Chlamydia infection increases the likeliness of being at hazard for HIV infection and cervical malignant neoplastic disease ( Steben, 2004 ) . Known as the “ concealed Venereal disease ”….
Methods and Research to Public Health
Modern public health promotion is a “new science”  because it encompasses concepts and strategies from the medical, social and behavioural sciences. Gellerman defined behavioural sciences as “the attempt to apply the classical scientific method to the study of human behaviour […] through the joint use of methods derived from such disciplines as psychology, sociology, anthropology, or economics” . Behavioural sciences paradigm creates the most valuable strategic and operational environment for public health promotion in regard to the design and implementation of different refinement programmes.
The noble and important task to make people healthier calls for integrative approach to public health research where medical variables (e. g. , the biology of the human body, genetics, etc. ) should be investigated altogether with economic variables (e. g. , development of drug industry, health providers’ organisational management, etc. ) and psychological ones (e. g. , risk perceptions and behaviours). The present paper seeks to overview how the concepts and research methods derived from behavioural sciences are applied to public health promotion of diabetes mellitus (DM) in the Kingdom of Saudi Arabia (KSA).
DM usually takes place when there are permanent and abnormally high concentrations of sugar in the blood. The state is explained by the corrupted ability of a human organism to regulate blood sugar levels. Type I (Insulin-Dependent Diabetes Mellitus or IDDM) occurs when the production of insulin (a hormone that controls the level of glucose/sugar in the blood) by the pancreas is insufficient. Experts found out that IDDM is usually caused by an autoimmune disorder “when the body’s immune system produces antibodies against the person’s own tissues” .
Type II (also Noninsulin Dependent Diabetes Mellitus, Adult-Onset Diabetes Mellitus or NIDDM) occurs when people do not have resistance to insulin but “their body cells do not use insulin effectively” . NIDDM is mainly caused by genetic pathologies. DM goes side by side with cardiovascular diseases and hypertension as well as with obesity; the latter is associated with resistance to insulin that helps to maintain sugar balance in blood. In the Kingdom of Saudi Arabia the overall prevalence of DM in adults reached 23. 7% .
The results were taken from a community-based national epidemiological health survey where Saudi people of the 30-70-years age group were examined over a 5-year period between 1995 and 2000. In the developing country with the population of over 12 million people the high ratio of diabetics give much food for thought. About 60 % of population is young people (20 years old and younger)  with the high prevalence of obesity. The KSA national ministry of health as well as a national and world-wide community of physicians is interested to create the authentic infrastructure for the prevention and elimination of dangerous disease.
The present paper seeks to investigate the general principles of research methods in application to DM in Saudi Arabia. Oxford medical journals database for the years of 2000-2006 was searched using the key words “diabetes mellitus” along with the term “Saudi Arabia”. The indexes of the Saudi Medical Journal were also hand-searched for relevant articles. The design of the present study was qualitative and implied the qualitative analysis of the articles from professional journals and databases to find out general patterns of medical research on the problem of DM within behavioural sciences paradigm.
Chronic illness and disability The application of behavioural sciences to the investigation of chronic illness and disability in the form of DM can be traced in the two case studies described in the Saudi Medical Journal. First, a physician Latif A. Khan described the acuteness of DM studies in the national settings in his letter to the editor of the Saudi Medical Journal (2001) . The author of the correspondence worked in a large hospital in Mecca. He reported about two patients with Diabetic ketoacidosis (DKA, the complication of IDDM) having been placed into the intensive care unit.
Both patients died. Though DKA is potentially threatening to human life, those two fatal cases were astonishing. As Khan stressed, “Given the health care infrastructure and facilities available in this country, a patient with a pure DKA should not die unless complicated or precipitated by some other illness” . Two male patients with IDDM were delivered to the hospital and properly diagnosed. The physician in charge assigned both patients to insulin intravenous infusions (I. V. ). Nevertheless, despite the fact that the diagnosis and treatment were correct, both patients died.
Khan applied the principles of behavioural sciences to investigate the case. Gellerman defined that method of behavioural sciences research as evidence-based study of behaviour in work settings. Besides medical issues the researcher took into account ethnographic, economic and organizational management issues which helped to analyse the case. To begin with, the men were taken into the hospital during the time of Haj, the annual Muslim mass pilgrimage to the Holy City. Consequently, all public places including intensive care units in the hospitals were overcrowded.
The accident happened partly because of the hospital infrastructure not being adjusted to force majeure situation. The number of personnel (physicians and nurses) in the hospital stayed the same as in ordinary circumstances despite the increase in the number of patients. To add, in spite of Haj and the tide of pilgrims in the city there was no additional supply of medical instruments and utensils to the hospital. Indirectly those management and organizational difficulties having been caused by ethnographic peculiarities of the country led to the fatal end.
Normally insulin intravenous infusions are done through infusion pumps. Due to the aforestated reasons the patients received their insulin doses through plain drip sets directly connected to insulin drip. To finish with the case, behavioural implications and evidence-based investigation let the physician reach specific important conclusions in regard to intensive care of the patients with IDDM in the national biased setting. Khan named a few medical methods being optimal for KSA hospitals. To mention a few, he stressed the importance of the more frequent monitoring of blood sugar and insulin I.
V. pulse infusion. In addition to the standard treatment protocols he suggested using the protocols of pathophysiology of the process and laboratory backups. In the sphere of health care organization the physician advised implementing quality management strategy in nursing care and forming expert case management teams. The second case of applying behavioural sciences principles to the research of DM in KSA was found in the research “Hypertension control in a community health centre at Riyadh, Saudi Arabia”  conducted by Siddiqui et al.
As it has been mentioned above, DM is often associated with obesity. In overall one-third of Arabs were reported to be obese judging from a body mass index (? 30 kg/cm2) . Obese people with DM are often hypertensive. To incorporate into the task of making the Saudis healthier, the group of researchers conducted the cross sectional study to design the programme regulating hypertension, promoting health education about life style and controlling the process with proper protocols. Siddiqui et al.
used the element of research design adopted from behavioural sciences. Brewer and Crano mentioned the so-called time-series and archival data exploitation to “obtain premeasures over an extended period specifically for the purposes of evaluation research” . Time-series designs often utilise statistical records and other archival documents that have been kept for purposes other than research. Siddiqui et al. used the case notes of 3747 patients who attended the primary care department of Alkharj Military Hospital.
The investigators examined the case notes to learn the ratio of hypertensives and non-hypertensives in a chosen sample. There was no sense in measuring the systolic and diastolic blood pressure in the sample and in interviewing people on medications they used to take all afresh. Those pieces of information have been already registered. Thus, the researchers saved time and effort to concentrate on the measures aimed at helping the Saudis to fight DM. Trying to find out the degree of control of blood pressure among the Saudi hypertensive patients, Siddiqui et al.
found out that there was 51% of hypertensive females with blood pressure of 141-160/90-100 mm Hg who were also obese. Those female patients self-reported about sedentary life style, poor eating habits, poor literacy and more frequent visits to general practitioners. The research resulted in stating that hypertension was a disease of complex etiology and called for the integrative strategy of healing. Altogether with pharmacological means of reducing the risk of hypertension and associated diseases including DM researchers advised to include some non- pharmacological methods (e. g.
, regular exercise programmes, the diet of vegetables and fruit, fat and tobacco abstinence, health education) into the list of healing actions. To summarise, there are useful behavioural sciences methods on the problem of chronic disease in the form of DM and associated illnesses (hypertension and obesity) such as evidence-based study of behaviour in work settings and archival data usage. Ethnographical, socioeconomic and organizational issues also contributed to designing special public health programmes aimed at preventing DM, hypertension and obesity in the KSA environment.
Life stress and health Besides genetic pathologies and immune system disorders, DM is provoked by physical load and strain, infection, illness, medications, fever, alcohol, diet, pregnancy and life stress. There are various definitions of life stress. The concepts used in medical anthropologic research are different from the ones used in everyday discourse. Unhappy life events (death, accident, divorce, etc. ) constitute only one category of stressors (Rahe and Arthur, 1978) with discrete and identifiable structure .
Dressler named also chronic social stressors as “risk factors that […] persist in the structure of everyday social roles and circumstances” . There is research on the non-fully investigated effects of life stress and the metabolic control that is essential for diabetes (IDDM) treatment, though the results are somehow contradictory. For example, Stein and Charles (1975)  hypothesised that activity in the sympathoadrenalmedullary system could alter, plasma cortisol levels could raise, and the secretion of glucagons and growth hormones were likely to enhance due to psychological stress.
Thus, according to Stein and Charles, patients with partly destroyed pancreatic beta cells are subjects for clinical manifestations of type I diabetes if they are physiologically susceptible and experience psychosocial stress. Barglow et al. (1983), Brand et al. (1986), Chase & Jackson (1981), Hanson et al. (1987) and many others  investigated the influence of stressful events on the metabolic control and course of IDDM diabetes. Whereas Brand et al. (1986), for example, saw direct correlation between negative life changes and diabetic symptoms, Delamater et al.
(1987) found no correlation between problematic events in the life of an individual and his metabolic processes. Chronic social stressors do have physiological effect since blood glucose levels increase due to increased levels of anxiety (Stabler et al. 1987) . An individual may change his dietary habits, athletic activity patterns, or health-related behavioural patterns because of either positive or negative stressful events as well as of social stressors. As Inge Seiffge-Krenke emphasised, DM (especially IDDM) required high rates of “the adolescent’s understanding, self-discipline, and responsibilities” .
A diabetic should keep to a strict schedule of taking insulin and stick to a specific diet. If the schedule and self-management of disease is changed due to this or that stressor, the flow of disease can also be influenced. Zhang et al. found out that diabetes was related to worse mental and physical health and a more disadvantaged social position . Diabetics are more likely to exposure themselves for depression than people without diabetes. Usually they rate their health as worse in comparison to non-diabetics and report more cases of cancer, hypertension, heart attack and stroke.
They are physically less active and less well-educated, have lesser income and may be persistently unemployed. The search of medical databases with the key words “life stress”, “diabetes mellitus” and “Saudi Arabia” produced no results. Therefore, there was nothing left but to search for the elements related to life stress in the articles which described general research on DM. Some insights were taken from the investigation carried out by Mohsen et al. who screened the population of the five KSA provinces on the ratio of diabetics .
The researchers used the interview as a very popular element of behavioural sciences research. By integrating the interviewing with medical tests the researchers were able to fit their investigation into the paradigm of behavioural sciences preserving the professional medical bias. It was interesting to observe now the national bias influenced the pattern of research. Less than 5% of the Saudis were reported to refuse to participate in the survey. The reason was that there was no male family member available in the house at the time of the visit.
The researchers found out that there were four etiological groups of factors influencing the high prevalence of diabetes mellitus in the Saudis: obesity, dietary habits, sedentary mode of life and genetic factors. Mohsen et al. mentioned that Saudi Arabia experienced sensible socioeconomic changes that considerably influenced the lifestyle of the people. Any change is associated with stress. Unfortunately, the researchers did not pause to investigate how those socioeconomic changes affected the life mode of diabetics and public health issues in regard to DM healing and prevention.
The research by Al-Saeedi et al. “Treatment-related misconceptions among diabetic patients in Western Saudi Arabia”  revealed some salient interconnections between life and social stressors and the cases of DM. For example, there is a variable of socioeconomic status (SES) that is defined as “a composite measure of one’s resources and prestige within a community (Krieger, Williams & Moss, 1997)” . Research demonstrated that people of lower SES experienced higher levels of life stress and, consequently, were easier prays for diseases (Chen et al.
2002, Kitagava & Hauser 1973, Marmot, Shipley & Rose 1984) . Al-Saeedi et al.  found out that 74. 8% of diabetics participating in the research had a low level of education. The level of education fits into SES framework and steps out as the source of social stress. Illiterate and non-educated people can misunderstand the instructions, underestimate the acuteness of DM for their health and endanger themselves by breaking dietary and medication schedules. Al-Saeedi et al.
used various methods of research adopted from behavioural sciences armoury including archival data utilisation (the sample consisted of the patients from 67 Primary Health Care Centres (PHCCs)) and structured questionnaires comprised of demographic information section, diabetes-related information section, and a list of misconceptions related to treatment of diabetes mellitus (DM). The results proved that higher educational level of the patient was associated with better knowledge regarding diabetes.
Besides, the importance of compliance to diet in addition to drugs to attain a good diabetic control was emphasised. Due to great socioeconomic changes the Saudis have been experiencing a great shift in their dietary habits in the last 20 years . Al-Khader reported that the energy intake had increased from 86 % of recommended daily allowances (RDA) in the 1960s to 140 % of RDA in the 1990s. The protein intake has increased from 91 % of recommended daily allowances (RDA) in the 1960s to 162 % of RDA in the 1990s. Women appear to be the most affected by the dietary changes.
The aforesaid facts are constantly revealed in various research and call for more attention to life stress in the aspects of diet, physical exercise, SES, etc. , to establish more direct correlations between stressors and the course of DM. The methods of research in regard to this task may be traditional: archival data utilisation, socioeconomic surveys, questionnaires and self-reports. Conclusion In the present paper an attempt was made to investigate the choice of research methods adopted from behavioural sciences in application to diabetes mellitus in Saudi Arabia.
This country experiences great economic and social changes. Altogether with genetic and ethnic issues these changes are likely to explain high disposition towards DM and associated diseases (hypertension, cardiovascular diseases, and obesity) among the Saudis. Several reports about the research conducted in KSA settings to investigate DM were taken from professional databases to search for specific methods within the paradigm of behavioural sciences. These methods appear to include evidence-based study of behaviour in work settings, archival data usage, structured interviews and surveys as well as self-reports.
The integration of the research methods adopted from behavioural sciences seems to enrich with new insights the integrative public health programmes designed to prevent and cure diabetes mellitus in Saudi Arabia. According to existing research socioeconomic and anthropological variables are taken into account altogether with medical parameters. References List 1. Macdonald G, Bunton, R. Health promotion: disciplinary developments. In: Bunton R, Macdonald G, editors. Health Promotion: Disciplines, Diversity, and Development. London: Routledge; 2002. p. 9-27. 2. Gellerman SW. Behavioural Science in Management.
Harmondsworth, England: Penguin Books; 1974. 3. McLaughlin E. Type 1 Diabetes Mellitus. 2002 Sept 12. Saudi Advisory Group Against Stroke (SAGAS) [homepage on the Internet]. Updated September 24, 2005 [cited 2006 Feb 13]. Group and Faculty Practice Physicians; [about 7 screens]. Available from: http://www. healthopedia. com/type-1-diabetes-mellitus/ 4. McLaughlin E. Type 2 Diabetes Mellitus. 2002 Sept 30. Saudi Advisory Group Against Stroke (SAGAS) [homepage on the Internet]. Updated September 24, 2005 [cited 2006 Feb 13]. Group and Faculty Practice Physicians; [about 7 screens].
Available from: http://www. healthopedia. com/type-2-diabetes-mellitus/ 5. Al-Nozha MM et al. Diabetes mellitus in Saudi Arabia. Saudi Medical Journal 2004; 25 (11): 1603-1610. 6. Al-Khader AA. Impact of diabetes in renal diseases in Saudi Arabia. Nephrol Dial Transplant 2001; 16: 2132-2135. 7. Khan LA. Insulin drip can be dangerous. Saudi Medical Journal 2001; 22 (1): 76. 8. Siddiqui S, Ogbeide DO, Karim A, Al-Khalifa I. Hypertension control in a community health centre at Riyadh, Saudi Arabia. Saudi Medical Journal 2001; 22 (1): 49-52 9. Brewer MB, Crano WD. Principles and Methods of Social Research. Mahwah, NJ: Lawrence Erlbaum Associates; 2002. 10. Seiffge-Krenke I.
Diabetic Adolescents and Their Families: Stress, Coping, and Adaptation. Cambridge, England: Cambridge University Press; 2001. 11. Dressler WW. Culture, Stress, and Disease. In: Johnson TM, Sargent CF, editors. Medical Anthropology: Contemporary Theory and Method. Westport, CT: Praeger Publishers; 1996. p. 252-272. 12. Zhang X, Norris SL, Gregg EW, Cheng YJ, Beckles G, Kahn HS. Depressive symptoms and mortality among persons with and without diabetes. American Journal of Epidemiology 2005; 161: 652-660. 13. El-Hazmi MAF, Warsy AS, Al-Swailem AR, Al-Swailem AM, Sulaimani R. Diabetes mellitus as a health problem in Saudi Arabia.
Saudi Advisory Group Against Stroke (SAGAS) [homepage on the Internet]. Updated February 18, 2006 [cited 2006 Feb 18]. Group and Faculty Practice Physicians; [about 12 screens]. Available from: http://www. sagas. org. sa/English%20Progress/Progress%20main. htm 14. Al-Saeedi M, Elzubier AG, Bahnassy AA, Al-Dawood KM. Treatment-related misconceptions among diabetic patients in Western Saudi Arabia. Saudi Medical Journal 2002; 23 (10): 1243-1246. 15. Brady SS, Matthews KA. The influence of socioeconomic status and ethnicity on adolescents’ exposure to stressful life events. Journal of Pediatric Psychology 2002; 27 (7): 575-583.