Sukar Ala Sukar: A Website for Diabetes Education and

Support for Saudi Arabian and Middle Eastern 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
Background
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

Content
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

Social Networking
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.

Biographies
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.