Cultural Competence in the Care of Muslim Patients and Their Families

Delivering high-quality care to patients of the Muslim faith requires an understanding of the differences in cultural and spiritual values. Important differences include diet, ideas of modesty, privacy, touch restriction, and alcohol intake restriction.[1] Globally, Muslims represent substantial portions of society, and Islam remains the fastest-growing religion in the world. It is highly likely that a healthcare professional will care for a Muslim patient during his or her career. The Muslim faith encompasses several ethnicities with diverse views regarding illness and healthcare. As a result, the care of Muslim patients provides challenges for many non-Muslim healthcare providers. The Islamic faith can influence decision-making, family dynamics, health practices, and risks and the use of healthcare.[2]

Understanding Islamic beliefs will assist healthcare professionals in delivering appropriate health care in a culturally sensitive manner. This can be accomplished by understanding religious implications, perspectives on family, health, illness, diet, the influence of traditional medicine, and privacy concerns. All health practitioners should be able to provide culturally competent care.[3]

When providing care to Muslim patients, it is important to understand the impact the Islamic faith has on the provision of healthcare. Healthcare professionals need to be aware of privacy and touch issues, dietary practices, and unacceptable medicines.[4]

When healthcare professionals interact with a Muslim patient, they should follow certain guidelines whenever possible. This includes minimizing eye and physical contact between a healthcare worker and a patient of the opposite gender when possible. Furthermore, male doctors may have to communicate through a spouse if the patient is female. For example, if a male healthcare professional is talking to or asking questions of a female patient while her partner is in the room, but the patient does not respond, the healthcare professional should ask the patient if she would prefer he talk to the partner. This may clear up any confusion and is usually not offensive. During a physical exam, it is desirable to have the healthcare professional be of the same sex. Obviously, there will be circumstances that this will not be possible. In these scenarios, having a third person in the room that is the same gender of the patient should comfort the patient. If a person of the opposite gender must perform the physical exam, the general rule of thumb is to inform the patient that an article of clothing must be removed for the examination, but it will be immediately returned. This minimizes exposure and tells the patient of the reasoning for removing any articles of clothing.

In men, beards are religiously symbolic, and most men will avoid shaving unless it is essential.

It is common knowledge that women dress modestly. Men are often dressed to the knees or past the knees as well. There is an impression that women dress modestly compared to men; however, many men follow many of the same rules of modesty. During Ramadan, the Holy Month of Islam, healthcare professionals should be particularly culturally sensitive and respectful. Clinicians who understand the Muslim religious practices will be better equipped to provide appropriate, individualized care of Muslim patients.

The Muslim population is growing significantly worldwide. Cultural and religious background influence an individual's attitudes, behaviors, and beliefs toward health, illness, and the provision of healthcare may present obstacles to the healthcare this population receives. Due to perceived restrictions in medical care, the Muslim population may be at an increased risk for several diseases. These limitations may include gender preference of healthcare providers, modesty, and misconception about what causes certain illnesses. These limitations may develop as a result of Islamic cultural beliefs and practices. Other barriers may be due to the complexity of the health care system and the lack of culturally competent medical services and professionals. Health professionals should be aware of cultural and religious factors that help provide culturally competent and appropriate promotion and education of health services to the Islamic population. Health professionals must be educated about Islamic teachings to appropriately encourage healthy behaviors and provide quality care to their Islamic patients.

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 their 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 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. It is important for this interprofessional approach 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]

Diet

Islam rules prohibit alcohol, non-Halal animal fats, pork, by-products of pork, and any animals that have slaughtered in the name another diety (i.e., other than Allah, the Abrahamic God). There is some difference of opinion on consuming meat not been slaughtered according to Islamic custom. Islam prayer times may interfere with medical care facility mealtimes, and special arrangements may need to be made. Some Muslims may refuse all hospital food, and accommodations may need to be made to allow food brought in from home. If this is not possible, provide eggs, fruits, seafood, and vegetables.

During Ramadan, Muslims fast. Fasting means that no food or liquids, including water, is ingested between sunrise and sundown. It is also important to note that the Muslim calendar is not the same as the traditional calendar resulting in Ramadan landing at slightly different times of the 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.

Patients who plan on fasting should be provided with fasting-focused diabetes education to help them avoid complications. A pre-fasting assessment of patients with diabetes is recommended so they can be made aware of the risks and strategies to avoid problems. Sometimes this may entail advising them to refrain from full observance due to their health status (which is allowed religiously) or at least have supplements readily available if symptoms of hypoglycemia should develop.

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 taught the importance of breaking the fast if blood glucose levels fall to dangerous levels, and there is a risk of severe hypoglycemia. They should be instructed to end the fast if signs or symptoms of hypoglycemia develop. These patients are also at risk of developing hyperglycemia and ketoacidosis in response to fasting.

During Ramadan, patients choose to fast because 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

The family unit, rather than the individual, is the core of the community, and there is a strong extended family support structure. The behavior and acts of the individual or the family are greatly influenced by the spouse, children, and relatives. The extended family is often consulted in all important decisions. The cultural values of the individual, family, and relatives all have an impact on the assessment of patients’ needs, as well as on the delivery of medical care.

Health versus Illness

For Muslims, health is a state of physical, psychological, spiritual, and social well-being and is considered the greatest blessing God has given humankind. Muslim patients receive illness with patience, prayers, and meditation. Even Muslim patients who are not actively practicing their faith may call for spiritual or religious intervention when they are facing significant challenges. Muslim patients believe illness, suffering, pain, and dying as a test from God, and perceive illness as a trial by which one’s sins are removed.

Islam attaches significant importance to health, so taking care of one’s health is a religious duty. For some Muslims, spiritual values are a component of their health belief, and, as such, spiritual needs may take precedence over physical needs. Religious beliefs may also influence a Muslim patient’s notions of healing.

Medications

Medications that contain gelatin or pork-based are forbidden. Use gelatin-free alternatives such as antibiotic liquids or halal gelatin tablets. Magnesium stearate is forbidden in tablets when derived from an animal source. If it is an emergency, and an alternative is not readily available, the 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 a 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
• IV fluids - No (dehydration warrants breaking fast)
• Donating blood- No
• Oral medications- No
• Any ill patient requiring any type of medication to improve health (oral, IM, Sub-Q, IV) warrants breaking the fast 

Privacy and Dress

Muslim patients’ privacy and modesty must be respected. 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 communications. If a male provider is examining a patient, it is of the utmost importance for the provider to explain the steps of the physical exam to the female patient and if clothing must be removed, to be removed for as little time as possible. In many circumstances, a female patient may avoid eye contact or shaking hands with a male healthcare professional. This should not be interpreted as 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. Request permission before uncovering any part of the body, and perform the exam sequentially, exposing as small an area as possible with each step.

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 typically receive multiple visitors as there is an obligation to visit according to Islamic teachings. The number of visitors can be overwhelming, and they may not adhere to official visiting times. 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. For Muslim women, they 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 in 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 around the world are compared, there are common features found in all countries, and the variations represent the basic features of the Muslim religious tenets. However, Muslims are not a homogeneous group, and different groups may have varying cultures even though they share the same religious practices. Often behaviors are shaped by cultural practices that are not in concordance with basic religious practices. The cultural or pre-Islamic practices observed by Muslims are given an Islamic dimension even though they are not typically part of Islamic practices.

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 recommended in the Quran and many Islamic medical texts for internal use or as a wound dressing. Many Muslim patients with diabetes use honey as a traditional remedy.

Olive oil: Muslims use olive oil to prevent and treat ailments. It is a source of dietary fat in the Mediterranean diet, which has a low death rate for cardiovascular diseases compared with other cultures. Some believed that regular olive oil consumption helps reduce inflammation, endothelial dysfunction, thrombosis, and improves carbohydrate metabolism.

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

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 patient’s 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 as a physical ailment 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 discuss 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.

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

Islamic Principles

• Muslims are required to pray five times a day
• Pilgrimage to Mecca is required at least once in their lifetime, 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, shellfish, and alcohol is prohibited

Daily Practices 

• Prayer 5 times a day facing Mecca (dawn, mid-day, midafternoon, 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 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 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 three times a day; Sunni Muslims pray five times a day.

Sunni Muslims

Sunni means 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.