Keywords

The main goal of this research was to build a cultural beliefs model of diabetes among first- and second-generation Arab American Muslims in Dearborn, Michigan, and the practices associated with those beliefs. Variations in beliefs were examined based on sex, age, generation, education level, and country of origin.

The research included two stages of data collection that combined different types of data collection approaches and analysis. This chapter answers the question, “Why Dearborn, Michigan?” and describe the research design and methods in details.

4.1 Research Setting

Detroit is “the home to the largest, most highly concentrated population of Arabs in North America” (Abraham & Shryock, 2000, p. 18). The population of Arab Americans in Detroit was estimated to be around two hundred thousand people in 2000 (Abdulrahim & Baker, 2009), but other sources place the number at over three hundred thousand (Americans, 2018). Immigration of Arab Americans to Detroit began in the 1880s, and thousands of Arabs kept arriving to Detroit every year, mostly from war zones such as Lebanon, Iraq, Palestine, Yemen, and Syria (Abdulrahim & Baker, 2009).

Dearborn, a suburb of Detroit, is the largest Arab American enclave in the United States. As soon as you enter the city, it is obvious that Arabs live there; there are shop signs written in Arabic, Arabic restaurants, coffee shops, barber shops, and groceries all run by Arabs. West Warren Ave is the main street in the city, with most of the Arab-owned shops in a segment just five or six blocks long. There are many dentists, chiropractors, and other clinics, small and large, lined up next to each other, all with Arab doctors’ names.

The women and men walking in the streets are wearing a vast combination of clothes; Yemenis mostly wear traditional clothes—women with the black “Abaya” and men wearing “thobs” (long white dresses). Lebanese and Syrian women wear jeans, tops, and head covers, and the men wear mostly jeans and shirts or t-shirts; Iraqi men and women wear something in between what the Yemini and Lebanese people wear.

Some people might say that being in Dearborn is just like being in the Middle East, but that is far from the truth. Dearborn is a combination of different Middle Eastern countries all represented in the same city. Little glimpses of Lebanon, Iraq, Yemen, Palestine, and Syria make the city of Dearborn a very special city with an interesting dynamic to live and study in.

In addition to the interesting composition of the city, the prevalence of diabetes among Arab Americans in Michigan is estimated to be two to three times higher than in the general US population (Jaber et al., 2004). Several studies have focused on this disease among Arab Americans, including studies on the effect of acculturation (Al-Dahir et al., 2013), diabetics’ access to healthcare services (Berlie et al., 2008), the presence of comorbidities such as hypertension (Dallo & Borrell, 2006), the reporting of diabetes (Jamil et al., 2008), self-management practices during Ramadan (Pinelli & Jaber, 2011), and family support (Pinelli et al., 2011). No study has yet derived an overall cultural model of diabetes among Arab Americans. The following sections describe the research design and methods, that were followed to achieve the goal of building a cultural beliefs model of diabetes and the practices associated with those beliefs.

4.2 Research Design and Methods

The two main objectives of this study are:

O1: To build a cultural model(s) of the belief’s diabetes among first- and second-generation Arab American Muslims in Dearborn, Michigan.

O2: To test variations in beliefs about diabetes in this population based on variables such as age, generation, sex, education level, and country of origin.

To achieve these objectives, data were collected in Dearborn for two years between 2016 and 2018. The data collection comprised two stages. The first stage was to answer the question: What are the cultural beliefs about the causes and symptoms of and treatments for diabetes among Arab Americans in Dearborn? In the second stage, I focused on measuring consensus in knowledge about those causes, symptoms, and treatments and discerning whether there was any variation in that knowledge based on sex, generation, education level, and country of origin. This research was approved by University of Florida Behavioral/Nonmedical Institutional Review Board.

4.2.1 Stage One of Data Collection

4.2.1.1 Participant Observation

Participant observation (DeWalt & DeWalt, 2011) was carried throughout the full period of data collection. The main goal for conducting the participant observation was to understand and experience the simple, everyday life tasks of Arab Americans—things like going to the grocery store, praying in the mosque, going to the pharmacy, and visiting a doctor, as well as the more complicated everyday life issues, like being Muslim in America.

During the participant observation, experiences, observations, and interactions with people on a daily basis were recorded in field notes (Bernard, 2017). Writing the field notes helped in approach people for interviews and guided the process in how to ask the questions, what to focus on, and what to avoid. The cultural patterns that became apparent while writing the field notes helped in mapping the participants in the city and select informants to interview. For example, if I was looking for male participants in their 60s from Yemen, then the coffee and doughnuts place was clearly the place to go, since most of the customers there were older men dressed in traditional Yemeni clothing.

4.2.1.2 Semi-structured/Structured Interviews

The goal for each interview was to cover a fixed set of topics while allowing the participant to speak freely and to share their opinions, experiences, and stories. The interview guide contained 15 questions, three of which involve the free-listing tasks that will be discussed in the next section. The other 12 questions covered topics that were derived from a pilot study conducted in summer 2015, as well as questions adapted from Kleinman et al. (1978) discussed in Chap. 1. This included questions about what diabetes does to the body, how severe diabetes is, the length of the illness, what people fear about diabetes, and the severity of diabetes. Each question was followed by probes to maximize the depth of the answers. The interviews were available in both English (Appendix A) and Arabic. All participants were given the chance to choose the language in which they would take the interview, and two participants chose to take the interview in Arabic. In addition, all participants choose whether to have their interview audio recorded or not and signed informed consent forms. The interviews were transcribed and coded by using MAXQDA. The data were coded by using 14 structured codes (based on the themes of the questions in the interview guide) and 6 data-driven codes/thematic codes (Bernard et al., 2016).

4.2.1.3 Free List

To determine the causes and symptoms of and treatments for diabetes, free lists were collected (Weller & Romney, 1988). Each participant was given a pen and paper and asked to first list all the causes of diabetes they could think of and then the symptoms of and treatments for diabetes. Thus, each participant produced three free lists. The participants were encouraged to talk, explain, and tell stories about each item they listed (Weller & Romney, 1988). In addition, elicitation probes (Brewer, 2002) were used to help people think of items they might add to the lists. In particular, the items they listed were read back to them one at a time and they were asked if they could think of additional, similar items to add to each list (Brewer, 2002).

4.2.2 First Stage Sampling

As mentioned previously, the interview guide included free list tasks and interview questions; both were collected from the same participants. The data were collected from 31 participants (22 women and 9 men). Both first- and second-generation Arab Americans, both men and women, from different countries were included as much as possible. A total of 31 interviews was an appropriate number, since previous studies have shown that 20 is often a sufficient sample size for in depth interviews (Handwerker & Wozniak, 1997). Also, when it comes to free lists, a sample of 20 to 30 informants is adequate to reach saturation for most cultural domains (Weller & Romney, 1988).

4.2.3 Stage Two of Data Collection

4.2.3.1 Cultural Consensus Survey

Building a cultural consensus survey is not an easy task. There is an art to this, as there is in making any culturally sensitive survey. Cultural consensus surveys can be designed using information from previous stages of data collection, from the literature on particular cultures, or from any other types of scientific publications (Weller, 2007). To build the cultural consensus survey, the following data were used: (1) The core items in the causes, symptoms, and treatments free lists—that is, items mentioned by at least by 10% of the participants; (2) the information collected in the interviews; (3) the field notes; and (4) information obtained with the Cornell Medical Index (Brodman et al., 1949) related to diabetes and cardiovascular disease—in particular, information not obtained from the interviews or the free lists. By using these four sources of data, 52 true–false statements about diabetes were developed, with 29 true statements and 23 false statements. The cultural consensus survey was available both in English (Appendix B) and Arabic (Appendix C). In conducting the survey, participants were allowed to read and answer each statement, and to ask questions if they had any.

4.2.4 Second Stage Sampling

For the second stage of data collection, a quota sample was used to select 78 participants: 19 first-generation women, 20 s-generation women, 20 first-generation men, and 19 s-generation men. The goal for the quota sample was to have approximately 20 participants for each generation and sex category (Weller & Romney, 1988). The sample included participants from Yemen, Lebanon, Syria, Palestine, Iraq, Jordan, and Egypt between the ages of 18 and 53.