Cultural Competence in the Care of Muslim Patients and Their Families

Function

There are several reasons to be culturally and spiritually sensitive to every culture and religion, including the Muslim population. There is an obvious ethical and moral duty of every healthcare provider to offer the best possible care to every patient. The Joint Commission, an independent, nonprofit organization that seeks to improve healthcare among its accredited healthcare members, holds hospitals accountable for addressing and maintaining patient rights. Joint Commission accreditation must have expertise in administrative affairs, clinical practice, policy, research, risk management, patient advocacy, cultural competence, and language access.[5][6][7]

Some of the Joint Commission's rights include the accommodation of cultural, personal, religious, and spiritual values. To accommodate compliance, healthcare professionals should care for patients as whole persons. This "wholeness" includes their body, mind, and spirit. The best healthcare approach is interprofessional. This interprofessional approach needs to be both culturally and spiritually sensitive as a positive spirit increases the patient's ability to fight off illness and survive. The goals of learning to treat a Muslim patient should be for all healthcare professionals to be empowered with the capacity, knowledge, and skills to respond to the special needs of each patient, and as importantly, a patient's family. Institutions seeking Joint Commission accreditation must have expertise in administrative affairs, clinical practice, policy, research, risk management, patient advocacy, cultural competence, and language access.[8][9]

Issues of Concern

Diet

Islam rules prohibit alcohol, non-Halal animal fats, pork, by-products of pork, and any animals that have been slaughtered in the name of another deity (i.e., other than Allah, the Abrahamic God). There is some difference of opinion on consuming meat not being slaughtered according to Islamic custom. Islam prayer times may interfere with medical care facility mealtimes, and special arrangements may need to be made. It is not uncommon for Muslims to decline all hospital food, and they may request to allow them to bring food in from home. If such arrangements cannot be made, alternatives such as fruits, vegetables, eggs, and fish might be appropriate.

During Ramadan, Muslims are supposed to fast from sunrise to sunset. Fasting implies that no food or liquids, including water, is ingested during this period. It is also important to note that Muslims fast according to the lunar or "Hijri" calendar, which is not the same as the traditional Gregorian calendar resulting in Ramadan landing about ten days earlier each year. This may result in significant health problems, especially for those with diabetes and in the summer months. Muslims about to begin fasting should be taught to eat pre-dawn and post-evening meals that include carbohydrates that release energy slowly.

Fasting can be particularly challenging for Muslims with diabetes. Muslim patients with diabetes who plan on fasting should be educated about strategies to help them avoid complications. Often such patients visit their healthcare provider every year before Ramadan to help confirm that they are healthy enough to fast. During such visits, they should be evaluated thoroughly and provided with appropriate education to manage diabetes while fasting. Sometimes this may entail advising them to refrain from fasting (for a few days or the whole month) due to their illness (which is allowed religiously) or at least have supplements readily available if symptoms of hypoglycemia should develop.

While fasting, patients can be at risk of both hypoglycemia and hyperglycemic complications (e.g., diabetic ketoacidosis and hyperosmolar hyperglycemic state). Muslim patients should be encouraged to monitor their blood sugars, especially if they are taking medications such as insulin or oral hypoglycemic agents. Patients must be reminded about the need to break the fast if blood glucose levels fall to dangerously low levels. They should be educated about symptoms of hyperglycemic and hypoglycemic states.

Ramadan is the most blessed and spiritual month of the Islamic year. Healthcare professionals treating any Islamic patient abstaining from food and drink should monitor them more closely. The Qur’an teaches that those who are too sick, pregnant, menstruating, or nursing are permitted to not fast and make up the days later in the year. Muslims who are chronically ill or elderly in whom fasting is unreasonable are also exempt, but they are required to provide food to an underprivileged person each day during Ramadan for which they missed fasting.

Hospitals are becoming increasingly aware that food served to Muslims must meet dietary rules, particularly with no pork products. This includes offering medications that don't contain pork or alcohol. Implementing sensitivity training to better educate workers about traditions and customs helps in maintaining cultural sensitivity in food preparation.

Family

Traditional Muslim families are nuclear with a strong extended family support structure. The behavior and acts of the individual or the family are greatly influenced by the spouse, children, and other relatives. The extended family is often consulted in all important decisions. The cultural values of the individual, family, and relatives may affect the delivery of medical care. However, it should be established with the patient if they want others to be part of the decision-making process or not.

Health versus Illness

For Muslims, good health involves the intertwining of physical, psychological, spiritual, and social factors. Good health is considered the greatest blessing and gift God has given humankind. Muslim patients receive illness with patience, prayers, and meditation. It is not uncommon for Muslim patients who are not otherwise actively practicing their faith to turn to God and seek religious intervention in times of hardship. One of the core beliefs of all Muslims infers illness, pain, and dying as a test from God. They also believe that any unforeseen hardship is a test by which one’s sins are washed away.

Since good health is a gift from God, Muslims believe that taking care of one’s health is a religious duty. However, this also implies that Muslims often prefer spiritual wellbeing over physical wellness. Religious beliefs may also influence a Muslim patient’s notions of healing.

Medications

Medications that contain gelatin or other pork-based ingredients are forbidden. Gelatin-free alternatives or halal gelatin tablets should be preferred for Muslim patients. Magnesium stearate is forbidden in tablets when derived from an animal source. The use of alcohol in medicines is debated but generally accepted. However, it is highly advisable to confirm a patient's preference before treating with an ingredient that may not be permissible for Muslims. Recreational narcotics are forbidden in Islam. For this reason, many Muslims may refuse the medicinal use of opioid analgesics as well and instead request alternatives.

It should also be kept in mind that if it is an emergency, and an alternative is not readily available, any drug may be used, but this should be explained to the patient. Islam permits the use of any drug in a life-threatening situation.

Fasting Muslims may create a challenge for the administration of drugs as they may refuse treatment. It is important for healthcare professionals to take the time to explain the importance of the medication to the patient. An informed and respectful approach will go a long way to helping the patient make the correct decision.

Medications During Ramadaan

• Eye Drops, Ear Drops, Dental Care - Yes
• Inhalers, Nebulizer Treatments, Nasal Sprays- Yes
• Immunizations/Vaccines, Insulin injections - A difference of opinion exists. It's best to ask the patient. In general, injections do not necessarily break the fast unless it is a supplement food or drink-for nutrition. Vaccines and insulin are usually acceptable.
• IV fluids - No (dehydration warrants breaking the fast)
• Donating blood - No
• Oral medications - No
• Any ill patient requiring any type of medication to improve health (oral, intramuscular, subcutaneous, or intravascular) warrants breaking the fast. 

Privacy and Dress

Muslim patients place a lot of emphasis on privacy and modesty. Ideally, it is best if they are cared for by a clinician and nurse of the same gender. This is very important if the patient requires obstetric or gynecologic care. If gender-specific care is impossible, a female staff member or patient relative should always be present during examinations or even communication. If a male provider is examining a female patient, it is of the utmost importance for the provider to explain the steps of the physical exam to the patient, and if clothing must be removed, it should be removed for as little time as possible. In many circumstances, a female patient may avoid eye contact or shake hands with male healthcare professionals. This should not be interpreted as a lack of trust or a sign of rejection. As in Muslims, this is a sign of modesty.

Muslim men and women are usually reluctant to expose their bodies for a physical exam. Regardless of a person's beliefs, it is highly advisable to request permission before examining any part of the body and perform the exam sequentially, exposing as small an area as possible with each step. This is especially true for more orthodox Muslims who place a lot of emphasis on modesty.

Touch between members of the opposite gender is strongly discouraged except immediate family members. It is permissible to touch a patient of the opposite sex when there is a medical reason, such as completing a clinical examination or procedure.

When entering a room of a Muslim patient, obtain permission before entering the room. Muslim patients may receive multiple visitors as many Muslims consider it a religious and cultural duty to visit the sick. The staff should be sensitive to the patient's need to receive visitors without compromising the clinical care of other patients. 

Islam requires modest dress to maintain moral and social order. Muslim women are required to wear clothes that are neither transparent nor shape-revealing. Arms, legs, and hair must be covered, especially in the presence of males who are not in the woman’s family. They may be extremely uncomfortable wearing hospital-provided gowns. Muslim dress varies differently depending on the country of origin. Some dress in a manner that is similar to their Western counterparts, although more conservative. Some Muslim women will cover their hair, arms, and legs. More orthodox Muslim women may choose a long wide black dress that covers their entire body, and some may wear a veil.

Few simple approaches can be taken to make the Muslim patient feel more comfortable. These include announcing the arrival of the healthcare professional allowing a female time to cover herself. If a woman is sick and needs to bathe, offer a shower instead of a bath. It is customary for Muslim women to breastfeed their newborn babies and prefer to do this in private.

Religion

Islam is a monotheistic faith, with only about 20% of Muslims being Arabs. In the United States, approximately 10% of Muslims are of Arabian descent, whereas the world’s largest community of Muslims is in Indonesia. In the United States, over half of Muslims are African Americans who have converted to Islam.

When the cultures of Muslims from different backgrounds are compared, there are many common traits found in all countries, and the variations reflect the basic features of the Muslim religious tenets. However, all Muslims are not the same, and different groups may have varying cultures even though they share the same core religious practices. Certain behaviors may be shaped by cultural practices that are not strictly in concordance with basic religious practices. The cultural or pre-Islamic practices observed by Muslims are often given an Islamic dimension, even though they might not be rooted in Islamic teachings.

Hospitals can't make assumptions about the needs of Muslim patients and families, so the best practice is to have Arabic and Urdu/Hindi-speaking staff. Hospitals should also hire Muslim chaplains to be available to patients.

Traditional Muslim Medical Practice

Muslims in certain cultures use folk remedies rooted in the passages in the Quran, Hadith, and Sunnah of the Prophet Muhammad. Folk treatments include the use of aloe, capers, chicory, dates, dill, fenugreek, pomegranate, indigo, Senna, olive, mustard, and truffles. Most of these are presumably harmless, but some may be unsafe. It is essential that all healthcare providers questions patients about what herbs or supplements they are ingesting, as well as any other nontraditional healthcare methods they are trying. Practitioners and patients who follow Islam may feel more comfortable using these supplements and remedies together with modern medicine and in conjunction with Western medical care. Healthcare practitioners should also remember that these remedies and herbs may be contraindicated or even dangerous when taken with specific prescribed modern medications.

Examples of Traditional Remedies

Cupping: Some Muslims use cupping to treat various disorders, including headaches, nausea, vomiting, stomach ache, sprains, muscular pain, sprains, insomnia, and jaundice. 

Cautery is used in many cultures when conventional treatment has been unsuccessful. It is used to treat headaches, eye problems, jaundice, mental illness, and cancer. Patients should avoid ancient methods of cautery and consult an appropriate healthcare professional.

Honey is revered by Muslims as it is mentioned in the Quran and many Islamic medical texts for internal use or as a wound dressing. Muslim patients with diabetes may use honey as a traditional remedy.

Figs: Figs, both in ripe and dry forms, are also considered to have miraculous medicinal properties.

Olive oil: Many Muslims consider olives to have miraculous properties. They may use olive oil to prevent and treat ailments.

Nigella Sativa: Some believe that this plant's oil and seeds treat a variety of gastrointestinal and respiratory complaints.

There are many traditional remedies that might not have an Islamic base but might be common in Muslims of certain cultural backgrounds. It is advisable to confirm all herbs and natural remedies a Muslim might be using in large amounts.

Special Considerations

Adoption

Adoption is generally not practiced in its true sense in Muslim communities. However, the Quran provides rewards for fostering orphans. Muslims may care for and raise children who need assistance, but they keep their family names and are made aware of their biological parents. Foster children are not considered as one’s own under Islamic doctrine, and they cannot be family heirs. However, if a mother breastfeeds an orphan, the child is considered linked to the family, and it will have more rights.

Bathing

When a Muslim patient is called to prayer, be considerate, and offer help with ablution or "wudhu." One must understand that this is not typical bathing. It is ritualistic bathing that starts with a certain sequence.

Congenital Disabilities

Muslims may perceive congenital disabilities as a test of their faith in God. Arabs and Muslims tend to be private about family matters, which prevents them from discussing the disability of a child. As with any religion, when addressing patients’ families with congenital disabilities, it is best not to focus on the congenital disability but to address the specific issue at hand. 

Circumcision

Contrary to popular belief, female genital mutilation (circumcision) is forbidden in Islam. Islam does require males to be circumcised.

Emergencies

Hospitals and clinics should strive whenever possible to have female physicians and providers care for female patients and for male providers to care for male patients. Muslim patients will often ask for same-sex providers. Hence, hospitals should be well-prepared to meet this demand. However, even most orthodox Muslims recognize that in a medical emergency, saving a patient's life takes precedence over finding a female or male professional and that having a male provider treat a female patient or a female provider treat a male patient is acceptable in an emergency situation.

Hospice Care

Many Muslim and Arab patients do not expect health professionals to tell them or remind them of their terminal illness. Hospice care may help the Islamic family fulfill a cultural and religious obligation if the focus is on comforting the patient rather than helping them to accept impending death. It is not uncommon for Muslim patients to not give up hope because they believe God has the power to create life and as well as cause death.

Hand Use

The left hand in Muslim culture is considered unclean. To avoid offense, use the right hand for medication administration, handing objects to patients, and assisting with feeding.

Mental Illness

Mental illness is sometimes not well understood in the Islamic faith. Some may believe that depression is not possible if the Islamic tenets are being followed and may not accept the need for antidepressants, antianxiety agents, or antipsychotics. This can be a significant problem for patients who experience common illnesses such as anxiety, depression, postpartum depression, or schizophrenia. One method of combating this is to describe these disorders similarly to physical ailments such as high blood pressure, which may break down some barriers to treatment.

Prayer

Prayer occurs 5 times a day. If possible, assist patients in determining the direction to Mecca. Once prayer begins, be respectful of giving the patient privacy and a place to pray. Avoid interruption; it typically only takes a few minutes. Bedridden patients may choose to pray in bed.

Sexuality and Domestic Violence

Muslims tend to avoid discussing sexual issues. Healthcare providers must be aware of these issues so that they can approach them in a culturally sensitive manner that increases patient trust in the provider. This is a conversation that should be done by a same-sex provider, preferably alone. Some unmarried women may not agree to pelvic examinations, Papanicolaou tests, or any invasive vaginal examinations unless it is life-threatening. Although reproductive system examinations and tests are regularly performed for married or previously married women, a single woman may refuse or be hesitant because such examinations could compromise a virginal female status. These barriers to reproductive health can make it very difficult to treat Muslim women effectively.  The best that the provider can do is to offer these services, explain that these services are not to imply any shame or any specific type of behavior but more for preventive measures. Because Arabs and Muslims tend to keep sexual matters private, patients may avoid discussing problems with sexual relationships or sexual dysfunction, making it difficult for healthcare professionals to diagnose problems and provide appropriate counseling.

The discussion of the risk of sexually transmitted disease is very sensitive as it can be misconstrued as a deviation from monogamy. It is important to explain the reasoning for the questions to help the patient understand that this is not an attack on her or him personally.

Islam forbids the mistreatment of women. However, women may not be open to discussing domestic violence due to fear of "dishonoring" the family that roots from the cultural backgrounds of certain Muslim countries. For this reason, women should always be reassured of support to open up about domestic violence issues.

Clinical Significance

Muslims, while ethnically diverse, can present common healthcare challenges due to their beliefs. Providers need to be aware of Islamic cultural values and accommodating these values when possible. In a hospital setting, Muslims prioritize gender-concordant care providers, providing food consistent with religious requirements and space for prayer.

Gender-concordant care can often be provided, except in emergencies where rapid life-or-death intervention is required. In regards to food preparation, hospitals have a history of accommodating patient preferences and providing space to meet the spiritual needs of patients. The healthcare administration may consider food services that provide the option of Kosher or vegetarian food and non-denominational hospital chapels with minimal modification.

Enhancing cultural competency by providing patient-centered care is a means by which healthcare challenges are improved. Efforts aimed to improve provider-level cultural enhanced care will go a long way to facilitate cross-cultural communication and respond to patient needs by tailoring healthcare to the Muslim culture. 

Understanding the values and reasons for special requests for healthcare will improve cultural competence and provide culturally sensitive health care that is good for the patient and their families.

The culture and religion of Muslims can greatly influence their perspectives about healthcare and healthcare providers. Healthcare providers need knowledge and understanding of these patients’ backgrounds and beliefs to provide culturally sensitive healthcare.

Recommendations

• Apologize for cultural mistakes
• Ask the patient and family how you can help make their experience more comfortable
• Avoid being judgmental
• Avoid making assumptions and be patient
• Avoid employees serving as interpreters for other employees
• Be aware of the uniqueness of Muslims and their special needs
• Be respectful
• Consider diverse recruitment and include Muslims in the recruiting effort
• Identify Muslim workers that can assist in the culturally sensitive care of the Muslim patients
• Integrate all holidays, including those of Muslims
• Observe body and facial language
• Recognize how values, behaviors, and beliefs may affect others
• Train staff about cultural competence
• Use medically competent and fluent interpreters with training in cultural competency

Other Issues

Islamic Principles

• Muslims are required to pray five times a day.
• Pilgrimage to Mecca is required at least once in their life for those who can afford it.
• Once a year, a Muslim gives 2.5% of one's wealth to a charitable cause.
• Ramadan is a month-long fast of drink, food, and sex during daylight.
• The Quran is the final revelation of Humanity.
• There is only one God, Allah.
• Muhammad is God's messenger.
• Complete submission to God
• Judgment day
• Oneness of God, his angels, scriptures, and messengers
• Life after death
• Reward and punishment

Food

• Children, women who are pregnant, and those who are ill may be exempt from fasting.
• Eat food that is clean, good, pure, nourishing, pleasant, tasteful, and wholesome.
• Eat with the right hand, considered to be the clean hand.
• Food not invoked in Allah's name may be prohibited.
• Use only vegetable oil.
• Pork and alcohol are prohibited

Daily Practices 

• Prayer 5 times a day facing Mecca (dawn, midday, mid-afternoon, sunset, night)
• Days of observance occur throughout the Muslim lunar calendar.
• Wash face, hands, and feet before prayer

Health

• Abortion is prohibited except in cases of incest, rape, and if the life of the mother is threatened.
• A fetus is considered a human being after 25 weeks gestation.
• Health providers are seen as helpers of God’s will.
• Most surgical procedures are permitted.
• No restrictions on amputations, biopsies, blood or blood products, medications, amputations

Death and Dying 

• Autopsy only for legal or medical reasons
• Confession of sins and begging forgiveness may occur before death.
• Death is in God’s plan.
• Euthanasia is prohibited
• Organ donation is permissible.
• Prayer for the deceased is led by a male within 72 hours after death; as a result, a death certificate should be signed quickly to facilitate the process.

Special Practices

• Customs prohibit handshakes or any contact between genders.
• Female patients may require a female physician but always ask the patient. 

Holy Days

• Congregational prayer - Fridays, the Holiest Day for Muslims, takes place at noon prayer.
• Eid-ul-Adha (Celebration of the Sacrifice of Abraham) - a three-day celebration beginning on the 10th day of the 12th month called Dhul Hijjah.
• Eid-ul-Fitr (Celebration of the Fast-Breaking) - held on the first day of the 9th of the lunar calendar.
• Ramadan one month long

Shia Muslims

Shia means Party of Ali.

Shia Muslims believe that when Muhammad died, it was his wish that Ali, his cousin, would be the new caliph. They believe that the leaders of Islam should be direct descendants of the Prophet Muhammad. Shia Muslims ignore the elected Sunni leaders and instead follow their leaders, which are direct descendants of Muhammad called Imams. Approximately 15% of Muslims are Shia. Iran and Iraq have a majority of Shia Muslims. Shia Muslims are a minority in the rest of the world. Shia Muslims pray up to 5 times a day. some Shia's will combine the noon and afternoon together, the same for Maghrib and Isha. Sunni Muslims pray five times a day.

Sunni Muslims

Sunni means the words and actions of the Prophet Muhammad. Sunni Muslims believe that when Muhammad died, it was his wish that the next leader would be elected. Sunni Muslims believe the leaders of Islam should continue to be elected. Most Muslims are Sunni.

Enhancing Healthcare Team Outcomes

The care of Muslim patients requires meeting the needs of specific cultures and beliefs. Islam provides spiritual guidance as well as an emphasis on maintaining health. Islamic beliefs affect Muslim patients' attitudes and behavior. It is important for healthcare professionals to have an understanding of these issues to provide culturally appropriate care. However, it is important for medical practitioners to remember that preservation of life overrides guidelines; in a life-threatening situation, there are no restrictions on medications or surgical interventions. Muslims believe Allah (God) preserves life, even if a health professional provides care. When caring for a Muslim patient, professionals should strive to understand that a Muslim patient may or may not be following recommended treatment because of his or her religious beliefs.