Integration of Arab and Muslim Health Education Into a Medical School Curriculum

Educational Objectives

By the end of this session, participants should be able to:

Introduction

Both Arab and Muslim Americans are historically underrepresented and understudied populations who face significant health disparities that have largely been unaddressed.^1,2 There are currently 3.5 million Arab Americans and 1.5 million Muslim Americans living in the United States.^3,4 Arab Americans are defined as individuals with ancestral, cultural, ethnic, linguistic, familial, or heritage ties to one or more of the 22 Arab League countries.⁵ Arab Americans are part of an ethnic group and practice a variety of religions. Islam, the religion practiced by Muslims, is one of the three monotheistic religions of the world. An estimated 10%–30% of Arab Americans are Muslim, and this overlap is the reason we chose to focus on both groups in this project.⁴ However, they are two separate populations, with Arab being an ethnic group and Islam being a religion.

The lack of ethnic and racial identifiers on census forms, albeit with past attempts at creating a Middle Eastern and North African category, results in Arab American classification as “White” on governmental forms and data.⁶ This places Arab Americans in a unique position—one in which they are a highly visible and stigmatized group in the general public but largely invisible with regard to government documentation and research.⁶ While both Arab and Muslim Americans in society are viewed as different than White Americans, their identity is not considered in governmental documentation. This makes it difficult to study social determinants of health and obtain any specific data on this population. Similarly, in the UK and France, where a large number of Arab and Muslim immigrants reside, research data and knowledge of health outcomes in this population are sparse in part due to lack of representation in census data.^7,8 Additionally, differences in nativity (i.e., first-, second-, and third-generation Arabs) and variations in social determinants dependent on country of origin make the study of health determinants of Arabs difficult.^5,6 The study of both Arab and Muslim Americans is essential to better address the social, economic, and health disparities faced by this growing population.

The social determinants of the health of Arab and/or Muslim Americans are influenced by immigration status, culture, religious practices, and discrimination.⁶ Specifically, health indicators may be different in the Arab and Muslim population because (1) Arab and/or Muslim Americans are disproportionately recent immigrants to the US, (2) they share a set of cultural norms that may be influenced by Islamic behavioral restrictions, and (3) in recent years, this group has been marginalized by the general population.⁶ Culture and religion contribute to one's social determinants of health and have an effect on Arab and/or Muslim patient health. This includes language barriers, differences in nonverbal communication across cultures, and the role of fasting during the holy month of Ramadan.⁴

Culturally competent health care providers and access are among many contributing factors to growing health disparities in this population. Both Arab and Muslim Americans have poor mental health outcomes associated with anti-Arab sentiment, perceived discrimination, lack of culturally competent mental health services, and cultural stigma against psychotherapy and counseling.^6,9–11 Sherief Y. Eldeeb explains that stigmatization in this community can prevent patients from sharing their mental health issues for fear of judgment from the community or even internally within themselves.¹² Additionally, language barriers and discomfort in having a translator participate in this sensitive topic prevent these conversations from occurring with health care providers. Patients also face financial barriers as well as lack of access to health care and proper resources. Importantly, a disconnect between providers and Arab and/or Muslim patients can prevent appropriate diagnosis and treatment. At the root lies discrimination/bias, difference in expectation of therapy, and lack of training in cultural and religious competency specific to the community.¹² Factors such as discrimination and financial struggles serve as barriers in access to health care. Both Arab and Muslim people in the UK and France experience high rates of reported ill health and disability, along with widespread poverty, as well as experiences of discrimination within the health care setting that may present barriers to obtaining health care.^7,8 In the Arab refugee population, issues such as financial barriers, difficulties obtaining health insurance, mental health due to premigration trauma as well as postmigration adjustments, and interruption of education are all components of their social determinants of health.¹³

Cultural differences in health care providers coupled with a diverse patient population can lead to poor communication and understanding of a patient's health practices, which contribute to poor health outcomes.¹⁴ Specific practice guidelines regarding diabetes management during Ramadan and disparities in regard to cancer screening can be addressed and mitigated by a culturally competent provider.^6,15–17 The implementation of cultural competency training can mitigate the existing health disparities. The Liaison Committee on Medical Education and the ACGME have called for cultural competency training in medical education since the early 2000s.^18,19 Despite the perceived importance of cultural competency training, there is still little clinical time allotted for this education, and medical trainees still report not feeling prepared to care for a diverse patient population.^20,21 Dr. Maya M. Hammoud and colleagues have demonstrated the unique cultural and religious factors that health care providers should understand in order to provide appropriate care for both Arab and Muslim patients.⁴

In an attempt to address these disparities, we implemented a cross-cultural training session for medical students about caring for both Arab and Muslim patients. This session was developed using a framework adapted by the ACGME, Dr. Joseph R. Betancourt, and others to create an effective cultural competency training session for second-year medical students prior to entering their clinical rotations.²² The session was one part of a monthlong Transitions to Clerkships course at the University of Michigan Medical School. We found no published sessions regarding training medical professionals on either Arab or Muslim health. Likewise, there are no MedEdPORTAL publications focused on cultural competency training of this specific population.

The goals of this session were to present medical students with general information about both Arab and Muslim culture and beliefs, introduce them to health disparities faced by this population, and provide techniques for how to appropriately and effectively care for both Arab and Muslim patients. The purpose was not to provide the knowledge and skills needed to care for this population with full competence. The educational objectives were created to address various topics that contribute to the social determinants of health of Arab and/or Muslim Americans. These included the effects of discrimination (Educational Objective 3), cultural stigma toward mental health (Educational Objective 4), and barriers to health care in the Arab refugee community (Educational Objective 5). They were preceded by providing participants with background information (Educational Objective 1) and key concepts to consider when seeing this patient population in clinical practice (Educational Objective 2). A large portion of the session was focused on Educational Objective 2—history and physical exam of a woman in a hijab—as this exam may be perceived as more sensitive due to religious and cultural views on modesty. These objectives were built to provide a baseline knowledge of Arab and/or Muslim patients and key health considerations so that medical trainees would be better equipped to care for them. Additionally, it is important to note that our session focused on common beliefs and practices of both the Arab and Muslim population and did not represent each individual in this community. This session was created to address a gap in health care and education and create a precedent for cultural competency training in the preclinical and clinical curriculum at the University of Michigan Medical School.

Methods

Materials

This session included a variety of teaching materials, each with a specific purpose and order of implementation. The study was determined not to be regulated by the University of Michigan's Institutional Review Board (IRB). Materials included an instructional packet for faculty (Appendix A), a student packet (Appendix B), pretest questions (Appendix C), an overview PowerPoint (Appendix D), an instructional history and physical exam video (Appendix E), posttest questions (Appendix F), and a survey of women who wear hijab (Appendix G). The faculty packet (Appendix A) and student packet (Appendix B) were created so that faculty and students would have access to learning objectives, information, time line for the session, and discussion questions for small groups, as well as associated articles both for core and supplemental reading.^12,23,24 The faculty packet differed in that it included answers to the discussion questions. The packets consisted of two cases for discussion: Case 1 was focused on mental health in Arab and/or Muslim patients. Question 1 included an article discussing how discrimination against Arab and/or Muslim Americans contributes to poor mental health outcomes; question 2 included an article about the cultural stigma of mental illness and barriers Arab and/or Muslim Americans face in accessing mental health resources. Case 2 was focused on refugee health; the associated article and questions addressed social determinants of health and health disparities faced by both Arab and Muslim refugees. Pre- and posttest questions (Appendices C and F) were a set of the same questions derived from the teaching material to gauge pre- and postsession knowledge and learning. The overview PowerPoint (Appendix D) consisted of general information on both Arab and Muslim cultural and religious beliefs and social determinants of health. An instructional history and physical exam video (Appendix E) was created to demonstrate inappropriate and appropriate methods of caring for Muslim women who wear hijab. This was created following an IRB-approved survey (HUM00181430) of 52 Muslim women who wear hijab (Appendix G). The survey included open-ended questions about what these respondents would like their health care provider to consider when caring for Muslim women in a hijab, as well as what difficulties they have faced with receiving medical care. The survey was distributed via social media and emailed to Muslim women who wear hijab in southeast Michigan. The purpose of this survey was to obtain ideas and feedback from these women on what topics would be important to share for this session and what considerations health care providers should make when caring for Arab and/or Muslim patients. The purpose was not to represent the viewpoints of all Muslim women.

Due to social distancing practices at the time of implementation, the session was conducted over Zoom; however, the session can effectively be carried out in person. Other resources the student participants and 16 small-group leaders used during the session included computers and Zoom.

Implementation

The development of this session was largely modeled after cross-cultural competency training guidelines and training of other patient populations.²²

Prior to the session

To begin, we provided students and faculty educators with instructional packets (Appendices A and B) 1 week prior to the session to allow them time to read and familiarize themselves with the overall structure of the session. This also allowed educators to familiarize themselves with teaching materials and ask questions of the facilitator prior to the session. Faculty educators were also given access to the history and physical exam video (Appendix E) to watch the week prior to the session. The day before the session, students were required to complete pretest questions (Appendix C), which were administered via the online platform Canvas. Answers were not displayed for the participants but were scored for the evaluation of presession knowledge and later used to evaluate the effectiveness of the session.

During the session

The session consisted of three parts: (1) an overview PowerPoint on both Arab and Muslim Americans and their health presented to all participants by the primary session facilitator, (2) division of participants into small groups where they were first shown the history and physical exam video, and (3) facilitation of small-group discussion based on the questions in the packet.

The session began with an overview PowerPoint (Appendix D) about Arab and/or Muslim health led by a medical student and physician who were both of Arab and Muslim descent. This portion ran approximately 30 minutes, with time for questions.

Next, participants and faculty advisors were divided into virtual breakout rooms. We had 16 small-group rooms consisting of one faculty member and 12 second-year medical students. Fifteen of the faculty were of Arab and/or Muslim descent, while one faculty member was not of Arab or Muslim descent but was trained prior to the session by the session facilitators. The training consisted of going through the attached materials with the faculty member and answering their questions about Arab and/or Muslim health related to the course material. The faculty physician watched the video and read the discussion topics with answers prior to the session. They were also paired with a senior Arab and Muslim medical student to help answer questions during the session.

To begin the small-group session, instructors were directed to use the instructions in their faculty packets (Appendix A) while students were instructed to open their packets and follow along (Appendix B). The small-group session started with the group watching a video on how to take an appropriate history and physical exam of a female patient who wears a hijab (headscarf; Appendix E). This video was author owned and created. The video has built-in instructions for when to pause for discussion. Discussion questions were included in the faculty packet, student packet, and video.

The next portion of the session consisted of breakout groups within the small-group sessions. The small-group leader divided their group into three, with each assigned one of the questions from the faculty and student packets. Students were instructed to read these articles to themselves during the session prior to answering their assigned question. They were given 20–30 minutes to discuss the articles associated with their assigned questions and to brainstorm answers with their breakout group. The small group then reconvened, and the group facilitator went through each case and allowed students to engage in discussion.

After the session

Upon completion of the session, students were instructed to answer the posttest questions (Appendix F) and fill out an online feedback survey.

Recommendations for implementation

Overall, the methods conducted by the authors are the recommended method of implementation of this session; however, there are key points that should be considered and altered. In regard to presession information, we recommend making Appendices A and E available to faculty 1 month prior to the session in order to allow faculty members ample time to review and ask questions about the materials prior to the session. Additionally, it is important not to share the instructional video (Appendix E) with students/participants prior to the session in order to accurately represent their baseline knowledge in the pretest questions.

In regard to recruitment of faculty to lead the sessions, we recommend attempting to recruit faculty or senior students who are of Arab and/or Muslim descent as they generally have experience and baseline knowledge on this particular topic. However, any faculty can be trained to lead this session. For all faculty members, the information in the video and topic was sufficient to run the sessions. We do recommend that all faculty watch the video and read over the small-group questions and associated articles so that they are familiar with the content. The main skill set required is the ability to review materials and facilitate discussion since answers and information are all included within the video and discussion material. This also applies to the overall session facilitator. Though it is ideal to have an Arab and/or Muslim facilitator (or someone very familiar with the culture and religion), the materials provided have sufficient information for anyone to lead the session.

We recommend that the session have an allotted time of approximately 3 hours in order to allow for in-depth discussion during the video and with the small-group articles. This also gives participants time to read their assigned article during the session. If the session can be 3–4 hours, we recommend that the time allotted for each section be slightly different than how the authors conducted the session. The overview PowerPoint should remain at 30 minutes, and 60–90 minutes should be allotted to watching and discussing the video. The final 90 minutes should be for participants to read associated articles and engage in discussion. This arrangement is based on verbal feedback from participants and session leaders on how much more time they would have liked to have for each section.

Results

The session consisted of 177 second-year medical students as part of a monthlong Transitions to Clerkships curriculum created to prepare students for upcoming clinical rotations. Prior to the session, we surveyed 52 Muslim women who wear a hijab about their experiences receiving medical care (Appendix G). Their responses were thematically assessed and included the following:

The survey results, reported in Tables 1 and 2, were used to guide the creation of the session video (Appendix E) and pre- and posttest questions (Appendices C and F).

Table 1. Demographics of Survey Respondents

Table 2. Survey Responses

The pre- and posttest questions examined whether the session was effective at teaching students the fundamentals of caring for Arab and/or Muslim patients. Responses for these questions were required for course completion. Participants scored significantly higher on the posttest questions (M = 8.1) than the pretest questions (M = 1.2; p < .01). This was analyzed by conducting an independent t test.

Following the session, trainees were also requested to complete a feedback survey (Figure). This asked students to rate the session from poor to excellent. The majority of respondents reported the session to be very good or excellent (63%). We also received direct feedback from both faculty and students. Written feedback was delivered directly via email from the students and faculty to the session leader. Statements included the following:

Discussion

The purpose of the design and implementation of this session was to provide an open and safe experience for medical students to learn about a patient population they have not previously been trained to care for. Arab culture and Muslim religion have many practices and teachings that often intersect with medical care, and in order for providers to administer safe and effective health care, this knowledge is essential.⁴ To create culturally competent physicians, cross-cultural teaching should begin early in their career, similar to how scientific training is presented.

Another goal of this session was to address and make students aware of the existing health disparities that occur in the Arab and/or Muslim population. The cases and associated articles gave students the opportunity to read about, discuss, and answer questions about these health disparities. The issue of discrimination and governmental policies affecting mental health is prominent in both Arab and Muslim communities.^6,9 There are also issues of stigma and barriers to access of culturally sensitive mental health resources.¹⁰ Providing this knowledge to future physicians can better guide them to identify and seek appropriate help for this vulnerable population.

The implementation of the session was made largely successful due to the enthusiasm and time investment given by the faculty physician leaders. The value of recruiting culturally diverse and competent faculty is essential for the implementation of this session. We found that our faculty member who was not of Arab or Muslim descent was able to confidently and effectively lead the session due to her reading the resources beforehand and asking clarifying questions before the session. This faculty member gave the following feedback: “This was a really great session and small group members were very engaged; I was very excited to teach (and learn!).”

The creation and implementation of the video demonstrating how to conduct a history and physical exam of a patient wearing hijab not only addressed the concerns of potential female patients as surveyed in Appendix G, but also provided a resource for incoming clinical students to refer to and feel more confident when examining this patient population on their rotations. Multiple questions on the pre- and posttests were aimed at identifying knowledge of physical exam and history taking of women who wear hijab. The significant improvement in responses to these questions on the posttest showed the utility of the video in addressing this knowledge gap.

The case discussions provided an opportunity for students to read and actively apply their reading about both Arab and Muslim health disparities in a small-group setting. The faculty and students felt that this portion of the session allowed them to ask questions and hear not only about the information presented in the readings but also about the personal experiences of Arab and/or Muslim faculty and students who were in each group. This allowed for discussion to extend beyond the coursework and gave students a safe space to ask questions.

Participant and faculty feedback was used to make improvements to the session. First, the recommended length of the session is suggested at 3–4 hours. This is due to faculty feedback that there was difficulty completing the material in the 2.5-hour time block. Faculty members recommended at least an additional 30 minutes for small-group discussion. We also recommend completing this session in person versus online as some faculty and students had difficulty entering breakout rooms and sharing screens on the Zoom platform.

Limitations

This session was focused on both Arab and Muslim health, which is the first time this medical school has incorporated cross-cultural teaching about this specific patient population. Given its novelty, there were challenges and areas for improvement. First, the 2.5 hours given to complete the course material was not sufficient, resulting in some groups not being able to finish discussion questions or complete the entire instructional video. Though they were instructed to read over the material and rewatch the video following completion of the session, this may have led to some groups not receiving the same education as others. We would recommend approximately 3–4 hours in order to complete all of the material. However, it is important to note that there is no time limit to teaching on a topic of this importance. While 3–4 hours is suggested to fit into a busy medical school curriculum, learning about the intersection of culture, religion, and health care as well as how to appropriately and sensitively care for Arab and/or Muslim patients cannot be considered complete with one session. Displaying cultural humility—that is, recognizing the importance of a topic like this—is central to this session.

Additionally, studies on cultural competency demonstrate the use of evaluating students via standardized patients as a method of effectively instructing them on how to complete a physical exam.²² This approach was considered; however, there was difficulty in finding Muslim women who wear hijab or have an understanding of hijab to volunteer due to concerns for modesty. Although the video did serve as a tool to instruct students on this, there was no way to evaluate whether they could conduct the exam themselves aside from posttest questions regarding the topic.

Furthermore, the video did not address how to care for Muslim men specifically; however, many of the same cultural considerations addressed in the video do apply to men as well. This session would have benefited from specific statements on how to also address and care for Muslim men. Administering the posttest questions months following the session would address the long-term utility of a one-time cross-cultural teaching session.

In regard to the evaluation of educational objectives, we did not formally evaluate how participants met each one. However, the questions in the pre- and posttest survey were constructed based on the learning materials that were used to fulfill the objectives. Lastly, it is important to note that this is a single session and is intended to be an overview of how to create and implement a session on both Arab and Muslim health for medical students. This approach may have been oversimplified, as the topic is broad and the session was conducted in 2.5 hours. The session does not provide the knowledge and skills needed to care for Arab and Muslim patients with full competence.

Future Directions

This cross-cultural teaching session can be expanded to other medical schools, residency programs, and health professional programs. All of the resources are standardized and can be implemented at any program. Our future plan begins with presenting the session to neighboring medical schools in Michigan, followed by training younger medical students at our institution in order to maintain the session each year. We plan to transform the overview presentation into training modules that can be implemented without a student or faculty lead.

We believe that cross-cultural training and sharing our session with the public can help educate and instill confidence in health care providers caring for both Arab and Muslim Americans. Our session also creates a model for programs to adopt for training regarding Arab and/or Muslim patients and focuses discussion on the health disparities of this understudied population.