Introduction and Aim: Since the beginning of the Syrian conflict, over 3.5 million Syrians have fled their homes and been living in Turkey. Lack of language skills is a major problem limiting the utilization of quality health care at community pharmacies. This study aimed to investigate the impact of a pictogram-assisted diabetes-counseling program provided by Syrian and Turkish pharmacists on the health-related outcomes of the Syrian diabetic patients.

Materials and Methods: This study was approved by Marmara University Institute of Health Sciences Ethics Committee. This prospective observational study was conducted at a community pharmacy in Istanbul. One hundred and twenty consecutive Syrian diabetes patients who visited the pharmacy were included in the study and were assigned to one of the following two groups: Group 1 (n=60): Patients provided with pictogram-assisted counseling by a Turkish pharmacist in Turkish language; Group 2 (n=60): Patients provided with pictogram-assisted counseling by a Syrian pharmacist in Arabic language. The pharmacists counseled the patients twice. At the first interview, the pharmacist collected relevant demographic and clinical information. The most recent HbA1c levels were recorded at both visits; therefore, not every patient had a new HbA1c measurement at the second visit.Medication Knowledge Test (MKT) and Morisky Medication Adherence Scale (MMAS) were administered to the patients. The patients received pictogram-assisted patient education. Within the scope of patient education, the patients were trained both verbally and with pictograms (on the intended use of drugs, the most frequent side effects and instructions for use). The second interview was held 2 weeks after the first interview. The same information recorded at the first visit was re-evaluated and recorded again. Statistical analysis was performed using the commercial statistics program SPSS® 11.5. Continuous variables are presented as mean [standard deviation] or median [min-max], while categorical variables are presented as percentage (%).

Results: Baseline characteristics of the patients (n=120) from both groups were similar: median [min-max] age was 53 [21-65]; 57.5% was female; majority could not speak (90%), read (90.8%) and understand Turkish (91.7%); 90% could not communicate on his/her own in the pharmacy (Mann Whitney U test; p>0.05 for all). They have been living in Turkey for median [min-max] 4 (1-12) years. Mean (standard deviation) weight [81.3 (15.8) kg], random blood glucose (RBG) [207.1 (50.3) mg/dL], fasting plasma glucose (FPG) [160 (29.6) mg/dL] and HbA1c [(8.1 (1.1) %] levels were similar for both groups (Mann Whitney U test; p>0.05 for all). MKT and MMAS scores significantly improved in both groups (Wilcoxon Sum Rank test;p<0.05 for both). RBG, FPG and HbA1c levels of the patients in Group 2 improved by pharmacist counseling (p<0.001) while they remained unchanged for the patients in Group 1 (Wilcoxon Sum Rank test).

Discussion and Recommendations: The positive impact of pictogram use was reflected by the improvement of MKT and MMAS scores. In addition to the pictogram use, the comprehensive patient education provided by the pharmacist speaking in the native language of the patient, helped the glycemic control improve.

Keywords: Pictogram; pharmacy; patient counseling; foreign patient.

Footnote: The authors declare that they have no conflict of interest.