Muslim

Cultural
Competenc
y
How to educate
healthcare
professionals
Mohammed Amar Afzal, DNP
Student
Charlene Douglas, PhD, MPH
 Disclosure
Approval statement: This continuing
nursing education activity was approved
by the Virginia Nurses Association, an
accredited approver by the American
Nurses Credentialing Centers
Commission on Accreditation.
Requirements to Receive Contact Hours/Criteria for Successful
Completion:

Criteria for successful completion

includes self-directed learning using the
PowerPoint Presentation and the
Scholarly article and completion of post-
test (a score of 90% is required).
Absence of Conflict of Interest
No individual in a position to control
content for this activity has any relevant
financial relationships to declare.
 Objectives
Describe the characteristics of Muslims in
the United States and the potential
barriers to providing culturally competent
care.
Understand the Islamic values and beliefs
that impact the delivery of healthcare to
Muslims such as modesty, fasting in
Ramadan, dietary practices, and end of
life care.
Emphasize the need for educating
unhealthy Muslim patients about the risks
of fasting in Ramadan.
 Objectives
Understand the specific dietary practices of
Muslims including permissible and
prohibited foods.
Highlight the importance of modesty for
Muslim women and its impact on the
delivery of healthcare.
Evaluate the need for mental health
services for Muslim patients and the need
to develop a therapeutic relationship.
Understand the Islamic beliefs related to
end of life care and respect the religious
beliefs of the patient.
 Modules
Module 1 Introduction & Basics
Module 2 Diabetes & Ramadan
Module 3 Dietary Practices of Muslims
Module 4 Modesty
Module 5 Mental Illness
Module 6 End of life care
 Module 1
Introduction & Basics
Withincreasing cultural diversity, and
specifically as a result of the growth of
Islam in America, there is a growing
need for healthcare professionals to
ensure holistic care is provided that is
culturally congruent, particularly for
those from minority or marginalized
ethnic backgrounds such as Muslims.
 There are 3.3 million Muslims of various
ages living in the United States.
The Pew Research projects that by 2040,
Muslims will be the second largest
religious group in the United States,
after Christians
(Besheer, 2016).
 Muslims are a racially and ethnically
diverse group.
Regardless of ethnicity or race, Muslims
share the core values of the Islamic
religion that influence their expectation
of healthcare
(Padela, Gunter, Killawi, & Heisler,
2012).
 Leiningers Theory of culture care diversity and
universality provides the theoretical
framework for this presentation.
Leininger is the founder of the transcultural
nursing movement with the goal of providing
culture-specific and universal nursing care
practices to promote health and well-being of
the entire community
(Creasia & Friberg, 2011; Wehbe-Alamah & Fry,
2014).
 Challenging for healthcare professionals to
provide culturally sensitive care to Muslim
patients as they have unique and distinctive set of
cultural practices
The aim of this course is:
to incorporate cultural humility while providing
care to Muslim patients.
 Healthcare professionals may exhibit a
general lack of knowledge while working
with Muslim patients and their families
Essential to understand the basic tenets
of Islam in order to develop a
therapeutic relationship with Muslim
patients
(Abell, Manuel, & Schoeneman, 2015; Al-
Yateem, Al-Yateem, & Rossiter, 2015).
 Monotheism is a crucial aspect of the Islamic
religion expressed in the belief in the only One
God, Allah.
Allah is All-Powerful and everything occurs only
with Allahs permission.
Islam is an Abrahamic religion
Prophets such as Adam, Noah, Jesus, and Moses
are highly regarded in Islam
(Ow & Saparin, 2014).
 Module 2
Diabetes & Ramadan
After interviewing several healthcare
professionals and Muslim patients, managing
diabetes during Ramadan was found to be a
culturally challenging task
Hard to understand why Muslim patients
would risk suffering from hypoglycemic and
hyperglycemic episodes
 Fasting helps Muslims feel compassion for the
less fortunate and underprivileged
Builds a sense of self-control and willpower, and
learn to control natural urges such as hunger
and thirst
Allows Muslims to better resist temptations for
daily things that are not necessary, such as
unhealthy or harmful substances and behaviors.
 Fasting also offers a time to purify the
body and the soul, by developing a
greater sense of humility, spirituality,
and community involvement.
Intermittent fasting limits energy intake
promoting weight loss in obese
individuals, which could be
cardioprotective
(Ibrahim et al., 2015).
 Muslims consider it an honor to fast in the
month of Ramadan.
Fast from dawn to dusk for the entire month
of Ramadan (29 or 30 days).
Medications need to be adjusted and certain
procedures (such as dental work or
procedures that require ingestion of contrast
dye) cannot be performed while fasting
(Al-Yateem, Al-Yateem, & Rossiter, 2015).
 Those at high risk of hypoglycemia and with
multiple diabetic complications should be
advised against prolonged fasting.
Education and discussion of glucose monitoring
and treatment regimens should occur several
weeks prior to Ramadan.
 Safe to use agents such as metformin,
thiazolidinediones and dipeptidyl
peptidase-4 inhibitors.
Not safe to use sulfonylureas,
chlorpropamide or glyburide during
Ramadan
(Ibrahim et al., 2015).
 Insulin pump therapy is effective in improving
glycemic control for type 1 diabetes during
Ramadan.
Insulin pump helps to provide a continuous basal
rate of insulin during the fasting period
Point of Care testing does not break the fast
Glucose monitoring reduces the risks of
hypoglycemia
(Ibrahim et al., 2015).
 Diabetic patients who are intent on fasting in
Ramadan should be educated about the risks of
fasting.
Educate about the symptoms of
hypoglycemia (excess sweating, excessive
hunger, fainting, fatigue, lightheadedness, or
shakiness, nausea or vomiting, mental confusion)
and
hyperglycemia (frequent urination, increased
thirst, blurred vision, fatigue, and headache).
 Verses of the Quran
And as for those who can fast with
difficulty, (e.g. an old man), they have
(a choice either to fast or) to feed a
Miskeen (poor person) (for every day)
[Quran, 2:184]
 whoever sights the new moon of the month, let
him fast it; and whoever is ill or on a journey -
then an equal number of other days. Allah
intends for you ease and does not intend for you
hardship (Quran, 2:185).
 Case Study
Mohammed Husain is a 55 year old Indian male who
presents for diabetes checkup and review of his lab results.
He is currently taking Glucophage(metformin)850mg three
times a day, lisinopril10mg a day andatorvastatin10mg a
day. He denies any hypoglycemic events and has no
complaints today except fatigue.
Exam: T 98.9, RR 14, HR 82, BP 160/88
Labs:HbA1c - 10.3 mg/dl
BUN= 15
Creatinine=0.7
LDL = 155
TRG = 100
HDL=52
Liver Function Tests=Within Normal Limits
CBC and Electrolytes= Within Normal Limits.
It is the month of Ramadan and the patient
wants to fast? What will you advise him?
Change metformin to 1000 mg twice daily
Start long-acting or intermediate acting insulin in
the evening
Short or rapid acting insulin with meals
Fasting is NOT recommended as HbA1C is 10.3
(very high risk category)
Perform Ramadan-focused diabetes education
Focus on individualized care
 Module 3
Dietary Practices of Muslims
Islamic law has strict dietary code
similar to Judaism.
The availability of medications that do
not contain alcohol or pork are major
concerns for Muslim patients
Medications that come in capsules
contain gelatin derived from pork.
Heparin is pork-based.
 Halal Foods
Halal is an Arabic word that means permissible
or lawful.
Halal meat is one that is prepared according to
Islamic law.
Grains and legumes are halal.
Food prepared by the people of the book (Jews
and Christians) is considered Halal (exceptions
include pork and alcohol)
All sea animals are halal.
 Haram Foods
Haram is an Arabic word that means prohibited.
Alcohol and other addictive and intoxicating drugs
are haram.
It is haram to consume blood and blood products.
Pork is prohibited
Foods dedicated to other gods are haram (Charles
& Daroszewski, 2012).
The next slide contains verses of the Koran which
discuss haram and halal foods.
 Verses of the Quran
Theyask you about wine and gambling. Say, "In
them is great sin and [yet, some] benefit for
people. But their sin is greater than their
benefit."(Quran, 2:219)
 Prohibited to you are dead animals, blood,
the flesh of swine, and that which has been
dedicated to other than Allah (Quran, 5:3).
 Case Study
A 35 year old female Muslim patient
presents with symptoms of anxiety and
depression. She scores a 20 on the PHQ-
9. You prescribe Prozac 40 mg. The
patient expresses her concern that she
does not want Prozac in a capsule form
that may contain gelatin derived from
pork.
As a culturally competent healthcare
professional, how will you address her
concerns?
Assure the patient that you will not
prescribe Prozac in a capsule form that
contains pork based gelatin
Prescribe the patient the tablet form of
Prozac
It is essential to respect the patients
cultural and religious values.
Module 4
Modesty
 "Tellthe believing men to lower their
gaze and be modest. That is purer for
them. Lo! God is Aware of what they
do. And tell the believing women to
lower their gaze and be modest, and to
display of their adornment only that
which is apparent, and to draw their
veils over their chests, and not to reveal
their adornment" (Quran 24:30).
 In the Muslim culture, modesty is associated with
religious beliefs and practices.
Muslim women are encouraged to obscure their
physical beauty to avoid evoking physical attrac
tion from male strangers.
 Muslim women are inclined to express
modesty through their choice of clothing
Exhibit a preference for loose-fitting
garments that cover arms and legs
(Jelbab), head scarves (hijab) and a veil
covering the face (burqa)
In health care settings, their behavior
toward male strangers and their desire
to cover most of their bodies may be
barriers.
(Salman, 2012).
 Muslim woman may be reluctant to remove her
clothing
Majority of Muslim women prefer female rather
than male health care providers
Refuse to be seen by a male health provider
without the presence of a female chaperone
 Muslim women in the United States
voice strong concern about the lack of
consideration for their modesty.
Muslim women may find discussing re
productive issues to be personal,
embarrassing and confidential
(Guimond & Salman, 2013).
 Cervical Cancer Screening
Recommendations
Ages 21-29: Pap every 3 years
For 30-65 year olds: Co-test with Pap and HPV
test every 5 years or Pap every 3 years if HPV
co-testing is not available
(American Congress of Obstetrician and
Gynecologists, 2016).
 Case Study
Zeynep is a 22 year old female of
Muslim background who presents for her
annual checkup. She does not wish to
take off her head covering or remove
any clothing for her physical exam.
Zeynep is reluctant to answer any
questions about her sexual history and
does not want to be seen by a male
physician.
 How will you approach this patient?
Ensure that this patient is seen by a female
healthcare professional
Perform a modified physical examination that
does not require her to take off her head covering
or remove any of her clothing
Identify concerns about seeking gynecologic care.
Answer her questions and emphasize
confidentiality
Reassure her that no man can enter the
examination room.
How will you approach this patient?
A female healthcare professional should
obtain the social and sexual history.
When asking direct questions about
sexual history, expect hesitancy and do
not press for answers.
Offer screening for cervical cancer.
If low risk, recommend cervical cancer
screening every 3 years to age 30, then
every 5 years with co-test for HPV.
 Module 5
Mental Illness
Muslim patients have suffered increased
discrimination and oppression leading to a
greater need for mental health services.
Ineffective healthcare interventions occur due to
lack of appreciation and respect for the Muslim
population
Poor therapeutic relationship
 Healthcare professionals are
uncomfortable working with Muslim
patients
due to a perception of Islam that is
associated with violence, terrorism, and
the subjugation of women
(Abell, Manuel, and Schoeneman, 2015)
 Muslim consider religion as a way to cope with
mental health problems
Incorporating religious beliefs into mental health
therapy and family involvement was found to
lead to positive health outcomes for Muslim
patients
Need to develop religion focused cognitive
behavior therapy
(Eltaiba, 2014;Maroney, Potter, & Thacore, 2014;
Mir et al., 2015; Walpole, McMillan, House,
Cottrell, & Mir, 2013).
 Verses of the Quran
After every difficulty there is relief
(Quran, 94:5)
And never give up hope of Allah's
soothing Mercy: truly no one despairs of
Allah's soothing Mercy, except those
who have no faith. (Quran, 12:87)
 And for those who fear Allah, He
always prepares a way out, and He
provides for him from sources he never
could imagine. And if anyone puts his
trust in Allah, sufficient is Allah for him.
For Allah will surely accomplish His
purpose: verily, for all things has Allah
appointed a due proportion. (Quran,
65: 2-3)
 Suicide is not permitted in Islam.
Euthanasia is also considered suicide and not
permitted.
Nor kill or destroy yourselves: for verily
Allah has been to you Most Merciful!
(Quran, 4:29)
Symptoms of postpartum depression such as
sadness, anxiety, and physical malaise were
interpreted as possession of evil spirits
(Hanely and Brown, 2014).
 Utilizeevidence based pharmacological
and psychotherapeutic techniques to
assist with symptoms of depression and
anxiety but Respect cultural beliefs.
Educate about the biological basis of
certain mental illness such as
schizophrenia and bipolar depression
and the need for medication
 PTSD
PTSD common among Muslim
immigrants from war-torn countries such
as Afghanistan, Iraq, and Syria
Essential to respect the cultural beliefs
during treatment
 Case Study
A 32 year old female Muslim patient suffers
from bouts of depression. Her father passed
away 6 months ago. For the past several
months, this patient has exhibited symptoms of
depression including feeling sad, tearful,
anhedonia, energy deficit, concentration deficit,
insomnia, weight loss, and inability to function
at work. Patient has a PHQ-9 score of 20. What
is your recommended treatment for this patient?
Treatment Recommendations
Combination of therapy/prayers and
medication is the gold standard for
treatment.
Prescribe antidepressant such as
Lexapro
Encourage patient to attend therapy
and pray/meditate to assist with
symptoms of depression
 Module 6
End of Life Care
Every soul will taste deathand to Us you will
be returned (Quran,21:35).
Religious faith is the centerpiece for a dying
Muslim patient
Muslims, like other Abrahamic religions, believe
that death is Gods will, no one can escape
death
Death comes at a specified time and location,
which cannot be altered.
A Muslim experiencing life threatening
illness will focus on spiritual and
religious issues in addition to medical
care.
Family members have a vital role in
addressing the spiritual and religious
needs of the dying patient
(Ow & Saparin, 2014).
 Muslims share a God-centric view of
healing and healing is accessed through
supplication and recitation of the Quran
Muslims view God as the one who
ultimately controls health and illness
(Padela, Killawi, Forman, DeMonner, &
Heisler, 2012)
 Education
Educate family members of a dying
Muslim patient that life support measures
such as a ventilator are extremely
PAINFUL for the patient
Endorse a better quality of life for dying
patient
Educate about hospice care and living will
 Education
The face of the dead or comatose Muslim
should be turned to face Mecca
Euthanasia is defined as murder or
suicide, both of which are forbidden.
Muslims should grieve for only three
days, and they are encouraged to not
grieve in public.
The Muslim patient must be buried within
24 hours of death
(Charles & Daroszewski, 2012).
 Case Study
A 95 year old Muslim patient with
advanced cancer is on a ventilator and
vasopressors in the intensive care unit.
The family believes that Allah gives life
and death so they want to continue all
life saving measures. How should a
healthcare professional proceed?
 Recommendations
Educate the family that life saving measures
such as the ventilator are Extremely PAINFUL
Inserting a tube into the patients mouth is a
painful procedure and requires the patient to be
completely sedated
Inform the family that many patients have pulled
out the tube because of pain
Advise family to consider comfort/hospice care
 References
American Congress of Obstetrician and Gynecologists. (2016). Practice
bulletin no. 168: Cervical cancer screening and prevention.Obstetrics &
Gynecology,128(4), e111e130.doi:10.1097/AOG0000000000001708
Abell, M. L., Manuel, J., & Schoeneman, A. (2015). Student Attitudes
toward Religious Diversity and Implications for Multicultural
Competence.Journal of Religion & Spirituality in Social Work,34(1), 91-
104. doi:10.1080/15426432.2014.943920
Al-Yateem, N., Al-Yateem, S., & Rossiter, R. (2015). Cultural and
Religious Educational Needs of Overseas Nurses Working in the
Kingdom of Saudi Arabia and the United Arab Emirates.Holistic Nursing
Practice,29(4), 205-215. doi:10.1097/HNP.0000000000000095
Besheer, M. (2016). A New Estimate of the U.S. Muslim Population.
Retrieved from http://www.pewresearch.org/fact-tank/2016/01/06/a-
new-estimate-of-the-u-s-muslim-population/
Charles, C. E., & Daroszewski, E. B. (2012). Culturally Competent
Nursing Care of the Muslim Patient.Issues in Mental Health
Nursing,33(1), 61-63. doi:10.3109/01612840.2011.596613
 References
Creasia, J. L., & Friberg, E. E. (2011). Conceptual
Foundations: The Bridge to Professional Nursing Practice
(5th ed.). St. Louis, MO: Elsevier Mosby.
Eltaiba, N. (2014). Counseling with Muslim Refugees:
Building Rapport.Journal of Social Work Practice,28(4),
397-403. doi:10.1080/02650533.2013.875523
Guimond, M. E., & Salman, K. (2013). Modesty Matters:
Cultural Sensitivity and Cervical Cancer Prevention in
Muslim Women in the United States.Nursing For Women's
Health,17(3), 210-217. doi:10.1111/1751-486X.12034
Hanely, J., & Brown, A. (2014). Cultural Variations in
Interpretation of Postnatal Illness: Jinn Possession amongst
Muslim Communities.Community Mental Health
Journal,50(3), 348-353. doi:10.1007/s10597-013-9640-4
 References
Ibrahim, M., Abu Al Magd, M., Annabi, F. A., Assaad-Khalil, S., Ba-
Essa, E. M., Fahdil, I., Umpierrez, G. E. (2015).
Recommendations for management of diabetes during Ramadan:
update 2015.BMJ Open Diabetes Research & Care,3(1),
e000108. http://doi.org/10.1136/bmjdrc-2015-000108
Maroney, P., Potter, M., & Thacore, V. R. (2014). Experiences in
occupational therapy with Afghan clients in Australia.Australian
Occupational Therapy Journal,61(1), 13-19. doi:10.1111/1440-
1630.12094
Mir, G., Meer, S., Cottrell, D., McMillan, D., House, A., & Kanter, J.
W. (2015). Adapted behavioral activation for the treatment of
depression in Muslims.Journal of Affective Disorders,180, 190-
199. doi:10.1016/j.jad.2015.03.060
Ow, R., & Saparin, N. B. (2014). Malay Muslim Worldviews: Some
Thoughts for Social Work Practice in Singapore.Journal of Religion
& Spirituality in Social Work,33(1), 73-94.
doi:10.1080/15426432.2014.874261
 References
Padela, A., Gunter, K., Killawi, A., & Heisler, M. (2012). Religious values and
healthcare accommodations: Voices from the American Muslim
community.Journal of General Internal Medicine,27(6), 708-715. doi:
10.1007/s11606-011-1965-5
Padela, A. I., Killawi, A., Forman, J., DeMonner, S., & Heisler, M. (2012). American
Muslim Perceptions of Healing: Key Agents in Healing, and Their Roles.Qualitative
Health Research,22(6), 846-858. doi:10.1177/1049732312438969
Salman, K. F. (2012). Health beliefs and practices related to cancer screening
among Arab Muslim women in an urban community. Health Care for Women
International, 33(1), 4574. doi:10.1080 /07399332.2011.610536
Walpole, S. C., McMillan, D., House, A., Cottrell, D., & Mir, G. (2013). Interventions
for treating depression in Muslim Patients: A systematic review.Journal of
Affective Disorders,145(1), 11-20. doi:10.1016/j.jad.2012.06.035
Wehbe-Alamah, H., & Fry, D. (2014). Creating a Culturally Sensitive and
Welcoming Academic Environment for Diverse Health Care Students: A Model
Exemplified With Muslim Physical Therapist Students.Journal of Physical Therapy
Education,28(1), 5-15. Retrieved from
http://search.proquest.com/openview/8779ba1a2af39495d94eb734674559df/1.pd
f?pq-origsite=gscholar