An evaluation of a culturally tailored presentation for diabetes education of indigenous communities of Bougainville, Papua New Guinea

Abstract

We evaluated the efficacy of culturally relevant health-promoting education about type 2 diabetes to the indigenous communities of Bougainville in Papua New Guinea. The Sugarman presentation is an interactive storytelling method that allows the causes, symptoms and risk factors associated with type 2 diabetes to be discussed. In order to evaluate the effectiveness of this program anonymous pre and post presentation written surveys were completed and analysed to determine changes in knowledge and understanding of diabetes. In the year 2010, 16 communities participated in a total of 26 Sugarman presentations. Overall, an improved understanding of the causes, symptoms and prevention of type 2 diabetes was demonstrated in these participants. The greatest improvement occurred in communities where very little was originally known about type 2 diabetes. The Sugarman presentation is a culturally sensitive education program that improved the understanding of type 2 diabetes in communities of Bougainville and can be employed more extensively.

Appendix 1

Outline of the ‘Sugarman’ presentation.

• 1. Discussion about ‘hidden sugar’ in foods. All foods have hidden sugar. Our bodies need sugar as energy (like a car needs petrol to drive), so we can go to school / work / walk / run etc. We need sugar in our muscles so we can do all of these things. However, some foods have more hidden sugar than other foods, and too much sugar is not a good thing.

Audience interaction: Questions posed to the audience about how many spoons of sugar in a can of soft drink, compared to a glass of water. Audience member physically spoons out ten teaspoons of sugar onto a plate in front of group. Visual display of various foods with how many ‘teaspoons of hidden sugar’.

Discussion about importance of being aware of hidden sugar in foods. General rule is that foods from the ocean, land, trees or soil have less hidden sugar than foods that come from the store or packaged.

• 2. Introduction to ‘Sugarman’ (large representation of human body laid on the ground with relevant organs to diabetes depicted, including eyes, mouth, stomach, kidneys, heart, feet, pancreas, muscles, arteries), see Fig. 2.

Audience interaction: audience members volunteer to place labels on Sugarman’s body parts.

• 3. Depiction of normal sugar metabolism in healthy person:

Audience interaction: volunteer from the audience represents ‘food’ (holding a large model of a piece of bread). Presenters prompt audience to advise the path that food takes in Sugarman’s body out loud. ‘Food’ volunteer physically walks through large Sugarman representation, following the path of food through Sugarman’s body, i.e. in the mouth, into the stomach. In the stomach, food is broken down into sugar (volunteer’s piece of bread replaced with large model of sugar), sugar then goes into the blood (arteries). Question posed to audience: where do we want the sugar? In the muscles. However there is a muscle doorman (another audience volunteer plays role of muscle doorman, holding a lock, preventing access to the muscle). Sugar tries to get into the muscle, but needs the special key. Special key comes from the pancreas, and is called ‘insulin’ (Another audience member volunteers to play the role of insulin, holding a large representation of a key, labelled insulin). Together, ‘sugar’ and ‘insulin’ approach the muscle doorman and ask to be let in to the muscle, as sugar has the insulin key, the muscle doorman unlocks the muscle and allows them inside.

Interactive summary with audience:

Does Sugarman have sugar in his muscles? Yes.

Is he a healthy Sugarman who can run and go to school and chase his Sugarlady? Yes.

• 4. Depiction of ‘Sik Suga’, or Diabetes.

Process starts again, however this time Sugarman is drinking lots of soft drink, eating lots of packaged food, biscuits, etc. (plate of locally available high sugar processed foods shown).

Audience interaction: (pathway of food and sugar spoken aloud by audience prompted by presenters)

Food goes into the mouth, down into the stomach, where it is broken down into sugar (lots of sugar this time). Sugar goes via the pancreas to get the insulin key, and together food and insulin go through the blood to the muscle, and ask the muscle doorman if they can be let in.

However this time, the muscle doorman is too tired and lazy to open the door, even though sugar has insulin, as Sugarman has been eating so much sugar, and the muscle doorman is tired from working so hard. Muscle doorman lies down and goes to sleep.

Sugar needs to get into the muscle, so sugar goes back to the pancreas to get more insulin keys, thinking this might help. The pancreas works very hard making extra insulin keys. Eventually the pancreas is too tired, and breaks down (‘Bagarap’—meaning ‘broken’ in local language—sign placed over pancreas). Sugar goes back to the muscle with all the extra insulin keys from the pancreas, and asks the muscle doorman if he can get into the muscle now. The muscle doorman is still too tired from all the times he has had to open the door from all the sugar Sugarman has been eating, and says no. Sugar is stuck in the blood.

Meanwhile, Sugarman keeps eating high sugar foods, and sugar keeps coming into the body. It cannot get into the muscles, because of the lazy muscle doorman. (Sugar models scattered all over Sugarman, everywhere except in the muscles, i.e. on the eyes, heart, feet, kidneys).

Summary questions for audience:

Does Sugarman now have any sugar in his muscles? No.

Does he have energy to run after his Sugarlady? No.

Is there lots of sugar in all the wrong places, like his eyes, feet, kidneys, heart? Yes

This is diabetes.

• 5. Complications of diabetes:

Discussion about the common complications of diabetes, or how Sugarman is feeling now, visually depicted by the model sugarcubes already covering Sugarmans eyes, kidneys, heart and feet. Discussion includes blindness, kidney failure, heart attacks, and sores on feet which can lead to amputation. Mention by local doctor (to remain culturally sensitive) of erectile dysfunction. Discussion includes early symptoms of these diabetic complications.

• 6. Prevention of diabetes:

Sugarman is feeling very unwell, and decides to see the local doctor to see what he could have done to prevent diabetes. This generates discussion of exercise, eating local and natural foods. Additionally, the importance of not smoking. Sugarman’s diet is discussed, and the audience counts how many spoons of sugar in the foods he has been eating.

• 7. Treatment of diabetes:

Even if Sugarman already has diabetes, he can improve it by eating well and exercising. If this is not enough, he can take medicine, which acts as the ‘muscle doorman’ to let his sugar into the muscles.

• 8. Summary and conclusion

Sugarman starts eating local foods, and stops drinking soft drink and packaged foods. He starts exercising, and his muscle doorman starts to wake up, and starts letting sugar into his muscles again, so some of it comes out of his eyes, heart, kidneys and feet. He now has energy in his muscles to chase his Sugarlady.