isolation (including older people who spend a lot of time alone at home)
  • Unemployment and poverty (as applies to refugees - many have significant financial issues and difficulties finding work)
  • Loss of standing in society
  • Being marginalized (race, cultural difference and refugee experiences)
  • Cultural adjustments impacted further by the lack of support from usual networks of family and community
  • Experiencing racial discrimination

Note that many Iranians currently migrating to New Zealand do so voluntarily. However New Zealand continues to accept refugees from Iran and some of these will be Asylum Seekers/Convention refugees and so may experience housing and financial problems due to the (limited) facilities and resources available for Asylum Seekers (as compared with Quota Refugees).

According to the Perumal (2010) report on MELAA people living in the Auckland Region, issues for Middle Eastern women include: 

  • Having the highest number of live births
  • A higher percentage of deliveries complicated by diabetes (compared with Others and Maori, but lower than the percentage for Pacific people)
  • Young adult Middle Eastern women (≥30 years) had a slightly higher rate of termination of pregnancy (TOP) compared with Others
  • Low levels of health screening, particularly in cervical and breast cancer screening
  • The need for more education around pregnancy and child birth in New
  • Zealand
  • Health issues related to refugee backgrounds (including resettlement):
  • Mental Health issues
  • Middle Eastern communities experience a disproportionately higher rate of mental health illness compared with the rest of New Zealand, largely due to their earlier life experiences and potential exposure to torture, violence, rape and harassment
  • There may also be strong emotions of grief and loss for family, culture, and country especially following refugee experiences and losses
  • Experiencing discrimination is strongly linked to high levels of anxiety and depression which negatively affects Post Traumatic Stress Disorders (PTSD)
  • Mental illness is stigmatised which results in limited use of appropriate assessment and treatment services, especially in smaller communities
  • A preference for women from these cultural backgrounds to use interpreters and health care practitioners of the same gender. For issues of trust, appropriateness and awareness, it is important to engage professional interpreters whenever possible
  • Contraception is generally accepted and practised in Iran
  • Traditionally, pregnancy provides women with status and self-esteem and giving birth to males accords higher levels of social acceptance
  • In Iran most women have their own obstetricians, and give birth in hospitals. It is reported that elective Caesarian sections are common
  • Fathers are not usually involved, or likely to attend at the birth, but this may be different with younger or more assimilated immigrants
  • Traditional Iranians may observe diet regimes that maintain humoral balance during the first 40 days after the birth
  • Breast feeding is practiced for up to a year with solids introduced at 4 – 6 months
  • Contraception is generally accepted and practised in Iran
  • Traditionally, pregnancy provides women with status and self-esteem and giving birth to males accords higher levels of social acceptance
  • In Iran most women have their own obstetricians, give birth in hospitals and it is reported that elective Caesarian sections are common
  • Fathers are not usually involved, or likely to attend at the birth. This may be different with younger and more assimilated immigrants
  • Traditional Iranians may observe diet regimes that maintain humoral balance during the first 40 days
  • Breast feeding is practiced for up to a year with solids introduced at 4 – 6 months

According to the Perumal (2010) report on MELAA people living in the Auckland Region, key health concerns for Middle Eastern people include:

  • Higher standardized mortality ratio (SMR) for children
  • Potential Avoidable Hospitalizations (PAH) rates in children from all causes was higher in Middle Eastern children compared with Others (dental conditions followed by gastroenteritis were the main causes)
  • The rates of hospitalisations due to asthma, pneumonia and bronchiolitis were higher in Middle Eastern children compared with Others
  • The percentages of Middle Eastern children at the 6 week, 3 month and 6 month mark who were exclusively or fully breastfed were lower than Others
  • In children aged 5 years and Year 8, Middle Eastern children had a greater proportion of children with caries than Others
  • Middle Eastern Year 8 children also had a higher mean number of decayed, missing and filled teeth compared with Others
  • There is a common misconception amongst Muslim boys that circumcision is a protection against sexual ‘disease’
  • Chlamydia infections are prevalent in all teenagers in the MELAA group

Males are circumcised within the first few days (except for Christians)

Males are usually circumcised within the first few days (except for Christians)

Ramadan is celebrated by practising Muslims

Ramadan (fasting month)

Eid al-Fitr (celebration after fasting)

Eid Al-Adha (important holiday for making pilgrimages to Mecca)

Moulid (celebrates birth and death

  • Muslims (Shiite)
  • Christians
  • Zoroastrians
  • Baha’is

About 90% of Iranians are Shiite Muslims. There are some Sunni Muslims. Adherence to religious practice varies considerably with the younger, more educated and professional Iranians tending to be less strict.

There are small numbers of Christians.

Other faiths include Zoroastrians and Baha’is. Baha’is tend to be the most oppressed by the Shiite majority. They are regarded as infidels because unlike the Muslims who believe that Mohammed is the final prophet and cannot be succeeded, the Baha’is believe that all major religions hold a place in the spiritual evolution of humans and therefore do not see Mohammed as necessarily the final prophet. The practice of the Bahai faith is prohibited under the current regime although torture and executions are less frequent since international pressure has been raised in recent years.

View references and resources in the Comprehensive Guide section.

  1. Jackson, K. (2006). Fate, spirits and curses: Mental health and traditional beliefs in some refugee communities. New Zealand: Rampart
  2. Kemp, C., Rasbridge, L. (2004). Refugee and Immigrant Health. A handbook for Health Professionals. Cambridge: University Press.
  3. Maqsood, R.W.  Thoughts on Modesty.  Islam for Today. Updated February 2015 from: http://www.thecall.ws/uploads/Thoughts_On_Modesty.pdf
  4. No author. History of Iran. Retrieved January 2007. Available at: http://en.wikipedia.org/wiki/History_of_Iran.
  5. No author. Iran Major Infectious Diseases. Index Mundi. Retrieved February 2015 from http://www.indexmundi.com/iran/major_infectious_diseases.html
  6. No author. Iranian Culture Information Centre. Retrieved January. Available at http://persia.org 
  7. Perumal L. Health needs assessment of Middle Eastern, Latin American and African people living in the Auckland region. Auckland: Auckland District Health Board, 2010. 
  8. Zoreh Karimi, Iranian community member and Interpreter, and Neda Tolouee, Community Facilitator at RASNZ. (February 2007). Personal consultation on Iranian culture and practices, in genera,l and in New Zealand. Auckland. 

Resources

  1. RAS NZ (Refugees As Survivors New Zealand) can provide assistance to mental health practitioners on clinical issues related to refugee and cultural needs, and contacts for community leaders/facilitators. They can be contacted at +64 9 270 0870.
  2. ARCC can provide information on resettlement issues and contacts for community leaders. Contact +64 9 629 3505.
  3. Refugee Services can be contacted on +64 9 621 0013 for assistance with refugee issues.
  4. A number of health fact sheets can be found in Farsi for download in pdf. at: http://www.healthtranslations.vic.gov.au/
  5. The http://www.ecald.com website has patient information by language and information about migrant and refugee health and social services.
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