This action might not be possible to undo. Are you sure you want to continue?
Children Nada Farhat, MD and Lisa Gualtieri, PhD, ScM Abstract
Although the rise in diabetes is across all ages and cultures, few websites are designed for children and even fewer meet children’s language and cultural needs. To address this gap, we designed a prototype website (see Figure 1) for children with diabetes, at risk of diabetes, or with diabetic family members who live in, or whose families are from, Saudi Arabia and other Middle Eastern countries. The main objectives of the website are to increase awareness about diabetes, to debunk myths and false information children might have concerning diabetes as an illness, and to reduce the stigma the Saudi culture carries around the disease. These objectives can only be reached when language and culture are intrinsic to the design of the website. We believe that this approach – to design for a culture from the start instead of retrofitting an existing site or content – is the only way to reach this target population with effective education and support.
Figure 1: Website homepage with separate sections for girls and boys
Diabetes Mellitus is one of the most prevalent diseases in Saudi Arabia affecting children and adults. In the Kingdom of Saudi Arabia, a country of over 12 million people, the prevalence of diabetes is on the rise as the result of urbanization and socioeconomic developments that are associated with lifestyle changes. For the same reason, there is a rise in diabetes in other Middle Eastern countries and in Middle Eastern families in the US. Saudis in other countries remain deeply committed to the cultural values, thus, even as lifestyle changes increase the prevalence of diabetes, education and support needs to be culturally competent to be effective. This website is thus designed to meet cultural needs. Even the name of the site, Sukar Ala Sukar, reflects this; it literally means sugar over sugar in Arabic but Sukar is also the Arabic term for diabetes, making it a double entendre likely to appeal to Saudi children.
Website Design Considerations
The target population of the website is fourth and fifth grade children. This is an age group where children are increasingly likely to have diabetes, be at risk of developing diabetes, or know people with diabetes. At the same time, they are old enough to learn from health education and make decisions that influence behavior. Within this population, children differ in significant ways from the perspective of website design: most importantly the type of schooling they receive since it influences whether their primary language will be English or Arabic, and gender, since societal norms segregate children and impact access to imagery. Arabic is the official language in Saudi Arabia. Currently, English as a second language is only taught in high school levels of education. On the other hand, most private schools introduce English classes starting from kindergarten level. As a result, there is an inconsistency in English proficiency among students in the country. Thus, we have included both English and Arabic components to our website design. By being in both Arabic and English, the website can target both Arabic-only speaking children and English-only speaking children. It will also be more acceptable to parents whose primary language is Arabic but whose children are studying in English. Another design consideration is the cultural limitations of not posting photographs of girls. To address this, website imagery is limited to cartoons rather than photographs to maintain consistency for both boys and girls. Also, out of respect for the culture, we segregate the genders as depicted in Figure 2.
Figure 2: Girls’ & Boys’ Sections
Although the overall content will be similar in both sections, some modifications will be made to accommodate each gender such as having a female doctor that girls can ask questions of, as depicted in Figure 3 and a male doctor for boys, as depicted in Figure 4.
Figures 3 & 4: Question and Answer Pages from Male and Female Physicians
Expert-generated content (text, audio, and video) will be developed to teaches children what diabetes is, how to manage it if they have it, and how to act if someone they know has it. Furthermore expert-generated content will teach them behavior change to increase a healthier lifestyle through diet and exercise in age-appropriate and enticing ways. All text will be written at an appropriate age level, tested for readability, and supported by visual imagery. Audio and video will similarly be age-appropriate. Since the target population is children, games will be included that teach about diabetes and its treatment, management, and physiology. The game options will differ in the girl’s and boy’s sections to suit each gender but will support the same educational objectives, as depicted in Figure 5. We will also provide suggested activities and recipes that the children can make themselves or with the assistance of a parent, as depicted in Figure 6. Since we want parents and teachers to use and promote the website as a resource, for them we will provide some educational content as well as seasonal recipes and activities.
Figure 5: Game Page
Figure 6: Recipe Page
We will explore the applicability of social media to support the target population, increase interest in and commitment to the site, and increase accountability and fun through peer interaction. While social networking is popular in many other realms, it is untested for this specific target audience and purpose (health education and support) so we see this as desirable but needing evaluation.
Development and Evaluation Plan
Our development plan is to build a website based on the designs in the figures and to use formative evaluation to test at all stages to make sure the website has the necessary appeal, usability, and effectiveness at diabetes education and support. We have access to Middle Eastern children of the target ages living in the US. As development continues, we plan a fuller study to evaluate appeal, usability, and effectiveness at diabetes education and support that we will run in the US and in Saudi Arabia. For this we will evaluate behavior change over time in addition to the other factors.
Nada Farhat is a Saudi Arabian physician (Pathologist) and artist from the Kingdom of Saudi Arabia who is currently working on a Master’s degree in Global Public Health at Tufts University School of Medicine. Farhat’s interest in diabetes springs from the fact that many of her family members have either Type 1 or Type 2 diabetes. In 2006, her aunt at the young age of 40 died due to complications of long standing diabetes that could have been avoided. Her goal is to merge her medical knowledge and artistic skills to develop health websites that change behaviors and save lives. Lisa Gualtieri is an Adjunct Clinical Professor at Tufts University School of Medicine. Through her courses, Online Consumer Health and Web Strategies for Health Communication, her research, and her consulting, she uses her skills and background in technology, web design, and usability to design and evaluate health websites for people of all ages and cultures. Her most recent project was an NIH-funded bilingual website for Latino Alzheimer’s caregivers.