University of Warwick institutional repository: http://go.warwick.ac.uk/wrap A Thesis Submitted for the Degree of PhD at the University of Warwick http://go.warwick.ac.uk/wrap/59612 This thesis is made available online and is protected by original copyright. Please scroll down to view the document itself. Please refer to the repository record for this item for information to help you to cite it. Our policy information is available from the repository home page. PhD Thesis ___________________________________________________________________ Health Inequalities and the Right to Healthcare of Negev Bedouin in Israel with Diabetes: A case study of a Marginalized Arab Indigenous Minority Ferial Alanood Alshamari Abu Nadi ___________________________________________________________________ This thesis is submitted in partial fulfilment of the requirements for Doctor of Philosophy degree at Warwick Medical School, University of Warwick Coventry, United Kingdom. First Supervisor: Prof Gillian Lewando Hundt Professor of Social Sciences in Health, Social Sciences and Systems in Health Unit, Division of Health Sciences, Warwick Medical School Second Supervisor: Dr Loraine Blaxter Social Sciences and Systems in Health Unit Division of Health Sciences, Warwick Medical School 2013 Table contact Table contact ............................................................................................................... 2 ABSTRACT ................................................................................................................ 5 ACKNOWLEDGEMENTS ........................................................................................ 7 ABBREVIATIONS .................................................................................................... 9 GLOSSARY .............................................................................................................. 10 List of tables and figures ........................................................................................... 13 List of Appendices .................................................................................................... 15 DECLARATION ...................................................................................................... 17 DEDICATION .......................................................................................................... 18 Introduction ............................................................................................................... 19 The study ............................................................................................................... 19 The thesis structure ............................................................................................... 21 Research Questions ............................................................................................... 21 Chapter 1 ................................................................................................................... 23 Literature Review ...................................................................................................... 23 Diabetes Worldwide .............................................................................................. 23 Indigenous People ................................................................................................. 25 Epidemiology of diabetes ...................................................................................... 26 Diabetes amongst indigenous people .................................................................... 28 Diabetes in the Arab world ................................................................................... 29 Obesity .................................................................................................................. 34 Obesity amongst indigenous people ................................................................. 35 Obesity amongst Arab populations ................................................................... 37 Explanations of the rise in diabetes ....................................................................... 40 Lay beliefs concerning diabetes ............................................................................ 43 Explanations of health inequalities ....................................................................... 46 Right to Health ...................................................................................................... 50 Community based lifestyle interventions .............................................................. 53 Clinical care interventions..................................................................................... 58 Conclusions ........................................................................................................... 61 2 Chapter 2 ................................................................................................................... 63 The Setting ................................................................................................................ 63 Bedouin in the Middle East ................................................................................... 63 Bedouin and Access to Health Care ...................................................................... 67 The Bedouin in Israel ............................................................................................ 71 Life style transition, poverty and Bedouin health ................................................. 76 Health services ...................................................................................................... 81 Bedouin Households ............................................................................................. 85 Conclusions ........................................................................................................... 89 Chapter 3 ................................................................................................................... 90 Research Methodology and Methods ........................................................................ 90 Fieldwork setting ................................................................................................... 91 Pilot Study ............................................................................................................. 92 Negotiating access to the Clinics .......................................................................... 93 Quantitative methods ............................................................................................ 96 Qualitative methods .............................................................................................. 96 Non -Participant Observation ................................................................................ 97 Semi-structured interviews with diabetic Bedouin patients ................................ 101 Natural Focus Group Interviews ......................................................................... 103 Positionality and Reflexivity in the field ............................................................ 105 Conclusions ......................................................................................................... 111 Chapter 4 ................................................................................................................. 113 Rights to Health Care .............................................................................................. 113 Right to Health .................................................................................................... 113 Aspects of Quality of Care .................................................................................. 114 Medical Records.................................................................................................. 115 Diabetic Patient records ...................................................................................... 117 Estimated Prevalence of Diabetes in the Health Centre...................................... 120 Clinical guidelines practice and implementation ................................................ 123 Daily routine work of clinic nurses and the quality of diabetes reviews ............ 127 Availability of Health Care ................................................................................. 135 Accessibility ........................................................................................................ 140 Economic accessibility ........................................................................................ 141 Acceptability of Health Care ............................................................................... 143 3 Conclusions ......................................................................................................... 151 Chapter 5 ................................................................................................................. 153 Explanatory Models and explanations of health inequalities .................................. 153 Socio-behavioural explanations of inequalities – Explanatory Models of illness ............................................................................................................................. 159 Lay explanatory models of Bedouin ................................................................... 161 Socio-Behavioural context of dietary habits ....................................................... 167 Physical activity and diabetes ............................................................................