Transcultural Nursing in Zambia: A Challenge for the 21st Century

Abstract

This article attempts to describe the concept of transcultural nursing, its importance, culture and health care and methods to promote it. Zambia is a multicultural nation comprising different ethnic groups. There is therefore, a need for cultural competence among nurses. The provision of cultural competent care by nurses in the country will result into improved quality nursing care for the multicultural populations living in Zambia.

Keywords: Transcultural nursing; Zambia; Challenge; 21^st century

Introduction

The concept of transcultural nursing was first coined by Madeleine Leininger in 1970. Transcultural nursing is defined as a comparative study of cultures to understand similarities and differences across human groups [1]. This is care that fits the people’s valued life patterns and set of meanings which is generated from the people themselves rather than based on predetermined criteria. The goals of transcultural nursing are to give congruent nursing care, and to provide culture specific and universal nursing care practices for the health and well-being of people or to aid them in facing adverse human conditions, illness or death in culturally meaningful ways.

Culturally congruent care may be distinct from the values and meanings of the professional health care system [2]. Therefore nurses need to learn clients’ cultures in order to provide cultural congruent care. Discovering clients’ culture care values, meanings, beliefs and practices as they relate to nursing and health care requires nurses to assume the role of learners of clients’ culture and copartners with clients and families in defining the characteristics of meaningful and beneficial care [1].

To be culturally competent nurses are required to posses’ specific knowledge, skills and attitudes acquired through professional education. Culturally competent nurses not only incorporate clients’ beliefs and practices into their nursing care but also maintain awareness of their own cultural beliefs and the effects of those beliefs on their nursing care. Such nurses are aware of stereotypes and their own potentially ethnocentric attitudes and are committed to preventing cultural conflict by taking time to develop a trusting relationship with clients and respecting the unique qualities of each client.

Zambia is a landlocked country located in southern Africa and has a total area of 752,618 kilometers. It borders Angola, Democratic republic of Congo, Malawi, Mozambique, Namibia, Tanzania, Zimbabwe and Botswana. Zambia has a tropical climate modified by the country’s altitude. Zambia is divided into 10 provinces and has 73 tribes. Due to this cultural diversity, Nurses in Zambia encounter cultural differences such as ethnic customs, traditional beliefs and taboos. These cultural differences are affecting the health care offered to clients.

Importance of transcultural nursing

Transcultural nursing is an essential component of health care today. Due to the numerous tribes that live in Zambia, quite often nurses in Zambia come across patients who belong to different tribes from themselves and fail to communicate when there is no translator. Because nurses spend more time providing nursing care to patients than any other health care providers they need to be culturally competent.

Moreover, there is an increasing number of people from other cultures working or immigrating to other parts of the world. Despite having so many tribes, it is not yet a mandate for Zambian nurses to be culturally competent in their practice. In addition, nurses are required to provide holistic nursing care to their patients. Holistic nursing care addresses the physical, psychological, social, and emotional and spiritual needs of patients [3]. This entails that nurses must identify and meet the patient’s needs in order to provide individualized care. After identification of the patient’s needs the next step is to plan the nursing care. Holistic care also takes into account patients’ cultural differences.

Culture and health care

Dochterman and Grace define culture as a pattern of values and beliefs that is reflected in the behaviours we demonstrate [4]. According to Leininger illness and wellness are shaped by various factors including perception and coping skills as well as the social level of the patient culture influences all spheres of human life. It defines health, illnesses and the search for relief from disease or distress.

Health and illness beliefs

Patients’ health and illness beliefs can have a profound impact on clinical care. Health and illness beliefs can impede preventive efforts, delay or complicate medical care and result in the use of folk remedies that can be beneficial or toxic [5]. Carteret states that culturally-based attitudes about seeking treatment are rooted in core belief systems about illness causation such as the personalistic, naturalistic, and biomedical theories.

In a personalistic system of belief, illness is believed to be caused by the intervention of a supernatural being or human being with special powers such as witchcraft or sorcery [5]. The naturalistic system of belief states that a person’s health is closely tied with the natural environment where a proper balance must be maintained and harmony protected, when balance is disturbed, illness results [5]. Biomedical theories postulate a core assumption of the value system which relies on the fact that diagnosis and treatment should be based on scientific data [5].

In the Zambian culture, the extended family has a significant influence and the oldest male in the family is often the decision maker and spokesperson. Furthermore, among Zambian, older family members and other relatives are respected and are often consulted on important matters involving health and illness. This can cause conflict with the decision of health workers because the family members have a greater say on the treatment of their relatives.

Cultural differences may affect patient’s attitudes about medical care and their ability to understand, manage, and cope with the course of an illness and the meaning of a diagnosis, however not all traditional beliefs negatively influence health and illness. Others have a positive influence on health.

Positive traditional practices

Some traditional practices which are regarded as positive include healthy postpartum practices based such as rest, cleanliness, love, good nutrition and long period of breast feeding practiced in many parts of Africa, and other developing countries such as Latin America, and Asia [6,7]. Long-term breastfeeding provides optimal nutrients for infants’ immunological defenses and facilitates both mothers’ recovery from childbirth and mother-infant attachment (ibid). Duncan et al., and Lucas et al., describe breastfed children to be less likely to have otitis media, allergies, diarrhoea, lower respiratory infections and bacterial meningitis [8,9].

Negative traditional practices

Cultural practices such as nutritional taboos ensure that pregnant women are deprived of essential nutrients, and tend to suffer from iron and protein deficiencies. Most communities throughout Africa have food taboos especially for pregnant women that exclude the consumption of nutrients essential for the expectant mother and fetus. A study carried out by Azumah in Kumasi, Ghana, respondents indicated that expectant mothers were forbidden to eat salty foods (including fish-‘koobi’, ‘momoni’), meat and eggs, oily foods, bananas, ripe plantain okro, garden eggs and snail [10]. When asked why they were forbidden to eat these foods, the respondents indicated that with the proteins (meat and eggs) this would facilitate having big babies thus leading to complications during delivery, which could lead to loss of life of both mother and baby. It was also believed that these foods could affect the child causing him/her to steal later in life. The ripe plantain and bananas were believed to cause premature contractions and subsequently miscarriage, and delaying falling off of the umbilical cord whereas okra and snail were said to cause slime in babies or dripping mouth.

Cultural practices and beliefs in Zambia which impact negatively on health

Findings of a study done by Maimbolwa and others reveal that traditional birth assistants advised women on the use of traditional medicine to widen the birth canal and to precipitate labour [11]. In the same study it was discovered that if something went wrong during labour, they relied on traditional beliefs and witchcraft to explain the mishap and expected the woman in labour to confess her purported ‘bad’ behavior. These birth assistants lacked understanding of the cause of obstetric complications during childbirth, and had inadequate knowledge of the appropriate management of labour.

The midwife is put in an awkward situation when handling such women in labour. Although health education starts in the antenatal period, women with such preconceived ideas are unlikely to co-operate with the initiative availed to them by the health care provider thus leaving them at risk of infection and other obstetric complications such as ruptured uterus.

Nsemukila et al., reported that in some communities in Zambia, pregnant women are not allowed to eat certain foods/drinks some of which are rich in nutritional value [12]. Examples are eggs, chicken, fish (red bream, cat fish and tiger fish), pork hare, tripe, alcohol, hot drinks and fresh meat. A pregnant woman should not eat meat of a hare because the baby will have a cleft palate and should not eat eggs because the bay will have no hair or have no vaginal opening if it is a girl. A pregnant woman should not eat chicken because the baby will be born without hair, should not eat fish because she will have abdominal pains or bleeding during pregnancy and not eat fresh meat because the placenta will come out in pieces during delivery. S pregnant woman should not drink alcohol as it will damage the baby and should not take hot drinks for fear of the bay being burnt.

Other food related beliefs and practices include not eating left over foods because the baby will be born with spots or pass stool before delivery and that a pregnant woman should not finish food on her plate when eating because she will open bowels during delivery and this is embarrassing.

Most of the sex-related traditional beliefs and practices are associated with consequences of extra-marital relations. It is widely believed that extra-marital sex during pregnancy will bring misfortune to the pregnant woman if her husband or the man responsible for the pregnancy engages in sex with another woman. It is believed that the woman may die during pregnancy or delivery due to obstructed or prolonged labour. The woman is also advised not to have sex in the last trimester of pregnancy because the bay may die during pregnancy, be covered with sperms at birth or have large or depressed Fontanelles.

In most communities, there are beliefs and practices a woman should follow after delivery [12]. For instance, a woman who has just delivered should not prepare food for other people or put salt in food until she is cleansed with traditional medicine otherwise the people who eat such food will have chronic cough. Such a woman is not allowed to cook until the baby’s umbilical stump drops off. After delivery, a woman should not eat meat until the umbilical cord stump drops offs otherwise the woman would experience abdominal pains and should not eat okra because her bleeding will not stop.

It is also commonly believed that the couple should not engage in sex after delivery for certain periods of time. Sexual abstinence after delivery is achieved by sending the woman to her parents until the baby grows.

Muller and Moyo conducted a research entitled “The influence of cultural practices on the HIV and AIDS pandemic in Zambia’ [13]. One of the practices mentioned in that research is that among the Chewa people, a girl is secluded when she has attained puberty. Thereafter a ritual is performed at the end of that period where she is subjected to sexual intercourse whether she is married or not as proof that she is able to practice what has been taught to her. This might subject her to acquiring HIV and AIDS as she might not know the HIV status of the sexual partner. Another cultural practice observed among the Ngonis and Tumbukas tribes is where a woman is unable to conceive and is made to have sex with another man, usually a relative to the husband. If he has HIV then she is likely to acquire the infection. The man equally can be made to have sex with another woman if his wife is unable to conceive thus subjecting him to the same consequences.

Ritual cleansing

Ritual cleansing is another practice which is which is documented as one of the most deep-rooted and widespread among Zambia’s 73 ethnic groups [14]. Though some tribes use other means to “cleanse’ the surviving partner of the spirit of the dead spouse, sexual cleansing is the known and acceptable way among most of Zambia’s big ethnic groups. These include the Tonga and allied groups of the Southern and Central Provinces, the Bemba speaking people and some allied ethnic groups of the Northern, Luapula, Central and Copper belt provinces, the Lunda-Luvale of Northwestern and some tribes found in the Eastern Province. The habit is not dying out as fast as it is expected.

Spouse inheritance and polygamy

Spouse inheritance is another negative cultural practice in Zambia. This involves marrying off the surviving partner to a relative of the deceased which was traditionally meant to ensure that there is continuity of the family, its reproductive role and to ensure proper care of the children of the deceased. Polygamy is a cultural practice where a man marries more than one wife ranging from two to ten or even more in some cases. Widow inheritance sometimes contributes to the bigger number of wives. Given the evidence that having many sexual partners increases one’s chances of being exposed to HIV, polygamy and extramarital relationships, both of which are culturally tolerated, play a part in increasing the HIV prevalence in Zambia.

“Dry Sex’ practice

“Dry sex’ is described as sexual intercourse with a woman who has a very tight vagina, achieved through the repeated use of local substances and herbs. Dry sex is traceable to the traditional society but has also continued being practiced in modern Zambia. A study done by Nyirenda in 1991 [15], found that as high as 86% of the respondents practiced dry sex resulting from the use of one type of herb or another. The practice of dry sex is meant to consolidate relationships. However, with the advent of HIV and AIDS, concerns have been raised linking it to HIV transmission due to genital ulceration of both male and female organs during sexual intercourse which in turn facilitates the exchange of blood agents, including HIV.

Methods of Healing

Herbal medicine

Some communities in Zambia believe that Witchcraft does exist and is responsible for some explained illnesses. To prevent witchcraft, traditional medicine should be taken either through orally, topically or through scarification.

Dreams are part of the powers of divination used by most traditional healers. For example, a traditional healer from Lundazi district in the Eastern province of Zambia, uses what he called the “African X-ray’ and uses his head or trained mind to determine what is wrong with the patient [16]. The traditional healer always dreams about trees whose roots are prescribed and the herbs will cure the particular disease, however difficult the disease might be. According to Tembo the prescriptions of medicines for diseases come from the traditional healer’s dreams. He dreams and then writes the names of the medicinal trees or herbs so that his children may be able to identify the medicinal trees and herbs in future. This is common in many families as the supernatural powers are passed from one generation to another.

Spiritual healing

Many people in Zambia believe in divine healing. For instance, the Life Tabernacle Assembly of the United Pentecostal Church of Zambia congregants’ believe that the first covenant that the Lord made with the children of Israel after they were brought out of Egypt was a covenant of healing [17]. Kwatu reports that spiritual and traditional healers are reported to have invaded Zimba and Kalomo districts of the Southern province of Zambia and are discouraging people living with HIV from taking antiretroviral drugs and instead quarantine them in camps for either taking salty water and herbs alongside prayers for them to be healed [18].

Music

Traditional African healers and healing ceremonies have been studied for years in an attempt to better understand the peoples and cultures. A study conducted by Benjamin Wilson in the Ashanti region of Ghana, West Africa, entitled, “The Drumming of Traditional Ashanti Healing Ceremonies’ Music has been shown to have a significant role in the healing ceremonies of many African peoples, ranging from the Zar cults of Ethiopia and Sudan, to the Tonga of Zambia, the Shona of Zimbabwe and the Malagasy of Madagascar [19]. Music is played at the shrines and the different social groups among the Ashanti often have specific drum rhythms performed at shrine ceremonies. In this study, Wilson concluded that drumming has a significant role in Ashanti healing ceremonies.

Narayan states that cultural competence could be best achieved by taking three progressive steps namely adopting attitudes to promote transcultural nursing care, developing awareness for cultural differences and performing a cultural assessment [20].

According to Narayan, caring is one of the four important attitudes necessary for promoting transcultural and culturally competent nursing care. To demonstrate a caring attitude, nurses should take time to understand and appreciate their patients’ cultural needs and perspectives. This also shows respect and concern for the patients. The second attitude necessary for promoting transcultural nursing and cultural competency is empathy. Empathy is the capacity to gain entry into the experience of another person, and to be able to see the world as it were through their eyes, and to communicate this understanding to him [21]. For a nurse to be empathetic, she/ he should view problems or situations from the patient’s cultural perspective. When a patient knows that his/her culture is understood and appreciated by the nurses taking care of him, she/he develops a sense of security. Openness is the third attitude for nurses to cultivate for effective transcultural nursing. Openness to the patient’s cultural perspectives shows the patient that nurses give consideration to their culture. It also shows that nurses appreciate cultural differences and diversity. The fourth attitude nurses should possess in order to cultural competent is flexibility. Nurses should demonstrate flexibility by showing their willingness to provide care based on their patients cultural ways which helps them feel assured that their care is individualized leading to the achievement of mutually set goals.

Nurses should develop awareness for cultural differences in order to provide culturally competent care. They should be aware that their patients may have various cultural differences. Therefore it is important to find out about each individual patient’s cultural preferences, however, nurses need to aware of cultural diversity within a cultural group. No person is a stereotype of a culture.

The final step that nurses need to take to be cultural competent is performing a cultural assessment on their patients. Cultural assessment helps a nurse to obtain necessary information about the patient’s his cultural preferences.

Challenges

Meyer discusses four major challenges providers and cultural competency in health care. The first challenge is that of recognizing clinical differences among people of different ethnic and racial groups [22]. The second challenge is communication. Establishing an environment where cultural differences are respected begins with effective communication. This occurs not just from speaking the same language but also through body language and other cues such as voice, tone and loudness. Patients may also not be free to talk about sensitive matters like sexuality especially if the nurse is younger than them. The third challenge is ethics. Respect for the belief systems of others and the effects of those beliefs on well-being are very important to the provision of culturally competent care. The last change is trust. For some patients, authority figures are mistrusted for no apparent reason.

Conclusion

Differences exist among individuals of all cultural groups. To provide cultural competent care nurses need to know and to understand culturally influenced health behaviours. Mc Laughlin and Braun state that nurses can employ strategies for working with patients in cross-cultural settings such as learning about the cultural traditions of the patients they are caring for; asking he patient and family open-ended questions to gain more information about their assumptions and expectations and lastly [23], remaining nonjudgmental when given information that reflects values that differ from theirs. This cannot be achieved if nurses do not have the ability and knowledge to communicate and understand health behaviours influenced by culture. Transcultural nursing, therefore warrant careful consideration.

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