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Opening cultural doors: Providing culturally sensitive healthcare to Arab American and American Muslim patients
Maya M. Hammoud, MD,a Casey B. White, PhD,b Michael D. Fetters, MD, MPH, MAc
Department of Obstetrics and Gynecology,a Oﬃce of Medical Education,b University of Michigan Medical School; Department of Family Medicine, University of Michigan Health System,c Ann Arbor, MI
Received for publication February 9, 2005; revised June 1, 2005; accepted June 14, 2005
Women’s health Arabic culture Islam Islamic religion
Differences in the social and religious cultures of Arab Americans and American Muslims raise challenges to healthcare access and delivery. These challenges go far beyond language to encompass entire world views, concepts of health, illness, and recovery and even death. Medical professionals need a more informed understanding and consideration of the rich and diverse array of beliefs, expectations, preferences, and behavioral make up of the social cultures of these patients to ensure that they are providing the best and most comprehensive care possible. Improved understanding will enhance a provider’s ability to offer quality healthcare and to build trusting relationships with patients. Here, we provide a broad overview of Arab culture and Islamic religious beliefs that will assist providers in delivering culturally sensitive healthcare to these groups. We offer insight into the behaviors, requirements, and preferences of Arab American and American Muslim patients, especially as they apply to women’s health. Ó 2005 Mosby, Inc. All rights reserved.
Healthcare providers in the United States recognize the challenges of providing care to patients from increasingly diverse ethnic and cultural backgrounds. Understanding the unique perspectives and beliefs of each patient is an essential component of providing culturally competent healthcare. The 2002 Institute of Medicine’s publication, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, states that ‘‘Racial and ethnic minorities tend to receive a lower quality of health care than non-minorities, even when access-related factors, such as patient’s insurance status and income, are controlled.’’1 The report calls for cross-
Reprints not available from the authors. 0002-9378/$ - see front matter Ó 2005 Mosby, Inc. All rights reserved. doi:10.1016/j.ajog.2005.06.065
cultural training for all providers because evidence indicates that stereotyping, biases, and uncertainty on the part of healthcare providers all contribute to unequal treatment. It is a challenge to provide important information about speciﬁc cultures without the appearances of stereotyping; thus, many educational programs are focused on helping learners to understand how to communicate with individuals from other cultures or with beliefs and experiences that are diﬀerent than their own. This kind of training, which embraces key components of selfawareness and self-reﬂection, helps learners to focus on exploring where patients are ‘‘coming from’’ and working with patients within a framework that makes sense to them and is not in conﬂict with their culture or beliefs.
1308 Unfortunately, unintentional violation of customs, rituals, or deeply held beliefs can prevent the establishment of relationships that allow healthcare providers to begin exploring important issues with patients from diﬀerent cultures. Therefore, we contend that there are at least 2 levels of cultural competence. The ﬁrst level is a basic understanding of certain beliefs, dynamics, and customs that can greatly inﬂuence the lives of individuals within certain cultures. This is not to say that all of these customs or beliefs apply to all individuals within a particular culture. However, such an understanding ‘‘opens cultural doors’’ to relationships with patients, which allows providers to advance to the next level, which is the exploration of individual and unique issues that are related to health and illness. We provide information about core cultural issues that should be considered when providing care to Arab American and American Muslim patients. Our overall intent is to enhance the ability of healthcare professionals to provide more culturally informed care, while never forgetting the ‘‘dynamic and even-changing nature of cultures that occur within cultural groups’’2 (ie, keeping in mind that each patient is a unique individual with his or own personal beliefs and practices.
Hammoud, White, and Fetters African American Muslim followers, and their numbers are increasing. This group comprises the majority of the converted American Muslim population.5 An estimated 10% to 30% of Arab Americans are Muslim.5 The faith of Muslims is important to healthcare practitioners because Islam dictates a comprehensive way of life that cannot be separated from the patient. Islamic customs inﬂuence everything in life from personal hygiene to socialization patterns.6 Although Americans tend to view themselves as human beings searching for spiritual experiences, Muslims are more likely to view themselves as spiritual beings having a human experience.7 It is also important to realize that, although Islam is a ﬂexible religion, individual Muslims may not be.
The family system, the role of the individual relative to social organization, and the assignment of primary gender roles are 3 major socialization diﬀerences between the Arab/Muslim culture and US culture that can impact the delivery of healthcare signiﬁcantly. In the United States, providers are accustomed to the Western emphasis on the individual, with some consideration of the family; Arab and Muslim cultures emphasize the family’s role in treating illness. These diﬀerences are vitally important to recognize, particularly in such situations as decisions that involve medical decisions for female patients or obtaining informed consent.
Arabs American and American Muslim populations
Arab Americans and American Muslims are 2 potentially separate and distinct populations. The ﬁrst is identiﬁed by ethnic origin; the second is identiﬁed by religious aﬃliation. However, because Islam sprang from and developed within the Arab world, there are many similarities between the 2 groups.
Verbal and nonverbal communication
To facilitate the provider-patient connection, it is important to establish personal relationships and to understand the nuances of communication, both verbal and nonverbal. When talking to recent immigrants, healthcare providers should assess language comprehension. If needed, an interpreter should be chosen and monitored with care. It is important to know that the use of ﬁrst-generation oﬀspring as interpreters can have adverse consequences on important family power structures, because family or friends may ﬁlter important parts of the conversation without fully informing the practitioner. Medical interpreters should be proﬁcient in both languages, understand medical terminology, and importantly understand general cultural issues like family structures and roles. An interpreter of the same gender is preferable, especially in discussing sensitive and intimate topics such as sexual relationships. When a professional medical interpreter is not available, the preferred alternative is a healthcare worker of the same cultural/religious background who does not have a personal relationship with the patient.8 Another important aspect of the establishment of an appropriate patient-provider relationship is the style of
The Arab American population
There are O3 million Arab Americans in the United States; more than one half of today’s Arab American individuals are third, fourth, and ﬁfth generation immigrants. Thus, Arab Americans vary in their mastery of the language and culture and in the educational and social levels that they have achieved. Most Arab Americans practice Christianity,3 and some of them prefer to identify themselves by their Christian sect rather than by the term Arab, such as the Chaldeans of Iraq.
American Muslim population
Islam is 1 of the 3 monotheistic religions of the world. Many cultures have embraced Islam, which makes it the fastest growing religion in the world, with 1.5 billion followers.4 In the United States, there are 6 to 8 million
Hammoud, White, and Fetters communication and the choice of words. Arabic speech is often repetitive and ﬂowery rather than short and straightforward, which means that the provider might want to engage more in social courtesies, especially when establishing a new relationship with a patient and the patient’s family. In addition, the provider should try to ask open-ended questions and avoid asking yes/no questions. The third person should be used when negative consequences are to be described. Certain religious requirements might interfere with the more traditional approaches that providers use to establish rapport with patients. For example, some Muslims, especially women who observe the hijab (covering the head and the body) and strict Muslim men, may not shake hands with someone of the opposite sex. It is best to avoid this unless speciﬁcally invited to do so. In addition, patting a patient’s arm or giving a woman a comforting hug should be avoided, unless the provider is of the same gender. Similarly, some Muslims do not make eye contact with the opposite sex. Without an understanding of and respect for these cultural norms, providers might unintentionally alienate Muslim patients, despite intentions to comfort them.
1309 about her care, the healthcare provider can ask her for permission to discuss the case with her husband outside of her presence.11 The permission and discussion should then be documented in the patient’s medical record. Some practitioners may not feel comfortable doing this. As with other clinical situations, such as Jehovah’s Witnesses, patients can be referred to another provider.
Cultural and religious requirements and preferences that impact clinical care
There are various diﬀerences between Muslim and Arab preferences that can potentially impact healthcare.
Islam commands both sexes to dress modestly, to maintain a moral social order, and to protect a person’s honor. The basic requirement for Muslim women is that clothes are neither transparent nor shape-revealing and that hair, arms, and legs are covered, especially in the presence of any young adult or adult male who is not in the woman’s direct lineage. How a Muslim woman dresses is a cultural interpretation, and it varies widely. Some Muslim women dress in a manner that looks no diﬀerent than their Western counterparts, although they tend to be more conservative. More observant Muslim women will cover their hair in addition to wearing clothes that cover their arms and legs. Very strict observant women may choose the long wide black dress that covers their entire body, and others may also practice veiling.
Informed consent and patient conﬁdentiality
The healthcare delivery system in the United States is oriented toward the autonomous patient, including full disclosure, conﬁdentiality, and informed consent. In providing care for patients from Arab and Muslim cultures, informed consent should be obtained in ways that are comprehensible and consistent with the person’s language, customs, and culture. Unique to the United States is that the assessment of patients, care plans, and rules governing patient conﬁdentiality are based on the concept of individual rights. In contrast, Arab and Muslim patients are likely to deﬁne themselves and their individual worth as relative to, rather than independent of, the rest of their family. Major decisions usually involve all members of the extended family, especially the men. Thus, patient autonomy and ‘‘next of kin’’ have little practical meaning for these patients.9 Patient conﬁdentiality issues that are already complicated by cultural customs may become further complicated with patients who do not speak or understand English well. For instance, a woman may expect and prefer that the healthcare provider consult with her husband and possibly away from the bedside. Agreeing to such arrangements might appear to be in conﬂict with informed consent requirements to make full and truthful disclosures and to allow autonomous decisionmaking.10 There are, however, fairly simple ways to work around this type of custom. In the case of a woman who prefers not to be included in discussions
Arab/Muslim women patients might feel more comfortable if the individual healthcare provider or team announces its arrival before entering her room, thus permitting time for her to cover herself. A notice can also be placed on the patient’s hospital room door asking for knocking and awaiting response before entering; this is essential for a Muslim patient in hijab because a woman would need time to cover her body and her hair. In addition, Muslim women speciﬁcally and Arab women in general do not tolerate unnecessary exposure of their bodies. For instance, they might refuse bed baths during a hospital stay, although if either is possible, they might prefer a shower as long as modesty can be maintained. In addition, Arabic women in general and Muslim women speciﬁcally prefer to breastfeed their newborn babies and to do so in private.12
In general, Muslim and Arab women prefer women healthcare providers. When this is not possible, the
Table Variable Intimate examinations Issues of human sexuality in the care of Arab patients Explanation
Hammoud, White, and Fetters
Sexually transmitted diseases Sexual relationship and counseling
Although typical reproductive system examinations and tests are permissible for married or previously married women, they are not permitted on their counterparts (never married female patients) for both Muslims and Arabs. Such examinations might compromise a girl’s virginal status, which could have grave implications for her in the future. Typically, unless there is a serious medical situation warranting it, unmarried female patients will not agree to examinations such as Papanicolaou tests, pelvic examination, or any other such invasive examinations. For similar reasons (ie, to protect the innocence of the young), sex education tends to be a subject that is avoided. For most Arabs and Muslims, a female will be ‘‘talked to’’ on her wedding day about the basics of sex. Depending on how blended into US culture the family is, a girl’s sexual knowledge varies signiﬁcantly. Arab and Muslim women tend to get offended when asked about sexually transmitted diseases because that would imply a deviation from monogamy. Because of the tendency to keep intimate matters private, Arab and Muslim patients usually would avoid discussing details of sexual relationships, even in situations of sexual dysfunction. This hinders the ability of the healthcare professional from properly diagnosing the problem and providing appropriate counseling. Islam forbids the mistreatment of women. The actual incidence of domestic violence is not known among Arabs and Muslims because it ﬁts with other taboo subjects.
patient should be informed and asked for alternate suggestions that will help to make her comfortable, such as having a relative or a female staﬀ member present while she is examined and treated by a male healthcare provider. Islam, under life-threatening conditions or when alternatives are not available, allows for crossgender provider-patient situations. However, even in these situations, care must be taken to minimize the exposure and invasion of the patient’s body. When it is not possible to be examined or treated by a woman, strictly observant Muslim women might refuse treatment no matter how urgent the situation.
blood and blood component transfusions invalidate a fast, although patients who require these interventions are generally too ill to fast.
Medications are generally well accepted to treat diseases and preserve life; however, observant Muslims avoid pharmaceuticals and over-the-counter medications that contain alcohol or narcotics. Healthcare providers should be aware that most Arabs also believe complete rest speeds recovery, even though this can be in conﬂict with current views that resuming activity can hasten recovery.
During the initial assessment before admission, the provider should determine the extent to which the patient follows halal or Muslim kosher requirements. They must eat non-pork or vegetarian meals. When treating a Muslim patient during the holy month of Ramadan, healthcare providers should inquire about fasting (which typically includes refraining from food, drink, or sexual activity from dawn to dusk). Some patients still want to fast even though their illness exempts them. If the patient can fast safely and take nourishment and medications during other hours, it may promote recovery because of the great comfort gained from this tradition. Intravenous ﬂuids or injections, total parenteral nutrition, intramuscular injections, or
Birth control and facilitation
Temporary birth control is acceptable in Islam, although some Muslims make a distinction between preand postcoital methods of birth control. Most Muslims will use birth control pills for preconception but will not use postcoital options such as the morning-after pill or the intrauterine device because these could result in the abortion of a fertilized egg. Although permanent sterilization (such as tubal ligation and vasectomy) is generally unacceptable to strict Muslims because of their permanence, it is best to discuss these issues individually with patients. Assisted reproductive techniques or the use of fertility drugs and procedures to enable pregnancy are acceptable if they do not violate the sanctity of the marital
Hammoud, White, and Fetters relationship or raise questions about a child’s parentage. Outside of Muslim inﬂuences, an Arabic patient’s preferences for birth control and facilitation can vary and might be very similar to those of Western patients.
1311 signiﬁcant for female patients who might experience common illnesses such as postpartum depression.
Many Muslim and Arab patients might not want to be told or reminded of their terminal illness. However, hospice care actually can help the family fulﬁll a cultural and religious obligation by focusing on comforting the patient, rather than helping him/her to accept impending death. Muslim patients do not give up hope because they believe that God, not medical science, has the power to create life and cause death. Arabs tend to be inﬂuenced by these Muslim beliefs about hospice care.
Speciﬁc clinical care issues
There are a number of sensitive issues that both Muslims and Arabs tend to avoid discussing (Table). Healthcare providers should be aware of these issues so that they can discuss them in a culturally sensitive manner and increase patient trust in the provider.
Although some Arabic and/or Muslim countries circumcise the female, Islam forbids it; however, Islam requires the circumcision of the male. Often, new mothers prefer that their newborn sons be circumcised before being discharged from the hospital.
The culture and religion of Arab Americans and American Muslims can greatly inﬂuence their perspectives about healthcare and healthcare providers. Knowledge and understanding of these patients’ background and beliefs can help providers deliver more culturally sensitive healthcare.
Legal adoption is unacceptable in Islam. However, the Quran states that God provides great rewards for fostering orphans. Many Muslims care for and raise children who need assistance, but these children must keep their own names and be aware of their biologic parents. Foster children must never be considered as one’s own; therefore, under Islamic doctrine, they cannot be heirs. However, if a mother breastfeeds an orphan for a signiﬁcant period of time, the child is considered linked to the family and, as such, will have more rights within that family. Adoption may be acceptable among Arab Christians.
We thank Elvana M. Hammoud and Kay Siblani for their contributions and appreciate their expertise in the Arabic culture and Islamic religion.
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Muslims perceive birth defects as a test of their faith in God and their patience. Arabs and Muslims both tend to be very private about family matters, which would preclude them from discussing a child who is born with any disability. Arabs might even be ashamed of a child with a mental birth defect; they might try to incorporate that child into everyday life, pretending the defect is nonexistent, or minimize the child’s interactions with the community.
Mental illness is considered culturally and religiously taboo. Many Muslims believe that one cannot be depressed if one is following the Islamic tenets. Therefore, they may not even acknowledge the legitimacy of antidepressants. Many Arabs, at least publicly, will not acknowledge mental illnesses, viewing these illnesses as a source of shame and a sign of weakness. This can be
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