Diabetic Muslim Patientsrsquo Medication Use Behavior and Perceptions Regarding Collaboration with Pharmacists during RamadanAhmed Alshehri12 PhD Jamie C Barner1 PhD Carolyn Brown1 PhD Kentya Ford1 DrPH Karen Rascati1 PhD Saeed Atif3 PhD

1The University of Texas at Austin College of Pharmacy 2Prince Sattam Bin Abdulaziz University College of Pharmacy 3Muslim Children Education and Civic Center

CONCLUSIONS

REFERENCES

BACKGROUND

OBJECTIVE

METHODSLIMITATIONS

bull Muslims in the US

bull Population

bull 28 million (08) in 2012

bull 63 were first generation immigrants1

bull 30 White 23 Black 21 Asian 6 Hispanic and 19 other or mixed race1

bull 45 had an income of less than $300001

bull Fasting during Ramadan (~30 days)

bull Purpose

bull Allow Muslims to experience the hunger and thirst of poor people2-5

bull Control their desires and to avoid committing sins2-5

bull Required All Muslims who are post-pubescent and sane2-5

bull Prohibited from sunrise to sunset (~15-17 hours)

bull Drinking eating and smoking

bull Oral and intravenous medications

bull Exempt Sick people breastfeeding and pregnant women (Quran 2 183)

bull Diabetic Patients During Ramadan

bull Fasting during Ramadan

bull 428 of type 1 and 787 of type 2 diabetics fast at least 15 days 6

bull Medication modification

bull Outside the US 6

bull 15-19 decreased oral medication dose

bull 247 decreased insulin dose

bull In the US7

bull 33 decreased oral medication dose

bull 9 increased oral medication dose

bull Diabetes education

bull Outside the US

bull 32 of type 1 and 38 of type 2 diabetes patients did not received recommendations regarding fasting6

bull In the US

bull 46 did not receive education on medication use during fasting7

bull Literature Gap

bull Of the few studies examining Muslim patients none

bull Used a theoretical framework to examine Muslims medication usage behavior during Ramadan

bull Addressed Muslimsrsquo perceptions regarding pharmacistsrsquo abilities to help them manage their medication during Ramadan

bull Study Objective are1 To describe Muslim predisposing enabling and need factors and satisfaction with

pharmacy services of Muslim patients with diabetes2 To describe the Muslimsrsquo diabetes medication usage and diabetes management

behaviors during Ramadan3 to determine if predisposing enabling and need factors and satisfaction with pharmacy

services have an impact on diabetic Muslimsrsquo medication usage during Ramadan4 To describe Muslimsrsquo perceptions of pharmacist engagement services during Ramadan

bull Study setting and population

bull Study instrument Cross-sectional survey (in English and Arabic) based on the Behavioral Model for Vulnerable Populations

bull Study sample Convenience sample of Muslims from four mosques in San Antonio

bull Inclusion criteria Adult (age 18 and older) with diabetes who used oral diabetic medications

bull Study variables

bull Dependent variables Medication Usagebull 7 items regarding what changes

patients made without health care providerrsquos approval

bull Changing medication time

bull Decreasing dose

bull Changing medication dosage form

bull Increasing dose

bull Changing medication frequency

bull Combining multiple doses

bull Stopping medicationbull Variable total score

bull Score 0 Did not make any changes or changed only medication time

bull Score 1 Made changes other than medication time

bull Independent variablesbull Predisposing factors (Age gender

marital status health belief race education employment family size country of birth acculturation perceived islamophobia)

bull Enabling factors (regular source of care insurance income social support health care barriers self-helpability of negotiate the system)

bull Need factors Perceived diabetic health stratus diabetes complications

bull Outcome factors Satisfied with pharmacist services

bull Statistical analysis Descriptive analysis amp Multivariate logistic regression

29

3936 34

1

2

3

4

5

Health Belief Related to Fasting in RamadanMea

n p

erce

pti

on

1=Strongly Disagree 5=Strongly Agree

Participantsrsquo Health Beliefs

Belief of Being Exempt From Fasting During Ramadan Due toDiabetesBelief of Religious Aspects and Self-efficacy

Beliefs Related to the Benefits of Fasting

Overall Scale Total

5158

46

31

48 46

1

2

3

4

5

6

Religiosity Scale

Mea

n p

erce

pti

on

Participantsrsquo Religiosity Scale

Reciting The Quran

Praying Prescribed Prayers

Attending Services at The Mosque

Practicing Fasting

Engaging in Free Prayer

Overall Scale Total

18

2622

1

2

3

4

5

Acculturation ScaleMea

n p

erce

pti

on

1=Not at all true of me5=Extremely true of me

Participantsrsquo Acculturation Level

Islam Identify American Norms Overall Scale Total

2936

31

1

2

3

4

5

IslamophobiaMEA

N P

ERC

EPTI

ON

1= Strongly disagree 5= Strongly agree

Participantsrsquo Islamophobia Perceptions

General Fear of Islam Islamophobia in Media

Overall Scale Total

bull Regular source of care

bull 842 had primary care physician and 487 had primary pharmacist

bull Insurance Insured (627)

bull Income bull lt $20000 (400) bull $20000 ndash $49999 (416)

bull Self-help and ability to negotiate

health care system

bull Overall score 37 (plusmn08) (1= Strongly disagree to 5 = Strongly agree)

29 2622 23 21 24

1

2

3

4

5

Healthcare Barriers

Mea

n p

erce

pti

on

1=Strongly Disagree 5=Strongly Agree

Participantsrsquo Healthcare Barriers

Cost Language

Trust Provider Characteristics

314 319

114 44

243

29

60739

57 7371 73

0102030405060708090

100

Fasting ability Medication management

Perc

ent

Social Support

Participantsrsquo Social Support

Family Friends Imam Physicians Pharmacists Nurses

bull Perceived diabetic health status

bull Excellent (0) Very good (162) Good (324) Fair (392) Poor (122)

bull Evaluated diabetic condition

bull Diabetic type

bull Type 1(230)

bull Type 2 (743)

bull Years of being diagnosed with diabetes 118 (plusmn95) years

bull Diabetes management

bull Oral Medication (750)

bull Insulin by injection (197)

bull Medication schedule

bull Oral medication

bull Every morning (596)

bull Twice day (386)

bull Insulin

bull Every morning (200)

bull Twice a day (267)

bull Diabetic complications

bull Had complications (671)

bull Number of hospitalization and emergency room visits

bull ge1 Hospital admission (106)

bull ge1 Emergency room visits (82)

bull Number of hyper and hypoglycemia episodes

bull Hypoglycemia 28 (plusmn69)

bull Hyperglycemia 25 (plusmn67)

436 38

35 37 36

1

2

3

4

5

Perception of Pharmacists Services

Mea

n p

erce

pti

on

1=Strongly Disagree 5=Strongly Agree

Participantsrsquo Satisfaction with Pharmacistrsquo Services

General Services Interpersonal

Communication Accessibility

Comprehensive Overall Scale Total

24 2331

38 39

0

1

2

3

4

Personal Health BehaviorMea

n P

erce

pti

on

0 = Never 4 = Always

Frequency of Health Behaviors 3 Months Prior to Ramadan

Diet Exercise

Check Blood Glucose Level Adhere to Oral Medicatons

Adhere to Insulin

50385

515 574667

0

20

40

60

80

100

Personal Health Behavior

Perc

ent

Who Did Not Change

Health Behavior Proportion Unchanged During Ramadan

Diet Exercise

Check Blood Glucose Level Adhere to Oral Medications

Adhere to Insulin

652

391

22 65

196130 130

182 18291

182

0091

000

20

40

60

80

100

Changed Time ChangedFrequency

ChangedDosage Form

Increased Dose Decreased Dose StoppedMedication

CombinedMultiple Doses

Perc

ent

Frequency of Medication Changes during Ramadan without Health Care Providersrsquo Approval

Changed Oral Medications Changed Insulin Medications

bull Demographic

bull Age 565plusmn138 years

bull bull Male (547)

bull Social structure

bull 507 were White

bull Education level Some college or less (654)

bull Country of birth Born outside the US (813)

bull Years of living in the US 238 (plusmn193) years

Independent variables

Coefficient β Standard Error

Wald Chi Square

P-Value a Odds Ratio

95 Confidence Interval

Health care barriers

197 083 571 0017 720 143 ndash 3635

Diabetic complications

040 033 147 0226 149 078 ndash 285

Satisfaction with care

- 077 060 165 0200 046 014 ndash 150

38 39 37 38 38

1

2

3

4

5

Perception of Proposed PharmacistEngagement Activities During Ramadan

Mea

n p

erce

pti

on

1=Strongly Disagree 5=Strongly Agree

Participantrsquos Perception of Pharmacist Engagement Activities during Ramadan

Encouragement and Support Regarding Fasting

Understanding Islamic ReligionCulture

Creating a Muslim-Friendly and Welcoming Environment

Modifying Medications for Fasting

Overall Scale TotalModel χ2 = 2057 df = 3 p lt 0001 a Significant at p lt 005

bull Generalizability

bull Results compared to generalize study such as Pew Research Studies

bull Scale reliability

bull Original scales were not designed for Muslims in the US

bull Reliability coefficients was between 067 and 091

bull Scale Validity

bull Scales were provided in 2 versions Arabic and English

bull Face validity was assessed in the pretest

DISCUSSION

1 Muslim Americans No Signs of Growth in Alienation or Support for Extremism (2011) United States Politics and Policy Retrieved April 04 2015 from httpwwwpeople-pressorg20110830muslim-americans-no-signs-of-growth-in-alienation-or-support-for-extremism

2 Blackwell A H (2009) Ramadan Infobase Publishing3 Hussain M (2012) The Five Pillars of Islam Laying the Foundations of Divine Love and Service to Humanity Kube Publishing Ltd4 Melton J G amp Baumann M (2010) Religions of the world a comprehensive encyclopedia of beliefs and practices ABC-CLIO5 Zaidi F (2003) Fasting in Islam--implications for midwifery practice British Journal of Midwifery 11(5) 289-292 6 Salti I Beacutenard E Detournay B Bianchi-Biscay M Le Brigand C Voinet C amp Jabbar A (2004) A Population-Based Study of Diabetes and Its Characteristics During the Fasting Month of Ramadan in 13

Countries Results of the Epidemiology of Diabetes and Ramadan 14222001 (EPIDIAR) study Diabetes Care 27(10) 2306-2311 7 Pinelli N R amp Jaber L A (2011) Practices of Arab American patients with type 2 diabetes mellitus during Ramadan Journal of Pharmacy Practice 24(2) 211-2158 Shah S M Ayash C Pharaon N A amp Gany F M (2008) Arab American immigrants in New York health care and cancer knowledge attitudes and beliefs Journal of immigrant and minority health 10(5)

429-436 9 Asfar T Ahmad B Rastam S Mulloli T Ward K amp Maziak W (2007) Self-rated health and its determinants among adults in Syria a model from the Middle East BMC Public Health 7(1) 17710Jaber L A Brown M B Hammad A Zhu Q amp Herman W H (2003) Lack of acculturation is a risk factor for diabetes in Arab immigrants in the US Diabetes Care 26(7) 2010-201411Abdulrahim S amp Baker W (2009) Differences in self-rated health by immigrant status and language preference among Arab Americans in the Detroit Metropolitan Area Social Science and Medicine 68(12)

2097-2103 doi 101016jsocscimed20090401712Mygind A Kristiansen M Wittrup I amp Noslashrgaard L S (2013) Patient perspectives on type 2 diabetes and medicine use during Ramadan among Pakistanis in Denmark International Journal of Clinical

Pharmacy 1-813Peterson S Nayda R J amp Hill P (2012) Muslim persons experiences of diabetes during Ramadan information for health professionals Contemporary Nurse 41(1) 41-47 doi 105172conu20124114114Muslims and Islam Key findings in the US and around the world (2017) United States Politics and Policy Retrieved June 16 2016 from httpwwwpewresearchorgfact-tank20170526muslims-and-

islam-key-findings-in-the-u-s-and-around-the-world15US Census Bureau (2016) Average Number Of People Per Family Household By Race And Hispanic Origin Marital Status Age And Education Of Householder 2016 access at

httpswwwcensusgovdatatables2016demofamiliescps-2016html16Kaiser Family Foundation analysis of the Center for Disease Control and Prevention (CDC)s Behavioral Risk Factor Surveillance System (BRFSS) 2013-2015 Survey Results access at httpkfforgdisparities-

policystate-indicatorno-personal-doctorcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D17Lange L J amp Piette J D (2005) Perceived health status and perceived diabetes control psychological indicators and accuracy Journal of psychosomatic research 58(2) 129-13718Centers for Disease Control Prevention (2014) Mean and Median Distribution of Diabetes Duration Among Adults Aged 18ndash79 Years United States 1997ndash2011 Retrieved from

httpswwwcdcgovdiabetesstatisticsdurationfig2htm19Hammoud M M White C B amp Fetters M D (2005) Opening cultural doors Providing culturally sensitive healthcare to Arab American and American Muslim patients20Morales L S Cunningham W E Brown J A Liu H amp Hays R D (1999) Are Latinos Less Satisfied with Communication by Health Care Providers Journal of General Internal Medicine 14(7) 409ndash417

httpdoiorg101046j1525-1497199906198x21Villani J amp Mortensen K (2014) Decomposing the gap in satisfaction with provider communication between English-and Spanish-speaking Hispanic patients Journal of immigrant and minority health 16(2)

195-20322Mafauzy M Mohammed W Anum M Zulkifli A amp Ruhani A (1990) A study of the fasting diabetic patients during the month of Ramadan Med J Malaysia23Aslam M amp Healy M (1986) Compliance and drug therapy in fasting Moslem patients Journal of Clinical Pharmacy and Therapeutics 11(5) 321-325

bull Health Belief participants

bull Cared more about fasting than about managing their diabetes

bull Were not sure (29 plusmn 07) whether they were exempt from fasting or not due to their diabetes

bull Participantsrsquo diabetic condition varied

bull Religiosity

bull Average religiosity scale was high (46 plusmn08)

bull Similarly 29 of Muslim showed a high level of religious commitment regarding mosque attendance daily prayer1

bull Acculturation

bull Had a low level of acculturation (22 plusmn06)

bull Agreed that they adhered to their Islamic identity

bull 69 of Muslims in the US believed that Islam was very important for their lives compared to 70 of Christians in the US1

bull Islamophobia

bull Participants

bull Were unsure (29 plusmn 08) regarding fear of Islam among non-Muslims Americans

bull Low level of interaction with non-Muslim Americans

bull Almost agreed (36 plusmn 11) about the presence of Islamophobic content in the US media

bull High frequency of watching and listening to various media sources

bull Federal Bureau of Investigation showed that

bull In 2014 the overall crime rate generally dropped

bull The hate crimes against Muslims increased by 14

bull Social support

bull In whether to fast or not

bull 614 followed the advice of their health care providers

bull 514 followed the advice of non-health care providers

bull Similarly 67 of US diabetic Muslim received advice from health care providers in regard to whether or not to fast7

bull In managing their diabetes while fasting

bull 754 depended on their health care providers for help

bull Health Care Barriers

bull Disagreed or were unsure (24 plusmn 05) about having barriers to health care

bull Reason 627 had health care insurance

bull Evaluated diabetic condition

bull Compared to the general US diabetic population

bull A higher proportion of study participants had

bull Type 1 diabetes (230 vs 5)18

bull Been Hospitalized (106 vs 29) or visited the emergency room (88 vs 48) due to their diabetes 18

bull Satisfaction with pharmacist services

bull Overall neutral to satisfied (36 plusmn 07) regarding pharmacist overall services

bull More willing to accept pharmacistsrsquo recommendations19

bull Diabetic medication users

bull Oral medication users

bull In the present study 196 decrease dose and 13 stopped using medications

bull In the literature 149 - 188 decreased dose and 11 - 21 stopped using medications7

bull Insulin medication users

bull In the present study 182 increased dose and 91 stopped using insulin

bull In the literature 82 - 107 increased dose7 and 3 - 8 stopped using insulin7

bull Health care barriers impact on participantsrsquo medication usage changes

bull As the score for health care barriers increased by one unit

bull The odds of changing medication usage without a health care providerrsquos approval increased by 720 times

bull As the health care cost increased by one unit

bull The odds of changing medication usage without a health care providerrsquos approval increased by 223 times

bull Although participantsrsquo incomes did not have a statistically significant relationship with medication usage changes during Ramadan

bull Perceptions regarding proposed pharmacist services during Ramadan

bull Overall positive perceptions (38 plusmn 07)

bull This showed that Muslims were positive regarding pharmacistsrsquo engagement during Ramadan

bull 76 Muslim diabetic participants completed the survey

Independent variables

Coefficient β Standard Error

Wald Chi Square

P-Valuea

Odds Ratio

95 Confidence Interval

Health care cost barriers

080 038 437 0037 223 105 ndash 472

Health care providersrsquo characteristics barriers

000 050 000 0998 100 038 ndash 267

Discrimination 066 050 173 0189 192 073 ndash 506

Diabetic complications

043 034 160 0206 154 079 ndash 302

Satisfaction with care

- 095 064 220 0138 039 011 ndash 136

RESULTS

PREDISPOSING FACTORS Enabling Factors

bull Pharmacists and other health care providers need to

bull know the importance of Ramadan

bull Understanding of Muslim patientsrsquo religion and culture

bull Identify strategies to mitigate health care barriers especially costs

Need Factors Outcome Factors

Model χ2 = 2246 df = 5 p lt 0001 a Significant at p lt 005