Healthcare Experts' views on the Barriers of Diabetes Management in Houston & Istanbul

Qualitative Comparison on Healthcare Experts’ views on the Barriers of Diabetes Management in Houston and Istanbul Anisah Khan 4/29/15

Type 2 diabetes can become very costly when adhering to treatment plans. http://www.zmescience.com/medicine/diabetes-treatment-risk-13012015/

Created for Global Urban Lab Rice University: School of Social Sciences

http://content.govdelivery.com/accounts/USCDC/bulletins/dc01b6

Table of Contents Table of Contents .......................................................................................................................... 1 I. Executive Summary ...................................................................................................................... 2 II. The Issue ..................................................................................................................................... 3 III. The Research Methodology ....................................................................................................... 4 IV. The Findings ............................................................................................................................... 6 A. Barriers in Diagnosis…………………………………………………………………………………………....…….6 B. Barriers in Treatment…………………………………………………………………………….………….……….9 C. Barriers in Follow-Up………………………………………………………………………………………….…….11 V. The Implications and Conclusion .............................................................................................. 13 Istanbul……………………………………………………………………………………………….……………………….13 Houston……………………………………………………………………………………………………………………….14 Concluding Thoughts……………………………………………………………………………………………………14 VI. Work Cited ............................................................................................................................... 16 VII. Acknowledgements ................................................................................................................ 18

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I. Executive Summary Type 2 Diabetes Mellitus, a chronic condition where blood glucose levels are high due to insulin resistance, has been increasing at a rapid rate for the past twenty years. As type 2 diabetes contributes to high mortality rates across the globe, it is important to understand the barriers in managing such uncontrolled elevated blood sugar levels. To further explore this issue, a qualitative study was conducted to identify what health experts’ regard as the major barriers in diabetes management in Houston and Istanbul.

When studying two global urban centers, which vary in healthcare models and cultural values, it is important to highlight noticeable similarities and differences in the diabetes management processes. Ultimately the diagnosis, treatment, and follow-up procedures for patients with type 2 diabetes are similar in Houston and Istanbul; however, factors such as access to healthcare, socio-cultural background, and level of diabetes education all pose barriers in the diabetes management processes.

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Report II. The Issue As type-two diabetes becomes more prevalent in populations around the world, there has been an increase in awareness and guidelines set in place for treating the chronic condition.

Houston and Istanbul are two global cities with especially high rates of patients living with type 2 diabetes. According to the International Diabetes Federation Diabetes Atlas, Turkey had 7,227,450 diabetes cases in the year 2014 (International). In comparison the United States had a total of 25,779,340 diabetes cases in the year 2014 (International). Type 2 diabetes is in an upward climb in both countries, and the projected increase of diabetes at a global scale has made diabetes management a major concern for the United States and Turkey.

In order to make diabetes management effective for patients, healthcare providers in Houston and Istanbul follow guidelines structured by accredited organizations. Most healthcare providers in Istanbul adhere to guidelines set-up by The Society of Endocrinology and Metabolism of Turkey (SEMT). Similarly a majority of healthcare providers in the United States follow the Standard of Medical Care In Diabetes outlined by the America Diabetes Association (ADA) (Standard). The guidelines are written to improve the diabetes management processes, which include diagnosis, treatment, and follow-up methods. While such guidelines provide healthcare providers with standards for patient care, external factors beyond the scope of medicine cause barriers in the adherence to such procedures.

Dr.Satman, corresponding author at the Division of Endocrinology and Metabolism, did a retrospective study on the adherence to the guidelines set by the SEMT. Through his research it can be found that the Clinical Practice Guidelines set by the SEMT are not properly adhered to since “age, gender, diabetes duration, history and number of chronic complications and body mass index (BMI) of patients, physician’s specialty and type of healthcare institution were tested as possible factors affecting guideline adherence�(Satman). The barriers identified in the study are just a few that affect the diabetes management processes and contribute to the increased prevalence of diabetes.

When analyzing the rate at which patients with type 2 diabetes is increasing, it can be seen that Turkey is growing faster than the United States. In more than a decade the prevalence of diabetes in Turkey has increased from 7.2% to 14.84% (Satman). In comparison

3|Page Map 1: Prevalence of Diabetes mellitus in adults (20-79 years), 2013 http://healthintelligence.drupalgardens.com/content/prevalence-diabetes-world-2013

the United States has a 9.3% prevalence of diabetes as of 2014 (International). As captured by Map 1, Turkey is one of the few nations with over a 12% prevalence of diabetes mellitus in adults from the ages of 20-79 years old (Prevalence).

With such varying and overall rising prevalence of diabetes at a global scale, it is vital to understand what healthcare experts’ view as barriers in the diabetes management processes in Houston and Istanbul. When analyzing the information gathered during the qualitative interviews there were both common and unique barriers that emerged in Houston and Istanbul. Before analyzing the data, however, it is important to understand the methods and limitations that apply to such a broad scope research topic.

III. The Research Methodology "A Patient-based Study on the Adherence of Physicians to Guidelines for the Management of Type 2 Diabetes in Turkey� authored by Satman et al, was the basis for this particular study. Exploring a similar topic on type 2 diabetes, this research study focuses on healthcare experts’ perceptions on the barriers of diabetes management in Houston and Istanbul. Once the research topic was established a Master Document was created to keep track of multiple literature reviews, agenda items, local contacts, appointments, and qualitative interview questions.

The next crucial step was to identify a local champion, an advocate and contact point for the study, in Houston and Istanbul. Dr.Bulent Ozseker, a radiologist with Acibadem Healthcare Group, was the local champion in Istanbul. Dr.Ozseker helped coordinate qualitative interviews with healthcare providers at Acibadem Hospital. Dr.LeChauncy Woodard, a primary care physician at the Michael E. DeBakey VA Medical Center, was the local champion in Houston. In addition to coordinating with the local champions, it was important to reach out to other healthcare experts in order to gage a broad range of viewpoints during the qualitative interviews.

To prepare for the qualitative interviews a 24 question-query was designed to address the barriers of diagnosis, treatment, and follow-up methods in Houston and Istanbul. The query included questions regarding clinical practices, the healthcare system in each of the respective cities, socio-economic backgrounds of patients with diabetes, and the influence of culture in healthcare. A total of 10 healthcare experts were interviewed for this study. The qualitative interviews in Houston were conducted with an internal-medicine physician, 2 family medicine physicians, and a public health expert. The interviews in Istanbul were conducted with an endocrinologist, nephrologist, diabetes nurse, 2 professors at the Koc University Nursing School, and the dean of the Koc University Medical School. To maintain consistency all of the qualitative interviews were conducted in person, but due to time constraints two of the Houston interviews were conducted over the phone. The qualitative interview questionnaire can be found below.

Once the initial contacts were established and the appointments were scheduled, the next step was to conduct the qualitative interviews in Istanbul and Houston. The qualitative 4|Page

interviews lasted approximately 20 minutes, and all the interviews were recorded for reference and accuracy. Once all of the qualitative interviews were complete in Istanbul and Houston, the next step was to analyze and compare the data collected.

Qualitative Interview on the Barriers of Diabetes Management: Background on the healthcare expert 1.

2.

3.

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Name: Specialty: Workplace: How long have you been working there?

Diagnosis: 1. Describe the general type 2 diabetes populations in Houston. a. What age range do most pre/diabetes patients fall in? b. Is there an overwhelming trend in gender or ethnicity? c. Is there an increase in the prevalence of diabetes in a certain group of people?

2. Do most undiagnosed/diagnosed type 2 diabetic patients have access to health insurance in Houston?

3. What are the initial steps taken before a patient is seen by the physician (paper work, checking blood pressure, weight, height, etc.)?

4. How you as the healthcare provider determine whether or not a patient is pre-diabetic or diabetic? a. HbA1c levels, fasting blood glucose, and postprandial blood glucose-is there sufficient equipment to perform these tests, and can patients afford such labs? b. Medical history c. Physical examination 5. What is the root cause of diabetes in Houston?

6. Do you as physician follow any specific guidelines when diagnosing patients? Are such guidelines practical/ useful in application?

7. On average, how long does each appointment generally last? Are multiple health issues addressed at the same time?

8. Are there any barriers in diagnosing diabetes patients?

9. How do these barriers affect patients with diabetes?

Treatment: 10. Once a patient is diagnosed with diabetes, what are the initial steps taken to treat the chronic disease? a. Medication b. Life-style change c. Education on what diabetes is and how to live with it 5|Page

11.

12.

13.

14.

15.

Describe the compliancy of the diabetes patients to the recommended treatment methods.

Are patients able to afford treatment methods and medication?

Describe the diabetes education programs available to patients.

What are some barriers in treating patients with diabetes?

How do these barriers affect patients with diabetes?

Follow-Up: 16. How often do healthcare providers follow up with patients with diabetes?

17. Describe how healthcare providers follow up with diabetes patients. a. Via phone or clinic b. What types of labs/tests are performed during follow up appointments 18. Describe the blood glucose levels in most diabetic patients during follow up appointments.

19. How do diabetes patients manage their diabetes care?

20. What are some barriers faced when following up with diabetes patients?

21. How do these barriers affect patients with diabetes?

General Feedback: 22. How effective is the healthcare system in Houston, in helping patients’ control/manage their diabetes?

23. Are there any socio-economic or cultural barriers that make the diabetes management process difficult?

24. What role do you think genetics and the social environment play in diabetes management?

IV. The Findings The findings from this comparative study can be described by evaluating what healthcare experts in Istanbul and Houston view as barriers in the diabetes management processes.

A. Barriers in Diagnosis B. Barriers in Treatment C. Barriers in Follow-up A. Barriers in Diagnosis Istanbul Diabetes management begins once healthcare providers diagnose patients with diabetes mellitus. After going over family history, running A1C blood glucose tests, and conducting other laboratory evaluations healthcare providers can determine whether or not patients have type 2 diabetes. While there are patients who have access to healthcare services and can receive a proper diabetes diagnosis, there are still 46.3% of the worlds population living with undiagnosed diabetes (International). Of the 7,227,450 people living with diabetes in Turkey, 2,191,360 of them are unaware of their condition (International). The barriers in 6|Page

diagnosing type 2 diabetes can be attributed to a multitude of reasons, beginning with access to healthcare.

Figure 1: The International Diabetes Atlas depicts the percentage of undiagnosed diabetes patients worldwide (International).

Since 2003 “Turkey has successfully introduced health system changes and provided its citizens with the right to health to achieve universal health coverage, which helped to address inequities in financing, health service access, and health outcomes”(Atun). With the new health care system “there are family clinics available, and everybody is assigned to a physician” according to Dr.Sevket Raucan, Dean of the Koc University School of Medicine. While modern Turkey has made efforts to transform healthcare, there are still many individuals who cannot access the help they need. In more rural areas of Turkey, specifically rural areas of Istanbul, there is a “shortage of medical and nursing labor” making access to the universal health system more difficult. (Carter). Dr.Aysecan Terzioglu, Professor at the Koc Univeristy Nursing School, explained that some individuals who have questions about their diabetes “have very limited access to doctors unless they visit hospitals, which is always a hassle” when trying to address immediate concerns.

In addition to the limitations in accessing healthcare services, another barrier in diagnosing patients with type 2 diabetes is the cultural taboo surrounding chronic conditions.

Many individuals living in Istanbul with undiagnosed type 2 diabetes may be aware of their symptoms, but they are too afraid to go into the doctor’s office to confirm their fears.

Dr.Aysecan Terzioglu believes that “any chronic illness limits social life”. She continues on to explain “Turkish people have issues with talking about their problems…they sometimes hide their condition and hospital visits from their closest friends”. Dr.Terziolgu also references the book Illness as a Metaphor by Susan Sontag. In the book Susan Sontag talks about how “illness is the night side of life” and describes “illness as being a citizen of another country” (Sontag). In order to maintain a healthy and fit appearance many individuals with undiagnosed type 2 7|Page

diabetes avoid receiving the life changing diagnosis.

Another barrier healthcare providers face when diagnosing patients with type 2 diabetes is the patient’s lack of understanding about the condition. Dr. Ayse Ferda Ocakci, Professor at the Koc University Nursing School, believes that patient education is one of the major barriers in diagnosing patients with the chronic condition. Patients correlated with low socio-economic backgrounds tend to have lower literacy rates, and a substantial portion of the individuals who are obese and have type 2 diabetes are a part of this low literacy and low socioeconomic background (Dijkshoorn). Four out of the six healthcare experts that were interviewed in Istanbul identified low literacy and a lack of diabetes knowledge as issues when diagnosing new patients. Low literacy, “in addition to inadequate public awareness and knowledge of diabetes symptoms may explain the failure of early diagnosis” in Istanbul (Shafaee). Since there are many newly diagnosed patients that are unaware of what type 2 diabetes is, there are a few facilities in Istanbul that have diabetes education nurses answer any questions the patients may have. Nurse Gulin Cevik, the diabetes education nurse at Acibadem Hospital, informs diabetes patients on how to check their blood glucose levels, how to inject insulin, and how to adjust their lifestyle according to their condition.

Houston Houston, like Istanbul, is a global center that has barriers in terms of diagnosing patients with type 2 diabetes. One of the major barriers in properly diagnosing individuals with type 2 diabetes in Houston is a lack of health insurance. With the passing of the Affordable Care Act (ACA) in 2009, there have been major changes to the quality and access of healthcare in Houston and across the United States. The ACA has helped over 10 million people gain access to healthcare across the United States, but Texas is one of the states with the highest number of individuals that remain uninsured. Lea Kiefer, public health expert at the Michael E. Debakey VA, explains that “with the roll out of the ACA, there was a portion of the law that was suppose to pick up the uninsured population with the expansion of Medicaid. The elected officials in Texas refused to accept that help from the federal government, and that has left a certain percentage of the people without access to healthcare. They make too much to qualify for Medicaid prior to the expansion, but they make too little to qualify for any of the health insurance premiums on the healthcare exchange. That leaves a lot of people stranded without access to healthcare”. Dr.Brian Reed, a family medicine physician with the Harris Health System, confirms that a majority of his patients do not have health insurance. He describes that in Harris Health “there is a sliding scale classification program that is dependent on household income and determines the type of discount patients receive...the patients rather pay out of pocket occasionally then pay a premium”. Many individuals that are uninsured try to avoid the doctor’s office and the cost associated with each visit; therefore, a majority of individuals with type 2 diabetes are unaware of their condition.

For the Houston population that is insured, there are still other barriers to diagnosing patients with type 2 diabetes. Dr.Jahangir Kabir, a family medicine physician with Cy-Fair Medical Parnters, views a lack of diabetes education as a major barrier in diagnosing patients with the chronic condition. A study done on Implementing Diabetes Self-Management 8|Page

Education in Primary Care has found that a “lack of access to education has been proposed as a potential barrier to reaching people with diabetes” (Emerson). When individuals are unaware of the basic symptoms of type 2 diabetes, they are less likely to recognize these signs as a concern for their health. Most family medicine appointments last about 20 minutes, so patients that are dealing with multiple conditions may fail to mention their symptoms of diabetes to the physician. Dr.Reed states “it is rare to have patients come in with only one complaint”, so it not unlikely that patients and physicians alike may overlook symptoms of emerging type 2 diabetes.

Most patients who are unable to recognize the symptoms of type 2 diabetes get diagnosed at a later stage. If patients were able to recognize and address their diabetes at an earlier stage, then preventative measures could have been taken to stop the progression of the chronic condition.

B. Barriers in Treatment Istanbul Once patients are aware of their diagnosis, their physician outlines a treatment plan for them. In Istanbul most of the treatment plans are followed from the guidelines set by the SEMT. All of the healthcare experts that were interviewed in Istanbul agreed that the SEMT guidelines, which are adapted from the guidelines set by the ADA, are useful in both diagnosing and treating type 2 diabetes patients. Unfortunately healthcare experts also believe there are barriers in treating type 2 diabetes patients, which are not addressed in the guidelines. The most common barrier that was brought up during the qualitative interviews was the patient’s psychological resistance to change. Turkey is “well known as the land of kebabs, sweet lokum, baklava and now, for an expanding waistline”, so it is difficult for patients with type 2 diabetes to adjust their long lasting habits for the sake of their health (Laher). Dr.Ozlem Sezgin Mericliler, an endocrinologist at Acibadem Hospital, believes that “ there is a very specific psychological problem in diabetic patients that disables them from accepting the condition and organizing their life according it. I think this is the most important barrier”. Patients with type 2 diabetes have a hard time accepting the fact that they have a life long chronic disease, but they also find it difficult to integrate the treatment plan into their daily life. Dr. Terzioglu speaks on her experience with diabetic patients and describes, “It is very hard for them (type 2 diabetes patients) to manage their daily lives and to find time to inject their insulin. They have to have a strict control of their daily lives because their lives are not supervised by the medical staff”.

Earlier Dr. Terzioglu explained that the cultural taboo surrounding chronic conditions is one of the barriers in diagnosing patients with type 2 diabetes, but the psychological acceptance of this cultural taboo makes following medication and insulin plans difficult for patients as well.

Dr. Mericliler speaks more to the psychological barriers in treating diabetic patients by explaining how “some of the patients reject using oral medications and insulin. They think they can change their diabetes with diet and exercise. If the blood glucose is not very high, then I sometimes give patients that chance to see what happens”.

A more common barrier in treating type 2 diabetes, which is essentially found worldwide, is the patient’s lack of understanding of the treatment plan. Most newly diagnosed type 2 diabetes patients are unfamiliar with the medical terminology surrounding diabetes, and 9|Page

Dr.Cukran strongly believes that “time is very important…if you spend the time and explain to them what all these changes are about, on a level that they can understand, then patients comply to treatment plans”. In reality physicians do not always have the time to give a thorough explanation on how to deal with diabetes, so many patients are referred to other healthcare provides. While Acibadem Hospital, a private healthcare group, does have a diabetes education nurse, there are many public hospitals in Istanbul that do not have such resources. Therefore patients, who have questions about their treatment plan but do not have a diabetes education center near them, must travel a great distance to get the help they need.

In addition, patients that require guidance on their diet are often required to pay out of pocket to consult with a dietician. Not all patients in Istanbul have access to diabetes education, so they are often left uneducated on how to use their insulin or follow their medication routine. In a study done on diabetes education in the Turkish population it was found that, “a 1-day diabetes education program has a positive impact on improving well-being of Turkish people with type 2 diabetes in short term. According to this study, having not attended a diabetes education program, insulin treatment, poor metabolic control, and being female are main factors related to lower well-being in subjects with type 2 diabetes in Turkey” (Ozer). Istanbul is slowly making strides towards improving the quality of life through increased education, but there is still a large portion of the population who is unable to reach such education due to external factors beyond their control (Shafaee).

Houston Similar to the psychological barrier patients in Istanbul face in accepting the diabetes diagnosis, patients in Houston have a difficult time understanding the long-term effects of diabetes. The shortsighted view on the chronic condition is a major barrier in patient’s adherence to treatment methods. Dr. Woodard expands on the issue by saying “diabetes is one of those conditions where you see the effects much later, after you have had diabetes for a long time. Not readily being able to see that connection (between diabetes and future complications) can be difficult”. When diabetic patients do not realize the importance of keeping up with the diabetes treatment plan, they are often faced with adverse effects in the future. Dr. Kabir adds to this topic by describing how “some patients who do not realize the reality of neuropathy or amputation continue on with their sedentary lifestyle, unhealthy diet, and incompliancy with treatment methods”. There are many reasons behind why type 2 diabetes patients lack adherence to treatment methods, including the lack of perceived seriousness of diabetes and future complications. A study done on Improving Patient Adherence states that “diabetes health care providers know that if only their patients adhered to their treatment recommendations, they could do well and avoid diabetes-related complications. The fact that so many patients do not can be very frustrating” (Delamater).

The misguided view on the implications of diabetes is a major barrier in treating patients with type 2 diabetes, but the inability of diabetes patients to afford treatment methods proves to be an equally important barrier. It has been established that not all patients with type 2 diabetes have health insurance, so this makes medication and other treatment methods very expensive. Public health expert Lea Kiefer expands on the issue by saying “diabetes is not limited to medication. There are also management supplies needed like the testing strips, the 10 | P a g e

insulin syringes, glucose tablets, hard candies-all those have a cost as well”. While there are places, like Wal-Mart and Kroger, where individuals can purchase $4 generic prescriptions, it does not cover insulin or any other supplies diabetes patients may need. According to a study done on Problems paying ouf-of-pocket medication costs among older adults with diabetes, “Out-of-pocket medication costs pose a significant burden to many adults with diabetes and contribute to decreased treatment adherence”(Piette). In an article in the New York Times, it can be found that “ Diabetes patients spend an average of $6,000 annually on costs for treating their disease, according to a recent survey conducted by Consumer Reports Health”(Parker). In addition to not being able to afford the medication and insulin, some type 2 diabetes patients are also unable eat healthy on a regular basis. The basic treatment recommendation made by most healthcare providers is to eat healthy. Dr.Reed recognizes that “eating healthy is expensive…Filling up on bread is a lot cheaper than buying vegetables. Even eating leaner meats would cost more”. There are many costs associated with having type 2 diabetes, and many patients are just not able to afford the direct and indirect costs with their limited income.

Figure 2: Represents the increased costs patients with diabetes incur. http://latestnewslink.com/2015/02/cost-ofhaving-diabetes-has-doubled-in-twodecades/

C. Barriers in Follow-Up Istanbul Throughout my qualitative interviews in Istanbul, the healthcare experts did not identify any substantial barriers in following-up with diabetes patients. Dr. Mericliler went over their protocol of “following-up with diabetes patients every three months in an in person appointment. Diabetes nurses occasionally follow-up via the phone”. The healthcare experts identified many barriers in the diagnosis and treatment aspects of diabetes, but they did not find any major barriers in following-up with patients.

A minor barrier in following-up with type 2 diabetes patients is their inability to take on a lifestyle change. According to Dr.Ocakci, “the barrier to following-up is the lifestyle, because it is too difficult to change”. Often times when type 2 diabetes patients’ return to see their healthcare provider, they have a higher risk of complications if they have not made positive modifications to their lifestyle. According to Dr. Terzioglu, patients may not return for follow-up

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visits because “they lack knowledge about the condition, or they have a poor attitude towards the disease and treatment plan”.

Houston It is essential for patients with type 2 diabetes to follow-up with their physicians on a regular basis, but that is often difficult when there is such limited time. One of the main barriers to following-up with diabetes patients is the lack of appointment availability. Dr. Woodard and Dr.Reed identified appointment availability as being a major concern when scheduling followup appointments with their patients. Due to the busy schedules of many primary care physicians, type 2 diabetes patients may be referred to other family physicians or specialists.

This rising issue of appointment availability can be attributed to the fact “the United States faces a shortage of as many as 90,000 physicians by 2025, including a critical need for specialist to treat an aging population that will increasingly live with chronic disease”(Bernstein). With a shortage of physicians and an influx of diabetes patients, it has become increasingly more difficult to follow-up on a regular basis. Map 2 reflects the increasing struggle patients face when trying to schedule an appointment with family physicians. When patients with type 2 diabetes are unable to discuss their progress or difficulties in dealing with their condition, it can lead to a lack of adherence to their treatment plan and other complications (Wiwanitkit).

Appointment availability is one of the main barriers in following-up with type 2 diabetes patients, but patient education on the topic of diabetes is another barrier in follow-up appointments. Diabetes patients who are uninformed on the importance of following-up with healthcare providers often skip their appointments. Dr.Reed identifies that the diabetes

Map 2: Increasing wait time in days to schedule an appointment with a family physician. http://www.bustle.com/articles/25845-the-average-wait-time-to-see-a-doctor-in-these-us-cities-is-a-little-bit/image/25845 12 | P a g

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patient’s education level is important because it empowers them to come in for follow-up visits.

V. The Implications and Conclusion Houston and Istanbul are both urban centers with a high prevalence of patients with type 2 diabetes. Through the qualitative interviews with health experts in Houston and Istanbul, there were important barriers identified in the diabetes management processes. After evaluating the findings above, there were a few themes that emerged within each city. The general themes found in the diabetes management processes reflect the views of healthcare experts interviewed for this study.

Istanbul Healthcare experts in Istanbul identified many barriers in diagnosing, treating, and following-up with patients with type 2 diabetes. From the healthcare experts viewpoint, the barriers have attributed to the increased prevalence of type 2 diabetes patients in the last twenty-years. After analyzing the barriers, there are three overall themes that can be identified as the root problems in diabetes management.

1. Difficulty in accessing healthcare 2. Cultural taboo towards type 2 diabetes 3. Lack of diabetes education Individuals living with type 2 diabetes require accessibility to healthcare providers because of the nature of their condition. Although the universal healthcare system has brought about substantial changes within Turkey, many individuals in areas of Istanbul are still unable to access healthcare. This issue arises form the fact that there are simply not enough primary care physicians evenly distributed around the city. Due to the uneven distribution of physicians and barriers surrounding transportation, many patients are unable to visit healthcare providers and get diagnosed with diabetes at a latter stage. In addition, many type 2 diabetes patients who cannot easily access healthcare facilities are left uneducated on how to take their medications and maintain a healthy diet. Without a nearby hospital or clinic, patients may miss their followup appointments leading to major complications like neuropathy and kidney disease.

Another major theme found in the barriers of diabetes management is the cultural taboo surrounding type 2 diabetes. In order to avoid any social stigma, individuals with symptoms of diabetes avoid the doctor for as long as possible. Even after receiving their diagnosis, many diabetes patients refuse to comply with the treatment plan because it interferes with their social life. With the cultural taboo surrounding diabetes, some patients refuse to speak about their condition and make little efforts to adjust their lifestyle. This form of denial causes an increase in blood glucose levels, but more importantly it continues to reinforce the detrimental cultural taboo.

The final theme established during the qualitative interviews is the lack of diabetes education among diabetic patients and the general public. While preventative campaigns have 13 | P a g e

started emerging in Istanbul, they are not as far reaching as they should be. The lack of diabetes education prevents individuals from identifying their symptoms, following their treatment plans, and reducing any risk of compilations during follow-up appointments. Education is one of the main factors in not only diagnosing patients but also making sure that their blood-glucose levels remain steady.

Houston Healthcare experts in Houston also identified many barriers in diagnosing, treating, and following-up with patients with type 2 diabetes. The barriers in diabetes management in Houston are driving forces in the increased prevalence of type 2 diabetes patients. After analyzing the barriers, there are two overall themes that can be identified as the root problems in diabetes management.

1. Difficulty in Accessing Healthcare a. High costs of healthcare 2. Lack of diabetes education Unlike Turkey, the United States does not have universal health care. It is due to the difficulty in accessing healthcare that may individuals with type 2 diabetes never get a proper diagnosis. A significant number of patients with type 2 diabetes fall under a low socio-economic bracket, and without health insurance many of these diabetic patients cannot afford the healthcare they need. Without a consistent primary care physician, type 2 diabetes patients cannot receive guidance on how to treat their condition or on what medications to take. In addition, if the diabetic patient has high blood glucose levels then the patient most likely needs insulin. Insulin, test strips, blood glucose meters, and other tools required to manage diabetes are often pricey and unaffordable for the patients that require them. For the patients that do have health insurance and a primary care doctor, there is often difficulty in scheduling an appointment to see the healthcare provider. The difficulty in accessing healthcare for diabetes patients is a concern of both time and money.

A lack of diabetes education is another major theme that contributes to the increased prevalence of diabetes in Houston. Individuals that are unable to recognize diabetes symptoms can often times remain undiagnosed until the condition has reached a detrimental state. On a similar notion, patients that do not understand what diabetes is or how to follow their treatment plan may also end up with some sort of complication. The lack of education seen among many diabetic patients reduces any sense of urgency or seriousness in treating and controlling the chronic condition.

Concluding Thoughts Istanbul and Houston are two cities with different demographics, but they both have very similar themes that prove to be barriers in diabetes management. While Istanbul has Universal healthcare, many patients in Istanbul are unable to access this care due to transportation and geographic issues. On a similar note, most patients with type 2 diabetes in

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Houston are unable to access healthcare because they cannot afford it. The theme may be the same, but the cause behind the lack of healthcare access is very different.

The concept of viewing diabetes as a cultural taboo is something that is unique to Istanbul. With that being said, Houston definitely has a cultural of obesity, which normalizes the idea of diabetes.

The major barrier and theme that most healthcare experts view as the source of increased prevalence of diabetes in both Istanbul and Houston, is the lack of patient education.

Diabetes populations, in Houston and Istanbul, are often times unaware of the symptoms of diabetes, how to follow treatment methods, and the importance of follow-up appointments.

The lack of diabetes education is almost like a pandemic, which has decreased the seriousness of the chronic condition.

Istanbul and Houston share similar themes surrounding the barriers of diabetes management, and both of the urban centers need to realign their healthcare focus towards helping type 2 diabetes patients. The themes found in both cities are pressing issues that need to be addressed immediately, because the coming years project an increase of type 2 diabetes patients world-wide.

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Delamater, A. M. "Improving Patient Adherence." Clinical Diabetes: 71-77. Print.

Dijkshoorn, H., V. Nierkens, and M. Nicolaou. "Risk Groups for Overweight and Obesity among Turkish and Moroccan Migrants in The Netherlands." Public Health: 625-30. Print Emerson, S. "Implementing Diabetes Self-Management Education in Primary Care." Diabetes Spectrum: 79-83. Print.

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Satman MD, Ilham. "Clinical Practice Guidelines for Diagnosis, Treatment and Follow-Up of Diabetes Mellitus and Its Complications." Turkish Journal of Endocrinology and Metabolism 14 (2010): 1-140. Print.

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VII. Acknowledgements This research project was only possible with the help of many special individuals. I would like to specially thank Ipek Martinez, the Associate Dean of Rice University’s Social Sciences Department and Director of the Gateway Program. I would also like to recognize Abbey Godley, the Gateway Administrator, who along with Ipek Martinez coordinated this years Global Urban Lab trip to Istanbul, Turkey. The trip to Istanbul was very special and eye opening, and it would not have been possible without their hard work and dedication. I would like to also recognize Giray Ozseker for guiding us and coordinating all the fun outings during the trip. I am also very grateful to have Dr. Nia Georges, Professor and Chair of the Anthropology department, as our faculty mentor for this research paper. Your guidance and feedback has been immensely helpful in writing this paper. I would also like to thank Dr.Ozseker and Dr. Woodard for being the local champions for the qualitative interviews in Istanbul and Houston. Without your enthusiasm and help the qualitative interviews would not be possible. Finally I would like to thank all the healthcare experts who took the time to participate in my qualitative interviews.

Your feedback and participation is greatly appreciated.

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