Version accepted for Disability &Rehabilitation:
Omu, O., & Reynolds, F. (2014). Religious faith and self-efficacy among stroke patients in
Kuwait: health professionals' views. Disability & Rehabilitation, 36(18), 1529-1535.
Religious Faith and Self-Efficacy among Stroke Patients In Kuwait: Health
Professionals’ Views
ABSTRACT
Purpose: This study explored health professionals’ views about the influence of Muslim
religious beliefs on Kuwaiti patients’ self-efficacy within stroke rehabilitation. It also explored
their confidence in discussing religious issues with patients during rehabilitation.
Method: Qualitative semi-structured interviews were conducted with 10 expatriate health
professionals of various religious faiths working in stroke rehabilitation (5 nurses, 4
physiotherapists and one physician). Data were analysed thematically.
Findings: Health professionals considered that self-efficacy in stroke rehabilitation was
strengthened by patients’ feelings of partnership with God which evoked hope and strength, by
retaining continuity of the moral self, and by viewing disability as a test of resilience. Fatalistic
beliefs and the belief that stroke is a punishment from God were thought to undermine selfefficacy. Health professionals sought to foster patients’ experience of religious empowerment by
using religious phrases during rehabilitation, and encouraging religious observance. Nurse
participants considered that discussing religious issues with their patients was intrinsic to
culturally competent care.
Conclusions: It is known that patients’ self-efficacy in rehabilitation can be strengthened
through a number of strategies such as goal-setting and feedback. This study suggests that for
Muslim patients in Kuwait, health professionals also need to be mindful of their need for
religious empowerment.
Key-words: stroke rehabilitation; religious faith; fatalism; religious coping; self-efficacy, Kuwait
1
INTRODUCTION
Stroke incidence in Arab countries is relatively low compared with the West, reflecting the small
proportion of over-65s in the population [1]. Nonetheless, stroke is the second leading cause of
death [2], and the condition most often responsible for severe functional disability among older
people in Kuwait [3]. Stroke is associated particularly with hypertension and diabetes, with
prevalence of these risk factors higher in Kuwait than in other Gulf States [4]. Multi-disciplinary
stroke rehabilitation offers an effective means of limiting disability post-stroke [5], and it is
therefore important to identify strategies to maximise its benefits.
Self-efficacy is a belief or confidence that one is capable of achieving a particular task or
behaviour [6], and is associated with positive coping, adaptation, and self-management of
illness and disability, including stroke [7,8,9]. High self-efficacy encourages persistence and
resilience in the face of difficult tasks [6], such as those encountered in rehabilitation.
Awareness of personal (or other people’s) success in achieving goals, receiving encouragement
and appropriate feedback about progress, and collaborative goal-setting are all experiences that
can increase patients’ self-efficacy [8,10]. These are all influences operating within the
therapeutic process itself. The broader resources that patients bring to rehabilitation, such as
religious faith, have received relatively little research attention. Awareness of such issues is
needed to promote more culturally competent, effective healthcare [11].
“Religion is concerned with public participation in a faith community with specific practices and
doctrines” [12:p. 232]. Available studies suggest that patients’ religious and spiritual beliefs and
affiliations are associated with subjective well-being [13,14], and provide resources for coping
with disability, giving meaning to life, providing social support and reducing distress [15,16].
However, in cases where patients believe their stroke has been a punishment from God,
emotional distress increases [16], highlighting the need to assess what type of religious coping
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strategies patients are using and to identify any negative coping such as denial or blaming.
Pargament [17,18] discusses positive and negative aspects of religious coping. Positive aspects
include spiritual support, collaborative religious coping, congregational support, and benevolent
religious reframing. Negative aspects of religious coping include discontent with religion and
God, and framing current difficulties as a punishment or retribution for wrong-doing. Among
Kuwaitis, religiosity appears to be associated with optimism and better mental health [13,14].
Nonetheless, the relationship between religious faith and self-efficacy in Muslim culture is
somewhat uncertain.
For patients engaging in stroke rehabilitation, religious faith may foster feelings of support and
hope, enhancing self-efficacy, whilst fatalism and/or religious beliefs that represent illness as a
punishment from God seem likely to diminish self-efficacy and perceived internal control [16,19].
Some Chinese stroke patients believe that religious support increases their sense of control
over the situation, and reduces their fear of stroke reoccurrence [20]. However, these
relationships have mostly been identified among participants holding Christian, Buddhist or
secular beliefs. Faith occupies a different position in Islamic cultures, infusing every aspect of
life [21]. The relevance of Muslim religious beliefs to self-efficacy has not been thoroughly
explored, although there is evidence that patients in Middle Eastern cultures derive support and
coping strategies from their religion [22-24]. In the Kuwaiti stroke rehabilitation context, a
previous study [25,26] found that health professionals of various religious affiliations regarded
their patients’ Muslim religious beliefs as likely to promote acceptance of disability. Such
acceptance was thought helpful for reducing stress post-stroke but as risky for encouraging
passivity in rehabilitation. This study explores these issues in more depth, with a further group of
health professionals.
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It is recognized that the views of health professionals on these matters does not offer objective
evidence of any relationship between religious faith and self-efficacy, but their views are
valuable for two key reasons. Firstly, patients may find it difficult to gain ‘distance’ from their own
religious faith to appreciate its influence upon their engagement with rehabilitation, especially in
a culture such as Kuwait’s where religiosity is culturally prescribed so private beliefs are difficult
for people to disclose. Secondly, health professionals in Kuwait typically have experiences of
working in cultures beyond Kuwait, with patients of different faiths, and as a consequence may
have developed rich understandings of the influence of religious faith on self-efficacy.
Study Aim
This study examined the perspectives of health professionals regarding the influence of
patients’ Muslim religious beliefs on their self-efficacy in stroke rehabilitation in Kuwait.
METHOD
Design
This was a descriptive qualitative study based on single semi-structured interviews with health
professionals working in stroke rehabilitation in Kuwait.
Ethical considerations
Ethical approval to explore health professionals’ views concerning the perceived influence of
culture on the stroke patients’ experience was granted by the Ethics Committee, School of
Health Sciences and Social Care, Brunel University. All participants were informed in writing of
the aims of the study and the voluntary nature of their participation. They gave written consent.
Confidentiality is observed and pseudonyms are used.
4
Participants
Ten health professionals working in stroke rehabilitation in Kuwait responded to information that
was circulated to staff members about the project. Adequate sample size is a matter of
judgement in qualitative research. Ten may be considered a suitable number for an exploratory
study given the relatively narrow scope of the study, the rich information given by each
interviewee, and appropriate caution about generalizing the findings [27, 28]. Similar sample
sizes (of 8-15 participants) have been used in relevant previous research [20,23,26,33]. It is not
possible to determine how many staff saw information about the project and declined to
volunteer. All participants were interviewed by the first author, a physiotherapist also working in
Kuwait. Five nurses, four physiotherapists and a physician took part. All were expatriate
workers, broadly reflecting the profile of the Kuwaiti health workforce [29, 30]. Nine were female
and nearly all originated from India. Participants described themselves as following Muslim,
Christian or Hindu faiths; none represented themselves as atheist or agnostic. Details are given
in Table 1.
---Insert Table 1 here---
Data collection
The semi-structured interviews took place in a quiet room in the workplace. Interviews were
conducted in English by the first author and took 45 minutes to one hour. In Kuwait, English is
the second official language, after Arabic. Medical education in Kuwait is conducted in English
and all participants were able to express themselves confidently in this language. Interviews
were initially wide-ranging, exploring the perceived influence of culture on rehabilitation, and
then focused on the influence of religious faith on patients’ experiences of stroke, rehabilitation
and self-efficacy. The topic guide for the exploration of self-efficacy was as follows:
5
1. General views about the influence of religious faith on self-efficacy in rehabilitation (including
probes to explore in more detail any suggested influences on confidence, acceptance,
passivity)
2. Specific examples about how religious faith might enhance or undermine patients’ selfefficacy, from their experiences of working with patients.
3. Reflection on the therapists' role and personal willingness to address religious beliefs in
stroke rehabilitation (including experiences that have encouraged or discouraged discussion
of religious beliefs with patients)
A reflective diary was kept to assist the interviewer in monitoring her assumptions and interview
skills, and to aid further elaboration of prompt questions used in subsequent interviews. So, for
example, the reflective diary helped the interviewer to be more aware of the potential influence
of her Christian beliefs on participants’ disclosures, and to develop supportive strategies if she
sensed that participants felt uncomfortable expressing any views deemed critical of their
patients’ faiths.
Qualitative data analysis
Interview transcripts were subject to inductive thematic analysis [31]. Themes were
independently coded by the two authors, not to establish agreement in a quantitative sense, but
to check the coherence and sensitivity of emerging themes. Differences in interpretation were
resolved through going back to the data carefully and further discussion. The various
professional experiences of the authors (the first being a physiotherapist working in Kuwait and
the second being a health psychologist working in the UK) were considered helpful for bringing
different academic perspectives to this task. The emerging themes from first two interviews
were shared with participants for comment in a face-to-face meeting, and accepted as
meaningful. After the authors were highly familiarized with the transcript data, they proceeded
with initial codes, and then linked these into larger themes through a reiterative process. Braun
6
and Clarke [31] observe that theme headings should be informative and that, as a set, they
should weave into a coherent narrative. The final stage involved refining all the themes and
identifying the essence of each theme. It also involved naming of the theme in a way that was
concise and meaningful.
FINDINGS
In the quotations below, the usual convention is followed, with … indicating editing for brevity,
and square brackets to indicate any words added for clarity.
The health professionals all viewed religious faith as strengthening or undermining their
patients’ self-efficacy, depending upon whether the patient perceived God, religious doctrines or
religious practices as supportive or punitive. Most regarded their patients’ Muslim religious faith
as empowering and supportive of self-efficacy leading to their more committed engagement in
stroke rehabilitation (Table 2).
---Insert Table 2----
Perceptions of positive influences of religious faith on self-efficacy
A sense of partnership with God
Most of the health professionals, regardless of their own religious faith, regarded patients who
experienced themselves as in partnership with God, as having higher self-efficacy.
“You believe you can do more” (Selvi, Physiotherapist, Christian).
This experience of partnership was regarded as empowering, providing the patient with
increased energy and tenacity needed to persist with effortful tasks in rehabilitation, and
maintaining their hope of eventual recovery. Some referred to religious faith as providing their
patients with a ‘mental boost’:
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“Stroke is a major trauma or insult in a person’s life. When someone is in such a terrible
situation one would look to their God, their faith and stuff like that… It would give some
mental boost, some hope. Hope is very important in rehabilitation. If they are not hopeful or
motivated, they may not participate in the programme” (Abdel, Physician, Muslim).
The professionals perceived that patients who experienced partnership with their God were
likely to feel psychologically stronger, which would enhance self-efficacy:
“Religion affects your inner person. Your inner person is made really strong and you are
more motivated, your self-efficacy will be really high and this has an impact on what you
have to do” (Nancy, Physiotherapist, Christian).
“Once you start praying, you get a lot of positive energy which helps you to understand that
you have hope. That hope is something that keeps you going and helps you accept it and
feel you can go further and get better.” (Selvi, Physiotherapist, Christian).
Feeling supported by their God, religious patients were thought likely to suffer less from
depression and hopelessness, which undermine self-efficacy. Such patients were considered
less likely to feel discouraged by slow progress and setbacks in recovery:
“When I say they are strong, I mean they have a strong belief in God so surely it must help
them… It helps them to take things positively. They will not take things negatively” (Adele,
Nurse, Christian).
Continuity of the ‘moral self’
Stroke readily shatters a person’s assumptions about the self and the future, and profoundly
challenges pre-stroke roles and relationships. Some health professionals regarded patients’
continued religious observances during rehabilitation as offering some sense of continuity,
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through preserving the ‘moral self’. Rather than feeling isolated and wholly defined by disability,
role loss and rehabilitation regimens, religious observance was thought to help patients to draw
strength from their unimpaired moral self. The experience of a persisting moral self was thought
to help build self-efficacy. The nurses in the sample placed more emphasis on this theme,
perhaps through their more holistic role, caring for patients throughout their stay in hospital
rather than in specific therapy sessions:
“They are religious and pray five times a day as the commandments of their religion,
whenever it is possible they do it in the name of God. So I think this has to help them
100%, they’re confident that their faith in God can help them”. (Adele, Nurse, Christian).
Jasmin, a Hindu nurse, described being aware of the direction of Mecca and thought it important
to encourage her patients’ prayer routines:
“There is a sign for the direction of prayer and there are Korans in every room and there is a
mosque also available… The nurse should allow patients to observe their own religious
practices, because this will help them to feel more confident and help in improving their
health condition”.
Nonetheless, such awareness was not confined to nursing professionals. Bahiya, a Muslim
physiotherapist, linked the patients’ experience of reconnection with meaningful rituals to hope:
“So when they are not able to pray they feel upset… on returning to prayers they feel they
are improved and might be able to recover fully. There was a disconnection with their
prayers due to the stroke but that reconnection helps give them hope”.
Abdel, a Muslim physician, thought that for some patients, reconnection with their religious
rituals would be a highly meaningful goal of stroke rehabilitation, further encouraging a sense of
continuity of self and self-efficacy:
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“Once they return to their rituals and prayers, they feel that they have achieved
something. That might be one of their goals as well, that they be able to return to their
prayers. So once they achieve that goal, the patient understandably feels fulfilled
spiritually …Prior to the stroke they were carrying out regular prayers with the belief that
God will help them, so not being able to do that after the stroke could be a major insult to
their life and routine. Once they are able to perform their rituals even in a different way,
for example praying when sitting, they feel a lot better, they feel God is with them …
Basically, once the patient gets the continuity back [of prayer life] they feel they have
regained what they have lost. In terms of religion and spirituality, once they get back to
their routine they feel that they are fulfilling their religious requirement. It’s like gaining
back something precious that you lost. So of course that continuity … will definitely help
the patient”.
Viewing disability as a test of resilience
Several participants thought that Muslim religious beliefs guided some patients to regard their
disability as a test from God, a test that they could manage actively through commitment to
therapy, as well as through religious observance such as prayer.
“As a Muslim … we believe everything is from God. The good things and the bad things,
This is our belief. So we say : “ Alhamdulila [thank God]”. Everything should be accepted
because it is from God. This is a testing from God not a punishment. He is testing us to
see how we can tolerate this and he will give a reward for it” (Alima, Nurse, Muslim).
Viewing disability as a test was thought helpful for increasing patients’ acceptance of the
appropriateness and effectiveness of treatment:
10
“Accepting that it [disability] is from God, and I have to take it as a test and do the correct
things like taking treatment” (Abdel, Physician, Muslim).
The Muslim health professionals seemed more understanding of this potential influence of
religious belief, compared with non-Muslim participants.
The patients’ sense of partnership with God is strengthened through health
professionals’ mediation
Many of the professionals, particularly the nurses interviewed, thought it helpful to invoke their
patients’ religious beliefs during therapy in order to further strengthen their hope and motivation.
Regardless of their own religion, these participants viewed the use of certain religious phrases
and rituals as helping patients to feel more supported by their God, and more able to draw on
religious strength as well as the technical expertise of their health professionals.
“Religious faith helps a lot, in Kuwait our population is 100% Muslim, and they have a
strong faith, so everything they do they start with: “Bismila [in the name of God]” so when
we do our work … we start it by saying, “In the name of God”. They are very confident
that this is going to work out for them.” (Adele, Nurse, Christian).
“They want us to start [therapy] with them using the religious words. That helps them.
Like some kind of positive energy they are getting. In all religion, when we pray we will
feel that we have some confidence and get some positive energy” (Chandra,
Physiotherapist, Hindu).
One participant also thought that invoking religious belief helped to make the rehabilitation
environment more homely and perhaps less intimidating, reducing patients’ stress and
increasing their confidence:
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“Patients want us to use their own religious words like: “Bismila [In the name of
God]”…this makes the patient more confident. If say these words when doing our
procedures the patients feel more confident. When we say these words it helps them
follow their own religious practices, feel more homely…it may be helpful regulating their
hormones” (Jasmin, Nurse, Hindu).
The nurses, in particular, considered that respecting the patients’ religious needs and
sensitivities were essential to practising competently within the Muslim culture of Kuwait. They
used their professional experience, as well as observation and empathy, to assess patients’
needs and willingness for them to make religious references within therapy. In contrast, two of
the physiotherapists were reluctant to encourage any form of religious coping, either for fear of
offending patients (especially if they did not share the patient’s Muslim faith), or from perceiving
religious beliefs as falling outside of their professional role:
“Actually I am in double thoughts with that. It’s such a touchy topic... I am not sure if as a
therapist I should speak to the patient how important it [religious belief] is” (Selvi,
Physiotherapist, Christian).
Perceptions of negative effects of religious belief on self-efficacy
Beliefs that stroke/disability is a punishment from God:
Several participants thought that patients who regarded their stroke or disability as a
punishment from God had lower self-efficacy. Those professionals who had become aware of
this negative belief had tried to guide their patients into regarding their stroke as a test set by
God, a reinterpretation that they believed was more supportive of self-efficacy:
“They have to understand that their condition is not a punishment, it is a test” (Alima,
Nurse, Muslim).
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Some commented that regarding disability as a punishment represented a misunderstanding of
the Muslim faith:
“I think it is more illiteracy…not understanding what the religious teaching is all
about…not taking it in the true sense. Yes, all religions do teach that conditions all come
from God and God can change the outcome or fate. Some people take it in a good way
that you have to pray to God and take appropriate measures to get it better, and you
pass the test by positively engaging in treatment and praying to God” (Abdel, Physician,
Muslim).
A distinction was also made between what was perceived by some of the participants as
‘superstitious beliefs’ that interpreted illness as a punishment or retribution for past evil, with
what they regarded as ‘truly religious’ beliefs which would be far more supportive of selfefficacy:
“Some people believe that someone has done something to them [such as the] evil eye,
superstitious beliefs, and until they get that cured that would not get better….I believe that
patients’ personal faith does have a [positive] influence on self-efficacy and coping but
superstitious beliefs don’t. The therapist has a role as an encourager in terms of religious
faith” (Bahiya, Physiotherapist, Muslim).
It appeared that the Muslim participants were more willing to discuss possible misinterpretations
of their faith whereas the non-Muslim participants were more cautious in their remarks.
Fatalistic beliefs that adversity/disability must be accepted without question or action:
The participants were also aware that their patients’ religious faith could encourage fatalism, a
belief that outcomes are not alterable by personal effort. Such beliefs were thought to be linked
13
with low self-efficacy in rehabilitation. However, only small numbers of patients, of various faiths,
were thought to hold such beliefs:
“There are certain groups of people that say it is from God and ‘I don’t want to do
anything [in rehabilitation]’.That group is a minority” (Abdel, Physician, Muslim).
“I see that [fatalistic beliefs] in all cultures actually. People who are very staunch in their
religious beliefs, they feel that they don’t need to do anything else. But I believe that is
the wrong concept. He [God] has given you the ability to learn and it’s for you to
incorporate it in your own life, and look to Him for guidance and support” (Selvi,
Physiotherapist, Christian).
DISCUSSION
Self-efficacy has been regarded as making an important contribution to outcomes following
stroke and rehabilitation, influencing patients’ coping, mastery and perseverance in the face of
setbacks [8,9,32]. The health professionals interviewed for this study regarded their stroke
patients’ Muslim religious beliefs as having an influence on their self-efficacy. Broadly, religious
beliefs were thought largely to support self-efficacy for rehabilitation by empowering the patient.
Self-efficacy was considered higher among patients who experienced a partnership with their
God, perceptions of on-going connection with their pre-stroke moral self, and confidence that a
potent combination of religious and technical resources would equip them to pass the ‘tests’ or
challenges ahead. Religious coping and certain religious practices, such as prayer, have been
found helpful for stroke and other patients in previous studies [12,33,34]. The health
professionals interviewed in this study suggested that religious observances help patients to feel
continuity with their pre-stroke moral self, thereby gaining strength and motivation to engage in
rehabilitation. Religious observances may also help to invoke a stronger sense of partnership,
14
or collaboration, with God, a form of religious coping identified previously by Pargament and
colleagues [17,18, 35]. Patients may then feel themselves to be working with the combined
power of both religious and professional resources. By placing their rehabilitation and nursing
interventions in the context of their patients’ religious beliefs (e.g. by using certain powerful
religious phrases), many of the health professionals believed that their patients’ confidence and
engagement in treatment would increase.
Participants regarded patients’ self-efficacy as undermined by religious beliefs that portrayed
disability as a punishment or as irrecoverable. Regarding illness or disability as a punishment
from God has been linked with emotional distress in previous research [16], and as potentially
undermining engagement in rehabilitation in Kuwait [26].These findings support previous
descriptions of the negative aspects of religious coping [18]. Fatalistic beliefs have been
associated with worse stroke outcomes [36], and also greater distress and poorer self-efficacy
in diabetes patients [37]. Some of the health professionals in this study distinguished fatalism
(interpreted as passivity and a perceived lack of entitlement to take any action to reduce the
impact of stroke) from attitudes of acceptance and trust in God which they thought could support
active engagement in rehabilitation, a view expressed previously by another group of Kuwaiti
health professionals [25-26].
These findings somewhat challenge previous research linking patients’ subjective religiosity to
lower levels of belief in internal control and increased belief in ‘‘powerful others’’ health locus of
control [19]. But this previous study focused on Western patients, largely with Christian religious
beliefs, and did not explore relationships between perceptions of control and non-Christian
religious beliefs and practices.
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In the sample interviewed, it was the nurses in particular who regarded respect for religious
beliefs and observances as central to offering holistic care within a Muslim culture. Such respect
for others’ beliefs and religious practices has been described as intrinsic to culturally competent
rehabilitation [11, 38], and recommended to promote effective and sensitive care of Muslim
patients [21,39, 40].
Clinical implications
Nurses in particular expressed the importance of using religious words such as ‘Bismilla’ [In the
name of God] or ‘Alhaduliah’ [Thank God] during nursing procedures. This was perceived to
make the patient feel more comfortable. Questions may arise from a Western point of view as
to how the health professional should identify which patient will accept and benefit from such
invocations, and when it is appropriate to make reference to religious beliefs. In the Kuwaiti
context, it is safe to assume that all [native] Kuwaiti citizens are Muslims and as such would be
expecting such words, and unlikely to be offended. Indeed, any insinuation of lack of religious
belief within the Kuwaiti culture might actually be deemed as offensive. However, two
physiotherapists mentioned their discomfort with discussing religious issues with patients, as
they did not share their religious beliefs. A safe starting point would be to establish rapport with
patients prior to attempting to use religious words or bringing up religious issues for discussion.
Nurses implied that they used observation and empathy, as well as patients’ direct requests, to
identify when religious invocation seemed helpful. There is also a need to distinguish between
the use of comforting religious words during procedures/therapy and engaging in in-depth
discussions regarding disability, personal psychological issues and religion. It appears that the
former might be appropriate in everyday therapeutic encounters, and perhaps the latter be
reserved for certain patients sharing the same religion as the therapist, if they seemed in
spiritual distress, and if deemed appropriate and helpful for achieving rehabilitation goals.
16
The health professional who considers using religious words or discussion needs to be aware of
the possible negative effects of religious beliefs on self–efficacy. As mentioned by the health
professionals interviewed, some religious understandings encourage passivity during
rehabilitation. However, caution must be taken in order not to label the patient’s beliefs as
‘superstitious’, as described by a few participants. This could lead to derogatory statements
being voiced which could offend the patient. The health professional needs to be sensitive in
managing what she/he personally deems as unhelpful or ‘superstitious’ beliefs.
Critical evaluation
The participants’ accounts mostly portrayed religious faith as supportive of self-efficacy in stroke
rehabilitation, but we acknowledge that the findings represent qualitative perceptions rather than
objectively measured relationships. Patients’ own views were not explored. It needs to be
acknowledged that the health professionals who volunteered for the study may have had
particularly positive attitudes towards religious faith which helped them feel comfortable talking
about such issues. It is not known how many health professionals saw information about the
study and decided against taking part through lack of interest or disquiet about religious issues.
It is also important to point out that although the interviewed health professionals thought selfefficacy could be inspired by religious references, health-related outcomes were not measured.
Therefore it is unknown whether any increase in self-efficacy mediated by religiousness leads
directly to an increase in health or functional outcome in this patient population in Kuwait.
Participants reported various faiths and none described themselves as atheist or agnostic, so it
is not known whether non-religious rehabilitation professionals would share the same attitudes.
All interviewees were expatriate workers who may have felt particularly obliged to offer culturally
17
sensitive care within their host country. Yet their position as expatriates with health professional
experience in other countries may also have helped highlight specific characteristics of the
Muslim culture of Kuwait, helping them to be more sensitive about the role of religious beliefs in
rehabilitation in this context. Almost all volunteers for this study were women. It remains
unknown whether female health professionals are more likely to acknowledge their patients’
religious understandings within the therapeutic alliance. The sample size is small and may not
represent the range of views among stroke rehabilitation specialists. The first author shared with
several of the participants a Christian, non-Kuwaiti background. This potentially could have led
to certain misunderstandings about the Muslim faith during interviewing, although all
interviewees were sufficiently fluent in English to clarify the points they were making. Some
confirmed the acceptability of the thematic analysis. The transferability of the findings to other
Muslim cultures, or to Muslim patients being cared for in multi-cultural contexts, is unknown.
CONCLUSIONS
The health professionals interviewed were largely positive about the influence of Muslim stroke
patients’ religious beliefs on self-efficacy for rehabilitation, believing that their religious patients
felt empowered by their experience of partnership with God, which gave strength, energy, hope
and motivation to succeed. Religious observance was thought to strengthen a sense of
connection with the unimpaired moral self, thereby increasing self-efficacy. Viewing disability
as a test rather than as a divine punishment was regarded as empowering patients’ confidence
to engage actively in rehabilitation, whilst fatalistic religious beliefs were thought likely to
undermine self-efficacy and induce passivity. Many of those interviewed, particularly the nurses,
felt it appropriate to invoke patients’ religious belief and encourage patients in their religious
observances, thinking that this helped strengthen their sense of self-efficacy.
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The Kuwaiti culture is unusual with very high levels of professed religiosity among the Muslim
citizen population and conservative social values. It is unknown whether the findings generalize
to other Arabic cultures or to multi-cultural rehabilitation contexts in the West. Nonetheless, a
better understanding of the power of religious beliefs to influence self-efficacy in rehabilitation
may contribute to culturally competent care that harnesses more of the resources of patients
and families.
Further research is required to investigate the appropriateness of making reference to religious
issues during rehabilitation especially when the health professional and the patient espouse
different religions. It is also unknown whether gender plays a role in discussion or acceptance of
religious advice/ support during rehabilitation.
IMPLICATIONS FOR REHABILITATION

Muslim religious beliefs may influence self-efficacy in stroke patients in the Kuwaiti context

Patients who regard themselves as working in partnership with their God may feel
empowered and more confident to achieve goals in rehabilitation

Patients who regard their stroke as a divine punishment may have lower self-efficacy.

Health professionals might support religious patients to retain a sense of their unimpaired
moral selves (for example, by enabling religious observance) as a means of enhancing selfefficacy in rehabilitation.
Declaration of interest:
The authors report no conflicts of interest. No funding was received for this study.
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Table 1: Participants’ details
Initials
Age
Gender
Background
Profession
Religion
N1
32
Female
Indian
Nurse
Hindu
N2
40
Female
Indian
Nurse
Christian
N3
34
Female
Jordanian
Nurse
Muslim
N4
39
Female
Indian
Nurse
Christian
N5
34
Female
Indian
Nurse
Christian
PT1
35
Female
Indian
Physiotherapist Christian
PT2
36
Female
Indian
Physiotherapist Muslim
PT3
32
Female
Indian
Physiotherapist Christian
PT4
35
Female
Indian
Physiotherapist Hindu
Dr
38
Male
Indian
Doctor
Muslim
Key: N – nurse; PT - physiotherapist
24
Table 2: Influence of religious faith on self-efficacy: themes
Positive influences on self-efficacy:

Patients’ sense of partnership with God (increases feelings of personal strength, hope, selfconfidence and mastery)

Patient’s confidence in the continuity of the ‘moral self’ (increases a sense of mastery
through maintaining religious observances in rehabilitation; maintaining family traditions).

Patients’ interpretation of disability as a test of resilience

Patients’ feeling closer to God through health professionals’ mediation (e.g. use of religious
phrases)
Negative influences on self-efficacy:

Belief that stroke/disability is a punishment from God

Fatalistic beliefs that adversity/disability must be accepted without question or action
25