Cultural adaptation of self-management models for Type 2 Diabetes in Saudi Arabia

According to the global prevalence of diabetes, Saudi Arabia is ranked 7th. Currently the Ministry of Health in Saudi Arabia spends around US $6 billion, or more than 16% of its budget on treating diabetes and its complications. The focus of this thesis is type 2 diabetes. Some countries have developed their own type 2 diabetes self-management education programmes. These programmes aim to educate individuals with type 2 diabetes to become independent and capable of taking initiative in dealing with their type 2 diabetes in order to have better health and quality of life. Saudi Arabia does not have such a programme. The main aim of this thesis was to carry out an initial need assessment for type 2 diabetes self-management education programmes to examine if the solutions provided through self-management education programmes can help individuals with type 2 diabetes in Saudi Arabia. This aim was pursued through three complementary studies, each of them aimed to cover a specific point of this need assessment. Study one aimed to evaluate needs based on the degree of success of self-management strategies used in any existing programmes or attempts. Evidence on such success was driven from published type 2 diabetes self-management studies in Saudi Arabia and sister Gulf Cooperation Council (GCC) countries. Study two examined demographic and clinical associations with type 2 diabetes in Saudi Arabia. Study three aimed to provide an insight into how health professionals dealing with type 2 diabetes and those under their care in Saudi Arabia perceive the current type 2 diabetes management options and if the solutions offered through self-management programmes are needed or could be of a benefit. The above approach was based on a model devised by Kumpfer and colleagues for need assessment and cultural adaptation. This model describes nine steps to assess the need of a self-management programme. Part of the need assessment is to assess the need for cultural adaptation to make the programme suitable for a new setting or population. Step one in this model recommends reviewing published literature, which was done through a systematic review. It also suggests examining factors associated with the healthcare condition targeted by the programme and understanding the views of those affected by this condition. This thesis systematically reviewed publications on type 2 diabetes self-management studies in Saudi Arabia and GCC. Although none of the reviewed studies (n=8) tested a full type 2 diabetes self-management programme, it was clear that teaching participants how to monitor their blood glucose, become more active or eat healthier, was associated with an improvement in the control of their diabetes. However, the systematic review also showed that the studies did not consider the concept of cultural adaptation. Without cultural adaptation to make the programme more suitable to the local context, one can expect the success of some aspects of such a programme to be compromised. In order to build on these recommendations suggested in the first step of Kumpfer’s model, this thesis used the Saudi Health Interview Survey, published in 2013, to investigate sociodemographic, health and lifestyle factors associated with type 2 diabetes and its control. The survey included the responses of a representative sample (n=10,827). Of Saudi adults 7.5% (n=808) had type 2 diabetes. Factors associated with type 2 diabetes were being a male, above 55 years and overweight. The analysis also showed comorbidity between hypertension and type 2 diabetes. However, some unexpected findings were encountered in this secondary data analysis. Factors such as physical activity and smoking were not statistically significant in association with type 2 diabetes. On the other hand, people who ate more fast food were less likely to have type 2 diabetes and those who ate more fruits and vegetable were more likely to have poorly controlled type 2 diabetes. Finally, to conclude the first step in the Kumpfer model, a qualitative study was designed to understand the views of participants who have type 2 diabetes (in-depth interviews with 12 participants with type 2 diabetes) and the health professionals (n=9 divided into two focus groups) responsible for their care at a specialised endocrinology centre. The study revealed some challenges to successful management of type 2 diabetes, which can be overcome with type 2 diabetes self-management programmes. All individuals with type 2 diabetes from the city, in which the specialised endocrinology centre is located, and the surrounding rural areas attended this one centre. This led to overcrowding in clinics. For many, particularly women, it was not easy to practice outdoor sports; indoor sport facilities were available, but not affordable for some. Many were dependent on cars, while some found it difficult to quit smoking. It was also useful to know that many, who started to eat healthier food such as vegetables, or had given up on eating fast food, had only started doing so after they were diagnosed with type 2 diabetes, which may explain some of the unexpected findings in the quantitative study. In summary, this thesis used three different research methods, systematic review, quantitative data analysis and qualitative study, in order to advise on the need for initiating a national type 2 diabetes self-management programme in Saudi Arabia. It is clear that a culturally adapted programme to be specific to Saudi Arabia is needed to help to tackle issues associated with clinic overcrowding, restrictions on achieving better physical activity levels and weight control for both sexes and all age groups, particularly older individuals who may require help to self-manage other chronic illnesses

Dietary factors and Type 2 diabetes in the Middle East : what is the evidence for an association? - A systematic review.

This review aims to search and summarise the available evidence on the association between dietary factors and type 2 diabetes mellitus (T2DM) in Middle Eastern populations, where diabetes prevalence is among the highest in the world. Electronic databases were searched; authors, libraries, and research centres in the Middle East were contacted for further studies and unpublished literature. Included studies assessed potential dietary factors for T2DM in Middle Eastern adults. Two reviewers assessed studies independently. Extensive searching yielded 17 studies which met the inclusion criteria for this review. The findings showed that whole-grain intake reduces the risk of T2DM, and potato consumption was positively correlated with T2DM. Vegetables and vegetable oil may play a protective role against T2DM. Dietary patterns that are associated with diabetes were identified, such as Fast Food and Refined Grains patterns. Two studies demonstrated that lifestyle interventions decreased the risk of T2DM. In summary, the identified studies support an association between some dietary factors and T2DM; however, many of the included studies were of poor methodological quality so the findings should be interpreted with caution. The review draws attention to major gaps in current evidence and the need for well-designed studies in this area

The Impact of poor glycaemic control on the prevalence of erectile dysfunction in men with type 2 Diabetes Mellitus: A Systematic Review.

To determine the impact of poor glycaemic control on the prevalence of erectile dysfunction among men with type 2 Diabetics aged 27 to 85 years.The databases Embase classic+Embase, Global health, Ovid Medline and PsychINFO, were searched for relevant studies in June 2014 using the keywords: (Diabetes Mellitus OR diabetes mellitus type2 OR DM2 OR T2DM OR insulin resistance) AND (erectile dysfunction OR sexual dysfunction OR impotence) AND glycaemic control.All study settings were considered (primary care, secondary care and tertiary care setting).Type 2 Diabetic Patients with erectile dysfunction.Included studies must include one of the following outcomes: (1) HBA1c for assess the level of glycaemic control; (2) Erectile dysfunction (any stage: IIEF-5 = 21 or less).Five cross-sectional studies involving 3299 patients were included. The findings pointed to a positive association between erectile dysfunction and glycaemic control. Three studies showed a significant positive association, while one study showed only a weak correlation and one study showed borderline significance. Patients age, diabetes mellitus duration, peripheral neuropathy and body mass index had positive association with erectile dysfunction. However, smoking and hypertension were not associated with erectile dysfunction in most included studies. Physical activity had a protective effect against erectile dysfunction.We may conclude that the risk of erectile dysfunction is higher in type 2 diabetic men with poor glycaemic control than those with good control

Systematic review of the safety of medication use in inpatient, outpatient and primary care settings in the Gulf Cooperation Council countries

Background Errors in medication use are a patient safety concern globally, with different regions reporting differing error rates, causes of errors and proposed solutions. The objectives of this review were to identify, summarise, review and evaluate published studies on medication errors, drug related problems and adverse drug events in the Gulf Cooperation Council (GCC) countries. Methods A systematic review was carried out using six databases, searching for literature published between January 1990 and August 2016. Research articles focussing on medication errors, drug related problems or adverse drug events within different healthcare settings in the GCC were included. Results Of 2094 records screened, 54 studies met our inclusion criteria. Kuwait was the only GCC country with no studies included. Prescribing errors were reported to be as high as 91% of a sample of primary care prescriptions analysed in one study. Of drug-related admissions evaluated in the emergency department the most common reason was patient non-compliance. In the inpatient care setting, a study of review of patient charts and medication orders identified prescribing errors in 7% of medication orders, another reported prescribing errors present in 56% of medication orders. The majority of drug related problems identified in inpatient paediatric wards were judged to be preventable. Adverse drug events were reported to occur in 8.5–16.9 per 100 admissions with up to 30% judged preventable, with occurrence being highest in the intensive care unit. Dosing errors were common in inpatient, outpatient and primary care settings. Omission of the administered dose as well as omission of prescribed medication at medication reconciliation were common. Studies of pharmacists’ interventions in clinical practice reported a varying level of acceptance, ranging from 53% to 98% of pharmacists’ recommendations. Conclusions Studies of medication errors, drug related problems and adverse drug events are increasing in the GCC. However, variation in methods, definitions and denominators preclude calculation of an overall error rate. Research with more robust methodologies and longer follow up periods is now required.Peer reviewe

The Influence of Medical Education on Knowledge, Beliefs and Preventive Behaviours Related to Type 2 Diabetes Mellitus Among Medical Students in Saudi Arabia

The purpose of this study was to assess the influence of academic medical education on knowledge, beliefs and preventive behaviours related to Type 2 Diabetes (T2D) among medical students at Qassim University, Saudi Arabia, and to explore the underlying factors. This study adopted the Health Belief Model as a theoretical framework and followed an explanatory sequential mixed-methods study design. Three study phases were applied, in addition to a systematic literature review. In the first phase, questionnaires were distributed among 195 first- and final-year medical students to assess and compare their knowledge, beliefs and preventive behaviours related to T2D. The second phase aimed to explain the reasons behind phase one's findings by interviewing 25 final-year medical students. The third phase complemented the phase two findings and provided a complete picture of the medical education role in promoting medical students' health behaviours. This phase involved analysing 38 medical education-related documents from three medical institutions in Saudi Arabia using the documentary content analysis approach. Although medical students were aware of the magnitude of T2D and believed in the severity of and their susceptibility to T2D, the following T2D preventive behaviours were below the recommended standards. The first phase of the study showed a lack of medical education's influence on the first- and final-year medical students’ T2D preventive behaviours. In the second phase, final-year medical students justified this outcome based on the limited resources and students’ wellbeing services. They highlighted the positive influencing role of social and religious values in promoting their health behaviours. The third phase revealed the great emphasis placed on these values compared to students’ wellbeing strategies in medical curricula. In conclusion, medical education in Saudi Arabia did not influence the medical students’ T2D preventive behaviours, and there is a need to consider medical students’ wellbeing through the medical curriculum

Anthropometric indices of Gambian children after one or three annual rounds of mass drug administration with azithromycin for trachoma control.

BACKGROUND: Mass drug administration (MDA) with azithromycin, carried out for the control of blinding trachoma, has been linked to reduced mortality in children. While the mechanism behind this reduction is unclear, it may be due, in part, to improved nutritional status via a potential reduction in the community burden of infectious disease. To determine whether MDA with azithromycin improves anthropometric indices at the community level, we measured the heights and weights of children aged 1 to 4 years in communities where one (single MDA arm) or three annual rounds (annual MDA arm) of azithromycin had been distributed. METHODS: Data collection took place three years after treatment in the single MDA arm and one year after the final round of treatment in the annual MDA arm. Mean height-for-age, weight-for-age and weight-for-height z scores were compared between treatment arms. RESULTS: No significant differences in mean height-for-age, weight-for-age or weight-for-height z scores were found between the annual MDA and single MDA arms, nor was there a significant reduction in prevalence of stunting, wasting or underweight between arms. CONCLUSIONS: Our data do not provide evidence that community MDA with azithromycin improved anthropometric outcomes of children in The Gambia. This may suggest reductions in mortality associated with azithromycin MDA are due to a mechanism other than improved nutritional status

Quality of Type 2 Diabetes Management in the States of The Co-Operation Council for the Arab States of the Gulf: A Systematic Review

Type 2 diabetes mellitus is a growing, worldwide public health concern. Recent growth has been particularly dramatic in the states of The Co-operation Council for the Arab States of the Gulf (GCC), and these and other developing economies are at particular risk. We aimed to systematically review the quality of control of type 2 diabetes in the GCC, and the nature and efficacy of interventions. We identified 27 published studies for review. Studies were identified by systematic database searches. Medline and Embase were searched separately (via Dialog and Ovid, respectively; 1950 to July 2010 (Medline), and 1947 to July 2010 (Embase)) on 15/07/2009. The search was updated on 08/07/2010. Terms such as diabetes mellitus, non-insulin-dependent, hyperglycemia, hypertension, hyperlipidemia and Gulf States were used. Our search also included scanning reference lists, contacting experts and hand-searching key journals. Studies were judged against pre-determined inclusion/exclusion criteria, and where suitable for inclusion, data extraction/quality assessment was achieved using a specifically-designed tool. All studies wherein glycaemic-, blood pressure- and/or lipid- control were investigated (clinical and/or process outcomes) were eligible for inclusion. No limitations on publication type, publication status, study design or language of publication were imposed. We found the extent of control to be sub-optimal and relatively poor. Assessment of the efficacy of interventions was difficult due to lack of data, but suggestive that more widespread and controlled trial of secondary prevention strategies may have beneficial outcomes. We found no record of audited implementation of primary preventative strategies and anticipate that controlled trial of such strategies would also be useful

Influence of Health Beliefs on Diabetes Self-care in Saudi Adults

The prevalence of Diabetes Mellitus Type 2 (DMT2) has increased among the adult population in Saudi Arabia. Many Saudi adults with DMT2 fail to follow the recommended daily self-care activities, increasing their risk for diabetes-related complications. Findings in the literature show that people’s health beliefs influence their self-care behaviors. However, limited studies were found to examine the association between the health beliefs of Saudi adults with DMT2 and their diabetes self-care. Therefore, the aim of this dissertation study was to examine the relationship between the health beliefs of adults in Saudi Arabia with DMT2 and their reported adherence to their self-care activities to manage their diabetes. Additionally, the study was conducted to explore Saudi perceptions of threats to their health due to having DMT2. The Health Belief Model was the conceptual framework for this study, and a descriptive, correlational design was used. Data was collected using self-reported questionnaires, and 202 Saudi adults with DMT2 were recruited from diabetes clinics in Riyadh, Saudi Arabia. The findings of the study showed that self-efficacy, internal health locus of control, and perceived benefits of doing self-care were the significant predictors of whether the participants followed their self-care activities to manage their diabetes. Therefore, health care providers are encouraged to assess the health beliefs of persons with DMT2 in order to maintain and improve the patients’ adherence to self-care activities

The Determinants of Physical Activity, Self-Monitoring of Blood Glucose, and Poor Glycemic Control Among Individuals Diagnosed With Type 2 Diabetes in Saudi Arabia: A Cross-Sectional Study Based on the Saudi Health Interview Survey (SHIS)

The prevalence of diabetes and poor glycemic control in Saudi Arabia has increased that contributed to the growing number of deaths in Saudi Arabia. It is known that type 2 diabetes (T2DM) can be prevented but there is a lack information about the magnitude of the of diabetes at national level as well as the risk factors for physical activity (PA), self-monitoring of blood glucose (SMBG), and poor glycemic. Thus, through utilizing Health promotion model (HPM), the aims are to examine the personal factors, cognitive-perceptual, and behavioral determinants of three outcomes; physical activity, SMBG, and poor glycemic control. A secondary data (Saudi health interview survey-2013) was used with two sample sizes for examining PA and SMBG (808 participants who reported to have T2DM and were 18 year or older) and poor glycemic control (391 participants who reported to have T2DM and had data about their blood glucose level) outcomes. Bivariate and multivariate logistic regression were conducted to address the research questions at alpha level of 0.05. The results showed that the prevalence of physical activity, SMBG, and poor glycemic control, were 9.1%, 55.4%, and 34%, respectively. Younger age (Adjusted odds ratio [AOR] = 2.84), and higher education (AOR = 3.14) were associated with PA, while health professional support for treatment (HPST) was inversely associated with PA (AOR = 0.35). Factors associated with SMBG were obesity (Adjusted prevalence ratio [APR] = 1.20), middle (APR = 1.30) and higher (APR =1.49) education, while shorter diabetes duration (AOR = 0.78 for \u3c 5 years and 0.78 for 5-9 years) and Eastern region (AOR = 0.66) were inversely associated with SMBG. For poor glycemic control, the only predictor was Eastern region (AOR = 1.55) compared to the Central region. Further analysis showed that region of residence, education, diabetes duration, and age were prominent predictors of all cognitive-perceptual and behavioral outcomes. The study suggested individualizing plan of care for diabetic patients due to disparity in the personal factors. The study supported the urgent change in the healthcare system to adapt healthcare professional team-based care. Finally, longitudinal studies at both national and regional levels are needed to determine the causal relationship focusing on both personal and psychological factors

Factors affecting the self-management practices of people with type 2 diabetes in Almadinah, Saudi Arabia

In the Middle Eastern Gulf Cooperation Countries, the prevalence of type 2 diabetes mellitus (T2DM) is increasing steadily. It has recently been estimated that up to 23% of the Saudi Arabian population meet the diagnostic criteria. Due to the potential for serious micro and macro-vascular complications such as peripheral vascular disease and nephropathy, T2DM places a significant burden on the individuals concerned and their families. In addition, T2DM is having catastrophic consequences for the health-care systems of many countries that are unable to cope with the increased demand for services. Furthermore, the prevalence is expected to increase and the burden of the disease is expected to worsen. As a consequence the Saudi government is implementing a number of strategies to address the issue, such as the National Plan to Combat Diabetes. The major problem is that T2DM is largely a lifestyle disease caused by an affluent diet and inactivity, and the goal of effective glycaemic control is impossible without competent patient self-management.This study identified factors affecting self-management practices among people who have T2DM in Almadinah, Saudi Arabia. The study had three phases. The first phase involved the development of a valid questionnaire instrument to measure diabetes self-management practices in Arabic speaking populations. The Summary of Diabetes Self-care Activities (SDSCA) instrument was translated into Arabic and validated according to the World Health Organisation’s Steps of Translation and Adaptation of Instruments. Two samples of T2DM participants were purposively recruited in this phase. The first sample consists of 33 while the second was 210 participants. Translation indicators showed satisfactory outcomes for each stage of the process.The Arabic Summary of Diabetes Self-care Activities (ASDSCA) instrument proved to have very acceptable psychometric properties: splithalf reliability (.90); test-retest (.912, p = <.001); and Cronbach’s alpha (.76). The internal consistency of the instrument’s sub-scales was good for diet (.89), exercise (.83), blood glucose testing (.92), and foot care (.77). Factor analysis revealed the presence of four components explaining 34.4%, 16%, 15.4%, and 11.2% of the variance of daily self-management practices for these items respectively (accumulated total of 77.1%). Based on these outcomes, the A-SDSCA was utilised in the second phase of the study.The second phase of the study measured diabetes self-management practices and identified socio-demographic factors affecting these practices. The sample of 210 T2DM participants purposively recruited from three primary health-care centres completed the A-SDCA (N=1,477). HbA1c scores indicated that only 30 (14.7%) participants had controlled blood glucose level (_ 7%). Bivariate analyses showed that blood glucose testing (85% _ four days/week) and exercise (47% _ two days/week) were the least practiced self-management activities. In contrast, selfmanagement levels were greatest for medication (75% 7days/week), diet (71% _ three days/week), and foot-care (56% _ three days/week). A regression model showed that high blood glucose level (-.122, p = .050) and smoking (-.192, p = .004) were negatively associated with self-management practices. On the other hand, being female (.321, p = .000) and having a good income (.129, p = .050) were positive factors. Overall, these factors accounted for 25% of the variability in everyday selfcare practices (R² = .251).The third phase further explored factors affecting self-management practices, not identified by the questionnaire alone. Using semi-structured interviews, qualitative data were collected from 24 T2DM participants and 12 health-care providers. Raw data were analysed by means of quantitative thematic analyses using the Chronic Care Model (CCM) as the conceptual framework. The result identified 30 sub-themes under the six CCM domains (themes). In total, 365 related statements were extracted. Major inputs were derived from health-care providers’ interviews (132 statements) followed by female (118 statements) and then male (115 statements) T2DM participants. Community domain was the most frequently identified theme (100 statements; 27%) while health system was the least frequently identified (38 statements; 10%). Factors relating to delivery system; decision making; clinical information system; and self-management represented 20%, 11%, 14% and 17% of the total identified statements, respectively.In conclusion, the fact that only 15% of participants had controlled glycaemic level despite a high level of dependence on medications is very good evidence that medication alone, is not the complete answer to the effective management of T2DM in the study context. The fact that the study participants demonstrated low levels of compliance with most other self-management practices indicates that they were facing difficulties and obstacles to practice optimal self-management activities. Furthermore, these findings reflect serious limitations in the way T2DM self-management is promoted and enhanced in the various study locations. The ASDSCA could be utilized by health-care researchers to measure self-management practices among T2DM people. Furthermore, the instrument might be used to measure improvements in self-management practices before and after self-management programs application