After reading this chapter, the nurse will be able to:
Discuss sociocultural influences in Uganda that differentiate Ugandan culture from American culture and affect assimilation of Ugandan Americans.
Discuss the hierarchical patterns of communication that may be utilized by Ugandan Americans.
Explain Ugandan customs related to space.
Discuss barriers Ugandan Americans may face when seeking health care or health information.
Name Ugandan practices surrounding childbearing and dying.
Explain tropical diseases and genetic diseases or impairments that may be observed in a Ugandan after arrival in the United States.
Identify nursing measures that can be taken to provide culturally competent, effective care to Ugandan Americans.
Overview of Uganda
Uganda is located in East Africa, along with Kenya and Tanzania. Named the “Pearl of Africa” by Winston Churchill for its lush green beauty, Uganda encompasses 91,135 square miles—approximately twice the size of Pennsylvania. Although it straddles the equator, its altitude of over 2037 feet at the lowest point above sea level moderates its temperature to an average range between 72° and 92° F, with variations related to location and season ( ; ). There are two rainy seasons, approximately March to July and September and October. There are three main areas: swampy lowlands, fertile plateaus, and desert regions. Lake Victoria, once the largest lake in the world, forms part of the southern border. The Nile, which begins at Jinja, meanders northwest across the country before continuing northward to the Mediterranean Sea. Five large national parks provide protection for large animals, such as elephants, hippos, giraffes, chimpanzees, and the endangered gorillas. Landlocked, Uganda borders the Democratic Republic of Congo on the west, Rwanda and Tanzania on the south, Sudan on the north, and Kenya on the east ( ).
Historically, the kingdom of Buganda was well established by the eleventh century, with an army and well-defined administration. When Uganda’s borders were drawn, the country included this and other kingdoms, plus many independent organizations. Missionaries arrived from Europe in the late nineteenth century, winning converts for the Protestant church (Britain) and for the Catholic Church (France), leading to religious skirmishes. When the British claimed Uganda as a protectorate, the British government set up a replica of the British system, and Protestantism spread. Today the religious denominations are Roman Catholic (42%), Protestant (42%), Muslim (12%), other (3%), and none (1%) ( ).
In 1962, independence was granted, with Milton Obote as prime minister and the Kabaka Mutesa II (King of Buganda) as president. Since then, Obote, Idi Amin, and Obote again have had dictator rule until 1986 when General Yoweri Museveni assumed power and formed the National Resistance Movement government. Museveni’s “non-party” democracy has brought sufficient improvement and stability to the country despite the uprising of the Lord’s Resistance Army (LRA). The LRA, supported by Sudan, conducted violent abduction of children at night, turning them into boy soldiers or sex slaves. The LRA killing raids have led to displacement of thousands into internal camps and have sent over 250,000 to flee to neighboring countries ( ). The LRA is no longer in Uganda but does operate on the borders of the Congo. After the new constitution of 1995 authorized elections, Museveni was elected president in 1996 and has remained in power ever since ( ).
Representatives to Parliament are elected from every county, with seats reserved for a woman from each district, disabled, youth, and workers ( ). Amin abolished the kingdoms, but in 1994 Museveni allowed the kingdoms to exist publicly, giving them little authority except to promote their respective cultural practices. In spite of efforts to stamp out bribery and corruption, government and other institutions are still heavily affected by these problems.
The economy is based on agriculture, providing income to 80% of the workforce; women perform most of this work. The primary cash crops are coffee, tea, tobacco, and cotton, but government efforts to diversify have led to increasing exports of tilapia, soybeans, spices, flowers, and other produce. Uganda is blessed with fertile soil and abundant rainfall, engaging the poor and illiterate in subsistence farming ( ). Economic recovery has taken remarkable strides under President Museveni. Reduction of poverty is the chief goal of the government. The population living in poverty declined in 2009 from 56% to 24%; however, 84% of the population live in poor rural areas and within that population, the poverty rate is between 40% and 60% ( ). Privatization of hotels and businesses formerly owned by the state has been a boon to economic stability. Transport is readily available in the capital city of Kampala, in the main towns, and on paved highways, but the rural areas suffer from a lack of public transport ( ).
Almost 84% of the population is rural, with the majority of urban dwellers inhabiting Kampala. Uganda is a melting pot of 48 distinct ethnic groups representing three different linguistic groups: Bantu, Nilo-Hamites, and Nilotic ( ). All of these groups were merged into the country of Uganda during the colonial period, setting the stage for later ethnic rivalries, armed conflict, and human rights abuses ( ). Buganda is the largest of the Bantu groups, making up 17% of the population and living in the southern part of the country (locals call it the “central” region). Colonialists curried favor with the people of Buganda and rewarded them with leadership positions. Thus, the seat of government developed in the central region. Some citizens of Asian descent reside in Uganda. The citizens who were deported by Amin in 1972 began returning to their businesses after a formal invitation from President Museveni in 1991 ( ). In addition, Uganda has hosted refugees from across its borders, especially Sudan, the Democratic Republic of Congo, and Rwanda.
The family is the most important center of life for Ugandans. Families tend to be very large, live in close-knit groups, and include extended family that both give and receive support—financial or otherwise—as needed. Although outlawed in Uganda, polygamy is culturally acceptable, providing the husband has the means to support more than one wife and the numerous children that are likely to follow ( ). In very rural communities, marrying the deceased brother’s wife, girls marrying at age 13, sex with children, and child sacrifices may still be practiced (Hunter, unpublished data, 2015). Children are indoctrinated into the roles and mores of their group, and the eldest provides for aging parents ( ). The couple’s parents have been known to negotiate marriage, usually after the couple have chosen to marry one another and often after they have one or more children. The groom’s family agrees upon the bride’s price, which is likely to include a number of cows but may also include goats, a dress for the bride’s mother, and money. An educated bride brings a higher bride’s price. Marriage means the husband has “ownership” of the wife, making divorce difficult, and spousal rape and abuses are accepted practices ( ).
By 2012, children composed up to approximately 56% of Uganda’s population. There are 2.7 million orphans in Uganda, of whom 1.2 million have been orphaned by acquired immunodeficiency syndrome (AIDS); one in seven children will die before he or she reaches the age of 5 years ( ). A son is favored over a daughter because of the expectation that he has more potential for earning a good living. Therefore, he is more likely to receive education and health care according to the father’s preferences. Though the report by the ANPPCAN indicates that only 20% of children in Uganda are malnourished, those figures don’t match this author’s findings, which indicate that 80% of the 440 children assessed had body mass indexes of 13 and were short for age as measured by World Health Organization (WHO) standards; 50% were microcephalic (Hunter, unpublished data, 2015).
The youth literacy rate in 2010 was 85.67%, with young men at 89% and young females at 64%; the overall adult literacy rate was only 73% ( ). Such literacy ability means the individual can, with understanding, read and write a short, simple statement on his or her everyday life. This makes teaching and learning about child and adult health somewhat problematic as terminology and written instructions are not understood or followed.
The gender equity campaign at the government level with Museveni’s support of women in politics still has a long way to go in changing mindsets of people outside of Kampala, as poverty, gender norms, and cultural traditions still dictate the future of girls in Uganda. reports that 12% of girls are married by age 15, with 48% married by 18. Women’s reproduction rate is 6.14 children/woman, which places Uganda fourth in the world for average birthrates. Given the decimation of their population from AIDS, it is understood why reproduction is encouraged; however, many of these women are poor, malnourished, cannot sustain a healthy full-term pregnancy or adequately breastfeed a newborn as they still have several toddlers suckling. The deaths of women during childbirth, though lower than previous reports, is still reported at 6000 per year, and 1 in 13 women are at high risk for dying while giving birth. Traditional practitioners deliver 41% to 43% of births at home or in a clinic setting, not by a trained health professional. One in 7 children do not reach adolescence. Women with higher education have decreased rates of child mortality because they have fewer children, better nutrition, better access to health care, and jobs. Unfortunately, higher education does not protect these women from domestic violence. Domestic violence is the norm, with more than 60% of women experiencing such violence in their lifetime. Personal communication with various professionals in Uganda since 2007 has found that much of the violence is related to alcohol consumption and the women who are able to obtain jobs although there are no jobs for the men ( ). Women are gaining their political voice because they constitute 25% of the legislators and 27% of government ministers ( ).
In 1996, universal primary education was passed into law, paving the way for all primary children to attend government-sponsored schools for free. However, parents must supply the uniforms, books, and pens. Attendance is not compulsory, but enrollment of primary age children is 100% ( ). The demand for free education is high, and there are not enough classrooms and supplies to handle the requests. It is not uncommon for classes to have well over 100 students, with very little in the way of facilities, with overworked teachers heading them. This means that for most of the population, especially those who want a higher quality education, the only other option is private school. In Uganda, private schools vary enormously in fees and quality. Paying school fees is beyond many families, especially when they have a lot of children. Depending on relatives to help with the finances or donations from foreigners interested in helping means that many children will go without an education, thereby limiting their future potential to support themselves or a family. Only 12% of females and 18% of males between ages 13 and 19 years are enrolled in secondary schools, and only 3% of the relevant age group is enrolled at the tertiary level ( ). Makerere University is the oldest and largest university of the seven in the country, with a growing student body and a wide range of programs, including public health, medicine, and nursing ( ).
Currently 7.2 % of the population is living with human immunodeficiency virus (HIV), with an estimated 1.4 million people that includes 190,000 children. Sixty-two thousand people died from AIDS in 2011, and the incidence in adolescents and young adults is rising, which is attributed to the same phenomenon that is occurring globally: young people believe that AIDS can be cured because of the drugs that are now available ( ). Despite these facts, with the increasing access to health care and treatment for HIV/AIDS, current estimates find the population is now 35,918,915, with a growth rate of 3.24%, birth-rate at 44.17 per 1000, infant mortality at 60.82 per 1000, and an increasing life expectancy at 54.46 years ( ).
In 2014 the median per capita income of Ugandans was $1375 ( , www.worldbank.org.easyaccess1.lib.cuhk.edu.hk/en/about/annual-report . Retrieved on September 24, 2015). This income must feed, house, clothe, educate, and obtain health care for the family members. On $3.76 or less a day, such costs are not possible. Construction appears to be the primary growth area. Agriculture is the highest employer of personnel but is unlikely to achieve high rates of growth because of supply-side constraints such as lack of infrastructure, irrigation, and modern machinery ( Table 26-1 ).
The health of Ugandans is precarious because health care is expensive. There is minimal primary health care, and few can afford to pay for the management and stabilization of chronic health problems. Public and environmental health has not been a top priority, and many Ugandans use traditional healers, often delaying entry into the medical center until it is too late. Many do not have adequate sanitation facilities, 56% do not have access to improved drinking water sources, and many are malnourished, especially the women and children (particularly lacking protein and essential vitamins and minerals). This puts them at risk for severe anemias, foodborne and waterborne tropical diseases such as malaria, typhoid fever, schistosomiasis, bacterial diarrhea, and hepatitis A. Malaria is still the leading cause of morbidity and mortality in Uganda, with the world’s highest malaria incidence (rate of 478 cases per 1000 population per year). Uganda has the third largest malaria burden in Africa and the sixth largest in the world. Malaria is responsible for up to 40% of all outpatient visits, 25% of all hospital admissions, and 14% of all hospital deaths. Child deaths due to malaria are between 70,000 and 100,000 every year, a death toll that far exceeds that of HIV/AIDS. Additionally, malaria affects maternal morbidity and mortality and is attributed as a direct or indirect cause of 65% of maternal mortality and 60% of spontaneous abortion. Additionally, 15% of life years lost to premature death are due to malaria, and families spend 25% of their income on this disease ( ).
Unfortunately, chronic hypoxia from the decreased oxygen-carrying capacity evident with decreased red blood cells (RBCs) and the destruction of RBCs that occurs with malaria has resulted in such sequelae in children as developmental delays, microcephaly, cognitive impairment, short stature, and impaired fertility ( ). This further exacerbates the precarious health state of many Ugandans.
Ugandans are latecomers as immigrants to America. From 1989 to 2000, the average intake of immigrants had been 423 per year, but from 2001 through 2004, that average rose to 553. In addition, between 2000 and 2004, the yearly average of Ugandans naturalized was 331, the yearly average granted asylum was 104, and the yearly average of refugees and asylees granted lawful permanent resident status was 50. A total of 5587 nonimmigrant Ugandans were admitted in fiscal year 2004 as students, workers, businessmen, tourists, or relatives of U.S. citizens ( ; ). At one time, refugees from the civil war were given scholarships to North American colleges. Many of those students continued in university education and became U.S. citizens. More recently, nonimmigrant visitors have joined students in seeking political asylum, often to escape persecution or rebel activity.
The cultural differences between Ugandan Americans and Black Americans are immense, especially considering that both cultures share similar origins and skin color. Ugandans, arriving from a country where they predominate culturally, perceive themselves to be more like Whites in the United States yet are dismayed to find themselves feeling like “cultural impostors” and assigned to low social status in a country where institutional racism prevails (Otengho, n.d.).
Western civilization has traditionally viewed Ugandans as passive people. Their willing servitude and nonaggressive behavior often are the results of tribal structure that discouraged individual self-promotion. The culture of the Baganda was authoritarian, and obedience to the king was crucial. The tradition of giving all power to a village chief, the era of colonialism, and the repressiveness of men like Obote and Amin had taught them obedience, even servitude, and survival.
English is Uganda’s official language. Refugees who lived in rural areas, however, find American culture is very different from what they left behind. American life poses challenges for those who have not seen escalators, refrigerators, traffic lights, and scan-your-own grocery checkouts. Many Ugandans immigrate for better educational opportunities. Unfortunately many immigrants not enrolled in a university are unable to work at the same position or in the same field in the United States without further study to meet American standards. A highly educated and skilled group of immigrants, Ugandan immigrants hold one of the highest proportions of postschool qualifications of any ethnic group and were the ethnic group with the highest proportion of qualified people who were unemployed (14%). More than 93% had completed secondary school in the United Kingdom, “O level,” and 46.2% were educated to diploma or degree level. Women’s educational levels lagged significantly behind men’s ( ). Ugandan immigrants experience discrimination from Blacks and Whites, not only on the basis of color but also because they are African immigrants (personal communication with American Ugandans, 2014).
Ugandan Americans tend to establish single-family homes where children learn reverence for God and their family and prefer to join family members already in the United States. Ugandan immigrants take part in community and school events in much the same way as other Americans. The children of Ugandan Americans assimilate into American culture. Immigrants with professional employment are geographically scattered, although significant communities have developed in metropolitan areas such as Atlanta, Sacramento, Dallas, and St. Petersburg ( ).
Ugandan culture is a mixture of various traditions and practices. In Uganda, people may break into song and dance, even in the streets, when they hear good news. If you are invited to someone’s home, it is polite, but not required, to bring a gift for your host or hostess. Wives are automatically included in invitations unless it is specified otherwise. In conversation, most topics can be discussed freely, and national and world affairs and the arts are the most popular topics. There are also many native languages. Luganda is probably the most widely known because it is the language of the largest group, the people of Buganda, and because it is widely spoken in the capital city. Native speakers of several other languages can readily understand it because of the similarities. English is spoken as a second language by nearly all people because they were born into a family that spoke a tribal language. Ugandan English diction and idioms strongly follow British English in vocabulary and pronunciation ( ).
Ugandan upbringing incorporates a strict code of conduct, including etiquette. To convey respect when meeting a friend or colleague, one must inquire about the other’s welfare using “madam” or “sir.” Then it is polite to make other inquiries about the person’s family, work, or sleep. One should stand to greet an elder or person of high status ( ). Taboos prevent children from speaking when adults are holding a conversation and younger people from expressing anger or their opinions to elders. Parents prefer to visit their children in person rather than by letter writing. Speaking softly is the norm, especially when showing deference. A person who raises his or her voice volume is considered to be rude and angry and is said to be “shouting.” Shaking hands upon meeting a friend or acquaintance is far more common than hugging and is expected. Shaking hands on departure is also appropriate. To express one’s pleasure at the meeting, a person will hold the right wrist with the left hand. Hugging is reserved for greeting special friends and relatives or visitors not seen for a long time. It is more prevalent in western Uganda. In public, no hand holding, embracing, stroking, or sexually suggestive touching is acceptable between the sexes, not even from sweethearts or spouses. Sometimes men will walk hand in hand with other men. Touch is acceptable as necessary for rendering health care, but unwanted touch causes emotional discomfort ( ).
Two nonverbal communication behaviors are significant because they demonstrate the hierarchical nature of the culture. It is considered impolite to make direct eye contact with a superior in age or status, so people direct their gaze downward while bowing the head slightly to convey respect. Traditionally in Buganda, a woman must kneel to the floor in respect when greeting a man; likewise, a child must kneel when greeting an adult. Any time a person uses both hands for giving or receiving a gift, intense appreciation is conveyed. Gestures may be used when talking. Sighing or stretching while visiting is considered rude, crossed arms are considered belligerent, and a woman crossing her legs when seated ignores this taboo ( ). Ugandans in pain have been acculturated to bear it in silence. Neither facial expression nor writhing nor moaning communicates that one is in pain (personal communication with health professional at Holy Innocents Children’s Hospital in Mbarara, ).
Ugandans guard their privacy about interpersonal relations and communication, extending to a lack of openness at times even with their children. In business dealings and friendships, they are very tactful and indirect when discussing sensitive issues in order to avoid embarrassment. Criticism is considered rude. Euphemisms are plentiful and masterfully used. For example, rather than say the word “intercourse” even in health care assessment or teaching, they will use terms such as “when the wife serves the husband” or “when the husband meets his wife” (personal communication with the health professionals and religious professionals in Mbarara, ). They are not averse to discussing information of an intimate nature but are diplomatic in their approach. Uganda was one of the earliest countries to launch an educational campaign for AIDS prevention that has proved successful because of the ability to publicly discuss specific prevention methods ( ).
Implications for Nursing Care
The style of speaking may be the first clue to many nurses that they are caring for an African immigrant rather than an American-born Black. Expressing interest in learning about them personally or their culture is likely to encourage trust and understanding. The nurse should listen carefully to their concerns and preferences, as well as any family members who may have information related to the patient. Preferences may include a care provider of the same sex.
The first introduction to the patient should be formal, using a title or both names, but friendly and solicitous about the patient and the family. Professional nursing was begun in Uganda in 1993, so current immigrants are not likely to appreciate the contribution that professional nurses can make to their health care. To build trust, take time with the introduction and then explain your nurse role in order to gain permission for your intended nursing actions. Because Ugandans have experience with being promptly treated for their symptoms, they may lack patience for a long history or for being asked similar questions at every visit, which American health professionals find necessary for making a diagnosis.
Maintaining a calm, conversational, low-volume tone will prevent offense to the patient. Nurses should also speak clearly and distinctly in a formal way, rather than use slang or colloquialisms, in order to avoid misunderstanding and repetition. Keep in mind that some American English vocabulary and medical terminology may be difficult for the Ugandan immigrant to grasp and understand fully (personal communication with a Ugandan trained as a nurse in the United States, 2013). Avoidance of joking, teasing, and sarcasm can prevent the misinterpretation that is more likely to occur in cross-cultural exchanges. Because euphemisms are commonly used, they may facilitate communication regarding matters of a delicate nature. Analogies may help in providing health education. However, evaluation of the effectiveness of the communication when using any method is essential. Ugandans, who note even small details, readily absorb visual illustrations, but use of illustrations is enhanced if any humans in the illustration bear some resemblance to people of their own ethnicity. Encouraging their personal and cultural character strengths of acceptance, determination, and optimism can support them in health-seeking behaviors while showing respect (Hunter, unpublished data, 2015).
Ugandan patients appreciate a handshake upon meeting and parting. It is essential to remember that for some Ugandan Americans, patting, stroking of the back or arms, or hand holding may be uncomfortable because touch, especially with strangers, is unacceptable. The provider should gain permission for touch necessary for health assessment or treatment. The family provides all personal care, including bathing, toileting, bed making, and feeding, whether in a Ugandan hospital or at home. Therefore, Ugandan patients are likely to feel more comfortable when female family members provide these services. They may also find comfort in having a family member nearby when their condition or treatment is discussed with them by the health professional.
Nurses must assess Ugandan patients carefully regarding the presence and extent of their pain. A master’s thesis completed at Mulago Hospital in Kampala, Uganda, found that the almost half the nurses lacked knowledge on key pain assessment principles and 44% did not always agree with patients’ statements about pain ( ). Some of this can be explained by the cultural traditions of not expressing pain and the belief that if one does complain, one is not seen as “strong” but as weak and therefore needs to “toughen up.” Nurses should offer pain control even though the patient demonstrates no signs of being in pain.
Ugandans may avoid eye contact with health care professionals as a sign of deference for their status and expertise. Maintaining eye contact is considered rude, much as in the Asian culture. Thus health professionals should learn to use eye contact appropriately to indicate they are listening and absorbing without appearing aggressive and disrespectful.
In Uganda, a spatial distance of about 3 to 4 feet is maintained face-to-face between men and women in public, with the same distance applied shoulder-to-shoulder in many instances. However, in public buses, churches, waiting rooms, or schools with space constraints, people sit very close together, with bodies, stools, or chairs touching each other.
Some Ugandan families do not allow the children to enter the bedroom of the parents or babies to sleep in the parents’ bed (personal communication with parents in Uganda, 2013). Other territorial proscriptions include not using the cup, eating utensils, or clothing belonging to elders or esteemed persons. Chairs are reserved for adults. Children must sit on mats on the ground or floor. In most households, guests leave their shoes at the door and will be offered the best chair in the house ( ).
Fathers seldom accompany their pregnant wives to the hospital for delivery and never accompany them during delivery. In the large teaching hospital in Uganda, fathers are not yet allowed in the labor ward. A baby is tied on the mother’s back at all times until the child can walk, and thereafter as necessary until a newborn sibling fills that space. Close physical contact allows breastfeeding to continue up to around 2 years ( ).
Implications for Nursing Care
While most conversation is conducted in Ugandans’ personal space, they are not insulted by invasion of their intimate space when nursing or health care dictates the necessity of it. Every effort should be made to avoid exposing the patient unnecessarily, especially from the waist to the knees. Some Ugandans feel embarrassed when they must accept care from a health care provider of the opposite sex; however, during this author’s experience in Uganda at the Children’s Hospital and in community outreach health assessments, no such embarrassment was noted. Patients were pleased they were being attended to regardless of gender.
Couples may need instruction about the value of husbands accompanying their wives into labor and delivery. Husbands may need additional information about specific behaviors they should demonstrate in relation to their wives and newborns in the various stages of childbirth and the postpartum period.
Breastfeeding for 2 years is the cultural norm for immigrants of African descent, with premature cessation considered a social stigma. In the West, breastfeeding is encouraged, but infant feeding remains the mother’s choice. The first-generation immigrant feels strong cultural and economic pressures to breastfeed. The challenge for nurses is to support Ugandan Americans in continuing this prevailing tradition and to teach them how to be socially appropriate in a country where exposed breasts in public has a different connotation from their traditional ethnic values, and where advance planning is required to continue breastfeeding when socioeconomic pressures demand early return to work.