INFLUENCE OF ISLAMIC PHILOSOPHY ON THE FAITH AND PRACTICES OF PATIENTS WITH DIABETES MELLITUS AND ITS MUSCULOSKELETAL MANIFESTATIONS

Transcultural care is an important aspect of patient care. This review paper discusses the influence of Islamic philosophy on the faith and practices of Muslim patients with diabetes mellitus and its musculoskeletal manifestations. Relevant articles were searched from the electronic databases Cumulative Index of Nursing and Allied Health Literature, PubMed, ProQuest, and Science Direct using the keywords “Islamic philosophy, the influence of Islamic Philosophy in Muslim patients, religious practice during sick, fasting months, and sick.” No time limitation was specified for article selection. The database search yielded 170 potential articles. The abstracts of these articles were screened, and 50 fulllength manuscripts were obtained, reviewed, and analyzed for their relevance to the subject matter. Discussions rooted in the ontology, epistemology, and methodology of Islamic philosophy were described in detail to provide a sound understanding of its influence on Muslim patients. The ontology of Islamic philosophy is based on four important concepts, namely, the Unity of Allah, the Unity of Creation, the Unity of Thought, and the Unity of Man. The epistemological approach can help Muslim patients search for knowledge on the basis of ontology and three principles, namely, Ilm’ Yaqin, Ainul Yaqin, and Haqqal Yaqin. The ontology and epistemology shape the methodology of Muslim patients’ daily life -according to the Islamic concepts of the Five Pillars and Six True Faiths. The issues patients with diabetes mellitus and its musculoskeletal manifestations encounter usually arise when they need to perform obligations during fasting and prayers. Understanding Islamic philosophy in caring for patients with diabetes is important among healthcare professionals to provide appropriate care. Better healthcare services may be provided to Muslim patients if their specific needs are fulfilled according to their beliefs and culture.


Introduction
Transcultural issues are among the greatest challenges faced by healthcare providers during delivery of care. Understanding transcultural matters will help healthcare providers in addressing the needs of patients of different ethnicities or with different beliefs. Healthcare delivery may pose challenges when healthcare providers are unable observe differences in transcultural matters (Maier-Lorentz, 2008). Thus, healthcare providers and patients should work together toward reaching realistic goals of care by finding commonalities in their transcultural views.
According to Clarke (2017), personal belief is a transcultural issue that often occurs during delivery of care. The beliefs of healthcare providers may differ from those of their patient. Therefore, if healthcare providers have insights into their patients' beliefs, they may be better equipped to provide the necessary care. Besides Christianity, Buddhism, and Hinduism, Islam is one of the major religions of the world (Pew Research Center, 2019). Discussions on the influence of Islamic philosophy on the Malaysian medical experience will be helpful in understanding the role of healthcare providers providing care toward patients with diabetic. Certain practices rooted in Islamic law may affect the everyday care of patients. For example, a patient with diabetic foot ulcers may want to fast during Ramadan. Therefore, some routine treatments may need adjustment after a proper assessment is carried out by the patient's doctor. Healthcare providers may have different views on this practice if they do not understand the importance of fasting during Ramadan to Muslim patients.
The availability of halal (permissible) food is another issue faced by Muslim patients. The definition of halal for non-Muslim healthcare providers may be different from that understood by Muslim doctors. Some doctors may consider food halal so long as it is not served with pork. However, halal food actually refers to food prepared in compliance with Shariah law; this means the origin of the food should be free from forbidden elements and be prepared according to the concepts of hygiene, sanitation, and safety (Baharuddin, Ahmad Kassim, Nordin, & Buyong, 2015). Publications directly discussing on the influence of Islamic philosophy on the faith and practices of Muslim patients during hospitalization are limited. Thus, the present review focuses on the effects of the ontology, epistemology, and methodology Islamic philosophy on Muslim patients.
The situation of patients with diabetes mellitus and its musculoskeletal manifestations is described in this article to discuss how Muslim life is affected during hospitalization. Diabetes is often associated with pain, disability, and morbidity (Merashli, Chowdhury, & Jawad, 2015). Moreover, the global prevalence of diabetes and its musculoskeletal manifestations has rapidly risen over the years. The total number of patients with diabetes mellitus worldwide is expected to reach 642 million in 2040 compared with the current figure of 415 million in 2015 (International Diabetes Foundation (IDF), 2015). Therefore, the impact of Islamic philosophy on the faith and practices of Muslim patients are elaborated in terms of sickness, cleanliness, stress management, food, and medical management.

Methods
The effects of Islamic philosophy on the care of diabetes mellitus and its musculoskeletal manifestations are reviewed by adopting the SPIDER strategy reported by Cooke, Smith, and Booth (2012). In the SPIDER strategy: 1) S means sample, which refers to the populations of Muslim patient and Muslim diabetic patients; 2) PI means phenomenon of interest, which is defined as care for Muslim patients during sickness or hospitalization; 3) D means design of the study; 4) E means evaluation or outcomes being assessed, that is, the care provided to Muslim patients; and 5) R means research type, which is means there are no restric-tion towards quantitative, qualitative or mixed method articles retrieval.
The electronic databases Cumulative Index of Nursing and Allied Health Literature (CINAHL), PubMed, ProQuest, and Science Direct were searched to obtain articles relevant to this work. The following key words were used to extract the relevant literature: "Islamic philosophy, influence of Islamic philosophy in Muslim patients, religious practice during sick, fasting months, and sick." No time restriction was specified for article selection. All of the articles were screened through the abstract prior to be included for analysis.

Results
The obtained literature was analyzed by applying the following focus review question: "What are ontology, epistemology, and methodology of Muslim patients affect their Islamic faith and practices during hospitalization?" An article was included in the review of its full text was available, if it was written in English, and if its study design was not restricted. Articles with only their abstract available and that did not answer the focus review question were excluded from the analysis.
A total of 170 articles were extracted from CINAHL, PubMed, ProQuest and Science Direct. Among 170 articles extracted, only 50 full articles were considered eligible for review and analysis according to the inclusion criteria of this study. These articles varied from intervention studies to narrative review articles.
The findings of the analysis were discussed in systematic process for better understanding of Islamic philosophy according to traditional narrative review. The discussion of Islamic philosophy was delineated according to subtopic of ontology, epistemology and methodology. In addition, the implication of Islamic philosophy on faith and practices were discussed according to the following concepts: sickness, cleanliness, stress management, food, and me-dical management, in order to get clearer picture for the understanding of its impact on faith and practices among Muslim patient.

Discussion
Ontology of Islamic Philosophy. Islamic philosophy is based on four concepts, namely, the Unity of Allah (Azram, 2011;Hanefar, Sa'ari & Siraj, 2016), the Unity of Creation, the Unity of Thought, and the Unity of Man (Azram, 2011). The concept of Unity of Allah states that Allah (the Almighty God) is the only Creator of the universe (Azram, 2011); He is the absolute one, not two or three. If an individual does not believe in Allah, his search for knowledge may be impeded by a lack of faith, blind imitation (Abdullah, 2015;Azram, 2011) and belief in superstition (Azram, 2011). A lack of faith in Allah may lead to the inability to search for knowledge because of one's inability to under-stand the message of the Al-Quran. This inability could lead a person to blind imitation or "taqlid," which means the person blindly follows ideas and knowledge without know whether they are right. The last one is believed in superstition, start to believe inappropriate and deviated thing such as believe to shaman.
The Unity of Creation underlies two principles, namely, determinism, which means every cause has an effect, and uniformity of nature, which means similar causes result in similar effects (Azram, 2011). These principles are observed among patients with diabetes mellitus. For example, diabetic foot ulcers may occur as a result of peripheral neuropathy and could lead to Charcot neuroarthropathy, a progressive manifestation of a deteriorating musculoskeletal system. The Charcot neuroarthropathy does reflecting the principle of determinism. Another principle, similar cause resulting in similar effects can be observed in the body's ability of controlling blood glucose level. If the blood glucose level is too high, it may lead to hyperglycemic state before other musculoskeletal manifestation shown.
The Unity of Thought. There are two types of knowledge in Islamic philosophy namely as revelation and reasoning/natural phenomena (Azram, 2011;Bakir, 2011). Revelations are the knowledge given by Allah through the Al-Quran through Prophet (Peace Be Upon Him (P.B.U.H.). Reasoning is the knowledge obtained from the senses, deep thinking, and perception. In the reasoning knowledge, the causality of knowledge is created by Allah, however, human rationalized the knowledge based on their reasoning. Al-Ghazali, a Muslim philosopher, described two types of knowledge, namely shari (revelation) and aqli (reasoning).
The last concept of Islamic philosophy known as the Unity of Man (Azram, 2011). Islam considers Adam to be the first human created by Allah and has been thought the "name of things which is symbolizing the knowledge transferred to him as human." Allah asked the angels to prostrate to Adam due to his superior knowledge, not his piety. This belief reveals the importance of knowledge and the responsibilities for human beings with this knowledge. The role of humans in the universe is to serve Allah (Hanefar, Sa'ari & Siraj, 2016). Humans must make full use of knowledge both in physical and spiritual as one of the ways to achieve permanent life in the hereafter (Mohamad, Abd Razak & Mutiu, 2011).
Epistemology of Islamic Philosophy. Epistemology in philosophy is regarded as how the knowledge can be derived and justified. Some areas in Islamic philosophy are related to epistemology. For example, the source of knowledge is either revelation or derivation (Athar, 2008). Revealed knowledge or al-Wahy is derived from Allah through the holy book, Al-Quran. Derived knowledge is acquired through the senses, research, and deep thinking.
Another aspect of epistemology in Islamic philosophy is based on three principles known as Ilm' Yaqin, Ainul Yaqin, and Haqqul Yaqin as source of knowledge derivation (Alias, 2017;Azram, 2011). Ilm' Yaqin or knowledge of cer-tainty is derived from what others say. For example, one's knowledge of the musculoskeletal manifestations of diabetes mellitus, for instance, hardening, and cracking of the skin of the foot skin and peripheral neuropathy, is derived from what a doctor says. Ainul Yaqin refers to the eye of certainty, which means knowledge is derived from what one sees. For example, one can actually see that a patient has the disease. Finally, Haqqul Yaqin refers to the truth of certainty. For example, one can test for higherthan-normal blood sugar levels and read the results of a radiograph to confirm Charcot foot. Therefore, the belief that a patient with diabetes may have musculoskeletal manifestations is based on what one sees. The principles in the epistemology of Islamic philosophy are shown in staggered; bottom down from Ilm' Yaqin, Ainul Yaqin, and Haqqul Yaqin (Figure 1).   JKI, Vol. 23, No. 3, November 2020, 184-193 month of Ramadan, paying zakat (a certain amount based on guidelines), and performing pilgrimage at Mecca if able. Figure 2 shows a summary of the Five Pillars.

Implication of Six True Faiths and Five Pillars for Patients with Diabetes Mellitus and Its Musculoskeletal Manifestations.
Performing the Five Pillars is a must, but the practice is flexible according to the patient's condition. For example, Muslims are required to perform five daily prayers. If the condition of patients is deteriorating, they can pray as many times as their condition allows. If unable to stand for prayer, one can pray while sitting. If still unable, one can pray while lying down or by moving their eyes. If they believe that angels document all of their actions, Muslims can still practice their faith in many ways.
Patients with diabetes mellitus and its musculoskeletal manifestations must seek the advice of their physician prior to practicing fasting during Ramadan (Pathan et al., 2012). Hassanein   JKI, Vol. 23, No. 3, November 2020, 184-193 189 Figure 3. Balance of the Five Pillars and Six True Faiths  2017), in collaboration with the IDF, produced a practical guideline that could help healthcare professionals manage patient with diabetes mellitus and its musculoskeletal ma-nifestations during the fasting month. Tablet/ oral medication can be taken within the permitted time to eat; however, if the patient develops a hypoglycemic attack during fasting, the fast can be broken. Patients must consult with their physician prior to fasting so that they can be assessed for suitability to practice fasting (Hassanein, 2016). The patient has done his best to fast but his condition does not permit him to continue. Thus, the patient may not be frustrated or feel guilty for not doing his task as Muslim (fasting) because the Qada' and Qadar has taken place which has put him to break fasting due to his condition.
A Muslim believes in Judgment Day. Therefore, if Muslims do not perform the Five Pillars accordingly, their destiny will be determined by Allah on the basis on their overall actions. Figure 4 summarizes of the implication of the Six True Faiths and Five Pillars in Muslim life.

Implication of Islamic Philosophy on the Following Aspects: Sickness, Cleanliness, Stress Management, Food, and Medical Management
Sickness. Allah tests his subjects through sickness to earn a great reward. Sickness also serves as a form of atonement or compensation for sins that have been committed (The Faith, 2016). It is believed that the sickness may lessen the sin according to the patient's condition. In Islam, sickness, patience, and pain are always correlated. For example, patients with diabetic foot ulcer may bear the pain and discomfort of the wound, thereby strengthening their faith in Allah. They may strongly believe that the ulcer is a test from Allah and must bear its burden. Patients may sick and get treatment and leave Allah to decide on their recovery.

Cleanliness.
Cleanliness is very important concept for a Muslim patient and constitutes part of the Muslim faith. Mizan al-Hikmat XE "Books: Mizan al-Hikmat", (v.5, p. 558) as cited in Kiani and Saeidi (2015) stated that cleanliness is half of the Muslim faith. Cleanliness is divided into two major components, namely, physical and environmental; some literature also includes a spiritual component. In the physical aspect, the body must always clean.
For instance, if a Muslim patient with diabetes mellitus and its musculoskeletal manifestations wants to pray, he must first perform ablution. A nurse could assist the patient by providing water spray or tayammum (if required) to perform the ablution and provide clean clothes.
Muslim patients should pay attention to their physical cleanliness. Cleanliness can protect patients from infection, especially that of diabetic wounds. If a diabetic patient maintains a clean body, the risk of infection may decline (Aiello, Larson, & Sedlak, 2008). Islam encourages maintaining good personal hygiene as a part of Muslim life. Patients with diabetes and musculoskeletal manifestations, such as a foot ulcer, need a clean environment prior to initiating prayers. Nurses can assist patients by providing clean bed sheets when they become soiled with blood or replace wound dressings regularly. Such changes need not be done every time the patient must begin prayers as long as the nurse assesses the cleanliness of the patient's environment and changes wound dressings whenever necessary.

Stress Management.
Stress management is another aspect of patient care that may benefit from considering the Muslim perspective. Diabetes and stress are well correlated. Hilliard et al. (2016)  (1) an emergency really occurred and it is not something that is uncertain. In other words, it already happens or exists where there is damage or illness to five general principles (religion, life, intelligence, linage and property) or the occurrence of damage has been confirmed. This must be made based on strong conviction which is led by experience or knowledge; (2) someone in an emergency situation is against the order or prohibition of Islamic law, or there is no requirement by the Islamic law to eliminate the harm except for things that is banned or prohibited; (3) efforts have to be made to ensure that the present halal materials could not prevent the harm from occurring to patients; (4) the usage of haram materials is a necessity; (5) during treatment, the usage of haram materials must be recommended, ensured and approved by doctors or Muslim health professionals who are fair, believed to practice its religion and beliefs and also have knowledge in that field.
In summary, Muslim patients require halal food and medication. However, under certain condition, haram medications may be used. Patients with diabetes, for example, must not use insulin from bovine sources; instead, an alternative type of insulin not obtained from bovine derivatives is advised.

Implication of Islamic Philosophy toward
The Nursing Practice. When nurses or healthcare professionals understand the needs and beliefs of Muslim patients, improved care may be provided. Knowledge of Islamic philosophy may also help establish good rapport and nurse-patient relationships. In this way, nurses can embrace the needs of different patients according to their religious practices. Hospital administrators may develop improved healthcare systems by providing the appropriate guidelines in line with the needs of Muslim patients. Because newly graduated nurses may have minimal experience, these guidelines may help them support the needs of their Muslim patients.

Conclusion
In conclusion, understanding Islamic philosophy will provide direction for improving patient care and nurse satisfaction. Understanding Islamic philosophy is important among healthcare professionals to provide appropriate care for patients with diabetes and musculoskeletal manifestations. Establishing the appropriate guidelines enhance support, and increase the quality of life, spiritual, and social wellbeing of Muslim patients. Better healthcare services may be provided to Muslim patients if their specific needs are fulfilled on the basis of their beliefs and culture is fulfilled. However, further exploration is needed improve the understanding of how Islamic concepts can be related to health.