Culturally driven attitudes and behaviors often create communication challenges between Middle Eastern patients and Western health care professionals. Middle Easterners approach life differently in significant ways from Westerners i.e., in terms of time control, power distance, male/female roles, personal space, and privacy. Similarly, problems in providing health care also develop around family involvement with patient care and ways of handling “bad news.” This article provides some general guidelines in understanding the cultural characteristics of Middle Easterners, but as always, it is crucial to see the individual in any health care encounter. The degree of exposure to Western and/or American culture greatly affects an individual’s attitudes and behaviors. Religious affiliations are also extremely influential. While it is useful to apply generalizations when learning about patterns of communication, it is also important to avoid applying hard and fast rules in any cross-cultural interaction.

Before reading further about the core values, beliefs, and cultural behaviors of people from the Middle East, it may prove helpful to learn more about what the term Middle Easterners encompasses.

The Importance of Family In Middle Eastern Cultures

Humans develop their sense of identity and self-esteem within a particular cultural context or group, and assuring in-group survival is arguably the strongest of human drives. Though the need to be affiliated with other persons is a universal human need, the intensity of the need varies among individuals and cultural groups. The need for affiliation is very strong among Middle Easterners. They thrive on a large network of relationships. During illness or crisis, Middle Easterners rely heavily on other persons in their “in-group” instead of trying to cope more individually as many Americans would typically do. A person seeking medical care may be accompanied by one or more persons in Middle Eastern culture who expect to be present during the examination or interview, who listen carefully and often answer for the patient. Usually it is an elderly person who will feel offended if not invited into the physician’s office. People close to the patient consider themselves duty bound to be there. The intense connection to family and close friends that is seen in many Middle Easterners is often accompanied by doubt about the intentions of those outside their intimate circle. Thus, family members typically see it as their job to make sure that the patient gets the best care possible from medical professionals. Repetition of demands is often made to show emphasis, as is a loud tone of voice. Family and friends are expected never to leave a patient alone and to constantly shower care and attention. A great deal of patience is sometimes needed in dealing with these “demanding” family members.

A Few General Guidelines for Dealing with Middle Eastern Families

(These do not apply to every individual. Ask questions of each patient/family to understand their own personal beliefs and behaviors.)

It is usually appropriate to speak first to the family spokesman. The one with the most authority in any situation is usually the oldest and most educated person. Sexual segregation is usually extremely important. Assign same-sex caregivers whenever possible, and maintain a woman’s modesty at all time. Accept the fact that women may defer to husbands for decision-making regarding their own and their children’s’ health. This is not necessarily a sign of extreme dominance on the part of the male; the female may very well prefer this culturally-based dynamic. Accept that the husband may answer questions addressed to his wife. Direct eye contact with members of the opposite sex may be interpreted as a sign of sexual interest particularly from female to male. Personal problems are usually taken care of within the family; they will probably not be receptive to counseling. Loud and expressive emotions are accepted, especially during childbirth, after someone has died, or when coping with pain. Negative information should be presented with great care. A common communication practice in the Middle East is to reveal the news of a tragedy or a poor prognosis in stages. Bad news is often not given to the patient directly.

High Context Communicators

Given the intensity and frequency of their relationships, Middle Easterners tend to be highly contextual communicators. This means that persons seek understanding of events by examining the context in which they occur. A Middle Easterner needs to know more about another person than an American does for a relationship to develop. American culture is low in context; the emphasis is on the verbal message and less so on the context in which the message is given.

Time Control

Punctuality is less important in the Middle East than in the United States. A patient might be late for an appointment, or not come at all, because another matter immediately at hand was seen as more important than the previously scheduled appointment. The matter taking precedence often involves meeting the needs of someone a person feels obligated to in a reciprocal relationship – i.e. a family member or close friend. Americans, being task-oriented, plan their days around getting things accomplished and are annoyed by a nonchalant approach to time. Americans who are left waiting for more than a few minutes may feel they are being disrespected; the late arriver should offer a good explanation for not showing up on time. Middle Easterners on the other hand may be offended by the Americans attention to getting things done rather than taking the time to establish a relationship.

Personal Space When Conversing

People from different cultures use space during conversation in very different ways. The appropriate conversational distance between Middle Easterners is twice as close as Americans are used to. Middle Easterners also touch more frequently. This difference in personal conversing space can make Westerns feel very uncomfortable. The collapsing of personal space may feel invasive or even somewhat aggressive.

Personal Privacy

People from the Middle East may tend to resist disclosing detailed personal information to strangers, including healthcare professionals. Data for health histories may not be willingly given and request for information may be viewed with some suspicion until it is clear why the questions are being asked. Once trust with a caregiver is established, personal information is given more freely.

Power Distance

Middle Easterners desire to please or to appear good, and less dominant persons must at all costs placate stronger ones. This is important to consider in the face of power distance in healthcare situations, especially between male doctors and their patients. Because the authority of a physician is never questioned, a Middle Easterner is not likely to ask questions or give information that would contradict or show disrespect. Also, depending on the degree of acculturation in the U.S., religious views, etc., a Middle Eastern person, especially a male, may feel uncomfortable interacting with a female doctor as a person of real authority. The emphasis in this last statement is on the possibility, not on any likelihood.

Health and Illness Behavior

Middle Easterners generally have respect for Western medicine. However, in working with any immigrant population, health care professionals should be aware of common folk beliefs and practices. Much like Latino people, Middle Easterners may believe in illness causation such as the Evil Eye. In this belief, anything that provokes jealousy in another gives the envious person the power to cause illness or misfortune for the lucky person or family. Often the object of envy is a beautiful baby or child. Much like Latino and Asian people, Middle Easterners believe in the importance of balancing “hot” and “cold” foods – qualities that do not necessarily have to do with actual food temperature. They avoid eating incompatible foods at the same meal. Health professionals have frequently observed among Middle Easterners a fatalistic acceptance of disease or death – it’s all in Allah’s hands. Preventive care is not practiced as commonly in the Middle East as it is in the United States. Also, medication is heavily used. Middle Eastern patients may expect to receive a prescription. Middle Easterners often fear hospital admission because hospitals are considered places of misfortune where people go to die. Moslems are concerned that a family cannot be sure that the body of one of its members will be treated correctly according to religious customs, should a patient die in hospital. Family members do not plan for death and never give up hope until a patient has actually died; grief is not permitted to be shown in the presence of a dying person. Once death has occurred, mourning may be loud and obvious. A person who is not overcome with emotion is not admired. It takes more time to consult with a Middle Eastern family, and that scheduling should be arranged accordingly when possible.

Conclusion

Western medical professionals may find that working with Middle Eastern patients can be challenging. However, once trust has been established, Middle Easterners are typically cooperative and willing to comply with their doctor’s recommendations for treatment. Working with Middle Easterners gives U. S. professionals the enriching opportunity to compare their own cultural values, beliefs, and behaviors with those of people from more traditional cultures. Every patient/family encounter is an opportunity to practice effective cross-cultural communication skills that help increase positive health outcomes.

REFERENCES

Galanti, G.: Caring for Patients Different Cultures. Fourth Edition. ISBN-10: 0812220315

Lewis, R.: When Cultures Collide. Third Edition. Pages 42-46. ISBN-10: 1-904838-02-9