Assignment 3 Quantitative research methods Fall Semester Leoni Ester

12 989 463

Provide a critique of the article. Address the overall design of the study in light of the research
question(s), measures, sampling, and assuming that the data analysis is done appropriately,
the interpretation of the results.
Starting from a present debate on equity and equality (between immigrants and non) in health care
system, the study focuses on the benefits from adherence to DM 2 disease management program
(DMP). On these basis, the study evaluates the different perceived benefits from German population
and Turkish immigrants in German. Given this inequality problem, the authors underline the
importance of equal access to health care system and, basing their study on the one of Rub-Thiel,
they expect an improvement of health care quality thanks to DMP.
The study was conducted between February 2008 and September 2011 and explores living
conditions, medical treatment and care, quality of life and health literacy of Turkish immigrants
with DM 2 in Hamburg and compared them to the non-immigrants. In particular, the non-immigrant
sample was N= 702 and the Turkish sample was N=102. From July 2008 to July 2009 Turkish
immigrants were personally interviewed (interviewers, 17/18 women). The recruitment of
participants was carried out following two methods:
1. In cooperation with doctors practices (130 patients recruited consecutively).
2. Through interviewers social networks, word-of-mouth and public relations (164 patients
recruited).
This recruitment combination assured more randomized data. The applied questionnaire contained
Rub-Thiel cross-sectional studys questions. Core data (of 1300 randomly chosen insures) were
given from statutory health insurance. The patients were then interviewed in German (29 carerelated items) and data protection was assured.
The measurement of the study proceeded distinguishing indicators for process quality and variables
for outcome quality for every group (in DPM):

Process quality analysis of frequencies of consultations. Examination of feet, referrals to

a podologist, receipt of documentation sheet and participation in diabetes training (process
quality indicators)
Outcome quality the indicators were HbA1c, blood pressure, body weight, intake of
vitamins and physical activity.

A sum score (0 to 5) identifies the patients benefits from DMP and a further score (0 to 7)
indentifies to what extent DMP criteria were met (see pag. 9727). The analysis was carried out with
SPSSTM with only univariate procedures (reason: non-immigrants raw data missing). A subgroup
analysis (sex stratified) was also conducted and differences between groups, proved through Chi2test. Significance level was established at p < 0,05. For what concerns results, of the 294 Turkish
immigrants, 108 stated to be in DPM. The distribution of sex was homogeneous in Turkish sample
but not balanced in the non-immigrant one. Even if the immigrants taken in account were in
Germany since 33 years, their educational level and their ability to speak and understand German
were very low.
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Assignment 3 Quantitative research methods Fall Semester Leoni Ester

12 989 463

Below the results obtained divided in outcome and process quality:

Process quality results 95% of Turkish sample seen their GP (past 12 months) 96% of nonimmigrants seen their GP (past three months). Turkish seen the ophthalmologist often than nonimmigrants. In both groups patients feet were checked regularly (no for 9% of non-immigrants).
Even if there were immigrants with diabetic foot, only 15 % have been referred to a podologist.
Outcome quality results ability to state current target value (74 % for non immigrants against
60% for immigrants). Also for the other outcome quality indicators, the immigrants proven to not
know different information (e.g. course of blood pressure) compared to non-immigrants. Forwhat
concern fruit and vegetables consumption, this increased in immigrants but there was anyway a
difference between immigrants (higher) and non-immigrants (lower) female BMI. The satisfaction
of DMP was high in both groups.
This study has anyway some limitations. First of all, Turkish sample is very small and recruited
from one single area (Hamburg) for this reason it cannot be considered representative. Moreover,
the generalization of data was hindered by the lack of non-immigrant raw data. Any casual
conclusion could not be done due to the cross sectional analysis. In the end, the match between selfreports responses and inscriptions in official documents was not possible.
What do you see as the most important implications of the study?
Considering the results obtained, it is important to underline the fact that the study gives the
possibility to understand the benefits from DMP programs. It is the first study concerning the issue
of unequal access for Turkish immigrants in German and thanks to the results obtained it is also
possible to improve DMP programs to better meet immigrants needs. In my humble opinion there
are not concrete important implications but there are relatively important findings which need to be
developed in a more consistent way. This could include other studies which consider less variables,
to see more clearly relationships. Anyway, it could be considered important the fact that trough this
study some more information have been found. For example, standard training programs are not
suitable for Turkish with low education, there is need of culturally adapted, individualized and life
contextual training programs in mother tongue and peer activities enhancement. At any rate, the
study could be considered important for this issue in this particular context and the most important
findings which could affect the benefits from DMP are for sure culture, health literacy skills and
education level.

Assignment 3 Quantitative research methods Fall Semester Leoni Ester

12 989 463

What questions do you see as most important to answer if a policy maker seeks to design a
communication program to improve diabetes management in Germany? Explain why these
answers are most important.
Basing this answer on the findings of the study read, I think that a policy maker before design a
communication program to improve diabetes management in Germany should identify and consider
different variables which could affect the participants. First of all, it should identify the recipients
and, given the division of immigrants and non in Germany population, decide if design a
communication for all the population or reframe it considering the minorities. Considering the fact
that today 3 million citizens of Turkish origin are living in Germany, it is important to take in
account is the educational level; this could affect the understanding of the communication program.
Also culture is very important in be opened or not to share and receive training. It could be also
important to consider peer groups activities, given the fact that in the previous study this seems to
have a big potential. Another important factor could be the understanding and perception of
healthy food for Turkish immigrants because it could be very different given the culture habits.
So it is important to design a communication program also specifying this kind of information.
Design a study that would provide the answer to one of your questions.
Even if I think that to create an effective DMP all the variables listed above should be taken in
account I focus on peer activities. In particular my question is:
How a DMP which include peer activities could improve immigrants training and knowledge on
their diabetes status?
I here take for granted that immigrants are not just informed of this possibility but are motivated to
do so. To provide an answer to this question, I think it could be useful to take a sample of only
Turkish immigrants and divide it in control and experimental group.

Control group: DMP without peer activities.

Experimental group DMP with peer activities.

Before every session the two groups have to fill a questionnaire or write a short essay about their
experience until now with DMP and after the session another questionnaire about this experience.
Also focus groups could be very useful in discussing the perceptions of participants.
Given the fact that some immigrants do not well understand German, the questionnaire could be
translated in mother tongue (back translation). In this way it could be easier to understand if peer
support and activities really affect the outcomes and the benefits of DMP.
Assuming that the result is positive, a policy maker could be able to improve diabetes management
building the communication program on this information. Obviously a study like this should be
more detailed and explained but this would take other many pages, this is only a draft.