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Background

The country of Afghanistan is found within the heart of south-central Asia [1]. There are over 40 languages spoken in Afghanistan, with Dari and Pashto declared as the two official languages of the country. About 77% of the population speaks Dari with 48% speaking Pashto [2]. The dominant religion practiced is Islam, predominantly Sunni Islam [1]. The most recent influx of Afghan immigrants came in 2021 during the Fall of Kabul (the capital of Afghanistan); in addition, prior decades of wars and conflicts have driven many to migrate to other countries including America [3].

Health Beliefs

  • For many Afghanis, most commonly Muslim, engaging in religious practices is a normal means of care [4].

    • For example, Mullah, or Muslim clergymen, blow the breath of healing while reciting prayers or write prayers on paper for the patient to consume in water or wear around their neck in leather [4].

Social Traits

  • Social hierarchy and gender role 

  • Filial 

  • Collectivistic 

  • Stoicism

Implications for Health Practitioners/Health Questions 

Greeting: If you are a male provider greeting a female Muslim patient, determine her comfort level before shaking her hand [5]. If she extends her hand, you can shake it. However, if she does not extend her hand, place your right hand on your chest as a gesture of polite greeting.

 

Social Etiquette: 

  • The left hand is reserved for hygienic purposes, so waving, shaking, touching, or handing items are often done with the right hand [6].

  • Exposing the bottom of one's feet is considered rude, so when sitting with a patient, it is recommended not to cross your legs [6]. 

  • Nodding is typically a sign of politeness [6]. This does not signify agreement or understanding, so following up with questions to ensure patient understanding is important.

 

Mental Health: Mental health is a highly stigmatized topic in the Afghan community. However, it is especially important to consider the impact of mental health in the overall health of these patients due to ongoing conflict within Afghanistan. Please see the “Immigrants and Mental Health” section for more information on how to support patients in this aspect of health.

 

Diet: Diet includes a wide variety of fruits and vegetables, legumes, grains, and dairy products [7]. Meat is often consumed when it meets requirements and is deemed halal. Some people may drink, but be mindful as it is prohibited in Islamic belief. 

  • Halal( حلال): denoting or relating to meat prepared as prescribed by Muslim law

  • Haram(حَرَام): forbidden or proscribed by Islamic law

Questions/Education

  • Healthcare Challenges: 

    • Does anyone in your family have a history of heart problems, diabetes, cancer, etc.?

      • Noncommunicable medical condition that is relevant to this visit

    • Does anyone in your family or close relatives were born with any chronic medical problems or anyone that passed away earlier in life (or a history of congenital disease)? 

      • It will be helpful to explain to the patients about congenital disease (as consanguinity marriage is common in many Middle Eastern and Arab cultures) [8]. 

  • Social History: 

    • What are your thoughts about smoking?

    • In one day, how often do you smoke? If not, how about the people around you?

    • Have others expressed concern about your smoking habits? 

  • Women’s Health: 

    • Allowing female patients to choose their preferred provider might be ideal in certain situations associated with sexual health and childbirth. 

    • If your patient has been pregnant previously:

      • Have you had any problems with your previous pregnancies? Including preeclampsia, gestational diabetes

        • Please explain each condition accordingly to your patient 

        • Were any of your children born with any heart problems?

      • Has anyone in your family or close relatives have any issues during pregnancy ?

        • If yes, you can ask: “Can you tell me more about it ?” 

    • If your patient is currently pregnant:

      • What medications or supplements are you currently taking?

      • Are you currently taking prenatal pills/folic acid supplements ( or vitamin B9) currently? 

  • Diet:

    • Tell me about your diet. 

      • If the patient follows halal diet:

        • Do you have access to halal foods?

    • Education about nutrition needs is highly encouraged for patients.

  • Medications:

    • Aside from Western medicine,  what other medicine do you use?

Health Challenges

Noncommunicable diseases are the major cause of death and disability for Afghans residing in Afghanistan as well as in America [9]. In 2019, the highest reported causes of death in Afghanistan were ischemic heart disease, conflict and terror, neonatal disorders, lower respiratory infections, and congenital defects. Heart and respiratory diseases stem from the use of tobacco; about 35.2% of men and 2.1% of women in Afghanistan smoke regularly, leading to an increase in smoking-related deaths [10].

 

Compared to other refugee populations, the Afghan refugee population is more vulnerable to skin conditions due to the high rates of infectious disease, refugee camp conditions, and migration on foot, or lack of access to health care [11]. Also, undernutrition is a major issue in Afghanistan. Many babies and children are unable to acquire a balanced diet, as only half of them are breastfed until 6 months old. Afghanistan has the world’s largest rate of stunting in children at 41% [12]. Furthermore, mothers are also likely to be malnourished, which propagates this cycle through generations [12]. 

 

The rate of consanguinity in the Afghan population was found to be 69% in a 2023 survey [8]. At the same time, consanguinity marriage practice is common in many Middle Eastern and Arab cultures. This may be a contributing factor to higher rates of congenital abnormalities in this population [8].

Women's Health

  • Access to new sanitary pads is very limited in Afghanistan along with education about menstruation due to its high stigmatization in the past [13].

  • Anemia is a prominent issue among women of reproductive age, as it relates to diet issues stemming from childhood [14].

  • Childbirth normally occurs in the home accompanied by a female midwife. It is important to be aware of common misconceptions such as using a pack of whiskey-soaked cotton balls to stop postpartum bleeding [4].

  • Due to Islamic practices, reproductive education should be done by female healthcare workers. All males, from family to healthcare personnel should be asked to leave the room prior to opening this conversation to maximize female patient comfort.

Family Structure

  • Afghani family units are large in nature with an average of 7-8 people per household including, but not limited to, the nuclear family (unwed daughters only), the spouses of the husbands, and the children [15].

    • Up to 3-4 generations could be living together [15].

  • Across different Afghani culture families are patriarchal and hold to an age hierarchy where the oldest male has the most executive power [15].

    • Men typically carry most of the economic burden of the family and the women usually handle domestic affairs [15].

  • Filial piety is strongly held in Afghani communities and elders are treated with deference and respect [15].

Conclusion

  • In the Afghan community, it is important to consider the religious values of Islam, the most prominent religion practiced. Specifically, consider ways to help patients feel more comfortable, especially if the patient is a woman.

  • There are major differences in medicine practiced in Afghanistan and Western medicine, so it is important to be mindful of them while still informing and caring for the patient. 

  • Undernutrition is of large concern for Afghan immigrants and refugees, so malnutrition and other conditions stemming from it, especially anemia, will need to be treated. 

  • Noncommunicable diseases are prevalent among the Afghan population due to lifestyle choices such as smoking tobacco. It is important to address cardiovascular disease, cancer, diabetes, respiratory disease, and mental health disorders as these are all prevalent in the Afghan population [16].

Resources

Practitioner Resources

This information was collected and organized by our team. As of this time, we have not yet been able to connect with any individuals in this community that could review this article. If you are interested in reviewing this article, please contact kaitlynn.borik@health.slu.edu 

References

(1) Ali, M., Dupree, L., Weinbaum, M. G., Dupree, N. H., Petrov, V. P., Allchin, F. R. (2024, March 14). Afghanistan: . Britannica. Retrieved March 16, 2024, from https://www.britannica.com/place/Afghanistan#ref21414

(2) Language data for Afghanistan. (n.d.). Translators without Borders. Retrieved March 16, 2024, from https://translatorswithoutborders.org/language-data-for-afghanistan

(3) Coronel, J. (2022, August 29). Since the collapse of Kabul, St. Louis region welcomes more than 600 Afghan refugees in 1 year. KSDK. Retrieved March 16, 2024, from https://www.ksdk.com/article/news/local/collapse-kabul-st-louis-region-welcomes-600-afghan-refugees-one-year/63-fe03b80c-f654-4a21-b3d4-a2407aada27b

(4) Grima, B. (2002). Women, Culture, and Health in Rural Afghanistan. Expedition Magazine, 44(3), 34-39. https://www.penn.museum/sites/expedition/women-culture-and-health-in-rural-afghanistan/

(5) A helpful guide to basic Muslim etiquette. (n.d.). NZ Curriculum Online. Retrieved March 16, 2024, from https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwi4rpK_wfmEAxV4jYkEHbEwB80QFnoECBYQAQ&url=https%3A%2F%2Fnzcurriculum.tki.org.nz%2Fcontent%2Fdownload%2F168213%2F1242444%2Ffile%

(6) Evason, N. (2019). Afghan Culture: Communication. Cultural Atlas. Retrieved March 16, 2024, from https://culturalatlas.sbs.com.au/afghan-culture/afghan-culture-communication

(7)Afghan food and cultural profile: dietetic consultation guide. (2016). Metro South Health. Retrieved March 16, 2024, from https://metrosouth.health.qld.gov.au/sites/default/files/dietetic-profile-afghan.pdf

(8)Pameer, A. K. (2023). Rate of Consanguineous Marriages in Afghan Society and Its Effects on Health. International Journal of Health Sciences, 6(2), 28–39. https://doi.org/10.47941/ijhs.1219 

(9)Afghanistan. (2019). Institute for Health Metrics and Evaluation. Retrieved March 16, 2024, from https://www.healthdata.org/research-analysis/health-by-location/profiles/afghanistan

(10)Ahmadi, A., Rahimi, A., Wardak, M. F., Ahmadi, H., Lucero-Prisno III, D. E. (2023, January 22). Tobacco harm reduction in Afghanistan: a recipe for improving smokers' health. Substance Abuse Treatment, Prevention, and Policy. Retrieved March 16, 2024, from BioMed Central.

(11)Mazumder, A., Mehrmal, S., & Chaudhry, S. B. (2022). Dermatologic needs of Afghan refugees. JAAD international, 9, 72–74. https://doi.org/10.1016/j.jdin.2022.08.002

(12)Afghanistan: Nutrition. (2021). Unicef. Retrieved March 16, 2024, from https://www.unicef.org/afghanistan/nutrition

(13)First ever 'Girls' Hygiene Day' held in Afghanistan. (2017, August 30). Unicef. Retrieved March 16, 2024, from https://www.unicef.org/afghanistan/press-releases/first-ever-girls-hygiene-day

(14)Flores-Martinez, A., Zanello, G., Shankar, B., & Poole, N. (2016). Reducing Anemia Prevalence in Afghanistan: Socioeconomic Correlates and the Particular Role of Agricultural Assets. PloS one, 11(6), e0156878. https://doi.org/10.1371/journal.pone.0156878

(15)Evason, N. (2019). Afghan Culture. Afghan Culture - Family -- Cultural Atlas. Retrieved March 16, 2024, from https://culturalatlas.sbs.com.au/afghan-culture/afghan-culture-family

(16) Afghanistan. (2024). Eastern Mediterranean Region. Retrieved March 16, 2024, from World Health Organization.

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