Every year, nearly two billion Muslims around the world observe the month of Ramadan, a time of prayer and reflection that includes a ritual fast from dawn until sunset. The practice is spiritually immersive and restorative, but it can also become complicated for people whose health or medication regimens are not conducive to periods of prolonged fasting. These folks may find themselves weighing whether they will compromise their fast for the sake of their health, or the other way around.
Thanks to Mohamed Amin PhD’13, a graduate of the UW School of Pharmacy, they don’t have to navigate that dilemma on their own. With his tool, RAMCOM, Amin is teaching health professionals and students alike how to counsel patients through periods of religious sacrifice without sacrificing their health in the process.
Upon starting his doctoral studies in the School of Pharmacy’s Health Services Research in Pharmacy program, Amin discovered a surprising lack of research into pharmacists’ knowledge of and patient counseling on fasting during Ramadan. He spent the next several years studying communication patterns and habits among patients, pharmacists, and other clinicians and publishing papers on how health professionals can best support their patients during Ramadan.
This work culminated in RAMCOM (short for Ramadan Communication), a tool that prepares clinicians to provide culturally relevant care and support patients through periods of religious fasting. Since the inception of RAMCOM, Amin has expanded its use to encompass fasts from several religions, including Judaism and Hinduism. RAMCOM made its official debut in the same place it got its start: when classes went online in 2020, it was incorporated into the curriculum of the School of Pharmacy’s Communication Lab, led by Amin’s mentor, pharmacy professor Betty Chewning MS’71, PhD’73.
Amin is now an associate professor on Alamein International University’s Faculty of Pharmacy in Alamein, Egypt. He has also been named the university’s social responsibility coordinator, a fitting role for a scholar who has dedicated his research to serving communities by meeting them where they are.
“My research, generally, is about giving that voice — whether you are in the U.S. or Lebanon, Egypt, or somewhere else — to someone who hasn’t been very visible by the health care system,” Amin says. “We need to make sure we’re building an environment where [a patient] feels more comfortable to say, ‘Hey, I’m different, and these are my needs, or perhaps there’s something I don’t know.’ [As a clinician], I’ll do my best, do my homework, [and] want to make sure we provide the best possible care.”
What kind of direction does RAMCOM offer clinicians for working with patients?
You would start by working with patients through a series of steps, making sure that patients’ needs are met and respected along the way. So, for instance, you would want to start by asking patients — [patients who are] Muslim, or a person of faith — what their intentions are in relation to fasting in Ramadan. If someone does not have that intention to fast, you don’t have to go in an elaborate manner through the rest of the tool. Perhaps you can provide some advice into if he or she is sharing the same meal schedules with individuals who are fasting [and ensuring] that they’re maintaining a healthy diet. If they’re planning on fasting, you would want to start looking into a lot of things — what their diet and exercise are like, what their medications are like, the last time they fasted, how has fasting impacted them — so that you can determine their level of risk for fasting if a risk exists, and you would do that so you can help them make an informed decision on fasting. … If someone needs to break their fast, they need to know when to break their fast. You need to ask them if they think the dosage form they’re using nullifies the fast or not. Most Islamic religious scholars think that if you take a pill with a glass of water, this nullifies the fast. Other dosage forms such as inhalers, injections, and eye drops are considered to nullify fasting by some, but not by others. It’s not really a religious issue here. It’s more of what the patients think. Sometimes what clinicians do is try to tell patients what they think does or does not nullify fasting according to religious guidance, but you need to work around what the patient thinks if they break the fast or not, not what you think as a provider.
How have patients and physicians been navigating these decisions in the absence of the direction RAMCOM provides?
At this point, there are a lot of missed opportunities for clinicians around the world. One of the items that we had in my PhD study that was done in Alexandria — in Egypt, a 90 percent Muslim country — [was] asking pharmacists, “When do you have that conversation, if you have it, and who opens it?” Most of the time when they have this conversation with patients it’s the night or two before fasting, or the first week of Ramadan. That was like 80 percent of our sample, and that is subject to social desirability bias — that’s a self-report — so it’s probably worse than that. … Sometimes patients would think, “Clinicians know I’m a Muslim patient, they know I’m having diabetes; and we haven’t covered [fasting], and the clinician knows that Ramadan is approaching. Because this clinician hasn’t covered [fasting], I would think that it is okay to fast.” I can tell there are a lot of missed opportunities in places that follow a bit of a paternalistic model of patient care. In such settings, some clinicians would be very visibly upset if they told [a patient that they] shouldn’t be fasting, and they end up fasting. Instead of working around the patient’s decision, they would be very judgmental — and I’m talking about some clinicians in Muslim countries, whom one would expect to be more understanding of the issue, that do that. Problems around this issue in non-Muslim countries include not having that clinician-patient conversation to begin with, and that gets back to the whole issue of invisibility, of not having that opportunity to get the care that one would need.
You’ve said that you think of pharmacists as accessible points of health care. How is your research helping to prepare them to fill this role?
Pharmacists in different countries underestimate the value of the very brief counseling that they [give] to patients. I think the kind of counseling that can be provided to patients can have a considerable impact on patients’ lives. Ramadan is an example. Let me start with someone who has access to and is being followed by an endocrinologist: you can provide brief counseling that tells them if they need to talk to physicians about the need to fast. If they end up doing that, then you’ve changed that trajectory that the patient would take during that month and beyond. If you are trained to provide more comprehensive counseling on safe fasting, and that patient does not want to go to a physician for a visit or cannot afford a physician, but you have provided counseling to that patient, you’ve made a different trajectory for that patient going forward. … In the Middle East, there are so many pharmacies in cities that we have a law in Egypt that says they need to be separated by 100 meters, so if you are having very well-trained health professionals right there in these places spread throughout a geographic area, then you are having a considerable public health impact where you’re at.