Dr. Sylvia Reitmanova (University of Ottawa) Ms. Khadija Haffajee (CAIR-Canada)

1. What does God have to do with it?: Cultivating spiritual and religious needs of Muslim patients to empower change toward building culturally safe healthcare Dr. Sylvia Reitmanova (University of Ottawa) Ms. Khadija Haffajee (CAIR-Canada) Imam Ahmed Limame (Gatineau Mosque)

2. Part 1: Rationale for developing culturally safe care (video) Two models of cross-cultural care Part 2: Demographic profile of Muslims in Canada Religious and spiritual needs of Muslims in mental and maternal healthcare Part 3: Islamic medical ethics Religious and spiritual needs of Muslims in palliative care Part 4: Insights from chaplaincy work with Muslim patients Tips for healthcare providers Workshop outline

3. Cross-cultural care: Why, how and for whom? Part 1

4. Rationale for the provision of culturally-safe health services The lack of culturally-responsive care Misunderstanding and miscommunication Patient general dissatisfaction Poor adherence to therapy and care Poor health outcomes Health and care disparities 4

5. Socially responsible healthcare • Association of Faculties of Medicine of Canada: the Social Accountability Initiative to address and advocate the changing needs of the communities • Liaison Committee on Medical Education: “… demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments.” “… to recognize and appropriately address gender and cultural biases in themselves and others, and in the process of health care delivery.”

6. Nurturing cultural competence in nursing: Promising practices for education and healthcare

7. Which term to use?: Two models of cross-cultural care

8. Cultural competence model culture = fixed patterns of learned beliefs, values, practices, ways of interacting and communicating shared among groups and passed between generations • all patients in one cultural group present the same health beliefs and behaviours • eliciting patients’ health beliefs, concepts of time, space and physical contact, communication styles, the role of family and gender, social expectations, and decision-making preferences • a list of “do’s and don’ts” • tolerance, inclusion, and appreciation 8

9. Cultural safety model culture = flexible system of values and world views that people live by and recreate continuously depending on larger social, economic and political circumstances • the role of the social, economic, political and historical context in health outcomes and healthcare delivery (variations in socioeconomic status, employment, and housing patterns, the effects of war, torture, and abuse) • intersectionality of culture, ethnicity, skin colour, gender, class, ability, age or sexual orientation in production of health • exploration of personal biases, fears, emotional reflexes, and psychological defences 9

10. Part 2 Health-related religious and spiritual needs of Muslims in Canada

11. Changing demographics of Muslims in Canada • Census 2011: Muslims 579,640 (52 % men) 11

12. 1st generation: 376,205 2nd generation: 31,785 3rd generation: 3,525 Canadian-born 137,835 Immigrants 415,840 Non-residents 25,970 12

13. Visible minority 497,270 English 422,250 French 37,135 Both languages 87,175 No official language 33,085 13

14. 1. A very diverse ethnic and cultural group 2. The majority are Sunni (following the Prophet’s tradition) 3. Substantial numbers belong to groups such as Shia, Ismaili, and Ahmadiyya 4. Diverse levels of dedication to teachings and practice within each group Many commonalities in beliefs and practices Health needs and requests for religious accommodation in the healthcare setting Prayer Fasting Dietary requirements Clothing Physical contact Spiritual therapy Dealing with a deceased body Grieving process

15. Mental health services spiritual life, moral values, family ties, and a non-materialistic approach to life internal strength, support, and understanding of the purpose of life

16. Barriers • Lack of information, long wait times, financial constraints, linguistic concerns • Cultural and religious considerations 1. Cultural incongruency: misunderstanding and ineffectiveness They [Canadian-born doctors] would never understand what I was going to say. I know that. There are a lot of things that I say to Canadian friends or neighbours and they just don’t know what I am talking about. Maybe understanding can be attained between the patient and the mental health provider, but after the understanding, there is treatment and help itself. I am not sure if there is a single recipe for everyone from different cultures.

17. 2. Cultural insensitivity I am not expecting from my family doctor to ask me to go and pray. One should admit it there is a difference [between cultures]. I do not expect him to ask me to recite my Holy Book. But I remember when I got cured from my condition and I said that “I want to thank God and you,” he asked me “Why do you put God in this one?” I told me that we always thank God for everything. It is a simple thing you do. But he did not understand why I [first] thank God and then to him. He expected maybe to thank only to him.

18. 3. Cultural validity of diagnostic methods Psychological testing: • Do you believe that the man should be the head of the family? • Having fits, Blue spells, Raw deal 4. Culturally inappropriate health promotion leisure activities Dance or drink: these are things we are offered to do and they [non-Muslims] will criticize us why we are not doing these things.

19. Maternal health services • Lack of information, lack of emotional and practical support, linguistic concerns • Cultural and religious considerations 1. Underutilization of prenatal classes They told me you can go. But I knew that other husbands will be there, so I didn’t go. When it is only for women I can go… but when men are there…[unfinished sentence].”

20. 2. Sex incongruency Yes, it was important for me [to have a female attendant] and I told them about this but they said: “Whoever is available.” They can’t guarantee a female doctor during labour. I just had to accept it…sometimes when the male doctor has a background about our culture and religion and he respects it that it’s good. Once I went before the delivery for a check up and it was a male doctor… and I found that he can understand it. He suggested that he will let a nurse to check me and she will tell him what she found. He was very helpful. But I want to say that there should be more female doctors here. And they should be flexible to come for a delivery when any woman needs. It’s the most important moment to have a female doctor during the delivery… if she is not there as if I did nothing [to protect my modesty].

21. 4. Lack of privacy 5. Lack of dietary accommodation 6. Lack of specific services (male circumcision)

22. 7. Stereotypes and prejudice She [a nurse] asked me, “And do you have cars in your country? Do you have electricity?” I think she thought we ride on camels, so I told her about my country You see their faces, you feel it that they think you are stupid and you don’t know anything about this world.

23. 8. Cultural insensitivity and misunderstanding If some Muslim physician can tell them about our culture that would be excellent. So they don’t think I have silly ideas or the nurse doesn’t tell me, “Oh, my God, you are beautiful, why you are wearing this scarf?” There was a male who entered my room. I asked nurses if they can knock before they enter so I can get dressed. I also put a sign on the door but they didn’t respect it. This man came and saw me [unveiled]. I was very upset and crying. One nurse came and she said, “Oh, why you are crying? You are beautiful! You don’t need to cover yourself.” They [nurses] made me very sad. I stopped asking them for anything.

24. Culturally safe health services for Muslim patients Physical environment, materials and resources Communication styles Social interaction Cultural conceptions of health, illness, and end of life Variations in diagnostic and treatment approaches Expectations from health professionals Cultural assumptions, attitudes and values Social determinants of health 24

25. Part 3 • Islamic medical ethics • Religious and spiritual needs of Muslims in palliative care