Iraqi | eCALD Cross-Cultural Resources

1

Introduction

Iraq has been besieged by incessant war, internal strife and tyranny since Saddam Hussein came to power in 1979: the Iran-Iraq war from 1980-1988, the Anfal (campaign to eliminate Kurdish culture), the Gulf War of 1990, and recently the U.S led war of 2003 which ousted Saddam Hussein and his Sunni-dominated Baath party. Political, religious and ethnic faction beleaguered the interim Iraqi-led government, and since the withdrawal of US troops in 2011 daily violence and bloodshed have continued in the face of sectarian dissent. In 2014 over 12,000 civilians were killed making it the ‘deadliest’ year since the sectarian bloodshed of 2006-07 (Reuters, 2015).

During the wars millions of Iraqis (including Kurds from ‘Iraqi Kurdistan’ in Northern Iraq) have fled, initially into the refugee camps in Saudi Arabia (Al Artawea and Rafha), into Iran, the US-occupied zone along the Iraq-Kuwait border, and more recently into Syrian and Jordanian refugee camps. Many Kurds fled to Turkey where they were forcibly settled in camps. Life has been harsh and conditions very poor in some of the camps and also in resettlement locations where conditions are overcrowded. In 1994 the US resettled large numbers of refugees from Rafha, and some Kurds from Turkey. Some were accepted by other countries including New Zealand. Political dissidents, Shiite Muslims, Kurds and Assyrian Christians were the groups most targeted since 1979.

Most Iraqi refugees arrived in New Zealand during the 1990s and were relocated in Auckland, with smaller groups in Wellington and Hamilton. The communities in these cities are well established and continue to grow as people from the ‘at risk’ groups (defined by the UNHCR) continue to arrive as well as through family re-unification programmes. Some Iraqis have resettled here as migrants.

2

Greetings

Muslim greetings

Hello

Salaam aleikum

Goodbye

Ma’a alsalam

Assyrian and Chaldean greetings

Hello

Shlamalugh

Goodbye

Push pshena

3

Languages

Arabic

The main language spoken in Iraq is Arabic. Most people are Arabs (about 75 – 80%) and about 15% Kurdish. There are small numbers of other ethnicities including Assyrians, Chaldean and Armenians (all Christians), Turkomans and some Iranian based ethnicities. Some less educated Kurdish people do not speak Arabic but a dialect (usually Sorani or Kurmani). Literacy in Arabic in Iraq is reported to be around 58%.

Assyrian and Chaldeans would very much appreciate being greeted in their own language although they would not be offended if greeted in Arabic (see above).

4

Communications

Gestures and interaction

Shake hands with the right hand, between men
Use customary greeting with women
It is acceptable to shake hands with Christian and Kurdish women unless they are elderly
Elders are usually treated with utmost respect
The right hand placed on the heart after hand shaking or greeting is a gesture of sincerity
Direct or prolonged eye contact is avoided, especially toward those in authority (Muslims)
Showing an interest in the culture will enhance relationship and compliance
Out if respect, clients are unlikely to ask questions. Practitioners can offer information and invite questions
Saying ‘no’ directly is not courteous, so affirmative responses may not always mean ‘yes’
Asking direct questions is considered impolite so practitioners will need to phrase questions sensitively
A negative response is indicated by a nod of the head and a click of the tongue and is easily misunderstood by westerners as an affirmative gesture
Shaking the head from side to side indicates a misunderstanding, not necessarily disagreement

Gestures and interaction

Hand shaking occurs between same sex members only (Muslims). Physical contact with women should be restricted to necessary physical examinations as propriety is highly valued and also required (it is usually acceptable to shake hands with Assyrian and Khurdish women unless they are elderly)
It is customary to greet males first (Muslims)
Use title and second name
The right hand placed on the heart after hand shaking or greeting is a gesture of sincerity
Pointing a finger is considered rude, and either the right hand or both hands are used to pass objects, NOT the left alone
Showing respect, especially for elders, is appreciated (the practitioner being on time for appointment, greeting them in their traditional way, greeting elders first)
Health practitioners are considered to have a high status and clients will not ask questions as it is considered disrespectful. Clients will expect that practitioners know this and will wait for practitioners to invite them to ask questions
Avoiding direct eye contact is considered respectful, especially between men and women, and between people considered to have different status. A person with lower status may lower their eyes, or heads to avoid eye contact. Second generation Iraqis may be more relaxed about eye contact.
Eye contact is more acceptable with Christian Iraqis
Saying ‘no’ directly is not courteous in Iraqi culture so an affirmative response from a client may not necessarily mean agreement or acceptance. Alternatively the client may answer with “I don’t know” rather than saying no. (Clients will also appreciate a more indirect way of saying ‘no’ from the health practitioner)
A negative response is indicated by a nod of the head and a click of the tongue and is easily misunderstood by westerners as an affirmative gesture
The Western custom of asking direct questions is considered impolite and can result in reticence to engage. Asking general questions about the wellbeing of the client (and importantly, family) will assist with establishing rapport and for the client to volunteer information for further questioning
Shaking the head from side to side indicates a misunderstanding, not necessarily disagreement
Showing an interest in the culture and practices will likely enhance compliance and the relationship with the practitioner

5

Traditional Family Values

Arabic Iraqis

Allegiance to the extended family and tribe is paramount
Traditionally men manage household finances and women are responsible for childrearing (a changing value)
Arranged marriages are common and early marriage is customary
Marriage to first-cousins is valued, particularly in New Zealand, as the backgrounds of other families are often unknown
Marriage is sacred and serves as a bond between families
Married women live in the husband’s extended households
Households are usually segregated according to gender
Women are usually subservient to men, although Iraqi women have higher status than in most other Islamic cultures
Children are cherished and indulged, although strictly punished for misbehaviour

Allegiance to the extended family and tribe is paramount
Traditionally men manage household finances and women are more responsible for childrearing. These roles may change after resettlement, depending on education and period since arrival
Arranged marriages are common and customarily girls are wedded as young as 12 or 13 in rural areas. Laws in resettlement countries curtail this practice. For people with formal education, marriage age is higher at 15 - 20.
Marriage to first-cousins is valued, particularly in New Zealand as backgrounds of other families are often unknown and futures therefore insecure
Marriage is sacred and serves as a bond between families
Married women live in the husband’s extended households
Households are usually segregated according to gender
Women are usually subservient to men although Iraqi women have higher status than in most other Islamic cultures (particularly amongst the Sunni where there are many educated and professional women)
Children are cherished and indulged although strictly punished for misbehaviour

Kurdish Iraqis

All the above points apply
Social organization is principally clan oriented
Males and parents are afforded great respect
Marriage must be sanctioned by the family
Khurdish women have higher status than in other Islamic cultures, and do not have to wear a veil
Khurdish women retain their own name after marriage, while the children carry their father’s name

All above applies
Social organization is principally clan oriented
Males and parents are afforded great respect
Marriage must be sanctioned by the family
Khurdish women have higher status than other Islamic cultures and do not have to wear a veil
Khurdish women retain their own name after marriage while the children carry their father’s name

Christian Iraqis

All above applies
Assyrian Christian women do not wear a veil

All above applies
Assyrian women do not wear a veil

6

Health Care Beliefs and Practices

Factors seen to influence health

Western concept of disease causation
Spiritual/religious
Supernatural
- Jinn spirit possession (usually not Christian)
- Evil eye
- Sorcery (not Christian)

Western biomedical concept of disease causation - This belief is well established although other attributions of ill health may co- exist along with western concepts
Spiritual/religious - Punishment from God for sins committed against God’s will (for some Iraqis life is believed to be pre-destined)
Supernatural
- Evil spirits known as ‘jinn’ in Islam can cause some illnesses, (often associated with mental health problems) (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)
Sorcery and witchcraft is believed to occur as a result of the actions of people and evil spirits working together (not for Christians)

Common Traditional treatments and practices

Western biomedical medicine
Traditional/complimentary practices
Magico-religious articles and religious/spiritual rituals

Western medicine - This has been well established since the 10^th century and is highly valued and commonly practised in Iraqi culture
Traditional/complimentary practices - There are variations across tribes and geographical areas but many herbs, henna dye, food items and rituals are used to treat common ailments (see Kemp and Rasbridge (2004, Ch. 21) for a list of examples
Magico-religious articles and religious rituals may be used. Articles such as amulets and the blue-glazed faience eye is common in Middle Eastern and North African cultures.

Important factors for Health Practitioners to know when treating Iraqi clients

Important factors for Health Practitioners to know when treating Iraqi clients
Same gender practitioners and interpreters are preferred by both men and women, but are imperative for gynaecological examinations Iraqi clients usually seek professional biomedical help early when feeling unwell The identified client is customarily accompanied by at least one family member who will often assist in answering questions. Treatment plans need to be discussed with family members as well Women retain their own name after marriage while the children carry their father’s name. Records need to accommodate this practice Trust may need to be established before clients will feel able to share enough information for a proper diagnosis When Iraqi people first resettle they usually expect a tangible intervention (prescription, injections etc.). If this is not offered at consultations rationale behind treatment plans may need explanation If medicine is prescribed, practitioners need to enquire about the use of herbal medicines to assess for potential drug interactions Compliance with prescriptions can be affected by language difficulties. Interpreters can assist with providing written instructions in the client’s own language Clients may refuse medication during Ramadan, or they may need to alter doses during this time Reasons for laboratory testing need to be clearly explained Doctors may need to explain the nurse's role as this role in a GP practice is not common in Iraq Dietary needs should be established if a client is to be hospitalized For older and more conservative Iraqi Muslims, western concepts of preventative medicine may conflict with beliefs that life has been pre-determined by God and should not be altered Any woman who has just undergone purification for daily prayer may not be touched When doing HOME VISITS: Give a clear introduction of nature of service, of roles and purpose of visit It is necessary to remove shoes before entering the home If food or drink is offered, it is acceptable to decline politely Iraqis regard their privacy highly and would appreciate assurances of absolute confidentiality at all times, but especially in dealing with mental health, fertility issues and terminal illness such as cancer Modest dress is appropriate No food or drink is consumed from sunrise to sunset during Ramadan

Same gender practitioners and interpreters are preferred by both men and women, but are imperative for gynaecological examinations
Iraqi clients usually seek professional biomedical help early when feeling unwell
The identified client is customarily accompanied by at least one family member who will often assist in answering questions. Treatment plans need to be discussed with family members as well
Women retain their own name after marriage while the children carry their father’s name. Records need to accommodate this practice
Trust may need to be established before clients will feel able to share enough information for a proper diagnosis
When Iraqi people first resettle they usually expect a tangible intervention (prescription, injections etc.). If this is not offered at consultations rationale behind treatment plans may need explanation
If medicine is prescribed, practitioners need to enquire about the use of herbal medicines to assess for potential drug interactions
Compliance with prescriptions can be affected by language difficulties. Interpreters can assist with providing written instructions in the client’s own language
Clients may refuse medication during Ramadan, or they may need to alter doses during this time
Reasons for laboratory testing need to be clearly explained
Doctors may need to explain the nurse's role as this role in a GP practice is not common in Iraq
Dietary needs should be established if a client is to be hospitalized
For older and more conservative Iraqi Muslims, western concepts of preventative medicine may conflict with beliefs that life has been pre-determined by God and should not be altered
Any woman who has just undergone purification for daily prayer may not be touched
When doing HOME VISITS:

Give a clear introduction of nature of service, of roles and purpose of visit
It is necessary to remove shoes before entering the home
If food or drink is offered, it is acceptable to decline politely
Iraqis regard their privacy highly and would appreciate assurances of absolute confidentiality at all times, but especially in dealing with mental health, fertility issues and terminal illness such as cancer
Modest dress is appropriate
No food or drink is consumed from sunrise to sunset during Ramadan

Important factors for Health Practitioners to know when treating Iraqi clients
As Iraqi who enter New Zealand have arrived as refugees, extra sensitivity and care in treatment is necessary given the possibility of extremely difficult pre-settlement experiences (see 5. below) Same gender practitioners and interpreters are preferred by both men and women, but are imperative for gynaecological examinations. A nurse will be preferred if only a male gynaecologist is available. Iraqi clients usually seek professional biomedical help early when feeling unwell. The identified client is customarily accompanied by at least one family member who will often assist in answering questions. Treatment plans need to be discussed with family members as well. Women retain their own name after marriage while the children carry their father’s name. Records need to accommodate this practice. Trust may need to be established before clients will feel able to share enough information for a proper diagnosis. When Iraqi people first resettle they usually expect a tangible intervention (prescription, injections etc.). If this is not offered at consultations clients may seek treatment elsewhere, or try their own. So rationale behind treatment plans may need more explanation than with western clients. After a period of resettlement however, the local traditions are understood and accepted. If medicine is prescribed, practitioners need to enquire about the use of herbal medicines to assess for potential drug interactions. Clients may refuse medication during Ramadan, or need to alter doses. They may need assistance with managing health regimes during this period. Compliance with prescriptions can be affected by language difficulties. Interpreters can assist with providing written instructions in the client’s own language. Reasons for laboratory testing need to be clearly explained. Doctors may need to take the time to explain the nurse's role to the client as this role in a GP practice is not common in Iraq. Dietary needs should be established if a client is to be hospitalized. For older and more conservative Iraqi Muslims, western concepts of preventative medicine may conflict with beliefs that life has been pre-determined by God and should not be altered. Any woman who has just undergone purification for daily prayer may not be touched. When doing HOME VISITS: Give a clear introduction of nature of service, of roles and purpose of visit It is necessary to remove shoes before entering the home If food or drink is offered, it is acceptable to decline politely. However, accepting would be appreciated as offering food is a gift of hospitality and it encourages openness and trust Iraqis regard their privacy highly and would appreciate assurances of absolute confidentiality at all times, but especially in dealing with mental health, fertility issues and terminal illness such as cancer. Modest dress is appropriate Be aware that no food or drink is consumed during sunrise to sunset during Ramadan

Important factors for Health Practitioners to know when treating Iraqi clients

As Iraqi who enter New Zealand have arrived as refugees, extra sensitivity and care in treatment is necessary given the possibility of extremely difficult pre-settlement experiences (see 5. below)
Same gender practitioners and interpreters are preferred by both men and women, but are imperative for gynaecological examinations. A nurse will be preferred if only a male gynaecologist is available.
Iraqi clients usually seek professional biomedical help early when feeling unwell.
The identified client is customarily accompanied by at least one family member who will often assist in answering questions. Treatment plans need to be discussed with family members as well.
Women retain their own name after marriage while the children carry their father’s name. Records need to accommodate this practice.
Trust may need to be established before clients will feel able to share enough information for a proper diagnosis.
When Iraqi people first resettle they usually expect a tangible intervention (prescription, injections etc.). If this is not offered at consultations clients may seek treatment elsewhere, or try their own. So rationale behind treatment plans may need more explanation than with western clients. After a period of resettlement however, the local traditions are understood and accepted.
If medicine is prescribed, practitioners need to enquire about the use of herbal medicines to assess for potential drug interactions.
Clients may refuse medication during Ramadan, or need to alter doses. They may need assistance with managing health regimes during this period.
Compliance with prescriptions can be affected by language difficulties. Interpreters can assist with providing written instructions in the client’s own language.
Reasons for laboratory testing need to be clearly explained.
Doctors may need to take the time to explain the nurse's role to the client as this role in a GP practice is not common in Iraq.
Dietary needs should be established if a client is to be hospitalized.
For older and more conservative Iraqi Muslims, western concepts of preventative medicine may conflict with beliefs that life has been pre-determined by God and should not be altered.
Any woman who has just undergone purification for daily prayer may not be touched.
When doing HOME VISITS:

Give a clear introduction of nature of service, of roles and purpose of visit
It is necessary to remove shoes before entering the home
If food or drink is offered, it is acceptable to decline politely. However, accepting would be appreciated as offering food is a gift of hospitality and it encourages openness and trust
Iraqis regard their privacy highly and would appreciate assurances of absolute confidentiality at all times, but especially in dealing with mental health, fertility issues and terminal illness such as cancer.
Modest dress is appropriate
Be aware that no food or drink is consumed during sunrise to sunset during Ramadan

Stigmas

Sue to add

Mental Health problems are seen as a stigma for Christian Iraqis
Suicide is forbidden by the Qur’an for Muslims so families with a suicide incident would feel shamed and stigmatized
Suicide is also not acceptable for Christians and a funeral service will not be conducted by the priest

Diet and Nutrition

Sue to add

Both Sunnis and Shiites observe ‘halaal’ laws. This involves eating halaal meat (meat that is blessed at slaughter by another Muslim in a prescribed way), and no alcohol or pork is consumed. (This does not apply to Assyrian Christian clients).

Meats, vegetables, rice and spices form the basis of the diet with flat bread ‘samoons’ part of most meals. Saffron, rose water and mint are typical flavourings. Nuts and raisins are another hallmark of Iraqi food.

For different reasons clients may not request special foods whilst in hospital and therefore may not eat much that is provided while hospitalized. Families are usually happy to supplement foods for family members. ‘Halaal’ meats needs to be provided for hospitalized Muslim clients.

Death and dying

Sue to add

Muslims

Life-support measures are acceptable to most Iraqis
Clients who are near death need to be turned to face Mecca
An opportunity to confess sins is customary
When death approaches, a male Muslim will recite verses from the Qur’an
Traditionally Muslims need to bury their deceased within 24 hours
Burial in a cemetery is required, cremation is not permitted
After death the male body is washed by a male relative or Imam (holy man), and a female by a female relative or midwife. They body is wrapped in a white cloth, not placed in a casket. The deceased should not be touched by non-Muslims, where possible, after death
The body is laid out in prescribed ways and prayers recited before it is taken to the cemetery
Women do not usually attend burials although it is becoming more common in resettled countries when they will remain at some distance from the graveside until the men have departed
Expression of grief varies sub-culturally. Sunnis are more restrained, and Shiites are expected to express their grief openly and intensely
Mourning ceremonies last 3 days followed by a further 40 where other ceremonies and celebrations are not attended by mourners
It is customary for family members to remain attached to the deceased and to honour the relationship in different ways

Christians (adherence depends on region orthodoxy)

A priest is called to administer the bukhra (holy bread) near death
Family members accompany the client at the last moments where possible
Traditionally Assyrians also bury their deceased within 24 hours
The body is placed in a casket which is buried (cremation is prohibited)
Traditionally a ceremony takes place in the home and then at the church
Grief is openly expressed by men and women
An important mourning ceremony is conducted on the 3^rd day following the death

Kurdish

Protocol and rituals are similar to Muslims in general (above). However women usually attend the burial and ceremony. After the funeral the family will stay home at least 3 days to 7 days to accept visitors

7

Health Risks and Concerns

As reported by Kemp and Rasbridge, 2004

Boutonneuse fever
Brucellosis or undulant fever
Cholera
Crimean-Congo hemorrhagic fever
Cysticercosis (tapeworm)
Dracumculiasis (Guinea worm disease)
Familial Mediterranean fever (Mediterranean area, primarily among persons of Sephardic Jewish, Armenian, and Arab ancestry)
Giardia
Helminthiasis (ascariasis,echinococcosis/hyatid disease, schistosomiasis)
Hepatitis B (13% carriage rate)
Hookworm
Leishmaniasis
Malaria
Plague
Sickle cell disease or sickle cell hemoglobulinopathies (occurs primarily in people of African lineage but to a lesser degree in Arabs)
Thalassemias
Toxocariasis
Trachoma
Trematodes (liver-dwelling: clonorchiasis and opisthorchiasis; blood-dwelling: schistosomiasis or bilharzias; intestine-dwelling; and lung-dwelling: paragonimiasis)
Trichinosis (trichinella)
Tuberculosis
Typhus
Post-traumatic stress disorder
Nutritional deficits

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 there were 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)
Mental health concerns due to experiences around deaths, sexual violence, war, physical abuse, and psychological trauma
- PTSD
- Depression
Low vitamin D deficiency (particularly women and girls which may be due to avoidance of sun and because of dress code to cover up)
Obesity after suffering malnutrition
Lack of sufficient daily physical exercise (higher amongst females)

Unexmundi (August 2014) lists the following as major diseases for people living in Iraq:

Hepatitis A and E
Typhoid fever
Malaria
Dengue Fever
Yellow Fever
Japanese Encephalitis
African Trypanosomiasis
Cutaneous Leishmaniasis
Plague
Crimean-Congo hemorrhagic fever
Rift Valley fever
Chikungunya
Leptospirosis
Schistosomiasis
Lassa fever
Meningococcal meningitis
Rabies

Social issues affecting health

Sue to add

Isolation (including older people who spend a lot of time alone at home)
Unemployment and poverty (many have significant financial issues and difficulties finding work)
Loss of standing in society
Being marginalized (race, cultural difference, clothes, education and refugee experiences)
Cultural adjustments impacted further by the lack of support from usual networks of family and community
Experiencing racial discrimination based on ethnicity (within own cultures)
Stigma of mental health and disability often means no societal support, and no disclosure of issues

8

Women's Health

For Iraqi women who have resettled as refugees a careful history taking will be needed to ascertain whether sexual abuse or rape has occurred
Some women re-locate alone as a result of family losses, separations and displacements

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 followed by African and Latin American women
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
Female Genital Mutilation (FGM/FGC) and its associated complications (See Introduction, Chapter 3 for more details)
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

For Iraqi women who have resettled as refugees a careful history taking will be needed to ascertain whether sexual abuse or rape has occurred. This is a frequent experience amongst refugee women in general. The history taking will need to be done when women only are present and disclosure will depend on rapport and trust built.

In general, refugee women (and men) need to be treated with extra sensitivity and care since they may suffer many of the conditions related to the tragedies and trauma of war, of trauma during flight, and re-location stress. In addition they are often responsible for the emotional wellbeing of the family who too may be weighted by similar psychological and physical loads. Some Iraqis re-locate alone without spouse or family support due to displacement and separation from families.

Traditional health practices and issues

Birth control is traditionally considered an interference with God’s will (as is abortion)
However, re-settled women are beginning to use oral contraception, depo-provera, IUDs, and tubal ligation
Resettled women are increasingly preferring female doctors over mid-wives
Women who have re-located without family may need extra emotional support, particularly for their first pregnancy
Deliveries traditionally take place at home, but in countries of resettlement women are more often choosing hospital births. Practitioners will need to explore preferences with clients
Men are usually not permitted to attend the birth
There is a preference for breastfeeding
For Kurds there is a ritual post-partum bath after 40 days to relieve the mother of bad spirits

Birth control is not common as this is considered an interference with God’s will (similarly for abortion)
Re-settled Iraqi women however, are beginning to use oral contraception, depo-provera, IUDs, and tubal ligation
Mid-wives play an important role in pre-natal care, childbirth and post-delivery care although resettled women are increasingly preferring female doctors
Women are usually relieved of regular household work by other household members and treated with extra care. Women who have re-located without family may need extra emotional support, particularly for first pregnancy
Deliveries traditionally took place at home with a midwife, particularly in rural areas. However this practice is changing both in Iraq and in countries of resettlement; women are more often choosing hospital births. Practitioners will need to explore preferences with clients
Childbirth is considered a female issue and men are usually not permitted to attend the birth. Women relatives and friends support the mother
There is a preference for breastfeeding
For Kurds there is a ritual post-partum bath after 40 days to relieve the mother of bad spirits

9

Youth Health

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)
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

Adolescent Health

Most resettled adolescents will be faced with role changes in the home, pressure from peers to integrate more quickly than they or their families may be comfortable with, and with the stigma of ‘difference’. Assistance and sensitivity from authority figures will be helpful
Many young children and adolescents have been subjected to violence themselves or have been witness to the atrocities leveled during the war, and in refugee camps
Symptoms of trauma may present as behaviour problems, withdrawal or learning difficulties as well as various somatic presentations
Some Islamic traditions, and the difficulty in explaining these because of language barriers, may deter children from attending social or school functions

Most resettled adolescents will be faced with:

Role changes at home
Pressures from peers to integrate more quickly than they or their families may be comfortable with
The stigma of ‘difference’. Assistance and sensitivity from authority figures will be helpful in the schools
Many young refugee children and adolescents have been subjected to violence or have been witness to the atrocities leveled at their families and communities during war, and in refugee camps. They may bear their experiences unnoticed. Parents managing the challenges of resettlement as well as their own pre- and post-relocation traumas are often unable to attend to, or to manage the distress of their children adequately. Sometimes children do not tell their parents in order to avoid added stress on the family, out of respect, or because they believe they are in some way to blame. Symptoms of trauma may present as behaviour problems, withdrawal, learning difficulties, poor concentration and motivation as well as with various somatic complaints. These presentations may mask post-traumatic stress, depression, anxiety and other mental health conditions. Practitioners and teachers need to be alert to the possibilities of pre-relocation trauma
Some Islamic traditions and the difficulty in explaining these to teachers and peers in a new language, may deter children from attending social or school functions (e.g. no cross-gender touching for adolescents, ablutions required during fasting and before prayers, time schedule for prayers, requirements of halaal food etc.)

Newborn Child Health

It is customary for Iraqi Muslims and Assyrian Christians to circumcise newborn boys within the first few days. This is followed by a feast
Kurds usually circumcise within the first 2 months
Traditionally it is preferred that females have their ears pierced at 1 week

It is customary for Iraqi Muslims and Assyrian Christians to circumcise newborn boys within the first few days, and to follow this with a feast
Kurds usually circumcise within the first 2 months
Traditionally it is preferred that females have their ears pierced at 1 week

10

Special Events

Muslims celebrate:

Ramadan
Id al-Fitr (celebration after fasting)
Id Arafa (important holiday for making pilgrimages to Saudi Arabia)
Moulid (celebrates birth and death of Prophet Mohammed, occurs during month after Ramadan). This may not be practiced by Sunni Muslims

Kurds celebrate New Year (Newroz) on March 21, which marks the independence of Kurds. They also observe Ramadan and the other Muslim ceremonies although the strictness of adherence to the rules on fasting varies according to their orthodoxy.

Christians celebrate Christmas, New Year, Easter, and various Saint’s days.

Muslims celebrate:

Ramadan
Id al-Fitr (celebration after fasting)
Id Arafa (important holiday for making pilgrimages to Saudi Arabia)
Moulid (celebrates birth and death of Prophet Mohammed, occurs during month after Ramadan). This may not be practiced by Sunni Muslims

Kurds celebrate New Year (Newroz) on March 21, which marks the independence of Kurds. They also observe Ramadan and the other Muslim ceremonies although the strictness of adherence to the rules on fasting varies according to their orthodoxy.

Christians celebrate Christmas, New Year, Easter, and various Saint’s days.

11

Spiritual Practices

Islam

Mostly Shiite
40% Sunni

Most Iraqis are Shiite Muslims with about 40% Sunni Muslims. Shiites tend to be more orthodox and strict in food, religious and social practices. Most women (especially older women and widows) usually wear full ‘hijab’ (purdah) where the entire body and face is covered. They are usually segregated from men both at home and in society. The political elite, military and merchant classes tend to be Sunni.

Kurds are usually Sunni Muslims and are not expected to be veiled.

Christianity

Assyrian Iraqis belong to the Assyrian Church of the East

Assyrian Iraqis belong to the Assyrian Church of the East. In Auckland, Iraqi Christians attend three main churches: the Chaldean Church, the Syrian Orthodox Church, and the Holy Apostolic Catholic Assyrian Church of the East.

12

References and Resources

View references and resources in the Comprehensive Guide section.

Alkass, E, & other Iraqi community members who wish to remain anonymous. (February 2007). Personal consultations on culture and practice amongst Christian and Muslim Iraqis resettled in New Zealand. Auckland.
Atallah, R. (1996). Voices of the Arab communities. Updated February 2015 from https://www.colorado.gov/pacific/sites/default/files/HPF_RH_Refugee-Iraqi-Refugees.pdf
Jackson, K. (2006). Fate, spirits and curses: Mental health and traditional beliefs in some refugee communities. New Zealand: Rampart
Kemp, C., Rasbridge, L. (2004). Refugee and Immigrant Health. A handbook for Health Professionals. Cambridge: University Press.
No author. (2014). Iraq Major Infections Diseases. Retrieved February 2015 from: http://www.indexmundi.com/iraq/major_infectious_diseases.html
Kemp, C. Iraqi Refugees. Retrieved November 2006 from www3.balor.ed/~Charles_Kemp/Iraqi_refugees.htm. Link no longer current in February 2015.
Maqsood, R.W. Thoughts on Modesty. Islam for Today. Updated February 2015 from: http://www.thecall.ws/uploads/Thoughts_On_Modesty.pdf
No author. Eating the Iraqi way. Updated February 2015 from http://www.ummah.com/forum/archive/index.php/t-129770.html
No author. Refugees International: Issues, Stories and Photos. Retrieved November 2006. Available at: http://www.refugeesinternational.org
Perumal L. Health needs assessment of Middle Eastern, Latin American and African people living in the Auckland region. Auckland: Auckland District Health Board, 2010.
Reuters (2015). 2014 deadliest year in Iraq for civilians since 2006-7 bloodshed – UN. Retrieved February 2015 at: http://www.trust.org/item/20150102111250-4e8ei/?source=spotlight
Veitch, J. & Tinawi, D. (2012). 'Middle Eastern peoples', Te Ara - the Encyclopedia of New Zealand. Downloaded February 2015 from: http://www.TeAra.govt.nz/en/middle-eastern-peoples
Yoab, B. (2006). Assyrian Rituals of Life-Cycle Events. Retrieved November 2006. Available at: www.aina.org/articles/yoab.htm

Resources

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.
ARCC can provide information on resettlement issues and contacts for community leaders. Contact +64 9 629 3505.
Refugee Services can be contacted on +64 9 621 0013 for assistance with refugee issues.
A number of health fact sheets can be found in Arabic and Assyrian for download in pdf. at: http://www.healthtranslations.vic.gov.au/
The http://www.ecald.com website has patient information by language and information about migrant and refugee health and social services.