As a result of migratory movements, many families of foreign origin have settled in the province of Almería (Spain), which now has an estimated 100,000 inhabitants of Muslim tradition.
During the last thirty years, spurred by the demand for workers in the agricultural sector (especially intensive cultivation, under plastic, the main economic driver of the area), the province of Almería has become transformed into a multicultural society. The province now has a population composed of over 130 nationalities, a characteristic that impacts on all aspects of society, including public health services. The arrival and establishment of cultures from all parts of the world, with idiosyncratic customs, values and beliefs, poses a new challenge for health professionals, whose patients have widely varying outlooks on life, death, health and sickness, and the origin and treatment of diseases (Plaza del Pino, Plaza del Pino, & Martínez, 2005).
In the natural evolution of the migratory process, the profile of the typical migrant has changed. Formerly, most were male, young and single, but today there are many families of immigrant origin that are permanently settled in Almería and elsewhere, either following family reunification or from the formation of new families.
Health care is a social environment in which people from different cultures are obliged to interact. However, this meeting point of diverse cultures seems to receive less research attention in studies of intercultural communication than other areas, such as education and employment (Plaza del Pino, 2010, p. 49), despite the significant role it plays in shaping feelings and life experiences.
It would be highly interesting (albeit arduous) to obtain first-hand accounts in this respect from patients of all types of migrant background, but in the present study we preferred to focus on one specific group, those of Muslim origin. This population constitutes one of the most numerous groups of foreigners resident in Almería. It is estimated that around 100,000 Muslims live in the province, accounting for 17-20% of the population. Among these migrants, the most numerous national groups is that composed of Moroccans (INE, 2017). In Spain, the migrants who are least appreciated by the host community are those from the Maghreb, followed by Roma and arrivals from sub-Saharan countries (Navas et al., 2004). By nationalities, Moroccans are believed to be located at the greatest cultural distance from the native population, mainly because of their Muslim religion.
This research forms part of a larger study supported by the Health Research Fund (PS09/1449) of the Spanish Ministry of Health.
To determine the importance of the family environment for patients living within the Muslim culture.
To consider the implications for nursing practice of the relationship between healthcare personnel and Muslim patients and their families.
This study uses a qualitative approach, that of discourse analysis, which is considered the most appropriate means of achieving a detailed understanding of the phenomena addressed, taking into account both the circumstances of the participants and their culture (De la Cuesta, 2006).
This study was conducted in full awareness that in qualitative investigations the researcher has an unavoidable influence on the process and, ultimately, on the results obtained; it is acknowledged that the researcher is a human instrument of the investigation (Higginbottom & Serrant-Green, 2005). Nevertheless, all possible care was taken not to ‘contaminate’ the study with our own ideas on the subject.
For this study, data were compiled by means of in-depth interviews and discussion groups. The interviews were conducted at locations chosen by the informants, usually in their own homes or in public places. The discussion groups met in spaces already used by groups of persons of Muslim origin, such as workshops and Spanish-language classes, within the premises of an immigrant-welfare association.
Our intention was that these encounters should take place in an environment suitable both for the interviewer and for the interviewees, thus promoting the sincere expression of feelings and emotions. The interviews and discussion groups, conducted in the language chosen by the informants, were all recorded. The average duration was 25 minutes.
Prior to each interview or discussion group, sociodemographic data were obtained to characterise the participants. In total, there were thirty-six interviews and two discussion groups.
The study population was composed of men and women of Muslim tradition who had been hospitalised at one of the public hospitals in Almería for at least three days. The informants were very diverse, being of different nationalities, with different levels of knowledge of Spanish, living in different administrative situations in Spain, etc. Participation in the study was voluntary.
Regarding the ethical aspects of the study, the participants were fully informed of the research goals and the method that would be employed. A code was assigned to each patient to ensure anonymity and confidentiality. This code was constructed as follows: the first letter designated the admitting hospital (T = Torrecárdenas, in Almería; P = Poniente, in El Ejido; H = La Inmaculada, in Huercal-Overa). A second letter, H or M (hombre, mujer), designated the patient’s gender, male or female, respectively. Finally, a number indicated the order of participation, by hospital and gender. For example, TM5 corresponds to the fifth female informant attended at the Torrecárdenas hospital.
This research was approved by the corresponding Ethics and Research Committee at each of the participating hospitals.
It should be emphasised that Muslims do not constitute a homogeneous group. The Muslim faith is practised worldwide, in all kinds of societies, which present widely varying cultural, political, socio-economic and ethnic origins (Plaza del Pino, 2010, p. 29). It is one of the world’s majority religions and, like Christianity, has several main branches, which in turn are divided into different sub-groupings and schools of belief. The participants in our study and, in general, the majority of immigrants in Spain of Muslim origin, come from North and Central Africa, where the Sunni faith is predominant, and within this, the Maliki school of law is most commonly observed. We do not know whether our informants were all aware of which school they belonged to, since this question was not asked. The significant degree of heterogeneity within Islam is evidenced in the festivities that are celebrated, in the legal practices observed and in adherents’ acceptance of different sources on which to base their beliefs.
It is sometimes difficult to discern between religious practices and specific traditions, such as the use of the veil. Furthermore, not all persons of Muslim origin practise their religion in the same way (Plaza del Pino & Veiga, 2013). Indeed, some of our informants stated they were non-believers, or did not practise their religion, despite having been educated and culturalised in this context:
Neither believer nor practitioner; 2%
Not stated; 18%
Believer and practitioner; 65%
In view of these considerations, we approached the practices and beliefs of the informants in this study exclusively through their testimonies and did not seek to determine whether these practices and beliefs were purely religious or not.
As illustrated above, most of the interviewees identify themselves as believers and practitioners of Islam. Others declare themselves to be believers but not practitioners. As Lacomba (2009) points out, many immigrants of Muslim origin might use religion and participation in collective rituals as a sign of group identity, thus reaffirming their beliefs and traditions and expressing their outlook on religion more overtly than in their country of origin, not because they feel more religious in Spain, but because these beliefs and practices allow Muslim immigrants to situate themselves within their new society. In other words, these expressed beliefs connect migrants with their origins, and provide a quick and accessible means of forming a group of equals, distinguishing them from other groups and individuals in the same society.
The importance of the family
The family is very important in Islam. The Koran encourages Muslims to marry and form a family. The family is viewed as a unit that must be respected by all its members and that can influence the behaviour of individuals. The theme of the family arose in many of the interviews held, although none of our questions specifically referred to this topic:
I think the family is important, especially before giving birth. Being with your mother ... is something else (TM2).
I remember everything went well, the only thing is, you always need your family when there is an operation, that’s all; you can’t feel well if you haven’t got your family to support you, you know? These things with the children remind me that I’m here alone, when I go into my room and I’m alone, it hurts [...] Tears come to my eyes when I think about my family (TM3).
No, no. They did have a lot of family visiting, but it didn’t bother me because they only came from time to time, and since I don’t have my family ... but it didn’t bother me (TM8).
In several interviews, patients who didn’t have their family nearby expressed feelings of loneliness, especially during their hospital stay. This point was sometimes the most sensitive of the whole interview. The lack of support from the family caused some problems in the hospital environment, such as heightened fears, worries about death, difficulty in relating to healthcare personnel and discomfort.
I thought I was going to die. I thought about my family, my wife and my children, and I couldn’t eat. I’ve been like that for a month. After one week, a woman came and asked why I wasn’t eating. I told her that nothing was wrong, and she said: “Then, why aren’t you eating? Don’t you eat khalifo [pork]? “And I told her, no, I didn’t eat khalifo. It wasn’t that, but she thought that’s why I didn’t eat (TH6)
That’s something else. Because my family’s in Morocco and can’t come here. I’ve had a hard time. Sincerely, I’d have been better off in Morocco. It gets me down when families come to see the patients (HH3).
Look, I’ve got no family here, it’s just me, on my own. If something happens and you think you’re going to die.. I’ve thought about it a lot. I didn’t speak a word until two days after I left [hospital].
Interviewer: Were you afraid?
Yes, because I haven’t got my mother here. I wanted to leave quickly so I could talk with my family. If I couldn’t call my mother or my father, I wasn’t going to speak because I wasn’t happy, I was very afraid. When my fellow countrymen came, I talked with them a little. A nurse asked me “Why are you here and you don’t want to talk?” I am here, but I’ve got other things to think about. If my family were here ... but they aren’t and I worry about many things (HH1).
The relationship between healthcare personnel, patients and their families
The relationship between medical staff and patients’ families is highly valued, and the participants greatly appreciated it when doctors and nurses acknowledged the importance of family members and allowed them to accompany the patients or included them in the provision of care.
We were very lucky with the nurse assigned to us. When my wife visited, the nurse talked to her. She was even allowed to stay while my operation wound was being dressed. We all trusted her. On the day I left the hospital, she came up and answered all my questions (PH5).
Impressions of cultural similarity
Many participants commented on perceived cultural similarities with Andalusian society, regarding the importance of the family and of being accompanied in the hospital.
For Moroccans, the family is always there with the patient for whatever they need, just like you. Spanish people are the same as us Moroccans. (PH4)
The study results show that for patients from the Muslim tradition, the family plays an important role in their lives. They consider it important to be accompanied by the family in hospital, to ensure a more satisfactory recovery. Therefore, it is an additional impediment to recovery if the family is not there, but in the country of origin. The medical staff, too, are in favour of letting the family take part in caring for the patient; they consider this an expression of cultural respect. For the study participants, there are many similarities between the Islamic and Andalusian cultures as regards the bond with the family and the importance of the family being there, too, in the hospital. This outlook is quite natural, as both communities form part of the Mediterranean culture.
However, it should be noted that the role of the family differs greatly from one cultural group to another. Thus, in the Mediterranean and Latin cultures, the family connection is very important, and so their presence in the hospital is almost constant, sometimes too much so, hindering the proper functioning of the service. On the contrary, in Anglo-Saxon and Slav cultures, patients may be totally unaccompanied and/or their families only pay brief visits. Far from criticising these forms of behaviour (so different from our own), we should respect them (Plaza del Pino, 2017, p. 127).
For Muslim patients and their families, guidelines should be set for family visits, to avoid too many relatives being present at the same time. Moreover, it is very important for all medical staff to follow the same criteria when dealing with patients’ families; this will greatly reduce conflicts in this regard.
Healthcare personnel should be aware of the importance of the family for Muslim patients. If hospital authorities respect the family, and if their culture and the roles they play are valued, they can provide excellent support for patient care. Given these conditions, the family will be cooperative, respecting the hospital rules and following the advice given for the patient’s recovery. The family, thus, will become an excellent ally for the hospital during the patient’s stay.
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09 April 2019
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Multicultural education, education, personal health, public health, social discrimination,social inequality
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Plaza del Pino, F. J., & Cala, V. C. (2019). The Family Environment Of Muslim Patients And Its Implications For Health Care. In E. Soriano, C. Sleeter, M. Antonia Casanova, R. M. Zapata, & V. C. Cala (Eds.), The Value of Education and Health for a Global, Transcultural World, vol 60. European Proceedings of Social and Behavioural Sciences (pp. 150-156). Future Academy. https://doi.org/10.15405/epsbs.2019.04.02.19