Introduction

Type 2 diabetes mellitus (T2DM) is a significant global public health challenge, impacting the well-being of individuals, families and societies.1 In 2023, T2DM resulted in a loss of 124 000 years of healthy life in Australia and contributed to 2.2% of the overall burden of disease. It ranked 11th highest specific cause of disease burden, with a rate of 4.7 per 1000 population.2–4 Additionally, studies consistently show a higher prevalence of T2DM among people from Middle Eastern (ME) and North African backgrounds who reside in high-income countries (HICs) compared with the general population.5 This is the case in 21 countries in Asia and Africa, which are characterised by cultural diversity, religious distinction and economic variations in ME countries, including Algeria, Bahrain, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Palestine, Qatar, Saudi Arabia, Syria, Tunisia, Turkey, the United Arab Emirates and Yemen.6

For instance, high prevalence of diabetes or elevated risk of developing T2DM compared with native populations has been found among Lebanese and Turkish immigrants in Denmark,7 Arab American populations8–10 and Arab and West Asian background communities living in Canada.11

T2DM prevention involves interventions targeting the development or progression of disease.12 According to Diabetes Australia, T2DM can be prevented or delayed, with estimates of up to a 58% reduction in disease incidence.13 This outcome pivots on prevention across modifiable behaviours, such as maintaining a healthy weight, engaging in regular physical activity, managing blood pressure and cholesterol levels, smoking cessation and adhering to a nutritious dietary regimen.14

The rationale is threefold. First, the global prevalence of diabetes is increasing, with a projected 9.3% (463 million individuals) of the global population impacted by T2DM in 2019, rising to 10.2% (578 million) by 2030 and 10.9% (700 million) by 2045.15 Moreover, the current prevalence of T2DM, at approximately 16.2%, is high among the ME population, and the number of people with diabetes among this population is expected to reach 136 million by 2045.2 Second, the prevalence of diabetes is higher in immigrant populations than in non-immigrant populations. Australia’s National Diabetes Services Scheme data reveal different diabetes prevalence rates among overseas-born residents living in Australia compared with people from Lebanese backgrounds who represent approximately 6% of diabetes cases.16 Moreover, a study using data from the 45 and Up Study baseline data set to examine disparities in the prevalence of chronic diseases between individuals of Lebanese descent and Australian-born individuals shows that individuals of Lebanese descent were at a higher risk of developing T2DM (OR 1.62; 95% CI 1.32 to 2.00) compared with individuals born in Australia.17 Third, ME populations residing in HICs constitute a unique community with distinct cultural and social practices that put them at a higher risk of developing T2DM.18 19

Accordingly, the objective of this systematic review was to evaluate the available evidence for interventions designed to prevent T2DM among ME populations residing in HICs. It aimed to achieve two key goals: (1) assess the efficacy and effectiveness of various interventions in improving health outcomes, such as weight loss, physical activity and glycaemic control, and (2) identify and analyse the barriers and facilitators influencing the implementation and effectiveness of interventions, with a focus on culturally sensitive approaches and modifiable risk factors.

Methods

A preliminary search of MEDLINE, the Cochrane Database of Systematic Reviews and the Joanna Briggs Institute (JBI) Evidence-Based Practice was conducted and found that no systematic reviews on the topic had been conducted or were underway.

Search strategy

This systematic review was conducted in accordance with the methodology outlined in the JBI Manual for Evidence Synthesis.20 Following JBI guidelines, the search strategy was designed to locate both published and unpublished studies. Databases searched included MEDLINE, ProQuest Central and Scopus. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe them, were used to develop a comprehensive search strategy tailored to each database. In addition, grey literature sources were searched using Google Scholar and Google Advanced Search as search engines, OpenGrey and other resources as shown in online supplemental appendix A.

The search scope was limited to studies in the English language. This restriction was underpinned by the observation that a substantial proportion of scholarly journals in the ME region predominantly adopt English as their publication language.21 Moreover, the timeframe for consideration was defined between 2000 and 2023. This timeframe was set because a considerable volume of pivotal research pertaining to diabetes prevention strategies surfaced in the literature post the year 2000.22

The search strategy included a combination of keywords, Medical Subject Headings terms and Boolean operators to ensure comprehensive coverage of the literature. Keywords related to type 2 diabetes mellitus, Middle Eastern background, generation(s), immigrants, immigration, high-income countries, diabetes prevention, T2DM, prediabetes, diabetes high risk, overweight, sedentary lifestyle, physical inactivity, gestational diabetes, interventions, strategies, barriers, facilitators, culturally appropriate approaches, health disparities, health outcomes, healthcare utilization, lifestyle changes, behavioral changes, glycaemic control and quality of life. The complete search strategy, including all keywords and Boolean operators, is detailed in online supplemental appendix A.

Study selection

Following the search, all identified citations were collated and uploaded into Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia). Following a pilot of the search strategy, titles and abstracts were then screened by two independent reviewers (AD and PRW) for the assessment against the inclusion criteria for the review. Full-text articles of potentially relevant studies were then retrieved, and their citation details were imported into the software. The full text of selected citations was assessed in detail against the inclusion criteria by three independent reviewers: AD, PRW and PA. Reasons for exclusion at full text were recorded and reported. Any disagreements that arose between the reviewers at each stage of the process were resolved through discussion. The results of the search and the study inclusion process were reported in full in the final systematic review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart.23

Review question

What is the evidence regarding the interventions, barriers and facilitators, and culturally appropriate approaches for the prevention of T2DM among ME background population living in HICs?

Subquestions

What factors contribute to the elevated prevalence of T2DM among ME background people residing in HICs, and how do these factors influence the occurrence of the disease?

Which interventions and strategies have been implemented for the prevention of T2DM among the ME background community living in HICs? What is the effectiveness of these interventions and strategies, and how do they impact the health outcomes of the participants?

What are the barriers to and facilitators of the implementation of T2DM prevention interventions among the ME background population residing in HICs? How can these identified barriers be overcome to improve the overall health outcomes of the participants?

Keywords

Barriers, modifiable factors, T2DM prevention, Middle Eastern backgrounds and strategies.

Study inclusion and exclusion criteriaEligibility criteria

Studies were eligible if they involved ME populations residing in HICs and focused on the prevention of T2DM in pre-diabetic patients or individuals at high risk of T2DM as defined by the Centers for Disease Control and Prevention (individuals who were overweight; 45 years or older; had a parent, brother or sister with type 2 diabetes; physically active less than three times a week; had ever had gestational diabetes or given birth to a baby who weighed over nine pounds).24

Specific exclusion criteria based on participant characteristicsIntervention/exposure

This review considered any interventions or strategies related to T2DM prevention among people from ME backgrounds. This includes behavioural interventions (diet, physical activity), pharmacological interventions, education programmes and other relevant health promotion approaches.

Comparator/control

Comparators or control groups, such as standard care, usual practice or alternative interventions, were considered where applicable.

Outcome measures

The primary outcomes of interest included diabetes incidence, lifestyle changes, healthcare utilisation, quality-of-life measures, knowledge, awareness and attitudes towards T2DM prevention.

Secondary outcomes included changes in body weight, blood pressure, lipid profiles and glycaemic control (HbA1c levels).

Types of sources

This systematic review considered both experimental and quasi-experimental study designs, including randomised controlled trials (RCTs), non-RCTs, before and after studies and interrupted time-series studies. In addition, observational studies, prospective and retrospective studies, case-control studies, cross-sectional studies, descriptive observational study and qualitative studies were considered.

Data extraction

A standardised data extraction form was developed based on the JBI Data Extraction Instrument.25 Data extracted included participant demographics, concept, context, study methods, study design, sample size, intervention details, outcomes and key findings relevant to the review questions. The extracted data were cross-checked by two reviewers (AD and PRW) to ensure accuracy.

Quality appraisal

The methodological quality of included studies was assessed by two independent reviewers (AD and PRW) using the JBI Critical Appraisal Tools specific to the study design.25 To assess RCTs, we used the 13 items comprising JBI’s Critical Appraisal Checklist for RCTs, while quasi-experimental studies were assessed using the nine items detailed in the JBI Checklist for Quasi-experimental Studies.25 Qualitative studies were appraised using the 10 items in the JBI Critical Appraisal Checklist for Qualitative Research. Cross-sectional studies were evaluated using the eight items in the JBI Critical Appraisal Checklist for Analytical Cross-sectional Studies.25 Using these tools provided a systematic approach to assessing the internal validity, methodological rigour and relevance of each study. For more details, please check online supplemental material.

Risk-of-bias assessment

To ensure the rigour and validity of our systematic review, we conducted a comprehensive risk-of-bias assessment for each included study using tools appropriate to each study design. For RCTs, the Cochrane Risk of Bias Tool was employed.26 The JBI Critical Appraisal Checklist was used for quasi-experimental and observational studies,27 and the JBI Checklist for Qualitative Research was applied to qualitative studies.28

Our assessment targeted several types of bias. We evaluated studies for selection bias, which refers to systematic differences in the baseline characteristics of the groups that could influence outcomes; performance bias which concerns if there were systematic differences in the care provided, in addition to the interventions being tested; detection bias concerns whether outcome measurements were influenced by differences in how outcomes were determined between study groups and reporting bias which relates to the potential impact of omissions in reporting study outcomes (and reporting a subset of outcomes that are typically favourable) on the overall interpretation of the results.29

Data synthesis

Given the heterogeneity of the study designs, populations and outcome measures, a meta-analysis was not suitable nor feasible.30 Instead, a narrative synthesis was conducted, in accordance with JBI guidance20, focusing on identifying the key patterns in the outcomes of intervention strategies and barriers across the studies. The findings from the included studies were synthesised narratively, with particular attention given to the cultural adaptation of interventions, the role of family and community support, and the impact of sociocultural barriers and facilitators on T2DM prevention.

Study registration

The systematic review protocol for this study is formally registered with the International Prospective Register of Systematic Reviews under the registration number: CRD42023457123. For more details, please check online supplemental material.

Patient and public involvement

None.

ResultsStudy selection

The PRISMA flowchart outlined the process of identifying and screening studies for inclusion in the systematic review. In the identification phase, a total of 2770 studies were identified from databases and registers, with the majority coming from ProQuest Central (1391). Other major sources included MEDLINE (735), Scopus (419) and Google Scholar as a search engine (225). Additionally, other references were sought from various sources, including grey literature databases like Ethos (9) and clinical trial registries (3), but no references were obtained from Google Advanced Search, OpenGrey or ProQuest.

Out of the 2770 identified studies, 296 references were identified as duplications by Covidence and were removed from the review. This refinement process left 2486 studies eligible for assessment. Following initial screening, 2451 studies were excluded based on predetermined criteria, and a total of 33 articles were selected for full-text screening, independently by three reviewers (AD, PRW and PA) for the assessment of eligibility. Ultimately, 13 studies were excluded from the review for reasons related to setting, outcomes, intervention or patient population. Finally, after meeting the eligibility criteria, a total of 20 studies were included in the review for data extraction as shown in the PRISMA flowchart (figure 1).

Figure 1

Process of study identification and screening for the systematic review: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart.

Study characteristics

This systematic review identified 20 appropriate studies conducted between 2003 and 2023 that explored the multifaceted domain of diabetes risk, prevention and management among ME populations residing in high-income nations. Seven studies were conducted in the USA, seven in Sweden, four in Australia, one in Canada and one in Germany. A variety of methodological approaches were used, comprising seven qualitative research studies, seven randomised clinical trials, four cross-sectional studies and two quasi-experimental trials.

Sample sizes varied considerably (n=28–579 participants), reflecting the diversity and scope of the populations under investigation. Participants encompassed a wide array of immigrant groups, including Arab Americans, Turkish and Arabic-speaking individuals, Iraqi migrants, ME immigrants and Muslim Turkish individuals, with different age groups and demographic profiles.

The systematic review provides a detailed summary of key information for each study, including primary authors, study years, titles, countries, study designs, participant characteristics, sample sizes, study objectives, durations, inclusion and exclusion criteria, recruitment methods and outcome measures as shown in online supplemental appendix B.

Risk of bias in included studies

The risk-of-bias assessment conducted on the included studies revealed varying levels of bias, which is crucial for interpreting the effectiveness and applicability of the findings,26–29 as shown in table 1. Selection bias was predominantly low across the studies, suggesting that the methods employed for participant selection were robust, which enhances the representativeness and applicability of the findings. Performance and detection biases were higher in qualitative studies due to the inherent challenges of blinding participants and researchers to the intervention, which might influence the behaviours observed and reported. In quantitative studies, performance and detection biases were lower, largely due to the ability to use blinding and control measures more effectively, thus minimising potential influences on outcome measurements. Reporting bias ranged from low to moderate across all studies, indicating a reliable presentation of research findings without selective reporting. Finally, attrition bias was generally low in most interventional studies, reflecting effective data handling and high retention rates that support the reliability of the outcome data.

Table 1

Risk-of-bias assessment summary

Data analysisStudy details and approaches

The 20 studies included in this review were divided into two main categories based on the study design. The first category included interventional studies, such as RCTs and quasi-experimental designs. The second category encompassed observational studies, which includes qualitative research, providing a broader spectrum of data on various aspects of T2DM prevention.

Interventional studies

Of the nine intervention studies, seven were RCTs and two were quasi-experimental trials. These studies predominantly focused on culturally adapted lifestyle modifications aimed at reducing T2DM risk factors such as weight and physical inactivity. For instance, Siddiqui et al 31 designed a lifestyle intervention for Iraqi immigrants in Sweden, featuring group sessions in Arabic that focused on diabetes and cardiovascular disease awareness, motivation and lifestyle maintenance.

Gender-specific and -responsive interventions also tailored to cultural preferences have been implemented and encourage physical activity and healthy eating. For example, Siddiqui et al implemented gender-specific group sessions and cooking classes32, and Hussien et al conducted an RCT among Arab Canadian Muslim women, offering a culturally tailored exercise and nutrition programme with Arabic music to address T2DM risk factors within a culturally sensitive framework.33

Nutritional counselling and culturally tailored cooking classes have been employed to encourage healthier eating behaviours. Siddiqui et al included cooking classes featuring ME cuisine in their intervention for Iraqi immigrants in Sweden.32 Hussien et al 33 offered nutritional counselling alongside a supervised exercise programme, with 1 hour weekly gym sessions. Saha et al 34 adapted the Diabetes Prevention Program for Middle Eastern immigrants, incorporating cooking classes and health coaches knowledgeable about ME culture, supported by professional translators. Furthermore, Jaber et al 35 included wise Arabic sayings, religious themes and imagery in their study. Structured exercise programmes with cultural elements have also been used. Hussien et al 33 introduced a programme featuring traditional Lebanese Dabka dance, focusing on endurance, flexibility and strength activities conducted three times a week.

Observational studies

The remaining 11 studies included 4 cross-sectional and 7 qualitative research studies. These studies provided important insights into the sociocultural factors that influence diabetes prevention. For instance, Bertran et al 36 conducted a qualitative study that used focus groups to explore Arab Americans' perceptions of diabetes, identifying key themes such as myths about diabetes aetiology and the influence of cultural practices, including the intersections with gender norms and religiosity, on health behaviours to inform culturally specific prevention programmes.

Providing health information and raising awareness about diabetes risk factors was a key component of prevention interventions. Lecerof et al 37 explored how educational level modified the relationship between access to health information and overweight prevalence among Iraqi migrants in Sweden, finding that higher education levels influenced health outcomes. Similarly, Caperchione et al 38 examined the sociocultural barriers to and facilitators of physical activity among culturally and linguistically diverse (CALD) women in Australia, revealing that family obligations and safety concerns significantly shape their activity behaviours.

Understanding the impact of acculturation on diabetes risk and lifestyle behaviours was crucial for tailoring interventions. Al-Dahir et al 39 assessed acculturation among Arab Americans using the Acculturation Rating Scale of Arab Americans, considering variables like food preference, language use and socialisation patterns.

Addressing psychosocial factors such as stress, social support and mental health was integral to diabetes prevention interventions. For instance, McConatha et al 40 found that patients benefit from family and community support in the management of their illness.

Outcome measures

The outcome measures in this systematic review varied across the studies, with distinctions made between interventional studies and observational studies. For interventional studies, outcome measures primarily focused on quantifiable health indicators such as weight loss, physical activity levels and cardiometabolic markers. For observational studies, outcome measures were more qualitative and focused on sociocultural influences and perceptions related to diabetes prevention such as perceptions and attitude, cultural barriers and facilitators, and health information and education, as detailed in table 2 and online supplemental appendix B.

Table 2

A comprehensive overview of the primary authors, titles, study designs, participant descriptions, study aims, inclusion and exclusion criteria, and outcome measures for each study included in the systematic review

Main outcomes and key findingsInterventional studies

Culturally adapted lifestyle interventions showed substantial weight loss. For example, Siddiqui et al 31 reported a reduction in body weight from 85.5 kg to 83.0 kg and a decrease in body mass index (BMI) from 31.0 to 30.4 kg/m2 among Iraqi immigrants in Sweden. Similarly, Jaber et al 35 found that by week 24, 44% of participants achieved at least a 7% weight loss. Furthermore, Hussien et al 33 observed a substantial increase in daily steps from 5040 to 11 926 within 12 weeks and a 7% reduction in body mass, with a 58% reduction in diabetes risk. Siddiqui et al 41 highlighted that replacing sedentary time with light-intensity activities could benefit diabetes prevention, with the intervention group significantly increasing their light-intensity physical activity, associated with a higher insulin sensitivity index (β=0.023, 95% CI 0.001 to 0.045, p=0.037).

Tailored lifestyle interventions also proved to be effective in improving cardiometabolic risk factors. Aktas et al 42 demonstrated decreased systolic and diastolic blood pressures by approximately 5 mm Hg among Muslim patients in Germany. Siddiqui et al 32 reported significant reductions in body weight, BMI and Low-density lipoprotein (LDL)-cholesterol, and increases in the mean insulin sensitivity index among Iraqi immigrants in Sweden. Hussien et al 33 found that Arab Canadian Muslim women in an intensive lifestyle intervention group achieved significant reductions in BMI (χ2(1) = 16.48, p=0.001), fasting blood glucose (χ2(1) = 52.26, p<0.001) and waist circumference (χ2(1) = 4.29, p=0.038) compared with the control group.

Sociocultural factors such as social support and family involvement were crucial in achieving weight loss outcomes. Pinelli et al 43 showed that family support during lifestyle intervention sessions was associated with higher rates of achieving weight loss goals among Arab Americans (70% vs 30%; p=0.0023). This emphasises the importance of familial and community support networks in facilitating behaviour change and sustaining weight loss efforts. Reports of racism and discrimination negatively affected health service access for CALD populations, as noted by Komaric et al.44

These studies provide evidence that culturally tailored interventions can effectively improve key health measures including weight loss and improvements in cardiometabolic outcomes, as detailed in table 3 and online supplemental material.

Table 3

A comprehensive overview of the primary authors, interventions, main outcomes, barriers, facilitators and Implications for preventive health practice

Observational and qualitative studies

Physical activity behaviours among immigrant populations were influenced by a range of psychological, sociocultural and environmental factors. Caperchione et al 38 identified themes like post-war trauma and social isolation and the impacts on reduced physical activity levels. Lecerof et al 37 found that 71% of Iraqi migrant women and 48% of men in Sweden did not engage in regular physical activity. Importantly, a lack of health information was considered a separate variable that was linked to overweight, independent of other factors such as migrant status. This absence of health information contributed to higher rates of overweight, especially among those less engaged in regular physical activity.37

Acculturation levels were found to influence diabetes risk. Al-Dahir et al 39 identified a negative correlation between Arab acculturation and diabetes risk among males (r=−0.216, p=0.044) and between American acculturation and diabetes risk among females (r=−0.222, p=0.032), and they reported that higher generation identification (second or third) was associated with lower diabetes scores for male respondents, suggesting differences in diabetes risk based on acculturation levels among Arab Americans.

Educational attainment played a significant role in shaping health behaviours. Lecerof et al 37 revealed that the impact of dietary information on overweight was most pronounced among those with high educational levels, demonstrating that higher education aids in the effective assimilation of health information.

Qualitative studies shed light on the lived experiences of immigrant populations and their challenges in adopting healthier lifestyles. McConatha et al 40 reported increased vulnerability and stress among ME immigrants due to diabetes management, impacting social integration and mental well-being. Sulaiman et al 45 revealed that social exclusion, racism and safety concerns acted as significant barriers to diabetes prevention efforts among Turkish and Arabic-speaking Australians. Conversely, Bertran et al 36 identified acculturative stress and healthcare access challenges as barriers, while the recognition of gender norms in culturally sensitive interventions were facilitators in diabetes prevention efforts for Arab Americans.

These studies highlight critical barriers such as cultural norms, language constraints, lack of healthcare access and social isolation, which impede lifestyle changes needed for T2DM prevention as detailed in table 3 and .online supplemental appendix C.

Barriers to T2DM prevention

As shown in table 3, lower acculturation levels have been associated with challenges in adopting healthy behaviours, such as consuming culturally specific foods.8 Lack of health insurance, safety concerns and social support have inhibited engagement with healthy behaviours and hindered intervention effectiveness.46

Cultural norms and expectations, language constrains, low socio-economic status, negative perceptions and limited culturally appropriate healthcare programmes also hinder behaviour modification and healthcare access among immigrant populations.31 36 44 45 47

Facilitators of T2DM prevention

As shown in table 3, family involvement and culturally sensitive interventions have significantly encouraged adherence to programme regimens and promoted positive outcomes in weight loss and lifestyle behaviours.33 40 43 Moreover, financial assistance and translated materials have improved accessibility and understanding of interventions and enhancing knowledge of diabetes risk factors among ME immigrants.48 49

Gender-responsive sessions and addressing language and cultural barriers have increased intervention engagement. Women-only facilities and professional translators promoted physical activity among Iraqi immigrants in Sweden.41 42 Furthermore, access to exercise centres and community support fostered healthier lifestyles, with government and local authority collaboration improving infrastructure, such as street lighting, for Turkish and Arabic-speaking Australians.45

Heterogeneity in study characteristics and meta-analysis

Due to the diverse interventions, outcome measures, study designs and participant characteristics among the included studies, a meta-analysis was not feasible to conduct.30 The studies implemented various interventions, which has resulted in diverse outcomes. The methodologies ranged from qualitative research to RCTs and observational studies, making it challenging to pool the results. The participant characteristics varied in age, gender, socio-economic status and cultural backgrounds, which has further contributed to the heterogeneity observed across the studies. Consequently, a narrative synthesis was used to comprehensively summarise and interpret the findings.

DiscussionOverview

This systematic review encompassed 20 studies that explored various intervention approaches for T2DM prevention among ME populations. These interventions included culturally adapted lifestyle interventions, dietary interventions and physical activity programmes tailored to the specific needs and preferences of the target populations.8 33 34 40

The findings revealed promising outcomes in modifying behaviours, improving health measures and reducing T2DM risk factors among participants. The evidence showed that tailored interventions have demonstrated preventive benefits including weight loss, increased physical activity levels and enhancements in cardiometabolic outcomes.36 43 48 49

In the experimental studies, the outcomes of gender-specific interventions such as women-only exercise programmes32 33 aligned with the findings from qualitative studies, where effectiveness improved when gender norms were acknowledged along with cultural preferences.36 41

Family involvement was a key facilitator for interventions in both the experimental studies43 and qualitative studies,45 showing that sociocultural factors significantly improve the outcomes of interventions. Conversely, the absence of family support during interventions was a barrier, indicating that family engagement strategies are critical for intervention effectiveness and sustainability.47

Implications for preventive health practice

Acculturation and cultural competence are pivotal in designing effective T2DM prevention and management strategies for immigrant populations. Understanding and respecting cultural backgrounds are essential when healthcare providers advise patients on lifestyle changes, acknowledging factors such as family roles and interactions, dietary habits and exercise preferences.40 Using reliable acculturation assessment tools can help providers measure the level of acculturation among immigrant groups and has been shown to aid the development of culturally competent T2DM interventions.39

Cultural adaptation of interventions is essential for ensuring their acceptability and effectiveness within immigrant populations. Tailoring interventions that respond to social and cultural barriers identified through qualitative studies is essential.31 32 Evidence indicates this enhances the effectiveness and sustainability of preventive efforts within ME communities in HIC, and examples include offering culturally adapted cooking classes, developing community-based physical activity facilities and recognising gender norms, religious beliefs, language support and involving people with lived experience, healthcare providers and community stakeholders to co-design interventions.36

Enhancing infrastructure for physical activity and improving healthcare access are important to facilitate T2DM prevention and management within immigrant communities. This includes initiatives such as improving safety through better lighting and well-maintained footpaths, offering gender-specific classes (especially women-only and mother-child friendly environments to enhance programme accessibility).38 Additionally, access to interpreters and culturally appropriate communication in healthcare settings, coupled with cultural competency training for healthcare professionals, is essential to facilitate effective intervention.44

Community-driven initiatives are important in addressing T2DM prevention among immigrant populations. Culturally sensitive interventions that aim to reach individuals but also their workplaces and/or communities are necessary for fostering behavioural changes and promoting healthy lifestyles.33 Holistic approaches that will provide personal support, access to relevant and appropriate health services, and lifestyle-specific programmes tailored to the cultural needs of ME populations will be crucial for long-term modifications.46

Involving families and providing economic support are integral components of effective diabetes prevention. Family-centred interventions aimed at behaviour modification can assist individuals in achieving weight loss and adopting healthier lifestyles.43 49 Additionally, providing economic support or subsidies to facilitate access to resources necessary for physical activity, like offering free gym memberships, can help overcome financial barriers among immigrant communities.41

Strengths and limitations

This systematic review followed the PRISMA guidelines, ensuring thorough coverage of pertinent literature. Each study underwent rigorous evaluation using JBI appraisal tools to assess scientific quality and minimise bias. The review encompassed diverse study types focusing on diabetes prevention interventions, ensuring a comprehensive examination of evidence. The search strategy employed robust methods, including multiple databases and manual searching of reference lists, to minimise the risk of missing relevant literature.

However, language bias may exist as only English-language studies were included, potentially overlooking pertinent literature published in other languages. The included studies encompassed a diverse range of interventions and outcomes, making it challenging to conduct a meta-analysis about the most effective approaches for T2DM prevention in this population. While we acknowledge the importance of Embase for biomedical and pharmacology literature, our initial search strategy encompassed Scopus, MEDLINE, Google Scholar, ProQuest Central, Google Advanced and clinicaltrials.gov, aimed at capturing a broad range of studies, including unpublished or ongoing research. Despite Scopus’s extensive coverage, which overlaps with Embase, excluding Embase might have led to omitting some pertinent studies, limiting the comprehensiveness of our systematic review. Finally, publication bias may exist as studies with positive results are more likely to be published, potentially affecting the overall findings.

Implications for future studies

This systematic review identified a gap in the literature regarding the role of healthcare providers in developing and designing interventions with the engagement of ME communities and stakeholders to prevent T2DM among ME populations in HICs. While some studies emphasised the importance of culturally sensitive interventions for T2DM prevention, there is limited exploration of healthcare settings' roles in this context. One of the most accessible healthcare settings is the community pharmacy, particularly for individuals with limited access to healthcare services.50 In Australia, pharmacists have initiated community diabetes care programmes, including medication management, self-management education and medication adherence. For instance, Armour et al 51 and Krass et al 52 demonstrated that pharmacists could achieve better health outcomes through patient education and medication reviews. Additionally, a systematic review by Saqf el Hait et al 53 revealed that pharmacists' roles as healthcare providers and educators in diabetes management have been effective in numerous Western countries. Another study by Alzubaidi et al 54 highlighted the feasibility of a community pharmacist-delivered screening of diabetes and cardiovascular disease (CVD) risk, where the model offered a platform to increase screening capacity within primary care and provided an opportunity for early detection and treatment of T2DM.

Additionally, there is limited research on the role of pharmacists and the needs of Arabic-speaking individuals in preventing T2DM in Australia. Therefore, collaboration between Arabic-speaking healthcare professionals, such as pharmacists, and ME community stakeholders knowledgeable about Arabic cultures, is needed. This collaboration could lead to the development of tailored T2DM prevention strategies focusing on medication management, patient education and lifestyle counselling to be implemented in community pharmacies.53 54 Such a collaborative effort could effectively address the gap in T2DM prevention within this community. Nonetheless, there is a need to assess pharmacists' cultural intelligence and their ability to provide culturally tailored services, including understanding cultural barriers and addressing cultural beliefs and practices related to T2DM prevention.55

Moreover, the literature lacks integration of cultural intelligence training for healthcare providers, including pharmacists, which could enhance their ability to deliver effective diabetes prevention within ME populations.55 Future research is required to explore the impact of training programmes on healthcare provider’s knowledge, attitudes and behaviours in this regard. Language barriers frequently challenge healthcare access, highlighting the need to investigate healthcare providers’ language competencies, particularly proficiency in Arabic, to improve communication and mutual understanding during the implementation of interventions.56

Addressing these gaps in the literature will contribute to a more comprehensive understanding of the factors influencing the effectiveness of T2DM prevention interventions among ME immigrant populations. This, in turn, will facilitate the development of more effective, culturally appropriate interventions to reduce the burden of T2DM within HICs.