Knowledge of diabetes mellitus and safe practices during Ramadan fasting among Muslim patients with diabetes mellitus in Singapore
Sueziani Binte Zainudin, MBBS, MRCPSG, Dun Yong Ang, MBBS, and Abel Wah Ek Soh, MBBS, MRCP
Additional article information
Abstract
INTRODUCTION
This study aimed to explore the level of knowledge of Muslim patients with diabetes mellitus (DM) regarding DM and the self-management of DM when fasting during Ramadan.
METHODS
Muslim patients with DM attending the Diabetes Centre of Singapore General Hospital, Singapore, were surveyed on their knowledge of DM and self-management of DM when fasting during Ramadan. Data on patient demographics, DM history and management of DM during the previous Ramadan was also collected.
RESULTS
A total of 92 patients (34 male, 58 female) were surveyed. The mean age of the patients was 53.4 ± 13.3 years. The patients were either Malay (91.3%) or Indian (8.7%), and most (66.3%) had at least a secondary school education. Most (89.1%) had Type 2 DM. The mean duration of DM was 8.7 ± 5.1 years and mean pre-Ramadan haemoglobin A1c was 8.4% ± 1.8%. DM treatment consisted of insulin therapy (37.0%), oral glucose-lowering drugs (35.9%) and combined therapy (22.8%). The mean DM knowledge score was 58.8% for general knowledge and 75.9% for fasting knowledge. During the previous Ramadan, although 71.4% of the patients consulted their physicians, 37.3% did not monitor their blood glucose levels and 47.0% had hypoglycaemic episodes. Among those who had hypoglycaemia, 10.8% continued to fast.
CONCLUSION
Unsafe self-management practices were observed among DM patients who fasted during Ramadan. Efforts should be made to bridge the gap between knowledge of DM and self-management of DM.
Keywords: diabetes mellitus, fasting, knowledge, self-management
INTRODUCTION
There is a global avalanche of patients with diabetes mellitus (DM). In 2013, 382 million people were living with DM, a number that is projected to increase to 592 million by 2035.(1) Even more alarming is the trend toward younger people developing DM. The global prevalence of DM in 2013 was estimated to be 8.3% among those aged 20–79 years, with the largest increment occurring in the Middle East and Africa (by approximately 100%).(1) In Singapore, the National Health Survey 2010 reported that DM affects 11.3% of those aged 18–69 years.(2) This is an increase from the 8.2% reported in 2004, with the largest increment occurring among the Malay population. As most Malays are Muslims, this increased prevalence of DM among Malays translates to the likelihood that more individuals with DM fast during the Islamic month of Ramadan. As Muslims practise daytime fasting for 30 consecutive days during Ramadan, Muslims with DM who fast have an increased risk of both hyperglycaemia and hypoglycaemia during Ramadan.(3)
Knowledge of DM is a prerequisite for appropriate self-management. Previous studies conducted in Singapore have demonstrated good levels of knowledge about DM among individuals with and without DM.(4-6) However, studies performed in other countries suggest that deficits in knowledge can result in inappropriate practices among DM patients who fast during Ramadan(7) and among healthcare providers caring for these patients.(8) In Malaysia, Yaacob et al found that knowledge deficits (especially regarding hypoglycaemia recognition) and inappropriate practices were prevalent even though their study population had a good attitude toward disease control and had pre-Ramadan consultations with their physicians.(7)
To the best of our knowledge, no study has specifically examined the knowledge adequacy of Muslim patients with DM in Singapore regarding the subject of self-management during Ramadan fasting. Thus, this study aimed to evaluate the knowledge of this group of patients about DM and self-management of DM during the fasting month of Ramadan.
METHODS
This cross-sectional study was approved by the local institutional ethics committee and performed in accordance with the ethical standards of the Declaration of Helsinki. It was conducted over a period of three months (June 2011–August 2011) at the Diabetes Centre of Singapore General Hospital (SGH), Singapore. SGH is a tertiary centre and the annual attendance of the Diabetes Centre is approximately 19,000 patients. The study participants were Muslim patients aged ≥ 16 years with DM who attended outpatient appointments at the Diabetes Centre. Consecutive patients attending their clinic appointments were approached. If they agreed to participate in the study, informed consent was obtained and they were included. Patients who were not able to complete the questionnaire were excluded.
This study was conducted using a self-administered questionnaire that was developed by one of the authors of the study. The questionnaire, which was available in both the English and Malay languages, required 15–20 minutes to complete. It included questions on the patients’ sociodemographic data, history of DM (i.e. type and duration of DM, treatment received for DM and pre-Ramadan haemoglobin A1c [HbA1c] level), knowledge of DM and information regarding the management of DM during the previous Ramadan.
The patients’ knowledge was assessed with questions that were grouped into four main sections; each section focused on a different aspect of knowledge about DM, including management of the disease when fasting during Ramadan. Section 1 tested the patients’ general knowledge of DM using a modified, 16-item version of the validated Michigan Diabetes Knowledge Test (MDKT).(9) All of the questions from the original MDKT were retained, except for Questions 4, 15, 17, 18, 19, 21 and 23, and one option each in Questions 1 and 2 were modified to better suit the Singapore population (Appendix). The patients were required to select the best answer for each of the 16 multiple-choice questions. Sections 2–4 focused on the patients’ knowledge of DM management when fasting during Ramadan. The questions were designed based on the recommendations made in the consensus statement by the American Diabetes Association for the management of DM during Ramadan (update 2010).(10) Section 2 had five questions assessing knowledge of the risks DM patients may face due to changes during Ramadan fasting (Appendix), Section 3 had 12 questions assessing knowledge of the symptoms and complications that DM patients may experience when fasting, and Section 4 had 11 questions assessing knowledge of safe practices and appropriate management of DM when fasting during Ramadan. The patients could answer ‘Yes’, ‘No’ or ‘Don’t know’ for each of these 28 questions. The maximum possible score for knowledge of DM (i.e. the cumulative score of the four sections) was 44. Questions on management of DM during the previous Ramadan were not scored.
The questionnaire was translated from English to Malay, and efforts were made to ensure that the translated version was semantically and conceptually close to the original questionnaire. The translation was done by a native speaker of Malay who was proficient in English. Another Malay native speaker reviewed the translated version and compared it with the original. The final version was completed and available for use after inconsistencies were resolved.
Data was analysed using IBM SPSS Statistics version 21.0 (IBM Corp, Armonk, NY, USA). Descriptive statistics were used to describe patient demographics, disease characteristics and knowledge scores. Percentages and frequencies were used for the categorical variables, while mean and standard deviation were calculated for the continuous variables. Correlation analysis was performed to determine the correlation between the patients’ knowledge scores and their demographics, and between the patients’ knowledge scores and their DM characteristics (i.e. type and duration of DM, treatment received for DM and mean pre-Ramadan HbA1c level). Linear regression with a check for multicollinearity was performed. In the reliability analysis, internal consistency was assessed using Cronbach’s alpha coefficient; Pearson’s correlation or Spearman’s rank correlation was used to assess the test-retest reliability. The criterion for accepting Cronbach’s alpha was a score > 0.6.