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10.1136/bmjopen-2023-082089
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Original Research
Palliative Care
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Somebody who understands the culture and their needs that can cater for them in their retirement time: a peer research study exploring the challenges faced by British Muslims with palliative care needs during the COVID-19 pandemic
https://twitter.com/brionyhudson
http://orcid.org/0000-0002-2907-1764
Hudson Briony F 12b.hudson@ucl.ac.uk

https://twitter.com/Dr_GClarke
http://orcid.org/0000-0001-8438-7131
Clarke Gemma 3G.C.Clarke@leeds.ac.uk

https://twitter.com/drnkupeli
http://orcid.org/0000-0001-6511-412X
Kupeli Nuriye 2n.kupeli@ucl.ac.uk

Rizk Noura 1Noura.Rizk@mariecurie.org.uk

Safdar Mansur 4mansur.safdar@gmail.com

Sherif Jamil 4Jamilsherif@gmail.com

Shafi Shuja 4msshafi12@gmail.com

1 Marie Curie, London, Greater London, UK
2 Marie Curie Palliative Care Research Department, University College London, London, UK
3 School of Medicine, University of Leeds, Leeds, UK
4 Muslim Council of Britain, London, UK
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

None declared.

Dr; b.hudson@ucl.ac.uk
2024
8 8 2024
14 8 e08208914 11 2023
30 7 2024
Copyright © Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
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https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

Abstract

Background

Inequities in palliative and end-of-life care access exist, with evidence of lower uptake of these services among people from the British Muslim community. Little research exists exploring the experiences of British Muslims with palliative care needs and their families during the pandemic or before.

Aim

To coproduce peer research exploring the experiences of British Muslims with palliative care needs and their families during the COVID-19 pandemic.

Design

A collaborative peer research interview study. Peer researchers were recruited and trained to undertake qualitative interviewing. Data were analysed using reflective thematic analysis.

Setting/participants

3 peer researchers conducted 11 telephone interviews (10 in English and 1 in Urdu) between August and September 2021 with 12 participants (5 people with palliative care needs and 7 family carers).

Results

Four themes were identified: (1) issues in accessing healthcare exacerbated by the COVID-19 pandemic, (2) the impact on family carers, (3) variation in support from community groups and (4) social and information exclusion. The COVID-19 pandemic exacerbated existing challenges to accessing healthcare services for British Muslims with palliative care needs. Family members experienced the cumulative impact of supporting people with palliative needs while also advocating for and supporting them to access the care they required. Language barriers, digital exclusion and uncertainly about how to access information, in addition to the apparent lack of consideration of important festivals in the Muslim calendar in the implementation of policies around lockdowns, culminated in a sense of exclusion from COVID-19-related policies and messaging for this population.

Conclusions

These findings support the need to involve people from diverse backgrounds in the design and delivery of healthcare services and policies. Learning from this unique time in our histories should be used to shape future delivery of culturally aware and inclusive care.

PALLIATIVE CARE
COVID-19
Community-Based Participatory Research
Health Equity
Health Services Accessibility
http://dx.doi.org/10.13039/501100000320 Alzheimer's Society 399 AS-JF-17b-016 http://dx.doi.org/10.13039/501100000654 Marie Curie n/a PPI bursary from the NIHR UCLH Biomedical Research Centre BRC834/PPI/BH/104990)
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pmcSTRENGTHS AND LIMITATIONS OF THIS STUDY

Peer researchers contributed to all aspects of the study from development to dissemination.

Bespoke training was developed to support the peer researchers, and ongoing relationships and trust were established.

Peer researchers spoke a range of languages, meaning that it was possible to offer participants a choice regarding the language that interviews were conducted in.

While collecting data over the telephone limited opportunities for non-verbal cues to be analysed, this method enabled flexibility regarding the time and location of data collection.

Introduction

People from minoritised ethnic groups experience unequal access to palliative and end-of-life care (PEoLC).1 Evidence links this to range of factors including lower health literacy around palliative care, hospice and advance care planning, mistrust of health care services, social determinents of health, medical racism, cultural and religious customs, and communication at end of life.2 Hussain et al highlighted the need for partnerships between organisations and communities, to cocreate evidence to understand and tackle inequities in palliative care.3

In England and Wales, the population of Muslims increased from 2.7 million (4.9%) in 2011 to 3.9 million (6.5%) in 2021, making them the second largest religious group. Almost one in three people from minoritised ethnic groups are British Muslims.4 Older British Muslims (aged over 65) display higher prevalence of chronic illnesses such as diabetes, heart conditions and high blood pressure compared with the rest of the UK population.5 Older Muslim women are twice as likely to report having ‘bad’ or ‘very bad’ health compared with other older women in England.5

During the COVID-19 pandemic, the highest age-standardised mortality rates of COVID-19 deaths were within minoritised ethnic groups6 who were also referred later to palliative care services than people from other groups.7 Policies such as restricted visitation and personal protective equipment disproportionately affected people from ethnically diverse groups, due to communication challenges and unmet religious and faith needs.8

These inequities highlight the need for research conducted in partnership with people with lived experience to enable detailed explorations of the realities of being a Muslim in Britain with palliative care needs, to identify barriers to support and suggestions for improvements for future experiences. In response, this study aimed to undertake peer research exploring the experiences of British Muslims with palliative care needs and their families during the COVID-19 pandemic.

Methods

Design

Peer research is a participatory method that involves working alongside people with a shared identity or lived experience. Peers, join the research team to enable a diverse group of voices to be considered throughout the project.9 This approach facilitates consideration of cultural, language and religious issues. The development of trust and rapport with research participants may be supported through the inclusion of people from communities or groups who are part of the research team.9

Peer research methods10 have been recommended when working with minoritised ethnic groups in palliative care research.11 In this study, peer researchers were equal partners at all stages of the research, from question formulation, topic guide development, data collection, analysis to recommendation building and are co-authors of this manuscript.

Recruitment

Peer researchers

The opportunity to join the research team as a peer researcher was advertised by the Muslim Council of Britain via its WhatsApp channels and mailing lists. This information was provided in six languages (English, Urdu, Arabic, Bengali, Guajarati and Punjabi). An online information session was held in which the rationale for the project, initial ideas about its aims and what involvement would entail were discussed.

Interview participants

An information sheet was codesigned with peer researchers and distributed via the Muslim Council of Britain’s networks, in six languages. Snowball sampling was used, this approach has been effective for recruiting people from minoritised communities and groups.12

Inclusion criteria were:

Participants were all of Muslim faith and came from diverse ethnic backgrounds.

Adults (18 years or older) with palliative care needs were included and had a variety of health conditions.

Participants were also included if they were current or past carer for someone with palliative care needs during the COVID-19 pandemic.

Exclusion criteria were:

People aged under 18 years.

People who did not identify as being Muslim, having palliative care needs or caring for someone with palliative care needs.

Lack of capacity to provide informed consent.

Training and support for peer researchers

Peer researchers had some previous experience in working with people from minoritised communities and had published reports.4 5 13 A bespoke training package was developed for peer researchers by BFH, GC and NK. This was based on existing training around research involvement developed by Marie Curie. It contained information about research involvement, qualitative research methods and analysis. This was delivered online to five people, three joined the team as peer researchers (SS, MS, JS).

The research team listened to interview recordings and provided support to peer researchers via online follow-up meetings to reflect on the data and process. An online survey was circulated to peer researchers following the training (online supplemental appendix 1). Each peer researcher reported finding the training to be useful or very useful.

Data collection

Peer researchers conducted telephone interviews between August and September 2021 using codesigned topic guides (box 1). All participants were given a choice of the language interviews could be conducted in. The potential for interview topics to elicit an emotional response in both peer researchers and participants was discussed and a distress protocol was established. Research team members with experience of qualitative research (BFH, GC, NK) met online with peer researchers frequently to discuss and reflect on data collected and the process of collecting data. The research involved people with complex health needs and researchers adapted the research processes based on COVID-19 pandemic restrictions on social contact that had only just been lifted in July 2021 in the UK.

Box 1 Topic guide for interviews

The impact of COVID-19 restrictions on Muslim people living in Britain.

The sources of COVID-19-related information.

Healthcare access.

Sources of support.

Experiences of bereavement.

Data analysis

Recordings were transcribed verbatim and pseudonymised. Data were analysed using reflective thematic analysis.14 This was iterative and inductive in nature. The researchers made a situated interpretative judgement to stop data collection, influenced by the richness of the data. Researchers recursively moved back and forth between coding and theme development. As reflective thematic analysis was used, researchers did not aim to achieve data saturation.15 An approach applied in other studies.16 17 Researcher subjectivity is an important analytic resource in reflexive thematic analysis for illuminating meaning.18 Initial themes were coded using qualitative analysis software NVivo V.R1 (2020) by BFH, GC and NK and were discussed and refined through online team meetings with BFH, GC, NK, NR, MS and SS.

Patient and public involvement

This research was conducted in partnership with the Muslim Council of Britain. Members of the public were involved, as peer researchers, in all stages of the project and its dissemination.

Results

Characteristics of peer researchers

All telephone interviews were conducted by male peer researchers (SS, MS, JS) from Pakistani Asian ethnic groups who spoke multiple languages including Urdu, Punjabi, French and English. They were all part of the Muslim Council of Britain Research and Documentation Committee. SS has a clinical background and clinical research experience; SS, MS and JS did not have any experience in undertaking social science research and had experience in supporting family members who had ill health.

Participant demographics

11 telephone interviews were conducted with 12 participants, 5 people with a life-limiting condition and 7 family carers. The majority of participants were interviewed on their own (n=10). The majority of interviews were conducted in English (n=10) and 1 in Urdu. The mean age of people living with life-limiting illness was 69 years (range=42–85), compared with 51 years (range=35–67) for family carers. Participants came from a range of ethnic backgrounds (online supplemental material). The majority of family carers were born in the UK (5, 71%), and all people with palliative care needs were born outside the UK. Diagnoses of participants included cancer, dementia, heart failure and multiple sclerosis.

Main findings

Four themes were identified:

Issues in accessing healthcare exacerbated by the COVID-19 pandemic.

Impact on the families of people with palliative care needs.

Variation in support from community groups.

Social and informational exclusion.

Theme 1: issues in accessing healthcare exacerbated by the COVID-19 pandemic

Due to rapid changes in how healthcare services were delivered during the pandemic, participants described delays in accessing care. Numerous challenges were outlined including accessing treatment or obtaining medications and making appointments with healthcare professionals. Participants felt that the shift to virtual or telephone services disadvantaged older people with lower levels of English proficiency and digital literacy. This compounded the multiple levels of access issues experienced and increased stress, frustration and social isolation.

If she did get through [on the phone] then she would have difficulty understanding or getting her point across. So, when she would be talking to the receptionist or whatever, the receptionist wouldn’t understand her maybe because of her accent. And my mum couldn’t hear her properly. There’s a language issue. (Rayyan, family carer)

Participants described how people with palliative care needs were unable to access the support, or experienced greater delays in accessing care during the pandemic, resulting in increased health problems.

All her problems they just piled up and I think that part of it was neglected. Where, we’d say, “Okay are your arms okay?” She’d say, “Yes, it’s okay.” Because she knew that if she goes to the doctors, they just take ages, the surgery is always busy. They’re slow about things. (Ali, family carer)

Patients and families were not always confident that services would understand or be able to meet their cultural, faith or communication needs. Concerns and fears about such experiences led many patients and families to avoid hospital admissions and support people at home for as long as possible.

So, yes, if my parents become ill or sick or whatever they may well be speaking in Punjabi or in Urdu or in whatever language. And the nurses may not be able to give them that care and attention. Yes, I would be reluctant to send them to the hospital. (Rayyan, family carer)

However, some participants felt reassurance when they spoke with healthcare professionals who had an understanding of their culture, as they felt they understood and supported in a way that met their needs.

The reason we managed to…get things done for my dad is because … my brother… spoke to an NHS worker… who is actually a Muslim guy. And it’s only because it’s a Muslim guy who understands the needs of my parents. (Rayyan, family carer)

Despite these challenges, family carers expressed understanding that services were required to adapt the way they care for people as a result of the pandemic.

I think the [GP] surgery was so not prepared for this that they weren’t able to cope either. So I don’t think they had a plan for dealing with old age, non-tech savvy, users of mobile devices and phone devices, laptops. I think they were really caught cold, I don’t think they had a plan for that. (Saad, family carer)

Theme 2: the impact on family carers

Given the multiple levels of challenges participants experienced trying to access virtual services, family members often had to step in and provide additional support. Family carers described mental and physical exhaustion and feelings of overwhelm and anxiety.

As he became more and more bed bound towards the end, myself and to a lesser extent, my sister, were … having to take care of him on a day-by-day basis, in terms of his physical needs and things. Helping him wash, go to the toilet, feed and things like that. (Rashid, family carer)

The desire to avoid hospital admissions placed even greater strain on families and increased their caring responsibilities further.

I tried to treat him at home when he had diarrhoea, and my brother had to intervene. And he wore masks and PPE when he was cleaning him. Eventually, he wasn’t passing urine. So, that’s when we had to call an ambulance again and he went into hospital. (Shehzeen, family carer)

There was a cumulative impact from the additional caring responsibilities. Some family members felt they were risking their own health and putting their own lives on hold to support their relative.

I know I was risking my own self… but I did eventually go in anyway. I would have liked to at least have access to him, to be able to feed him and communicate his needs… with the medical staff that are dealing with him. But we didn’t have that facility for the first four or five days. So, by the time they did let me stay with him – I stayed for 12 hours. Really exhausting. But I did have to put my studies on hold and everything else. But I felt that it was really necessary. (Shehzeen, family carer)

Although caring responsibilities placed a great burden on participants, they experienced both positive and negative impacts. Family members cared deeply for their relatives and described taking on a caring role as part of their identity and responsibilities.

Culturally that’s our nature. So, as Muslim children… you’re thinking about your loved ones… You’re always thinking about your own children. You’re always thinking about your partner. You’re always thinking about your parents certainly. Siblings… generally, you know very family orientated. (Rayyan, family carer)

Care and support were often embedded within the family network, and decision-making about health was frequently shared across the family.

We need to think of how we’re going to deal with it. I’ve called all the siblings and we’ve had these discussions; how we’re going to deal with it. (Rayyan, family carer)

Theme 3: variation in support from community groups

The level and type of support people received from local councils, communities and mosques during the pandemic was mixed. Many participants felt isolated, while others received a range of supports. Some participants described regular welfare checks and offers of support with shopping from their local council.

The council rang, they offered to drop the shopping in every week and I refused to because I already had the shopping and I would want somebody else to take that, who needed it more than I did…I got letters from the council saying that if you needed help or if you wanted to change anything, let us know. (Reema, living with life limiting illness)

The patchwork nature of this support led some participants to query whether people who were less embedded in their neighbourhood would receive the same level of support.

There’s been a lot of community help, but that’s mainly because my parents have been in this area for a long time, and they are known in this area. So, I feel for people that don’t know anyone. I think it’s really hard. There’s no systematic help if that’s what you’re thinking. (Fawiza, family carer)

Experiences of support from local mosques and local Muslim community groups varied. Some felt that mosques should have been more proactive in reaching out people with life-limiting illness or in trying to create a sense of community despite restrictions.

I think this would have been a great opportunity for the Mosque to take an active role in the wellbeing of the people…But it didn’t happen that way. It’s an opportunity lost. (Hussain, living with life limiting illness)

For others, the wider ‘mosque community’, with the mosque working together with local Muslim groups, families and individuals, provided support.

The Mosque were reaching out to say subscribe to the vulnerable families’ packs and stuff like that…. So, that was good, but Alhamdulillah, I don’t think we needed that support, but it was on offer. (Ali, family carer)

Examples of support from local community faith groups were also shared, which made people feel included and supported.

Each time I had to go for my COVID jab, they [community group] took me. And for other appointments… it’s a voluntary service, they do wonderful work, they pick me they put me in their car and then they have an attendant with them… and once I have finished, they take me back… they also bring food whenever I want. (Hasan, living with life limiting illness)

Technology was useful for maintaining contact with the community while restrictions were in place. Unlike in relation to accessing services, technology strengthened community and social connections during the pandemic.

I run women’s group voluntarily when there is translation and explanation of Quran [The Holy book]…[after the second lockdown] we started our classes online on zoom, after that things started getting better. At least we could have our classes, and could talk to few people. (Dunia, living with life limiting illness)

Theme 4: social and information exclusion

During the pandemic, access to information about COVID-19 was varied. Some participants felt confident in accessing the information they needed.

Yes, she’s educated to a level, so I guess she’s kept that going really. She likes both, like Islamic knowledge and current affairs, keeping up to date. She missed the fact that I used to bring her the Metro morning and evening from work. But then we brought her a phone, so she reads stuff on the phone and she knows how to use the TV and stuff. (Ali, family carer)

Other participants felt they lacked information about COVID-19 and were concerned that older members of the Muslim community may be struggling, in terms of access to information and support.

I would say not much has been really done to make our elderly, or those who are very vulnerable in our community- I don’t think there was very much that was focused on- I don’t think there was much literature or information focused that we could really provide to our mum. Only, what we told her. (Zainab, family carer)

As with access to healthcare services, language barriers prevented some participants accessing information about COVID-19. One participant suggested that information posted in Urdu and Punjabi would have been more accessible.

More [information] could be provided. And if the NHS provided better leaflets and maybe better online. Or even news itself in a better way. Maybe use WhatsApp messages or some kind of media messages where they could post in Urdu or Punjabi or in a different language where they could get information out in different languages. (Rayyan, family carer)

It was particularly distressing for those who lacked information about their own or their family member’s condition, such as where to go for help and what to do about symptoms.

It’s been very traumatic in the sense that we didn’t know what to do. He’s very agitated and he’s anxious, he is depressed, so our experience has been that we haven’t been well prepared, we didn’t know what to do and I think also things meant that we weren’t very good at it. (Saad, family carer)

Overall, many participants felt excluded by public health messaging and government policies during the pandemic. Policies around COVID-19 were felt to be implemented without consideration for important aspects of Muslim faith. This was especially pertinent for people with palliative care needs who felt impacted on multiple levels, by the pandemic itself and by their age and healthcare needs. Language barriers, digital literacy and the view that aspects of faith and culture were not adequately considered in wider political and societal considerations compounded a sense of social exclusion.

EID is a festival which we celebrate and hold very dear to us. But obviously EID was cancelled. That decision…. had a massive impact on the Muslim community…. And the day before EID to put in such restrictions. And then decide that it was okay for Christmas… And, it’s affecting the elderly, the vulnerable a lot more than it might be the youths…. And, yes, it is kind of traumatising because we’ve been doing it all our lives, right. (Rayyan, family carer)

Discussion

This study, conducted in partnership with people from the British Muslim community, highlighted some of the factors fuelling inequitable access to palliative care. The data collected draws on participants’ experiences during the COVID-19 pandemic, but the findings and recommendations have relevance for tackling the inequity the pandemic has highlighted.

Main findings/results of the study

Challenges in accessing healthcare were multifaceted and included delay accessing appointments and medications, language and communication difficulties and digital exclusion. Families provided a high level of practical and emotional support as a result of both culture and difficulties accessing care from other sources. A range of positive and negative experiences were described relating to support from local councils, communities and mosques. Uncertainty was common around where and how to access reliable information about COVID-19 and the support services that were available and feelings of not being considered in policies and messaging were described.

How does these findings link to the literature?

There is limited research on the needs and challenges of Muslims in accessing PEoLC services in non-Muslim majority countries.19 Themes identified in this research echo existing literature calling for more culturally sensitive healthcare services, providing healthcare professionals with training that allows for support to be tailored to the values and beliefs of minoritised ethnic groups.1922 Caring for family is considered a moral duty and important to Muslims,19 23 therefore it may be needed to be inclusive of family in communication and care decisions.24 The impact of language and communication barriers on minoritised ethnic groups accessing support and making informed decisions hass been highlighted previously,20 21 25 as well as the need for greater support for people who were isolated.21 There is a need to engage with communities to raise awareness of PEoLC and sources of support among different groups21 26 27 and develop services that are responsive to local populations.2

Implications for future research and practice

To address inequities in palliative care access, an approach to research, service and policy development is needed that works in partnership with people experiencing inequity. Coproduction28 is essential in understanding and addressing factors that fuel inequitable access. Peer research was feasible and fruitful in this context and warrants greater use in PEoLC research. Other studies have used peer researchers with older adult population29 and those of four intersecting communities (mental health service user/survivor, people who use drugs, racialised and trans/non-binary communities).30 Benefits included building trust, rapport and empathy with participants who are less actively involved in research.31 It also enables cultural competent researchers with shared identify to be involved, the lack of cultural sensitivity has been identified as a barrier to involving minoritised ethnic groups in research.11

Healthcare providers and organisations must endeavour to understand their local context and population and consider this in the development, delivery and communication of their services. National guidelines have also been developed on the importance of community partnerships to tackle inequities at the end of life.32 Consideration of how to understand and incorporate the needs of different groups is essential.

What this study adds

British Muslims with palliative care needs faced challenges in accessing healthcare support and treatment. This was compounded by digital exclusion and language barriers. Families took on extra caring responsibilities and described feeling isolated and anxious. Where support worked well, social support was delivered in partnership with community and faith groups. Participants described uncertainty around how to access information or support for their care needs.

Future research should incorporate peer research methodologies to ensure people with lived experience play a central role in the design, development and dissemination of research, service development and palliative care practice. In particular, the involvement of people with lived exprience in research exploring culturally appropriate approaches to advance care planning is needed, to ensure wishes and preferences towards care and support are known and can be acted on.

Limitations

The experiences of people with heritage from other parts of the world may not be represented and should be explored in future research. Understanding the experiences of people without access to support from family members should also be explored. Other limitations include the potential of recall bias and the inability to observe body language and visual cues of participants when conducting telephone interviews.

Conclusion

Access to healthcare for people with life-limiting illness is fundamental to quality of life, and life course inequities persist at the end of life. The study highlights the difficulties and challenges people from the British Muslim community with palliative care needs experienced during the COVID-19 pandemic and beyond, including language barriers and digital exclusion. There is a need to build stronger links with groups experiencing inequitable access, using peer research methodologies is one way to amplify voices that may otherwise be under-represented in research.

We must ensure learning from this unique time in our histories is taken forward to ensure that future care delivery is culturally aware and inclusive if we are to end inequity in end-of-life experiences.

supplementary material

10.1136/bmjopen-2023-082089 online supplemental file 1

10.1136/bmjopen-2023-082089 online supplemental table 1

Acknowledgements

We would like to thank the people who generously shared their time and experiences with us to support the project including people who shared their stoties, members of the Muslim Council of Britain and Marie Curie staff from Caring Services, the Policy and Research Team and members of the Ethnic Diversity at Marie Curie staff network for their insights, thoughts and contributions.

Data availability statement

Data are available upon reasonable request.

Review Process File
8 8 2024

Funding: BFH, NR and GC’s roles were supported by Marie Curie. NK’s role was supported by the Marie Curie Palliative Care Research Department at University College London and by an Alzheimer’s Society Junior Fellowship grant (Grant Award number: 399 AS-JF-17b-016). MS, SS and JS were supported by the Muslim Council of Britain. This project was also supported by a Public Patient Involvment Bursary from the National Institute for Health Research at University College London Hospital Biomedical Research Centre (ref: BRC834/PPI/BH/104990).

Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online (https://doi.org/10.1136/bmjopen-2023-082089).

Provenance and peer review: Not commissioned; externally peer reviewed.

Patient consent for publication: Not applicable.

Ethics approval: This study involves human participants and was approved by University College London (reference: 6202/004, approval received on 17 June 2021). Participants gave verbal informed consent to participate.

Patient and public involvement: Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
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