CE Home > Occupational Therapy > OT441 Awareness Enhances Care for Muslim Patients

Erdogan Ozen*, a 44–year–old Turkish Muslim engineer visiting the United States on business, sustained an acute MI. His physician has ordered occupational therapy to improve endurance during ADLs. The OT, a 27–year–old, single female, greets Mr. Ozen by offering her hand and looking him in the eye as a way to show her direct attention. She is taken aback when Mr. Ozen refuses to participate in shower training, simple bedside self–care, or even toilet transfers.

Amira Assan* is brought to outpatient rehab by her granddaughter. Mrs. Assan speaks only Arabic; her granddaughter explains she has orders for rehabilitation after a tendon repair in her right foot. Mrs. Assan is fully covered; only her eyes and hands are visible.

Would you know how to interview, assess, and treat these patients while respecting their beliefs?

The Arabic word for peace is salam; it’s also the word from which Islam is derived. Unfortunately, after Sept. 11, 2001, anti–Muslim feelings have increased. American Muslims may perceive that they are being singled out and their actions monitored. This may present a threat to health promotion and the delivery of care to this growing population.¹ Caregivers can boost cultural competency by increasing their understanding of followers of Islam and how cultural beliefs may affect healthcare.

The occupational therapy practice framework identifies values, beliefs, and spirituality as client factors, acknowledging their key influence in motivating clients to engage in occupations and living a life of meaning.² Culture, at a minimum, is a social context that refers to the interrelated conditions that surround the client and influence occupational performance.²

Islam ... 101

Islam is the second–largest and fastest–growing religion in the world. Islam is often associated with the Middle East, but a large number of Muslims in the United States are African American and Asian. Two–thirds are foreign born, according to a 2007 report by the Pew Research Center for People and the Press titled Muslim Americans: Middle Class and Mostly Mainstream.¹ Among the foreign–born, most have immigrated since 1990. Of the roughly one–third of Muslim Americans who are native–born, the majority are converts and African American. The survey also reported ethnicity of Muslims in the U.S. as 37% white, 24% black, 20% Asian, 15% "other/mixed race," and 4% Latino.³

Followers of Islam are known as Muslims or Moslems. It’s also acceptable to refer to followers as “Islamic.” The supreme being of Islam is Allah, the religion’s founder is the Prophet Muhammad, and the holy book is the Koran, or Quran. Additional teachings of Muhammad, the Hadith and the Sunna, complement the Quran and guide Muslims in daily living. While not mandatory, some Muslims use prayer beads and prayer rugs and pin amulets and charms to clothing. Statues, figurines, or other likenesses that attempt to personify Allah or Muhammad are considered idol worship and are forbidden.

Sunnis represent about 90% and Shiites 10% to 15% of traditional Muslims. There are also several smaller sects, including Sufi, Ahmadiyya, Wahhabi, Ismaili, and Dawoodi Bohra.⁴

Sunni Muslims pray five times a day, even during illness. The more fundamentalist Shiites pray three times a day. Patients with conditions that prevent praying on the floor may pray in bed. Regardless, Muslims pray while facing Mecca, to the northeast of the U.S. A quiet, uninterrupted environment is necessary, except in emergencies.

First and foremost, healthcare providers should remember that not all people who identify with a particular religion practice all aspects of that faith. Geographical, cultural, and ethnic factors significantly influence the beliefs, values, and practices of Muslims. Remember that differences in practices may exist between Arab, Asian, African, and African–American Muslims.

Caregivers can sometimes have difficulty accepting and understanding unfamiliar healthcare values and beliefs, and patients can sometimes underestimate how cultural vales can impact health. U.S. healthcare is rooted in Western beliefs and values autonomy, individuality, individual decision making, and taking personal responsibility for one’s own health. Muslim beliefs focus on interconnectedness, benevolence, and care for others and the community.⁵ “Good” health is the absence of visible disease or disability. Limited appreciation exists for personal independence and preventive care or screening for silent or insidious diseases.^6,7 This is often in conflict with mainstream U.S. beliefs about healthcare and may predispose healthcare professionals to not realize cultural clashes as they impact therapeutic interactions and care delivery. Muslims may interpret caregivers’ lack of awareness of Muslim values as disrespectful, which may reduce their willingness to seek care. In reality, an invisible but correctable mutual misunderstanding is at play.

Traditional Muslims have a concept of modesty that can be quite different from that of mainstream U.S. culture. More than just appropriate clothing or modesty (defined as hejab), it’s primarily about respect: It’s an attribute to be admired and attained. While it is not one of the five pillars of the Islamic faith, in some countries and cultures it is taken so seriously that it is considered a “sixth pillar.”⁸ “Keeping covered” and appropriate relationships between the sexes are integral to modesty. Traditionally acceptable clothing typically doesn’t reveal the shape of a woman’s body. Much like many regional cultures in America, individual interpretation determines the extent that Muslim women cover themselves. Some women cover all but the area around the eyes; others wear Western clothing.

Best practice in the U.S. is always to respect patients’ modesty by asking permission to uncover or touch any body part. Even entering a patient’s room should be done with respect, ideally by knocking and asking permission rather than “barging in.” Extending this universal courtesy to Muslim patients is especially important.

In America, direct eye contact is considered respectful, a sign that you are giving the client your undivided attention. OTs have extensive training in speaking directly and within the therapeutic relationship about intimate topics such as dressing, safety during sexual relations, toilet hygiene, and so on. OTs are often the only practitioner who has training in speaking about mundane but important ADLs and IADLs. However, direct eye contact with the opposite sex and discussing bodily functions with the opposite sex are inappropriate in the Muslim culture. This may challenge clinicians’ assessment skills, particularly when screening a patient of the opposite sex for mental health issues, such as depression, performing neurological exams, or assessing ADLs. Some caregivers may interpret the lack of eye contact as rejection, a lack of interest, mistrust, or diminished self–esteem. The downward glance is, however, a sign of humility and respect; Islam holds healthcare providers in high esteem because of their authority and dedication to healing at a time of need.⁷

Like any rule, exceptions apply to cultural beliefs. In extreme emergencies, Muslim patients may receive care from members of the opposite sex.⁸ When it is absolutely necessary for a male provider to care for a female patient, a female chaperone — a staff member or a family member — should remain with the patient at all times.

Cleanliness is crucial for Muslim patients because it is associated with religious values. More than just an a.m. bath and p.m. care, Muslims will want to rinse their mouth and wash their hands, face, forearms, and feet before praying. Cleaning one’s body before prayer is called ablutions, or wudu.⁹ Perineal washing is required after urination or a bowel movement. Provide patients of both sexes with a perineal wash squirt bottle or at least make sure that disposable cups are handy by the bathroom sink.

Muslim practices with respect to cleanliness have been shown quite beneficial in hospital settings, and healthcare providers should facilitate them. One study found a striking reduction in the incidence of Clostridium difficile infection among hospitalized Muslims.¹⁰

Death, Dying, and Pain

Muslims believe in divine predestination — the occurrence of illness, injury, and suffering as the will of Allah and atonement for sins. This belief, however, does not preclude Muslims from seeking treatment and relief from discomfort, because the Quran charges Muslims with the responsibility of protecting their health.⁹ Stoicism and the reliance on prayers to reduce suffering are common. For this reason, caregivers should be especially attentive to physical manifestations of pain (such as elevated pulse and blood pressure and guarding), question patients often, and offer measures for pain relief. Pain assessment scales designed for patients unable to verbally communicate may be helpful, such as the Pain Assessment Behavioral Scale.¹¹ Use of complementary and alternative practices for pain reduction, such as prayer, meditation, and distraction can be better choices.¹²

Muslims regard death as a return to their creator in an afterlife. While attitudes about end–of–life issues are still evolving in Muslim culture, suicide, assisted suicide, and euthanasia are strictly forbidden. Organ donation is permissible if it was the patient’s wish. With regard to issues like brain death and DNR, Muslim patients often respect the physician’s determination of medical futility and the best course of action.¹³

After death, Muslims observe specific customs, and withholding them may lead to spiritual distress and altered grieving among those left behind.¹⁴ Sunni Muslims typically believe that showing emotion at the time of death is a rebellion against the will of Allah. Shiite Muslims may openly mourn. Regardless, do not view a lack of overt emotional expression by family members as denial or inappropriate grieving.¹⁵

Religious observance is considered an IADL within OT practice.² When death is imminent, the patient’s face should be turned east, toward Mecca. After death, family members often conduct postmortem care rituals, including cleansing of the body under running water by a family member of the same sex and shrouding in simple white cloth. Ideally, burial takes place in 24 hours, and the funeral may take place sometime after the burial.¹⁴ Muslim beliefs require handwashing after providing postmortem care, but caregivers should still be sure that gloves are available in the room. Many Muslims make arrangements for washing and shrouding to take place at a funeral home rather than in the hospital. This varies by state and the resources available at funeral homes.

Muslims will most likely reject grief counseling and traditional Western psychotherapy. However, they may embrace counseling focusing on enhancing spiritual qualities because they often see psychological disorders as a manifestation of a soul that has become distanced from the creator. Some Muslim families may consult a religious adviser, such as an imam or sheikh, to help during a medical crisis and especially for end–of–life situations.¹⁶

Screening and Wellness

The impact of modesty on healthcare screening encompasses the lifespan, and with age, this becomes a concern. Interactions with health providers tend to diminish significantly for Muslim women after childbearing, reducing health screening and promotion opportunities. Even if they agree to screening despite modesty concerns, older foreign–born Muslim women may face transportation, language, and financial issues. One study revealed that Muslim women face numerous stressors that threaten their mental health, including discrimination, acculturative stress, and trauma.⁶

Islamic teachings encourage Muslims to seek treatment when they become ill. Yet because Muslims seek care primarily for illness, not prevention, they may be at a higher risk for preventable diseases and from diseases that can often be successfully treated when detected early, such as breast, prostate, and colon cancer.⁸ Older Muslim women may also be less likely to seek treatment for sensitive issues, such as urinary incontinence.¹⁷ Younger Muslims may have greater access to screening because of work and school requirements. 

Perspectives on health and healthcare interventions may also differ from Western beliefs and choices. Many predominantly Muslim countries view being overweight as a sign of prosperity and well–being, so Muslims who are overweight may seek treatment for medical problems later than other people. Muslims may use holistic interventions — including herbs, meditation, music and art therapy, and modifications in diet and exercise — before seeking, or in conjunction with, care from Western healthcare practitioners.¹⁸ It is important to learn about these and assess for any contraindications or adverse interactions with Western protocols.

Touchy Topics

Muslim customs and practices condemn pre– and extramarital sexual relationships, homosexuality, and drug use and mandate male circumcision. Circumcision has been associated with a lower risk for HIV infection and other STDs.^19,20 Not surprisingly, then, the incidence of HIV/AIDS and other STDs among practicing Mulstims is significantly less than among the general population. This does not, however, eliminate the need to obtain the same history, including information about sexual practices that you would from any other patient, using extreme sensitivity. Sexual activity is considered an ADL in the practice framework and should be included in all ADL assessments, When language barriers exist, the patient’s responses to such highly sensitive questions may be dramatically different if family or friends are interpreting as opposed to a staff member.²¹ Patients may be less likely to disclose substance abuse or sexual contact outside marriage in front of family or friends. Using a trained staff member to interpret may yield more accurate information.

Devout Muslims may use (and occasionally share as a sign of respect) a toothstick, or miswak, for oral hygiene. At the end of a pilgrimage to Mecca, or Hajj, Muslims customarily shave or trim their hair. Sharing razors and eating utensils or receiving medical care or blood in less–developed countries (where universal precautions may not be adhered to and the blood supply may not be screened) may place Muslims at risk for bloodborne pathogens.²¹ (Muslims do not have restrictions on receiving blood transfusions.²¹)

Decisions, Decisions

Mentally competent Muslim adults of both sexes may accept or refuse medical treatment, but close family members may significantly contribute to the decision–making process. For this reason, when procedures, tests, and treatment options are explained and consent is required, caregivers should ask patients whom they wish to be present.⁹ When explaining treatments to patients, clinicians should talk about the pros and cons of the intervention and any possible contraindications.

Because mind–altering substances are prohibited, caregivers must explain medications that may cause drowsiness and sensory or behavioral changes with respect to medical necessity. Often, an objection to a medicine is related to a concern that it will alter consciousness, preventing a patient from being in a pure state and therefore unable to complete ablutions and pray. Objections to therapy can be connected to the necessity to pray at certain times of the day, and working with the family or spiritual counselor can help OTs develop a plan that will meet patients’ spiritual and physical needs. Habits, routines, rituals, and roles are an important aspect of performance patterns and should be evaluated as part of the occupational profile conduced with each patient.²

While alcohol used to intoxicate is forbidden, it is permitted as a medicinal agent (such as to cleanse before injections or as a component of cough medication). Likewise, while cocaine or morphine as recreational drugs are forbidden, their use as anesthetic agents or for pain relief is acceptable.²² Some patients, however, will refuse any contact with cocaine or morphine, even for therapeutic reasons, and alternatives must be used. Individual interpretation of spiritual beliefs may dictate which medications are acceptable. Understanding these concerns and working with the nursing staff can help OTs schedule rehab sessions around pain cycles and medications.

When visitors come to the hospital, they may arrive in large numbers because Muslims are encouraged to visit the sick. Providers may notice a lack of open expression of affection between the sexes in front of strangers, but they shouldn’t misinterpret it as a sign of a dysfunctional family or abuse. Although also cautious when greeting strangers, Muslims are affectionate with friends and family, and men often greet family members and close friends by kissing them on the cheek. Scheduling OT sessions may require a team approach to respect visitors but also ensure patients’ individual needs are prioritized in balance with essential needs for social participation.²

Muslim traditions can benefit clinicians’ coordinating care: Islam highly values caring for the ill and elderly at home, and family members view this role not only as responsibility but as an opportunity to be blessed themselves. People with disabilities (social, economic, or physical) are viewed as equals, and Muslims see it as a responsibility to recognize the plight of others and help correct inequities.²³ OTs can also use this insight to plan meaningful and purposeful activities related to ADL training.

Truthful communication, even when conveying bad news, is important. Maintaining sensitivity while preserving hope is important, but an inaccurate or incomplete explanation may be interpreted as a lie, considered a great sin, and will undermine a therapeutic relationship.9 And yet, most families hold back emotions to avoid stressing or sending a negative message to the patient, especially when the diagnosis or prognosis is poor. Often families will ask providers to keep the news of a terminal prognosis from the patient to preserve the patient’s mental well–being. This may vary among Muslims and is part of cultural and customary norms than on religious beliefs.

To Eat or Not to Eat …

One of the most misunderstood of Muslim practices is the fasting associated with Ramadan, the ninth month of the Muslim calendar. Muslims commemorate Ramadan as the time when the Holy Quran was sent down from heaven. It’s a time when Muslims worship and contemplate their faith rather than focus on everyday concerns. Muslims abstain from physical satisfaction in the form of food, drink, sex, and smoking from daylight until sundown. Illness, menstruation, pregnancy, diabetes, breastfeeding, and travel exempt people from fasting, but some may still do so. If so, the provider may have to adjust meals, medications, and rehabilitation treatments. During Ramadan, Muslims often rise before sunrise to eat and pray, fast until sunset, and go to sleep later than usual after a celebratory fast–breaking meal. This affects circadian rhythms and metabolism. The addition of a daytime nap may help combat daytime fatigue, and therapy sessions will need to be scheduled to respect this spiritual practice.

Because dietary and meat preparation concerns of Muslims are similar to those of Jewish patients who keep kosher, if specific halal (humanely slaughtered and blessed) food is not available, often a kosher–prepared meal may be acceptable. Pork and alcohol are strictly forbidden.

Fasting may affect when you see patients for specific complaints. Changes in dietary intake and sleep patterns during Ramadan have been shown to alter the timing and presentation of acute coronary events:²⁴ Fasting Muslims are less likely to present to the ED with acute coronary syndromes in the early morning and more likely to present in the afternoon.²⁵ Fasting can also affect physical assessment and laboratory findings. Blood pressure and RBC production have been shown to decrease during Ramadan fasting.²⁶

Understanding Ramadan is an excellent example of how OT practice is framed: client factors are intimately interconnected with occupational performance in all domains.²

Healthy Eating

Muslims, especially those from rural areas and those with less formal education, may lack knowledge about dietary recommendations for specific disease processes (such as avoiding a high–fat diet with coronary artery disease and a high–sodium diet with hypertension). But a lack of knowledge may be mitigated by shying away from a Western diet. The traditional diet of many Muslims, especially those from Europe, Africa, and Asia, is rich in fiber and low in fat, and it features nuts, fruits, and vegetables, similar to a modified Mediterranean diet.²⁵ The absolute lack of pork products is also beneficial; pork is one of the highest sources of dietary fat, and eliminating it can reduce cardiac risks.^27,28

Pregnancy and Childbirth

Muslims in rural settings may have more traditional approaches to religious observance and health matters than urban Muslims. Women from rural families may be tightly bound to traditions surrounding women’s health and fear deviation. Education may increase the likelihood of being open to alternatives to traditional treatment options during pregnancy, delivery, and the postpartum period. Highly educated Muslim women are more likely to accept Western options. Because decisions are often a collaborative process, when it is necessary to inform a less–educated Muslim woman about her treatment options, involving a highly educated Muslim woman may be beneficial, especially when complex treatment options must be explained.²⁹

In the case of a stillbirth or the death of a newborn, OTs who work in neonatal intensive care units may need to alter their routine to assist Muslim parents with grieving. Often, the parents will be unable to make decisions without family or community support. Also, don’t assume that the parents want handprints, footprints, photos, and locks of hair as mementos; Muslims may consider this a desecration of the body. And yet, don’t hesitate to explain that many other parents keep mementos of their infant, and that if they are interested, you can gather items they desire. OTs can direct them to scrapbooking groups that are now commonly offered within NICU settings and support groups for parents of premature babies. As with any occupational activity, let the expressed wishes of the parents guide your actions and recognize that not all Muslims interpret their religious beliefs in the same way.¹⁴

When a Coworker Is Muslim

The Prophet Muhammad apparently knew the value of hand hygiene more than 1,400 years ago because he urged frequent handwashing under running water to promote exterior purity.²² Today, alcohol–based hand rubs may be substituted if running water is unavailable. Some Muslim providers may oppose using alcohol–based products because alcohol is forbidden.²² Again, this varies by individual. But because alcohol–based hand rubs are not used to intoxicate but to clean, most providers will agree to their use. And patients will not object to providers using them.²² Regardless of what is used to clean the hands, remember that the left hand is considered unclean; avoid using the left hand to pass medicine or food to patients.

Salam and Goodbye

Islam is not only a religion but a holistic and spiritual way of life that can affect healthcare delivery and health maintenance among individuals and families and in communities. OTs consider religious observance to be an important area of occupation.² Further, the context and environment in which culture occurs influences patterns of engagement and must be understood if competent practice is to be employed. By focusing on the positive health practices of Islam and identifying respectful and sensitive ways to encourage routine screenings and reduce risk factors, healthcare professionals can promote wellness among Muslim patients.

*A fictional patient.

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