How Turkish and Arabic Speaking How Turkish and Arabic Speaking Communities (TASC) View Diabetes Communities (TASC) View Diabetes

and Pre diabetes?and Pre diabetes?

A qualitative StudyA qualitative StudyNabil Sulaiman, Doris Young, John Furler, Nabil Sulaiman, Doris Young, John Furler,

Elaine Hadj, Helen CorbettElaine Hadj, Helen Corbett

Medical Research Grants Restricted Purposes funds

DiabetesDiabetes Australia Facts 2008 Australia Facts 2008

Type 2 Diabetes (T2DM) in CALD populations:Type 2 Diabetes (T2DM) in CALD populations:

1.1. Prevalence of diabetesPrevalence of diabetes

2.2. Prevalence of risk factorsPrevalence of risk factors

3.3. ComplicationsComplications

4.4. Hospitalisations due to non-Hospitalisations due to non-treatable diabetestreatable diabetes

5.5. Death rates due to diabetesDeath rates due to diabetes

DM in M.E born Vs. Australian bornDM in M.E born Vs. Australian born

• highest SRR for self-reported DM highest SRR for self-reported DM

• ~ twice the rate (79.8 vs 46.2/1000) of DM ~ twice the rate (79.8 vs 46.2/1000) of DM

• highest hospitalisations rate, andhighest hospitalisations rate, and

• 22ndnd highest MRR from DM highest MRR from DM

AIHW Cat. No. AUS 38. Canberra, 2003.AIHW Cat. No. AUS 38. Canberra, 2003.

Diabetes & CVD in HumeDiabetes & CVD in Hume

DALYs for diabetes in Hume is the highest DALYs for diabetes in Hume is the highest in Victoria (6.8 vs. 4.1 per 1,000 female) in Victoria (6.8 vs. 4.1 per 1,000 female) (6.6 vs. 4.5 per 100,000 males)(6.6 vs. 4.5 per 100,000 males)

DALYs for cardiovascular disease is the DALYs for cardiovascular disease is the second highest in Victoria (31.9 vs. 27.6 per second highest in Victoria (31.9 vs. 27.6 per 1,000 females) (35.4 vs. 32.2 per 1,000 1,000 females) (35.4 vs. 32.2 per 1,000 males)males)

Diabetes in Arabs & Turks Diabetes in Arabs & Turks

M.E. born highest age-standardised:M.E. born highest age-standardised:– Prevalence ratio in M (3.60) and F (2.43)Prevalence ratio in M (3.60) and F (2.43)– Incidence rate ratios M(1.73) F(2.30) Incidence rate ratios M(1.73) F(2.30) – Hospitalisations ratios M(2.07) F(1.52)Hospitalisations ratios M(2.07) F(1.52)

Death rates higher in Arabic speaking Death rates higher in Arabic speaking residents in NSW (25.4 vs 13.4 per residents in NSW (25.4 vs 13.4 per 100,000)100,000)

Diabetes in Arabs & Turks Diabetes in Arabs & Turks

>40% Arab American have dysglycemia:>40% Arab American have dysglycemia:– 18% diagnosed or undiagnosed diabetes 18% diagnosed or undiagnosed diabetes – 23% impaired fasting glucose or impaired 23% impaired fasting glucose or impaired

glucose tolerance glucose tolerance

12.3% in Turks living in Holland vs 3% in 12.3% in Turks living in Holland vs 3% in ethnic Dutchethnic Dutch

35% in Bahrain, 13% in Turkey 35% in Bahrain, 13% in Turkey

Risk Factors: Hume Household Risk Factors: Hume Household Survey (Survey (PHPPHP 1999) 1999)

76% were physically inactive compared 76% were physically inactive compared with 43% average for Victoriawith 43% average for Victoria

62% had weight problems62% had weight problems 39% had high cholesterol 39% had high cholesterol 49% smoked 49% smoked

What could be done?What could be done? 57% reduction of T2D by modifying 57% reduction of T2D by modifying

physical activity and dietary change physical activity and dietary change ((LindstromLindstrom et al, 2003 and Knowles et al, 2003) et al, 2003 and Knowles et al, 2003)

Uptake of such lifestyle changes in lower Uptake of such lifestyle changes in lower SES & CALD groups has been poorSES & CALD groups has been poor

>50% of people born in M.E. countries >50% of people born in M.E. countries did not undertake physical exercise did not undertake physical exercise compared with 34% of Australian-born compared with 34% of Australian-born

Meta-analysis of 11 trials in CALDMeta-analysis of 11 trials in CALD

1.1. Improved HbA1c after intervention at 3M Improved HbA1c after intervention at 3M 2.2. Weight Mean Difference -0.3% at 3M and Weight Mean Difference -0.3% at 3M and

0.6% at 6M0.6% at 6M3.3. Knowledge scores improved at 3MKnowledge scores improved at 3M4.4. Healthy life style improvement at 3MHealthy life style improvement at 3M5.5. No difference in secondary outcomes: No difference in secondary outcomes:

lipid levels, qoL, self-efficacy, BP lipid levels, qoL, self-efficacy, BP

Hawthorne K, Robles Y, Cannings-John R, Edwards S. Culturally appropriate health education for type 2 Hawthorne K, Robles Y, Cannings-John R, Edwards S. Culturally appropriate health education for type 2

diabetes in ethnic minority groups. diabetes in ethnic minority groups. Cochrane Database Cochrane Database of Systematic Revies 2008 (3) of Systematic Revies 2008 (3)

AimsAims Explore insight, perception, attitudes and Explore insight, perception, attitudes and

practices of TASC, in relation to physical practices of TASC, in relation to physical activity (PA), diet and obesity activity (PA), diet and obesity

The feasibility of peer led model of The feasibility of peer led model of engaging the community in diabetes engaging the community in diabetes prevention prevention

MethodsMethods

Focus GroupsFocus Groups In depth interviews with key informants In depth interviews with key informants

(b(bilingual GPs, diabetes educators, practice ilingual GPs, diabetes educators, practice nurses, dieticians, physios etc.nurses, dieticians, physios etc.

Develop Develop culturally sensitive resources for culturally sensitive resources for TASC in Turkish and Arabic languages. TASC in Turkish and Arabic languages.

Focus Groups - recruitmentFocus Groups - recruitment Who?Who?

– Over the age of 45 yearsOver the age of 45 years– Speaks Arabic or Turkish languageSpeaks Arabic or Turkish language– Family history of diabetesFamily history of diabetes

– OverweightOverweight– Don’t do exercise regularlyDon’t do exercise regularly

How?How?– BHS bilingual staffBHS bilingual staff– Adult Day Activity CentreAdult Day Activity Centre– Community Centre- Blair StreetCommunity Centre- Blair Street– Families and FriendsFamilies and Friends

ParticipantsParticipants Three FG with Turkish speakingThree FG with Turkish speaking Two FG with Arabic speakingTwo FG with Arabic speaking Mean age= 58.8 (range 41y –73 y)Mean age= 58.8 (range 41y –73 y) F:M = 41 : 11F:M = 41 : 11 All living in and around HumeAll living in and around Hume Interpreters from TISInterpreters from TIS Facilitators: Elaine Hadj and NSFacilitators: Elaine Hadj and NS Transcribed by Sue FoleyTranscribed by Sue Foley Analysis and cross analysis (NS& Helen) Analysis and cross analysis (NS& Helen)

Focus Group ThemesFocus Group Themes What does the word ‘diabetes’ mean to What does the word ‘diabetes’ mean to

you?you? ? causes diabetes? causes diabetes ? factors associated with diabetes? factors associated with diabetes ? factors increase risk of diabetes? factors increase risk of diabetes ? diabetes and diet?? diabetes and diet? ? diabetes and overweight/ obesity? diabetes and overweight/ obesity ? role of exercise in diabetes? role of exercise in diabetes

Focus Group ThemesFocus Group Themes

Is adult diabetes preventable? How can you Is adult diabetes preventable? How can you prevent diabetes?prevent diabetes?

? type of exercise is appropriate for your ? type of exercise is appropriate for your community/ yourself? How often do community/ yourself? How often do you/your community exerciseyou/your community exercise

? motivate you/ your community to do ? motivate you/ your community to do exerciseexercise

? types of diet do you/your family/ ? types of diet do you/your family/ community prefer?community prefer?

? diabetes and body weight? diabetes and body weight

Findings: Findings: what diabetes meant to you?what diabetes meant to you? Acknowledgement of the severity: Acknowledgement of the severity: “it’s a bad “it’s a bad

disease which is second to cancer”,disease which is second to cancer”,

Physical and psychological well being:Physical and psychological well being:“All of “All of my ancestors, they have Diabetes, this why I my ancestors, they have Diabetes, this why I said it is said it is horrible diseasehorrible disease, and some of , and some of them they had amputations of their limbs. them they had amputations of their limbs. Three of them their hands or their legs they Three of them their hands or their legs they were amputated, but one of them refused to were amputated, but one of them refused to do such a thing ….”. do such a thing ….”.

What diabetes meant to you?What diabetes meant to you? Specific:Specific:

– ““It means stress” It means stress” or or “It means a lot of food “It means a lot of food that you can’t eat”.that you can’t eat”.

– ““When the pancreas is not working so well it When the pancreas is not working so well it is not producing Insulin for the body to is not producing Insulin for the body to maintain the sugar levels and the amount of maintain the sugar levels and the amount of sugar in the blood goes quite high …”.sugar in the blood goes quite high …”.

What do you associate with What do you associate with Diabetes?Diabetes?

It affects the eyes It affects the eyes swelling and ulceration of the legsswelling and ulceration of the legs (“The (“The

legs get swollen and sometimes blood will legs get swollen and sometimes blood will come out and it doesn’t heal”).come out and it doesn’t heal”).

Cuts don’t healCuts don’t heal Increased thirst and urinationIncreased thirst and urination Poor dietary habits or eating the wrong Poor dietary habits or eating the wrong

food, limitations on food choicesfood, limitations on food choices Stress Stress (“Stress is one of the main things (“Stress is one of the main things

that causes illnesses”)that causes illnesses”) Lack of exercise, Cholesterol, High blood Lack of exercise, Cholesterol, High blood

pressurepressure

Causes of diabetesCauses of diabetes Lifestyle: Poor diet and eating habits Lifestyle: Poor diet and eating habits

““We eat so much, I don’t know, maybe because we eat We eat so much, I don’t know, maybe because we eat so many times a day like 10 o’clock, 11 we eat. We eat so many times a day like 10 o’clock, 11 we eat. We eat …. and then we watch TV, we eat chips, so a sign of we …. and then we watch TV, we eat chips, so a sign of we eat all of the timeeat all of the time.”.”

““I think its because we eat I think its because we eat too much foodtoo much food, not the way , not the way we prepare, but we eat too much.”we prepare, but we eat too much.”

Stress and tension Stress and tension ““Diet and stress. I am worried that it will come” Diet and stress. I am worried that it will come” ““Anxiety is another reason behind many diseases, the Anxiety is another reason behind many diseases, the

anxiety, tension and stress” anxiety, tension and stress” ““its destiny”its destiny” ““its hereditary”its hereditary”

Causes: Anxiety, tension & Causes: Anxiety, tension & stressstress

““That also stress causes Diabetes as well if That also stress causes Diabetes as well if someone is overly stressed for long lengthy someone is overly stressed for long lengthy periods.”periods.”

““The Diabetes well the sugar level in my body if The Diabetes well the sugar level in my body if I was sad or happy it either picks up and goes I was sad or happy it either picks up and goes quite high or drops down to very low levels with quite high or drops down to very low levels with sadness or happiness.”sadness or happiness.”

““And I was adding to that stress that …illnesses And I was adding to that stress that …illnesses including Diabetes is caused by stress. Stress is including Diabetes is caused by stress. Stress is one of the main things that causes illnesses.”one of the main things that causes illnesses.”

Causes:Causes: FoodFood ““fast food” as the culprit. fast food” as the culprit. ““You get very sick when you have bad food. Fast You get very sick when you have bad food. Fast

food anyway. It’s terrible for your body and you food anyway. It’s terrible for your body and you getting sick.” getting sick.”

““I think I shouldn’t eat any Takeaway food. None I think I shouldn’t eat any Takeaway food. None whatsoever. I ate McDonalds once and fell ill for a whatsoever. I ate McDonalds once and fell ill for a couple of days; so home cooking. What I mean is, couple of days; so home cooking. What I mean is, they are too fatty.”they are too fatty.”

““Í think meat and rice in my opinion is not right, Í think meat and rice in my opinion is not right, but again meat and bread also another issue.”but again meat and bread also another issue.”

Environmental factorsEnvironmental factors ““climate change I don’t know that my sugar climate change I don’t know that my sugar

levels going to Turkey for instance is quite levels going to Turkey for instance is quite maintained when I am over there and when I maintained when I am over there and when I come back here it creeps up again.”come back here it creeps up again.”

 “ “I should say that it is not only going overseas I should say that it is not only going overseas but going to but going to high placeshigh places up in the hills or the up in the hills or the forest or something, living there for a while I forest or something, living there for a while I often maintain my sugar levels.”often maintain my sugar levels.”

 “ “I don’t know again but it is because of the I don’t know again but it is because of the clarity of the airclarity of the air maybe and the oxygen level is maybe and the oxygen level is quite high.”quite high.”

Environmental factors - contEnvironmental factors - cont ““All the ….. the skin, the meat, they all contain All the ….. the skin, the meat, they all contain

additives and we eat every cold chicken for additives and we eat every cold chicken for example; I believe that my condition had developed example; I believe that my condition had developed because of that.”because of that.”

““For example you go to Turkey and you get an egg, For example you go to Turkey and you get an egg, a village egg, it will be natural and the eggs here a village egg, it will be natural and the eggs here they don’t have any vitamins.”they don’t have any vitamins.”

““(In Australia) it is the way they grow their food, (In Australia) it is the way they grow their food, everything has a chemical additive, if they want to everything has a chemical additive, if they want to grow bigger eggs, bigger fruit, there is chemicals grow bigger eggs, bigger fruit, there is chemicals …….”…….”

Physical activityPhysical activity Walking is goodWalking is good It’s the cheapest exercise, it is healthy and it is It’s the cheapest exercise, it is healthy and it is

outdoorsoutdoors Exercise brings your blood sugars downExercise brings your blood sugars down Helps with weight controlHelps with weight control Improves blood circulationImproves blood circulation Maintains sugar levelsMaintains sugar levels Helps in weight reductionHelps in weight reduction Improved state of mindImproved state of mind

Physical activityPhysical activity ““it is incidental walking yes that you don’t have the it is incidental walking yes that you don’t have the

benefit of a car, you are only there for a short period but benefit of a car, you are only there for a short period but you have to walk a lot and at some places you have got you have to walk a lot and at some places you have got no choice but to walk, you know 10 kilometres a day or no choice but to walk, you know 10 kilometres a day or 15.”15.”

““When I went to Syria I lost 8 Kilos I walked a lot and When I went to Syria I lost 8 Kilos I walked a lot and didn’t do any exercise bike, and I ate a lot. ……. Here you didn’t do any exercise bike, and I ate a lot. ……. Here you get into the car and you just drive in the car.”get into the car and you just drive in the car.”

““the session I have had with a Diabetes Nurse and she the session I have had with a Diabetes Nurse and she told me that … My sugar levels were quite high up to 16 told me that … My sugar levels were quite high up to 16 and 20 and when I have started walking which was and 20 and when I have started walking which was recently I now walk every day and 1 ½ hours each day so recently I now walk every day and 1 ½ hours each day so my sugar levels have come down dramatically to about my sugar levels have come down dramatically to about 7.”7.”

Barriers to regular exerciseBarriers to regular exercise Not feeling safe from dogs and other people Not feeling safe from dogs and other people (“Walking in (“Walking in

the street is not safe.”)the street is not safe.”) Housework to completeHousework to complete Family commitments like babysitting, housework etc.Family commitments like babysitting, housework etc. Women don’t make time for themselvesWomen don’t make time for themselves LazinessLaziness Historically, exercise is not a part of Turkish lifeHistorically, exercise is not a part of Turkish life Not culturally appropriate for older women to walk in the Not culturally appropriate for older women to walk in the

streets or go swimming streets or go swimming (…..60, 70 year old woman going (…..60, 70 year old woman going under and going swimming or walking, it is not looked upon under and going swimming or walking, it is not looked upon as nice.”)as nice.”)

Too old or too illToo old or too ill Not enough timeNot enough time

Regular exercise & Regular exercise & facilitatorsfacilitators

When directed to do so by their doctorWhen directed to do so by their doctor Group walks and group exercises Group walks and group exercises Ethnic dancing Ethnic dancing Teacher or leader for walking and exercise groupsTeacher or leader for walking and exercise groups Exercise equipment or machine at homeExercise equipment or machine at home Attending the gym and cycling Attending the gym and cycling Illness and illness prevention Illness and illness prevention Weight controlWeight control A desire to get out of the house, a means of socialising A desire to get out of the house, a means of socialising for relaxation (gardening)for relaxation (gardening) ““As a community, unless you are ill and you have to As a community, unless you are ill and you have to

exercise so you won’t die, then that is the motivation.”exercise so you won’t die, then that is the motivation.”

Diabetes preventionDiabetes prevention “…“….there are many factors for me, the diet, .there are many factors for me, the diet,

exercises and tensions, stress.”exercises and tensions, stress.”

““Well, you can prevent by watching what Well, you can prevent by watching what you eat, doing exercise, walking, less stress, you eat, doing exercise, walking, less stress, no stress, keep away from stress.”no stress, keep away from stress.”

““You can’t prevent it from happening, but You can’t prevent it from happening, but you can …… or the amount of Diabetes you you can …… or the amount of Diabetes you get can be controlled. The severity of it.”get can be controlled. The severity of it.”

Work and DiabetesWork and Diabetes ““As a person I only found that I had As a person I only found that I had

Diabetes when I left work after about six Diabetes when I left work after about six months of leaving work.”months of leaving work.”

““I used to be working in the past and as I I used to be working in the past and as I have given up work I have sustained have given up work I have sustained Diabetes, I think it may have been because Diabetes, I think it may have been because of inactivity that I have sustained Diabetes of inactivity that I have sustained Diabetes and not enough exercise anymore.”and not enough exercise anymore.”

Other CausesOther Causes Obesity: “The amount of fat in your body Obesity: “The amount of fat in your body

that is as you get fatter you would have that is as you get fatter you would have less chance of being active and inactivity less chance of being active and inactivity causes … and your pancreas would slow causes … and your pancreas would slow down.”down.”

Old ageOld age EthnicityEthnicity

Diabetes and diet. Diabetes and diet. Foods that were detrimental to their health Foods that were detrimental to their health

and to the health of people with diabetes: and to the health of people with diabetes: – Fast foodsFast foods– Fatty/oily foodFatty/oily food– SweetsSweets– BreadsBreads– RiceRice– PastaPasta– Many fruitsMany fruits– Fatty meatsFatty meats

Diet and DiabetesDiet and Diabetes ““Eating anything and everything” Eating anything and everything” ““Sweets, bread. All sugary things are bad Certain Sweets, bread. All sugary things are bad Certain

fruits for instance … grapes, oranges.” fruits for instance … grapes, oranges.” ““Eating has something to do with it of course, you Eating has something to do with it of course, you

can eat anything but you have to eat it in can eat anything but you have to eat it in moderation. It is the amount of food that is quite moderation. It is the amount of food that is quite important.” important.”

““I just gave up bananas and I found out that if you I just gave up bananas and I found out that if you eat quite mature bananas that could have effects on eat quite mature bananas that could have effects on your level of Diabetes but if you have not so mature your level of Diabetes but if you have not so mature like almost green bananas that is probably okay and like almost green bananas that is probably okay and having not 2 oranges but maybe ½ an orange or ½ having not 2 oranges but maybe ½ an orange or ½ an apple would be okay.”an apple would be okay.”

Diet and DiabetesDiet and Diabetes ““we used to eat anything that was culturally we used to eat anything that was culturally

appropriate we eat a lot of nuts and things so appropriate we eat a lot of nuts and things so handfuls of it usually and she (diabetes educator) handfuls of it usually and she (diabetes educator) told us that you can eat these nuts still but only that told us that you can eat these nuts still but only that fits in the palm of your hand.” fits in the palm of your hand.”

““Because it is sour I tend to eat green apples and Because it is sour I tend to eat green apples and grape fruit tend to bring down the levels of sugar”. grape fruit tend to bring down the levels of sugar”. ……”Just like grape fruit and lemon I think it has the ……”Just like grape fruit and lemon I think it has the affect of dropping down the sugar level because of affect of dropping down the sugar level because of the sourness. The green apple has the same effect the sourness. The green apple has the same effect and the red apple lifts up the levels of Diabetes.”and the red apple lifts up the levels of Diabetes.”

Foods that counter sweetnessFoods that counter sweetness ““Because it is sour, I tend to (eat) green apples Because it is sour, I tend to (eat) green apples

and grape fruit tend to bring down the levels of and grape fruit tend to bring down the levels of sugar.”sugar.”

” ” I have read in the paper that eating Grape Fruit I have read in the paper that eating Grape Fruit can cause death…..” I don’t know how but I read can cause death…..” I don’t know how but I read it in a health section of the paper, I used to like it in a health section of the paper, I used to like grape fruit but as Diabetics don’t take it anymore. grape fruit but as Diabetics don’t take it anymore. I used to eat two grape fruits a day thinking it was I used to eat two grape fruits a day thinking it was a fruit of life, you know a fruit that would maintain a fruit of life, you know a fruit that would maintain your life, lengthen your life and I had a tree in the your life, lengthen your life and I had a tree in the backyard when I learnt about the affects of it I backyard when I learnt about the affects of it I chopped it down.”chopped it down.”

Diabetes and obesityDiabetes and obesity Lots of weight, being overweight and it is Lots of weight, being overweight and it is

heredity as well, you can’t help it heredity as well, you can’t help it sometimes.sometimes.

““the main cause of Diabetes is being the main cause of Diabetes is being overweight and if someone is overweight overweight and if someone is overweight they almost surely will have Diabetes”.they almost surely will have Diabetes”.

““What is happening is if you eat and eat What is happening is if you eat and eat and keep the nutrition in your body without and keep the nutrition in your body without burning, it’s not like a petrol tank. If you burning, it’s not like a petrol tank. If you went and filled up with petrol you can’t put went and filled up with petrol you can’t put more when it is full, but the body is able to more when it is full, but the body is able to take more and more and it stores more, it take more and more and it stores more, it increases your risk.” increases your risk.”

Health Education Health Education The doctor and the hospitalThe doctor and the hospital In some instances nurses, dieticians and other educators In some instances nurses, dieticians and other educators Negative experiences with Doctors and Hospitals “Negative experiences with Doctors and Hospitals “I have I have

been seeing the doctors and the Diabetes specialists for been seeing the doctors and the Diabetes specialists for many years and they could not help me and I have just many years and they could not help me and I have just seen an educator here and she has helped me.”seen an educator here and she has helped me.”

Need for InterpretersNeed for Interpreters“I went for an appointment (to have “I went for an appointment (to have my eyes checked) and an interpreter wasn’t booked and my eyes checked) and an interpreter wasn’t booked and with that I couldn’t understand what the doctor was with that I couldn’t understand what the doctor was saying and they have given me another appointment in a saying and they have given me another appointment in a years time and now I don’t know what the hell is going years time and now I don’t know what the hell is going on.”on.”

Community Empowerment Community Empowerment Limited responseLimited response Volunteering for peer support is Volunteering for peer support is

limitedlimited Wiling to participate in peer-led Wiling to participate in peer-led

diabetes preventiondiabetes prevention PPartnerships with:artnerships with:

– Local CouncilLocal Council– Community Health CentresCommunity Health Centres– Exercise centresExercise centres

Health Education Health Education ResourcesResources

Written information to be shown to other Written information to be shown to other family members or friends family members or friends

Information is best provided when translated Information is best provided when translated to languages other than Englishto languages other than English

Suggestions:Suggestions:– Doctors Doctors – The hospital, Health CentresThe hospital, Health Centres– Ethno-specific newspapers, Brochures and flyersEthno-specific newspapers, Brochures and flyers– Community radioCommunity radio– Meetings similar to the focus group to share Meetings similar to the focus group to share

information and provide support to one another information and provide support to one another

ConclusionsConclusions Good understanding of the severity of Good understanding of the severity of

diabetes diabetes The need to alter life styeThe need to alter life stye More informationMore information More educationMore education Cultural and social barriersCultural and social barriers Interventions:Interventions:

– Doctors Doctors – Groups Groups

Sulaiman ND, Furler JS, Hadj EJ, Corbett HM, Young D.

Health Promot J Austr. 2007 Apr;18(1):63-8