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Final report "Gesundheitskompetenz von türkischstämmigen Diabetikern" (German)



Project lead and contact:
Christopher Kofahl 

040 7410-54266


Ayfer Rink, 
Zeynep Yaylaoglu, 
Anne Evers, 
Jannis Hollman, 
Babak Sobhani

Universitätsklinikum Hamburg-Eppendorf, Institut für Medizin-Soziologie, Martinistr. 52, 20246 Hamburg

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Health competence of diabetics of Turkish origin depending on course of illness, care concept, socioeconomic status and integration


In contrast to the well examined psychosocial and socioeconomic situation of German type-2 diabetics, only very little is known about the situation of diabetics of non-German origin. Among the migrants living in Germany, the population group of Turkish origin is seen as having a particularly high risk of falling ill from type-2 diabetes. In particular, the so-called guest workers presumably benefit only to a limited degree from health-conducive and preventative offers due to their low integration in the German social system, even though they continue to be exposed to above-average health risks due to their social position and life situation. However, so far, there is no sufficient empirical basis for an adequate estimation of the life situation of this patient group.


Research questions



The project was designed as an exploratory quantitative-empirical progression study with two measurement time points. In cooperation with 12 doctors' practices in Hamburg, in the first cross-sectional survey in the period from July 2008 to July 2009, 294 diabetics of Turkish origin were surveyed by 18 Turkish-speaking female interviewers. In the follow-up survey one year later, 203 of those surveyed were reached and interviewed again.

The recruitment of patients ensued in 130 patients consecutively through the doctors' practices. A maximum of 30 patients per doctors' practice were recruited in order to avoid an over-sampling of individual practices. In a second recruitment strand, the recruitment of 164 patients ensued through mouth-to-mouth propaganda, through public events in mosques and mosque associations as well as through the social networks of the interviewers.

The experiences and perspectives of the physicians, diabetes counsellors, health insurance employees and other relevant actors were gathered in 34 qualitative focus group interviews. The expert support was provided by an advisory board consisting of practitioners and academics.



The persons of Turkish origin with diabetes examined in the study are an average of 59 years old (s=9.1), and 53% are women. The participants have been living in Germany for an average of 32 years /s=8.6, min= 1 year, max=47 years) and 87% continue to possess Turkish nationality. On the whole, the educational level is low: a quarter of those surveyed have no school education (35% of women, almost 12% of men), and approximately half (49%) attended school for only 4-5 years. Almost half of the participants can barely read and write, with women performing particularly badly in this area. The proportion of persons with good German language comprehension is also low, at almost 29%.

78% of the interviewees are married and almost all have children (96%, average 3.6 children per person). The average household size amounts to three persons, and only 14% live alone.

Among the interviewees, the diabetes mellitus type 2 has already existed for an average of nine years (s=7.6), and 39% are insulin-dependent. On average, the patients suffer from 2.2 concomitant or secondary illnesses (s=1.5), with women indicating an average of 2.6 concomitant or secondary illnesses (s=1.4) and men only 1.8 illnesses (s=1.5) p = 0,000, Mann-Whitney-Test). Risk factors such as alcohol and tobacco consumption play barely any role: 86% state that they never drink alcohol and only a fifth of those surveyed smoke, although double the amount of women than men. Nevertheless, the average body mass index is fairly high, at 32 kg/m2 (s=6.3).

According to process-quality indicators, the DMP patients (DMP self-information) are better cared for than the non-enrolled patients. Thy are more frequently referred to an optician (96.3 % vs. 81.4 %, p = 0.000), their feet are more frequently examined (89.8 % vs. 65.7 %, p = 0.000) and the majority possess a diabetic's passport (85.2 % vs. 43.9 %, p = 0,000). Moreover, the enrolled patients express a greater treatment satisfaction than the non-enrolled (satisfied to very satisfied: 87.9 % vs. 72.1 %, p = 0.002 [Mann-Whitney-Test]). In terms of these indicators, this group of Turkish enrolled patients does not differ from a group of 702 mainly German patients who are insured with the GEK health insurance company in the diabetes-2-DMP (Ruß-Thiel 2008). Around two in three persons surveyed in our study have already taken part in diabetes training, of whom 60% attended Turkish-language training. The allocation to a German, Turkish or mixed-language training corresponds relatively precisely to the degree of comprehension of the German language as it was measured here. The proportion of those who took part in German-language training without or with uncertain German comprehension only amounts to 11.4%. The majority report being satisfied with the training, although 43% of the women ad 34% of the men state that the training brought them little or nothing. Those with a higher level of school education tend to benefit more strongly from the training. 62% of those surveyed cite a need for training or further training.

Evidently, the participation in a specific training program contributes to extending the knowledge of diabetes. For instance, those who had already taken part in one or several diabetes training programs provided the correct answers to questions of the knowledge test significantly more frequently (p=0.000 Mann-Whitney-Test). Nevertheless, only almost half (46%) of those surveyed were able to describe the illness in at least a rudimentary manner. An explanation that contained the interplay between blood sugar and insulin was only provided by a total of 15% of those surveyed. The situation is similar for the term "HbA1c" or an alternative term used in practice such as "long-term blood sugar", "blood sugar memory" etc.

Over the course of 12 months, the care situation remains stable on the whole. In this respect, the physicians evaluate the DMP in terms of this target group as very helpful, particularly due to the recall system. However, improvements or stability in the target value of HbA1c is only reached by the group of patients with the target agreement "decrease HbA1c", while the group with the target agreement "maintain HbA1c" deteriorates slightly.



Low educational level and low SES are the main explanatory factors for low diabetes knowledge and lacking health competence. Due to the poor access to education, illiteracy, and low German knowledge, the development of training programs for the affected group of persons which are adapted to educational level and culture, have no writing involved and are in the native language are to be recommended. Moreover, the unexploited potential of self-help groups should be fostered, as in the examined group only one person reported having sought help in this area. However, in the interpretation of the project results, it is doubtful whether diabetes training alone – even if it is adapted to the specific needs – is sufficient for the diabetes self-management of this target group. Rather, the target group should receive health-conducive measures (such as exercise) in their respective setting and in relation to their everyday lives. To this aim, it would be appropriate to offer comprehensive diabetes initiatives for persons with a Turkish (and others) migration background as a suitable measure. Furthermore, such types of intervention foster the networking process between the relevant actors of the social and health care systems, the autonomous migrant organisations and self-help.


Project funding and cooperation

The project is funded by the BMBF from 02/08 to 09/11 in the framework of care-based research in the area of "chronic diseases and patient orientation". Cooperation partners are, besides the participating physicians' practices, the AG diabetes and migrants of the German Diabetic Association, the German Diabetic Association of Hamburg e.V., the Association of Diabetes Counselling and Training Professions in Germany e.v., the Alice-Salomon-Fachhochschule Berlin, the Institute for General Medicine at the University of Hamburg-Eppendorf Medical Center and the AG health system analysis at the Helmholtz Centre Munich.

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