Communication
Effective communication with Middle Eastern patients is often assumed to be two-way. You many need to share information about yourself in order for them to share information about themselves. Healthcare providers may be expected to take a personal interest in their patients.

Direct eye contact with members of the opposite sex may be interpreted as a sign of sexual interest, particularly from female to male. Thus, female patients may avoid direct eye contact with maleproviders.

Repetition of demands is often made to show emphasis, as is a loud tone of voice.

For many Iranians, “thumbs up” is a rude gesture and should be avoided.

World View
Islam is a dominant force in the lives of many Middle Easterners. Give patients the opportunity to pray privately several times a day, facing east toward Mecca. Many have a fatalistic attitude regarding health (it is all in Allah’s hands), so they may see their health-related behavior as being of little consequence. Inshallah means “God willing.”

Time Orientation
Arabs tend to have a past and present time orientation. Human interaction is given higher priority than clock time, so if being on time is important, emphasize it.

Iranians tend to be more future oriented, although a fatalistic attitude can interfere with adherence to preventive medicine. Social time can be flexible.

Pain
Patients tend to be very expressive about pain, particularly in front of family. Pain is feared and should be minimized. Explaining the source of pain and the prognosis may improve these patients’ ability to cope with it.

Family & Gender Issues

Middle Easterners are very family oriented. The family is seen as more important than the individual. Expect many familial visitors to see the patient.

Be patient with “demanding” family members; they may see it as their job to make sure that the patient gets the best care possible.

Personal problems are usually taken care of within the family; they may not be receptive to counseling.

Traditionally, the eldest male is the decision maker. Even among the more acculturated, the entire family (including extended family) may participate in decision-making.

Sexual segregation can be extremely important. Assign same-sex caregivers whenever possible, and maintain a woman’s modesty at all time. Offer a gown that provides maximum coverage if possible.

Women may defer to husbands for decision-making regarding their own and their children’s health. In fact, the husband may answer questions addressed to his wife.

Pregnancy & Birth
Arab women may delay prenatal care because pregnancy is seen as a normal condition.

They may not make many preparations for birth because planning can be seen as challenging the will of Allah.

It is acceptable for women to be very loud & expressive during labor and delivery. Iranian women often receive a gift of expensive jewelr to compensate for their “suffering.”

A female relative may be the birth attendant; Arab men are not expected to participate. However, acculturated Persian men are more likely to participate.

Colostrum is believed to be harmful to the baby, so breastfeeding is often delayed for the first few days.

End of Life Issues
When offering chemotherapy, offer all options for administration. While a ventricular assist device may seem the most convenient, it may be determined that it has rendered a Muslim “unclean,” thus preventing him or her from praying.

When a patient is diagnosed as terminal, family members may wish to shield him or her from that fact. On admission (or before the need arises, if possible) ask patients to identify how much information they want to be given regarding their condition, or to whom the information should be provided.

They may not want to plan for death, since doing so can be seen as challenging the will of Allah. You might approach them by saying, “Some [Muslim] families feel that making such decisions is interfering with the will of Allah. Is this a belief you share, or do you want to begin discussing the decisions that need to be made?”

Avoidance of planning for death may also interfere with acceptance of hospice care. Another factor contributing to lower use of hospice is the belief that the family should be the one to care for the patient. When discussing hospice, be sure to explain that it can be done at home.

Muslims may not allow organ donation, since according to Islam, the body should be returned to Allah in the condition in which it was given: whole. Those who are in favor of it say that because organ donation can save a life, it falls under the Islamic doctrine that “necessity allows the prohibited.” For the same reason, they may be reluctant to allow an autopsy, but will if required by law.

Health Related Practices
Muslims may not take medications, eat, or drink from sunrise to sunset during the month of Ramadan. This period of fasting, self-sacrifice, and introspection is based on the Islamic calendar and thus occurs at a different time each year. Although they may be exempt during illness or pregnancy, Muslims may have to make up for it later on, which is much more difficult since no one else will be doing so at that time.

They may see the expectation of self-care as a lack of caring. Family members and caregivers are often expected to take care of them. Because of this, include family members in any patient education.

Injections may be preferable to pills based on the belief that injections are more effective. Offer options when possible.

Damp, cold, drafts, and strong emotions may be thought to lead to illness. For example, the “evil eye” (envy) may be thought to cause illness or misfortune. Amulets to prevent this may be worn and should not be removed. Such amulets include the hamsa, which looks like a hand with a blue stone in the palm, and a round blue stone with a blue and white “eye” in the center.

They may be used to heavy use of medications & may feel slighted if not given prescription.

When providing meals, be aware that observant Muslims and Jews do not eat pork. Muslims are also expected to abstain from alcohol, which may be found in cough medicine. Medications that contain geletin may also be a problem.

If a patient offers you food, it may be perceived as rude to refuse it. The second time it is offered, it is best to accept it.

Note: Some of this information is based on material from Meleis, A. I. (2005) Arabs. In J. G. Lipson and S. L. Dibble, eds. Culture and Clinical Care, 42-57. San Francisco: UCSF Nursing Press; and Hafizi, H. (2005) Iranians. In J. G. Lipson and S. L. Dibble, eds. Culture and Clinical Care, 246-276. San Francisco: UCSF Nursing Press.