Accepted Manuscript

Impact of patients’ religious and spiritual beliefs in Pharmacy: From the perspective of
the Pharmacist

Moustafa Daher , BPharm, Hons Betty Chaar , PhD Bandana Saini , PhD

PII: S1551-7411(14)00069-2
DOI: 10.1016/j.sapharm.2014.05.004
Reference: RSAP 521

To appear in: Research in Social & Administrative Therapy

Received Date: 10 March 2014

Revised Date: 22 May 2014
Accepted Date: 22 May 2014

Please cite this article as: Daher M, Chaar B, Saini B, Impact of patients’ religious and spiritual beliefs
in Pharmacy: From the perspective of the Pharmacist, Research in Social & Administrative Therapy
(2014), doi: 10.1016/j.sapharm.2014.05.004.

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 ACCEPTED MANUSCRIPT

Impact of patients’ religious and spiritual beliefs in

Pharmacy: From the perspective of the Pharmacist

Moustafa Daher BPharm(Hons)

Betty Chaar (PhD)

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Bandana Saini (PhD)

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Faculty of Pharmacy University of Sydney

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Correspondence:
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Dr Bandana Saini
Faculty of Pharmacy,
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The University of Sydney Room Number S303, Building

Number A15 The University of Sydney NSW 2006
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Telephone: +61 2 93516789

Fax: + 61 2 93514791
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Email: bandana.saini@sydney.edu.au
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Keywords: Religion; Medicine; Ingredients; Pharmacy

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Word Count: 4,990 (excluding title page, abstract, references,

tables and figures)

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Abstract

Background: Socio-cultural perspectives including religious and spiritual beliefs affect

medicine use and adherence. Increasingly communities that pharmacists serve are diverse and

pharmacists need to counsel medicine use issues with ethical and cultural sensitivity as well as

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pharmaceutical competence. There is very little research in this social aspect of pharmacy

practice, and certainly none conducted in Australia, an increasingly multicultural, diverse

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population.

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Objectives: The purpose of this study was to explore, from a pharmacy practitioner’s viewpoint,

the frequency and nature of cases where patients’ articulated religious/spiritual belief affect

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medicine use; and pharmacist perspectives on handling these issues.
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Methods: Qualitative method employing semi-structured interviews with pharmacy

practitioners, constructed around an interview guide. Pharmacist participants were recruited

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purposively from areas of linguistic diversity in Sydney, New South Wales, Australia. Verbatim
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transcription and thematic analyses were performed on the data.

Results: Thematic analyses of 21 semi-structured interviews depicted that scenarios where

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religious and spiritual belief and medication use intersect were frequently encountered by
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pharmacists. Patient concerns with excipients of animal origin and medication use while

observing religious fasts were the main issues reported. Participants displayed scientific
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competence; however, aspects of ethical sensitivity in handling such issues could be improved.
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This novel study highlights the urgent need for more research, training and resource

development for practitioners serving patients in multi-faith areas.

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Background

An increased emphasis on human rights and bioethical constructs in healthcare emerged in the

Post World War II era, when, in, 1946, the World Health Organisation (WHO) defined health to

be the complete state of mental, physical and social well-being and not merely the absence of

disease or infirmity 1. In contrast to the biomedical reductionist approach prevalent in the earlier

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half of the century, the more holistic biopsychosocial model was conceived in the 1970s from an

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ethno-medical perspective, and in line with the WHO definition, suggests that health is best

understood in terms of a combination of biological, psychological, and social factors rather than

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purely in biological terms 2. This model further posits that to understand the individual’s

experiences of the illness and to be able to influence health and treatment related behaviours, the

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social, economic, familial, professional and political milieu of that individual needs to be
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understood. It is now increasingly recognised that spirituality and religious beliefs form an

integral part of an individual’s psychological make-up 3. This focus on the patient and their
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social context shapes current thinking in medicine, where medical sociologists have now
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embellished the bio psychosocial model further to the 'biopsychosocial-spiritual model' of health
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care 4.

Religious beliefs as well as spirituality often have a pivotal role in influencing an individual's
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willingness to seek and/or obtain treatment. Religion and spirituality are related but conceptually
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different. Religion may be defined as ‘a set of beliefs, texts, rituals, and other practices that a

particular community shares regarding its relationship with the transcendent’ 5. Spirituality by
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contrast, is ‘the ways in which a person habitually conducts their life in relationship to the

question of transcendence’ 5. Studies demonstrate that this aspect of individual belief systems

affects health behaviours and, in turn, health outcomes. Religiosity and spirituality

have been shown to be associated with decreased levels of anxiety /depression and increased

levels of happiness and well-being 6. Research demonstrates that greater religious involvement

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is associated with lower blood pressure, lower rates of death from heart disease, fewer strokes

and longer survival 7. The influence of religious/spiritual belief on health is well established and

many in the field assert that the question for clinicians and researchers is no longer whether

religiosity or spirituality are relevant, but rather to explore pathways by which this domain is

functionally tied to health outcomes 6. The biopsychosocial spiritual model of health provides a

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framework for integrating spirituality into clinical practice 4.

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The technological advances in the latter part of the last century and the aftermath of the Second

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World War may have engendered developments in the field of bioethics, which has evolved

contemporaneously with the newer health care paradigms. Bioethicists frame patient care around

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four key pillars autonomy, beneficence, justice and non-maleficence 8. In medicine, the field of
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bioethics has addressed a broad spectrum of inquiry, ranging from debates over the boundaries
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of life, resource allocation, and the patient's right to refuse medical care for religious or cultural

reasons. Inquiry in this field highlights many scenarios where religious/spiritual belief plays a
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key role in health and outcomes. The controversial case of the Jehovah Witness society’s
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prohibition of blood transfusions and the consequences for patients of that faith undergoing

surgery, illustrates these tensions clearly 9-13. Key research discussions in this area include
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balancing respect for patient’s autonomy with constructs such as beneficence, justice and non-

maleficence, so that overall patient welfare is not overlooked13.

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Synchronous to this patient centred movement in health care, is the increasing appreciation of

multiculturalism in many societies. Most developed countries such as the US, Australia, and

European nations like Norway now have a heterogeneous populace resulting from migration for

reasons of opportunity or refuge 12,14. Australia has seen an influx of migrants from countries

across the globe. The national census in 2011 indicated that over one quarter (26%) of

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Australia's population were born overseas 15.This multiculturalism manifests in many kinds of

diversity such as language, belief systems, religious/spiritual belief, lifestyle preferences and

social norms. Health care professionals have adapted easily to linguistic diversity through

effective government subsidised translator services, or availability of relevant language

information materials for many health conditions. On the other hand, services that accommodate

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religious or spiritual belief have not been as simple to develop or implement. Australia has a

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network of approximately 5000 community pharmacies serving as a primary point of health care

entry for minor ailments and as an outlet for prescription medications 16. The community-based

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venue brings pharmacist practitioners into contact with patients from all walks of life.

Pharmacists are trained to communicate effectively so that they are able to elicit and address

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patient beliefs, particularly with regards to medication use. Medication use (and non-use) like
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other health behaviours may be influenced by patient's health related and other beliefs as well as
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psychosocial factors. In a Norwegian study conducted with a community based sample of

people who had migrated to Norway from Pakistan, it was clear that aspects of faith and
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religious beliefs influenced the way participants used medications, choosing, for example to
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alter medication regimens during the fast of Ramadan, without consulting their physicians14.

However, the influence religious and spiritual belief have in terms of medications has yet to be
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explored in the pharmacy setting. Beliefs pertaining to the consumption of animal products may
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overlap with the use of certain medicines or ingredients in medicine formulations that are animal
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derived. For example, gelatin is an excipient that may be bovine or porcine derived, a source

that is prohibited in certain faiths and beliefs 17. In a study conducted in America, physician and

patient perspectives about the presence of religiously contravening ingredients in medications

was explored 18. This study indicated that patients had concerns about medications and

ingredients derived from sources that were not in harmony with participant’s religious/spiritual

belief. Key ingredients of concern included those derived from porcine or bovine sources.

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Results from this pilot study conducted by Sattar et al., (2004), cited above, also highlighted that

more than half of the participating patients preferred their physicians to inform them about

treatment components that might flout their religious/spiritual belief. It is also noteworthy to

mention that the majority of the physicians in the study were unaware of the presence of

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religiously contravening ingredients in medications, outlining a potential void in current medical

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training. There are however no exploratory studies of this nature examining the extent or effect

of the problem from the perspective of community pharmacists who interface between treatment

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prescription and actual medication use.

Despite the increasing recognition of the influence of religiosity and spirituality in health,

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research in clinical pharmacy on this issue is scant. An exploration of cultural and linguistic
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differences in health and their impact on pharmacy practice has been undertaken to some extent;
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however, the influence of patients’ religiosity/spirituality on medication-taking and how it

impacts the practice of pharmacists is an under-researched area. Considering the cultural

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diversity in modern day Australia, this gap in social pharmacy research needs to be addressed.
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The purpose of this study was to explore, from a pharmacy practitioner’s viewpoint, the

frequency and nature of cases where patient’s articulated religious/spiritual belief affect
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medicine use; pharmacist perspectives on handling these issues and their resource needs for
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future practice.
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Methods

A qualitative inductive method was utilised with semi-structured interviews used as the data

gathering tool.

Sample:

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A purposive non-probability (convenience) based sample of practicing pharmacists from

Western and South Western regions of Sydney, New South Wales was recruited. This sampling

was purposive as it was expected that pharmacists in these areas serve clients following a wide

variety of faiths and religious practices. According to the Australian Social Health Atlas, these

areas have a high ethnic diversity with greater than 30% of residents being from non-English

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speaking backgrounds. Participants from community pharmacies in these areas were identified

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using local directories, and invited to participate through a mailed invitation, followed by a

phone call after a week. In each pharmacy, the pharmacist-in-charge, or any other pharmacist

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who responded either to the mail or phone invite was recruited into the study. One participant

was invited based on the researcher knowledge of the area they worked in. Given that the data

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were not being subjected to probability statistics, the non-random nature of identifying and
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recruiting participants using a convenience based approach was deemed appropriate.
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Data Collection:
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Key topic areas were explored using an interview guide that consisted of both open ended and
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structured questions; this is illustrated in Figure 1. The interview guide and prompts were

developed by a thorough review of the current literature as described in the introduction and also
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drew on the practice experiences of the research team. The interview guide was designed so that

initial queries were straightforward, such as demographics of the participant and their pharmacy.
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The guide allowed the interviewer to graduate to more cognitively challenging probes in the
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latter part of the interview. Towards the end of the interview, a brief hypothetical vignette where

a patient queries medication ingredients with respect to a spiritual belief about not harming

animals was presented, and the participants asked to comment on how they would handle the

query and assist the patient. The topic guide was pilot tested with a few practicing pharmacists

prior to undertaking research interviews.

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Insert Figure 1 Here

Figure 1: Interview topic guide

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All interviews were conducted face to face with the pharmacists by one member of the research

team and were digitally recorded then transcribed verbatim for analysis. The interviewer was

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trained to use skills such as probing, reframing, clarifying and summarizing to ensure credibility

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of collected data 19. Some (n=5) interviews were independently transcribed to ameliorate bias

potential; however, the primary author transcribed the majority of interviews.19, 20 Interviews

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were carried out until thematic saturation was reached. The length of interviews ranged from
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eight to eighteen minutes, with pharmacists more familiar about religious/cultural influences in

their practice providing more data and longer interviews.

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Data Analysis:
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Given that no previous data on this issue from the community pharmacy perspective exists, the

transcripts were analysed using a grounded theory approach. The verbatim transcripts for all
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interviews were entered into QSR NVivo 10 Software. Members of the research team first read

and re-read the transcripts for familiarization with the data. Themes apparent in these transcripts
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were coded. A coding framework was identified and further interviews were analysed bearing
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the framework in mind. Codes were added to the framework as they emerged iteratively. Two

interviews were randomly selected and coded by two independent research members for

validation. The framework was used for a descriptive analysis as this was an exploratory study.

Ethics:

The research was approved and conducted in compliance with the requirements of the Human

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Research Ethics Committee of The University of Sydney (Protocol number 2013/638).

Results

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Twenty-one semi-structured face-to-face interviews were conducted with current practicing

pharmacists in New South Wales. Collectively, the pharmacists who participated in this study

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had a wide range of pharmacy experience ranging from two to forty years. Most participants

were males (n=17), females (n=4). Furthermore, participating pharmacists reported the

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frequency of religious/spiritual encounters from once a day to once every three months.

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Analysis of the transcripts revealed several key themes, which are presented below. The themes

are identifiable in italicized headers and are outlined along a sequence starting from the
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frequency and type of encounters participants report with the religious/spiritual beliefs of their

patients, strategies employed in dealing with these issues and practice support desired by
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participants to equip them to handle these issues professionally in a competent manner.

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Frequency and nature of encounters

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All participating pharmacists reported having previously experienced scenarios in which they
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needed to meet the spiritual or religious beliefs of their patients. The frequency of cases they

were presented with ranged from twice a day to at least once every three months. A majority of

participating pharmacists explained that the nature of their encounter was ingredient related, in

which the contents of a desired product contained an ingredient that their patient deemed as

religiously or spiritually contravening.

“So, basically anything with gelatine is normally of a concern to them, so all the capsules.”

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(Pharmacist 14)

“You got some of the multivitamins which are bit cautious on the gelatin in their Muslim belief

and Jewish belief and don’t allow for pork products.” (Pharmacist 12)

However some participants felt that from a health perspective, their patient’s religious/spiritual

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beliefs could impede desired health behaviors.

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“There is stronger adherence and compliance with their medication regime when they know its

okay to take it. A lot of people stop taking their medication when they discover it’s got

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something inside it that they religiously cannot take.” (Pharmacist 9)

Attending to issues
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Many strategies were employed by participants in dealing with patients whose religious/spiritual
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beliefs led them to be unsure of using a particular product or medication. Several interesting

themes emerged as participants described their professional decision-making in these scenarios.

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Respect for patients autonomy

All participating pharmacists reported that when faced with such scenarios, their foremost action
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was to provide their patient all possible options in terms of treatment, even in situations when
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options were limited. All participants ensured that the patient had the final say in deciding
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whether or not to accept a form of medication. Pharmacists claimed they always sought the

patient’s consent when supplying a particular treatment where the patient had expressed concern

with respect to their religious/spiritual beliefs and the content of the medication.

“I’d double check with the patient...Once they are aware they’ll make a judgment whether

they’ll take it or not” (Pharmacist 1)

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Disclosure

Most participants reported that if they suspected that a particular medication/ingredient/excipient

might be at odds with a patient’s religious/spiritual beliefs, they were likely to disclose this and

allow the patient to make an informed choice towards medication use. In these cases, the

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pharmacists had prior knowledge of the patient’s belief, for example for regular patients. In

some cases, visible clues such as head scarves [such as the Hijab, a veil/scarf worn by some

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Muslim women, when attending a public place] provided a cue for pharmacists to discuss these

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issues. It is worthwhile to note that very few participants pro-actively sought information from

the patient about possible beliefs that may preclude them from using certain medications.

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“If it's the case that it's a patient I don't know personally, I'm not going to go down to him [from
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the dispensary to the front of shop] and try and alert him to things that he might not care

about… I would rather leave it to him.” (Pharmacist 18)

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“Okay (because he is a regular customer) I would intervene and tell him. I wouldn’t give it to
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him without letting him know.”(Pharmacist 13)

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Practicalities
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After participants recounted the strategies they employed to work around patient’s belief. In
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some cases, participants were competent in being able to correctly identify the source of origin
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of the implicated medications, for example to ascertain if these were in concordance with

Islamic dietary laws (Halal).

“Especially with vitamin D capsules and that. You've got the XXXX brand now - they've got the

halal logo on there. So, the companies are becoming more aware” (Pharmacist 17)

If participants were presented with a medication that exists in multiple formulations, they all

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suggested they would change the formulation from a gelatin capsule to an animal source free

formulation, such as a syrup. If possible, a few participants reported that an alternative

formulation could be extemporaneously prepared. However, the majority of participants tended

to seek reliable advice from industries, though this strategy proved to be futile in some

instances.

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“A lot of the times, the company people that you actually speak to have no idea. So, it's

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sometimes very difficult, especially with your time constraints.”(Pharmacist 17)

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Barriers faced by pharmacists

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Lack of industry transparency: AN
Participating pharmacists highlighted through their encounters that the pharmaceutical industry

tended to be unclear, if not ambiguous, with regards to assisting a patient choosing a form of
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therapy.
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“Some sort of transparency to help us instead of when people come in they ask us, we don’t
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know, we have to ring the company it’s like a merry go round that may take 15-20 minutes.”

(Pharmacist 12)
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“A lot of the ingredients that are in medications, they don't really specify the source or whether
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it's animal-derived.” (Pharmacist 17)

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A few participants reporting using the internet to source information quickly so as to be able to

help their patients quickly.

Supersession of beliefs over health

Some participants expressed concern that in some cases patients tended to abide by their

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personal beliefs even when potentially jeopardising their medical condition.

“For some people it doesn’t matter how important the medication is for that person, the cultural

or religious belief for that person overpower that (need for medication)” (Pharmacist 10)

Participants were also asked about the influence religious practices, such as fasting had on

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medication use. Some highlighted that a few of their clients would stop taking their medication

without seeking consultation from their regular doctor

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“So, diabetics who are told that they need to eat regular smaller portions - they will still fast,

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regardless of what their doctors say. Some of them would even stop their medications during the

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month of fasting, thinking that, I'm not eating so I don't have an issue. I see it quite often, this
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one, yes.” (Pharmacist 14)

Future Developments
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The majority of participating pharmacists strongly suggested a need for further resources from
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pharmaceutical manufacturers to assist both patient and pharmacist in selecting a form of

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therapy that is within the limits of religious or spiritual belief.

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“Well, I think something …to say… free of animal products, on the CMI or on the box would be

a good place to start.” (Pharmacist 19)

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Many also suggested the need for additions to existing medication databases or other standard

information sources that could identify the origin of medications or excipients in formulations.

“Well, it would be good if we had a list of all products that do contain the gelatin in it. So if

that’s available to the pharmacist it’s a quick guide and it’ll give us an indication to what we

can advise and what we can’t advise to use.”(Pharmacist 10)

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“A database of medications that are halal or kosher or vegetarian would make it so much

easier for everyone.” (Pharmacist 3)

The notion of adding extra information to currently utilised materials such MIMS (Medical

Information Management System) Online or the Australian Pharmaceutical Formulary was

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common ideas put forward by pharmacists.

“If that sort of information was readily available in the standard reference we had like MIMS)

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and AMH (Australian Medicines Handbook) it would be extremely helpful.”(Pharmacist 5)

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Education

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Some participants conveyed the concept of training or providing some form of religious/spiritual
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competency training for pharmacist or pharmacy students, to help them deal with similar

scenarios.
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“Well when I went to university none of this was ever an issue and was never discussed so
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certainly yes it should be covered in university.” (Pharmacist 5)

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Discussion
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This study highlighted that religious and spiritual beliefs often intersect with medication use;
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such case scenarios are encountered reasonably frequently by Australian community

pharmacists who were the participants of focus in this research. Whilst much research on the

effect of religiosity and spirituality on health and health outcomes has been carried out,

particularly where surgical procedures or life related decisions are involved, the effect of such

beliefs on regular medication use has not been explored. The frequency of encounters reported

by the sample pharmacists in their practices suggests the need to study the influence religious

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and spiritual beliefs have on medication use. Given the scant research in this area, this

exploratory study actuates a way to better understand religio-cultural issues affecting medication

use. The study also demonstrated the need for comprehensive resources that support health

professionals at the patient interface and for education and training to improve the skills and

competence of pharmacists in incorporating their patients’ religious/spiritual beliefs in daily

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practice. Furthermore, this study provides both the practicing pharmacist and industry a

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description as to how religious and spiritual belief may impact on treatment adherence and

product choice.

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Religious/spiritual beliefs and their impact on medication use were described by sample

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pharmacists under two main categories. Firstly, the presence of prohibited ingredients or
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excipients in medications led to concerns about use in some patients. The second issue
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pertained to religio-cultural practices such as fasting. In the first category, one of the main

ingredients of concern was gelatin, and it appeared to trespass beliefs across several faiths, or
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general spiritual beliefs about harm to animals. Apart from the study carried out by Sattar et al
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in 2004, no other research study has explored the impact religiously prohibited ingredients have

in medicine. Ingredients mentioned by pharmacists in this sample were similar to those reported
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by Sattar (2004); i.e. gelatin, alcohol, or animal sourced products. For the second category
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where religious practices appeared to affect medication use, Ramadan, a fast performed by
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adherents of the Islamic faith was one of the key practices mentioned, possibly as the study was

conducted in the few weeks after the fasting period for 2013. Considering that the Islamic

population in Australia is approximately 484,000 15; Ramadan would theoretically have an

impact on the medication profile of thousands of individuals who fast and are suffering from an

illness for which they are taking medications. Additionally, there are a variety of other fasts that

other religious adherents practice; all these religious denominations exist in Australian society

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and thus it is imperative that health professionals are aware of these issues. Several pragmatic

strategies were employed by participants to handle these case encounters. These included:

sourcing information about key ingredients, counselling the patient, finding alternatives or

compounding alternative formulations. In this sense, pharmacist practitioners displayed

pharmaceutical competence. In terms of religious practices, participating pharmacists were well

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equipped in counselling patients who were fasting throughout out the day. Dosage adjustments

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were suggested and undertaken after consultation with the doctor, in order to accommodate

patients who were required to use multiple daily doses of their medications.

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Participating pharmacists faced several issues in handling these scenarios. All participating

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pharmacists expressed frustration in sourcing information when trying to address the queries of
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devout patients. This was particularly an issue with excipients in medications, where accessing
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credible information to ascertain whether ingredients were animal derived and/or Halal or

Kosher-approved proved difficult. In most scenarios, pharmacists in the sample reported

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resorting to contacting the manufacturers, who at times were not able to provide a definite
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answer. Failing this avenue some pharmacists reported accessing the internet for any form of

information they could work with. Suggestions were made to improve the lack of resources such
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as; providing the source of gelatin in standard consumer leaflets for medicines or on professional
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drug databases or approved product information materials. Addressing these recommendations

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would assist pharmacists and other health professionals when requested to search for an

ingredient’s source; such resources would also reassure worried patients and hence improve

their adherence to treatment. Professional moves in this arena have been commenced. The

Pharmaceutical Society of Australia has recently released a series of books titled ‘The Halal

Index’, to address the issue of porcine derived medication ingredients 21. Although this

addresses the dietary laws prescribed for Muslims, it may not be applicable to adherents of other

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faiths. Nonetheless, this information sets a starting point for training pharmacists to be culturally

competent in a multicultural, multi-faith nation. In this virtual era, many innovative practice

tools can also be developed and implemented. Recently, an application (App) that is readily

accessible via mobile i-Phones titled “Care of Muslim Patients” 22 has become available. This

application, developed by Elsevier Singapore, provides both patients and physicians a user-

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friendly reliable resource to assist them in understanding the possible conflict that may arise

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between Islam and Medical practice. Again, this addresses issues relevant to one religious

denomination only, but should serve as a forerunner for similar tools that could address a wider

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variety of religio-spiritual faiths and practices.

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Although practitioners displayed scientific competence in dealing with such encounters, some
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more deeply rooted issues regarding ethical sensitisation of these practitioners were evident.
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Pharmacists in the sample reported observing transparency in the light of patient queries and in

observing respect for the patients’ autonomy. All pharmacists believed these cases must be
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addressed in a manner to ensure the patient’s own decision to use or not use a product is
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respected. However, whilst being supportive of their patients’ beliefs when discussions were

broached by the patient themselves, most participants in the sample would not proactively seek
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information about the patients’ religious/spiritual beliefs, and issues were handled only if
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initiated by the patient. This finding is similar to that established by Sattar et al., in 2004 who
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reported that although physicians in their study believed it is important to inform patients about

potentially contravening medications, very few actually put that into daily practice18. In the case

of pharmacy practitioners, by not proactively revealing implicated ingredients to patients,

practitioners by pass the bioethical principle of ensuring informed consent, which underpins true

respect for autonomy. In a study conducted in the USA, with urology patients, physicians

previously inadvertently prescribing oral medication with gelatin, noticed that if this information

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was provided to their patients, 51% chose not to use the medication, highlighting the importance

of informed consent in such scenarios 23. One issue highlighted by pharmacists in our study was

not knowing if patients may hold such beliefs, and thus being unwilling to tread on their

privacy.

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Another key issue raised by the research is that of professional training. In this information era,

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many patients are aware of these ingredients and as such have their own desire whether they will

accept or reject a form of treatment. Good practice would suggest that pharmacists be at least

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aware of these issues and be prepared to address the issues when they arise in a manner that

achieve equilibrium between the patients autonomy and the pharmacists professional knowledge

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about therapeutic necessity and patient health outcomes. An issue associated with this is that
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health professionals would be required to have a knowledge of the origin of active and inactive

ingredients in the medications they prescribe 24. From a review of the literature, the majority of
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patients and medical professionals included in research studies were unaware of the presence of
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animal derived or religiously/spiritually implicated excipients in medicines. Most physicians are

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not trained in this aspect, nor are pharmacists. Pharmacists are aware of excipients in general,

but not aware of how their patients’ beliefs might have them choose to avoid a medication based
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on the excipient type and origin. Training about cultural competency could address this
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awareness gap. Several proactive medical educators in American Medical Schools have

espoused this idea by recently incorporating spiritual studies as an elective in the curriculum 25.
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The learning objectives of such courses aim to enhance the students’ understanding of patients’

spirituality within the context of health and disease. Having some element of this in

undergraduate training or continuing professional education for pharmacists would permit all

pharmacy practitioners to deal with occasional encounters in a way that allows better outcomes

for their patient by allowing informed decision making. The multicultural and multi faith aspect

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of Australia necessitates an awareness of spiritual needs that may be visited in the healthcare

setting, particularly in pharmacy practice, a frontline primary health care profession.

Pharmacists should be trained to not only have the knowledge about medication ingredient

issues that may contravene patient religious/spiritual belief but also be trained about sourcing

possible alternative choices. Further in their compounding role, pharmacists can also prepare

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products extemporaneously using non-gelatin capsule shells, or even prepare an alternative

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medication formulation such as oral liquids or tablets. Besides the scientific and clinical practice

training, enhancing ethical sensitivity would facilitate improving patient outcomes whilst

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accommodating their religious/spiritual practice as posited by the bio psychosocial-spiritual

model of care 4. Inclusivity of the spiritual domain in health care provision can influence health

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seeking, health outcomes, life satisfaction and trust in the medical system 26.
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Practice interventions specifically designed to educate patients about harmonising their

medication use and their desire to participate in a religious fast, for example, have been shown
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to improve health outcomes; and educational programs covering dietary advice, meal planning
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and exercise, have been shown to affect positive outcomes in fasting diabetic Muslim patients 24.

Without the benefit of health professional interventions, studies have indicated the significant
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increase in adverse events such as hypoglycaemic episodes occurring amongst diabetic fasting

patients during Ramadan 27, 28 suggest that during Ramadan, differences in dietary consumption
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or erratic nutrition intake may be responsible for poor health related outcomes amongst fasting

adherents 29

. The implications of these studies should be interpreted in the context of modern day pharmacy

practice. Understanding simple interventions that promote positive health outcomes of fasting

patients with chronic conditions such as diabetes should be developed and their effect evaluated.

Figure 2 summarises key action points that our research has raised.

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The limitation of this study is related to the qualitative style of this research that attempts to

generalise the entire population of pharmacist Australia. The data obtained from the selection of

two metropolitan areas in Sydney cannot represent all areas of Australia. The majority of the

participants were male; however the gender of the participant may or may not have had a

bearing on their reported observations. Further, other health professionals, patients or religious

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leaders were not interviewed. These wider perspectives need to be explored prior to shaping

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practice improvement in any one setting such as community pharmacy.

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Insert Figure 2 here please

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Figure 2: Future roles and developmental issues for various key players at the patient
religiosity/spirituality interface
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The diversity in the Australian population will bring about challenges in the future, and perhaps
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it already does. Most professionals would have experienced an occasional dilemma of this
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nature, and dealt with it on the basis of their clinical and life experience. The results of the

current study highlight that these issues exist and that the pharmacists possess a high level of
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pharmaceutical-related competence. However, this competence might not be matched with the
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same level of ethical sensitivity. By providing competence through both practical training and
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supportive resources, pharmacist would be better equipped in handling these issues whilst

demonstrating ethical sensitivity and respect for their patient’s autonomy.

Conclusion

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In conclusion, it can be suggested from this study that the religious and spiritual belief of

patients may have an impact on their medication management. Participating pharmacists

recalled this to be of a frequent occurrence particularly in terms of the presence of ingredients

sourced from animals whose consumption are prohibited in particular faiths. Despite recent

activity, participants still believe improvements are required to further enhance the ability of

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pharmacists to deal with such scenarios. Further research needs to be undertaken to explore the

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perspective of the patient, particularly in terms of medication compliance and adherence.

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References

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Awareness about Awareness about

medications whose medication ingredients
consumption may not be whose consumption may not
allowed by certain spiritual or be allowed by certain spiritual
religious beliefs/practices? or religious beliefs/practices?

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Vignette: to assess
participants handling of a

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mock scenario
Consider the case of a middle age
male regular customer who comes

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to the pharmacy with a
prescription for Amoxil 500 mg 1
Description of incidents where
a patient’s belief affected
tds. As you approach him to ask
medication use:

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about generics, he tells you he is
I. Issue with medication
worried as he is quite strictly
ingredients
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vegetarian and he feels that
capsules are made with gelatin, II. Issue with practices.
which is derived from "animal III. Medication related
bones." He says if the capsules beliefs
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contain gelatin shells he will prefer

to not use the antibiotics which
have been prescribed for lower
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respiratory tract infection.

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Participant’s decision  Awareness about

whether to inform a any recent trends in
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patient who is unaware the industry with

of the presence of respect to this topic
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religiously/spiritually
contravening ingredients

Participant’s opinion
regarding any future
developments to address
this topic
Figure 1: Interview topic guide

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Enhancing ethical Enhancing or Counselling and

PRACTITIONERS
sensitivity maintaining communication
pharmaceutical skills
Undertake continuing competence Undertake training in
professional incorporating spiritual
development and beliefs in medication
training supply and counselling
encounters

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Database Continuing
development Professional
Development

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PROFESSIONAL
Incorporating Opportunities

PHARMACY
relevant information

BODIES
about medicine Ensure pharmacists

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ingredients in existing are offered continuing
data bases such as professional
MIMs developing development and

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new ones training opportunities
in this area.
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PHARMACEUTICAL
MANUFACTURERS
Better labelling Information Access
practices

INDUSTRY &
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Ensure that Medical

Ensure that product Information Staff are
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labels identify products equipped to provide

to be of vegetable information about
origin, or specify ingredient sources to
product excipients that health professionals
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may be animal derived efficiently

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Education Research
ACADEMIA

Provide pre-registration More research in this area

pharmacists with some
exposure to issues
relating to intersect
between
spirituality/religiosity and
medication use
of social
medicine/pharmacy.
Development and
evaluation of programs
that can assist patient
education, or the use of
the bio psychosocial
spiritual model in
pharmaceutical care

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Figure 2: Future roles and developmental issues for various key players at the patient
religiosity/spirituality interface

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