Introduction

Providing culturally and linguistically competent care and education for their patients can be a challenge for home care and hospice clinicians, particularly those without access to the resources of a hospital library. The Internet offers a wealth of information on world cultures as well as resources for multilingual patient education materials. Identifying them can be time consuming for the busy clinician. This article reviews Web sites that discuss the culture of the Middle East and provide access to patient education materials in Middle Eastern languages.

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Sources vary in their definition of "Middle East." For the purposes of this article, the author is using the criteria of The World Factbook (Central Intelligence Agency, 2009), which considers Armenia, Azerbaijan, Bahrain, the Gaza Strip, Georgia, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, Syria, Turkey, the United Arab Emirates, the West Bank, and Yemen as the countries of the Middle East. Although Arabic is the predominant language, Armenian, Azerbaijani, Farsi (Persian), Hebrew, Kurdu, Turkish, and Urdu, among others, are also spoken (Table 1). It is important to be aware that there are a variety of Arabic dialects. A patient who indicates that he or she speaks Arabic may not understand someone who uses a different Arabic dialect.

The number of immigrants from the Middle East has grown steadily in the United States over the past decade. The Office of Immigration Statistics (2011) reported 494,669 persons from the aforementioned countries obtained legal permanent resident status in the United States from 2001 to 2010. More than 126,000 immigrants came from Iran. More than 65,000, the next largest group, emigrated from Iraq.

Middle Eastern Culture Overview

Family is the foundation of Arab culture. It is a concept that goes beyond the immediate relatives and extends to all members of a tribe. Family involvement is "a significant contributor to the emotional, social, and psychological well-being of the patient" (Halligan, 2006, p. 1568). In hospital situations, decisions are made by the family and may dictate the extent of care to be provided. Some families may insist on knowing the diagnosis before the patient and may then decide how much to actually relay to the patient. Bushnaq (2008) recommended using euphemisms when responding to family questions. For example, if a hospice clinician is asked about the patient's prognosis, the response might be that the patient "is really in a critical condition, and it is the right time for him to meet his family and to prepare for the hereafter in case he/she deteriorates" (p. 1292).

Older people, mothers in particular, are respected. Cheraghi et al. (2005) observed that "the eldest family members are regarded as a source of spiritual blessing, religious faith, wisdom, and love" (p. 470).

A study of older Iranian immigrants discussed how their definition of health differs from the concept in Western medicine (Martin, 2009). The Persian language has one word for health, salamati, which encompasses mental, physical, and spiritual health. The participants in the study saw good health as having a "proper combination of mental/emotional, physical, and spiritual health as well as a balanced diet and social life" (p. 65). Illness is perceived as a lack of balance.

Martin (2009) recommended greeting patients with a smile and inquiring about their life and family. This interest suggests that their healthcare provider cares about more than just the patient's symptoms.

Food is important in Iranian culture, with diet seen as playing an important role in both health and illness. The people associate certain foods with different illnesses and feel that American physicians do not pay enough attention to this connection. Foods are considered warm or cold, which is not related to temperature. Rather certain food combinations are used to combat illness and regain the proper healthy balance. In addition to the warm and cold diet, Iranian traditional medicine includes warding off the evil eye and the use of herbal medicines. Elder Iranians are reluctant to take prescription drugs. They believe that many medications have unwanted side effects that negate the value of the drug.

A study of Arab American immigrants in New York City identified the language barrier as "one of the most profound and pervasive barriers to health care access" among the participants (Shah et al., 2008, p. 432). Although they could speak English, the women in the study still preferred to see healthcare providers who speak Arabic. They felt that they could not properly explain their health issues in English. Both men and women in the study questioned why so few Arabic resources on health concerns are available.

The most pervasive influence on culturally competent care of immigrants from the Middle East is an understanding of the Muslim religion, the dominant faith in that region. It impacts all aspects of patient care and the attitudes of the patients themselves. Life and death are believed to be determined by the will of Allah. Illness is perceived as atonement for one's sins. Illness and death are accepted with meditation and prayer. Dying is believed to be a passage from this world to the resurrection. Muslims believe that after the cessation of biophysical processes, the spirit continues to live. The healthcare provider's support for the patient's spiritual needs plays an important role in recovery from illness.

Table 1. Languages of the Middle East

Alcohol is prohibited by Muslim law, and smoking by females is considered unacceptable. Asking about use of either in taking a patient history may be offensive to some patients.

Modesty is extremely important. Muslim practice requires females to cover their faces in the presence of a male. Keeping one's arms covered is also expected. Disrobing in public is considered immodest, even in the hospital setting. Touching in public between members of the opposite sex is offensive and healthcare providers should be cautious in their use of unnecessary touch since it may not be welcome. This includes shaking the hand of an unrelated person of the opposite sex.

The Muslim call to pray five times a day may be disruptive of sleep and rest patterns for a devout Muslim and the schedule should be factored into provision of care. Before saying prayers, the individual must be ritually clean. Seriously ill patients may need assistance with this ritual.

Many Muslims want a dying patient to be positioned with his or her feet facing Mecca. Certain religious text should be read to the dying patient and after death as well. The patient should be encouraged to recite prayers if possible. Surrounding family members will remind the patient of God's forgiveness and mercy.

Online Resources for Middle Eastern Cultures

http://www.cal.org/co/pdffiles/Iraqis.pdf

The Cultural Orientation Resources Center offers a 44-page "backgrounder" that provides an introduction to the history, culture, and background experiences of refugees from Iraq. It includes sections on family life, the treatment of women, marriage, food, dress, beliefs and values, and the individual ethnic subgroups of Iraq. It also reminds healthcare providers that psychological distress in this population is an issue of concern.

http://www.miceastmelb.com.au/documents/mep/H&PCarekit.pdf

The Migrant Information Centre in Melbourne, Australia, has produced the Home and Personal Care Kit: Cultural and Religious Profiles to Assist in Providing Culturally Sensitive Care and Effective Communication. The tool includes both an Iranian profile and a Muslim profile. They address attitudes and issues with aging, attitudes to disability and mental illness, customs/values, communication styles, and health beliefs and practices. The discussions of beliefs, food, health beliefs and practices, and communication styles are of particular value to the home healthcare clinician. The document also includes some basic greetings in Farsi with an approximation of the English pronunciation.

http://www.dhhs.nh.gov/omh/refugee/documents/ethnicprofiles.pdf

The Manchester, New Hampshire, Health Department and Baylor University have collaborated to produce Ethnic Community Profiles to provide information on the various ethnic groups that have resettled in New Hampshire. The document includes a section on Iraqi refugees. The traditional medicine section covers herbs and practices, funerals, health risks, and recommended laboratory tests.

There is a separate section discussing the Kurds, who come from Iraq as well as Turkey, Iran, Syria, and certain areas of the former Soviet Union. The document reviews culture, communication, social relations, home remedies, birthing, child-rearing practices, and aging and identifies health risks.

http://erc.msh.org/mainpage.cfm?file=5.4.2.htm&module=provider&language=English

The Provider's Guide to Quality & Culture, a joint project of Management Sciences for Health and the U.S. Department of Health and Human Services, offers an extensive menu with links to information about Arab Americans. The profile discusses challenges to health and well-being and principles for culturally competent health services, such as honoring fasting during Ramadan and being sensitive to the practice of female circumcision. There is also a section on cultural similarities in the various peoples from the Arab World.

The Provider's Guide also has a component on Muslims. Discussion includes strengths and protective factors in Muslim families and communities, challenges to the health and well-being of Muslim families and communities, and principles for culturally competent health services for Muslim families and communities.

http://www.healthcarechaplaincy.org/userimages/Cultural%20&%20Spiritual%20Dictio

The HealthCare Chaplaincy in New York's A Dictionary of Patients' Spiritual & Cultural Values for Health Care Professionals has several useful chapters, including a discussion of the Muslim religion that defines the differences between the Sunni and Shia sects. It also has sections on Iranian Americans and Arab Americans. Topics covered include family structure; dress; food practices; health, illness, and death; and pregnancy, birth, and postpartum.

http://www.ethnicityonline.net/islam.htm

Ethnicity Online has an extensive discussion of Muslims. Of particular interest to home care clinicians are the sections on dietary guidelines, dying, physical examinations, and taking a clinical history. There are links to each section from the main page.

http://www.health.qld.gov.au/multicultural/support_tools/islamgde2ed.pdf

Health Care Providers' Handbook on Muslim Patients is a 22-page document prepared by Queensland Health in Australia. The initial portion of the document provides guidelines for health services to Muslims. Section 2 addresses Islamic beliefs affecting healthcare. Coverage includes food, holy days, fasting, dress, mental health and/or cognitive dysfunction, embryo experimentation and stem cell research, transplants and organ donation, sexual and reproductive health, and death and dying.

http://www.bu.edu/bhlp/Resources/Islam/health/index.html

The Boston Healing Landscape Project has an extensive section about Islam and health on their Web site. General guidelines are presented for modesty and respect, gender issues, language and communication, dietary regulations, medications, medical decision making, sexual health, maternal and child health, mental health, and end-of-life issues.

http://cirrie.buffalo.edu/culture/monographs/muslim/

The Center for International Rehabilitation Research Information and Exchange at the University of Buffalo offers a 63-page monograph Disability and the Muslim Perspective: An Introduction for Rehabilitation and Health Care Providers. After an introduction and general discussion of the sociocultural background of Islam, there are chapters on "Family and Community Perspectives on Health and Disability," "Accommodating Service Delivery to Muslim Clients with Disabilities," and "Tools and Approaches for Cultural Brokering." There are links to each section from the table of contents on the initial page of the Web site.

Online Patient Education Resources in Middle Eastern Languages

http://www.nlm.nih.gov/medlineplus/languages/languages.html

The U.S. National Library of Medicine's well-respected consumer health Web site MedlinePlus has links to patient education resources in Armenian, Arabic, Farsi, Turkish, and Urdu. The most extensive coverage is for publications in Arabic. The topics range alphabetically from acne to X-rays. There is information on various surgical procedures, cancer, cardiovascular disorders, various infections, and mental health issues. Topics of particular interest to home care clinicians include diabetes, blood thinners, chronic obstructive pulmonary disease (COPD), dialysis, and sleep apnea.

The Armenian, Farsi, Turkish, and Urdu resources are primarily related to vaccinations against infectious diseases such as pneumonia, meningitis, and influenza. The Urdu page also links to information on diabetes.

http://www.rhin.org/Default.aspx

Another site sponsored by the National Library of Medicine is the Refugee Health Information Network. From the homepage, one can select the language needed. Middle Eastern languages include Arabic, Farsi, Kurdish, and Urdu. There are only nine documents in Urdu relating primarily to diabetes, immunizations, and nutrition. The 11 Kurdish documents cover emergencies, nutrition, and diabetes. In addition to these topics, the Farsi section has links to material on hypertension, tuberculosis, and several viral infections. The Arabic section includes all these subjects as well as resources for various respiratory illnesses.

http://www.refugees.org/resources/for-refugees-immigrants/health/healthy-living-

The U.S. Committee for Refugees and Immigrants offers Healthy Refugee Toolkit Downloads in Arabic and Farsi. Topics covered include personal and home hygiene, pregnancy and child health, diabetes, heart disease, several respiratory diseases, and women's health.

http://palantir.lib.uic.edu/nahip/?q=node/13

The University of Illinois at Chicago Library of Health Sciences has collaborated with the Heartland Alliance for Human Needs and Human Rights to produce the New Americans Health Information Portal. The documents on the site were created by Heartland's Refugee Health Programs. They offer an extensive selection of material in Arabic, covering such concerns as blood, heart, and circulation disorders; cancer, children's health, colonoscopy, diabetes, influenza, men's health, pain management, and women's health.

http://www.healthtranslations.vic.gov.au/

The state government of Victoria, Australia, maintains an extensive Health Translations Directory. Middle Eastern language material is available in Arabic, Armenian, Assyrian, Farsi, Hebrew, Turkish, and Urdu. The Web site arrangement is somewhat cumbersome, as it divides the resources into those produced by the state of Victoria, those produced by the national government, and those produced by other Australian states and territories. To be complete in one's search for a topic, one must look under each of these major divisions. For example, each Arabic section contains information on cancer. Within each geographical division, the materials are listed alphabetically by subject.

The coverage varies from language to language. All languages, however, offer "Cue Cards" developed by the Eastern Health Transcultural Services. They are designed to help healthcare providers communicate with patients and their families who are not fluent in English. The link is in the section for national resources under the "General Health" subheading.

The Cue Cards are the only link under Hebrew. There are 9 Armenian resources, which primarily focus on dementia. The 17 Assyrian resources include two fact sheets about medical procedures. There are more than 130 links under Farsi. Subjects available include older adult care, nutrition and food safety, cancer, diseases and conditions, and mental health.

More than 550 items in Turkish and over 750 in Arabic are identified. Cancer and mental health have extensive coverage as do children's health, women's health, infections, and medical procedures. Motor neuron disease, incontinence, celiac disease, pressure ulcer prevention, and aged care are among the topics of particular use to home care clinicians.

http://www.mhcs.health.nsw.gov.au/publicationsandresources/languages.asp

The New South Wales, Australia, Multicultural Health Communication Service also provides access to free multilingual patient education materials. Diabetes materials are available in Arabic and Turkish. There are links to information in Arabic about breast cancer. Prostate cancer resources are identified in Arabic, Farsi, and Turkish. A skin cancer fact sheet is available in Arabic, Assyrian, and Turkish. The site also offers an extensive A to Y list of links to material in Turkish and Farsi.

http://www.healthtranslations.com/aspx/aboutus/default.aspx

The Missouri Hospital Association (MHA) sponsors Health http://Translations.com, which features "communication boards" with pictures of health-related procedures and descriptions of various conditions in English and seven languages including Arabic and Farsi. The resources primarily focus on diabetes and infectious diseases. They include translations of MHA's own publications as well as those from established agencies such as the Centers for Disease Control and the American Diabetes Association.

http://www.health.state.mn.us/divs/translation/index.html

The Minnesota Department of Health has translated materials in Arabic and Urdu. The Urdu resources are limited in topic to heart attack and stroke. The Arabic publications include the same information as well as items addressing bioterrorism, emergency preparedness, influenza, food safety, and tuberculosis.

http://healthlibrary.stanford.edu/resources/foreign/_intro.html

This Stanford Hospital and Clinics Web site provides a portal to multilingual health information in Arabic, Kurdish, Persian, and Urdu. There are links to diabetes information in all four languages. A bilingual document on diagnostic tests is also available in Arabic and a bilingual one on osteomalacia is available in Urdu.

https://www.healthinfotranslations.org/

Health Information Translations was developed by four central Ohio healthcare providers. Information is provided in 18 languages including Arabic. The resources include print as well as audio and video material. The list of Arabic titles is extensive and includes diagnostic tests, diseases and conditions, pregnancy and baby care, stress and coping, and surgeries. Of particular interest to home care clinicians are the pamphlets on various active range-of-motion exercises, atrial fibrillation, Coumadin (warfarin), deep vein thrombosis, and hip and knee replacements.

http://www.fightdementia.org.au/information-in-other-languages.aspx

Alzheimer's Australia is one of many disease research and patient support organizations that offers multilingual resources on its Web site. It has a series of help sheets available in Arabic, Armenian, and Turkish. The sheets explain dementia and its diagnosis and offer families suggestions for planning for and communicating with relatives who have received this diagnosis.

http://www.alzheimers.org.uk/pubsotherlanguages

The Alzheimer's Society in the United Kingdom offers a dozen fact sheets each in Arabic and Turkish. Topics include explanations of dementia and Alzheimer's, the progression of the disease, and dealing with aggressive behavior.

http://www.mmha.org.au/mental-health-information-and-resources/resources-and-pub

Mental Health in Multicultural Australia offers a "What is?" series of fact sheets in Arabic, Assyrian, and Farsi. The selection includes anxiety disorder, bipolar mood disorder, depressive disorder, eating disorder, personality disorder, and schizophrenia. The organization also has information in Arabic, Farsi, and Turkish on mental health issues in general and one on mental health and coronary heart disease.

http://www.cancervic.org.au/other_languages/

Cancer Council Victoria (Australia) has a small collection of fact sheets in Arabic and Turkish. They address diagnosis, treatment, nutrition, and relaxation. In addition, there are resources specific to prostate, bowel, cervical, skin, and breast cancer.

http://www.continence.org.au/resources.php?language

Home care and hospice clinicians will find the Continence Foundation of Australia Web site particularly helpful. It offers resources on bladder and bowel control, pelvic muscle training, and continence products in Arabic, Persian, and Turkish. The Web site also offers a guide for addressing continence issues with culturally diverse patients.

http://www.parkinsonsvic.org.au/languages.htm

Parkinson's Victoria, in Australia, has made available fact sheets about the disease, its treatment, and living with the disease. They are available in several languages including Arabic and Turkish.

http://www.lunguk.org/you-and-your-lungs/translated_information/

British Lung Foundation includes a limited amount of multilingual material on its Web site. Documents on COPD and tuberculosis are available in both Turkish and Urdu.

http://www.britishlivertrust.org.uk/data/5/pages/2.aspx?pid=132

The British Liver Trust has resources available in Urdu. The subjects offered include Hepatitis B, guides to liver disease diagnostic tests, and liver cancer.

http://www.diabetes.org.uk/Other_languages/

Diabetes UK has 13 documents in Arabic. In addition to basic information about management and diet, there are also brochures on potential complications such as cardiovascular disease, neuropathy, kidney disease, and retinopathy.

http://www.diabetesaustralia.com.au/en/NDSS-Content/Resources/Multilingual/

Australia's National Diabetes Services Scheme also has resources in Arabic as well as Turkish. Of particular interest among their topics is "Depression and Diabetes." They also offer separate documents on blood glucose monitoring, medications, and insulin instead of one general management handout.

http://www.thewomens.org.au/MultilingualFactSheets

The Royal Women's Hospital in Australia has posted a selection of multilingual fact sheets on various women's health issues. The information in Arabic and Turkish includes several documents on benign breast conditions. There is also an Arabic resource about reducing the risk of blood clots in the legs or lungs and Turkish material on bladder training and pelvic floor exercises.

http://www.arthritisaustralia.com.au/index.php/arthritis-information/information

Arthritis Australia has 13 information sheets in Arabic. Particularly useful are: "Medicines and Arthritis," "Methotrexate," "NSAIDs," and "Paracetamol." There are also documents for "Complementary Therapies," "Fish Oil," and "Glucosamine and Chondroitin."

http://www.beyondblue.org.au/index.aspx?link_id=102.942

Beyondblue, in conjunction with Multicultural Health Australia, offers information about depression in Arabic, Farsi, and Turkish. The material has been translated by accredited translators with the assistance of mental health professionals as well as consumers. The information is aimed at patients and their families and includes brochures on living with and helping an individual with depression. Another pamphlet offered discusses antidepressants. The organization also has resources on postpartum depression in Arabic, Farsi, and Turkish.

Conclusion

Culture is defined by many factors, including economic status, education level, environmental factors, race, and religion. Knowing about a patient's cultural background and being able to provide resources in the language with which that patient is most comfortable will enable home care and hospice clinicians to provide the most effective care.

AHRQ Offers Free Toolkit to Strengthen Medication Reconciliation

A free toolkit to help acute care and postacute care facilities evaluate and improve their current medication reconciliation process is now available from the Agency for Healthcare Research and Quality.

The toolkit, titled "Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation," can help facilities reduce patient harm due to adverse drug events or medication errors.

MATCH offers the following advantages:

* promotes compliance with The Joint Commission's National Patient Safety Goal for maintaining and communicating accurate patient medication information;

* can lead to better care transitions and fewer unnecessary readmissions by helping to ensure patients receive the right medication in the right dose at the right time;

* provides a framework to capture complete, accurate medication information through electronic health records; and

* enables building a medication reconciliation process from scratch or redesigning an existing process.

MATCH features a comprehensive work plan with procedural guidelines and flowcharts, modifiable templates, pilot-test recommendations and other resources to help your facility improve its medication reconciliation process step by step.

For a free toolkit, please e-mail [email protected] or call 1-800-358-9295.

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