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Barriers and facilitators to perceived diabetes self-management in Arab American patients with diabetes
ARTICLE IN PRESS
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p r i m a r y c a r e d i a b e t e s x x x ( 2 0 1 9 ) xxx–xxx
Contents lists available at ScienceDirect
Primary Care Diabetes journal homepage: http://www.elsevier.com/locate/pcd
Original research
Barriers and facilitators to perceived diabetes self-management in Arab American patients with diabetes Dana El Masri a,∗ , Nikolas Koscielniak b , Gretchen Piatt b , Rosanne DiZazzo-Miller c , Judith Arnetz d , Linda A. Jaber a a
Department of Pharmacy Practice, Wayne State University, 259 Mack Avenue, Suite 2134, Detroit, MI, 48201, USA Department of Learning Health Sciences, University of Michigan, 1111 E. Catherine Street, Ann Arbor, MI, 48109, USA c Department of Health Sciences, Wayne State University, 259 Mack Avenue, Suite 2212, Detroit, MI, 48201, USA d Department of Family Medicine, Michigan State University, 788 Service Road, B103 Clinical Center, East Lansing, MI, 48824, USA b
a r t i c l e
i n f o
a b s t r a c t
Article history:
Aims: To assess perceptions surrounding diabetes self-management (DSM) behaviors in Arab
Received 23 February 2019
American patients with diabetes.
Received in revised form
Methods: A 39-item survey was constructed from focus group discussions designed to better
30 August 2019
understand the impact of Arab American culture on DSM behaviors. The survey assessed
Accepted 6 September 2019
perceptions about diet, adherence to medications, exercise, healthy lifestyle, and family
Available online xxx
support.
Keywords:
interviews. Most patients were female (59%), over fifty years of age (79%), and immigrated
Diabetes self-management
from Lebanon (73%). Receiving instructions in Arabic, having family support, family under-
Arab Americans
standing of food choices, and employment status were found to be important predictors of
Results: Two hundred Arab Americans with diabetes completed the survey via face-to-face
Type 2 diabetes
the perceived importance of DSM.
Education
Conclusions: Our findings suggest that there are multiple factors that dictate Arab American’s perception of the importance of DSM. The survey that was constructed may serve as a valuable tool for providers to assess DSM perceptions in order to provide patient-centered care that will help to improve diabetes outcomes. This study supports the importance of integrating cultural influences into DSM education and support when providing care to a population with a strong cultural identity. © 2019 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
∗
Corresponding author. Present address: Beaumont Health, 18101 Oakwood Blvd, Dearborn, MI, 48214, USA. E-mail address: [email protected] (D. El Masri). https://doi.org/10.1016/j.pcd.2019.09.002 1751-9918/© 2019 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: D. El Masri, et al., Barriers and facilitators to perceived diabetes self-management in Arab American patients with diabetes, Prim. Care Diab. (2019), https://doi.org/10.1016/j.pcd.2019.09.002
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1.
Introduction
The American Diabetes Association recommends that all individuals with diabetes receive diabetes self-management education and support (DSMES) at diagnosis and as needed thereafter [1]. Diabetes self-management education is essential as it facilitates patients’ knowledge and skills with the overall objective of improving patient outcomes and health-related quality of life; however, it is not sufficient for sustained behavior change. Diabetes self-management support is the fundamental process that provides instrumental support to patients with the goal of sustaining behaviors needed to successfully manage their diabetes [2]. A welldeveloped body of evidence demonstrates the effectiveness and cost-effectiveness of DSMES, including reductions in hospital admissions and readmissions [3–5], and lifetime health care costs related to a lower risk for complications [6]. DSMES is also associated with reduction of diabetes complications [7,8], improvements in quality of life [9–13], and reductions in diabetes-related distress [14,15]. These improvements highlight the importance of DSMES and validate its role in managing patients with diabetes. A key component of DSMES is to adopt an individualized approach to diabetes self-management (DSM) that reflects a patient’s cultural background and identity [2]. This is particularly critical in the Arab American population, where self-management behaviors are highly influenced by cultural norms. However, there remains a lack of sufficient evidence on DSM practices and behaviors in the Arab American population. Such knowledge may ultimately lead to improved patient outcomes. Cultural traditions held by Arab Americans either facilitate or impede DSM [16]. These traditions include food sharing, religious beliefs, and gender roles. Arab American females indicated that gender roles and female modesty impact their ability to engage in physical activity [16]. Religious practices, such as participation in the Ramadan fast, have also been expressed by Arab Americans to be a barrier for incorporating DSM into their lives [16]. Arab Americans face certain barriers that interfere with their ability to adopt a healthy lifestyle and practice DSM [17]. These include awareness of the need, financial considerations regarding medication, and traditional gender roles. Therefore, developing culturally appropriate programs requires understanding effective strategies that promote DSM behavior change in the Arab American community. To address this gap, the purpose of this study was to assess perceptions regarding DSM behaviors, among Arab Americans with diabetes, in order to inform future individualized care plans by health care providers.
2.
Methods
A descriptive cross-sectional study design was used to assess perceptions of DSM behaviors and to understand barriers to participating in DSM by Arab Americans with type 2 diabetes. Study personnel recruited participants from the community at large and from pharmacies located in a pre-defined geographic area of Michigan mainly populated by Arab Amer-
icans. Pharmacist referrals and snowball sampling were employed. Individuals who qualified for this study were nonpregnant, Arabic-speaking individuals or Arab Americans (≥18 years of age) with a documented diagnosis of type 2 diabetes (T2DM). Arab ancestry and diagnosis of T2DM were determined by self-report. The study was conducted at Wayne State University (WSU) and at the Arab American Pharmacist Association pharmacies or facilities. When individuals presented for the study, the research team explained the risks and benefits of participating in the study and individuals were asked to provide informed consent. Participants were compensated for their time with a $10 gift card upon completion of the survey. The WSU Institutional Review Board approved all procedures prior to data collection. The authors developed a 39-item survey based on prior focus group discussions that aimed to better understand the relationship between Arab American culture and DSMES [16]. The survey was pilot-tested in 20 Arab Americans with T2DM, revised, and translated into Arabic by three Arab American research members. A professional translator reviewed the translated survey and approved the final revisions. Surveys were administered to participants by two trained Arab American research assistants. Interviews lasted approximately 45 min. The survey was divided into two components. The first component collected demographic information including age, gender, level of education, marital, employment and health insurance status, country of origin, and primary language spoken at home or with friends. Additional data collected were date of last physician appointment, general health rating, and date of diabetes diagnosis. The second component assessed the perceived importance of DSM, factors that facilitate DSM behaviors and practices, and factors that impede DSM behaviors and practices. Participants were asked about the following self-care behaviors: maintaining a healthy lifestyle, engaging in physical activity, regular self-monitoring of blood glucose, adherence to medications, adopting healthy coping mechanisms, implementing problem solving techniques and utilizing risk reduction strategies. Finally, participants were encouraged to share additional thoughts regarding DSM through open-ended questions. Responses were transcribed and coded. Survey data were extracted, tabulated, and independently examined by two reviewers prior to data analysis. Measures of central tendency were used to describe the sample. Pearson Chi-Square tests were used to determine associations between perceptions of DSM importance and factors which facilitate or impede DSM behaviors and practices. Logistic regression was also used to control for demographic factors and to obtain odds ratios between covariates and outcomes associated with perceived importance of DSM behaviors. The criterion for statistical significance was set at p < 0.1 for chi-square analyses due to the small sample size, type of study design, and to observe trends in the relationships between factors. Trends were tested using logistic regression, however, statistical significance was set at p < 0.05 for these analyses. STATA 15 was used for all statistical analysis. The qualitative analysis component of the study was completed using a data-driven inductive approach in an effort to establish codes and common themes derived from the data [18,19]. Two trained researchers independently read both tran-
Please cite this article in press as: D. El Masri, et al., Barriers and facilitators to perceived diabetes self-management in Arab American patients with diabetes, Prim. Care Diab. (2019), https://doi.org/10.1016/j.pcd.2019.09.002
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Fig. 1 – Relationship between employment status and perceived importance of regular exercise for DSM.
scripts and assigned codes for commonly occurring themes. Once the transcripts were coded, they were then reviewed by two other members of the research team to ensure consistency in coding. Differences were resolved through group discussion. With repeated readings, similar codes were grouped into main themes with a consensus of >80% (Fig. 1).
3.
Results
3.1.
Sociodemographics
Two hundred Arab Americans with T2DM completed the survey via face-to-face interviews and were included in the final analysis. Table 1 outlines the demographic characteristics of participants. Participants were primarily female (59%), over fifty years of age (79%) and immigrated from Lebanon (73%). Seventy-nine percent reported no educational degree. Over half of participants (56%) reported that their general health was fair or poor. Approximately 33% of the sample was
employed, while 43% reported they were either unemployed or homemakers.
3.2.
Quantitative findings
Perceptions about approaches to DSM varied widely across the sample. Chi-square tests resulted in significant associations between regular exercise and family understanding of food choices (p = 0.026), discussion of care with a clinician and family encouragement of health (p = 0.010) and time spent with family (p = 0.066), while portion control (p = 0.061), regular exercise (p = 0.021), and maintaining a healthy lifestyle (p = 0.001) were all significantly associated with receiving instructions in Arabic. Logistic regression models were used to analyze these associations further while controlling for demographic variables (age, gender, education status, marital status, employment status and health insurance status). The association between the factor of receiving instructions in Arabic and outcomes of food selection [OR = 6.66, p = 0.014; 95% CI = 1.48–30.03]
Please cite this article in press as: D. El Masri, et al., Barriers and facilitators to perceived diabetes self-management in Arab American patients with diabetes, Prim. Care Diab. (2019), https://doi.org/10.1016/j.pcd.2019.09.002
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Table 2 – Logistic regression analyses for DSM behaviors by employment status. Employment OR (p)
Variable Portion control Food selection Taking medications as directed Regular exercise Regular blood glucose monitoring Discussing care with clinician Maintaining a healthy lifestyle
Homemaker
Disabled
Retired
Unemployed
0.27 (0.20) 0.38 (0.38) – 0.19 (0.006) 0.85 (0.91) 1.28 (0.86) 0.23 (0.42)
0.51 (0.61) – – 0.37 (0.14) 0.21 (0.28) 0.60 (0.70) –
0.41 (0.49) 0.42 (0.51) – 0.47 (0.30) 0.36 (0.51) – 0.26 (0.38)
0.15 (0.05) 0.22 (0.14) – 0.30 (0.05) 0.48 (0.61) 0.99 (099) 0.14 (0.14)
Table 1 – Baseline demographics of patients. Patient characteristics
n (%)
n
200
Age <50 years ≥50 years
42 (21) 158 (79)
Gender Female Male
117 (58.5) 83 (41.5)
Country of origin Lebanon Other
146 (73) 54 (27)
General health rating Excellent Very good Good Fair Poor
10 (5) 26 (13) 52 (26) 83 (41.5) 29 (14.5)
Date of diabetes diagnosis <1 year ago 1–5 years ago 5–10 years ago >10 years ago
29 (14.5) 51 (25.5) 42 (21) 78 (39)
Educational level None Elementary/high school College/university
49 (24.5) 109 (54.5) 42 (21)
Employment status Employed/self-employed Homemaker Disabled/retired Unemployed/student
63 (31.5) 53 (26.5) 47 (23.5) 37 (18.5)
Marital status Married Single/divorced/separated/widowed
144 (72) 56 (28)
and maintaining a healthy lifestyle [OR = 43.98, p = 0.003; 95% CI = 3.75–515.24] both were significant in these models; however, portion control continued to demonstrate a trend association [OR = 3.67, p = 0.066; 95% CI = 0.92–14.75]. The association between family encouragement and discussion of care with a clinician remained significant [OR = 71.35, p = 0.003; 95% CI = 4.28–1189.06]. The association between family understanding food choices and engaging in regular exercise remained significant [OR = 2.41, p = 0.03; 95% CI = 1.09–5.35] (Table 2). A logistic regression model was used to evaluate the association between each perceived DSM behavior and
demographic covariates only. An association was observed between perceived importance of regular exercise to DSM and employment status. Participants who were homemakers or unemployed were 82% and 70% less likely to perceive regular exercise as an important DSM behavior, respectively, compared to employed patients [(homemakers: OR = 0.187, p = 0.006; 95%CI = 056–0.620), (unemployed: OR = 0.30, p = 0.046; 95% CI = 0.093–980)].
3.3.
Qualitative findings
Some participants provided additional thoughts and concerns regarding DSM. One participant stated that “it’s very important to eat healthy foods and to stay away from processed foods, and we should receive guidance on diseases that can occur as a result of unhealthy eating.” Many participants agreed that “good diet and exercise help control diabetes” and that “exercise is key to helping control diabetes.” Two participants expressed concerns regarding discussions with their physicians. One participant stated that “doctors should help more”, and the other participant stated that “doctors should give patients more information to help them manage their diabetes.” Finally, one participant stated that “we should focus on improving our education system in such a way as to promote educating our children starting at a young age” and that “younger generations need to receive education on diseases that can arise as a result of having a poor lifestyle and making unhealthy food choices.”
4.
Discussion
This study uniquely demonstrates perceived barriers and facilitators to DSMES among Arab American patients with diabetes. Findings suggest that receiving instructions in Arabic, having family support, family understanding food choices, and being employed are important predictors of the perceived importance of DSM (Table 3). Consistent with previous research, having family support and receiving instructions in Arabic emerged as important predictors of DSM [20–22]. A study by Pinelli et al. found that Arab Americans who had family support during sessions were more likely to attain their weight loss goal compared to those who did not have family support [20]. Fritz et al. demonstrated that providers are faced with the challenge of providing culturally appropriate materials to their Arab American patients, which would impede DSM [21]. Therefore, health care providers should focus on the role of family and the
Please cite this article in press as: D. El Masri, et al., Barriers and facilitators to perceived diabetes self-management in Arab American patients with diabetes, Prim. Care Diab. (2019), https://doi.org/10.1016/j.pcd.2019.09.002
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ARTICLE IN PRESS – – – – 0.06 – 0.10 – – – – 0.07 – 0.07 – – – 0.52 – – – – – – 1.39 – – – 0.51 0.51 – 0.64 0.10 0.71 0.10 0.49 1.77 – 0.79 5.56 1.55 6.31 0.07* 0.01* – 0.5 0.17 0.16 0.004* Statistical significance. ∗
0.41 0.48 – 2.41 0.57 0.17 0.33 Portion control Food selection Taking medications as directed Regular exercise Regular blood glucose monitoring Discussing care with clinician Maintaining a healthy lifestyle
0.16 0.31 – .03* 0.55 0.13 0.27
4.45 5.28 – 0.68 – 64.70 –
0.52 0.20 – 0.75 – 0.004* –
0.85 2.67 – 1.39 0.40 – 5.78
0.80 0.19 – 0.38 0.39 – 0.13
3.67 6.66 – 0.67 4.05 4.38 40.60
Healthy p cultural food selection (OR) P Receiving instructions in Arabic (OR) p Time spent with family (OR) p Family encouragement of health (OR) p Family understands (OR) Variable
Table 3 – Logistic regression analyses for each factor influencing the perception of a DSM behavior.
Stressful lifestyle (OR)
p
Having health insurance (OR)
p
p r i m a r y c a r e d i a b e t e s x x x ( 2 0 1 9 ) xxx–xxx
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importance of DSM educational materials during their interactions with Arab American patients. Our study suggests that a strong relationship exists between employment status and engaging in regular exercise, which is a finding that is supported by data collected from the National Health and Nutrition Examination Survey [23]. Fulltime employment was shown to be positively associated with activity levels in men and job type was found to be a strong predictor of daily activity levels in both men and women [23]. In addition, data was analyzed from a World Health Organization study that comprised samples of adults aged 50 years and older from six countries [24]. They found that employment was consistently associated with meeting physical activity guidelines [24]. Findings also suggest some interesting views about the nature of the patient-provider relationship. Two patients voiced concerns regarding discussions with their physicians. They identified the need for receiving additional guidance and resources to allow them to better manage their diabetes. This is of particular concern with Arab Americans since patients view their provider as a respected authority with the best guidance on DSM [25]. It’s important to note that both patients were male, which is an expected finding given the Arab American culture. Men usually speak on behalf of women in their family, especially when discussing a stigmatized disease that can reflect poorly on the reputation of the family [25]. Given that the majority of our patients were females, this could explain why they did not express similar concerns when prompted to provide additional comments. Therefore, an area of opportunity for health care improvement lies in the hands of physicians and other health care providers caring for this patient population. There are some acknowledged limitations to the current study. First, even though the sample recruited for this study immigrated from different countries in the Middle East, the majority of patients were Lebanese. Lebanon has been described as a multicultural, cosmopolitan society and is known as the most westernized Arab nation [26]. Therefore, generalizability of findings should be considered with caution. Second, this was a cross-sectional survey study which obtained self-report data that are open to recall bias and social desirability responses. This is unlikely to have affected study results since interviews were conducted by Arabic speaking women who expressed non-judgmental attitudes. Third, the survey was not tested for reliability and validity. However, it was pilot tested in twenty Arab Americans with T2DM and shown to be a reliable assessment tool. Despite these limitations, this study adds new knowledge to the literature in relation to the perceived importance of DSM behaviors in the Arab American population. Future studies examining the role of Arab American culture on DSM with larger and more diverse samples are needed to further improve care in this population. Additionally, more robust analyses may be indicated to demonstrate generalizability of findings. Study findings suggest that Arab Americans have several perceptions surrounding DSM behaviors that either help or deter successful management of diabetes. The survey that was constructed may serve as a valuable tool for health care providers to assess perceptions in order to provide patientcentered care that will ultimately help to improve short- and
Please cite this article in press as: D. El Masri, et al., Barriers and facilitators to perceived diabetes self-management in Arab American patients with diabetes, Prim. Care Diab. (2019), https://doi.org/10.1016/j.pcd.2019.09.002
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long-term outcomes of the disease. Specifically, this study lends support to the importance of integrating cultural influences into DSMES when providing care to a population with a strong cultural identity. Study findings can serve as a guide for health care providers in their encounters with Arab American patients. These encounters should include prompt administration of the survey in order to assess gaps in knowledge and identify barriers and facilitators to DSM. Once identified, the barriers should be addressed at subsequent visits until there is a noticeable improvement in DSM behaviors. Implementing a patient-centered approach that heavily integrates cultural influences will also help to improve outcomes in a population that is disproportionately affected by diabetes. A study by Lynch et al. demonstrated that a 28-session culturally tailored program focused on diet and physical activity resulted in sustained improvements in glycemic control in an African American population [27]. Additionally, researchers found improvements in glycemic control in different ethnic groups, including African Americans, Hispanic Americans, and Chinese Americans, when culturally tailored approaches were implemented [28]. Therefore, these findings are generalizable and can also be applied to other minority populations who share similar cultural beliefs.
Funding This work was supported by the Eugene Applebaum College of Pharmacy and Health Sciences Faculty Research Award Program.
Conflict of interest The authors state that they have no conflict of interest.
Acknowledgements Koscielniak N assisted with statistical analysis and manuscript writing. El Masri D was involved in data collection and significantly contributed to manuscript writing. Piatt G provided guidance on statistical analysis/interpretation and manuscript writing. DiZazzo-Miller R was involved in methodology and manuscript writing. Arnetz J was involved in methodology and manuscript writing. Jaber LA was involved in project supervision and administration, conceptualization, data collection, and manuscript writing.
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[25] M.R. Mourad, M.T.A. Carolan, An ecological approach to culturally sensitive intervention for Arab American women and their families, Fam. J. 18 (2) (2010) 178–183. [26] M. Neal, J. Finlay, R. Tansey, My father knows the minister: a comparative study of Arab women’s attitudes towards leadership authority, Women Manag Rev. 20 (7) (2005) 478–497. [27] E.B. Lynch, L. Mack, E. Avery, et al., Randomized trial of a lifestyle intervention for urban low-income African Americans with type 2 diabetes, J. Gen. Intern. Med. 34 (7) (2019) 1174–1183. [28] M. Peyrot, L.E. Egede, M.M. Funnell, et al., US ethnic group differences in self-management in the 2nd diabetes attitudes, wishes and needs (DAWN2) study, J. Diabetes Complicat. 32 (6) (2018) 586–592.
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Contents lists available at ScienceDirect
Primary Care Diabetes journal homepage: http://www.elsevier.com/locate/pcd
Original research
Barriers and facilitators to perceived diabetes self-management in Arab American patients with diabetes Dana El Masri a,∗ , Nikolas Koscielniak b , Gretchen Piatt b , Rosanne DiZazzo-Miller c , Judith Arnetz d , Linda A. Jaber a a
Department of Pharmacy Practice, Wayne State University, 259 Mack Avenue, Suite 2134, Detroit, MI, 48201, USA Department of Learning Health Sciences, University of Michigan, 1111 E. Catherine Street, Ann Arbor, MI, 48109, USA c Department of Health Sciences, Wayne State University, 259 Mack Avenue, Suite 2212, Detroit, MI, 48201, USA d Department of Family Medicine, Michigan State University, 788 Service Road, B103 Clinical Center, East Lansing, MI, 48824, USA b
a r t i c l e
i n f o
a b s t r a c t
Article history:
Aims: To assess perceptions surrounding diabetes self-management (DSM) behaviors in Arab
Received 23 February 2019
American patients with diabetes.
Received in revised form
Methods: A 39-item survey was constructed from focus group discussions designed to better
30 August 2019
understand the impact of Arab American culture on DSM behaviors. The survey assessed
Accepted 6 September 2019
perceptions about diet, adherence to medications, exercise, healthy lifestyle, and family
Available online xxx
support.
Keywords:
interviews. Most patients were female (59%), over fifty years of age (79%), and immigrated
Diabetes self-management
from Lebanon (73%). Receiving instructions in Arabic, having family support, family under-
Arab Americans
standing of food choices, and employment status were found to be important predictors of
Results: Two hundred Arab Americans with diabetes completed the survey via face-to-face
Type 2 diabetes
the perceived importance of DSM.
Education
Conclusions: Our findings suggest that there are multiple factors that dictate Arab American’s perception of the importance of DSM. The survey that was constructed may serve as a valuable tool for providers to assess DSM perceptions in order to provide patient-centered care that will help to improve diabetes outcomes. This study supports the importance of integrating cultural influences into DSM education and support when providing care to a population with a strong cultural identity. © 2019 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
∗
Corresponding author. Present address: Beaumont Health, 18101 Oakwood Blvd, Dearborn, MI, 48214, USA. E-mail address: [email protected] (D. El Masri). https://doi.org/10.1016/j.pcd.2019.09.002 1751-9918/© 2019 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: D. El Masri, et al., Barriers and facilitators to perceived diabetes self-management in Arab American patients with diabetes, Prim. Care Diab. (2019), https://doi.org/10.1016/j.pcd.2019.09.002
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1.
Introduction
The American Diabetes Association recommends that all individuals with diabetes receive diabetes self-management education and support (DSMES) at diagnosis and as needed thereafter [1]. Diabetes self-management education is essential as it facilitates patients’ knowledge and skills with the overall objective of improving patient outcomes and health-related quality of life; however, it is not sufficient for sustained behavior change. Diabetes self-management support is the fundamental process that provides instrumental support to patients with the goal of sustaining behaviors needed to successfully manage their diabetes [2]. A welldeveloped body of evidence demonstrates the effectiveness and cost-effectiveness of DSMES, including reductions in hospital admissions and readmissions [3–5], and lifetime health care costs related to a lower risk for complications [6]. DSMES is also associated with reduction of diabetes complications [7,8], improvements in quality of life [9–13], and reductions in diabetes-related distress [14,15]. These improvements highlight the importance of DSMES and validate its role in managing patients with diabetes. A key component of DSMES is to adopt an individualized approach to diabetes self-management (DSM) that reflects a patient’s cultural background and identity [2]. This is particularly critical in the Arab American population, where self-management behaviors are highly influenced by cultural norms. However, there remains a lack of sufficient evidence on DSM practices and behaviors in the Arab American population. Such knowledge may ultimately lead to improved patient outcomes. Cultural traditions held by Arab Americans either facilitate or impede DSM [16]. These traditions include food sharing, religious beliefs, and gender roles. Arab American females indicated that gender roles and female modesty impact their ability to engage in physical activity [16]. Religious practices, such as participation in the Ramadan fast, have also been expressed by Arab Americans to be a barrier for incorporating DSM into their lives [16]. Arab Americans face certain barriers that interfere with their ability to adopt a healthy lifestyle and practice DSM [17]. These include awareness of the need, financial considerations regarding medication, and traditional gender roles. Therefore, developing culturally appropriate programs requires understanding effective strategies that promote DSM behavior change in the Arab American community. To address this gap, the purpose of this study was to assess perceptions regarding DSM behaviors, among Arab Americans with diabetes, in order to inform future individualized care plans by health care providers.
2.
Methods
A descriptive cross-sectional study design was used to assess perceptions of DSM behaviors and to understand barriers to participating in DSM by Arab Americans with type 2 diabetes. Study personnel recruited participants from the community at large and from pharmacies located in a pre-defined geographic area of Michigan mainly populated by Arab Amer-
icans. Pharmacist referrals and snowball sampling were employed. Individuals who qualified for this study were nonpregnant, Arabic-speaking individuals or Arab Americans (≥18 years of age) with a documented diagnosis of type 2 diabetes (T2DM). Arab ancestry and diagnosis of T2DM were determined by self-report. The study was conducted at Wayne State University (WSU) and at the Arab American Pharmacist Association pharmacies or facilities. When individuals presented for the study, the research team explained the risks and benefits of participating in the study and individuals were asked to provide informed consent. Participants were compensated for their time with a $10 gift card upon completion of the survey. The WSU Institutional Review Board approved all procedures prior to data collection. The authors developed a 39-item survey based on prior focus group discussions that aimed to better understand the relationship between Arab American culture and DSMES [16]. The survey was pilot-tested in 20 Arab Americans with T2DM, revised, and translated into Arabic by three Arab American research members. A professional translator reviewed the translated survey and approved the final revisions. Surveys were administered to participants by two trained Arab American research assistants. Interviews lasted approximately 45 min. The survey was divided into two components. The first component collected demographic information including age, gender, level of education, marital, employment and health insurance status, country of origin, and primary language spoken at home or with friends. Additional data collected were date of last physician appointment, general health rating, and date of diabetes diagnosis. The second component assessed the perceived importance of DSM, factors that facilitate DSM behaviors and practices, and factors that impede DSM behaviors and practices. Participants were asked about the following self-care behaviors: maintaining a healthy lifestyle, engaging in physical activity, regular self-monitoring of blood glucose, adherence to medications, adopting healthy coping mechanisms, implementing problem solving techniques and utilizing risk reduction strategies. Finally, participants were encouraged to share additional thoughts regarding DSM through open-ended questions. Responses were transcribed and coded. Survey data were extracted, tabulated, and independently examined by two reviewers prior to data analysis. Measures of central tendency were used to describe the sample. Pearson Chi-Square tests were used to determine associations between perceptions of DSM importance and factors which facilitate or impede DSM behaviors and practices. Logistic regression was also used to control for demographic factors and to obtain odds ratios between covariates and outcomes associated with perceived importance of DSM behaviors. The criterion for statistical significance was set at p < 0.1 for chi-square analyses due to the small sample size, type of study design, and to observe trends in the relationships between factors. Trends were tested using logistic regression, however, statistical significance was set at p < 0.05 for these analyses. STATA 15 was used for all statistical analysis. The qualitative analysis component of the study was completed using a data-driven inductive approach in an effort to establish codes and common themes derived from the data [18,19]. Two trained researchers independently read both tran-
Please cite this article in press as: D. El Masri, et al., Barriers and facilitators to perceived diabetes self-management in Arab American patients with diabetes, Prim. Care Diab. (2019), https://doi.org/10.1016/j.pcd.2019.09.002
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Fig. 1 – Relationship between employment status and perceived importance of regular exercise for DSM.
scripts and assigned codes for commonly occurring themes. Once the transcripts were coded, they were then reviewed by two other members of the research team to ensure consistency in coding. Differences were resolved through group discussion. With repeated readings, similar codes were grouped into main themes with a consensus of >80% (Fig. 1).
3.
Results
3.1.
Sociodemographics
Two hundred Arab Americans with T2DM completed the survey via face-to-face interviews and were included in the final analysis. Table 1 outlines the demographic characteristics of participants. Participants were primarily female (59%), over fifty years of age (79%) and immigrated from Lebanon (73%). Seventy-nine percent reported no educational degree. Over half of participants (56%) reported that their general health was fair or poor. Approximately 33% of the sample was
employed, while 43% reported they were either unemployed or homemakers.
3.2.
Quantitative findings
Perceptions about approaches to DSM varied widely across the sample. Chi-square tests resulted in significant associations between regular exercise and family understanding of food choices (p = 0.026), discussion of care with a clinician and family encouragement of health (p = 0.010) and time spent with family (p = 0.066), while portion control (p = 0.061), regular exercise (p = 0.021), and maintaining a healthy lifestyle (p = 0.001) were all significantly associated with receiving instructions in Arabic. Logistic regression models were used to analyze these associations further while controlling for demographic variables (age, gender, education status, marital status, employment status and health insurance status). The association between the factor of receiving instructions in Arabic and outcomes of food selection [OR = 6.66, p = 0.014; 95% CI = 1.48–30.03]
Please cite this article in press as: D. El Masri, et al., Barriers and facilitators to perceived diabetes self-management in Arab American patients with diabetes, Prim. Care Diab. (2019), https://doi.org/10.1016/j.pcd.2019.09.002
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Table 2 – Logistic regression analyses for DSM behaviors by employment status. Employment OR (p)
Variable Portion control Food selection Taking medications as directed Regular exercise Regular blood glucose monitoring Discussing care with clinician Maintaining a healthy lifestyle
Homemaker
Disabled
Retired
Unemployed
0.27 (0.20) 0.38 (0.38) – 0.19 (0.006) 0.85 (0.91) 1.28 (0.86) 0.23 (0.42)
0.51 (0.61) – – 0.37 (0.14) 0.21 (0.28) 0.60 (0.70) –
0.41 (0.49) 0.42 (0.51) – 0.47 (0.30) 0.36 (0.51) – 0.26 (0.38)
0.15 (0.05) 0.22 (0.14) – 0.30 (0.05) 0.48 (0.61) 0.99 (099) 0.14 (0.14)
Table 1 – Baseline demographics of patients. Patient characteristics
n (%)
n
200
Age <50 years ≥50 years
42 (21) 158 (79)
Gender Female Male
117 (58.5) 83 (41.5)
Country of origin Lebanon Other
146 (73) 54 (27)
General health rating Excellent Very good Good Fair Poor
10 (5) 26 (13) 52 (26) 83 (41.5) 29 (14.5)
Date of diabetes diagnosis <1 year ago 1–5 years ago 5–10 years ago >10 years ago
29 (14.5) 51 (25.5) 42 (21) 78 (39)
Educational level None Elementary/high school College/university
49 (24.5) 109 (54.5) 42 (21)
Employment status Employed/self-employed Homemaker Disabled/retired Unemployed/student
63 (31.5) 53 (26.5) 47 (23.5) 37 (18.5)
Marital status Married Single/divorced/separated/widowed
144 (72) 56 (28)
and maintaining a healthy lifestyle [OR = 43.98, p = 0.003; 95% CI = 3.75–515.24] both were significant in these models; however, portion control continued to demonstrate a trend association [OR = 3.67, p = 0.066; 95% CI = 0.92–14.75]. The association between family encouragement and discussion of care with a clinician remained significant [OR = 71.35, p = 0.003; 95% CI = 4.28–1189.06]. The association between family understanding food choices and engaging in regular exercise remained significant [OR = 2.41, p = 0.03; 95% CI = 1.09–5.35] (Table 2). A logistic regression model was used to evaluate the association between each perceived DSM behavior and
demographic covariates only. An association was observed between perceived importance of regular exercise to DSM and employment status. Participants who were homemakers or unemployed were 82% and 70% less likely to perceive regular exercise as an important DSM behavior, respectively, compared to employed patients [(homemakers: OR = 0.187, p = 0.006; 95%CI = 056–0.620), (unemployed: OR = 0.30, p = 0.046; 95% CI = 0.093–980)].
3.3.
Qualitative findings
Some participants provided additional thoughts and concerns regarding DSM. One participant stated that “it’s very important to eat healthy foods and to stay away from processed foods, and we should receive guidance on diseases that can occur as a result of unhealthy eating.” Many participants agreed that “good diet and exercise help control diabetes” and that “exercise is key to helping control diabetes.” Two participants expressed concerns regarding discussions with their physicians. One participant stated that “doctors should help more”, and the other participant stated that “doctors should give patients more information to help them manage their diabetes.” Finally, one participant stated that “we should focus on improving our education system in such a way as to promote educating our children starting at a young age” and that “younger generations need to receive education on diseases that can arise as a result of having a poor lifestyle and making unhealthy food choices.”
4.
Discussion
This study uniquely demonstrates perceived barriers and facilitators to DSMES among Arab American patients with diabetes. Findings suggest that receiving instructions in Arabic, having family support, family understanding food choices, and being employed are important predictors of the perceived importance of DSM (Table 3). Consistent with previous research, having family support and receiving instructions in Arabic emerged as important predictors of DSM [20–22]. A study by Pinelli et al. found that Arab Americans who had family support during sessions were more likely to attain their weight loss goal compared to those who did not have family support [20]. Fritz et al. demonstrated that providers are faced with the challenge of providing culturally appropriate materials to their Arab American patients, which would impede DSM [21]. Therefore, health care providers should focus on the role of family and the
Please cite this article in press as: D. El Masri, et al., Barriers and facilitators to perceived diabetes self-management in Arab American patients with diabetes, Prim. Care Diab. (2019), https://doi.org/10.1016/j.pcd.2019.09.002
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ARTICLE IN PRESS – – – – 0.06 – 0.10 – – – – 0.07 – 0.07 – – – 0.52 – – – – – – 1.39 – – – 0.51 0.51 – 0.64 0.10 0.71 0.10 0.49 1.77 – 0.79 5.56 1.55 6.31 0.07* 0.01* – 0.5 0.17 0.16 0.004* Statistical significance. ∗
0.41 0.48 – 2.41 0.57 0.17 0.33 Portion control Food selection Taking medications as directed Regular exercise Regular blood glucose monitoring Discussing care with clinician Maintaining a healthy lifestyle
0.16 0.31 – .03* 0.55 0.13 0.27
4.45 5.28 – 0.68 – 64.70 –
0.52 0.20 – 0.75 – 0.004* –
0.85 2.67 – 1.39 0.40 – 5.78
0.80 0.19 – 0.38 0.39 – 0.13
3.67 6.66 – 0.67 4.05 4.38 40.60
Healthy p cultural food selection (OR) P Receiving instructions in Arabic (OR) p Time spent with family (OR) p Family encouragement of health (OR) p Family understands (OR) Variable
Table 3 – Logistic regression analyses for each factor influencing the perception of a DSM behavior.
Stressful lifestyle (OR)
p
Having health insurance (OR)
p
p r i m a r y c a r e d i a b e t e s x x x ( 2 0 1 9 ) xxx–xxx
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importance of DSM educational materials during their interactions with Arab American patients. Our study suggests that a strong relationship exists between employment status and engaging in regular exercise, which is a finding that is supported by data collected from the National Health and Nutrition Examination Survey [23]. Fulltime employment was shown to be positively associated with activity levels in men and job type was found to be a strong predictor of daily activity levels in both men and women [23]. In addition, data was analyzed from a World Health Organization study that comprised samples of adults aged 50 years and older from six countries [24]. They found that employment was consistently associated with meeting physical activity guidelines [24]. Findings also suggest some interesting views about the nature of the patient-provider relationship. Two patients voiced concerns regarding discussions with their physicians. They identified the need for receiving additional guidance and resources to allow them to better manage their diabetes. This is of particular concern with Arab Americans since patients view their provider as a respected authority with the best guidance on DSM [25]. It’s important to note that both patients were male, which is an expected finding given the Arab American culture. Men usually speak on behalf of women in their family, especially when discussing a stigmatized disease that can reflect poorly on the reputation of the family [25]. Given that the majority of our patients were females, this could explain why they did not express similar concerns when prompted to provide additional comments. Therefore, an area of opportunity for health care improvement lies in the hands of physicians and other health care providers caring for this patient population. There are some acknowledged limitations to the current study. First, even though the sample recruited for this study immigrated from different countries in the Middle East, the majority of patients were Lebanese. Lebanon has been described as a multicultural, cosmopolitan society and is known as the most westernized Arab nation [26]. Therefore, generalizability of findings should be considered with caution. Second, this was a cross-sectional survey study which obtained self-report data that are open to recall bias and social desirability responses. This is unlikely to have affected study results since interviews were conducted by Arabic speaking women who expressed non-judgmental attitudes. Third, the survey was not tested for reliability and validity. However, it was pilot tested in twenty Arab Americans with T2DM and shown to be a reliable assessment tool. Despite these limitations, this study adds new knowledge to the literature in relation to the perceived importance of DSM behaviors in the Arab American population. Future studies examining the role of Arab American culture on DSM with larger and more diverse samples are needed to further improve care in this population. Additionally, more robust analyses may be indicated to demonstrate generalizability of findings. Study findings suggest that Arab Americans have several perceptions surrounding DSM behaviors that either help or deter successful management of diabetes. The survey that was constructed may serve as a valuable tool for health care providers to assess perceptions in order to provide patientcentered care that will ultimately help to improve short- and
Please cite this article in press as: D. El Masri, et al., Barriers and facilitators to perceived diabetes self-management in Arab American patients with diabetes, Prim. Care Diab. (2019), https://doi.org/10.1016/j.pcd.2019.09.002
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long-term outcomes of the disease. Specifically, this study lends support to the importance of integrating cultural influences into DSMES when providing care to a population with a strong cultural identity. Study findings can serve as a guide for health care providers in their encounters with Arab American patients. These encounters should include prompt administration of the survey in order to assess gaps in knowledge and identify barriers and facilitators to DSM. Once identified, the barriers should be addressed at subsequent visits until there is a noticeable improvement in DSM behaviors. Implementing a patient-centered approach that heavily integrates cultural influences will also help to improve outcomes in a population that is disproportionately affected by diabetes. A study by Lynch et al. demonstrated that a 28-session culturally tailored program focused on diet and physical activity resulted in sustained improvements in glycemic control in an African American population [27]. Additionally, researchers found improvements in glycemic control in different ethnic groups, including African Americans, Hispanic Americans, and Chinese Americans, when culturally tailored approaches were implemented [28]. Therefore, these findings are generalizable and can also be applied to other minority populations who share similar cultural beliefs.
Funding This work was supported by the Eugene Applebaum College of Pharmacy and Health Sciences Faculty Research Award Program.
Conflict of interest The authors state that they have no conflict of interest.
Acknowledgements Koscielniak N assisted with statistical analysis and manuscript writing. El Masri D was involved in data collection and significantly contributed to manuscript writing. Piatt G provided guidance on statistical analysis/interpretation and manuscript writing. DiZazzo-Miller R was involved in methodology and manuscript writing. Arnetz J was involved in methodology and manuscript writing. Jaber LA was involved in project supervision and administration, conceptualization, data collection, and manuscript writing.
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