Practical challenges for mental health services among Rohingya refugee in Bangladesh.

Rohingya Muslims have been forcefully displaced from their mother land, Rakhaine State, Myanmar to Bangladesh, a country with about 170 million population with a treatment gap of more than 90% for standard mental health care. Due to the experienced trauma and displacement, high prevalence of depression, anxiety and post-traumatic tress disorders has been identified among Rohingya refugees in addition to the enduring mental health burden of Bangladesh. Very little has been known regarding the practical challenges of mental health services among Rohingya refugees in Bangladesh. In this commentary, we aimed to highlight the practical challenges for mental health services in Rohingya camps in Bangladesh along with our speculative ways forward based on available evidence, work experience, and informal communications. We highlighted the available mental health services, several major challenges including awareness, perception and belief towards mental health, language and cultural barriers, dearth of skilled service providers, inadequate services for severe mental illness, dearth of mental health services for children, inadequate provision of supervision and 'Care for Caregivers' program, and privacy and confidentiality of the clients. Although significant improvements have been made in the mental health field in the emergency crisis sector in Cox's Bazar over the past years, concentrated efforts are urgently required to actualize proposed solutions in this paper.

Analysis of residential satisfaction: An empirical evidence from neighbouring communities of Rohingya camps in Cox's Bazar, Bangladesh.

This study aims to understand the level of residential satisfaction of the host communities' aftermath of the influx of Rohingya in Bangladesh. A total of 151 household heads were randomly interviewed from Ukhiya and Ramu Upazila of Cox's Bazar district, Bangladesh. A residential satisfaction index is developed with a total of twenty-two variables comprised of four components- social environment (SE), neighbourhood environment (NE), public services and facilities (PS&F), and dwelling units (DU). The coefficients of the components indicate that the PS&F, SE, and NE impact much on the overall residential satisfaction compare to the DU. The analysis demonstrates that the people who have tertiary level education, who is Muslim and whose work opportunities remain the same as before, are more satisfied, but older people are less satisfied than younger. Besides, the degradation of social harmony, livestock and agricultural land losses, and decreased wages were the significant causes of dissatisfaction. These findings may contribute to taking appropriate policies and programs for the host communities taken by the government and non-government organizations.

Prevalence and factors associated with antenatal care service access among Indigenous women in the Chittagong Hill Tracts, Bangladesh: A cross-sectional study.

BACKGROUND: Prevalence of accessing antenatal care (ANC) services among Indigenous women in the Chittagong Hill Tracts (CHT) is unknown. This study aims to estimate the prevalence of accessing ANC services by Indigenous women in the CHT and identify factors associated with knowledge of, and attendance at, ANC services. METHODS: Using a cross-sectional design three Indigenous groups in Khagrachari district, CHT, Bangladesh were surveyed between September 2017 and February 2018. Indigenous women within 36 months of delivery were asked about attending ANC services and the number who attended was used to estimate prevalence. Socio-demographic and obstetric characteristics were used to determine factors associated with knowledge and attendance using multivariable logistic regression techniques adjusted for clustering by village; results are presented as odds ratios (OR), adjusted OR, and 95% confidence intervals (CI). RESULTS: Of 494 indigenous women who met the inclusion criteria in two upazilas, 438 participated (89% response rate) in the study, 75% were aged 16-29 years. Sixty-nine percent were aware of ANC services and the prevalence of attending ANC services was 53% (n = 232, 95%CI 0.48-0.58). Half (52%; n = 121) attended private facilities. Independent factors associated with knowledge about ANC were age ≥30 years (OR 2.2, 95%CI 1.1-4.6), monthly household income greater than 20,000 Bangladeshi Taka (OR 3.4, 95%CI 1.4-8.6); knowledge of pregnancy-related complications (OR 3.6, 95%CI 1.6-8.1), knowledge about nearest health facilities (OR 4.3, 95%CI 2.1-8.8); and attending secondary school or above (OR 4.8, 95%CI 2.1-11). Independent factors associated with attending ANC services were having prior knowledge of ANC benefits (OR 7.7, 95%CI 3.6-16), Indigenous women residing in Khagrachhari Sadar subdistrict (OR 6.5, 95%CI 1.7-25); and monthly household income of 20,000 Bangladeshi Taka or above (OR 2.8, 95%CI 1.1-7.4). CONCLUSION: Approximately half of Indigenous women from Chittagong Hill Tracts Bangladesh attended ANC services at least once. Better awareness and education may improve ANC attendance for Indigenous women. Cultural factors influencing attendance need to be explored.

Should Bangladeshi Race Be Considered as an Independent Risk Factor for Multi Vessel Coronary Artery Disease?

INTRODUCTION: Coronary Artery Disease (CAD) continues to be on the rise not only in the Western developed world but also affecting the South Asian race, particularly Bangladeshis. The objectives of this study were as follows: To determine whether or not risk factors of Bangladeshis differ from non-Bangladeshis, whether there is any difference in the extent of CAD for both groups, and if there are risk factors that can significantly affect the extent of CAD. METHODS: All patients with a diagnosis of CAD admitted to our 800-bed tertiary care hospital between January 2001 and December 2015 were retrospectively analyzed. We reviewed the age, sex, body-mass index (BMI), cardiac risk factors such as family history of CAD, dyslipidemia, hypertension, diabetes and smoking. We also reviewed coronary angiographic findings of these consecutive 150 Bangladeshis and a randomly selected group of 193 non-Bangladeshis. RESULTS: A total of 343 medical records were evaluated, this included two groups: 193 non-Bangladeshis and 150 Bangladeshi subjects. The Bangladeshi group was older than the non-Bangladeshi group (63.49 vs 59.22, p-value=0.001), and included a larger proportion of males than the non-Bangladeshi group (28.7% vs 15.68%, p-value=0.0116). Bangladeshi subjects are more likely to be smokers than non-Bangladeshi (11.75% vs 6.67%, χ2=12.7, p-value=0.0004). Non-obstructive, 1-vessel, 2-vessel and 3-vessel accounts for 13.33%, 36.67%, 22%, and 28% for Bangladeshis, and 16.39%, 20.77% 34.43% and 28.42% for non-Bangladeshis, respectively. The difference of extent of CAD is significant between two groups (χ2 =12.397, p-value=0.0061). The findings suggest that Bangladeshi ethnicity has almost 2 times the likelihood of having 1-vessel CAD at coronary angiography (OR=2.361, 95% CI 1.452-3.839, p=0.0005). CONCLUSION: This study is a pivotal starting point for further evaluating the link between Bangladeshis and CAD. In our study we found that being Bangladeshi increases the risk of having CAD and may be an independent risk factor for multi-vessel CAD.

Cognitive interviewing to improve women's empowerment questions in surveys: Application to the health and nutrition and intrahousehold relationships modules for the project-level Women's Empowerment in Agriculture Index.

In 2015, the United Nations adopted the Sustainable Development Goals, which include fostering gender equality and women's empowerment and ending hunger and malnutrition. To monitor progress and evaluate programmes that aim to achieve these goals, survey instruments are needed that can accurately assess related indicators. The project-level Women's Empowerment in Agriculture Index (pro-WEAI) is being developed to address the need for an instrument that is sensitive to changes in empowerment over the duration of an intervention. The pro-WEAI includes new modules with previously untested survey questions, including a health and nutrition module (focused on women's agency in this area) and an intrahousehold relationships module. This study uses cognitive interviewing to identify how new survey questions might be misinterpreted and to understand what experiences women are referencing when they respond to these questions. This was undertaken with the goal of informing revision to the modules. The study was conducted in Bangladesh with women from nuclear, extended, and migrant-sending households and from two regions of the country to identify difficulties with interpretation and response formulation across these groups. Findings revealed that questions were generally understood, but participants occasionally responded to the wrong part of the question, did not understand key phrases, or were uncomfortable with questions. The findings also suggested ways to revise the modules and strengthen the pro-WEAI. The revised pro-WEAI health and nutrition and intrahousehold relationships modules will advance the ability to measure changes in these domains and their relationship with the health and nutritional status of women and their children.

Treatment of alcohol use disorder among people of South Asian ancestry in Canada and the United States: A narrative review.

To explore access and treatment for alcohol use disorders (AUDs) among people of South Asian ancestry living in Canada or the United State, EQUATOR guidelines were applied to 34 manuscripts identified through an English language literature search (1946-2017) for this narrative review. The population studied has poor access to and engagement with treatment for AUD. Early evidence suggests benefit from adopting language-specific materials, offering South Asian-specific therapy groups, and incorporating traditional healers. Specific engagement and therapy considerations may increase AUD treatment access and effectiveness among South Asians living in Canada or the United States.

Generational health improvement or decline? Exploring generational differences of British ethnic minorities in six physical health outcomes.

Objectives: To explore ethnic and generational differences in six physical health outcomes and whether these differences can be explained by health-related behaviors and socio-economic status. Design: Multivariate analyses using nationally representative data in 2010-2011 on self-assessed general health, activity-limiting illness, doctor-diagnosed diabetes, doctor-diagnosed high blood pressure, doctor-diagnosed asthma and body mass index from 21,651 White British, 997 Pakistanis, 695 Bangladeshis, 1,126 Indians, 573 Black Caribbeans and 873 Black Africans, adjusted for age, gender, health-related behaviors and socio-economic status. Results: While ethnicity is of great importance in patterning health differences, we find that ethnic differences in activity-limiting illness, diabetes, asthma and body mass index vary across generations. Health-related behaviors and socio-economic status are shown to partly explain ethnic and generational differences in some health outcomes. Conclusions: This study enables a better understanding of more nuanced patterns of ethnic and generational differences in health, highlighting the need to understand ethnicity as a fluid and changing characteristic, and the importance of socio-economic status and health-related behaviors in shaping ethnic differences in certain health outcomes.

Cultural adaptation of an existing children's weight management programme: the CHANGE intervention and feasibility RCT.

BACKGROUND: Excess weight in children is a continuing health issue. Community-based children's weight management programmes have had some effect in promoting weight loss. Families from minority ethnic communities are less likely to complete these programmes but, to date, no programmes have been culturally adapted to address this. OBJECTIVES: We aimed to (1) culturally adapt an existing weight management programme for children aged 4-11 years and their families to make it more suited to Pakistani and Bangladeshi communities but inclusive of all families and (2) evaluate the adapted programme to assess its feasibility and acceptability, as well as the feasibility of methods, for a future full-scale trial. DESIGN: In phase I, a cultural adaptation of a programme that was informed by formative research and guided by two theoretical frameworks was undertaken and in phase II this adapted programme was delivered in a cluster-randomised feasibility study (for which the clusters were the standard and adapted children's weight management programmes). SETTING: Birmingham: a large, ethnically diverse UK city. PARTICIPANTS: In phase I, Pakistani and Bangladeshi parents of children with excess weight, and, in phase II, children aged 4-11 years who have excess weight and their families. INTERVENTIONS: A culturally adapted children's weight management programme, comprising six sessions, which was delivered to children and parents, targeting diet and physical activity and incorporating behaviour change techniques, was developed in phase I and delivered in the intervention arm to 16 groups in phase II. The eight groups in the comparator arm received the standard (unadapted) children's weight management programme. MAIN OUTCOME MEASURES: The primary outcome was the proportion of Pakistani and Bangladeshi families completing (attending ≥ 60% of) the adapted programme. Secondary outcomes included the proportion of all families completing the adapted programme, the feasibility of delivery of the programme, the programme's acceptability to participants, the feasibility of trial processes and the feasibility of collection of outcome and cost data. RESULTS: The proportion of Pakistani and Bangladeshi families and all families completing the adapted programme was 78.8% [95% confidence interval (CI) 64.8% to 88.2%] and 76.3% (95% CI 67.0% to 83.6%), respectively. The programme was feasible to deliver with some refinements and was well received. Ninety-two families participated in outcome data collection. Data collection was mostly feasible, but participant burden was high. Data collection on the cost of programme delivery was feasible, but costs to families were more challenging to capture. There was high attrition over the 6-month follow-up period (35%) and differential attrition in the two study arms (29% and 52% in the intervention and comparator arms, respectively). LIMITATIONS: The study was not designed to address the issue of low participant uptake of children's weight management programmes. The design of a future trial may include individual randomisation and a 'minimal intervention' arm, the acceptability of which has not been evaluated in this study. CONCLUSIONS: The theoretically informed, culturally adapted children's weight management programme was highly acceptable to children and families of all ethnicities. Consideration should be given to a future trial to evaluate clinical effectiveness and cost-effectiveness of the adapted programme, but the design of a future trial would need to address the logistics of data collection, participant burden and study attrition. TRIAL REGISTRATION: Current Controlled Trials ISRCTN81798055. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 33. See the NIHR Journals Library website for further project information. Kate Jolly is part-funded by the Collaboration for Leadership in Applied Health Research and Care West Midlands.

Many programmes have been designed for children with excess weight and their families to help them try and lose weight. Often families start going to these programmes but do not complete them. This has been noted to be an issue in families from ethnic minority communities. We aimed to adapt an existing programme for families of primary school children with excess weight to make it more suitable for Pakistani and Bangladeshi families. We asked parents from these communities who had experience of the existing programme what they thought about it and what they would like to change. We used this information to help us adapt the existing programme. We also aimed to make the programme acceptable to families of all ethnicities. We then aimed to (1) test delivery of the adapted programme, (2) see whether or not it was acceptable to Pakistani and Bangladeshi families and families of other ethnicities and (3) test methods to be used in a future research study to determine whether or not the adapted programme helps children to lose weight and provides value for money. We asked parents and children who attended and the staff delivering the new programme for their views. A panel of Pakistani and Bangladeshi parents helped us to plan our study methods. The programme was successfully delivered and the parents, children and staff all enjoyed it. Overall, 76% of families from all ethnic backgrounds who started attending the programme completed it. This was substantially higher than the 58% of families who completed the standard (unadapted) programme. We identified several issues that we would need to take into account when designing a future study. These include making sure that the families taking part are not overburdened and that we take steps to make sure that as many families as possible are followed up until the end of the study.

A lifestyle intervention programme for the prevention of Type 2 diabetes mellitus among South Asian women with gestational diabetes mellitus [LIVING study]: protocol for a randomized trial.

AIM: This study aims to determine whether a resource- and culturally appropriate lifestyle intervention programme in South Asian countries, provided to women with gestational diabetes (GDM) after childbirth, will reduce the incidence of worsening of glycaemic status in a manner that is affordable, acceptable and scalable. METHODS: Women with GDM (diagnosed by oral glucose tolerance test using the International Association of the Diabetes and Pregnancy Study Groups criteria) will be recruited from 16 hospitals in India, Sri Lanka and Bangladesh. Participants will undergo a repeat oral glucose tolerance test at 6 ± 3 months postpartum and those without Type 2 diabetes, a total sample size of 1414, will be randomly allocated to the intervention or usual care. The intervention will consist of four group sessions, 84 SMS or voice messages and review phone calls over the first year. Participants requiring intensification of the intervention will receive two additional individual sessions over the latter half of the first year. Median follow-up will be 2 years. The primary outcome is the proportion of women with a change in glycaemic category, using the American Diabetes Association criteria: (i) normal glucose tolerance to impaired fasting glucose, or impaired glucose tolerance, or Type 2 diabetes; or (ii) impaired fasting glucose or impaired glucose tolerance to Type 2 diabetes. Process evaluation will explore barriers and facilitators of implementation of the intervention in each local context, while trial-based and modelled economic evaluations will assess cost-effectiveness. DISCUSSION: The study will generate important new evidence about a potential strategy to address the long-term sequelae of GDM, a major and growing problem among women in South Asia. (Clinical Trials Registry of India No: CTRI/2017/06/008744; Sri Lanka Clinical Trials Registry No: SLCTR/2017/001; and ClinicalTrials.gov Identifier No: NCT03305939).

Attitudes towards a programme of risk assessment and stratified management for ovarian cancer: a focus group study of UK South Asians' perspectives.

OBJECTIVE: Population-based risk assessment, using genetic testing and the provision of appropriate risk management, could lead to prevention, early detection and improved clinical management of ovarian cancer (OC). Previous research with mostly white British participants found positive attitudes towards such a programme. The current study aimed to explore the attitudes of South Asian (SA) women and men in the UK with the aim of identifying how best to implement such a programme to minimise distress and maximise uptake. DESIGN: Semistructured qualitative focus group discussions. SETTING: Community centres across North London and Luton. PARTICIPANTS: 49 women and 13 men who identified as SA (Indian, Pakistani or Bangladeshi), which constitutes the largest non-European ethnic minority group in the UK. METHODS: Seven community-based focus groups were held. Group discussions were transcribed verbatim, coded and analysed thematically. RESULTS: Awareness and knowledge of OC symptoms and specific risk factors was low. The programme was acceptable to most participants and attitudes to it were generally positive. Participants' main concerns related to receiving a high-risk result following the genetic test. Younger women may be more cautious of genetic testing, screening or risk-reducing surgery due to the importance of marriage and childbearing in their SA cultures. CONCLUSIONS: A crucial first step to enable implementation of population-based genetic risk assessment and management in OC is to raise awareness of OC within SA communities. It will be important to engage with the SA community early on in programme implementation to address their specific concerns and to ensure culturally tailored decision support.

Understanding the consumption of folic acid during preconception, among Pakistani, Bangladeshi and white British mothers in Luton, UK: a qualitative study.

BACKGROUND: To review the similarities and differences in Pakistani, Bangladeshi and White British mothers health beliefs (attitudes, knowledge and perceptions) and health behaviour regarding their consumption of folic acid pre-conception, to reduce the risk of neural tube defects. METHODS: Our study used a descriptive qualitative research approach, implementing face-to-face focus group discussions with Pakistani, Bangladeshi or White British mothers (normal birth outcomes and mothers with poor birth outcomes) and semi-structured interviews or focus groups with service providers using semi-structured topic guides. This method is well suited for under researched areas where in-depth information is sought. There were three sample groups: 1. Pakistani, Bangladeshi and White British mothers with normal birth outcomes (delivery after 37 weeks of gestation, in the preceding 6 to 24 months, weighing 2500 g and living within a specified postcode area in Luton, UK). 2. Pakistani Bangladeshi and white British bereaved mothers who had suffered a perinatal mortality (preceding 6 to 24 months, residing within a specificied postcode area). 3. Healthcare professionals working on the local maternity care pathway (i.e. services providing preconception, antenatal, antepartum and postpartum care). Transcribed discussions were analysed using the Framework Analysis approach. RESULTS: The majority of mothers in this sample did not understand the benefits or optimal time to take folic acid pre-conception. Conversely, healthcare professionals believed the majority of women did consume folic acid, prior to conception. CONCLUSIONS: There is a need to increase public health awareness of the optimal time and subsequent benefits for taking folic acid, to prevent neural tube defects.

"It's Totally Destroyed Our Life": Exploring the Pathways and Mechanisms Between Precarious Employment and Health and Well-being Among Immigrant Men and Women in Toronto.

Precarious employment is rapidly growing, but qualitative data on pathways to and mechanisms for health and well-being is lacking. This article describes the cumulative and intersecting micro-level pathways and mechanisms between precarious employment and health among immigrant men and women in Toronto. It draws on semi-structured interviews conducted in 2014 with 15 women and 12 men from 11 countries of origin. The article describes how precarious employment, conceptualized by workers as encompassing powerlessness, economic insecurity, work for multiple employers, nonstandard and unpredictable schedules, hazardous working conditions, and lack of benefits and protections, negatively impacts workers' physical and mental health as well as that of their spouses or partners and children. It documents pathways to health and well-being, including stress, material and social deprivation, and exposure to hazards, as well as commuting difficulties and childcare challenges. Throughout, gender and migration are shown to influence experiences of work and health. The findings draw attention to dimensions of precarity and pathways to health that are not always highlighted in research and discourse on precarious employment and provide valuable insights into the vicious circle of precarious employment and health.

Variations in Duchenne muscular dystrophy course in a multi-ethnic UK population: potential influence of socio-economic factors.

AIM: To explore variation in clinical course and steroid treatment in Duchenne muscular dystrophy (DMD) by ethnic origin and socio-economic status. METHOD: In this longitudinal cohort study, clinical outcome was defined as age at loss of ambulation (LOA). Ages are presented as months for accurate calculation. Steroid use was reviewed against national guidelines. Kaplan-Meier survival analysis was used to determine probabilities over time of LOA. Log-rank test was used to evaluate comparisons between ethnic and socio-economic groups. RESULTS: From 2005 to 2014, 71 children were newly diagnosed with DMD. Complete data were available on 69, including 33 of white British heritage and 23 of South Asian heritage. Mean age at diagnosis (without known family history) was 45.7 months; white British ethnicity 42.1 months (range 14-86mo), South Asian ethnicity 50.2 months (range 5-98mo). Twenty-four males lost ambulation. Those of South Asian heritage lost ambulation earlier (mean LOA 105.8mo [8y 10mo]) than those of white British heritage (mean LOA 117.8mo [9y 10mo]): log-rank test score 0.012 (p<0.05). Those most deprived did worse: mean age at LOA 130.0 months (10y 10mo) for the top 20 per cent and 102.5 months (8y 6mo) in the lower 20 per cent: log-rank test score 0.035 (p<0.05). The most socially deprived were diagnosed earlier and started steroids earlier. Of those of South Asian heritage, 18 per cent declined steroids, compared with 9 per cent of white British heritage. Also, 44 per cent of those of South Asian heritage stopped steroids compared with 17 per cent of those of white British heritage. INTERPRETATION: Patients from South Asian and deprived backgrounds had earlier LOA. Genetic disease modifiers are likely to be implicated, but social and cultural factors influence access to treatment.

Ethno-cultural Preferences in Receipt of Heart Health Information.

OBJECTIVE: We attempted to understand how people of South Asian and Chinese descent prefer to receive health information. METHODS: To achieve this end we conducted a search of academic and grey literature articles published between 1946 and 2016. To be included, articles had to be focused South Asian and Chinese specific ethno-culturally-based preferences of receiving health information. RESULTS: A total of 3478 abstracts were retrieved, of which, 27 articles met the inclusion criteria. We were able to identify South Asian and Chinese people's preferences for and facilitators of receiving health information. South Asians and Chinese preferred health information and programs that were more culturally relevant and appealing, had translations into South Asian and Chinese languages, and used simple terms as opposed to technical jargon. CONCLUSIONS: There is little direction regarding for how to tai- lor health information South Asian and Chinese ethno-cultural groups. Having evidence-based information about how South Asians and Chinese prefer to receive health information has potential to enhance patients' learning and health literacy, improve clinical outcomes, and reduce health disparities.

Shodagor Family Strategies : Balancing Work and Family on the Water.

The Shodagor of Matlab, Bangladesh, are a seminomadic community of people who live and work on small wooden boats, within the extensive system of rivers and canals that traverse the country. This unique ecology places particular constraints on family and economic life and leads to Shodagor parents employing one of four distinct strategies to balance childcare and provisioning needs. The purpose of this paper is to understand the conditions that lead a family to choose one strategy over another by testing predictions about socioecological factors that impact the sexual division of labor, including a family's stage in the domestic cycle, aspects of the local ecology, and the availability of alloparents. Results show that although each factor has an impact on the division of labor individually, a confluence of these factors best explains within-group, between-family differences in how mothers and fathers divide subsistence and childcare labor. These factors also interact in particular ways for Shodagor families, and it appears that families choose their economic strategies based on the constellation of constraints that they face. The results of these analyses have implications for theory regarding the sexual division of labor across cultures and inform how Shodagor family economic and parenting strategies should be contextualized in future studies.

Provider- and patient-related determinants of diabetes self-management among recent immigrants: Implications for systemic change.

OBJECTIVE: To examine provider- and patient-related factors associated with diabetes self-management among recent immigrants. DESIGN: Demographic and experiential data were collected using an international survey instrument and adapted to the Canadian context. The final questionnaire was pretested and translated into 4 languages: Mandarin, Tamil, Bengali, and Urdu. SETTING: Toronto, Ont. PARTICIPANTS: A total of 130 recent immigrants with a self-reported diagnosis of type 2 diabetes mellitus who had resided in Canada for 10 years or less. MAIN OUTCOME MEASURES: Diabetes self-management practices (based on a composite of 5 diabetes self-management practices, and participants achieved a score for each adopted practice); and the quality of the provider-patient interaction (measured with a 5-point Likert-type scale that consisted of questions addressing participants' perceptions of discrimination and equitable care). RESULTS: A total of 130 participants in this study were recent immigrants to Canada from 4 countries of origin-Sri Lanka, Bangladesh, Pakistan, and China. Two factors were significant in predicting diabetes self-management among recent immigrants: financial barriers, specifically, not having enough money to manage diabetes expenses (P = .0233), and the quality of the provider-patient relationship (P = .0016). Participants who did not have enough money to manage diabetes were 9% less likely to engage in self-management practices; and participants who rated the quality of their interactions with providers as poor were 16% less likely to engage in self-management practices. CONCLUSION: Financial barriers can undermine effective diabetes self-management among recent immigrants. Ensuring that patients feel comfortable and respected and that they are treated in culturally sensitive ways is also critical to good diabetes self-management.