Integrated Islamic Doctrine to Promote Antiretroviral Therapy Adherence Among Southern Thai-Muslim Patients: Action Research Study

Study Design

An action research (AR) with a collaboration concept was conducted. AR was selected as a suitable research design since it could serve to identify the particular problems faced by Thai-Muslim PWHAs and to encourage them to act on maintaining ART adherence by incorporating Muslim cultural background and Islamic beliefs into their daily drug-taking on their behalf (Polit & Beck, 2021). Transcultural nursing, particularly the concept of cross-cultural competence of care, was also utilized and blended in the program activities throughout.

To develop Islamic-based intervention program, three core Islamic doctrines were utilized. Islamic faith emphasizes the centrality of beliefs in the Divine Decree, that implies the predestination of God “for being HIV-positive”; Islamic practice focuses on “the declaration of oneness of God” and “the centrality of prayer,” termed Namaz and Du’ar (a ritual worship five times a day and making a wish after praying) (Syracuse University, 2021). Islamic moral beliefs highlight the “Wayib” concept, that designates duties to take care of oneself inherent in taking ART consistently (Balogun, 2010), including the “Verse of Brotherhood” concept, that denotes “All Muslim are brothers” and must look after one another (Al-Hujurat Q49:10).

Ethical Considerations

This research was approved with certified MHESI 68105/2534 by Ethics Committee of University Institution. It was also granted by the Provincial Ethics Committee. Prior to data collection, consent documents were informed and signed by all participants.

Study Setting

Due to an unrest situation at that time, Pattani Province was selected as a safe place to conduct a research study. A public VCT clinic in Kok Bhoe District Hospital was selected as a study site since it served for about 125 PWHAs (65 Buddhists and 60 Muslims) per month. Antiretroviral (ARV) drugs were provided free of charge, basically once a month.

The primary health care staff were mainly Thai-Buddhist. Both a physician and a pharmacist acted as advisors for medication regulation and therapeutic guidance. A lead nurse, together with an assistant, managed and directed the nursing staff team. Three registered nurses provided regular HIV care, supportive counseling, and phone consultations. During the health care analysis year (2018), the results indicated that 52% of those PWHAs were Thai-Muslims, with 20% experiencing low income and unemployment. Within this segment, 5% habitually missed medical appointments and had inconsistent adherence to ART.

Participant Identification and Recruitment

Prior to the data collection, a public announcement detailing the research was issued. HCPs at the VCT clinic included five registered nurses (all Thai-Buddhist), along with a doctor and a pharmacist (both Thai-Muslims). Prospective PWHAs participants were informed in a similar fashion. Purposive sampling focused on Muslims who had been on ART for at least a year, experienced inconsistent adherence within the past 6 months (ART adherence score < 95%), and showed no clear signs of AIDS.

Ten individuals with HIV/AIDS joined the study. Five health care VCT team members (HCPs), except the head nurse and the assistant, agreed to take part. Altogether, 15 participants contributed to this research. HCPs: All were female, aged 29–47 years, and had worked at the VCT clinic for approximately 5–10 years, having expertise in HIV management, counseling, and ART medication monitoring. These nurses delivered regular health care services, tracked ART adherence, and provided health education and counsel on ART services. PWHAs: gender distribution of PWHAs mirrored the true demographic balance (1:1 male to female). Ten individuals with PWHAs were thus equally chosen from each gender; ages ranged from 19 to 45, with four married, four single, and two widowed. Employment status: three worked in manual labor, three were homemakers, and three were unemployed; all had limited educational backgrounds and low-income levels. In seven participants, diagnoses occurred within the last 5–10 years, while three occurred over a decade ago. HIV acquisition involved unprotected sex (n = 7), injection drug use (n = 2), and vertical (mother-to-child) transmission (n = 1). Six disclosed their HIV status to partners or family, while four kept their test results private. The duration of ART varied: under 3 years (n = 5), 4–17 years (n = 4), and over 17 years (n = 1). All received guidance on medication before starting ART. Almost all reported side effects of the drugs; ART adherence scores were below 95% (ranging from 64% to 89%) within the past 6 months, and with low drug-taking scores between 11 and 18 (max = 60).

Data Collection and Analysis

Data were gathered from January 2017 to July 2018 using in-depth interviews and participant observation methods. Notes and journals recorded all participant responses, interactions, and thoughts observed during interviews and observational sessions (Lincoln & Guba, 1985). The journals were also utilized to track what methods worked effectively during program activities (Polit & Beck, 2021). All interviews were audio-recorded and transcribed. Audio, transcriptions, and notes were kept confidential. Participants’ information was safeguarded by the authorized researcher. The researchers reviewed the transcripts with participants and another researcher to ensure accuracy (Polit & Beck, 2021).

The research team listened to the audio recordings. The transcription data then underwent readability checks, coding, and categorization. Statements showcasing participant motivations, beliefs, and understandings were identified and organized into themes reposing their responses. Comparative methods guided the development and refinement of themes (Polit & Beck, 2021). Emergent themes were used to guide the steps of the research process. Coding and thematic development were done manually by the team. This initial phase was followed by content validation using a “member check” technique, where excerpts from the transcript demonstrated how participant stories are categorized. Initial interview results formed the basis for further data collection, using the same systematic approach. Codes were applied across subsequent interviews and refined to prevent repetition or ambiguity. Content analysis of reflective notes, participant memos, and stakeholder discussions was also performed (Polit & Beck, 2021).

Trustworthiness

Establishing the study’s trustworthiness utilized Lincoln and Guba’s (1985) criteria, with credibility achieved through triangulation techniques and member checks. Dependability arose from the comprehensive descriptions of the research context, approaches, and activities. Consistency of data classification ensured reliability, achieved through peer verification of emergent themes’ accuracy. Confirmability was assured via an inquiry audit throughout the project, whereby all researchers assessed the data and documentation (Polit & Beck, 2021).

Phase 1: Assessment (Underlying Causes, Barriers, and Needs Identified)

Each participant was interviewed for about 30 minutes (in Thai language) once or twice in a private room at the VCT clinic. Individual semi-structured in-depth interviews and dialogues were conducted with each clinical nurse. Using open-ended questions, clinical nurses were asked about their routine HIV-care services, clinical management, perceived underlying causes and barriers of ART non-adherence, understanding of Muslim cultures, Islamic beliefs, and their needs of integrating this knowledge into ART drug-care provision. Medical treatments and drug counseling were made certain by the physician and the pharmacist. Open-ended questions were also held with 10 Muslim patients, focusing on their awareness, beliefs, underlying causes and barriers of ART non-adherence, and their motivations to keep ART adherence. For example, “Can you tell me about the ART non-adherence situations you encountered?” and “How do you handle with drug side effects problems?” Needs for adherence support and reasons for loss of motivation on ART adherence were also explored.

The perceived causes and barriers of ART non-adherence, including the needs to improve HIV-care services, were identified. Four main themes emerged: Cognitive relevance that comprised forgetfulness, misunderstanding (of feeling well and symptom-free), inadequate knowledge (poor management of drug side effects), and barely used sound reminders; Psychological barrier that denoted the “boredom” from long-term ART drug-taking; Socioeconomic/financial barriers that demonstrated by transportation problems; and a Need for social respect that signified by non-disclosure of HIV-serostatus to family member. Religious and Spiritual Importance was also mentioned. Islamic doctrines, however, were seldom used to support patients’ ART adherence. The needs to integrate Islamic doctrines with ART adherence support were strongly reported by all Thai-Buddhist clinical nurses.

Phase 2: Planning (Action Plans)

The second phase involved program development, by designing and planning the program interventions through the weekly meetings and later the workshops with three clinical nurses. According to AR, the research team ran mutual collaboration with clinical nurses to address the underlying causes, barriers, and to best address their needs, that is, integrating Islamic doctrines to improve the ART non-adherence problem and HIV-care services (Polit & Beck, 2021). The concept of transcultural nursing (also known as cross-cultural care) was utilized throughout. The field researcher acted as facilitator, encouraging clinical nurses to express their thoughts, ideas, needs, and expectations concerning the proposed program. Field observations were also collected. Dialogues regarding program goals, plans, and potential approaches for integrating Islamic doctrine into patient’s beliefs and their daily practice were discussed. These nurses were also asked to comment on the original work proposed by the research team (derived from the evidence-based practice). Data collected during each meeting and workshop, through participant observations, were categorized and structured by the research team. Data were then validated by the clinical nurses at the beginning of the next meeting or workshop. Data collection and data analysis composed an interactive process, in accordance with the interviews. A workshop refinement was finally organized, in which the nurse participants were asked to validate the program adequacy with respect to their needs and also to appraise how well the program met patients’ needs and enhanced their clinical practice.

After the underlying causes, barriers, and needs had been identified, the program goals, contents, and structures were then clarified. The proposed solution was an action plan that integrated Islamic doctrine and concept of collaboration. The program consisted of a 4-week period: began with a baseline pre-assessment, followed by program activity sessions and final evaluation. The program was structured under four approaches of health education, motivation raising, workshop practice, and follow-up (phone-call visits) (see Figure 1). During each session, several program activities together with various strategies were utilized. Prior to program implementation, a program guideline and flowchart were co-developed to support field researcher and clinical nurses (as project partners) following the project activities correspondingly. Details of each program session were presented below.

A baseline pre-assessment activity with three subsessions was developed: assessment of demographic information; assessment of drug adherence score, drug-taking behaviors scores, including residual drug pill-counts report; and assessment of patients’ knowledge, awareness, beliefs, and understandings in ART drug adherence and side effect management. The pre-assessment activities were gathered accordingly.

Health education approach aimed to address the core inadequate knowledge and misconceptions of Islamic beliefs that lead to inconsistent ART drug use. To increase patient’s awareness and emphasize the importance of drug adherence, program activities with various tools and strategies were utilized. Islamic faith focusing on the beliefs implying that “HIV-infected situation” was a predestination of God (Syracuse University, 2021). Islamic teachings on health and illness statements were read and discussed together. For example, Allah Subhanho Watala (SWT) brings illness to test us whether we could endure such hardship’ (Baqara 2:155-156). “Allah assures us of treatment (that is, ART drug) for our illness” (adapted verse 3578, The Hadith). In addition, Islamic practices such as, “Azan calling time”—using the pretext of Azan calling for “Na-maz” (ritual Muslim praying) (“Adhan,” 2021) was proposed as a familiar “sound reminder” to help reminding daily drug-taking time. An optional sound reminding device, such as, a mobile phone (alarming) time or TV news time were also suggested. The newly developed ART drug-care handbook (written in Thai) outlined drug efficacy, drug side effects, and tips on how to handle drug problems/drug-care management. The handbook embedded with Islamic teachings was used as a primary source of informational support besides drug-checklist form.

Motivation raising approach aimed to raise awareness of patients’ important role in keeping ART adherence consistently, and to strengthen the patients’ spirits, particularly those losing their motivation, due to the boredom of lengthy drug-taking periods. Within this context, each program session began with Islamic greetings to enhance warm cultural care services. Selective Islamic moral beliefs and Islamic practice were then utilized. For instance, the “Wayib” concept denoting that “Muslims had duties and responsibilities to take care of themselves when getting sick” (Balogun, 2010) was introduced to reinforce patients’ motivations in maintaining ART adherence. The “Verse of Brotherhood” concept denoting that “All Muslim are brothers” (Al-Hujurat Q49:10) was also applied alongside a “role-model story” of “Bung M”^¥. Special Islamic practice, namely “Namaz HaYat” (an extra Islamic praying for a special occasion (ART adherence in this regard) and “Du’ar” (making a wish, after special praying) were incorporated into the “Namaz HaYat”–“SanYa Jai” activity (special praying for Allah SWT and promise to commit taking one’s ART consistently). To help promote patients’ intentions to keep ART adherence, commitment forms were then signed by the patients (in front of clinical nurses, as eyewitness). Besides, the sayings that “Muslims must do one’s duties in response to a Mercy from Allah” (Balogun, 2010) was also incorporated in the drug-care handbook.

Of note, two special strategies were developed and utilized. First, a special story of “Bung M”^¥ was used as a true “role-model” patient at the VCT clinic; “Bung” means older brother in Muslim word. Bung M is the only one patient who could have successfully endeavored his tactics/practical skills in keeping ART drug-taking consistently, for almost 3 years. The story was extracted from his real-life experiences. The “role-model” story was then distributed to read and discuss in peer groups session, expecting to increase patient’s self-confidence that “I can do it like Bung M.” Second, the Thai-Muslim nurse, working at a chronic care clinic nearby, was invited to run the religious and culturally relevant activities in substitute of the Thai-Buddhist clinical nurses. In this regard, all of the VCT nurses admitted they had insufficient cultural competence compared to that of the Muslim nurse.

To accord with Muslim cultural beliefs, the workshop practice approach was co-developed and aimed to address the “forgetfulness” in patients’ daily life (Perngmark et al., 2022). In the workshop practice activity, the patients were encouraged to practice residual drug pill-counts, fill in drug-checklist forms, and make a “drug-reminding box for Allah,” by posted symbols representing periods of time to help keeping drug-taking consistently. The drug-care handbook that integrated verses of Allah’s teachings and Azan calling time was further utilized as extra reminding devices. The follow-up visit approach, using “phone-call” visits sessions (due to patients’ fear of HIV stigma), aimed to closely monitor drug-care management. During each phone-call visit, the nurse asked whether predetermined goals of ART adherence had been achieved. Emotional support with positive reinforcement was provided throughout.

New program tools were validated by a nurse with expertise in HIV/AIDS care and a pharmacist well experienced in ART drug care. These new tools were validated for whether the contents were valid, easy to read, used simple words, and conveyed messages that fit with Muslim PWHAs (regarding culturally sensitive care). Besides, a Muslim instructor with expertise in Islamic teachings had also verified the program contents and materials and provided its content validity. Words and messages were examined for their accuracy (in the meaning) and the appropriateness for Muslim PWHAs.

Phase 3: Implementation

The third phase aimed to implement the program over a 4-week period. The program was implemented by asking the clinical nurses and patients whether they agree on the contents, structures, and adequacy of the program with respect to their needs. Data collection and data analysis constituted an interactive process. During the program activity sessions, the same logbook was used to document their efficacy. Data collected were categorized and structured by the research team. Data were validated by all of the participants at the end of each session (after the activities finished, to initially confirm the study results).

The program was administered as planned in terms of topic order and contents, its tools, strategies, and methods used. Minor details in the program were adjusted to meet stakeholder’s feedback suggestions. For instance, a symbol (familiar to Muslim culture, such as a half-moon stands for night time) was suggested to be posted on a drug-reminding box. Meaningful phrases of Islamic teachings, such as “Sickness is a test from Allah. Allah brings medication along with the sickness. As Muslim, we must endure it and accept to take drugs consistently for the Mercy of Allah” were also recommended to be posted on the drug-reminding box.

The duration of one session (i.e., the workshop practice) was longer than expected. The length of time was quite flexible devoted to each topic. There was no attrition in this study. All patients continued involvement in all program sessions.

Phase 4: Outcome Evaluation

Three methods of data collection were used to evaluate the program outcomes: semi-structured in-depth interviews, an informal group discussion seeking feedback concerning the whole program, and participant observation (of activity sessions) and the logbook analysis. The program feasibility, acceptability, adequacy, and satisfaction were also gathered. Participant’s ART adherence scores were monitored whether the score increased to the desire level (≥ 95%). Drug-taking behaviors scores, residual pill-counts report, patients’ commitment in keeping ART adherence, and suggestions for program improvement were also investigated. The adequacy of program contents was assessed through participant observation. Content analysis and thematic analysis of the interview transcripts was undertaken to provide participants’ in-depth data on the overall program (Polit & Beck, 2021). Of note, patients’ viral loads and CD4 cell counts were not utilized for monitoring changes, owing to the incompatible time of laboratory testing and the financial problems in the expense (of testing fee).

The program overall was well received. All participants reported that the program met their needs. Four themes of feasibility, adequacy, acceptability, and satisfaction were identified. The program new tools were viewed as applicable, appropriate, and realistic for clinical practice:

. . . the ideas of using an option of a (drug) sound reminder is good. Using “Azan calling time” or using a “mobile preset (alarming) time” is simple, but it really works. (a Pharmacist)

The program was evaluated by all Thai-Buddhist nurses and the Thai-Muslim nurse as useful and feasible. Through the clear and easy-to-follow program guidelines and the flowchart made it effective. Another theme “Better for Muslim patients” was emerged:

This program is good. It’s useful and fits well with Muslim patients. I’m happy to join and give hands for the project. I think we should run this project further for the better sake of these Muslim patients with HIV/AIDS. (the invited Thai-Muslim Nurse)

The program activities and new tools that integrated core Islamic doctrines were seen to fit well with religious and Muslim cultural practices. Most of the patients were satisfied with the program activities with various new tools provided. Among those losing faith, the “role-model” of Bung M’s story was appreciated as being helpful and touched their heart:

. . . thank you “Bor-mor” for conducting these activities. They’re really helpful, particularly Bung M’s story . . . It touched my heart. His story sounds like mine. He used to turn away from Allah, and misbehaved all sorts of thing, but now he lives his life for the “Mercy of Allah.” The ways he manages drug-taking and the tactics he provides made it easier. I felt much better with what he vowed “All Muslims are Brothers.” After this, I’ll do “Namaz HaYat” & Du’ar to support my ART drug-taking. (male, Patient 2)

Through using the drug-care handbook, most of the patients reported that they had better understandings of drug efficacy, drug side effects, and drug-care management; gained more awareness of their important role in keeping ART adherence:

In the past, “I used to skip taking drugs, or taking drugs inconsistently some of the time.” I didn’t realize how much importance the ART adherence is. After this, I will do my best to keep on drugs-takings consistently. (female, Patient 5)

The core program aims appeared to have been met. Improved in patients’ ART adherence scores, increased drug-taking behavior scores, and reconciled motivations to take drugs consistently were evidenced (see Table 1). Most patients reported that they would further keep engaging special “Namaz HaYat” and Du’ar to support their ART adherence after the program.

OPEN IN VIEWER

Table 1.

Measurement Indices of Program Implementation: At Baseline and After Implementation.

Baseline assessment	NeedsY= yes	After implementation
ART adherence (PWHAs)
Low adherence a score (%))	Y (all)	Improved (all, increased > 95%)
Range = 64–89.29		Range= 95.53-98.21
Drug-taking Behaviors (PWHAs)	Y (all)
Low drug-taking b scores (%)		Improved (all, increased scores)
Range = 11–18 (max 60)		Range = 22-25
Underlying Causes & Barriers (ART non-adherence)
1. Cognitive Relevance (PWHAs)		Improved (all)
Forget to take drugs (infrequent)	Y (all)	-Better manageable, used drug box
Barely used sound reminders (n =8)	Y (mostly)	All started using sound reminders
—Few (n = 2) used handy sound reminders		—used Azan calling time (n=8)
mobile phone alarm (n= 1), TV news time (n = 1)		—used mobile phone (1), TV news time (1)
Misunderstandings (symptom-free, feeling well)	Y (some)	Corrected (all)
Inadequate Knowledge & Insufficient skills	Y (all)	Increased (all)
(drug side effects & drug-care management)	Y (all)	—used new tip/tricks, as shared
Experiences drug side effects	Y (some)
—Skipped taking ART occasionally	Y (some)	Improved (all)
2. Psychological Barriers		Improved (all)
Boredom with long-time drugs taking periods	Y (mostly)	Increased motivations/intentions
- Getting tired of taking drugs (over 3 years)	Y (some)	- were encouraged by “Bung M’s true story”
leading to loss motivation to keep ART adherence	Y (mostly)	- appreciated by the “Verse of Brotherhood”
		- promised to use “Namaz HaYat” & Du’ar (as spiritual support in taking drugs)
3. Socioeconomic & Financial Barriers	Y (Pts, some)	Improved (some)
Have transportation problems		- arranged drug-care management, by sending via post
(due to low incomes)	Y (Pts, some)	office, when necessary(by Nrs’ & Pharmacist)
4. Need for Social Respect		Potentially improved
Non-disclosure HIV-serostatus (to Fm)	Y (Pts, some)	- Pts’ plan to disclosed HIV status to couples/Fm (after
(due to fear of stigma)		receiving counseling)
Lack of family support (in drug care & transportation)		*couple counseling may be needed
Never used peer group support	Y (Pts, all)	- Accepted the “Brotherhood” concept, to help support each other (all)
5. Religion/Spiritual Importance (PWHAs/Nrs)
Seldom use Islamic beliefs/Islamic praying (to support drug-taking, ART adherence) (PWHAs)	Y (Pts & Nrs)	Improved (by all PWHAs)- Obeyed & Followed to Allah’s teachings
		- Accepted & Utilized the “Wayib” concept
		- Practiced special “Namaz HaYat” & Du’ar
The needs for better integration of Islamic beliefs	Y (Nrs, all)
(into ART adherence) (Nrs)		Satisfied with a new co-developed & integrated Islamic
—Expressed needs for better HIV-cultural care (integrating Islamic doctrines in ART drug care)	Y (Nrs, all)	and Muslim cultural care program activities (by all Nrs)
- Being aware of Islamic & cultural care importance	Y (Nrs, all)	Increased Knowledge & skills in cultural care (all Thai-Buddhist VCT Nrs)

Note. Tools used: ^aART adherence score (assessed by using drug pill-counts along with formula calculation): Adherence level (%) = (Doses Taken/Total Expected Doses) *100 Adherence; ^bDrug-checklist report form; Pts = Muslim Patients with HIV (PWHAs), Nrs = clinical nurse; Fm =family member.

Limitations

Our research does have some limitations. The findings should be approached with caution due to the limited number of participants, which affects representation. In addition, a social desirability bias may result from the purposive sampling method. Despite these constraints, our study underlines the potential effectiveness of Islamic-based intervention programs, alongside stakeholder collaboration, for improving ART adherence among Muslim HIV/AIDS patients.

Implications

Our findings hold significant implications for HCPs. Incorporating Islamic principles, cultural beliefs, collaboration, and transcultural nursing could enhance medication adherence among Muslim PWHAs. The results underscore the importance of integrating religious and cultural systems into care strategies. We recommend that Islamic beliefs and cultural practices be incorporated into nursing interventions to improve medication adherence. Educating staff about cultural and religious practices should be a priority. Nursing undergraduate and post-graduate students needing education that highlights how Islamic teachings and beliefs influence health behaviors and associated risks among Muslim PWHAs. Implementing culturally informed patient care can facilitate ART adherence and improve outcomes for Muslim PWHAs. Further research should explore this area more deeply.