Predictors of Diabetes Fatalism Among Arabs: A Cross- Sectional Study of Lebanese Adults with Type 2 Diabetes

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1 J Relig Health (2018) 57: ORIGINAL PAPER Predictors of Diabetes Fatalism Among Arabs: A Cross- Sectional Study of Lebanese Adults with Type 2 Diabetes Ola Sukkarieh-Haraty 1 Leonard E. Egede 2,3 Joelle Abi Kharma 4 Maya Bassil 4 Published online: 8 June 2017 Ó Springer Science+Business Media, LLC 2017 Abstract Fatalism is a grounded cultural belief that is common among Arabs and is known to hinder self-care in chronic diseases including diabetes (Nabolsi and Carson in Scand J Caring Sci 25(4): , 2011). The purpose of this study is to identify predictors of diabetes fatalism in this population. Data on 280 Lebanese patients with type 2 diabetes (mean age ± years; mean HbA1c 7.90 ± 1.90%; 53.76% females) recruited from one hospital in greater Beirut, Lebanon, and from the community using snowballing technique were examined. Multiple linear regression was used to assess the independent association between diabetes fatalism and demographic and patient characteristics. Age (b =-.14, 95% CI -.27, -.002), BMI (b =.35, 95% CI.15;.54), level of education (b =-3.98, 95% CI -7.64; -.32) and number of diabetes problems (b =-5.03, 95% CI -9.89; -.18) were significantly associated with diabetes fatalism in the regression model. The combination of demographic and patient characteristics accounted for 14.5% of the variance in diabetes fatalism scores change. Patients with type 2 diabetes who exhibited more fatalistic attitudes were younger, of lower education levels, had higher BMI and had fewer diabetes comorbidities. Such findings are crucial for healthcare practitioners to identify fatalistic patients and to tailor culturally appropriate strategies in diabetes management. Further studies are warranted to explore other potential determinants of diabetes fatalism with larger sample and non-lebanese Arabic population. Keywords Diabetes fatalism Predictors Arabs Lebanon Type 2 diabetes & Maya Bassil mbassil@lau.edu.lb Alice Ramez Chagoury School of Nursing, Lebanese American University, Byblos, Lebanon Center for Health Disparities Research, Medical University of South Carolina, Charleston, SC, USA Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA Department of Natural Sciences, School of Arts and Sciences, Lebanese American University, Chouran, Beirut , Lebanon

2 J Relig Health (2018) 57: Introduction Diabetes, a chronic condition affecting 415 million people worldwide in 2015 (International Diabetes Federation [IDF] 2015), mandates lifelong glucose control for optimal health outcomes. Accordingly, the American Diabetes Association (ADA) highlights the importance of diabetes self-management (DSM) as a crucial element in disease treatment and prevention of diabetes-related complications (ADA 2015). However, DSM necessitates tremendous commitment and determination from the patient and is affected by various factors including cognitive ones that can facilitate or hinder it (Haas et al. 2012). Specifically, research reveals that the beliefs of patients with chronic illnesses such as diabetes can predict their self-management and disease outcomes (Lange and Piette 2006). Among these beliefs, fatalism mostly exhibited in diabetes and cancer has been documented to be a barrier for optimal self-management (Nabolsi and Carson 2011; Unantenne et al. 2013). Fatalism is a belief that a higher power, mainly God, predetermines health outcomes. Hence, the individual loses all means of self-control and becomes totally dependent on the higher power (Unantenne et al. 2013). More importantly, fatalism exhibits as inhibitory and passive attitudes in seeking out medical attention and healthcare utilization (Powe and Finnie 2003; Franklin et al. 2007). Diabetes fatalism, in particular, is defined as a complex psychological cycle characterized by perceptions of despair, hopelessness, and powerlessness (Egede and Ellis 2010). Studies have shown that diabetes fatalism is associated with uncontrolled glycemic levels, poor health outcomes and decreased quality of life (Egede and Bonadonna 2003; Egede and Ellis 2010; Walker et al. 2012). The impact on glycemic control is mediated through poor diet compliance and lack of proper foot care and blood sugar testing (Osborn and Egede 2010). Moreover, there exists a direct significant relationship between diabetes fatalism and poor medication adherence, yet no significant association with exercise (Osborn and Egede 2010; Walker et al. 2012). Osborn et al. (2010) found that less fatalism as well as more diabetes knowledge and more social support was an independent direct predictor of diabetes self-care that in return was related to glycemic control. Previous findings (Walker et al. 2012) revealed that diabetes fatalism is a personality trait and that it becomes stable over time. Hence, it is an important psychosocial construct to incorporate when tailoring interventions as patients with this personality trait or life outlook may benefit from targeted interventions (Walker et al. 2012). Fatalism in diabetes has been studied in ethnic groups such as African-Americans (Egede and Bonadonna 2003; Egede and Ellis 2010), South Asians in UK (Patel et al. 2015), Latinos/Hispanic (Lange and Piette 2006) and Iranians (Abdoli et al. 2011), all of which exhibited increased fatalistic beliefs and practices, thereby jeopardizing their diabetes self-care and glycemic control. Lebanon is a developing country where diabetes prevalence accounts for 12.2% of the population (IDF 2015); it is a diverse community of multiple religions that belongs to the Arab region. The Arabs, whether Muslims or Christians, share many common cultural and religious values and beliefs such as fatalism (Nabolsi and Carson 2011). However, little attention has been paid to how people with chronic illnesses in general and diabetes in specific resort to fatalism and its implications on disease management. Only three qualitative studies have reported fatalistic beliefs among Arab patients with chronic diseases when asked about their perception of the disease. In specific, patients viewed the disease as something coming from God, over which they do not have control and power (Nabolsi and Carson 2011; Omu et al. 2014; Doumit et al. 2010).

3 860 J Relig Health (2018) 57: While this belief has helped them accept and cope with their disease, it is not clear how it impacts disease self-management (Omu et al. 2014; Doumit et al. 2010). In Lebanon, one study observed that patients with diabetes are more likely to endorse fatalistic attitudes to justify mal-adherence to diabetes self-management (Sukkarieh- Haraty and Howard 2015). In order to achieve optimal health outcomes, this grounded cultural belief mandates an in-depth understanding of its determinants while taking into consideration ethnic, cultural and religious differences, as outlined in the ADA standards of care (2015). Determinants of diabetes fatalism were only explored previously in the Western culture, whereby diabetes fatalism was inversely associated with education levels and income and positively related to recent symptoms and number of comorbidities in an ethnically diverse sample of American adults with diabetes (Lange and Piette 2006). Given its ubiquitous presence in the Arab world and its established impact on DSM as reported in Western countries, exploring diabetes fatalism and its determinants in the region is needed. Accordingly, healthcare professionals can assess these factors to identify fatalistic patients and tailor culturally appropriate strategies in diabetes management. Without this contextual insight of culturally rooted beliefs, understanding the patient as a whole remains obsolete. Therefore, the aim of this paper is to explore the predictors of diabetes fatalism in Lebanese Arabs with type 2 diabetes. Methods Sample We recruited 280 patients using convenience sampling from one hospital in greater Beirut, Lebanon, and from the community using snowballing technique. Eligible patients were 18 years or older with a minimum of one-year diagnosis of type 2 diabetes mellitus (T2DM), with the absence of psychiatric conditions and with the ability to read and write Arabic. Patients who were non-lebanese, illiterate or with mental illness were excluded from the study. We sought the approval of the institutional review board of our institution and hospital prior to the study initiation. Procedure Eligible participants were approached and provided with a description of the study. Those interested were asked to fill out questionnaires after providing their written consent. Data were collected on self-reported age, weight and height, as well as gender, marital status, level of education, employment status, perceived income and health insurance coverage. Additional information included duration of diabetes, family history, previous education about diabetes and problems associated with diabetes. To obtain recent glycemic control, for inpatients, we abstracted the latest HbA1c levels from medical records, and for community patients, we asked the patients for their latest laboratory tests results of HbA1c.

4 J Relig Health (2018) 57: Instruments and Study Variables We administered the following questionnaires in Arabic. Demographic Characteristics Age was treated as a continuous variable. Gender was dichotomized into males and females. Marital status was categorized into four groups: (1) single, (2) married, (3) divorced, (4) widowed. The level of education was categorized into: (1) less than 11 years, (2) high school, (3) above high school. Employment status was categorized into: (1) employed, (2) unemployed, (3) unable to work due to health condition. Perceived income was categorized into: (1) have more than enough to make ends meet, (2) have enough to make ends meet, (3) do not have enough to make ends meet. Health insurance coverage was dichotomized into yes and no. Patient Characteristics The patient-specific variables included weight and height that were treated as continuous variables. Body mass index (BMI) was calculated using the following formula weight: weight in kg/height in m 2, and treated as a continuous variable. The duration of diabetes was categorized into: (1) less than 5 years, (2) 5 10 years, (3) at least 11 years. The family history was dichotomized into yes and no. The previous education about diabetes was dichotomized into yes and no. The problems associated with diabetes included: hypoglycemia, hyperglycemia, heart problems, sexual difficulties, damage to the retina of the eye, nerve damage and kidney problems. The total number of comorbidities was counted and entered for patients who specified C1. The variable was then categorized into: (0) no problems experienced, (1) one problem experienced, (2) two problems experienced, (3) three or more problems experienced. Diabetes Fatalism Diabetes fatalism was assessed using the Arabic version of the 12-item Diabetes Fatalism Scale (DFS-Ar). It is conceptualized in three subscales: (1) emotional distress (despair); (2) religious and spiritual coping (hopelessness); and (3) perceived self-efficacy (powerlessness). Items are scored on a 6-point Likert scale, whereby higher scores represent more fatalistic attitudes toward diabetes. The original version of the scale (Egede and Ellis 2010) is a well-established tool with internal consistency of a Cronbach s alpha =.804 and has been shown to be independently associated with increased HbA1c. We have translated the 12-item DFS to Arabic by expert panel using back translation with a convenience sample of Lebanese adults (N = 260). DFS-Ar demonstrated sound psychometric properties (Cronbach s alpha of.86) and significantly predicted HbA1c (b =.21, p \.01) (Sukkarieh-Haraty, Egede, Abi Kharma, and Bassil, under review). Statistical Analyses Descriptive analysis was used to summarize the study variables and to check for out-ofrange values. Categorical variables were described as frequencies and percentages, while means and standard deviations were used to represent continuous variables. Using simple

5 862 J Relig Health (2018) 57: linear regression models, diabetes fatalism was regressed on the demographic and patient characteristics. A multiple linear regression model was run thereafter to assess the independent association between diabetes fatalism and demographic and patient characteristics. Variables were selected for inclusion in the model based on a p values\.2 and on clinical relevance. Diabetes fatalism was the primary dependent variable and BMI, age, duration of diabetes, previous education about diabetes and problems associated with diabetes were the independent variables, while gender, level of education, perceived income and employment were included in the model as covariates. All analyses were completed using STATA version 11, and a two-tailed alpha of.05 was used to assess for significance. Results A total of 280 patients with type 2 diabetes mellitus were enrolled in the study. Demographic characteristics of the sample are presented in Table 1. The mean age was (SD 3.48). The majority were females (53.76%), married (74.29%) and had minimal education with 39.75% completing less than 11 years of education. Almost half of the participants (51.29%) were unemployed; 54.85% reported that they had enough to make ends meet, but 59.35% did not have health insurance. The sample was almost equally distributed among the diabetes duration categories, whereby one-third of the participants had diabetes for either less than 5 years, 5 10 years or more than 10 years. Mean hemoglobin A1c was 7.90 (SD 1.90), and mean BMI for females was (SD 10.19) and that for males was (SD 5.62). Bivariate regression analysis of diabetes fatalism and demographic characteristics indicated that younger individuals (for age: b =-.12, p =.02), those who perceived their income as not enough to make ends meet (b = 5.80, p =.005) (compared to those that had enough or more than enough to make ends ) and those who were not insured (b = 3.92, p =.006) had higher diabetes fatalism scores. Conversely, higher levels of education (b =-4.07, p =.02) were associated with lower diabetes fatalism scores (Table 2). Bivariate analysis of diabetes fatalism and patient characteristics indicated that individuals who were not previously educated about diabetes had higher diabetes fatalism scores than those who were educated (b = 4.80, p =.003). Individuals who experienced diabetes problems had lower diabetes fatalism scores compared to those who never experienced any problem (for one diabetes problem: b =-7.73, p =.002). No other demographic or patient characteristic was significantly associated with diabetes fatalism. Results from the multiple linear regression model, as listed in Table 3, indicate that age, BMI, level of education and number of diabetes problems remained significant after correcting for covariates (gender, previous education about diabetes, perceived income and employment). Therefore, age, BMI, level of education and number of diabetes problems were found to be independent predictors of diabetes fatalism, and the model explained 14.5% of diabetes fatalism.

6 J Relig Health (2018) 57: Table 1 Demographic and patient characteristics of study participants Data are presented as mean ± SD for continuous variables and N (%) for categorical variables M (SD) Age (years) (13.48) BMI (kg/m 2 ) (8.40) DFS (11.59) N (%) Gender Female 150 (53.76%) Social status Single 18 (6.43%) Married 208 (74.29%) Divorced 15 (5.36%) Widowed 39 (13.93%) Level of education \11 years 110 (39.57%) High school 76 (27.34%) Above high school 92 (33.09%) Occupation Employed 119 (43.91%) Unemployed 139 (51.29%) Unable to work due to health condition 13 (4.80%) Insurance Yes 165 (59.35%) Income Have more than enough to make ends meet 55 (20.52%) Have enough to make ends meet 147 (54.85%) Do not have enough to make ends meet 66 (24.63%) Diabetes duration \5 years 90 (32.37%) 5 10 years 97 (34.89%) At least 11 years 91 (32.73%) Family history Yes 205 (73.74%) Previous education about diabetes Yes 211 (75.90%) Smoking Yes 136 (49.82%) Number of comorbid conditions 0 30 (10.75%) 1 94 (33.69%) 2 69 (24.73%) 3? 86 (30.82%)

7 864 J Relig Health (2018) 57: Table 2 Unadjusted linear regression model of associations of demographic and patient characteristics with diabetes fatalism (DFS score) a Reference group male b Reference group single c Reference group \11 years d Reference group employed e Reference group have more than enough to make ends meet f Reference group yes g Reference group \5 years h Reference group yes i j Reference group yes Reference group 0 k Reference group yes * p \.05 Variables Coefficient p value Age (years) * BMI * Gender a Social status b Married Divorced Widowed Level of education c High school * Above high school Occupation d Unemployed Unable to work due to health condition Income e Have enough to make ends meet Do not have enough to make ends meet Insurance f * Diabetes duration g 5 10 years At least 11 years Family history h Previous education about diabetes i * Number of comorbid conditions j * * 3? * Smoking k Discussion This is the first study that explores the determinants of diabetes fatalism in the Arab word. After correcting for covariates, age, level of education and number of diabetes comorbidities were independently and negatively associated with diabetes fatalism, while higher body mass index (BMI) predicted diabetes fatalism. Fatalism is generally defined as a belief that life events and/or outcomes are related to external factors that are beyond the person s control. These factors are usually linked to a higher power ( God ), since fatalism is mostly present in religious communities (Berardi et al. 2016; Franklin et al. 2007). Likewise, in the present study, participants are Lebanese adults with type 2 diabetes, and Lebanese, like Arabs, are either Christians or Muslims who have strong rooted religious beliefs (Nabolsi and Carson 2011). Also, the Diabetes Fatalism Scale (DFS) used in the present study does include a religious and spiritual subscale (Egede and Ellis 2010). We used the Arabic version of the DFS (DFS-Ar) that showed sound psychometric properties (Sukkarieh-Haraty et al. under review), similar to the original version of the scale. In addition, DFS-Ar was independently associated with

8 J Relig Health (2018) 57: Table 3 Adjusted multiple linear regression model of demographic and patient characteristics with diabetes fatalism (DFS score) as the outcome Coefficient CI p value Age (years) ; * BMI.35.15;.54 \.001* Gender a ; Social status b Married ; Divorced ; Widowed ; Level of education c High school ; * Above high school ; Occupation d Unemployed ; Unable to work due to health condition ; Income e Have enough to make ends meet ; Do not have enough to make ends meet ; Insurance f ; Diabetes duration g 5 10 years ; At least 11 years ; Family history h ; Previous education about diabetes i ; Number of comorbid conditions j ; * ; ? ; Smoking k ; a Reference group male b Reference group single c Reference group \11 years d Reference group employed e Reference group have more than enough to make ends meet f Reference group yes g Reference group \5 years h Reference group yes i j Reference group yes Reference group 0 k Reference group yes * p \.05

9 866 J Relig Health (2018) 57: poor glycemic control (HbA1c) (Sukkarieh-Haraty et al. under review), in line with the literature and mediated through poor diabetes self-care (Egede and Bonadonna 2003; Egede and Ellis 2010; Walker et al. 2012). Level of education was an independent predictor of diabetes fatalism in our sample, consistent with the literature (Lange and Piette 2006). Education was assessed categorically in the present study; in specific, participants who had high school education or above were less fatalistic. In line with this finding, lack of education was recognized by Arab physicians as top barrier hindering diabetes self-care in the Middle East (Assaad-Khalil et al. 2013). Furthermore, BMI was positively associated with diabetes fatalism. Excess weight or body fat is known to be an independent predictor of poor glycemic control in type 2 diabetes, due to its deleterious effect on metabolic outcomes like insulin resistance and blood lipids (Narayan et al. 2007). Fatalistic attitudes could be an additional risk factor that contributes to poor compliance and outcomes among patients with type 2 diabetes and higher BMI; hence, it should be targeted by health practitioners as part of the treatment. To our surprise, number of diabetes problems was inversely and independently related to diabetes fatalism in our sample. This contradicts previous reports that showed higher fatalism with greater number of diabetes comorbidities in a multiethnic American population (Lange and Piette 2006). One possible explanation for this discrepancy is that in the study by Lange and Piette (2006), diabetes fatalism was assessed differently using a scale with 2 items only. In addition, the participants in the latter study scored low on diabetes fatalism, whereas our sample exhibited relatively increased fatalistic attitudes. Another interpretation of this finding is that fatalism in other cultures is commonly described as a contextual construct, expressed mostly during hardship and illnesses (Keeley et al. 2009). Although this was not assessed in our sample, fatalism in the Arab population is a constant, more grounded cultural trait and not only triggered by adverse events (Nabolsi and Carson 2011). In other terms, one could argue that Arabs with diabetes resort early on to fatalism in the hope of preventing the occurrence of diabetes complications as opposed to exhibiting fatalism upon the occurrence of complications; hence, the inverse relationship between diabetes fatalism and comorbidities was obtained. This could also explain the inverse relationship between age and diabetes fatalism observed in the present study. Unlike previous findings showing higher fatalism with lower income (Lange and Piette 2006), this relationship was not established in our sample. This could be due to the fact that the majority of our participants (80%) reported having decent income, expressed as having enough or more than enough to make ends meet. Our study results should be interpreted with caution. Limitations include recruiting a convenience sample of Lebanese type 2 diabetes patients, and thus, findings cannot be generalized. Future studies with a larger, more representative sample from Lebanon and other Arab countries are warranted. Most of the participants (235 out of 280) in the present study were recruited from the community (84%), while the rest were hospital patients (16%). Due to the small percentage of subjects recruited from the hospital, the sample was not divided for analysis. However, when we compared the subjects from the community to those from the hospital, there was no difference in gender, level of education, social status, occupation, income, previous diabetes education, smoking status, number of diabetes complications and HbA1c. On the other hand, subjects from the community were younger, with higher BMI and shorter diabetes duration, while higher percentage of hospital patients reported having family history of diabetes and health insurance. Another limitation that is inherent to the study methodology is that data were self-reported and thus is prone to subjectivity, recall bias or incorrect interpretation of one s health status and characteristics (weight, height, number of comorbidities, income, etc.). Moreover, the cross-sectional

10 J Relig Health (2018) 57: nature prevents inferences about causation, and thus, it is unclear whether some variables predict fatalistic beliefs or is it the other way around. It should be noted that Lebanon is a country with religious diversity, primarily Christianity and Islam. While both religions were shown to exhibit fatalistic beliefs, this construct is a complex multidimensional one that can be expressed differently in different cultures and religions (Leyva et al. 2014). For instance, in addition to dependence on God, some Muslims believe in the concept of destiny or predetermined life events that occur beyond a person s control. Therefore, exploring fatalism in individual religions in the region is needed for a better understanding of its impact and management. Nevertheless, studies like ours are highly needed to assist health practitioners in the Arab world to understand the cognitive, emotional and spiritual constructs governing patients with type 2 diabetes and hindering self-care. Indeed, patient s lifestyle was ranked first by Arab physicians as a potential barrier to diabetes care, and addressing cognition is one step toward behavior and lifestyle modification. In conclusion, the present study is the first to explore determinants of diabetes fatalism among Arabs. Age, BMI, education level and diabetes comorbidities were found to be predict fatalism with the model explaining 14.5% of the outcome variance. Future studies are warranted to confirm results and to explore other potential variables associated with fatalism. Acknowledgements The authors Ola Sukkarieh-Haraty and Maya Bassil contributed equally to the work. The authors would like to thank the Lebanese American University Medical Center-Risk Hospital (LAUMC-RH) for enabling access to the patients. The authors would like to extend their appreciation to Nutrition students at the Lebanese American University for their valuable contribution. Funding This study was funded by the Lebanese American University. Compliance with Ethical Standards Conflict of interest All authors declare that they have no conflict of interest. Ethical Approval All procedures performed in this study were in accordance with the ethical standards of the LAU institutional review board and with the 1964 Declaration of Helsinki and its later amendments. Informed Consent Informed consent was obtained from all individual participants included in the study. References Abdoli, S., Ashktorab, T., Ahmadi, F., Parvizy, S., & Dunning, T. (2011). Religion, faith and the empowerment process: Stories of Iranian people with diabetes. International Journal of Nursing Practice, 17(3), doi: /j x x. American Diabetes Association. (2015). Standards of medical care in diabetes 2015: Summary of revisions. Diabetes Care, 38(Supplement 1), S4 S4. Assaad-Khalil, S. H., Al Arouj, M., Almaatouq, M., Amod, A., Assaad, S. N., Azar, S. T., et al. (2013). Barriers to the delivery of diabetes care in the Middle East and South Africa: a survey of 1,082 practising physicians in five countries. International Journal of Clinical Practice, 67(11), Berardi, V., Bellettiere, J., Nativ, O., Ladislav, S., Hovell, M. F., & Baron-Epel, O. (2016). Fatalism, diabetes management outcomes, and the role of religiosity. Journal of Religion and Health, 55(2), Doumit, M. A., Huijer, H. A. S., Kelley, J. H., El Saghir, N., & Nassar, N. (2010). Coping with breast cancer: A phenomenological study. Cancer Nursing, 33(2), E33 E39. Egede, L., & Bonadonna, R. (2003). Diabetes self-management in African Americans: An exploration of the role of fatalism. The Diabetes Educator, 29(1), doi: /

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