The Role of Religion, Spirituality and Fasting in Coping with Diabetes among Indian Migrants in Australia: A Qualitative Exploratory Study

Abstract

Australia has a high proportion of migrants, with an increasing migration rate from India. While many factors influence diabetes self-management among Indian migrants, very little is known about the influence of religious beliefs and spirituality. This study explored the religious beliefs of Indian migrants in Australia and the influence of those beliefs on their diabetes self-management. Semi-structured interviews were conducted with a convenience sample of 23 Indian migrants. All interviews were audio-recorded, transcribed verbatim and thematically analysed. Most participants believed that prayers helped them alleviate stress and improve diabetes management participants also believed that receiving blessings/prayers from religious leaders prevent or cure diseases including diabetes. There were mixed views on beliefs about using insulin obtained from animal sources. Some participants were concerned about the use of animal-based insulin as it was against their religious beliefs and teachings. Some participants believed that religious fasting does not have any impact on their diabetes while others believed that it can be detrimental to their health. Religious beliefs therefore played an important role in how Indian migrants managed their diabetes. Healthcare professionals should consider their patients’ religious beliefs during consultations, enlist support, such as religious scholars, to better address people’s misconceptions, and identify strategies for effective diabetes management that consider religious beliefs.

Appendices

Appendix 1 Qualitative Study Interview Protocol

Interview Protocol and Data Sheet-Patient Interviews

Patients will be informed verbally by the researcher about the study; will then be given the Participant Information Statement to read, and asked to read and sign the consent form, if agreeing to participate in the study. Participants will be encouraged to ask the interviewer if there is anything unclear, or if they need more information.

The process will then begin as follows:

Before we formally begin the interview, I would quickly like to ask you a few questions:

Interview questions:

Question 1: What do you know about accessing the Australian healthcare system?

Prompts;

• If you were sick or your family member, how would you go about getting help?

• From where can you get OTC medicines?

• If you had a minor illness, what would you do?

• If you had a more major issue, what would you do?

• If you have an emergency, where do you need to go?

Question 2: When do you seek help for your diabetes illness?

Prompts;

• Please share your experience about when you went to see your doctor?

• Regularly visit/irregular visit, why?

• When my diabetes uncontrolled?

Question 3: How were you diagnosed with diabetes and how do you feel being diabetic?

Prompts:

• Went to see doctor for other disease? Suspect symptoms of diabetes?

• How did you feel when the doctor first told you that you had diabetes?

• How has your feeling changed over time?

• How has diabetes and the medication(s) you take for diabetes affected your day to day living?

• How has diabetes and the medication(s) you take for diabetes affected your lifestyle in general?

Question 4: Where and from whom, do you get information about your diabetes and medications you take for diabetes?

Prompts;

• In your day to day life where you get information about diabetes and its medications? (healthcare professional in hospital, community pharmacy, internet, media or other)

• Do you think that information in Hindi is more useful to you compared to in English

Anything you would like to suggest to improve health information

Question 5: What are some of your difficulties and facilitators (motivators) for you for seeking diabetic care in Australia?

Prompts;

• What are problems you face while needing help regarding diabetes and its medications?

• In your personal experience, what are the factors affecting you visiting a clinic in Australia?

• What are the enablers while seeking healthcare in Australia?

• Was there anything that you liked or didn’t like?

Question 6: What are your thoughts about the level and amount of information that healthcare professionals provide/give to you about your diabetes?

Prompts;

• Do you feel that it is easy or difficult to understand?

• Do you feel that you need more or less information?

Question 7: What are your thoughts about your knowledge about diabetes and its medications?

Prompts;

• Inadequate knowledge

• Do you think you need more information

• Is there anything in particular that you are interested in knowing about (diabetes or medications or both)

• Do you think that you manage your diabetes well?

Question 8: What have your experiences with diabetes management been while you have been living in Australia?

Prompts;

• In your experience what are the major differences in India and in Australia

• How do you seek help?

Question 9: What does health or well-being mean to you? What do you do to keep yourself as healthy as possible, considering that you have diabetes?

Prompts;

• Please tell me what you do in terms of food intake, types of food you eat; in terms of exercise to keep blood sugar normal

• Easy or hard to manage as compared to India, why?

Question 10: How do you manage to take medications as per prescribed by your physician?

Prompts;

• Based on your experience, please suggest strategies that you think might help to improve medications adherence?

Question 11: Do you or have you used any Indian traditional medicines to control your blood sugar? Why? How have they worked?

Prompts;

• In Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy (AYUSH), which system you follow and why?

• In your opinion what are the reasons that you and your family consider to use this medicine. (more effective, safe, less expensive and side effects, better to control blood sugar or permanent cure)

• How often do you take them?

• How you know about these medicines and from where do you get them?

• Have you / do you inform your doctor about these medicines? Reason?

Question 12: What are your thoughts about spiritual health? How do you believe it impacts or influences your diabetes or what you do about your diabetes?

Prompts;

• What is your personal experience or views about meeting a spiritual healer like a priest (Hindu), imam (islam), father (Christian), darbar sahib (sikhs), etc., or traditional healers or religious leaders to seek prayers

• What is the reason for getting this help?

Question 13: What are your religious beliefs about insulin and other medications? How do these beliefs impact your diabetes management?

Prompts;

• Bovine insulin (cow)

• Porcine insulin (pork)

• Haram and halal

• Neutral (no effect)

Question 14: How do you manage your blood sugar during religious fasts?

Prompts;

• Based on your personal experience, please suggest strategies that you used to manage diabetes during fasting? (It’s difficult or easy, diet control, managing side effects, Fasting is good to control diabetes?, feel weak?).

Appendix 2 COREQ (Consolidated Criteria for Reporting Qualitative Research) Checklist

Item no	Topic	Guide questions/description
	Domain 1: Research team and reflexivity
	Personal characteristics
1	Interviewer/ facilitator	Akram Ahmad
2	Credentials	BPharm, PharmD (Post Baccalaureate)
3	Occupation	PhD Candidate and Registered Pharmacist
4	Gender	Male
5	Experience and training	A registered pharmacist from India; with experience in teaching and research. Trained in qualitative techniques
	Relationship with participants
6	Relationship established	Before each interview began, the researcher established relationship with the participant to the best of his ability
7	Participant knowledge of the interviewer	Before starting an interview, each participant received a participant information statement (PIS) in their preferred language (English or Hindi) approved by the University of Sydney 's Human Research Ethics Committee, Australia The name and address of the researchers and their affiliation (Sydney University) was also included as part of the letter head appearing on the PIS document. Participants have knowledge about that. The researcher (name, affiliation, and role in the research) also introduced himself before each interview started
8	Interviewer characteristics	PhD Candidate, academic researcher, and pharmacist. The researcher has remained to the best of our knowledge, Unbiased during the interviews
	Domain 2: Study design
	Theoretical framework
9	Methodological orientation and Theory	No methodological orientation underpinned the study design. Thematic analysis was used to analyse the findings
	Participant selection
10	Sampling	The convenience and snowball sampling used to locate the participants in Australia. The participants were recruited based on criteria set for the study for inclusion and exclusion
11	Method of approach	Usage of different techniques to find the participants The methods have been described in qualitative methods section
12	Sample size	23 participants completed the study
13	Non-participation	19 [initially 42 participants shows their interest to participate in the study, later some of them not available due to various reasons and later we reached saturation and no contact has been made further]
	Setting
14	Setting of data collection	Public venue suitable for the participant
15	Presence of nonparticipants	In 18 interviews, only the participant and researcher were present. 2 participants were accompanied by spouse and 1 participant were accompanied her mother-in-law
16	Description of sample	Indian born migrants living in Australia [ethnicity]. The detailed description given in qualitative methods
	Data Collection
17	Interview guide	The interview guide is shown in Appendix 1
18	Repeat interviews	Repeated interviews were not performed and do not apply to this study
19	Audio/visual recording	Audio recording was used to collect the data
20	Field notes	Field notes were made right after each interview
21	Duration	The mean average duration of the interviews was 42.45 min
22	Data saturation	Data saturation was reached
23	Transcripts returned	Transcripts have been transcribed verbatim and checked against audio to ensure accuracy prior to analysis. Transcripts were not returned for statement or correction to the participants
	Domain 3: analysis and findings
	Data analysis
24	Number of data coders	AA and PA were analysed data using a framework for TA. The first four interview recordings were transcribed by AA and reviewed by PA. These four transcripts independently analysed by AA and PA; and the remaining analysed by (AA). The interviews recordings were fully transcribed and thematically analysed
25	Description of the coding tree	The coding tree (diagram) is presented in qualitative method chapter (Fig. 6.2)
26	Derivation of themes	Wide themes were used to build interview guide to answer research objectives. Specific themes developed from interviews, one of which appears here
27	Software	Microsoft Word was used to manage the data
28	Participant checking	Participants did not provide feedback on the findings
	Reporting
29	Quotations presented	Representative quotations were presented while the findings were reported
30	Data and findings consistent	There is consistency in the data and findings presented
31	Clarity of major themes	Major themes are presented in Fig. 6.2 (qualitative method)
32	Clarity of minor themes	Major themes are presented in Fig. 6.2 (qualitative method)