Overview, Inhabited Localities, and Topography Overview Ireland is an island located on the extreme northwest of the continent of Europe

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Chapter 33

People of Irish Heritage Stephanie Myers Schim

The author would like to thank Sarah A. Wilson for her contribution to this chapter in previous editions.

Overview, Inhabited Localities, and Topography Overview Ireland is an island located on the extreme northwest of the continent of Europe. The North Channel, the Irish Sea, and St. George’s Channel narrowly separate Ireland from England, Scotland, and Wales to the east and the waters of the Atlantic Ocean surround the is- land to the west, north, and south. Called Éire, the Emerald Isle, and the Island of Saints and Scholars, Ireland is divided politically into 26 counties that make up the Republic of Ireland and six counties that comprise Northern Ireland. The Republic of Ireland, whose capitol city is Dublin, covers most of the south part of the island. With a population of 4.6 million people, the Republic of Ireland at a landmass of 26,595 square miles is slightly larger than the state of West Virginia (CIA World Factbook, 2011a). The remainder of the island, Northern Ireland, with its capitol city of Belfast, is officially part of the United Kingdom (UK). Northern Ireland has a land- mass of 5158 square miles and a population of over 1.6 million (CIA World Factbook, 2011b). Ireland continues to function as a single entity across the par- tition in areas such as transport, telecommunications, energy, and water systems, and is considered as a whole with regard to many religious, cultural, and sporting organizations. The two countries differ in many other respects including politics and economics.

Geographically Ireland resembles a basin consist- ing of a central plain rimmed with low mountains. Surrounded by water, Ireland has a cool maritime cli- mate with an average annual rainfall between 31 and 110 inches. The winters are mild, with temperatures of 40ºF in January; the summers are also mild, with temperatures of 66ºF common in July (MET éireann, 2011). With this climate, the island is ideal for growth of turfgrass which provides excellent pasture for sheep and cattle and which is the source of the peat

traditionally used for heating homes and cooking. The intense green of the rolling grassland is the likely source for nicknames such as the Emerald Isle and the Auld Sod.

Formerly a country with an agricultural economy, the Republic of Ireland underwent extraordinary eco- nomic growth from the early 1990s to 2008. Termed the Celtic Tiger, Ireland became a leader in high- technology industries, and people from all over the world, and especially from other European countries, moved into Ireland (Economic and Social Research Institute [ESRI], 2011). This expanding diversity re- sulted in the need for people in Ireland to specify their ancestry for the first time with the 2006 census. The global economic recession of recent years has also slowed the Irish economy. With expanding hardships among Ireland’s trading partners and reduced de- mand for Irish exports, the unemployment rate is cur- rently about 12 percent and is expected to rise as the recession continues. However, the Irish investment in higher education, high-tech industries, and interna- tionally traded services is likely to yield a continuing place for Ireland as one of the largest economic engines of Europe (ESRI, 2011).

The history of the Irish people is a chronicle of spirit, pride, strife and bloodshed, and global migra- tion. Due to complex social, cultural, and economic factors, for several centuries the largest export from Ireland was her people. The Irish Diaspora includes massive and persistent emigration to the United Kingdom, the United States, Canada, Australia and New Zealand, many countries of South and Central American, South Africa, and continental Europe (Boyle & Kichin, 2008; Lee, 2009) In the 2000 U.S. Census, the percent of the U.S. population re- porting their primary ancestry as Irish, Scotch-Irish, or Celtic was slightly over 10 percent or about 22.6 million people (U.S. Census Bureau, 2010).

The history of the Irish in America has been marked by many of the trials and tribulations experienced by

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2 Aggregate Data for Cultural-Specific Groups

other immigrants including religious persecution and economic discrimination. Irish Americans are now as diverse a group as any other, and health-care providers must be careful to avoid generalizations and assump- tions because individuals within cultural groups demonstrate wide variability. Factors that influence Irish Americans’ cultural beliefs include, but are not limited to, geographic heritage, socioeconomic status, education, religion, generation, and length of time away from their homeland as well as other variant cul- tural characteristics (see Chapter 1 in the third edition of this book).

Heritage and Residence Historically, Ireland experienced successive invasions and conflicts in part due to its strategic location in northern Europe close to Great Britain. The Celts came to the area from Europe approximately 10,000 years ago. The Gales, a subgroup of Celtic people, gave Ireland the name Éire. The ancient Gaelic stock mixed with English, Scottish, Welsh, French, Flemish, Norse, and German colonists. England dominated Ireland in the 16th and 17th centuries, creating deeply rooted divisions between English Anglicans, Scottish Presbyte- rians, and Irish Catholics (Nolan, 2011).

Irish people immigrated to North America in large numbers beginning in the 1600s. The earliest settle- ments of Irish Roman Catholics in the United States were in the colonies of Virginia and Maryland. The Irish ship St. Patrick arrived in Boston harbor in 1636. Irish Catholics experienced legal, social, and political discrimination in the predominantly Protestant early America, and by 1699, Irish Catholic immigration was restricted in the colonies of Virginia, Maryland, and South Carolina. For most of the 18th century, immi- gration from Ireland was dominated by Presbyterians since Irish Catholics were not welcome. In the 19th and 20th centuries, most Irish immigrants were Roman Catholic. Irish Catholics were the first Roman Catholics to come to the United States in large num- bers (Byrne, 2000). Although many of the first Irish immigrants settled in industrial areas along the Atlantic coast in the northeast, more recent histori- cal analyses have demonstrated that Protestant and Catholic Irish settled in the early American South as well as in the West (Nolan, 2009). The Northern cities of Philadelphia, New York, and Boston had the largest Irish settlements, followed by commercial and industrial centers in Ohio, Illinois, and Michigan.

At the end of the 18th century, Ireland experienced rapid population growth supported by the cultivation of potatoes beginning in the 1720s. By the 1830s the Irish population was estimated at over 8 million people, but when blight destroyed potato crops between 1845 and 1848, almost a million Irish starved to death. Over two million people left Ireland in the

10 years from 1845 to 1855 (Lee, 2009). After that time, movement out of Ireland continued steadily due to the country’s ongoing inability to provide food or jobs for its citizens. Between 1841 and 1925 about 4.75 million Irish came to the United States, around 75,000 went to Canada, and almost 400,000 went to Australia. By 1911 about one-third of all people born in Ireland were living elsewhere (Lee, 2009).

In 1920, 90 percent of all Irish Americans were re- siding in urban areas. As with immigrants from many other parts of the world, many newly arrived Irish lived in urban tenements or small, cheaply built wooden houses referred to as shanties. From this comes the derogatory term for poor, ignorant, and un- skilled urban dwellers as shanty Irish. In spite of often deplorable living conditions, many Irish in America continued their traditional practice of hanging lace curtains in their windows. Observers, seeing the lace as a sign of pride and pretension in the Irish ghettos, coined the term lace-curtain Irish which is offensively applied to someone who pretends to higher social sta- tus than that to which he or she is entitled. Additional derisive terms for the Irish include Mick and Paddy. The origins for Mick are debated, but one explana- tion refers to the common Celtic surnames that start with “Mc” and “Mac” (as in McSorely, McFarland, MacDonald). Paddy probably derives from the com- mon Irish given name of Patrick, a beloved Irish saint. In large U.S. cities like New York and Boston, such a large percentage of local police forces in the early 20th century were of Irish heritage, that police vehicles used to remove prisoners became known as paddy wagons.

Reasons for Migration and Associated Economic Factors Ireland had a population of 8.5 million until the Great Potato Famine of 1846 to 1848, when the pop- ulation decreased to 3.4 million. During the Potato Famine, almost a million Irish died from malnutri- tion, typhus epidemics, dysentery, and scurvy, and millions emigrated. Mass burials were organized because the demand for coffins could not be met and almost every family experienced loss.

Religious persecution and deplorable economic con- ditions were primary reasons for early immigration to America. The first Irish immigrants to arrive in America in the 1600s were Roman Catholics. They came because of discrimination from Protestant English and Scots moving into Ireland at the urging of the English gov- ernment. Oliver Cromwell, a Protestant leader in the English Parliament, ordered English armies into Ireland. Irish Catholics were forbidden to acquire land or lease land from Protestants for more than 31 years. They were taught only English in the national schools and were actively discouraged from learning or using Irish (Irish Language, 2011). Many Irish immigrants

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People of Irish Heritage 3

who came to the United States had a homeland history of oppression, violence, and suffering.

Much of the Irish American experience was similar to that of other immigrant groups, except for three unique features. First, the period of immigration lasted longer for the Irish. For well over a century, many first-generation Irish Americans saved money to send home so other family members could come to America. Second, unmarried Irish women immigrated apart from family groups. This was in contrast to other immigrant groups and was without parallel in the history of European immigration (Nolan, 2009). At the beginning of the 20th century, over 60 percent of the Irish who came to the United States were single women (Dezell, 2002). Opportunities for young female employment as cooks, domestic servants, and childcare workers enticed many to cross the Atlantic alone or in small groups of girls. Third, established Roman Catholic parishes filled a cultural and religious role for the Irish in America and became the centers of their lives and symbols of cultural identity. The Roman Catholic Church has remained one of the cornerstones of the Irish American community.

Part of Irish success in America is attributed to the fact that they spoke the same language (although often with a unique accent termed the Irish brogue (Corrigan, 2010). Arriving Irish had the same general physical appearance as other European Americans, and they quickly mastered the American political sys- tem. They may have assimilated less than other ethnic groups because it was easier for them to blend in (Dezell, 2002). One-third of U.S. presidents trace their lineage to Irish descent, although mostly through an- cestry in the Protestant north. It was not until the early 1960s that the first Irish Catholic U.S. President, John Fitzgerald Kennedy, was elected. In 2008 an estimated 36.3 million U.S. residents claimed Irish ancestry (U.S. Census Bureau, 2010). The Irish in America have become a central part of “mainstream” American culture.

Educational Status and Occupations The educational system in modern Ireland is among the finest in the world. Observing that historically the country’s largest export was her people, the Irish gov- ernment invested in advancing public education so that Irish youth would be able to better compete for jobs in growing global markets. With an emphasis on education and training in emerging high-technology and service sectors, universities, institutes of tech- nology, colleges of education, private colleges, and various state-aided institutions provide advanced ed- ucation for over 55 percent of Irish students who com- plete secondary education programs. Ireland also boasts a National Framework of Qualifications that allows graduates from diverse programs to be part of a unified, coherent, award system and lifelong learning

society (Enterprise Ireland, 2011). The availability of a highly educated workforce able to supply a variety of high-tech and knowledge-based employment fields has recently led to dramatic growth in the Irish econ- omy and an influx of workers to Ireland from around the world.

Early in the U.S. experience, many Irish children were put to work at a young age, often at the expense of their educations, because they were needed to help provide for their families and to send money home to Ireland. Educational attainment increased for each subsequent U.S.-born generation, with the descen- dants of Irish immigrants surpassing the general population in overall educational attainment. Accord- ing to estimates based on the U.S. Census, 92 percent of Irish Americans are high school graduates and 32 percent hold bachelor’s degrees or higher (Cooper, 2011). Early Irish immigrant men were primarily agri- cultural laborers who were considered unskilled labor in the rapidly advancing industrial workforce in America. Irish farmers were not well prepared for life in large cities or educated for the skilled jobs then available. However, early Irish male immigrants contributed sig- nificantly to the growth of America by helping build the Erie Canal, the transcontinental railroad, and many of the first skyscrapers. They also served their new country by fighting in major military conflicts. The Catholic priesthood was the leading career choice for second- generation Irish men in the early 1900s.

Communication Dominant Languages and Dialects The major languages spoken in Ireland are English and Irish (Gaelic), the latter of which is the official language and is spoken in a growing number of communities. Kept alive in a few areas called the Gaeltacht heartland in spite of English efforts to eradicate it, Irish is now being encouraged and supported as a fully fledged mod- ern European language (Government of Ireland, 2010).

The Celts relied on oral transmission of traditions, laws, customs, philosophy, and religion, and Gaelic was developed in a written form relatively late in Celtic/Gaelic history. Language used in oral traditions is often more descriptive and flexible than written forms, and poetry is a useful mnemonic device in oral traditions. Tales of ancient Irish folk heroes, such as Finn MacCool (“Finn MacCool,” 2011), Cuchulain (Bulfinch, 1913), and Saint Patrick (Freeman, 2005) have been passed down through the generations in po- etry, song, and storytelling in oral and literary forms. Many authors have suggested that modern-day Irish priests, politicians, and others share the love of using many words and playing with language not only for communication but also for enjoyment and entertain- ment. This characteristic use of language is often called the Gift of Gab (Hughes, 2007). Many people

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of Irish heritage enjoy puns, riddles, limericks (five- line humorous poetry named for County Limerick), and other storytelling. When one becomes accus- tomed to hearing the Irish-accented English used by newer immigrants, there is usually little difficulty in understanding. The Irish accent has a nasal quality and is spoken with a strong inflection on the first syl- lable of a word, resulting in a loss of weak syllables (Dalton & Chasaide, 2005). Words ending in a vowel weaken the consonants following them. Some Irish speakers, particularly those from southeastern coun- ties, replace the “th” diphthong with a “d” sound so “Mother” may sound like “Mudder” (Corrigan, 2010).

The Irish tend to use low-context English, which calls for many words to explicitly articulate a thought. In order to convey detailed meanings in communica- tion, people in low-context cultures may need to provide additional information to the listener or reader. Although one might expect that low-context communications are necessarily wordier because they must carry more information, the opposite is often true: there may be great attention paid to economy and precision of language use to make every word meaningful (O’Hara-Devereaux & Johansen, 2011). The writings of famous Irish authors illustrate the richness and variety of the Irish use of the English lan- guage. Examples include Jonathan Swift’s Gulliver’s Travels (Swift, 1726/2011); Lady Morgan’s The Wild Irish Girl (Joyce, 1806/2008), James Joyce’s The Dublin- ers (Joyce, 1914/2010), Ulysses (Joyce, 1922/1986), and Finnegan’s Wake (Joyce, 1939/1999); and Frank McCourt’s Angela’s Ashes (1999), among many others. Since these are examples of books and not really being referenced, I do not think they need to be on the reference list. Commom practice is to access Amazon or other online book store. We did not give publish- ers of books that are listed in the chapters in the printed book.

Cultural Communication Patterns Even though many Irish and Irish Americans delight in storytelling, they may be much less expressive when discussing personal matters unless they are talking with close friends or family members. Even then, many remain reluctant to express their innermost thoughts and feelings. Humility, circumspection, and emotional reserve are considered virtues. Displays of emotion and affection in public are avoided and often found to be difficult in private. Humor and teasing may be used as expressions of affection. Many people of Irish heritage are sensitive to personal boundaries and respect one another’s right to privacy. Family members may be expected to know that they are loved without being told. To many, caring actions are more important than verbal expression.

The Irish use direct eye contact when speaking with one another. Not maintaining eye contact may be

interpreted as a sign of disrespect, guilt, or evidence that the other person cannot be trusted. Among many people with Celtic (Scottish/Irish) origins in the United States, particularly those from the Ap- palachian region, sustained direct eye contact may be uncomfortable in conversation especially with strangers and taken as a sign of disrespect (Kephart, 1914/2010).

Personal space is commonly important to Irish Americans, who may require greater distance in spa- tial relationships. Although the Irish may be less phys- ically expressive with hand and body gesturing, facial expressions are readily displayed, with frequent smil- ing even in the face of adversity. However, the health- care provider must remember that responses vary from person to person so individual observation and assessments are necessary.

Temporal Relationships Irish Americans, with their strong sense of tradition, may be somewhat past oriented. They put a premium on their Irish heritage and have an allegiance to the past and their ancestry. Many, however, are past, pres- ent, and future oriented. While respecting the past, they plan for the future by investing in education and saving money. Working toward a better life personally and for the family is indicative of a strong sense of in- ternal control, independence, and autonomy. Many Irish Americans see time as being elastic and flexible. Therefore, some Irish Americans may have to be encouraged to arrive 10 to 15 minutes early for a scheduled appointment. Others place a premium on punctuality and may arrive early and find waiting for others bothersome.

Format for Names Mac or Mc before a family name means “son of,” whereas the letter O in front of a name means “de- scended from.” Gaelic names such as Brian, Maureen, Sheila, Sean, and Moria have become popular as first names for American children. Roman Catholic and Protestant Irish Americans are often given middle names honoring saints or deceased family members. Names are written with the surname, and the person may prefer to be addressed by their first name in in- formal situations. Nicknames are commonly used among family and friends, but care should be taken not to presume to address patients (especially those older than the health-care provider) informally with- out first asking permission.

Family Roles and Organization Head of Household and Gender Roles American family life is described as having a strong con- tinuity over generations. Families in western and south- ern Ireland were farmers who married young (especially

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People of Irish Heritage 5

younger women with older men) and had large families. The family structure was patrilineal, with land divided among surviving sons. The father ruled the family, but the mother had a significant influence over management of the household and education of children. The Irish have a strong sense of family obligation, and this pattern frequently continued when they emigrated. As the Irish settled in all parts of America, the roles of women ex- panded. It has been reported that Irish women have more power in family life than women in many other ethnic groups (Dezell, 2002). In traditional Irish culture, families commonly lived with rigid rules maintained by the social, religious, and moral pressures of society. In modern-day Ireland and among the large population of Irish Americans, family structures and social norms are changing toward more open and egalitarian structures.

Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents Kinship, family, and sibling loyalty are important to the Irish. Most Irish families emphasize independ- ence and self-reliance in children. Boys are allowed and expected to be more aggressive than girls. Girls are raised to be respectable, responsible, and re- silient. Children are expected to have self-restraint, self-discipline, and respect and obedience for their parents and older people.

In addition to having self-restraint and self-discipline, adolescents are expected to obey and show respect for their parents as well as church and community figures. The adolescent years are a time for experiencing emotional autonomy, independence, and attachments outside the family, while remaining loyal to the family and maintaining traditional Irish beliefs. Peer group pressures at school may have a significant influence and often are incongruent with the belief systems of Irish Americans. Whereas rebellion may be viewed negatively by parents, it can provide a functional benefit for teenagers by helping them to become autonomous in- dividuals of whom the family can be proud. During adolescence, close family relationships may contain mixed feelings of love and hate as well as acceptance and rejection. Health-care providers may need to help family members to reframe family tensions in terms of normal adolescent development and assist family mem- bers to find ways to keep communications open in spite of tensions.

Family Goals and Priorities The traditional Irish family is nuclear, with parents and children living in the same household. Children are cherished, and primary socialization is aimed at mak- ing them productive and independent members of so- ciety, providing necessary educational experiences, and preparing them to bring additional status to the family.

Whereas marriage in ancient Ireland was often de- layed until after the age of 30 (especially among the

men), Irish Americans marry at an age comparable with that of the rest of the U.S. population. As in many cul- tural groups, Irish immigrants were under pressure to marry within the Irish community; the pressure was es- pecially strong for Irish Catholics to marry other Irish Catholics, and this pattern persisted into the mid-20th century. Today, marriage between different cultural and religious groups is more common; however, it is still more socially acceptable to marry within one’s group, thereby assuring the transmission of culture within the Irish American community.

Irish Americans usually respect the experience of older people and seek their counsel for decision making. Early Irish immigrants provided assistance to older Irish through immigrant aid societies, which were fraternal or religious in nature. However, since the Great Depres- sion and passage of the Social Security Act, assistance for elder care is provided through Social Security, private pensions, and private insurance. A noticeable shift in caring for the growing aging population occurred early in the 20th century, when placing older family members in nursing homes became more widely acceptable. By the mid-20th century, families were relying on govern- mental and institutional support to care for older people (Dezell, 2002). Although many Irish families are dis- persed across the country and around the globe, and may have infrequent contact, their beliefs regarding familial obligation can lead to displays of social support in times of crisis or need.

People with Irish heritage often value physical strength, endurance, employment, the ability to per- form work, and the ability to provide their children with education to attain respectable socioeconomic status and professional accomplishments. Members of the clergy in diverse religions are respected as are members of religious orders.

The Irish contributed to the growth of the Roman Catholic Church in America by providing leadership, membership, and money. Excluded from publicly supported Protestant schools and institutions, they established and built Catholic schools and colleges, health-care institutions, and social service agencies. Each Catholic parish was encouraged to build a school and so the parochial system flourished in the United States. John Carroll, son of an Irish immigrant, was the first Catholic bishop in the United States and the founder of Georgetown University. Women in Irish religious orders such as the Sisters of Mercy and the Sisters, Servants of the Immaculate Heart of Mary have made, and con- tinue to make, enormous contributions to education and health care across the United States (National Catholic Education Association [NCEA], 2010).

Alternative Lifestyles Although alternative lifestyles are becoming more accepted both in Ireland and in the United States, sig- nificant stigma remains. To gain acceptance, the Gay

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Lesbian Equality Network (2011) has been advocating same-sex marriage in Ireland. There is an Irish-American gay, lesbian, and bisexual group in Boston, Massachu- setts, and the Lavender and Green Alliance, an organ- ization of New York City Irish lesbian, gay, bisexual, and transgender people, became more visible after a gay New York Fire Department chaplain was killed in the line of duty on September 11, 2001 (Fay, 2011). Although the doctrines of the Roman Catholic Church remain anti-gay, attitudes are shifting toward greater acceptance in some communities and parishes (Helminiak, 2011). Information for referrals to gay- friendly Catholic parishes, other inclusive places of worship, and GLBT support organizations is easily found with an Internet search.

Workforce Issues Culture in the Workplace Most Irish immigrants came to America with a strong desire to work, survive, and send money to family back home. Consistently excluded and discriminated against, Irish immigrants were viewed as a cheap, will- ing, and disposable source of hard labor. Jobs in mills and factories, mining, construction, and other high- risk occupations contributed to excess mortality rates among Irish immigrants.

Over time, the Irish have made places for themselves in the workforce and are represented in all occupations and professional roles. The Irish have been described as good organizers, skillful at establishing networks and making contacts. By the late 1960s, Irish Americans were overrepresented in law, medicine, and the sciences and slightly underrepresented in the social sciences and business. Second- and third-generation Irish American women are widely represented in occupational and pro- fessional fields and, compared with other groups, are overrepresented in law, teaching, and clerical work. Often, they moved from traditional service occupations to positions in education, health, and business.

High-technology industry injected a much-needed boost in the Irish economy in the 1990s. Ireland has a young and well-educated workforce. Foreign investors consider the quality and “can do” flexible attitude of the Irish people to be two of the country’s greatest ad- vantages. Irish workers are good at applying knowl- edge; they want to do it right the first time and do it better and faster (ESRI, 2011). Because of the large shared heritage between Ireland and the United States, Irish immigrants assimilate relatively easily into the American workforce. Many endure short-term deprivations to achieve their long-term goals of sta- bility, prosperity, and good quality of life.

Issues Related to Autonomy Most past-oriented ethnic groups believe that the future is controlled by a higher power or fate, humans

must live in harmony with their surroundings, they re- spect authority rather than challenge it, and find group identity to be more important than individual identity. Even though the Irish are typical of past-oriented groups in other ways, many Irish Americans are future oriented and question the status quo of the American workforce. When individual efforts were unsuccessful in improving the work environment, Irish Americans joined forces and helped pave the way for change with leadership toward unionization and became one of the groups responsible for the current union culture in the American workforce. Within the labor movement, Terrance Vincent Powderly, the son of Irish immigrants, became the head of the Knights of Labor, the most powerful labor union of its day. Joe Curran founded the National Maritime Union and was its first president. Mike Quill organized the Transport Workers of America. Irish women were at the forefront of the American labor movement in the 19th century. Mary Harris Jones, also known as Mother Jones, an immigrant from County Cork, Ireland, was active in the labor movement into her 90s. Mary Kenney Sullivan was recruited by Samuel Gompers to be the first woman organizer of the American Federation of Labor (Dezell, 2002).

Irish Americans speak English, and most value ed- ucation and achievement; even newer Irish immigrants do not encounter many language barriers in the work- place. The use of low-context language, in which most of the message is explicit, may enhance communica- tions in the workplace.

Biocultural Ecology Skin Color and Other Biological Variations Most Irish either are dark haired and light skinned or have red hair, ruby cheeks, and fair skin; however, as with other ethnic groups, there are other variations in hair and skin colors. Although natural red hair remains common among Irish Americans, it is becoming less prevalent in Ireland as that island’s genetic isolation diminishes. The appearance of red cheeks or a ruddy fa- cial or neck complexion is often a result of a skin con- dition known as rosacea that occurs commonly among those with Celtic ancestry, especially among women. The fair complexions of Celtic Irish people place them at increased risk for skin cancer. Yearly checks for der- matological changes are advisable along with consistent use of ultraviolet (UV) ray sun-blocking preparations, brimmed hats, and protective clothing. Many Irish people are taller and broader in build than the average European American, Asian, or Pacific Islander. Tallness and a sturdy body build are considered attractive assets among the Irish and Irish Americans.

Diseases and Health Conditions Cardiovascular disease and cancer remain the leading causes of premature death in the Republic of Ireland

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People of Irish Heritage 7

accounting for 63 percent of all deaths in 2009, but over the last decade major reductions in prevalence in both categories have been observed (Department of Health and Children [DOHC], 2010). Mortality rates for cardiovascular disease are 16.5 percent below and for all cancers 5.5 percent above European Union (EU) averages. Many premature deaths are preventa- ble with improved lifestyle choices such as avoidance of smoking, reduction in alcohol consumption, and maintenance of a healthy weight.

Smoking has been identified as the major risk fac- tor causing premature mortality from lung cancer in Ireland; however, in recent years, there has been a steady decline in use of cigarettes and alcohol (DOHC, 2010). Smoking-cessation programs with group and one-to-one counseling are some important activities through which health providers can help Irish and Irish Americans improve their health. As so- cioeconomic conditions improve in Ireland and broader food options from around the world become more readily available, obesity for men and women has increased an estimated 30 percent in the past decade (DOHC, 2010). Irish Americans are also in- creasingly at risk, as is the rest of the U.S. population, due to epidemic obesity. Counseling regarding im- proved food choices, portion control, and increasing exercise are appropriate to support those who want to make positive lifestyle changes.

The percentage of the population in Ireland who self-rate their health as “good” or “very good” is about twice the EU average, and since 2002 life ex- pectancy in Ireland has exceeded the EU average (DOHC, 2010). In addition to significantly extended life expectancies, men and women in Ireland share the likelihood of more “healthy life years” than their same-age EU counterparts. The exceptions to such major advances in population health in Ireland are found among the Travellers (DOHC, 2010). Travellers, who are sometimes referred to as tinkers or pavees, are a nomadic Irish social group with a separate identity, social organization, and dialect that distance them from the majority Irish population. Living outside the cultural norms of Irish life, they have many similar characteristics to the Romani Gypsies and are often distrusted and reviled in the same ways. There are many, often highly interconnected, families of Irish Travellers in the United States today. Some of these groups have gained a reputation for swindling people in such industries as roofing and home improvement; however, many are simply trying to live their lives within their traditionally “outsider” cultural context (Vernon & O’hAodha, 2007).

The infant mortality rate in Ireland dropped by 50 percent between 1987 (5.3/1000) and 2004 (2.9/ 1000), and the major cause of infant mortality shifted from congenital malformations to prematurity. Im- provements have been attributed to better maternal

health and pregnancy care and more widespread pre- conceptual intake of folic acid (Baxter, 2009). In the Republic of Ireland public health nursing services are universally available to new mothers and babies as an effective population-based intervention by which home visits for assessment and support are done within 48 hours of hospital or birthing center discharge (O’Dwyer, 2009). The Irish in America are counted with all other white, non-Hispanic groups. In 2006 the infant mortality rate in the United States for the population that includes Irish Americans was 5.6 per 1000 (Centers for Disease Control and Prevention [CDC], 2010). The much higher infant mortality rate in the United States is attributed largely to the higher incidence of preterm births; 1 in 8 infants in the United States are born prematurely whereas 1 in 18 Irish babies are preterm (MacDorman & Mathews, 2009).

Variations in Drug Metabolism No studies on drug responses specific to the Irish could be found in the professional literature. Most studies of pharmacologic responses that included people of Irish descent used data aggregated under the category of non-Hispanic Whites. Because Irish diets are similar in carbohydrate, protein, and fat ratio to many other European and American diets, until further research is done, the health-care provider might expect the pharmacodynamics of drug metab- olism among Irish Americans to be similar to those of other white, non-Hispanic people.

High-Risk Behaviors The use of alcohol, tobacco, and intravenous drugs is associated with major health problems among Irish and Irish Americans as within other populations. Immigrants are identified as being at high risk for many additional health conditions because they are confronted with many challenges as they adapt to new environments and lifestyles. Alcohol problems in Ireland are frequently noted, but the Irish mortality rate from selected alcohol-related causes (56.2/100,000) is 10 percent lower than the reported rate for other EU countries (62.5/100,000) (DOHC, 2010). Irish Americans rank among the highest of all ethnic groups in alcohol use; 88 percent of Irish Catholics in the United States report alcohol use compared with 67 percent of the overall population (Dezell, 2002). Purnell and Foster (2003a, 2003b), in their multinational review of the lit- erature on alcohol use, reported that the percentages of people in the United States, Ireland, and England who drink is the same; however, alcohol-related be- havior problems such as motor vehicle accidents and interpersonal violence occur more often among the Irish. Researchers on Irish alcoholism for the most part agree that the single factor of Irish ancestry puts people at risk for developing drinking problems (Dezell, 2002).

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One of the main cultural institutions that migrated around the globe with the Irish Diaspora was the Irish Pub. In early Celtic society one of the most important roles was that of briugu or brewer/hospitaller who ran a “public house” that provided food, drink, and a resting place along rural roads (Molloy, 2003). Such public houses, or pubs, became community centers for entertainment, recreation, communication, and com- merce. In Ireland before grocery stores and supermar- kets, the local pub was the source of 95 percent of the foodstuffs and consumable household goods used. Of the approximately 13,000 licensed pubs in the Repub- lic of Ireland and Northern Ireland today, about 200 are said to have been run by the same families for over a century (Molloy, 2003). In the United States and in most other countries, an Irish pub is easily identified as a gathering place with food and alcohol beverage service and often featuring musical entertainment in the Celtic folk tradition. In a recent research study a pub was defined as a place that served Irish beer on tap and which had an Irish name (for example, Murphy’s or O’Donnell’s) or an establishment with sig- nage claiming it as an “Irish Pub” (Connolly et al., 2009). The legacy of socializing in pubs continues in America. Irish pubs are popular establishments synony- mous with alcohol intake, lively music, and a good time.

Healthcare Practices The Irish and Irish Americans have a reputation as a group with persistent alcohol problems, and the image of the heavy drinking “paddy” is often reinforced with St. Patrick’s Day celebrations, pub crawls, and media coverage. In Ireland the average amount of alcohol consumed per person is reported to be 12.4 liters per year. This is about 490 pints of beer, 129 bottles of wine, or 46 bottles of spirits per adult. However, it is also reported that one-fifth of Irish adults do not drink at all, so actual per person consumption is likely to be higher (Alcohol Action Ireland [AAI], 2011). The Irish drink about 20 percent more than other Europeans, and alcohol-related disorders and acci- dents are a common reason for hospital admissions. Binge drinking is common, and many alcohol-related crimes and socially disruptive behaviors occur on weekends and holidays. Alcohol is associated with a wide range of problems including cancers, cirrhosis, birth defects, child abuse, domestic violence, as well as mental health issues and an increased risk of suicide.

Unfortunately, Irish alcohol consumption and al- coholism patterns are also seen among those of Irish ancestry living outside the Emerald Isle. Stivers (2000) believes the Irish in America drink because they are expected to be heavy drinkers. However, many factors, including family characteristics, social and economic conditions, psychological orientation, and genetics in- fluence alcoholism. Recently there has been interesting progress with regard to identifying the role of genetics

in the development of alcoholism among the Irish (Hack et al., 2011; Kendler et al., 2006; Sintov et al., 2010). Widespread community patterns reinforce the stereotype of the drunken Irishman, but health-care providers need to be careful not to ascribe this label to all Irish or Irish Americans. Individual assessment of intake patterns including the type, quantity, and frequency of alcohol use as well as specific family, so- cial, and medical histories are recommended. Because drinking may be a way of coping with problems, health professionals may need to assist Irish American patients in exploring less-risky coping strategies and caution them against the dangers of mixing alcohol with medications or driving while impaired. Pregnant women should be cautioned to avoid alcohol (Bainbridge, 2009).

Smoking tobacco, another high-risk behavior, re- mains common in Ireland with an estimated 33 percent of the population continuing to use cigarettes, cigars, and pipe tobacco. Ireland has banned smoking in pub- lic places, including all pubs, raised taxes on cigarettes, and outlawed the display of cigarettes for sale, but many people still smoke. Forty-five percent of Irish smokers are young people aged 16 to 30 (Bray, 2009), and smoking during adolescence has been associated with other high-risk behaviors (O’Cathail et al., 2011).

Thirty-eight percent of current Irish smokers are men, and 28 percent are women (Bray, 2009). Although smoking is declining in the male population, it is increasing among females. The incidence of lung cancer in the United States is similar to that of Ireland, with men having higher mortality rates asso- ciated with smoking than women. However, the rate of lung cancer is increasing among women as more women smoke. Health-promotion efforts should be directed at decreasing the incidence of smoking among Irish Americans. Of particular interest is the apparent persistence of smoking in Irish pubs in defi- ance of recent U.S. laws prohibiting indoor smoking in bars and restaurants (Satterlund, Antin, Lee, & Moore, 2009).

The incidence of AIDS among young Irish-born people has risen sharply in the last decade. Even with this increase, just less than 1 percent of all 15- to 49-year-olds are HIV positive or have AIDS (O’Cionnaith, 2010). Although there are anecdotal reports about Irish Americans living with HIV and AIDS, particularly in the gay, lesbian, bisexual, and transgendered community, statistical estimates are not specific to Irish Americans. Health promotion efforts should continue to be directed at educating Irish Americans about avoidance of high-risk behav- iors for HIV/AIDS, and individual assessment of risk factors, knowledge, and behaviors is indicated.

Both Irish and Irish Americans may ignore symp- toms and may delay seeking medical attention until symptoms interfere with activities of daily living. In a

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People of Irish Heritage 9

study of women seeking care for self-identified symp- toms of breast cancer, researchers found that delay was significantly related to knowledge and beliefs about the symptoms, to the level of anxiety experi- enced, and to social role and social support issues (O’Mahony & Hegarty, 2008, 2009). For young people in Northern Ireland, seeking help for emotional and mental health concerns was found to be related to parental support and knowledge of available resources (Teahan, McNamee, & Donnelly, 2006). Many Irish Americans believe that having a strong religious faith, keeping one’s feet warm and dry, dressing warmly, eating a balanced diet, getting enough sleep, and exercising are important for staying healthy.

Nutrition Meaning of Food Food is an important part of daily life, health main- tenance, and celebration for Irish Americans. Within their religious framework, most Irish Catholics feel they should use food in moderation and in ways that are not injurious to health. Traditional Catholic holi- days that are celebrated with food include the Solem- nity of Mary (Mother of God), January 1; Easter; Ascension Thursday, 40 days after Easter; the Feast of the Assumption, August 15; All Saints’ Day, November 1; the Feast of the Immaculate Concep- tion, December 8; and Christmas, December 25. Many devout Catholics fast and abstain from meat on Ash Wednesday, Good Friday, and all Fridays in Lent. Fasting is viewed as a spiritual discipline. Many holi- days and special events are celebrated with specific foods appropriate to the occasion.

Common Foods and Food Rituals Meat, potatoes, and vegetables are the staples of both Irish and Irish American diets. Lamb, mutton, pork, and poultry are common meats. Seafood includes salmon, mussels, mackerel, oysters, and scallops. Pop- ular dishes include Irish stew, made with lamb, pota- toes, and onions.

Potatoes are used in a variety of ways. Colcannon, a dish often associated with Halloween, is made with hot boiled potatoes mashed with cabbage, butter, and milk and seasoned with nutmeg. Champ is a popular dish made with mashed potatoes and scallions. Scallions, in- cluding the green tops, are cut in small pieces, boiled in milk until tender, and then added to mashed potatoes and served with butter. Dulse (also known as Irish moss), iodine-rich seaweed found in northern latitudes, may be used in place of scallions. Potato cakes, made with mashed potatoes, flour, salt, and butter, are shaped into patties and fried in bacon grease. Potato cakes are served hot or cold with butter and sometimes molasses or maple syrup. Dublin coddle, made with bacon, pork sausage, potatoes, and onions is also a favorite.

Oatmeal is popular in Ireland. During times of food shortage, oatmeal was a staple food sometimes watered down to make it last longer. Soda bread, popular in Ireland and America, is made with flour, baking soda, salt, sugar, cream of tartar, and sour milk. In Ireland, it is usually made fresh daily. Ale and beer are common beverages with meals, and Irish whiskey is exported around the world. Although commonly associated with Irish Americans, corned beef and cabbage are not traditional foods in Ireland.

Irish food is unpretentious and wholesome if eaten in moderate portions. Because the Irish American diet is potentially high in fats and cholesterol, the health- care provider may need to assist patients with balanc- ing food selections, limiting portions, and adapting preparation practices to reduce the risks of cardiovas- cular disease. Obesity is now becoming a health prob- lem in Ireland, and health promotion efforts are directed at educating the public on healthier food choices. Irish Americans have a great variety of foods available, and the selection in Ireland is similar to the rest of the European Union countries. Where starva- tion was once the major threat to health, obesity is now a major concern.

Mealtime is an important occasion for Irish fami- lies to socialize and discuss family concerns. Meals are usually eaten three times a day, with a hearty break- fast, dinner (the main meal) around noon, and a late supper. Some Irish and Irish Americans continue the afternoon tradition of a light sandwich or a biscuit with hot tea. Most Irish Americans have acculturated to the mainstream American pattern of breakfast, lunch, and dinner with the evening meal being the main meal.

Dietary Practices for Health Promotion Eating balanced meals is considered important even if it means the individual is late for an appointment. Vitamins are commonly used as dietary supplements. Generally, fast foods are considered less healthy than home-prepared foods but are conveniently available in most places.

Nutritional Deficiencies and Food Limitations No specific nutritional deficiencies or food intoler- ances specific to Irish Ancestry were found in the lit- erature. However, low-BMI Irish and Irish American women are at increased risk for osteoporosis and may need to increase their intake of dietary calcium and vitamin D.

Pregnancy and Childbearing Practices Fertility Practices and Views Toward Pregnancy Fertility practices for many Irish are influenced by Roman Catholic religious beliefs and the tendency to

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view sexual relationships as a marital duty with the purpose of procreation. The only acceptable methods of birth control are abstinence and the rhythm method. Many Catholic families practice other means of birth control, but no statistics are available. Abor- tion is considered morally wrong and is against the law in Ireland. Women’s groups have been vocal in Ireland and in America about women’s rights, espe- cially reproductive rights.

Prescriptive, Restrictive, and Taboo Practices in the Childbearing Family Prescriptive beliefs for a healthy pregnancy include eating a well-balanced diet. Some Irish believe that not eating a well-balanced diet or not eating the right kinds of food may cause the baby to be deformed. In addition, the Irish share the belief common to many other ethnic groups that the mother should not reach over her head during pregnancy because the baby’s cord may wrap around its neck. A taboo behavior in the past, which some women still respect, is that if the pregnant woman sees or experiences a tragedy during pregnancy, a congenital anomaly may occur.

Eating a well-balanced diet after delivery continues to be a prescriptive practice for ensuring a healthy baby and maintaining a mother’s health. Plenty of rest, fresh air, and sunshine are also important for maintaining a mother’s health. Many Irish believe that going to bed with wet hair or wet feet causes illness.

Death Rituals Death Rituals and Expectations The Irish’s reaction to death is a combination of pagan and Celtic traditions and current Christian faiths. The Celts denied death and ridiculed it with humor. The Irish tend to be fatalists and acknowledge the inevitability of death. However, American empha- sis on technology and dying in the hospital may be in- congruent with the Irish American belief that family members should stay with the dying person. After death, family and friends make every effort to be pres- ent for the funeral even if this means long-distance travel. Funeral services may be delayed until family members can gather.

Responses to Death and Grief A traditional practice in Ireland and the United States was for a deceased family member to be “laid out” at home for a final farewell by the family. U.S. family vis- itation is now usually done in a funeral home designed for this purpose before a funeral service in the church. Ancient Gaelic women practiced “keening” or “loud wailing” at wakes, while men socialized with drinking and smoking. The wake continues as an important tradition in contemporary Irish and Irish American families. Often done at home after the church service

10 Aggregate Data for Cultural-Specific Groups

and interment, a wake is a time of melancholy, rejoic- ing, pain, and hopefulness as well as a time to share food and drink in honor of the deceased. Cremation is an individual choice, and there are no proscriptions against autopsy.

Spirituality Dominant Religion and Use of Prayer The predominant religion of most Irish is Roman Catholicism, and the church is a source of strength and solace for many Irish Americans. In times of ill- ness, Irish Catholics receive the Sacrament of the Sick, which includes anointing, Communion, and a blessing by the priest. The Eucharist, a small wafer made from flour and water, is given to the sick as the food of heal- ing and health. Family members and health-care staff may participate if they wish. The obligation to fast and abstain from meat on specified days is suspended in times of illness. Other religions common among Irish Americans include various Protestant domina- tions, such as Church of Ireland, Presbyterian, Quaker, and Episcopalian.

Prayer is an individual and private matter. In the health-care setting, patients should be given privacy for prayer whether or not a clergy member is present. In times of illness, the clergy may offer prayers for the sick, as well as the family, because they too need sup- port. Attending Mass daily is a common practice among many traditional Irish Catholic families. For those Irish Catholics who practice their religion regu- larly, holy day worship begins at 4 p.m. the evening preceding the holy day. All Sundays are considered to be holy days.

Meaning of Life and Individual Sources of Strength Many Irish are fatalistic and view humans as subject to the harshness of nature. To help overcome stresses associated with life’s hardships, many Irish view life with humor and use their capacity for satire and self- burlesque as a coping mechanism (Dezell, 2002), which helps them keep problems in perspective. In addition, they gain meaning in life through the home, religion, the church, and the pub, which are centers of social life in Irish communities.

Many Irish have a strong faith and a passion for freedom. Christianity existed in Ireland before the arrival of Ireland’s patron saint, St. Patrick, in the 5th century. The theology and philosophy of Christi- anity were interwoven with the older Gaelic culture, creating a lasting identification between faith and the nation (Tifley, 2000). A history of colonization and religious persecution over the centuries made religion a central focus of many Irish conflicts including the major division of the island into the Republic of Ireland and Northern Ireland.

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People of Irish Heritage 11

Spiritual Beliefs and Health-Care Practices Religion is important for many Irish Americans in their daily life and in times of sickness. Irish Catholics continue to receive the sacraments when sick. Health- care providers should inquire whether the sick person wants to see a member of the clergy either from their home parish or an available chaplain, even if they have not been active in the church. Some Irish Americans may wear religious medals to demonstrate devotion and maintain health. These emblems provide them with solace and should not be removed without patient permission.

Health-Care Practices Health-Seeking Beliefs and Behaviors The Irish tendency toward a fatalistic outlook and ex- ternal locus of control also influence health-seeking behaviors. Irish Americans may use denial as a way of coping with physical and psychological problems. Many Irish discount and understate symptoms when ill. For some Irish Americans, illness behavior does lit- tle to relieve suffering and perpetuates a self-fulfilling prophecy. Illness or injury may be linked to guilt and be associated with having done something morally wrong or sinful.

Many Irish Americans believe that people are obli- gated to use ordinary means to preserve life. Therefore, extraordinary means may be withheld or withdrawn to allow a person to die a natural death. The sick person and family define extraordinary means; the decision is usually influenced by finances, quality of life, and effects on the family.

Responsibility for Health Care Good health is generally valued by Irish Americans, but because they may not be very descriptive or spe- cific about their symptoms, diagnosis and treatment may be more difficult. Early Irish American immi- grants depended on fraternal organizations and reli- gious institutions for assistance with health care in times of need. Today, the majority of Irish Americans have some type of coverage for health care such as pri- vate insurance, Medicare, and Medicaid. Health care in Ireland combines a system of universal public health care with private-sector health insurance plans.

Folk and Traditional Practices Studies show the practice of traditional home reme- dies increasing in the United States, and most patients do not discuss these home remedies with their health- care providers (Kessler et al., 2001). Irish American folk medicine practices include traditional remedies passed down through generations and effective in health promotion. These include eating a balanced diet, getting a good night’s sleep, exercising, dressing warmly, and not going outside with wet hair. Other

folk practices include wearing religious medals to pre- vent illness, using cough syrup made from honey and whiskey, drinking hot tea for nausea, drinking tea and eating toast for a cold, and putting a cool damp cloth to the forehead for a headache (Spector, 2009). Some folk practices, such as the regular use of senna as a laxative to cleanse the bowels, eating a lot of fatty foods, and avoiding or delaying medical care, may be harmful.

Common illnesses such as colds, stomachaches, and sore throats may be treated at home. Honey with lemon is given for a sore throat. Hot tea with whiskey is used for treating a cold or an upset stomach. No data are available to indicate that the Irish use over- the-counter medications more or less than any other group. The health-care provider should ask Irish Americans about their explanatory model of illness including what they call the problem, why the problem has occurred, what they think will happen if the prob- lem is untreated, what they fear, how the problem should be treated, what they have already done or usu- ally do to treat themselves (including home remedies and consulting other healers), and who they turn to for help with decision making (Kleinman, 1981).

Barriers to Health Care Most Irish Americans have few barriers to health care. Irish Americans in lower socioeconomic classes expe- rience health-care barriers such as lack of transporta- tion, money, insurance, and knowledge about the availability of health-care resources.

Cultural Responses to Health and Illness In a classic study on pain and ethnicity, Zborowski (1969) described differences in the pain responses of Irish, Italian, Jewish, and Yankee subjects. The behav- ioral response of many Irish to pain was characterized as stoicism. Stoic responses include ignoring, down- playing, or minimizing pain. Irish Americans in an- other classic study were observed to deny pain and delay seeking medical treatment longer than Italians (Zola, 1966). More recently these findings have been challenged (Neill, 1993), with more emphasis placed on generational differences in responses to pain. Much more research evidence is needed in this area, and gen- eralizations about pain response based on race/ethnicity should be avoided in favor of individual observation and assessment.

Psychiatric care in Ireland has undergone radical changes since the 1960s, when the primary services were institutional in nature and child psychiatric services were virtually nonexistent. The incidence of mental- health problems in second-generation Irish Americans is high compared with that in other groups. One expla- nation for high rates of mental illness may be associated with Irish suppression of emotions and not easily ex- pressing feelings. Health-care providers can encourage

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the expression of emotions and feelings and provide a safe and confidential environment for patients. In the past, the mentally and physically ill were taken care of in the home, not because of the stigma associated with mental illness and the family’s desire to shield them, but rather because of the Irish American family’s prefer- ence for caring for one another whenever possible.

Although some Irish Americans attribute illness to sin or guilt, they readily excuse sick persons from their obligations and become supportive in assuming the sick person’s normal roles until they regain functioning.

Blood Transfusions and Organ Donation Blood transfusions are acceptable to most Irish Americans. Information on organ donation and organ transplant specific to Irish Americans was not found in the literature. No religious or cultural pro- scriptions exist regarding organ donation among the common Irish belief systems. Many people partici- pate in organ harvest and indicate their willingness to do so on their driver’s license. Health-care profession- als should obtain information on an individual basis, be sensitive to client and family concerns, explain procedures involved with organ donation and pro- curement, answer questions factually, and explain the risks and benefits involved.

Health-Care Providers Traditional Versus Biomedical Providers In most Irish families, nuclear family members are consulted first about health problems. Mothers and older women are usually the family members who pos- sess the knowledge of folk practices to alleviate com- mon problems such as colds. The Irish are one of the few ethnic groups that do not have a hierarchy of folk and traditional providers. When home remedies are not effective, the Irish seek the care of biomedical providers.

Although Irish Americans are not noted for being overly modest, many may prefer intimate care from someone of the same gender. In general, men and women may care for one another in the health-care setting as long as privacy is maintained and sensitivity demonstrated.

Status of Health-Care Providers Although some Irish people may not readily seek pro- fessional health care for early symptoms, they gener- ally respect health-care providers. Nursing in Ireland is considered a worthwhile occupation, especially for women, however about 12 percent of Irish nurses are male. Entry into practice as a Registered Nurse re- quires a 4-year course of study and examination by the Irish Nursing Board (An Bord Altranais, 2011). Nurses trained in Ireland are consistently in demand around the world, and many have played significant

historical roles in the development of the nursing pro- fession globally (Yeats, 2009). The Irish Nurses and Midwives Organization maintains a Web site (http:// www.inmo.ie) with useful information on specific health needs, and its journal, The World of Irish Nurs- ing, is available online.

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For case studies, review questions, and additional information, go to http://davisplus.fadavis.com

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