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American Journal of Obstetrics and Gynecology (2005) 193, 1307–11

www.ajog.org

CLINICAL OPINION

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

KEY WORDS Differences in the social and religious cultures of Arab Americans and American Muslims raise
Women’s health challenges to healthcare access and delivery. These challenges go far beyond language to
Arabic culture encompass entire world views, concepts of health, illness, and recovery and even death. Medical
Islam professionals need a more informed understanding and consideration of the rich and diverse array
Islamic religion 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 cultural training for all providers because evidence
the challenges of providing care to patients from in- indicates that stereotyping, biases, and uncertainty on
creasingly diverse ethnic and cultural backgrounds. the part of healthcare providers all contribute to unequal
Understanding the unique perspectives and beliefs of treatment.
each patient is an essential component of providing It is a challenge to provide important information
culturally competent healthcare. The 2002 Institute of about specific cultures without the appearances of stereo-
Medicine’s publication, Unequal Treatment: Confronting typing; thus, many educational programs are focused
Racial and Ethnic Disparities in Health Care, states that on helping learners to understand how to communicate
‘‘Racial and ethnic minorities tend to receive a lower with individuals from other cultures or with beliefs
quality of health care than non-minorities, even when and experiences that are different than their own. This
access-related factors, such as patient’s insurance status kind of training, which embraces key components of self-
and income, are controlled.’’1 The report calls for cross- awareness 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
Reprints not available from the authors. them and is not in conflict with their culture or beliefs.

0002-9378/$ - see front matter Ó 2005 Mosby, Inc. All rights reserved.
doi:10.1016/j.ajog.2005.06.065
1308 Hammoud, White, and Fetters

Unfortunately, unintentional violation of customs, African American Muslim followers, and their numbers
rituals, or deeply held beliefs can prevent the establish- are increasing. This group comprises the majority of the
ment of relationships that allow healthcare providers to converted American Muslim population.5 An estimated
begin exploring important issues with patients from 10% to 30% of Arab Americans are Muslim.5 The faith
different cultures. Therefore, we contend that there are of Muslims is important to healthcare practitioners
at least 2 levels of cultural competence. The first level is because Islam dictates a comprehensive way of life
a basic understanding of certain beliefs, dynamics, and that cannot be separated from the patient. Islamic
customs that can greatly influence the lives of individ- customs influence everything in life from personal
uals within certain cultures. This is not to say that all of hygiene to socialization patterns.6 Although Americans
these customs or beliefs apply to all individuals within a tend to view themselves as human beings searching for
particular culture. However, such an understanding spiritual experiences, Muslims are more likely to view
‘‘opens cultural doors’’ to relationships with patients, themselves as spiritual beings having a human experi-
which allows providers to advance to the next level, ence.7 It is also important to realize that, although Islam
which is the exploration of individual and unique issues is a flexible religion, individual Muslims may not be.
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 Provider-patient relationship
American Muslim patients. Our overall intent is to
The family system, the role of the individual relative to
enhance the ability of healthcare professionals to pro-
social organization, and the assignment of primary
vide more culturally informed care, while never forget-
gender roles are 3 major socialization differences be-
ting the ‘‘dynamic and even-changing nature of cultures
tween the Arab/Muslim culture and US culture that can
that occur within cultural groups’’2 (ie, keeping in mind
impact the delivery of healthcare significantly. In the
that each patient is a unique individual with his or own
United States, providers are accustomed to the Western
personal beliefs and practices.
emphasis on the individual, with some consideration of
the family; Arab and Muslim cultures emphasize the
Arabs American and American family’s role in treating illness. These differences are
vitally important to recognize, particularly in such
Muslim populations situations as decisions that involve medical decisions
Arab Americans and American Muslims are 2 poten- for female patients or obtaining informed consent.
tially separate and distinct populations. The first is
identified by ethnic origin; the second is identified by
religious affiliation. However, because Islam sprang
Verbal and nonverbal communication
from and developed within the Arab world, there are To facilitate the provider-patient connection, it is im-
many similarities between the 2 groups. portant to establish personal relationships and to un-
derstand the nuances of communication, both verbal
and nonverbal. When talking to recent immigrants,
The Arab American population healthcare providers should assess language comprehen-
There are O3 million Arab Americans in the United sion. If needed, an interpreter should be chosen and
States; more than one half of today’s Arab American monitored with care. It is important to know that the
individuals are third, fourth, and fifth generation immi- use of first-generation offspring as interpreters can have
grants. Thus, Arab Americans vary in their mastery of adverse consequences on important family power struc-
the language and culture and in the educational and tures, because family or friends may filter important
social levels that they have achieved. parts of the conversation without fully informing the
Most Arab Americans practice Christianity,3 and practitioner. Medical interpreters should be proficient in
some of them prefer to identify themselves by their both languages, understand medical terminology, and
Christian sect rather than by the term Arab, such as the importantly understand general cultural issues like
Chaldeans of Iraq. 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
American Muslim population professional medical interpreter is not available, the
preferred alternative is a healthcare worker of the same
Islam is 1 of the 3 monotheistic religions of the world. cultural/religious background who does not have a
Many cultures have embraced Islam, which makes it the personal relationship with the patient.8
fastest growing religion in the world, with 1.5 billion Another important aspect of the establishment of an
followers.4 In the United States, there are 6 to 8 million appropriate patient-provider relationship is the style of
Hammoud, White, and Fetters 1309

communication and the choice of words. Arabic speech about her care, the healthcare provider can ask her for
is often repetitive and flowery rather than short and permission to discuss the case with her husband out-
straightforward, which means that the provider might side of her presence.11 The permission and discussion
want to engage more in social courtesies, especially should then be documented in the patient’s medical
when establishing a new relationship with a patient and record. Some practitioners may not feel comfortable
the patient’s family. In addition, the provider should try doing this. As with other clinical situations, such as
to ask open-ended questions and avoid asking yes/no Jehovah’s Witnesses, patients can be referred to an-
questions. The third person should be used when neg- other provider.
ative consequences are to be described.
Certain religious requirements might interfere with
the more traditional approaches that providers use to Cultural and religious requirements and
establish rapport with patients. For example, some preferences that impact clinical care
Muslims, especially women who observe the hijab (cov-
ering the head and the body) and strict Muslim men, There are various differences between Muslim and Arab
may not shake hands with someone of the opposite sex. preferences that can potentially impact healthcare.
It is best to avoid this unless specifically invited to do so.
Dress/hijab
In addition, patting a patient’s arm or giving a woman a
comforting hug should be avoided, unless the provider is Islam commands both sexes to dress modestly, to
of the same gender. Similarly, some Muslims do not maintain a moral social order, and to protect a person’s
make eye contact with the opposite sex. Without an honor. The basic requirement for Muslim women is that
understanding of and respect for these cultural norms, clothes are neither transparent nor shape-revealing and
providers might unintentionally alienate Muslim pa- that hair, arms, and legs are covered, especially in the
tients, despite intentions to comfort them. 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 interpre-
Informed consent and patient tation, and it varies widely. Some Muslim women dress
confidentiality in a manner that looks no different than their Western
counterparts, although they tend to be more conserva-
The healthcare delivery system in the United States is tive. More observant Muslim women will cover their
oriented toward the autonomous patient, including full hair in addition to wearing clothes that cover their arms
disclosure, confidentiality, and informed consent. In and legs. Very strict observant women may choose the
providing care for patients from Arab and Muslim long wide black dress that covers their entire body, and
cultures, informed consent should be obtained in ways others may also practice veiling.
that are comprehensible and consistent with the per-
son’s language, customs, and culture. Unique to the Privacy/modesty
United States is that the assessment of patients, care
Arab/Muslim women patients might feel more comfort-
plans, and rules governing patient confidentiality are
able if the individual healthcare provider or team
based on the concept of individual rights. In contrast,
announces its arrival before entering her room, thus
Arab and Muslim patients are likely to define them-
permitting time for her to cover herself. A notice can also
selves and their individual worth as relative to, rather
be placed on the patient’s hospital room door asking for
than independent of, the rest of their family. Major
knocking and awaiting response before entering; this is
decisions usually involve all members of the extended
essential for a Muslim patient in hijab because a woman
family, especially the men. Thus, patient autonomy and
would need time to cover her body and her hair. In
‘‘next of kin’’ have little practical meaning for these
addition, Muslim women specifically and Arab women
patients.9 Patient confidentiality issues that are already
in general do not tolerate unnecessary exposure of their
complicated by cultural customs may become further
bodies. For instance, they might refuse bed baths during
complicated with patients who do not speak or under-
a hospital stay, although if either is possible, they might
stand English well. For instance, a woman may expect
prefer a shower as long as modesty can be maintained. In
and prefer that the healthcare provider consult with her
addition, Arabic women in general and Muslim women
husband and possibly away from the bedside. Agreeing
specifically prefer to breastfeed their newborn babies and
to such arrangements might appear to be in conflict
to do so in private.12
with informed consent requirements to make full and
truthful disclosures and to allow autonomous decision- Staff gender
making.10 There are, however, fairly simple ways to
work around this type of custom. In the case of a In general, Muslim and Arab women prefer women
woman who prefers not to be included in discussions healthcare providers. When this is not possible, the
1310 Hammoud, White, and Fetters

Table Issues of human sexuality in the care of Arab patients


Variable Explanation
Intimate examinations 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.
Sexually transmitted diseases Arab and Muslim women tend to get offended when asked about sexually transmitted
diseases because that would imply a deviation from monogamy.
Sexual relationship and counseling 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.
Domestic violence 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 blood and blood component transfusions invalidate a
suggestions that will help to make her comfortable, such fast, although patients who require these interventions
as having a relative or a female staff member present are generally too ill to fast.
while she is examined and treated by a male healthcare
provider. Islam, under life-threatening conditions or Medications
when alternatives are not available, allows for cross- Medications are generally well accepted to treat diseases
gender provider-patient situations. However, even in and preserve life; however, observant Muslims avoid
these situations, care must be taken to minimize the pharmaceuticals and over-the-counter medications that
exposure and invasion of the patient’s body. When it is contain alcohol or narcotics. Healthcare providers should
not possible to be examined or treated by a woman, be aware that most Arabs also believe complete rest
strictly observant Muslim women might refuse treat- speeds recovery, even though this can be in conflict with
ment no matter how urgent the situation. current views that resuming activity can hasten recovery.

Dietary requirements Birth control and facilitation


During the initial assessment before admission, the Temporary birth control is acceptable in Islam, al-
provider should determine the extent to which the though some Muslims make a distinction between pre-
patient follows halal or Muslim kosher requirements. and postcoital methods of birth control. Most Muslims
They must eat non-pork or vegetarian meals. will use birth control pills for preconception but will not
When treating a Muslim patient during the holy use postcoital options such as the morning-after pill or
month of Ramadan, healthcare providers should inquire the intrauterine device because these could result in the
about fasting (which typically includes refraining from abortion of a fertilized egg. Although permanent steril-
food, drink, or sexual activity from dawn to dusk). ization (such as tubal ligation and vasectomy) is gener-
Some patients still want to fast even though their illness ally unacceptable to strict Muslims because of their
exempts them. If the patient can fast safely and take permanence, it is best to discuss these issues individually
nourishment and medications during other hours, it may with patients.
promote recovery because of the great comfort gained Assisted reproductive techniques or the use of fertility
from this tradition. Intravenous fluids or injections, drugs and procedures to enable pregnancy are accept-
total parenteral nutrition, intramuscular injections, or able if they do not violate the sanctity of the marital
Hammoud, White, and Fetters 1311

relationship or raise questions about a child’s parentage. significant for female patients who might experience
Outside of Muslim influences, an Arabic patient’s pref- common illnesses such as postpartum depression.
erences for birth control and facilitation can vary and
might be very similar to those of Western patients. Hospice care
Many Muslim and Arab patients might not want to be
Specific clinical care issues told or reminded of their terminal illness. However,
hospice care actually can help the family fulfill a cultural
Human sexuality and religious obligation by focusing on comforting the
patient, rather than helping him/her to accept impend-
There are a number of sensitive issues that both Muslims
ing death. Muslim patients do not give up hope because
and Arabs tend to avoid discussing (Table). Healthcare
they believe that God, not medical science, has the
providers should be aware of these issues so that they can
power to create life and cause death. Arabs tend to be
discuss them in a culturally sensitive manner and increase
influenced by these Muslim beliefs about hospice care.
patient trust in the provider.

Circumcision Comment
Although some Arabic and/or Muslim countries cir- The culture and religion of Arab Americans and Amer-
cumcise the female, Islam forbids it; however, Islam ican Muslims can greatly influence their perspectives
requires the circumcision of the male. Often, new about healthcare and healthcare providers. Knowledge
mothers prefer that their newborn sons be circumcised and understanding of these patients’ background and
before being discharged from the hospital. beliefs can help providers deliver more culturally sensi-
tive healthcare.
Adoption
Legal adoption is unacceptable in Islam. However, the Acknowledgments
Quran states that God provides great rewards for foster-
ing orphans. Many Muslims care for and raise children We thank Elvana M. Hammoud and Kay Siblani for
who need assistance, but these children must keep their their contributions and appreciate their expertise in the
own names and be aware of their biologic parents. Foster Arabic culture and Islamic religion.
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
References
time, the child is considered linked to the family and, as 1. Smedley BD, Stith AY, Nelson AR. Unequal treatment: confront-
such, will have more rights within that family. Adoption ing racial and ethnic disparities in health care. Washington (DC):
may be acceptable among Arab Christians. The National Academy Press; 2002.
2. Tervalon M. Components of culture in health care for medical
Birth defects students’ education. Acad Med 2003;78:570-6.
3. Zogby J. Zogby international’s Arab American demographics
Muslims perceive birth defects as a test of their faith in report. Washington (DC): Zogby International; 2002.
God and their patience. Arabs and Muslims both tend 4. Huntington S. The clash of civilizations and the remaking of world
order. New York, NY: Touchstone Books; 1998. p. 65-6.
to be very private about family matters, which would 5. Nu’man FH. The Muslim population in the United States: a brief
preclude them from discussing a child who is born with statement. Washington (DC): American Muslim Council; 1992. p. 13.
any disability. Arabs might even be ashamed of a child 6. Matar NI. Islam for beginners. New York: Writers and Readers
with a mental birth defect; they might try to incorporate Publishing; 1992. p. 51-5.
that child into everyday life, pretending the defect is 7. Sachedina A. Living Islam in America, lecture series on Ashura’a,
Islamic House of Wisdom. Dearborn Heights, MI: Islamic House
nonexistent, or minimize the child’s interactions with the of Wisdom, 1998.
community. 8. Graham E. Guidelines for interpreted visits, ethnic medicine guide.
Seattle, WA: Harborview Medical Center, University of Wash-
Mental illness ington; 1995-96.
9. Sengstock MC. Family & gender among American Muslims: issues
Mental illness is considered culturally and religiously facing Middle Eastern immigrants and their descendants. Phila-
taboo. Many Muslims believe that one cannot be delphia: Temple University Press; 1996. p. 271-97.
depressed if one is following the Islamic tenets. There- 10. Gostin LO. Informed consent, cultural sensitivity, and respect for
fore, they may not even acknowledge the legitimacy of persons. JAMA 1995;274:844-5.
11. Freedman B. Offering truth: one ethical approach to the unin-
antidepressants. Many Arabs, at least publicly, will not formed cancer patient. Arch Intern Med 1993;153:572-6.
acknowledge mental illnesses, viewing these illnesses as a 12. Quran. Tahrike Tarsile Quran, Inc: Elmhurst, NY: 1995. Surah
source of shame and a sign of weakness. This can be 2:233.