This was a qualitative study conducted among Thai Haj pilgrims and one pilgrim guide during their travels in Mecca, Saudi Arabia.

The lead investigator (MT) indicated to each participant that the interview was strictly for research purpose and not a part of any medical examination or treatment procedure. Participants who showed sign of physical or emotional distressed were to be immediately dismissed from their participation. The procedures followed in this study were in accordance with the standards the Helsinki Declaration of 1975 (2013 revision). Permission to travel to Saudi Arabia to collect data for the study was granted by Province of Songkla University (Order No. 50555/2561 dated 28 September 2018).

The original sample size for this study was 24 pilgrims and pilgrim guides (12 from the Muslim-majority Deep South provinces, 6 from relatively affluent Bangkok Metropolitan Area, and 6 from other regions). The proportion of province of origin was to reflect the proportion among Thai Haj pilgrims.

Inclusion criteria: Above the age of 18 years; able to communicate in either Thai or Malay languages and history of diagnosis with at least one non-communicable disease. The lead investigator (MT) recruited a total of 19 pilgrims and one pilgrim guide. Other individuals who met the inclusion criteria could not be contacted later during the data collection period.

Exclusion criteria: Participants who refused to allow the lead investigator to make voice recording of the interview were excluded from the study.

The study instrument was a semi-structured questionnaire. The questionnaire was created in Thai language, but the interview was administered in both Thai and Malay, depending on the mother tongue of the participant. The questions were reframed by the interviewer according to the natural flow of conversation. The questionnaire consisted of three parts, as follow:

In Thailand, the Thai Haj Medical Office, Thai Ministry of Public Health, was contacted and notified verbally and in writing by the lead investigator (MT) about the study and data collection activities in Saudi Arabia. Later, Thai pilgrim group leaders were contacted, explained about the study, and inquired about pilgrims in each group who had chronic conditions. The group leaders were informed that the interview information would be kept strictly confidential and used only for research purpose. MT then contacted the pilgrims with chronic condition at their room of accommodation, provided information about the study, and inquired about the pilgrim’s interest in participation in the interview and, among those who expressed interest, the time and place of convenience for the interview was fixed. MT also visited the field hospital established by the Thai Haj Medical Office and contacted the Chief Medical Officer on duty to verbally request permission to recruit participants and conduct the study interview. The medical officer and staff then prepared a room for interview of outpatients and recruited outpatients by convenience sampling on MT’s behalf. The medical officer also allowed MT to contact inpatients at the field hospital to recruit additional participants.

In both the hotel and field hospital settings, MT explained the study procedures in details. MT also asked for the potential participant’s permission to make voice recording of the interview, and that MT would place the recorder in front of the participants. MT was the only person who conducted the interviews, and obtained all informed consent verbally prior to conducting each interview. MT also ensured that the interview setting provided adequate privacy and confidentiality, and that no other person in addition to MT could hear the responses. Each interview took approximately 30 minutes to one hour.

Furthermore, before departing for Saudi Arabia, Thai Haj pilgrims were required to undergo two vaccination visits with medical examinations by local government physicians assigned by the Thai Ministry of Public Health. The examinations included interviews regarding medical history, physical examination, X-ray, and fasting blood glucose test. Based on the results of the medical examinations, the pilgrims were categorised into categories or “codes” regarding risk of health problems during the pilgrimage. There were three codes: Normal or “Green” (no elevated risk of health problems); Caution or “Yellow” (elevated risk of health problems, monitoring required), and; Dangerous or “Red” (significantly elevated risk of health problems) [9]. All groups were allowed to travel, although the code designations helped Thai health officials who worked with the pilgrims to be aware of the pilgrims’ health status predeparture. Provincial Public Health Office staff then recorded the pilgrim’s medical conditions and code on the Haj Handbook, which each pilgrim was required to carry during the pilgrimage. During the interview in Saudi Arabia, MT asked for the participants’ permission to see their Haj handbook and recorded information regarding their medical condition and health status code verbatim.

Data Management and Analyses

MT saved the voice recording files in an offline harddisk space in a password-protected personal computer. MT then hired a trained transcription writer who was fluent in both Thai and Malay to transcribe the interviews, on condition of confidentiality regarding the names and details of the study participants. Interviews conducted in Thai were transcribed into Thai, and interviews conducted in Malay were interpreted and transcribed into Thai. MT and the transcription writer than replaced all names of the participants with pseudonyms, and used only the pseudonyms in the study reports and all subsequent publications.

MT and co-investigators (CC and WW) analysed the transcription texts. With regard to health beliefs on management of chronic diseases during the Haj, the investigators used content analysis with the health belief model [10] as the theoretical framework. With regard to changes and adaptations in daily routines during the Haj, MT and WW used content analysis.

Descriptive statistics were used and transcription texts were analysed using content analysis.

Among the 20 participants, 16 were above the age of 60. There was a wide variety in level of education with slight over representation of participants from the Deep South provinces and under representation of participants from regions other than the Deep South and the Bangkok Metropolitan area [Table/Fig-1]. Diabetes, hypertension and lipidemia were the most common chronic conditions.

With regard to heath beliefs, participants expressed concerns about occurrence or recurrence of illness but accepted illness as being unavoidable [Table/Fig-2]. Participants also understood the consequence of not managing chronic conditions and the possibility of serious complications and death, although they regarded maintaining good health as following religious principles. Having a state of health that is adequately well to perform the pilgrimage according to assessment by physicians, however, was seen as God’s will and that the pilgrim should not be stubborn and act against medical advice. Participants perceived the Haj as a service ritual that requires good health, and that it is desirable to perform the Haj without the assistance from others, when possible. One participant identified the rush to perform all rites in a hurry as a potential barrier to maintain a proper state of health and safety.

The pilgrims adapted their daily routine according to their own medical and physical limitations, such as choosing to go to pray at the Al-Haram Mosque only when it is physically convenient to do so [Table/Fig-3]. Pilgrims also indicated a strong sense of medication adherence and care-seeking behaviour when experiencing illnesses. The extent and method of self-care varied, but dietary compliance for diabetes control seemed to be the most commonly mentioned issue of concern.

This study described health belief of Thai Haj pilgrims with regard to management of chronic diseases and adaptations in their daily routine. Although the pilgrims strived to maintain their health to complete the pilgrimage and return home safely, they also perceived their susceptibility and the severity of potential complications of chronic diseases during the pilgrimage. Participants seemed to adapt their daily routine to meet this aim, with awareness of the need for medication compliance.

Spirituality emerged as one of the main themes in health beliefs pertaining to chronic diseases among our participants. Spirituality can be an important resource for coping for Muslim patients who are confronted with chronic diseases [11], and the pilgrimage may have heightened this sense of spirituality. The acceptance of poor health as a sign that God had not allowed for the pilgrim to make the journey, as well as the acceptance of the possibility of serious illness or death while on the pilgrimage, could be influenced by the belief in qadar or God’s predestination [12] and is used as a psychological defense mechanism. The desire to maintain good health, on the other hand, may reflect the influences of various Quranic verses and traditions [13]. The findings of the study has implications on the key role that spirituality can play an important role in health promotion. Achieving good health and management of chronic diseases can be considered as a mean to embark on the pilgrimage and successfully complete the Haj, which includes physically demanding rituals in the holy land. Furthermore, in consideration of the prevalence of chronic diseases in the elderly population and that most pilgrims are elderly persons with varied backgrounds [3,4], future studies should explore the extent that the patients were educated and advised by healthcare providers and pilgrimage operators about management of their chronic conditions during Haj-specific rituals, and adherence to these advices [5]. The strength of the study was that the data were collected during the pilgrimage, thus reducing the possibility of recall-associated errors.

A number of weaknesses should be considered as caveats in the interpretation of the study findings. Firstly, the use of semi-structured questionnaires and adaptation of interview questions according to the flow of the conversation precluded standardisation of the questions and responses. Secondly, inaccuracies in translation of Malay-language interview recordings into Thai-language transcripts could have introduced errors to the study data. Lastly, data were collected only from pilgrims from Thailand, which limited the study’s generalisability.

In-depth interview of Thai Haj pilgrims showed perceived susceptibility and severity of chronic disease complications, but also a sense of spirituality and adaptation of daily routine to cope with physical limitations. Pilgrims also appeared to have high level of medication adherence during the Haj. The results complement the findings of previous studies, although a number of caveats and limitations should also be considered.