Defining the cultural care needs of Syrian university students in Türkiye using Leininger's Sunrise Model

Nurses are expected to recognize the cultures of their patients and provide suitable medical service. Accordingly, the medical services to be provided to foreign students who come from different cultures and whose numbers are on the rise should be adapted to the cultures of these students. This study aimed to use the Leininger’s Sunrise Model for determining the cultural care needs of Syrian University Students in Türkiye. This qualitative study was conducted using the ethno-nursing research method. The sample of the study consisted of 19 Syrian undergraduate students. The Consolidated criteria for reporting qualitative research (COREQ) reporting guidelines were used in both the framing and reporting of this study to guarantee that sufficient details on the methods of data collection, analysis and interpretation were provided. The data examined under the 12 titles was assessed with the descriptive analysis method used in qualitative research. Students noted that care was provided voluntarily in their cultures, that families had the responsibility of providing care, that they needed professional and religious care simultaneously, and that the obstacles of receiving nursing care were language, gender, and privacy. Results in this study indicate that cultural values and beliefs had a significant impact on receiving medical care, and that professional and traditional treatments were used based on relevant cases.


Introduction
Students migrate to other countries to receive education in line with their personal goals.International student movements have reached beyond five and half million all over the globe [1].The number of international students has recently increased in many countries including Türkiye [2].These students, who constitute a large group of people, experience psychological, financial, socio-cultural, and language-related problems in the countries where they study [3].Relevant studies indicate that students experience cultural shock while trying to adapt to the culture of the countries they are studying in [4,5].Research conducted with the international students in Türkiye found that students suffered issues due to cultural differences [6,7].Syrian students in Türkiye perceive social exclusion in such dimensions as economic, spatial, citybased, education and health.In addition, when the problems of Syrian university students arising from being refugees combined with educational problems in higher education, they cause multiple disadvantages [8].A study in Syrian Students in Türkiye had descripted the framework of various basic problems such as acceptance, social interaction, uncertainty, foreignness, stigmatization, and marginalization [9].Another research, the participants mentioned that they had some problems in their relations with the Turkish students at the university, the faculty members and the student affairs officers.Researchers conducted with the international students in Türkiye had founded that student suffered issues due to cultural differences [10].Another a study finding of the study indicate that Syrian students in Türkiye have difficulties in expressing themselves to their friends, teachers and other agents [11].Another study conducted with Syrian students indicated that they had problems accessing the medical services, too [12].Cultural traits affect people's perceptions of health and diseases as well as their attitudes.Nurses are expected to recognize the cultures of their patients and provide suitable medical service [13,14].Accordingly, the medical services to be provided to foreign students who come from different cultures and whose numbers are on the rise should be adapted to the cultures of these students.Based on the number, Syrian students rank first among the foreign students in Türkiye [15].A research results had showed some prejudice and stereotypes produced through Syrian refugees such as university entrance without examination, free and privileged education [16].A study determined that Syrian immigrant nursing students have difficulties in communicating with patients and their relatives and the team in the application.In addition, the students stated that they found nursing education difficult, that they were marginalized by Turkish nurses, patients and students, that some of the academicians found their approach negative and that they could not understand the lessons [17].Healthcare professionals' cultural prejudices toward individuals' cultural beliefs, attitudes, and perceptions affect the care they provide.Their awareness of their bias is closely associated with the quality of healthcare provided [18].However, no studies defining the cultural care for the Syrian students in Türkiye were found.Defining a cultural care program for these students is believed to be useful for both nurses and other medical personnel in terms of planning and offering medical services to both Syrian university students and other Syrian people.Models and guides are known to be the best instruments for defining the cultural traits and proper care.Cultural data can be accessed in a more systematic and standardized manner using the cultural models and guides.Leininger's Sunrise Model is one of the most commonly used instruments thus developed in this field [13].The number of people from different cultures has been steadily increasing in Türkiye, and these people demand care suited to their cultures.Receiving such care will increase the satisfaction from nursing care, care quality, and patient outputs.To provide a culturallysuitable care, cultural traits of the people being cared for as well as the definition of health, disease, and care in their cultures and the factors affecting these concepts should be revealed.

Materials and Methods
This qualitative study was conducted using the ethno-nursing research method between October 13, 2017, and August 9, 2018.The COREQ [19] reporting guidelines were used in both the framing and reporting of this study to guarantee that sufficient details on the methods of data collection, analysis and interpretation were provided.The population of the study consisted of 68 Syrian undergraduate students who studied at a state university in west of Türkiye during the 2017-2018 academic year.The aim was to reach everyone in the population.The inclusion criteria were being a Syrian and a student of the university where the study was being conducted, and the ability to understand and speak Turkish.A total of 23 students who met the aforenoted criteria were reached, and the study was conducted with 19 of them who volunteered to participate in the study.The data was collected using the semi-structured interview form.The interview form consisted of two sections.The first section included descriptive items regarding participants' age, gender, marital status, duration of living in the city where they were studying, their department, and their grade.The second section of the interview form consisted of Leininger [Leininger, 2002].Data was collected by the researchers using an in-depth face-to-face interview method between October 2017 and March 2018 as the necessary privacy conditions were ensured.Interviews were conducted for 60-90 minutes, and participants' statements were recorded after receiving their permission.The transcription of participants' statements was performed by the researcher considering the 12 titles in the interview form.Instead of students' names, the letters "F" and "M" were used to reflect their gender, and numbers were added next to these letters based on the order of interview.For instance, the first female interviewed was coded as F-1.Data was created by the researcher who transcribed the records.After the transcription phase, checks were done by the researchers through the repeated listening sessions.The data examined under the 12 titles in line with the guide was assessed with the descriptive analysis method used in qualitative research [21].A frame was formed for the descriptive analysis in parallel to the interview form, and data was processed to the thematic frame.The results were defined and interpreted in line with the processed data.

Ethical Consideration
Before the initiation of the study, necessary permissions were received from the Ethical Committee (2011-KAEK-2017-E.84729),Directorate General of Migration Management (62103649-604.02.02-44368), and the rector's office of the university where the study was performed (78179085-044-E.110179).Participants also gave their written permissions.

Results
Students were between 19 and 24 years of age.Of the students, 4 were female and 15 were male, and all of them were single.All of the students were undergoing undergraduate education.The duration of time living in the city where they were studying ranged from 1 to 54 months (Table 1).
The cultural care traits of the Syrian students were defined under 12 titles in line with Leininger's Semi-Structured Inquiry Guide.

Worldview:
Students generally noted that all people were equal for them, and that people needed to be benevolent and not be racist.M-4 "The world is a place where people live as different groups.We may be from different countries, but we are still humans, regardless of our countries of origin.We have spread over different locations, and cultures, and are in various countries, but we still live in the same environment…" Table 1.Descriptive traits of Syrian students.
was coded as F-1.Data was created by the researcher who transcribed the records.After the transcription phase, checks were done by the researchers through the repeated listening sessions.The data examined under the 12 titles in line with the guide was assessed with the descriptive analysis method used in qualitative research [21].A frame was formed for the descriptive analysis in parallel to the interview form, and data was processed to the thematic frame.The results were defined and interpreted in line with the processed data.

Ethical Consideration
Before the initiation of the study, necessary permissions were received from the Ethical Committee (2011-KAEK-2017-E.84729),Directorate General of Migration Management (62103649-604.02.02-44368), and the rector's office of the university where the study was performed (78179085-044-E.110179).Participants also gave their written permissions.

Results
Students were between 19 and 24 years of age.Of the students, 4 were female and 15 were male, and all of them were single.All of the students were undergoing undergraduate education.The duration of time living in the city where they were studying ranged from 1 to 54 months (Table 1).

Ethnohistory:
Of the participants in the study, 14 were Arabic, four were Turkmen and one was Kurdish.Of these students, 14 stated that their roots were from Syria and mentioned the Syrian city they were from, four stated that their ancestors were from Türkiye, and one student indicated a migration from Egypt to Syria in his background.F-1 "My family is Arabic.One of my grandfathers is from Egypt while the other one is from Türkiye.

Kinship and Social Factors:
Students generally mentioned that their families and friends were highly important for them.M-9 "Family is everything for us, protecting and guiding us.Families are invisible heroes.They are everything, from a financial and spiritual perspective…".Stating that offering care had a significant place in their culture, students said that the people who provided care or whose care was desired by the students were their family members, particularly the women in their families.All the students mentioned that families had the responsibility of proving care.F-1 "…No patient is deprived of care in Syria because people there give utmost importance to care.An elderly person in a Syrian family is cared for by his/her children.They consider this very important.Women generally provide care."

Cultural Values, Beliefs and Lifeways:
Students mentioned cultural values including social reputation, privacy, and avoidance from malevolence and lying.F-2 "Living in line with Islam is important.Avoiding harming anyone or anything or staying away from stealing, talking to males within certain rules as a female, and respecting the elders."

Religious/Spiritual/Philosophical Factors:
Students stated that they needed to receive professional religious care when they had a disease, that they might need religious care before nursing care, and that religious practices helped them relax.They added that religion enabled them to cope with the disease, search for a cure, and accept death.M-5 "I think this is valid not only for Islam, but also for other religions.You can hold onto life if you believe in the presence of God.For instance, if I did not believe in life after death, I would get upset about my cousin who passed away, thinking that we would not be able to meet again.As I believe in life after death, I get upset relatively less as I think we will meet again."Students stated that they performed certain rituals such as performing prayers, reading Quran, giving alms, and praying when they were ill.M-15 "… My friends and family should pray for me.Giving alms.
Animals are sacrificed after recovering from a disease.I want to read and listen to Quran." 6. Technological Factors: Students mentioned that technology was useful in the fields of health, education, and communication, and that it might be harmful only when used in an inappropriate manner.They added they would obligatorily use technological instruments if they needed them to recover from a disease or to survive.M-5 "…I would use to survive.Society would also use.If I would die because I did not use technology, that would be equal to committing suicide.Nobody wants anything like that."

Economic Factors:
Students noted that money was important for having an examination, purchasing medicine, consuming healthy products, and buying medical equipment, stating that it therefore affected their health.M-3 "Money is necessary to see a doctor, buy medicine or undergo a surgery.The more money you have, the more opportunities you gain."These students also mentioned that parents and older children are included in money earning activities.Moreover, women were also included in such activities, and women, in certain cases, undertook the responsibility of caring for the entire family as well as maintaining the domestic finances.M-1: "Both a mother and father.My older brother also earns."

Political and Legal Factors:
Most of the students believed that political and legal factors were effective in accessing and using medical services.F-1 "…Of course they have an impact.For instance, having no medical insurance is a great problem.In such cases, people need to pay a certain sum to have an examination which is not so cheap here in Türkiye."

Educational Factors:
Most of the students indicated that education had a positive impact on staying healthy or an illness.M-3 "…Educated people act in a healthy manner.Educated people know when to visit a hospital.However, uneducated ones do not visit a hospital, or they just ask for help from a religious authority."

Language and Communication Factors:
Stating that they speak in Arabic with their families and friends, students mentioned that they generally used verbal and face-to-face communication, body language, gestures, and facial expressions, and that they preferred to communicate through eye contact.F-2 "Eye contact and body language are important and common."M-7 "I do not desire verbal or body language solely.These two communication forms become effective when used collectively."

Emic and Ethic Care Beliefs and Practices:
Students defined the concept of disease as a physical disorder and a punishment from Allah, while they defined the concept of health as physical and psychological integrity, or physical and psychological wellness.They explained wellness as not being ill, being healthy spiritually and physically, and being around beloved ones.M-1 "Health is consuming good products, doing sport, and living peacefully.Wellness means there are no problems.No problems in health and life itself… I do not consider a disease as a punishment by Allah.There should certainly be a reason… Not everybody thinks like me though.Some consider diseases as a trouble or punishment by Allah...".Some of the students stated that social healthcare treatments did not help stay healthy or recover or even harmed their health in certain cases, while some believed these practices/people would help them.Furthermore, a couple of students thought that such treatments would be beneficial in the early phases of a disease or for less serious diseases, while some noted they preferred these methods as they did not want to see a doctor.M-2 "I drink chamomile tea when I have headache.Elderly people generally perform cupping for diseases.I have not researched this, but I think cupping has no impact on cleaning the blood."M-3"…I want to receive professional care.Social healthcare treatments may be used based on the disease.Dislocation of a joint, for example."

General and Specific Nursing Care Factors:
Students noted that care meant meeting the personal needs, showing attention, or raising a child.They added that caring for a person was a positive and benevolent action in their culture, that providing care was a voluntary action, and that providing care was considered as a good deed or favor by the society.M-4 "Showing attention to people and meeting their needs are good and benevolent things.Especially when provided to the relatives and elderly…" Students stated that they valued and respected professional medical personnel, that they needed to receive care from the nurses in case of a severe disease, and that they wanted to receive care from a nurse in a hospital setting and from their families in a domestic setting.
M-14 "It may be in the hospital.For the elderly, it may be in the home."Students explained the obstacles of good nursing care as the inability to speak the same language, privacy, gender, bias, and absence of religious and cultural knowledge.According to the students, nurses should display an approach appropriate to their culture, have no bias against them, and be respectful and cheerful in order to provide good nursing care.M-3 "Language and gender."F-3 "If the nurse is a male, I should not touch him, and I should have a distance from him.If the nurse is a female, there is no problem."M-7"When in Türkiye, we need to know the Turkish culture.However, if a Turkish nurse learns our culture and tries to make an effort to provide service in accordance with our culture, that would be a professional service..."

Discussion
Studies conducted with Muslim Syrians indicated that their world views focused on the Syrian culture and Islam.They believe that life is a test, that one needs to be peaceful, respectful, and tolerant toward people from other religions [22,23].This study indicated that religious beliefs and cultural traits are reflected in the world views of Syrian students, which is a result in line with the relevant literature.Students emphasized the importance of being respectful and living in peace.Family is considered as the building stone of society in Muslim communities [22].and providing care is a significant responsibility in Muslim Syrian families.This action is considered as meeting the needs of other people in a helpful manner [24].Studies conducted with people from similar cultures, such as Lebanese [25], Jordanian [26] and Arabic people [27,28] associate providing care with the domestic role of women.The present study found that family was important, that family and particularly the women in a family came to mind first when the concept of care was mentioned, that family members were responsible for one another in terms of providing care, and that providing care was considered as a positive and benevolent voluntary action, which suited the results of other studies conducted with Muslim Syrians and people living in similar regions.Muslim Syrians believed that the care provided in line with the religious rules improved health and prevented diseases, and that religion supported spiritual health and gave them peace [24].Additionally, in a study conducted with Muslims, methods such as showing patience, performing meditation and praying were used to cope with diseases and death [22].Students in the present study noted that religion and religious rituals helped them cope with the disease, find solutions to their medical problems, and accept death.Furthermore, students stated that technology had benefits for health and care and that it might be harmful only when used in an inappropriate manner.In a study conducted with Muslim Syrians, participants said that advanced technology would contribute to better medical services and be acceptable if it suited Islam, but that technological addiction might be harmful [29].The results of the relevant studies suit the result of the present study.Religious views should be considered while using technology to provide medical and care services to Muslim Syrians.Students in the present study stated that they had communicationrelated problems while receiving medical and care services, and they mentioned the inability to speak a foreign language and privacy as the reasons for these problems.Relevant studies indicate that certain obstacles are experienced while trying to communicate with Syrians, with the most distinctive one being language [30][31][32].Another study conducted with nurses similarly indicated that the inability to speak a foreign language was an important issue [33].Use of an interpreter can help increase the quality of medical service and reduce such conflicts [34].Furthermore, studies conducted with Muslim Arabs indicated that other than language, gender could be an obstacle before hand-shaking or establishing eye contact [26,27].Overall, the obstacles in communication were the inability to speak a foreign language, gender, neglecting privacy and not showing respect, which suited the results in the relevant literature.An important parameter in shaping the care is how the concepts of health, disease, and wellness are perceived in a specific culture.Students in this study considered health as physical and psychological wellness, while a disease was a physical problem or a punishment and test from Allah.Studies indicated that Muslims thought about their health and physical, mental, social, and psychological wellness.They considered disease and death as a natural process, and as a test by Allah which eradicated their sins [22].Muslim Syrians believe that their bodies warn them when they need to pay attention to their bodies.Moreover, disease was also considered as a sign of Allah's love and a reminder of the duty of praying [24].Syrian students in this study had medical and disease-related perceptions like those of the Muslim Syrians in other relevant studies.Attitudes regarding traditional treatments and healers can be seen in care-focused approaches regarding health, disease, and other relevant concepts.Students in the present study stated that traditional treatments or healers were not reliable but that they still utilized these methods against certain diseases or mild disorders rather than visiting a hospital.Other studies with Syrians indicated that herbal and traditional treatments were used to treat diseases [23,35].Participants of this study said they wanted to receive care from a nurse in case of a severe disease and also added that they needed this nursing care in a hospital setting but that they would want to receive care from their families in a home setting.According to these students, the obstacles to good nursing care were the inability to speak the same language, gender, bias, and absence of religious and cultural knowledge.The literature indicates that Syrian Muslims wanted to receive care from nurses on the condition that the gender factor was considered [24], and spiritual needs as well as privacy would be valued while providing care to Muslim patients [22].All Syrian students in the study said they were Muslims.Moreover, ethnic roots of the majority of the students were Arabic.As there were no participants with a different religious belief (other than Islam) and ethnic background, updating the data for this group of people is challenging.

Conclusion
This study indicated that Islam and cultural traits affected Syrian students' lifestyles, world views, and care-related perceptions.Moreover, these students considered care as the benevolent act performed to meet the needs of people and as a domestic responsibility in their culture.Education as well as technology, legal amendments, and personal finance had direct impact on health and medical services.Furthermore, it was observed that religion was a significant determinant factor for health/disease and care, and that religious beliefs helped them cope with disease and death and determined the type of medical service to be received.Results also indicated that cultural values and beliefs had a significant impact on receiving medical care, and that professional and traditional treatments were used based on relevant cases.Students accepted nursing care but there were certain obstacles such as the inability to speak the language, gender, and privacy.Moreover, they would prefer to receive nursing care in the hospital setting rather than in their homes.

Acknowledgment
This research was accepted as a master's thesis in Çanakkale Onsekiz Mart University, Institute of Health Sciences, Department of Nursing.This study was produced from the thesis of Nursel Gülyenli 516683 https://tez.yok.gov.tr/UlusalTezMerkezi/tezDetay.jsp?id=5KMwEy2yRJzIT9WPhFe2Vg&no =EUaB6EjvonfEs7pav55ohg This research was presented as an oral presentation at the 2nd International 5th National Intercultural Nursing Congress (2019, Bursa / Türkiye).
This study will help nurses determine what sort of care they should provide to Syrian people and what they need to consider while providing the care.Moreover, it will serve as a guide for determining what so This study aimed to define the cultural care for Syrian university students with this Leininger's Sunrise Model.

Table 1 .
Descriptive traits of Syrian students.
The cultural care traits of the Syrian students were defined under 12 titles in line with Leininger's Semi-Structured Inquiry Guide.