Arab-American Cultural Competencies and Healthcare

Who is an Arab?
The term Arab is associated with a particular region of the world. Almost all people living in the region extending from the Atlantic coast of Northern Africa to the Arabian Gulf call themselves Arabs. This classification is based largely on a common language (Arabic) and a shared sense of geographic, historical, and cultural identity. The term Arab is not a racial classification; it includes peoples with widely varied physical features. The total population of the Arab world is approximately 230 million in 22 nations.

There are 10 Arab countries in Africa (Algeria, Djibouti, Eritrea, Egypt, Libya, Morocco, Mauritania, Somalia, Sudan, and Tunisia) and 11 countries in Asia (Bahrain, Iraq, Kuwait, Jordan, Lebanon, Oman, Qatar, Saudi Arabia, Syria, United Arab Emirates, and Yemen) and includes the Palestinian people. (Palestinians are presently either living under Israeli rule, autonomy of partial Palestinian Authority in the West Bank and Gaza, or dispersed throughout the world). Despite the national boundaries dividing the Arabs into nation states in the post-colonial period, Arabs generally view themselves as a unified entity.

Arab countries are not homogeneous with respect to religious beliefs. They include Christians, Jews, and Muslims. The large majority of Arabs are Muslim (92 percent), however, in total Arabs comprise only about 17 percent of the Islamic population worldwide. The majority of non-Arab Muslim populations live in Central Asia, Indonesia/Malaysia, Iran, South Asia, Sub-Saharan Africa, and Turkey. The religion of Islam is closely associated with Arab identity because of the origin of Islam in the Arabian peninsula and the fact that the language of Arabic is the sacred language of the Holy Qur'an.

Ethnic minority groups live in many Arab countries. These include Persians, Turks, Kurds, Berbers, and other minorities. Differences within Arab culture also exist between people living in urban and those in rural areas, and among countries.

Language: An important aspect of culture The Arabic language can be divided into three categories classical Arabic, the language of the Quran; Modern Standard Arabic, used in newsprint and newscasts throughout the Arab World. While many people understand it, Modern Standard Arabic is not used in conversations; colloquial Arabic, or local dialects, which vary among countries and regions and are not easily understood by those who speak another dialect.

Other languages spoken in the Arab World include Aramaic, an ancient language of Mesopotamia, which is still used in Chaldean and Assyrian church services. Berber is commonly spoken in North Africa, and Kurdish is spoken in regions of Syria and Iraq.

Traditional society:
Arab society was traditionally organized and governed by families or tribes, and the family remains an important institution. Families are generally patrilineal. This means that children strongly identify with the lineage of the father, and the paternal relatives hold primary responsibility for the children. In traditional Arab society, Christians prefer to give their children a Biblical name, followed by the father's first name, then by the family name. Muslims commonly use the names of Mohammed and others in his family as well as "servant of God names" (Abdul-Rahman "Servant of the Compassionate", Adbul-Aziz "servant of the Beloved"). Names may also carry secular meaning (e.g., Hasan, "good", Laila "night"). Ibn( bin) or bint means son or daughter of, respectively, and may follow the middle name. Last names may denote a person's profession or their city of origin.

Some cultural commonalities impacting health:
Despite the great diversity in this region of the world, there are some cultural and health-related commonalities among peoples from the Arab World. These commonalities may include: preferring to be treated by a medical practitioner of the same sex; preferring medical treatment that involves prescribing pills or giving injections, rather than simple medical counseling; among observant Jews and orthodox Muslims, following a kosher (Jewish) or halal (Muslim diet) which restricts the types of meat and seafood that they eat and may preclude them from mixing dairy with either meat or seafood. In some countries, strictly secluding women from men; in these countries, women may have little contact outside of the home. Other countries in the region may allow women more freedom to mix with relatives and neighbors; among devout Muslims, praying as many as five times a day, starting before sunrise and ending at night; among devout Muslims, abstaining from alcohol is mandatory; among devout Muslims, fasting during the holy month of Ramadan, with no food or drink consumed between sunrise and sunset, is required. The ill are supposed to be exempt from fasting, but among people who are fasting, oral medication and IV solutions are prohibited. Muscular injections are permitted.

North Africans: A distinct identity
North African Arab countries are Algeria, Morocco, and Tunisia. These three countries are located on the western edge of the Arab World and have historical and cultural characteristics distinct from other Arab nations. People from this region call themselves the "Maghreb," the Arabic word for "sunset." The culture and history of these countries is usually considered distinct from that of Africa, Europe, or the Middle East.

North African patients may have a sense of cultural identity that is distinct from Arabic speakers from other Arab nations. Some North African patients may identify more closely with European values; others may identify more closely with Arab culture, while others may consider themselves Muslim, above all else.

Berber people inhabited North Africa when the Arab Muslims invaded in the 7th century. Today, the Berbers are the largest minority group in North Africa and have maintained their culture and traditions and even communities separate from the rest of society. Many Berbers have intermarried with members of other Arab cultures, but there are still nomadic groups as well as communities that have settled in the oases of the Sahara.

The majority of North Africans, including the Berber groups, are Muslim. Communities are organized in tribes, which may be divided into smaller subgroups. Both the larger tribes and smaller subgroups have elder councils, an indication of an egalitarian society. Elder council decisions are made by a group of people, and not one dominant leader.

Arab Americans

Arabs immigrated to or arrived as refugees in the United States in two major waves. The first wave was comprised primarily of Christian Arabs from Lebanon and Syria who arrived in the US during the late 19th and early 20th centuries. Long settled in the United States, Arab Americans descended from these early immigrants represent the majority of Arab Americans, and most are Catholic or Orthodox Christians.

Beginning in the 1950s, Muslim Arabs began to emigrate to the United States in larger numbers. Most Muslim Arab immigrants to the US come from Egypt, Palestine, Yemen, and Iraq. Some wear traditional Islamic dress. Not all Arab immigrants to the US are Christians or Muslims. Arabs may also be Jewish or Druze.

Arab American Demographics
More than 80 percent of all Arab Americans are US citizens, and 63 per cent were born in the United States. Fifty-one percent speak a language other than English at home. Arab Americans tend to have larger families than the general population-32.6 percent have families with more than four people. Although Arab Americans have settled throughout the country, one-third of all Arab Americans live in three states:California, New York, and Michigan.

Strengths and Protective Factors in Arab-American Families & Communities

Arab Americans have a wide range of cultural and religious traditions and personal and family histories. Community, family, and respect for Western medicine, however, are three protective factors that the majority of this diverse group of peoples may have in common.

Community bonds
Arabs have strong community bonds. This strong sense of community transcends national boundaries. This sense of community is helpful to newer Arab immigrants, who often find support from well-established Arab communities, even if their members may not have come from the same country of origin.

Family and honor
Strong family ties can be a protective factor in Arab families and communities. Honor (sharaf), is an important aspect of the family. When one member of the family does something good, honor is brought to the reputation of the whole family. In the same respect, the actions of an individual can bring shame to the family, so honor as it relates to family can also be seen as a health challenge.

Respect for Western medicine
Many Arabs place a high value on Western medicine, and generally do not wait long to seek help. In fact, much of Western medicine originated from Arabic medicine.

Challenges to Health and Well-Being of Arab American Families & Communities

A major stressor for Arab Americans is racism and stereotyping of the Arab people, which has been exacerbated by recent world events. Arabs do not usually get fair representation in the media, which stereotypes them as, for example, rich oil sheiks or terrorists. Arabs are classified as "White" by the US census, but they face discrimination that European Americans may not. Fortunately, there are several groups that work to provide support to Arab Americans, as well as provide education to the media, politicians, and the general public.

Preventive health care: A low priority
Many Arab immigrants may not place a priority on preventive care and may not seek those services. They may stop taking the medicines once their symptoms improve, and may not return for a follow-up visit. It is clinically advisable to actively follow up with these patients to assure adherence to treatment regimens. Understanding the culture and language of these patients will certainly increase adherence to medical advice. Among Arabic patients, many may be used to receiving a variety of medications, including antibiotics and pain relievers, from the pharmacist without a prescription. In addition, they may be surprised or disappointed if they are not treated with a variety of medications for an illness.

Denial and fatalism
In the case of bad news, denial and fatalism may play a role in inhibiting recovery. Acceptance of terminal illness may be gradual and difficult.

Mental illness stigmatized
Mental illness is often stigmatized in Arab communities, as it is in most societies. A person with mental distress may not seek advice from professionals, or even family members. Male family members are the major bread winners for their families, and male unemployment can affect the mental health of men more than women (who are most often housewives and caregivers).

Depression
In addition to posttraumatic stress disorders resulting from war, dislocation, oppression, and torture, many new Arab immigrants face other stressful events such as economic hardship, assimilation into a new culture, racism, and other forms of discrimination. Many immigrants may have held professional occupations in their home countries but are unable to find comparable employment in the United States. Stressors related to loss of previously held social and economic status may precipitate some forms of depression. Some conservative Arab immigrant women may be more isolated from the wider society than are Arab men. Isolation may be one of the factors to precipitate depressive illness.

Principles for Culturally Competent Health Care for Arab American Families & Communities

The most basic aspect of cultural competence relates to the provision of linguistically and culturally appropriate services. Limited provider awareness of Arab-American cultural values and religious traditions can be an important factor in the lack of access to culturally competent care. Cultural competence must address cultural and societal barriers to receiving and accessing health services of all types. In particular, providers must learn about and be respectful of the cultural traditions of their Arab-American clients. It is important to respect the cultural diversity of Arab Americans. Be sensitive to the diverse backgrounds and traditions of Arab Americans. Be sure to assess the medical, psychological, social, and cultural needs of each patient in order to provide quality care.

Be willing to involve family members in the treatment of an individual client.
Family plays an important part in health care. Families may themselves act as care providers for hospitalized family members. In addition to bringing the patient food and other personal items, family members might want to extend their visits periods and include other relatives in the visits. Culturally responsive providers should recognize that this type of family support is part of the healing process. Many Arabs prefer to be informed only of "good news" about illness and may actually prefer that test results be given to the family rather than directly to the patient.

Understand the traditional role of men in how health care decisions are made for women.

• A husband bringing his wife to the clinic may speak for her even if she is able to speak English herself. Health care service providers need to focus upon the woman as the primary patient, being careful not to exclude her from the visit. Women patients may be reluctant to discuss their concerns with or be examined by male providers, and often a family member will sit in on the visit. The patient may also be reluctant to disclose personal information about herself or her family. Childbirth may be considered a strictly female issue, and the father may not be involved in the birth process at all. However, if the pregnant woman does not have a female support network in the US, the health care provider may make a stronger attempt to include the father in the care of the expectant mother.
• Show respect for the knowledge and involvement of elders. Elders have prestigious status in Arab society, and thus may be consulted when health problems arise. Elders may suggest home or natural remedies, which may be viewed as complimentary to western medicine.
• Ask about the use of traditional remedies.

Clinicians should note that in North Africa, traditional herbal remedies are commonly used as a complement to Western medicine. Be sure to ask North African clients what herbal remedies they may be using, and discuss any possible conflicts with traditional herbal treatments. Among your Egyptian patients, some may believe that eating fish, eggs, or onions will worsen a cold. Older, more traditional Egyptians may believe that bathing during menstruation may affect future fertility.

• Be prepared for and sensitive about female circumcision/female genital mutilation.
  A sociomedical issue that may pose a challenge to health care practitioners treating patients from Arab and Sub-Saharan African countries is that of female circumcision or female genital mutilation (FC/FGM).
• Respect religious traditions, such as fasting during the holy month of Ramadan.
  Among Arab Muslims, fasting is required during the holy month of Ramadan, with no food or drink consumed between sunrise and sunset. The ill are considered exempt, but for some believers, fasting may extend to medications, including injections, during this important holy period.

Used with permission from Management Sciences for Health