Religious and cultural distance in beliefs about ... - Health Advance

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International Journal of Nursing Studies 40 (2003) 627–643

Religious and cultural distance in beliefs about health and illness in women with diabetes mellitus of different origin living in Sweden Katarina Hjelma,b,*, Karin Bardb, Per Nybergc, Jan Apelqvistd a Department of Community Medicine, University of Lund, Sweden Department of Health Science and Social Work, University of Vaxj . o, . Sweden c Department of Neuroscience, University of Lund, Sweden d Department of Endocrinology, Malmo. University Hospital, University of Lund, Sweden b

Received 3 October 2002; received in revised form 20 November 2002; accepted 6 December 2002

Abstract The study explored beliefs about health and illness in females with diabetes mellitus (DM) from different religious backgrounds living in Sweden. Swedes showed an active self-care behaviour and a healthy and controlled life-style. ExYugoslavian Muslims emphasised enjoyment of life and a passive self-care attitude, lesser inclination to self-monitoring of blood glucose and preventive foot care. Arabs emphasised adaptation to DM and a lot of ‘musts’ concerning diet, and had a lower threshold for seeking care. They also emphasised being a believing Muslim, and although explaining the cause of DM as ‘the will of Allah or God’, in contrast to ex-Yugoslavians, they actively searched for information about management of DM. Cultural and religious distance are essential for understanding self-care practice and careseeking behaviour, and need to be considered in the planning of diabetes care. r 2003 Elsevier Science Ltd. All rights reserved. Keywords: Beliefs about health/illness; Care-seeking behaviour; Diabetes mellitus; Migrants; Self-care

1. Introduction Sweden, like many other European societies, has changed due to extensive global migration and has become a multicultural society. Individual beliefs are culturally determined and may affect health, self-care practices, type of health care sought and degree of concordance (Helman, 2000; Glasgow et al., 1997). A previous study showed differences in beliefs about health and illness between females born in ex-Yugoslavia and Sweden, leading to passive vs. active self-care behaviour (Hjelm et al., 1999). Cultural distance, i.e. differences *Corresponding author. Department of Health Science and . 35195 V.axjo, . Sweden. Social Work, University of V.axjo, Tel.: +46-470-70-83-05; fax: +46-470-363-10. E-mail address: [email protected] (K. Hjelm).

between cultures in language, social structure (e.g. family), religion, standard of living and cultural values (Triandis, 2000), may influence an individual’s obligation to behave in a healthy way and thus health (Hjelm et al., 1997). No studies have been found concerning beliefs about health and illness in Arabic-speaking migrants with diabetes mellitus (DM). Nor are there any investigations discussing the influence of cultural distance on health in persons with DM among different migrant groups. Culture is described as a set of guidelines (both implicit and explicit) which individuals inherit as members of a particular society, and which tells them how to view the world, how to experience it emotionally, and how to behave in it in relation to other people, to supernatural forces or gods, and to the natural environment (Helman, 2000). Culture must always be seen in its particular

0020-7489/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0020-7489(03)00020-8

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K. Hjelm et al. / International Journal of Nursing Studies 40 (2003) 627–643

context, which is made up of historical, religious, economic, social, political and geographical elements that mutually influence culture and are also influenced by culture. Migrants from the Middle East constitute the biggest group of non-European migrants in Sweden. Many are refugees and have fled from war and persecution in their home countries. People born in the former Yugoslavia constitute the second largest migrant group in Sweden. They have mainly immigrated as labour migrants or as refugees fleeing from war (Lund and Ohlsson, 1994). In a multicultural society the contact frequency with migrants with DM will increase, as well as the need for knowledge of beliefs about health and illness, which have been studied to a very limited extent (Hawthorne et al., 1993; McCord and Brandenburg, 1995; Bury, 1997). The previously implemented investigation comparing females born in ex-Yugoslavia and Sweden (Hjelm et al., 1999) is the only study with the focus on both health and illness beliefs in persons with DM and with a comparative approach. Previous investigations concerning DM in persons of different ethnic origin have focused on living with the disease and its consequences (William-Olsson, 1986; Hawthorne et al., 1993; Quatromoni et al., 1994; Maillet et al., 1996; Chin et al., 2000) or causes or explanations of DM (Lang, 1989; Dechamp-Le-Roux et al., 1990; Luyas, 1991; Rios-Itturino, 1992; Cosby and Houlden, 1996; Gittelsohn and Harris, 1996; Hunt et al., 1998; Alcozer, 2000; Thompson and Gifford, 2000) and not on factors which are good for health (the salutogenetic perspective). All studies concern non-European populations living in non-Scandinavian countries, and only one has a comparative approach (Dechamp-Le-Roux et al., 1990). European cultural distance/differences in beliefs about health and illness have previously been studied by comparing females born in Sweden and ex-Yugoslavia (Hjelm et al., 1999). In this study, the influence of European and non-European cultural distance will be investigated by comparing Swedes with Arabic and Yugoslavian migrants. Thus, comparisons will be made between a non-westernised and two westernised cultures and three different religious groups. Both migrant groups originate from societies where Islam is the dominating religion, and thus Islam functions as a societal order, although to varying degrees (Hj.arpe, 1992; Svanberg and Westerlund, 1999). 1.1. Aim of the study The aim of the present study was to explore the influence of cultural distance on health and illness beliefs and self-care practices in women with DM from different cultural backgrounds living in Sweden.

2. Theoretical framework Beliefs are defined as things that are accepted as true, especially as a tenet or a body of tenets, in contrast to knowledge which is considered as true (Purnell and Paulanka, 1998). Beliefs are built on knowledge held by a person. An attitude towards a particular behaviour represents a summation of beliefs about that behaviour and determines the behaviour. Beliefs are culturally determined, learned by socialisation and transmitted through language (Berger and Luckmann, 1991). Explanations of disease guide strategies for self-care measures, treatment of disease and health care seeking. According to the lay theory model of illness causation (Helman, 2000), illness can be perceived as caused by factors related either to the individual (lifestyle, behaviour, personality, bacterial invasion, inheritance, physical constitution, organ function), nature (chemical or natural substances, e.g. drugs, climate, the influence of sun, moon and planets, environmental factors such as poisons, smoke, pollution, exhaust fumes), social relations (relations between people, interpersonal conflicts, people considered to possess evil forces, e.g. the evil eye), or the supernatural sphere (influence of fate, spirits, God/gods). In the model for health-care-seeking behaviour (Kleinman, 1980) health care may be sought in the popular, folk or professional sector. The popular sector comprises non-professionals in the family, among friends or relatives. The folk sector has certain individuals, often termed folk-healers, who specialise in different forms of healing, sacred or secular. In western countries alternative or complementary medicine belongs to this area. The professional sector is the organised, legally sanctioned healing professions, such as modern western scientific medicine or biomedicine. Health-related behaviour is explained by the health belief model (HBM; Rosenstock et al., 1988) and perceived locus of control (Rotter, 1966). The key components are: threat in terms of perceived susceptibility to an ill-health condition (or acceptance of a diagnosis) and perceived seriousness of the condition; outcome expectations expressed as perceived benefits of specified action and perceived barriers to taking that action; and efficacy expectations, i.e. the conviction of one’s ability to carry out the recommended action (selfefficacy). Sociodemographic factors such as age, sex, education, race/ethnicity and income are believed to influence behaviour indirectly by affecting these components. The stronger self-efficacy is perceived to be, the more active and persistent are the persons. Outcomes interpreted as successful raise self-efficacy. Positive mood enhances perceived self-efficacy; mastery experiences have the greatest impact (Bandura, 1995). Cultural differences may promote different selfefficacy appraisals. Children brought up in a society

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based on ‘dependent collectivism’ with a high degree of power distance and hierarchical relationships learn to obey authorities. This implies a less independent behaviour with lowered self-efficacy. Individuals brought up in societies based on ‘independent individualism’ are treated as equals and children are encouraged to be independent and find their own direction and pace of learning, increasing the perception of self-efficacy (Oettingen, 1995). Societies in the Middle East, for example Iran, and Yugoslavian society, have previously been described as based on ‘dependent collectivism’ in contrast to ‘independent individualism’ in Sweden (Hofstede, 1984). Islamic countries have also been described as being bureaucratic with a large power distance and a strong uncertainty avoidance, which means a high need for rules or regulations in contrast to low power distance and weak uncertainty avoidance in non-bureaucratic Scandinavian countries, such as Sweden. The power distance and the need for rules (uncertainty avoidance) are described as higher in the Middle East, exemplified by Iran, than in ex-Yugoslavia. The degree of acculturation is dependent on language, culture and time as well as circumstances when immigrating to a new country (Berry, 1990). As there are great cultural and linguistic differences between Arabs, Yugoslavians and Swedes, it is reasonable to assume dissimilarities in the degree of acculturation between the migrant groups. In the context of stressful life transitions, such as migration, general beliefs of efficacy may serve as a personal resource or vulnerability factor. A high sense of perceived self-efficacy is a buffer against distressing experiences (Jerusalem and Mittag, 1995). The general model of locus of control (Rotter, 1966) is described as experienced personal control over the environment. The model distinguishes between events related to one’s own qualities or behaviour (internal locus of control) or circumstances outside one’s own control as a result of luck, chance and fate (external locus of control). Those who feel they have control over their health are more likely to carry out health-related behaviours and show concordance.

3. Methods 3.1. Study design Data were collected through focus group interviews. This technique has been considered appropriate in the verbalisation of different cultural beliefs and values, and emphasises the participants’ perspective. The group process facilitates the members’ ability to express and clarify their beliefs, and may also encourage participants to disclose behaviour and attitudes that might not consciously be revealed in one-on-one

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situations (Krueger, 1994; Kitzinger, 1995). The technique is especially useful in understanding the target group’s perspective and assisting health care providers to develop health care strategies that are sensitive, and that reflect the participants priorities (Basch, 1987). 3.2. Sampling procedure and study population A purposive sampling procedure was used. Apart from cultural background, education and sex have been shown to influence beliefs about health and illness (Rosenstock et al., 1988). The group of informants was chosen so as to minimise the influence of these factors. Criteria for inclusion were thus: diagnosis of DM, duration of disease >1 year, being a female, and low educational level (o9 years of education). The number of respondents was determined by the principle of saturation in data analysis (Krueger, 1994). This means that the researcher decide the number of focus groups needed as the focus groups are carried out. When no new themes are found in the data analysis then there is no need to carry out more focus groups. The staff at an in-hospital diabetes clinic were asked to recruit Arabic respondents to participate in the study according to set inclusion criteria. Swedes and Yugoslavians were recruited from four health care centres and one association for Yugoslavian migrants. For further information see the previous study (Hjelm et al., 1999). The study population comprised 41 females with DM, 13 born in Arabic countries (from Iraq 7, Palestine 3, Lebanon 2, and Egypt 1), 13 born in ex-Yugoslavia and 15 born in Sweden (Table 1). All the Arabic females were refugees while the exYugoslavian group comprised mainly refugees but also labour migrants. The Arabic group had been residents in Sweden for a longer time than the ex-Yugoslavians (10 (0.2–19) vs. 5 (2–30) yr Md). Eight persons in each foreign-born group had received their diagnoses of DM in Sweden. As regards clinical characteristics, Arabic females had a shorter duration of DM and were more often treated with insulin than Yugoslavians and Swedes who were similar in characteristics. However, the majority were treated with oral antidiabetic drugs. There were no major differences in sociodemographic data and complications related to DM between the studied groups. None of the Arabic females were working and the majority were dependent on social assistance, as were the Yugoslavian females. Five of the Arabs and two of the Yugoslavians were illiterate. Females were chosen, as a previous study had indicated foreign-born women in low social position to be a susceptible group to poorer objective health (Hjelm et al., 1996).



Table 1 Characteristics of the studied populations Variable

Arabic-speaking diabetic females N ¼ 13

Ex-Yugoslavian diabetic females N ¼ 13

Swedish diabetic females N ¼ 15

Agea (yr) Time of residence in Sweden (yr)a Reason for immigration to Sweden Refugee Refugee with family ties (husband in Sweden) Labour migrant

52 (22–63) 10 (0.2–19)

55 (33–73) 5 (2–30)

57 (36–64)

9 4 0

9 0 4

Duration of DM (yr)a Diagnosis of DM in Swedena (n)

5 (1–16) 8 (5>5 yr)

7 (1–25) 8

Treatment of DM (n) Diet Oral agents Insulin Combination with insulin

0 9 4 0

3 6 2 2

1 9 5

Complications related to DM (n) Eye Kidney Heart Lower extremity

6 2 2 9

6 3 5 5

4 3 4 9

Educational level Illiterate o9 yr Upper secondary school (9–12 yr) University o2 yr University >2 yr

5 5 0 0 3

2 9 2 0 0

0 12 2

Students (n) Work (part/full-time) Social allowances (n) Unemployment (n) Early retirement pensioners (n) Old-age pensioners (n)

2 0 7 1 3 0

2 2 7 5 0 0

2 2 0 1 10 0

Family circumstances (n) Unmarried Cohabiting Married Widow Divorced

2 0 8 2 1

1 0 6 6 0

1 3 6 4 1

a

8 (1.5–20)

1

Values are medians (range).

3.3. Ethics The study was approved by the Ethics Committee of the University of Lund, and was carried out with written informed consent from the respondents, and in accordance with the Helsinki Declaration. In the case of respondents being illiterate the information was read

and explained by the interpreter and then signed by the participant. 3.4. Interview guide A thematised interview guide with open-ended questions including scenarios of common problems related to


DM was used, and is described in a previous study (Hjelm et al., 1999). 3.5. Procedure Before the group sessions an individual standardised interview lasting about 15 min was carried out with each participant. In the interview sociodemographic and medical back ground data was collected without threatening confidentiality and rapport was created. The focus group interviews were led by a female diabetes-educated nurse (first author) not involved in either the diabetes clinic or the management of the patients. When needed, an authorised female Arabic or Serbo-Croatian speaking interpreter was used and the sequential interpretation technique (word for word) was applied. The interviews were held in secluded rooms outside the clinic. It was assessed that the focus groups should not comprise more than four persons to minimise interpretation needs, and the same size was also considered appropriate for the Swedes in order to allow the same group dynamics. One person in each group participated only in the first session, one Yugoslavian female dropped out due to illness and the others since they were unable to participate in the subsequent sessions. Each focus group was planned to be homogenised with respect to nationality. In order to maximise the exploration of differences within the group setting, people of different ages, time of residence in Sweden, duration of disease and treatment were brought together (Kitzinger, 1995). Each focus group comprised 3–4 persons, repeated interviews were held and each group met 2–5 times in free-flowing discussions for about 1.5–2 h, which were audio-taped and transcribed verbatim (E970 pages in total). The first session was used as a pilot-test (Krueger, 1994) and some minor changes were made concerning the wording and sequencing of questions. 3.6. Analysis of data Collection and analysis of data proceeded simultaneously, until it was judged that no new information was obtained (theoretical saturation; Krueger, 1994). The analyses was performed in accordance with the method described for focus group interviews (Krueger, 1994). Thus, we strove to be open to as much variation in the material as possible, and searched for regularities, contradictions, patterns, and themes by comparing the respondents’ statements. Analyses focused on differences between groups. Directly after the group sessions the tapes were listened through and notes were taken about general findings and ideas about emerging themes. Topics were identified by reviewing each line of the texts and clustering in the form of categories. The lay theory model of illness causation and the model for health care

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seeking behaviour, as previously described (Hjelm et al., 1998, 1999), were used as main analytical categories in the investigation of factors of importance for health, causes of disease, and health-restorative activities when ill. Analyses were made independently by two researchers, showing high agreement. In this investigation results from the Yugoslavian and the Swedish group are given as descriptive summaries while quotations will be found in a previous report (Hjelm et al., 1999) from which we used results for making comparisons with the studied groups.

4. Findings 4.1. Beliefs about illness Arabic females, as well as Yugoslavians and Swedes, had mainly sought help from the physician (professional sector) on receiving the diagnosis of DM. Arabs did not suspect their symptoms (tiredness, thirst, polyuria, polydipsia, etc.), to be related to the presence of DM. Many Swedish females suspected and related their symptoms to DM and thus searched the physician. Among Yugoslavian females a delay in diagnosis and a more severe condition was described since they had more often sought help for other reasons than DM, mainly various infections, and also had more often been admitted to hospital because of, for example, diabetes coma and infections such as pneumonia. All respondents believed their DM was caused by factors related to the individual (Table 2). Non-Swedish females mostly discussed sorrow and emotional stress due to migratory experiences and thoughts about relatives left behind, expressed as: ‘when my husband became illyhe was operated on three timesyI was worried for himyThe horror of warythat Saddam bombarded usyPalestinians always have been in sorrow yMy daughter phoned and said ‘‘I don’t feel well yI am ill’’, and what will happen to me as a mother? Here it is fine and if it had not been for them not being well in Iraq then everything would have been fine.’ They also talked about ‘heredity’. Arabs also mentioned ‘fatty foodyabundance of food’ and ‘anaemia’. Swedes talked about hereditary factors, obesity, and infections. Also treatment with cortisone (factors related to nature) and a combination of using diuretics, having pancreatitis and obesity (factors related to the individual and nature) were mentioned. Non-Swedish females gave few examples of different factors and explanations when a list of potential causes of DM was presented. Swedes gave a variety of alternatives and focused on genetic factors, inappropriate diet, inactivity, obesity, infections, drugs, etc. Factors in the social sphere, such as disturbed relations to other people and to dead family members, and



Table 2 Causes of DM Main analytical categorya

Factors related to the individual

Diabetic females Arabic-speaking

Ex-Yugoslavian

Swedish

Sorrow and psychic/mental pressure due to migratory experiences and thoughts about relatives left behind

Feelings of anxiety, worries, fear, agony and dread related to difficult experiences in the home country and adaptation to life in Sweden

Genetic factors—Inheritance

Overweight—obesity Mental problems Genetic factors—Inheritance

Infections Genetic factors—Inheritance

Abundance of food Anemia Factors related to nature

Drugs (Cortisone)

Factors related to the individual and nature

A combination of pancreatitis and diuretic drugs and overweight Fateb

Supernatural factors

‘When I stopped wearing black clothes I got diabetes at once’— Her mother had died 2 yr ago

‘It came by itself’

Fateb Evil spiritsb Punishment by God or godsb

Evil spiritsb

Disturbed relations to othersb

Disturbed relations to othersb

Fateb Evil eyeb The will of Allah or Godb Factors related to the social sphere

Disturbed relations to othersb Disturbed relations to dead family members or relativesb

a b

Analytical categories according to the lay model of illness causation by Helman (2000). Explanations of causes of DM evolved in discussions of a list of potential causes of DM.

supernatural causes, mainly expressed as fate and the will of Allah or God, were mentioned among nonSwedes. Mental discomfort was spontaneously expressed as an important explanation of DM by Arabs. Most non-Swedish females confirmed lack of knowledge when discussing consequences of DM and effects of insulin. Arabs discussed unspecific symptoms (polyuria, polydipsia, tiredness and subjectively perceived ill health) or complications related to DM, while Yugoslavians talked about symptoms such as pain or weakness. Knowledge about the function of insulin was limited in both groups. Swedes in general gave more differentiated explanations, such as lack of insulin and insulin effect of distribution of sugar in the body, and complications related to DM. The effect of treatment was expressed as decreased blood sugar, and profound explanations were given about sugar transports in the cells.

Both Yugoslavians and the majority of Swedes considered DM to be chronic, although Swedes also saw it as potentially curable due to new research and losing weight, while few Arabs considered the seriousness of the disease and did not know how long it would last. One person said that ‘only God knows’. Although the majority of Arabs and Swedes did not discuss the danger of DM they expressed and related their fear of the disease to specific complications, such as impaired vision. Arabs also added stroke, thrombosis and hypertension and Swedes added kidney dysfunction. Yugoslavians in general expressed fears of survival, intercurrent diseases irrespective of DM, and the future. As consequences of the disease most Arabic respondents emphasised mental discomfort in terms of sorrow and dark thoughts. A few discussed the dietary recommendations and expensive food as consequences,


while another talked about the need for a higher awareness of her well-being and the need to take care of herself more seriously nowadays. The majority of Yugoslavians talked about physical discomfort and a sense of being an outsider. Many Swedes also talked about being outsiders and focused on restrictions such as time schedules and regularity. 4.2. Health-restorative activities and care-seeking pattern Arabs in general had a lower threshold for seeking support from nurses and physicians (professional sector) than the majority of Yugoslavians and Swedes who practised self-care to a higher extent. Self-care measures were categorised as related to the individual and/or nature but with different strategies (Table 3). As a response to the feeling of tiredness, feebleness, being ‘out of sorts’ in combination with loss of appetite, most Arabs did nothing or changed diet by ‘lowering the intake of food, bread, or fruit’, self-monitoring of blood glucose (SMBG) and exercise. Their explanations of discomfort were ‘I don’t know’ or ‘I don’t bother’ but also ‘raised blood glucose’ and ‘too much medicine’. Many Yugoslavians changed their level of physical activity and stated levels of blood glucose as explanations of the condition. Most Swedes identified hyperglycaemia as the cause, performed SMBG and acted with dietary changes. The majority of Arabs would seek advice from the professional sector (nurses or physicians) and said: ‘I have asked the nursey’ or ‘I have sought help from the doctory’. Yugoslavians and Swedes had sought help to a restricted extent from the professional sector of health care. In general Arabic females claimed they had not received any information from health care staff about poor glycaemic control (increased HbA1C). In the case of information they related it to ‘wrong diet’ or ‘wrong time for meal intake’ or ‘didn’t know’ and made dietary changes such as to ‘eat less foodyno sugaryless fatyand more frequent small meals’. Many Yugoslavian females related poor glycaemic control to wrong diet or fate and showed a fatalistic and passive attitude towards the control and claimed they could not influence it even with dietary adjustment. Most Swedes related the problem to improper diet and stress and performed increased SMBG, changed diet with intake of more fibres and less food, and stated that they had to ‘pull themselves together’. Rather similar discussions were heard in all respondents concerning symptoms indicating hypoglycaemia, with statements such as: ‘I eat bready, something sweety, I drink juice, milky’. Arabs also said: ‘I eat lessy’, and ‘I make a cup of teaysometimes of rose leaves’ and ‘I took Alvedon (Paracetamol)’. They explained that ‘It is caused by the sugaryit is high or low, no lowyI don’t know’ and, like the other

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respondents, had problems in differentiating between high and low blood glucose. Further explanations added were lack of food throughout the day, illness, menopause or hormonal changes by many Yugoslavians and lack of salt by one Swede. None of the Arabs had sought help, one female explained that ‘it takes too longyyou just have to drink some juiceyand it will disappearyyou learn to handle it by yourself’ and another said that she does not get any help as ‘they just tell you that you should take the pills’. In a few cases Yugoslavians and Swedes had been into contact with a nurse or physician (professional sector). Contacts with the popular sector (family, friends or relatives) and the folk sector (folkhealers) were also sparse. Few Arabs and Swedes had experienced repeated episodes of hypoglycaemia, in contrast to the majority of Yugoslavians. Non-Swedish females expressed substantial lack of knowledge as they ‘didn’t know’ the cause. Arabs had needed to contact a physician or nurse to handle the situation by ‘change of medication’, while Yugoslavians had cured it with intake of food. One Yugoslavian female used a drink of vitamins and sugar bought from the folk sector in her native country. Swedes identified the causes as too much insulin and decreased blood glucose and cured the condition with intake of milk, bread or juice. Symptoms indicating nocturnal hypoglycaemia had been experienced by few of the Arabs and Swedes in contrast to a majority of Yugoslavians. Symptomatic actions such as taking off the bedclothes were found among non-Swedish females. Swedes handled the situation by eating and SMBG. One Swede also had injections of Glucagon administered by her husband (the popular sector) and one Yugoslavian female used natural remedies in the form of drops from Bosnia. Gastroenteritis (GI) had less often been experienced among non-Swedish females than Swedes. All respondents increased their intake of fluids but the kind of fluid differed among the groups as well as the explanations of the condition (A: influenza or cold under progress; Y: non-infectious problems from the gastrointestinal tract (diarrhoea, cholecystectomy, constipation); S: invasion of bacteria). Many Yugoslavians also talked about eating gruel or pur!ees of carrots and the majority of Swedes discussed turning back to ordinary diet after eating bananas, blueberry soup or potato flour mixed with mineral water. Examples of preventive measures were taking whisky in the case of GI in the children and use of aloe vera in Swedes, and intake of paracetamol and acetylsalicylic acid in Arabs. Some Yugoslavians and Swedes had sought advice from the nurse or physician and one Arabic female had contacted the hospital for help (professional sector). All respondents claimed that they drank a lot of hot or cold drinks, took antipyretics and rested to cure

Self-monitoring Dietary change: m dietary fibres, k food

Intake of Alvedons

Wrong diet and at wrong time Do not know

m blood glucose Do not know Do not bother Too much medication/ side-effects

Problems

A

Intake of food; milk, bread, juice, etc.

Reduction of medication

Do not know

Nocturnal hypoglycaemia: Waking late in the night or very early in the morning with a strange feeling in the head and being in a cold sweat Injections of k blood glucose Intake of food; Take off clothes Eat Nature cure banana, water drops bought in Glucagon Change of Self-monitoring A cold Change of Bosnia bedclothes bedclothes

Repeated episodes of hypoglycaemia Intake of food; milk, bread, juice, etc. Drink of vitamins and sugar from the folk sector in native country

Repeated attacks in the late afternoon with headache, impaired concentration in combination with trembling, cold sweats and hunger m or k blood Intake of food Intake of food Intake of food Intake of Dietary change: Rest glucose antipyretics/ k food No measures Do not know analgesics Tea, e.g. from rose Headache after (Alvedon s) leaves Ramadan Self-monitoring k blood glucose

Being told by the nurse or physician about long-term impaired glycaemic control (m HbA1c) Dietary changes; k ‘Pull myself ‘Pull myself Change of food, no sugar, k together’ together’ medication Dietary changes Dietary changes fat, eating rice m no. of small (as above) (as above) Self-monitoring meals

Rest Activity

S

and trembling Do not know k blood glucose Lack of food

Do not know Eating sugar or fat Change of temperature

m or k blood glucose Lack of food Illness Menopause

Wrong diet Fate

m or k blood glucose

Y

k blood glucose Lack of food

Too much insulin k blood sugar

m or k blood glucose Lack of salt

Wrong diet Stress

m blood glucose

S

Explanations of the problems described/critical incidents

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Nothing Dietary change: k food, no sugar, k bread, fruit, boiled food Intake of food Exercise Self-monitoring

Feeling of tiredness, feebleness, being out of sorts, in combination with loss of appetite

Y

A

S

A

Y

Health restorational activities (nature cure or pharmaceutical measuresb)

Health restorational activities (individual measuresa)

Table 3 Results of discussions concerning health-restorational activities and explanations of described scenarios of common problems related to diabetes mellitus in diabetic females born in Arabic-speaking countries (A), ex-Yugoslavia (Y) and Sweden (S)

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Dietary changes; intake of tea, gruel or pur!ee of carrots

Rest Warm beverages

Rest Warm beverages

Dietary changes; beverages: Coke, water, mineral water, teas, lemonade etc. Intake of banana, potato flour. Preventive measures: whisky, aloe vera

Antipyretics (Aspirins, Alvedons, Panodils) Nature cure medicine: Herbs, roseleaves Prophylaxis: Vaccination

Intake of analgesics/ antipyretics (Alvedon s, Treo s)

Antipyretics Nature cure medicine: teas, garlic, sodium chloride as nasal drops Prophylaxis: vitamins

Antipyretics Nature cure medicine: teas, garlic, sodium chloride as nasal drops were used to a higher extent than in Arabs and Yugoslavians

Signs indicating claudication; spasm in the calf Massage Activity Activity Support—e.g. Massage Massage Wait and see Wait and see walking frame Warm shower Wait and see

Rub feet and leg with nonprescription ointment

Signs of sensory neuropathy; feelings of burning, impaired sensitivity, walking on ‘cushions’, and coldness in the feet Legs in elevated Warmth Acceptance Rub feet and leg position with ointment Stimulating The importance Rest circulation with of appropriate Analgesics/ Warm foot bath activities and footwear antipyretics Stimulating massage (Alvedons) circulation with massage

Rest Warm beverages

Common cold and pharyngitis

Gastroenteritis. Dietary changes; intake of yoghurt, milk or tea without sugar, lemonade, lemon drink, no fat food

Do not know DM m blood glucose

Do not know DM Always oedematic feet Walking too much m blood glucose

The weather; warmth inside and cold outside, it comes in the spring All get a cold

Critical

The flu By fever

Smoking Something natural, ageing

Few had experienced the problem and didn’t explain it at all

Few examples: Climate and viral infection Food poisoning Draught

Non-infectious problems from the gastrointestinal tract; cholecystectomy, constipation, ventricular ulcer, intestinal dysfunction

k circulation Smoking Something

Poor circulation of blood Inactivity Increased blood glucose

Few examples; Viral infection Decreased cleansing m blood glucose

Restricted examples. Bacteria m blood glucose

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b

a

Antiinflammatory drugs s (Alvedon s Treo comp, ) Corticosteroids ‘Pills’

Antiinflammatory drugs Do not know Being worn out m or k blood glucose Inflammation in the muscles

Varicose veins

Do not know Being worn out

Rheumatic disorders Stress Anxiety

Lack of zinc

Explanations of the problems described/critical incidents

According to the lay theory model of illness causation (Helman, 1994) these measures were categorised as belonging to the individual sphere. Nature. Within these main analytical categories the subcategories are stated.

Activity

One took a bit of sugar and ascribed it to lack of zinc

Health restorational activities (nature cure or pharmaceutical measuresb)

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Pain in joints and muscles No measures at all

Legs in elevated position

Put on stockings and shoes

Health restorational activities (individual measuresa)

Table 3(continued)

natural

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themselves when having caught a cold or pharyngitis, but the explanations of the condition differed (A: weather or climate; Y: climate, draught, viral infections, food poisoning; S: virus). Prophylactic measures were vaccination in some Arabs and vitamin C in some Yugoslavians. Natural remedies were used by some persons in all groups but to a lesser extent in Arabs and Yugoslavians compared to Swedes. Yugoslavians and Swedes talked about different teas (Swedes used green tea) and garlic. Arabs had sought help from the health care centre and were not satisfied as they had not been helped, while a minority of Yugoslavians had consulted health care centres (professional sector) and were satisfied as they had received support in change of medication and prescription of antibiotics. Non-Swedish females in general could not explain the cause of signs indicating sensory neuropathy but used strategies believed to improve peripheral circulation. Many Arabs also tried to manage this by elevation of the lower extremity and analgesics. Some Swedes accepted the condition and related it to DM and tended to take protective measures such as adequate footwear. Pain in joints and muscles was experienced by most of non-Swedish females and only some Swedes. Most of the non-Swedish females were unaware of the cause, but some Arabs related it to DM without being able to explain how, and some Yugoslavians related it to longterm workload. Swedes discussed rheumatic disorders, stress and anxiety. Arabs mainly did nothing about it while some used different kinds of non-specified pills and physiotherapy. A nurse had also been consulted in order to obtain an activity programme (professional sector). Yugoslavians predominantly used self-care and non-prescription anti-inflammatory drugs while Swedes used various activities such as physiotherapy (the professional sector). The folk sector had been consulted by one person from each group for treatment of pain. In the discussions of the situations above, a certain pattern appeared. The consensus was that Swedes talked about symptoms of imbalance of blood glucose, Arabs focused on pain in joints, muscles and lower extremities, and Yugoslavians emphasised pain in joints and muscles but also expressed a poorer overall subjective feeling of health, both verbally and non-verbally. Three different kinds of self-care behaviour were described. The majority of Arabs had a lower threshold for health care seeking, actively searched for information about DM, and in activity level they fell in between most of the Yugoslavians, who showed a passive attitude and relied on health care staff, and Swedes in general, who took active part in selfcare and let SMBG guide their actions. The nonSwedish females as a whole were emotionally oriented while most Swedes expressed themselves in medical and technical terms.

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4.3. Self-care advice and the inclination to follow advice Neither Arabic nor Yugoslavian respondents claimed they had received any advice about foot care either in Sweden or in the home country, whereas most Swedes spontaneously said that they were very careful with their feet in order to prevent foot ulcers. Some had received restricted information, e.g. the ‘importance of cleaning and drying the feet and appropriate footwear’. The respondents reported experiencing varying recommendations regarding the frequency of self-monitoring, from twice a week to several times daily. Most of the Arabic and the Swedish respondents tested their blood glucose themselves, but Swedes often tested on a routine basis and changed strategy accordingly. Yugoslavian females preferred to have their blood glucose tested by health care professionals and preferred help from the nurse or district nurse in primary health care. In advice given concerning diet, similarities were found in all groups regarding the importance of intake of fibres and vegetables, as well as reduction of fat. In the Swedish and Yugoslavian group ‘the model of the plate’ and reduction of sugar intake were frequently mentioned. Only one Arabic woman talked about the model and another about sugar intake in terms of ‘it is better to take real sugar than something elseyif you are going to bake a cake.’ This group had more discussion of advice about brown bread, reduction of the number of pieces of fruit taken at the same time, the importance of several meals per day (usually three main meals and two snacks), and reducing the fat intake by grilling meat. Some said that ‘there is a difference in Arabic and Swedish food. I like food rich in fatyWhen I eat such fatreduced food I feel that I haven’t eaten anything’, and thus the advice was sometimes not followed completely by all Arabs but by most of them. Yugoslavians stated that they followed the advice whereas Swedes said that they followed it in general. Swedes had more often been given dietary lists and prescriptions. Thus, they expressed problems with conflicting advice because of new discoveries and perceived difficulties in knowing what is valid. Most Yugoslavians and Swedes had been given information by a dietician and/or a nurse, in contrast to the Arabs who were informed by nurses and to a limited extent. In the interviews they often posed questions showing they were in need of further information, such as: ‘It is good to eat whole fruitsyis it bananas or apples? Grapefruit is sour, does it also contain sugar? As regards advice about exercise, all groups had been informed about the importance of taking walks, biking and swimming. Most stated they followed the advice about walking but in the Arabic group some said that they were scared of swimming, had pain in their legs or the weather was too bad and thus became a barrier. One person said that ‘I do not take exercise. I do work in my home throughout the whole day, that gives exercise.’



Few respondents participated in self-help groups run by diabetes associations. Arabs and Yugoslavians did not participate, saying that ‘I don’t know anything about that’ or that ‘I don’t want to participate. You feel even worse. They all talk about their diseasesythe worst thing is listening to the one who’s the worst.’ Yugoslavians also said they were too ill or feeble to participate. Many Swedes had left due to similar negative experiences. However, some of the Arabic-speaking persons desired lectures about DM. Both Arabs and Swedes felt their economy to be a limiting factor that might affect health, in contrast to Yugoslavian females. This had consequences for buying appropriate food among Arabs and for foot care among Swedes. Arabic females stated: ‘bread for example is expensiveyvegetables, meatyI can’t buy it, fruit.’ One said that ‘sometimes I don’t have money to pay the doctoryHowever, I go to see him [the doctor] but then I have to pay at the post office and then I have to pay extra’, and another said: ‘sometimes other things are more important than my medication.’ Despite their limited means, a majority of the Arabs emphasised the importance of spending their money on food and medication even though it was expensive. 4.4. Beliefs about health Health was described in all groups within the category of individual factors such as ‘freedom from disease’ and ‘feeling healthy and brisk’. Quality of life was also discussed but to a higher extent among Swedes. The majority of Yugoslavian females talked about ‘a comfortable and untroubled life’. Arabs focused on individual factors as being important for health, while Yugoslavians and Swedes discussed individual and social factors such as relations with others, particularly the family. Most Arabs emphasised mental well-being and adaptation to DM: ‘The mental state is also important. I brood a lotyas soon as I get nervous or brood, it [the blood glucose] gets too high’ and ‘one must adapt to a lot of thingsyone has to exerciseythe most important thing is the diet.’ The importance of exercise was mentioned only by a few persons. A great deal of self-perceived obligations were experienced: ‘I must visit the doctoryI must decrease my blood sugaryone must take walks.’ Yugoslavians in general described enjoyment of life and emphasised freedom and security in life, enjoying food and retaining previous habits (e.g. eating too much fat and sweets) as the important factors for health. Most Swedes strove to be able to control the disease by themselves and consequently applied a healthy lifestyle with healthy food, low in fat and rich in fibres, and lived a regular life. Most Arabs, as well as Yugoslavians, did not consider instrumental tangible support from the family in

treatment of DM as important as the majority of Swedes did. They said: ‘it is we ourselves that must retain our health’ and ‘I am the one helping all others’. Health care personnel was seen as a security that could help and also give advice, while the majority of Swedes saw them as a possible source from which to acquire knowledge (informative social support). For most Arabs continuity and accessibility were the most important concepts in contacts with health care staff: ‘It is important to see the same doctor or nurse every timeyI have been referred yand they call meyand then I have to tell the whole story again and again.’ Factors having a negative influence on health among the majority of Arabs were mental discomfort, disrupted kin groups, thoughts and feelings about the situation in their native country, and stress caused by waiting for a permit from the Swedish authorities to stay in Sweden. Yugoslavians in general emphasised stress due to strained relations, poor economy and unemployment. Most Swedes discussed lifestyle factors, such as inactivity, smoking and unhealthy diet. To prevent complications related to DM, all respondents used measures related to the individual. Arabs in general gave limited examples, some talked about reducing worries, one stated the importance of knowledge for active self-care measures and another mentioned exercise, whereas adaptation of dietary habits was seldom mentioned. The majority within the Yugoslavian group expressed themselves in a more general way, e.g. in terms of appropriate diet, activity and avoiding hyperglycaemia related to anxiety caused by past migratory experiences. Some Swedes gave precise examples of self-care, such as foot care, control of the disease, and drinking water to dilute their blood glucose. Most Arabs did not know about or did not believe in the use of alternative medicine or natural remedies. Many Yugoslavians used natural remedies, such as e.g. teas, cider vinegar, herbs, chromium, walnuts, etc., bought from the folk sector to a higher extent than Swedes. They also said that they perceived a higher confidence in physicians in providing treatment and thus used natural remedies as a complement. Some Swedes used alternative medicine, for example acupuncture, reflexology, etc. against pain in head, neck, and shoulders, and herbs, teas, etc. with a general effect on the body. Religion was considered to be of great importance for all except two of the Arabs and of importance for most of the Yugoslavian and Swedish females by giving feelings of peace, security and strength. Some Yugoslavian females claimed a loss of faith in religion related to war experiences. Traditions such as Ramadan were considered less important for the majority of Arabic females here in Sweden as it was impossible to celebrate due to the


disruption of the extended family or kin group: ‘Here you can’t follow the traditions as you do in your own countryyall have to come together during Ramadan ybut here it is impossible.’ The traditions may even have a negative influence as ‘when the feast comesyand we are aloneyit doesn’t make us happy, on the contrary one becomes sad.’ Many Yugoslavians and Swedes, on the other hand, talked about the importance of celebrating feasts to retain social networks with relatives and friends, but the negative consequences of isolation were also mentioned. Some Arabs also mentioned that their DM was a barrier to celebrating Ramadan as they need to take their medication and food several times a day and during Ramadan ‘one doesn’t eat, drink or smokeyfrom sunrise to sunsetythen you can eat’. Among many Yugoslavians Ramadan and the celebration of the subsequent feast Bajram were considered to cause problems in following dietary advice. Bajram is celebrated in a similar way to Christmas in Sweden, when people eat a lot of food throughout the day which is rich in fat and sugar and made following old recipes.

5. Discussion The findings of the present study indicate differences, although there were also similarities, between Arabic, ex-Yugoslavian and Swedish females with DM regarding beliefs about health and illness. Even if it has not been possible to clarify to what extent the findings are related to the culture of origin or the persons’ belonging to a minority culture, dissimilarities between migrants and Swedes are not just myths or ‘social constructions of reality’. This is, as far as we know, the first study concerning beliefs in Arabic females with DM. The comparative approach is also unique, investigating migrants with differing cultural distance, originating from one European and one non-European Islamic society, and an indigenous population.

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objective is to obtain the maximum amount of information (Tang and Davis, 1995). It is considered important to select homogeneous groups as regards socio-economic class to facilitate discussion (Krueger, 1994). As a consequence of incongruent information in medical records and the actual status of the respondents, three groups (one in each ethnic group) became heterogeneous, but no communication problems arouse. By selecting inclusion criteria such as low education and female sex, possible differences due to sex and education were minimised. As only a ‘native’ makes first-order interpretations of the culture as it is his or her culture (Geertz, 1973), culturally competent interpreters were used and culturespecific phenomena were discussed with the interpreters in direct connection with the interviews to compensate for second-order interpretations of the foreign cultures studied. The possible effects of language problems related to interpretation were reduced by using a restricted number of interpreters who were certified and culturally competent, and by using the sequential interpretation technique. Many of the respondents took the opportunity to gain knowledge from the interview sessions, and all Arabs took the opportunity to interview the investigator or each other. In order not to create an interviewer bias (Krueger, 1994), the questions posed were transferred to the group for discussion, primarily to obtain all the respondents’ opinions first before they answered them, or if more appropriate the opinions were politely noted and it was asked that they should be discussed after the interview sessions; they should thus not have influenced the results. Focus group interviews have advantages of being used for both investigation and health education (Basch, 1987). After the interviews many respondents expressed positive experiences in having gained new knowledge, and all Arabs claimed they would follow the information gained from the sessions concerning, for example, foot care and diet.

5.1. Methods 5.2. Results This study had an explorative aim, and the main goal in focus group research is to understand reality and not to explain it by making crude generalisations (Krueger, 1994). However, carefully conducted and appropriately analysed focus groups give the opportunity to use the results for making generalisations to other respondents who possess similar characteristics. The group sizes (mainly three to four members) could be seen as a limiting factor, but the outcome depends more on the involvement of the participants in each group than on the actual number of participants (Krueger, 1994). When having an exploratory aim one should run groups with smaller size, as the prime

Among all respondents beliefs about health and illness were mainly related to factors in the individual, combined with nature, social relations in the social sphere, and supernatural explanations, although the supernatural influence was higher in the foreign-born groups. To restore health when ill, self-care was practised to a lesser extent by Arabs than Yugoslavians and Swedes. The majority of Arabs had a lower threshold in searching for advice and information from physicians or nurses (the professional sector). The folk sector (folk healers) was consulted to acquire natural remedies but to a lower extent in Arabs than in Swedes



and Yugoslavians. Thus, the respondents showed a similar behaviour to that described in westerners (Kleinman, 1980; Helman, 2000). In the explanatory models westerners were suggested to focus on the individual and nature and consult the professional sector, in contrast to non-westerners who emphasise the social or supernatural spheres and first contact the popular sector (family, friends or relatives) and then the folk sector. The results fell in between these models, which might be explained by the restricted empirical testing of the models and the lack of testing in migrants in the country of immigration. It is worthwhile recognising that all respondents in this study regardless of cultural background defined health from a pathogenetic perspective (Antonovsky, 1987). However, attitudes to DM and beliefs about health differed between Europeans and non-Europeans. The general picture was that Swedes showed a healthy and controlled lifestyle, Yugoslavians expressed enjoyment of life, and Arabs emphasised feelings of mental well-being, adaptation to DM and a lot of ‘musts’, particularly concerning diet. This illustrates three different attitudes to chronic illness as a living condition previously described (Charmaz, 1991). Immersion, as exemplified by living a regular and controlled life based on SMBG results and with the whole existence focused on the illness. Intrusion, as illustrated by the persons striving to minimise the influence of the disease by making deviations from advice received and retaining previous habits. Interruption, as demonstrated by not accepting the disease as chronic but ultimately ending in recovery, and thus initiating a battle against it, for example by living a healthy life and searching for information about how to manage the disease. DM has been shown to be a demanding disease requiring adaptation and mental balance (William-Olsson, 1986; Ternulf-Nyhlin, 1990; Wikblad et al., 1991). In this study dissimilarities in self-care measures and care-seeking behaviour between Europeans and nonEuropeans were also shown, although the majority of non-Swedish females had received their diagnosis of DM in Sweden and thus were supposed to have been given the same information as Swedes and to behave similarly. Most Arabs had a lower threshold for health care seeking, were more reliant on professional care even in the case of insignificant symptoms. In activity level they fell in between the majority of Yugoslavians, who showed a passive self-care attitude, and Swedes in general, who showed an active self-care behaviour, being more technically oriented and knowledgeable. Although many Arabs explained the cause of DM with ‘the will of Allah or God’ they actively searched for information about management of DM, not least by interviewing the investigator and each other. The main explanation for the dissimilarities between the European and nonEuropean migrants might be related to the influence of

religion. Most Arabs emphasised being a believing Muslim. The interpretation of the Koran message may also differ, as there are dissimilarities between Islam in the Balkans and the Middle East (Hj.arpe, 1992; Popovic and Veinstein, 1996; Svanberg and Westerlund, 1999). Muslims in the Middle East are described as being more prone to follow the rules of the Koran. Islam emphasises mental and physical well-being and diet as important factors for promoting health, which is in accordance with the findings of this study and recommendations for persons with DM. The Islamic religion functions as a societal order that influences the culture and civilisation with a particular kind of lifestyle, whether one is a believing Muslim or not (Hj.arpe, 1992; Popovic and Veinstein, 1996; Svanberg and Westerlund, 1999; Samuelsson, 2001). Societies in the Middle East have also been described as bureaucratic and with a high need for rules (high uncertainty avoidance; Hofstede, 1984). Arabs in general also seemed to be more religious than Yugoslavians as they more often discussed the influence of Allah or God as the cause of DM, in contrast to many Yugoslavians who focused on Fate. Arabs also claimed that they could not retain the former tradition of celebrating Ramadan (the fasting month) in Sweden as it could not be celebrated in the appropriate manner and the same way as in the home country, while most Yugoslavians felt it to be of great importance mainly in socialising with others. Yugoslavians might have better social networks than Arabs due to the migratory background. All Arabs said that they were refugees and had left parts of their families in their home country, while the Yugoslavian group claimed to be refugees or labour migrants. Yugoslavian labour migrants immigrated to Sweden on a voluntary basis and sometimes together with their family (Lund and Ohlsson, 1994), and thus the number of disrupted extended families among Arabs was higher and the social networks weaker. Other explanatory factors for the dissimilarities between the European and the non-European migrants are the influence of migratory experiences related to time of residence and the presence of post-traumatic stress disorders (PTSD) affecting the level of self-efficacy. Arabs had a longer time of residence in Sweden than Yugoslavians (10 vs. 5 yr Md), and thus a higher degree of acculturation (Berry, 1990). In the discussions of scenarios of common problems related to DM the nonSwedish females expressed poorer well-being, particularly emphasised (verbally and non-verbally) in Yugoslavians. This might be an indication of the influence of previous or present PTSD, related to the migratory experiences, and acting as a confounding factor (Nyga( rd and Malterud, 1995; Sundquist et al., 1998). The influence of traumatic experiences in the home country is higher at the beginning of residence in the new country and decreases over time as the focus changes to


adaptation to the new life (Sundquist et al., 2000). Previous studies of refugee women from Bosnia have shown them to have poorer well-being in all areas, social, physical and mental, compared to Swedes, probably related to experiences as a refugee and the presence of PTSD (Sundquist et al., 1998). This might influence the level of self-efficacy (Bandura, 1995) as the presence of PTSD may function as a filter against information received (Oettingen, 1995) and thus explain the lower level of knowledge and also the dissimilarities in activity levels between the migrant groups. Cultural differences might promote different selfefficacy appraisals (Oettingen, 1995). Societies in the Middle East, e.g. Iran, and ex-Yugoslavian societies have been described as being patriarchal and grouporiented cultures and societies with high power distance, in contrast to the Swedish society which encourages ‘independent individualism’ and low power distance (Hofstede, 1984). Being brought up under these conditions implies that children learn to obey authorities and show less independent behaviour, with lowered selfefficacy, or are encouraged to be independent and find their own direction, which increases the perception of self-efficacy (Oettingen, 1995). This might be an explanation for the lower self-efficacy demonstrated in Arabic and ex-Yugoslavian females compared to Swedish women in this study. Other factors influencing selfefficacy are the struggle for control over life including chronic disease, in addition to the adaptation to the new society, language difficulties, cultural distance, and further losses related to chronic disease and migration (Hull, 1979; Hofstede, 1984; Strauss et al., 1984; Charmaz, 1991; Jerusalem and Mittag, 1995; Oettingen, 1995). The immigrant woman has to deal not only with the chronic disease but also with her marginality, lack of social support, social isolation and alienation in a foreign culture, which is in agreement with observations in non-diabetic subjects (Andersson, 1991). The lowered self-efficacy inhibits their capacity to receive information (Bandura, 1995), which may result in dissimilarities in perceived susceptibility and severity of disease. The motivation to take active part in self-care may thus decrease, as the person does not understand the benefits of the measures and just experiences barriers to changed behaviour according to the health belief model previously described (Rosenstock et al., 1988). The greater need for rules and regulations in Islamic countries (Hofstede, 1984) and the influence of the Islamic doctrine which urges an active search for knowledge, health-promotive activities, and recommendations that those who are ill should strive to do everything to regain their health (Samuelsson, 2001) might explain the higher self-efficacy and activity level in Arabs compared to Yugoslavians. All the ‘musts’ and dissimilarities in dietary advice described by the majority of Arabs raise the question

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about the extent to which the influence of differences in previous habits (diet, exercise, etc.), as well as the emotional orientation (with the focus on stress and migratory experiences) in Arabic females are considered in diabetes care in Sweden, which is technically oriented and based on discussion of medical facts. Yugoslavians in general did not express any self-perceived obligations which might indicate a greater cultural distance and thus more conflicting advice in Arabs. Lack of communication and differences in cultural beliefs were shown to be the main obstacles in a previous study regarding health care professionals’ experiences (Hjelm et al., 1998). It is noticeable that most Arabs claimed to have been informed by dieticians to a restricted and lesser extent than Swedes. The difference could be due to organisational matters such as lack of or limited access to dieticians in different health care institutions, but also to patients’ unfamiliarity with the structure of diabetes care in a system like the Swedish one. According to the Swedish Health and Medical Services Act (1982) all patients, whatever their origin, should be treated on equal terms. Inequalities need to be noted and avoided and thus diabetes education should not be delivered by the least competent staff to the group with the highest need. The final question is whether Arabic respondents had experienced care as not being congruent with their culture. It has been suggested that although Asians had received similar information to British persons it might have been presented in a way they could not understand or accept (Hawthorne, 1990). Culturally appropriate health education has been shown to improve knowledge and glycaemic control in British Pakistani women with type 2 DM (Hawthorne, 2001). The groups investigated in this study originate from European societies and non-European societies where cultural distances have been revealed in different areas. The single previous comparative study claims that Europeans cite various explanations with regard to causes of DM compared to North Africans who cite either stress or fate (Dechamp-Le-Roux et al., 1990). The Arabic and the ex-Yugoslavian females in this study were surprisingly similar in beliefs to the North Africans, with a more fatalistic view of the disease in terms of factors lying beyond one’s own control (external locus of control; Rotter, 1966).

6. Conclusions and implications The differences between Arabic, Yugoslavian and Swedish females with DM illustrate that beliefs about health and illness are influenced by cultural and religious distance and are essential for self-care practice and careseeking behaviour. The cultural differences are related to religious beliefs. The influence of religion as a social



order is important to consider irrespective of whether a person is a believer or not. The present study emphasises the importance of health care staff recognising the variety of beliefs in the migrant population. It is important to develop a health care organisation that responds to every individual’s need for knowledge. Nursing care should be planned to meet self-care deficits. Orem (2000) has emphasised the need to find individual self-care deficits and the importance of planning nursing care strategies that sometimes fully compensate for, partly compensate for or just support or teach an individual with self-care deficit. The respondents in this study desired to have information about the management of DM in discussion groups led by medically skilled staff, and we recommend the use of it. Thus the participants would benefit from the double advantages of focus group interviews: investigation and health education at the same time (Basch, 1987), as well as its therapeutic use in sharing the burden of disease (Folch-Lyon and Trost, 1981). Cooperative activities with voluntary organisations such as the diabetes association, religious congregations and immigrant associations give opportunities to meet patients’ desires for group discussions and need to be further developed. It is also of great importance to consider cultural differences and needs in diabetes education (Hawthorne, 1990; Hawthorne, 2001). All persons with DM need knowledge about the management of DM, so it is important to organise care that satisfies individual needs and favours patient education, aiming at empowering patients’ participation in self-care.

Acknowledgements This work was supported by grants from the Faculty of Medicine, Lund University, The Swedish Foundation for Health Care Sciences and Allergy Research (V(ardalstiftelsen), The Swedish Diabetes Association, . h.also- och sjukva( rdsforskning) the and HSF (Ra( det for . Council of Health Care Research Lund/Malmo.

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