Diabetes: a cross-cultural interview study of immigrants from Somalia

ORIGINAL ARTICLE

doi: 10.1111/j.1365-2702.2007.02099.x

Diabetes: a cross-cultural interview study of immigrants from Somalia Anne-Marie Wallin

MA, RN

¨ rebro County Council, O ¨ rebro, and School of Doctoral Student, Department of Community Medicine and Public Health, O Health Sciences, Department of Nursing Science, Jo¨nko¨ping University, Jo¨nko¨ping, Sweden

Monica Lo¨fvander

MD, PhD

Centre for Family Medicine, Department of Neurobiology, Caring Sciences and Society, Karolinska Institute, and Rinkeby Health Centre, Stockholm, Sweden

Gerd Ahlstro¨m

PhD, RNT

Professor, School of Health Sciences, Department of Nursing Science, Jo¨nko¨ping University, Jo¨nko¨ping, Sweden

Submitted for publication: 17 December 2006 Accepted for publication: 27 April 2007

Correspondence: Anne-Marie Wallin School of Health Sciences Department of Nursing Sciences Jo¨nko¨ping University PO Box 1026 SE-551 11 Jo¨nko¨ping Sweden Telephone: þ46 36101195 E-mail: [email protected]

¨ FVANDER M & AHLSTRO ¨ M G (2007) WALLIN A-M, LO

Journal of Nursing and Healthcare of Chronic Illness in association with Journal of Clinical Nursing 16, 11c, 305–314 Diabetes: a cross-cultural interview study of immigrants from Somalia Aim. To describe how diabetic immigrants from Somalia experience everyday life in Sweden and how they manage diabetes-related problems, with inclusion of a gender perspective. Background. To treat and care for minority populations successfully, healthcare staff in Sweden must thoroughly understand the illness experiences of different ethnic groups. However, no studies have so far been reported that focus on immigrants from Somalia with diabetes. Design. Descriptive, qualitative interview study with 19 diabetic adults born in Somalia and now living in Sweden. Method. Cross-cultural interviews with the aid of an interpreter. The transcribed interviews were subjected to qualitative latent content analysis, resulting in sub-themes and themes. Results. Four themes emerged: experience of distress in everyday life; everyday life continues as before; comprehensibility gives a feeling of control; and being compliant. A major finding was the variation in how the participants managed the fasting month of Ramadan. Several participants fasted and did not see the diabetes as an obstacle, others did see it as an obstacle or indicated that fasting was not compulsory for a sick person. Conclusions. This study provides healthcare staff with information about how a minority group experience and manage diabetes. The results indicate the importance of considering cultural background, as well as religious traditions such as Ramadan, in diabetes care. They also indicate that men and women differ in their reaction to diabetes and that care should be adapted to this. Relevance for clinical practice. It is important to develop evidence-based guidelines for diabetes care in ethnic groups that are fasting during Ramadan to prevent complications and promote relevant self-care. Further, the prescribed dietary advice must be culturally appropriate.

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Key words: cross-cultural interview study, diabetes, ethnic minorities, everyday life, interpreter latent content analysis

Introduction Diabetes mellitus (DM) is a global public health problem. About 150 million have the disease and the number is expected to double by 2025 (WHO 2002). Diabetes is divided into two major types, type 1 and type 2. The latter constitutes about 85% of all DM cases (Zimmet et al. 1997). Populations of developing countries, minority groups and population groups in industrialized countries with unfavourable living conditions are the ones who face the greatest risk of having diabetes (King & Rewers 1993, Zimmet 2000). As diabetes is a chronic disease, the people who have it must cope with it for the rest of their lives (Gillibrand & Flynn 2001). To have diabetes is like having a full-time occupation (Armstrong 1987). The treatment includes dietary adjustment, physical activity, self-monitoring of blood sugar, medication, behavioural strategies to promote lifestyle changes and education regarding how to integrate these components into one’s daily life (Hjelm et al. 2003). The goal of self-care is to prevent acute and long-term complications and to maintain a high quality of life. Gillibrand and Flynn (2001) point out that people with diabetes face a complex management problem in having to achieve and maintain a balance between quality of life and medical regime, at the same time keeping proper control of their metabolic condition. Dissimilarities between men and women’s experiences of living with diabetes have also been found. Women perceived that having diabetes had restricted their choices in life; men, on the other hand, perceived that it had had a positive effect on their lifestyle (Koch et al. 1999, 2000). In another study, men reported diabetes as less of hindrance in their normal daily activities than did women (Fitzgerald et al. 1995). Wenzel et al. (2005) found that women identify more barriers and psychosocial adjustment problems because of diabetes whereas men experience physical limitations. There are also dissimilarities between different ethnic groups in their experiences of chronic illness. Since Sweden, like many other countries, has become a multicultural society because of increased immigration, healthcare staff must understand immigrants’ illness experiences and how such experiences affect these people’s lives (Sutton et al. 2000, Saleh Stattin 2001). Hjelm (1998) states that there is a lack of studies focusing on people with diabetes and born in countries culturally remote from Sweden. Refugees from Somalia are 306

the biggest group of African immigrants in Sweden. The majority of them came in the early 1990s in connection with the civil war in Somalia. The aim of the present study was to describe how persons from Somalia with diabetes experience everyday living and how they manage diabetes-related problems. The findings will also be explored from a gender perspective.

Methods The design is descriptive and qualitative cross-cultural interviews were performed with the aid of an interpreter to reduce possible effects of language problems. The research project has been approved by the Regional Research-Ethical ¨ rebro University Hospital and the Central Committee of O Ethical Review Board, Uppsala.

Setting and participants The study was conducted at six primary health centres in two towns in central Sweden. Permission was received from the superintendent of each of the centres. Inclusion criteria for participation in the study were Somali-speaking adults (>18 years) diagnosed as having had diabetes for at least six months. If the person had other diseases, these should have been stable during the past year. Contact was made with the diabetic nurses at each primary health centre to get access to data in the medical records of the Somali-speaking diabetic patients who fulfilled the inclusion criteria. An informational letter about the study, translated into Somali, was sent to the 33 persons who fulfilled the inclusion criteria. After 3–4 days, they were contacted by telephone by the first author, or by the interpreter if they did not understand Swedish. They were given additional information about the study before being asked whether they would participate or not. They were guaranteed confidentiality and informed that participation was voluntary and that they could terminate their interview at any time without giving a reason. Of the 33 eligible persons, 19 agreed to participate. The participants and the drop-outs are presented in Table 1.

Data collection The first author performed individual face-to-face qualitative interviews. The interviewees were allowed to choose the

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Living with diabetes

Table 1 Participants and drops-out

Male/female Age: mean (range) Years in the country of exile: mean (range) Disease-duration, years: mean (range) Type of diabetes Type 2 diabetes Treatment Oral anti-diabetes drugs Combinations of tablet and insulin Insulin Diet Reason for drop-out Refused Not available on telephone Did not respond Unknown address

Respondent (n ¼ 19) number

Non-respondent (n ¼ 14) number

8/11 54Æ9 (30–83) 9Æ9 (1–14)

7/7 49Æ6 (30–71)

6Æ9 (1–13)

5Æ9 (0Æ7–18)

19

14

11 5

7 1

2 1

4 2 7 3 3 1

Except age, years in the country of exile land and duration of diabetes (mean and range).

place of the interview. Thus, 12 were interviewed in their homes, five in secluded but public places, one at a primary health centre and one at the interviewer’s workplace. The interviews were conducted with the aid of two bilingual professional interpreters originally coming from Somalia, one man and one woman. This was in case any participant wanted an interpreter of the same sex. Two participants did not want an interpreter; instead their husband or wife helped to translate when necessary. Characteristics of interviewer, interpreters and participants are shown in Table 2. To begin with, a meeting was held with the interpreters about the aim of the study, the data collection and the

interpreter’s role. The style of the interpretation during the interviews was consecutive, which means that only one person speaks at a time (Baker et al. 1991). The interpreter rendered the essential meaning of what was said. In most cases, the interviewer and interpreter sat side by side facing the interviewee. Sometimes, this arrangement was not convenient when the interview was performed in the person’s home. In such cases, a triangular seating arrangement was used. The interpreters were not previously known to most of the interviewees. The interviews lasted approximately two hours and were tape-recorded after permission from the interviewee. Field notes were taken with regard to two interviewees who did not want to be tape-recorded. The questions were open-ended to encourage the participants to speak freely. The opening question was: ‘what is it like to live with diabetes?’ If the subjects described problematical situations, follow-up questions were asked, such as: ‘what did you think at that time? ‘what did you feel at that time?’ and ‘what did you do?’ The intention was that the interview should be in the form of a narrative to provide a more indepth understanding and explore the topic from the participant’s angle without influence from the interviewer.

Analytical procedure The tape-recorded interviews were transcribed verbatim in Swedish and subjected to latent content analysis, involving an interpretation of the underlying meaning of the text (DowneWamboldt 1992, Graneheim & Lundman 2004). Each interview was analysed separately by the first author. The following steps were performed. First, the interview transcripts were read several times to obtain a sense of the whole. Second, the interview text was sorted into two broad content areas: (a) experiences of living with diabetes in everyday life; (b) management of diabetes in everyday life. Third, the text in each content area was divided into meaning units including words, sentences or paragraphs that related to the same

Table 2 Characteristics of the interviewer, interpreters and participants The interviewer

The interpreters

Female Age 50> Married

Male About 40 Married

Female About 20 Unmarried

Children Christian Swedish Experience of working with interpreters in clinical settings

Children Muslim Somalian Both have experience of working as an interpreter, but not in qualitative research interviews

No children Muslim Somalian

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The participants 11 women 8 men Aged 30–82 11 married, 4 widow/widower, 3 divorced, 1 unmarried All except one have children All Muslims Somalian Experience of earlier research unknown

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central meaning (Graneheim & Lundman 2004). Each meaning unit was, thereafter, condensed and in the next step the condensed meanings were abstracted and inductively labelled with codes. Finally, the codes were compared with an eye to differences and similarities and sorted into subthemes and themes. To strengthen credibility, the second and third authors performed a co-assessment of the data analysis. The authors discussed and refined sub-themes/themes until the most plausible interpretation of the data was reached. To strengthen the credibility of the findings further, one of the interpreters was included in the analytical procedure. The first author presented the interpreted findings and exemplified with quotations. The findings were discussed in depth by this author and the interpreter.

Findings The findings were expressed in four themes and 11 subthemes (Table 3). Quotations have been added from the interviews when statements included descriptions of cultural behaviour or faith. To emphasize that the participants were unable to communicate without an interpreter, quotations are in the third person. After all the theme findings, a summary regarding similarities and differences within and between the themes from a gender perspective is presented.

Experience of distress in everyday life This theme comprised four sub-themes: ‘physical deterioration has changed things’, ‘giving up activities and habits’, ‘need for strict everyday management’ and ‘difficulty of managing everyday life’ (Table 3).

Physical deterioration has changed things The participants narrated how diabetes had a negative influence on their body. They described how the disease affected them with physical powerlessness. Other negative effects were eye problems, headache, leg pain, impotence, insomnia and oscillation of blood sugar levels. The participants indicated that life had been simple without diabetes and that the disease had affected their health and life in a negative way. Giving up activities and habits Some mentioned that they had to give up activities and habits because of diabetes. One of the participants spoke of inactivity after the diagnosis, which had given rise to loneliness and isolation from friends. The disease as an obstacle to contact with friends was mentioned particularly in connection with not feeling well. Some mentioned that they had withdrawn from education and avoided situations that could give rise to irritation. One was worried about diabetes as an obstacle to future choice of vocation. A more common problem was having to give up traditional eating habits and the disease as an obstacle to celebrating Ramadan (the fasting month) – not being able to celebrate Ramadan gave a bad conscience: She said it’s for Allah’s sake you’re fasting. When she sees others fasting and she can’t do it herself she feels bad. (Interviewee 17)

Need for strict everyday management Some of the statements dealt with the lack of freedom caused by diabetes. The participants felt tied by having to test blood sugar levels, keep to a prescribed diet and take medicine at appropriate times. One participant spoke of walking a

Table 3 The participants’ experiences of everyday living and their management of illness-related problems

Themes

Sub-themes

Experience of distress in everyday life

Physical deterioration has changed things Giving up activities and habits Need for strict everyday management Difficulty in managing everyday life Maintaining religious practices Not feeling ill Becoming acquainted with warning signs from the body and coping with them Permitted to restrain from fasting during Ramadan Must do as they say Difficulty of doing as they say Being dependent on others

Everyday life continues as before Comprehensibility giving a feeling of control

Being compliant

308

Number of meaning units

Number of interviews

36 13 14 20 21 20 42

2, 4–5, 7, 9, 12–16, 19 5–7, 9, 13, 16–17, 19 1–2, 6, 8, 10, 12, 17, 19 1, 3–5, 7,13, 15–18 3, 5–6, 9–12, 16, 18–19 1, 3, 5–6, 8, 10–12, 14, 16, 1 1,4–9, 11–14, 16–19

19

3–4, 7–8, 13–15, 17–18

46 25 9

1, 3–7, 9–12, 14, 16–19 1, 3, 5, 7–9, 12–13, 15–19 3, 6–7, 12–15

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tightrope between previous and current lifestyle. Another participant longed to be able to eat all the traditional food again: She’d like to eat just about everything. She says she’d eat any Somalian food. (Interviewee 12)

Difficulty in managing everyday life For some of the participants, everyday life was filled with worries, especially regarding high blood sugar levels. There was worry about not complying with medical advice because of illiteracy and there was fear of dying from the complications of diabetes. Difficulty in managing everyday life resulted from a lack of understanding on the part of family and friends. This was mentioned especially in connection with the need to keep to a strict diet. One participant, a single parent, spoke of how difficult it was for her to see to everything herself when at the same time she had diabetes. There was mention of difficulty concerning injecting the appropriate amount of insulin during pregnancy, of cultural difficulties with regard to having to adapt to regular routines of eating and of insecurity regarding what could be eaten of the traditional foods: Our diet, she says, is mostly made up of sweet and fat food and when you can’t eat that you can’t really eat at all. (Interviewee 13)

Everyday life continues as before This theme comprised the following sub-themes: ‘maintaining religious practices’ and ‘not feeling ill’ (Table 3). Maintaining religious practices Many participants talked about the importance of celebrating Ramadan and did not see diabetes as a barrier to this practice. They used to fast even though, according to the Quran, it is not obligatory to do so if it can be dangerous to health. The participants who celebrated Ramadan were treated with oral anti-diabetes drugs and maintained that fasting and drugs can be combined for example by taking one dose earlier at the meal before sunrise: She takes one tablet in the morning and one in the evening. Early in the morning before sunrise she takes one and the other one in the evening. No problem, she says, because she eats after sunset. (Interviewee 16)

Some of the participants spoke of fasting as being beneficial to health, for which reason it was important to do the fasting as long as they had the energy for it. One participant experienced improved health during Ramadan:

Living with diabetes His health is much better during the days he’s fasting than on his ordinary days. After Ramadan you can add one week of fasting and he usually does that too. He has no problem with it at all. (Interviewee 11)

Not feeling ill Several of the participants did not perceive themselves as ill. They did not think about having diabetes and considered themselves as living a normal life like everybody else and without an increased number of problems. Having diabetes was not different from having normal health.

Comprehensibility giving a feeling of control This theme comprised the following sub-themes: ‘becoming acquainted with warning signs from the body and coping with them’ and ‘permitted to restrain from fasting during Ramadan’ (Table 3). Becoming acquainted with warning signs from the body and coping with them Several of the participants perceived when blood sugar levels were too high and managed the situation by means of exercise or insulin injections. They had learned from experience that physical exercise regulated a high blood sugar level. One participant, for instance, had noticed that her blood sugar level had much improved after she had started regular physical training. Further, the participants were aware of the importance of their food intake in relation to the blood sugar level. A few participants avoided situations which could cause irritation because they had discovered that anger affected their blood sugar in a negative way. Permitted to restrain from fasting during Ramadan The participants indicated that fasting was not compulsory for a Muslim who has an illness such as diabetes, because ‘fasting takes too much of your energy’, or ‘too many hours without food’ is not good for diabetics. Some disclosed that the decision whether to fast or not depended on when the fasting month occurred and how they felt. If they thought that fasting might jeopardize their health, they refrained from it because their health was more important. If you must restrain from fasting, you can replace this in other ways: She’s been to the mosque and asked the Imam what she could do instead of fasting. He said she has to give food to the poor. So she sent money to Somalia, where there are a lot of poor people. (Interviewee 18)

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Being compliant This theme comprised three sub-themes: ‘must do as they say’, ‘difficulty of doing as they say’ and ‘being dependent on others’ (Table 3). Must do as they say The participants followed the prescribed diet, but had made great changes in their traditional food, a substantial personal sacrifice. Some of the new food was difficult to get used to but they tried to be compliant for the sake of their health. One participant, for instance, being advised to eat vegetables and beans but finding this difficult, solved the problem by mixing them into a soup. Another participant spoke of keeping to the recommended healthy food despite not liking it. Some had found it difficult to give up the traditional foods. Some tried to follow the advice as strictly as possible: The health professionals tell him to utilize the ‘plate model’. Vegetables, potatoes or rice like this [showing how to place it on the plate]. They tell him not to eat too much of anything. They’ve told him to eat brown bread as well, so the family utilizes brown bread. The family purchases the things the health professionals have recommended, like food for diabetics that’s marked with a keyhole. When the family see food with a keyhole, they buy it. (Interviewee 6)

The participants also tried to comply with the advice to do some sort of physical activity every day. One participant found it difficult to go for a walk but followed the doctor’s advice to walk indoors instead. Another participant mixed physical exercise with public transport: For instance, he usually does like this when he comes to the town centre by bus: he gets off at [X] and then walks the whole distance to the mosque and then walks back to [X] and gets the bus home. He tries to do some walking every day. (Interviewee 19)

For almost all of the participants, lifestyle changes were not enough, they needed to take medication too. Several of them described their compliance with regard to taking their medicine and how their health was much improved as they started to take the prescribed medication. One participant emphasized the importance of following the doctor’s advice to prevent long-term complications. Difficulty of doing as they say Following the advice of health professionals and changing one’s lifestyle were considered hard work. The participants mentioned many barriers to changes in lifestyle, particularly when it came to eating habits. Poor financial situation and 310

tastelessness of the prescribed diet were among the barriers mentioned. Also, it was difficult to give up the traditional food and follow the ‘plate model’. Barriers also existed with respect to physical exercise, mainly that of a cold climate in the winter, which prevented outdoor walks. Being dependent on others After the participants had received their diagnosis, they found themselves more dependent on others. A few were dependent on personal assistants or relatives to inject appropriate amounts of insulin and to do the cooking. One participant, who did not test the blood sugar herself, turned to healthcare staff when she felt ill and so did another when the blood sugar got too high. There were also narratives going in the other direction. An illiterate participant struggled to be independent and to manage the prescribed self-care this participant tried to learn all the advice from the health professionals by heart. The participant did not deny that there had sometimes been misunderstandings. Analysis of the four themes from a gender perspective Living with diabetes had involved a lack of freedom for the participants. Men spoke of reduced physical power and complications due to diabetes, whilst women in general expressed concern about the effects of having a reduced level of health. Both men and women felt tied by the task of testing their blood sugar levels, keeping to a prescribed diet and taking medicine. Women emphasized the necessity of physical exercise and proper food intake to control their blood sugar, men only talked about food intake. Women talked about difficulties with regard to managing everyday life when there was lack of support from the family, men saw cultural difficulties with regard to adapting to regular meal-times and routines. Different aspects dependent on gender were mentioned with regard to fasting. Many, both men and women, did not see diabetes as an obstacle when it came to celebrating Ramadan but a minority, especially women, did perceive it as such. Women who did not fast said that Ramadan was not compulsory for those who were ill, whilst men took the decision to fast or not depending upon when Ramadan occurred. To manage everyday living, the participants, irrespective of gender, tried to comply with the advice they had been given about diet, daily physical activity and medicine. However, difficulties were mentioned, especially with regard to the diet: the prescribed food was often expensive and had no taste. Women spoke of having become more dependent on others after being diagnosed as having diabetes. Irrespective of gender, the participants did not generally perceive themselves

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as ill even though manifestations of disease symptoms were present.

Discussion No studies have, as far as we know, been reported that focus on immigrants from Somalia with diabetes. The findings of the present study indicate the importance of considering cultural background as well as religious traditions in diabetes care. The findings also indicate that care needs be adapted to gender-related differences in the experience of diabetes. Celebrating Ramadan by fasting was important for many participants and they did not see diabetes as an obstacle. However, patients with chronic diseases often insist on fasting even though they are not obliged to according to Islamic rules (Aadil et al. 2004). The reason for this can be difficulty in not fasting if the rest of the household does so, or a feeling of being less spiritual if one does not fast (Green 2004). Celebrating traditions can also be considered important for health (Hjelm et al. 1999, 2005), or a means of preserving one’s identity for the consolidation of the feeling of togetherness within the ethnic group in a new country (Jonsson et al. 2002a). The importance of celebrating Ramadan was brought out in a population-based survey study where almost 43% of patients with type 1 diabetes and almost 79% with type 2 had fasted for at least 15 days during Ramadan (Salti et al. 2004). In Ramadan, a Muslim fasts from sunrise to sunset (Qureshi 2002). Those who celebrated Ramadan in our study were being treated with oral anti-diabetes drugs and several of them had changed their drug intake during Ramadan. This is in agreement with Aslam and Healy’s (1986) study where 37 out of 81 Asian patients had changed their drug intake during Ramadan. There is no medical agreement as to whether it is safe for a person with diabetes to fast. One opinion is that diabetics can fast if they are given the appropriate advice about diet and the time that should elapse between doses of medicine (Sulmani et al. 1988). Another opinion is that Muslims who have DM should be advised not o fast, unless their diabetes is treated with diet alone (Barber et al. 1979). Benaji et al. (2006) sum up in their review that fasting is acceptable for persons with well-balanced type 2 diabetes who are compliant with regard to both medicine and diet. However, as Qureshi (2002) pointed out, a big evening meal (Iftari) with extra sweet and savoury foods is taken after sunset and a light meal (Sehri) before sunrise, during Ramadan. Some Muslims omit the latter meal because they do not want disturb their non-Muslim neighbours. Health professionals need to know about such practices when they are to give dietary advice to those who celebrate Ramadan.

Living with diabetes

Those participants who did not celebrate Ramadan pointed out that fasting was not compulsory for a Muslim with a disease. Especially women mentioned this, while men’s decision to fast or not depended upon when Ramadan occurred. Ramadan is a lunar month, which means it occurs 11 days earlier from year to year (Benaji et al. 2006) and can thus occur in any of the four seasons and varies from 11 to 18 hours a day (Aadil et al. 2004). Those who are unable to fast may replace their fast by providing food for one person for each day of the fasting period. The food is usually replaced by a sum of money which is sent to a charity (Hill 2006). This was practised by some in the present study. Most participants in our study expressed a lack of freedom because of a strict everyday management. This is in line with what has been found in earlier studies with type 1 diabetes patients (Lundman et al. 1990) and type 2 diabetes patients (McCord & Brandenburg 1995). Women in the present study found it hard to follow the prescribed diet when support from the family was lacking and the same thing has been found in earlier studies (El-Kebbi et al. 1996, Samuel-Hodge et al. 2000). Also mentioned was uncertainty as to what to eat of the traditional food. A reason might be, as Nthangeni et al. (2002) have suggested, that advice is seldom culturally appropriate. Especially, women in our study said that they had the required knowledge to manage hyperglycaemia. This was in disagreement with the results of a study with a Pakistani Moslem diabetic population where men had better knowledge than women in this respect (Hawthorne & Tomlinson 1999). Many of the participants stated that they had followed the advice they had received to cope with the disease. Similar statements have been made by participants in other studies (McCord & Brandenburg 1995, Hawthorne & Tomlinson 1999). However, some participants found it hard to follow dietary advice because of lack of money, the tastelessness of the prescribed food and the difficulty of giving up traditional food. This, too, is in line with other studies (El-Kebbi et al. 1996, Nthangeni et al. 2002). A Swedish study with Somalian women indicated that food can be a means of constructing ethnic identity in exile (Jonsson et al. 2002b). This indicates the importance of offering culturally adapted food advice to achieve a high level of compliance with dietary prescriptions. Many of the participants, both men and women, did not perceive themselves as being ill. This has also been found earlier in the case of people with type 1 diabetes (Ternulf Nyhlin et al. 1987) and type 2 diabetes (Koch et al. 2000). However, in a study by Koch et al. (1999), women did see themselves as ill.

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Methodological considerations When interpreting the findings of this study, it should be borne in mind that those who dropped out are likely to have experienced more distress in everyday life and to have had more difficulty in coping with the problems arising from diabetes. A recent review of the literature concerning qualitative cross-cultural interview studies involving interpreters (Wallin & Ahlstro¨m 2006) highlighted the fact that methodological issues related to working with an interpreter had received only limited attention. Particular attention has been paid in this study to describe the interpreter’s competence and style of interpreting and to indicating the seating arrangement during an interview, which are prerequisites for the reader’s in determining the trustworthiness of a cross-cultural interview study involving an interpreter (Wallin & Ahlstro¨m 2006). Issues about ‘matching’ the interpreter and participants with respect to gender, ethnicity, age and other characteristics that can influence the content of the interview have been investigated in the literature (Freed 1988, Baker et al. 1991, Jentsch 1998). However, the matching process should also be guided by the aim of the interview and by the interviewee’s wishes (Baker et al. 1991, Murray & Wynne 2001). For instance, the participants in the present study had the opportunity to choose gender of the interpreter, but this was not of any importance for most of them. One explanation of this can be that the topic of the research was considered rather neutral with respect to gender. We used professional interpreters, as recommended by some when language is a barrier (Lo¨fvander 1997, Esposito 2001) and we used more than one. This may have resulted in slightly different interpretations that could have influenced the reliability of the findings. The interpreters were not known to most of the participants. Jentsch (1998) considers this advisable because when the interviewees know an interpreter and the latter is familiar with their situation, the interpreter will sometimes answer the interviewer’s questions without first asking the interviewee. It is not uncommon that refugees are unwilling to participate in research studies. Therefore, it is of particular importance to consider ethical aspects (Samarasinghe & Arvidsson 2002). In this study, only oral informed consent was used, because written consent could be perceived as an affront, implying that the researcher did not take them at their word (Lipson & Meleis 1989). A threat does exist to trustworthiness if the data analysis is performed without involving someone who understands the language and culture of the participants (Edwards 1998, Tsai et al. 2004). To strengthen the credibility of the findings in the present study, an in-depth discussion was held with one of 312

the interpreters where the findings were presented and exemplified with quotations from the data to make sure the interpretations were correct. To ensure additional rigour in the study, we used Im et al.’s (2004) five evaluation criteria: cultural relevance, contextuality, appropriateness, mutual respect and flexibility. To ensure cultural relevance and contextuality, in this study, the first author was discussed the research project with a person originally from Somalia before the start and the research questions were discussed with the two interpreters. We used appropriate verbal communication styles as we used two interpreters originally from Somalia and we paid particular attention to describing the interpreter’s competence, style of interpreting and role in the procedure of data and data collection and analysis. Trust and mutual respect are important in all studies. In our study, the participants had the opportunity to choose an interpreter of the same sex and the interviews was performed with openended questions to allow the participants to describe their own experiences. Finally, we were flexible in that the participants had the opportunity to choose both the time and place of the interview. The pre-understanding of the interviewer, based upon long experience as a nurse in primary care settings with a large proportion of foreign-born people, could have influenced the results in both a positive and a negative way. The positive way is that the interviewer has extensive experience of communicating with an interpreter. The negative is that this pre-understanding may have induced participants to answer in a way they thought the interviewer wanted to hear, as they may have seen her as a nurse instead of as a neutral interviewer. However, the impression was that the participants felt confident with both researcher and interpreter and gave trustworthy accounts. None of the participants had a dependent relation to the interviewer which could have influenced the results.

Conclusion Diabetes had restricted the participants’ freedom because of the need for strict everyday management. Many complied with what was prescribed by the health professional, but found it difficult to follow dietary advice because of its not being culturally appropriate. Many participants had fasted during Ramadan and did not see diabetes as an obstacle to this.

Implications for nursing The results demonstrate that, in diabetes care, it is important to consider both cultural background and religious traditions

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such as Ramadan. Health professionals must be aware that a person’s religion may be of primary importance to him or her (Green 2004). As many Muslim diabetics seem to be fasting, there is a need for evidence-based guidelines to prevent complications and promote relevant self-care. Furthermore, there is commonly a longing for traditional food, so it is important that dietary advice be culturally appropriate. Finally, the results imply that health professionals should understand the need for different treatment for men and women.

Acknowledgements We wish to thank the two interpreters for their interpreting and the male interpreter for his function as cultural broker when the results of the study were discussed. We also wish to thank Prof. Peter Engfeldt for his support and introduction of the study at primary health centres in the two towns where the study was performed. The research was supported by grants from the Research Committee and Department of ¨ rebro County Community Medicine and Public Health, O ¨ Council, Orebro, Sweden.

Author contributions Study conception and study design: AMW and GA; data collection, data analysis and drafting the paper: AMW; and data analysis and manuscript preparation: GA, ML.

References Aadil N, Houti IE & Moussamih S (2004) Drug intake during Ramadan. British Medical Journal 329, 778–782. Armstrong N (1987) Coping with diabetes: a full-time job. Nursing Clinics of North America 22, 559–568. Aslam M & Healy MA (1986) Compliance and drug therapy in fasting Moslem patients. Journal of Clinical Hospital Pharmacy, 11, 321–325. Baker P, with Hussain Z & Saunders J (1991) Interpreters in Public Services: Policy and Training. Venture Press, London. Barber SG, Fairweather S, Wright AD, FitzGerald MG & Malins JM (1979) Muslims, Ramadan and diabetes mellitus. British Medical Journal July 7, 46–47. Benaji B, Mounib N, Roky R, Aadil N, Houti IE, Moussamih S, Maliki S, Gressier B & El Ghomari H (2006) Diabetes and Ramadan: review of the literature. Diabetes Research and Clinical Practice 73, 117–125. Downe-Wamboldt B (1992) Content analysis: method, applications and issues. Health Care for Women International 13, 313–321. Edwards R (1998) A critical examination of the use of interpreters in the qualitative research process. Journal of Ethnic and Migration Studies 24, 197–208.

Living with diabetes El-Kebbi IM, Bacha GA, Ziemer DC, Musey VC, Gallina DL, Dunbar V & Phillips LS (1996) Diabetes in urban African Americans. V. Use of discussion groups to identify barriers to dietary therapy among low-income individuals with non-insulin-dependent diabetes mellitus. The Diabetes Educator 22, 488–492. Esposito N (2001) From meaning to meaning: the influence of translation techniques on non-English focus group research. Qualitative Health Research 11, 568–579. Fitzgerald JT, Anderson RM & Davis WK (1995) Gender differences in diabetes attitudes and adherence. The Diabetes Educator 21, 523–529. Freed AO (1988) Interviewing through an interpreter. Social Work July/August, 315–319. Gillibrand W & Flynn M (2001) Forced externalization of control in people with diabetes: a qualitative exploratory study. Journal of Advanced Nursing, 34, 501–510. Graneheim UH & Lundman B (2004) Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today 24, 105–112. Green V (2004) Understanding different religions when caring for diabetes patients. British Journal of Nursing 13, 658–662. Hawthorne K & Tomlinson S (1999) Pakistani Moslems with type 2 diabetes mellitus: effect of sex, literacy skills, known diabetic complications and place of care on diabetic knowledge, reported self-monitoring management and glycaemic control. Diabetic Medicine 16, 591–597. Hill J (2006) Management of diabetes in South Asian communities in the UK. Nursing Standard 20, 57–64. Hjelm K (1998) Migration, Health and Diabetes Mellitus. Studies Comparing Foreign- and Swedish-Born Diabetic Subjects Living in Sweden. Doctoral dissertation, Department of Community Health Sciences, Lund University. Hjelm K (1999) Beliefs about health and illness essential for self-care practice: a comparison of migrant Yugoslavian and Swedish diabetic females. Journal of Advanced Nursing 30, 1147–1159. Hjelm K, Mufunda E, Nambozi G & Kemp J (2003) Preparing nurses to face the pandemic of diabetes mellitus: a literature review. Journal of Advanced Nursing 41, 424–434. Hjelm KG, Bard K & Apelqvist J (2005) Beliefs about health and diabetes in men of different ethnic origin. Journal of Advanced Nursing 50, 47–59. Im EO, Page R, Lin LC, Tsai HM & Cheng CY (2004) Rigor in cross-cultural nursing research. International Journal of Nursing Studies 41, 891–899. Jentsch B (1998) The ‘interpreter effect’: rending interpreters visible in cross-cultural research and methodology. Journal of European Social Policy 8, 275–289. Jonsson IM, Wallin AM, Hallberg LR & Gustavsson IB (2002a) Choice of food and food traditions in pre-war Bosnia-Herzegovina: focus group interviews with immigrant women in Sweden. Ethnicity and Health 7, 149–161. Jonsson IM, Hallberg LR-M & Gustafsson IB (2002b) Cultural foodways in Sweden: repeated focus group interviews with Somalian women. International Journal of Consumer Studies 26, 328–339. King H & Rewers M (1993) Global estimates for prevalence of diabetes mellitus and impaired glucose tolerance in adults. Who Ad Hoc Diabetes reporting group. Diabetes Care 16, 157–177.

Ó 2007 The Authors. Journal compilation Ó 2007 Blackwell Publishing Ltd

313

A-M Wallin et al. Koch T, Kralik D & Sonnack D (1999) Women living with type II diabetes: the intrusion of illness. Journal of Clinical Nursing 8, 712–722. Koch T, Kralik D & Sonnack D (2000) Men living with diabetes: minimizing the intrusiveness of the disease. Journal of Clinical Nursing 9, 247–254. Lipson JG & Meleis AI (1989) Methodological issues in research with immigrants. Medical Anthropology 12, 103–113. Lo¨fvander M (1997) Illness, Disease, Sickness. Clinical Factors, Concepts of Pain and Sick Leave Patterns Among Immigrants in Primary Health Care. Effects of Different Therapeutic Approaches. Dissertation, Department of Clinical Neuroscience and Family Medicine, Division of Family Medicine, Karolinska Institutet, Stockholm, Sweden. Lundman BM, Asplund K & Norberg A (1990) Smoking and metabolic control in patients with insulin-dependent diabetes mellitus. Journal of Internal Medicine 227, 101–106. McCord EC & Brandenburg C (1995) Beliefs and attitudes of persons with diabetes. Family Medicine 27, 267–271. Murray CD & Wynne J (2001) Researching community, work and family with an interpreter. Community, Work and Family 4, 151– 171. Nthangeni G, Steyn NP, Alberts M, Steyn K, Levitt NS, Laubscher R, Bourne L, Dick J & Temple N (2002) Dietary intake and barriers to dietary compliance in black type 2 diabetic patients attending primary health-care services. Public Health Nutrition 5, 329–338. Qureshi B (2002) Diabetes in Ramadan. Journal of the Royal Society of Medicine 95, 489–490. Saleh Stattin N (2001) Immigrant Patients with Diabetes. How They Understand, Learn to Manage and Live with Their Diabetes. Doctoral dissertation, Department of Public Health and Caring Sciences, Health Services Research, Uppsala University, Sweden. Salti I, Be´nard E, Detournay B, Bianchi-Biscay M, Le Brigand C, Voinet C, Jabbar A on behalf of the EPIDIAR study group. (2004) A population-based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries. Results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study. Diabetes Care 27, 2306–2311. Samarasinghe K & Arvidsson B (2002) ‘It is a different war to fight here in Sweden’ – the impact of involuntary migration on the

314

health of refugee families in transition. Scandinavian Journal of Caring Sciences 16, 292–301. Samuel-Hodge CD, Headen SW, Skelly AH, Ingram AF, Keyserling TC, Jackson EJ, Ammerman AS & Elasy TA (2000) Influences on day-to-day self-management of Type 2 diabetes among AfricanAmerican women. Diabetes Care 23, 928–933. Sulmani RA, Famuyiwa FO & Laajam MA (1988) Diabetes mellitus and Ramadan fasting: the need for a critical appraisal. Diabetic Medicine 5, 589–591. Sutton M, McGrath C, Brady L & Ward J (2000) Diabetic foot care: assessing the impact of care on the whole patient. Practical Diabetes International 17, 147–151. Ternulf Nyhlin K, Lither F & Norberg A (1987) Experience of being diabetic – ‘it is up to oneself to manage’. Scandinavian Journal of Caring Sciences 1, 59–62. Tsai JH-C, Choe JH, Lim JMC, Acorda E, Chan NL, Taylor V & Tu S-P (2004) Developing culturally competent health knowledge: issues of data analysis of cross-cultural, cross-language qualitative research. International Journal of Qualitative Methods 3, Article 2. Retrieved 7 March 2005 from http://www.ualberta.ca/iiqm/ backissues/3_4/pdf/tsai.pdf Wallin A-M & Ahlstro¨m G (2006) Cross-cultural interview studies using interpreters: systematic literature review. Journal of Advanced Nursing 55, 723–735. Wenzel J, Utz SW, Steeves R, Hinton I & Jones RA (2005) ‘Plenty of sickness.’ Description by African Americans living in rural areas with type 2 diabetes. The Diabetes Educator 31, 98–107. WHO (2002) Definition, Diagnosis and Classification of Diabetes Mellitus and Its Complications. Report of a WHO Consultation. Part 1: Diagnosis and Classification of Diabetes Mellitus. World Health Organization, Department of Noncommunicable Disease Surveillance, Geneva. Zimmet P (2000) Globalization, coca-colonization and the chronic disease epidemic: can the Doomsday scenario be averted? Journal of Internal Medicine 247, 301–3110. Zimmet PZ, McCarty DJ & de Courten MP (1997) The global epidemiology of non-insulin-dependent diabetes mellitus and the metabolic syndrome. Journal of Diabetes and Its Complications 11, 60–68.

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