After reading this chapter, the nurse will be able to:
Describe the political, historical, and religious influences that have shaped modern Jordan and influenced migration of Jordanians to the United States.
Describe how advances in communications and travel influence acculturation of Jordanian immigrants now and in the future.
Explain the cultural values related to space among traditional Jordanian Americans.
Identify social customs related to social interactions among family members and between unrelated men and women commonly observed among Jordanian Americans.
Explain the importance of the past to traditional Jordanian Americans.
Recognize the influence of Islamic values on the acceptability of various infertility treatments and of genetic screening for heritable conditions.
Identify hereditary diseases that are prevalent among Jordanians and describe how culture has contributed to incidence.
Describe the effects of Western lifestyle practices on health outcomes among Jordanians and Jordanian Americans.
Overview of Jordan
The Hashemite Kingdom of Jordan is a developing country in the Middle East, bound by Israel and the Palestinian lands on the west, Syria on the north, Iraq on the east, and Saudi Arabia on the east and south. In land area, Jordan is slightly smaller than Indiana. In 2007, the population was estimated at 6,407,085 people ( ), with 33% of the population residing in the capital city of Amman ( ). In 2013, the gross domestic product was U.S. $40.02 billion, which yields a $6100 per capita rate ( ). The average number of persons per family is 5.1, and the fertility rate is 3.8. The birth rate (per 1000 population) is 25.23 with an average birth interval of 31 months ( ; ). Unlike some countries in the region, Jordan has no oil or gas reserves. Thus, it has been said that the most valuable export has been their human capital, university-educated professionals such as engineers and health care workers, including nurses. Many of these professionals immigrate to the West because of their technical expertise and because their English skills are strong. English is taught in elementary schools in Jordan, and the universities teach the sciences in English using textbooks from Great Britain and the United States.
Several hundred years ago, the collective area of Jordan, Palestine, and Syria was a single administrative entity, a vilayet, of the Turkish Ottoman Empire. At the conclusion of World War I, the Western powers divided the remains of the Ottoman holdings. Under the League of Nations mandate, the area east of the Jordan River was given over to the British and was called Transjordan. In 1946 the mandate ceased, and the country became fully independent, with its own constitution under the reign of a member of the Arabian Hashemite dynasty, King Abdullah ibn Hussein. At this juncture, the formal name was changed to the Hashemite Kingdom of Jordan. After the assassination of King Abdullah in 1951, he was succeeded by his grandson, King Hussein bin Talal, in 1952. For nearly 50 years, King Hussein ruled Jordan as a constitutional monarchy with a bicameral legislature. During his reign, significant advances were made in education, public health, modernization, and infrastructure development ( ). King Abdullah bin al-Hussein assumed power following the death of his father, King Hussein, in 1999 and has maintained the existing policies of a constitutional monarchy with a bicameral parliament.
As a result of policies that promoted education, health, and public welfare, there is evidence of consistent improvement in quality of life in Jordan. For example, in 2009 the population of Jordan was 6.4 million, which is twice the number counted in 1988 and four times that of 1970 ( ; ). This dramatic increase in population has been attributed to a high population growth rate, plus dramatic improvements in life expectancy and reduced infant mortality. For example, life expectancy at birth increased from 46.9 years in 1960, to 62.6 years in 1980, to 70.6 years in 2000, to 72.7 in 2008, and to 74 in the year 2012 ( ). Although fertility levels have declined from a high of 8 children born per woman in 1964 to a low 3.3 in 2013, improved childhood survival rates have increased the numbers of young people who will soon enter marriageable age. According to the report, 35.8% of the population was under age 15 years, whereas only 5.1% of the total population was over the age of 65 ( ). However, Jordan’s centralized regional location and political stability during the reign of King Hussein and his son King Abdullah have been affected by periodic waves of refugees from the West Bank, the Gaza Strip, Lebanon, and Iraq. Although persons of Palestinian descent make up more than half the total population, the number of registered Palestinian refugees and the recent influx of Iraqi and Syrian refugees is estimated at 1.7 million persons ( ).
Jordan is often referred to as a labor-exporting country, this by virtue of a well-educated and skilled labor force ( ; ). College education is free at public universities for those who qualify, and unemployment is a significant problem in the country for almost all graduates. Thus, entire graduating classes of engineers, physicians, and pharmacists look for work elsewhere in the Middle East, in Great Britain, and in the United States. The nursing shortage is a consistent finding worldwide, but Jordanian nurses often seek work outside of Jordan because of better salaries and opportunities to work in hospitals with better technological infrastructures. Even when labor migration is permanent, the practice of remittance of a portion of the worker’s salary to family members in Jordan is common. This practice continues today in the United States and is an indication of continuing ties and identity between an immigrant and the family of origin.
Although there has been an influx of Palestinians into Jordan over the past century, they have retained their tribal identity. Thus, Jordan has two main tribal groups: (1) Jordanians whose ancestors were Bedouins and (2) Palestinians. Both groups include Muslims and a small minority of Christians, about 2.2% of the total population of Jordan ( ; ). Like other Arabs, Palestinians have maintained their ethnic identity and may make this evident by displaying or wearing their tribal kaffiyeh, the traditional Arab man’s scarf head covering. The Palestinian design is distinctive, an open black basket weave pattern on a predominantly white fabric, compared with the Jordanian design, which is a denser network design of bright red embroidery on a white background. The scarf may be worn in the traditional fashion as a head covering by men, along with a special woven rope crown, an egal . When there is an escalation in conflict in the West Bank in Israel, wearing the Palestinian kaffiyeh in the United States is likely to convey political solidarity for families who are endangered by the conflict. On these occasions, both men and women in the United States may wear clothing with the Palestinian design or prominently display the kaffiyeh in their shops and businesses.
Overview of Jordanian Americans as an Ethnic Group
Between 2006 and 2010, there were 60,056 resident Jordanian Americans ( ). Arab Americans live throughout the United States, and about one third of Arabs are concentrated in California (Los Angeles County), Michigan (Wayne and Oakland counties), and New York (Brooklyn). Another third reside in Illinois, Maryland, Massachusetts, New Jersey, Ohio, Texas, and Virginia. On the average, Arab Americans are better educated than other Americans. Likewise, college attendance is also higher than average, and the percentage of those earning degrees is double. As a group, Arab Americans are more likely to be self-employed, entrepreneurs, or in sales. About 60% of those employed do so as executives, professionals, and office and sales staff. As with other workers, types of employment are also related to area of residence. For example, there are more Arab-American executives in Washington, DC, and Anaheim, California; more sales workers in Cleveland, Ohio, and Anaheim; and more manufacturing workers in Detroit, Michigan. Nationally, Arab Americans have incomes that are higher than average, although incomes are below average in certain locations, such as in Detroit and Anaheim ( ; ).
Immigration of Jordanians to the United States
Large waves of Arab immigration to the United States can be traced to as early as 1875 and continued until about 1920. Most of these early immigrants were Christian. This early period was a reflection of economic depression in Lebanon and Syria resulting from Japanese competition in the silk market and a plant epidemic that affected vineyard production. A second wave of immigration began in the 1940s as a result of the Arab–Israeli conflict and civil war. This second wave of immigration included many more asylum seekers, students, persons who were financially secure, and Muslims ( ; ).
The electronic age has provided immigrants ready access to news and contact with their home country and family of origin. As a result, the process of acculturation for the current generation of immigrants has changed substantially. The information age has provided real-time access to happenings in almost any city in the world. The Internet, Web cameras, social networking programs (e.g., Facebook, Twitter), Internet-based phone services (e.g., Skype), and satellite communications have created affordable access to native-language newspapers, live video, contemporary music and films, and local television programming from places on the other side of the globe. International telephone service is more reliable and affordable than ever before, which allows immigrants to communicate with families and communities much more easily and much more often. The proliferation of ethnic specialty stores in the United States has made it easier for immigrants to maintain native food patterns and to furnish their homes in the same style as relatives at home. The growth of ethnic communities in the United States has also facilitated the building of mosques and churches, which provide religious services in the native style and language. As a result of these technological innovations and changes in U.S. communities, Jordanian Americans and other ethnic groups will be able to maintain or re-establish their cultural identity and cultural preferences much more easily than previous generations. Thus, it is important for nurses to be informed about cultural differences to provide culturally sensitive and culturally specific care to patients, based on their individual ethnic background and country of origin.
Arabic is a Semitic language derived from Aramaic, Hebrew, various Ethiopian languages, and others. It is the official language of Jordan and dates back to pre-Islamic Saudi Arabia. Arabic is also the language of the Qur’an, the holy book of Islam. However, there is a small minority of people who have another native language (such as Circassians and Armenians). In addition, English is currently taught as a second language at the elementary school level. Jordanian university programs also teach engineering and the sciences in English, using U.S. and British textbooks. Arabic has a formal written and spoken form, Modern Standard Arabic, which is used in books and newspapers, as well as in diplomatic settings and on television news. In colloquial use, Jordanians are said to employ the Levantine dialect of Arabic ( ; ).
Social custom dictates that greetings between persons are ritualized with greetings such as “Welcome” and “How is your health?” and responded in kind with “Welcome to you” and “My health is good, thanks be to God.” Among friends and family, these exchanges can be very animated between persons of the same sex or between older persons and much younger persons. These verbal greetings among friends and family are often observed, along with a handshake and a kiss on both cheeks (right cheek to right cheek first, and then left to left). In formal or business settings, greetings are more likely to be limited to a more formal verbal exchange and handshaking alone. Muslim women, particularly those who are covered, usually refrain from touching or shaking hands with men other than family members. These women often lift the right hand and place it flat on the upper chest just below the left clavicle. This gives visual acknowledgment of the other person’s intention to shake hands but avoids physical contact. A proper response to this gesture is a slight bow or nod of the head or the same hand motion and placement. Some covered women may actually shake hands with a man but only after quickly pulling her long sleeve over her hand to prevent actual skin-to-skin contact.
Jordanians often raise their voices when trying to convey important information or to make a particular point. Children may complain loudly about a minor need or in defense of their behavior. In health care settings, they may exaggerate physical symptoms of pain ( ). In business and family settings, both men and women speak loudly and quickly over each other to clarify their vantage point in the discussion. No offense is taken or given in these verbal exchanges, which might be taken as offensive or hostile by the average American.
Public display of affection between men and women is highly discouraged, and touching is very limited between unrelated men and women in Jordan. This prohibition is related to the importance of family honor, sharaf el ‘aar . Loss of honor primarily results from the loss of virginity or the promiscuity (actual or perceived) of women in the family. A breach in family honor is an important family concern and a significant source of stress among mothers of female teenagers in newly immigrated families ( ). Jordanian social custom supports behaviors that visibly separate women from men outside of the family group. Avoidance of touch in social settings may be more pronounced, particularly among covered Muslim women. For example, a covered woman will avoid sitting directly next to a man on public transportation. She will seek out seating next to another woman or child first or avoid sitting if at all possible. Taking a child, particularly a boy child, along on grocery shopping excursions also provides a social and physical barrier to having too much contact with unrelated men. Thus, Jordanians may appear to go to extreme means to cloister females to guard against even the perception of impropriety.
However, there is a great deal of touching permitted by persons of the same sex without an assumption of homosexual behavior. Although it is more common to see men holding hands or women holding hands as they walk down the street in Jordan, this behavior is less likely to be observed in the United States because of the greater sensitivity to homosexual behavior in the United States. In contrast, within the family, Jordanians are very affectionate with their children. Hugging and touching are also fairly common between children and are frequently focused on the smallest child in any family group.
In formal settings, communication is measured but is hospitable and very gracious. Among friends and family, a great deal of collective energy and focus is invested in communication. In greetings, negotiations, or disagreements, voices are often raised and speech is very rapid. Disapproval, such as when a child misbehaves, is often expressed in a minimal fashion by shaking the head “no” or by making a clicking noise with the tongue. It is very uncommon to observe physical violence or spanking in this culture.
Along with a propensity to speak loudly, Jordanians also use their hands for emphasis while speaking. Commonly, the hands are kept close to the body while gesturing. Just as with the prohibitions against touching between sexes, eye contact in public between unrelated men and women is generally avoided.
Implications for Nursing Care
Because there are different communication behaviors expected of men and women in the Jordanian culture, nurses must be prepared to conform to gender-based expectations as well. Male nurses may be limited in trying to interact with Muslim girls and women but conversely find that the men are more than ingratiating. Female nurses will find fewer barriers to entering the home and working with mothers and children, while Jordanian-American men may seem more distant or too aggressive. In addition, recently immigrated women who do not work outside the home may have poor English-language skills and not know what to expect from health care providers in the United States. Children may be called upon to act as translators, which may limit the nurse’s ability to conduct detailed health histories or to inquire about sensitive family issues, such as family violence, abuse, or infertility.
Although there are few limits to same-sex touch and contact, proximity takes on a negative connotation between the sexes outside of the family group. Jordanians are highly affiliative and value close proximity within the extended family group. Close proximity is reserved for families, and all children have close physical contact with all adult members. Nonfamily may also be welcomed into the family circle, but this interaction will be much more limited if the parties are not of the same religion, either Christian or Muslim. Visitors who are women will be expected to interact more with the women of the family, and male visitors will be expected to interact more with the male members of the household.
In traditional home settings, there will often be one or two large sitting rooms with multiple stuffed chairs and couches, plus many small end tables. These rooms are furnished to accommodate large family gatherings while allowing for the men to congregate in one room and the women in the other. If there is only one sitting room, women may congregate in the kitchen area, or men will congregate outside if weather permits.
Implications for Nursing Care
It is essential to remember that close proximity is reserved for family and that all children have close contact with adult family members. Therefore, the astute nurse should remember that because Jordanians are highly affiliative and tend to value close proximity within the extended family group, it is important to respect distance in the relationship between the nurse and client. In addition, it may be necessary to include the entire extended family in the plan of care for the Jordanian client.
Regardless of religion, social life and identity are centered on the family and family roles. The extended family and patrilineal family ties to clans and tribes persist in modern-day Jordan. For example, after marriage both Christian and Muslim women may keep their family name, and the children take the name of the father. Gender and age affect roles in the family, with home life being a focus of women and higher social status afforded to older members of the family. Children are highly valued in the Arab culture, and infertility is viewed as a significant problem in the family context and for the couple, especially the woman. Traditionally, women were expected to have children very soon after marriage, and the birth of a son was an important milestone of achievement for the woman and for the individual nuclear family. However, in Jordan, violence against women may occur when family “honor” is threatened. The most extreme form of violence against women is an “honor killing.” Human Rights Watch continues to publicly object to Jordanian law where murder of a relative believed to be engaged in extramarital sex carries a reduced sentence as a function of protecting the family’s honor ( ). Thus an intentional or unintentional violation (e.g., rape or even suspicion of sexual activity) can bring dishonor. Thus, the family, not just the spouse or father, may perceive the social injury and feel compelled to act on it. Therefore, in situations where cultural ties are still strong, the family may condone and contribute to domestic violence against women by male family members (including siblings and uncles).
As with other immigrant populations, the degree of acculturation will depend upon the time since immigration, proximity to communities of similar ethnic background, and how closely the migrated family maintains contacts with the family of origin. Jordan has enjoyed a positive political relationship with the United States for many years ( ). As a result, short-term visas for entry into the United States have always been available under certain conditions. Conversely, visas to enter Jordan have few limitations. Owing to the emphasis on family connections, even those who are U.S. born are readily welcomed back into the family group with few reservations. Many families also sponsor the immigration of other family members into the United States. As a result, a given family may be able to maintain a strong Jordanian identity some generations after immigration.
Even today, it is not uncommon for a Jordanian-American man to travel to Jordan just to find a suitable spouse. Although these marriages are not arranged in the strict sense, the family plays an important part in finding and approving the final choice. Family background is extremely relevant to the suitability of a prospective bride or groom. This is but one reason why spouses are often selected from within the extended family. However, culturally preferred consanguinity poses significant risks; as a result, mandatory premarital genetic testing for β–thalassemia carriers began in 2004 ( ).
Although many Americans view Arabs as Muslim, the social and political history of Jordan includes both the Christian and Muslim religions. Because Christian Arabs immigrated to the United States much earlier than most Muslims, this subpopulation may not be as readily visible as more recent Muslim arrivals. For example, the churches in Jordan are almost exclusively Orthodox Catholic but include others, such as Seventh Day Adventist and Baptist churches. In the United States, there are numerous Maronite Catholic churches that provide services in Arabic. Thus, Arab Americans can maintain religious and language traditions long after immigrating.
On the other hand, the growth of Islam in America is much more recent. However, mosques also provide instruction in Arabic because their holy book is in Arabic. Their tradition states that the meaning of the text is purer in Arabic and that translation dilutes the intended meaning. As a result, Jordanian-American children can receive ongoing religious and language instruction that reinforces the traditional values and ethnic identity of the family. The number of mosques in the United States has grown significantly, with 1583 mosques counted in 2006 ( ), up from 1209 in 2001 and 962 in 1994. In 2001, 32% of mosques were started in the 1980s, and 30% were established in the 1990s. About 80% are located in metropolitan neighborhoods, with fewer in the West than in other regions of the country. Mosque membership is diverse, but the average percentage of Arab Americans is 25% nationally. Of the general membership, 75% are men, 81% have high school diplomas, 48% are college graduates, 47% are age 35 or younger, 11% are over age 60, and 24% have household incomes below $20,000, compared with the U.S. median household income of $41,000 ( ).
In general, Jordanians are Sunni Muslims who are characterized as more moderate in their practices than, for example, the Shiites of Iran. Islam has some important rubrics and practices that should inform health care delivery and nursing practice. The duties of Muslims for the five pillars of Islamic faith are shahada, affirmation of the faith; salat, daily prayer; sakat, almsgiving; sawm, fasting during the month of Ramadan; and hajj, pilgrimage to Mecca ( ). In addition, abstinence from alcohol, abstaining from sex outside of marriage, and dietary restriction against pork or pork products are important prohibitions. Islam encourages women (and girls after the onset of menses) to be devout by being modest in dress and action. This includes not drawing attention to themselves by speaking loudly or displaying their beauty, particularly their hair, in the presence of men outside the immediate family. Among Sunni Muslims, the choice and degree of “covering” is the choice of the individual woman and is not supposed to be coerced by spouse or family. Some women choose to cover themselves from head to toe by wearing a headscarf, veil, gloves, and a floor-length skirt, all in black. However, this practice is not common among Jordanian women. More often, Jordanian-Muslim women do not cover their faces and will wear head scarves that compliment their long coatlike dresses that cover their usual clothing (e.g., slacks and blouses).
Religion, either the tradition of Christianity or Islam, is woven into the fabric of family history and identity. Thus, Jordanian-American families may have very strong feelings against marriage outside the faith. In particular, women may suffer family expulsion for dating a man who is not of the same faith. Further, interfaith marriages are likely to suffer from forced isolation and will lose access to important family supports. This can have a long-term impact on both parties, such that the woman may lose the support of her mother, sisters, and aunts for her maternal role and the man may lose financial and occupational contacts for employment or business.
Implications for Nursing Care
Because of the emphasis on confidentiality in health care, it may seem awkward when the families of Jordanian patients offer little privacy during encounters with health care providers. In order to balance the imperatives of patient confidentiality and the cultural norms of the patient, it is always advisable to ask permission from the patient before discussing their health matters in front of family members who may be present. This may be particularly important if the nurse suspects rape, abuse, or suspicious accidents. Also, nurses should be aware that the virginity status of unmarried woman of any age is an extremely sensitive and serious issue. Although this may become a standard practice in many settings, it is better for the nurse to err on the side of protecting the privacy and safety of all patients. This may include taking immediate action when protective services are indicated (e.g., a women’s shelter or protective custody of a minor).
Dietary issues, fasting during Ramadan, and limited cross-gender contact present important challenges for direct nursing care. Nursing staff must be attentive to provide food that does not violate religious or cultural preferences. That is, patients and families will need assurance that meals provided will be halal (kosher) or they may not eat at all. Likewise, nurses must be aware of the practice of fasting from food and water over daylight hours during the month of Ramadan. Although the seriously ill are exempt from this religious requirement, nurses will need to assess and counsel diabetic patients about their individual risks before Ramadan begins. Safe adjustments can be made in medication dosing based on having only early morning and late night meals, but patients need careful anticipatory education to avoid complications ( ). In addition, adult Muslim patients may refuse care by health care providers of the opposite sex, even in emergency settings, particularly if care involves intimate contact ( ). Thus, nursing staff should anticipate this sensitivity about cross-gender interaction with Muslim patients to avoid miscommunication that can interfere with delivering quality nursing care.
Given the increasing number of Arab and Middle-Eastern immigrants to the United States, it is important to recognize the role of religion in the lives of these special groups. In addition, we all need to be aware of prevalent stereotypes that infer that every Arab or every person wearing a black-and-white Palestinian scarf is a Muslim, which is not true. Even so, the increasing religious diversity of the population simply means that nurses need a working understanding of related practices and how they may affect patient behavior and nursing practice. When the objective is providing better care for patients, community and religious leaders can also serve a key role in providing contacts and access to hard-to-reach groups in their midst. For example, the recent innovation of “parish nursing” can be extrapolated to offering services for women and children at a local mosque. Thus, nurses and local health care agencies can capitalize on how religious tradition brings these immigrant communities together to improve access to care overall.