607356

research-article2015
TDEXXX10.1177/0145721715607356The Diabetes EDUCATORBertran et al

The Diabetes EDUCATOR

748

The Impact of Arab American

Culture on Diabetes
Self-management Education

Elizabeth A. Bertran, PharmD Purpose

Heather Fritz, PhD
Malak Abbas, BS
Sandra Tarakji, MD, MPH
Rosanne DiZazzo-Miller, DrOT
Fredrick D. Pociask, PhD
Catherine L. Lysack, PhD
Judith Arnetz, PhD
Linda A. Jaber, PharmD
From Eugene Applebaum College of Pharmacy and Health Sciences,
Department of Pharmacy Practice, Wayne State University, Detroit,
Michigan (Dr Bertran, Miss Abbas, Dr DiZazzo-Miller, Dr Pociask,
Dr Lysack, Dr Jaber); Institute of Gerontology, Wayne State University,
Detroit, Michigan (Dr Fritz); and Department of Family Medicine and
Public Health Sciences, Wayne State University, Detroit, MI (Dr Tarakji,
Dr Arnetz).
Correspondence to Linda A. Jaber, PharmD, Eugene Applebaum College
of Pharmacy and Health Sciences, Wayne State University, Detroit, MI,
USA (ljaber@wayne.edu).
Funding: The Eugene Applebaum College of Pharmacy and Health
Sciences of Wayne State University’s Faculty Research Award Program,
Detroit, Michigan, USA, and the Arab American Pharmacists Association,
Dearborn, Michigan, USA, funded this study. Dr Arnetz’s effort was
partially funded by the Center for Urban Responses to Environmental
Stressors (CURES), Grant number P30 ES020957, Detroit, Michigan,
USA.
The purpose of this study was to better understand barri-
ers and facilitators of diabetes self-management educa-
tion (DSME) among Arab American patients with
diabetes. Little is known about the impact of Arab culture
on DSME.
Methods
Arab American adults (N = 23) with medically managed
diabetes participated in 1 of 3 focus groups. An Arabic-
speaking, trained moderator conducted video-recorded
sessions. Verbatim Arabic transcripts were translated into
English. Transcripts underwent a qualitative content
analysis approach.
Results
Arab American cultural traditions such as food sharing,
religious beliefs, and gender roles both facilitated and at
times impeded DSME. Patients also held conflicting
views about their interactions with their providers; some
participants praised the authoritative patient-physician
relationship style while others perceived the gaps in
communication to be a product of Arab culture.
Participants expressed that lack of available educational
and supportive resources are key barriers to DSME.

DOI: 10.1177/0145721715607356 Conclusion

© 2015 The Author(s) Arab American culture affects DSM activities, and cul-
turally sensitive educational resources are lacking.

Volume 41, Number 6, December 2015


Development of DSME programs tailored to address
relevant aspects of Arab culture might improve DSME
outcomes in Arab American population.
Introduction
Diabetes self-management (DSM) education (DSME)
and support (DSMS) are integral elements of diabetes
treatment, facilitating the knowledge and skills necessary
to engage in informed decision making, implement
healthy lifestyle behaviors, problem solve, and effec-
tively collaborate with providers.1 Effective DSME
requires changing and maintaining behaviors that are
inherently shaped by the individual’s culture. A well-
developed body of evidence illustrates that culture influ-
ences how individuals enact DSM.2 Subsequently,
unrecognized cultural barriers may contribute to what
health care providers might perceive as lack of adherence
to DSM.3-6
The impact of culture on DSME may be especially
salient for groups such as Arab Americans, who exhibit
substantial differences in health beliefs, lifestyles, and
behaviors from the general US population.7 Approximately
one-third of the entire Arab American population lives in
California, New York, or Michigan.8 Detroit is in the top
6 of metropolitan areas with Arab American population,8
where over 80% of Michigan Arab Americans live.9
Epidemiologic data estimate that 18% of metropolitan
Detroit Arab American adults are affected by diabetes.10
Despite this disease burden, Arab American patients
receive suboptimal care and achieve fewer treatment
goals compared to the national average,7 likely in part
due to reported disparities in health care access in this
group.11 This disparity is attributed not only to lack of
insurance but also cultural norms and health behaviors.11
The impact of culture on DSME is likely more signifi-
cant among less acculturated Arab Americans because
lack of acculturation in this population has been linked to
higher risk of dysglycemia.12
Culturally specific DSME interventions have been
developed and evaluated among several different racial
and ethnic groups, including African Americans,13,14
Latinos and Mexican Americans,15,16 Chinese Americans,17
and Hawaiian Asian Pacific Islanders.18 Findings suggest
that culturally tailored interventions are effective at
improving health outcomes13-17 and increasing engage-
ment in healthy DSM behaviors.13-15,18 However, the abil-
ity to develop DSME programs tailored to Arab Americans
Bertran et al
Diabetes Self-management Education in Arab Americans
749
remains limited due to the lack of insights about how
Arab American culture may uniquely affect DSME. To
address this continued gap, the purpose of this study was
to understand barriers and facilitators to DSME in Arab
Americans with diabetes.
Methods
Research Design
Focus group methodology was employed to produce
rich data on patients’ perceived barriers and facilitators
to DSME. The focus group (FG) method has become
the research method of choice to understand individual
experiences, assess the impact of new protocols and
practices, and identify a range of factors that influence
behavior.19,20
Participants/Sampling
Study personnel recruited participants from the com-
munity at large and from pharmacies located in a pre-
defined geographical area of Michigan mainly populated
by Arab Americans. Pharmacist referrals and snowball
sampling, an approach that has been effective in this
close-knit community,21 were employed. Participants
were included if they self-identified as Arab or Arab
American, were 18 years or older, spoke primarily Arabic,
had a self-reported diagnosis of diabetes, and currently
received at least 5 medications for diabetes or other
comorbid conditions. The language requirement would
include less acculturated individuals in whom DSME
would presumably be most affected by culture. The crite-
rion for multiple medications was meant to select patients
with more complex management regimens. Pregnant
individuals were excluded due to inherent differences in
DSME during pregnancy. The Wayne State University
Institutional Review Board approved study design and
recruitment procedures prior to data collection. All par-
ticipants provided informed consent.
Data Collection
A senior member of the research team trained all study
personnel in focus group methodology based on the text
Moderating Focus Groups by R.A. Krueger.19 An Arab
American moderator conducted all sessions in Arabic.
The moderator presented guided questions to explore the
participants’ perceptions of DSM. Sessions lasted 36 to
49 minutes and were audio and video recorded. At the
The Diabetes EDUCATOR

750

conclusion of these sessions, participants completed a

sociodemographic survey. The research team held Table 1
debriefings immediately after sessions to discuss and
Participant Characteristics
document preliminary impressions of participant views.

Data Analysis Focus group (N)

  Mixed gender 15
All focus group discussions were transcribed verbatim   Female only 8
and translated from Arabic to English by trained, bilin- Gender, female (N) 13
Age (median) 58
gual student research assistants. Transcripts were then
Country of origin (N)
reviewed and compared to video recordings by the mod-  Lebanon 10
erator to ensure accuracy. The first and second author  Yemen 8
independently performed data analysis using a data-  Iraq 4
driven, inductive qualitative content analysis approach  Syria 1
Highest educational degree received (N)
without a priori categories.22 This conventional content  None 12
analysis method is appropriate since there is a lack of   High school 6
extant literature concerning Arab American culture’s   Technical school/junior college (2 y) 0
affect on DSME.22 The first and second authors began the  College 4
process by indepently coding the transcripts and then met  Master’s 1
Marital status (N)
to review the coded data. When coding differed, they  Married 19
returned to the interview texts and discussed them until  Widowed 2
consensus was reached. The data were then recoded using  Divorced 2
the revised coding scheme. Once codes were grouped Have children (N) 22
into primary themes, the moderator further reviewed and Number of children in the home (median) 5
“In general you believe your health is” (N):
examined the accuracy of interpretations. This step of  Excellent 0
data triangulation was included because the primary cod-   Very good 3
ers were not Arabs. In this way, the authors sought to  Good 7
validate their interpretations of the impact of the Arab  Fair 7
culture on DSME with a member of the Arab American  Poor 6
community who was not involved in the transcript cod-
ing. Following this step, the authors met to review the
primary themes that emerged through the data analysis in examples of how Arab American culture, as manifested
relation to the research questions and study aims. through beliefs, traditions, and daily life practices, both
supported and at times impeded DSM and DSME.
Specifically, participant narratives illustrated the impact
Results of Arab culture on the enactment of DSM behaviors, the
expectations and perspective on the patient-provider
Participants
relationship, and the apparent and perceived lack of
Participant demographic characteristics are presented DSME resources for Arab American patients. Each of
in Table 1. Twenty-three Arab Americans with diabetes these themes, presented in further detail in the following
participated in 3 focus group sessions: 2 mixed-gender text, includes anonymous participant quotes to exemplify
groups (N = 15) and 1 female-only group (N = 8). Most main points.
participants were female (57%) and originated from
Influence of Arab American Culture on
Lebanon or Yemen (78%). Approximately half (52%)
Enactment of DSM Behaviors
reported no educational degree. The majority of partici-
pants (57%) reported that their health was fair or poor. Participants discussed the influence of Arab culture on
Participant knowledge about diabetes and approaches key DSM behaviors, including diet, exercise, self-­
to DSM and DSME varied widely across the sample. As monitoring, and coping. Especially insightful were par-
participants described their DSM activities, they p­ rovided ticipants’ discussions about traditional foodways, which

Volume 41, Number 6, December 2015


revealed the ways that cultural food norms could be both
facilitative and inhibitory:
Just like we used to eat back in the country, we eat here.
. . . In our home, legumes, lentils and chick peas and
bulgur, we eat all this at home. Canned food or the like,
restaurants or such we do not go to. (Female)
Americans don’t eat a lot at home, they eat outside . . .
yes this is not healthy. . . . We cook at home, but the
problem [is] that we cook in big quantities . . . because
we love our kids and the family . . . and we are like
“come on, eat.” I used to make my kids big plates until
they became fat but now my son lost weight because he
was on a strict diet. (Female)
In addition to eating a healthy diet, cultural views on
gender roles and female modesty impacted another impor-
tant component of DSM behavior: physical activity. Female
participants perceived more restrictions in how females
could engage in physical activity. While walking was con-
sidered universally acceptable, discussions about the use of
exercise facilities sparked debate. Some participants felt that
it was inappropriate for females to access mixed-­gender
exercise facilities, regardless of their exercise regimen:
Mixed [exercise is] no[t acceptable], due to respect for
our head cover [hijab], and our religion. Our religion
doesn’t allow that. (Female)
Others in the group held more flexible views about
gender practices. The following quote illustrates how
judgments about the appropriateness of using mixed-
gender fitness facilities depended on what types of exer-
cise were engaged in:
On the machines then it is ok [to exercise with men].
But swimming, no. (Female)
Another important way that culture impacted DSME
was through religious practices. One example of this was
participants’ discussion about their participation in the
Ramadan fast, which consisted of refraining from food
from dawn to dusk for 29 to 30 days. Participant quotes
illustrate how the desire to participate in this cultural
tradition could supersede the advice of the provider and
potentially impede DSME:
My doctor doesn’t give me permission to fast, but I fast
every year and I feel a big difference. My doctor won’t
believe [me] when I tell him that. (Male)
Bertran et al
Diabetes Self-management Education in Arab Americans
751
I feel my vision is blurry, like not 100% perfect for
farsightedness . . . but I try to resist until I break the
fast. (Male)
Participants also provided a range of examples illus-
trating their perception that stress and sadness could
directly cause diabetes or affect DSM and DSME. One
participant expressed his stress to be associated with
attempting to lead the family in cultural traditions:
Your sugar level increases and blood pressure increases,
especially when your kids deviate from the traditions,
your customs, from your life values. . . . The psycho-
logical status affects [diabetes]. (Male)
Another participant believed that psychological stress
caused by war in her home country caused her diabetes:
In our family we do not have diabetes. It is not genetic.
However, in 2003 the war on Iraq we saw it live on TV,
the bombing, and such, we felt that no one was alive
from our families, everyone died. As a result, I got
diabetes. My psychological state had an affect. (Female)
Expectations and Perspective on the
Patient-Provider Relationship
Participants readily discussed their perspectives
regarding the relationship with and the role of the physi-
cian in the context of their DSME efforts. The range of
opinions offered suggests that culture impacts the nature
of the patient-provider relationship. Notably, the
females in the group appeared most accepting of the tra-
ditional “authoritative” physician role. For these women
in the sample, listening to the physician and following
his directives was seen as essential to facilitating
DSME:
Yes, you cooperate only with the physician specialized
for diabetes. He eases what is necessary. And if you
follow the things he tells you about, then that means
you have crossed a good path. Because if you do not
cooperate with your physician, then do not depend on
what you hear. The physician is supposed to be the one
that determines what is necessary and what is required.
(Female)
However, other participants felt that (compared to
American physicians) Arab American physicians avoided
patient-centered care, preferring instead to focus on test
results and medications:
The Diabetes EDUCATOR
752
Americans [physicians] have schedules and a certain
number of patients, because they have to take care of
the patients who seek their help. While our doctors,
well, some of them . . . they accept as much patients as
they receive. They want to do business, not being
humanitarian, not caring so much. Maybe 5%-10%
care but I don’t know that much about the American
doctors. This is, by itself, a disease in our Arabic soci-
ety. (Male)
Participant comments also suggest that because of the
emphasis on maintaining a favorable reputation in the
Arab culture, patients may be less willing to publicly
express dissatisfaction regarding an Arab doctor since
this could harm the physician’s reputation:
The American doctor is scared from making a mistake
and from being held accountable. . . . The Arabic doctor
doesn’t care. Whatever happens to you, you feel
uncomfortable to complain about him. You feel uncom-
fortable to hurt him. It happens to me. . . . Just because
he is Arabic, I can’t hurt his reputation. (Male)
Lack of Self-Management Resources
for Arab Americans
Evident from participants’ discussions of their chal-
lenges with enacting DSM behaviors and navigating the
patient-provider relationship was a need and desire for
improved DSME and DSMS resources. For some partici-
pants, the lack of patient-physician communication
underscored the critical lack of educational resources
available to Arab American patients. Only 2 participants
reported having received formal and comprehensive
DSME and DSMS (while living elsewhere). Several par-
ticipants expressed ardent support for education classes
and that improved education was essential for ameliorat-
ing many of the challenges associated with DSME:
We are not educated about the disease we have. We eat
everything, we drink everything, and after all we look
back [and say] “Oh, what did we eat?” There should be
a special committee for Arab American people that
have diabetes that holds meeting at least one a week or
twice a week . . . to give us lessons, and educate us
about the disease. (Male)
Discussion
Culture shapes health beliefs and perceptions that ulti-
mately influence health behaviors relevant to DSME. To
our knowledge, this is the first study exploring the
cultural influences on DSME in Arab American patients
with diabetes. The study provides insights into how Arab
Americans in our sample understood DSM and the ways
that cultural beliefs and traditions could impact DSME.
These findings suggest opportunities for improving
DSME programs targeting Arab Americans.
A notable area of opportunity for health care improve-
ment as identified by most participants is the lack of
available DSME resources. The impact of this gap is
readily evident in participants’ discussions of their DSM
practices. While some key DSM elements were identi-
fied by participants, others (eg, prevention and manage-
ment of acute or chronic complications and healthy
coping strategies) were notably missing.1 Moreover,
even though participants identified important elements
such as dietary management and engaging in physical
activity, their narratives suggested a superficial under-
standing of how to enact such behaviors. For example,
dietary management was extensively cited by partici-
pants but only in general terms, such as avoiding
“sweets.” This finding can be linked to the participants’
reported lack of general DSME resources and the dearth
of resources that feature culturally appropriate food or
physical activity options23 or that account for the role of
religious practices.
While further research needs to be conducted to
assess the generalizability of these findings, the chal-
lenges raised by participants draw attention to possible
elements to include in DSME programs targeting Arab
Americans. For example, these findings align with
existing research suggesting that an overlooked oppor-
tunity in Arab Americans is health care provider consul-
tation and supervision during Ramadan fasting. 24
Culturally tailored DSME programs could help ensure
safe fasting by including information and guidelines
about physician-supervised fasting and encouraging
patients to discuss their practices during Ramadan with
their providers. Because of the potential impact of gen-
der practices on DSME, programs could also strategi-
cally partner with local community organizations to
establish and maintain gender-separated exercise facili-
ties, such that women can feel comfortable attending
these places. Organization of walking groups or clubs
may be feasible, cost-effective, and especially success-
ful among Arab Americans since participants did not
believe walking needed to be gender separated, though
further research would need to investigate the accept-
ability of such elements.
Volume 41, Number 6, December 2015

Findings also suggest some interesting views about
the patient-provider relationship that likely impact
DSME. The perceived interaction style of the physician
and the comprehensiveness of care were the 2 most
prominent features that impacted participants’ views of
the patient-provider interaction. Notably, those in the
female-only group expressed satisfaction with a less
interactive and more directive style. The shift to diabetes
“self-management” has occurred in step with the para-
digm shift in the patient-provider relationship from the
traditional “directive” approach to care provision to a
more “partnering” approach.25,26 While the latter (part-
nering) approach has gained acceptance,27 findings sug-
gest that some individuals might expect or prefer the
authoritative approach.28 A myriad of strategies have
been proposed to improve patient-provider interactions.
Given the potentially unique intersection of social status
and gender roles in Arab culture, further research is war-
ranted to better understand relevant approaches to
improving patient-provider interactions that may work in
this population.
Despite the important contributions of these study
results, there are limitations. The small convenience
sample in this study recruited from a less acculturated
population in a single geographic area limits the range of
perceptions reported here, and thus findings should be
interpreted with caution. However, it was hypothesized
that less assimilated participants would likely experience
the most cultural barriers to DSME and that the percep-
tions of this group would better answer the original ques-
tions regarding the effect of Arab American culture on
DSME. Furthermore, although not every Arab national-
ity was represented, individuals from 4 different coun-
tries participated, including Iraq and Lebanon, which are
2 of the most common Arab American nationalities.29
The data presented here provide new insights into the
meaning of DSM for Arab Americans and the specific
ways in which Arab culture may impact DSME. Future
studies examining the role of Arab American culture on
key DSME behaviors and activities with larger and more
diverse samples are needed to further improve care in
this population. In addition, alternative methodology for
answering the research questions could have included
development and administration of a survey. This would
have enabled a much higher study sample size and would
have probably represented more Arab nationalities.
However, the severe lack of data regarding self-­
management in Arab Americans precluded development
Bertran et al
Diabetes Self-management Education in Arab Americans
753
of ­reliably relevant questionnaire items, and thus an
exploratory qualitative design was chosen to better
inform future questionnaire development efforts.
Based on study findings, the authors are developing a
questionnaire designed for health care professionals to
readily identify culturally specific gaps in DSME and
DSMS for their Arab American patients. The question-
naire would optimize time during the patient visit by
enabling providers to focus and direct their efforts regard-
ing DSME and DSMS. The authors also plan to administer
this questionnaire to a larger and more diverse sample of
Arab Americans to evaluate the scope and the frequency
of each cultural barrier and facilitator in the population.
This will allow health care providers and other stakehold-
ers to strategically plan programs and allocate resources.
Conclusion
Findings draw attention to the impact of Arab
American culture on DSME and suggest important ele-
ments to consider in the development of culturally sensi-
tive DSME programs. Specifically, findings suggest that
programs could improve DSME outcomes in the Arab
American populations by including culturally sensitive
nutrition education and options for exercise (especially
for females). Because of the diversity in perspectives
regarding the patient-provider interactions, future
research should examine this further. DSME programs
could begin to address this challenge through including
information on how to engage with the provider and
advocate for their needs during clinical encounters. This
includes empowering patients to discuss religious beliefs
and practices with their provider to ensure safe medical
management, such as during Ramadan. Culturally appro-
priate programs have shown to improve outcomes in
minorities.30,31 Findings from this study support the need
for culturally appropriate DSME and DSMS for Arab
American patients with diabetes.
Implications for Diabetes
Educators
Study findings can guide physicians and other health
care providers in their clinical encounters. It is now recog-
nized that some Arab American patients prefer more indi-
vidualized discussions on their management plans and
seek culturally appropriate recommendations regarding
diet and exercise. Additionally, it should be recognized
The Diabetes EDUCATOR
754
that the behaviors recommended to patients are not neces-
sarily the same as the behaviors patients actually adopt
and why, for example, unsupervised fasting during
Ramadan. Therefore, educators should inquire more spe-
cifically into how patients enact DSM in order to further
examine cultural factors influencing DSME. Adequately
addressing each of these components in the limited time-
frame of a medical appointment is highly unlikely.
Development of a standardized questionnaire tool to
assess an individual patient’s unique cultural barriers to
DSME will allow educators to focus their limited time on
the patient’s specific barriers.
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