الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Fasting the holy month of Ramadan is one of the five pillars of Islam, so the month-long fast is mandatory for all Muslims adults, with certain groups exempts, including some people who suffer from chronic diseases such as Diabetes Mellitus (DM). Despite potentially being exempt, the majority of diabetics choose to fast.
Estimates reveal there are more than 150 million Muslims suffering from DM worldwide. Therefore, Ramadan has a major impact on the management and control of this chronic disease.
Primary health care is the cornerstone for prevention and management of Ramadan DM complications, in particular, pre-Ramadan counseling. However, limited studies have addressed assessing the knowledge and attitude concerning DM management among Primary Health Care Physicians (PHCPs).
Therefore, this current study aimed to quantitatively assess the level of knowledge of PHCPs about good diabetes care before and during Ramadan in Alexandria, as well as trying to explore the barriers and facilitating factors for PHCPs to update their information or training regarding diabetes care in the holy month of Ramadan.
Accordingly, the knowledge level of 53 PHCPs working in all Family Health Centers (FHCs) in Alexandria Governorate was assessed through a mixed quantitative and qualitative methods study, where the quantitative part of the study was conducted on all PHCPs working in nine FHCs through a pre-designed self-administrated questionnaire. However, the qualitative part targeted any PHCPs, or family physician (FP) working in the FHCs in Alexandria Governorate. Interviews were recorded on a digital audio recorder, then transcribed verbatim into document files and revised for any mistakes or incompleteness. The quantitative questionnaire designed to measure the level of knowledge of PHCPs was comprised of three sections: risk stratification for individuals with DM who choose to fast during Ramadan, pre-Ramadan health education provided to DM patients before and during the holy month, as well as management of DM patients in Ramadan.
6.2. Conclusions
Analysis of the study results revealed the following conclusions:
1. The present study has shown inadequate total knowledge levels about management of diabetic patients fasting during Ramadan between PHCPs working in family health centers (FHCs) in Alexandria. Only 3.8% of participants scored more than 75%, with the majority (more than 69%) of participants scored between 50% and 75%.
2. Knowledge levels of PHCPs regarding risk stratification of diabetic patients who fast during Ramadan was also low, more than 62% of participants scored less 50% on this section.
3. Knowledge levels of PHCPs regarding pre-Ramadan education provided for diabetic patients who fast during Ramadan was better than the other two sections in this study, only 1.9% of participants scored less 50% on this section, with the majority of PHCPs (98.1%) scoring more than 75% on this section.
4. The greater inadequacy in PHCPs knowledge levels was regarding management of diabetic patients who choose to fast during Ramadan, more than 58% of participating PHCPs scored less than 50% on this section.
5. Motives for seeking updated knowledge about the management of diabetic patients who fast during Ramadan were found to be providing greater benefit to the patients, being more distinguished between their peers, and to secure better working opportunities.
6. Motivation for learning about new therapeutic regimens for fasting diabetic patients in Ramadan was lacking due to the paucity of oral antidiabetic drugs in the essential drug list within the Ministry of Health and Population (MOHP). The lack of Egyptian guidelines concerning fasting Ramadan for diabetic patients might have contributed to low levels of knowledge among PHCPs.
7. Regulations within the MOHP family health sector regarding referral of diabetic patients may be an inhibiting factor for PHCPs to gain updated knowledge about fasting and Ramadan. Increased workload and work force shortages also had a negative influence on PHCPs knowledge seeking behavior.
8. Willingness of PHCPs to get involved in management of diabetic patients who fast during Ramadan varied, some PHCPs were willing to be involved while others were not as willing. Educational qualifications of PHCPs seemed to influence their willingness to be involved in management of diabetic patients who fast during Ramadan; the higher the educational qualification of the PHCP the more willing she/he was to be involved in management of diabetic patients who fast during Ramadan. Patient willingness to be managed by a PHCP was also found to be of influence upon the participants to either get involved or not with management of diabetic patients during Ramadan and hence their knowledge seeking behavior.
9. Participants perceived their fellow’s knowledge seeking behavior differently, while some thought positively of their fellow PHCPs, other thought negatively of their fellow PHCPs. Participating PHCPs perceptions of their fellows’ knowledge seeking behavior revolved around age, years since graduation, and personality traits they might possess. Younger and freshly graduated fellows were viewed positively regarding their knowledge seeking behavior, while PHCPs having an attitude of improving themselves were also viewed in a positive manner.
10. Participating PHCPs had different perceptions on what key opinion leaders (KOLs) thought of their knowledge seeking behavior: perceptions were divided with some viewing KOLs as positive influence on their knowledge seeking behavior while others thought the opposite.
11. Confusion about their role as PHCPs in management of diabetic patients who fast during Ramadan was found to have a negative influence on their knowledge seeking behavior. Fear of being held accountable -if a patient develops any complications, or if MOHP inspection and audit teams were to raise questions on how patients were managed- was a barrier for PHCPs to get involved in the management of diabetic patients who fast during Ramadan.
12. Some participants showed confidence in their ability to seek updated knowledge about management of diabetic patients who fast during Ramadan.
13. The circumstances related to training e.g., the geographical location of the training venue, the style of training, and the availability and accessibility of online resources had varying influence on PHCPs knowledge seeking behavior.
14. Participants perceptions on how their supervisors and administrative authorities supported them in their knowledge seeking pursuit varied, some PHCPs viewed their supervisors as encouraging while others had opposite opinions.
15. Participating PHCPs explained their preferences on training about management of diabetic patients who fast during Ramadan to be; most preferred lectures followed by case discussions, yet other methods of training were mentioned by some PHCPs e.g., clinical examination videos, and clinical studies presentations.
6.3. Recommendations
Recommendations arising from this study could be classified into:
A. Recommendations to the Ministry of Health and Population (MOHP):
1. Development of an Egyptian national guideline about the management of diabetic patients who fast during the holy month of Ramadan which should be directed to PHCPs as well as other HCPs and choosing the proper methods for its dissemination throughout the facilities of the MOHP.
2. Adoption and integration of international guidelines concerned with management of diabetic patients who fast during the holy month of Ramadan into PHC/FM setting.
3. Providing annual training for PHCPs about Ramadan and fasting in a proper time before the holy month.
4. Encouragement of PHCPs to engage in caring for diabetic patients who fast during Ramadan.
5. Updating the essential drug list with newer generations of existing drugs and adding newer drug groups that have been proven safer for use in Ramadan.
6. Maintain workforce numbers suitable for the process of training and providing a better work environment that encourages continuous medical education for HCPs within the MOHP.
7. Reviewing and exploring reasons why might some HCPs consider the MOHP as a low rewarding work environment.
8. Take advantage of HCPs within the MOHP system whether they are physicians, pharmacists, or nurses and train them in management of diabetic patients in Ramadan to empower teamwork which would eventually lead to better care being provided to the patient.
9. Utilize services of drug information centers (DIC) in FHCs or FHUs in the training and management of diabetes in Ramadan. Drug information centers services that might be included are giving information to PHCPs on adverse effects of drugs, checking for drug-drug interactions and communicating with treating physicians about their possibility, and disseminating information about novel drugs or drug groups that are introduced in the market.
10. Provide institutional access to medical online sites and smart phone applications that require paid subscription.
11. Equipping FHCs and FHUs with internet accesses to encourage dissemination of information within the MOHP facilities.
B. Recommendations to healthcare providers:
1. Attending the annual Diabetes and Ramadan international alliance conference for updates and the available online training workshops or lectures.
2. Better understanding of the role of PHC in management of diabetic patients in Ramadan.
3. Perform pre-Ramadan individualized assessment for diabetic patients 4 to 6 weeks before Ramadan as recommended by international guidelines.
4. Expand knowledge about anti-diabetic medications beyond what may be available in FHCs or FHUs.
5. Focus on communicating effectively with colleagues and other HCPs within the facility aiming at maximizing patient benefit and to avoid any harm that might affect the patient.
C. Recommendations for the High Institute of Public Health:
1. Designing and testing tailored training programs that meet the expectations of PHCPs.
2. Conducting further research upon a larger population while keeping up to date with the guidelines issued from international scientific organizations.
3. Collaboration with other interested parties to conduct nationwide research on diabetes and Ramadan.
4. Inclusion of more PHCPs in further research would be beneficial to better describe knowledge levels.
5. Reporting study findings to the local authorities as the Health Directorate and to the Ministry of Health And Population.
D. Recommendations to the community:
1. Raising awareness of the need for counselling for diabetic patients prior to Ramadan.
2. Propagation of healthy Ramadan dietary practices and physical exercise importance.
3. The emphasis on the “Fatwa” produced from “Dar al Iftaa” in Egypt that diabetic patients who might be harmed from fasting during Ramadan are exempted from fasting and that the caring physician is the one who is responsible to give such advice based on an individualized pre-Ramadan medical assessment.