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