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The lifestyle and health of Saudi women with special reference to type 2 diabetes mellitus Al-Bannay, Hana 2013

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The Lifestyle and Health of Saudi Women with Special Reference to Type 2 Diabetes Mellitus by Hana Al-Bannay MA, Royal Roads University, 2008  A DISSERTATION SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES (Rehabilitation Sciences) THE UNIVERSITY OF BRITISH COLUMBIA  (Vancouver)  June 2013 © Hana Al-Bannay, 2013  ABSTRACT Although the health of Saudi women has been severely compromised by lifestylerelated conditions like Type 2 Diabetes Mellitus (T2DM), this topic has been understudied particularly in relation to women’s cultural and religious contexts. This thesis constitutes exploratory work with the aim of informing lifestyle-related health studies for women in Saudi Arabia. Its objectives included: Study One, to examine Saudi women’s lifestyle-related health beliefs and behaviours and their understanding of religious teachings in relation to health behaviours and; Study Two, to explore the outcomes of a pilot intervention study of a T2DM education program, based on international standards and adapted to participants’ cultural and religious contexts, and compare outcomes of this intervention with outcomes of usual care for diabetes in Saudi Arabia. The studies were conducted in Dammam, Saudi Arabia. In Study One, a crosssection of women (n=407) participated in interviews based on a survey questionnaire about lifestyle-related health beliefs and behaviours, and related religious teachings. In Study Two, women at risk of or diagnosed with T2DM (n=35 including drop-outs) were assigned to two groups; an Intervention Group participated in a T2DM education program, based on international standards and tailored to Saudi women’s cultural and religious contexts, and a Usual Care Group received the usual care for diabetes in Saudi Arabia. Outcomes included blood glucose, body composition, six-minute walk test, life satisfaction, quality of life, and diabetes knowledge. At the end of the study, the Intervention Group participated in a focus group discussion of their program experience. For the analysis of our data, we used mixed methods; descriptive statistics (SPSSv.20) were used to analyze the quantitative data and Atlas.ti® software to code themes in the  ii  qualitative data. Results from Study One showed that Saudi women commonly report lifestyle-related conditions that are associated with unhealthy behaviours in contrast to their positive beliefs about healthy lifestyle and their understanding of related Islamic teachings. Study Two showed that Saudi women may benefit from a T2DM education program, based on international standards and adapted to their cultural and religious contexts. These findings provide several avenues for future research related to the health of Saudi women.  iii  PREFACE Studies described in Chapters Three and Four on which this thesis is based were approved by the UBC Human Ethics Board (UBC BREB # H10-01825, H11-02361 for Study One and Study Two, respectively) and the Ministry of Health in Saudi Arabia. Specific chapters of this dissertation are in preparation for publication. Chapter Two has been published in Health Promotion Journal. The Description of the tailoring of the Harvard Special Health Reports on diabetes to the cultural and religious contexts of women in Saudi Arabia in Chapter Four was accepted as a book chapter. Chapters Three and Four are in preparation for publication. All chapters have multiple authors. The details of authorship contributions are listed below. Chapter 2: Co-authors are Dr. Elizabeth Dean, Dr. Lyn Jongbloed, Dr. Tal Jarus, and Dr. Maya Yazigi. Dr. Dean was responsible for jointly writing the paper with me as well as reviewing and editing all chapters. Dr. Jongbloed, Dr. Jarus, and Dr. Yazigi contributed to designing, reviewing, and editing the chapter draft. Chapter 3: Co-authors are Dr. Elizabeth Dean, Dr. Lyn Jongbloed, and Dr. Tal Jarus. Dr. Dean was responsible for jointly developing the study concept with me, as well as reviewing and editing all chapters. Dr. Jongbloed and Dr. Jarus contributed to the study design and data analysis as well as reviewing the chapter draft. Chapter 4: Co-authors are Dr. Elizabeth Dean, Dr. Lyn Jongbloed, and Dr. Tal Jarus, Dr. Dean was responsible for jointly developing the study concept with me, as well as reviewing and editing all chapters. Dr. Jongbloed and Dr. Jarus contributed to the study design and data analysis as well as reviewing the chapter draft.  iv  Chapter 4: Tailoring the Harvard Special Health Reports on Diabetes to the Cultural and Religious Contexts of Women in Saudi Arabia; co-authors are Dr. Elizabeth Dean, Dr. Lyn Jongbloed, Dr. Tal Jarus, and Dr. Zhenyi Li. Dr. Dean was responsible for jointly developing the study concept with me, as well as reviewing and editing all chapters. Dr. Jongbloed, and Dr. Jarus contributed to the study design and data analysis as well as reviewing the draft. Dr. Li contributed to the reviewing and editing the draft.  v  TABLE OF CONTENTS ABSTRACT ................................................................................................................................... ii PREFACE ...................................................................................................................................... iv TABLE OF CONTENTS.............................................................................................................. vi LIST OF TABLES ......................................................................................................................... x LIST OF FIGURES ....................................................................................................................xiv ACKNOWLEGEMENTS ............................................................................................................ xv DISCLAIMER ........................................................................................................................... xvii DEDICATION ......................................................................................................................... xviii 1.  INTRODUCTION, LITERATURE REVIEW, AND RATIONALE FOR THE THESIS ................................................................................................................................................. 1 1.1. Introduction ..................................................................................................................... 1 1.2. Literature Review .......................................................................................................... 1 1.2.1. Smoking ............................................................................................................................. 1 1.2.2. Hypertension ................................................................................................................... 2 1.2.3. Obesity ............................................................................................................................... 3 1.2.4. Diabetes Mellitus............................................................................................................ 3 1.2.5. Women and Diabetes.................................................................................................... 4 1.2.6. Health Promotion and Diabetes Management in Saudi Arabia .................... 5 1.2.7. The World Health Organization Recommendations for Diabetes SelfManagement .................................................................................................................... 7 1.2.8. Diabetes Management and Culture ......................................................................... 7 1.2.9. Islamic Perspective on Health................................................................................... 8 1.2.10. The International Classification of Functioning, Disability and Health . 10 1.2.11. Health Behaviour Theories ..................................................................................... 11 1.2.12. Health Behaviour Definitions ................................................................................. 12 1.2.13. The Social Ecological Model of Health Behaviour .......................................... 12 1.2.14. Community and the Social Ecological Model of Health Behaviour .......... 13 1.2.15. Health Promotion and Health Education ........................................................... 14 1.2.16. Saudi Arabia: Historical and Cultural Backgrounds ...................................... 15 1.2.17. Women’s Health in the Islamic Culture of Saudi Arabia .............................. 19 1.3. Rationale for the Thesis............................................................................................ 20 1.3.1. Rationale ........................................................................................................................ 20 1.3.2. Goals and Objectives .................................................................................................. 21 1.4. Thesis Chapters ........................................................................................................... 22  vi  2.  CULTURE AS A VARIABLE IN HEALTH RESEARCH: PERSPECTIVES AND CAVEATS ........................................................................................................................... 24 2.1. Summary ........................................................................................................................ 24 2.2. Introduction .................................................................................................................. 25 2.2.1. Culture and Research Paradigms.......................................................................... 27 2.2.2. Culture in Health Promotion Research............................................................... 28 2.3. Culture as a Variable in the Research Processes ............................................ 29 2.3.1. The Research Problem .............................................................................................. 31 2.3.2. Sampling ......................................................................................................................... 32 2.3.3. Surveys ............................................................................................................................ 35 2.3.4. Interviews ...................................................................................................................... 37 2.4. Conclusion ..................................................................................................................... 39  3.  STUDY ONE: LIFESTYLE-RELATED HEALTH BELIEF AND BEHAVIOURS OF SAUDI WOMEN LIVING IN DAMMAM....................................................................... 40 3.1. Introduction .................................................................................................................. 40 3.2. Research Objectives ................................................................................................... 41 3.2.1. Primary Objectives ..................................................................................................... 41 3.2.2. Secondary Objectives ................................................................................................ 41 3.3. Methods .......................................................................................................................... 41 3.3.1. Sampling Frame ........................................................................................................... 41 3.3.2. Sampling and Recruitment ...................................................................................... 42 3.3.3. Survey Questionnaire Construction .................................................................... 43 3.4. Data Analysis ................................................................................................................ 45 3.4.1. Quantitative Data ........................................................................................................ 45 3.4.2. Qualitative Data ........................................................................................................... 45 3.5. Results ............................................................................................................................. 46 3.5.1. Response Rate .............................................................................................................. 46 3.5.2. Demographic Data ...................................................................................................... 46 3.5.3. Subject Characteristics ............................................................................................. 46 3.5.4. Health Status ................................................................................................................. 47 3.5.5. Health Conditions ....................................................................................................... 47 3.5.6. Physical Activity Behaviours .................................................................................. 47 3.5.7. Nutrition Behaviours ................................................................................................. 47 3.5.8. Smoking, Stress, and Sleep Behaviours .............................................................. 48 3.5.9. Health Beliefs................................................................................................................ 48 3.5.10. Quotes Reported by Participants .......................................................................... 48 3.6. Discussion of the Results in Relation to the Study Objectives ................... 48 3.6.1. Participants’ Health Profiles with Special Reference to Lifestyle-related Conditions ...................................................................................................................... 48 3.6.2. Participants’ Lifestyle-related Health Behaviours ......................................... 51 3.6.3. Participants’ Lifestyle-related Health Beliefs .................................................. 59 vii  3.6.4. 3.6.5. 3.7. 3.8. 3.8.1. 3.8.2. 3.8.3. 3.9. 3.10. 4.  Participants’ Understanding of Islamic Teachings in Relation to Health Behaviours ..................................................................................................................... 60 Participants’ Responses from the Open-Ended Question Section ........... 61 Informing Study Two................................................................................................. 61 Strengths, Limitations and Future Implications ............................................. 62 Strengths ........................................................................................................................ 62 Limitations..................................................................................................................... 63 Future Implications .................................................................................................... 63 Conclusion ..................................................................................................................... 63 Tables .............................................................................................................................. 65  STUDY TWO: EVALUATION OF AN EDUCATION PROGRAM RELATED TO TYPE 2 DIABETES MELLITUS FOR SAUDI WOMEN: A PILOT INVESTIGATION ............................................................................................................. 88 4.1. Introduction .................................................................................................................. 88 4.2. Diabetes Prevention and Management .............................................................. 89 4.3. Study Goals and Objectives ..................................................................................... 91 4.4. Methodology ................................................................................................................. 92 4.4.1. Theoretical Background ........................................................................................... 92 4.4.2. Trained Researcher .................................................................................................... 93 4.4.3. Sampling and Recruitment ...................................................................................... 94 4.4.4. Grouping Participants ............................................................................................... 95 4.4.5. Measurements and Psychometrics ...................................................................... 96 4.4.6. Assessment and Re-evaluation .............................................................................. 98 4.4.7. Procedures..................................................................................................................... 99 4.4.8. Deliverables ................................................................................................................107 4.4.9. Data Analysis ..............................................................................................................107 4.5. Results ...........................................................................................................................108 4.5.1. Participants’ Discussion of their Health Behaviours after the Education Program ........................................................................................................................108 4.5.2. Outcome Variables ...................................................................................................112 4.6. Discussion ....................................................................................................................115 4.6.1. Objective One: Outcomes of a T2DM Education Program Adapted to the Cultural and Religious Contexts of Saudi Women ........................................115 4.6.2. Objective Two: Informing Future Studies Related to the Health Needs of Women in Saudi Arabia ..........................................................................................125 4.7. Strengths and Limitations .....................................................................................129 4.7.1. Strengths ......................................................................................................................129 4.7.2. Limitations...................................................................................................................130 4.8. Conclusion ...................................................................................................................130 4.9. Tables and Graphs ....................................................................................................132  BIBLIOGRAPHY ..................................................................................................................... 168 viii  APPENDICES .......................................................................................................................... 188  ix  LIST OF TABLES Table 3.1 Participants’ Reporting of their Ages, Heights and Weights ............................ 65 Table 3.2 Participants’ Demographic Characteristics ....................................................... 66 Table 3.3 Self-reported Physical Health Measures and General Health ........................... 67 Table 3.4 Self-reported Morbidity .................................................................................... 68 Table 3.5 Self-reported Other Morbidity .......................................................................... 68 Table 3.6 Types of Physical Activity Participants Reported Performing ......................... 69 Table 3.7 Amount of Time Participants Reported Spending to Performing Physical Activities of Various Difficulties .............................................................................. 70 Table 3.8 Average Weekly Consumption of Rice, Pasta, Bread and Cereals Reported by Participants ................................................................................................................ 70 Table 3.9 Times per Week Participants Reported Consuming Rice, Pasta, Bread and Cereals ....................................................................................................................... 70 Table 3.10 Types of Bread Participants Reported Consuming ......................................... 71 Table 3.11 Types of Soft Drinks Participants Reported Consuming ................................ 71 Table 3.12 Cans per Week of Soft Drinks Participants Reported Consuming ................. 72 Table 3.13 Types of Oil Participants Reported Consuming ............................................. 73 Table 3.14 Participants Reporting of Being on a Diet and Consuming of Sugar Substitutes ................................................................................................................................... 73 Table 3.15 Average Consumption of Fruits, Vegetables and Dates Reported by Participants ................................................................................................................ 74 Table 3.16 Times per Week Participants Reported Consuming Fruits, Vegetables and Dates .......................................................................................................................... 75 Table 3.17 Number of Daily Servings Participants Reported Consuming Fruits and Vegetables ................................................................................................................. 75 Table 3.18 Average Weekly Consumption of Meat, Poultry and Seafood Reported by Participants ................................................................................................................ 76  x  Table 3.19 Times per Week Participants Reported Consuming Meat, Poultry and Seafood ................................................................................................................................... 76 Table 3.20 Average Weekly Consumption of Eggs, Nuts and Legumes Reported by Participants ................................................................................................................ 76 Table 3.21 Times per Week Participants Reported Consuming Eggs, Nuts and Legumes ................................................................................................................................... 77 Table 3.22 Average Weekly Consumption of Milk and Dairy Reported by Participants 77 Table 3.23 Times per Week Participants Reported Consuming Milk and Dairy ............. 77 Table 3.24 Types of Milk and Dairy Participants Reported Consuming .......................... 78 Table 3.25 Self-reported Behaviours of Smoking, Stress and Sleep ................................ 78 Table 3.26 Average Number of Hours Participants Reported Sleeping ........................... 79 Table 3.27 Number of Hours Participants Reported Sleeping .......................................... 79 Table 3.28 Participants’ Beliefs in the Importance of Health Behaviours for the Overall Health......................................................................................................................... 80 Table 3.29 Participants’ Beliefs in the Importance of Health Behaviours for the Treatment and Management of Diabetes ................................................................... 80 Table 3.30 Hadith and Qur’anic Verses on Health in General Reported by Participants . 81 Table 3.31 Hadith and Qur’anic Verses on Nutrition Reported by Participants .............. 82 Table 3.32 Hadith and Qur’anic Verses on Physical Activity Reported by Participants . 83 Table 3.33 Hadith and Qur’anic Verses on Sleep Reported by Participants .................... 84 Table 3.34 Qur’anic Verses on Stress Reported by Participants ...................................... 84 Table 3.35 Participants’ Quotes of Health Priorities, the Implications of Islamic Teachings of Health Behaviours, Proverbs on Health, Health Advice, Social and Cultural Barriers to Health Behaviours; and a Reform to the Social Structure ......... 85 Table 4. 1 Content Covered in Sessions One and Two of the Type 2 Diabetes Mellitus Health Education Program (Source: Harvard Health Publications: Diabetes: A Plan for Living)................................................................................................................ 132 Table 4. 2 Topics Covered from the Harvard Publications on Health ............................ 133  xi  Table 4.3 Posters and Pamphlets .................................................................................... 137 Table 4.4 Discussion Topics: Personal, Enviromental, and Social Factors that Affect Weight ..................................................................................................................... 138 Table 4.5 Tailoring the Harvard Education for Positive Psychology with Religious Quotes ...................................................................................................................... 139 Table 4.6 Other Examples of Tailoring Health Education to the Saudi Culture .......... 139 Table 4.7 Participant Characteristics by Group .............................................................. 140 Table 4.8 Physical Measurements, Pre-Program (Baseline) and Post-Program by Group ................................................................................................................................. 141 Table 4.9 BMI Categories, Pre-Program (Baseline) and Post-Program by Group ......... 142 Table 4.10 Waist-to-Hip Ratio Categories, Pre-Program (Baseline) and Post-Program by Group ....................................................................................................................... 143 Table 4.11 Physical Measurements, Pre-Program (Baseline) / Post-Program Difference by Group .................................................................................................................. 144 Table 4.12 SF12 Sub-Domain Scores (0 to 100) and Totals, Pre-Program (Baseline) and Post-Program by Group ........................................................................................... 145 Table 4.13 SF12 Sub-Domain Scores (0 to 100) and Totals, Pre-Program (Baseline) and Post-Program ........................................................................................................... 146 Table 4.14 SF12 Sub-Domain Scores (0 to 100) and Totals, Pre-Program (Baseline) / Post-Program Difference by Group ......................................................................... 147 Table 4.15 SF12, Group Comparisons for Pre/Post Differences .................................... 148 Table 4.16 Life Satisfaction, Pre-Program (Baseline) and Post-Program by Group ...... 148 Table 4.17 Life Satisfaction, Pre-Program (Baseline) and Post-Program Totals and Pre/Post Difference by Group.................................................................................. 151 Table 4.18 Diabetes Knowledge Test, Number and Percent Correct, Pre-Program (Baseline) and Post-Program by Group ................................................................... 152 Table 4.19 Diabetes Knowledge Test, Pre-Program (Baseline) and Post-Program Totals and Pre/Post Difference by Group ........................................................................... 153 Table 4.20 Types of Physical Activity Participants Reported Performing, Pre-Program (Baseline) by Group................................................................................................. 154 xii  Table 4.21 Amount of Time Participants Reported Performing Physical Activities of Various Difficulties, Pre-Program (Baseline) by Group ......................................... 155 Table 4.22 Self-reported Physical Health Measures and General Health, Pre-Program (Baseline) by Group................................................................................................. 156 Table 4.23 Self-reported Morbidity, Pre-Program (Baseline) by Group ........................ 157 Table 4.24 Average Weekly Consumption of Rice or Pasta, Bread and Cereals, Meat, Poultry, Seafood, Eggs, Nuts, Legumes, and Milk and Dairy Reported by Participants, Pre-Program (Baseline) by Group ...................................................... 158 Table 4.25 Average Consumption of Fresh Fruits, Vegetables, and Dates Reported by Participants, Pre-Program (Baseline) by Group ...................................................... 159 Table 4.26 Average Consumption of Soft Drinks Participants Reported, Pre-Program (Baseline) by Group................................................................................................. 159 Table 4.27 Types of Soft Drinks, Bread, and Oil Participants Reported Consuming, PreProgram (Baseline) by Group .................................................................................. 160 Table 4.28 Participants Reporting of Being on a Diet and Consumption of Sugar Substitutes, Pre-Program (Baseline) by Group........................................................ 161 Table 4.29 Self-Reported Behaviours of Smoking, Stress and Sleep, Pre-Program (Baseline) by Group................................................................................................. 161 Table 4.30 Average Hours of Sleep Participants Reported, Pre-Program (Baseline) by Group ....................................................................................................................... 162 Table 4.31 Exit Interview for Program Satisfaction, Post-Program with the Intervention Group ....................................................................................................................... 162 Table 4.32 Exit Interview for Recommending Program, Post-Program with the Intervention Group .................................................................................................. 162  xiii  LIST OF FIGURES Figure 4.1 BMI Categories, Pre-Program (Baseline) and Post-Program by Group........ 163 Figure 4.2 SF12, Physical Functioning to Vitality, Pre-Program (Baseline) and PostProgram by Group ................................................................................................... 164 Figure 4.3 SF12, Social Functioning to Mental Component, Pre-Program (Baseline) and Post-Program by Group ........................................................................................... 165 Figure 4.4 Diabetes Knowledge Test, Pre-Program (Baseline) and Post-Program by Group ....................................................................................................................... 166 Figure 4.5 Life Satisfaction, Pre-Program (Baseline) and Post-Program by Group ....... 166 Figure 4.6 Waist to Hip Ratio, Pre-Program (Baseline), Post-Program, and Pre/Post Difference by Group ................................................................................................ 167 Figure 4.7 Six Minute Walking Test Distance, Pre-Program (Baseline), Post-Program, and Pre/Post Difference by Group ........................................................................... 167  xiv  ACKNOWLEGEMENTS I am mostly thankful to Almighty God, Allah, for my accomplishments during my years in Canada as an international student aspiring for a higher education. I am thankful to God for overcoming some challenges and obstacles and for enabling me to reach the final stages of completing my thesis. I would like to give special thanks to my supervisor Dr. Elizabeth Dean for her wise guidance throughout the years of my PhD studies. Special thanks to my supervisory committee, Dr. Lyn Jongbloed and Dr. Tal Jarus, for their supportive attendance to my progress. Special thanks to John-Paul Baker for his edits in the second chapter of this thesis, and Dr. Maya Yazigi for her collaboration in the development of the thesis proposal. Special thanks to Doug Talling for his intellectual guidance and contribution for the statistical analysis of my both studies. Special thanks to Ellen O’Brien for her thorough edits of my thesis. Very special thanks to Dr. Tawfik Khoja for his continuing support to facilitate the launching of my two studies in Saudi Arabia. Special thanks to Dr. Sami Abdulwahab for his willingness to provide support during my field work in Saudi Arabia. Special thanks to Dr. Zeyad Al-Sabbagh and my brother in-law Dr. Baker Ashour for their support in launching my second study at the Iskan Clinic. Special thanks to the staff at the Iskan Clinic for their cooperation and support while conducting the education sessions of the second study. Special thanks to all my family particularly my mum, Batool Ismaeil, and my sisters, Dr. Ameera Al-Bannay, Engr. Zahra and Sukaina AlBannay, for their familial and instrumental support during the times I encountered challenges while launching my studies in Saudi Arabia. Special thanks to my friends and colleagues in the Department of Rehabilitation Sciences particularly Mineko Wada, xv  Regina Casey, Shalini Li, and Tahereh Mosavi for being there for me during the times I needed them. Finally, special thanks to the Michigan Diabetes Research and Training Center for their permission to use the diabetes knowledge survey instrument in my research. Also, special thanks to QualityMetric for providing me with a license to score my data for the health-related quality of life (SF12 v.2) questionnaire.  xvi  DISCLAIMER  Discussions on the social and political backgrounds of the Saudi Arabian cultural in this thesis are based on cited references and do not reflect my personal opinions.  xvii  DEDICATION To mum To all women in my family To all Saudi women To all Arab women To all Muslim women To all women  xviii  1. INTRODUCTION, LITERATURE REVIEW, AND RATIONALE FOR THE THESIS 1.1.  Introduction As in other Middle Eastern countries, the discovery of oil in Saudi Arabia has  contributed to urban lifestyles with a major transition to fast food consumption, smoking, and physical inactivity (Dean, 2008; Al-Nuaim, Bamgboye, Al-Rubeaan, & Al-Mazrou, 1997, Al-Nozha et al. 2007; Al-Nozha et al., 2004a; Al-Nozha et al., 2004b; Al-Nuaim, 1997; Al-Rajeh, Awada, Niazi, & Larbi, 1993). Lifestyle-related conditions including ischemic heart disease, smoking-related conditions, hypertension, type 2 diabetes mellitus (T2DM) and obesity have become leading causes of morbidity and mortality among men and women in Saudi Arabia (Al-Nuaim, Bamgboye, Al-Rubeaan, & Al-Mazrou, 1997; Al-Malki, Al-Jaser, & Warsy, 2003; Elhadd, Al-Amoudi, & Alzahrani, 2007). In this chapter, we discuss literature in relation to lifestyle-related conditions and diabetes management and health promotion services in Saudi Arabia. We also discuss the World Health Organization recommendations for diabetes management, tailoring culture and religion to health promotion, and the international classification of functioning, disability, and health. We then discuss theories of health behaviours and definitions of health behaviours, health education, and community. Finally, we briefly discuss the history of Saudi Arabia, the sociocultural context, and women health in that country. 1.2.  Literature Review  1.2.1.  Smoking  Tobacco smoking, a risk factor for several lifestyle-related conditions, is socially unacceptable for women in Saudi Arabia especially in rural areas. Therefore, more men in Saudi Arabia smoke tobacco than women (Al-Dawood, 2000; Jarallah, Al-Rubeaan, 1  Al-Nuaim, Al-Ruhaily, & Kalantan, 1999). Based on recent statistics in Saudi Arabia, men reported smoking cigarettes twice as much as women; however, the stigma against women smoking likely contributes to their underreporting smoking (Jarallah et al., 1999). The Saudi culture like other Arab cultures stigmatizes women who smoke cigarettes (Jarallah et al., 1999). Urban women, however, appear less concerned about stigma and continue to smoke cigarettes. Cigarette smoking among married couples in Saudi Arabia has become prevalent (Al-Dawood, 2000). Moreover, shisha smoking (water pipe) like cigarette smoking is becoming more common. Scholarly articles use different Arabic words to refer to shisha smoking such as narghile smoking, water pipe smoking, hookah, and hubble bubble (Nuwayhid, Yamout, Azar, Al Kouatly, & Kambris, 1998). In Saudi Arabia, shisha smoking is preferred to cigarette smoking, considered more socially acceptable for women, and perceived as less harmful than cigarette smoking (Nuwayhid et al., 1998; Saudi Gazette, 2011). More women in Saudi Arabia and other Arab countries therefore prefer to smoke shisha than cigarettes even when they are pregnant (Nuwayhid et al., 1998; Millat & Florey, 1992; Saudi Gazette, 2011). Nuwayhid et al. (1998) cite two primary reasons for the scant data related to the patterns and hazards of shisha smoking in Arab cultures: first, shisha smoking is a relatively recent trend in Arab societies; and second, shisha smoking is less prevalent in western cultures. Whether smoking among women in Saudi Arabia is a social trend or used by them to reduce stress is not reported. 1.2.2.  Hypertension  Hypertension has increased in Saudi Arabia over the last decade (Al-Nozha et al., 2007). A 10% incidence of hypertension has been reported in the Saudi population between the ages of 40 and 60 years (Al-Rajeh et al., 1993). This condition has been 2  associated with an urban lifestyle, illiteracy, poor nutrition, overweight and obesity (AlNozha et al., 2007; Al-Nozha et al., 2004b, Siddiqui et al., 2001). Older age, especially among women, is associated with increased incident of hypertension in Saudi Arabia (AlNozha et al., 2007; Al-Nozha et al., 2004b, Siddiqui et al., 2001). In the Qassim region of Saudi Arabia, 25% of men and 20% of women with hypertension reported not knowing their blood pressures (Kalantan, Mohammed, Al-Taweel, & Abdul Ghani, 2001). Moreover, two thirds of people with hypertension across Saudi Arabia reported being unaware of having the condition (Siddiqui, Ogbeide, Karim, & Al Khalifa, 2003). The prevalence of hypertension in the Saudi Arabia population depicts the reported increase of hypertension in the United States. In this respect, recent data shows that one in three adults in the United States has high blood pressure, and 8% of American adults have undiagnosed hypertension (American Heart Association, 2012. p.e88). 1.2.3.  Obesity  Obesity is an independent risk factor for T2DM (Baird, 2007). Urban living is believed to be a primary contributor to increased prevalence of overweight and obesity among Saudi women (Al-Nuaim, 1997). In contrast to the reporting that diabetes was higher among men than women in Saudi Arabia, other studies report that Saudi women have higher rates of obesity than men. This increases women risk of ischemic heart disease and other lifestyle conditions such as T2DM, hypertension, and stroke (Al-Khaldi & Khan, 2000; Al-Nuaim et al., 1997; Al-Nozha et al., 2007; Al-Nozha et al., 2007; AlNozha et al., 2004b; Al-Rajeh et al., 1993). 1.2.4.  Diabetes Mellitus  Data before 1998 shows that the prevalence of insulin-dependent diabetes mellitus, non-insulin-dependent diabetes mellitus and impaired glucose tolerance in Saudi men 3  was 0.23%, 5.63% and 0.50% respectively, and in Saudi women was 0.30%, 4.53% and 0.72% respectively (Aftab, 2007; El-Hazmi et al., 1998). The reporting of diabetes mellitus was higher in men compared to women in all provinces of Saudi Arabia except in the Eastern province (Aftab, 2007; El-Hazmi et al., 1998). Gestational diabetes mellitus is prevalent in Saudi women and ranged from10.3% to 19.3% (Elhadd, AlAmoudi, & Alzahrani, 2007; AlShawaf, Akeil, & Mograby, 1998; Mwambingen, Al Meshari, & Akeil, 1988; Khawja, AlSuleiman, & al-Sibai, 1989). Type 2 diabetes mellitus is a health risk factor that varies in frequency (2% to 12%) across regions of Saudi Arabia (Al-Nozha et al., 2004a; Al-Rajeh et al., 1993). Family history of T2DM, obesity, age, overweight, and geographic locations are factors that are believed to account for variations in the prevalence of T2DM in Saudi Arabia (Akbar & Al-Ghamdi, 2000; Akbar, 2001; Al-Nuaim, 1997). A study that examined glucose intolerance in people living in rural and urban communities in Saudi Arabia has reported that T2DM is higher in those living in urban rather than in rural areas (Al-Nuaim, 1997). 1.2.5.  Women and Diabetes  Diabetes mellitus is a stronger risk factor for fatal ischemic heart disease in women than in men (Barrett-Connor, Cohn, Wingard, Edelstein, 1991). In this respect, SchenckGustafsson (2012) reported that “diabetes mellitus increases the risk of cardiovascular disease by three to four times in women and two to three times in men, after adjusting for other risk factors” (p.1). This observation is explained by “increased risk-factor burden and comorbidity in women compared with men with diabetes [and] less aggressive preventive treatment in women with diabetes” (Schenck-Gustafsson, 2012, p.3). Another suggested explanation was that insulin resistance is impacted by sex hormones and lifestyle factors (Schenck-Gustafsson, 2012). The increased risk of ischemic heart 4  diseases in women with diabetes is yet to be elucidated but highlights the importance of preventing and managing T2DM in women. 1.2.6.  Health Promotion and Diabetes Management in Saudi Arabia  Health promotion in Saudi Arabia is mostly introduced through primary health care. The ministry of health manages the health care system in Saudi Arabia (Almalki, Fitzgerald, & Clark, 2011). It provides free health care to Saudi citizens at three levels: primary, secondary, and tertiary. The primary level in primary health clinics provides prevention and treatment services and a referral for conditions that require specialized care to public hospitals, the secondary level of care (Almalki, Fitzgerald, & Clark, 2011). Public hospitals give referrals for the more complex cases such as cancers and complex surgeries to specialized hospitals with more advanced health care system, which are the tertiary level of care (Almalki, Fitzgerald, & Clark, 2011). Health promotion preventive services in Saudi Arabia are mostly focused on maternal and child health care such as immunization and antenatal care (Almalki, Fitzgerald, & Clark, 2011). Services for disease control, on the other hand, are focused on infectious diseases such as tuberculosis and malaria (Almalki, Fitzgerald, & Clark, 2011). Health education services are expected to be performed by nurses (Jradi, Zaidan, & Al Shehri, 2012). Recent studies however show that most nurses in Saudi Arabia are expatriates from non-Arabic speaking countries and thus unable to communicate effectively with patients (Jradi, Zaidan, & Al Shehri, 2012). Moreover, these nurses and others including those who speak Arabic as their first language were not trained in public health or health promotion (Jradi, Zaidan, & Al Shehri, 2012). With the gradual increase of lifestyle-related conditions and the growing need to provide competent health promotion services to the population in Saudi Arabia, a few 5  studies have explored the efficacy of health promotion services in Saudi Arabia. One recent study in the Aseer region of Saudi Arabia reported that standards of health promotion in primary health care are not efficient for the prevention of diabetes, as 21% of study participants were identified as pre-diabetic (Al-Shahrani & Al-Khaldi, 2011). The investigators suggested providing preventive care for lifestyle-related conditions in primary care settings. Another study suggested the need to integrate culture and religion in Saudi Arabia in another type of health promotion, specifically hand hygiene (Allegranzi, Memish, Donaldson, & Pittet, 2009). Health education programs such as those for T2DM are not well established in Saudi Arabia (Abahussain & El-Zubier, 2005). At present, diabetes education programs in Saudi Arabia tend to target people diagnosed with diabetes rather than including those at risk and aiming to increase patients’ awareness of diabetes care through medical instruction and care with less emphasis on lifestyle modification and prevention (ElHazmi, Warsy, AR. Al-Swailem, AM, Al-Swailem, & Sulaimani, 1998; Sharaf, 2010). Thus, self-management through lifestyle modification and prevention has been relatively neglected in practice in favour of medical management in Saudi Arabia (Al-Elq, 2009; Sharaf, 2010). Education for T2DM in Saudi Arabia is conducted by physicians, particularly in health centers where there are no diabetes educators (Al-Hussein, 2008). According to a study that examined a diabetes education program in the Asir region of Saudi Arabia, 27% of diabetic patients received no health education and of the remaining 73% of patients who received education, only 26% of them reported receiving instructions about exercise in managing diabetes (Al-Khaldi & Khan, 2000). Overall, diabetes education in Saudi  6  Arabia does not comply with the World Health Organization recommendations that require active collaboration between educators and the program recipients (Al-Khaldi & Khan, 2000; Al-Hussein, 2008). 1.2.7.  The World Health Organization Recommendations for Diabetes SelfManagement  Through its ‘Diabetes Action Now’ initiative, the World Health Organization advocates aggressive self-management approach to control T2DM (WHO, 2004a, and 2004b). The World Health Organization has formulated international standards for diabetes self-management that are evidence-based and aim to improve the patients’ quality of life (Mensing et al., 2003; Funnell et al., 2009). These international standards are based on lifestyle modification strategies such as increased physical activity, healthy nutrition, reduced stress, sound sleep, and non-smoking (WHO, 2004a, and 2004b). 1.2.8.  Diabetes Management and Culture  Evidence suggests that diabetes education programs based on international standards are more effective when tailored to the cultural contexts of targeted groups (Osuna et al., 2011; Goody & Drago, 2009; Hawthorne, Robles, Cannings-John, & Edwards, 2010; Song et al., 2010; Osborn et al., 2010). Culturally appropriate programs for diabetes selfmanagement among African-Americans and Mexican-Americans, for example, could improve the outcomes of diabetes education (Anderson et al., 2005; Brown & Hanis, 1999). Moreover, the relationship between health and religion has been advocated as a promising mediator in health education programs (Ellison & Levin, 1998, Holt & McClure, 2006; Benjamins, Ellison, Krause, & Marcum, 2011; Kenneth, Maton, & Wells, 2010). For example, the involvement in a religious community and attending religious services can positively impact both the physical and psychological wellbeing of 7  individuals (Ellison & Levin, 1998, Holt & McClure, 2006; Benjamins, Ellison, Krause, & Marcum, 2011). A study that examined religious involvement in African American communities and health behaviours, for example, showed that religious beliefs could lead to positive health behaviours (Holt, Roth, Clark, & Debnam, 2012). 1.2.9.  Islamic Perspective on Health  A call for a lifestyle that is based on an Islamic perspective on health was raised for the first time in the “the Amman Declaration on Health Promotion”. In 1989, the World Health Organization Regional Office for the Eastern Mediterranean convened “the Amman Declaration on Health Promotion” consultation with the Islamic Organization for Medical Sciences and the Royal Academy for Research in Islamic Civilization along with a group of theologians and scholars of various disciplines such as physicians, economists, sociologists, scientists, and journalists to discuss the adaptation of health promotion to Islamic teachings (World Health Organization, 1996). The objectives of this consultation were twofold: 1. to provide a detailed description of a lifestyle that is consistent with the religious teachings of Islam; 2. to identify unhealthy behaviours that are forbidden in Islam (World Health Organization, 1996). Moreover, based on the premise that faith is an “essence” that contributes to overall physical, psychological, and spiritual wellbeing (World Health Organization, 1996, p.12), the consultation aimed to identify relevant Islamic teachings about health. To achieve these objectives, the consultation suggested collaboration among members and groups specialized in Islamic, scientific, and cultural education (World Health Organization, 1996). In short, the Amman Declaration was convened by the World Health Organization to help align the wisdom of the Qur’an and Hadith to contemporary health issues, e.g., smoking.  8  The Qur’an is the holy book for Muslims and its words are believed to be direct revelations from Almighty God, Allah. From this book, Muslims learn appropriate conduct so that their behaviours are shaped by God’s messages. Muslims believe that obedience to God will lead to a blessed life and afterlife. The Hadith is another trusted source for Muslims to learn about their religious teachings. The Hadith is a collection of the “saying(s) or action(s) ascribed to the Prophet [peace be up on him] (PBUH) or acts(s) approved by the prophet (PBUH)” (Al Khayat, 1997). The Prophet Mohammad (PBUH) is considered to be the model for all Muslims; therefore Muslims use the Hadith to learn from the Prophet’s morals and follow his words and behaviours. In short, the Qur’an and Hadith are the two main sources that describe how Muslims should lead their lives. Health is one of the many topics addressed in the Qur’an and Hadith (Al Khayat, 1997). (a) Excerpts from “the Ammam Declaration on Health Promotion” Meeting Health is a blessing from God. “People should make good use of it, and preserve the blessing of health by strengthening and developing it.” (World Health Organization, 1996, p.7). By recognizing the blessing of health and maintaining it, people will become more connected to God. To avoid illnesses and diseases, people require awareness about healthy lifestyles (World Health Organization, 1996). Thus, health education based on religious messages could be employed as a tool to educate the Umah (Muslim public) about healthy lifestyles (World Health Organization, 1996). Islamic health messages can be found in the two primary sources of Islamic teachings: the Qur’an and Hadith. For example, God in his Holy Book, Qur’an, has advised people to maintain balanced lives (World Health  9  Organization, 1996). He warned against excessiveness including excessive eating and drinking (World Health Organization, 1996). 1.2.10. The International Classification of Functioning, Disability and Health The International Classification of Functioning, Disability and Health (ICF) reflects a historical shift from other models that defined disability as a medical impairment (World Health Organization, 2011b). Following the medical model, the social model emerged. The social model acknowledges societal factors as contributors to disability (World Health Organization, 2011b). The ICFlater added a broader psychosocial context within which to frame an individual’s ill health or disability, namely, personal and environmental factors (World Health Organization, 2011b). The ICF was developed by the World Health Organization in 2001 to understand and evaluate health and disability (World Health Organization, 2011b). According to the ICF, health and disability can be framed at two levels: the individual level and the environmental level (World Health Organization, 2011b). The ICF frames health and disability within three health and health related domains, specifically body functions and structure, activities, and participation (World Health Organization, 2011b). Each of these domains is influenced by personal factors and environmental factors (World Health Organization, 2011b). Examples of personal factors in the ICF include gender, age, and education (World Health Organization, 2011b). Environmental factors include culture, work, and government legislation (World Health Organization, 2011b). Body Functions and Structures include the state of a person’s underlying anatomy, physiology, and psychology (World Health Organization, 2011b). Activity refers to the functioning status of an individual such as self-care and capacity to perform household chores (World 10  Health Organization, 2011b). Participation refers to an individual’s capacity to participate in society such as social interaction and interpersonal relationships (World Health Organization, 2011b). According to the ICF, health and disability are universal experiences of people around the world. Health and disability can be measured by examining the body structure and its functions and whether impairments exist, the level of activity and factors that limit activity, and the degree of social participation and factors that restrict individuals from participating in their societies (World Health Organization, 2011b). At all levels: body functions and structures, activity, and participation, factors that affect the overall experience of health or disability include personal, environmental, or both (World Health Organization, 2011b). In line with the ICF, the World Health Organization had defined health as "complete physical, mental, and social functioning of a person and not merely the absence of disease” (World Health Organization, 2006). 1.2.11. Health Behaviour Theories Health behaviour came to the attention of scholars interested in the social determinants of health in the 1980s (Glanz, Rimer, & Viswanath, 2008). This provided a basis for a holistic approach to health promotion that includes social, political, and economic factors (Glanz, Rimer, & Viswanath, 2008). Improving health behaviour, in this respect, supported the need for a social reform at multiple levels starting with the individual and extending to family, community, and social and political institutions (Glanz, Rimer, & Viswanath, 2008).  11  1.2.12. Health Behaviour Definitions Early scholars of health such as Gochman (1982, 1997), Kasl and Cobb (1996a, 1996b) have attempted to define health behaviour (Glanz, Rimer, & Viswanath, 2008). A contemporary definition of health behaviour is “actions of individuals, groups, and organizations, as well as their determinants, correlates, and consequences, including social change, policy development and implementation, improved coping skills, and enhanced quality of life” (Glanz, Rimer, & Viswanath, 2008, p.13; Parkerson and others, 1993). Kasl and Cobb (1996a, 1996b) have classified health behaviour into three categories: one, preventive health behaviour; two, illness health behaviour; and third, sick role behaviour (Glanz, Rimer, & Viswanath, 2008). 1.2.13. The Social Ecological Model of Health Behaviour The term ecology “refers to the interrelations between organisms and their environments” (Glanz, Rimer, & Viswanath, 2008, p.466). Thus, the social ecological model of health behaviour focuses on interactions between individuals and their environments (Stokols, 1992; Glanz, Rimer, & Viswanath, 2008). Environment, in this respect, refers to economical, political, and socio-cultural contexts that affect individuals and their communities (Glanz, Rimer, & Viswanath, 2008). According to the social ecological model, health behaviour is influenced by factors at multiple levels. These factors include intrapersonal, interpersonal, organizational, community, and public policy (Glanz, Rimer, & Viswanath, 2008). Health behaviour in this sense co-interacts at all levels and behavioural change should be targeted across these levels. Intervention studies based on the social ecological model have been shown to be mostly effective when agencies across various levels cooperate to provide healthy choices for individuals (Glanz, Rimer, & Viswanath, 2008). 12  Only recently, the social ecological model of health behaviour has been applied to health promotion interventions (Glanz, Rimer, & Viswanath, 2008). Examples are: McLeroy and others (1988), Stokols and others (2003), Glanz and others (2001), and Glass and McAtee (2007). To maximize the outcomes of an intervention, according to the social ecological model of health behaviour, individuals need to be educated about healthy choices while providing supportive environments for the individuals to make such choices (Glanz, Rimer, & Viswanath, 2008; Ottawa Charter for Health Promotion, 1986). For example, by providing facilities for physical activity and healthy eating options for individuals in their communities, people will be better able to adopt healthy behaviours in daily life (Glanz, Rimer, & Viswanath, 2008). In brief, for a health promotion intervention to be effective, it needs to address both the individual and the environmental levels (Glanz, Rimer, & Viswanath, 2008). Up to now, the social ecological model of health behaviour has been adopted as a basis for several initiatives (Glanz, Rimer, & Viswanath, 2008). Among these are Healthy People 2010 (U.S. Department of Health and Human Services, 2000), the World Health Organization Framework Convention on Tobacco Control and strategies for lifestylerelated health behaviours including nutrition, obesity, and physical activity (World Health Organization, 2003, 2004). 1.2.14. Community and the Social Ecological Model of Health Behaviour The construct of community is fundamental to the social ecological model. Community can be defined as “a group of people having a common interest or identity and goes beyond the physical environment. Community includes the physical, social, and symbolic characteristics that cause people to connect” (Purnell & Paulanka, p.21).  13  In turn, the social ecological model of health behaviour is central to the conceptualization of community (Glanz, Rimer, & Viswanath, 2008). Community in the social ecological model refers to an autonomous geographical location, population characteristics, physical environment, social structure, and all other interrelating contexts (Glanz, Rimer, & Viswanath, 2008). The term community organization was developed in the late 1800s by social workers in the United States to categorize the health needs of immigrant communities (Glanz, Rimer, & Viswanath, 2008). Later in 1950 and onwards, social movements such as women’s rights, gay rights, and anti-abortions movements have adopted the concept community organization in reference to the targeted communities (Glanz, Rimer, & Viswanath, 2008). Moreover, in1980s, the World Health Organization has employed health promotion strategies through social changes at the community level with the objective of increasing individuals’ control to make healthy choices (Glanz, Rimer, & Viswanath, 2008; World Health Organization, 1986). According to Glanz, Rimer, and Viswanath (2008) the term community has developed to integrate the concepts of community building and community organization. Community, in this respect, can be defined as a geographical location in which people share characteristics such as ethnicity, language, and religious orientation (Glanz, Rimer, & Viswanath, 2008). In short, community refers to a “collective identity” (Hunter, 1975; Glanz, Rimer, & Viswanath, 2008, p.290). 1.2.15. Health Promotion and Health Education Early scholars of health promotion such as Griffiths (1972) and Green (1980) attempted to define health education. A comprehensive definition of health education is “the process of assisting individuals, acting separately or collectively, to make informed 14  decisions about matters affecting their personal health and that of others” (Glanz, Rimer, & Viswanath, 2008, p.10). Objectives of health education include prevention of diseases, disease management and prevention, and rehabilitation (Glanz, Rimer, & Viswanath, 2008). Health education can be delivered in multiple settings such as schools and universities, hospitals, community centers like recreation centers, religious institutions such as temples, mosques and churches, and worksites; and through the mass media (Glanz, Rimer, & Viswanath, 2008). 1.2.16. Saudi Arabia: Historical and Cultural Backgrounds The population of Saudi Arabia is 27 million including 8.4 million foreign residents (Royal Embassy of Saudi Arabia Washington, DC, 2013). The capital city is Riyadh, located in the center of the country. Saudi Arabia is divided into 13 provinces, each with its capital (Royal Embassy of Saudi Arabia Washington, DC, 2013). Islam is the only religion practiced in Saudi Arabia. Official spoken languages are Arabic and English (Royal Embassy of Saudi Arabia Washington, DC, 2013). The latter is mostly spoken in urban areas (Royal Embassy of Saudi Arabia Washington, DC, 2013). Saudi Arabia is located in the middle of a desert, surrounded by seawater at its south and east borders (Royal Embassy of Saudi Arabia Washington, DC, 2013). The size of Saudi Arabia is around 1.96 million square kilometers, the 14th largest country in the world (Royal Embassy of Saudi Arabia Washington, DC, 2013). Saudi Arabia was recognized as a kingdom in 1932. Saudi Arabia is “the most theocratic state in the contemporary Sunni Muslim world” (Humphreys, 1979). It is based on the Wahhabi interpretation of Islam (Humphreys, 1979). The Wahhabi religion of Islam was introduced to Saudi Arabia by Mohammad bin Abdulwahab, a native scholar 15  from Najad (Riyadh today) (Humphreys, 1979). In 1740, Mohammad bin Abdulwahab bonded with Saud bin Abduaziz, the founder of Saudi Arabia, to establish a religious state based on the Wahhabi interpretations of Islam (Humphreys, 1979, Baki, 2004). The followers of Wahabbi Islam call themselves Salafis (Dekmejian, 1994, p.637). Based on the Salafi doctrine, Muslims should strictly follow the Qur’an and Sunnah (Prophet Mohammad and his followers) (Dekmejian, 1994; Humphreys, 1979). It considers the period lived by Prophet Mohammad and his followers the golden era of Islam (Dekmejian, 1994; Humphreys, 1979). According to the Salafis, Muslims today are required to follow the lifestyle of Prophet Mohammad and his followers (Dekmejian, 1994; Humphreys, 1979). Moreover, an Islamic state has to be socially and politically structured similar to the sociopolitical system during the golden era of Islam (Dekmejian, 1994; Humphreys, 1979). Anything that came after that golden era of Islam is considered an inventory to Islam (bida’a) (Dekmejian, 1994; Humphreys, 1979). The Salafi doctrine as such forbids modern lifestyles including western norms and customs (Dekmejian, 1994; Humphreys, 1979). Under the Salafi doctrine in Saudi Arabia, religious authorities intervene in every aspect of public social life (Dekmejian, 1994; Humphreys, 1979). This is instituted to prevent people getting diverted from the Islamic behaviours of the golden era of Islam (Dekmejian, 1994; Humphreys, 1979). In Saudi Arabia, one’s social behaviours are expected to conform to his/her affiliated group and Islamic behaviours (Baki, 2004; Rugh, 1973). Social behaviours in public are observed and regulated by the religious police, the Committee of Encouraging Virtue and Preventing Vice (Baki, 2004).  16  The political system in Saudi Arabia is authoritarian and based on a monarchy, consistent with the law of governance during the golden era of Islam. Authority is shared among the Saudi King and his royalty and religious leaders (Ulama) (Baki, 2004; Humphreys, 1979). Education in Saudi Arabia is also structured to correspond with the Islamic teachings of the golden era of Islam. It emphasizes obedience to God, the prophet, and those in authority (Prokop, 2004; Baki, 2004). Some scholars argue that in Saudi Arabia, the “philosophy of education in teaching inculcates passivity, dependence, an a priori aspect for authority and an unquestionable attitude” (Prokop, 2004, p.80). Religious authorities dominate curricula starting from kindergarten to university. Girls are segregated from boys in schools and universities (Prokop, 2004; Baki, 2004). Girls have a different curriculum to boys even at university. Sports, for instance, are allowed only for boys (Mobaraki & Söderfeldt, 2010; Prokop, 2004). Some fields such as law, journalism, and civil engineering are not available for female students. Conservatives initially resisted the establishment of formal education for women until the 1960s (Mobaraki & Söderfeldt, 2010). Based on recent data, female students constitute over 50 percent of Saudi university students (Mobaraki & Söderfeldt, 2010; Baki, 2004; Prokop, 2004). Despite these, around 30% of women in Saudi Arabia are illiterate (Mobaraki & Söderfeldt, 2010). The Ulama have opposed the employment of women (Baki, 2004; Prokop, 2004). They restricted women participating in the work force by forbidding them to drive (Baki, 2004; Prokop, 2004). Thus, working-women need to hire a driver to get to work. At work, women are placed in secondary positions to men in line with the Salfi beliefs that women  17  are subordinate to men (Baki, 2004). Decision-making is not allowed for women in the Saudi patriarchal system even in high-ranking positions (Baki, 2004). For instance, female university professors have to forward students’ exam papers after marking them to male professors for their reviews (Baki, 2004). Saudi law, called Shariah, is based on the Salafi interpretations of Islam (Mobaraki & Söderfeldt, 2010; Baki, 2004; Prokop, 2004). These interpretations contribute to placing women in a subordinate position (Mobaraki & Söderfeldt, 2010; Prokop, 2004). Woman, for example, are required to get the consent of a man related to her in if she wants to pursue education, work, travel, or even undergo invasive medical surgery (Mobaraki & Söderfeldt, 2010). In the tribal system of Saudi Arabia, women are treated as properties of men (Mobaraki & Söderfeldt, 2010). Unmarried, women are properties of their fathers (Mobaraki & Söderfeldt, 2010). Divorced and widowed women are properties of their sons (Mobaraki & Söderfeldt, 2010). Historically, before the emergence of Islam, Arab elite women veiled their faces to represent their prestigious status (Baki, 2004). The Salafi Islam has adopted the veiling practice for women and sometimes has forbidden women from showing their faces in some regions of Saudi Arabia (Mobaraki & Söderfeldt, 2010). Only recently a Saudi woman has been allowed to have official government identification, show her face in the photo of her identification, and do not require the consent of a male relative to attain such identification (Mobaraki & Söderfeldt, 2010). Before the discovery of oil, Saudi Arabia was a poor country. The national income relied mostly on the revenues paid by pilgrims to Mecca and Medina, the two holiest  18  cities for Muslims (Rugh, 1973). Oil for the first time was discovered in 1938, which led to the economic development of the country (Rugh, 1973). With the establishment of the Arabian-American Oil Company (Aramco) in 1949, foreigners including Americans and other westerners migrated to Saudi Arabia for skilled jobs in that company (Rugh, 1973). With the upward economy in the 1970s, Saudi Arabia continued to receive immigrants from around the world (Rugh, 1973). These immigrants have limited access to citizenship or integration into the native culture of Saudi Arabia. Saudi employees after the discovery of oil were mostly unskilled workers (Rugh, 1973). As time went by, Saudis acquired more education that qualified them to attain highly skilled jobs (Rugh, 1973). (a) Saudi Arabian Society Based on a Clearly Defined Class Structure The upper class in Saudi Arabia includes the royal family, top Ulama, and wealthy merchants (Rugh, 1973). The Lower class includes nomads and unskilled workers (Rugh, 1973). Upper middle class includes educated professionals such as medical doctors, engineers, and professors (Rugh, 1973). Lower middle class includes skilled workers such as clerics and those working in administration (Rugh, 1973). Traditionally, extended family members live in the same household. With the emergence of the middle class, extended families gave way to nuclear family households (Rugh, 1973). Polygyny is vanishing with the increased cost of marriage and household living (Rugh, 1973). 1.2.17. Women’s Health in the Islamic Culture of Saudi Arabia Cultural characteristics can be either primary or secondary. Primary characteristics of culture refer to “things that a person cannot easily change” or can be changed with challenging transformations (Purnell & Paulanka, p.7). These include “nationality, race, color, gender, age, and religious affiliation” (Purnell & Paulanka, p.7) Secondary 19  characteristics of culture include “educational status, socio-economic status, occupation, military experience, political beliefs, urban versus rural residence […] physical characteristics, gender issues, reason, for migration” (Purnell & Paulanka, p.7). In reference to these classifications, we discuss the Saudi Arabian culture in relation to its primary characteristics. The Saudi Arabian culture is structured by fundamental Islamic teachings. These teachings include the belief that women should remain inside their homes and be excluded from public physical activities such as riding a bike or running in public. Women’s activities in Saudi Arabia are thus centered at their homes (Abahussain & ElZubier, 2005). Whether cultural factors contribute to the findings that Saudi women have poorer diet adherence than men is not known (Al-Khaldi & Khan, 2000). Saudi women’s health beliefs and behaviours are framed by the Saudi culture and the Islamic faith. In a study that describes Saudi women’s knowledge and beliefs about illnesses, for example, women reported causes of illness as God, in addition to contact with an ill person, the weather, and germs (Ide & Sanli, 1992). As mentioned earlier, the Saudi Arabian socio-cultural context is structured in line with the Salafi interpretations of Islam. These could impose limitations on Saudi women’s adaptabilities to adopt healthy lifestyle. Saudi women thus may require special health needs that may be distinct from the needs of Muslim women living in other Islamic countries. 1.3.  Rationale for the Thesis  1.3.1.  Rationale  Women’s health in Saudi Arabia is only now emerging as a primary concern, recognized as being underrepresented in literature. Women in Saudi Arabia have special 20  health needs including the prevention and management of T2DM. The degree to which cultural and religious factors impact Saudi women’s lifestyle-related health beliefs and behaviours is unclear. The outcomes of international standards for T2DM education have not been previously studied in Saudi Arabia particularly in women. 1.3.2.  Goals and Objectives  (a) Study One The goal was to examine the self-reported health status of Saudi women, their lifestyle-related health beliefs and behaviours, and their understanding of related Islamic teaching, to serve as a basis for designing and implementing a T2DM education program, based on international standards and adapted to the cultural and religious contexts of Saudi women. i) Primary Objectives With respect to Saudi women and lifestyle-related conditions: 1. To examine their self-reported health profile 2. To elucidate their lifestyle-related health beliefs and behaviours 3. To examine their understanding of Islamic teachings in relation to health behaviours ii) Secondary Objectives 1. To inform recommendations for a subsequent study, Study Two, to explore the outcomes of a pilot intervention study of a T2DM education program based on international standards and adapted to the cultural and religious contexts of Saudi women  21  (b) Study Two In the absence of existing data, the goal was to conduct a pilot intervention study to explore the outcomes of launching a T2DM education program, based on international standards and tailored to the cultural and religious contexts of Saudi women, compared with outcomes of usual care for diabetes in Saudi Arabia. Our primary research question was “What are the outcomes of a pilot intervention study of a T2DM education program based on international standards and adapted to the cultural and religious contexts of Saudi women?” i) Primary Objectives 1. To explore whether a T2DM education program, based on international standards and adapted to the cultural and religious contexts of Saudi women, could impact health outcomes (e.g., physical measures, diabetes knowledge, life satisfaction and health-related quality of life) compared to outcomes of those who receive usual care for diabetes in Saudi Arabia 2. To use knowledge gained from conducting this pilot study to inform future studies related to the health needs of women in Saudi Arabia 1.4.  Thesis Chapters This thesis is organized as follows. Chapter 1 (INTRODUCTION, LITERATURE  REVIEW, AND RATIONALE FOR THE THESIS) is an overview and a discussion of the literature and rationale for the thesis. Chapter 2 (CULTURE AS A VARIABLE IN HEALTH RESEARCH: PERSPECTIVES AND CAVEATS) is the basis of an article that addresses culture as an important methodological consideration in health research (Al-Bannay, H., Jarus, T., Jongbloed, L., Yazigi, M., & Dean, E. (2013). Culture as a variable in health research: Perspectives and caveats. Health Promotion International, 22  28(1), 1-9). Chapter 3 (STUDY ONE: LIFESTYLE-RELATED HEALTH BELIEF AND BEHAVIOURS OF SAUDI WOMEN LIVING IN DAMMAM) is Study One in this thesis i.e. the self-reported health status of Saudi women, their lifestyle-related health beliefs and behaviours, and their understanding of related Islamic teaching. Chapter 4 (STUDY TWO: EVALUATION OF AN EDUCATION PROGRAM RELATED TO TYPE 2 DIABETES MELLITUS FOR SAUDI WOMEN: A PILOT INVESTIGATION) is Study Two, i.e., a study that explored the outcomes of a pilot intervention study of a T2DM education program, based on international standards and tailored to the cultural and religious contexts of Saudi women, compared with outcomes of usual care for diabetes in Saudi Arabia.  23  2. CULTURE AS A VARIABLE IN HEALTH RESEARCH: PERSPECTIVES AND CAVEATS This chapter is the basis for the following article: Al-Bannay, H., Jarus, T., Jongbloed, L., Yazigi, M., & Dean, E. (2013). Culture as a variable in health research: Perspectives and caveats. Health Promotion International, 28(1), 1-9. 2.1.  Summary To augment the rigor of health promotion research, this article describes how cultural  factors impact the outcomes of health promotion studies either intentionally or unintentionally. It proposes ways in which these factors can be addressed or controlled in designing studies and interpreting their results. We describe how variation within and across cultures can be considered within a study, e.g., the conceptualization of research questions or hypotheses, and the methodology including sampling, surveys and interviews. We provide multiple examples of how culture influences the interpretation of study findings. Inadequately accounting or controlling for cultural variations in health promotion studies, whether they are planned or unplanned, can lead to incomplete research questions, incomplete data gathering, spurious results and limited generalizability of the findings. In health promotion research, factors related to culture and cultural variations need to be considered, acknowledged or controlled irrespective of the purpose of the study, to maximize the reliability, validity and generalizability of study findings. These issues are particularly relevant in contemporary health promotion research focusing on global lifestyle-related conditions where cultural factors have a pivotal role and warrant being understood.  24  Key words: cultural variation; health promotion research; lifestyle-related conditions; methodological considerations 2.2.  Introduction The need to increase awareness of culture as a variable in health promotion research  is germane for three reasons. First, health promotion research is mostly conducted in high-income countries that are experiencing unprecedented immigration of people from diverse cultures. The populations of the countries of North America and Europe, for example, have become increasingly culturally diverse. Second, research related to lifestyle-related conditions, given their global prevalence and enormous social and economic burdens, (Dean et al., 2011; World Health Organization, 2011a) is a priority. Lifestyle practices cannot be addressed independently from people’s cultural backgrounds. Third, health promotion research often originates from investigators in high-income and western countries, whose personal cultural biases and perspectives influence their lenses of scientific inquiry. Despite the need to consider culture as an important variable in health research, debate persists regarding the elements and definition of this construct. Culture has been defined in many ways, for example, “an historically transmitted pattern of meaning embodied in symbols, a system of inherited conceptions expressed in symbolic forms by means of which men (sic) communicate, perpetuate and develop their knowledge about and attitudes toward life” (Geertz, 1973, p.89). Another definition of culture is “a socially constructed and historically transmitted pattern of symbols, meaning, premises, and rules” (Philipsen, 1992, p.7-8). According to Trinandis (1994), culture is classified as either objective or subjective. Objective culture “refers to the institutional aspects of culture, such as political and 25  economic systems, and to the products of culture, such as art, music, cuisine, and so on” (Landis, Bennett & Bennett, 2004, p.151). Subjective culture, on the other hand, “refers to the experience of social reality formed by the experience of the social reality formed by a society’s institutions, in other words, the worldview of a society’s people” (Landis, Bennett & Bennett, 2004, p.151). A contemporary definition of culture is “a system of meaning that guides the construction of reality in a social community” (Cheney, Christensen, Zorn & Ganesh, 2004, p.76). Purnell, in her book “Guide to Culturally Competent Health Care” (2009), notes that “major influences that shape people’s worldview and the extent to which people identify with their cultural group of origin are called the primary and secondary characteristics of culture. The primary characteristics are nationality, race, color, gender, age, and religious affiliation. The secondary characteristics include educational status, socioeconomic status, occupation, military experience, political beliefs, urban versus rural residence, enclave identity, marital status, parental status, physical characteristics, sexual orientation, gender issues, reason for migration (sojourner, immigrant, or undocumented status), and length of time away from the country of origin” (p.3). For the purposes of this article, we have selected a definition of culture that includes many agreed upon elements, that is, “patterned ways of thinking, feelings, acquired and transmitted mainly by symbols, consisting of the distinctive achievements of human groups” (Kluckhohn, 1951a, p. 86 note 5 as cited by Hofstede, 1981, p. 23). Culture is often confused with race, which categorizes people based on their “physical appearance, name, language, history, religion, nationality”, and also ethnicity, which categorizes people based on their biological characteristics (Isaacs, 1975, p.386). In turn, cultural  26  variation reflects a collection of variables that define the uniqueness of individuals within groups based on race, ethnicity, symbols, traditions, language, and customs (Kim, 1993). Cultural sensitivity is another key construct fundamental to health promotion research. It can be defined as “sensitivity to the characteristics of a culture or to the dynamics of a social group” (Marin, 1993, p.151) and is achieved with increased awareness of cultural differences in relation to norms, beliefs and values (Ridley, Mendoza, Kanitz, Angermeier, & Zenk, 1994). Sensitizing researchers about their views in relation to their cultures increases their awareness of cultures other than their own. Also researchers who are aware of their personal biases may more likely identify their biases when studying other cultures. This article examines the proposition that health promotion research is often crosscultural serendipitously as well as by design. We argue that by systematically considering the impact of culture on the elements of their study proposals, investigators can augment their outcomes. Specifically, we describe how variation across cultures can be considered within a study including the conceptualization of research questions or hypotheses, sampling with respect to methodology, and in constructing and administering tools such as surveys and interviews. In describing these elements, we provide multiple examples of how cultural factors affect the interpretation of a study’s results. 2.2.1.  Culture and Research Paradigms  Qualitative researchers argue that qualitative methods are those of choice for universal studies designed to explore the influences of social, cultural and historical contexts on health (Veugelers & Kephart, 2001). Given that physical, mental and emotional wellbeing are influenced by cultural contexts, culture in itself has become of greater interest in health studies (Boddington & Raisanen, 2009). Similar to the evolution 27  of universal health as a construct that accounts for cultural variation in health disparity or unequal delivery of healthcare, researchers in health disparity are adding “socio-cultural beliefs and values” to their definition of health disparity (Fink, 2009, p. 354). The same trend can be observed in measures designed to examine quality of life, one’s subjective experience of one’s health overall (Saylor, 2004). Favouring one theoretical approach over others should not necessarily limit adopting culture into health promotion research. Rather, a study’s goal(s) and objective(s) shape the way culture informs its methodology. 2.2.2.  Culture in Health Promotion Research  Culture can be conceptualized as either static or dynamic (Aneas & Sandin, 2009). Static aspects of culture “remain relatively constant” whereas the dynamic aspects of culture “shift over time” (Martin & Nakayama, 2010, p.75). For instance, based on the dynamic perspective, relationships “are constantly in flux, responding to various personal and contextual dynamics” (Martin & Nakayama, 2010, p.391), and individuals’ identities changes over time. The static perspective, on the other hand, is based on the premise that relationships are structured by cultural ideologies and identities are fixed entities within individuals (Martin & Nakayama, 2010). In short, culture is a dialectical conception (Martin & Nakayama, 2010). In contrast to the dynamic conceptualization of culture that perceives culture as homogenous, and relationships and individual identities as changing in response to changes in time and contexts, the static culture involves homogeneity, predictable relationships, and generalizability from individual-based experiences (Levy, Plaks, Hong, Chiu, & Dweck, 2001). Because the dialectical nature of culture can be challenging to researchers, scholars of culture have suggested quantitative tools to study the static aspects of culture and qualitative methods to study the dynamic ones (Aneas & Sandin, 2009). When studying 28  nutritional behaviours among cultural groups, for example, demographic characteristics such as religion and ethnicity can be quantified as predictive variables. If a researcher wants to examine how religious beliefs affect eating patterns of a cultural group however, qualitative methods may be preferable. Until recently, biomedical research relied almost exclusively on quantitative methods. This maybe reflected by the reductionist analysis and the belief that objective reality is achieved by controlling external factors to study the variables of interest. Alternatively, others argue that reality is framed by “a complex interaction between the objective and subjective worlds” (Eckersley, 2007, p.194) and culture in itself is a primary predictor of health. Given these trends, we argue that attention to culture-related variables at all levels across various types of research studies could augment not only their scientific rigor but also the richness of their quality. To illustrate these points, we describe examples at these various levels, i.e., inception of a study and formulation of its research questions, the design, sampling, analysis, and interpretation of the study results. 2.3.  Culture as a Variable in the Research Processes According to Hofstede (1980), cultures can be classified in relation to their  characteristics with respect to individualism versus collectivism, masculinity versus femininity, power distance, and uncertainty avoidance. These characteristics are known as cultural dimensions to the description of cultures. Cultural dimensions have been useful tools to study cultures. Individualism versus collectivism refers to “the form of the relationship between the individual and the collectivity in a given society” (Bochner & Hesketh, p.236). Based on these two opposing notions, people from Asian cultures like Japan are collectivistic and they “give priority to in group goals rather than to personal goals” (Triandis, 2004, p.90). 29  In some circumstances however, individuals can have both individualistic and collectivist traits if they grew up in collectivistic cultures and later lived in individualistic cultures or the reverse happened (Triandis, 2004). Moreover, prosperity and affluence in collectivistic cultures make people more adaptable to individualistic traits over time (Triandis, 2004). Similar critique applies to other dimensions of culture. Masculinity versus femininity refers to the definition of gender roles in a culture in relation to the biological sexes of men and women. In masculine cultures, men are expected to be “assertive, ambitious, and competitive, to strive for material success” whereas women are expected to care for the domestic chores and their families. In feminine cultures, gender roles of men and women are overlapping and not necessarily defined by their biological sexes (Hofstede, p.390). With women having comparable education to men in masculine cultures, however women are adapting to social roles that are similar to men’s. Masculine societies are gradually becoming feminine, and the distinction between masculinity and femininity is dissipating. Other dimensions of culture are power distance, defined as “the degree of inequality existing between a less powerful and a more powerful person” (Bochner & Hesketh, 1984, p.235); and uncertainty avoidance, which refers to societal tolerance of ambiguity and uncertainty. According to these two notions, Asian cultures like Japan are distinguished from western cultures like the United States by being hierarchically structured and regulated by tight rules and norms (Triandis, 2004). As cultures modernize and astride to democracy however, power is being distributed and cultures are becoming closer with respect to accepting diverse rules from various groups in a given society.  30  In the following sections, we examine the role of cultural factors at each level of the health promotion research process. 2.3.1.  The Research Problem  Typically, scientific studies first conceptualize the research problem. Intercultural studies classify research methods in two categories. The culture-specific (emic) approach is where the research problem focuses on a particular culture and generalizations made within the contextual boundaries of that particular culture (Aneas & Sandin, 2009; Morris, Leung, Ames, & Lickel, 1999). For example, the findings of a study on the relationship between religious beliefs and eating preferences of a Buddhist community in Canada may be distinct from the findings of a similar study with a sample of Buddhists in Thailand. Another way to study the relationship between religion and eating preferences is to use demographic data to determine whether people’s adherence to their religion predicts such preferences. Using demographic information to study culture in this manner is referred to as a culture-general (etic) approach (Aneas & Sandin, 2009; Morris, Leung, Ames, & Lickel, 1999). In this view, the goal is usually to understand the impact of culture on people’s attitudes and behaviours (Aneas & Sandin, 2009; Schaffer & Riordan, 2003). To further illustrate this point, an Israeli study examined parents’ compliance with home rehabilitation therapy for children with disabilities. Bedouin parents tended to adhere less to home therapy for their children than Jewish parents (Galil, Carmel, Lubetzky, Vered, & Heiman, 2001). Because these findings cannot be generalized to Jewish and Bedouin parents in countries other than Israel, these findings could be used to make cross-cultural comparisons (Aneas & Sandin, 2009; LeCompte, 1982). In the example of eating preferences in Buddhist communities, Buddhist communities in Canada can be compared with those in Thailand. Such comparisons may elucidate 31  similarities and differences among cultures and expand knowledge. 2.3.2.  Sampling  Sampling techniques in cross-cultural research are governed by two rules. One, an identical representation of a culture is only achieved when the population of that culture is homogeneous (Lonner & Berry, 1986; Ember & Outterbein, 1991; Sekaran, 1983). Two, the purpose of a study and the distinctiveness of study participants are two determinants of the sampling methods (Lonner & Berry, 1986; Sivakumar & Nakata, 2001; Sekaran, 1983). Contrary to the traditional belief that random sampling is more representative of a population than structured sampling, in cross-cultural studies, where the aim is to make comparisons based on culture, structured sampling such as stratified sampling and systematic sampling may be more justifiable. Systematic sampling in biomedical research will improve a study’s reproducibility. By replicating a study across cultures, researchers can better assess the generalizability of their findings. Complex cultural factors in scientific studies of experimental designs can be measured by systematic sampling of the target population. Systematic sampling in scientific research will enable researchers to define the uniqueness of the study sample and later replicate the study. Non-random sampling techniques, e.g., convenience and purposive sampling, can be useful to systematically define the culture of a population in health promotion research. Cultural dimensions are less apparent in cultures where immigration is in flux. When people emigrate, they experience a range of enculturation processes. Although some become more acculturated through successive generations, others choose to live in enclaves for expediency, and the transmission of their traditions including religion and language continue to be transmitted from one generation to the next (Landis, Bennett, & 32  Bennett, 2004). The degree to which each generation is acculturated to the adopted country’s traditions varies widely, thus, cannot be assumed. One means of sampling individuals from cultural groups in western countries is to categorize them as traditional, transitional and acculturated (Lonner & Berry, 1986; Hubert Snider, & Winkleby, 2005). With respect to immigration to Arab countries, immigration to these countries has diversified communities and, in places, has contributed to ethnic and cultural segregation. This has given rise to discrimination and other social problems. Fargues (2011) argues that expatriates living in Arab countries have limited residential rights. Expatriates in the Arab countries are foreign workers with temporary residencies, low job security, and not allowed to have an access to citizenship or participate in the society (Fargues, 2011). Arabs interact with foreign workers in the workplace only; foreign workers in Arab countries are integrated into the economic structure but excluded from the social one (Skok, & Tahir, 2011; Forgoes, 2011). The transition from the traditional structures from the time Arabs lived as tribes to modern times post oil discovery, may contribute to Arabs attitudes to the treatment of immigrant workers as minorities (Forgoes, 2011). Selecting a sample representative of a culture varies with and within the social and political situations of the countries where cultural groups are targeted. For instance, the culture of Arab countries such as Iraq, Kuwait and Saudi Arabia are more homogeneous than western cultures. This assumption is attributed to the fact that Arab countries are unified by one language, religion, and ethnicity whereas in western countries, immigrants come from multiple ethnic and religious backgrounds with various cultural norms and values (Harris, Gleason, Sheean, Boushey, Beto, & Bruemmer, 2009; Lonner & Berry, 1986; Trimble, 1990).  33  When sampling, researchers need to distinguish ethnicity and culture as overlapping constructs. Ethnic categories such as race, language and nationality can be used to represent elements of a culture but not define it (Bradby, 2003). In the previous example, people in Arab countries more likely descend from one ethnic category, whereas in a mosaic culture such as the United States and Canada, an American or Canadian can be virtually of any ethnicity or combination of ethnicities. Sampling in multicultural countries constitutes unique methodological considerations. Because of practical considerations and resources, e.g., convenience and time, however, optimal sampling may be compromised. Nonetheless, it behooves researchers to address this as a limitation. Contemporary health promotion research largely depends on volunteers. Volunteers are often recruited through posters and signs in public places and clinics. Readers of the advertisement self-select and decide whether to phone or contact a research coordinator. Although common practice in western cultures this method may be a barrier to recruitment in other cultures. First, it relies on an individual having the necessary literacy skills to understand the poster. Second, volunteering for research studies is not a common practice in non-western cultures due to factors such as trepidation and distrust. Third, should an immigrant respond to the notice, it is likely that a base level of communication skills is required, and potential participants can be excluded at this stage due to inadequate communication skills which are important for safety, following instructions and adhering to a regimen. Fourth, adhering to a regimen and/or the requirement to return for a follow-up visit can be foreign to people in some cultures. Fifth, signing a consent form can be daunting and formidable for people in some cultures, thus may discourage participation. Overall, recruiting study participants through self-volunteering, e.g.,  34  responding to notices and posters (which respects individuals’ right to select and not be coerced), may exclude potential immigrant groups who comprise the mainstream population; or, in other cultures, will only attract a minimal number of participants, potentially educated or familiar with this as a western practice. Comparable to variations among cultures, individual differences within cultural groups warrant consideration. For example, one way of sampling adolescents to study their sexual practices is clustering regions of a geographic region into strata and randomly selecting schools from each region. Random selection of students from each school however does not exclude differences with respect to sexual beliefs, views and practices as a result of individuals’ acculturation experiences. One way to measure the impact of acculturation experiences in this example is to replicate the study in another age group, e.g., university students and comparing the results of both age groups. A key question is ‘how can we ensure a representative sample of students when their identities change over time through their acculturation experiences?’ Answering this question makes the traditional way of categorizing individuals based on the duration of their acculturation experiences spurious. 2.3.3.  Surveys  Familiarity with a nation’s research enterprise through media reports on biomedical breakthroughs varies within and between cultures. People in cultures that have less exposure to the translation of research advances or access to media reports about findings of health promotion research may be less comfortable with the research process. This is supported by the work of Barata, Gucciardi, Ahmad, & Stewart (2006, p.487) who noted that “lack of accessibility due to fewer opportunities to hear about individual research projects” makes people suspicious of researchers and unwilling to participate. Moreover, 35  in cases where researchers are from cultures different than the culture of participants, participants may be concerned about the image of their culture and withhold responses that portray their culture negatively (Sekaran, 1983). Researchers therefore need to establish rapport and trust with study participants to make them comfortable with the process and willing to provide valid information. Interestingly, using incentives to encourage participation may not work well across cultures. Whereas people in western cultures often welcome incentives, particularly financial, some cultures view incentives suspiciously as a bribe and being offensive (Rosenthal, 1963). In accordance with the universal code of ethics, the Helsinki Declaration has highlighted cultural differences to researchers that could lead to participant exploitation (WMA Declaration of Helsinki-Ethical Principles for Medical Research Involving Human Subjects). Participants are not exempt from giving their consent to participate in cultures where people are illiterate. In this case, researchers need to explain the study to participants transparently including a literate advocate or family member who could consent and sign as needed on a person’s behalf. In cross-cultural studies, translation approaches usually provide semantic rather than literal translation. Translators pay particular attention to the equivalence of concepts, items, and measures such as scales and factor scores (Sperber, Devellis, & Boehilecke, 1994). An established translation method is back translation where translators with proficiency in the two dialects/languages translate research items from the source language to the target one (McGorry, 2000). Then, translators translate the items back to the original language. In this way, culturally insensitive items can be revised, as well as their validity evaluated based on systematic comparison of the original version and the  36  back translated version. Providing a dialectical translation to research consent forms may help illiterate participants to better understand the research process and their rights to withdraw before giving consent to participate. 2.3.4.  Interviews  Participants’ responses to questionnaires or interview questions are reflected by their cultural values or what is called “cultural response set” (Matsumoto, 1994; Clarke, 2001; Fischer, 2004). In Chinese culture, for instance, inner strength may be viewed as a virtue and ill health caused by sins committed by the ill person or his or her family (WaxlerMorrison, Anderson, Richardson, & Chambers, 2005). To avoid embarrassment and save face, Chinese people may avoid acknowledging pain to healthcare providers (WaxlerMorrison, Anderson, Richardson, & Chambers, 2005). Although the impact of cultural response set is not always avoidable, researchers can minimize its influence by being aware of participants’ cultural attitudes (Matsumoto, 1994; Fischer, 2004). A noteworthy example of cultural attitudes toward health is the stigma associated with psychological and neurological illnesses in South East Asian cultures. In these cultures, the parents of children with mental health problems may hide related diagnoses from healthcare providers to save face and protect their children’s marriage prospects (Waxler-Morrison, Anderson, Richardson, & Chambers, 2005). Similar attitudes have been reported in Middle Eastern cultures where people may be unwilling to admit psychosocial complains to avoid social stigma (Hamdan, 2009; Harakati, Shaheen, Tamim, Taher, Al Qublan, & Al Sayyari, 2011; Becker, 2004). Stigma in these cultures encourages people to use socially acceptable forms of illnesses such as headache and fatigue to report consciously or unconsciously their psychosocial health problems (Al-  37  Krenawi & Graham, 2000). Knowledge of such attitudes can help to reduce response bias and potentially invalid responses and results. Another example that illustrates the need for researchers to understand cultural considerations is the issue of cultural attitudes toward gender. In some Muslim cultures, men may prefer to confer with men, and women with women (Al-Shahri, 2002). In Bedouin cultures, women are expected to veil their faces and not expose their faces to men, even in the form of a photograph (Yehia, 2007). In both situations, researchers are advised to modify their research process in a way that does not violate these cultural norms. Muslim participants should decide on whether researchers of the same gender will interview them and whether they prefer to be segregated on this basis. When using Photovoice® method (Wang, Yi, Tao, & Carovano, 1998) with Bedouin women, researchers need to inform female participants if male researchers will view their photographs. Women may not agree to participate in such a study thus, informing them of such a possibility before they sign consent is ethically required. Cross-cultural research ethics highlight the need to modify research methods to the cultural needs of the people being studied. To be culturally sensitive, we recommend paying attention to the language used by researchers when examining cultures. In questionnaires, researchers may need to avoid using both medical terms and questions directly addressing mental health. Instead of asking participants, for example, “Have you ever been diagnosed with depression?” a researcher might ask, “Have you ever been diagnosed with health problems related to your mood?” Engaging participants in pilot work before initiating the study will help researchers ascertain participants’ cultural attitudes and avoid language that may lead  38  participants to give biased responses. Communicating with participants will help to develop trust and rapport. 2.4.  Conclusion Because culture profoundly impacts health, lifestyle choices, perception of healthcare,  and health seeking behaviour, cultural factors need to be considered in designing health promotion studies. However, the dimensions of culture remain hotly debated, which contributes to challenges in describing how cultural variations need to be considered in health research particularly health promotion. Health care researchers could benefit from cultural knowledge to date although this remains limited, given that they are not trained as interculturalists. In this article, we described how researchers can account for cultural variations in their studies and could minimize serendipitous contaminating cultural factors and skewing the results in some unforeseen way. We discussed issues related to cultural variation throughout a study’s process including its inception and research questions or hypotheses, methods of sampling, and developing and administering surveys and interviews. Given that lifestyle-related conditions are closely associated with cultural factors and are a global priority, we propose that cultural factors be addressed in healthrelated studies. Finally, the interface between health care and cultural factors points to a rich and fertile collaboration between health practitioners and researchers, anthropologists, sociologists, and others in intercultural studies in the pursuit of best practices in health care.  39  3. STUDY ONE: LIFESTYLE-RELATED HEALTH BELIEF AND BEHAVIOURS OF SAUDI WOMEN LIVING IN DAMMAM 3.1.  Introduction The incidence and prevalence of lifestyle-related conditions such as ischemic heart  disease, smoking-related conditions, hypertension, type 2 diabetes mellitus (T2DM), and obesity continue to increase in Saudi Arabia (Al-Nozha et al., 2007; Al-Nozha et al., 2004b; Al-Nuaim et al., 1997; Al-Rajeh, Awada, Niazi, & Larbi, 1993). Saudi women have a higher prevalence of obesity than men, which increases their risk of lifestylerelated conditions like T2DM (Al-Nuaim et al., 1997). T2DM and obesity have become prevalent in Saudi women constituting substantial social and economic burdens (AlNozha et al., 2007; Al-Nozha et al., 2004b; Al-Nuaim et al., 1997; Al-Rajeh, Awada, Niazi, & Larbi, 1993). Because Saudi women are restricted from public physical activities and they are expected to center their roles at their homes, their health needs are distinct from those of men (Abahussain & El-Zubier, 2005). Overall, lifestyle-related conditions among women in Saudi Arabia are influenced by social, cultural, and religious factors however these factors are rarely addressed in literature in relation to health (Khatib, 2004, Al-Khaldi & Khan, 2000; Al-Hussein, 2008). In the interest of increasing attention to the impact of Islamic teachings on health, the World Health Organization has initiated an Islamic perspective on health promotion (World Health Organization, 1996). In this respect, health promotion will address the context of Islamic faith to disseminate health messages (Ide & Sanli, 1992, World Health Organization, 1996). In Saudi Arabia, the degree to which cultural and religious factors impact Saudi women’s lifestyle-related health beliefs and behaviours is unclear. For this study, thus, we were interested in examining Saudi women’s self-reported health status, 40  their lifestyle-related health beliefs and behaviours, and their understanding of related Islamic teaching, to serve as a basis for designing and implementing a T2DM education program based on international standards and adapted to the cultural and religious contexts of Saudi women. 3.2.  Research Objectives  3.2.1.  Primary Objectives  With respect to Saudi women and lifestyle-related conditions: 1. To examine their self-reported health profile. 2. To elucidate their lifestyle-related health beliefs and behaviours 3. To examine their understanding of Islamic teachings in relation to health behaviours 3.2.2.  Secondary Objectives 1. To inform recommendations for a subsequent study, Study Two, to explore the outcomes of a pilot study of a T2DM education program based on international standards and adapted to the cultural and religious contexts of Saudi women  3.3.  Methods The research proposal was reviewed by the relevant institutional ethics boards,  namely, the University of British Columbia and the Saudi Administration of Medical Research. Participants provided informed consent and were assured confidentiality of their responses. 3.3.1.  Sampling Frame  There were no existing data on which to base a power analysis and to derive a sample size, thus, a descriptive exploratory study was conducted based on sample size estimates 41  from studies conducted in other countries in the region. Comparable health surveys in Kuwait and Singapore have reported sampling sizes ranged from 50 to over 800 (Li, Peng, Bodner, Dean, in preparation; Alfadley, Al-Mazeedi, Bodner, Dean, in preparation; Wong et al., 2012). The one study that described Saudi women’s knowledge and beliefs about illnesses was based on a sample size of 50 women (Ide & Sanli, 1992). For our preliminary study in Saudi Arabia, we selected an intermediate sample size (N=400) that could be used to estimate sample size in subsequent studies. 3.3.2.  Sampling and Recruitment  The study consisted of a cross-sectional survey questionnaire. The primary investigator interviewed women from Dammam, the capital city of the Eastern Province in Saudi Arabia. This province is one of the largest populated regions in the country. The most recent census (2004) reported that its population was 3,360,031 and in Dammam was 745,658 (Central Department of Statistics & Information). The study was conducted over 6 months. Sequential convenience sampling was used. A sample of 407 Saudi women was selected. The number of participants was proportionately selected based on the number of visiting patients to the 21 primary health centers in Dammam. Since the establishment of primary health clinics in Saudi Arabia, each family is registered with a primary health clinic in its residential neighborhoods. Using proportional sampling (i.e., the number of visitors registered at each center in proportion to the overall number of visitors at all centers in Dammam), the number of women was proportionally selected from each center (Appendix 2). Inclusion criteria were women, 17 years of age and over, living in the residential areas of Damman, Saudi Arabia, where the health centers were located. Exclusion criteria 42  were the inability to complete the survey questionnaire interview based on preliminary screening to assess cognition (specifically, whether the respondent was able to indicate reasonable knowledge about requirements of the survey questionnaire as it was explained, and respond to basic demographic information, e.g., age, marital status, and occupation). Ten women participated in piloting the survey questionnaire and ensuring that participants were able to respond to all questions within the Saudi context. Eligible women were approached for potential face-to-face interviews with the primary researcher who was responsible for collecting the survey questionnaire data, for consistency in the data collection. Participants were approached sequentially in the waiting rooms of the participating general health centers. Participants in the waiting areas were visiting the clinics for reasons such as their children’s checkups, to accompany a family member or a friend, or to see doctors for their own medical checkups. 3.3.3.  Survey Questionnaire Construction  The survey questionnaire was mostly a composite of other established and published questionnaire surveys. These were modified somewhat to be culturally appropriate. To examine the effectiveness of this, the closed-ended and open-ended questions were piloted with ten women. Section 3 in the survey questionnaire was extracted from a survey questionnaire study conducted in the neighboring Gulf State of Bahrain titled “National Non-communicable Diseases Risk Factors Survey 2007, Kingdom of Bahrain” and was validated by the World Health Organization. The other sections of the survey questionnaire were based on a tool that was trialed in other countries such as Singapore (Wong et al., 2012) and in China and Kuwait (Li, Peng, Bodner, & Dean, in preparation; Alfadley, Al-Mazeedi, Bodner, & Dean, in preparation).  43  The survey questionnaire consisted of six sections of closed-ended and open-ended questions. The sections were demographic data, self-reported health status, lifestylerelated health behaviours, lifestyle-related health beliefs for the overall health, beliefs related to diabetes prevention and management, and understanding of health-related religious teachings. The survey questionnaire appears in Appendix 1. It was designed to be completed within twenty minutes. Section 1 of the survey questionnaire included closed-ended questions related to demographic data, i.e., gender, age, height, weight, education, marital status, and number of children. To the best of our knowledge, no national data for the scaling of income in Saudi Arabia exists. We therefore used our local knowledge and data of average monthly income by job category and region in Saudi Arabia to categorize income (Salary Explorer, 2012; Pay Scale, 2013). To assess participants’ socioeconomic status, thus, income was grouped into four categories ranging from low income (<SR 3,000/month) to high income (>SR 10,000/month). Section 2 assessed participants’ self-reports of their health status with closed-ended questions. The first question in this section was related to weight with answers on a 3point scale ranging from ‘underweight’ to ‘over weight’ and ‘I don’t know’ answer. The next three questions were related to heart rate, blood pressure, and blood sugar with answers on a 3-point scale ranging from ‘low’ to ‘high’ and ‘I don’t know’ answer. The fifth question was related to health status with answers on a 5-point scale ranging from ‘excellent’ to ‘poor’ and ‘I don’t know’ answer. The sixth question in this section was related to morbidities with ‘yes’ or ‘no’ answers. Section 3 consisted of closed-ended questions to assess participants’ lifestyle-related health behaviours: a. physical activity  44  and exercise; b. diet and nutrition; c. smoking behaviours; d. stress and sleep behaviours. Section 4 consisted of closed-ended questions to assess participants’ lifestyle-related health belief for the overall health: a. physical activity and exercise beliefs; b. diet and nutrition beliefs; c. smoking beliefs; stress and sleep beliefs. Section 5 consisted of closed-ended questions to assess participants’ beliefs related to the prevention and management of diabetes. Section 6 consisted of open-ended questions to assess participants’ understanding of health-related religious teachings; the sayings of the Qur’an and Hadith about physical activity and exercise, diet and nutrition, smoking, stress and sleep, and health and healthy living. 3.4.  Data Analysis  3.4.1.  Quantitative Data  Descriptive statistics (SPSS v20.0.0) were used to analyze data for the sections of the survey questionnaire with closed-ended questions and discrete responses. Tables and graphs were used to show frequencies, mean, median, and mode of the variables of interest. 3.4.2.  Qualitative Data  Atlas.ti®, a software program, was used to code and organize the qualitative data from the open-ended questions in Section 6. The responses to these questions were coded and analyzed based on key words and phrases in accordance with the thematic analysis approach (Braun & Clarke, 2006). This approach facilitated the classification of data into categories for collation. Themes were then processed in Excel for frequency of occurrence.  45  3.5.  Results  3.5.1.  Response Rate  Of 480 women approached, completed survey questionnaires were obtained from 407. Refusals were due to time constrains, lack of interest, being sick at the time, or looking after a sick child. Tables 3.1 to 3.29 show the results of participants’ socio-demographic characteristics, their age, height, and weight, health profiles, physical activity behaviours, nutritional behaviours, stress and sleep behaviours, lifestyle-related health beliefs, and finally their beliefs about the importance of a healthy lifestyle for the prevention and management of diabetes. Participants’ responses to Section 6 questions, the sayings of the Qur’an and Hadith about good health (i.e., physical activity and exercise, diet and nutrition, smoking, stress and sleep, and health and healthy living, cultural and religious quotes about lifestylerelated health, suggestions and advice to maintaining good health) are shown in Tables 3.30 to 3.35. Frequencies of the quoted Qur’anic verses and Hadith sayings are also included. Our data are based on participants ‘self-reporting of their age, weight, and height. The accuracy of participants’ reporting was not examined. 3.5.2.  Demographic Data  The majority of participants reported they were between the ages of 17 and 30 years (54.1%), their heights between 155 to 178 cm (64.1%), and their weights between 55 and 75 kg (61.2%). Table 3.1 shows participants ‘demographic characteristics with means and standard deviations. 3.5.3.  Subject Characteristics  The majority of respondents were married (80.8%), had 3 to 8 children (54.1%), had secondary school education or lower (57.2%), were homemakers and unemployed 46  (55.9%), had their guardians or husbands as a primary source of income (65.7%), and were in the middle-income category (35.8%). Participants’ demographic characteristics appear in Table 3.2. 3.5.4.  Health Status  The majority of respondents reported their weight was normal (44.0%), their resting heart rates was normal (80.5%), their blood sugar was normal (89.1%), their blood pressure was normal (82.5%), and their health was average (44.4%). Participants’ reporting of their health measures and general health appears in Table 3.3. 3.5.5.  Health Conditions  In total, 35 health conditions were reported by participants. The most common health conditions reported were anaemia (19.4%), irritable bowel syndrome (19.9%), and irregular menstrual cycles (18.9%). Tables 3.4 and 3.5 show participants’ reports of their morbidity. 3.5.6.  Physical Activity Behaviours  The majority of participants (98.3%) responded with yes to the question “Do you do physical activity for more than 10 minutes daily?” Of all participants, 51.3% reported performing moderate activities such as brisk walking, riding a bike or carrying objects of lightweight, and only 9.8% reported performing strenuous physical activities such as running or carrying heavy objects. Table 3.6 shows the types of physical activities reported. Table 3.7 shows the means and standard deviations for the amount of time participants reported spending to performing various physical activities. 3.5.7.  Nutrition Behaviours  Poor nutrition habits reported by participants were: low consumption of brown bread (36.9%), high consumption of soft drinks (62.8%), low consumption (less than 6 to 7 47  times a week) of fresh fruit (67.3%) and vegetables (51.1%), and low consumption of nuts and legumes (89.9%). Poor nutrition habits are highlighted in Tables 3.10, 3.11, 3.12, 3.16, and 3.21. 3.5.8.  Smoking, Stress, and Sleep Behaviours  Most participants reported healthy behaviours with respect to smoking and sleep behaviours. Most participants (97.7%) reported they did not smoke and over half of the participants (60.9%) reported that they slept soundly. On the other hand, the majority of participants (89.0%) reported their stress levels as moderate to high. Participants’ reporting of smoke, stress, and sleep behaviours appear in Table 3.25. 3.5.9.  Health Beliefs  The majority of participants believed that exercise (99.2%, 98.5%), nutrition (99.7%, 99.7%), smoking (98.5%, 93.9%), and stress (97.2%, 97.7%) impact health in general, and affect the management for treatment of diabetes in particular, respectively. Participants’ responses under this section appear in Tables 3.22 and 3.23. 3.5.10. Quotes Reported by Participants At the end of the survey questionnaire, participants reported their health priorities, the implications of Islamic teachings of health behaviours, proverbs on health, health advice, social and cultural barriers to health behaviours, and a reform to the social structure. Participants’ quotes are listed in Table 3.35. 3.6.  Discussion of the Results in Relation to the Study Objectives  3.6.1.  Participants’ Health Profiles with Special Reference to Lifestyle-related Conditions  Ours is the first study to provide a detailed description of Saudi women’s lifestylerelated health beliefs and behaviours. Most apparent in Saudi culture with respect to 48  health is the escalating rate of overweight and obesity, both established risk factors for T2DM (Badran & Laher, 2012; Musaiger, 2011). Obesity and its related conditions continue to increase among women and men in Saudi Arabia and other Arab Gulf countries (Badran & Laher, 2012; Musaiger, 2011). AL Qauhiz (2012) reported an increase in obesity among Saudi female university students in Riyadh. Of participants in her study, 31.4% were overweight (AL Qauhiz, 2012). Similar weight patterns were observed among men in the Qassim region of Saudi Arabia (Al-Rethaiaa, Fahmy, & AlShwaiyat, 2010). In our study, 38% of participants reported that they were overweight, and 10.9% reported not knowing their weight. In addition to those who reported not knowing their weight, 43.2% did not know their height. Not reporting their weight, we propose, could be attributed to women avoiding embarrassment should they have a negative body image. Other studies suggest that husbands’ perceptions of their wives’ weights can influence women’s images of their bodies (Sotoudeh, Khosravi, Karbakhsh, Khajehnasiri, & Khalkhali, 2008, p.99). Similar trends have been observed in Saudi women. In a study conducted in Saudi Arabia, 33.8% of obese women considered their weights to be normal (Rasheed, 1998). In general, awareness of the relationship between weight and height and its related impact on health among Saudi women is lacking. More attention on women’s awareness of their body mass index and how it influences their lifestyle-related behaviours is needed. People in Saudi Arabia can be at risk of or having T2DM without their knowledge (Al-Baghli, Al-Turki, Al-Ghamdi, El-Zubaier, Al-Ameer, & Al-Baghli, 2010). A recent study conducted in the Eastern Province of Saudi Arabia reported that in a random screening for T2DM, 30.4% of those who were screened were diagnosed with T2DM  49  (Al-Baghli, Al-Turki, Al-Ghamdi, El-Zubaier, Al-Ameer, & Al-Baghli, 2010). We propose that some overweight participants in our study may have had T2DM but were unaware. The Saudi public likely lacks awareness of obesity as a risk factor for T2DM. A recent study of Saudi women showed that in addition to obesity, low dietary calcium and vitamin D contribute to bone impairments (Rouzi, Al-Sibiani, Al-Senani, Radaddi, & Ardawi, 2011; Alissa, Qadi, Alhujaili, Alshehri, & Ferns, 2011). Despite considerable amounts of sunshine in Saudi Arabia, vitamin D deficiency is alarmingly high among women in Saudi Arabia (Kanan, Al Saleh, Fakhoury, Adham, Aljaser, & Tamimi, 2012; Ardawi, Qari, Rouzi Maimani, & Raddadi, 2011), and studies support that increased vitamin D intake could curb T2DM risk factors (Maxwell & Wood, 2011). Furthermore, strategies are needed to enable women to access more sunlight, given their traditional clothing and their limited access to outdoors. Rheumatoid arthritis as well as bone conditions are also prevalent among women in Saudi Arabia (Attar & Al-Ghamdi, 2009; Pereira, Peleteiro, Araújoyza, Brancoxa, Santoska, & Ramosyza, 2011) and both were prevalent in participants in our study, where 13.7% reported having rheumatoid diseases, 6.4% had osteoarthritis, 1.2% had osteoporosis, and 3.2% had other bone conditions. The prevalence of osteoarthritis among participants of our study is consistent with research findings that osteoarthritis increases with age. For example, in a study in the Qassim region of Saudi Arabia, the onset of knee osteoarthritis increased with age and 30.8% of participants between 46 and 55 years of age had the condition (Al-Arfaj et al., 2002). Obesity is believed to be a leading factor contributing to osteoarthritis and related bone conditions in women (Asokan, Hussain, Ali, Awate, Khadem, & Al-Safwan, 2011).  50  Hematological conditions are alarmingly prevalent among Saudi women (AlQuaiz, Abdulghani, Khawaja, & Shaffi-Ahamed, 2012). This was confirmed in our study in which women (21.1%) reported having such a condition. Some of these conditions are genetic such as sickle cell and G6PD (Jastaniah, 2011). Others are related to iron deficiency and low hemoglobin (AlQuaiz, Abdulghani, Khawaja, & Shaffi-Ahamed, 2012). The latter conditions are prevalent among female adolescents and women of child bearing age and are largely preventable with lifestyle modifications such as weight loss, consuming natural foods high in iron, and exercising (Jalambo, Hamad, & Abded, 2012). Menstrual irregularities are common among women in Saudi Arabia particularly in those who are obese (Al-Nuaim, 2011). One fifth of our study participants (18.9%) reported menstrual irregularities. Obesity and psychosocial distress are believed to be contributing factors to menstrual irregularities and pre-menstrual pain (Al-Nuaim, 2011). Stress also contributes to gastrointestinal conditions such as irritable bowel syndrome (Humaida, 2012). One fifth of our study participants (19.9%) reported having irritable bowel syndrome. 3.6.2.  Participants’ Lifestyle-related Health Behaviours  (a) Nutrition Behaviours With respect to nutrition, the consumption of whole grains in Saudi Arabia has decreased over recent time (Bakhotmah, 2012). Saudi women have been reported to be less partial to the taste of whole grains and tend to consume more refined cereals (Bakhotmah, 2012). This trend was supported by our findings in that only 36.9% of participants reported eating brown bread. Based on research findings, the source of fibber intake for people in Saudi Arabia continues to be mostly from vegetables, fruit, and cereals (Musaiger, Takruri, Hassan, & Abu-Tarboush, 2012). 51  Kabsa, a traditional Saudi dish of rice and meat, is common and consumed by most people in Saudi Arabia (Bakhotmah, 2012, Midhet, Al Mohaimeed, & Sharaf, 2010; Alhemoud, 2011). Rice is “one of the oldest food sources [in the country and] has played a major role in the cultural, social and economic aspects of the lives of the Saudi people” (Alhemoud, 2011, p.93). Rice is consumed almost daily by Saudi people (Mohieldein, Alzohairy, & Hasan, 2011). In our study, participants reported consuming rice and bread almost daily. The pattern of rice consumption in Saudi Arabia can be explained by the way Alhemoud (2011) referred to rice as inferior. In other words, rice is an affordable food item for almost all Saudi people regardless of their socioeconomic status. Traditional Saudi food such as kabsa and ghee (butter) contain large amounts of fat (Winter, King, Stafford, Winkleby, Haskell, & Farquhar, 2012; Bakhotmah, 2012; Midhet, Al Mohaimeed, & Sharaf, 2010). In our study, only 14.7% of participants reported using butter or margarine in food preparation. Further, all participants reported consuming chicken rather than red meat. Participants’ reporting of their consumption of chicken, shrimp, and fish appear in Tables 3.18 and 3.19. Our findings confirm the suggestion that “the intake of animal source foods is growing steady [and] poultry and eggs were more consumed compare to red meat, and fish less than that of poultry and eggs” (Musaiger, Takruri, Hassan, & Abu-Tarboush, 2012, p.2). Our study participants consumed nuts less frequently than eggs and legumes less frequently than nuts. Of those who reported 6 to 7 times per week consumption, only (29.3%) reported consuming eggs, 23.6% consumed nuts, and 10.1% consumed legumes. Similar pattern of legumes consumption among participants in our study has been reported among female university students in Riyadh (Abdel-Megeid, Abdelkarem, & El-  52  Fetouh, 2011). Of those students, only 5.5% consumed legumes on a daily basis and of the remained group, and 5.6% rarely consumed legumes (Abdel-Megeid, Abdelkarem, & El-Fetouh, 2011). Generally, consumption of eggs, legumes and nuts in Saudi Arabia and other Arab Gulf countries is lower than that recommended for optimal health (Musaiger, Takruri, Hassan, & Abu-Tarboush, 2012). Dates, a traditional nutrient source that is rich in sugar, are consumed almost daily in Saudi Arabia (Al-Rethaiaa, Fahmy, & Al-Shwaiyat, 2010; Winter, King, Stafford, Winkleby, Haskell, & Farquhar, 2011). Bakhotmah (2012) reported that “Most Saudis were Bedouin Arabs who lived in a wide dry country with limited resources. They relied on consuming the available foods in their environment which included dates as the main fruit” (p.321). The majority of our study participants reported consuming dates regularly. Comparable to the nutrition trends of people in other Arab countries, the nutrition of Saudis “has shifted towards a high-energy-density diet with more fat and added sugar in foods” (Musaiger, Takruri, Hassan, & Abu-Tarboush, 2012, p. 2). The recent influence of the western lifestyle on the Saudi culture is considered responsible for the increased consumption of fat and junk food in Saudi Arabia (Winter, King, Stafford, Winkleby, Haskell, & Farquhar, 2011; Alfawaz, 2012). Soft drinks are consumed widely in Saudi Arabia (Mohieldein, Alzohairy, & Hasan, 2011; Midhet, Al Mohaimeed, & Sharaf, 2010). In our study, over half of participants (62.8%) consumed soft drinks. Few participants (8.1%) reported heavy consumption of soft drinks. For example, 2.7% consumed 21 to 31 cans and 0.2% consumed 48 cans in a week. These findings suggest an association between consumption of soft drinks and obesity and T2DM among Saudi women.  53  The consumption of fruit and vegetables among people in Saudi Arabia and other Gulf countries is below daily-recommended requirements (Al-Rethaiaa, Fahmy, & AlShwaiyat, 2010; Bakhotmah, 2012; Musaiger, Takruri, Hassan, & Abu-Tarboush, 2012). According to the Food-Based Dietary Guidelines for the Arab Gulf Countries (Musaiger, Takruri, Hassan, & Abu-Tarboush, 2012), one should consume 3 to 5 servings of vegetables and 2 to 4 servings of fruit daily. Similar recommendations are based on cross-cultural food pyramids (Painter, Rah & Lee, 2002). In our study, 12.3% participants did not consume fruit and 6.1% ate no vegetables at all. Only 32.8% of fruit consumers and 49.0% of vegetable consumers reported eating fruits and vegetables respectively 6 to 7 times a week. Participants’ reporting of their consumption of fruits and vegetables appear in Tables 3.15, 3.16, and 3.17. The nutrition profile of university students in Riyadh shows slightly lower consumption of vegetables (23.9% consumed vegetables daily) than our participants but, overall, a similar pattern of fruit consumption (AbdelMegeid, Abdelkarem, & El-Fetouh, 2011). In the Jeddah region of Saudi Arabia, women acknowledged their low consumption of fruit and vegetables yet expressed interest in achieving the recommended servings (Bakhotmah, 2012). Low intake of fruit and vegetables by inhabitants of the Qassim and Riyadh regions of Saudi supports the overall low consumption of fruit and vegetables in Saudi women (AL Qauhiz, 2012). Low dairy intake predisposes Saudi women to health risks (Alissa, Qadi, Alhujaili, Alshehri, & Ferns, 2011). Osteoporosis and bone conditions for example are prevalent among Saudi women who suffer from vitamin D deficiency and low calcium (Alissa, Qadi, Alhujaili, Alshehri, & Ferns, 2011; Attar & Al-Ghamdi, 2009). Overarching risk factors such as low calcium intake, physical inactivity, smoking, and wearing a face-veil  54  affect the absorption of vitamin D that contributes to bone conditions that are prevalent in Saudi women (Alissa, Qadi, Alhujaili, Alshehri, & Ferns, 2011; Kanan, Saleh, Fakhoury, Adham, Aljaser, & Tamimi, 2012; Rouzi, Al-Sibiani, Al-Senani, Radaddi, & Ardawi, 2011). To combat the prevalence of bone conditions in Saudi Arabia, medical scholars have suggested women increase their intake of calcium and vitamin D from milk and dairy products (Alissa, Qadi, Alhujaili, Alshehri, & Ferns, 2011; Kanan, Saleh, Fakhoury, Adham, Aljaser, & Tamimi, 2012). Despite these suggestions, the consumption of milk and dairy is still poor among Saudi women (Musaiger, Takruri, Hassan, & Abu-Tarboush, 2012). In our study, 23.6% of participant reported not drinking milk and 4.2% reported not consuming any dairy products. Participants’ reporting of their consumption of milk and dairy appear in Tables 3.22, 3.23, and 3.24. Findings of studies of the nutritional practices of people living in the Riyadh region of Saudi Arabia reported that only about one third of study participants (29.5%) consumed milk daily (Al Qauhiz, 2010) and 36.1% of female consumers consumed full fat milk (Abdel-Megeid, Abdelkarem, & El-Fetouh, 2011). In Jeddah, on the other hand, women acknowledged their low consumption of milk and dairy and their wish to increase it (Bakhotmah 2012). Overall, Saudi health authorities need to consider launching health awareness campaigns addressing the importance of increasing the intake of milk and dairy products in Saudi Arabia to minimize the risk factors of vitamin D deficiency. (b) Physical Activity Behaviours The sedentary lifestyle of women in Saudi Arabia and its relation to obesity has been well discussed (Al-Eisa & Al-Sobayel, 2012; Rouzi, Al-Sibiani, Al-Senani, Radaddi, & Ardawi, 2011; Alissa, Qadi, Alhujaili, Alshehri, & Ferns, 2011). No data, however, exist on Saudi women’s self reported physical activity. In our study, 51.2% of participants 55  performed moderate physical activity, and only 9.8% performed strenuous physical activity. In Saudi Arabia, women are not permitted to drive and require a male guardian when they commute in some regions of the country. These constrains were identified as cultural barriers to Saudi women to be physically active outside their homes (Al-Eisa & AlSobayel, 2012). AlQuaiz and Tayel (2009) listed barriers to healthy lifestyle among Saudi women including women’s lack of resources for accessing sports clubs, lack of determination and motivation, lack of time, and lack of social support. Women from lower socioeconomic backgrounds in Saudi Arabia are confronted with financial constraints such as membership fees for women-only sports clubs and/or the cost of transportation to such clubs (AlQuaiz & Tayel, 2009). Suggestions in overcoming the social and cultural barriers for women in Saudi Arabia for the prevention and management of lifestyle-related conditions include integrating physical activity into female education curriculum and integrating Islamic teachings into the education of physical activity in schools (Winter, King, Stafford, Winkleby, Haskell, & Farquhar, 2012). (c) Smoking Behaviours Smoking continues to increase in Saudi Arabia and neighbouring Arab Gulf countries (Musaiger, Takruri, Hassan, & Abu-Tarboush, 2012). “The smoking of shisha (water pipe) has [...] increased sharply in the region and become more acceptable in the community” (Musaiger, Takruri, Hassan, & Abu-Tarboush, 2012, p.4). In our study, only 1.7% reported smoking shisha and 0.5% smoked cigarettes. Moreover, a few participants (1.5%, 1.6%) respectively stated that smoking has no negative impact on health and quitting smoking is not important for the prevention and management of T2DM and its 56  complications. Although a small group, our participants and potentially Saudi women could benefit from more awareness of health risk as a result of smoking and the exposure to smoke. (d) Stress Related Behaviours Psychosocial conditions and mental illnesses have been reported to be prevalent among women in Saudi Arabia (Al-Gelban, Al-Amri, & Mostafa, 2009; Alqahtani & Salmon, 2008). Pressures of modern living and daily stresses contribute to somatic symptoms among Saudi women such as irritable bowel syndrome, gastrointestinal ulcers, and blood pressure problems (Alqahtani, & Salmon, 2008; Hassellund, Flaa, Sandvik, Kjeldsen, & Rostrup; 2011; Kanno et al., 2012). In our study, 57.3% of participants reported their stress as moderate, and 31.7% reported their stress as high. Stressors reported included conflicting demands between home and work, if they were employed. Stressors at home were attributed to taking care of children, schooling children, increased household chores but having no maids, conflict in relationships with husbands, family problems, and household responsibilities in general. At work, participants reported long working hours and increased job demands as stressors. Other stressors that participants reported included being obese, having illnesses and pain, addiction to caffeine, having husbands who smoke, having a sick family member, daily stressors, unemployment, lacking purpose in life, financial problems, housing problems, separation from loved ones, school demands, irritation, bad mood, psychosocial distress, worries, lack of sleep, unreasonable sadness, nervousness, fear and uncontrolled thoughts, thinking of future, time pressure, and other stressors they chose not to divulge. Comparable stressors to these reported by our participants have also been reported in Arab women in the United Arab Emirates (Hamdan, Hawamdeh, & Hussein, 2008). 57  A link between obesity and depression has been documented in Saudi women (AbdelFattah, Asal, Hifnawy, & Makhlouf, 2008). Based on these findings, Saudi women would benefit from education on establishing life balance and managing stress in their lives. Tailoring psychological approaches for the prevention and treatment of emotional and mental conditions to the socio-cultural contexts of people in Saudi Arabia and other Arab cultures was suggested (Ratner & El-Badwi, 2011; Sayar & Kose, 2012; Gearing et al., 2012). (e) Sleep Behaviours Few studies have examined sleep disorders in the people of Saudi Arabia. Recent findings suggest that sleep disorders, such as insomnia and obstructive sleep apnoea are common but not routinely screened by physicians in primary care settings (Senthilvel, Auckley, & Dasarathy, 2011). Moreover, obstructive sleep apnoea is identified as an alarmingly prevalent condition among obese Saudi women and this problem increases with aging (BaHammam, 2011a; Linné, 2004). Insomnia, on the other hand, can be a somatic condition and is associated with chronic conditions like T2DM (Linné, 2004). A key finding is that abnormal sleep conditions are associated with obesity and the prevalence of T2DM across age groups (AlDabal & BaHammam, 2011; Kathrotia, Rao, Paralikar, Shah, & Oommen, 2010). To combat the epidemic of sleep deprivation for people in Saudi Arabia, prescription of sleep medicine was suggested (BaHammam, 2011a). In our study, 27.9% of the respondents reported an average of 4 to 5 hours sleep nightly, and 4.5% reported 2 to 3 hours of sleep each night. Participants in these two groups reported that the amount of sleep they had was not sufficient. Saudi women would therefore benefit from increasing the awareness about healthy sleep and strategies to have a good night sleep. Muslim health scholars have addressed the Qur’anic teachings of 58  sleep behaviours and suggested educating Saudi physicians and other health care providers about the significance of early detection of sleep conditions for better treatment outcomes (BaHammam, 2011b; Senthilvel, Auckley, & Dasarathy, 2011). 3.6.3.  Participants’ Lifestyle-related Health Beliefs  Findings in the Jeddah region of Saudi Arabia show a discrepancy between Saudi women’s knowledge of nutrition and their healthy eating behaviours (Bakhotmah, 2012). All but one participant in our study believed that nutrition has an impact on overall health and is important for the management and treatment of T2DM and its complications. The impact of health beliefs on Saudi women’s physical activity has received some attention in recent literature (Al-Eisa1 & Al-Sobayel, 2012). The socialization process of women in the Saudi Arabian culture contributes to women’s “lower internal sense of control and lower confidence level” and potentially their beliefs about their abilities to maintain physical activity (Al-Eisa1 & Al-Sobayel, 2012, p.3). In our study, only 0.8% of participants believed that exercise has no impact on health and only1.5% stated that physical activity is not important for the treatment and management of T2DM and its complications. To date, there appear to be no studies on the health beliefs of Saudi women related to stress, and their stress management strategies. In our study, only a very small group of women (2.8%) were not aware of the negative impact of stress on health. Saudi women in other studies have reported increased stress after being diagnosed with T2DM (Farag & Gaballa, 2010). In brief, our findings indicate that Saudi women are generally aware of the negative impacts of stress for the treatment and management of T2DM.  59  3.6.4.  Participants’ Understanding of Islamic Teachings in Relation to Health Behaviours  With respect to Islamic religious teachings, participants in our study were overall able to list Qur’anic verses and quotes from the Hadith on physical activity, nutrition, stress, and sleep. Whether the level of participants’ knowledge of Islamic teachings in relation to health can predict personal health behaviours was beyond the scope of our study. Most religious quotes reported by our participants were general statements about domains such as the physical body, physical activities, night and sleep, and variety of food. The quotes were Qur’anic verses and sayings of the prophet Mohammad and are open to interpretations. For instance, the Qur’anic verse “Do not throw yourselves into destruction” can be interpreted in diverse contexts. In a health context, one could interpret this verse as a religious admonition to avoid unhealthy behaviours such as smoking, excessive eating, and sleep deprivation. In another context, this verse could be interpreted as a call for taking precautions and considering safety issues in each and every situation. This also applies to quotes from the Hadith with respect to context-based interoperations. For example, the Hadith “O young boy, say Bismillaah, eat with your right hand, and eat from what is directly in front of you” could be interpreted as a religious tenet for eating habits, a direct order to eat with moderation, or both. Given the various interpretations of the Qur’anic verses and Hadith quotations, one cannot assume that awareness of Islamic-related health teachings will reflect on the individual’s health behaviours. In the case of our study findings, it is more appropriate to conclude that participants were able to perceive the consistency between Islamic teachings and healthy lifestyle; given that Muslims believe that Islamic teachings are for the benefit of the individual. Muslims are accustomed to the belief that quotes directly 60  from God in the Qur’an and the sayings of Prophet Mohammad in Hadith are to direct individuals to desirable behaviours, including healthy lifestyle, and to refrain them from wrong doing. Muslims thus may better adapt to the content of health education if it is framed with Islamic teachings, as per the World Health Organization’s initiative with respect to health education through religion. Saudi women, we propose, will benefit from health education programs that are adapted to their religious and cultural contexts, to combat the prevalence of T2DM and other lifestyle-related conditions. Participants’ Responses from the Open-Ended Question Section  3.6.5.  At the end of the interview survey, participants articulated their health priorities, their understanding of the implications of Islamic teachings with respect to health behaviours, proverbs on health, health advice, the social and cultural barriers to health behaviours, and potential reform to the social structure to access their health needs as listed in Table 3.35. The novelty of our study lies in the contribution of participants’ voices to addressing the social and cultural obstacles Saudi women experience when having their health needs met. This is unlike some recent studies that discuss the social and cultural hindrances to women’s health that are based on the researchers’ views only (Al-Rethaiaa, Fahmy, & Al-Shwaiyat, 2010; Winter, King, Stafford, Winkleby, Haskell, & Farquhar, 2012). 3.7.  Informing Study Two The findings are consistent with the literature. They provided a solid basis for Study  Two, a pilot intervention study to explore the outcomes of tailoring an education program related to T2DM, based on international standards and tailored to the cultural and religious contexts of Saudi women, compared with outcomes of usual care for diabetes in Saudi Arabia. 61  Findings in this study provided us with the following information: 1. the health of Saudi women is compromised with lifestyle-related conditions due to unhealthy lifestyles such as poor nutrition and inactivity; 2. women dealt with stresses they rated high; 3. most women believed in the importance of a healthy lifestyle for overall health and for the treatment and management of T2DM and its complications; 4. some women were aware that Islamic teachings are consistent with healthy lifestyles, and were able to provide religious quotes in relation to health behaviours; 5. women acknowledged their poor adherence to healthy lifestyles and endorsed social and cultural barriers as factors that prevented them from healthy behaviours; and 6. they expressed their need for health awareness and strategies to overcome social and cultural barriers to healthy living. From these findings, we propose that Saudi women could benefit from: 1. a health education program focused on lifestyle modification in relation to physical activity, nutrition, and stress-management; 2. integrating the social and cultural barriers to women’s health in Saudi Arabia into the content of the health education program we referred to in one; and 3. adapting the content of the health education program to Islamic teachings, as per the World Health Organization initiative with respect to health education through religion. 3.8.  Strengths, Limitations and Future Implications  3.8.1.  Strengths  One of the strengths of this study is the large sample size drawn from across the city of Dammam in the Eastern Region of Saudi Arabia. Participants highlighted the social and cultural factors that impacted their overall health. This is the first study in the Eastern Region of Saudi Arabia that examined Saudi women’s lifestyle-related health beliefs and behaviours, and their understanding of related religious teachings. The findings of this 62  study were essential in informing the design of an education program related to T2DM in Study Two. 3.8.2.  Limitations  This study has several limitations. Selected participants were visitors to primary health clinics in Dammam and this limited the outreach to other participants. Next, our findings cannot be generalized beyond the city of Dammam. The Eastern Province of Saudi Arabia is a large area consisting of several cities. Finally, although much information can be gained easily in a survey interview questionnaire, the responses are limited by being self-report. 3.8.3.  Future Implications  Studies are needed to validate the information our study provided. Replicating this study in other cities and regions of Saudi Arabia will assist in expanding the description of Saudi women’s health status. More studies are needed to assess Saudi women’s knowledge of religious teachings in relation to health. This information will assist in designing health education programs based on religion, as per the World Health Organization initiative. 3.9.  Conclusion The health of Saudi women is compromised by unhealthy lifestyles in contrast to  their positive beliefs about healthy lifestyles and their understanding of related Islamic teachings. More research on the social and cultural barriers to the health of women in Saudi Arabia will help to design health education programs that address these barriers. The findings of this study, for the first time, have provided benchmark profiling of the health of women living in the Eastern province of Saudi Arabia. In addition, these data served as a basis for tailoring health education to the needs of these Saudi women in 63  Study Two. Establishing health education programs and potentially health awareness campaigns, based on up to date research findings, would help to curb the social and economic burdens of lifestyle-related conditions among Saudi women. Given the pivotal role of women in their families, targeting Saudi women will likely impact the health of their families.  64  3.10. Tables Table 3.1 Participants’ Reporting of their Ages, Heights and Weights Standard Standard Variable Valid N Mean Median Deviation Error Minimum Maximum Age (beginning of study) 407 32.0 30.0 9.4 .5 17 60  95% CI 31.04, 32.87  Height (cm)  231  156.7  157.0  8.0  .5  110  178  155.71, 157.78  Weight (kg)  361  69.1  67.0  17.8  .9  30  160  67.25, 70.93  65  Table 3.2 Participants’ Demographic Characteristics Variable Category N Age categories (yr) 17 to 30 220 31 to 45 143 46 to 65 44 Total 407 Height categories (cm) 110 to 154 83 155 to 178 148 Total 231 Weight categories (kg) 55 to 75 175 76 to 90 76 91 to 125 32 126 to 160 3 Total 286 Marital status Married 320 Single 55 Divorced 14 Separated 0 Widowed 7 Total 396 Number of children 1 62 2 to 3 120 4 to 5 63 6 to 13 69 Total 314 Educational status No formal education 25 Primary 49 Intermediate 56 Secondary 101 Diploma 73 University 97 Graduate 3 Total 404 Occupational status Homemaker 208 Employed 142 Student 31 Retired 0 Unemployed 11 Total 392 Source of income Personal 48 Husband or guardian 262 Both 89 Other 0 Total 399 Income (SR) < 3,000 56  Percent 54.1% 35.1% 10.8% 100.0% 35.9% 64.1% 100.0% 61.2% 26.6% 11.2% 1.0% 100.0% 80.8% 13.9% 3.5% .0% 1.8% 100.0% 19.7% 38.2% 20.1% 22.0% 100.0% 6.2% 12.1% 13.9% 25.0% 18.1% 24.0% .7% 100.0% 53.1% 36.2% 7.9% .0% 2.8% 100.0% 12.0% 65.7% 22.3% .0% 100.0% 13.9%  3,000 to 5,000  105  26.1%  5,000 to 10,000  144  35.8%  > 10,000  97  24.1%  402  100.0%  Total SR, Saudi riyals (U.S. $1.00 = 3.75 SR)  66  Table 3.3 Self-reported Physical Health Measures and General Health Variable Category N Percent Valid Percent Weight Underweight 28 6.9% 7.8% Normal weight 178 43.7% 49.3% Over weight 155 38.1% 42.9% I don't know 44 10.8% .0% Not answered 2 .5% .0% Total 407 Heart rate Low 9 2.2% 2.5% Normal 326 80.5% 89.3% High 30 7.4% 8.2% I don't know 40 9.9% .0% Total 405 Blood sugar Low 2 .5% .5% Normal 360 89.1% 92.3% High 28 6.9% 7.2% I don't know 14 3.5% .0% Total 404 Blood pressure Low 16 4.0% 4.2% Normal 334 82.5% 87.0% High 34 8.4% 8.9% I don't know 21 5.2% .0% Total 404 Health Excellent 142 35.1% 35.1% 60 14.8% 14.8% Above Average  Total Percent 6.9% 43.7% 38.1% 10.8% .5%  Total N  361  407  365  407  390  407  390  407  405  407  2.2% 80.1% 7.4% 9.8% .5% 88.5% 6.9% 3.4% 3.9% 82.1% 8.4% 5.2% 34.9% 14.7%  Average  180  44.4%  44.4%  44.2%  Below Average  18  4.4%  4.4%  4.4%  Poor Total  5  1.2%  1.2%  1.2%  405  Valid N  67  Table 3.4 Self-reported Morbidity No Variable Heart disease Lung disease High blood pressure Stroke Obese Diabetes Cancer Rheumatoid arthritis Osteoarthritis Osteoporosis Anemia Multiple sclerosis Parkinson's disease Irritable bowel syndrome Ulcers Premenopausal Menstrual, irregular cycles Menopausal Other health conditions  N 399 400 373 407 351 379 406 363 381 402 328 405 407 326 395 396 330 391 342  Yes Percent 98.0% 98.3% 91.6% 100.0% 86.2% 93.1% 99.8% 89.2% 93.6% 98.8% 80.6% 99.5% 100.0% 80.1% 97.1% 97.3% 81.1% 96.1% 84.0%  N 8 7 34 0 56 28 1 44 26 5 79 2 0 81 12 11 77 16 65  Total Percent 2.0% 1.7% 8.4% .0% 13.8% 6.9% .2% 10.8% 6.4% 1.2% 19.4% .5% .0% 19.9% 2.9% 2.7% 18.9% 3.9% 16.0%  N 407 407 407 407 407 407 407 407 407 407 407 407 407 407 407 407 407 407 407  Percent 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%  Table 3.5 Self-reported Other Morbidity Variable Bone diseases  N 13  Percent 21.7%  Asthma  5  8.3%  Migraine  3  5.0%  Blood pressure problems  2  3.3%  Gestational diabetes  3  5.0%  High cholesterol  3  5.0%  Systemic lupus eryth  1  1.6%  Urinary diseases  1  1.6%  Mental illnesses  1  1.6%  Gastro diseases  3  5.0%  Uterus diseases  2  3.3%  Eye diseases  2  3.3%  Nephritis  2  3.3%  Thyroid  1  1.6%  Clot  8  11.6%  Allergies  2  3.3%  Calcium deficiency Unclassified illnesses  2 6  3.3% 10.0%  68  Table 3.6 Types of Physical Activity Participants Reported Performing Yes Variable  No  Total  Physical activity  N 395  Percent 98.3%  N 7  Percent 1.7%  N 402  Percent 100.0%  Strenuous physical activity  39  9.8%  360  90.2%  399  100.0%  Moderate physical activity  205  51.2%  195  48.8%  400  100.0%  69  Table 3.7 Amount of Time Participants Reported Spending to Performing Physical Activities of Various Difficulties Variable Strenuous physical activities (days per week)  Standard Standard Valid N Mean Median Deviation Error Minimum 36 3.1 2.0 2.0 .3 1  Maximum 7  95% CI 2.41, 3.76  Strenuous physical activities (hours per day)  10  .9  1.0  .2  .1  1  1  0.75, 1.05  Strenuous physical activities (minutes per day)  28  22.7  30.0  12.9  2.4  10  60  17.69,27.67  Moderate physical activities (days per week)  206  3.1  2.0  2.0  .1  1  7  2.85, 3.40  Moderate physical activities (hours per day)  82  1.5  1.0  .8  .1  1  5  1.29, 1.65  Moderate physical activities (minutes per day)  135  24.3  30.0  11.1  1.0  6  60  22.38, 26.15  Table 3.8 Average Weekly Consumption of Rice, Pasta, Bread and Cereals Reported by Participants Variable Rice or pasta (times per week) Bread and cereals (times per week)  Standard Standard Valid N Mean Median Deviation Error Minimum Maximum 95% CI 389 5.0 7.0 2.3 .1 1.0 7.0 4.80, 5.26 400  6.2  7.0  1.7  .1  Table 3.9 Times per Week Participants Reported Consuming Rice, Pasta, Bread and Cereals 1 to 2 3 to 5 6 to 7 Variable N Percent N Percent N Percent Rice or Pasta 87 22.5% 84 21.7% 216 55.8% Bread or Cereals 25 6.3% 57 14.3% 317 79.4%  1.0  7.0  6.18, 6.01  Total N 387 399  Percent 100.0% 100.0%  70  Table 3.10 Types of Bread Participants Reported Consuming Variable Category N Percent Do you eat white bread? Yes 330 81.1% No 77 18.9% Total 407 100.0% Do you eat brown bread? Yes 150 36.9% No  257  63.1%  Total  407  100.0%  Highlights indicate poor nutrition  Table 3.11 Types of Soft Drinks Participants Reported Consuming Variable Category N Percent Drink soft drinks Yes 253 62.8%  Types of soft drinks  No  150  37.2%  Total  403  100.0%  Regular  213  84.5%  Diet  28  11.1%  Both  11  4.4%  Total  252  100.0%  Highlights indicate poor nutrition  71  Table 3.12 Cans per Week of Soft Drinks Participants Reported Consuming Variable Regular soft drinks (cans per week) Diet soft drinks (cans per week)  Standard Standard Valid N Mean Median Deviation Error Minimum Maximum 95% CI 223 5.6 3.0 6.4 .4 1.0 48.0 4.71, 6.41 37  5.6  2.0  7.0  1.1  1.0  28.0  3.24, 7.90  Highlights indicate poor nutrition  72  Table 3.13 Types of Oil Participants Reported Consuming Variable Category N Vegetable oil Yes 390 No 17 Butter or margarine Yes 60 No 347 All types of oil Yes 23 No 384 Olive oil Not at all 58  Percent 95.8% 4.2% 14.7% 85.3% 5.7% 94.3% 14.4%  Rarely  63  15.6%  Sometimes  161  40.0%  Often  64  15.9%  Very often  57  14.1%  Total  403  100.0%  Table 3.14 Participants Reporting of Being on a Diet and Consuming of Sugar Substitutes Variable  Category  Type of diet  I don't follow any diet  N 336  Percent 83.8%  Diet prescribed by a specialist  Drugs Herbs Diet food Follow more than one Total Yes  4 1 59 1 401 22  1.0% .2% 14.7% .2% 100.0% 32.8%  Sugar (sweeteners) substitute  No Total Not at all  45 67 353  67.2% 100.0% 88.3%  Rarely  4  1.0%  Sometimes  17  4.3%  Often  10  2.5%  Very often  16  4.0%  Total  400  100.0%  73  Table 3.15 Average Consumption of Fruits, Vegetables and Dates Reported by Participants Standard Standard Variable Valid N Mean Median Deviation Error Minimum Maximum 95% CI Fruit (times per week) 357 3.9 3.0 2.3 .1 1.0 7.0 3.69, 4.18 Fruit (servings per day)  357  2.2  2.0  1.0  .1  1.0  7.0  2.09, 2.31  Vegetables (times per week)  382  4.8  5.0  2.3  .1  1.0  7.0  4.62, 5.07  Vegetables (servings per day)  382  3.8  4.0  1.3  .1  1.0  8.0  3.69, 3.96  Dates (times per week)  338  5.3  7.0  2.3  .1  1.0  7.0  5.08, 5.56  74  Table 3.16 Times per Week Participants Reported Consuming Fruits, Vegetables and Dates 1 to 2 3 to 5 6 to 7 Total Variable N Percent N Percent N Percent N Percent Fresh Fruit 133 37.3% Fresh Vegetables 74 19.4% Dates 64 18.9% Highlights indicate poor nutrition  107 121 66  30.0% 31.7% 19.5%  117 187 208  32.8% 49.0% 61.5%  357 382 338  100.0% 100.0% 100.0%  Table 3.17 Number of Daily Servings Participants Reported Consuming Fruits and Vegetables  Fresh Fruit  N 228  1 to 2 Percent 65.1%  N 113  3 to 4 Percent 32.3%  Fresh Vegetables  70  18.4%  167  43.8%  Variable  N 8 139  5 to 6 7 to 8 Percent N Percent 2.3% 1 .3% 36.5%  5  1.3%  N 350  Total Percent 100.0%  381  100.0%  75  Table 3.18 Average Weekly Consumption of Meat, Poultry and Seafood Reported by Participants Variable Beef or sheep  Valid N 268  Mean 2.4  Median 2.0  Standard Deviation 1.7  Standard Error .1  Minimum 1.0  Maximum 7.0  95% CI 2.24, 2.65  Meat products  187  2.1  2.0  1.7  .1  1.0  7.0  1.88, 2.36  Chicken  385  4.8  5.0  2.2  .1  1.0  7.0  4.55, 4.99  Fish  264  2.0  2.0  1.5  .1  .5  7.0  1.82, 2.18  Shrimp  134  1.6  1.0  1.1  .1  1.0  7.0  1.37, 1.76  Table 3.19 Times per Week Participants Reported Consuming Meat, Poultry and Seafood 1 to 2 3 to 5 6 to 7 Variable N Percent N Percent N Percent  Total  Beef or Sheep  181  67.5%  62  23.1%  25  9.3%  N 268  Percent 100.0%  Meat Products  141  75.4%  33  17.6%  13  7.0%  187  100.0%  Chicken  82  21.3%  125  32.5%  178  46.2%  385  100.0%  Fish  205  77.9%  43  16.3%  15  5.7%  263  100.0%  Shrimps  121  90.3%  10  7.5%  3  2.2%  134  100.0%  Table 3.20 Average Weekly Consumption of Eggs, Nuts and Legumes Reported by Participants Valid N 339  Mean 3.7  Median 3.0  Standard Deviation 2.3  Standard Error .1  Minimum 1.0  Maximum 7.0  95% CI 3.46, 3.95  Nuts  199  3.1  2.0  2.4  .2  1.0  7.0  2.79, 3.45  Legumes  219  2.3  2.0  1.8  .1  1.0  7.0  2.11, 2.58  Variable Eggs  76  Table 3.21 Times per Week Participants Reported Consuming Eggs, Nuts and Legumes 1 to 2 Variable  3 to 5  6 to 7  Total  Eggs  N 141  Percent 41.7%  N 98  Percent 29.0%  N 99  Percent 29.3%  N 338  Percent 100.0%  Nuts  108  54.3%  44  22.1%  47  23.6%  199  100.0%  Legumes  153  70.2%  43  19.7%  22  10.1%  218  100.0%  Highlights indicate poor nutrition  Table 3.22 Average Weekly Consumption of Milk and Dairy Reported by Participants Variable Milk Dairy products  Valid N 311  Mean 1.7  Median 2.0  Standard Deviation .4  Standard Error .0  Minimum 1.0  Maximum 2.0  95% CI 1.69, 1.79  390  6.1  7.0  1.8  .1  1.0  7.0  5.95, 6.30  Table 3.23 Times per Week Participants Reported Consuming Milk and Dairy 1 to 2 Variable  3 to 5  6 to 7  Total  Milk  N 311  Percent 100.0%  N 0  Percent .0%  N 0  Percent .0%  N 311  Percent 100.0%  Dairy products  32  8.2%  53  13.6%  305  78.2%  390  100.0%  77  Table 3.24 Types of Milk and Dairy Participants Reported Consuming Variable  Category  Milk  Full Fat  N 177  Percent 56.0%  Dairy products  Low Fat Full Fat and Low Fat Total Full Fat  87 52 316 225  27.5% 16.5% 100.0% 57.7%  Low Fat  83  21.3%  Full Fat and Low Fat  82  21.0%  Total  390  100.0%  Table 3.25 Self-reported Behaviours of Smoking, Stress and Sleep Variable  Category  N 2  Percent .5%  Smoking  Cigarettes  Stress level  Shisha Nargille Gadw I don't smoke Total High  7 0 0 389 398 126  1.8% .0% .0% 97.7% 100.0% 31.7%  Sleep  Moderate Low Total Soundly  228 44 398 243  57.3% 11.1% 100.0% 60.9%  I don't sleep well  156  39.1%  Total  399  100.0%  78  Table 3.26 Average Number of Hours Participants Reported Sleeping Variable Average hours of sleep  Valid N Mean Median 398 6.4 6.0  Standard Deviation 1.9  Standard Error .1  Minimum 2.0  Maximum 16.0  95% CI 6.21, 6.58  Table 3.27 Number of Hours Participants Reported Sleeping 2 to 3 Variable Hours of sleep  N 18  Percent 4.5%  4 to 5 N 111  Percent 27.9%  6 to 8 N 234  Percent 58.8%  9 to 10 N 30  Percent 7.5%  11 to 16 N 5  Percent 1.3%  Total N 398  Percent 100.0%  79  Table 3.28 Participants’ Beliefs in the Importance of Health Behaviours for the Overall Health Variable Exercise  Nutrition  Smoking  Stress  Category Disagree Not sure Agree Total Disagree Not sure Agree Total Disagree Not sure Agree Total Disagree  N 3 0 396 399 0 1 398 399 6 0 393 399 5  Percent .8% .0% 99.2% 100.0% .0% .3% 99.7% 100.0% 1.5% .0% 98.5% 100.0% 1.3%  6  1.5%  Agree  388  97.2%  Total  399  100.0%  Not sure  Table 3.29 Participants’ Beliefs in the Importance of Health Behaviours for the Treatment and Management of Diabetes Variable  Category  Exercise  Important  N 386  Percent 98.5%  Nutrition  Not important Total Important  6 392 394  1.5% 100.0% 99.7%  Non smoking  Not important Total Important  1 395 369  .3% 100.0% 93.9%  Stress management  Not important Total Important  24 393 380  6.1% 100.0% 97.7%  Not important  9  2.3%  389  100.0%  Total  80  Table 3.30 Hadith and Qur’anic Verses on Health in General Reported by Participants Hadith and Qur’anic Verses  N  Hadith “There should be neither harming [darar] nor reciprocating harm [diraar]”(Imam Nawawi 32)  5  “The Muslims are like a body, if one part of the body hurts, rest of the body will also suffer”(Muslim)  1  “There are two blessings that many people are about to lose: health and free time”(Sahih Al-Bukhari 8.421)  2  “One third for his food, one third for his drink and one third for his breath”(Tirmidhi & Ibn Majah)  8  Total  16  Qur’an “Do not throw yourselves into destruction”(Al-Baqarah 1:195)  18  “And if you would count the graces of Allah, never could you be able to count them”(An-hl 16:18)  1  “And when I am ill, it is He who cures me”(Ash-Shu'ara' 26: 80)  2  “And proclaim the Grace of your Lord” (Ad-Duha 93:11)  1  “There comes forth from their bellies, a drink of varying colour wherein is healing for men” (An-hl 16:69)  2  Total  24  81  Table 3.31 Hadith and Qur’anic Verses on Nutrition Reported by Participants Hadith and Qur’anic Verses  N  Hadith “We are a people who do not eat until we are hungry. And if we eat, we do not eat to our fill” (Burhan addeen alhalabi)  5  “No human ever filled a vessel worse than the stomach. Sufficient for any son of Aadam are some morsels to keep his back straight” (alTirmidhi --saheeh by al-Albaani)  5  “Do not drink (all water) once like camels, but drink twice and thrice and mention the Name of Allah before you drink, and praise Allah when you finish”(Tirmidhi)  1  “O young boy, say Bismillaah, eat with your right hand, and eat from what is directly in front of you” (al-Tirmidhi, 1858; Abu Dawood, 3767; Ibn Maajah, 3264; Saheeh Sunan Abi Dawood, 3202)  3  “A house without dates has no food”(Muslim)  1  Total Qur’an “By the Fig, and the Olive”(At-Tin 95:1)  14 1  “And shake the trunk of date-palm towards you, it will let fall fresh ripe-dates upon you” (Maryam 19:25) “Eat and drink but waste not by extravagance” (Al-A'raf 7:31)  2 12  “And fruit; that they may choose” (Al-Waqi'ah 56:20) 2 “And the flesh of fowls that they desire” (Al-Waqi'ah 56:21) “We have made from water every living thing” (Al-Anbiyah' 21:30)  1 6  “He allows them as lawful At-Taiyibat [(i.e. all good and lawful) as regards things, deeds, beliefs, persons, foods, etc.], and prohibits them as unlawful Al-Khaba'ith” (Al-A'raf 7:157)  2  “Eat of the lawful things that We have provided you with” (Al-Baqarah 2:172)  8  Total  34  82  Table 3.32 Hadith and Qur’anic Verses on Physical Activity Reported by Participants Hadith and Qur’anic Verses  N  Hadith “The strong believer is better and more beloved to Allah than the weak believer” (Muslim)  3  “Teach your children swimming, archery and horse-riding” (Albahegi)  35  “Your body has right upon you” (Al-Bukhari 6134)  13  Total  51  Qur’an “And have made the day for livelihood” (An-Naba' 78:11)  20  “And (He has created) horses, mules and donkeys, for you to ride and as an adornment” (An-Nahl 16:8)  1  “Strive hard with your wealth and your lives in the Cause of Allah” (At-Taubah 9:41)  1  Total  22  83  Table 3.33 Hadith and Qur’anic Verses on Sleep Reported by Participants Hadith and Qur’anic Verses  N  Hadith Prophet Mohammad encouraged us to take a nap, said: "Take a nap, for the devils [shayaateen] do not take naps" (al-Tabaraani. Al-Saheehah, 2647)  1  He replied: "Let her sister cover her with her garment" (Muslim)  1  Total  2  Qur’an “And it is He Who makes the night a covering for you, and the sleep (as) repose” (Al-Furqan 25:47)  36  “(Remember) when He covered you with a slumber as a security from Him” (Al-Anfal 8:11)  1  Total  37  Table 3.34 Qur’anic Verses on Stress Reported by Participants Hadith and Qur’anic Verses  N  Qur’an “Allah burdens not a person beyond his scope” (Al-Baqarah 2:286)  1  Total  1  84  Table 3.35 Participants’ Quotes of Health Priorities, the Implications of Islamic Teachings of Health Behaviours, Proverbs on Health, Health Advice, Social and Cultural Barriers to Health Behaviours; and a Reform to the Social Structure Health Priorities I wish to lose weight until I'm 55 kg I wish to be less quick tempered, especially with my kids, as it causes my body to ache I wish everyone good and long lasting health Implications of Islamic Teachings on Health Behaviours Islamic teachings pronounce times during the day for prayers and these prayers are like daily physical exercise Proverbs Eat lunch then relax eat dinner then walk Go to bed early and wake up early, you will see how you feel Health is like a crown above the head of the healthy Fast and you become healthy A healthy brain is in a healthy body Being active is a blessing The stomach is the house for disease and prevention is the essence of medicine Health Advice We can’t increase our lifespan but we should adapt to healthy living Women should undergo regular check-ups for breast cancer Healthy behaviours, healthy diet, and good sleep are all important, but indolence is an obstacle Healthy diet and going for walks regularly are both important Excessive eating could make one less bright Caring for one’s health is very important Caring for one’s health and healthy eating are very important Regular exercise is very important Social and Cultural Reform and Women Health Needs Recreation Centers We need to have recreation centers, like the ones in Kuwait, in every neighborhood to go to with our kids for relaxing activities and healthy food choices We need to have recreation centers Recreation centers are very important for women’s health There should be recreation centers for women We should have swimming pools for women  85  Table 3.35 Participants’ Quotes of Health Priorities, the Implications of Islamic Teachings of Health Behaviours, Proverbs on Health, Health Advice, Social and Cultural Barriers to Health Behaviours; and a Reform to the Social Structure We need to have recreation centers and swimming pools in every neighborhood, large and open to the fresh air We should have gyms and swimming pools with affordable memberships and in every neighborhood We need recreation centers in every neighborhood for free There must be private walking areas for women only Saudi society imposes limitations on women’s physical activity. Women as a result stay mostly in their homes, physically inactive and become overweight. Women in Saudi are restricted from joining gyms sometimes by their husbands, their families or work demands. The Saudi culture limits spreading health awareness and motivating women to be physically active There is no opportunity for women in Saudi to exercise, be physically active or even walk regularly We need gyms for women. A woman wishes to have a slim figure. The fewer opportunities for women to go to gyms and spending most of their times in their homes eating, contribute to increasing overweight among Saudi women We need to have gyms with trainers for women Breaks between Working Hours Women need breaks between working hours for exercise I wish there are times between work hours for rest and exercise to help decrease stresses associated with work Rest is important but we have no time for rest. We are busy almost all day with work then we’re exhausted by the end of the day Thursdays are the only days we have for rest and amusement; all other days we are exhausted with work We need time for rest during work hours I wish they (the ministry of health) would decrease our work hours More Options for Healthy Food We are not allowed to use a microwave at work therefore we eat from restaurants only. Restaurants with delivery service have no healthy options in their menus so we end up eating junk and unhealthy food. We are not allowed to have breaks for snacks Dietary Education We need dietary education to learn about healthy diets and cooking healthy meals for our families There is a lack of awareness about healthy eating. Parents should educate their kids how to pick healthy snacks. People should learn how to prepare healthy food for social gatherings. Fast food consumption, very prevalent in our culture, causes colon diseases Teaching girls about health beliefs and healthy behaviours at an early age, specifically during adolescence, will help to initiate healthy behaviours in our society Health principle and healthy eating should be taught in elementary schools and added to their curricula Healthy snacks should be sold in schools for students to eat during breaks  86  Table 3.35 Participants’ Quotes of Health Priorities, the Implications of Islamic Teachings of Health Behaviours, Proverbs on Health, Health Advice, Social and Cultural Barriers to Health Behaviours; and a Reform to the Social Structure More Focused Health Care for Women Women, especially the older ones, need regular and full check-ups once to twice a year Saudi women need different health care that addresses their social, physical and psychosocial needs Women should be provided with more medical attention for hypertension and diabetes There should be different health education for women above 43 years old Driving Women Saudi women should be allowed to drive to decrease their daily stresses that result from their inability to be mobile Social Assistance and Pensions There should be pensions for women over 40 years of age if they are unemployed, and social assistance for those who are unemployed (at least 200 SR) The ministry of health should make the option of early retirement available for their female employees Workshops on First Aid There should be workshops on first aid everywhere and for everyone to attend Smoking Cessation Campaigns There should be more smoking cessation campaigns to prevent smoking Health Education Campaigns There should be health education centers to teach families how to adapt to healthy living and how to teach kids healthy behaviours Families in Saudi need health educators to visit them in their homes and educate them about healthy lifestyles. Health education does not work via media alone Saudi mothers need more help from health educator  87  4. STUDY TWO: EVALUATION OF AN EDUCATION PROGRAM RELATED TO TYPE 2 DIABETES MELLITUS FOR SAUDI WOMEN: A PILOT INVESTIGATION 4.1.  Introduction The incidence and prevalence of lifestyle-related conditions such as ischemic heart  disease, smoking-related conditions, hypertension, type 2 diabetes mellitus (T2DM), and obesity continues to increase in Saudi Arabia (Al-Nozha et al., 2007; Al-Nozha et al., 2004b; Al-Nuaim et al., 1997; Al-Rajeh, Awada, Niazi, & Larbi, 1993). Saudi women have a higher prevalence of obesity than men, which increases their risk of lifestylerelated conditions such like T2DM (Al-Nuaim et al., 1997). T2DM and obesity have become prevalent in Saudi women constituting substantial social and economic burdens (Al-Nozha et al., 2007; Al-Nozha et al., 2004b; Al-Nuaim et al., 1997; Al-Rajeh, Awada, Niazi, & Larbi, 1993). Because Saudi women are restricted from public physical activities and they are expected to centre their roles at their homes, their health needs are distinct from those of men (Abahussain & El-Zubier, 2005). Overall, lifestyle-related conditions for women in Saudi Arabia are influenced by social, cultural, and religious factors however these factors are rarely addressed in literature in relation to health (Khatib, 2004; Al-Khaldi & Khan, 2000; Al-Hussein, 2008). Health education programs that target lifestyles mostly emanate from western cultures thus could be less effective in improving the lifestyles of people living in Islamic cultures like Saudi Arabia. In the interest of raising attention to the impact of Islamic teachings on health, the World Health Organization has initiated an Islamic perspective on health promotion (World Health Organization, 1996). In this respect, health education strategies address the context of Islamic faith in disseminating health messages (Ide & Sanli, 1992; 88  World Health Organization, 1996). The impact of such a program in Saudi women is unknown. 4.2.  Diabetes Prevention and Management Most of the literature on approaches to the prevention and management of T2DM has  emanated from research conducted in western countries such as Australia, the United Kingdom, and the United States. This research has provided the basis for current internationally recognized standards of care (Cockram, 2000; Alberti et al., 2007; AlFaris, Amin, & Al-Rukban, 2006; Heitzer, Peterson, Thompson, & Fluder 2006; Uusitupa et al., 2000; Murphy, 2004; World Health Organization, 2004a, 2004b; Bjaras et al., 1997). International standards for the prevention and management of T2DM focus largely on self-management strategies such as avoiding smoking, optimal nutrition, healthy body weight, and increasing daily physical activity, in addition to medical intervention (World Health Organization, 2004a; Al-Faris et al., 2006; Heitzer et al., 2006; Uusitupa et al., 2000; Murphy, 2004; Bjaras et al., 1997). Evidence suggests that diabetes education programs based on international standards are more effective when tailored to the cultures of targeted groups (Osuna et al., 2011; Goody & Drago, 2009; Hawthorne, Robles, Cannings-John, & Edwards, 2010; Song et al., 2010; Osborn et al., 2010). Moreover, the relationship between health and religion has been suggested as a promising mediator in health education programs (Ellison & Levin, 1998; Holt & McClure, 2006; Benjamins, Ellison, Krause, & Marcum, 2011; Kenneth, Maton, & Wells, 2010). For example, “expecting God to reward expressions of piety, devotion, observance, or obedience with health and well-being may be enough to account for positive health outcomes” in health education programs (Ellison & Levin, 1998, p.708). Scientific evidence suggests that the involvement in a religious community 89  and attendance of religious services can positively impact both the psychological and physical wellbeing of individuals (Ellison & Levin, 1998; Holt & McClure, 2006; Benjamins, Ellison, Krause, & Marcum, 2011). For instance, a study that examined the relationship between religious involvement in African American communities and health behaviours revealed that religious beliefs could lead to positive health behaviours (Holt, Roth, Clark, & Debnam, 2012). To the best of our knowledge, up until the time of the development of our study, only four studies had addressed the cultural context in relation to lifestyle education programs related to T2DM. In the United States, African American women were targeted for a nutrition program for diabetes prevention. This study included a control group or Group 2 (n=196) and an intervention group or Group 1 (n=202), but the number of analyzed subjects in both groups for the reporting of the study was smaller (n=152) based on posttest assessment at 6 months (Williams et al., 2006). Results of this study indicate that participatory-based strategies can be effective in designing culturally appropriate education programs (Williams et al., 2006). In another study, Mexican Americans were selected for diabetes self-management education (n=256, 60% women in the intervention group) with posttest evaluations for 12 months. Cultural adaption in the Mexican American study included: language, diet, social emphasis, family participation, and incorporation of cultural health beliefs. Outcome variables in the Mexican Americans study which included metabolic control (HbA1c and fasting blood glucose), diabetes knowledge, and diabetes related health beliefs, demonstrate the effectiveness of culturally competent diabetes self-management education for the management of diabetes (Brown, Garcia, Kouzekanani, & Hanis, 2002). A study in Finland recruited 523 subjects (which  90  was decreased to 152 in the intervention group and 143 in the control group) with two years of lifestyle interventions and subsequent evaluations. The aim of the study was to assess the efficacy of a lifestyle intervention, which focused on physical activity and healthy diet for overweight men and women. The goal of the intervention was to prevent or delay the onset of T2DM in individuals with impaired glucose tolerance, and reduce risk factors for atherosclerotic and cardiovascular vascular diseases. Although no cultural adoptions are discussed, lifestyle interventions in the Finnish study confirm the efficacy of lifestyle programs in preventing and delaying T2DM (Usitupa et al., 2000). In Sweden, researchers followed up with 3200 subjects for 10 years. The lifestyle intervention program focused on risk factors related to physical inactivity, poor nutrition and obesity, and cigarettes smoking and aimed to promote healthy behaviours and healthy environment. Interventions in this study involved communities collaborating on political, administrative and economic levels, and its effectiveness was measured by reported changes in physical activities, weight, nutrition, and tobacco consumption (Bjaras et al., 1997). Because of the paucity of knowledge in this area, we were interested in studying the outcomes of a pilot intervention study of an education program related to T2DM adapted to the cultural and religious contexts of Saudi women. 4.3.  Study Goals and Objectives In the absence of existing data, the goal was to conduct a pilot intervention study to  explore the outcomes of launching a T2DM education program, based on international standards and tailored to the cultural and religious contexts of Saudi women, compared with outcomes of usual care for diabetes in Saudi Arabia. Our primary research question was “What are the outcomes of a pilot intervention study of a T2DM education program based on international standards and adapted to the cultural and religious contexts of 91  Saudi women?” The primary objectives of the study were: 1. To explore whether a T2DM education program, based on international standards and adapted to the cultural and religious contexts of Saudi women, could impact health outcomes (e.g., physical measures, diabetes knowledge, life satisfaction and health-related quality of life) compared to outcomes of those who receive usual care for diabetes in Saudi Arabia 2. To use knowledge gained from conducting this pilot study to inform future studies related to the health needs of women in Saudi Arabia 4.4.  Methodology The research proposal was reviewed by the relevant institutional ethics boards,  namely, the University of British Columbia and the Saudi Administration of Medical Research. After receipt of an ethical approval from the Saudi Administration of Medical Research in the Ministry of Health, the Ministry of Health forwarded its approval to the Directorate of Primary Health in the Eastern Province to inform the Directorate that the study would be taking place at the primary health centres in Dammam. 4.4.1.  Theoretical Background  Participatory research, also known as community-based research and communitybased participatory research, involves participatory collaboration of stakeholders in the decision making process to implement change (Stringer, Guhathakurta, Mwajuma, & Waddell, 2008; Stoecker, 2009). Community-based participatory research methods have been used for intervention studies when input from community members is used to reflect their social and cultural contexts to improve the outcomes of programs (Gullan, Feinberg, Freedman, Jawad, & Leff, 2009). Evidence suggests that participatory action research is ideally suited for community health studies (Minkler, 2000) particularly for those that are 92  related to diabetes prevention and management (Giachello et al., 2003). We chose the principles of participatory research as a basis for our study to engage primary stakeholders, specifically Saudi women at risk of or diagnosed with T2DM, to participate in self-management of T2DM based on an internationally accepted and evidence-based health education. At present, diabetes education programs in Saudi Arabia tend to target people diagnosed with diabetes rather than including those at risk and aim to increase patients’ awareness of diabetes care through medical instruction and care with less emphasis on lifestyle modification (Sharaf, 2010; El-Hazmi, Warsy, AR. Al-Swailem, AM. Al-Swailem, & Sulaimani, 1998). Our intention was to engage Saudi women as stakeholders in our pilot study to compare outcomes of a T2DM education program, based on international standards and tailored to the cultural and religious contexts of Saudi women, with outcomes of usual care for diabetes in Saudi Arabia. Given that this is the first study of its kind, the study was a pilot intervention study to compare the outcomes of a T2DM program based on international standards and adapted to the cultural and religious contexts of Saudi women, with outcomes of usual care for diabetes in Saudi Arabia. The structured part of the program was six weeks, with outcome evaluation post program at six weeks. The outcomes of interest were evaluated in the Intervention and Usual Care Groups before and after the six-week period. 4.4.2.  Trained Researcher  The primary researcher served as the research coordinator and conducted the education program. She is qualified in intercultural communication and health education with concentration in T2DM. She is Arabic speaking and originally from the Eastern province of Saudi Arabia, thus, is familiar with the local culture and customs. In conducting the pre and post measures, she was blind to other test values such as pre and 93  post exercise measures (Appendix 6), and body composition measures (Appendix 7) to minimize recorder bias. She was trained in conducting and administering the measures, which were selected for this study, objectively. The advantages of having a researcher with local knowledge of the Saudi bureaucracy were twofold: 1. she was able to liaise with the director of primary health in the Eastern province to schedule an appropriate space for conducting the education program; and 2. she was able to liaise with the administrations of the selected clinics for the recruitment of eligible participants. Having one individual participate in all levels of conducting the program was consistent with real-world contingencies of being a diabetes educator. 4.4.3.  Sampling and Recruitment  The study was carried out in Dammam, the capital city of the Eastern province in Saudi Arabia. Potential participants were recruited from health centres that had agreed to participate. The primary researcher approached all women in the waiting areas or women working in health clinics, thus, providing a sample of convenience. Inclusion criteria were women 17 to 70 years of age, at risk of or diagnosed with T2DM. Women who were pregnant were excluded. Participants were informed that if they became pregnant during the study they would not be excluded if cleared by their physicians. Our recruitment procedure was designed to simulate a real world situation in which women in the community are medically identified as being diagnosed with or identify themselves as being at risk of T2DM. When one participant under 18 years of age expressed interest in participating in the study, the researcher asked her to provide a parental signature for her consent to participate. Most women who were approached by the researcher were interested in participating in the study; but twenty participants said they could not participate because 94  of transportation issues. Saudi women encounter challenges with transportation because women are prohibited from driving and the lack of public transportation in the country. For these reasons, we facilitated participation by launching the six-week education program in a primary health center that was located at a large residential compound. Participating women, thus, could get to the health center within a few minutes walking. The intended sampling frame was partially compromised when some women from the selected clinic withdrew from the study, necessitating the recruitment of additional participants from two other primary health clinics in Dammam to increase the participant pool. These participants constituted the Usual Care Group. The primary researcher visited these clinics on days when women were scheduled for their check-ups with their doctors. Women in the waiting areas and those who were working at the clinic expressed interest in participating in the study when they learned that they were not required to attend education sessions; donating time for pre and post evaluations was the only requirement. Women who worked in the clinics referred some of their co-workers to the program who were diabetic, overweight, or had a family member diagnosed with diabetes. 4.4.4.  Grouping Participants  Participants were assigned to one of two groups. Assigning participants to a group was based on their location and willingness and ability to attend the sessions of the sixweek education program. Dividing the two groups based on their location assisted in preventing contamination of the study sample i.e. participants from both groups did not communicate with each other during the ongoing of the study. Participants who worked at the first primary health centre were all interested in attending the education sessions since the classroom was in the same health centre.  95  Intervention Group: Fourteen women participated (including dropouts): those at risk of T2DM (n=8) and those diagnosed with T2DM (n=6) in a T2DM education program based on international standards and adapted to the cultural and religious contexts of Saudi women, they also continued with their usual care. Usual Care Group: Six women participated: Women at risk of T2DM (n=4) or diagnosed with T2DM (n=2) received the usual care for T2DM only. The total number of recruited participants in our study was 35 with initial dropouts of 16 prior to the start of the program. Total number of participants before the six-week education program was then 19. Dropouts before the education program were mostly related to transportation issues (n=12) in addition to work schedule conflicting with the demands of participating in the study (n=4). Dropouts during the education program (n=5) were related to conflicting schedule. The total number of participants who completed the study in both groups was 14, 8 in the Intervention Group and 6 in the Usual Care Group. Number of participants and dropouts appear in Appendix 11. 4.4.5.  Measurements and Psychometrics  For all participants, objective measures included random blood sugar based on fingerprinking device (mg/dl), the ratio of the circumference of the waist to hip measurements (WHR), weight (kg), height (cm), and body mass index (BMI) [weight (kg)/height (m2)] were repeated at baseline and at 6 weeks. Study design and pre and post measurements appear in Appendix 2. The life satisfaction (LISAT), health-related Quality of life (SF12), diabetes knowledge test (DKT), and program satisfaction questionnaires were completed by 96  participants in the two groups at baseline (prior to the onset of the study), and at 6 weeks (at the end of the education program). The LISAT-9 item is designed to assess various aspects of life satisfaction. It is composed of one item to assess overall life satisfaction and eight other items that are domain-specific (i.e. self-care management, contact with friends, vocational life, family life, partner relationships, financial, leisure situations, and sex-life) (Rehab Measures, 2013). Because sex-life is bounded by marital relationship and considered a private matter in the Islamic culture of Saudi Arabia, we deleted the question of satisfaction with sex-life for the participants in our study. Answers of all eight questions were based on a 6-point Likert scale ranging from 1’very dissatisfied’ to 6 ‘very satisfied’ (Rehab Measures, 2013). We used SPSSv.20 to compute the mean score of each item. Total LISAT score was computed from the mean of the 8-item scores. SF12 is a shorter version of the SF-36. It is composed of 12 questions to measure quality of life based on functional health and wellbeing (QualityMetric, 2013). The first question is related to general health with answers on a 5-point Likert scale ranging from ‘excellent’ to ‘poor’. The second question is dichotomous and is related to physical functioning with answers on a 3-point scale ranging from ‘limit a lot’ to ‘no limit at all’. The third question is dichotomous and is related to role functioning (physical) with answers on a 5-point scale ranging from ‘all of the time’ to ‘none of the time’. The fourth question is related to bodily pain with answers on a 5-point scale ranging from ‘extremely to ‘not at all’. The fifth question is related to vitality with answers on a 5-point scale ranging from ‘all of the time’ to ‘none of the time’. The sixth and seventh questions are dichotomous and are related to role functioning (emotional) and mental health, respectively, with answers on a 5-point scale ranging from ‘all of the time’ to ‘none of  97  the time’. The eight question is related to social functioning with answers on a 5-point scale ranging from ‘all of the time’ to ‘none of the time’. The physical and mental health measures in the questionnaire are referred to as PCS-12 and MCS-12, respectively (SF36.org, 2013). Average score of each question is 50 (SF-36.org, 2013). To score our data of SF12, we obtained a scoring license from QualityMetric. We used SPSSv.20 to compare the scoring results of SF12 of the two groups before and after the education program. The diabetes knowledge test (DKT) is composed of 23 items developed by the Michigan Diabetes Research Training Center (MDRTC). The 23 items in this questionnaire are designed to test the general knowledge of diabetes (The Michigan Diabetes Research Training Center, 2013). The first 14 questions of the test are relevant to non-insulin users (The Michigan Diabetes Research Training Center, 2013). All 23 questions are relevant to insulin users (The Michigan Diabetes Research Training Center, 2013). For participants in our study, we removed items 5, 15, and 17, as these items are more appropriate to test the knowledge of health professionals and beyond the scope of knowledge we expected from our study participants. The psychometric properties of the DKT test appear in Appendix 5. The test was designed to be completed within 15 minutes. To score our data of this test, we computed the percentage of correct answers for each question. 4.4.6.  Assessment and Re-evaluation  (a) Assessment Session 1 (30 minutes) Each participant was assessed over two 30-minute sessions at baseline and reevaluated at six weeks after the commencement of the study. The primary researcher scheduled these sessions at the participants’ convenience. Each participant completed the 98  survey questionnaires by interview, i.e., diabetes knowledge test (DKT) (Appendix 4), life satisfaction questionnaire (LISAT) (Appendix 7), and health-related quality of life (SF12) (Appendix 8). The survey questionnaire of lifestyle-related health beliefs and behaviours and related religious teachings (Appendix 1), which we used in Study One, was included for baseline assessment to confirm whether the results we gained from Study One applied to participants in Study Two or not. (b) Assessment Session 2 (30 minutes) Body composition measures were conducted with standard objective tools and procedures. Participants were requested to wear light and comfortable gym clothes and shoes but most of them preferred their working clothes. A standard clinical weight scale with a height feature was used to record weight and height from which body mass index (BMI) was calculated. Because of the association of the waist: hip ratio (WHR) and health risks (Yusuf, S. et al., 2005) waist and hip girths were measured in a standardized manner with a semi-flexible measuring tape. The six-minute walk test (6MWT) was carried out to assess and evaluate the participants’ functional status and walking capacity. The runway for the 6MWT varied among the three health centers where assessments and evaluations were conducted. Participants were tested at both times on the same runway to avoid measurement error. The data sheet for recoding the pre and post walk measures at baseline and subsequent time period included heart rate, blood pressure, blood glucose (blood sugar monitoring device) and subjective rating of perceived exertion (scale from 0-10 where 0 is nothing at all and 10 is maximum exertion). 4.4.7.  Procedures  Within two weeks of the commencement of the study, participants in both groups 99  underwent baseline testing. At the end of six weeks, women in the Intervention Group were advised about continuing to practice what they had learned in the education program. Women in the two groups were scheduled for re-evaluation at six weeks, the duration of the education program for the Intervention Group. All participants had the baseline testing repeated. Testing was completed within two weeks. (a) Tailoring the Harvard Special Health Reports on Diabetes to the Cultural and Religious Contexts of Saudi Women Consistent with the World Health Organization’s initiative, education programs related to type 2 diabetes mellitus (T2DM) based on international standards and adapted to the cultural and religious contexts of participants, will lead to better health outcomes than those that do not consider such contexts (World Health Organization, 2004a; Osuna et al., 2011; Goody & Drago, 2009; Hawthorne, Robles, Cannings-John, & Edwards, 2010; Song et al., 2010; Osborn et al., 2010). The Harvard Special Health Reports are based on up to date scientific knowledge for the management and treatment of T2DM. For the education program in the Intervention Group of our study, we selected five reports from the Harvard Health Publications that are related to T2DM lifestyle behaviours, particularly, weight reduction and physical activity, healthy eating for T2DM, and positive psychology (Harvard Health Publications, 2012a, b, c, d, 2011). This section presents the details of how the content of the Harvard Special Health Reports was tailored to the cultural and religious contexts of participants in the Intervention Group. (b) Tailoring the Harvard Special Health Reports on Diabetes to the Saudi Islamic Culture The Harvard special health reports are oriented primarily to western cultures. In contrast to the secular-based western cultures, religious traditions are tightly interwoven 100  with the culture of Muslims in Islamic countries (Norris & Inglehart, 2012). To address an Islamic perspective on health, the World Health Organization has convened the “Amman Declaration on Health Promotion” in 1989 (World Health Organization, 1996). The Amman Declaration was convened to help align the wisdom of the Qur’an and Hadith to contemporary health issues, e.g., smoking. To tailor the content of the Harvard special health reports related to diabetes to the cultural and religious contexts of study participants, the researcher used religion-based quotes, recommended behaviours, and beliefs from the Saudi culture that matched with topics from the Harvard special health reports on diabetes. (c) Adapting the Harvard Reports on Weight Reduction and Physical Activity to the Islamic Culture of Saudi Arabia The Saudi culture has adopted a sedentary lifestyle that contributed to weight increase and reduced physical activity. According to the Harvard special health reports on diabetes (Harvard Health Publications, 2012a), factors that lead to weight increase are personal, environmental and social. Participants discussed these factors by reflecting on their lifestyles and the Saudi culture. Table 4.4 presents personal, environmental, and social factors which participants listed in their discussion of factors that contributed to weightgain in Saudi Arabia. In the Saudi Arabian culture, it is inappropriate for women to exercise in public or in their communities, which differs from the assumption on which the Harvard guidelines are based. For instance, it is not appropriate for women in Saudi Arabia to go outdoors for biking, jogging, or running. Women-only gyms in Saudi Arabia are available; however they are few and often small, unaffordable, or distant from where women live. Women in Saudi Arabia may experience challenges with mobility due to prohibiting 101  women from driving and the lacking of public transportation system in the country. In such circumstances, a woman who wants to join a gym is left with the only option of renting a driver with a car, which can be costly or unaffordable. Walking is usually the most convenient exercise for women in Saudi Arabia. According to the Harvard Special Health Reports on weight management (Harvard Health Publications, 2012c), walking is a safe exercise for beginners and those with chronic health conditions like T2DM. Participants were advised to walk regularly throughout the week for a minimum of 10 minutes each time with a moderate increase of heart rate at each bout. As beginners, participants are recommended to “start out slowly, and increase the pace and duration” (Harvard Health Publications, 2012d, p.20) with the goal of maintaining at least 2½ hours of exercise per week. Walking exercise is however not without challenges for Saudi women. The Saudi clothing traditions limit women to a modest dress code, which restricts them from wearing light clothes and creates a barrier for them from benefitting fully during an exercise. Moreover, all participants in the Intervention Group veiled their faces with the traditional niqabs, which is another obstacle for them to benefit from the breathing techniques during the exercise (Alghadir, Aly, & Zafar, 2012). With the heat waves in Saudi summer (often exceeding 45oC), people avoid outdoors and walking becomes uncomfortable, particularly for women. Participants stated their preferences to go walking with a partner or as groups to maintain their safety and keep themselves motivated. Altogether, outdoor physical activities and joining gyms are inappropriate, unaffordable or inconvenient for women in the Saudi culture. Participants were advised to increase their physical activities inside their homes and decrease their reliance on  102  housemaids for the household chores. Light activities that are mentioned in the Harvard Special Health Report on physical activity and suggested for participants included: climbing the stairs instead of taking the elevator, stretching and walking back and forth in the room instead of sitting down while watching television, standing up instead of sitting down, decreasing hours of watching television, rope jumping, and dancing. Some basic stretches were also introduced to participants and recommended for them during their working hours. (d) Adapting the Harvard Reports on Healthy Eating for T2DM to the Islamic Culture of Saudi Arabia Dieticians in Saudi Arabia are well trained in diabetes nutrition. To adapt the Harvard education guidelines on healthy eating for diabetes (Harvard Health Publications, 2012b) to the Saudi culture, the researcher recruited a volunteer dietician to teach a session on healthy eating to the participants, the content of which was based on the Harvard guidelines but modified to the local Saudi context. Because of cultural differences between foods consumed in Saudi Arabia and the western diet reflected in the Harvard guidelines, modifications were needed. During the session, participants learned: calculating calorie intake, low-diet food recipes, options for healthy meals during working hours, healthy snacks, shopping for healthy food, nutrition for T2DM, and the management of insulin intake during working hours. (e) Adapting the Harvard Reports on Positive Psychology to the Islamic Culture of Saudi Arabia The Harvard guidelines for meditation exercise are designed for people in secular, western cultures. These guidelines are different than the rituals of meditation and mindfulness that are practiced by Muslims daily during their performance of the Islamic 103  five prayers (Ali. & Liu, 2004). Participants were therefore unfamiliar with the Harvard meditation techniques when they were introduced and presented by the researcher. To tailor the Harvard meditation techniques to the Islamic teachings, the researcher matched the Harvard meditation exercise with the Islamic prayers that participants typically did five times a day. An example is “During our daily five prayers, we are focusing on the moment, and what we are saying to pray; if you get distracted by thoughts of our worldly life, allow those thoughts to go without judgment and return back to the focus on your prayers and the connection to God.” When participants started to learn to meditate, they expressed dislike of the techniques and refused to follow the Harvard meditation exercise despite being adapted to the Islamic prayers. Some participants did not close their eyes while meditating and others interrupted the moments of silence with jokes and fun comments. When finished, they said meditating made them feel sleepy. Nonetheless, by the following session, some participants reported taking the meditation exercise more seriously. One participant said, “Yesterday my son and I were in the hospital for an appointment with the doctor. While I was waiting in the waiting room, I closed my eyes and started to meditate. I felt so relaxed.” In the subsequent education sessions, participants requested to practice the meditation exercise together with the researcher. As time went by, they became more familiar with the techniques and expressed their appreciation for the relaxed feelings they had during the exercise. Participants also learned other relaxation exercises such as belly breathing, deep breathing, and focusing on the body sensations.  104  Next, participants learned self-talk to help minimize unhealthy behaviours. One participant said, “My problem is that whenever I feel stressed, sad, or angry, I cannot resist the temptation of craving sweets.” The researcher commented as, “whenever you feel that urge to eat sweets, talk to yourself and say: I’m feeling this because my brain wants me to do something that makes me happy. Instead of eating sugar and unhealthy food, I’ll do something that makes me happy and healthy.” (f) Other Examples that Elucidate the Tailoring of the Harvard Reports on Diabetes to the Islamic Culture of Saudi Arabia Other tools the primary researcher employed to make the Harvard Special Health Reports relevant to the Saudi culture included: 1. positioning concepts from the Harvard report into the Saudi social structure; and 2. using cultural images to explain concepts from the Harvard reports. For example, motherhood is an honourable role for Muslim woman and participants live that role daily. To illustrate the point of self-compassion from the Harvard Special Health Report on positive psychology (Harvard Health Publications, 2011), the primary researcher linked the image of a loving and caring mother to her children to one becoming compassionate and forgiving of herself. Other examples are presented in Table 4.6. (g) Classroom Setting Participants in the Intervention Group received a six-week education program. The primary researcher facilitated the education sessions that were scheduled over six weeks and conducted these sessions for a minimum of twice a week to cover the content. Women were invited to tailor the delivery and format of the content and include more sessions as they believed were needed. They however gave no input except their suggestions of sessions’ times and location. During the first week of the program, 105  participants attended the sessions in the classroom. As most of the women worked at the clinic, participants suggested moving the sessions to a room which most of them were working at. This way, fewer participants were likely to miss sessions because of work duties. (h) Educational Strategies Education sessions were mostly based on interactive discussions. Participants were encouraged to interrupt the presenter for questions, comments, or reflections on their personal experiences. For more engagement with the topic of nutrition and the food pyramid (Moore et al., 2009), colouring was used during the session describing the healthy food pyramid. Participants picked different colours to fill in the components of the healthy food pyramid on sheets that were handed to them while discussing food options and benefits from each component of the pyramid. Videos, an interactive tool for diabetes education (Wheeler et al., 1985) from online-show airing exercise strategies by professional trainers, were presented to introduce participants to exercising for beginners. Handouts in Arabic and reading material based on the Harvard Special Health Reports for diabetes were organized in files and provided to all participants. All sessions referenced the Harvard reports except the first two sessions. Both sessions were planned in advance by the research team. Session One was designed to reintroduce participants to the sixweek education program and the purpose and goal of the study. Participants learned how to calculate their body mass index(s) in Session Two. The content of the two sessions is detailed in Table 4.1. (i) Topics Covered During the Six-week Education Program All topics that were covered during the six-week education program appear in Table 4.2. Table 4.3 shows topics that were demonstrated with posters and pamphlets, which 106  were prepared and printed by other health institutions such as the Qatif Central Hospital and Dammam Central Hospital. (j) Debriefing the Diabetes Knowledge Test At baseline evaluation, participants were asked to complete the DKT. After the sixweek education program, participants in the Intervention Group were interviewed in a group and handed sheets to mark their answers to the questions in the questionnaire. After selecting their answers to each question, the researcher discussed all possible answers and debriefed participants on the correct one. Participants in the Usual Care Group were interviewed individually and debriefed after they marked their answers to each question. (k) Focus Group Discussion with the Intervention Group To learn about participants’ input on the six-week education program, the researcher had a recorded focus group discussion with the Intervention Group. 4.4.8.  Deliverables  Participants were awarded one of two certificates. The standard certificate was awarded to participants in the Usual Care Group (Appendix 13), and the advanced certificate was awarded to those in the Intervention Group (Appendix 14). 4.4.9.  Data Analysis  Focus group data: Atlas.ti® software was used to organize and code the qualitative data from the focus group discussion with the Intervention Group at the end of the education program in accordance with the thematic analysis approach (Braun & Clark, 2006). SPSSv.20 was used to analyze demographic data, body composition data, exercise data, questionnaires related to diabetes knowledge, program satisfaction, and life satisfaction before and after the education program in both groups. 107  Outcome measures: data were organized to provide descriptive statistics of participants’ socio-demographic characteristics, their age, their health profiles, and their stress and sleep behaviours in both groups. Descriptive statistics and frequency of occurrence for participants in both groups before (pre) and after (post) the education program were provided for the following variables: physical measurements including weight, BMI, WHR, blood sugar, and 6MWT distance, and score results of DKT, LISAT, and SF12. To detect tendencies in the variables after the six-week period of the education program in both groups, we calculated the differences (post-pre intervention) for the physical measurements, DKT, LISAT, and SF12. To minimize type 1 error due to the small sample size, we used 95% confidence intervals to examine the pre/post differences of the sample means of physical measurements, DKT, LISAT, and SF12 in both groups. Significance of the difference in the two groups is determined by whether zero is in between the upper bound and lower bound of the confidence intervals or not, i.e. if there is no zero, the difference in the two groups is significant. 4.5.  Results In total, 8 participants completed the study in the Intervention Group and 6 in the  Usual Care Group. 4.5.1.  Participants’ Discussion of their Health Behaviours after the Education Program  Findings from the focus group discussion with participants in the Intervention Group showed that participants had benefited from the six-week education program. Themes that emerged from the focus group were: 1. increased physical activity 108  2. improved nutritional behaviours 3. improved stress management behaviours 4. disseminating knowledge, which participants learned from the education program (a) Increased Physical Activity Participants reported increasing their physical activity in response to the education program. They reported walking as their preferred exercise. One participant said that she and her kids went walking and dancing together. Participant A.M. talked about her stretching exercises. “After the education program, I began to exercise as I learned in the education program. I was exercising in my room once and my mother came. She thought I was lying on the ground because I was injured so she panicked and said in panicking voice ‘Are you okay? What happened?’ I replied laughing hardly, ‘I’m okay. I’m just stretching’ ”. D.L. noted how she felt every morning after the education program. “I feel more active now compared with the past. Before the education program, I used to be so sedentary. I used to wake up in the morning feeling lazy and not wanting to get out of bed. Now however, once I open my eyes to get up, I jump right out of bed; as if the fat I used to have in my body is now decreased.” A.M. began to attain a sense of independence despite arthritic pain and T2DM complications. “I’m learning to be more independent by not asking others around me to help me with tasks I can do myself. For instance, I would not ask others to grab a glass of water for me. I would now get it myself.” D.L. said she joined the gym after the education program. Gyms for women are available in Saudi Arabia but are often small and expensive, she noted. Z.M. said, “We 109  need public and free of charge gyms. There should be gyms for us at least in hospitals and other health centers.” (b) Improved Nutritional Behaviours Participants noted improvement in their personal nutritional behaviours. D.L. mentioned that she had never liked eating fruits and vegetable until the education program. She said, “I started eating garden salads and fruits, which is very contrary to how I was in the past. Before the education program, we had all kinds of fruit and vegetables in the fridge but I never liked fruit or craved it. Now however, I eat apples, oranges, carrots…etc.” Selecting low fat food became important for participants after the education program. Participant A.M. said, “From the education program, I learned to select low fat food options only. My lunch yesterday was fat free. I now eat green salads and fruits. Yesterday I ate three dates the way the dietician suggested.” A.S. said she replaced white bread with whole wheat bread, full fat milk and dairy with low fat, and reduced the amount of food she eats in general. At work, participants used to eat white bread only until they learned about the health benefits of whole wheat bread. After the education program, they said they are gradually working on replacing their usual unhealthy breakfasts with healthy ones. Participant R.A. enrolled in a diet program. She now pays more attention to the amount of sugar and salt in her food and what she eats at parties. She would eat only one dish from many selections offered at dinner parties. Participant S.A. said she increased the amount of water she drinks daily. Participants D.L. and A.M. said they stopped napping after lunch. D.L. said, “I now don’t eat until I am full and don’t take naps right after lunch. If I want to nap, I do so 110  before eating and while I am hungry.” A.M. said, “I stopped taking naps right after lunch. I now wait an hour or two until the food is digested. I also learned to take my medication regularly. Yesterday I took my insulin at work unlike before the education program; I used to delay taking my insulin until I got home. After I took my insulin yesterday, I had a light snack to keep my blood sugar balanced. The dietician from the education program instructed me about taking my insulin regularly.” Participant Z.M. trains her kids to drink fewer soft drinks. “I’m trying to convince my kids to stop drinking Pepsi but sometimes they insist and I buy them diet Pepsi as an alternative to the regular one. I’m drinking fresh juices instead.” (c) Improved Stress Management Behaviours Participants mentioned that they liked the education session on happiness and wellbeing. Participants A.S. and R.A. said they practice the relaxation exercises they learned regularly. (d) Disseminating Knowledge, Which Participants Learned From the Education Program Participants reported being more aware of obesity risk factors in their children after the education program. Z.M. mentioned that she applied the knowledge she learned by teaching her children healthy nutrition habits. She said, “I now teach my kids to eat healthy with me. Now we get together to eat and I’m usually the one who serves everyone. If I serve them large amounts they say: ‘mum that is more than enough’. If one of them wants to eat more, his brother would say: ‘Stop it. You could be full already. More eating is not good for you.’ I usually resolve this by suggesting eating fruits together. I use plates identical in size to make each aware of the amount he eats. If I have the urge to eat more, I don’t eat; that is to teach my kids that one does not have to be full to stop eating. 111  My younger son is becoming health conscious. He often consults with me on the food he eats and whether it is good for his diet or not.” Participant Z.M. said she passed on the knowledge she learned from the education program to her diabetic mother. “I taught my mother to add no sugar to her food. My sister is the one who cooks for my mother so I am teaching my sister healthy food preparations. For instance, I advised her to use canola oil and olive oil. I also instructed her about the less fat in chicken breasts than chicken legs thus it is better to use the chicken breasts for my mother’s soups. I know how beneficial fibber to health can be therefore I asked my sister to include fruit and vegetables in my mother’s food. The dietician from the education program mentioned that the total calories that exist in three dates are equal to the calories in one pear so I told my mother she could skip eating a fruit if she wants to eat dates.” Z.M. said she passed the knowledge from the education program to others in her social network. “Whenever I get together with other women, I discuss what I have learned from the education program with respect to healthy nutrition and physical activities.” 4.5.2.  Outcome Variables  (a) Socio-demographic Characteristics In the Intervention Group, the baseline mean age for participants was 45.5 years. The baseline average height and weight were 156.1 cm and 84.6 kg respectively. Most participants (38.5%) were married, all but two had children, 53.9% had intermediate school and lower, 69.2% were employed, 53.8% were financially independent, and 38.5% were in the upper middle social class.  112  In the Usual Care Group, baseline mean age for participants was 39.3 years. Baseline average height and weight were 153.3 cm and 86.3 kg respectively. All participants were married, 83.3% had 3 to 10 children, 83.3% had high school diplomas and above, all were employed, non were financially independent, all were supported by their husbands in addition to their personal incomes, and their socioeconomic status was all above the upper middle category. Table 4.7 shows the demographic characteristics of participants in both groups. Table 4.8 shows baseline age and height for participants in both groups. (b) Participants’ Health Conditions In the Intervention Group, participants reported 10 health conditions whereas in the Usual Care Group, 8 health conditions were reported. Table 4.23 shows health conditions that were reported by participants in both groups. (c) Pre/Post Differences after the Six-week Program Our data show some tendencies toward improvement in physical measurements for participants in the Intervention Group compared with the Usual Care Group after the sixweek education program. Pre/post differences in physical measurements for participants in both groups appear in Table 4.11. The distance walked in the 6MWT tended to increase in both groups. The 95% CI of pre/post difference for the 6MWT distance was significant in the Intervention Group but not significant in the Usual Care Group. Measures of pre/post differences of blood sugar levels, on the other hand, reveal a minor decrease in the Intervention Group and a minor increase in the Usual Care Group with no significance in the Intervention Group or the Usual Care Group. Graph 4.7 shows pre-program and post-program 6MWTD in both groups. 113  The pre/post differences of DKT scores show that more participants in the Intervention Group (68.4%) gave correct answers after the six-week education program compared with (31.6%) of participants in the Usual Care Group. The 95% CI of pre/post differences of DKT scores in the Intervention Group and the Usual Care Group show that pre/post differences of DKT were significant in both groups. Table 4.19 shows pre/post difference in DKT among participants in both groups. Table 4.18 shows the percentage of participants who gave correct answers in the DKT. Figure 4.4 shows pre-program and post-program DKT scores in both groups. Measurements of waist to hip ratio (WHR) show a minor decrease of WHR for participants in the Intervention Group and a minor increase of WHR in the Usual Care Group after the six-week education program. The 95% CI in both groups reveal that there was no significance for pre/post difference in WHR for participants in the Intervention Group or the Usual Care Group. Figure 4.6 shows pre-program and post-program WHR measurements in both groups. Life satisfaction (LISAT) scores tended to decrease in both groups after the six-week education program as shown in Figure 4.5. The health-related quality of life (SF12) scores show a minor increase in the Intervention Group and a minor decrease in the Usual Care Group but with no significant difference in the two groups. Table 4.15 shows the 95% of CI of group comparison for pre/post differences in physical and mental components and Totals. Graphs 4.2 and 4.3 show pre-program and post-program SF12 sub-domains scores in both groups. The pre/post differences of the SF12 and LISAT scores in both groups appear in Tables 4.15 and 4.17 respectively. Figure 4.5 shows preprogram and post-program LISAT scores in both groups.  114  Pre/post measurements of BMI tended to increase in the Intervention Group and decrease in the Usual Care Group. Results of the 95% CI in the Intervention Group and Usual Care Group show that there was no significant difference in both groups. BMI categories for pre-program and post-program in both groups appear in Figure 4.1. (d) Satisfaction of the Intervention Group with the Education Program All participants in the Intervention Group reported satisfaction with the education program in their exit interviews. Of all participants, 50.0% reported they were extremely satisfied with the knowledge they had learned from the education program, 62.5% of them were very satisfied with the way they were treated by the primary researcher and the dietician during the education program, 87.5% were extremely satisfied with the number of sessions they received during the education program, 62.5% were extremely satisfied with the education program overall. Tables 5.24 and 5.25 show the reporting of participants in the Intervention Group’s satisfaction with the education program. 4.6.  Discussion Under the following sections, we discuss our study findings in relation to the study  objectives. 4.6.1.  Objective One: Outcomes of a T2DM Education Program Adapted to the Cultural and Religious Contexts of Saudi Women  In this section, we discuss the outcomes of the T2DM education program, which were based on international standards and adapted to the cultural and religious contexts of Saudi women, compared with the outcomes of usual care for diabetes in Saudi Arabia. To present these, we first discuss the changes in outcome variables (BMI, WHR, 6MWTD, DKT, LISAT, and SF12) after the six-week education program. Second, we discuss the Intervention Group focus group discussion of their experience with the education 115  program. Third, we discuss the satisfaction of the Intervention Group with the education program. (a) Pre/Post Differences in Outcome Variables (BMI, WHR, 6MWTD, DKT, LISAT, SF12) in the Intervention Group Compared with the Usual Care Group Our findings of pre/post differences reveal tendencies toward improvement in the Intervention Group and a decrease in the Usual Care Group with respect to health-related quality of life. This corresponds with literature reports of short-term improvement in quality of life in response to diabetes education (Funnell et al. 2009; Steed, Cooke, & Newman, 2003). To the best of our knowledge, no data exist on Saudi women’s life satisfaction or quality of life. Studies that examined life satisfaction and quality of life in women have reported menopausal age, diabetes, chronic illnesses, sedentary lifestyle, overweight and obesity as factors that negatively impacted their life satisfaction and quality of life (Nisar & Sohoo, 2010; Strine, Chapman, Balluz, Moriarty, & Mokdad, 2008; Kolotkin, Crosby, & Williams, 2002; Bacevičienė, Rėklaitienė, & Tamošiūnas, 2009; Ball, Crawford, & Kenardy, 2004; Hulens, Vansant, Claessens, Lysens, Muls, & Rzwenicki, 2002). Participants in both groups in our study had blood pressure problems, obesity, diabetes, rheumatoid arthritis, osteoarthritis, and anemia. In the Intervention Group, participants reported having additional health problems such as irritable bowel and menopausal conditions. Ongoing support has been suggested to improve the quality of life for women with diabetes (Tang, Brown, Funnell, & Anderson, 2008). Further, when exercise and diet are combined, quality of life for obese, older adults with arthritis improves (Rejeski, Focht, Messier, Morgan, Pahor, & Penninx, 2002).  116  Based on our findings, there was a tendency of further improvement in the 6MWT distance after the six-week education program in the Intervention Group compared with the Usual Care Group. No data exist on the performance of the 6MWT in healthy adults in Saudi Arabia. Findings from an American report show differences in women’s performance of the 6MWT based on their BMI(s) and health status (Hergenroeder, Brach, Otto, Sparto, & Jakicic, 2011). The distance which women walk in the 6MWT is inversely related to their BMIs (Hergenroeder, Brach, Otto, Sparto, & Jakicic, 2011). To the best of our knowledge, the only study that documented the performance of the 6MWT distance in Saudi Arabia was based on 6MWT distance for patients with chronic obstructive pulmonary diseases (Al Moamary, 2009). Findings from this study indicated that the mean of the 6MWT distance for patients with chronic obstructive pulmonary diseases was between 117.1 and 218 (m) (Al Moamary, 2009). Our results reveal tendencies of improvements with respect to blood sugar levels after the six-week education program in the Intervention Group but not so in the Usual Care Group. Random blood sugar testing, performed for participants in both groups, is normally used to measure blood glucose levels during the day regardless of the time of last eating (WebMed, 2013). Random blood sugar testing is a useful indicator of normal blood sugar levels in healthy people (WebMed, 2013). That is, in healthy people, blood glucose levels will stay normal regardless of when they last ate before undergoing the test (WebMed, 2013). Random blood sugar testing however cannot be used to diagnose diabetes (WebMed, 2013). Baseline average blood sugar level among participants in the Intervention Group was 154.1 mg dl and in the Usual Care Group was 99.3 mg dl. Since, these values were a result of random blood sugar testing; we could not use them to  117  confirm the onset of diabetes in study participants. Moreover, we did not know whether participants were fasting before the test or not and thus could not confirm whether the results were actually above normal or not. In the Intervention Group, the value 154.1 mg dl, if fasting, means that blood sugar was above normal. In the Usual Care Group, the value 99.3 mg dl, if fasting, was in the normal limits. Normal blood sugar ranges appear in Appendix 11. Diabetic participants in the Intervention Group reported that they became more disciplined in monitoring their blood sugar, and taking their medicine and insulin if they were prescribed insulin. These behavioural changes, we suggest, could have reflected the decrease in blood sugar levels among participants in the Intervention Group after the sixweek education. Studies show that self-monitoring of blood sugar is associated with significant glycemic control in diabetic patients who take pharmaceutical drugs for the treatment of their diabetes (Karter et al., 2001; Moreland et al., 2006). Our findings indicate that results of diabetes knowledge test scores tended to further increase in the Intervention Group after the six-week education program compared with the Usual Care Group. Findings from a community-based diabetes education program have reported improvement in diabetes knowledge and self-reported behaviours (Chapman-Novakofski & Karduck, 2005). Results of a study that examined people’s knowledge of diabetes showed that people in Saudi Arabia had a poor knowledge of diabetes risk factors and preventive measures (Aljoudi & Taha, 2009). Another recent study that examined diabetes knowledge, attitudes, and practices of women in the Qassim region of Saudi Arabia showed a modest level of diabetes knowledge (56.14%) but poor  118  attitudes and practices toward diabetes management (Saadia, Rushdi, Alsheha, Saeed, & Rajab, 2010). Our findings noted no improvement in the body mass index (BMI) in the Intervention Group after the six-week education program. Minor improvement of BMI after the education program was noted in the Usual Care Group only. For all women in both groups, BMI was above 30 (kg/m2), which is above the healthy weight according to the Canadian Guidelines for Body Weight Classification in Adults (Food and Nutrition, 2003). No guidelines officially exist for Saudis. Data based on BMI measures in the Eastern Mediterranean region reported a sharp increase in overweight and obesity across age groups for both men and women recently. In men, “overweight and obesity (BMI ≥ 25 kg/m2) ranged from 30% to 60%, whereas among women it ranged from 35% to 75%” (Musaiger, 2004, p.790). An urban lifestyle and higher socioeconomic status, multiple pregnancies, and social and cultural barriers are associated with increased obesity among women in the Eastern Mediterranean region (Badran & Laher, 2012; Musaiger, 2004). Other factors associated with obesity include young age (30 to 50 years), more education, marriage, hot climate, employment, high income, watching television for more than 2 hours per day, consuming fresh fruit less than 3 times a week, and decreased physical activity (Badran & Laher, 2012; Musaiger, 2004). Studies suggested that Saudi women who do daily household chores might not find time to exercise (Midhet, Al Mohaimeed, & Sharaf, 2010). In a recent study that examined the relationship between fast food consumption and BMI among female university students in Riyadh, 4.3%, 2.1%, and 1.4% of participants were in the 4th, 5th, and 6th obese groups, respectively (Alfawaz, 2012). In another study  119  conducted in Riyadh, the maximum BMI among female participants was reported to be 45 by kg/m2 (Al-Eisa & Al-Sobayel, 2012). In the Qassim region of Saudi Arabia, on the other hand, 55.4% of female participants were reported to be obese (Mohieldein, Alzohairy, & Hasan, 2011). Our findings confirm Saudi women’s tendency to be obese, which exposes them to a range of health risks. With respect to waist to hip ratio (WHR) after the six-week education program, there was a minor decrease of WHR in the Intervention and a minor increase of WHR in the Usual Care Group. These minor differences contradict with the noted increase of BMI in the Intervention Group and the noted BMI decrease in the Usual Care Group. We therefore assume that the pre/post differences of WHR in both groups are due to measurement errors. Like BMI, baseline waist to hip ratio (WHR) in a critical range is likely to contribute to health risks (James, Leach, Kalamara, & Shayeghi, 2011). For the measurement of obesity, BMI is often used and obese people have larger WHR (Cashdan, 2008). In our study, mean WHR for participants in both groups was above 0.8 (minimum=0.8 and maximum=1.9). Compared with women in other countries, the BMI(s) of Saudi women are in the obese range and their WHR(s) are correspondingly high (Cashdan, 2008). WHR among women increases with age in response to cultural images of women’s bodies. For example, in some cultures, men prefer to have overweight wives and obesity in others is a symbol of affluence (Cashdan, 2008). According to the World Health Organization, women who are WHR are more than 0.8, like in our study, are at greater health risks (World Health Organization, 2011a). (b) Participants Personal Remarks about their Health Behaviours in Response to the Education Program Four themes emerged from the focus group discussions with participants in the 120  Intervention Group of their experience with the education program at the end of the program: first, increased physical activity; second, improved nutritional behaviours; third, improved stress management behaviours; and fourth, disseminating knowledge, which participants learned from the education program. i) Theme One: Increased Physical Activity Evidence has noted ongoing support as a key for the persuasion of health behaviours in participants of diabetes education program (Funnell et al., 2009). Our study participants acknowledged the role of ongoing encouragement and motivation to their persuasion of healthy behaviours. They reported increasing their physical activity and walking as their preferred exercise in response to the education program. One participant said she had joined a gym. Another reported she and her children went walking and dancing together. Increased physical activity in response to diabetes education is confirmed in literature (Lindström et al., 2003). Although the effectiveness of low-pace walking for the prevention and management of T2DM has not been confirmed (Jeaon, Lokken, Hu, & van Dam, 2007), participants’ reporting of their efforts to increase their physical activity confirms the suggestion that knowledge, which participants acquire from diabetes education, leads to changes in their behaviours (Chapman-Novakofski & Karduck, 2005). In our study, when participants learned about the health benefits of physical activity, they became motivated to walk for 30 minutes before starting work in the morning. One morning they informed the researcher that they had been for a walk together early that day. Further to that, participants were eager to try using a pedometer to count their daily steps, as advocated by the Harvard guidelines, but were unable to find where they might purchase such items in their communities. 121  Another example that demonstrated participants’ willingness to change their behaviours is when the primary researcher explained the objective of the six-minute walk test, which assesses participants’ fitness, to them. Participants expressed their wishes to increase their physical activity after they had completed the six-minute walk test. For example, when participant N.A. was performing the test, she said, “I maybe should do this exercise very often in my house and around the garden”. S.A said, “I wish if we could this six-minute walk test everyday”. For other participants like K.L., performing the six-minute walk test was a reminder of their health needs during their working hours. She said, “There should be a health professional for us to advise us on occupational health and motivate us to do this kind of exercise between working hours”. Participant M.D. reported that she would perform the six-minute exercise more often in her office. She said, “Since I am on diet, I should do this exercise everyday in my office to burn some fat.” ii) Theme Two: Improved Nutritional Behaviours Our participants’ reporting of improved nutritional behaviours is consistent with scientific evidence that diabetes education yields improvements in self-reported behaviours (Lindström et al., 2003; Chapman-Novakofski & Karduck, 2005). The Finish Diabetes Prevention study, for instance, has reported long-term improvements in nutritional behaviours and increased physical activity (Lindström et al., 2003). During our study, participants enjoyed learning to calculate their BMIs but at the end of the session were disappointed to discover that their BMIs were above average. By the next session, most of them reported making attempts to change their health behaviours. For example, one participant reported starting a diet program to lose weight. Another said  122  she gave more attention to the amount and variety of fruit and vegetables she bought when she went to grocery shopping. After the six-week education program, participants noted improvement in their personal nutritional behaviours. They reported increasing their consumption of fresh fruit and vegetables, decreasing the amount of fat in their diet, and replacing white bread with whole wheat bread. iii) Theme Three: Improved Stress Management Behaviours Scientific studies confirm psychosocial improvements in response to diabetes education (Funnell et al., 2009; Steed, Cooke, & Newman, 2003). Participants in our study reported that they liked the education session on happiness and wellbeing. One participant said she practiced the relaxation exercise regularly. Others reported adopting the meditation techniques, which they learned from the education program, in their daily lives. Our findings are consistent with literature on mental health in Muslim cultures. Muslims’ perceive the teachings of Islam regarding positive mental health as a foundation of psychological therapy (Haque, 2004). Participants in our study favoured the Harvard stress-management strategies when framed with the Islamic faith. During the session on positive psychology, for instance, there was a discussion on the role of psychology to overcome daily stresses and major life events. Being oriented to Islamic beliefs about the role of faith with respect to one’s resilience and overcoming difficulties, participants agreed less with the Harvard suggestion on the impact of positive attitudes on successfully getting through stressful events. They believed that it is faith in God that helps one overcoming stressful events. One participant said, “It does not matter how old  123  the person is, it is the degree of one’s faith that determines the ability to overcome difficulties.” Evidence-based studies of diabetes education have reported better improvements when education programs incorporating psychological approaches (Funnell et al., 2009). Moreover, such programs were reported as more effective when adapted to the culture of participants (Funnell et al., 2009). In short, whether participants’ reporting of behavioural changes in response to the program is an outcome of integrating mental health into the education program, adapting mental health education to Islamic faith, or tailoring diabetes education to the culture of participants, warrants subsequent investigations. iv) Theme Four: Disseminating Knowledge, Which Participants Learned from the Education Program Since passing knowledge to others is among the teachings of Islam, participants during the education program were reminded of their roles in passing diabetes education to others. Participants perceived that role as a religious obligation and reported passing the knowledge they had from the education program to their families and friends. Participants passing diabetes education into communities corresponds with the World Health Organization initiative of peer support programs in diabetes (World Health Organization, 2007). The impact of the role of our study participants in promoting healthy behaviours in their communities warrants further investigations. Studies to investigate the feasibility of conducting peer support diabetes education in Saudi women are also needed. (c) The Intervention Group Satisfaction with the Education Program At the end of the study, participants in the Intervention Group reported their overall satisfaction with the education program. Participants’ satisfaction of the education 124  program, although a marking of the primary researcher’s success as a diabetes educator, is not a measure of the effectiveness of the education program. The satisfaction questionnaire we used in our study was based on closed-ended questions at the end of the education program and this could have limited participants’ responses. Future studies similar to ours would benefit from open-ended questions of a satisfaction questionnaire presented to participants for their responses at the end of each educational session (Griffin, Gilliand, Perez, Helitzer, & Carter, 1999). Such questionnaire will be a useful tool for the evaluation of the program delivery with participants’ suggestions to improve it. 4.6.2.  Objective Two: Informing Future Studies Related to the Health Needs of Women in Saudi Arabia  In the following sections, we discuss our suggestions for studies related to the health needs of women in Saudi Arabia. To present these we first discuss the challenges we encountered in launching our study. Second, we discuss practical obstacles that can be avoided for the launching of related studies. Third, we discuss extension studies using other participants, e.g. men. Fourth, we provide examples of future studies that are informed by our pilot findings and will assist in providing further information related to the health needs of women in Saudi Arabia. (a) Challenging Factors This pilot study is the first attempt to explore the outcomes of an intervention program of a six-week T2DM education, based on international standards and tailored to Saudi women’s cultural and religious contexts, and compare outcomes of this program with outcomes of usual care for diabetes in Saudi Arabia.  125  Conducting our research in the Saudi Arabian culture was associated with multiple challenges. First, the research process is less familiar to the public compared with western countries, and often viewed with suspicion (Tessler & Jamal, 2006). To minimize this possibility in our study, the primary researcher employed strategies that helped assure participants’ confidentiality. These strategies included presenting the ethical approval of the study to participants and informing them about their rights to withdraw anytime without providing explanation, should they decide to not disclose their reasons. Participants were also allowed to take a copy of the consent to discuss it with their families before making the decision to participate, should they choose to do so. Second, Saudi research ethics are different than the Canadian ones. In the case of our both studies, we needed to modify the study design to be consistent with the ethical guidelines from the Ministry of Health in Saudi Arabia. For instance, based on the Saudi research ethics, our study was to be launched in health centers only and was not permitted in other public settings in communities. Third, the Saudi culture has imposed societal restrictions on female researchers in Saudi Arabia. The primary researcher in our study was a woman working in the field by herself and as such she was exposed to societal restrictions that compromised her own safety. For example, because women in Saudi Arabia are not allowed to drive and no public transportation is available in the country, the primary researcher hired a male driver, whose identity could not be verified, to get to health centers in suburbs and isolated areas for the purpose of recruiting participants. Future research of studies similar to ours, we suggest, would benefit from including a team of male and female researchers to balance out the demands of the research process with minimum safety compromises.  126  i) Practical Barriers Previously, we described the reasons why women dropped out of the study. Among these reasons was the transportation factor. Saudi women encounter challenges with transportation because women are prohibited from driving and the lack of public transportation in the country. For these reasons, we facilitated participation in this study by launching the six-week education program in a primary health centre that was located at a large residential compound. Participating women, thus, could get to the health centre within a few minutes walking. We assigned participants into two groups. Assigning participants to a group was based on their location (i.e. if they lived close to the classroom, they were assigned to the Intervention Group), and willingness and ability to attend the sessions of the six-week education program. Future programs need to consider how women will be transported back and forth to the classes, what provision is being made for childcare, and what provision is being made for time away from work. The women in our Intervention Group appreciated, and we believed adhered to the program more so, because it was organized through their workplace. The number of participants, who completed our study in the Intervention Group (8), although small, falls within a suggested range of (2 to 20) for a group size receiving health education (Tang, Funnell, & Anderson, 2006). An average of ten participants in a group, as suggested by Tang, Funnell, & Anderson (2006), will allow for interactions between members of a group. According with these, future studies should consider a minimum of ten participants for the sample size of participants in the Intervention Group. This number can be achieved by facilitating transportation for participating women.  127  ii) Future Replications Replicating this study in other regions in Saudi Arabia will shed light on further social and cultural contexts that could be augmented to the content of a T2DM education program. Also, replicating this study in Saudi men of all age groups will provide insights regarding similar and different needs of men. Future studies, we suggest, should pay attention to the need of launching diabetes education in school children and university students. iii) Potential Future Studies Future studies can include: 1. A randomized controlled trial of a T2DM education program tailored to the cultural and religious contexts of Saudi women and compared with outcomes of usual care for diabetes in Saudi Arabia. These studies should have larger sample size, long-term follow-ups, and a control group in addition to the Intervention Group and Usual Care Group. 2. Research studies to adapt international standards of health education related to other lifestyle-conditions like hypertension to Islamic faith, as per the World Health Organization initiative, and examine the outcome of these programs in Saudi women. 3. Studies to examine the outcome of an evidence-based education related to nutrition only, which is modified to the Saudi culture, in Saudi women. 4. Studies to examine the outcomes of inside the home physical activities that are similar to the ones we recommended to participants in our study based on the Harvard suggestions to increase physical activity.  128  5. Studies to examine the outcomes of walking exercise in Saudi women who veil their faces with niqabs, given that face-veils may restrict breathing during physical activities such as walking (Alghadir, Aly, & Zafar, 2012). 6. Studies to examine the outcomes of stress-management techniques, which are based on international standards and adapted to the cultural and religious contexts of Saudi women. 7. Studies to assess the life satisfaction and health-related quality of life in Saudi women. 8. Studies to explore means of encouraging Saudi women to participate in the development and implementation of health education programs. 4.7.  Strengths and Limitations  4.7.1.  Strengths  This study was based on the findings of Study One that examined Saudi women lifestyle-related health beliefs and behaviours and their understanding of religious teachings in relation to health behaviours. To the best of our knowledge, this present study is the first intervention pilot study that explored the outcomes of a T2DM education program, based on international standards and adapted to the cultural and religious contexts of Saudi women, compared with outcomes of usual care for diabetes in Saudi Arabia. Our study provided detailed description of how international standards for a T2DM education program could be adapted to the culture and religion of women in Saudi Arabia. It demonstrated the outcomes of an intervention program of a six-week T2DM education, based on international standards and tailored to Saudi women’s cultural and religious contexts, with pre and post measurements and evaluations. It sheds light on Saudi women’s insights in response to their experience of participating in a six-week 129  T2DM education tailored to their cultural and religious contexts. Our findings provided a baseline description of Saudi women’s life satisfaction and health-related quality of life, given that no previous studies examined life satisfaction or health-related quality of life for women in Saudi Arabia. Finally, the description of our findings is based on mixed methods of data analysis. Such broad base of data analysis, we think, will provide multiple avenues for future related research. 4.7.2.  Limitations  This study has its limitations. First, the study was based on a short-term follow-up and thus provided short-term outcomes only; long-term benefits remain to be evaluated. Second, as a pilot study, the sample size of study participants was small which limited the scope of the statistical tests in the analysis. Third, sampling was based on non-random sampling, which minimized the potential generalizability of our findings. Fourth, we used random blood sugar testing based on home monitoring devices, which is not a reliable way to test for the presence of diabetes. Fifth, baseline scores of blood sugar testing were different in the two groups (above normal in the Intervention Group and normal in the Usual Care Group). This indicates that the two groups had different health needs in relation to T2DM to start with. Sixth, the paucity of knowledge about Saudi women’s life satisfaction and quality of life precludes the use of comparative data. Seventh, the diabetes knowledge test we used, although validated for use in Arab cultures, was designed to evaluate the diabetes knowledge of health care professionals. Its use to evaluate the diabetes knowledge of research participants, in response to an intervention education, has not been previously reported to our knowledge. 4.8.  Conclusion Establishing culturally appropriate T2DM education programs could benefit women 130  in Saudi Arabia. Health education through religion could be a primary approach, given that Islamic teachings are consistent with healthy lifestyles. Findings from our pilot study support positive responses to a T2DM education program that was adapted to the cultural and religious contexts of Saudi women. Our findings have provided a framework for future replication and extension studies related to T2DM education programs not only for women but also for men in Saudi Arabia and other neighbouring countries.  131  4.9.  Tables and Graphs  Table 4. 1 Content Covered in Sessions One and Two of the Type 2 Diabetes Mellitus Health Education Program (Source: Harvard Health Publications: Diabetes: A Plan for Living) Session One Welcome and introduction Purpose of the study (education program) o T2DM is a serious life-threatening condition, so it is important to prevent it, reverse it which can be done in some cases, as well as control and manage it o International standards in diabetes education have been established. This program provides education to you about your diabetes and how to control it, and either eliminate it or reduce its severity o We want to demonstrate that 1) Saudi women may respond positively like other women to a six-week diabetes education program, and 2) Saudi women have the opportunity to modify the format of the program to suit their learning needs and wants Think about definitions of health Self-management construct o T2DM is a lifestyle condition that affects metabolism which means your body’s ability to function o Your metabolism is essential to life and living healthily o Abnormal metabolism associated with T2DM is mostly affected by dietary choices (sweets, fats, and refined foods), by inactivity, and there has been some relationship with smoking o T2DM was a relatively rare condition in Saudi Arabia until the country became richer which enabled people to buy more sugar and sweets, fats, and meat (which meant people were eating less vegetables, fruit, and whole grains, and legumes) Session Two o What is BMI? o How to calculate it?  132  Table 4. 2 Topics Covered from the Harvard Publications on Health What is diabetes?  Normal blood sugar levels  Who is at risk for type 2 diabetes mellitus?  Prevention is possible Diagnosing diabetes  The symptoms  Guidelines for diabetes screening  Dealing with the diagnosis Managing your diabetes: An overview  The ABC’s of diabetes control  A team approach Weight-loss strategies for diabetes  Lifestyle changes make a difference  Eating strategies for weight loss  Seek support  Healthy eating guidelines o Diabetes diet target  The importance of exercise  Tips for healthy eating away from home o Types of exercise  Caution for people with diabetes complications Short-term complications  Low blood sugar (hypoglycemia)  Treating low blood sugar Pregnancy and diabetes Long-term complications Lose Weight and Keep it Off Overweight and obesity: What’s behind the growing trend?  Why people become overweight  Genetic factors  Environmental factors  The food factor o Personal, environmental, and social factors that affect weight  The exercise equation  Stress, sleep, and other lifestyle issues  Everyday stress  Emotional backlash  Time pressures  Speed eating  Not enough ZZZ’s  Friends and family  What is binge eating disorder? o How sleep loss may lead to weight gain?  Other causes of obesity  133  Table 4. 2 Topics Covered from the Harvard Publications on Health  The trouble with TV: Sedentary snacking Weight-loss basics  Counting calories: How many do you need?  Meeting your calorie target  Physical activity: How much is enough?  How to burn about 150 calories  What determines your metabolic rate?  The NEAT factor  Exercise prescription  Starting an exercise program Choosing the diet that fits you best  The diet studies  Low-fat: Doesn’t taste great… and is less filling  Low carbohydrates: quick weight loss but long-term safety questions  Mediterranean-style: Healthy fats and carbs with a big side of fruits and vegetables What to eat: a week of daily menus  Restaurant meals: The dieter’s downfall 10 habits to help you lose weight  What is cognitive behavioural therapy?  Set small, specific, and realistic goals  Start self-monitoring o A sample of behaviour chain  Create a behaviour chain  Find a support network  Energize your exercise  Make sure you’re getting enough sleep  Eat breakfast-slowly and mindfully every morning  Monitor and modify your screen time  Shop smarter  Reward yourself with (nonfood) pleasures Healthy Eating for Type 2 Diabetes Understanding diabetes  Blood sugar testing o A guide to blood pressure levels  The ABC’s of diabetes control  Blood pressure targets  Cholesterol levels The first-line treatment: Weight loss  Weight-loss strategies  Metformin: A diabetes standby  Calorie-cutting methods  Eating away from home  Exercise: The essential adjunct  Keeping the weight off  Doing plenty of physical activity  Eating a diet low in calories and fat  134  Table 4. 2 Topics Covered from the Harvard Publications on Health  Eating breakfast  Keeping tabs on how much they eat  Stopping on the scale regularly  Watching little television  Eat s-l-o-w-l-y  Get enough ZZZ’s The elements of a healthy diet  Carbohydrates  Figure 3 Healthy eating pyramid  Glycemic index and glycemic load  Eating principles of low-glycemic eating  Fiber  Fats o The skinny on fats  Diet and your blood cholesterol  Proteins  Other dietary components  Calcium  Salt  Sugar and sugar substitutes  Natural and added sugars  Artificial sweeteners  Vitamins and minerals Meal-planning basics  Meet with a registered dietician  Calculate your caloric needs  Choose a meal plan  The exchange system  Carbohydrate counting  Handling hypoglycaemia Exercise A program you can live with The inside scoop: Exercise and your body  Energy to burn What can exercise do for you?  Improves quality of life  Protects mobility and vitality  Wards off depression and anxiety  Sharpens wits  Improves sleep The fundamentals: What you need to know to get started  How much exercise do I need  Time  Calories  Calories, miles, and minutes: How long will it take?  How often should I exercise?  How long must my exercise sessions be?  135  Table 4. 2 Topics Covered from the Harvard Publications on Health  How vigorously should I exercise?  Gauging the intensity of your workout  Building up Creating a personal exercise plan  Aerobic activities  How much  Get started Find a safe place to walk Buy a good pair of shoes Dress for comfort and safety Do a five minute warm-up and cool-down Practice good techniques  Step by step  Stretching training Exercising safely  If you have health problems  Advice for people with arthritis  Advice for people with diabetes: Before diving in Once you have the go-ahead Strength training exercises, 10 basic stretches Positive psychology A science of satisfaction  History of positive psychology  Positive emotions and the brain o Maslow’s “hierarchy of needs” Defining and measuring happiness  Is it genetic?  Why pleasure fades o Is happiness genetic  The happiness/health connection  Better health  Have we evolved toward unhappiness?  What makes you happy?  Things that make you happy Feeling good Engaging fully Doing good  Things that won’t make you happy Money and material things Youth Children Your strength and virtues o Six virtues and their underlying strengths Gratitude  136  Table 4. 2 Topics Covered from the Harvard Publications on Health  Studying gratitude  Counting your blessings Savoring pleasure  Single task  Celebrate  Slow down  Underscore  Simplify  Share the moment  Be active Flow: Becoming more engaged  Flow at work  How to get in the flow o High skill + high challenge = flow Mindfulness o Mindfulness techniques  Learning mindfulness  A mindfulness exercise to try: a meditation exercise  Practicing awareness in daily life Self-compassion  What is self-compassion?  How to develop self-compassion: Comfort your body Write a letter to yourself Give yourself encouragement Practice mindfulness The meaningful life Do unto others  Table 4.3 Posters and Pamphlets  Calculating the risk factors for type 2 diabetes mellitus  Obesity and how to avoid it  How to measure the body mass index  Recommended exercise for diabetic patients  Healthy food pyramid  Diabetes  Woman and obesity  137  Table 4.4 Discussion Topics: Personal, Environmental, and Social Factors that Affect Weight Personal factors  Sitting most of the day to work on a computer  Stress  Eating fast food during working hours Community, social, and social norms and values factors  Hospitality to guests by serving them big amounts of food and expecting them to eat most of it if not all  Social gatherings are usually provided with a variety of food options including sweets, junk, and fatty food  No gyms for women  No walking areas for women  No public transportation and women are not allowed to drive  Fast food is the most convenient option to eat during working hours  Kids prefer to eat from fast food restaurants  On Wednesdays (last day of the week), families prefer to eat in restaurants  Media Advertisements for the deals of combo size meals  Kids spend most of their days watching television  Kids eat junk food while watching television  Few available options for entertainment that include eating in restaurants or going shopping in malls  Cultural images for ideal body type of a female. Men like their wives to look average weight or overweight  Kids have nowhere to go and play other than inside the homes  Menus in restaurants are not provided with calories counting for each served meal  138  Table 4.5 Tailoring the Harvard Education for Positive Psychology with Religious Quotes Topic  Quote  Science of satisfaction Maslow’s “hierarchy of needs”  The saying: “satisfaction is an infinite treasure” Hadith: “one third for yourself, one third for your food, one third for your drink” Qura’nic verse: “money and children are accessories of the worldly life” Hadith: “don’t be angry” Hadith: “Allah is beautiful, loves beauty” The saying: “be beautiful you would see the world beautiful”  Things that won’t make you happy Temperance and self control Transcendence and appreciation of beauty Spirituality Gratitude  Counting your blessings Hope Matching your skill level The meaningful life  Altruism  Qura’nic verse “Remember me, I remember you Qura’nic verse: “always talk about your God’s gifts to you” Hadith: “don’t look to those whom above you, look at those who are below you” Qura’nic verse: “if you count God’s gifts, you would find them countless” Qura’nic verse: “be optimistic, you would find the good” Qura’nic verse: “don’t fall into despair of Allah’s help” Qura’nic verse: “Allah doesn’t make a soul to carry more than it can” Hadith: “treat people the way you like them to treat you” Hadith: “the way Muslims compassionate, supportive, and corporate with each other is like one body” Hadith: “Love for your brother what you love for yourself”  Table 4.6 Other Examples of Tailoring Health Education to the Saudi Culture Harvard Concept Fitting the Concept to the Saudi Culture Self-Compassion  “Treat yourself the way you treat your kids”  Positive relationships  “Encourage your teens to do something meaningful for their communities like volunteering in a mosque”  Flow experiences to do together  “Make a small monthly donation for charity” “Collaborate on cooking” “Pray or attend services” “Practice meditation” “Go for walks”  139  Table 4.7 Participant Characteristics by Group Intervention Variable  Category  Marital status  Number of children  Educational status  Occupational status  Source of income  Income (SR)  Usual Care  Married Single Divorced Separated Widowed Total 0-2 3-10 Total No formal education Primary Intermediate Secondary Diploma University Graduate Total Homemaker Employed Student Retired Total Personal Husband or guardian Both Other Total < 3,000  N 5 1 2 1 4 13 3 8 11 1 1 5 4 1 1 --13 3 9 1 --13 7 3 2 1 13 2  Percent 38.5% 7.7% 15.4% 7.7% 30.8% 100.0% 27.3% 72.7% 100.0% 7.7% 7.7% 38.5% 30.8% 7.7% 7.7% --100.0% 23.1% 69.2% 7.7% --100.0% 53.8% 23.1% 15.4% 7.7% 100.0% 15.4%  N 6 --------6 1 5 6 ------1 3 2 --6 --6 ----6 ----6 --6 ---  Percent 100.0% --------100.0% 16.7% 83.3% 100.0% ------16.7% 50.0% 33.3% --100.0% --100.0% ----100.0% ----100.0% --100.0% ---  >=3,000 to <5,000  4  30.8%  ---  ---  >=5,000 to <=10,000  5  38.5%  1  16.7%  2  15.4%  5  83.3%  13  100.0%  6  100.0%  > 10,000 Total SR, Saudi Riyals (U.S. $1.00 = 3.75 SR)  140  Table 4.8 Physical Measurements, Pre-Program (Baseline) and Post-Program by Group Standard Standard Valid N Mean Median Deviation Error Minimum Maximum  Variable PRE-PROGRAM (BASELINE)  Group  Age (beginning of study) Height (cm)  Intervention Usual Care Intervention  13 6 9  45.5 39.3 156.1  47.0 41.0 159.0  11.3 7.1 8.0  3.1 2.9 2.7  17.0 26.0 145.0  66.0 46.0 165.0  38.72, 52.36 31.86, 46.80 149.97, 162.25  Weight (kg)  Usual Care Intervention  6 10  153.3 84.6  153.5 87.0  3.4 9.4  1.4 3.0  149.0 65.5  158.0 96.0  153.33, 149.72 77.93, 91.37  Waist circumference (cm)  Usual Care Intervention  6 10  86.3 49.6  87.0 45.5  14.3 14.6  5.8 4.6  67.0 39.0  105.0 89.0  71.35, 101.32 39.17, 60.03  Hip circumference (cm)  Usual Care Intervention  5 10  41.7 47.3  42.0 47.5  4.8 3.4  2.2 1.1  34.0 40.0  47.0 52.0  35.72, 47.68 44.84, 49.66  BMI (kg/m2)  Usual Care Intervention  5 9  48.7 36.0  51.0 35.0  6.4 6.1  2.9 2.0  40.0 29.0  55.0 45.7  40.71, 56.69 31.32, 40.75  Waist to hip ratio  Usual Care Intervention  6 10  36.8 1.1  36.2 1.0  6.7 .3  2.7 .1  29.6 .8  46.7 1.9  29.81, 43.80 0.83, 1.27  Blood sugar (mg/dl)  Usual Care Intervention  5 8  .9 154.1  .8 112.0  .1 84.5  .1 29.9  .8 74.0  1.0 302.0  0.72, 1.01 83.50, 224.75  Six minute walking test (m)  Usual Care Intervention  4 10  99.3 92.6  100.5 89.3  14.9 9.8  7.4 3.1  82.0 80.5  114.0 110.3  75.60, 122.90 85.59, 99.61  Usual Care  5  119.1  121.5  24.7  11.0  87.5  151.0  88.39, 149.71  Weight (kg)  Intervention  10  85.5  86.8  8.1  2.6  69.0  98.0  79.66, 91.24  Waist circumference (cm)  Usual Care Intervention  5 10  81.9 43.9  85.0 46.0  10.9 4.1  4.9 1.3  66.0 36.0  92.0 48.5  68.40, 95.41 41.01, 46.89  Hip circumference (cm)  Usual Care Intervention  5 10  43.5 47.2  44.0 47.3  2.8 2.4  1.2 .8  39.5 43.0  46.0 50.0  40.04, 46.96 45.41, 48.89  Usual Care  5  47.7  50.0  6.1  2.7  40.0  53.0  40.11, 55.25  95% CI  POST-PROGRAM  141  Table 4.8 Physical Measurements, Pre-Program (Baseline) and Post-Program by Group Variable BMI (kg/m2)  Standard Standard Group Valid N Mean Median Deviation Error Minimum Maximum Intervention 9 36.2 34.8 5.5 1.8 28.8 46.6  95% CI 31.92, 40.44  Waist to hip ratio  Usual Care Intervention  5 10  34.5 .9  34.9 .9  4.4 .1  1.9 .0  29.7 .8  39.3 1.1  29.11, 39.92 0.87, 0.99  Usual Care Intervention Usual Care Intervention  5 6 5 9  .9 144.2 119.0 111.7  .9 125.5 106.0 114.8  .1 57.1 40.5 19.5  .0 23.3 18.1 6.5  .8 110.0 74.0 74.3  1.1 260.0 170.0 135.0  0.82, 1.02 84.25, 204.08 68.72, 169.28 96.67, 126.72  Usual Care  3  100.3  94.5  31.2  18.0  72.5  134.0  22.92, 177.74  Blood sugar (mg/dl) Six minute walking test (m)  Table 4.9 BMI Categories, Pre-Program (Baseline) and Post-Program by Group 25.0 to 29.9 Group  N PRE-PROGRAM (BASELINE) Intervention 2 Usual Care 1 POST-PROGRAM Intervention 1 Usual Care 1  30.0 to 34.9  ≥ 40.0  35.0 to 39.9  Total  Percent  N  Percent  N  Percent  N  Percent  N  Percent  22.2% 16.7%  2 2  22.2% 33.3%  3 1  33.3% 16.7%  2 2  22.2% 33.3%  9 6  100.0% 100.0%  11.1% 20.0%  4 2  44.4% 40.0%  2 2  22.2% 40.0%  2 0  22.2% .0%  9 5  100.0% 100.0%  142  Table 4.10 Waist-to-Hip Ratio Categories, Pre-Program (Baseline) and Post-Program by Group ≤ 0.80 > 0.80 Total Group N Percent N Percent N Percent PRE-PROGRAM (BASELINE) Intervention Usual Care POST-PROGRAM Intervention Usual Care  0 3  .0% 60.0%  10 2  100.0% 40.0%  10 5  100.0% 100.0%  1 0  10.0% .0%  9 5  90.0% 100.0%  10 5  100.0% 100.0%  143  Table 4.11 Physical Measurements, Pre-Program (Baseline) / Post-Program Difference by Group Standard Standard Variable Group Valid N Mean Median Deviation Error Minimum Maximum BMI Pre-Post Difference Intervention 9 .1 -.2 1.6 .5 -2.4 3.8 Usual Care 5 -.3 .0 1.4 .6 -2.6 .8 Weight Pre-Post Difference Intervention 9 .5 -.5 4.0 1.3 -5.0 10.0  95% CI -1.10, 1.39 -2.00, 1.36 -2.58, 3.58  Waist Pre-Post Difference  Usual Care Intervention  5 9  -.7 -6.9  .0 -.5  3.2 17.5  1.4 5.8  -6.0 -53.0  2.0 2.0  -4.67, 3.27 -20.35, 6.57  Hip Pre-Post Difference  Usual Care Intervention  4 9  2.5 -.9  2.0 -1.0  2.1 1.1  1.1 .4  .5 -2.5  5.5 1.0  -0.88, 5.88 -1.76, -0.01  Usual Care  4  -1.0  -1.1  .9  .5  -2.0  .0  -2.51, 0.46  WHR Pre-Post Difference  Intervention  9  -.1  .0  .4  .1  -1.1  .1  -0.42, 0.17  Blood Sugar Pre-Post Difference  Usual Care Intervention  4 4  .1 -42.8  .1 -23.0  .1 98.0  .0 49.0  .0 -176.0  .2 51.0  -0.03, 0.17 -198.61, 113.11  Six Minute Exercise Pre-Post Difference  Usual Care Intervention  3 8  9.0 18.2  -3.0 20.4  25.2 16.0  14.6 5.6  -8.0 -11.5  38.0 45.8  -53.70, 71.70 4.87, 31.56  Usual Care  2  18.9  18.9  39.1  27.6  -8.8  46.5  -332.13, 369.88  144  Table 4.12 SF12 Sub-Domain Scores (0 to 100) and Totals, Pre-Program (Baseline) and Post-Program by Group Variable Group PRE-PROGRAM (BASELINE) Physical Functioning Intervention Usual Care Role Physical Intervention Usual Care Bodily pain Intervention Usual Care General health Intervention Usual Care Vitality Intervention Usual Care Social functioning Intervention Usual Care Role Emotional Intervention Usual Care Mental Health Intervention Usual Care Physical Component Intervention Usual Care Mental Component Intervention Usual Care Total Intervention Usual Care POST-PROGRAM Physical Functioning Intervention Usual Care Role Physical Intervention Usual Care Bodily pain Intervention Usual Care General health Intervention Usual Care Vitality Intervention Usual Care Social functioning Intervention Usual Care Role Emotional Intervention Usual Care Mental Health Intervention Usual Care Physical Component Intervention Usual Care Mental Component Intervention Usual Care Physical Component Intervention Usual Care Mental Component Intervention Usual Care  Valid Standard Standard N Mean Median Deviation Error Minimum Maximum 11 3 11 3 11 3 11 3 11 3 11 3 11 3 11 3 11 3 11 3 11 3  31.8 41.7 12.5 25.0 52.3 100.0 80.0 90.0 40.9 33.3 75.0 83.3 20.5 25.0 48.9 62.5 41.6 49.0 39.2 40.1 410.7 508.3  50.0 50.0 12.5 25.0 50.0 100.0 85.0 85.0 25.0 25.0 100.0 75.0 25.0 25.0 50.0 62.5 41.6 48.3 38.1 38.5 417.8 498.4  22.6 14.4 11.2 .0 34.4 .0 21.0 8.7 30.2 38.2 35.4 14.4 8.4 .0 24.7 12.5 7.3 1.5 7.7 3.7 96.3 42.7  6.8 8.3 3.4 .0 10.4 .0 6.3 5.0 9.1 22.0 10.7 8.3 2.5 .0 7.4 7.2 2.2 .9 2.3 2.1 29.0 24.7  .0 25.0 .0 25.0 .0 100.0 25.0 85.0 .0 .0 .0 75.0 .0 25.0 .0 50.0 29.6 48.0 23.1 37.6 184.7 471.5  50.0 50.0 25.0 25.0 100.0 100.0 100.0 100.0 75.0 75.0 100.0 100.0 25.0 25.0 87.5 75.0 53.0 50.8 49.9 44.3 530.7 555.1  11 6 11 6 11 6 11 6 11 6 11 6 11 6 11 6 11 6 11 6 9 3 9  27.3 25.0 15.9 20.8 77.3 83.3 81.4 83.3 27.3 37.5 56.8 75.0 14.8 18.8 62.5 45.8 43.4 46.0 37.5 36.9 1.6 -2.5 .8  25.0 25.0 25.0 25.0 100.0 100.0 85.0 85.0 25.0 25.0 75.0 87.5 25.0 25.0 50.0 50.0 44.6 48.0 34.9 37.8 1.0 1.6 .6  20.8 22.4 11.3 10.2 39.5 25.8 21.8 12.9 28.4 30.6 46.2 38.7 12.3 10.5 20.2 30.3 7.4 6.0 9.2 6.4 6.2 7.5 9.3  6.3 9.1 3.4 4.2 11.9 10.5 6.6 5.3 8.6 12.5 13.9 15.8 3.7 4.3 6.1 12.4 2.2 2.4 2.8 2.6 2.1 4.4 3.1  .0 .0 .0 .0 .0 50.0 25.0 60.0 .0 25.0 .0 .0 .0 .0 37.5 12.5 29.4 37.1 26.2 28.4 -8.4 -11.2 -10.5  50.0 50.0 25.0 25.0 100.0 100.0 100.0 100.0 75.0 100.0 100.0 100.0 25.0 25.0 87.5 87.5 53.1 52.3 51.7 45.8 10.6 2.2 16.8  3  -3.2  -1.9  5.4  3.1  -9.2  1.4  145  Table 4.12 SF12 Sub-Domain Scores (0 to 100) and Totals, Pre-Program (Baseline) and Post-Program by Group Variable Total  Group Intervention Usual Care  Valid Standard Standard N Mean Median Deviation Error Minimum Maximum 11 416.7 469.3 133.9 40.4 161.0 581.6 6 447.4 470.2 62.4 25.5 331.3 499.2  Table 4.13 SF12 Sub-Domain Scores (0 to 100) and Totals, Pre-Program (Baseline) and Post-Program Variable PRE-PROGRAM (BASELINE) Physical Functioning Role Physical Bodily pain General health Vitality Social functioning Role Emotional Mental Health Physical Component Mental Component SF12 Total POST-PROGRAM Physical Functioning Role Physical Bodily pain General health Vitality Social functioning Role Emotional Mental Health Physical Component Mental Component SF12 Total  Valid N  Mean Median  Standard Deviation  Standard Error  Minimum  Maximum  14 14 14 14 14 14 14 14 14 14 14  33.9 15.2 62.5 82.1 39.3 76.8 21.4 51.8 43.2 39.4 431.7  50.0 18.8 50.0 85.0 25.0 87.5 25.0 50.0 44.0 38.3 458.1  21.0 11.2 36.4 19.2 30.6 31.7 7.6 22.9 7.1 6.9 95.6  5.6 3.0 9.7 5.1 8.2 8.5 2.0 6.1 1.9 1.8 25.5  .0 .0 .0 25.0 .0 .0 .0 .0 29.6 23.1 184.7  50.0 25.0 100.0 100.0 75.0 100.0 25.0 87.5 53.0 49.9 555.1  17 17 17 17 17 17 17 17 17 17 17  26.5 17.6 79.4 82.1 30.9 63.2 16.2 56.6 44.3 37.3 427.6  25.0 25.0 100.0 85.0 25.0 75.0 25.0 50.0 45.3 36.5 469.3  20.7 10.9 34.5 18.7 28.7 43.4 11.5 24.7 6.8 8.1 112.5  5.0 2.6 8.4 4.5 7.0 10.5 2.8 6.0 1.7 2.0 27.3  .0 .0 .0 25.0 .0 .0 .0 12.5 29.4 26.2 161.0  50.0 25.0 100.0 100.0 100.0 100.0 25.0 87.5 53.1 51.7 581.6  146  Table 4.14 SF12 Sub-Domain Scores (0 to 100) and Totals, Pre-Program (Baseline) / Post-Program Difference by Group Standard Variable Group Valid N Mean Median Deviation Standard Error Minimum Maximum Role Physical Pre-Post Difference Intervention 9 6.9 12.5 15.5 5.2 -25.0 25.0 Usual Care 3 .0 .0 .0 .0 .0 .0 Bodily pain Pre-Post Difference Intervention 9 33.3 50.0 33.1 11.0 .0 75.0 Usual Care 3 -16.7 .0 28.9 16.7 -50.0 .0 General health Pre-Post Difference Intervention 9 .0 .0 7.5 2.5 -15.0 15.0 Usual Care 3 .0 .0 15.0 8.7 -15.0 15.0 Vitality Pre-Post Difference Intervention 9 -19.4 .0 44.7 14.9 -75.0 50.0 Usual Care 3 16.7 25.0 62.9 36.3 -50.0 75.0 Social functioning Pre-Post Difference Intervention 9 -11.1 .0 51.7 17.2 -100.0 75.0 Usual Care 3 -16.7 25.0 72.2 41.7 -100.0 25.0 Role Emotional Pre-Post Difference Intervention 9 -1.4 .0 7.5 2.5 -12.5 12.5 Usual Care 3 .0 .0 .0 .0 .0 .0 Mental Health Pre-Post Difference Intervention 9 22.2 25.0 19.5 6.5 -12.5 50.0 Usual Care 3 -25.0 -37.5 21.7 12.5 -37.5 .0 Physical Component Pre-Post Difference Intervention 9 1.6 1.0 6.2 2.1 -8.4 10.6 Usual Care 3 -2.5 1.6 7.5 4.4 -11.2 2.2 Mental Component Pre-Post Difference Intervention 9 .8 .6 9.3 3.1 -10.5 16.8 Usual Care 3 -3.2 -1.9 5.4 3.1 -9.2 1.4 SF12 Total Pre-Post Difference Intervention 9 32.9 38.8 55.5 18.5 -41.8 122.2 Usual Care  3  -47.4  -70.1  66.7  38.5  -99.8  27.7  147  Table 4.15 SF12, Pre/ Post Differences for Combined Groups Mean Std. Error Variable Valid N Difference Difference Physical Component 12 4.06 4.32 Mental Component 12 4.01 5.76 SF12 Total 12 80.29 38.61  95% CI of the Difference -5.57, 13,68 -8.83, 16.85 -5.73, 166.31  Table 4.16 Life Satisfaction, Pre-Program (Baseline) and Post-Program by Group Intervention Variable Category PRE-PROGRAM (BASELINE) My life as a whole Very satisfying Satisfying Rather satisfying Rather dissatisfying Dissatisfying Very dissatisfying Total Vocational life Very satisfying Satisfying Rather satisfying Rather dissatisfying Dissatisfying Very dissatisfying Total Leisure situation Very satisfying Satisfying Rather satisfying Rather dissatisfying Dissatisfying Very dissatisfying Total Contact with friends and Very satisfying acquaintances Satisfying Rather satisfying Rather dissatisfying Dissatisfying Very dissatisfying Total Ability to manage self-care Very satisfying Satisfying Rather satisfying Rather dissatisfying Dissatisfying Very dissatisfying Total  Usual Care  N  Percent  N  Percent  3 5 3 0 0 0 11 2 7 1 0 0 0 10 1 6 3 1 0 0 11 3 6 0 0 2 0 11 6 3 2 0 0 0 11  27.3% 45.5% 27.3% .0% .0% .0% 100.0% 20.0% 70.0% 10.0% .0% .0% .0% 100.0% 9.1% 54.5% 27.3% 9.1% .0% .0% 100.0% 27.3% 54.5% .0% .0% 18.2% .0% 100.0% 54.5% 27.3% 18.2% .0% .0% .0% 100.0%  0 4 0 0 0 1 5 0 4 0 0 1 0 5 0 1 0 2 0 2 5 1 3 0 0 1 0 5 1 3 0 1 0 0 5  .0% 80.0% .0% .0% .0% 20.0% 100.0% .0% 80.0% .0% .0% 20.0% .0% 100.0% .0% 20.0% .0% 40.0% .0% 40.0% 100.0% 20.0% 60.0% .0% .0% 20.0% .0% 100.0% 20.0% 60.0% .0% 20.0% .0% .0% 100.0%  148  Table 4.16 Life Satisfaction, Pre-Program (Baseline) and Post-Program by Group Intervention Variable Category N Percent Family life Very satisfying 1 9.1% Satisfying 8 72.7% Rather satisfying 2 18.2% Rather dissatisfying 0 .0% Dissatisfying 0 .0% Very dissatisfying 0 .0% Total 11 100.0% Psychological health Very satisfying 2 18.2% Satisfying 6 54.5% Rather satisfying 2 18.2% Rather dissatisfying 0 .0% Dissatisfying 1 9.1% Very dissatisfying 0 .0% Total 11 100.0% POST-PROGRAM My life as a whole Very satisfying 0 .0% Satisfying 10 100.0% Rather satisfying 0 .0% Rather dissatisfying 0 .0% Dissatisfying 0 .0% Very dissatisfying 0 .0% Total 10 100.0% Vocational life Very satisfying 0 .0% Satisfying 9 90.0% Rather satisfying 1 10.0% Rather dissatisfying 0 .0% Dissatisfying 0 .0% Very dissatisfying 0 .0% Total 10 100.0% Leisure situation Very satisfying 0 .0% Satisfying 6 60.0% Rather satisfying 3 30.0% Rather dissatisfying 0 .0% Dissatisfying 1 10.0% Very dissatisfying 0 .0% Total 10 100.0% Contact with friends and Very satisfying 1 10.0% acquaintances Satisfying 8 80.0% Rather satisfying 1 10.0% Rather dissatisfying 0 .0% Dissatisfying 0 .0% Very dissatisfying 0 .0% Total 10 100.0%  N 1 2 2 0 0 0 5 0 3 0 1 0 1 5  Usual Care Percent 20.0% 40.0% 40.0% .0% .0% .0% 100.0% .0% 60.0% .0% 20.0% .0% 20.0% 100.0%  0 3 1 0 0 0 4 1 2 1 0 0 0 4 1 1 2 0 0 0 4 0 3 1 0 0 0 4  .0% 75.0% 25.0% .0% .0% .0% 100.0% 25.0% 50.0% 25.0% .0% .0% .0% 100.0% 25.0% 25.0% 50.0% .0% .0% .0% 100.0% .0% 75.0% 25.0% .0% .0% .0% 100.0%  149  Table 4.16 Life Satisfaction, Pre-Program (Baseline) and Post-Program by Group Intervention Variable Category N Percent Ability to manage self-care Very satisfying 1 10.0% Satisfying 6 60.0% Rather satisfying 3 30.0% Rather dissatisfying 0 .0% Dissatisfying 0 .0% Very dissatisfying 0 .0% Total 10 100.0% Family life Very satisfying 2 20.0% Satisfying 6 60.0% Rather satisfying 2 20.0% Rather dissatisfying 0 .0% Dissatisfying 0 .0% Very dissatisfying 0 .0% Total 10 100.0% Psychological health Very satisfying 1 10.0%  N 1 2 1 0 0 0 4 0 3 1 0 0 0 4 0  Usual Care Percent 25.0% 50.0% 25.0% .0% .0% .0% 100.0% .0% 75.0% 25.0% .0% .0% .0% 100.0% .0%  Satisfying  8  80.0%  3  75.0%  Rather satisfying  1  10.0%  1  25.0%  Rather dissatisfying  0  .0%  0  .0%  Dissatisfying  0  .0%  0  .0%  Very dissatisfying  0  .0%  0  .0%  Total  10  100.0%  4  100.0%  150  Table 4.17 Life Satisfaction, Pre-Program (Baseline) and Post-Program Totals, and Pre/Post Difference by Group Standard Standard Variable Group Valid N Mean Median Deviation Error Life Satisfaction Questionnaire Total Pre-Program Intervention 11 2.2 2.1 .6 .2 Usual Care 5 2.8 2.4 1.0 .4 Life Satisfaction Questionnaire Total Post-Program Intervention 10 2.2 2.2 .2 .1 Usual Care 4 2.3 2.2 .2 .1 Life Satisfaction Questionnaire, Pre / Post-Program Intervention 8 -.1 -.1 .4 .1 Difference Usual Care 3 -.6 -.3 1.1 .6  Minimum Maximum 95% CI 1.3 3.4 1.83, 2.58 1.8 4.4 1.57, 4.03 1.9 2.4 2.04, 2.31 2.1 2.6 1.87, 2.63 -1.0 .2 -0.43, 0.21 -1.8  .3  -3.29, 2.09  151  Table 4.18 Diabetes Knowledge Test, Number and Percent Correct, Pre-Program (Baseline) and Post-Program by Group Pre-Program Post-Program Intervention Usual Care Intervention Usual Care Variable N Percent N Percent N Percent N Percent Diabetic diet 6 46.2% 4 66.7% 1 16.7% 5 83.3% Highest in carbohydrate 2 15.4% 3 50.0% 5 83.3% 1 16.7% Highest in fat 5 38.5% 0 .0% 5 83.3% 1 16.7% Best method to test blood glucose 6 46.2% 1 16.7% 4 66.7% 2 33.3% Effect of unsweetened fruit juice on blood glucose 2 15.4% 0 .0% 6 100.0% 0 .0% NOT to be used to treat low blood glucose 9 69.2% 4 66.7% 4 66.7% 2 33.3% Effect of exercise on blood glucose 11 84.6% 4 66.7% 2 33.3% 4 66.7% Infection is likely to cause 7 53.8% 4 66.7% 1 16.7% 5 83.3% Best way to care for your feet 10 76.9% 5 83.3% 2 33.3% 4 66.7% Food low in fat decreases which risk 10 76.9% 4 66.7% 1 16.7% 5 83.3% Numbness and tingling may be symptoms of 9 69.2% 3 50.0% 1 16.7% 5 83.3% Which is NOT associated with diabetes 7 53.8% 3 50.0% 4 66.7% 2 33.3% Changes you should make if you have flu 5 38.5% 4 66.7% 1 16.7% 5 83.3% What to do if just before lunch realized you forgot to take Pre-breakfast 3 23.1% 2 33.3% 2 33.3% 4 66.7% insulin If you are beginning to have an insulin reaction, you should 4 30.8% 0 .0% 2 33.3% 4 66.7% Possible cause of low blood glucose 5 38.5% 3 50.0% 3 50.0% 3 50.0% Took morning insulin & skipped breakfast; blood glucose level will 5 38.5% 3 50.0% 1 16.7% 5 83.3% Possible cause of high blood glucose 6 46.2% 3 50.0% 1 16.7% 5 83.3% Most likely cause of an insulin reaction 3 23.1% 1 16.7% 4 66.7% 2 33.3%  152  Table 4.19 Diabetes Knowledge Test, Pre-Program (Baseline) and Post-Program Totals, and Pre/Post Difference by Group Variable Pre-Program Post-Program Pre / Post Program Difference  Intervention Usual Care Intervention Usual Care Intervention Usual Care  G Valid rN 11 o 5u 10 p 5 9 4  Mean 10.5 10.2 14.3 12.8 3.3 2.3  Median 10.0 10.0 14.5 13.0 4.0 2.0  Standard Deviation 2.5 1.3 3.0 1.5 3.1 .5  Standard Error .8 .6 1.0 .7 1.0 .3  Minimum 6 9 10 11 -3 2  Maximum 14 12 19 15 6 3  95% CI 8.72, 12.84 8.45, 12.55 11.70, 16.52 10.03, 15.47 0.96, 5.70 1.45, 3.05  153  Table 4.20 Types of Physical Activity Participants Reported Performing, Pre-Program (Baseline) by Group Intervention Variable  Usual Care  Category  N  Percent  N  Percent  Physical activity  Yes/No  8/3  72.7%/27.3%  5/1  83.3%/16.7%  Moderate physical activity  Yes/No  3/8  27.3%/72.7%  4/2  66.7%/33.3%  Strenuous physical activity  Yes/No  2/9  18.2%/81.8%  0/5  0.0%/100.0%  154  Table 4.21 Amount of Time Participants Reported Performing Physical Activities of Various Difficulties, Pre-Program (Baseline) by Group Standard Standard Valid N Mean Median Deviation Error Minimum Maximum  Variable  Group  Strenuous physical activity (days/week)  Intervention  2  4.5  4.5  3.5  2.5  2  7  -27.27, 36.27  Usual Care  0  .  .  .  .  .  .  .  Intervention  0  .  .  .  .  .  .  .  Usual Care  0  .  .  .  .  .  .  .  Intervention  2  20.0  20.0  14.1  10.0  10  30  -107.1, 147.1  Usual Care  0  .  .  .  .  .  .  .  Intervention  3  3.7  4.0  1.5  .9  2  5  .  Usual Care  4  2.3  2.5  1.0  .5  1  3  .  Intervention  1  2.0  2.0  .  .  2  2  .  Usual Care  1  1.0  1.0  .  .  1  1  .  Intervention  2  22.5  22.5  10.6  7.5  15  30  .  Usual Care  3  22.3  30.0  13.3  7.7  7  30  .  Strenuous physical activity (hours/day) Strenuous physical activity (minutes/day) Moderate physical activity (days/week) Moderate physical activity (hours/day) Moderate physical activity (minutes/day)  95% CI  155  Table 4.22 Self-reported Physical Health Measures and General Health, Pre-Program (Baseline) by Group Intervention  Usual Care  Variable  Category  N  Percent  N  Percent  Weight  Underweight  0  .0%  0  .0%  Normal weight  3  23.1%  1  16.7%  Over weight  10  76.9%  5  83.3%  I don't know  0  .0%  0  .0%  Total  13  100.0%  6  100.0%  Low  1  7.7%  0  .0%  Normal  9  69.2%  3  50.0%  High  2  15.4%  3  50.0%  I don't know  1  7.7%  0  .0%  Total  13  100.0%  6  100.0%  Low  1  7.7%  0  .0%  Normal  8  61.5%  4  66.7%  High  4  30.8%  2  33.3%  I don't know  0  .0%  0  .0%  Total  13  100.0%  6  100.0%  Low  1  7.7%  0  .0%  Normal  5  38.5%  3  50.0%  High  7  53.8%  3  50.0%  Heart rate  Blood sugar  Blood pressure  Health  I don't know  0  .0%  0  .0%  Total  13  100.0%  6  100.0%  Excellent  2  15.4%  1  16.7%  Above Average  4  30.8%  0  .0%  Average  6  46.2%  5  83.3%  Below Average  0  .0%  0  .0%  Poor  1  7.7%  0  .0%  Total  13  100.0%  6  100.0%  156  Table 4.23 Self-reported Morbidity, Pre-Program (Baseline) by Group Intervention Variable  N/Percent  Lung disease High blood Pressure Stroke Obese Diabetes Cancer Osteoporosis Anemia Multiple sclerosis Irritable bowel syndrome Ulcers Premenopausal Menstrual, irregular cycles Menopausal Other health problems  Usual Care  N Percent N Percent N Percent N Percent N Percent N Percent N Percent N Percent N Percent N Percent N Percent N Percent N Percent N Percent N  Yes 0 .0% 8 61.5% 0 .0% 7 53.8% 5 38.5% 0 .0% 1 7.7% 3 23.1% 0 .0% 4 30.8% 0 .0% 1 7.7% 0 .0% 4 30.8% 4  No 13 100.0% 5 38.5% 13 100.0% 6 46.2% 8 61.5% 13 100.0% 12 92.3% 10 76.9% 13 100.0% 9 69.2% 13 100.0% 12 92.3% 13 100.0% 9 69.2% 9  Yes 0 .0% 3 50.0% 0 .0% 2 33.3% 2 33.3% 1 16.7% 0 .0% 1 16.7% 0 .0% 3 50.0% 0 .0% 0 .0% 0 .0% 0 .0% 3  No 6 100.0% 3 50.0% 6 100.0% 4 66.7% 4 66.7% 5 83.3% 6 100.0% 5 83.3% 6 100.0% 3 50.0% 6 100.0% 6 100.0% 6 100.0% 6 100.0% 3  Percent  30.8%  69.2%  50.0%  50.0%  157  Table 4.24 Average Weekly Consumption of Rice or Pasta, Bread and Cereals, Meat, Poultry, Seafood, Eggs, Nuts, Legumes, and Milk and Dairy Reported by Participants, Pre-Program (Baseline) by Group Variable  Category  Standard Standard Valid N Mean Median Deviation Error  Minimum  Maximum  Intervention Usual Care Bread and cereals (times/week) Intervention Usual Care Beef or sheep (times/week) Intervention  10 5 11 6 9  4.6 4.6 6.8 4.7 2.2  4.5 4.0 7.0 4.5 2.0  2.0 2.3 .6 2.1 1.1  .6 1.0 .2 .8 .4  2.0 2.0 5.0 2.0 1.0  7.0 7.0 7.0 7.0 4.0  Usual Care Intervention Usual Care Intervention Usual Care Intervention Usual Care Intervention Usual Care Intervention Usual Care Intervention Usual Care Intervention Usual Care Intervention Usual Care Intervention Usual Care  4 3 1 10 4 8 3 2 1 11 4 8 5 8 3 11 4 11 6  2.0 1.3 2.0 3.3 3.8 2.5 1.0 1.0 1.0 1.6 1.8 2.0 1.4 2.3 1.7 5.5 5.8 6.3 5.0  2.0 1.0 2.0 3.0 3.5 2.0 1.0 1.0 1.0 1.0 1.5 2.0 1.0 2.0 1.0 7.0 6.0 7.0 5.5  .0 .6 . 1.7 1.0 1.6 .0 .0 . .8 1.0 1.1 .9 1.5 1.2 2.2 1.5 1.3 2.3  .0 .3 . .5 .5 .6 .0 .0 . .2 .5 .4 .4 .5 .7 .7 .8 .4 .9  2.0 1.0 2.0 1.0 3.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 2.0 4.0 3.0 2.0  2.0 2.0 2.0 7.0 5.0 6.0 1.0 1.0 1.0 3.0 3.0 4.0 3.0 5.0 3.0 7.0 7.0 7.0 7.0  Rice or pasta (times/week)  Meat products (times/week) Chicken (times/week) Fish (times/week) Shrimp (times/week) Eggs (times/week) Nuts (times/week) Legumes (times/week) Milk Dairy products  Highlights indicate poor nutrition  158  Table 4.25 Average Consumption of Fresh Fruits, Vegetables, and Dates Reported by Participants, Pre-Program (Baseline) by Group Variable  Category  Valid Standard Standard N Mean Median Deviation Error Minimum Maximum  Fresh fruit (days/week) Intervention  10  4.1  3.0  2.2  .7  1.0  7.0  Usual Care  5  3.6  3.0  2.1  .9  2.0  7.0  Fresh fruit or juice (servings/day)  Intervention  11  2.2  2.0  1.0  .3  1.0  4.0  Usual Care  5  2.2  2.0  .8  .4  1.0  3.0  Fresh vegetables (times/week)  Intervention  10  4.6  5.0  2.6  .8  1.0  7.0  Usual Care  5  4.4  4.0  2.5  1.1  2.0  7.0  Fresh vegetables (servings/day)  Intervention  10  3.0  3.0  1.3  .4  1.0  5.0  Usual Care  5  3.8  4.0  .8  .4  3.0  5.0  Dates (times/week)  Intervention  8  5.1  7.0  2.6  .9  1.0  7.0  Usual Care  3  3.3  2.0  3.2  1.9  1.0  7.0  Highlights indicate poor nutrition  Table 4.26 Average Consumption of Soft Drinks Participants Reported, Pre-Program (Baseline) by Group Valid Standard Standard N Mean Median Deviation Error Minimum Maximum  Variable  Category  Regular soft drinks (times/week)  Intervention  3  1.3  1.0  .6  .3  1.0  2.0  Usual Care  2  1.0  1.0  .0  .0  1.0  1.0  Regular soft drinks (cans/week)  Intervention  2  1.5  1.5  .7  .5  1.0  2.0  Usual Care  2  1.8  1.8  1.8  1.3  .5  3.0  Diet soft drinks (times/week)  Intervention  0  .  .  .  .  .  .  Usual Care  1  1.0  1.0  .  .  1.0  1.0  Diet soft drinks (cans/week)  Intervention  0  .  .  .  .  .  .  Usual Care  1  3.0  3.0  .  .  3.0  3.0  159  Table 4.27 Types of Soft Drinks, Bread, and Oil Participants Reported Consuming, Pre-Program (Baseline) by Group Intervention  Usual Care  Variable  Category  N  Percent  N  Percent  Drink soft drinks  Yes  3  27.3%  3  50.0%  No  8  72.7%  3  50.0%  Total  11  100.0%  6  100.0%  Regular  3  100.0%  2  66.7%  Diet  0  .0%  1  33.3%  Both  0  .0%  0  .0%  Total  3  100.0%  3  100.0%  Yes  6  54.5%  5  83.3%  No  5  45.5%  1  16.7%  Yes  9  81.8%  4  66.7%  No  2  18.2%  2  33.3%  Yes  10  90.9%  5  83.3%  No  1  9.1%  1  16.7%  Yes  4  36.4%  3  50.0%  No  7  63.6%  3  50.0%  Not at all  1  9.1%  0  .0%  Rarely  0  .0%  1  16.7%  Sometimes  7  63.6%  2  33.3%  Often  1  9.1%  0  .0%  Very often  2  18.2%  3  50.0%  Total  11  100.0%  6  100.0%  Types of soft drinks  White bread Brown bread Vegetable oil Butter or margarine Olive oil  160  Table 4.28 Participants Reporting of Being on a Diet and Consumption of Sugar Substitutes, Pre-Program (Baseline) by Group Intervention  Usual Care  Variable  Category  N  Percent  N  Percent  Type of diet  I don't follow any diet  10  90.9%  4  66.7%  Drugs  0  .0%  0  .0%  Herbs  0  .0%  0  .0%  Diet food  1  9.1%  2  33.3%  Follow more than one diet  0  .0%  0  .0%  Total  11  100.0%  6  100.0%  Yes  0  .0%  1  50.0%  No  1  100.0%  1  50.0%  Total  1  100.0%  2  100.0%  Not at all  7  63.6%  3  50.0%  Rarely  0  .0%  0  .0%  Sometimes  2  18.2%  2  33.3%  Often  0  .0%  0  .0%  Very often  2  18.2%  1  16.7%  Total  11  100.0%  6  100.0%  Diet Prescribed by a specialist Sugar substitutes  Table 4.29 Self-Reported Behaviours of Smoking, Stress and Sleep, Pre-Program (Baseline) by Group Intervention  Usual Care  Variable  Category  N  Percent  N  Percent  Do you smoke  Cigarettes  0  .0%  0  .0%  Shisha  0  .0%  0  .0%  Nargille  0  .0%  0  .0%  Gadw  0  .0%  0  .0%  I don't smoke  11  100.0%  6  100.0%  High  4  36.4%  4  66.7%  Moderate  7  63.6%  2  33.3%  Low  0  .0%  0  .0%  Soundly  6  54.5%  2  33.3%  I don't sleep well  5  45.5%  4  66.7%  Cigarettes  0  .0%  0  .0%  Shisha  0  .0%  0  .0%  Nargille  0  .0%  0  .0%  Gadw  0  .0%  0  .0%  I don't smoke  2  100.0%  0  .0%  Rate the stress in your life  How do you sleep? Do you smoke  161  Table 4.30 Average Hours of Sleep Participants Reported, Pre-Program (Baseline) by Group Standard Standard Valid N Mean Median Deviation Error  Variable  Group  Average number of hours of sleep  Intervention  11  6.5  6.0  2.3  Usual Care  6  5.3  5.0  1.9  Minimum  Maximum  95% CI  .7  4.0  12.0  4.94, 7.97  .8  3.0  8.0  3.38, 7.29  Table 4.31 Exit Interview for Program Satisfaction, Post-Program with the Intervention Group Variable  N/Percent  Your satisfaction with your knowledge of diabetes in the past N 6 weeks. Percent Satisfaction with how the program staff treated you  Extremely satisfied  Very satisfied  Satisfied  3  4  1  0  0  8  37.5%  50.0%  12.5%  .0%  .0%  100.0%  N Percent  Overall satisfaction with the education program  2  5  1  0  0  8  62.5%  12.5%  .0%  .0%  100.0%  7  1  0  0  0  8  87.5%  12.5%  .0%  .0%  .0%  100.0%  N Percent  Helpfulness of the information to care for your diabetes  5  2  1  0  0  8  62.5%  25.0%  12.5%  .0%  .0%  100.0%  2  2  3  1  0  8  25.0%  25.0%  37.5%  12.5%  .0%  100.0%  N Percent  Total  25.0%  Satisfaction with the frequency program staff talked with you N Percent  Extremely Dissatisfied dissatisfied  Table 4.32 Exit Interview for Recommending Program, Post-Program with the Intervention Group Variable  N/Percent  Would recommend the program to someone with diabetes  N Percent  Yes  No  Total  8  0  8  100.0%  .0%  100.0%  162  Figure 4.1 BMI Categories, Pre-Program (Baseline) and Post-Program by Group  BMI Categories Percent by Pre/Post-Program and Group  50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0%  Pre  Post  Intervention  Pre  Post  Pre Post  Pre Post  Pre Post  Usual Care  Intervention  Usual Care  Intervention  25.0 to 29.9  30.0 to 34.9  Pre  Post  Usual Care  35.0 to 39.9  Pre Post Intervention  Pre Post 0% Usual Care  ≥ 40.0  BMI Category  163  Figure 4.2 SF12, Physical Functioning to Vitality, Pre-Program (Baseline) and Post-Program by Group  Physical Functioning to Vitality 100 80 60 40 20 0  Pre Post Intervention  Pre Post Usual Care  Physical Functioning  Pre Post Intervention  Post  Pre Post  Pre Post  Pre Post  Pre Post  Pre Post  Pre Post  Usual Care  Pre  Intervention  Usual Care  Intervention  Usual Care  Intervention  Usual Care  Role Physical  Bodily Pain SF12 Sub-Domains  General Health  Vitality  164  Figure 4.3 SF12, Social Functioning to Mental Component, Pre-Program (Baseline) and Post-Program by Group  Social Functioning to Mental Component 100 80 60 40  20 0  Pre Post  Pre Post  Pre Post  Intervention  Usual Care  Intervention  Social Functioning  Pre  Post  Usual Care  Role Emotional  Pre Post  Pre Post  Pre Post  Pre Post  Pre Post  Pre Post  Intervention  Usual Care  Intervention  Usual Care  Intervention  Usual Care  Mental Health SF12 Sub-Domains  Physical Component  Mental Component  165  Figure 4.4 Diabetes Knowledge Test, Pre-Program (Baseline) and Post-Program by Group  Diabetes Knowledge Test by Group 16  Intervention Usual Care  14 12 10 Score  8 6 4 2 0 Pre-Program  Post-Program  Pre/Post-Program Difference  Figure 4.5 Life Satisfaction, Pre-Program (Baseline) and Post-Program by Group  Life Satisfaction by Group 3.0  Intervention  2.5  Usual Care  2.0 1.5 Score 1.0 0.5 0.0 -0.5 -1.0  Pre-Program  Post-Program  Pre/Post-Program Difference  166  Figure 4.6 Waist to Hip Ratio, Pre-Program (Baseline), Post-Program, and Pre/Post Difference by Group  Waist to Hip Ratio by Group 1.20  Intervention  1.00  Usual Care  0.80 0.60 Ratio  0.40 0.20 0.00 -0.20 Pre-Program  Post-Program  Pre/Post-Program Difference  Figure 4.7 Six Minute Walking Test Distance, Pre-Program (Baseline), Post-Program, and Pre/Post Difference by Group  Six Minute Walking Test Distance by Group 140 Intervention  120  Usual Care  100 80 Metres  60 40 20 0 -20 Pre-Program  Post-Program  Pre/Post-Program Difference  167  BIBLIOGRAPHY Abahussain, N.A., & El-Zubier, A.G. 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Lancet, 366(9497), 1640-9.  187  APPENDICES Appendix 1: Lifestyle-related Health Beliefs and Behaviours Survey Questionnaire SECTION 1 Personal Data Subject Name Phone Number Sex Age (yrs)  Skip  Height (cm) Weight (kg) Marital Status Number of children  Level of education  No formal education  Primary  Intermediate  Secondary  Diploma University D  Graduate D Occupation  Homemaker  Employed  Student  Retired Other………………………………….. Source of income  Personal  Husband or guardian Income  < SR 3, 000  SR 3, 000 to SR 5, 000  SR 5, 001 to SR 10, 000  >SR 10, 000  188  SECTION 2 Health Status  I am My heart rate is generally My blood pressure is My blood sugar is   underweight  normal weight  over weight.  I don’t know  low  normal  high  I don’t know  low  normal  high  I don’t know  low  normal  high  I don’t know  How would you rate your health?  Excellent  Above average  Average   Below average   Poor  Do you have any of the following conditions? Disease name  Yes  No  Heart disease Lung disease High blood pressure Stroke Obesity Diabetes Cancer Rheumatoid arthritis Osteoarthritis Osteoporosis Anemia Multiple sclerosis Parkinson’s syndrome Irritable bowel syndrome Ulcers Premenopausal Menstrual irregularities Menopausal Other  189  SECTION 3 Lifestyle behaviours A. Physical Activity and Exercise: Personal Behaviours 1. Do you do any physical activity for more than 10 minutes each time? 2. Do you do hard physical activities, such as running or carrying heavy objects for 10 minutes at least? 3. If yes, how many days in a typical week do you do hard physical activities? 4. On a typical day, how much time you spend for this hard work? 5. Do you do moderate activities, such as brisk walking or riding a bike or carrying of objects of light weight for 10 minutes at least? 6. If the answer is yes, how many days per week do you do moderate activities 7. How many hours or minutes do you usually take to complete moderate physical activity in a typical day of the week?   Yes  No  Yes No ......days ......hours/.......minutes  Yes No ......days ......hours/......minutes  190  B. Diet and Nutrition: Personal Behaviours 1. How many times a week usually eat rice or pasta? 2. How many times a week, you eat bread and cereals (corn flakes)? 3. What type of bread you usually eat?  4. What kind of oil or ghee, which you use mostly in food preparation?  5. Do you use olive oil in food preparation?  6. Do you have any type of diet? 7. If the answer is yes, does this diet have been prescribed to you by a specialist? 8. Do you use alternative sugar (sweeteners) for tea, coffee or food?  9. Do you drink soft drinks? 10. If the answer is yes, what types do you drink?  10. How much do you drink soft drinks in a week? 11. How many days a week (except for parties) you eat fresh fruit? 12. How many servings of fresh fruit or fresh juice do you usually consume every day? 14. How many days a week you usually eat fresh vegetables? 15. How many servings of fresh vegetables you normally eat every day?  ......Times a week ......Times a week  White  Brown  Other……………………..  Vegetable oil Butter or margarine  Other......  No specific oil  Don’t use any type  Not at all  Rarely  Sometimes  Often  Very often  Don’t follow any diet  Drugs  Herbs  Diet food  Follow more than one diet  Yes  No  Not at all  Rarely  Sometimes  Often  Very often  Yes  No  Normal  Diet  Both  Normal........can/week  Diet.............can/week ...........Times a week. .........servings (medium piece of fruit, 10 pieces of grapes or cherries or half cup of fruit salad or juice) ........Times a week. .........servings ( a cup of fresh vegetables or half cup of cooked vegetables of juice)  191  How many times a week –do you usually , (except for certain occasions) eat the following? Dates Beef or sheep Meat products (burger, hot dogs, shawrama) Chicken Fish Shrimps Eggs Nuts (pistachio - cashew - peanuts) Legumes (kidney beans - peas - beans) How many times a week you usually drink milk? What kind of milk you usually drink?  How many times a week you usually eat dairy products? Which of these kinds you eat?  ..........Times a week ..........Times a week ..........Times a week ..........Times a week ..........Times a week ..........Times a week ..........Times a week ..........Times a week ..........Times a week ..........Times a week  Full fat  Low fat  Other.....  All ..........Times a week  Full fat  Low fat  Other.....  All  C. Smoking: Personal Behaviours Do you smoke?  Cigarette  Shisha  Nargille  Gadw  I don’t smoke  D. Stress and Sleep: Personal Behaviours How would you rate the stress in your life?  High  Moderate  Low What are the main causes of stress in your life? ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… …………………………………………………………………………………… I sleep:  Soundly  I don’t sleep well. I sleep ……………….. hours a night on average.  192  SECTION 4 Beliefs Related to Healthy Lifestyle for the Overall Health Do you believe that physical activity/exercise makes a difference to a person’s health overall? Do you believe that what a person eats makes a difference to his or her health in general? Do you believe that smoking has a bad effect on a smoker’s health? Do you believe that stress has a negative effect on a person’s health?   Strongly disagree  Disagree  Not sure  Agree Strongly agree  Strongly disagree  Disagree  Not sure  Agree Strongly agree  Strongly disagree  Disagree  Not sure  Agree Strongly agree  Strongly disagree  Disagree  Not sure  Agree Strongly agree  SECTION 5 Beliefs Related to the Prevention and Management of Diabetes Please check the correct answer: Disease Diabetes and it’s concomitants  Exercise  Important  not  Diet/Nutrition  Important  not  Quitting Smoking  Important  not  Stress  Important  not  193  SECTION 6 Understanding of Health-related Religious Teachings A. As you best recall, what do the Qur’an and Hadith say, if any, about the following areas of health: -Physical activity and exercise ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… -Food and nutrition ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… -Stress and sleep ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… B. Are there any other important things you are aware of that the Qur’an or Hadith say about health and living a healthy life that you have not mentioned? ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… We thank you very much for your time in answering this questionnaire on health and sharing your opinions with us. The information is very valuable, and will help health professionals and government provide better health services. Any other comments? ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………  194  Appendix 2: Proportions of Recruited Participants from Primary Health Centers in Dammam Number  Primary Health Clinic  Number of Visitors  Number of Participants  1  Jalawaya  4346  26  2  Adama  1728  12  3  Iskan  2666  17  4  Azizia  2450  16  5  Itisalat  1753  12  6  Al-Badia  5610  34  7  Ibn Rashid  1936  13  8  Al-Qadesia  2013  13  9  Al-Khaleej  2855  15  10  Al-Mubarakia  3397  22  11  Badar  7906  49  12  Ghurnata  2541  18  13  Al-Nakheel  1583  12  14  Uhud  6375  38  15  Al-Badea  2355  15  16  Al-Jame’ian  4361  27  17  Al-Anood  3167  20  18  Al-Iskan Al-Muaisar  424  3  19  Al-Shifa  5060  31  20  Ibn Khaldun  746  6  21  Al-Mazroua’  1113  8  22  Total  64385  407  195  Appendix 3: Study Two Design  Time  Intervention Group  Usual Care Group  Baseline Assessment and Evaluation  Session 1 Blood glucose check-up  Session 1 Blood glucose check-up  Body composition measures  Body composition measures  Six minute walk test  Six minute walk test  Session 2 Survey questionnaires (diabetes knowledge, life satisfaction, health-related quality of life, lifestyle-related health beliefs and behaviours)  Session 2 Survey questionnaires (diabetes knowledge, life satisfaction, health-related quality of life, lifestyle-related health beliefs and behaviours)  1-6 weeks  Education program Sessions > 2x1 week  Follow up with their physicians if they are diabetic  1-2 weeks  Session 1 Blood glucose check-up  Session 1 Blood glucose check-up  Body composition measures  Body composition measures  Six minute walk test  Six minute walk test  Session 2 Survey questionnaires (diabetes knowledge, life satisfaction, health-related quality of life)  Session 2 Survey questionnaires (diabetes knowledge, life satisfaction, health-related quality of life)  196  Appendix 4: Diabetes Knowledge Test Excerpted from (Michigan Diabetes Research and Training Center)  1.  9.  d.  The diabetes diet is: the way most Saudi people eat a healthy diet for most people too high in carbohydrate for most people too high in protein for most people  a, b. c. d.  Which of the following is highest in carbohydrate? Baked chicken Swiss cheese Baked potato Peanut butter  10. Infection is likely to cause: a. an increase in blood glucose b. a decrease in blood glucose c. no change in blood glucose  a. b. c. d.  Which of the following is highest in fat? Low fat milk Orange juice Corn Honey  a. b. c.  2.  3.  4. a b. c. d.  5.  Which of the following is a “free food”? Any unsweetened food Any dietetic food Any food that says “sugar free” on the label Any food that has less than 20 calories per serving  a. b. c. d.  Glycosylated hemoglobin (hemoglobin A1) is a test that is a measure of your average blood glucose level for the past: day week 6-10 weeks 6 months  a. b. c.  Which is the best method for testing blood glucose? Urine testing Blood testing Both are equally good  a. b. c.  What effect does unsweetened fruit juice have on blood glucose? Lowers it Raises it Has no effect  a. b. c. d.  Which should not be used to treat low blood glucose? 3 hard candies 1/2 cup orange juice 1 cup diet soft drink 1 cup skim milk  6.  7.  8.  a. b. c.  For a person in good control, what effect does exercise have on blood glucose? Lowers it Raises it Has no effect  11. The best way to take care of your feet is to: a. look at and wash them each day b. massage them with alcohol each day c. soak them for one hour each day d. buy shoes a size larger than usual 12. Eating foods lower in fat decreases your risk for: a. nerve disease b. kidney disease c. heart disease d. eye disease 13. Numbness and tingling may be symptoms of: a. kidney disease b. nerve disease c. eye disease d. liver disease 14. Which of the following is usually not associated with diabetes: a. vision problems b. kidney problems c. nerve problems d. lung problems 15. Signs of ketoacidosis include: a. shakiness b. sweating c. vomiting d. low blood glucose 16. If you are sick with the flu, which of the following changes should you make? a. Take less insulin b. Drink less liquids c. Eat more proteins d. Test for glucose and ketones more often  17. If you have taken intermediate-acting insulin (NPH or Lente), you are most likely to have an insulin reaction in: a. 1-3 hours b. 6-12 hours c. 12-15 hours d. more than 15 hours 18. You realize just before lunch time that you forgot to take your insulin before breakfast. What should you do now? a. Skip lunch to lower your blood glucose b. Take the insulin that you usually take at breakfast c. Take twice as much insulin as you usually take at breakfast d. Check your blood glucose level to decide how much insulin to take 19. If you are beginning to have an insulin reaction, you should: a. exercise b. lie down and rest c. drink some juice d. take regular insulin 20. Low blood glucose may be caused by: a. too much insulin b. too little insulin c. too much food d. too little exercise 21. If you take your morning insulin but skip breakfast your blood glucose level will usually: a. increase b. decrease c. remain the same 22. High blood glucose may be caused by: a. not enough insulin b. skipping meals c. delaying your snack d. large ketones in your urine 23. Which one of the following will most likely cause an insulin reaction: a. heavy exercise b. infection c. overeating d. not taking your insulin  197  Appendix 5: Diabetes Knowledge Test, Test of Reliabilities Excerpted from Michigan Diabetes Research and Training Center. (2013). Retrieved from http://www.med.umich.edu/mdrtc/profs/survey.html  Community Component1 General Test (1 - 14) Item 1 Item 2 Item 3 Item 4 Item 5 Item 6 Item 7 Item 8 Item 9 Item 10 Item 11 Item 12 Item 13 Item 14 Insulin Use (15 - 23) Item 15 Item 16 Item 17 Item 18 Item 19 Item 20 Item 21 Item 22 Item 23  Percent Correct .87 .42 .36 .61 .29 .79 .59 .54 .90 .78 .88 .88 .81 .93 .16 .86 .47 .55 .90 .74 .60 .79 .43  Item-Total Corr  (n=312) .19 .38 .16 .29 .27 .25 .36 .42 .28 .28 .40 .30 .41 .38 (n=111) .35 .36 .36 .51 .21 .52 .49 .48 .45  Michigan Public Health  Alpha  Percent Correct  .70  Item-Total Corr  (n=499) .82 .46 .29 .53 .28 .72 .51 .52 .81 .80 .88 .84 .75 .90  .74  Alpha  Percent Correct  .71 .23 .32 .26 .38 .18 .28 .35 .38 .30 .29 .33 .40 .43 .37  (n=195) .20 .74 .34 .59 .79 .70 .67 .65 .35  Total  (n=811) .84 .45 .32 .56 .29 .74 .54 .53 .85 .79 .88 .85 .77 .91  .76 .34 .41 .44 .24 .36 .53 .53 .55 .50  Item-Total Corr .22 .34 .23 .35 .22 .27 .36 .39 .30 .28 .35 .37 .43 .37  (n=306) .19 .78 .39 .58 .83 .71 .64 .70 .38  Alpha .71  .75 .33 .40 .42 .33 .32 .53 .51 .53 .49  1 Missing items are scored as incorrect.  198  Appendix 6: Data Sheet for Pre and Post Exercise Measures Participant Code:  Baseline  Six Weeks  3 Months  Date  RESTING MEASURES  Heart Rate  Blood Pressure  Glucose  Rating of Perceived Exertion (0-10)  199  Baseline  Six Weeks  3 Months  Date  POST SIX MINUTE WALK TEST  Heart Rate  Blood Pressure  Glucose  Rating of Perceived Exertion (0-10)  6 Minute Walk Distance  200  Appendix 7: Life Satisfaction Questionnaire (LISAT 9) *Question on sex life is removed Here are a number of statements concerning how satisfied you are with different aspects of your life. For each of these statements please mark a box indicating how you feel. Very satisfying 1.  My life as a whole is:  2.  My vocational situation is:  3.  My financial situation is:  4.  My leisure situation is:  5.  My contact with friends and acquaintances is: My ability to manage my self-care is: (dressing, hygiene, transfers, etc.) My family life is: have no family My partner relationship is: have no steady partner/relationship  6.  7. 8.  9.  Satisfying  Rather satisfying  Rather dissatisfying  Dissatisfying  Very dissatisfying  My physical health is:  10. My psychological health is:  201  Appendix 8: Health-related Quality of Life Questionnaire (b) SF-12v2 ® Health Survey Scoring Questionnaire This survey asks for your views about your health. This information will help you keep track of how you feel and how well you are able to do your usual activities. Answer every question by selecting the answer you indicated. If you are unsure about how to answer a question, please give the best answer you can. General Health In general, would you say your health is 1.  Excellent  2.  Very good  3.  Good  4.  Fair  5.  Poor  Physical Functioning Are you now limited in moderate activities, such as moving a table, pushing a vacuum cleaner, bowling or playing golf? Does your health now? 1.  Limit you a lot  2.  Limit you a little  3.  Not limit you at all  How about climbing several flights of stairs? Would you say your health now? 1.  Limit you a lot  2.  Limit you a little  3.  Not limit you at all  202  Role Functioning (Physical) During the past 4 weeks, how much of the time have you had any of the following problems with your work or regular daily activities as a result of your physical health? How much of the time have you accomplished less than you would like? 1.  All of the time  2.  Most of the time  3.  Some of the time  4.  A little of the time  5.  None of the time  How much of the time were you limited in the kind of work or other activities you could do? 1.  All of the time  2.  Most of the time  3.  Some of the time  4.  A little of the time  5.  None of the time  Bodily Pain During the past four weeks, how much did pain interfere with your normal work including both outside the home and housework, would you say...? 1.  Extremely  2.  Quite a bit  3.  Moderately  4.  A little bit  5.  Not at all  203  Vitality How much of the time during the past four weeks did you have a lot of energy? Would you say...? 1. All of the time 2.  Most of the time  3.  Some of the time  4.  A little of the time  5.  None of the time  Role Functioning (Emotional) During the past four weeks, how much of the time have you had any of the following problems with your work or other daily activities as a result of any emotional problems, such as feeling depressed or anxious? How much of the time have you accomplished less than you would like? 1.  All of the time  2.  Most of the time  3.  Some of the time  4.  A little of the time  5.  None of the time  How much of the time did you have trouble doing work or other activities as carefully as usual? 1.  All of the time  2.  Most of the time  3.  Some of the time  4.  A little of the time  5.  None of the time  204  Mental Health How much of the time during the past four weeks have you felt calm and peaceful? Would you say...? 1.  All of the time  2.  Most of the time  3.  Some of the time  4.  A little of the time  5.  None of the time  How much of the time during the past four weeks have you felt downhearted and blue? 1.  All of the time  2.  Most of the time  3.  Some of the time  4.  A little of the time  5.  None of the time  Social Functioning During the last four weeks, how much of the time has your physical health or emotional problems interfered with your social activities, like visiting with friends, relatives, etc.? 1.  All of the time  2.  Most of the time  3.  Some of the time  4.  A little of the time  5.  None of the time  205  Appendix 9: Body Composition Data Sheet Participant: Code: Date:  Baseline  6 weeks  3 months  Date  Date  Date  Waist girth (cm) Hip girth (cm)  Waist:hip ratio  Weight (kg)  Height (cm)  Body mass index  206  Appendix 10: Program Satisfaction Questionnaire Adapted from the work of (Clark, Snyder, Meek, Stutz, & Parkin, 2001) to measure patients’ satisfaction with a managed care environment to improve diabetes outcomes Knowledge and information 1. In the past 6 weeks, how satisfied have you been with your knowledge of your diabetes? (satisfied, very satisfied, extremely satisfied, dissatisfied, extremely dissatisfied)  2.  How helpful is the information that you received from the education program about taking care of your diabetes or preventing it? (excellent, very good, good, a lot)  Program staff 1. How satisfied are you with the way the educator treated you? (satisfied, very satisfied, extremely satisfied, dissatisfied, extremely dissatisfied)  2.  How satisfied are you with the number of times that the educator talked with you? (satisfied, very satisfied, extremely satisfied, dissatisfied, extremely dissatisfied)  Program recommendation 1. Overall, how satisfied are you with the education program? (satisfied, very satisfied, extremely satisfied, dissatisfied, extremely dissatisfied) 2. “Will recommend the education program to someone else?” (yes, no)  207  Appendix 11: Number of Participants and Dropouts Time Period Recruitment Before the start of the education program During the education program Completed the study  Intervention Group Usual Care Group Drop-out Remaining Drop-out Remaining 16 19 3 13 13 6 5 -  8 8  0 -  6 6  208  Appendix 12: Chart of Normal and Abnormal Blood Sugar Levels Excerpted from MD India Network for Health. (2013). Retrieved from http://www.medindia.net/patients/calculators/bloodsugar_chart.asp#ixzz2Ht8lasd0 Category of a person  Fasting  Normal  70  100  Post Prandial Value 2 hours after consuming glucose Less than 140  Early Diabetes  101  126  140 to 200  Established Diabetes  More than 126  -  More than 200  Minimum  Maximum  mg / dl  mg / dl  209  Appendix 13: Certificate for Participants in the Usual Care Group  210  Appendix 14: Certificate for Participants in the Intervention Group  211  

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