Feasibility of Diabetes Prevention in Arab Americans: Final Focus Group Report

FEASIBILITY OF DIABETES PREVENTION IN ARAB AMERICANS

National Diabetes and Digestive and Kidney Diseases Advisory Council

PI: Linda A. Jaber, Pharm.D. Associate Professor ‐ Pharmacy Practice ‐ Wayne State University NIH Grant # 1‐R34‐DK076663‐01A1

R I S K AWAR EN E S S , B A R R I E R S TO P A R T I C I P A T I ON , AND F E A S I B I L I T Y OF I N T E R V EN T I ON :

Focus Group Analysis Report

Prepared by

Stephen J. Sills, PhD Assistant Professor of Sociology

University of North Carolina at Greensboro 320 Graham Building

Greensboro, NC 27402‐6170 Phone 336.792.1191• Fax 336.334.5283

March ∙ 2010

D I A B E T E S P R E V E N T I O N I N A R A B A M E R I C A N S

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Table of Contents TABLE OF CONTENTS.................................................................................................................................................. I

TABLES..................................................................................................................................................................... III

FIGURES................................................................................................................................................................... III

BACKGROUND .......................................................................................................................................................... 1

ARAB AMERICANS IN THE DETROIT METROPOLITAN AREA ..............................................................................................................1 FOCUS GROUPS IN DIABETES HEALTH RESEARCH ..........................................................................................................................2

PILOT STUDY............................................................................................................................................................. 3

PROCEDURES .........................................................................................................................................................................4 RESULTS ...............................................................................................................................................................................6 Turn‐Taking ....................................................................................................................................................................6 Verbosity ........................................................................................................................................................................7 Self‐Disclosure ................................................................................................................................................................7

SEPARATE INTERVENTIONS BY SEX..............................................................................................................................................8 PILOT TESTING CONCLUSIONS ...................................................................................................................................................9

INTERVENTION FOCUS GROUPS .............................................................................................................................. 10

PURPOSE OF THE FOCUS GROUPS IN THIS STUDY ........................................................................................................................10 PROCEDURES .......................................................................................................................................................................10 CHARACTERISTICS OF THE PARTICIPANTS ...................................................................................................................................11 GROUP CHARACTERISTICS ......................................................................................................................................................11 Pre‐intervention Groups ...............................................................................................................................................11 Education Conversion Groups.......................................................................................................................................12 Refusal to Participate Groups.......................................................................................................................................12 Post‐Ramadan Group ...................................................................................................................................................13 Lifestyle Completer Groups ..........................................................................................................................................13

POST SESSION EXIT SURVEYS ..................................................................................................................................................13

DIABETES KNOWLEDGE AND HEALTH BELIEFS.......................................................................................................... 15

WHAT IS DIABETES? .............................................................................................................................................................15 Symptoms.....................................................................................................................................................................15 Blood Sugar ..................................................................................................................................................................16 Types of Diabetes .........................................................................................................................................................16 Genetic Predisposition..................................................................................................................................................17 Lifestyle ........................................................................................................................................................................17

ACCULTURATIVE STRESS AS A FACTOR.......................................................................................................................................18 PREVALENCE........................................................................................................................................................................18 RISK PERCEPTION .................................................................................................................................................................19 COMMUNITY AWARENESS......................................................................................................................................................19 DIABETES PREVENTION AND TREATMENT ..................................................................................................................................19 MYTHS...............................................................................................................................................................................20 Herbal Remedies...........................................................................................................................................................21 Stigma ..........................................................................................................................................................................21

BARRIERS TO CARE ...............................................................................................................................................................22

REASONS FOR PARTICIPATION IN INTERVENTION.................................................................................................... 22

FEAR OF THE RISK OF DIABETES FOR SELF OR FAMILY ...................................................................................................................23


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CONVERSION FROM THE EDUCATION PROGRAM.........................................................................................................................23 OTHER REASONS ..................................................................................................................................................................23

BARRIERS TO PARTICIPATION IN INTERVENTION ..................................................................................................... 24

ISSUES WITH TIME OR SCHEDULING..........................................................................................................................................24 MIXED‐SEX GROUPS .............................................................................................................................................................25

EDUCATIONAL INTERVENTION FEEDBACK................................................................................................................ 25

SUGGESTIONS FOR IMPROVEMENT...........................................................................................................................................27 REASONS TO CONTINUE IN THE LIFESTYLE PROGRAM...................................................................................................................28

LIFESTYLE INTERVENTION FEEDBACK....................................................................................................................... 29

FEEDBACK SURVEY................................................................................................................................................................29 FOCUS GROUP FEEDBACK ......................................................................................................................................................30 Encouragement ............................................................................................................................................................30 Learning How to Count Calories and Shop ...................................................................................................................31 Accomplishing Personal Goals......................................................................................................................................32 Additional Health Benefits............................................................................................................................................33 Impact on Family and Beyond ......................................................................................................................................33

SUGGESTIONS FOR IMPROVEMENTS .........................................................................................................................................34 More Dynamic Content ................................................................................................................................................34 Additional Health Experts.............................................................................................................................................35 Cooking Classes ............................................................................................................................................................35 More Time for Exercise.................................................................................................................................................35 Calorie Count for Arab Foods .......................................................................................................................................36 More Training on How to Teach Others .......................................................................................................................36 Better Cultural Fit of the Intervention ..........................................................................................................................37

CONCLUSIONS AND RECOMMENDATIONS............................................................................................................... 40

KEY FACTORS WHICH INFLUENCED PARTICIPATION .......................................................................................................................40 BARRIERS TO PARTICIPATION...................................................................................................................................................41 OVERALL PROGRAM FEEDBACK ...............................................................................................................................................41

REFERENCES............................................................................................................................................................ 43

APPENDIX A PROJECT DELIVERABLES....................................................................................................................... 45

APPENDIX B TRANSCRIPT CONCORDANCE ............................................................................................................... 47


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Tables Table 1 ‐ Select Post‐Focus Group Survey Measures.......................................................... 8 Table 2 ‐ Focus Group Scripts ........................................................................................... 10 Table 3 ‐ Post Session Exit Survey Summary Table........................................................... 14 Table 4 ‐ Feedback Survey Summary Table ...................................................................... 29 Table 5 ‐ Concordance of Scripts, Filenames, Group Descriptions, and Project Goals .... 48

Figures Figure 1: Age Distribution of Focus Group Participants ................................................... 11


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Background This analysis of focus group data was completed per the request of Dr. Linda A. Jaber, Principal

Investigator of the Feasibility of Diabetes Prevention in Arab Americans project (NIH R34 Grant #

1‐R34‐DK076663‐01A1). The focus group protocol was designed by Dr. Stephen J. Sills at the University

of North Carolina Greensboro and based on the project proposal submitted to the National Diabetes and

Digestive and Kidney Diseases Advisory Council in 2007. The goal of the focus groups, as stated in the

NIH proposal, was to “identify barriers to participation in a diabetes prevention program and to

demonstrate the feasibility of recruitment and retention by pilot testing a community‐based, culturally

specific diabetes prevention intervention.” In particular, focus groups sought information from

participants that would help in refining the Lifestyle Intervention Program and its complementary

educational intervention for diabetes prevention among Arab Americans.

Arab Americans in the Detroit Metropolitan Area

Arab immigrants have been settling in the United States since the late nineteenth century. According to

the United States Census Bureau estimates for 2008, there were about 1.6 million individuals who claim

Arab ancestry in the US (U.S. Census Bureau, 2008). However, it is recognized that this figure is

inaccurate and well below the actual total. According to the Arab American Institute the true figure of

those who have Arab ancestry is at least 3.5 million (Arab American Institute 2009a). Arab Americans,

both foreign‐born and their descendents, are a steadily growing population in the United States.

Between 1990 and 2000 this population grew by 38% (de la Cruz and Brittingham 2003). While

temporary visitors from the Middle East have dropped in recent years, the number of individuals

permanently immigrating from Arabic‐speaking countries has remained constant post 2001 (Kayyali

2006).

Michigan is home to the largest Arab population in the United States and the second highest

concentration of Arabs outside of the Middle East. The Arab‐American community represents the third

largest minority population in Michigan. About 400,000 Arab Americans live in the Detroit Metropolitan

Area (Arab American Institute 2009b). A previous cross‐sectional, population‐based study of Arab

Americans of Dearborn, Michigan found that the community is largely homogenous with striking


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uniformity in cultural identity based on commonality of the spoken Arabic language, the Muslim faith,

and adherence to traditional values and practices. Most (95%) were immigrants with a mean length of

stay in the US of only 11 years. The majority were Lebanese (65%) followed by Yemenis and Iraqis. A

large proportion came from rural areas of the Middle East. Approximately 69% of men and 49% of

women had completed high school education. About 80% of men were employed, compared to 19% of

women. Acculturation, measured by multiple factors including age at immigration, language proficiency

and preference, friends’ ancestry, and socioeconomic status, was low in men and women (Jaber, Brown,

Hammad, Nowak, Zhu, Ghafoor, and Herman 2003; Jaber, Brown, Hammad, Zhu, and Herman 2003).

Focus Groups in Diabetes Health Research

The focus group, or group interview, is a common methodology that has been used as a means of data

collection in the social sciences for at least a century. Focus groups gained popularity in the 1930s and

40s with Robert K. Merton who used them as a tool for gauging reactions to wartime propaganda

materials (Morgan, 1988; Hollander 2004). Since then, the methodology has been employed in a wide

variety of research settings that call for a deep understanding of a groups’ perspective on a particular

issue. It is through the synergistic, collaborative, and interactive atmosphere of the focus group that

participants are influenced to express many ideas that may have been more difficult to express

individually (Morgan, 1988).

There are many advantages to using focus groups in health‐related research as they provide an effective

method for assessing needs, identifying barriers, framing appropriate health messages, and designing

relevant strategies for outreach (Garfield, Malozowski, Chin, Narayan,Glasgow, Green, Hiss, and

Krumholz 2003). Vincent, Clark, Zimmer, and Sanchez (2006) note that focus groups are an “efficient

method of obtaining information about an underserved population’s experience” (96). Focus groups

produce more in‐depth information than quantitative research methods, yet the value of focus group

research is largely dependent on how well the focus groups are designed and executed and how

carefully the data are collected and analyzed.

Focus groups have often been used when conducting research in ethnic or immigrant communities

especially when developing culturally tailored interventions or instruments (Willgerodt 2003; Rice,

Weglicki, Templin, Hammad, Jamil, & Kulwicki 2003). Health‐related focus group studies in the Arab‐


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American community have included investigations of tobacco use among adolescents (Rice et al 2003),

elders' views about health and social support (Ajrouch 2005), cultural considerations for mental health

counseling (Nassar‐McMillan and Hakim‐Larson 2003), ways in which to enhance health services

(Kulwicki, Miller, and Schim 2000), and on the importance of culturally and linguistically appropriate

health interventions (Shah, Ayash, Pharaon, and Gany 2008).

Investigators have used focus groups to explore diabetes care and behavior change issues among various

cultural groups. Past research has demonstrated the effectiveness of the focus group technique in

identifying important health beliefs and nutrition practices of urban Caribbean Latinos and Native

Americans with diabetes (Quatromoni, Milbauer, Posner, Carballeira, Brunt, Chipkin 1994; Hosey 1993).

They have also been used to identify diabetes care issues for urban African Americans (Anderson,

Satterfield, German, and Anderson, 1996) and Latinos with diabetes (Anderson, Goddard, Garcia,

Guzman, and Vazquez 1998). They are especially useful in studying the cultural, psychosocial, and

contextual influences on self‐care practices relevant to diabetes prevention (Anderson, 2001). Focus

groups can help identify culturally specific health beliefs and which health beliefs are amenable to

change.

Pilot Study Focus groups, though commonly used in health research and quite useful in developing culturally

appropriate interventions, may also present “methodological challenges” (Peek and Fothergill 2009). The

focus group is a social interaction in which customs and normative behaviors of a society may be

reenacted, limiting voice of some within the group. Smithson (2000), notes that some individuals tend to

dominate the discourse in the focus group setting resulting in the silencing of others. Hollander (2004) in

fact says that focus groups are less a methodology and more the site of social process that is being

observed by the facilitator. Hollander (2004) advises researchers to consider the social context of the

focus groups asking:

Who has status or power in the situation? Who speaks first in the discussion? What kinds of thoughts, feelings, or experiences might be expected in the context, and what kinds might not be expected? Are these expectations the same for all participants? What are the


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consequences (both immediate and long term) for individual participants of disclosing sensitive information? What are the potential rewards for conformity or nondisclosure? (627)

The achieved and ascribed statuses of focus group participants may determine the amount of power and

voice one has in the interaction (Peek and Fothergill 2009). The sex of the speaker (or their gender

identity) may play a significant role, in particular when discussing gendered issues. As Morgan notes,

"group interaction requires mutual self‐disclosure, it is undeniable that some topics will be unacceptable

for discussion among some categories of research participants" (1996:140).

Some methodologists recommend segmentation of focus groups (separation on the basis of gender or

other attributes) as a solution to power imbalances or in the case of sensitive topics (Goldman and

McDonald 1987; Morgan 1996). Yet, as Bristol points out, “evidence in support of the gender

assumption is nonexistent” (1999:479). Hollander also notes that segmentation does not necessarily

lead to more disclosure though it may make some participants feel more comfortable (Hollander 2004).

In the case of research with Arab‐Americans though, many researchers have chosen to segment their

groups. While most researchers do not explain their rationale for gender segmentation, Peek and

Fothergill (2009) elaborate on how they decided to segment Arab women from men:

Some of the groups said it would be easier to meet as a mixed male‐female group, while others requested that the interview be conducted with an all‐female or all‐male group. One student told Peek over the telephone that she did not think the Muslim women would be comfortable talking about some of the issues they had faced in front of their male counterparts. Thus, Peek segmented the groups according to sex in part at the request of the students, but she tried to conduct all‐female or all‐male groups if possible because it became apparent that the students in the sex‐segregated groups seemed more comfortable and talked more openly about sensitive topics. (39‐40)

Procedures

During the pilot phase of the project, a series of tests were conducted to determine the degree of

“silencing”, or lack of self‐disclosure, that may occur in mixed‐sex, focus group sessions. Based on our

understanding of gendered roles and behaviors in the Arab‐American community, we contemplated that

in some instances women may feel less likely to disclose health information, health beliefs, or provide


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candied feedback when men would be present. We also examined if participants felt strong preferences

for delivery of the intervention and educational components of the project in single‐sex or mixed‐sex

settings. Thus, we devised a test in which focus groups were conducted with participants in three

conditions: a male‐only group, female‐only group, and a mixed‐sexed group. The content of the pilot

script dealt primarily with diabetes awareness, perceptions of risk, diabetes health beliefs, and perceived

barriers to health care.

A total of three pilot focus groups were conducted. The groups ranged from eight to twelve participants

and from 90 minutes to 115 minutes in duration. The test compared the volume of linguistic output and

the number of turns taken by each sex in male‐only, female‐only, and mixed‐sex focus groups.

Participants were randomly assigned to a male‐only, female‐only, or mixed group. Most indicated having

families in the USA (19 of 29 mentioned family in the warm‐up). The majority of the women indicated

that they were homemakers (12 of 18). Of those who indicated that they work working outside of the

home, nine were in professional occupations (teachers, engineers, etc.), two were in business, and one

was in a service occupation.

Focus groups were digitally recorded, transcribed, and then translated into English. Qualitative analysis

was performed using MAXqda2 software. The analysis included the generation of thematic codes and

subcodes grounded in the participant’s discourse. Content analysis was also performed using MAXDictio.

All text was coded as being generated by males or females. Character, word, line, and paragraph counts

were made as well as the number of turns per individual. Averages were computed per person per

minute.

In addition, post‐focus group surveys were administered to explore issues of self‐disclosure and to assess

issues with silencing, comfort, and willingness to participate in future focus groups. This strategy has

been a common technique for comparing individual level data to that produced in the group. For

example, Corfman (as cited in Bristol 1999) employed pre‐and post surveys to “gather information on

member characteristics and reactions to the group” (479). The survey also collected demographic

information. Survey responses were coded and entered into a spreadsheet. Simple descriptive and

bivariate analysis was conducted with the survey data using SPSS.


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Results

The primary goal of the series of pilot focus groups was to determine the degree of silencing that may

occur in mixed‐sex Arab focus groups as a result of perceived male dominance. The pilot focus group

design was meant to create a test with male‐only and female‐only control groups and a mixed‐sex

experimental group. However, several complications affected the research design. First, the groups were

not of equal size (one group of 12, one of 8, and one of 9 members), thus the measure (amount of text in

turns, lines, or words) was averaged by the number of group members. Second, the focus groups were

not of the same duration (the women‐only group lasting for 1 hour and 45 minutes, the men‐only for 1

hour and 30 minutes, and the mixed group for 1 hour and 40 minutes). The mixed group was also

imbalanced, with only three males and six females. Finally, at one point about three‐quarters of the way

into the discussion in the experimental mixed group, the facilitator may have biased the outcome by

interjecting that the men were not talking very much:

Facilitator‐ (talking to men) You thought that women are reluctant to speak when men are present… well in this session, women are talking more than you

FG3‐Man3‐ (Smiling) Good

FG3‐Man1‐ Because we are outnumbered

FG3‐Woman2‐ No no it is not about numbers. Women can express themselves freely in front of men.

FG3‐Man1‐ Excuse me I am just joking.

ALL LAUGHING

None‐the‐less, two separate approaches to discourse analysis were performed to compare males and

females and the amount of text produced by each: one looking at turn taking, the other at the amount

of text or utterances produced (verbosity). By all measures, men were found to speak more than women

in all conditions.

Turn‐Taking

On average men took 30 turns in the male‐only group compared to 23 turns for women in the female‐

only group. Men in the mixed group took 41 turns, while women took only 20. Thus, in the mixed group,


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where men were the minority, they spoke more than twice as often as women. Individual analysis shows

that several participants dominated the conversations in their respective focus groups; particularly Man7

in the men‐only group; and Man 3 in the mixed group. Women’s turn taking was more equitably

distributed, though some women clearly took fewer turns than others (see for example Woman 10 and

12 in the female‐only group, and Woman 6 in mixed‐sex group.

Verbosity

Utterances could be measured by the number of words, characters, paragraphs, or lines produced by a

speaker. This quantifies the amount of language an individual contributed to the transcription. A rate can

also be computed based on the average number of words generated per individual per minute (See

Table 3). Using this approach we see that men in both the men‐only as well as the mixed group

produced more utterances. In particular, men in the Mixed group contributed twice as much text to the

transcripts given that were half as many of them. Women’s utterances were, however, consistent in

both the mixed group and the women‐only group.

Self‐Disclosure

It is difficult for a focus group moderator to really tell if someone is holding back information. Often, if

the moderator focuses in on one person alone, the dynamic atmosphere of a focus group will be lost.

We determined that a brief post‐focus group survey would be most helpful in determining if there was

information that was not disclosed during the focus group. Analysis of the post‐test survey shows that

women were more likely to agree with the statement “I had things to say which I kept to myself” than

men (47.0 percent of women compared with 37.5 percent of men). Women were more likely to agree

with the statements “I could have said more than I did” (55.6 percent of women compared with 50.0

percent of men), “I felt awkward sharing in front of the group” (27.8 percent of women compared with

10.0 percent of men) and “I feel more comfortable in same‐sex groups” (64.7 percent of women

compared with 45.5 percent of men). Yet males were more likely to agree with the statement that “I felt

others dominated the discussion” (31.1 percent of women compared with 36.4 percent of men).


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Table 1 ‐ Select Post‐Focus Group Survey Measures

Percent Agree or Strongly Agree

Question F M I had things to say which I kept to myself 47.0 37.5 I could have said more than I did 55.6 50.0 I felt awkward sharing in front of the group 27.8 10.0 I felt others dominated the discussion 31.3 36.4 I feel more comfortable in same‐sex groups 64.7 45.5

Within the mixed group, all three men disagreed with the statement “I had things to say which I kept to

myself,” while three of the six women agreed. Similarly, all of the men disagreed with the statement “I

felt awkward sharing in front of the group” while the same three women agreed. Four of the six women

agreed that “there were uncomfortable moments during the focus group,” while none of the men

agreed. Finally, all three men in the mixed group were neutral on the issue of feeling more comfortable

in same‐sex groups; however, three of the six women strongly agreed that they would be more

comfortable in same‐sex groups.

Separate Interventions by Sex

About a quarter of the participants expressed a clear preference for same‐sex intervention and

education groups. A little more than half of the men in the male‐only group (5 of 8), and two of the

women in the women‐only group seemed to prefer a separation of the sexes for informational sessions.

As one women noted; “possibly we can express ourselves more freely in women session.” Most of the

remaining 29 participants seemed to agree that mixed‐sex groups were acceptable. A male participant in

the mixed group notes, “You should define the community you will deliver the speech to. As an example

in the ICD, we have mixed gender lectures where men and women are seated separately, but in the

same place, where they listen to the same lecture at the same time. However, there are separate

lectures for women only on Wednesdays at 1:00 PM that deals with topics important to women, so it

depends on the place and topic.”

Part of the Lifestyles Intervention Program includes consultation and courses on healthy food

preparations. There was a general consensus that cooking was the “women’s realm” and that many men


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“would not be interested” in attending a course on healthy food preparation. One female participant

commented, “It is a part of the Arabic culture that men are not interested in cooking.” However, another

female participant also observed, “When men attend these sessions, they will communicate with us

better, listen and accept the meals we cook... I think you should invite women and their husbands.” Yet,

this also presented a problem for childcare. One father said, “In my case [only] one of us could attend

because of the children.”

There was an agreement among participants regarding same‐sex versus mixed‐sex exercise classes.

Most felt that separate classes should be offered. The only exception was in walking groups. While there

was debate over who walked faster, men or women, there was agreement that this activity was not

gendered and that mixed groups were fine: “Walking in groups around the neighborhood is encouraging

and supportive. It can be done in group with family, or friends, certainly.” On the other hand, anything

that involved “physical activities that require bending or movements,” were considered to be best

practiced separately.

Pilot Testing Conclusions

By all measures, Arab‐American men were found to take more turns and to speak with more verbosity

than Arab‐American women. Speech in groups with men (male only and mixed sex), tended to be

dominated by a few speakers, while the female group was more equitable in the turn‐taking and

amount of discourse per participant. Women were more reluctant to share in general, yet the male

domination of the mixed‐sex group made the discussion even more awkward for the women and limited

their responses. Thus, the reluctance to self‐disclose in mixed‐sex groups may result in loss of important

information as women were more likely to talk less, more likely to feel awkward, and more likely to keep

information to themselves. Moreover, they indicate preference for same‐sex groups.

These finding have direct implications for future studies with Arab‐American populations using focus

group methods as well as for interventions that include male and female participants. It was clear from

the focus group participants that separate or segmented focus group sessions would work best so as not

to alienate a significant proportion of the Arab‐American community. The findings provide empirical

evidence for the current practices of many qualitative researchers in the Arab‐American community who

already gender‐segment their focus groups.


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Intervention Focus Groups Purpose of the Focus Groups in this Study

There were three major objectives of the focus groups: 1) to understand what social, cultural, and

individual factors influence those who choose to participate in the lifestyle intervention; 2) to identify

what elements of the educational training promote willing participation in the lifestyle intervention; and

3) identify the barriers for those declining to participate in the lifestyle intervention. Focus groups were

also used to evaluate the outcomes of the lifestyle intervention. Seven scripts were developed to

coincide with each of the study conditions and goals (see Table 2).

Procedures

Participants met in the clinic conference room at the Arab Community Center from Economic and Social

Services (ACCESS), a well‐established and well respected health and social service agency that serves

primarily Arab‐Americans in Dearborn, Michigan. Groups were facilitated by an Arabic‐speaking

moderator. Up to two additional staff members were present acting as note‐takers and operating the

recording equipment. The sessions were digitally recorded, transcribed, and then translated into English

by professional translators. The Principal Investigator then reviewed the transcripts for accuracy before

forwarding them for analysis. Exit surveys were administered following the focus group sessions to

gauge the level of comfort, the degree of self‐disclosure, and other issues regarding group dynamics.

Qualitative analysis of the transcripts was performed by the consultant using a grounded approach. The

analysis included the generation of thematic codes and sub‐codes rooted in the participant’s discourse.

Univariate and bivariate descriptive analysis of the surveys was conducted with SPSS 17.

Table 2 ‐ Goals of Focus Group

Script Cohorts Goal

Script FG1 Pre‐intervention focus group with willing participants Identify reasons for decision to participate Script FG2 Focus groups with unwilling participants Identify barriers to participation Script FG3 Post‐education focus groups with those willing to

proceed with intervention Identify reasons for decision to participate in education and intervention

Script FG4 Focus group with post‐education yet unwilling to proceed to intervention

Identify barriers to participation

Script FG5 Evaluation focus groups with intervention completers Evaluate Program Script FG6 Evaluation focus groups with intervention non‐

completers Evaluate Program and determine reasons for leaving program

Ramadan Post‐education focus groups with current intervention participants

Gauge adherence to lifestyle program during cultural/religious holidays


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Figure 1: Age Distribution of Focus Group Participants

Characteristics of the Participants

Based on exit surveys 65% of participants were female and 35% male. Lebanese participants comprised

the majority (72%); a slightly greater proportion than presented than in the Detroit MSA data reported

earlier. Iraqis were the next largest group (15% of participants), followed by Yemenis (6%). The

remaining 7% included participants from Egypt, Jordan, Kuwait, Sierra Leone, Syria, and the United

States. The average age of participants was 49 years (mean) with a range from 31 years old to 82 years

old (see Figure 1).

Group Characteristics

Including the three pilot groups, a total of seventeen focus groups were conducted between November

2007 and April of 2009 (See Appendix C for a concordance of transcripts, scripts, file names, and stage of

project). The groups ranged from six to fourteen participants.

Pre‐intervention Groups

Three focus groups were conducted in the pre‐intervention stage with participants willing to begin the

Lifestyle Intervention Program (labeled as "Lifestyle Accept"). The goal of these focus groups was to

identify the reasons for participation in the intervention. The first group met on March 20, 2008. All

seven participants were female and from Lebanon. They identified principally as mothers and


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housewives and were between the ages of thirty‐three and fifty‐two. All but one spoke Arabic in the

home. The second group also met on March 20, 2008 with seven participants ‐ six male and one female

of whom five were Lebanese, one Iraqi, and one Yemeni. No other background information was

collected for the second group. The third group met on October 30, 2008 with fourteen participants;

four men and ten women. The group was divided between Lebanese (6) and Iraqis (4), with one

Jordanian and three others who did not report their nationality. They had been in the United States

between six and thirty‐three years. This group included a mix of stay‐at‐home mothers, skilled

professionals, business owners, and a student.

Education Conversion Groups

There were three focus groups with participants willing to continue to the Lifestyle Intervention Program

after they completed a series of education sessions (labeled as “Education Conversion”). The goal of

these focus groups was to identify the reasons for their decision to participate in the education sessions

and continue to the intervention. Feedback regarding the efficacy of the educational program was also

discussed. The first group met on May 16, 2008. All but one of the nine participants was from Lebanon.

Three of the nine were males. The second group met on June 20, 2008 with six participants. No

demographic information was recorded for this group. The last group met on August 12, 2008 with ten

participants: seven female, three male. The majority of the group members were again from Lebanon,

with one participant from Iraq and another from Syria.

Refusal to Participate Groups

Three focus groups were conducted with individuals who declined participation in the intervention

program (labeled as “Refusal to Participate”). The goal of these focus groups was to identify the reasons

for refusal. The first group was held on June 20, 2008 and included six participants (four males and two

females). Four of these participants were from Lebanon, one was Syrian, and the other Iraqi. All of the

members in this group had attended educational sessions, but declined further participation. On June

27, 2008, another group was held with six participants (three male and three female). Five were from

Lebanon and the sixth was Egyptian. None had participated in the educational sessions. The last group

was held on July 1, 2008 with four females and one male. Five of the groups were Lebanese and the

other was Yemeni. One participant spoke English only.


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Post‐Ramadan Group

Nine participants (four male and five female) were present for the Post‐Ramadan group to gauge their

adherence to Lifestyle Intervention program during this cultural and religious holiday. In particular, the

discussion explored their traditional and customary observance of Ramadan and how they may have

altered these practices as a result of the program.

Lifestyle Completer Groups

Four focus groups were conducted between August of 2008 and April of 2009 with participants who had

completed the Lifestyle Intervention program. The goal of these focus groups was to provide formative

feedback on the program. Participants discussed the things they liked about the program as well as areas

for improvement. Groups varied from 9 to 12 participants. No additional background information was

collected as these individuals were previous attendees of Pre‐Intervention or Educational Conversion

groups.

Post Session Exit Surveys

Following each of the focus groups a post‐session survey was completed by the participants. This was

the same survey as found in the Pilot Focus group sessions. The survey explored the participant’s

comfort level in the group setting, group dynamics, and degree of self‐disclosure.

Complete surveys results are presented by sex in Table 3 on the following page. Overall participants

were comfortable sharing with the groups (88.3% strongly agreed), felt free to express their opinions

(87.5% strongly agreed), and felt that others were open to what they had to say (69.6% strongly agreed).

Some participants did report withholding information. For example, 28.8% agreed or strongly agreed

that they had things to say which they kept to themselves and 37.1% agreed or strongly agreed that they

could have said more than they did. A few (15.7% agreed or strongly agreed) felt awkward sharing in

from of the group while more (21.2% agreed or strongly agreed) felt that others in the group dominated

the discussions. Similarly, a few (13.1% agreed or strongly agreed) felt that there were uncomfortable

moments during the focus group session. Group size was not a major issue as only 9.6% agreed or

strongly agreed that there were too many people in the group. About a third (30.6% agreed or strongly

agreed) would have felt more comfortable in same‐sex groups. This figure was higher for females

(33.3%) than for males (25.7%). Most were happy to participate in the project (85.3% strongly agreed)

and reported that they would participate in a future focus group (78.2% strongly agreed).


14

Table 3 ‐ Post Session Exit Survey Summary Table

Strongly Disagree Disagree

Neither Disagree

nor Agree Agree

Strongly Agree

Female 1.3% 0.0% 1.3% 5.1% 92.3%

Male 0.0% 0.0% 0.0% 19.0% 81.0% I was comfortable sharing my perspective in this group setting

Total 0.8% 0.0% 0.8% 10.0% 88.3%

Female 1.3% 0.0% 0.0% 9.0% 89.7%

Male 0.0% 0.0% 0.0% 16.7% 83.3% I felt free to express my own opinions Total 0.8% 0.0% 0.0% 11.7% 87.5%

Female 1.3% 1.3% 0.0% 26.7% 70.7%

Male 0.0% 2.5% 5.0% 25.0% 67.5% I felt others were open to what I had to say Total 0.9% 1.7% 1.7% 26.1% 69.6%

Female 37.7% 23.4% 6.5% 26.0% 6.5%

Male 39.0% 29.3% 9.8% 17.1% 4.9% I had things to say which I kept to myself Total 38.1% 25.4% 7.6% 22.9% 5.9%

Female 30.7% 29.3% 5.3% 18.7% 16.0%

Male 13.2% 31.6% 13.2% 28.9% 13.2% I could have said more than I did Total 24.8% 30.1% 8.0% 22.1% 15.0%

Female 59.2% 21.1% 9.2% 5.3% 5.3%

Male 51.3% 17.9% 5.1% 7.7% 17.9% I felt awkward sharing in front of the group Total 56.5% 20.0% 7.8% 6.1% 9.6%

Female 53.8% 12.8% 6.4% 15.4% 11.5%

Male 50.0% 27.5% 12.5% 5.0% 5.0% I felt others dominated the discussion Total 52.5% 17.8% 8.5% 11.9% 9.3%

Female 65.3% 18.7% 4.0% 5.3% 6.7%

Male 57.5% 12.5% 15.0% 7.5% 7.5% There were uncomfortable moments during the focus group

Total 62.6% 16.5% 7.8% 6.1% 7.0%

Female 56.0% 30.7% 4.0% 6.7% 2.7%

Male 53.8% 28.2% 7.7% 7.7% 2.6% I felt there were too many people in the group

Total 55.3% 29.8% 5.3% 7.0% 2.6%

Female 36.1% 25.0% 5.6% 13.9% 19.4%

Male 46.2% 23.1% 5.1% 15.4% 10.3% I feel more comfortable in same‐sex groups Total 39.6% 24.3% 5.4% 14.4% 16.2%

Female 3.9% 0.0% 0.0% 9.1% 87.0%

Male 0.0% 2.6% 0.0% 15.4% 82.1% I was happy to participate in this research Total 2.6% 0.9% 0.0% 11.2% 85.3%

Female 1.3% 1.3% 2.6% 11.5% 83.3%

Male 2.4% 4.9% 7.3% 17.1% 68.3% I will participate in a future focus group Total 1.7% 2.5% 4.2% 13.4% 78.2%


Diabetes Knowledge and Health Beliefs A series of questions were designed to examine the understanding of diabetes and health beliefs

regarding the disease. Specifically, the participants were asked to explain what they knew about the

disease, its symptomatology, the perceived prevalence in the Arab community, their personal risk for

becoming diabetic, and what they understood of ways to lower risk of becoming diabetic. The questions

were asked during the Pilot, Life‐Style Accept, Life‐Style or Education Refuse, and Education Conversion

groups.

What Is Diabetes?

Participants showed a range of understandings, and misunderstandings, about the disease. Some

admitted no knowledge. For example, one participant said she had no personal experience or exposure

to diabetes and had no relatives who had suffered from the disease. Meanwhile others had many family

members who had been afflicted, serving as motivation for them to learn about it. One participant noted

that the death of a family member was partial motivation for them to be present in the study: "…my

brother died because of Diabetes, but I do not know about Diabetes…. I will tell you honestly, because my

brother died from Diabetes. I did not want to know anything about it. I came so that to learn."

Symptoms

Many participants, however, were fairly accurate in reporting the symptoms of diabetes. One participant

identified the following symptoms: “dryness of the mouth, eyes blurring, using the bathroom a lot to

urinate, they feel thirsty a lot.” Another said, "dryness of the mouth, and urinating a lot, in an abnormal

way. In spite of drinking, as if the person has not drank. These are the symptoms. Dizziness. Fatigue

happens towards the end. It raises the blood pressure. Perhaps lowers it."

Several members understood these symptoms as a result of personal contact with someone who is

diabetic:

My husband who is diabetic has dry mouth. He has dry skin. His skin splits. He has dry feet. He has blurred vision. During the night, no matter what he eats, he feels hungry. He wants to eat anything, mostly something sweet.


16

Blood Sugar

While participants were generally knowledgeable of the symptoms of diabetes, they did not always

understand its causes. Answers touched on many of the factors associated with increased risk of

diabetes including genetics/family history, stress, high blood pressure, diet, drinking alcohol, lack of

exercise, obesity, and age. Many seemed to understand that the disease is related to the pancreas and

that it results in difficulty regulating blood glucose levels. Thus, they also knew that blood sugar

imbalances are related to food and metabolic processes:

The first thing is the way we eat, the quality of food we eat, eating sweet products more than it is necessary. It is the lack of balance in the body between what is necessary food to eat the necessary food and the sweet products that one eats more.

Participants identified that diabetes results from an imbalance of sugars and is related to the secretion of

insulin: “The body may not secrete sufficient insulin.” They were also aware that this imbalance results

from problems with the pancreas: “It is the malfunctioning of pancreas. To be more specific, when

pancreas malfunctions, there will be sugar either in the blood or in the urine.”

Yet, participants attributed diabetes to a number of causes. One participant felt it was due to the over

consumption of sugar: As the sister mentioned:

I used to think that if one ate more sweets would have more energy. I remember when I used to work in a hotel in Amsterdam, Holland, I would put approximately 6, 7, 8 cubes of sugar. Everyday I would increase sugar cubes. A Belgian told me to be careful. In this way, at the end you will become diabetic. I paid attention. I was young that time and I did not know.

Types of Diabetes

Members of the focus groups comprised of individuals who had not attended education sessions were

very unclear about the types of diabetes: “I think there are two types of diabetes. The most known is

sugar in the urine or in the blood.” Another refuser explained: “There are two types; one when the level

of sugar rises and the other when the level of sugar lowers.” Still others were very unclear as to how

many types: Another “There is up to the limit of seven. The seventh type is the most dangerous.”


17

Meanwhile, those who had attended the education sessions correctly identified the two types, as well as

gestational diabetes:

A type for children and a type for adults. For adults, as we said, it is hereditary from third or fourth generation, or it happens from the amount of insulin the liver secretes. Or at the time a baby is born, the mother may have diabetes so the baby is born very big.

A participant in one pre‐intervention group noted that diabetes may develop when a woman is

pregnant. Both groups correctly identified that there were two types of diabetes, but there was

misinterpretation on what the two types were with thinking that they were related to advancement of

the disease: "I think type two is the first stage of Diabetes and type one is the more advanced."

Genetic Predisposition

Participants correctly identified that some people have a genetic predisposition to the disease: "…it is

hereditary. This is more difficult. In case of hereditary, one has to protect oneself more from the normal

person, because he has it in the family." One member of the pre‐intervention focus group explained that

diabetes is inherited from parents: “All I know that some have it through hereditary from parents that

may affect the children. Some people have diabetes from hereditary.”

Lifestyle

The participants clearly recognized that diabetes is in many ways a "preventable" lifestyle disease

making them open to the intervention approach: "I have to care what I should eat, to lessen eating

sweets, fat, and to prevent so as not to have diabetes early on." They also noted that without medication

and modification of lifestyle there would be a long‐term impact on the body: "If one has Diabetes and is

not treated and did not take the right medications, over time, the person will have kidney failure."

Another identified elevated blood pressure and body fat as factors: “Whoever has blood pressure is at

risk for diabetes disease. When a person has other diseases, he is at risk to diabetes disease. Fatness, or

mostly when a person has a large belly is at risk for disease.”


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Acculturative Stress as a Factor

Several participants eluded to their status as immigrants as increasing the risk of diabetes. This was

attributed to a lack of adherence to traditional practices in the homeland as well as a lack of

acculturation to an American way of life. One participant explained:

Since we came to this country [the United States], we have to live a different way of life and in consideration of the American way of life, whether moving by cars, etc. However, over there [in home country], one could walk a long distance. The closeness of life there [in home country], makes you exert an effort. The fats are secreted from the body. Here, it is not so. The Americans controlled this life style. They go to the gym, for example, whether men or women. They know the equation because of lack of activity limited to the office and home. Hence, they go to the gym daily for an hour. We, as Arabs, between parenthesis, we took their disadvantages. Their disadvantage is lack of activity, for example. The advantages and the disadvantages of the Americans. Their disadvantage is lack of activity, for example. We do not go to the gym because we either do not have time or we do not care or each one has a special reason. Our problem, as Arabs in America, we did not live as Americans 100%, nor we kept our Arabic lives; walking, seeing our walking friend, going to the next appointment by walking to a neighbor or to a friend, etc. We neither kept our Arabic life nor did we walk with the Americans.

He went on to add that the economic difficulties that many migrant face today necessitates a longer

working day and perhaps even more stress, and to greater risk of diabetes:

…the reality of the American life is that I have work and have no free time. I do not work 15 hours in my home country. Here, I must work from 12 to 15 hours a day. This cumulative stressful situation causes تراآمات in me sluggishness/laziness خمول. Sluggishness will lead to cholesterol like we just said in this hour.

Prevalence

Participants were asked to estimate the prevalence of diabetes in the community. They felt the

prevalence of the disease was so high that every family was affected: “I think in every home there is one

who is diabetic whether a mother, a father, a child or one of the relatives. I think everyone became aware

of diabetes because they have someone in the family who is diabetic.” Most said that there were many

people they knew with the disease. Participants felt that diabetes was a common ailment in the Arab

world that had recently become more prevalent with changes in diet.


19

The general consensus of those in the pilot focus groups was that the rate was above 50 percent among

Arabs with most respondents estimating in the 60 to 70 percent range. Estimates in other groups ran as

high as 50 percent or more: "half of the people. I think more than half of the people." However,

education sessions seemed to help dispel this myth. A member of a post‐education group placed the

rate at “between 18‐28%” for the Arab community.

Risk Perception

The perception of personal risk for developing diabetes was quite high. Almost all participants felt they

were at risk due to their weight, high blood pressure, heredity, lack of a healthy diet, or lack of exercise.

One female respondent noted that many within her own family were diabetic, causing a fear that she or

her children would become diabetic: "My grandmother died from Diabetes. My uncle died from

Diabetes. My second uncle has Diabetes. My mother, now, has Diabetes. My sister has Diabetes. We do

not have fear from Diabetes. But we have four twins." Nearly all felt that they were at some personal risk

of developing the disease. Most felt this personal risk due to heredity and lifestyle. Only one person out

of the pre‐intervention groups felt she was not a risk for the disease. As she explained: "Because the

world is beautiful and good for us. Its sweetness is more than enough for us. All my family has Diabetes, I

do not have."

Community Awareness

Awareness was also seen as an issue. A member of a post‐education group said that only about half of

the Arab community is aware: “I think that 50% of people know about diabetes and 50% of the people

are ignorant.” They noted that ACCESS has played a significant role in raising awareness:

I come frequently to the center here [Arab Community Center for Economic and Social Services]. I pick up flyers that give information and calls for meetings, seminars to battle against diabetes. Mostly it is at this center. Then, there are clinics that you visit. The very first thing they have put there for you is about diabetes and what must be done.

Diabetes Prevention and Treatment

Participants were well‐versed in ways in which to prevent diabetes, yet indicated that willpower, time,

and other factors limited their attempts to diet and exercise. They listed regular walking and exercise,


20

healthy diet (including reduction of fried foods, portion control, reduction in sweets and carbohydrates,

and fewer “junk foods”), regular checkups, reduction in stressors, and increasing personal knowledge or

awareness. Many participants noted that while they understood that prevention was possible and

necessary, the issue became laziness, time, and/or lack of will power.

Participants in the pre‐intervention focus groups were well aware of many of the lifestyle changes that

could help to prevent or reduce the chances of becoming diabetic. They correctly identified that

prevention was dependent upon exercise and changes in diet. One participant noted: "One must pay

attention about his life style. One must not eat too much sugar. One must watch about everything,

because this disease is very sensitive. The sugar level rises very fast and to lower the level is very difficult."

They also noted that changes to diet and exercise not only reduced the chances of becoming diabetic,

but increased health in general: "Gym helps a lot to fight Diabetes; using the sauna, the steam room and

swimming pool. I did all these at the gym. I used to go for a number of years, 10 years. When I used to go

there I lost weight and felt better." One participant noted that successful treatment of a diabetic

depended upon both lifestyle changes and medication, but that there was no way to "cure" diabetes:

"He must not eat sweets, carbohydrates. He must watch his food. He must go to the doctor and follow

the doctor's instructions. Diabetes does not have a medication that completely treats it."

Members of all three refusal groups were also quite clear that lifestyle changes could help in prevention

or lowering of risks. They discussed diet and exercise, as well as monitoring for signs of diabetes.

Members of the post‐education group also noted that there is no cure: “What we understood from the

seminar that I heard from the doctor that there is no 100% treatment for diabetes.”

Myths

There was a commonly held belief that being upset, anxious, worried, or under stress could cause

diabetes. One participant felt, "90% is one being upset or sad." Others believed that diabetes could result

from an emotional shock or surprise. They gave anecdotes of this kind of occurrence: "… my brother

when he had a shock, he became diabetic." Another member of Pilot noted that, “if one of my sons has

an accident, this will be like ‘volcano eruption’ and I might develop the disease at once.” A member in the

post‐education group correctly refuted the myth that shock or emotional duress causes diabetes: “Being


21

upset does not cause diabetes. Diabetes is how much you store food, how much you eat. It is not that

when a person is upset, he becomes diabetic. It has no connection with diabetes...” However, some in

other groups still held the belief that diabetes was related to emotional trauma: “Diabetes is the result of

shocks. In addition, being upset has an effect. Any person, who experiences a shock and being upset

regarding a loved one, becomes diabetic. This greatly affects a person.” Other myths linked diabetes to

blood‐pressure or cholesterol medications, eating before bedtime, use of sugar substitutes, and sudden

anger or sadness.

Herbal Remedies

Beyond diet, exercise, and medication, another theme emerged from discussions of diabetes

prevention: the use of naturopathic remedies. There were several herbs mentioned, though the

transcriptions of the names of these herbs may not be accurate (please reference original Arabic

transcripts). By name, azagan (also spelled as ataman), and quat [khat] were mentioned. One female

noted that medical doctors in her home country used these herbal remedies: "My mother's sugar level

reached 600. They could not lower the sugar level in the old fashioned way, and the "azaqan" lowered it.

Now, when my mother goes to the female doctor, if the doctor finds it [sugar level] high she tells her go

and drink from it. This is something popular." This remedy was mentioned by several focus group

members as way of not only treating, but preventing diabetes: "Drink every day a glass of "azaqan" you

prevent it in all your life totally. Quat [khat or تاق] was another folk treatment was mentioned not as a

cure, but as a way to lower the sugar level in the blood: "Quat, you know, Quat lowers the level of sugar

in the blood….It lowers a little bit. It is bitter, bitter herbs. Everything that is bitter lowers Diabetes. It does

not cure, but it lowers Diabetes a little bit."

Stigma

There was also recognition that within the Arab‐ American community there is stigma to illness: "they

used to keep secret about the diseases. There are things that could be in the family [hereditary], however,

but they do not tell anyone, especially someone died from something, fearing that someone would know.

They do not tell." This stigma resulting in a reluctance not only to disclose information but to asking

questions about diseases like diabetes: "…here, in our community there is shame. We have shame in our

community to ask."


22

Barriers to Care

The major barrier to health care was lack of health insurance and the high cost of seeing a physician:

“many do not have medical insurance and so cannot see doctors regularly… they pay to see a doctor.”

This lack of insurance causes many to delay care until it is absolutely necessary. A male participant noted

that this problem is especially acute among recent arrivals who are searching for employment: “When

people come from the old country they do not find a job right away or find a job without health

insurance; most companies are now cutting back anyway. All things that relate to health insurance such

as the financial factor, the person does not find job.”

Other barriers discussed included a fear or dislike of doctors or medicine; a lack of awareness;

negligence, laziness, or stubbornness, and transportation issues. Language issues, while acknowledge to

be a concern, were not seen as a true barrier to care. About half of the participants expressed a

preference for co‐ethnic caregivers. It was seen that most routine medical care was the domain of the

wife/mother, yet there was sentiment for shared responsibility between men and women, especially in

making decisions about serious health issues.

Reasons for Participation in Intervention Three Pre‐Intervention sessions were conducted with participants. As stated previously, the goal of

these pre‐intervention focus groups was to identify the reasons for participation in the intervention. Two

principal reasons emerged: (1) to gain more information about the prevention of the disease and (2) to

help the Arab community by spreading accurate information to others. One participant succinctly

underscored the collective nature of the Arab‐American community and that information that an

individual learns will be useful to all:

Honestly, to gain information. The first thing you can give information to a person. Secondly, I will have general information about this disease even though the person did not happen to have this illness. If one is among people, one has knowledge about it or can help someone. You can give simple information that could teach and help someone else. It is not only necessarily you. For that reason….We are all Arabs. We need to encourage each other in order to build our future, our community.


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Fear of the Risk of Diabetes for Self or Family

Fear of the risk of diabetes may have been a motivator many. As noted, most participants in the pre‐

intervention groups felt that their personal risk for eventually becoming diabetic were quite high. About

half of the participants agreed that this fear was a factor for joining in the intervention or educational

sessions: “In fact, my grandmother died from Diabetes and I don't want to take her place. As the saying

says "An ounce of prevention is worth a pound of cure." Another, in a later group, noted: “It was the

danger for me. If one has not improved [in knowledge] or does not have information, he may experience

this disease or other diseases. So, I wanted to increase my knowledge about the dangers of diabetes

disease so as to improve my health.” This concern also extended to the future of their children as well: “I

have children and I am afraid that they may be at risk. I will try as much as possible to teach my children

and protect them from these all.”

Conversion from the Education Program

The Education Program seemed to be an effective method for recruiting individuals who were initially

uncertain about committing to the Intervention. When offered the choice between Lifestyle Program

and Education program, chose to enroll in the Education program as a gateway to understanding the

issues associated with Diabetes. They explained: “When you talked about education, I changed from

Lifestyle to Education. One has to have enough education in order to enroll in Lifestyle.” Similarly others

explained that they were not yet ready to commit to a six‐month program so they signed up for the

Education Program to see if there was a benefit before agreeing to continue: “Thank God, we found that

it was good and now we requested to join the second program because we benefited. It was better not to

start the six months program and stop. Now, we are ready to continue the six months program, if God

willing.”

Other Reasons

One participant noted that the personal appeals and telephone calls from the staff persuaded her to

join: “When you called, you called me more than once for which I thank you. You know, I hesitated

because of the house work and the children. At the end I was convinced by you 100%.” Interestingly, the

offer of incentives played little role in their decision to participate: “They [the gifts] are nice but they are

not the reason that one joins the program.” However, a participant did say that money for gasoline


24

would make a good incentive. “Mutual support” was commonly given as a reason for perseverance in

the program among the converters. Group members said that there were many ways to learn things, but

that working together in a group reinforced their commitment to completing the program. Finally, the

location and timing were simply convenient for some while not for others: “timing was convenient. In

the morning is good.”

Barriers to Participation in Intervention Three focus groups were conducted with those who refused to participate in the Intervention Program.

These groups sought to examine the barriers to participation.

Issues with Time or Scheduling

The major barrier to continued participation in the program was time: “This subject is important. As you

noticed that we care about these subjects and listen. However, we do not have time.” There were a

number of responsibilities that were limiting participation: family and childcare, work, school,

businesses, and one person even mentioned that some people would rather watch television. A

participant tried to explain:

I think it was good for the community; however each one had an excuse. The housewives have children and did not have time. I am at my work. Naturally, during the day I do not have the time. I think there are many people who would like to attend however they do not have time to come and attend. And there are people who may not know about the program or are not receiving information about the program.

Suggestions were made to have several time slots available, preferably with weekend hours or evening

hours: “It is possible if it can be on a Saturday. Some people are off and may be convenient to many

people. Not all people can come during the week because of the work.” Also, as some participants

explained they needed flexibility to attend different time slots each week as their schedules were

variable: “My work does not allow me. My shift does not allow. Sometimes I work from 12 midnight until

10 am. Other days I work from 12 noon until 10 evening. Approximately, every month my schedule is

different.”


25

Mixed‐Sex Groups

Mixed‐sex groups were brought up as another possible barrier specifically for the Yemeni and Iraqi

communities. Some participants felt that the presence of men may prohibit participation by women

from these communities. There was considerable discussion on this topic in one of the groups:

FGRefuser.01: Yes for some people but not the majority. There could be some women who would not like to mix with men; however they are not a big number. Some people are used to come to a public place to take lessons. It does not matter to them if there are men or women; however, some women may not come to class if there are men.

FGRefuser.02: This is not a barrier that a woman sits with men.

FGRefuser.01: I am not saying it is a barrier for all people. I will say that for some people it may.

FGRefuser.02: I know some people. For example you are a man and you are far away from me and them. They listen and I listen. I do not think there is a barrier.

FGRefuser.01: Even at Islamic centers, at mosques, people come. Men come with their wives to pray. They come because of special occasions. I do not think it is a problem. The person is not doing something wrong.

FGRefuser.03: It is not that a person is doing something wrong. I think it is the culture of the Arabs. It’s their culture. We Yemenis, men and women do not mix. Always they are separated.

FGRefuser.02: The Iraqis likewise.

FGRefuser.03: The same thing. We don’t mix men and women.

FGRefuser.04: This is a principle.

FGRefuser.02: We, the Lebanese, no. We mix.

FGRefuser.03: If you did separate classes for women, you might get some.

Educational Intervention Feedback A key element of the education conversion focus groups was to gather feedback regarding the education

sessions. Participants said that they had learned a lot about diabetes in these few sessions and that they


26

had already begun changing their cooking and exercise practices in the home. For example, one

participant notes how she has begun to walk regularly and change the foods she and her family eat:

At the beginning I did not know how much walking helps. How healthy walking is for your body. Now, for example, I have my children, and their health is very well. I did not know how to regulate their food. I did not know how to prepare the food.

Participants noted that the sessions were well paced and were neither “too long nor too short.” One

participant said, “One hour is enough because more than one hour it may become boring.” They agreed

that the time, day of the week, and location of the sessions were convenient. They were happy with the

amount of content that they received, but did not feel overwhelmed. They especially liked that the

seminars were in the form of a discussion more than instruction. There was also general agreement in

the groups that the educational program was appropriately tailored to the Arab community. One person

pointed out that, “there is nothing that conflicts with the community or anything.”

Participants explained that several myths or misbeliefs they held previously had been dispelled by the

information received during the sessions: “There were many things which were somehow unclear. They

were clarified in this program.” For example one participant recounted the new things she had learned:

Prevention by changing food, for example excess fat is not good. How diabetes disease starts with a person. We have to take precautions. If the level of sugar passes 100 or 120 means that the person started becoming diabetic. All these things we did not know about.

Importantly, those in the education program were better able to indicate that diabetes is related to

insulin levels, that the body converts carbohydrates into sugars, that high blood pressure and high

cholesterol are associated with risk, that there are two types of diabetes (correctly identified by their

causes), and that lifestyle changes were an effective way to reduce risk:

We did not know, for example, that the sugar that is stored in the body, hits the pancreas, the liver. We thought that if someone ate sugar/sweets, he has to reduce it because he may become diabetic. We did not know about carbohydrates, fats that pile in the body and is transformed into diabetes in the future.


27

The myth that at single emotional shock or trauma could cause diabetes was also dispelled: “Most of us

(I am one of them) thought that diabetes disease has a relationship with the psychological condition and

being upset.” While the program dispelled myths it also highlighted risk that participants face. One focus

group member said the educational program was “like a stop sign,” telling them to stop and take note of

bad habits.

Suggestions for Improvement

While feedback was positive, there were a few suggestions for improving the educational program.

Several suggestions were made with the goal of helping to improve the program:

One participant felt that among program participants there was too broad a range of educational

backgrounds making it difficult for instruction. She explained: “if you are going to do a program,

the educational level of the participants in a group [needs] to be comparable; groups that

comprehend ideas fast and groups that want to know exactly what to eat and what they have to

cook in spite of it is very good and very beneficial.”

It was suggested by a younger member of the focus group that alternative ways of

communication be explored. The participant suggested, “electronic communication, electronic

conferences, e‐mail to be once a week” as a way for some to maintain the needed support.

Participants also felt that for the program to be effective it should research a larger and broader

audience: “It could have been better in regards to the number of participants. It could be more

awareness among the people so as to attend these programs. It could be that this number is

sufficient; however, the program is very important.” One participant suggested groups of up to

30 or 40 people. This invoked a discussion on the proper size of the group with some saying it is

better to have smaller more focused groups and others arguing for greater outreach into the

Arab community. They did agree that information was quick to spread in the Arab community:

“… [a] good thing in the Arabic community is that there is a difference from learning a fact and

like to pass it to a brother, sister, neighbor, and a friend. That is especially good for a woman to

have general education. That is a person (i.e woman) to pay attention to.”


28

Several felt that the outreach efforts of the current program were too limited: “We are 10 out of

100,000. It is nothing.” There was discussion on the serious need within the community to

engage in broader dissemination: “When I come and sit at the table, I meet about 180 women,

among them 35 or 40 women are diabetic. Sometimes, I help them to learn what to do. Really,

there is ignorance, especially, especially among our women.”

Participants were also eager to learn more about specific food products they should buy. It is

acknowledged that this is covered later in the Lifestyle Intervention, yet participants were not

aware of this.

There was also concern over starting on time, primarily as a concern of some participants that

others were causing the program to start late or that they were not present for every session:

“Even if somebody is late, start without them. That’s very important. We all have lives outside

this.”

Reasons to Continue in the Lifestyle Program

Participants in these three groups agreed to continue learning about diabetes through the Lifestyle

Intervention Program after they completed the education sessions. They explained that what they had

learned in the few classes had given them enough information to encourage them to continue. Others

spoke about the need for enough “basic information” before progressing to the “implementation.”

Family and community also played a role. Several participants talked about the need to learn more in

order to protect their children or to help educate their community: “I am mother and I have my children

so as I educate them from now. This is the reason.” Several were convinced to continue based on the

lifestyle changes they had already begun at home and the desire to learn more:

I noticed that there is benefit, and I started to change my lifestyle in order to reduce this disease among us and coming to our house. I followed a special calorie diet, and regular exercise and food. For this reason, I am going to enroll in the second program of Lifestyle.

The promise of hands‐on learning was also an enticement: “What also encouraged me is that the doctor

[Dr. Jaber] said that we will go to stores and we will learn about which food is healthy and which is not.


29

Also, the exercise classes encouraged me.” A few, however, expressed possible limitations to their

further participation. In particular scheduling was a concern. Busy work lives as well as summer travel

plans posed limitations to their ability to attend all sessions of the intervention.

Lifestyle Intervention Feedback Feedback on the Lifestyle Intervention program was obtained both through a series of four focus groups

with completers (N=42) and through a post‐focus group feedback survey.

Feedback Survey

Following the final focus group with intervention completers, a post‐session survey was completed by

the participants. The survey sought feedback from them on the impact and outcomes of the program.

Complete survey results are presented in Table 4 below.

All 42 participants, felt that their knowledge of diabetes had increased as a result of the program (100%

strongly agreed). All had changed the way they eat (100% agreed or strongly agreed). Most had also

Table 4 ‐ Feedback Survey Summary Table

Strongly Disagree

Disagree Neither Disagree nor Agree

Agree Strongly Agree

This program increased my knowledge about diabetes 0.0% 0.0% 0.0% 0.0% 100.0%

As a result of this program, I changed the way I eat 0.0% 0.0% 0.0% 14.3% 85.7%

As a result of this program, I changed the way I exercise 0.0% 0.0% 2.5% 32.5% 65.0%

As a result of this program, I believe my risk of diabetes has been reduced

0.0% 0.0% 2.4% 17.1% 80.5%

As a result of this program, I feel healthier 0.0% 0.0% 2.4% 19.0% 78.6%

I achieved my goals as a result of this program 0.0% 0.0% 0.0% 24.4% 75.6%

Because of my participation in the program, members of my family have changed their lifestyle

2.4% 0.0% 4.9% 46.3% 46.3%

Because of my participation in the program, members of my community have changed their lifestyle

0.0% 5.0% 15.0% 42.5% 37.5%

The instructors in this program were informative 0.0% 0.0% 2.4% 2.4% 95.1%

The peer mentors in this program provided good support in achieving my goals

0.0% 0.0% 0.0% 0.0% 100.0%

The materials in this program were culturally appropriate 0.0% 0.0% 2.4% 7.1% 90.5%

The lessons in this program taught me things I did not know 0.0% 0.0% 2.4% 12.2% 85.4%

I would recommend this program to others in my community 0.0% 0.0% 0.0% 4.9% 95.1%


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changed the way in which they exercise (97.5% agreed or strongly agreed). Nearly all felt as if their risk of

diabetes had diminished as a result of the intervention (97.6% agreed or strongly agreed). Likewise

97.6% agreed or strongly agreed that they were currently feeling healthier as a result of the program. All

reported that they had achieved their personal goals for the program (100% agreed or strongly agreed).

The impact of the program extended well beyond the immediate participants. Most (92.7%) agreed or

strongly agreed that members of their family had changed their lifestyle as a result of the Lifestyle

Intervention. Similarly, many (80%) reported that because of their own participation, members of the

community had changed their lifestyles as well.

Feedback regarding the instructors and materials was also overwhelmingly positive. Instructors were

seen as informative (97.6% agreed or strongly agreed), and peer mentors as providing good support

(100% strongly agreed). The materials were perceived to be cultural appropriate (97.6% agreed or

strongly agreed). The lessons were seen to present material that was new to the participants ((97.6%

agreed or strongly agreed). All would recommend the program to others in the community (100%

agreed or strongly agreed).

Focus Group Feedback

As found in the surveys, participants were overwhelmingly positive about the program yet survey results

alone are insufficient in providing formative evaluation feedback for the purposes of refining this

program for future application. Thus, focus groups were held to elicit more detailed input from the

participants. In general, they felt the pacing and content was appropriate. They liked many of the

practical aspects of the program such as exercise sessions, calorie counting, and shopping trips. They felt

well supported and encouraged in their efforts.

Encouragement

The respondents in all groups said they liked the mutual support and camaraderie: “Working as a

collective was more beneficial than one‐on‐one.” Another person concurred: “Working together as a

group was encouraging to each other.” A participant in another group echoed a similar sentiment, “This

way is better because the group encourage each other more. The group setting is better. I prefer like

this.” They also agreed that there was a lot of encouragement by program staff and other participants:


31

“The presence of the group. The instructors were good. The subject was scientific, and we encouraged

each other.” Moreover, the program made them feel comfortable by not being commercial and instilling

a feeling of trust:

I have participated in 20 programs and in different countries; in Iran, Iraq, and in Dubai. I have seen the programs of different cultures, exercise issues; a part was related to specialties because teaching was my profession. This program was very useful to me. I felt comfortable. I did not feel any pressure. It was really nice and was not commercial. You do not feel that the program is commercial. It is scientific. You feel assured. It is not the money. It is about the education, giving accurate knowledge. Almost you are in the safe side. There is the feeling of safety or trust.

Learning How to Count Calories and Shop

Participants also liked the practical aspects of the program. In particular they discussed the “calorie

count” and “how to select food” activities. The participants liked these tools as they provided the ability

to do things for themselves. One likened the experience to being provided the materials to fish rather

than being given fish: “…in the former programs that I participated in, they offered us the fish ready

made, everything 1, 2, 3, 4, 5, whereas in these meetings, we obtained the hook and learned how to

fish.” For example, in one group most agreed that the calorie book and the activity of recording their

daily intake was useful:

Writing the calories helped me a lot. I counted the number of calories I ate for breakfast. I counted the number of calories I ate for dinner. I count my daily calorie intake of about 1500 calorie. This believe me is too much food. It is more than enough. If I ate 2000 calories, I regret it the second day. I try to eat 500 calories less during the following day. It helped me a lot.

The shopping trip also came up often and in several of the groups as a favorite activity. One participant

explained that this was the most useful part of the intervention: “Mostly it is the manner of shopping.

The points that we learned were how to shop and prepare foods. One reads and watches what is very

useful.” Another echoed a similar sentiment about the shopping trip:


32

I liked the most when we went to Kroger. I used to only pay attention to the fat or the cholesterol content being low, because I have high blood cholesterol. I did not watch for the transfat, the salt, the calories and these things. Now, I watch for everything; every element in the kind of food that I get.

Accomplishing Personal Goals

Participants estimated that they attained 60% to 90% of their goals in weight reduction, cutting calorie

intake, and maintaining their exercise regimens. They felt supported by mutual reinforcement, but

admitted that some elements of the program were difficult at first: “At the beginning I found it a little bit

difficult. Every time that you eat something you have to write it. You keep on writing back and forth.

Later, I got used to it. I learned it and I wrote them.”

Most participants reported shedding weight. One noted, “I lost 10 pounds, which is good, and I felt

good.” Another noted, “My size was 24, now it became 18.” Many had received compliments from

family and friends that reinforced their desire to stick to the calorie counting regimen. This weight loss

was the most important feature of the program to some: “Regarding the topic, the most important thing

that was helpful to us was losing weight. We felt comfortable. We felt ourselves more active. We

regulated our food in an incredible way.” For some, the weight loss and modifications to the diet began

during the Educational Program and continued during the Lifestyle Intervention with dramatic results:

I attended the program and initially I lost about 15 pounds. My weight before was about 164 pounds. My weight went down to 152 or 150 pounds. Then I followed the Lifestyle Program and my weight lowered to 136 pounds; from 152 pounds to 136 pounds and even less 135.5 pounds. The program is very good. First, the program strengthened my determination. Whenever I desired to eat something, I would remember that my weight would increase, so I would just taste it or eat just a little bit. Then, everyday I do half an hour exercise. This also helps me and strengthens my determination also. I do not let myself go as it wishes.

Temptations such as sweets were difficult for some to avoid at first and might prove to be a problem still

in the future. One participant explained, “I am afraid from one thing that after the program I will not be

able to control over myself regarding eating sweets. I am afraid from this only.” Also, some participants

felt that exercising for an hour would be difficult for them: “It is the time element. Sometimes I do not


33

have the time to do the exercise. I could exercise for half an hour or for smaller intervals. An hour exercise

is difficult.”

Additional Health Benefits

In addition to the loss of weight, many reported feeling stronger and more energetic. Moreover, in each

of the focus groups with completers there was discussion over the reduction in blood pressure and

cholesterol. One participant, since beginning the program, had stopped needing as much of her blood

pressure medications: “My blood pressure went down; instead of taking the complete medication dose

that I used to take, I am taking half of the dose.” Several described dramatic reductions in cholesterol:

My cholesterol was 264. Fat was high. The doctor told me that I had to watch for fatty foods and also my sugar. Either you have to watch or I will prescribe you medication. I followed the methodology of this program. A month ago or less, I did tests. Everything is normal. Truly, thank God, cholesterol, sugar, everything is normal. This is not an advertisement. I am telling you what happened with me.

Impact on Family and Beyond

Nearly all reported the ancillary impact of changes in lifestyle among family members and friends. As

they changed their eating habits at home, their families also became a part of the intervention. “This

program is very useful. It helped us. It helped our children. It helped our friends because we sat together

and talked about the program and encouraged them to join this program.” This was particularly evident

with female participants who were more often the cooks in the home: “Whatever we cook at home, the

family eats.”

Beyond the family, neighbors and friends were impacted as they noticed the loss of weight or changes in

eating habits: “I tell my friends about the program that I have joined and what we do. So, they started

watching their food. If they had to use fat in the food, they use instead a little bit oil. Also, they

benefited.” Likewise, family and friends were recruited to become exercise partners: “My sister in law,

she came with me to the park to Maysoon’s class. Now, she calls me asking: “Don’t you have any more

exercise classes? When are we going? Let us go.” She comes to me and asks me to walk together. The

exercise raised her enthusiasm in many things.


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While there were several discussions in the focus groups regarding the need for additional health

marketing in the community, it was recognized that the participation of a few in the initial program had a

great impact on the entire community:

We do not need religious centers. We do not need advertisement. We became the advertisement. We are the ones that we give. First of all we started with our children, our husbands, our families. Now, my sisters say, this method I followed and I benefited. Let me try with my husband and children. My brother is the same thing. My neighbors followed, too. Slowly, it is being found.... it spreads more and more.

Suggestions for Improvements

More Dynamic Content

There were several suggestions for improving the program. First, there were a number of comments

that alluded to the program lacking dynamism. As one participant put it: “It lacked a little bit of the

excitement elements.” Another participant felt that some sessions were too much like going to school:

“writing on the board kills me when I come to attend sessions.” Others talked about the classes being too

long: “The program could be shorter so that one does not get bored.” A suggestion was made to spread

out the dense or complicated topics over the course of several sessions with activities interspersed to

make it more fun. Since much of the content of the program was “front loaded” rather than spread out

throughout, it was felt that some participants may have dropped out early. A focus group member

explains, “if the information material is heavy, everybody is gonna come, but toward the end less and less

people came; somebody would come, somebody wouldn’t come. I think sessions should be spread over

the six months rather than do everything in the beginning.”

Several people commented on the handouts saying there was “too much paper work” and that the

handouts were “tiresome.” Another participant suggested making the course livelier by reducing the

number of handouts, making the handouts that were passed around more engaging, and using videos.

She explains: “a video makes teaching interesting for the person and not only learning from reading and

writing and doing this or that…. it could be exciting by having a video.” The idea of using videos came up

in other groups as well: “For example, you are telling that you are going to prepare food. There should be


35

in the video someone preparing the food in front of us. The way they show on T.” Similarly, another

participant recommended using slides to make the content more dynamic and visual:

For example, you are writing on the board. There are other things than writing on the board; the way of the presentation. Instead of writing it on the board, there are slides. Slides could be videos. You could know from the slides. A woman did a presentation for Rotary Club about Lebanon. She got the slides and the video about Lebanon. They were very impressed how she combined the slides with the video. Until now, people talk about the presentation. There are still things that make a person not to forget, other than the old way of writing only. Writing impacts but not a lot

Additional Health Experts

Another discussion on improvement centered on brining in additional experts. They liked having experts

visit to discuss health, nutrition and exercise: “the fact that you had a nutritionist, a health doctor, and a

variety of knowledgeable people here, they gave us a lot of information. We asked them and they were

very helpful.” Yet, it was noted that while the psychology of weight loss and lifestyle changes were talked

about, there was not a mental health expert present to address these issue as there was for other topics:

“You have the nutritionist. You have the health department doctor. We’re missing the psychiatrist.”

Cooking Classes

There was also significant discussion on the limited amount of time spent practicing and applying

lessons: “This program is not sufficient to be theoretical, it needs to be practical along with the

theoretical part….” Participants wanted more time to actually engage in application of the material. As

one said, “Even if there would be a small kitchen to cook a small dish.” This theme emerged in a later

group as well: “If one could do like a cooking class instead of using the video. I am not sure whether you

could do this here at the center. There isn’t a kitchen here. It helps if you can get someone to cook the

thing in front of you.”

More Time for Exercise

Similarly, many participants felt there were not enough exercise sessions to actually practice and refine

what they had learned: “Increase the exercise sessions. The time was not sufficient enough. They should

be more sessions.” This participant went on to say that there should be at least two exercise sessions per


36

week. Another participant reasoned that at least half the program should be application of the exercise

lessons:

“If we consider that exercise has a role for about 50% [of reducing diabetes risk] in this aspect, we have to give educational sessions equal to the practical sessions. We are listening to 50 hours to theoretical subjects and learn them; however, practically I am not doing anything.”

Moreover, there was misunderstanding and confusion in one group over the provisions that were made

for exercising. Many thought they could only go to Bally Total Fitness. This was not acceptable for some

women who were unaware that Curves was also available to them:

I like that she got membership to all of us to go to the Bally fitness but as you know, a lot of sisters here are covered. They cannot go there. It’s mixed. I cannot go there. I personally don’t like to be in mixed area. I am not covered, but I do not feel comfortable. I wish you, because you know, most of the members they like that kind of environment. I wish you got membership or the deal, I don’t know if report or not, but I wish you got the membership with the gym that has this kind of privacy.

Calorie Count for Arab Foods

Most participants mentioned how much they liked the calorie counting book and materials. However,

there were also a few who suggested that it would be more useful if it better fit their ethnic cuisine and

the foodstuffs they commonly find in the grocery stores catering to the Arab community: “I would

suggest if you come up with the calorie content of things sold in the Arabic shops or sweet shops that we

buy from. For example, the sweet shops, if there would be a program to label how much calories or fat

each kind of stuff contains.”

More Training on How to Teach Others

Several participants felt that their role and purpose for being there was to eventually disseminate what

they had learned to the broader community. In particular they worked within their own families: “We

shared the things that we learned and implemented them together as a family.” While they clearly felt

they were making some impact (especially with the cooking in their own homes), they still felt limited.


37

There was a feeling that the training was not sufficient for them to be able to go into the community and

train others:

We are going to be the pioneers in the community. Isn’t it right? Our aim is to learn and teach others as leaders. So, if the leaders/forerunners did not learn well, they will not be able to teach, otherwise, what the prophet can do in the جارعملاو ءارثإلا يف [Reference to the prophet way of teaching].

Alternatively, it was suggested that the Lifestyle Intervention program attempt to reach a broader

audience by using local the local imams, cultural and social institutions in the community, and the Arabic

language media:

I was surprised is that the community does not have sufficient information about what you are doing. It is important what you are doing, however, it is necessary there to be an advertising method to reach the community. I do not know how the advertisement method to be. For example, you could be on TV, or on satellite TV; LBC just to target the community. To speak what you are doing because it is an important thing what you are doing. The community is not aware of it. I was surprised to find out that there are a lot of information about food which I did not know, manner of exercising, and how to shop one’s food, the quality of food. This changed our home. It is important that it changed however, it is important that other people know about it. The advertisement should be more powerful than this.

Better Cultural Fit of the Intervention

Even though the materials were perceived to be culturally appropriate (97.6% agreed or strongly

agreed in the survey), a series of critiques in one early focus group (August 2008) revolved around

the question of a cultural match between the implementation and the Arab‐American community.

As one person put it, the intervention was “sensitive, but is it enough?” She went on to say, “It

lacked the cultural face of the Arab. It was purely scientific material. It was not crafted with Arabic

culture, even the terminologies… Even the suggested names, the examples were void of culture.

Relationship to the culture is weak. In particular, there was a feeling that the handouts and

examples should reflect the history, the diversity, and the religiosity of the Arab community. One

participant suggested:


38

Bring wise old Arabic sayings from the Chaldean culture in the Iraqi history to the Greek Arabic culture that was in Lebanon and all cultures. You can find subjects or stories about nutrition and medicine dealing with nutrition. All these, if we include, it will feel that this is a book automatically; a special book that includes ethnic matters.

Another participant commented on difficulty with the vocabulary on the handouts. She explained

that though she had been an English teacher, there were many words that she did not know used

in the handouts”

I wish opposite to the words to be written the meaning in Arabic. Khas [lettuce] is khas and not to say lettuce. Bamia [okra] is bamia. Our purpose is education. Science is good in the language of a person who understands it before implementing it….I wish that there were Arabic words next to the English words. It would have been simpler and easier for the student to understand. The purpose is the practical implementation.

Later focus groups (April 2009) did not feel the same about the cultural “fit” of the materials. In fact they

commented that the materials accurately reflected the cultural identity of the community: “…we, in

general, are a Middle Eastern society or even a religious society. You took into account this. You asked,

for example, Islamic quotes or “Alhadith” to include in that. It was good very much.” Yet the same

participant did note that the references to Arabic food were limited and perhaps more reflective of the

Lebanese community:

It was not sufficient, because, in general, the majority of the community here is Lebanese. However, it would have been good if there were examples from the Iraqi community or the Yemeni community. It was not sufficient. There should be more variety of the cuisine, because our Arabic community is large. There is a variety of cuisine.

These later groups did discuss the appropriateness of the mixed‐sex exercise sessions. Many felt it was

inappropriate for a female physical trainer to be teaching males and for males and females to exercise

together:

FGCompleters2.08: The only thing that was not appropriate was the exercise for men with Maysoon. It was inappropriate. Honestly, it was not appropriate. There is no hypocrisy.


39

Moderator: Can you repeat it?

FGCompleters2.08: It is necessary that you bring men to train and exercise men. A women standing in front of men and doing this or that movement was not appropriate.

The discussion of this issue extended to the topic of access to the exercise clubs. There was a clear

preference that women should not go mixed‐sex clubs, “Men train with men and women train with

women, because a woman whether covered or uncovered, it is not our custom. She will not be

comfortable in front of men.”


40

Conclusions and Recommendations Including the pilot focus groups, a total of 17 sessions were transcribed and analyzed for this report.

Additionally, 29 post‐focus pilot surveys, 42 pre‐focus group feedback surveys, and 121 post‐focus group

surveys were collected to help triangulate or “to confirm, cross‐validate, or corroborate findings”

(Creswell et al., 2003). As stated previously, there were three major objectives to these focus groups: 1)

to understand what factors influence participation in the lifestyle intervention; 2) to identify what

elements of the educational training which led to participation in the lifestyle intervention; and 3) to

identify barrier for those declined to participate in the intervention. Additionally, focus groups were used

to evaluate the outcomes of the lifestyle intervention.

Key factors which influenced participation

There are several key factors which influenced participation in both the educational sessions as well as

the intervention program. These factors are in part cultural and may be understood primarily as having

to do with preservation of self or as social obligations to family and community. Motivating factors

included:

Fears of becoming diabetic (self‐preservation)

Fears of family members becoming diabetic (self‐preservation/ social obligation)

Family history of diabetes (self‐preservation)

Desire to help the Arab‐American community or raise awareness among Arab‐Americans (social obligation)

Personal appeals from/ ties to project staff (social obligation)

Those who participated in the education program prior to the lifestyle intervention (education

conversion groups), also noted that their own personal awareness had to be heightened for them to see

the necessity of the lifestyle changes before they would commit to the program.

In developing health marketing for future programs it is recommended that organizers recognize the

key factors which influenced participation in this implementation. Future marketing should be

designed to make use of social obligations and emphasize the importance of lifestyle changes as a

means of improving health outcomes. However, there is a delicate balance in appealing to self‐

preservation and using fear as an appeal (see for example Witte and Allen 2000).


41

Barriers to participation

Barriers to participation may also be reduced to a few fundamental reasons: logistics, personal

characteristics, cultural impediments, and misperceptions or misunderstandings about healthcare.

According to participants, their obstacles to involvement may include:

Lack of time (logistics)

Transportation issues (logistics)

Lack of “will power” (personal characteristic)

“Laziness” (personal characteristic)

Myths about the causes of diabetes that are not influenced by lifestyle change, ie. ‘being startled’

(misperceptions)

Fear or mistrust of healthcare professionals (misperceptions)

Stigma of diabetes in community (misperceptions)

Mixed‐sex groups (cultural impediment)

Among intervention refusers, mixed‐sex groups was brought up as a barrier specifically for the Yemeni

and Iraqi communities, but was not necessarily an issue for those who did participate. Pilot group data as

well as exit surveys showed that about a quarter of participants (see Table 3) preferred single‐sex groups

particularly for exercise. It is recommended that 1) future program offer more timeslots on more days

(mornings and evenings, weekdays and weekends); 2) provide session in multiple venues or even in

some neighborhood homes; and 3) emphasize that exercise classes will be segregated by sex.

Overall Program Feedback

Participants were asked to provide suggestions for improving the programs. Those who attended the

educational session made a two recommendation that could be feasible in future implementations.

First, the program should explore alternative ways of communication (email groups, chats, or other

technologies) especially for younger participants. This could be used as a means of mutual support and

reinforcement between sessions. Also, the education information sessions should be redesigned for a

larger and broader audience in order to have a greater impact on the community and work as a more

effective recruitment tool for lifestyle implementation.


42

Lifestyle completers also had a number of recommendations. The “hands‐on” elements of the program

were especially appealing and they would like for there to be more of these. In particular, the

participants wanted to spend more time cooking and engaging in exercise. At times they felt there was

too much “paper work” and wished for a variety of instructional material. They mentioned wanting

more multi‐media as well as additional visits from experts. Finally, while 97.6% agreed that the materials

were a cultural fit for the program, there were some elements that could use revision. First, participants

suggested that the calorie count information be provided with more Arab foods listed. Second, these

foods should include those for a pan‐Arab community (comments were made that the food references

were more reflective of Lebanese community).

Feedback from both the intervention and the educational components were positive. Intervention

participants indicated on the exit survey that they had increased their knowledge about diabetes (100%

agree), and changed the way they eat (100% agree) and exercise (97.5% agree). Overall they felt

healthier (97.6% agree) and believe their risk of diabetes has been reduced (97.6% agree). Participants

estimated that they attained 60% to 90% of their goals in weight reduction, cutting calorie intake, and

maintaining their exercise regimens. While many were aware of the necessity of lifestyle changes prior

to the intervention, they needed the structure and mutual support offered by the group to be able to

engage in making changes.

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Appendix A Project Deliverables

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Project timeline and products

1. June 2007 ‐ focus group protocol

2. October 2007 ‐ focus group facilitator training in Detroit

3. November 2007 ‐ pilot focus group scripts

4. November 2007 ‐ focus group survey

5. February 2008 ‐ focus group 1 & 2 scripts

6. February 2008 ‐ pilot focus group report

7. May 2008 ‐ focus group 3 script

8. August 2008 ‐ focus group 5 script

9. November 2008 ‐ presentation at 5th National Conference on Health Issues in the Arab American community

10. April 2009 ‐ presentation at the Southern Sociological Society Annual Meeting

11. February 2009 ‐ focus group 6 script

12. February 2009 ‐ preliminary focus group report

13. September 2009 – Post‐Ramadan focus group script

14. December 2009 ‐ paper submitted to Qualitative Health Research:

Sills, S., Pinelli, N. & Jaber, L. “Sex and self‐disclosure: methodological issues of mixed sex focus groups in Arab Americans”

15. December 2009 ‐ final focus group report

16. January/February 2010 ‐ paper preparation for Diabetes Care:

Sills, S., & Jaber, L. “Knowledge and perception of diabetes risk among Arab Americans”

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Appendix B Transcript Concordance

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Table 5 ‐ Concordance of Scripts, Filenames, Group Descriptions, and Project Goals

# Date Script Goal Focus Group Description N File Name

P1 11/13/2007 Pilot Women‐only pilot session 12 Pilot Focus Group‐Women.linda.rtf

P2 11/13/2007 Pilot Mixed‐sex pilot session 9 Pilot Focus Group‐Mixed.linda.rtf

P3 12/11/2007 Pilot

Identify potential for silencing; Identify diabetes knowledge and health beliefs

Men‐only pilot session 8 Pilot Focus Group‐ Men session.linda.rtf

1 3/20/2008 FG1 Lifestyle Accept Club House 7 Lifestyle_InitialAccept_Clubhouse_ 3.20.2008.doc

2 3/20/2008 FG1 Lifestyle Accept Mona 7 Lifestyle_InitialAccept_Mona_3‐20‐08.doc

3 10/30/2008 FG1

Identify reasons for decision to participate in intervention

Lifestyle Accept Deeb 14 Lifesyle initial accept. Deeb group.doc

4 5/16/2008 FG3 Education Conversion Ali 9 FocusGroupTranscript_Education_Converted_ALI.final.doc 5 6/18/2008 FG3 Education Conversion Ammena 6 Post Education‐Accept LifeStyle (Ammena group).doc 6 8/12/2008 FG3

Identify reasons for decision to participate in education and intervention

Education Conversion Diana 10 Post education converters. Diana group.doc

7 6/20/2008 FG4 Education Refusal Matar 6 Post Education‐Refuse LifeStyle (Mariam group).doc

8 6/27/2008 FG2 Refusal Focus Group Khalil 6 Refusers. Khalil group.doc

9 7/1/2008 FG2

Identify barriers to participation

Refusal Focus Group Jehan 6 Refusers. Jehan Group.doc

10 8/27/2008 FG5 Lifestyle Completers Mona/Club 11 Lifestyle completers. Mona‐Club house.doc 11 10/23/2008 FG5 Lifestyle Completers Ali 10 Lifestyle Completers. Ali Group.doc 12 4/30/2009 FG5 Lifestyle Completers Diana 12 Lifestyle completers. Diana group.doc 13 4/30/2009 FG5

Evaluate Program

Lifestyle Completers ‐ Firas 9 Lifestyle Completers – Firas Group.doc

14 10/9/2008 Post ‐Ramadan

Gauge adherence to lifestyle program during cultural/religious holidays

Ramadan 9 Ramadan Corrected.doc

Feasibility of Diabetes Prevention in Arab Americans: Final Focus Group Report

Documents

Transcript of Feasibility of Diabetes Prevention in Arab Americans: Final Focus Group Report