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Management of Type 2 Diabetes in Non-Western Patient Groups

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Management of Type 2 Diabetes in Non-Western Patient Groups Management of Type 2 Diabetes in Non-Western Patient Groups Results from Pakistani and Kurdish immigrant populations in Norway and from the native population in the United Arab Emirates Walaa Abuelmagd Pharma Use Research Group, Department of Pharmacy, School of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Norway Oslo, Norway 2019 Submitted for the Degree of Philosophiae Doctor (Ph.D) © Walaa Abuelmagd, 2020 Series of dissertations submitted to the Faculty of Mathematics and Natural Sciences, University of Oslo No. 2217 ISSN 1501-7710 All rights reserved. No part of this publication may be reproduced or transmitted, in any form or by any means, without permission. Cover: Hanne Baadsgaard Utigard. Print production: Reprosentralen, University of Oslo. To my beloved family and friends all over the GLOBE! Til min kjære familie og alle venner i hele VERDEN! إلى أهلي وأصدقائي في جميع أنحاء العالم! پورى دنيا ميٮ ميرے ݒيارے عڒيڒوں اور دوستوں! بوكس وكار وهو رييا نم له هه موو جيهاندا! iii iv List of Publications Paper I: Walaa Abuelmagd, Helle Håkonsen, Khadijah Qurrat-ul- Ain Mahmood, Najmeh Taghizadeh, Else-Lydia Toverud Living with Diabetes: Personal Interviews with Pakistani Women in Norway Journal of Minority and Immigrant Health. 2018; 20:848-53 (Reprinted with permission from Springer) Paper II: Walaa Abuelmagd, Bachar Afandi, Helle Håkonsen, Seham Khmidi, Else-Lydia Toverud Challenges in the Management of Type 2 Diabetes among Native Women in the United Arab Emirates Diabetes Research and General Practice. 2018; 142:56-62 (Reprinted with permission from Elsevier) Paper III: Walaa Abuelmagd, Bavi Botan Osman, Helle Håkonsen, Anne Karen Jenum, Else- Lydia Toverud Experiences of Kurdish Immigrants Regarding the Management of Type 2 Diabetes: A Qualitative study from Norway Scandinavian Journal of Primary Health Care. 2019; 37:345-52 (Open Access -Taylor & Francis) v Summary Type 2 diabetes mellitus (T2DM) is a major public health challenge. The increased prevalence of T2DM is explained, to a great extent, by societal changes inducing obesity through energy excess and sedentary behaviours, as in populations who have migrated to Western countries, in native populations in the Middle East who have experienced rapid economic growth, and as a result of general urbanization in many countries. Management of T2DM is multifactorial and is often a substantial challenge for patients. The aim of this thesis was to investigate how three adult non-Western patient groups, representing populations with high T2DM prevalence, managed the treatment of their disease. The patient groups were Pakistani immigrant women in Norway, native Emirati women in the United Arab Emirates, and Kurdish immigrants of both genders in Norway. One hundred and twenty Pakistani women and ninety Emirati women were interviewed one by one in their native language (Urdu and Arabic) using a structured questionnaire. Additionally, clinical values for the Emirati women were extracted from medical records. Focus group interviews conducted in Norwegian were used for the study of the Kurds (nine women and nine men). The Kurdish participants had to be proficient in the Norwegian language to be eligible. The level of education that was reported by the Pakistanis and the Emiratis was low (illiteracy levels: 27% and 51%), whereas there was no illiteracy among the Kurdish participants. The mean age was 55.7 years among the Pakistanis, 57.5 years among the Emiratis, and 51.2 years among the Kurds. One-third of the Pakistani and the Emirati women reported poor or very poor health, and 37% and 46% from respectively the Pakistanis and the Emiratis needed assistance to measure their blood glucose levels. One in four Pakistani women and three out of ten Emirati women were using anti-hyperglycaemic medications in both oral and injectable forms. The majority of both study populations (71% and 68%) had macrovascular comorbidities. Information from medical records revealed that almost all the Emirati women had achieved target systolic blood pressure, two-thirds had achieved target low-density lipoprotein cholesterol values, and 49% had achieved the HbA1c target of < 7.0%. While the Pakistanis and the Emiratis focused on their health status, the Kurdish participants, expressed their experiences with living with T2DM during focus group interviews, whereof the majority described it as stressful. It was commonly discussed how daily blood glucose measurements were important, and many of the participants reported incorporating this task into their daily routines, even vi though it was painful. Only a few of the Kurdish participants reported using both oral and injectable anti-hyperglycaemic medications. Some of the Kurdish participants talked about comorbidities such as high cholesterol and hypertension for which they had received treatment. One in four of the Pakistani women and almost all the Emirati women reported that they fast during the month of Ramadan. These participants reported that they had altered/stopped their medication intake during that time due to religious fasting. None of the Kurdish participants fasted during Ramadan. With regards to lifestyle habits, the majority of the Pakistani and the Emirati participants reported daily eating habits that reflected an unhealthy diet, with big meals and calorie-rich snacks. Only 3% of the Emiratis had a body mass index within the normal range. The Kurdish participants were, in general, aware of healthy dietary habits and talked about how hard they tried to change their habits to healthier ones. The majority in both the Pakistani and the Emirati groups reported very low levels of physical activity. The situation for the Kurdish participants was similar, and only a few seemed to be aware of the benefits of physical activity. In all three study groups, the treating physician (the general practitioner in the Norwegian- based studies and the endocrinologist in the Emirati study) was the primary and most trusted source of information about T2DM. Poor Norwegian language proficiency among the Pakistanis made understanding the information difficult, and low literacy reduced, the capacity of the Pakistanis and the Emiratis to understand basic health information. The situation for the Kurds was different from the two other groups, since they had sufficient oral Norwegian language skills and had a degree of education which made them capable of reading and understanding medical information. In conclusion, this thesis showed that Pakistani immigrant women in Norway and native Emirati women in the United Arab Emirates reported suboptimal self-management of T2DM in terms of lifestyle habits, blood glucose monitoring and medication adherence during Ramadan. Linguistic barriers, as observed in the Pakistanis, low literacy, as observed in the Pakistanis and the Emiratis, and religious factors, as observed in the Pakistanis and the Emiratis, made management difficult for both patient groups. On the other hand, the Kurds, who possessed good Norwegian language skills and were literate, expressed that their management of T2DM was largely successful. vii Acknowledgements The present thesis is the result of work that I carried out during the period 2013–2019 at the Pharma Use Research Group, Department of Social Pharmacy, School of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Norway. I want to thank the faculty for giving me the opportunity and the facilities to perform my Ph.D. I also want to express my gratitude to the Norwegian Ph.D. School of Pharmacy and the Norwegian Pharmaceutical Society for the grants that I have received to publish my work in many national and international conferences. Many people have contributed in different ways to this project, and without their dedication, support and help, this thesis would not have been a reality! I would, therefore, like to thank: Professor Emeritus Else-Lydia Toverud, principal supervisor. Thank you for sharing your knowledge in the field of immigrant health, for your thorough supervision, and your enthusiasm and encouragement to share knowledge with the public. Thank you for your important contributions to all three publications. Associate Professor Helle Håkonsen, co-supervisor. Thank you for evaluating my work with a critical eye, for your constructive comments, and for making the three publications better. Professor Anne Karen Jenum, co-supervisor. Thank you for your supportive words, for sharing your knowledge on diabetes among non-Western immigrant populations, and for your contributions to Paper III. Co-authors of Paper I-III. I would like to thank my co-authors, master’s students Khadijah Qurrat-ul-Ain Mahmood, Najmeh Taghizadeh (Paper I), Dr. Bachar Afandi and Mrs. Seham Khmidi (Paper II) and master’s student Bavi Botan Osman (Paper III). I would also like to thank the key representatives in the Pakistani and Kurdish groups in Norway and the nursing staff at the diabetes outpatient clinic at Tawam hospital in the UAE for their support. I would also like to thank all the study participants for their time and contribution in the different papers. viii My former and present colleagues at the Department of Social Pharmacy. Thank you for the nice gatherings around Christmas and other social events and for all the projects we have planned, organized, and corrected for first, second and fourth years’ pharmacy students during the past six years. I would also like to thank all my pharmacy colleagues at Apotek 1 Legevakten, Ditt Apotek Heggedal, Vitus Apotek Rykkinn, and Vitus Apotek Røyken for all the support and motivation during my study period. My friends whom I was lucky to meet during my PhD journey! Lars P. Austdal, Shaista Ayub, Shaista Basit, Iren D. Borgen, Noor Jdid, Mariya Khomich, Zill-e-Huma Latif, Angela Lupatelli, Silje S. Lie, Øyvind Midtvedt, Riia-Liisa Rasimus, Aslaug J. Risøy, Karin Svensberg and Astrid Torbjørnsen. Thank you for our interesting moments and your support. My friends in Australia, Egypt, Norway, Sweden, the UAE, the US, and the rest of the globe! Thank you all for the encouraging talks, messages, inclusion, discussion and love you showered me with over the past years.
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