In Australia, type 2 diabetes and prediabetes are more prevalent in culturally and linguistically diverse (CALD) communities than mainstream Australians.
Diabetes is a major and complex health problem worldwide. A recent systematic review showed that racial and ethnic minorities bear a disproportionate burden of the diabetes epidemic; they have higher prevalence rates, worse diabetes control, and higher rates of complications [
This is particularly true in Australia, where diabetes is rising amongst Culturally and Linguistically Diverse Communities (CALD) and particularly those from the Middle Eastern Region [
Diabetes prevention programs tailored specifically to the needs of the Turkish- and Arabic-speaking people have the potential to significantly reduce the incidence of diabetes and its impact on individuals, their families, the health care system, and community at large. Our previous work [
The study is participatory action research. The research design is one-group Pre-test-Post-test intervention trial.
An expert advisory group was formed to advise on the implementation of the study, which involved three phases: (1) developing a culturally appropriate interactive peer lead diabetes prevention program (the package), (2) testing the education program in ten interactive, peer-supported, small group discussion, and (3) data collection to evaluate the program using predefined outcome measures related to physical activity and diet.
The advisory group consisted of the research team including academic general practitioners, endocrinologist, epidemiologist, dietician, diabetes educator, physiotherapist, self-management consultant and consumer representative. The team enrolled consumer representatives from the Arabic- and Turkish-Speaking communities, diabetes Australia, Victoria, relevant divisions of general practice (organized regional groups of general practices in Australia).
The Group Education Intervention program based on the training manual is included in Table
The peer leader training manual was based on guidelines and multilingual resources from the International Diabetes Institute, Diabetes Australia, and the “Better Health Self-Management program” developed by Stanford patient Education Research Center. The manual was modified based on our experience from our pilot study [
Each leader recruited ten participants who attended
The small group education intervention was based on the training manual and delivered using interactive strategies aided by education materials comprising of culturally sensitive picture booklet on Turkish and Arabic food, exercise leaflets, food basket for displaying healthy food and healthy cooking, Pedometer, drink bottles containing sugar, and the Australian Guide to Healthy Eating posters and Sugar poster.
A media release was sent to ethnic radio stations and Arabic and Turkish print media. As a result ten bilingual peer leaders were recruited (five from the Arabic and five from the Turkish community) including ethnic workers, interpreters, health promotion workers, and teachers. The peer leaders assisted by the research team recruited group participants; these were males or females people who are 40-year old or older with one or more of the following criteria: overweight, a family history (a parent, brother, or sister) of diabetes, of Turkish or Arabic backgrounds, have had gestational diabetes, high blood pressure (140/90+), high cholesterol and/or high lipids (triglyceride), fairly inactive, or exercise fewer than three times a week. Participants were recruited through Community Health Centres and other partners, mainstream local media as well as ethno-specific radio and newspapers, community organizations and migrant resource Centres, local general practitioners, and family members of diabetic patients from the target communities.
Data collection was performed before and after three months intervention. Participants were requested to complete a self-administered questionnaire on the outcome indicators listed below. Peer-leaders measured participants’ body weight and waist circumference before and 3-month after intervention using the same scales. Outcome indicators included changes in body weight and waist circumference, changes in knowledge and attitudes towards healthy eating, and changes in specific food shopping behaviours including dairy product, type of meats, and soft drinks.
The data was analysed using SPSS (Statistical Package for Social Sciences) for windows version 14.0. To test the differences in continuous variables between pre- and postintervention measurements, paired-samples
A total of 94 subjects participated and completed the program. Women represented 73.4% (
Characteristics of study subjects enrolled in the peer-supported self-management diabetes prevention program for Turkish- and Arabic-speaking communities of Australia (
Variable |
|
% |
---|---|---|
Gender | ||
Male | 25 | 26.6 |
Female | 69 | 73.4 |
Age | ||
40–45 | 41 | 46.6 |
46–50 | 19 | 21.6 |
51–55 | 3 | 3.4 |
56–59 | 12 | 13.6 |
60 and above | 13 | 14.8 |
Country of birth | ||
Turkey | 42 | 44.7 |
Lebanon | 11 | 11.7 |
Iraq | 37 | 39.4 |
Syria | 3 | 3.2 |
Other | 1 | 1.1 |
Weight mean (sd) | 78.1 (14.1) | |
Height mean (sd) | 161 (9.8) | |
Waist circumference mean (sd) | 99.5 (14.2) | |
BMI kg/m2 mean (sd) | 30.3 (6.3) | |
<18.5 | — | — |
18.5–24.9 | 18 | 19.1 |
25.0–29.9 | 29 | 30.9 |
30.0–34.9 | 29 | 30.9 |
≥35 | 18 | 19.1 |
About half (
sources of health information as reported by subjects attending peer-supported self-management diabetes prevention program for Turkish- and Arabic-speaking communities of Australia (
Significant reduction in weight (mean weight before
Comparing knowledge and perceived risk of getting diabetes among study subjects before and after a peer-supported self-management diabetes prevention program for Turkish- and Arabic-speaking communities of Australia.
Before | After |
|
|||
---|---|---|---|---|---|
|
% |
|
% | ||
Knowledge | |||||
| |||||
Do you think Diabetes can be prevented? | |||||
Yes | 62 | 69.7 | 74 | 78.7 | 0.055** |
What can increase a person's chance of getting diabetes? | |||||
Overweight | 76 | 80.9 | 79 | 84 | 0.690 |
Underweight | 22 | 23.4 | 19 | 20.2 | 0.711 |
Having family member with diabetes | 67 | 71.3 | 77 | 81.9 | 0.121 |
High blood pressure | 51 | 54.3 | 62 | 66 | 0.090** |
High cholesterol | 58 | 61.7 | 72 | 76.6 |
|
Physical inactivity | 52 | 55.3 | 52 | 55.3 | 1.00 |
Eating lots of food with sugar | 58 | 61.7 | 55 | 58.5 | 0.761 |
Giving birth to large babies | 36 | 38.3 | 39 | 41.5 | 0.701 |
Being over 45 | 51 | 54.3 | 55 | 58.5 | 0.585 |
Stress | 76 | 80.9 | 77 | 81.9 | 1.00 |
Smoking | 45 | 47.9 | 57 | 60.6 | 0.073** |
Other | 9 | 9.6 | 13 | 13.8 | 0.424 |
What behaviours can help prevent diabetes? | |||||
Healthy Lifestyle | 80 | 85.1 | 72 | 76.6 | 0.200 |
Healthy Diet | 77 | 81.9 | 84 | 89.4 | 0.210 |
More exercise | 77 | 81.9 | 83 | 88.3 | 0.286 |
Weight control | 76 | 80.9 | 79 | 84.0 | 0.664 |
Regular checkups | 77 | 81.9 | 66 | 70.2 | 0.090** |
Others | 17 | 18.1 | 15 | 16.0 | 0.832 |
| |||||
Perceived risk of getting diabetes | |||||
| |||||
How likely do you think you are to get diabetes? | |||||
Unlikely | 17 | 18.1 | 15 | 17.9 | 0.069** |
Likely | 28 | 29.8 | 46 | 54.8 | |
Not sure | 38 | 40.4 | 23 | 27.4 | |
Why do you think you are at risk of developing diabetes? | |||||
Overweight | 56 | 59.6 | 68 | 72.3 |
|
Family member with diabetes | 55 | 58.5 | 67 | 71.3 |
|
High blood pressure | 36 | 38.3 | 46 | 48.9 | 0.154 |
High cholesterol | 43 | 45.7 | 61 | 64.9 |
|
Doing little exercise | 51 | 54.3 | 57 | 60.6 | 0.451 |
Eating fatty food | 38 | 40.4 | 46 | 48.9 | 0.256 |
Being under stress | 53 | 56.4 | 64 | 68.1 | 0.108 |
Smoking | 27 | 28.7 | 48 | 51.1 |
|
Others | 8 | 8.5 | 11 | 11.8 | 0.629 |
*Significant
**Borderline significance (
The group education intervention program based on the training manual.
Topic | Title | Time/min. |
---|---|---|
Session 1 | ||
| ||
(1) | Welcome and introduction | 20 |
(2) | Program outline | 5 |
(3) | Prediabetes talk | 25 |
(4) | Benefits of healthy lifestyle | 10 |
(5) | Weight management | 25 |
(6) | Reducing fats and sugars | 25 |
(7) | Pedometer | 5 |
(8) | Quiz A | 5 |
| ||
Session 2 | ||
| ||
(9) | Exercise session | 10 |
(10) | Review homework from previous week | 10 |
(11) | Physical activity | 30 |
(12) | Healthy eating | 30 |
(13) | Self care | 10 |
(14) | Stress management | 10 |
(15) | Quiz B | 5 |
(16) | Bringing it altogether | 15 |
| ||
Education tools | ||
| ||
(i) Electronic weight scale and tape measure | ||
(ii) Poster: the Australian guide to healthy eating for display | ||
(iii) Food basket for display | ||
(iv) Pedometer | ||
(v) Oil spray | ||
(vi) Sugar poster | ||
(vii) Drink bottles containing sugar | ||
(viii) Picture booklet: foods and exercise | ||
(ix) Butchers’ paper, bulldog clips, blue tack |
An understanding of the preventable nature of diabetes improved after the program from 70% to 80% (
79.6% of participants modified their lifestyle (increased exercise and modifying their eating habits) as a result of intervention. Average time spent in walking increased significantly postintervention (
Self-reported lifestyle change postintervention as reported by subjects attending peer-supported self-management diabetes prevention program for Turkish- and Arabic-speaking communities of Australia (
Upon completion of the program, participants were asked to rate the effectiveness of peer-supported small group sessions in providing diabetes prevention on a scale from 1 (not effective at all) to 10 (very effective). The majority (68.2%) of participants (
The results of this study show that a limited intervention administered by trained lay bilingual peers equipped with culturally tailored educational resources in the native language was associated with significant and lasting (three months) improvement in anthropometric measurements, knowledge, and attitudes to diabetes prevention. The outcome was an increase in exercise as well as significant modification of shopping, cooking, and eating habits by a significant majority of the participants. These findings are consistent with a similar study of community-based, peer-supported diabetes self-management program for Spanish-speaking people [
A positive aspect of our program is the significant reduction in participant’s weight and waist circumference after only four hours of intervention. Whether greater outcomes could be achieved by longer intervention remains to be clarified. Factors significantly related to this reduction were not identified in this study. The self-reported changes in behaviour were liable to bias. Similarly the measurements of weight and waist circumference were also prone to bias because it was conducted by the peer leaders; they would have been more valid if measured by independent assessors.
The success of our program is consistent with the conclusion of the most recent systematic review of 11 RCTs of culturally tailored diabetes education programs for ethnic minorities with type 2 diabetes living in developed countries that identified “culturally tailored health education” as more effective than “usual care” in improving blood sugar control and knowledge of diabetes [
This study is based on self-reporting of changes in behavior; thus it is prone to bias. However, changes in weight were recorded from self-reports as well as objective weighing of participants by peer leaders and were therefore less prone to bias. Similarly changes in waist circumference were measured by peer leaders. A possible overestimation of the intervention effectiveness may be due to some characteristics of the sample such as voluntary participation, gender (mainly females), and frequent GP visits. The education program was of three months duration, and it is possible that the observed changes may not be sustainable. On the other hand, a longer program may yield more impressive results. The encouraging results obtained by our group should be confirmed by a larger controlled study, and replication of the study in other ethnic groups should be encouraged.
A short-term, cost-effective diabetes prevention program comprising of two 2-hour group education sessions supported by lay bilingual peers and reinforced with telephone reminders was successful in changing lifestyle behaviour and reducing weight and waist circumference. Sustainable changes may be achieved by trained peers employed by community health services.
All authors declare no conflict of interests in relation to the research project, which was funded by Diabetes Australia Research Fund.
The authors thank Jeanette Hourani for managing the project and John Furler Department of General Practice, and Rhonda Petschel Dianella Community Health, for their active participation in preparing the education program and training peers. They also thank Sue Hunt Diabetes Australia Victoria, Marnie Graco One Step Ahead project and Debra O’Connor Dianella CHS for their contributions in the initial stage of the project. The authors are grateful to Professor James Dunbar for his valuable input during the project and for editing the paper. They thank Professor Hatem Salem and Ahmad Sulaiman for editing the paper. The authors are also grateful to the TFA Technology Hong Kong Limited for donating all the pedometers used in the project and to Diabetes Australia Research Trust for funding the project. The project was funded by Diabetes Australia Research Trust (DART), 2004.