Abstract
This chapter includes the book’s discussion and conclusion, highlighting the main objectives, arguments, and results. In addition, this chapter will include the study’s shortcomings and a roadmap for future research.
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The goal of this book was to build a cultural belief model of diabetes among Arab American Muslims in Dearborn, MI. In doing so, knowledge related to causes, symptoms, and treatments of diabetes was discovered. In addition, the book provided an insight into the community regarding who can have diabetes and what it does to the body. This book is the result of two years of ethnographic fieldwork in Dearborn, MI, which added depth to the discussion of diabetes and its relation to the historical, social, and political expression of Arab American Muslims in Dearborn, MI.
Regarding the causes of diabetes, there is strong evidence that first- and second-generation Arab American Muslims in Dearborn believe that diabetes is caused by genetics. This confirms what researchers have found in the belief systems of other cultures, including North Africans (Skelly et al., 2006), Canadian Anishinaabe (Garro, 1996), South Asians (Lawton et al., 2007), and Latino populations (Weller et al., 1999). Although studies have shown that people from various cultures believe that diabetes can be caused by genetics, the studies did not examine how close the genetic relationship must be for a person to have diabetes. As discussed in Chap. 5, for Arab Americans, the fear of having diabetes that is caused by genetics is limited to having parents or grandparents who have diabetes (the relation can be clearly tracked throughout the narratives discussed in the chapter). Statements such as “My brother has diabetes because my father has it” and “Because my grandmother has diabetes, I might have it” indicate that people think diabetes is caused by genetics and can run in their family.
The belief that being “chubby” (Everett, 2011), “fat” (Garro, 1996), or overweight is a cause of diabetes has been noted in several studies. This belief is similar among Arab American Muslims in Dearborn, many of whom believe that being “fat” and “lazy” indicate an inactive lifestyle and can cause diabetes.
Studies have shown that stress is one of the main causes of diabetes across many cultures. Stressors such as being an immigrant and going through traumatic experiences, including violence and death, were mentioned as reasons for stress across several cultures (Lawton et al., 2007; Mendenhall et al., 2010; Weller et al., 1999). Arab American Muslims in Dearborn share similar explanations for stress. Many diabetics are first-generation immigrants who came from war-torn countries such as Syria, Iraq, Yemen, and Lebanon. Most of the time, those immigrants were forced to leave their countries, leaving behind their life, homes, and extended family. Most of them, as they shared, fled with nothing and underwent a challenging journey till they reached the United States. Their arrival to the states did not mean that all difficulties diminished as they started a new life, learning English, finding permanent homes, finding jobs, and navigating the new social and political reality they lived in.
In addition, two other sources of diabetes-related stress are worth highlighting for this population. First, people who cannot fast because of illness are not required in Islam to do so during Ramadan (Dukes, 2009-2017; Navigator, 2018). Although this knowledge is common among Arab American Muslims in Dearborn, the data showed that some people who have diabetes refuse or try their best not to break their fasting during Ramadan. Many consider being unable to complete the religious duty of fasting due to diabetes a sign of weakness. This creates stress over the ability to fast, maintaining a “strong” image in front of others, and how people with diabetes should alter their daily lives to be able to fast from sunrise to the sunset for a month. Second, people who have diabetes and choose to break their fast during Ramadan or were forced to by their doctors due to health complications experience financial stress because they give to charity as compensation for not fasting during Ramadan (discussed in Chap. 5), especially people with low income.
Many studies across cultures have shown that thirst and fatigue are symptoms of diabetes (Culhane-Pera et al., 2007; Jezewski & Poss, 2002; Skelly et al., 2006; Weller et al., 1999). Arab American Muslims believe feeling thirsty and tired might be a sign of diabetes. What is worth noticing here is that all symptoms of diabetes that the participants listed were physical ones; none of the participants listed an emotion or a feeling as a symptom of diabetes.
When it comes to treatments, it is very interesting—and promising—that Arab American Muslims listed medication as the first treatment of diabetes. Although medication was listed as a well-known treatment recognized by the population, knowing did not correlate with their medication consumption behavior. Many participants expressed difficulties regarding how long they would have to take the medicine, adherence, and understanding the right dosages and ways of storing the medicine.
In addition to medicine, Arab American Muslims in Dearborn acknowledged the importance of a healthy diet as a treatment for diabetes. Many participants recommended giving up fast food, having a healthy diet, and giving up delicious Arabic sweets as a must for people who have diabetes. This awareness of the importance of a healthy diet among Arab Americans confirms the results of studies of other cultures (Garro, 1996; Lawton et al., 2007; Skelly et al., 2006; Weller & Romney, 1988).
Most Arab American Muslims’ cultural beliefs related to the treatment of diabetes are similar to those of other cultures (Culhane-Pera et al., 2007; Jezewski & Poss, 2002; Weller et al., 1999), but clear differences emerge regarding whether diabetes can be cured. Most Arab American Muslims in Dearborn believe that diabetes can cause death if it is not treated or managed well.
Furthermore, the data showed participant knowledge regarding the side effects of diabetes treatment, which was not explored enough in other studies of cultural beliefs. Participants in this study noted that treatments for diabetes in general—and insulin specifically—can lead people to gain or lose weight, that is, that diabetes can make a person fat or skinny, but they did not know why the medication would have different effects on different people.
Following the same thread regarding stress stemming from the causes, symptoms, and treatments of diabetes, participants did not list any psychological treatments for diabetes. Two questions consequently arise. First, if the participants were asked, “What can a person do to prevent having diabetes?” would they include any psychological treatments to deal with stress? Second, does this mean that Arab American Muslims in Dearborn don’t believe that a person who has diabetes needs to manage their stress and therefore needs psychological treatment? This study clearly shows that more attention needs to be given to understanding the relation between chronic illness and mental illness among Arab American Muslims in Dearborn, with a focus on the stigma and cultural beliefs.
In addition, diabetes management is an important aspect of treatment. Several studies have shown that the better the family involvement and help for the diabetic family member, the better the diabetes management outcome (Edelstein & Linn, 1985; Henderson, 2010; Pinelli et al., 2011). For Arab Americans in Dearborn, diet management, carrying the financial burden, dealing with their emotions, reminding them of medication, going with them to doctor’s appointments, and carrying the workload with the decrease in physical activity are the types of support and care provided.
Pinelli and Jaber (2011) and Pinelli et al. (2011) found that help with diet, physical activities, and medication management are the main problems that diabetic Arab Americans deal with during Ramadan. My study confirms the findings of Pinelli et al. (2011), and with ethnographic data, it adds the viewpoint of family members regarding the care they provide during Ramadan as well as stories of people who have diabetes feeling dizzy, passing out, and going to the emergency room due to fasting.
In Chap. 6, I explored the first CCA model for Arab American Muslims’ cultural beliefs about diabetes. In general, the models have shown that Arab American cultural knowledge of diabetes does not contradict the medical knowledge. The model also showed the cultural beliefs regarding fasting in Ramadan and the evil eye/envy.
In Chap. 7, I argued that the results from the CCA models for illness cross cultures and can be used to fill the gaps of “cultural knowledge” in the current healthcare systems. An effort to provide culturally competent healthcare has been made, but with many limitations (Brach & Fraser, 2002; Brach & Fraserirector, 2000; Handtke et al., 2019; Pocock et al., 2020; White et al., 2019). Many studies have shown the important of cultural knowledge and included it as an important aspect in developing cultural competence techniques and models to be used in providing healthcare services cross cultures (Anderson et al., 2003; Brach & Fraserirector, 2000; Campinha-Bacote, 2002; Kagawa-Singer & Chung, 1994; Weech-Maldonado et al., 2012).
This study focused on studying the community cultural knowledge of diabetes. The sample included people who did not have diabetes, but experienced diabetes through their diabetic family members. I was able to collect narratives and stories of experiences of people dealing with diabetes in relation to their family members in daily life including the month of Ramadan. In addition, I was also able to gain insight into the family dynamics of people who have diabetes, especially the help that family members provide to diabetics. Although the community cultural knowledge of diabetes is important, its essential to conduct future studies that focus on building cultural knowledge of people who have diabetes, which was not part of this study. In addition, one of the other shortcomings of the study is that the participants were mostly young, between the ages of 18 and 25, which did not allow for greater comparison based on age.
Researchers can eliminate this study’s limitations by including people who have diabetes in the sample and comparing their cultural belief model with the cultural model found in this study. Also, it would be interesting for researchers to compare the care provided for people with diabetes from the family’s point of view and that of the diabetic person who received the care. Do they see their family managing their diabetes medication and their diet as a good thing? Is it helpful? Does it cause them stress? A cross-comparison would show how effective family members’ care and management practices actually are for diabetics. Most important, more efforts are needed in studying Fasting in Ramadan and diabetes among Muslims in America, as well as studying the link between mental illnesses and chronic illnesses among immigrants in general and Arab Americans specifically.
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Al-Kuwari, S.H. (2024). Discussion and Conclusion. In: Arab Americans in the United States. International Perspectives on Migration(). Springer, Singapore. https://doi.org/10.1007/978-981-99-7417-7_8
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