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Background

Bosnia and Herzegovina (also referred to as Bosnia and Hercegovina)  is a country in the Balkan Peninsula of Europe. It consists of Bosnia to the north and Herzegovina to the south, which are not separate countries but geographical boundaries based on historical distinctions [1]. The most common languages spoken include Bosnian, Croatian and Serbian. The dominant religion for this country is Islam with Orthodox Christianity and Roman Catholicism following, respectively [2].

 

Many Bosnians in St. Louis came to America during the time of the Bosnian War from 1992-1995.3 This conflict took 100,000 lives and displaced 2 million Bosnians with many migrating to America [3].  As of 2022, the Bosnian population in St. Louis was estimated at 50,000 to 70,000 of the city's 2.8 million population [3].

Health Beliefs

  • In general, Bosnians do not have significant differences in terms of health beliefs when compared to Western medicine.

  • Some Bosnians may exhibit extreme fear toward serious complications and disease [4]. Thus, healthcare providers may be expected to provide specific and detailed explanations regarding complications and treatments [4].

  • Common beliefs like the fear of mental health stigmatization, wanting to tackle problems on their own, thinking health complications will resolve eventually, and disregarding medical advices may inhibit the treatments and healing process of Bosnian patients [5].

  • Many Bosnians may also turn to home remedies and alternative therapies or use them in conjunction with Western medicine. Part of this may also include obtaining medications from Bosnia where they are more affordable.

Social Traits

  • Gender roles

  • Strong conception of masculinity and femininity 

  • Patriarchal 

  • Age hierarchy/Respect for the elderly

  • Selflessness 

  • Collectivist

Implications for Health Practitioners/Health Questions

Greeting: In Bosnian culture, it is preferable to stand while greeting someone and shaking their hand, as it can be considered impolite to sit while introducing yourself [2]. Small talk (asking about family, commenting on weather, etc) at the beginning of the interaction is common and expected on behalf of the patient. This helps ease any discomfort that may be present.

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*Caveat: If you are a male provider greeting a female Muslim patient (particularly if she is wearing a hijab), wait to see what her comfort level is before shaking her hand. If she extends her hand, you can shake it. However, if she does not extend her hand, place your hand on your chest briefly to show respect [6]. 

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Mental Health: Mental health is a stigmatized topic in the Bosnian community. Many young Bosnians growing up in America recognize the impact of the Bosnian War on their parents’ mental health and daily lives [7]. However, cultural and social factors, compounded by the trauma itself, have perpetuated a stigma, which acts as a barrier hindering open communication on the topic of trauma and mental health. This highlights a unique socio-cultural impact that war had on refugees, which is not confined solely to the Bosnian community [7]. Hence, it is especially important to consider the impact of mental health in holistic care for these patients due to generational trauma resulting from the Bosnian War. 

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Diet: Diet often includes refined grains, high-fat dairy and processed meats and poor intake of whole grains, nuts and fish resulting in a high rate of obesity in this population [8].

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Questions/Education

  • Healthcare Challenges:

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

      • Pay special attention to coronary artery disease/ cardiovascular disease as they are relevant in this community [9].  

  • Social History:

    • What are your thoughts about smoking?

      • In the elderly population, asking a patient to stop smoking may be difficult due to strong cultural habits.

  • 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. 

  • Diet:

    • Tell me about your diet? What does a healthy diet look like to you?

Health Challenges

Noncommunicable diseases are the major cause of death and disability for Bosnians residing in Bosnia as well as in America [9]. In 2019, the highest reported causes of death in Bosnia were ischemic heart disease, stroke, lung cancer, and diabetes, respectively [9]. Research has shown that there is a greater risk of coronary heart disease in Bosnian immigrants and refugees living in the St. Louis area compared to other Americans [10]. 

 

High prevalence of smoking in this culture is notable. A study found that Bosnians who currently smoke believe that smoking can cause heart disease and lung cancer; however, they also perceive their risk of acquiring these diseases to be less likely than other smokers their age [11]. Additionally, most Bosnians living in St. Louis believed that smoking can also negatively impact the health of children but did not modify smoking habits around children [12]. Many older Bosnians smoke to cope with PTSD experienced as a result of war, relocation, and resettlement. 

Women's Health

  • As of March 2024, there is not much information available on this topic. 

  • 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. 

  • Due to the social impact of the Bosnian War, reproductive health care education in Bosnia has been inconsistent throughout the country. It is unknown what resources are offered to female immigrants and refugees in this community upon arrival to the US [13].

Family Structure

  • The family structure in Bosnia is built on mutual trust among its members, with the parents reserving the final say on a matter. Many family units are multi-generational including members of the extended family and it is common to see grandparents caring for children while the parents are at work. Mothers and fathers hold equal role and authority in the household [14].

  • Bosnians are collectivist and tend to rely on family, relatives, and close friends for information, networking, and help.

Conclusion

  • The Bosnian population does not have significantly different views of medicine compared to Westernized medicine. However, use of alternative medicine and home remedies might be higher than in the general American household.

  • In this population, 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.

  • For Bosnian immigrants and refugees living in Saint Louis, there is a greater risk of developing coronary heart disease, potentially due to the high prevalence of smoking in this population.

Resources for Patients

Practitioner Resource

This information was read and approved by Dr. Ajlina Karamehic-Muratovic, a sociology professor at Saint Louis University and proud member of the Bosnian community. Her research interests include the topics of mental health and social dynamics within the Bosnian community.

References

(1) Pickering, P., Lampe, J. R., Malcolm, N. R. (2024, March 22). Bosnia and Herzegovina. Geography & Travel. Retrieved March 23, 2024, from Britannica .

(2) Evason, N. (2017). Bosnian Culture. Cultural Atlas. Retrieved March 23, 2024, from https://culturalatlas.sbs.com.au/bosnian-culture/bosnian-culture-greetings#bosnian-culture-greetings

(3) Ellis, S. (2022, January 17). St Louis: The US city transformed by heartbreak. BBC. Retrieved March 23, 2024, from https://www.bbc.com/travel/article/20220117-st-louis-the-us-city-transformed-by-heartbreak 

(4) Allotey, P., Manderson, L., Nikles, J., Reidpath, D., Sauvarin, J. (n.d.). Bosnian Muslims - A Guide for Health Professionals. Queensland Health. Retrieved March 23, 2024, from https://www.health.qld.gov.au/__data/assets/pdf_file/0025/153907/bos_musl.pdf 

(5) Bransteter, Irina. (2016). Bosnian Refugees' Understanding of Their Health and Well-Being in A U.S. Context. Retrieved March 23, 2024, from ETD Archive.

(6) 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%

(7)Karamehic-Muratovic, A., Sichling, F., & Doherty, C. (2022). Perceptions of Parents' Mental Health and Perceived Stigma by Refugee Youth in the U.S. Context. Community mental health journal, 58(8), 1457–1467. https://doi.org/10.1007/s10597-022-00958-2

(8)Gicevic, S., Gaskins, A. J., Fung, T. T., Rosner, B., Sabanovic, E., Milesevic, J., … Willett, W. (2019). Demographic and socio-economic predictors of diet quality among adults in Bosnia and Herzegovina. Public Health Nutrition, 22(17), 3107–3117. doi:10.1017/S1368980019001988 

(9) Bosnia and Herzegovina. (2021, December 11). Institute for Health Metrics and Evaluation. Retrieved March 23, 2024, from Institute for Health Metrics and Evaluation.

(10) Bourdillon, M. T., Akhter, A. S., Vrtikapa, D., Avdagic, A., McNeese, M. A., Lee, R., & Hui, D. S. (2018). Cardiovascular Health in St. Louis Bosnian-Americans. Journal of immigrant and minority health, 20(5), 1147–1157. https://doi.org/10.1007/s10903-017-0641-1 

(11) Harris, J. K., Karamehic-Muratovic, A., Herbers, S. H., Moreland-Russell, S., Cheskin, R., & Lindberg, K. A. (2012). Perceptions of personal risk about smoking and health among Bosnian refugees living in the United States. Journal of immigrant and minority health, 14(3), 413–419. https://doi.org/10.1007/s10903-011-9511-4 

(12) McKay, V., Herbers, S., Mueller, N., Moreno, I., Harris, J. (2009). Coffee and Cigarettes: An Assessment of the Bosnian Immigrant Community. Retrieved March 23, 2024, from https://cphss.wustl.edu/items/coffee-and-cigarettes-an-assessment-of-the-bosnian-immigrant/

(13) Balkan Diskurs. (2022, July 20). A Bosnian perspective on the US fight for reproductive rights. Retrieved March 23, 2024, from https://globalvoices.org/2022/07/20/a-bosnian-perspective-on-the-us-fight-for-reproductive-rights/ 

(14) Exploring the Culture of Bosnia and Herzegovina . (2008, February 19). Retrieved March 23, 2024, from https://www.afsusa.org/countries/bosnia-and-herzegovina/#afs-nav-people 

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