Readchapter26 and27 of the class textbook and review the attachedPowerPointpresentations. Read Content chapter 26 & 27 in Davis Plus Online Website. Once done answer the following questions; 1.Which c

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Readchapter26 and27 of the class textbook and review the attachedPowerPointpresentations. Read Content chapter 26 & 27 in Davis Plus Online Website. Once done answer the following questions;

1.Which countries are known as the Baltic nations?

2. Discuss how the Baltic nations view the delivery of evidence-basedhealthcareand their beliefs related to health and disease.

3. Give an overview of the Brazilian heritage, how do they see health and disease and if there is any similarity between them and the Baltic nations.

You must cite at least 3 evidence-based references no older than 5 years excluding the class textbook. A minimum of 800 words must be presented excluding the first and reference page.

Readchapter26 and27 of the class textbook and review the attachedPowerPointpresentations. Read Content chapter 26 & 27 in Davis Plus Online Website. Once done answer the following questions; 1.Which c
1 Chapter 26 People of Baltic Heritage: Estonians, Latvians, and Lithuanians Rauda Gelazis Overview, Inhabited Localities, and Topography Overview People of Baltic descent come from Estonia, Latvia, and Lithuania. The countries of origin of these ethnic groups are sometimes referred to as the Balticsor the Baltic countriesbecause each of them is located in Europe on the Baltic Sea. Historical, cultural, reli- gious, and language differences prevent the group from being one cultural entity. These countries represent three distinct ethnic groups and are treated as such. Estonia is on the Baltic Sea. Estonia is bordered by the Gulf of Finland in the north, Russia in the east, Latvia in the south, and the Baltic Sea in the west. The Estonians are a Finno-Ugric people whose language is related to Finnish (Raun, 1991). The Union of Soviet Socialist Republics (USSR) forcibly annexed Estonia in 1940 and maintained control until 1991, when Estonia reasserted its independence. The capital and largest city is Tallinn. Estonia’s population is 1,282,963 (CIA World Factbook, 2011a). Estonians accounted for 89 percent of the population at the be- ginning of Soviet rule, but by 1989, they were only 61.5 percent of the population. During this period, immigration increased the Russian population 10-fold to 30 percent (Estonia, 1993). Currently Russians comprise 25.6 percent of Estonia’s population. Esto- nians are 68.7 percent of the population. Belarusians (1.2 percent) and Ukranians (2.1 percent) make up the other ethnic groups in Estonia. Latvia, situated between Estonia and Lithuania on the Baltic Sea, was independent from 1918 to 1940, when it was forcibly annexed by the USSR. Latvia re- gained its independence in 1991. The population is 2,204,704 people, of whom only 59 percent are Latvians or Letts. Russians make up 27.8 percent of the popula- tion; the remainder is made up of Belarussians,Ukrainians, and Poles (CIA World Factbook, 2011b). About 68 percent of the Latvian population live in cities; Riga is the capital and largest city. Most ethnic Latvians speak a Baltic language related to Lithuanian. Lithuania is also on the eastern shore of the Baltic Sea. It is bordered in the north by Latvia, in the east by Belarus, in the southwest by Poland and a part of Russia (called Kaliningrad), and in the west by the Baltic Sea. Lithuania was an independent country from 1918 to 1940, when the USSR forcibly annexed it. In 1990, Lithuania redeclared its independence from Soviet rule. The Lithuanian population is 3,535,547, of whom 84 percent are Lithuanians, 4.9 percent are Russians, 6.1 percent are Poles, and 3.7 percent are other (CIA World Factbook, 2011c). The urban population is 66.6 percent of the popula- tion; 33.4 percent of the population lives in rural areas. On March 11, 1990, Lithuania reestablished its independence—the first Soviet republic to do so. On September 17, 1991, Lithuania was admitted into the United Nations. In May 2001, Lithuania was admitted into the World Trade Organization. In March 2004, Lithuania was accepted into the North Atlantic Treaty Organization (NATO), and on May 1, 2004, Lithuania joined the European Union (Lithuania, 2005, 2006). Latvia and Estonia were also accepted into NATO and the European Union in 2004 (O’Connor, 2006). Lithuanian is a Baltic language related to Latvian (Gerutis, 1969). The capital city is Vilnius; its popula- tion is 546,000 people (CIA World Factbook, 2011c). The topography of the Baltic countries consists of lowlands. Estonia has many lakes and rivers because of its glacial origin. Thirty-five percent of Estonia is forest, whereas about 10 percent of its territory in- cludes islands in the Baltic Sea. Latvia also has many lakes and rivers, with estuaries providing ice-free com- mercial and fishing harbors. The highest elevation in Latvia is 984 ft. Lithuania also forms an extension of 2780_BC_Ch26_001-012 03/07/12 9:53 AM Page 1 2Aggregate Data for Cultural-Specific Groups the eastern European plain, with its highest elevation at only 960 ft. It is also of glacial origin and is dotted with lakes and rivers (Lithuania, 1993). The Baltic countries today are democratic, growing economically, and successful compared with many other former Soviet Union countries in which poverty and dic- tatorship have been predominant (O’Connor, 2003). All three Baltic countries have established strong ties to Western democratic countries, but Russia continues to maintain a hold on other former Soviet Union countries such as Georgia. For this reason, there is concern, espe- cially among the people of Baltic descent living in the United States, that the former Soviet regime may try to reinsert itself into leadership in the Baltics, and hence, Russian ties would once again become strong. Heritage and Residence The Baltic peoples are believed to have lived along the Baltic Sea since 2000 BC, when they settled this region (Gimbutas, 1985). The four tribes that settled along the coast of the Baltic Sea made contacts with a vari- ety of people such as the Scandinavians, Slavs, and Finns. The Latvians and Lithuanians are the only remnants of these tribes. The other Baltic groups of Old Prussians and Yatvingians became extinct in the latter part of the Middle Ages (Sabaliauskas, 1986). Lithuania’s territory spread over a large part of east- ern Europe until it made an alliance with Poland. Since then, its power declined, and in the 18th and 19th centuries, Poland and Russia ruled this territory (Gerutis, 1969). Migration from the Baltic countries to North America has been intermittent. As early as 1640, a few Latvian and Estonian settlers came with Swedes to New Sweden in Delaware and Pennsylvania. In 1687, a group of Latvian immigrants from a colony on the island of Tobago settled in Boston. Since then, a small but steady number of Latvians have settled in New York, Pennsylvania, the Midwest, and California. By 1850, the U.S. Bureau of the Census recorded 3160 Latvians and Lithuanians (American Factfinder, 2000). The two groups were counted together because they spoke a similar lan- guage. By 1870, their numbers reached 4644. Most of the early arrivals were sailors or artisans; a few were missionaries. The immigrants who came to the United States in the late 19th and early 20th centuries settled in metropolitan areas and industrial centers, or they followed jobs on the railroad or in coal mines. As a result, Latvian commu- nities exist in New York, Boston, and Philadelphia in the Northeast; in Chicago, Milwaukee, Cleveland, and Kalamazoo and Grand Rapids, Michigan, in the Midwest; and in Los Angeles, San Francisco, Portland, Seattle, and Tacoma on the West Coast. Before 1890, immigrants were also located in the mining districts of Pennsylvania. By 1910, the largest communities ofLithuanians were in Chicago, New York, Boston, Philadelphia, and Cleveland. By 1970, over half of the Estonian American population lived in the Washington to Boston corridor, about 15 percent lived in the Great Lakes region, and 19 percent were on the West Coast (Thernstrom, 1980). Reasons for Migration and Associated Economic Factors It was not until the mid-19th century that immigration from the Baltic countries increased. One reason for this was the abolition of serfdom in the 1860s in Lithuania and the other Baltics, which lifted legal re- strictions that had previously limited the mobility of villagers. Another factor was the development of the tsarist railroad by the Russian Empire. Railroads facilitated travel to Russia and points beyond. In the late 1860s, a severe famine disrupted the Lithuanian peasant economy. In 1874, the Russian government introduced a comprehensive system of conscription, and many men from the Baltics emigrated to escape service in the tsarist army. Thus, Lithuanian peasants made their way to the United States, and a migrant network began. By 1914, this network had expanded such that few villages were unaffected by the increas- ing migration to America. The rate of return migra- tion was high; between 1899 and 1914, there was one departure from the Baltics for every five immigrants who returned. In 1918, all three Baltic countries declared their independence. During the years as independent countries, 1918 to 1940, much progress was made in each country (O’Connor, 2003). In 1940, the three Baltic countries lost their inde- pendent status to Germany; and then, to the USSR in 1941. During this time, hundreds of thousands of Latvians, Lithuanians, and Estonians were deported in cattle cars to Soviet prison camps in Siberia. Fear- ing death or deportation by the Communist regime, Estonians, Latvians, and Lithuanians fled to the West by any means possible. The post–World War II influx of immigrants to the United States came in 1949. Because the immigrants fled from the religious, cultural, and political persecution of the Soviet regime and could not return to their native countries after World War II, the U.S. Congress facilitated their entry by enacting laws designating them as displaced persons (Baskauskas, 1985). Many of these immigrants were well educated and had professional occupations. However, language barriers forced them to take positions in manual labor in the United States. Gradually, many immi- grants improved their economic status. Because one of the conditions of emigration to the United States for this group was having American citizens to spon- sor and accept financial responsibility for them, this group was quickly assimilated into the workforce (Baskauskas, 1985). 2780_BC_Ch26_001-012 03/07/12 9:53 AM Page 2 People of Baltic Heritage: Estonians, Latvians, and Lithuanians3 The Baltic immigrants continued their native tradi- tions, which held the communities together and added diversity to the many cultural groups and organiza- tions to which they belonged. Maintaining the cultural identities of Estonians, Latvians, and Lithuanians was important, and schools were established in the native languages to preserve their language and culture. Many youth and student groups that existed in inde- pendent Estonia, Latvia, and Lithuania, such as the Boy Scouts and student fraternities, were re-created in the United States. Many of the post–World War II refugees were professionals; thus, each group formed its own specialized ethnic association of professionals in the United States. For example, the Lithuanian- American Federation of Engineers and Architects was formed in the 1950s and continues today (Alilunas, 1978). Each group published its own journal or newsletter; the Latvian American newspaper Laiks continues to be published today. The Lithuanian newspapers Draugasand Dirvaare also still published. Folk dance and song ensembles were formed to promote the cultural identity of each country. Music and songs are particularly important to people from the Baltics. The songs are sung by people in their native lands and in America. All three Baltic coun- tries continue to have regular song festivals and dance festivals in the United States and in the native countries as well. The Baltic countries are strong in the arts, and theater, opera, music of all types, and film continue to flourish (Lithuania, 2005; Pabriks & Purs, 2001). Since the Baltics regained independence, starting with Lithuania in 1990, immigrants have continued to come to the United States; however, restrictions in the United States and in their native countries have limited their numbers. Travel back to the Baltics is now possible without restrictions. Under Soviet rule, travel to these nations was severely restricted, was limited to 5 days in the country, and entailed entrance and exit only through Moscow. With independence has come a resurgence of interest for Americans of Baltic descent in travel to their native countries, and many have revisited their countries of origin. Economic ties continue to be established as Americans invest in the Baltic economy with a variety of projects ranging from fast food to petroleum. For example, imports such as linen, women’s suits, and amber jewelry from these countries are increasing and can now be found in stores and boutiques throughout the United States. The new freedoms mean that artistic and cultural groups from the Baltics can come to the United States to tour (Gelazis, 1994). One such group is a Latvian Boys’ Choir from Riga. Such appearances help Baltic Americans reinforce their cultural identity. Many Americans of Baltic descent become U.S. citizens, fully participate in American society while continuing to use their native language, and are involved in theculture of origin through the many organizations still in existence in America. Most people of Baltic descent participate in the maintenance of their culture. Studies indicate that, for several generations, the native culture has re- mained important to individuals in varying degrees (Baskauskas, 1985). Therefore, it is important to as- sess the meaning of each individual’s cultural her- itage, whether they are a first- or later-generation American of Baltic descent. In recent years, the Baltic countries have made strides in linking with the United States and Western Europe, relying less and less on old ties with Russia (Jundzis, 1999). All three Baltic countries have been accepted into NATO and the European Union. Western ties were strengthened in Lithuania in 1997 when Valdas Adamkus, a Lithuanian American, was elected presi- dent twice (Lithuania, 2005; Longworth & Bukio, 1998). In 1999, Latvians also elected an expatriate as president. Vaira V ı¯k¸ e-Freiberga, a retired Latvian Canadian pro- fessor, was elected president of Latvia. Estonia also has Western-oriented leadership (Smith, 2002). Educational Status and Occupations Education is highly valued by people of Baltic de- scent. All three Baltic countries have high literacy rates; each country’s literacy rate is above 99 percent (CIA World Factbook, 2011a, 2011b, 2011c). For small countries, the Baltic countries spend significant amounts of their budget for education. Lithuania, for example, designated 4.7 percent of its GDP for edu- cation (CIA World Factbook, 2011c). Education is valued and seen as a way of improving life circum- stances. These immigrants made many sacrifices so their children could become educated. As a result, many Americans of Baltic descent have advanced de- grees. Many are professionals in medicine and law. Because the Baltic countries were agrarian, early im- migrants came from farming communities. These immi- grants were attracted to the mining and industrial communities on the East Coast and in the Midwest. The post–World War II Baltic immigrants also settled in the industrial centers of the United States. Second- and third-generation immigrants, however, are often skilled professionals. Since the mid-1990s, the three Baltic countries have experienced a “brain-drain” to some extent because many of their highly educated citizens have emigrated to the United States and Europe. Since entrance into the European Union has made it possible for persons from the Baltics to travel to member countries to ob- tain jobs, many have left for countries such as Great Britain and Ireland where jobs are available. Lithua- nia, for example, lost about 400,000 people to emigra- tion since 1990 (Emigrantus šauks atgal i˛ Lietuva, 2007). This is a concern in a relatively small country. The world economic crisis in 2008 affected the Baltic 2780_BC_Ch26_001-012 03/07/12 9:53 AM Page 3 4Aggregate Data for Cultural-Specific Groups countries. The economic growth in the Baltics since 2000 has taken a downturn. The public debt in each country has risen in recent years. Latvia received substantial financial assistance from the EU and other partners in the last few years (CIA World Fact- book, 2011, b). The unemployment rate in Latvia is 14.3 percent, in Lithuania it is 17.9, and in Estonia the unemployment rate is 17 percent (CIA World Factbook, 2011a, 2011b, 2011c). Young people find it particularly difficult to get jobs and are drawn to find work in the EU countries or the United States. Communication Dominant Languages and Dialects The Latvian and Lithuanian languages are among the oldest in the world—closely related but not the same. Latvian endings for nouns, for example, are shorter than those in Lithuanian. Latvian and Lithuanian are the only remnants of the ancient Indo-European lan- guage related to Sanskrit (Thieme, 1958). Estonian is more closely related to Finnish and is part of the Baltic-Finnic branch of the Uralic languages, which also includes the Hungarian language (Raun, 1991). Cultural Communication Patterns People of Baltic descent share thoughts and feelings readily. The stereotype of quiet, stoic individuals is not borne out by observation or research. For exam- ple, humor can be used to relate to these patients and is appreciated if used appropriately (Gelazis, 1994). Older individuals from these cultural groups may be first-generation Americans or immigrants who came to the United States after World War II. These indi- viduals may not be as acculturated as younger people and may prefer to speak their own languages. Health- care professionals need to be sure that any instructions given to these patients are well understood. Individuals from these cultural groups usually comply with med- ical regimens and medications as long as they under- stand them clearly and know the reasons for them. Patients of Baltic origin may hesitate to share inti- mate thoughts and feelings related to their cultural sense of decorum, but this does not mean that they do not experience feelings and emotions. They may wait to see whether the health-care professional is caring and takes the time to actually listen to them. Recent imigrants may hesitate to use the health- care system available if they have no jobs. Because health insurance usually is part of job benefits in the United States, both old and young people may not have health insurance. This issue may be addressed as the United States looks at its health-care policies in the future. As a whole, people of Baltic descent are not flam- boyant or highly volatile, but individual differences are always present. Some individuals enjoy touch andclose contact, whereas others do not. Individuals from these cultures are receptive to a caring use of touch from family and close friends, but they may appear to be more aloof with strangers. Health-care profession- als who help patients with crises are encouraged to use touch appropriately to convey caring and support. Temporal Relationships People of Baltic descent give attention to the past, present, and future. The past is revered in the sense that significant historical events for each cultural group continue to be celebrated and acknowledged. For example, commemorative programs are held each year when Estonian Americans celebrate their inde- pendence day on February 24, Latvian Americans on November 18, and Lithuanian Americans on February 16. These were held even during the years when the countries were oppressed under Communist rule. More recently, the new dates of independence may also be commemorated, and significant dates may be remembered. For example, January 13 is commem- orated in Lithuania each year to remember the lives sacrificed in 1990 when Russian Soviet tanks rolled into Vilnius and fired upon demonstrators surround- ing the television tower who were trying to keep broadcasts going in order to unite the country to press for independence from the USSR (Pecˇeli¯unaite˙, 2007). People of Baltic descent value frugality because they have had hard times in the past. Many have worked very hard since coming to the United States and have saved enough money to buy homes and pay for their children to complete college. These cultural groups are well able to plan for the future and are pa- tient enough to persevere to reach their personal goals. People of Baltic descent view time in a way similar to that of the dominant American culture. They have become acculturated to the awareness of time and deadlines and arrive at their appointments on time. Because their work ethic is strong and work is highly valued, individuals of Baltic descent take pride in using their time wisely and being efficient. Socially, however, they may be less aware of time and tend to be late. Social and family interactions, especially those in- volving cultural events, are also highly valued. The view of well-being is holistic, and a balance is sought in life. Therefore, work activities are valued and so are the social and leisure time activities shared with family and friends. Format for Names Individuals of Baltic descent generally use their American last name. First names of women end in “a,” and first names of men end in “as” or “s.” In their native languages, the last name indicates whether the person is male or female; for females, the last name indicates whether the woman is married or single. In 2780_BC_Ch26_001-012 03/07/12 9:53 AM Page 4 People of Baltic Heritage: Estonians, Latvians, and Lithuanians5 Lithuanian, for example, the author’s last name would be Gelazˇiene˙, indicating that she is married. If the author were single, the last name would be Gelazˇyte˙. The male last name is Gelazˇis. The typical Lithuanian last name ends with “as” or “is.” The suffix “iene˙” in- dicates a married woman, and the suffix “aite˙” or “yte˙” indicates a woman’s single status. In Latvian, the typical last name ends in “ans,” “ins,” or “e,” with the endings indicating masculine or feminine genders. Estonian names are similar to Finnish names. Family Roles and Organization Head of Household and Gender Roles The father is the head of the household in the typical family of Baltic heritage. Although both men and women in the family may have jobs and discuss major decisions, the father or father figure is still generally considered the head of the household. Health care and other major decisions are made jointly by both spouses. Women in the family are given respect, and decision making is done by both men and women (Bindokiene˙, 1989). Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents The Baltic people value children, and children and adolescents are given every opportunity for growth and development. Because education is highly valued, parents encourage and supervise children in their schoolwork and progress. Corporal punishment was used by older generations but is practiced less by younger families. Cultural activities, such as song or dance groups and ensembles, frequently unite people of all ages. Religious beliefs also strongly influence family life and the rearing of children in each culture. Family Goals and Priorities The traditional nuclear family is still the standard in these cultural groups. Family is highly valued, and divorce is still fairly rare. Lithuanian Americans are predominantly Roman Catholic, and their religion supports strong family values. Because both spouses tend to work, child care may be shared by grandpar- ents. The extended family is important, and visiting among them is frequent, but extended family members live separately. Older people are respected in the Baltic cultures. If grandparents are unable to live independently, every effort is made to have them move in with an adult child, usually a daughter. Nursing homes are used when needed. Because many women work outside the home, families may find it necessary to use long-term-care facilities to care for infirm older members. Culturally based nursing home facilities are available. For example, the Matulaitis Nursing Home in Connecticut is for older Lithuanian Americans (Gelazis, 1994).Older members of these cultures often come from large families. Extended families live apart because family members may have been separated in their escape from the Baltics. Many tragic events, such as the Soviet deportations of hundreds of thousands of Estonians, Latvians, and Lithuanians to Siberian concentration camps in the 1940s and later in the 1950s, separated family members forever by death and distance. When people fled their homelands to escape Communist tyranny, they emigrated to whatever free country they could. Therefore, the extended family may include mem- bers throughout the world in such faraway places as Australia, Canada, Europe, and South America. When the Baltics regained their independence, family members from the United States were able to visit their homelands for the first time in years. Before this, many Americans of Baltic descent were afraid to visit their native lands because they feared for their families and even for themselves. During the years of oppression, mail was censored, and free communica- tion, even among relatives, was severely restricted. Many people of Baltic descent sent money and other material support home for years to help their extended families (Fainhauz, 1991). In their native countries, status was given to individ- uals with professions such as physicians and lawyers and those with academic degrees. In America, a certain amount of respect is still given to professionals, but each cultural group has more of an egalitarian sense of community. The preservation of Baltic culture and language holds people of varying status, education, and age together for a common purpose. Furthermore, when immigrants first came to the United States, many had to take jobs of lesser status. This increased their sensitivity for individuals of all social and economic classes. For example, some physicians had to take po- sitions as laboratory technicians, and teachers as labor- ers and factory workers. This pattern continues today with new immigrants, but there is a tendency for new immigrants to stay within their professions, and Eng- lish has replaced Russian in most schools in the Baltics, making transition into the United States and the United Kingdom easier than in the past. In Lithuania, for example, more people now speak English than Russian (CIA World Factbook, 2011c). Alternative Lifestyles The literature does not include information about same-sex couples in these cultures. Because the domi- nant religions of the Baltic countries do not sanction homosexuality, few individuals and couples are openly homosexual, making it hard to obtain statistics. Recent increases in HIV rates in former Soviet Union coun- tries, including the Baltics, may be indicative of an increase in homosexual activity but may also indicate an increase in casual sex in heterosexuals who are more mobile today than in the past (Rowe, 2006). 2780_BC_Ch26_001-012 03/07/12 9:53 AM Page 5 Workforce Issues Culture in the Workplace Individuals of Baltic descent value their family, culture, and beliefs and view work as important. Material aspects are seen as secondary to the more-important family val- ues. Responsibility is taken seriously and is encouraged. Political awareness and responsibilities of citizen- ship are considered essential aspects of life. People of Baltic descent adapt readily to American values of timeliness in the workplace. Issues Related to Autonomy People of Baltic descent have no difficulty maintaining their sense of autonomy and readily take on work roles, responsibility, and decision making. They usually do not like to directly confront those in authority and find ways to deal with difficult situations or people through the use of humor or deference. Recent immigrants who have lived under the Soviet regime may not be accustomed to making decisions for themselves or acting autonomously. In previous governmental regimes, individuals and their rights were not considered important. For the most part, Americans of Baltic descent are fluent in English as well as their own languages. Exceptions might be identified among older people or recent immigrants. Friends, family, or community members can act as translators if absolutely necessary. The Baltics have high literacy rates. Biocultural Ecology Skin Color and Other Biological Variations People of Baltic descent have white skin. Estonians are similar to the Finns with brown hair and eyes, though some are blond and blue-eyed. Latvians and Lithuanians have fair complexions with blond hair and blue eyes. Assessment of health status is similar to that of other fair-skinned individuals. Diseases and Health Conditions Recent immigrants from Estonia, Latvia, and Lithuania may be at risk for cancer because of the current indus- trial pollution, including radiation exposure resulting from the Chernobyl nuclear disaster in 1988. Because Chernobyl is close to the Baltic countries, some contam- ination occurred in the Baltics and other Northern European countries. Furthermore, because the Soviet regime did not consider human needs over the needs of the state, nuclear waste on land or in the Baltic Sea may not yet be publicly known. This may constitute a health hazard and may affect both recent immigrants and vis- itors to these countries. Lithuania has had to improve safety procedures at Ignalina (Chernobyl-type reactors) in order to avoid a disaster similar to the Chernobyl ex- perience and to protect the Lithuanian people as well as its neighbors (Lane, 2001).Some immigrants are survivors of political torture, having spent years in prison labor camps in Siberia. As a result of such experiences, their health status is affected. For example, hearing loss has occurred as a result of beatings and other torture in prisons (Gelazis, 1994). Some may show evidence of post-traumatic stress disorder (PTSD) due to past years of high stress war situations. When performing health assessments, health-care providers need to be alert to ill health re- sulting from the conditions that immigrants endured because of the political situations in their countries of origin. Obtaining a history of individuals and their life experiences is important. People of Baltic descent have illness rates similar to those of the general American population (CIA World Factbook, 2011a, 2011b, 2011c). Morbidity rates in the Baltic countries show that the leading causes of death are heart disease and cancer, with rates similar to those of the general population in the United States. More recently, however, as mentioned previously, as a result of industrial pollution and nuclear waste contamina- tion brought on by the Soviet regime, cancer rates have increased in the Baltic countries. The incidence of alcoholism is high in the Baltics (British Broadcasting Corporation, 1994). For example, alcoholism is a health problem in Latvia and is partly responsible for the particularly low life expectancy for men (Pabriks & Purs, 2001). The life expectancy for Latvian men is 67.56 years, and for Latvian women, it is 78.07 years (CIA World Factbook, 2011b). Life expectancy for Estonian men is 68.02 years, and for Estonian women, it is 78.97 years (CIA World Fact- book, 2011a). Life expectancy for Lithuanian men is 70.2 years, and for women, it is 80.48 years (CIA World Factbook, 2011c). Strong educational antismoking and antialcohol campaigns would help to increase the life expectancy in Latvia and the other Baltic countries. Better health also has positive consequences econom- ically for both individuals and countries. Suicide is also increasing in the Baltics (Agence France Presse, 1995). Considerations for health-care professionals include health teaching such as decreasing smoking, changing dietary habits, and decreasing the use of alcohol. Health-care professionals should assess for a family history of heart disease, cancer, or alcoholism. Variations in Drug Metabolism In addition to the previously mentioned considera- tions, the Ashkenazi Jews from the Baltic countries may respond differently to neuroleptic agents (Levy, 1993). For example, in studies of the use of clozapine to treat schizophrenia, 20 percent of Jewish patients developed agranulocytosis, but this adverse reaction occurs in only 1 percent of chronic schizophrenic pa- tients in the general population (Lieberman et al., 1990). Genetic testing reveals that a specific haplotype was found in 83 percent of patients who developed 6Aggregate Data for Cultural-Specific Groups 2780_BC_Ch26_001-012 03/07/12 9:53 AM Page 6 People of Baltic Heritage: Estonians, Latvians, and Lithuanians7 agranulocytosis. All Ashkenazi Jewish patients af- fected had this haplotype, and only 8 percent did not develop this reaction. Characteristically, this haplo- type is found in less than 1 percent of the white population in America (Levy, 1993). High-Risk Behaviors Cigarette smoking is decreasing in the United States and Canada; however, European countries, especially Eastern European countries, have not followed this trend. Although some Americans of Baltic descent have stopped smoking, the younger generation— those in their late 20s to 30s—has shown a similar trend to that of other Americans of the comparable age group (Gelazis, 1994). Smoking has decreased among Americans of Baltic descent in the United States, but people living in their native countries have continued to smoke. In fact, some American tobacco companies have begun negotiations with Baltic countries, such as Lithuania, for possible future investments (Linderfalk, 1996). Individuals who have emigrated to the United States since the early 1990s tend to continue to smoke. The latest statistics on smoking rates in the Baltic countries continue to remain high, as much as 45 per- cent of the people smoke (Gilmore et al., 2004). Another health problem is the use of alcohol. Although many people of Baltic descent maintain jobs and are able to function, their use of alcohol is high. The rate of alcoholism in the Baltic countries and other Eastern European countries is high, and drug use is on the rise (Reuters World Service, 1994). Alcohol consumption, especially beer among young adults, is actually increasing (Zaborskis, Sumskas, Maser, & Pudule, 2006). This is not to imply that alcohol abuse is a problem for all individuals of this cultural group, but the issue should be carefully assessed. Health-care professionals are encouraged to be subtle and indirect in these assessments, because denial of the problem is part of the pathology. Greater freedom to move about, especially in the Eu- ropean Union countries, also has implications regarding the health of persons in the Baltics. One example is that casual sex related to truck drivers carrying goods to and from other countries has raised rates of sexually trans- mitted disease, HIV, and tuberculosis in the Baltics and other countries. All of these diseases, particularly rising HIV rates, have dire consequences for the public-health systems of each country as well as any countries to which affected persons emigrate (Rowe, 2006). Health-Care Practices Americans of Baltic descent readily seek medical care and prefer to obtain it from professionals of their own background, when possible. Older people, who may have difficulty with English, are more at ease when they can speak with their health-care providers in their own language.Americans of Baltic descent are health conscious and believe that a well-balanced lifestyle maintains health and well-being. For example, well-being among Lithuanian Americans is typically described as a ho- listic concept—that is, a state of being in which the person’s physical, spiritual, psychological, and social health are in balance (Gelazis, 1994). Moderation is perceived as desirable in living a healthy life. Natural foods are preferred, and whenever possible, vegetables and fruits are homegrown. These are then preserved for use throughout the year. Exercise and physical activity are valued, and people of these cultures make an effort to get a reasonable amount of exercise. Sports are also considered an im- portant part of maintaining one’s culture. Participa- tion in sporting activities promotes a sense of unity and cultural identity along with being an important part of a healthy lifestyle. Young people in particular are encouraged to be active in sports, and team sports are organized and encouraged. For example, Latvians enjoy soccer, whereas Lithuanians have volleyball and basketball teams. Teams from Chicago, Cleveland, and Toronto have tournaments or sports festivals (Sporto Švent˙esin Lithuanian) featuring track and field events and team sports such as volleyball. Several years ago, a sports festival was held in Lithuania in which Lithuanian Americans joined Lithuanians from all over the world in a variety of sports events for the first time in over 50 years. Latvians and Estonians have similar events. The Baltic countries favor sports such as basketball and soccer and such Olympic events as running, bicy- cling, and ice skating. Lithuania boasts of professional basketball players who came to the United States to play professional basketball successfully. One example is Arvydas Sabonis, who has been in the National Basketball Association (NBA) for over a decade. He founded a basketball school in Lithuania that gives scholarships for general education and room and board to disadvantaged children (Daukša, 2006). Some people, as they get older, become more seden- tary and may need to be encouraged to be as active as possible. Most Americans enjoy walking and the out- doors, and health-care professionals can encourage such activities. Older Baltic Americans tend to stay as active as possible; in fact, many enjoy gardening. Women take pride in having beautiful flower gardens, with the rue (ru¯tain Lithuanian) plant having a special place in Lithuanian gardens. Such activities should also be encouraged as a form of exercise. Nutrition Meaning of Food As previously mentioned, before World War II, the Baltic countries were largely agrarian. Industri- alization started before World War II when these 2780_BC_Ch26_001-012 03/07/12 9:53 AM Page 7 countries were forcibly annexed into the USSR. At that time, all private ownership ceased, and farms were collectivized. The Americans of Baltic descent who came to the United States in the late 1940s and early 1950s have roots in the villages of Estonia, Latvia, and Lithuania. Although many came from towns and cities and had professions, many others were farmers. Because many individuals who left the Baltics after World War II experienced food short- ages and times of starvation, food is important to these people. Recent immigrants have left the Baltics for economic reasons and have also experienced food shortages. Common Foods and Food Rituals Some foods common among this cultural group are meats such as pork, chicken, and beef. Rye and whole-grain breads are popular. Baked goods such as bacon rolls, yeast-baked goods, and rich tortes and cakes are common. Fresh fruits and vegetables are enjoyed. Potato dishes such as pancakes, kugel, and dumplings are popular in the home and at festive events. Beets, mushrooms, and cabbage are used in soups and sauces. Dairy products such as sour cream, butter, and yogurt are included daily in their meals (Gelazis, 1994). Grain porridges are popular, especially among Latvians who have putras(por- ridges). The content of porridges varies according to regions in Latvia. Food is a symbol of the culture. Foods enjoyed by people of Baltic descent include smoked and unsmoked sausages and smoked fish, eel, and pork. The spices used are rather mild compared with those of other cultures, but foods may be high in salt content. Food is also connected with festive occasions and celebrations. Certain foods are asso- ciated with particular holidays. For example, Latvians serve gray peas on New Year’s Eve. These must be completely eaten because they signify tears, and one does not want any tears to follow them into the new year. Because Lithuanians are mostly Roman Catholic, many foods relate to Catholic holidays. For example, the meal on Christmas Eve is meatless and includes 12 different foods representing the 12 apostles of Christ. Straw is placed under the tablecloth, symbolizing the manger in which Christ was born. The Christmas wafer is shared with each family member. All family members make an effort to be present at the Christmas Eve meal, which is shared together. After the dinner, the family attends Midnight Mass. People of Baltic descent are becoming acculturated into American food choices and habits. Rituals related to food may include certain holidays, but no set rituals are used on a daily basis. The noon meal was the largest meal of the day in an agrarian society. Thispractice may no longer exist, but health-care providers can encourage it when possible, especially for retired or older people. Dietary Practices for Health Promotion Individuals of Baltic descent enjoy natural, fresh fruits and vegetables and prefer they be homegrown. Diets tend to be well balanced. Health teaching may be nec- essary regarding salt, fat, and cholesterol content be- cause many of the preferred foods are high in these components. Nutritional Deficiencies and Food Limitations Nutritional deficiencies are similar to those of the general population in the United States. Some indi- viduals of Baltic descent may have deficits as a result of food or nutrient deprivation earlier in life. For example, some age groups may have a greater inci- dence of dental caries caused by a lack of calcium at a crucial stage of life. There are no major limitations of food availability for Baltic people in America. However, socioeconomic conditions may prevent some individuals from obtain- ing a balanced diet. Pregnancy and Childbearing Practices Fertility Practices and Views Toward Pregnancy The fertility practices of these cultural groups mirror those of the general population of the United States. The families of younger generations are smaller, and even Lithuanian Americans who are Roman Catholic use birth control practices. In the Baltic countries, a variety of factors cause low birth rates. Under Soviet rule, large families were encouraged, and mothers who gave birth to many children were rewarded with state medals (Gelazis, 1994). Since regaining independence, the Baltic countries have experienced economic difficulties, and many goods, including medical supplies and medications, are scarce. For this reason, many birth control meth- ods are not available to Estonians, Latvians, and Lithuanians. Therefore, abortion rates are high (Priest, 1994); No up-to-date information about abortion rates could be found. In 1998, Latvia and other Baltic countries had a negative population growth. In addition, Latvia had 15.2 infant deaths per 1000 births that same year. In 2009 the infant mortality rate was 8.42 (CIA World Factbook, 2011b). This compares very unfavorably with other European countries such as Sweden, which had 4 infant deaths per 1000 births in 1998 (Pabriks & Purs, 2001). The Baltics need to address these health issues and educate people about prenatal care and birth control methods to reduce both abortion and infant mortality rates. 8Aggregate Data for Cultural-Specific Groups 2780_BC_Ch26_001-012 03/07/12 9:53 AM Page 8 People of Baltic Heritage: Estonians, Latvians, and Lithuanians9 Prescriptive, Restrictive, and Taboo Practices in the Childbearing Family Americans of Baltic descent use modern Western medicine practices, are likely to obtain early prenatal medical care, and are likely to be receptive to health teaching for prenatal and postnatal care. Because they prefer natural processes, some women and families from these cultural groups prefer natural childbirth and breastfeeding. Statistics of these preferences are not available, but research indicates that well-being is defined by Lithuanian Americans as a holistic, well-balanced approach to life (Gelazis, 1994). Some older individuals of Baltic descent may re- member and still believe in past restrictive beliefs about pregnancy. For example, pregnant women are to remain calm and receive no shock or frightening news. In the past, once the child was born, ceremonies and rites included the father’s greeting the child into the family. Now, these rites have given way to Chris- tian baptism ceremonies. The godparents are impor- tant in the child’s life and traditionally give gifts, including candy, to each other and guests. Prenatal care in the Baltic countries today leaves much to be desired. These countries are struggling to improve standards of health care but, unfortunately, have not yet caught up to U.S. standards. Prenatal vitamins may not be available, and the diet may be low in calcium and protein owing to shortages of meats (Trickey, 1993). Death Rituals Death Rituals and Expectations Death is viewed as part of life, and ceremonies of the wake and funeral are linked with Christian religious services. Life and death events are very important and expressed socially within the community. The death of a family member is a loss to the community, which is typically close knit. The funeral may take place within 3 to 4 days following the death, providing time for out-of-town friends and relatives to gather. Family, friends, and community members want to be present at the wake and the funeral ceremony. At the wake, organizations to which the deceased belonged send representatives to express their loss to the family. The funeral is usually a Christian service, followed by a meal at which all attendees are welcomed. Burial is the usual practice. Cremation is permissible now, even among Roman Catholics, especially if the deceased expressed a wish to have his or her ashes taken to the homeland (Fainhauz, 1991). Responses to Death and Grief Grief is expressed by sadness, crying, and talking about the deceased with fondness and respect. Individ- uals from these cultures express emotions readily but not in highly dramatic ways. Decorum is maintainedin public and with strangers. The dead are often re- membered with frequent visits to the cemetery. Roman Catholics have masses said for their deceased relatives on a regular basis, particularly at the anniversary of their deaths. All Souls’ Day, November 2, Ve˙line˙s, is a significant day for Lithuanian Americans, with reli- gious ceremonies commemorating the dead. In Lithua- nia on this day, candles are lit at the graves, which are decorated. Family and friends in each village and town gather for prayers, hymns, and religious services. In the United States, Lithuanian Americans pray for their deceased family members and friends and make every effort to visit the cemeteries (Gelazis, 1994). Spirituality Dominant Religion and Use of Prayer Estonian Americans and Latvian Americans are pre- dominantly Lutherans, but some are Catholics, whereas Lithuanian Americans are predominantly Roman Catholic. All these groups celebrate major Christian religious holidays, particularly Easter and Christmas. Individuals of these cultures consider themselves as having spiritual roots, which may be closely linked with the value they place in their language, country, and culture. Americans of Baltic descent have many concerns about the state of religion and the values of Estonians, Latvians, and Lithuanians. Under Soviet rule, all forms of religion were forbidden, and the Communist government made every effort to eradicate all traces of religious belief. Religion was replaced by Commu- nist dogma for 50 years. Thus, several generations of Estonians, Latvians, and Lithuanians have grown up hearing antireligious propaganda most of their lives. Only the older generation maintained strong religious beliefs. Now that the Baltic countries are independent, efforts are being made to reintroduce religious values. Religious groups from America have sent missionaries to these and other Eastern European countries. Although Christianity has been the religion of the Baltics for hundreds of years, the ancient religion, wherein elements of nature were worshipped, still has an influence, as evidenced in their respect for nature and ecology. To this day, some pagan holidays are commemorated in the form of Christian holidays. For example, St. John’s Eve (June 21) is celebrated by all Baltics and is part of the celebration of the summer solstice. Latvians and Estonians in particular celebrate this holiday with special songs, dances, bonfires, and decorations. A very small percentage of Latvians maintain their ancient pagan religion, called Dievtui (those with God), which has a high priest as its head. Stories include myths and folk wisdom in rhyme as an important part of their content. Most Americans of Baltic descent consider prayer to be an individual expression of their faith. The nurse 2780_BC_Ch26_001-012 03/07/12 9:53 AM Page 9 or health-care professional should allow the client and family to take the lead with regard to prayer. Because prayer is individualized, some patients welcome time for individual or shared prayer, whereas others do not wish to pray. Many have been sustained through hard- ships by their strong religious faith and continue to have strong religious needs. Meaning of Life and Individual Sources of Strength Americans of Baltic descent are a spiritual people, and religion is a source of strength. In addition, the family and the community of Estonian Americans, Latvian Americans, and Lithuanian Americans, as well as their cultural and national identity, are significant sources of support, pride, and strength. Enormous effort goes into preserving their language, culture, customs, and traditions. The changes in their native countries brought about by the Soviet rule are a source of pain for people of Baltic descent. Contact with their homeland and their people has increased their awareness of differences in values, and many are concerned about these differences. Spiritual Beliefs and Health-Care Practices Spiritual and religious considerations are considered private and may not be readily shared with health-care professionals. A trusting relationship with the individ- ual must be established before deep spiritual beliefs are shared. Clergy from the client’s church are usually welcome; thus, the nurse may wish to contact the church. Patients find considerable comfort in speaking with the clergy in times of crises and serious illness (Gelazis, 1994). Health-Care Practices Health-Seeking Beliefs and Behaviors Individuals of Baltic descent adhere to modern med- ical regimens and readily use the health-care system available to them. Because they consider health and well-being important, they take an active interest in healthy lifestyles, nutrition, and exercise. As noted pre- viously, natural foods such as rye and whole-grain breads, fruits, and vegetables are preferred. Fresh air is considered important, and walking, especially in natural settings such as parks, is enjoyed by all ages. The Baltic countries were improving economically until 2008. Estonia, in particular, made the fastest progress economically with the help of investments from Scandinavian countries. By 1993, Estonian trade had reoriented itself toward Western markets. Eston- ian exports are processed goods based mostly on timber, textiles, and food rather than heavy industry. Latvia and Lithuania, however, continue to have agri- cultural and natural resources as the basis for foreign trade (O’Connor, 2003). Economic growth has bothhealth-care and political consequences. For example, a growing economy encourages professionals to re- main in the country, where health needs can be ad- dressed and economically supported through their political stability. The Communist or Socialist parties, for example, can appeal more easily to populations in which economic need is greatly felt and experienced. Democratic processes and government are easier to maintain when the economy is stable and growing. The Baltics need a sound economy as a basis for po- litical growth. In the past year the economies of each of the Baltic countries have begun to rebound from the worldwide economic crisis of 2008/2009, and slight growth is evident (CIA World Factbook, 2011a, 2011b, 2011c). Responsibility for Health Care People of Baltic descent assume responsibility for their own health. Because work is highly valued, most are in the workforce and have insurance coverage. In- dividuals are generally well informed by their physi- cian, friends, and the community about available resources. Because these people place a high value on family, family members are concerned about one an- other and help one another obtain medical and dental care when needed. Because Baltic Americans take a holistic approach to life and health, and cultural roots enter into wellness and health promotion, they encourage youth groups to par- ticipate in sports and camps. At a campsite, Ganezers, in Michigan, Latvian American youth can learn the Latvian language, history, and other cultural practices while participating in swimming and other outdoor sports and activities. In addition, folk songs and dances are part of the program. Several similar camps are located in New Jersey, New York, and western states. Lithuanian Americans and Estonian Americans have comparable summer camps. Scouting is part of each cultural group, and selected activities encourage the use of the native language, customs, and songs. Christian youth groups also hold summer and winter camps with outdoor activities. For example, the Lithuanian American group, Ateitis, fosters Christian and cultural values and physical activities. Their goal is to have well-rounded, Christian Lithuanian American citizens who are healthy and aware of their cultural roots while respectful of political values associated with U.S. citizenship. Medical care and hospitalization are sought readily. Attempts are made to maintain health even into old age. Baltic countries have recently developed a growing interest in “natural” and vegetarian diets, yoga, alter- native medicine, and swimming, even in icy waters. This is the result of Eastern philosophy and influence. However, the standards of medical care available in the Baltic countries at present are below those of the United States. 10Aggregate Data for Cultural-Specific Groups 2780_BC_Ch26_001-012 03/07/12 9:53 AM Page 10 People of Baltic Heritage: Estonians, Latvians, and Lithuanians11 People in the United States, Canada, and other countries send money, medical supplies, and medica- tions to Estonia, Latvia, and Lithuania to help with the shortages, but the current state of health care is poor. In the past, the U.S. State Department issued warnings to travelers about the poor medical care avail- able in these countries. In 1994, a U.S. Lithuanian– sponsored clinic opened in Vilnius. The clinic provides health care for travelers who need medical attention; treatment is covered by U.S. medical coverage plans (Economist Intelligence Unit, 1994). Recent immigrants from the Baltics to America may have different values because they lived under a Communist regime in which the government “took care” of their medical needs in a health-care system that was very different from that of the United States. These immigrants often need help understanding the American health-care system and may be reluctant to use it if they have no medical insurance coverage. Folk and Traditional Practices Individuals of Baltic descent use less folk medicine than they did in the past. Older Americans of Baltic descent are more likely to use more-current healing practices. Chamomile and linden blossom teas may be used for fevers and colds (Gelazis, 1994); honey is used for colds and sore throats. The nurse or health-care provider should ask about teas or folk remedies that may have been used before the client sought medical help. Younger people prefer to use over-the-counter cold remedies and analgesics. The use of natural substances for healing purposes is not customary among this generation. Barriers to Health Care People of Baltic descent have few problems obtaining access to health care. Among older Baltic immigrants, language may continue to present difficulty if they have not learned English well. However, most have friends and relatives who are willing to help by trans- lating. Most recent immigrants who may have part- time jobs and have no health-care coverage may need help in finding medical and health care, such as free clinics, that are available to them. Cultural Responses to Health and Illness Many older people of Baltic descent had lives with hardships both before and after coming to America. Many individuals may tolerate pain as a part of life and may not complain about it or report it. Health- care professionals need to assess older patients for postoperative pain. Some stigma is attached to mental illness, but med- ical care is sought. The family encourages compliance with prescription medications and treatments. Most people of Baltic descent accept physical handicaps, mental illness, and mental retardation. Thefamily usually cares for the individual at home. The community is also supportive. Americans of Baltic descent do not enjoy the sick role and avoid it when possible. Work is highly valued, and the person returns to normal responsibilities as soon as possible. This attitude may be a problem if prolonged rest is required. The nurse or health-care professional needs to understand individual responses to illness and the sick role. Blood Transfusions and Organ Donation Most people of Baltic descent accept blood transfu- sions and organ donation and transplantation. The use of extraordinary means to preserve life is an indi- vidual decision, but living wills are frequently used. In some instances, it may be up to the nurse to inform the patient and family of their rights; the advocate role of the nurse can be exercised if necessary. Health-Care Providers Traditional Versus Biomedical Providers The literature reports no variations in beliefs that Baltic American health-care providers have toward each other. As with other cohort groups, variation be- tween and among different groups of health-care providers may be significant. Besides family members and friends providing informal traditional health prac- tices, no traditional health-care providers are found among people of Baltic descent in the United States or in the Baltics. Another important factor in giving care is allowing patients to make decisions about their care so that in- dividual differences and needs are granted and insti- tutional policies are not adhered to blindly. These individuals are highly sensitive to impersonal treat- ment or to lack of consideration of their individual needs. Health-care professionals who wish to form sat- isfactory relationships with patients of Baltic descent need to put patients’ individual needs above the insti- tution or routines that meet the staff ’s needs rather than those of the patient. Status of Health-Care Providers Because education is highly valued by people of Baltic descent, physicians, dentists, and nurses are held with respect. Advice given to their patients is usually fol- lowed. It is important to be sure that all health teach- ing is well understood; otherwise, the patient may rigidly adhere to an incorrect medication regimen. People of Baltic descent are used to both men and women giving direct physical care. Physicians in the Baltic countries may be female. Nurses and health-care practitioners need to provide for privacy and consider the modesty needs of female and male patients of these cultures as they would for any client. Older patients of both sexes are used to being treated with respect. 2780_BC_Ch26_001-012 03/07/12 9:53 AM Page 11 REFERENCES Agence France Presse. (1995, February 6). Suicide rate soaring in Estonia. Paris: Author. Alilunas, L. J. (1978). Lithuanians in the United States: Selected studies. San Francisco: R & E Research Associates. American Factfinder. (2000). Retrieved from http://factfinder. Baskauskas, L. (1985). An urban enclave: Lithuanian refugees in Los Angeles. New York: AMS Press. Bindokiene˙, D. B. (1989). Lietuviuˇ paprocı˘ai ir tradicijos išeivijoje [Lithuanian customs and traditions in exile]. Chicago: Lithuanian World Community. British Broadcasting Corporation. (1994, May 13). Latvia: Alcohol- induced illness on the increase due to cheap imported spirits. London: Author. CIA. (2011a). World FactBook: Estonia. Retrieved from https:// geos/en.html CIA World Factbook. (2011b). World FactBook: Latvia. Retrieved from geos/lg.html CIA World Factbook. (2011c). 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For case studies, review questions, and additional information, go to 12Aggregate Data for Cultural-Specific Groups 2780_BC_Ch26_001-012 03/07/12 9:53 AM Page 12

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