How Turkish and Arabic Speaking Communities TASC View Diabetes and Pre diabetes A qualitative Study Nabil Sulaiman, Dori

1. How Turkish and Arabic Speaking Communities (TASC) View Diabetes and Pre diabetes? A qualitative Study Nabil Sulaiman, Doris Young, John Furler, Elaine Hadj, Helen Corbett

2. Diabetes Australia Facts 2008 Type 2 Diabetes (T2DM) in CALD populations: Prevalence of diabetes Prevalence of risk factors Complications Hospitalisations due to non-treatable diabetes Death rates due to diabetes

3. DM in M.E born Vs. Australian born highest SRR for self-reported DM ~ twice the rate (79.8 vs 46.2/1000) of DM highest hospitalisations rate, and 2nd highest MRR from DM AIHW Cat. No. AUS 38. Canberra, 2003.

4. Diabetes & CVD in Hume DALYs for diabetes in Hume is the highest in Victoria (6.8 vs. 4.1 per 1,000 female) (6.6 vs. 4.5 per 100,000 males) DALYs for cardiovascular disease is the second highest in Victoria (31.9 vs. 27.6 per 1,000 females) (35.4 vs. 32.2 per 1,000 males)

5. Diabetes in Arabs & Turks M.E. born highest age-standardised: Prevalence ratio in M (3.60) and F (2.43) Incidence rate ratios M(1.73) F(2.30) Hospitalisations ratios M(2.07) F(1.52) Death rates higher in Arabic speaking residents in NSW (25.4 vs 13.4 per 100,000)

6. Diabetes in Arabs & Turks >40% Arab American have dysglycemia: 18% diagnosed or undiagnosed diabetes 23% impaired fasting glucose or impaired glucose tolerance 12.3% in Turks living in Holland vs 3% in ethnic Dutch 35% in Bahrain, 13% in Turkey

7. Risk Factors: Hume Household Survey (PHP 1999) 76% were physically inactive compared with 43% average for Victoria 62% had weight problems 39% had high cholesterol 49% smoked

8. What could be done? 57% reduction of T2D by modifying physical activity and dietary change (Lindstrom et al, 2003 and Knowles et al, 2003) Uptake of such lifestyle changes in lower SES & CALD groups has been poor >50% of people born in M.E. countries did not undertake physical exercise compared with 34% of Australian-born

9. Meta-analysis of 11 trials in CALD Improved HbA1c after intervention at 3M Weight Mean Difference -0.3% at 3M and 0.6% at 6M Knowledge scores improved at 3M Healthy life style improvement at 3M No difference in secondary outcomes: lipid levels, qoL, self-efficacy, BP Hawthorne K, Robles Y, Cannings-John R, Edwards S. Culturally appropriate health education for type 2 diabetes in ethnic minority groups. Cochrane Database of Systematic Revies 2008 (3)

10. Aims Explore insight, perception, attitudes and practices of TASC, in relation to physical activity (PA), diet and obesity The feasibility of peer led model of engaging the community in diabetes prevention

11. Methods Focus Groups In depth interviews with key informants (bilingual GPs, diabetes educators, practice nurses, dieticians, physios etc. Develop culturally sensitive resources for TASC in Turkish and Arabic languages.

12. Focus Groups - recruitment Who? Over the age of 45 years Speaks Arabic or Turkish language Family history of diabetes Overweight Don�t do exercise regularly How? BHS bilingual staff Adult Day Activity Centre Community Centre- Blair Street Families and Friends

13. Participants Three FG with Turkish speaking Two FG with Arabic speaking Mean age= 58.8 (range 41y �73 y) F:M = 41 : 11 All living in and around Hume Interpreters from TIS Facilitators: Elaine Hadj and NS Transcribed by Sue Foley Analysis and cross analysis (NS& Helen)

14. Focus Group Themes What does the word �diabetes� mean to you? ? causes diabetes ? factors associated with diabetes ? factors increase risk of diabetes ? diabetes and diet? ? diabetes and overweight/ obesity ? role of exercise in diabetes

15. Focus Group Themes Is adult diabetes preventable? How can you prevent diabetes? ? type of exercise is appropriate for your community/ yourself? How often do you/your community exercise ? motivate you/ your community to do exercise ? types of diet do you/your family/ community prefer? ? diabetes and body weight

16. Findings: what diabetes meant to you? Acknowledgement of the severity: �it�s a bad disease which is second to cancer�, Physical and psychological well being:�All of my ancestors, they have Diabetes, this why I said it is horrible disease, and some of them they had amputations of their limbs. Three of them their hands or their legs they were amputated, but one of them refused to do such a thing �.�.

17. What diabetes meant to you? Specific: �It means stress� or �It means a lot of food that you can�t eat�. �When the pancreas is not working so well it is not producing Insulin for the body to maintain the sugar levels and the amount of sugar in the blood goes quite high ��.

18. What do you associate with Diabetes? It affects the eyes swelling and ulceration of the legs (�The legs get swollen and sometimes blood will come out and it doesn�t heal�). Cuts don�t heal Increased thirst and urination Poor dietary habits or eating the wrong food, limitations on food choices Stress (�Stress is one of the main things that causes illnesses�) Lack of exercise, Cholesterol, High blood pressure

19. Causes of diabetes Lifestyle: Poor diet and eating habits �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 �. and then we watch TV, we eat chips, so a sign of we eat all of the time.� �I think its because we eat too much food, not the way we prepare, but we eat too much.� Stress and tension �Diet and stress. I am worried that it will come� �Anxiety is another reason behind many diseases, the anxiety, tension and stress� �its destiny� �its hereditary�

20. Causes: Anxiety, tension & stress �That also stress causes Diabetes as well if someone is overly stressed for long lengthy periods.� �The Diabetes well the sugar level in my body if I was sad or happy it either picks up and goes quite high or drops down to very low levels with sadness or happiness.� �And I was adding to that stress that �illnesses including Diabetes is caused by stress. Stress is one of the main things that causes illnesses.�

21. Causes: Food �fast food� as the culprit. �You get very sick when you have bad food. Fast food anyway. It�s terrible for your body and you getting sick.� �I think I shouldn�t eat any Takeaway food. None whatsoever. I ate McDonalds once and fell ill for a couple of days; so home cooking. What I mean is, they are too fatty.� �� think meat and rice in my opinion is not right, but again meat and bread also another issue.�

22. Environmental factors �climate change I don�t know that my sugar levels going to Turkey for instance is quite maintained when I am over there and when I come back here it creeps up again.� ��I should say that it is not only going overseas but going to high places up in the hills or the forest or something, living there for a while I often maintain my sugar levels.� ��I don�t know again but it is because of the clarity of the air maybe and the oxygen level is quite high.�

23. Environmental factors - cont �All the �.. the skin, the meat, they all contain additives and we eat every cold chicken for example; I believe that my condition had developed because of that.� �For example you go to Turkey and you get an egg, a village egg, it will be natural and the eggs here they don�t have any vitamins.� �(In Australia) it is the way they grow their food, everything has a chemical additive, if they want to grow bigger eggs, bigger fruit, there is chemicals ��.�

24. Physical activity Walking is good It�s the cheapest exercise, it is healthy and it is outdoors Exercise brings your blood sugars down Helps with weight control Improves blood circulation Maintains sugar levels Helps in weight reduction Improved state of mind

25. Physical activity �it is incidental walking yes that you don�t have the 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 no choice but to walk, you know 10 kilometres a day or 15.� �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 get into the car and you just drive in the car.� �the session I have had with a Diabetes Nurse and she told me that � My sugar levels were quite high up to 16 and 20 and when I have started walking which was recently I now walk every day and 1 � hours each day so my sugar levels have come down dramatically to about 7.�

26. Barriers to regular exercise Not feeling safe from dogs and other people (�Walking in the street is not safe.�) Housework to complete Family commitments like babysitting, housework etc. Women don�t make time for themselves Laziness Historically, exercise is not a part of Turkish life Not culturally appropriate for older women to walk in the streets or go swimming (�..60, 70 year old woman going under and going swimming or walking, it is not looked upon as nice.�) Too old or too ill Not enough time

27. Regular exercise & facilitators When directed to do so by their doctor Group walks and group exercises Ethnic dancing Teacher or leader for walking and exercise groups Exercise equipment or machine at home Attending the gym and cycling Illness and illness prevention Weight control A desire to get out of the house, a means of socialising for relaxation (gardening) �As a community, unless you are ill and you have to exercise so you won�t die, then that is the motivation.�

28. Diabetes prevention ��.there are many factors for me, the diet, exercises and tensions, stress.� �Well, you can prevent by watching what you eat, doing exercise, walking, less stress, no stress, keep away from stress.� �You can�t prevent it from happening, but you can �� or the amount of Diabetes you get can be controlled. The severity of it.�

29. Work and Diabetes �As a person I only found that I had Diabetes when I left work after about six months of leaving work.� �I used to be working in the past and as I have given up work I have sustained Diabetes, I think it may have been because of inactivity that I have sustained Diabetes and not enough exercise anymore.�

30. Other Causes Obesity: �The amount of fat in your body that is as you get fatter you would have less chance of being active and inactivity causes � and your pancreas would slow down.� Old age Ethnicity

31. Diabetes and diet. Foods that were detrimental to their health and to the health of people with diabetes: Fast foods Fatty/oily food Sweets Breads Rice Pasta Many fruits Fatty meats

32. Diet and Diabetes �Eating anything and everything� �Sweets, bread. All sugary things are bad Certain fruits for instance � grapes, oranges.� �Eating has something to do with it of course, you can eat anything but you have to eat it in moderation. It is the amount of food that is quite important.� �I just gave up bananas and I found out that if you eat quite mature bananas that could have effects on your level of Diabetes but if you have not so mature like almost green bananas that is probably okay and having not 2 oranges but maybe � an orange or � an apple would be okay.�

33. Diet and Diabetes �we used to eat anything that was culturally appropriate we eat a lot of nuts and things so handfuls of it usually and she (diabetes educator) told us that you can eat these nuts still but only that fits in the palm of your hand.� �Because it is sour I tend to eat green apples and grape fruit tend to bring down the levels of sugar�. ���Just like grape fruit and lemon I think it has the affect of dropping down the sugar level because of the sourness. The green apple has the same effect and the red apple lifts up the levels of Diabetes.�

34. Foods that counter sweetness �Because it is sour, I tend to (eat) green apples and grape fruit tend to bring down the levels of sugar.� � I have read in the paper that eating Grape Fruit can cause death�..� I don�t know how but I read it in a health section of the paper, I used to like grape fruit but as Diabetics don�t take it anymore. I used to eat two grape fruits a day thinking it was a fruit of life, you know a fruit that would maintain your life, lengthen your life and I had a tree in the backyard when I learnt about the affects of it I chopped it down.�

35. Diabetes and obesity Lots of weight, being overweight and it is heredity as well, you can�t help it sometimes. �the main cause of Diabetes is being overweight and if someone is overweight they almost surely will have Diabetes�. �What is happening is if you eat and eat and keep the nutrition in your body without burning, it�s not like a petrol tank. If you went and filled up with petrol you can�t put more when it is full, but the body is able to take more and more and it stores more, it increases your risk.�

36. Health Education The doctor and the hospital In some instances nurses, dieticians and other educators Negative experiences with Doctors and Hospitals �I have been seeing the doctors and the Diabetes specialists for many years and they could not help me and I have just seen an educator here and she has helped me.� Need for Interpreters�I went for an appointment (to have my eyes checked) and an interpreter wasn�t booked and with that I couldn�t understand what the doctor was saying and they have given me another appointment in a years time and now I don�t know what the hell is going on.�

37. Community Empowerment Limited response Volunteering for peer support is limited Wiling to participate in peer-led diabetes prevention Partnerships with: Local Council Community Health Centres Exercise centres

38. Health Education Resources Written information to be shown to other family members or friends Information is best provided when translated to languages other than English Suggestions: Doctors The hospital, Health Centres Ethno-specific newspapers, Brochures and flyers Community radio Meetings similar to the focus group to share information and provide support to one another

39. Conclusions Good understanding of the severity of diabetes The need to alter life stye More information More education Cultural and social barriers Interventions: Doctors Groups