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A Comparison of the Prenatal Health Behaviors of Women from Four Cultural Groups in Turkey: An Ethnonursing Study

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This research was conducted to uncover women's health behaviors during prenatal periods using a transcultural approach. The qualitative ethnonursing method was used, and the research was conducted at the family health center in Bornova District in Izmir. The data were collected between November 2007 and August 2008 using the purposive sampling method. Eighteen pregnant women were included in the study and in-depth face-to-face semi-structured interviews were recorded on an audio recording device. A thematic analysis revealed four main themes: family, social learning-tradition transfer, perceptions, and behavioral changes.
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Nursing Science Quarterly
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DOI: 10.1177/0894318413489180
2013 26: 257Nurs Sci Q
Emel Tasçi-Duran and Umran Sevil
Ethnonursing Study
A Comparison of the Prenatal Health Behaviors of Women from Four Cultural Groups in Turkey: An
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Article
This study is a report of women’s health behaviors during the
prenatal periods using a transcultural approach. The research
was conducted in a regional family health center in the Izmir
metropolitan municipality in Turkey. Its goal was to illumi-
nate women’s prenatal health behaviors in relation to culture
using a transcultural approach. The potential findings regard-
ing the participants’ culturally valued practices could be
incorporated into prenatal care programs for Turkish women
from different cultural groups.
Related Literature
Pregnancy and childbirth are almost universally associated
with culturally based ceremonies and rituals (Brathwaite &
Williams, 2004). In Turkish culture, having a child carries eco-
nomical, psychological, and social value (Taspinar & Demir,
1999). Traditions and customs are transferred from one gen-
eration to the next within the family, and it is possible that
family-related factors might play a causative role in the vari-
ous circumstances that impair an individual’s health (Burk,
Wieser, & Keegan, 1995; Ozcelik, 1997). These traditions and
customs might include traditional health behaviors that could
lead to a mothers death (Brathwaite & Williams, 2004).
Insufficient nourishment and education, an excessive
number of births, an unhealthy birth environment, and insuf-
ficient perinatal healthcare are the main reasons for infant
and maternal death in Turkey (Taspinar & Demir, 1999).
Factors such as the mothers education level, age, number of
births, and socioeconomic status also directly affect the
usage level of maternal care services (Duzgun, Baytekin,
Ozsan, Kıyak, & Erbaydar, 2004). The percentage of moth-
ers who receive prenatal care in western Turkey is 94.7%; in
the eastern regions, it is 76.8% (Türkiye Nüfus Saglık
Araştırması, 2008). The pregnancy-related mortality rate is
38.3 (±2.8) per 100000 in Turkey; however, there are consid-
erable differences among regions. The highest pregnancy-
related mortality rate is 93.3 (±17.2) and is found in the
northeastern part of the Anatolia region (Koc et al., 2005).
Most pregnancy-related deaths can be prevented by high-
quality medical care. In Turkey, the healthcare systems
include private and state institutions. The health facilities
that are available to most women are family health centers,
which are the first-degree health institutions at the neighbor-
hood level. In these centers, antenatal care can be provided
by nurses, midwives, and physicians.
Culture is a learning form that is shared by the transfer of
a group’s lifestyles, values, and religious knowledge in a way
that affects the group members’ thoughts, decisions, and
behaviors (Leininger, 2002). Turkey has a rich cultural diver-
sity (Ayata, 1997). Cultural norms and traditional beliefs
489180NSQ
XXX10.1177/0894318413489180Nursing Science QuarterlyDuran and Sevil
research-article2013
1
Assistant Professor, Süleyman Demirel University,
Health Sciences Faculty, Nursing Department, Gynecology and Obstetrics
Nursing, Isparta, Turkey
2
Professor, Ege University, Nursing Faculty, Izmir, Turkey
Corresponding Author:
Emel Tas¸çı-Duran, Suleyman Demirel University, Health Sciences Faculty,
Nursing Department, Gynecology and Obstetrics Nursing, Isparta 32260,
Turkey.
Email: tasciemel@gmail.com
A Comparison of the Prenatal Health
Behaviors of Women from Four Cultural
Groups in Turkey: An Ethnonursing Study
Emel Tas¸çı-Duran, RN; PhD
1
and Umran Sevil, RN; PhD
2
Abstract
This research was conducted to uncover women’s health behaviors during prenatal periods using a transcultural approach.
The qualitative ethnonursing method was used, and the research was conducted at the family health center in Bornova
District in Izmir. The data were collected between November 2007 and August 2008 using the purposive sampling method.
Eighteen pregnant women were included in the study and in-depth face-to-face semi-structured interviews were recorded
on an audio recording device. A thematic analysis revealed four main themes: family, social learning-tradition transfer,
perceptions, and behavioral changes.
Keywords
ethnonursing, Leininger, transcultural healthcare, immigrants/migrants, qualitative
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258 Nursing Science Quarterly 26(3)
affect women’s quality of care and their health-related
behaviors during pregnancy. Some studies of health-related
behaviors provide examples of these effects (Burk et al.,
1995; Brathwaite & Williams, 2004; Essen et al., 2000;
Taspinar & Demir, 1999; Sukhdev, Bhagat, & Lynda, 2008;
Vonderheid, Montgomery, & Norr, 2003).
A discussion of personal traditions and practices should
be considered as part of the birth plan and should take place
between the mother and the nurse or midwife during the pre-
natal period. Midwives and nurses and mothers must not
only advise but also understand the characteristics that form
the cultural differences between individuals (Hung, 2001).
During a prenatal interview, factors affecting a mothers
health status should be detected as well as the educational
needs in relation to care (Vonderheid et al., 2003).
Research showing differences in pregnancy-related health
behaviors among the different cultural groups in Turkey is
important, as is research that provides information about
these health behaviors, particularly in terms of planning
health services for migrants. No large-scale, qualitative
research on this subject has been conducted in Turkey to date.
Immigration and Prenatal Care
Childbirth experiences differ in different societies
(Brathwaite & Williams, 2004). Migrating families might
have different cultural structures compared with native
groups. Studies have found that migration is characterized by
increased health-related problems (Essen et al., 2000; Topcu
& Beser, 2006). The difficulties women face as a result of
immigration are often aggravated by poor Turkish language
skills and limited social opportunities to improve those skills;
different patterns of personal health practices and coping
skills; and diverse values, beliefs, and practices about, among
other things, gender roles (Reitmanova & Gustafson, 2008).
Studies have indicated that women who migrate make
little use of antenatal care services; these women have a
greater risk of delivering a baby with low birth weight, who
is premature, and who has congenital anomalies, as well as a
higher rate of perinatal mortality (Alderliesten et al., 2008;
Bollini, Pampallona, Wanner, & Kupelnick, 2009; Hayes,
Enohumah, & McCaula, 2011; Roosmalen & Zwart, 2009;).
Furthermore, studies have also stated that immigrant women
receive less antenatal care than native women because of cul-
tural barriers (Alderliesten et al., 2008; Bollini et al., 2009;
Essen et al., 2000; Reitmanova & Gustafson, 2008).
Therefore, it is essential to understand immigrant women’s
experiences of childbirth to preserve the health of the mother
and child (Brathwaite & Williams, 2004).
Conceptual model
This study was conceptualized within The Theory of Culture
Care Diversity and Universality (Leininger, 2002).
Transcultural nursing studies have shown that there may be
cultural differences between the healthcare provider and the
care recipient that could affect the patient’s well-being. The
culture care theory provides a holistic guide for learning
about the lifestyles of pregnant Turkish women and using this
knowledge to explain and understand prenatal care within the
cultural context of the patient. The Sunrise Model (Leininger,
2002) was used as a comprehensive cognitive map to exam-
ine cultural components that could influence care such as eth-
nohistory, language, the social and structural factors of
religion/spirituality, technology, kinship/social relationships,
cultural values/lifestyle, economy, and education (Leininger
&McFarland, 2002). This model of cultural care reflects the
influences of worldview on the cultural and social structure
dimensions that affect language and the environment. These
factors then influence the folk, professional, and nursing sys-
tems (Hitchcock, Schubert, & Thomas, 2003). The model
illustrates a differential conceptual and theoretical research
method that can be used to examine the diversity and univer-
sality of care phenomena. This model has been developed
during the past two decades and is being used by several
nurse researchers. The focus of the model is to generate
knowledge concerning basic and applied health and illness
care. This model is presented here to help researchers concep-
tualize the ethnonursing field of research and to note the value
of conceptualizing macro, middle, and micro types of theory,
research, and methodological approaches (Leininger, 1998).
Research questions
An ethnonursing study was conducted to answer the follow-
ing research questions: How do women’s cultural attributes
affect their health behaviors during the prenatal period?
What are the differences in health behaviors among women
with different cultural attributes during the prenatal period?
Methodology
Design
The qualitative ethnonursing method was used in this study.
The ethnonursing method was developed by Leininger in the
early 1960s and has been used to study many cultures and
subcultures. The method was designed to fit the culture care
theory to obtain meaningful data. The ethnonursing method
focuses on naturalistic, open discoveries, and it uses largely
inductive approaches to document, describe, explain, and
interpret the informants’ worldviews, meanings, symbols,
and life experiences related to actual or potential nursing
phenomena. The method supports the goal to become knowl-
edgeable about the informants’ emic (or the insiders’) per-
spective while remaining attentive to the etic (or the
outsiders’) knowledge related to worldviews, professional
attitudes, biases, racial, and gender views as well as other
factors that could influence the collection and interpretation
of data (Leininger, 1998; Leininger & Mcfarland, 2002).
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Duran and Sevil 259
Setting
The research took place at a family health center in Bornova
District in Izmir. Bornova, one of the central districts of
Izmir, is a slum district in Turkey with the highest rate of
immigration (Bornova, 2009). Both native families of Izmir
and immigrant families reside in the region of the Bornova
family health center. The research data were collected
between November 2007 and August 2008. The data were
collected during the week at a time when it was appropriate
to meet the women who participated in the study.
Research Ethics
Permission to conduct the study was granted by the Board of
Scientific Ethics of the Ege University School of Nursing.
Additionally, written permission to conduct the study was
granted by the Family Health Center in Bornova District in
Izmir. Verbal consent was obtained from all participants stat-
ing that they were willing to participate in the study.
Participants
The study population consisted of pregnant women between
the ages of 15 and 49 years. The households whose identifi-
cation cards indicated that they were served by the family
health center in Bornova District in Izmir were examined,
and pregnant women living in homes in these regions were
identified. Researchers examined the records of these preg-
nant women and collected their information. Additionally,
researchers noted the cities from which the potential partici-
pants migrated to Izmir. The distribution of migration in the
region of the health center was evaluated at the beginning of
the study, and it was discovered that there was a considerable
amount of migration in this region. To allow comparisons,
the towns of Kars, Agri, Izmir, and Manisa were chosen to
provide the sample group of women. During the data collec-
tion, we observed that Kars and Agri were dominated by
women with different cultural features (family structure, tra-
ditions, traditional structure). The groups from Izmir and
Manisa were combined because they have similar cultural
features (family structure, traditions, traditional structure).
Kars and Agri are in eastern Turkey, and Izmir and Manisa
are in western Turkey.
In this study, the purposive sampling method of qualita-
tive research was used. Thirty pregnant women met the sam-
ple criteria. A total of 19 women who lived within the
sampling boundaries were pregnant and agreed to participate
in the study. There is no required sample number in qualita-
tive research. In accordance with the purpose and fieldwork
methodologies used in ethnonursing studies, 10 to 15 partici-
pants are desired (Leininger, 1998). The criteria for inclusion
in the study were as follows: the participant had to be from
Izmir, Manisa, Kars, or Agri, as well as be in the third trimes-
ter of pregnancy, be free from any chronic illness, have a
healthy pregnancy, be able to understand and participate in
the conversations (in Turkish), and agree to participate in the
study.
Data collection
The data collection tool consisted of two parts: an informa-
tion form identifying the women and a semistructured inter-
view form. The interview questions were created by the
researcher for the purpose and method used in this research;
they were based on the Sunrise model in accordance with the
appropriate literature (Burk et al., 1995; Hung, 2001; Korcun,
Keceli, & Sanli, 2008; Taspinar & Demir, 1999; Vonderheid
et al., 2003; Willis, 1999). The interview questions were
evaluated by experts who specialize in the field of sociology
of health and obstetrics and gynecology nursing.
The interview form consisted of questions relating to fam-
ily structure, culture, health, illness definitions, health behav-
iors related to the prenatal period, prenatal care taken, and
the use of healthcare services. A pilot study was conducted to
ensure the interview form’s validity and reliability. During
the pilot study, one pregnant woman was interviewed at the
family health center and two pregnant women were inter-
viewed in their homes. At the end of the interviews, the inter-
view form was reviewed and rearranged by the researchers
and specialists.
The interviews were conducted in the women’s home
environments on previously determined dates. The data were
collected during the second interview; the first interview was
used to allow the researcher and the participants to become
acquainted and comfortable with each other. The interviews
were conducted face-to-face using an in-depth interview
technique. Each semistructured interview was recorded on
an audio recording device. There were no issues related to
the participants being uncomfortable about being recorded.
Observations about the participants’ nonverbal behaviors
were noted after the interviews. After the interviews, the
interactions were listened to repeatedly and transcribed into
a typed format using a computer. Depending on the answers
given by the women, the discussions lasted 90 to 120
minutes.
Data analysis
A thematic approach was used for the data analysis. The anal-
ysis was performed according to Leiningers (1998) six steps
of thematic and pattern analysis for qualitative data: Step 1:
Identify and list the descriptors (pieces of raw data) of nursing
observations and experiences or the domain under study.
Step 2: Combine the raw data and descriptors into meaningful
sequential units or larger units, known as patterns. Step 3:
Identify mini or micro patterns and determine how they relate
to the patterns and themes. Step 4: Synthesize several patterns
to obtain a broad, comprehensive, and holistic view of the
data in terms of themes and subthemes. Step 5: Formulate
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260 Nursing Science Quarterly 26(3)
theme statements to test or reaffirm further nursing phenom-
ena. Step 6: Use the confirmed themes for developing hypoth-
eses, decisions, and nursing interventions.
The material was transcribed word for word from the
audiotapes. The data were reviewed repeatedly. To classify a
document’s key ideas, the researchers identified its themes,
issues, and topics. During the interviews, the researchers
took field notes related to the woman’s home environment
and the activities that were occurring in the home.
The transcripts of the field notes and the interviews were
coded independently by four experts, one of whom was a
sociologist who specialized in the sociology of health. The
experts then met to come to an agreement on the codes.
Through this process, the researchers identified emerging
cultural themes. The first author did all of the transcription
herself. Once the interview transcripts were completed, they
were thoroughly reviewed before the coding process began.
This was achieved by repeatedly reading each transcript to
define the core aspects of what each informant communi-
cated. The meaning of each statement (the code) was then
written in the margin of the transcript. Through this process,
the author simultaneously identified recurring key phrases
and patterns of statements. The codes and responses were
subsequently organized into categories according to the
recurrences of major themes and subthemes, and then all the
data were interpreted according to theme and reported.
The purposive sampling method was used to increase the
reliability and validity of the study; furthermore, data varia-
tion allowed participants from regions with different fea-
tures to be included in the study. The interviews were also
supported by observations. In this study, four specialists and
the researchers conducted the analysis. The participants
were asked whether to add or remove any topics, and the
data were reviewed again. A detailed description of the top-
ics is provided below, and in many cases, direct quotations
are presented.
Findings
The average age of the Izmir and Manisa women was 28.28
(±6.15) years. The average age of the Agri women was
26.62 (±5.39) years. The average age of the Kars women
was 33.00 (±6.37) years (Table 1). When the sociodemographic
characteristics of the women in each group were examined,
it was found that 42.9% of the women in the Izmir and
Manisa group were high school graduates. It was deter-
mined that 75% of the women in the Agri group were pri-
mary school graduates. In the Kars group, 42.9% of the
women were primary school graduates (Table 2).
Four of the women were from Kars, eight were from
Agri, and seven were from Izmir and Manisa. From the
interviews, four themes were identified, and subthemes
were generated. The main themes were family, social learn-
ing and the transfer of tradition, perceptions, and behavioral
changes (Table 3). In the quotes below, (I) represents the
Izmir and Manisa group, (K) represents the Kars group, and
(A) represents the Agri city group.
Family
The family theme consists of three subthemes: power structure
in the family, family value system, and family dynamics.
Power structure in the family. This theme is related to the fam-
ily power structure and the decision-making process in the
family that is related to this structure. A democratic method
is used in families that have a common decision-making pro-
cess; for families in which elders are dominant in the decision-
making process, a patriarchal structure is present. The
majority of the women in the Izmir, Manisa, and Kars groups
indicated having a democratic structure in the family. The
majority of the women in the Agri group indicated that their
families have patriarchal structures and that women are
under pressure from family elders, usually women in the
extended family: “The opinions of my mother-in-law are
given more importance. For instance, when I’m going some-
where, I need to get permission from all of them and inform
them all [mother-in-law, father-in-law]” (A5).
Family value system. In this section, some of the patterns
related to the family value system and some values related to
attitudes and behaviors are included. Some of the women in
the Agri group mentioned that there are certain sanctions in
the family: “I have to think like ‘I wonder what happens if I
do it like this or put it here.’ You’ve got to act according to
the rules [traditional rules]” (A5).
Table 1. Averages for selected sociodemographic characteristics.
Izmir/Manisa Agri Kars
±SD (Min-Max) ±SD (Min-Max) ±SD (Min-Max)
Age 28.28±6.15 20-39 26.62±5.39 19-34 33.00±6.37 27-42
Duration of stay in Izmir 23.57 ±8.92 12-39 16.01 ±11.52 0.6-34 19.00 ±9.55 8-27
Number of children 0.85±1.06 0-3 1.37±1.06 0-3 1.25±1.26 0-3
Number of pregnancies 2.14±1.34 1-5 2.75±0.88 2-4 2.00±1.41 1-4
Marriage years 7.00±6.11 1-17 7.75±6.11 3-19 4.50±4.04 1-8
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Duran and Sevil 261
Family dynamics. In general, the term family dynamics
described domestic family interactions and domestic family
functions under the influence of social and cultural factors.
Traditions, communication styles, behavioral patterns, and
emotional interdependence all influence the dynamics among
family members. In the Izmir and Manisa group, healthy
family functions are expressed within the domestic family
functions. In the Izmir, Manisa and Kars groups, some of the
women reported that they independently made decisions
related to family and health: “They [mother-in-law, father-in-
law] do not bother me. My husband says ‘my wife will go to
the hospital;’ that is it, it is not up to them” (I1). “My mother-
in-law does not interfere with anything [decisions]” (K4).
In the Agri group, the dependence on unhealthy family
functions is often mentioned: “I cannot even go to the health
center. I have to go to the hospital with my husband or hus-
band’s family. Our family income is dependent on them
[mother-in-law, father-in-law]” (A5).
In a healthy family, members communicate with each
other clearly in a complementary and appropriate way. One
of the women from the Agri group expressed the existence of
ethnic communication (the language spoken by people of
Kurdish ethnic origin) among people in the family and the
impact of this type of communication on health. “I do not
speak Turkish; it is spoken among young people. Even with
my husband, I speak Kurdish. They [the elders of the family]
cannot speak Turkish. When women who do not know
Turkish get sick, one of the Turkish-speaking people goes to
the hospital with them.”
Once I went to a doctor. One woman came with her mother-in-
law and father-in-law. I think she did not speak Turkish [because
of the traditions; Turkish communication is prohibited for a
woman with mother-in-law and father-in-law]. Her mother-in-
law did not speak it either. The doctor asked if the woman had
swelling, but she did not speak Turkish, because the woman was
with her mother-in-law. She was eight months pregnant and her
situation was critical (A3).
Social Learning and the Transfer of Tradition
There are differences among groups in terms of social learn-
ing and transmission of tradition. These differences are
described here. In the Agri group, some women made state-
ments about the transmission of some traditions from
Table 2. Sociodemographic characteristics.
Characteristic Category Izmir/Manisa N Agri N Kars N
Education Literate ------ 2 ------
Primary school 3 6 2
Secondary school 1 ------ 1
High school 3 ------ 1
Intermarriage Yes 6 ------ ------
Income Don’t know ------ 4 ------
0-478 lira
a
2 ------ ------
479-800 lira 1 1 3
801-1200 lira 2 3 1
1201-1500 lira and 2 ------ ------
Social security No 5 ----- ------
a
1 lira=0.53 USD
Table 3. Themes.
Themes Subtheme
Family Power structure in the family
Family value system
Family dynamics
Social learning and the transfer of tradition ------
Perceptions Perception of health
Perception of illness
Perception of pregnancy and related traditional attitudes
Behavioral changes Safety/protection during pregnancy
Nutrition habits and cultural behaviors during pregnancy
Traditional thoughts about sleep during pregnancy
Practices related to birth and the use of the health care system
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262 Nursing Science Quarterly 26(3)
generation to generation. “Our traditions are very different.
For example, we stay with our mother-in-law, and you never
fail in respect to her” (A1). “We, eastern people [east
Anatolia], give birth at home” (A2).
Some of the women in the Izmirand Manisa group stated
that they did not obey traditional advice during pregnancy
and did not care. “I never listen to my mom or mother-in-law
for this kind of thing [about health]. For me, what the doctors
say is important” (I5).
The women in the Agri group had a predominantly
Kurdish ethnic origin. In some families, the women are
viewed as having been assimilated during the time they have
lived in Izmir. The families do not believe they belong to the
Kurdish ethnic group.
Perceptions
The subthemes of the perceptions theme include perception
of health, perception of illness, perception of pregnancy, and
related traditional attitudes.
Perception of health. The data show how these perceptions
vary according to culture and their importance to health, and
they reveal health behaviors related to the perception of
pregnancy. Women from all of the groups made statements
about the importance of health. “Being healthy is very impor-
tant always” (I4).
Some women in the Agri group expressed statements
about how religion might affect health. “When Ramadan
passes, I think about going to the health center [this woman
had a gynecological complaint during the interview but
delayed visiting the health center because it was during
Ramadan]” (A6).
Perception of illness. The perception of illness varies with the
health behavior. In all groups, the women made statements
that illness was a bad thing. “A very bad thing [illness]. I do
not even want to hear” (A7).
A woman in the Agri group stated that when she was sick
during pregnancy, she continued to work inside the house. “I
have to do the same tasks [work inside the house] when I am
ill” (A5).
Perception of pregnancy and related traditional attitudes. A
large number of the women in all the groups reported per-
ceiving pregnancy as a normal situation. “It is not an illness;
pregnancy is something normal” (I7). “Pregnancy is, of
course, a normal situation” (A8). “It is quite normal; I do not
perceive it as an illness” (K2).
Varying proportions of women in the groups indicated
changes in their health status (edema, anemia) that were
attributable to pregnancy. These situations were not viewed
as an illness. “For several months now, I cannot walk, my
breath is running out when I walk, my hands and feet are
shaking, my hands and feet get loose [a symptom of anemia].
It is because of the last months of pregnancy. I have fatigue.
However, I’m fine” (A7). “For example, the swelling of my
feet is because of my pregnancy. That is normal, not an ill-
ness. I know that if it is because of pregnancy, then it is nor-
mal” (K4).
The women in the Agri group perceived that in their own
culture, perhaps because pregnancy is accepted as normal,
pregnant woman are not exempt from any role; they are con-
sidered able to continue their normal day’s work and difficult
duties. “Ours is different [tradition]. Pregnant women in the
village do work. While I was pregnant, my mother-in-law
had animals [cows], and I used to take care of them. We
could not rest, you must continue your work” (A2). Most
women in the Agri group stated that there was pressure in
their culture to have more children. “They [family elders]
want many children. Indeed” (A4).
However, the women in Kars noted some traditional
beliefs, such as “pregnant women cannot pour down warm
water without besmele [the word of Allah];” “it is not good
for a pregnant women to go out at night without bread or to
come out alone.” “[Pregnant women] should not go to the
tomb.”
Behavioral Changes
The subthemes of the behavioral changes theme include
safety/protection during pregnancy, nutrition habits and cul-
tural behaviors during pregnancy, traditional thoughts about
sleep during pregnancy, practices related to birth, and the use
of the healthcare system.
Safety/protection during pregnancy. Various behaviors regard-
ing drug use, smoking, food cravings, edema, and sexuality
were discussed in terms of the baby’s safety and protection
among women in all the groups:
There is one pain relief pill offered by the doctor, and I
barely take any of them. They say if you do not eat [a craved
food], something will grow on the child’s body. My husband
is very concerned that something bad will happen to him [the
baby] [regarding sexuality]. (I3)
Nutrition habits and cultural behaviors during pregnancy. Unlike
the Agri group, the women in the Manisa, Izmir and Kars
groups generally expressed that they mostly ate vegetables.
The women in all the groups added milk and milk products
to their diets. Some cultural and religious beliefs and assump-
tions can interfere with health-related behaviors and ways of
life. One of these beliefs is related to fasting in Islamic soci-
ety. Only some of the women in the Agri group made state-
ments about fasting during pregnancy. “I do fast” (A6). “I do
fast for two days” (A8).
In different cultures, different ideas are reported regarding
feeding patterns during pregnancy. Some of the women in
the Izmir and Manisa group mentioned cultural behaviors
related to nutrition during pregnancy, such as “they say they
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Duran and Sevil 263
do not eat fish or the child will be born fish-mouthed; do not
touch liver or the child will have a stain on her skin; do not
eat too much parsley or it will cause miscarriage; ice cream
eating might cause a hole in the baby’s head.” Despite these
statements, many of the women did not believe the accuracy
of the rhetoric. Some of the women in the Agri group stated
that there are so many traditional prejudices and cultural
norms that they did not pay attention to nutrition during
pregnancy. They ate large amounts of high-carbohydrate
foods and were led to believe that pregnant women should
taste food cooked anywhere, even outside of the home.
“They [elder women] do not care [about nutrition]. Pregnancy
is something normal and simple” (A1). “If food is cooked,
the pregnant woman will be served wherever she goes. They
say if you do not eat, it is not good [harmful for baby]; it will
not be good for the baby” (A3).
Traditional thoughts about sleep during pregnancy. Some
of the women from the Izmir and Manisa group and the Agri
group expressed traditional stereotypes related to sleep.
“When I say I am sleepy, they [elder women] say a baby boy
is coming. They say sleep so you can rest; the baby needs it”
(I5). “When you sleep too much, they say do not sleep too
much. They think the baby doesn’t move inside. They say
that when you sleep too much, the baby becomes lazy. They
say stand up and take a walk” (A8).
Practices related to birth and the use of the healthcare
system. The majority of the women in the Izmir, Manisa, and
Kars groups indicated that they go for a walk throughout
their pregnancies to ensure an easy birth. Some of the women
in the Agri group talked about taking walks and avoiding
weight gain as preparation for the birth, and they expressed
thoughts that an easy delivery was Allah’s [God’s] desire.
Some of the women in the Agri group discussed the advice
that they received about birth. “I try to walk as much as I can.
I think that it will be easy” (I1). “I try not to get too fat. It [a
previous birth] was more difficult when I got fat and large”
(A6). “I go for a walk in the evening” (K4). “There were
such recommendations as take a walk close to delivery; do
not sleep much; never sit and stay; when you sit, you swell
[edema]” (A3).
The women in the Agri group indicated that it is common
in their culture to give birth at home and that the elder women
of the village help during birth. In general, the women stated
that family elders scare pregnant women into not giving birth
at the hospital. “I was frightened by people surrounding say-
ing they put too much pressure on your belly. I was scared a
lot” (A2). “At home, mostly the elder women help you do it
[birth]. My grandma used to help. Elder women do not allow
hospital births, saying they [health professionals] ruin the
infant and mother. They [elder women] say it is better to do
it at home. My mother-in-law gave birth to eight babies, all
at home” (A4).
The women in all three groups described the use of the
health centers, the conditions under which they would seek a
private physician examination, the use of a health center for
antenatal check-ups, and the use of a private health center for
monthly checkups. “I also go to my antenatal checkups con-
sistently. We had our tests performed—triple, quadruple tests
together —thank Allah, nothing was wrong. I did not neglect
the monthly antenatal checkups” (I6). “I went one or two
times; they said the baby is fine, and I did not go there [the
health center] again. My midwife tells me to go every month.
The first time I went, I was four months pregnant” (A7). “I
regularly go to both the hospital and the health center every
month” (K2).
In the Agri group, some of the women reported that there
is a negative attitude in their culture about receiving health-
care during pregnancy, and it constitutes an obstacle for
pregnant women to obtain health services. In accordance
with the rules of the patriarchal family structure, pregnant
women can have access to healthcare only if it is allowed by
the family: “I cannot go anyplace other than the hospital. I
cannot even go to the health care center. [The participant and
her husband live with the husband’s family]” (A5).
Discussion
The data show that pregnant women from different cultures
have different health behaviors during the prenatal period.
However, there are different cultural characteristics among
the groups. Group differences were found for the perception
and transfer of culture; for the perception and behavioral dif-
ferences of themes, cultural structures, behaviors, and atti-
tudes; and for the impact of these variations on the lives and
health of pregnant women. The main themes identified were
family, social learning and the transmission of traditions,
perceptions, and behavioral changes.
The findings are based on qualitative research that focuses
on the meanings and interpretations of women’s statements.
Qualitative research, namely ethnonursing, provides a
sophisticated methodology to understand how and why peo-
ple act in particular ways. However, the findings generated
by a qualitative method cannot be generalized across the
whole population. Although a small-sample ethnographic
study can increase the depth and detail of the information
gathered, it is limited with respect to the generalizability of
the findings.
The concept of family power is considered of vital impor-
tance, especially for the health decision-making process.
Some of the women in the Agri group continued their lives
with elders (from the husband’s family) living in the same
house or in an apartment building. All of the families in the
Agri group have characteristics of a large family structure
and show a patriarchal decision-making structure. It is note-
worthy that some women are not able to go to any health
care center or similar facility without permission, and they
expressed that they are uncomfortable with this oppression.
Sharing an income with the family elders can affect the
decision-making process, especially for the women in the
Agri group.
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264 Nursing Science Quarterly 26(3)
In the Izmir, Manisa, and Agri groups, the pattern of judg-
ments placed pressure on women to engage in certain behav-
iors. In societies where there is financial dependency on the
family, as in the Agri group, tight relationships and mutual
dependency are esteemed much more highly than indepen-
dence (Kagitcibasi, 1990). In line with this dependence,
some of the women in the group could not go anywhere with-
out the permission of the family elders. The testimony of a
woman in the Agri group, a new immigrant, clearly demon-
strated the way that ethnic communication can affect the
health of women. Other studies showed that language profi-
ciency is a significant risk factor for inadequate use of ante-
natal care (Alderliesten et al., 2008; Degni, Suominen,
Esse´n, Ansari, & Inen-Julkunen, 2011; Hoang, 2008).
In this study, especially in the Agri group, traditions were
adopted by the individuals. This transfer of traditions and
customs is also reflected in the women’s health behaviors. In
the Kars and Izmir and Manisa groups, it was observed that
most women have authority over their own decisions; they
have a high status within the family and want to apply correct
information about health issues. Women play a leading role
in maintaining the cultural values of these ethnic groups.
Other studies have reported similar findings (Burk et al.,
1995; Simpson & Carter, 2008).
Religious beliefs and assumptions were found to affect
health behaviors in the Agri group and some of the women in
the other groups. The number of women with a fatalistic
mentality was remarkable. A belief in fate has an important
place in Islamic societies. Burk, Wieser, and Keegan (1995)
reported that fatalism prevents people from taking responsi-
bility for their health and illnesses, and some women do not
want to receive a medical examination from a doctor.
Additionally, a woman’s religious faith can hamper her from
receiving timely health services.
Most women in the study reported believing that preg-
nancy is a normal situation. According to some studies, preg-
nancy is viewed as a normal physiological phenomenon that
does not require intervention by healthcare professionals
(Anderson et al., 2010; Essen et al., 2000). This type of
thinking can lead some women to attribute their discomforts
to pregnancy and not consider them important enough to
consult a health professional. Another cultural condition that
affects women’s health is the pressure to have multiple chil-
dren. In Agri, large numbers of children are desired; how-
ever, no such data were found for the city of Kars, which is
also in the east. This difference between these cities, which
are very close to each other, is thought to arise from cultural
differences. Cultural and religious beliefs and assumptions
can influence the desired family size, interpregnancy inter-
vals, and contraceptive choices (Anderson et al., 2010).
Fasting practices during Ramadan (the ninth month of the
Islamic calendar. It is the Islamic month of fasting, in which
participating Muslims refrain from eating, drinking, having
sex, smoking, and indulging in anything that is in excess or
ill-natured from dawn until sunset), which might be harmful
during pregnancy, were observed in some of the pregnant
women in the Agri group. In the Islamic religion, pregnant
women are exempt from fasting during Ramadan. Limited
research exists that explores the impact of fasting every day
for a month on pregnancy (Anserdon et al., 2010). Among
the groups studied, walking with partners, physical activity,
and not gaining weight were common recommendations for
an easy birth. Liamputtong, Yimyam, Baosoung, Baosoung,
and Sansiriphun (2005) stated in their study of different cul-
tures that working during pregnancy or continuing routine
tasks could facilitate childbirth. Although some of these rec-
ommendations are true, they can lead to risky behaviors.
Essen and colleagues (2000) reported that to avoid having a
large fetus and complications during delivery, many women
eat less than they did before pregnancy.
The women in the Agri group indicated that it is common
in their culture to give birth at home and to have the elder
women of the village help with childbirth. In general,
women are taught to be fearful of giving birth in a hospital
by their family elders. In Sahin’s (1996) study on Agri
women, women who gave birth at home described their
beliefs about births in health facilities with such statements
as “they kill people in the hospital, they press her abdomen.”
On the other hand, they interpreted births with a Nene (the
public midwife) as more comfortable than a birth at home.
For childbirth in Agri, village-based midwives who are self-
trained in child health and care fill the gap in this area
(Alpaslan, 1995).
Conclusions
The cultural structure and women’s health behaviors differ in
different groups in Turkey. Women’s health behaviors are
affected by family structure, socioeconomic status, women’s
status, ethnic origin, religious factors, and the culture struc-
ture, as suggested by Leininger‘s sunrise model (1998,
2002). Therefore, the most important support individuals
(the husband and his family) must participate in the manage-
ment of prenatal care, and prenatal education programs that
intensify the relationship between pregnant women and their
families should be developed. Care values, meanings, and
expressions are largely embedded in the worldview, environ-
mental context, language, ethnohistory, and social structure.
The findings illustrate that the cultural knowledge of nurses
is essential for nurses to plan and provide healthcare that is
beneficial and satisfying to pregnant Turkish women. These
study results are important for the development of a good
prenatal care practice. This study adds to the literature by
providing an additional understanding of the cultural context
related to the prenatal care practices of Turkish women.
Although the findings are not generalizable to all of the
women in Turkey, these findings point to the need for a
reevaluation of how prenatal care is delivered.
When providing healthcare, the cultural characteristics of
societies should be considered. Leininger (1998, 2002)
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Duran and Sevil 265
suggested that individuals’ health beliefs and behaviors
based on culture, family stories, health stories, and existing
symptoms are important; caregivers should be aware of
them. The development of positive health-related behavior in
women requires education, and this training must take famil-
ial and cultural characteristics into account. For the families
who have maintained the language of their ethnic group, a
Turkish-speaking translator who knows the dominant lan-
guage of the region must be commissioned at health centers.
Care must be provided in the home environment for pregnant
women, and it must include their families. Informational
meetings must be held in the area by clerics to provide accu-
rate information on issues that affect health, and these reli-
gious leaders must provide statements to the media and
families. Finally, in-service training must be given to family
health center personnel on culture-based holistic nursing and
midwifery approaches.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect
to the authorship and/or publication of this article.
Funding
The authors received no financial support for the authorship and/or
publication of this article.
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... Theoretical formulations or concepts in light of the Theory of Diversity and Universality of Cultural Care (17)(18)23,25,28,32,(36)(37)(38)(39) Cultural anthropology (15,21) , of health and symbolic (27) Pedagogical principles of education for social change in the concept of nursing practice as a partnership to transform health behaviors (29) Approach to the four fundamental principles of health ethics (16) Conceptual models of Critical Success Factors and Critical Success Factors and the Model for the Evaluation of Rural Sustainability (24) Analytical framework of habitus, capital and the field (20) Therapeutic Narratives (26) Methodological ...
... Ethnography (15)(16)(21)(22)29,31,39) , focused ethnography (19)(20)31) , institutional ethnography (24,(34)(35)(40)(41)44) and ethnonursing (17)(18)23,(25)(26)(27)(28)(32)(33)(36)(37)(38)(42)(43) Informants Mid-level nursing workers (16,(26)(27)29), teaching nurses, managers and/or care nurs es (16,20,22,24,31,(34)(35)37,(43)(44), doctors (24) , midwives (16,31), administrators (24) , and other staff (17) Pregnant women (15,17,21,23,(32)(33)42) , parturients (25,28,30) , puerperal women (18)(19)37) , mothers (36,(40)(41) , family members (17,(25)(26)37,39) , friends (17,25) , companions (25) and community (17) Scenarios Hospitals, Maternities, Nursing Homes, Clinics and Family Health Cente rs (15)(16)(17)(19)(20)22,(24)(25)(26)(27)(28)(29)(30)(31)(32)(34)(35)38,44) Households (17,21,33,37,(39)(40)(41) and communities (18,21,23,36,42) Obstetric events Childbirth (16,(19)(20)22,(24)(25)28,(30)(31)(34)(35)(39)(40)(41) , pregnancy (15,17,21,23,(32)(33)38,(42)(43) and postpartum (18)(19)(26)(27)29,(36)(37)44) Data collection techniques Participant (15,(21)(22)(26)(27)29,(31)(32)37,39) and non-participant (16,30) observation (20,(33)(34)(35)38,44) ; structured (43) and non-structured (27) observation ...
... Ethnography (15)(16)(21)(22)29,31,39) , focused ethnography (19)(20)31) , institutional ethnography (24,(34)(35)(40)(41)44) and ethnonursing (17)(18)23,(25)(26)(27)(28)(32)(33)(36)(37)(38)(42)(43) Informants Mid-level nursing workers (16,(26)(27)29), teaching nurses, managers and/or care nurs es (16,20,22,24,31,(34)(35)37,(43)(44), doctors (24) , midwives (16,31), administrators (24) , and other staff (17) Pregnant women (15,17,21,23,(32)(33)42) , parturients (25,28,30) , puerperal women (18)(19)37) , mothers (36,(40)(41) , family members (17,(25)(26)37,39) , friends (17,25) , companions (25) and community (17) Scenarios Hospitals, Maternities, Nursing Homes, Clinics and Family Health Cente rs (15)(16)(17)(19)(20)22,(24)(25)(26)(27)(28)(29)(30)(31)(32)(34)(35)38,44) Households (17,21,33,37,(39)(40)(41) and communities (18,21,23,36,42) Obstetric events Childbirth (16,(19)(20)22,(24)(25)28,(30)(31)(34)(35)(39)(40)(41) , pregnancy (15,17,21,23,(32)(33)38,(42)(43) and postpartum (18)(19)(26)(27)29,(36)(37)44) Data collection techniques Participant (15,(21)(22)(26)(27)29,(31)(32)37,39) and non-participant (16,30) observation (20,(33)(34)(35)38,44) ; structured (43) and non-structured (27) observation ...
Article
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Objective: To characterize ethnographic research in the area of obstetric nursing regarding its theoretical, methodological and analytical aspects. Method: An integrative review performed in the MEDLINE®, LILACS, BDENF and CINAHL databases, as well as the SciELO virtual library. Results: Thirty (³⁰) articles formed the analytical corpus after screening and reading the primary references in full. The most used methods were ethno-nursing, ethnography and institutional ethnography; the immersion time in the field ranged from 12 visits to 48 months occurring in institutional contexts. The main data collection techniques were observation, individual interviews and training guides for ethno-nursing. The data were organized as themes and subthemes, analyzed through the ethno-nursing analysis guide, implementing the Theory of Diversity and Universality of Cultural Care as theoretical reference. Conclusion: Ethnographic studies in the area of obstetric nursing are within the scope of microethnographies and are operationalized based on theoretical-methodological nursing references, being useful to analyze the complexity of phenomena involving obstetric nursing care, and focusing on the etic (professional) and emic (women) perspectives.
... Step three: testing the analytic framework The findings from the included studies at step three (studies [22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38] were then mapped to the amended framework to check that all the themes continue to have explanatory power, and to make sure no themes were missing [text in red in Tables 1 and 2, and in the (Table S2) represent the studies identified in step three]. As in the planned analytic strategy, this comprised both a reciprocal process (when the data could be mapped to the framework) and a refutational one (to check if any of the data could not be mapped). ...
... This could be done by including service design (incorporating the environment where care is delivered) and delivery approaches that provide psycho-social and emotional support for staff and service users, and that enhance physiological processes, hope and positive feelings, to help women to understand and deal with normal changes in pregnancy, and to prepare actively for labour, birth and mothering. Positive pregnancy Achievement/maintenance of optimal health and psycho-social wellbeing for mother and baby Sociocultural normality 1,6,7,11,16,17,18,24,27,31,32,34,38 Turkey ( Even where pregnancy is unwanted, but kept. In some settings this is about demonstrably following the biomedical model, in others it is the opposite Healthy pregnancy/normal birth/healthy baby 1,2,4,6,7,8,9,11,12,18,19,23,25,28,32,34,36,37,38 Turkey Including prayer and traditional remedies to reduce spiritual threat, power of religious belief in dictating pregnancy norms, religious fasting during pregnancy. ...
... Including awakening sense of (nonreligious) spirituality. In some cases, fatalism (adverse outcomes are 'Gods will') Biomedical/clinical 1, 4, 5, 6,7,8,9,10,14,15,16,20,23,24,30,31,33,35,37 Turkey ( , 4, 5, 7, 9, 12, 13, 14, 15, 16, 20, 30, 31, 36, 37 Vietnam ( ...
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... Whereas women in southwest Nigeria consumed herbal concoction to have smaller babies and ease delivery (15). Women in Turkey avoid fish for fear of having fish-mouthed babies and liver for fear of having babies with stained skin (16). Women in south-eastern Nigeria and a rural district in Kenya avoided snails, bushmeat and eggs which were their main daily source of protein also due to fear of big babies and prolonged labour (17,18). ...
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... During labour, women suffer negative traditional beliefs that demand that they confess unfaithfulness to their partners when labour is delayed especially for those who deliver at home [4]. Specific dietary restrictions such as avoidance of fish in diet may predispose the pregnant woman to dietary deficiencies [20,[25][26][27]. ...
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Communication problems due to language and cultural differences between health care professionals and patients are widely recognized. Finns are described as more silent whereas one concurrent large immigrant group, the Somalis, are described as more open in their communication. The aim of the study was to explore physicians-nurses/midwives' communication when providing reproductive and maternity health care to Somali women in Finland. Four individual and three focus group interviews were carried out with 10 gynecologists/obstetricians and 15 nurses/midwives from five selected clinics. The health care providers considered communication (including linguistic difficulties), cultural traditions, and religious beliefs to be problems when working with Somali women. Male and female physicians were generally more similar in communication style, interpersonal contacts, and cultural awareness than the nurses/midwives who were engaged in more partnership-building with the Somali women in the clinics. Despite the communication and cultural problems, there was a tentative mutual understanding between the Finnish reproductive health care professionals and the Somali women in the clinics.
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