Muslims and End-of-Life Healthcare in Non-Muslim Majority Nations: A Systematic Literature Review.

CONTEXT: As Muslim populations in non-Muslim majority nations grow and age, they will increasingly require culturally appropriate healthcare. Delivering such care requires understanding their experiences with, as well as preferences regarding, end-of-life healthcare. OBJECTIVES: To examine the experiences, needs, and challenges of Muslim patients and caregivers with end-of-life, hospice, and palliative care. METHODS: A systematic literature review using five databases (MEDLINE, Scopus, Web of Science, CINAHL, Cochrane Library) and key terms related to Islam and end-of-life healthcare. Papers were limited to English-language empirical studies of adults in non-Muslim majority nations. After removing duplicates, titles, abstracts, and articles were screened for quality and reviewed by a multidisciplinary team. RESULTS: From an initial list of 1867 articles, 29 articles met all inclusion criteria. Most studies focused on end-of-life healthcare not related to palliative or hospice services and examined Muslim patient and caregiver experiences rather than their needs or challenges. Content analysis revealed three themes: (1) the role of family in caregiving as a moral duty and as surrogate communicators; (2) gaps in knowledge among providers related to Muslim needs and gaps in patient/family knowledge about advance care planning; and (3) the influence of Islam on Muslim physicians' perspectives and practices. CONCLUSION: There is scant research on Muslim patients' and caregivers' engagement with end-of-life healthcare in non-Muslim majority nations. Existing research documents knowledge gaps impeding both Muslim patient engagement with end-of-life care and the delivery of culturally appropriate healthcare.

"I'm not Alone; He will be There for Me": A Mixed-Method Approach Exploring the Impact of Spousal Support on Mammogram Utilization and Health Beliefs.

Regular mammogram screenings are effective for early breast cancer (BC) detection and decreased mortality rate. However, immigrant Muslim Arab women (IMAW) are less likely to adhere to these screenings although the rate of BC among IMAW is high. Recent studies have explored low mammogram screening rates among immigrant Muslim and/or Arab women from a limited perspective, overlooking the fact that husbands have an influence in IMAW's health behaviors toward cancer screenings. Thus, this mixed-method approaches were employed to (a) explore the association between spousal support and IMAW's health beliefs toward mammograms and their utilization, (b) to understand IMAW's experiences of spousal influence related to their mammogram use and health beliefs. The quantitative portion of the study, recruitment and data collection were conducted via online surveys in Arabic and English. Logistic regressions were used to explore relationships between perceived spousal support and IMAW's mammogram utilization and health beliefs. The qualitative portion of the study was conducted on a purposive sample of IMAW. A semi-structured interview guide in Arabic and English was used during one-on-one interviews. Arabic interviews were translated into English and transcribed by professionals. Interviews were analyzed by thematic analysis according to Braun and Clarke (2008). A total of 184 IMAW completed the survey with mean age of 50.4 (SD = 5.58, range = 45-60). Results revealed low mammogram screening rate among IMAW. Only 32.6% adhered to mammograms. Spousal support was positively associated with ever having obtained a mammogram and IMAW's adherence to mammogram. The 20 qualitative interviews, 16 in Arabic and four in English, produced rich description supporting results from the survey which includes, (a) types of spousal support, (b) impact of spousal support on participants' mammogram utilization and experience, and (3) impact of spousal support on participants' health beliefs toward mammograms. Findings from surveys and interviews show that a husband's support is positively associated with IMAW's mammogram utilization and health beliefs. Suggesting a new approach to integrate husbands in culturally appropriate interventions to increase mammogram screening rates among IMAW.

Breast cancer screening among immigrant Muslim arab women in the United States: Analyzing relationships between beliefs, knowledge, spousal support and mammogram utilization.

BACKGROUND: Regular mammogram screenings contribute to a decreased breast cancer (BC) mortality rate. Women from ethnic minorities in the United States, however, often underutilize mammogram screenings; in particular, immigrant Muslim Arab (IMAW) women have low mammogram screening rates. OBJECTIVE: To explore the associations between mammogram utilization and (a) health and religious beliefs, (b) level of knowledge about mammograms, (c) health care provider (HCP) recommendations, and (d) spousal support. METHODS: A cross-sectional study employed online data collection. An Arabic or English survey was completed by women who were 45 or older and married, had immigrated from Arab countries, and had no history of breast cancer. Logistic regression was conducted for data analyses. RESULTS: Of the 184 Immigrant Muslim Arab survey participants, 86.6% reported having had at least one mammogram in their lifetime, and 32.6% adhered to mammograms. Ever having obtained a mammogram and adherence to mammograms were negatively associated with perceived mammogram barriers and positively associated with (a) spousal support, (b) level of mammogram knowledge, and (c) perceived self-confidence. Receiving (HCP) recommendation increased the likelihood of ever having obtained a mammogram. Finally, participants who reported higher levels of perceived mammogram benefits were more likely to have obtained a mammogram within the last 2 years compared to their counterparts. CONCLUSIONS: IMAW have demonstrated low mammogram adherence rate. IMPLICATIONS: Nursing clinicians and scholars must play a role in designing and implementing interventions to promote women adherence to mammograms. Involving husbands in these interventions may improve immigrant Muslim Arab women's mammogram adherence rates.

Cancer Screening Differences Among Muslims and Non-Muslims: Insights from the Chicago Multiethnic Prevention and Surveillance Study.

BACKGROUND: While cancer screening disparities along socioeconomic and racial/ethnic lines are well studied, differences based on religious affiliation are under-researched. Though diverse in terms of race/ethnicity, Muslim Americans appear to share values and beliefs that similarly inform their health and healthcare seeking behaviors. Cancer screening disparities among Muslim Americans are also understudied. METHODS: To examine differences in cancer screening behaviors based on Muslim affiliation, we analyzed data from a longitudinal cohort study examining lifestyle, healthcare access, environmental, and genetic factors on the health of Chicagoans. RESULTS: Of 7552 participants, 132 (1.7%) were Muslim. Between Muslim and non-Muslims, there were no significant differences in prostate, cervical, and breast cancer screening rates, but Muslims were less likely to undergo colorectal cancer screening. When differences in obesity and insurance status were accounted for in a multivariate regression model, religious affiliation was no longer significantly associated with screening rates. DISCUSSION: Religious values can influence cancer screening behaviors; hence, tracking cancer screening along religious lines may illuminate previously unknown disparities. Our analysis of a predominately African American cohort of Chicagoans, however, did not reveal religious affiliation to predict cancer screening disparities.

Changing Mammography-Related Beliefs Among American Muslim Women: Findings from a Religiously-Tailored Mosque-Based Intervention.

Background To advance the literature on religiously-tailored interventions and on Muslim cancer screening disparity research, we report on a behavioral intervention that used religiously-tailored messages to address salient mammography-related barrier beliefs. Methods We crafted specific, religiously-tailored messages and designed a two-session, peer-led, mosque-based educational program to deploy them. t-tests assessed pre- and post-intervention changes in mammography knowledge, intention to obtain mammography, and levels of agreement with mammography-related barrier and facilitator beliefs, while ordered logistic regression models assessed predictors of change. Results 58 women participated, 29 who were South-Asian and 18 Arab. Mean mammography knowledge increased post-intervention. Participants' overall mean agreement with facilitator beliefs trended upward and there was a significant decrease in agreement with the belief "Breast Cancer Screening is not important because God decides who will get cancer," Discussion Religiously-tailored messages provide an opportunity for addressing barriers to preventive health in a theologically consonant way.

The Development and Validation of a Modesty Measure for Diverse Muslim Populations.

This paper reports on the multi-phase development of an English-language modesty measure for use among Muslim populations. The process yielded a 10-item measure that has high levels of internal consistency reliability (Cronbach's α of 0.83), and has acceptable discriminant and predictive validity. Specifically although our modesty measure for Muslim women was found to be significantly correlated with measures of positive and negative religious (Islamic) coping, it was not significantly correlated with religious practice-based religiosity (discriminant validity). Further logistic modeling revealed higher modesty levels positively associated with forgoing mammography because of concerns about lack of same-sex providers (predictive validity).

Adapting a religious health fatalism measure for use in Muslim populations.

OBJECTIVE: Fatalism has been shown to influence health behaviors and outcomes among different populations. Our study reports on the adaptation of the Religious Health Fatalism Questionnaire for a Muslim population (RHFQ-M). DESIGN: The original RHFQ wording was modified for a Muslim context and cognitively tested in 6 focus groups (FG). Items were revised by Muslim and non-Muslim healthcare researchers based on FG responses regarding the theological "accurateness" of the questions. The revised 9-item measure was administered to 58 English-speaking Muslim women (≥40 years old) recruited from two mosques in the Chicago area in order to assess psychometric properties. MAIN OUTCOME MEASURES: Cronbach's alpha and exploratory factor analyses were used to assess internal consistency and measure dimensionality, respectively. Statistical correlations with several fatalism and religiosity measures were computed to assess convergent and discriminant validity. RESULTS: After testing with an ethnically and racially diverse group of Muslims, the RHFQ-M was found to be reliable (Cronbach's α is 0.79), comprised of two distinct underlying subscales, and is correlated with, but distinct from, other measures of fatalism and Islamic religiosity. CONCLUSION: Our adapted measure, RHFQ-M, appears to accurately assess Islamic dimensions of fatalism and is ready for use in the health literature.

Reducing Muslim Mammography Disparities: Outcomes From a Religiously Tailored Mosque-Based Intervention.

OBJECTIVE: To describe the design of, and participant-level outcomes related to, a religiously tailored, peer-led group education program aimed at enhancing Muslim women's mammography intention. METHOD: Using a community-engaged approach and mixed methods, we identified and addressed barrier beliefs impeding mammography screening among Muslim American women. Our religiously tailored, mosque-based, peer-led intervention involved facilitated discussions and expert-led didactics conveying health-related religious teachings, and information about the benefits and process of mammography. Barrier beliefs were addressed through reframing, reprioritizing, or reforming such beliefs. Participant surveys were collected preintervention, postintervention, 6 months postintervention, and 1 year postintervention. These measured changes in mammography intention, likelihood, confidence, and resonance with barrier and facilitator beliefs. RESULTS: A total of 58 Muslim women (mean age = 50 years) that had not had a mammogram in the past 2 years participated in the two-session program. Self-reported likelihood of obtaining a mammogram increased significantly ( p = .01) and coincided with a positive trend in confidence ( p = .08). Individuals with higher agreement with barrier beliefs preintervention had lower odds for positive change in likelihood (odds ratio = 0.80, p = .03), while those who were married had higher odds for positive change in likelihood (odds ratio = 37.69, p = .02). At 1-year follow-up, 22 participants had obtained a mammogram. CONCLUSION: Our pilot mosque-based intervention demonstrated efficacy in improving Muslim women's self-reported likelihood of obtaining mammograms, and increased their mammography utilization, with nearly 40% obtaining a mammogram within 12 months of the intervention. IMPACT: Our conceptual model for religiously tailoring messages, along with its implementation curriculum, proved effective in enhancing the likelihood and receipt of mammograms among Muslim American women. Accordingly, our work advances both the theory and practice of faith-based interventions and provides a model for addressing Muslim women's cancer screening disparities.

Developing religiously-tailored health messages for behavioral change: Introducing the reframe, reprioritize, and reform ("3R") model.

RATIONALE: As community health interventions advance from being faith-placed to authentically faith-based, greater discussion is needed about the theory, practice, and ethics of delivering health messages embedded within a religious worldview. While there is much potential to leverage religion to promote health behaviors and improve health outcomes, there is also a risk of co-opting religious teachings for strictly biomedical ends. OBJECTIVE: To describe the development, implementation, and ethical dimensions of a conceptual model for religiously-tailoring health messages. METHOD: We used data from 6 focus groups and 19 interviews with women aged 40 and older sampled from diverse Muslim community organizations to map out how religious beliefs and values impact mammography-related behavioral, normative and control beliefs. These beliefs were further grouped into those that enhance mammography intention (facilitators) and those that impede intention (barriers). In concert with a multi-disciplinary advisory board, and by drawing upon leading theories of health behavior change, we developed the "3R" model for crafting religiously-tailored health messages. RESULTS: The 3R model addresses barrier beliefs, which are beliefs that negatively impact adopting a health behavior, by (i) reframing the belief within a relevant religious worldview, (ii) reprioritizing the belief by introducing another religious belief that has greater resonance with participants, and (iii) reforming the belief by uncovering logical flaws and/or theological misinterpretations. These approaches were used to create messages for a peer-led, mosque-based, educational intervention designed to improve mammography intention among Muslim women. CONCLUSIONS: There are benefits and potential ethical challenges to using religiously tailored messages to promote health behaviors. Our theoretically driven 3R model aids interventionists in crafting messages that address beliefs that hinder healthy behaviors. It is particularly useful in the context of faith-based interventions for it highlights the ethical choices that must be made when incorporating religious values and beliefs in tailored messages.

Hymenoplasty and Muslim Patients: Islamic Ethico-Legal Perspectives.

BACKGROUND: Hymenoplasty, commonly called "revirginization," is a controversial procedure that pushes the scope of medical practice to satisfy cultural and/or religious "needs." AIM: To outline the sociocultural contexts underlying patient requests for hymenoplasty and present Islamic juridical views on the moral status of hymenoplasty for Muslim patients. METHODS: Narrative review of the extant bioethics literature and leading Islamic ethico-legal verdicts. OUTCOMES: We identified "Western" and Islamic bioethical debates on hymenoplasty and the critical concepts that underpin ethical justifications for and against the procedure. RESULTS: From a Western-ethics perspective, the life-saving potential of the procedure is weighed against the role of the surgeon in directly assisting in a deception and in indirectly promoting cultural practices of sexual inequality. From an Islamic bioethical vantage point, jurists offer two opinions. The first is that the surgery is always impermissible. The second is that although the surgery is generally impermissible, it can become licit when the risks of not having postcoital bleeding harm are sufficiently great. CLINICAL IMPLICATIONS: Patient requests for hymenoplasty should be approached by surgeons with a willingness to understand patients' social contexts and reasons for pursuing the procedure and are ethically justified by leading Islamic jurists in particular circumstances. STRENGTHS AND LIMITATIONS: This article presents emic and etic perspectives on hymenoplasty in Muslim patients, although our review of the Islamic bioethical stances might have missed some juridical opinions and important considerations. Further, Muslims, even devout ones, might not be beholden to Islamic juridical views on medical procedures and thus physicians should not make assumptions about the rationale for, and ethical views of, patients seeking hymenoplasty. CONCLUSION: This article provides critical insight into how Muslim patients, and Islamic jurists, evaluate the moral contexts of hymenoplasty. Bawany MH, Padela AI. Hymenoplasty and Muslim Patients: Islamic Ethico-Legal Perspectives. J Sex Med 2017;14:1003-1010.

Changing global policy to deliver safe, equitable, and affordable care for women's cancers.

Breast and cervical cancer are major threats to the health of women globally, particularly in low-income and middle-income countries. Radical progress to close the global cancer divide for women requires not only evidence-based policy making, but also broad multisectoral collaboration that capitalises on recent progress in the associated domains of women's health and innovative public health approaches to cancer care and control. Such multisectoral collaboration can serve to build health systems for cancer, and more broadly for primary care, surgery, and pathology. This Series paper explores the global health and public policy landscapes that intersect with women's health and global cancer control, with new approaches to bringing policy to action. Cancer is a major global social and political priority, and women's cancers are not only a tractable socioeconomic policy target in themselves, but also an important Trojan horse to drive improved cancer control and care.

Religious beliefs and mammography intention: findings from a qualitative study of a diverse group of American Muslim women.

OBJECTIVE: Studies suggest that American Muslim women underutilize mammography. While religion has a strong influence upon Muslim health behaviors, scant research has examined how religion-related beliefs inform Muslim women's intention for mammography. Our study identifies and examines such beliefs. METHODS: Muslim women aged 40 years and older sampled from mosques participated in focus groups and individual interviews. Drawing upon the theory of planned behavior, interviews elicited salient behavioral, normative, and control beliefs regarding mammography and the influence of Islam upon screening intention. RESULTS: Fifty women participated in 6 focus groups and 19 in semistructured interviews, with near-equal numbers of African American, South Asian, and Arab Muslims. Forty-two percent of participants had not had a mammogram within the past 2 years. Across differences in race/ethnicity and mammography status, women voiced four religion-related salient beliefs that inform mammography intention: (1) the perceived duty to care for one's health, (2) religious practices as methods of disease prevention, (3) fatalistic notions about health, and (4) comfort with gender concordant health care. CONCLUSIONS: Religious beliefs influence decisions to pursue mammography across the ethnic/racial diversity of Muslim women. Notions about duty to God and the stewardship of one's body appear to enhance mammography intention. Theocentric notions of cure and illness and varied views regarding personal agency also inform decisional frames that impact mammography intention. Given the salience of religion among our participants, religiously tailored messages in interventions have the potential to enhance cancer screening.

Associations between religion-related factors and breast cancer screening among American Muslims.

American Muslims have low rates of mammography utilization, and research suggests that religious values influence their health-seeking behaviors. We assessed associations between religion-related factors and breast cancer screening in this population. A diverse group of Muslim women were recruited from mosques and Muslim organization sites in Greater Chicago to self-administer a survey incorporating measures of fatalism, religiosity, discrimination, and Islamic modesty. 254 surveys were collected of which 240 met age inclusion criteria (40 years of age or older). Of the 240, 72 respondents were Arab, 71 South Asian, 59 African American, and 38 identified with another ethnicity. 77% of respondents had at least one mammogram in their lifetime, yet 37% had not obtained mammography within the past 2 years. In multivariate models, positive religious coping, and perceived religious discrimination in healthcare were negatively associated with having a mammogram in the past 2 years, while having a PCP was positively associated. Ever having a mammogram was positively associated with increasing age and years of US residency, and knowing someone with breast cancer. Promoting biennial mammography among American Muslims may require addressing ideas about religious coping and combating perceived religious discrimination through tailored interventions.

Associations between religion-related factors and cervical cancer screening among Muslims in greater chicago.

OBJECTIVE: This study aimed to assess rates of Papanicolaou (Pap) testing and associations between religion-related factors and these rates among a racially and ethnically diverse sample of American Muslim women. MATERIALS AND METHODS: A community-based participatory research design was used in partnering with the Council of Islamic Organizations of Greater Chicago to recruit Muslim women attending mosque and community events. These participants self-administered surveys incorporating measures of fatalism, religiosity, perceived discrimination, Islamic modesty, and a marker of Pap test use. RESULTS: A total of 254 survey respondents were collected with nearly equal numbers of Arabs, South Asians, and African American respondents. Of these respondents, 84% had obtained a Pap test in their lifetime, with individuals who interpret disease as a manifestation of God's punishment having a lower odds of having had Pap testing after controlling for sociodemographic factors (odds ratio [OR]=0.87, 95% CI=0.77-1.0). In multivariate models, living in the United States for more than 20 years (OR=4.7, 95% CI=1.4-16) and having a primary care physician (OR=7.7, 95% CI=2.5-23.4) were positive predictors of having had a Pap test. Ethnicity, fatalistic beliefs, perceived discrimination, and modesty levels were not significantly associated with Pap testing rates. CONCLUSIONS: To our knowledge, this is the first study to assess Pap testing behaviors among a diverse sample of American Muslim women and to observe that negative religious coping (e.g., viewing health problems as a punishment from God) is associated with a lower odds of obtaining a Pap test. The relationship between religious coping and cancer screening behaviors deserves further study so that religious values can be appropriately addressed through cancer screening programs.

Perceptions of obstetrical interventions and female genital cutting: insights of men in a Somali refugee community.

OBJECTIVES: Somali women are at increased risk of adverse pregnancy outcomes. Anxiety and perceived stigmatization toward female genital cutting (FGC) further fuels an atmosphere of miscommunication and distrust, contributing to poorer health outcomes. While the attitudes and experiences of Somali refugee women toward healthcare are widely known, the views of Somali refugee men are largely unknown. This study examines the perspectives of Somali men toward FGC and women's childbirth experiences in one refugee community in the USA. DESIGN: Community-based participatory research partnerships with key stakeholders within the Somali refugee community incorporated qualitative methods comprising semi-structured focus groups and individual interviews to elicit male participants' perspectives on FGC, experiences during childbirth, and the perception of increased cesarean deliveries among Somali women. Qualitative analyses involved a framework and team-based approach using grounded theory and conventional content analysis. RESULTS: Acculturation influenced changes in traditional gender roles fostering new dynamics in shared decision-making within the household and during childbirth. Participants were aware of FGC-related morbidity, ongoing matriarchal support for FGC, and were generally not supportive of FGC. They perceived health-care providers as being unfamiliar with caring for women with FGC fueling profound aversion to cesarean deliveries, miscommunication, and distrust of the health-care system. CONCLUSION: Our work yields new insights into Somali reproductive healthcare through Somali men, namely: strong matriarchal support of FGC, discomfort in men's presence during delivery, and a strong aversion to cesarean delivery. Our findings support the need for advocacy to engage Somali women, their partners/spouses, and health-care providers in facilitating greater continuity of care, building greater trust as men become engaged throughout the spectrum of care in the decision-making process while respecting traditional norms. Cultural health navigators should bridge communication and support between providers and patients. Our work provides foundational knowledge to inform culturally appropriate health interventions within a Somali refugee community.