-
Social and Cultural Aspects of Living with Type 2
Diabetes for Ethnic Minorities in Canada
by Peyman Namdarimoghaddam
Grad. Cert. (Science & Tech. Commercialization), Simon Fraser University, 2018
B.Sc. (with distinction), Simon Fraser University, 2017
Thesis Submitted in Partial Fulfillment of the
Requirements for the Degree of
Master of Science
in the
Master of Science Program
Faculty of Health Sciences
© Peyman Namdarimoghaddam 2020
SIMON FRASER UNIVERSITY
Spring 2020
Copyright in this work rests with the author. Please ensure that any reproduction or re-use is done in accordance with the relevant national copyright legislation.
-
ii
Approval
Name: Peyman Namdarimoghaddam
Degree: Master of Science
Title: Social and Cultural Aspects of Living with Type 2 Diabetes for Ethnic Minorities in Canada
Examining Committee: Chair: Travis Salway Assistant Professor
Scott A Lear Senior Supervisor Professor
Hasina Samji Supervisor Assistant Professor
Valorie Crooks Examiner Professor Department of Geography
Date Defended/Approved: April 30, 2020
-
iii
Ethics Statement
-
iv
Abstract
Diabetes is a chronic progressive disease that affects one in three Canadians
and ethnicity is one of its risk factors in Canada. Type 2 diabetes (T2DM) which
constitutes the vast majority of the cases, is highly impacted by social and cultural
factors. However, we know very little about how social and cultural factors impact living
with T2DM in for ethnic minorities in Canada. A systematic review of the existing
literature and survey-based assessment of patient perceptions were conducted. The
most important social and cultural determinants of health for patients were diabetes
education, social support, cultural competency of institutions (e.g. healthcare system, the
government), patient trust for institutions, perceptions of self, and the perception of
financial barriers. The social and cultural factors of importance can be understood in
three categories of (1) diabetes education, (2) perceptions of self and perceived relations
with others, (3) perceived financial constraints.
Keywords: type 2 diabetes; social; cultural; ethnic minority; Canada
-
v
Acknowledgements
I would like to express my gratitude for the opportunity to work within the Cities
Changing Diabetes program in Vancouver. This collaboration allowed me to take a novel
multidisciplinary approach towards describing and analyzing patient perspectives.
A big thank you to Novo Nordisk for providing partial funding towards the
Vancouver Diabetes Priorities Assessment (VDPA) which constitutes one of the main
studies in this thesis.
Many thanks to Veronica de Jong, Nisa Onsel, Emily Ross, Dr. Adeleke
Fowokan, and the staff at the Community Heart Research Team (CoHeaRT) who have
played an important role in my learning, participant recruitment, and data collection.
Special thanks to Dr. Anna Volkmann and Dr. Diane Finegood for their early
feedback on the ideation and planning of this thesis.
I would like to thank Dr. Greg Bondy; Aboriginal Mother Center Society, First
Nations Healing Circle, Native Health Clinic, The Lu’ma Medical Clinic, Praise in the
Park community church, and Diabetes Health Center, The John Ruedy
Immunodeficiency Clinic (IDC), and Healthy Heart Department at St. Paul’s Hospital for
assisting with recruitment efforts.
I would like to thank Heide Felton, Matthew Felton, and Melanie Ho whose
support has made my contribution to this research possible.
I am grateful for the continuous support of Dr. Scott Lear and Dr. Hasina Samji
who were at the forefront of my learning and provided me with extensive training and
feedback.
-
vi
Table of Contents
Approval ............................................................................................................................ ii Ethics Statement ............................................................................................................... iii Abstract ............................................................................................................................ iv Acknowledgements ........................................................................................................... v Table of Contents ............................................................................................................. vi List of Tables ................................................................................................................... viii List of Figures................................................................................................................... ix
Chapter 1. Introduction ................................................................................................ 1 1.1. Diabetes Mellitus ..................................................................................................... 1 1.2. Ethnicity ................................................................................................................... 1 1.3. Social and Cultural Factors ..................................................................................... 2 1.4. Urban Diabetes ....................................................................................................... 4 1.5. Purpose ................................................................................................................... 4 1.6. Structure .................................................................................................................. 5 1.7. Positionality Statement ............................................................................................ 5 1.8. References .............................................................................................................. 6
Chapter 2. A Summary of Current State of Knowledge: Social and Cultural Factors among Ethnic Minorities Living with Type 2 Diabetes in Canada - A Systematic Review .............................................................................................. 11
2.1. Abstract ................................................................................................................. 11 2.2. Introduction ........................................................................................................... 12 2.3. Methodology .......................................................................................................... 13 2.4. Results .................................................................................................................. 15
2.4.1. Indigenous ..................................................................................................... 15 2.4.2. Black ............................................................................................................. 16 2.4.3. South Asian ................................................................................................... 16 2.4.4. East Asian ..................................................................................................... 17
2.5. Discussion ............................................................................................................. 17 2.6. References ............................................................................................................ 20 2.7. Tables and Figures ............................................................................................... 26 2.8. Supplementary Material ........................................................................................ 40
Chapter 3. Patient Perspectives on Social and Cultural Aspects of Living with Type 2 Diabetes in a Heterogeneous Urban Population Using Q Methodology
................................................................................................................... 59 3.1. Abstract ................................................................................................................. 59 3.2. Introduction ........................................................................................................... 61 3.3. Methodology .......................................................................................................... 63 3.4. Results .................................................................................................................. 66 3.5. Discussion ............................................................................................................. 70 3.6. References ............................................................................................................ 73
-
vii
3.7. Tables ................................................................................................................... 77 3.8. Supplementary Material ........................................................................................ 81
Chapter 4. Discussions ............................................................................................. 88 4.1. Discussions ........................................................................................................... 88 4.2. References ............................................................................................................ 94
-
viii
List of Tables
Table 1-1-1 listing the social and cultural factors that impact life with T2DM. ................... 3 Table 2-1 Demonstrating keywords crossed with “Type 2 Diabetes” AND “Social OR
Cultural” ................................................................................................... 27 Table 2-2 Result of quality appraisals for eligible qualitative papers .............................. 28 Table 2-3 Result of quality appraisals for eligible cohort papers ..................................... 29 Table 2-4 Result of quality appraisals for eligible cross-sectional papers ....................... 30 Table 2-5 Summary of characteristics of eligible papers ................................................ 31 Table 2-6 Detailed characteristics of eligible papers ....................................................... 32 Supplementary I: Table 2-7 Areas of content covered in eligible papers categorized by
ethnicity ................................................................................................... 40 Supplementary II: Table 2-8 Data extracted from each eligible paper ............................ 41 Table 3-1 Characteristics of participants across different factor arrays .......................... 77 Table 3-2 Detailed statement rankings of each factor array ........................................... 79 Supplementary I: Table 3-4 The 64 statements used in the online sorting activity ......... 81 Supplementary II:Table 3-5 List of the social and cultural factors that impact life with
T2DM. ...................................................................................................... 84 Supplementary IV: Table 3-3 Characteristics of those who did versus those who did not
significantly load on the factor arrays ...................................................... 86
-
ix
List of Figures
Figure 1-1 Schematic demonstration of the intermediary role of social and cultural factors in the relationship between ethnicity with health-related behaviours as a part of lifestyle. ................................................................ 2
Figure 2-1 PRISMA chart showing the process of screening papers for this systematic review ...................................................................................................... 26
Supplementary III: Figure 3-1 structure of the thirteen-column matrix for the statement sorting activity .......................................................................................... 85
-
1
Chapter 1. Introduction
1.1. Diabetes Mellitus
Diabetes Mellitus (diabetes) affects more than 10.8 million Canadians (1) and
imposes a substantial burden on the healthcare system. An average 19 Canadians die
of diabetes every day (2) and the cost of diabetes and its complications exceed 10% of
the country’s annual healthcare budget (3; 1). The level of this burden is also on the rise
as the prevalence of diabetes in Canada is projected to grow by 21% by 2028 (4).
Diabetes is a chronic progressive disease that is characterized by the prolonged
presence of excessive levels of glucose in the blood. Diabetes often leads to micro- and
macro-vascular complications of the heart, kidneys, eyes, and lead to the amputation of
extremities of the body. The largest cause of mortality among diabetes patients is
cardiovascular complications. The prominent mechanisms underlying diabetes either
involve the inability of the beta cells of the pancreas to produce insulin (type 1) or the
inability of the tissue cells (e.g. muscles, liver) to take up glucose from the blood stream
(type 2). Type 2 diabetes (T2DM) constitutes the majority of diabetes cases (roughly 90
– 95%) and has risk factors that are primarily related to lifestyle.
1.2. Ethnicity
Ethnicity is a risk factor for T2DM. The largest visible ethnic minorities in Canada
are Indigenous, Black, East Asian, South Asian, and Southeast Asian communities,
many of whom are at an elevated risk for T2DM compared to the general population.
The age-standardized prevalence estimates for diabetes among Indigenous
communities are 17.2% among on-reserve First Nations, 10.3% among off-reserve First
Nations, 7.3% among Métis, compared to 5.0% in the general population (5). For
Canadians of Chinese origin, the age- and sex-standardized diabetes incidence
increased by 15 fold between 1996 and 2005 while it only rose by 24% in people with a
European background (6). People of South Asian descent living in Canada are three to
five times more likely to develop T2DM compared to the general population (7). The
odds of Black Canadian men and women being diagnosed with diabetes are 1.95 and
2.74 times that of their White counterparts (8).
-
2
Ethnicity is a complex multidimensional construct reflecting an interplay of
biological, geographical, cultural, economic, political and legal factors, as well as racism
(9). There are no universal tools to objectively measure ethnicity. This inability to
measure ethnicity is an especially important challenge in Canada, an ethnically diverse
country, where cross-ethnic influences and multi-ethnic families are common. There are
individuals whose genetic, social, and cultural aspects of ethnic identity might not always
align. For many people in Canada, the standard ethnic categories fail to capture the true
state of their ethnic identities. However, for the purposes of this thesis, we will consider
ethnicity to be a self-declared membership in a single group with a unique set of adopted
norms and practices.
1.3. Social and Cultural Factors
The unique norms and practices of each ethnic group constitute what is known
as their culture. These cultural factors together with social elements shape the lifestyle of
individuals, including their health-related behaviours. Figure 1 shows this relationship
schematically.
Figure 1-1 Schematic demonstration of the intermediary role of social and cultural
factors in the relationship between ethnicity with health-related behaviours as a part of lifestyle.
Previous studies have primarily examined the T2DM-related ethnic disparities
from biological (10), environmental (11), behavioural (12), and healthcare-related (13;
14) perspectives. The biological contributors to the ethnic disparity in T2DM include (but
are not limited to) glucose metabolism and insulin resistance (15; 16; 17; 18; 19; 20; 21),
Ethnicity
Lifestyle
Health-Related
Behaviours
Social Factors
Cultural Factors
-
3
obesity (10), genetics (22), and glycemic control (23; 24; 25). However, there has been
limited research on the social and cultural contributors to the ethnic disparities in T2DM.
Table 1 lists the cultural determinants of living with T2DM which comprise of
agency and opportunity, traditions and conventions, perceptions of health and illness,
ideas of self and other, change and transition (26). This table also lists the social
determinants of living with T2DM which comprise of financial, time, resource, and
geographical constraints (26). These factors determine patients’ abilities to partake in
healthy activities such as exercise and sourcing healthy foods (26).
Table 1-1-1 listing the social and cultural factors that impact life with T2DM.
Cultural Factors
Agency and Opportunity: How much of the decisions made by an individual are truly their own and whether they have the freedom to modify their own behaviours.
Traditions and Conventions: The unique practices of an ethnic group which may act as barriers to effective self-care, for example, by dictating gender roles or promoting unhealthy
diets. Perceptions of Health and Illness: Perceptions such as stigma attached to being diabetic
that can lead to poor care-seeking behaviours and resistance against lifestyle modifications. Ideas of Self and Other: How an individual perceives themselves compared to the
community around them can encourage or discourage healthy activities. For example, patients who see large body size as a norm in their community, may perceive slimming as
unnecessary. Change and Transition: Rapidly growing and changing environments can cause significant
levels of stress which lead to poor health outcomes.
Social Factors
Financial Constraints: Reduce patients’ abilities to pay for health resources. Time Constraints: Family and work commitments take away from one’s ability to attend
healthy activities. Resource Constraints: Low levels of education and a lack of availability of or a lack of
awareness about healthcare resources which prevent patients from being able to access healthy activities.
Geographical Constraints: Unfavorable climate, pollution, high crime levels, or lack of infrastructure that act as barriers to healthy activities (e.g. outdoor exercise).
As a part of this thesis, I will comment on the dual (objective and perceived)
nature of some of the social and cultural factors listed above. Many of the social and
cultural factors can be seen from an objective or perceived perspective. The measures
of the two perspectives may not always align. For example, the objective measure of
financial constraints would be the amount of a patient’s annual income in dollars,
whereas, the perceived nature of their financial constraints would be a self-reported
assessment of the level of financial barriers they are facing to care. The findings of these
two measures may indicate different and sometimes conflicting findings. Moreover, there
-
4
are other factors that are solely perceived in nature. For example, the cultural factor,
perceptions of health and illness, only takes into account the perceived aspect of the
factor. Previous research has demonstrated that both objective (27) and perceived (28)
barriers to care have a real impact on diabetes health outcomes.
1.4. Urban Diabetes
Approximately two-thirds of all people with diabetes live in urban environments
(29). Despite the many benefits that cities provide, such as access to education,
healthcare, and employment, cities have seen an increased burden of diabetes (30).
Some of this increased burden may be explained through sedentary lifestyles (31; 32),
consumption of energy-dense foods (33; 34), and low levels of physical activity (35; 36)
in the urban environment.
This thesis was conducted in parallel to the Cities Changing Diabetes (CCD)
global initiative which was structured to understand the driving socio-cultural factors
behind the rise of diabetes in urban areas (37). The Canadian member city of this
initiative was Vancouver, BC. Vancouver was commonly thought of as a health-
conscious city, however, according to a new analysis coordinated by CCD, almost 10%
of the population are living with diabetes, one quarter of which are yet to be diagnosed
(38). Importantly, the prevalence of diabetes in Vancouver has been shown to differ
greatly between neighbourhoods. Estimates show the prevalence in the more affluent
Westside of Vancouver to be only 5.2%, whereas it is 7.8% in the Downtown Eastside,
and as high as 10.1% in South Vancouver. In this city, socioeconomic status, ethnicity,
and community environment intersect with many other complex factors to determine
diabetes risk (39; 40).
1.5. Purpose
The purpose of this thesis was to provide a comprehensive account of social and
cultural aspects of living with T2DM in the ethnic minorities of Indigenous, Black, East
Asian, South Asian, and Southeast Asian communities in Canada. The aims of this
thesis were:
-
5
1. To summarize the existing literature on the social and cultural aspects of living
with T2DM for ethnic minorities in Canada.
2. To investigate patient perspectives on social and cultural aspects of living with
T2DM in an urban environment in Canada (Vancouver).
1.6. Structure
The next chapter, chapter 2, will present a systematic review of the existing
literature on the previously published relevant papers. This review will be conducted via
the use of a keyword search strategy across multiple databases. The following chapter,
chapter 3, will present the findings of a survey-based primary research that employed Q
methodology. The findings of this study will present the subjective perceptions of T2DM
patients from ethnic groups of interest on a wide array of social and cultural factors
concerning health, well-being, and diabetes. Finally, the last chapter of this thesis,
chapter 4, will discuss the findings of the two previous studies and highlight their
implications. This thesis will be concluded by providing a set of recommendations for
future programs and services to help reduce the gap in the quality of health care and
health outcomes for the ethnic minorities of interest with T2DM in Canada.
1.7. Positionality Statement
I am a male immigrant to Canada in my mid 20s from a Persian background. My
personal experience with diabetes has been limited to observing my family members’
journeys with T2DM. Their struggle with the management of diabetes has made me
aware of the acute and chronic health implications of living with T2DM. However, my
understanding of other ethnic groups’ unique needs and perspectives around diabetes
remain limited. Furthermore, during my time in Canada I have only lived in an urban
environment. Health care-related challenges that might be faced by individuals living in
rural and reserve communities have not been a part of my personal experience. These
elements affect my worldviews and may have played a part in the discussion and
interpretation of my findings in this thesis.
-
6
1.8. References
1. Diabetes Atlas, Eighth Edition Committee. IDF Diabetes Atlas - 8th Edition. 2017.
2. Standing Committee on Health. A Diabetes Strategy for Canada. Ottawa : House of
Commons, April 2019.
3. Canadian Institute for Health Information. National Health Expenditure Trends, 1975
to 2018 . 2018.
4. Diabetes Canada. Diabetes 360º: A Framework for a Diabetes Strategy for Canada.
2018.
5. Chronic Disease Surveillance and Monitoring Division, Centre for Chronic Disease
Prevention and Control. Diabetes in Canada: Facts and figures from a public
health perspective. Ottawa, ON : Public Health Agency of Canada, 2011.
6. Rapid Increase in Diabetes Incidence Among Chinese Canadians Between 1996 and
2005 . Avreet Alangh, Maria Chiu, Baiju R. Shah. May 2013, Diabetes Care, p.
DC_130052.
7. Prevention and Management of Diabetes in South Asians. S.Sohal, Parmjit. 3, 2008,
Canadian Journal of Diabetes, Vol. 32, pp. 206-210 .
8. Black–White Health Inequalities in Canada. Patterson, Gerry Veenstra & Andrew C.
2016, Journal of Immigrant and Minority Health, Vol. 18, pp. 51–57.
9. Race and health: basic questions, emerging directions. DR, Williams. 5, 1997, Ann
Epidemiol., Vol. 7, pp. 322-33.
10. Race/Ethnic Difference in Diabetes and Diabetic Complications. Elias K. Spanakis,
Sherita Hill Golden. 6, 2013, Curr Diab Rep., Vol. 13.
11. Neighborhood resources for physical activity and healthy foods and incidence of type
2 diabetes mellitus: the Multi-Ethnic study of Atherosclerosis. Auchincloss AH,
-
7
Diez Roux AV, Mujahid MS, Shen M, Bertoni AG, Carnethon MR. 18, 2009, Arch
Intern Med., Vol. 169, pp. 1698-704.
12. Racial and ethnic disparities in self-monitoring of blood glucose among US adults: a
qualitative review. Kirk JK, Graves DE, Bell RA, Hildebrandt CA, Narayan KM. 1,
2007, Ethn Dis., Vol. 17, pp. 135-42.
13. Use of diabetes preventive care and complications risk in two African-American
communities. Gregg EW, Geiss LS, Saaddine J, Fagot-Campagna A, Beckles G,
Parker C, Visscher W, Hartwell T, Liburd L, Narayan KM, Engelgau MM. 3, 2001,
Am J Prev Med. , Vol. 21, pp. 197-202. .
14. The influence of outpatient insurance coverage on the microvascular complications
of non-insulin-dependent diabetes in Mexican Americans. Pugh JA, Tuley MR,
Hazuda HP, Stern MP. 4, 1992, J Diabetes Complications. , Vol. 6, pp. 236-41. .
15. Health disparities in endocrine disorders: biological, clinical, and nonclinical factors--
an Endocrine Society scientific statement. Golden SH, Brown A, Cauley JA, Chin
MH, Gary-Webb TL, Kim C, Sosa JA, Sumner AE, Anton B. 9, 2012, J Clin
Endocrinol Metab., Vol. 97, pp. E1579-639.
16. Increased insulin resistance and insulin secretion in nondiabetic African-Americans
and Hispanics compared with non-Hispanic whites. The Insulin Resistance
Atherosclerosis Study. Haffner SM, D'Agostino R, Saad MF, Rewers M,
Mykkänen L, Selby J, Howard G, Savage PJ, Hamman RF, Wagenknecht LE. 6,
1996, Diabetes, Vol. 45, pp. 742-8.
17. Independent association of insulin resistance with larger amounts of intermuscular
adipose tissue and a greater acute insulin response to glucose in African
American than in white nondiabetic women. Albu JB, Kovera AJ, Allen L,
Wainwright M, Berk E, Raja-Khan N, Janumala I, Burkey B, Heshka S, Gallagher
D. 6, 2005, Am J Clin Nutr., Vol. 82, pp. 1210-7.
-
8
18. Influence of ethnicity and familial diabetes on glucose tolerance and insulin action: a
physiological analysis. Ferrannini E, Gastaldelli A, Matsuda M, Miyazaki Y, Pettiti
M, Glass L, DeFronzo RA. 7, 2003, J Clin Endocrinol Metab., Vol. 88, pp. 3251-7.
.
19. Ethnic differences in insulin sensitivity and beta-cell function in premenopausal or
early perimenopausal women without diabetes: the Study of Women's Health
Across the Nation (SWAN). . Torréns JI, Skurnick J, Davidow AL, Korenman SG,
Santoro N, Soto-Greene M, Lasser N, Weiss G, Study of Women's Health Across
the Nation (SWAN). 2, 2004, Diabetes Care. , Vol. 27, pp. 354-61.
20. Comparison of measured and estimated indices of insulin sensitivity and beta cell
function: impact of ethnicity on insulin sensitivity and beta cell function in
glucose-tolerant and normotensive subjects. Chiu KC, Chuang LM, Yoon C. 4,
2001, J Clin Endocrinol Metab. , Vol. 86, pp. 1620-5.
21. Increased in vivo insulin resistance in nondiabetic Pima Indians compared with
Caucasians. Nagulesparan M, Savage PJ, Knowler WC, Johnson GC, Bennett
PH. 11, 1982 , Diabetes, Vol. 31, pp. 952-6. .
22. Genomics, type 2 diabetes, and obesity. MI, McCarthy. 24, 2010, N Engl J Med., Vol.
363, pp. 2339-50.
23. Ethnic disparities: control of glycemia, blood pressure, and LDL cholesterol among
US adults with type 2 diabetes. Kirk JK, Bell RA, Bertoni AG, Arcury TA, Quandt
SA, Goff DC Jr, Narayan KM. 9, 2005, Ann Pharmacother. , Vol. 39, pp. 1489-
501. .
24. Review Disparities in HbA1c levels between African-American and non-Hispanic
white adults with diabetes: a meta-analysis. Kirk JK, D'Agostino RB Jr, Bell RA,
Passmore LV, Bonds DE, Karter AJ, Narayan KM. 9, 2006 , Diabetes Care. , Vol.
29, pp. 2130-6.
-
9
25. Disparities in A1C levels between Hispanic and non-Hispanic white adults with
diabetes: a meta-analysis. Kirk JK, Passmore LV, Bell RA, Narayan KM,
D'Agostino RB Jr, Arcury TA, Quandt SA. 2, 2008 , Diabetes Care. , Vol. 31, pp.
240-6. .
26. Cities Changing Diabetes. Urban Diabetes: Understanding the Challenges and
Opportunities. s.l. : Novo Nordisk, 2015.
27. Individual and community-level income and the risk of diabetes rehospitalization
among women and men: a Canadian population-based cohort study. Gupta N,
Crouse DL, Balram A. 1, Jan 14, 2020, BMC Public Health, Vol. 20, p. 60.
28. Association Between Perceived Barriers to Diabetes Self-management and Diabetic
Retinopathy in Asian Patients With Type 2 Diabetes. Man, R. E. K., Fenwick, E.
K., Gan, A. T. L., Sabanayagam, C., Gupta, P., Aravindhan, A., … Lamoureux, E.
L. 12, 2017, JAMA Ophthalmology, Vol. 135, p. 1387.
29. International Diabetes Federation. IDF Diabetes Atlas, 7th edition. Brussels :
International Diabetes Federation, 2015.
30. —. International Diabetes Federation Atlas. s.l. : International Diabetes Federation,
2017.
31. Sedentary lifestyle and risk of obesity and type 2 diabetes. FB, Hu. 2, February
2003, Lipids, Vol. 38, pp. 103–108.
32. Physical activity, sedentary behaviors and the incidence of type 2 diabetes mellitus:
the Multi-Ethnic Study of Atherosclerosis (MESA). Joseph, J. J., Echouffo-
Tcheugui, J. B., Golden, S. H., Chen, H., Jenny, N. S., Carnethon, M. R., …
Bertoni, A. G. 1, 2016, BMJ Open Diabetes Research & Care, Vol. 4, pp.
10.1136/bmjdrc-2015-000185.
33. Obesity, insulin resistance and diabetes—a worldwide epidemic. Seidell, J. C. S1,
2000, British Journal of Nutrition, Vol. 83, pp. S5-S8.
-
10
34. Dietary Energy Density Predicts the Risk of Incident Type 2 Diabetes. Jing Wang,
Robert Luben, Kay-Tee Khaw, Sheila Bingham, Nicholas J. Wareham, and Nita
G. Forouhi. 11, 2008, Diabetes Care, Vol. 31, pp. 2120–2125.
35. Daily physical activity and type 2 diabetes: A review. Hamasaki, Hidetaka. 12, 2016,
World Journal of Diabetes, Vol. 7, pp. 243–251.
36. Exercise and Type 2: Diabetes The American College of Sports Medicine and the
American Diabetes Association: joint position statement. Sheri R. Colberg,
Ronald J. Sigal, Bo Fernhall, Judith G. Regensteiner, Bryan J. Blissmer, Richard
R. Rubin, Lisa Chasan-Taber, Ann L. Albright, and Barry Braun. 12, 2010,
Diabetes Care, Vol. 33, pp. e147–e167.
37. Cities Changing Diabetes. Bending the Curve on Urban Diabetes. s.l. : Novo
Nordisk, 2017.
38. InSource. Rule of Halves Analysis. Vancouver : Cities Changing Diabetes, 2016.
39. Ethnic differences in the relationships between obesity and glucose-metabolic
abnormalities: a crosssectional population-based study. Razak, F., Anand, S.,
Vuksan, V., Davis, B., Jacobs, R., Teo, K. K., & Yusuf, S. 6, 2005, International
Journal of Obesity, Vol. 29, p. 656.
40. The relationship between waist circumference and metabolic risk factors: cohorts of
European and Chinese descent. Lear, S. A., Chen, M. M., Frohlich, J. J., &
Birmingham, C. L. 11, 2002, Metabolism-Clinical and Experimental, Vol. 51, pp.
1427–1432.
-
11
Chapter 2. A Summary of Current State of Knowledge: Social and Cultural Factors among Ethnic Minorities Living with Type 2 Diabetes in Canada - A Systematic Review
2.1. Abstract
Background: Type 2 diabetes (T2DM) disproportionately affects ethnic minorities
in Canada. Previous research on T2DM and ethnicity has primarily focused on the
biological and socioeconomic factors. However, this study will summarize available
evidence on social and cultural aspects of living with T2DM among ethnic minorities in
Canada.
Methods: Studies that were included examined a social or cultural factor among
ethnic minorities of interest with T2DM in Canada. CINAHL, WoS, and MEDLINE
databases were used to conduct a keyword search. Two reviewers used PRISMA
guidelines to independently shortlist the papers. CASP checklists were used to assess
the quality of the papers and Cochrane and Joanna Briggs Institute (JBI) forms were
used to extract data.
Results: A set of 22 papers were shortlisted from the 32,138 that matched our
criteria. It was found that, in the Indigenous communities, diabetes knowledge was
limited, patients were subject to post-colonial practices, and family remained the best
source of social and emotional support. In the South Asian communities, patients
believed that diabetes management was impossible, Western medicine was inadequate
for their cultural needs, and female family members remained a great source of social
support. In the East Asian communities, there was a sense of stigma around insulin
injection and patients did not trust Western medicine.
Interpretation: Limited diabetes knowledge, complaints of inadequate cultural
competency in Western medicine, and the positive value of social support was evident in
all groups. Each ethnic minority in Canada has different needs which require tailored,
culturally appropriate approaches to address them.
-
12
2.2. Introduction
More than 3.4 million Canadians currently live with diabetes, (1) constituting
9.3% of the general population. Canada spends roughly $21 billion per year on diabetes
and diabetes-related health complications, (9.9% of the country’s annual health
spending) (2; 3). Despite this spending, diabetes remains a chronic progressive disease
and claims 15,700 adult lives in Canada every year (3).
It has been estimated that 90% to 95% of diabetes cases among Canadians are
type 2 (4) and the risk factors for type 2 diabetes are heavily lifestyle-based. A non-
exhaustive list of these risk factors includes obesity (5), poor diet (6; 7), sedentary time
(8), and level of exercise (9). Many of the lifestyle-based risk factors have deep roots in
social and cultural identities of individuals. As a result, diabetes does not affect all
Canadians uniformly.
Ethnicity often represents different social and cultural identities and it has been
identified as a risk factor for diabetes. People of First Nations (10), Chinese (11), and
South Asian (12) communities have been found to be at a disproportionately higher risk
for developing diabetes when compared to the Caucasian population in Canada.
Ethnicity consists of two distinct components: genetic differences and sociocultural
factors. Many studies have previously examined the genetic differences between ethnic
groups leading to type 2 diabetes susceptibility (13), however, little has been done to
investigate the sociocultural factors.
Social and cultural factors affect type 2 diabetes by shaping individuals’
understanding of diabetes and their long-term behaviours. Cultural determinants of living
with type 2 diabetes comprise of agency and opportunity, traditions and conventions,
perceptions of health and illness, ideas of self and other, change and transition. Social
determinants of living with type 2 diabetes comprise of financial, time, resource, and
geographical constraints. Each ethnic group’s unique social and cultural understanding
of the world leads to their unique understanding of diabetes. It is the complex interaction
of this understanding of the disease, long-term behaviours, and available resources that
determine a patient’s health outcomes and quality of care experience.
This study will provide a review of the existing knowledge available on the social
and cultural aspects of living with type 2 diabetes among the largest visible ethnic
-
13
minorities (Indigenous, Black, East Asian, South Asian, and Southeast Asian) in
Canada.
2.3. Methodology
Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)
was used as a guideline (14). A review protocol was registered with PROSPERO
(registration number: CRD42018115617). Cumulative Index to Nursing and Allied Health
Literature (CINAHL), Web of Science (WoS) and Medical Literature Analysis and
Retrieval System (MEDLINE) databases were used to search for keywords for each
ethnic group as listed in Table 1. The ethnicity keywords were crossed with the terms:
“Type 2 Diabetes” AND “Social OR Cultural”. The search was limited to papers
published up to Dec 6th, 2018.
The inclusion criteria were as follows: studies that (a) examined at least one
social or cultural factor as one of the objectives of the study, (b) examined a population
in Canada, (c) included at least one of the ethnic groups of interest (Indigenous, Black,
East Asian, South Asian, and Southeast Asian) as defined by each study, (d) focused on
a population with type 2 diabetes (must satisfy at least one of the following conditions:
Self-report; on hypoglycemic medications; FPG ≥ 7.0 mmol/L; A1C ≥ 6.5%; 2hPG in a 75
g OGTT ≥ 11.1 mmol/L; Random PG ≥ 11.1 mmol/L). The exclusion criteria were as
follows: (a) studies that were written in a language other than English, (b) works in
progress, conference abstracts, and incomplete papers, (c) review papers and
intervention studies. The search strategy had two steps. The first step identified a large
set of papers that examined at least one of the minority groups of interest in Canada
regarding a T2DM-related topic. The second step of the search strategy involved two of
the authors (PN and NO) reviewing all the titles and abstracts together to (a) determine
each paper’s focus on social or cultural factors, (b) validate the T2DM definitions, and (c)
exclude any papers that met the exclusion criteria.
Quality assessments were conducted using the Critical Appraisal Skills Program
(CASP) Guidelines for qualitative (15) and cohort (16) studies. Two reviewers conducted
the quality assessments independently (PN and NO). The scoring system used in this
-
14
study assigned a score of 1 to every “YES”, a score of 0 to every “Undetermined”, and a
score of -1 to every “NO” answer. The scores from both reviewers were summed to
determine the final quality score for each paper.
Data extraction was conducted by one of the authors (PN). For extracting data
from qualitative studies and quantitative studies Cochrane (17) and Joanna Briggs
Institute (JBI) (18) data extraction forms were used, respectively. For mixed methods
studies, both forms were used.
Data analysis was conducted using thematic analysis. The main themes
discussed in each paper were identified. These themes were re-structured into the
categories of social and cultural factors and then into the sub-categories: social sub-
categories (financial constraints, time constraints, resource constraints, geographical
constraints) and cultural sub-categories (agency and opportunity, traditions and
conventions, health and illness, change and transition, self and other). Themes could be
assigned to multiple sub-categories.
Once a list of all the themes pertaining to each sub-category was generated, the
extracted data relating to each theme were used to generate an outline of the contents
to be presented in that section. The outline was used to identify any correlation and/or
contradictions in the findings across different papers. Elaborations on the content of
each theme were produced and correlations/contradictions were highlighted to generate
the results sections. The thematic analysis was conducted one of the authors (PN).
Discussions started with a summary of the findings, followed by positioning these
findings in the greater landscape of literature, and concluded by identifying the existing
gaps in knowledge. Finally, recommendations were made pertaining to better clinical,
policy, community, and research practices.
-
15
2.4. Results
A total of 32,138 papers matched our search. A final list of 22 papers were
generated based on the inclusion and exclusion criteria (Figure 1). Critical appraisals
were conducted (Tables 2, 3, 4), with quality scores ranging between 72.7% and 95.0%.
No papers were excluded as a result of the appraisals.
The majority of papers were published after 2006 (77.3%), used qualitative
methodologies (59.1%), or focused on Indigenous groups (68.2%) (Table 5). We found
no studies on the Southeast Asian community in Canada and only one study (4.5%) on
the East Asian community. More than half of the studies (63.6%) included an urban
population. Patients from Ontario, British Columbia, and Manitoba consisted the target
populations for 86.4% of the studies.
2.4.1. Indigenous
Diabetes knowledge was limited in Indigenous communities (19; 20; 21; 22).
Access to health services and diabetes education were challenging due to geographic
isolation and financial constraints (19; 23; 20). A group of 20 urban Indigenous patients
with T2DM attributed diabetes to alcohol, genetics, eating too many sweets, obesity,
arrival of the “White man”, and dietary changes from traditional to processed foods (22).
They adhered to an understanding of diabetes which was characterized by the
inevitability of developing diabetes and virulent progression of a disease that defied
personal and professional control (22).
A group of First Nations patients believed that “Western medicine” was not
sufficient in meeting all their needs (20). They, much like the broader Indigenous
community, reported experiencing an assembly-line approach where primary care was
reduced to referrals and prescriptions (24; 20). Patients across multiple Indigenous
communities reported exposure to post postcolonial practices in the healthcare system
by the ways of authority, control, and unilateral decision-making (23; 24). Many
Indigenous patients found health services intimidating and led to cases of resistance
against treatment plans (23; 19). A group of rural patients reported seeking refuge in
their traditional foods and medicinal plants to manage their diabetes (25).
-
16
Close family remained the best source of social and emotional support (26) (23)
(27). This support helped many overcome feelings of shame, isolation, guilt,
hopelessness, defeat, anger, depression, and fear as related to diabetes diagnosis and
management (28; 19; 20; 22). Peer groups helped motivate individuals to be more
physically active (28).
2.4.2. Black
A study with 11 participants reported the level of knowledge and awareness
about type 2 diabetes to be limited in the black community. This limitation prevented
many from seeking timely medical attention and led to significant diabetes complications.
The lack of knowledge also resulted in feelings of shock and fear upon diagnosis as
patients did not understand the etiology and prognosis of the disease (29).
A larger study with 102 participants indicated the patients’ preference to receive
care outside the traditional setting of “Western medicine” such as hospitals and move
towards community health centers (30). Patients were generally engaged in their own
care and their use of healthcare resources were at a considerably high level (30).
2.4.3. South Asian
Diabetes knowledge was limited in South Asian communities. Access to health
services and diabetes education were limited due to geographic isolation, lack of free
time, financial constraints, and patient illiteracy (31; 32). A group of patients believed that
long-term management of diabetes was impossible (31). Even those who achieved
glycemic control thought that their diabetes was cured, and thus stopped following their
treatment plans (31). Another group reported the belief that their sole responsibility was
to follow the course of their prescribed medications (32).
Western medicine did not meet the needs of the South Asian communities either.
Patients found their physicians to be non-culturally competent (32). The clinical
guidelines did not inform the traditionally prepared foods of this community which were
often buffet-style with deep fried meals and sweets (31) (33). Dietary management was
the primary challenge of this community.
-
17
South Asian patients received substantial support from family and friends (34),
however, this support was a gender-based experience. Women in the South Asian
community reported receiving limited social support and experienced feelings of self-
blame (34). They were typically the meal-preparer at home who bore the responsibility
for dietary modifications upon diagnosis of a male in the family (32). When they were
diagnosed themselves, they often had to cook a second dish for each meal (31).
2.4.4. East Asian
Diabetes knowledge was an issue in the East Asian community. A group of
patients believed that the prescription of insulin injection indicated a past failure to
properly care for oneself (35). They worried about the inconvenience of getting injections
and had a fear of losing their personal freedom (35).
There was a sense of mistrust towards Western medicine in this community. A
group of East Asian patients found physicians in the healthcare system to be non-
culturally competent. Hence, they resorted to the more familiar system, Chinese
medicine (35).
2.5. Discussion
The purpose of this study was to provide an overview of the existing knowledge
on social and cultural aspects of living with type 2 diabetes for ethnic minorities in
Canada. Our findings indicate the identification of three main areas: diabetes knowledge,
cultural compatibility of Western medicine, and social support. We found evidence of
limited diabetes knowledge in all ethnic groups, complaints of inadequate cultural
competency in Western medicine, and the value of substantial presence of social
support from family, friends, and peer groups.
Researchers reported limited diabetes knowledge among all ethnic groups. This
limited knowledge was a result of challenges such as geographic isolation, financial
constraints, time constraints, and limited literacy which affected patients’ ability to access
diabetes education. Similar findings were reported among diabetes patients of Hispanic
origin in the United States (36), Pacific Islands people in Auckland (37), Vietnamese
women in Australia (38), and non-native Norwegian speakers in Norway (39). These
-
18
groups demonstrated less knowledge about diabetes and diabetes-related complications
compared to their non-minority counterparts. These studies also reported challenges
around linguistic and cultural literacy which contributed to the limited diabetes knowledge
among all ethnic minorities.
There was a varying degree of mistrust towards Western medicine among all
ethnic minorities. Non-culturally competent providers of care were at the core of this
mistrust. Many patients experienced an assembly-line approach in their care and were
subject to what they perceived as colonial practices of authority such as unilateral
decision making. The same findings were also reported in the United States where
ethnic minorities had less positive perceptions of their physicians (40) and France where
racialized care was provided to patients of ethnic minorities (41).
Social support was an important part of Indigenous and South Asian groups’
experience with diabetes management. There was a shortage of evidence on East
Asian, Southeast Asian, and Black groups regarding social support. Findings of this
paper are in agreement with previous Canadian studies in the area of oral health which
found great social support available to ethnic minorities (42). Similar findings were
reported in the United States among the elderly from ethnic minorities preventing death
or hospital readmission (43).
The results of this paper demonstrate that the needs of different ethnic minorities
in Canada are vastly similar with respect to needing more culturally competent care and
education. However, the best way to address these needs might differ for each group.
There is room for capacity building in primary care and diabetes education to engage
friends and families of patients. Friends and families are already an existing part of
patients’ informal care. Their engagement in the formal healthcare system is a matter of
acknowledging them as legitimate stakeholders in delivery of patient care and education.
This legitimization combined with a more culturally competent care structure could allow
for reconciliation of patient’s perceived forces of Western medicine with their personal
experience of diabetes. This reconciliation could lead to establishing a more honest
relationship with patients based on trust and mutual understanding.
The primary strength of this study was in its comprehensive search for all
relevant papers across multiple databases despite the limitations of conventional
-
19
keywords to search for social and cultural elements of care. This strength allowed us to
provide a comprehensive profile of existing state of knowledge. However, the primary
shortcoming of this study was that the papers included were not uniformly similar in their
design or reporting, which made direct comparison challenging. Nevertheless, the
insights provided in this paper followed a rigorous thematic analysis approach in their
methodology and included studies from the realms of quantitative and qualitative
research.
In conclusion, Canada needs to provide more diabetes education to ethnic
minorities, improve the cultural competence of primary care and diabetes education
programs, and capitalize on the social and emotional support available to patients from
friends and family. Cultural competency of care providers is at the core of cultural needs
of ethnic minorities in Canada. Further research is needed to examine what strategies
could be used to identify the social and cultural needs of each patient and how best to
address them.
-
20
2.6. References
1. Diabetes Canada. Diabetes Statistics in Canada. [Online] 2015. [Cited: 07 26, 2018.]
http://www.diabetes.ca/how-you-can-help/advocate/why-federal-leadership-is-
essential/diabetes-statistics-in-canada#_ftn1.
2. Canadian Institute for Health Information. National Health Expenditure Trends, 1975
to 2016. Ottawa : Canadian Institute for Health Information, 2016.
3. International Diabetes Federation. International Diabetes Federation Atlas. s.l. :
International Diabetes Federation , 2015.
4. Diabetes mellitus: complications and therapeutics. Tripathi BK, Srivastava AK. 7,
2006, Med Sci Monit., Vol. 12, pp. RA130–147.
5. Obesity genes and insulin resistance. Belkina AC, Denis GV. 5, 2010, Curr Opin
Endocrinol Diabetes Obes., Vol. 17, pp. 472–477.
6. A prospective study of whole-grain intake and risk of type 2 diabetes mellitus in US
women. Liu S, Manson JE, Stampfer MJ, Hu FB. et al. 9, 2000, Am J Public
Health., Vol. 90, pp. 1409–1415.
7. Diet and risk of type II diabetes: the role of types of fat and carbohydrate. Hu FB, van
Dam RM, Liu S. 2001, Diabetologia, Vol. 44, pp. 805–817.
8. Global and societal implications of the diabetes epidemic. Zimmet P, Alberti KG, Shaw
J. 6865, 2001, Nature, Vol. 414, pp. 782–787.
9. lifestyle, and the risk of type 2 diabetes mellitus in women. Hu FB, Manson JE,
Stampfer MJ. et al. 11, 2001, N Engl J Med., Vol. 345, pp. 790–797.
10. Public Health Agency of Canada. Diabetes in Canada: Facts and figures from a
public health perspective. Ottawa : Public Health Agency of Canada, 2011.
-
21
11. Rapid Increase in Diabetes Incidence Among Chinese Canadians Between 1996
and 2005 . Avreet Alangh, Maria Chiu, Baiju R. Shah. May 2013, Diabetes Care,
p. DC_130052.
12. Diabetes Canada. Do genes or ethnicity determine your diabetes risk factor?
Diabetes Canada. [Online] Dec 12, 2014. [Cited: Nov 19, 2017.]
https://www.diabetes.ca/publications-newsletters/diabetes-current-
newsletter/diabetes-current-archive/diabetes-current-december-2014/research-
in-progress/do-genes-or-ethnicity-determine-your-diabetes-risk.
13. Diabetes, genetics and ethnicity. . Carulli, L., Rondinella, S., Lombardini, S., Canedi,
I., Loria, P. and Carulli, N. 2005, Alimentary pharmacology & therapeutics, Vol.
22, pp. 16-19.
14. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA
statement. Moher D, Liberati A, Tetzlaff J, Altman DG. 4, s.l. : Annals of internal
medicine, 2009, Vol. 151. 264-9.
15. Critical Appraisal Skills Programme. CASP Qualitative Checklist. [Online] 2018.
https://casp-uk.net/wp-content/uploads/2018/03/CASP-Qualitative-Checklist-
2018_fillable_form.pdf.
16. —. CASP Cohort Study Checklist. [Online] 2018. https://casp-uk.net/wp-
content/uploads/2018/03/CASP-Cohort-Study-Checklist-2018_fillable_form.pdf.
17. Adherence to tuberculosis treatment: a qualitative systematic review of stakeholder
perceptions. Munro S, Lewin S, Smith H, Engel M, Fretheim A, Volmink J. 7,
2007, PLOS Medicine, Vol. 4, p. e238.
18. Joanna Briggs Institute Reviewer's Manual. The Joanna Briggs Institute. [ed.] Munn
Z Aromataris E. 2017.
19. Exploring structural barriers to diabetes self-management in Alberta First Nations
communities. Kulhawy-Wibe, S., King-Shier, K. M., Barnabe, C., Manns, B. J.,
-
22
Hemmelgarn, B. R., & Campbell, D. J. 1, 2018, Diabetology & Metabolic
Syndrome, Vol. 10.
20. Exploring the Experiences of Urban First Nations People Living with or Caring for
Someone with Type 2 Diabetes. Sherifali, D., Shea, N., & Brooks, S. 4, 2012,
Canadian Journal of Diabetes, Vol. 36. 10.1016/j.jcjd.2012.07.005.
21. Diabetes care and health status of First Nations individuals with type 2 diabetes in
Alberta. Oster, R. T., Virani, S., Strong, D., Shade, S., & Toth, E. L. 2009,
Canadian Family Physician, Vol. 55, pp. 386-393.
22. Exploring the experience of type 2 diabetes in urban aboriginal people. Gregory, D.,
Whalley, W., Olson, J., Bain, M., Harper, G. G., Roberts, L., & Russell, C. 1,
1999, Canadian Journal of Nursing Research, pp. 101-115.
23. Using narrative inquiry to elicit diabetes self-care experience in an Aboriginal
population. Barton, S. S. 30, 2008, Canadian Journal of Nursing Research, Vol.
40, pp. 16-36.
24. Health care experiences of Indigenous people living with type 2 diabetes in Canada.
Jacklin, K. M., Henderson, R. I., Green, M. E., Walker, L. M., Calam, B., &
Crowshoe, L. J. 3, 2017, Canadian Medical Association Journal, Vol. 189.
10.1503/cmaj.161098.
25. The diabetes experiences of Aboriginal people living in a rural Canadian community.
. Barton, S. S., Anderson, N., & Thommasen, H. V. 4, 2005, Australian Journal of
Rural Health, Vol. 13, pp. 242-246. 10.1111/j.1440-1584.2005.00709.x.
26. Living with Diabetes on Baffin Island Inuit Storytellers Share Their Experiences. Bird,
S. M., Wiles, J. L., Okalik, L., Kilabuk, J., & Egeland, G. M. 1, 2008, Canadian
Journal of Public Health, Vol. 99, pp. 17-21.
27. Foot abnormalities in Canadian Aboriginal adolescents with Type 2 diabetes.
Chuback, J., Embil, J. M., Sellers, E., Trepman, E., Cheang, M., & Dean, H. 7,
-
23
2007, Diabetic Medicine, Vol. 24, pp. 747-752. 10.1111/j.1464-
5491.2007.02133.x.
28. Beating Diabetes Together: A Mixed-Methods Analysis of a Feasibility Study of
Intensive Lifestyle Intervention for Youth with Type 2 Diabetes. Huynh, E., Rand,
D., Mcneill, C., Brown, S., Senechal, M., Wicklow, B., . . . Mcgavock, J. 6, 2015,
Canadian Journal of Diabetes, Vol. 39, pp. 484-490. 10.1016/j.jcjd.2015.09.093.
29. Optimizing Diabetes Literacy: Lessons from African Canadians in Calgary about
Type 2 Diabetes Diagnosis. Jane I. Ekong, Shelly Russell-Mayhew, Nancy Arthur
PhD. 2013, Canadian Journal of Diabetes, Vol. 37, pp. 231-236.
30. Self-Management, Health Service Use and Information Seeking for Diabetes Care
among Black Caribbean Immigrants in Toronto. Ilene Hyman, Enza Gucciardi,
Dianne Patychuk, Joanna Anneke Rummens, Yogendra Shakya, Dragan Kljujic,
Mehreen Bhamani, Fedaa Boqaileh. 2014, Canadian Journal of Diabetes, Vol.
38, pp. 32-37.
31. Dietary Education Tools for South Asians with Diabetes. Mian, S. I., & Brauer, P. M.
1, 2009, Canadian Journal of Dietetic Practice and Research, Vol. 70, pp. 28-35.
10.3148/70.1.2009.28.
32. Exploring diabetes management amongst immigrant Sikhs in the Greater Toronto
Area: A qualitative study. Uppal, G., Sibbald, S. L., & Melling, J. 6, 2016,
Ethnicity & Health, Vol. 21, pp. 551-563. 10.1080/13557858.2016.1143088.
33. Rethinking peer support for diabetes in Vancouvers South-Asian community: A
feasibility study. Tang, T. S., Sohal, P. S., & Garg, A. K. 8, 2015, Diabetic
Medicine, Vol. 32, pp. 1077-1084.
34. Self-monitoring of blood glucose in Black Caribbean and South Asian Canadians
with non-insulin treated Type 2 diabetes mellitus: A qualitative study of patients’
perspectives. Gucciardi, E., Fortugno, M., Senchuk, A., Beanlands, H., Mccay,
-
24
E., & Peel, E. E. 1, 2013, BMC Endocrine Disorders, Vol. 13. 10.1186/1472-
6823-13-46.
35. Cultural Barriers to Initiating Insulin Therapy in Chinese People With Type 2
Diabetes Living in Canada. Ho, E. Y., & James, J. 4, 2006, Canadian Journal of
Diabetes, Vol. 30, pp. 390-396. 10.1016/s1499-2671(06)04004-4.
36. The Impact of Hispanic Ethnicity on Knowledge and Behavior Among Patients With
Diabetes. Amit Bhargava, Siddharth A. Wartak, Jennifer Friderici, Michael B.
Rothberg,. 3, 2014, The Diabetes EDUCATOR, Vol. 40, pp. 336-343.
37. Ethnic differences in diabetes knowledge and education: the South Auckland
Diabetes Survey. Simmons D, Shaw L, Kenealy T, Scott D, Scragg R. 978, 1994,
N Z Med J, Vol. 107, pp. 197-200.
38. Knowledge of gestational diabetes among a multi-ethnic cohort in Australia. .
Carolan M, Steele C, Margetts H. 6, 2010, Midwifery., Vol. 26, pp. 579-88.
39. Knowledge of gestational diabetes mellitus at first consultation in a multi-ethnic
pregnant population in the Oslo region, Norway - a cross-sectional study. Borgen
I, Garnweidner-Holme LM, Jacobsen AF, Fayyad S, Cvancarova Småstuen M,
Lukasse M. 2019, Ethn Health., Vol. 16, pp. 1-14.
40. Racial and ethnic disparities in perceptions of physician style and trust. Doescher
MP, Saver BG, Franks P, Fiscella K. 10, 2000, Arch Fam Med., Vol. 9, pp. 1156-
63.
41. Colonial Hauntings: Migrant Care in a French Hospital. Kehr, J. 8, 2018, Med
Anthropol., Vol. 37, pp. 659-673.
42. Impact of social support on oral health among immigrants and ethnic minorities: A
systematic review. Dahlan R, Ghazal E, Saltaji H, Salami B, Amin M. 6, 2019,
PLoS One, Vol. 14, p. e0218678.
-
25
43. High perceived social support and hospital readmissions in an older multi-ethnic,
limited English proficiency, safety-net population. Chan B, Goldman LE, Sarkar
U, Guzman D, Critchfield J, Saha S, Kushel M. 1, 2019, BMC Health Serv Res,
Vol. 19, p. 334.
-
26
2.7. Tables and Figures
Figure 2-1 PRISMA chart showing the process of screening papers for this systematic review
All 31,648 non-duplicate citations were reviewed, and inclusion/exclusion criteria were applied by two authors together. The remaining 285 articles were reviewed independently by two authors. After reconciliation of the outcomes, 22 articles were shortlisted to be included in this systematic review.
-
27
Table 2-1 Demonstrating keywords crossed with “Type 2 Diabetes” AND “Social OR Cultural”
Indigenous Black East Asian South East Asian South Asian
OR Indigenous OR First Nation
OR Metis OR Inuit OR Indian
OR African OR Chinese OR Japanese OR Korean OR
Mongolian OR Taiwanese
OR Thai OR Filipino OR Vietnamese OR Cambodian OR
Singaporean OR Indonesian OR
Malaysian OR Lao OR Burmese OR
Myanmarese OR Bruneian OR
East Timorese
OR Afghani OR Bangladeshi OR Bhutanese OR
Indian OR Nepalese OR Pakistani OR
Sri Lankan OR Maldivian OR
Dhivehin”
Each column demonstrates an ethnic group of interest included in this review. The first row includes the primary keyword for each ethnic group. The second row includes the alternative keywords that were included for each group. The final keyword search was composed as “Type 2 Diabetes” AND “Social OR Cultural” AND “Primary1 OR Alternative1 OR Primary2 OR Alternative2 OR …”
-
28
Table 2-2 Result of quality appraisals for eligible qualitative papers Study Yes Cannot
Tell No Number of items
with scoring conflict
Quality Score [-20, 20]
Quality Score (%)
Hernandez, 1999
17 3 0 1 17 92.5%
Ho & James, 2006
15 4 1 1 14 85.0%
Mian & Brauer, 2009
13 5 2 3 11 77.5%
Uppal et al., 2016
16 4 0 0 16 90.0%
Kulhawy‑Wibe et al., 2018
14 2 4 0 10 75.0%
Gregory et al., 1999
14 6 0 0 14 85.0%
Sherifali et al., 2012
14 4 2 0 12 80.0%
Jacklin et al., 2017
18 2 0 0 18 95.0%
Bird et al., 2008 16 3 1 2 15 87.5% Gucciardi et al.,
2013 16 3 1 2 15 87.5%
Barton et al., 2005
13 6 1 1 12 80.0%
Barton, 2008
12 7 1 2 11 77.5%
Huynh et al., 2015
12 6 2 0 10 75.0%
Ekong et al., 2013
16 4 0 0 16 90.0%
CASP checklists were used to assess quality of each paper by two independent reviewers. The scoring mechanism assigned a score of +1 to every “Yes”, a score of 0 to every “Can’t Tell”, and a score of -1 to every “No”. Number of items from the checklist that received a different score from each reviewer are indicated. Total scores from both reviewers were added up to calculate the final quality score. The quality score was translated into a percentage by adding 20 to the existing score and dividing it by 40.
-
29
Table 2-3 Result of quality appraisals for eligible cohort papers Study Yes Can’t Tell No Number of
questions with scoring conflict
Quality Score [-26, 26]
Quality Score (%)
Daniel & Messer, 2002
22 3 1 2 21 90.4%
Tang et al., 2014
21 1 4 1 17 82.7%
Rose et al., 2008
24 0 2 0 22 92.3%
Huynh et al., 2015
16 6 4 0 12 73.1%
Hyman et al., 2014
18 6 2 0 16 80.8%
CASP checklists were used to assess quality of each paper by two independent reviewers. The scoring mechanism assigned a score of +1 to every “Yes”, a score of 0 to every “Can’t Tell”, and a score of -1 to every “No”. Number of items from the checklist that received a different score from each reviewer are indicated. Total scores from both reviewers were added up to calculate the final quality score. The quality score was translated into a percentage by adding 26 to the existing score and dividing it by 52.
-
30
Table 2-4 Result of quality appraisals for eligible cross-sectional papers Study Yes Cannot
Tell No Number of
questions with scoring conflict
Quality Score [-22, 22]
Quality Score (%)
Allan et al., 2008
18 0 4 0 14 81.8%
Chuback et al., 2007
20 0 2 0 18 90.1%
Oster et al., 2009
17 1 4 1 13 79.5%
Daniel et al., 2001
16 0 6 0 10 72.7%
CASP checklists were used to assess quality of each paper by two independent reviewers. The scoring mechanism assigned a score of +1 to every “Yes”, a score of 0 to every “Can’t Tell”, and a score of -1 to every “No”. Number of items from the checklist that received a different score from each reviewer are indicated. Total scores from both reviewers were added up to calculate the final quality score. The quality score was translated into a percentage by adding 22 to the existing score and dividing it by 44.
-
31
Table 2-5 Summary of characteristics of eligible papers Characteristics Number of Papers (%), N = 22 Dates
1999 2 (9.1%) 2000 - 2005 3 (13.6%) 2006 – 2010 8 (36.4%) 2011 – 2015 6 (27.3%) 2016 - 2018 3 (13.6%)
Study Design Qualitative 13 (59.1%)
Quantitative 8 (36.4%) Mixed Methods 1 (4.5%)
Target Population Indigenous 15 (68.2%)
Black 2 (9.1) East Asian 1 (4.5%)
South Asian 4 (18.2%) Southeast Asian 0 (0.0%)
Setting (overlapping categories) Urban 14 Rural 6
Reserve 9 Province (overlapping categories)
Alberta 4 British Columbia 6
Manitoba 5 Nunavut 1 Ontario 9
Social Factors (overlapping categories) Financial Constraints 4
Time Constraints 0 Resource Constraints 14
Geographical Constraints 6 Cultural Factors (overlapping categories)
Agency and Opportunity 4 Traditions and Conventions 5
Health and Illness 8 Self and Other 10
Change and Transition 10 Indigenous includes Aboriginal, First Nation, Metis, Inuit, and Indian; East Asian includes Chinese, Japanese, Korean, Mongolian, and Taiwanese; South East Asian includes Thai, Filipino, Vietnamese, Cambodian, Singaporean, Indonesian, Malaysian, Lao, Burmese, Myanmarese, Bruneian, and East Timorese; South Asian includes Afghani, Bangladeshi, Bhutanese, Indian, Nepalese, Pakistani, Sri Lankan, Maldivian, and Dhivehin.
-
32
Table 2-6 Detailed characteristics of eligible papers Author, Year
Purpose Ethnic Group Setting Study Design Theoretical Background
Number of Participants
Sampling Data Collection
Huynh et al., 2015
To assess the feasibility and lived experiences of an intensive group-based lifestyle intervention for
youth with type 2 diabetes
Indigenous Urban Mixed methods Thematic analysis in conjunction with paired
samples t-test
12 (quantitative), 5 (qualitative)
Sampling strategy not reported for quantitative, convenience sampling for qualitative
Clinical measures, blood tests, one-on-one
or paired interview
Kulhawy‑Wibe et al.,
2018
To gain insight into the financial &
structural barriers to self-management
experienced by First Nation individuals
with diabetes
Indigenous Not reported
Qualitative Inductive thematic analysis
5 Purposive sampling
Semi-structured telephone interviews
Barton et al., 2005
To explore experiences of
Nuxalk people living with the challenges of diabetes health
services in culturally specific ways
Indigenous Rural Qualitative Thematic analysis
8 Purposive sampling
Interviews in a hospital
family room
Barton, 2008
To examine an Indigenous person’s experience of living
with diabetes
Indigenous Rural Qualitative Narrative inquiry
4 Purposive sampling
5 years of scholarly and
personal exploration
-
33
Author, Year
Purpose Ethnic Group Setting Study Design Theoretical Background
Number of Participants
Sampling Data Collection
Gregory et al., 1999
To determine the experience of
Indigenous people living with type 2
diabetes
Indigenous Urban Qualitative Naturalistic approach; person-centered
interviewing
8 Purposive sampling
Semi-structured
conversational interviews
Bird et al., 2008
To explore the experiences of food choice, perceptions
of diabetes, and health management among those with diabetes in a small Arctic community
Indigenous Rural Qualitative Narrative inquiry based
on hermeneutic
phenomenological philosophy,
holistic thematic analysis
4 Purposive sampling
In-depth interviews,
field observations, and informal interviews
Hernandez, 1999
To determine how First Nations clients
with diabetes perceive and live
with their diabetes and to determine
whether the theory of integration is
applicable to First Nations people
Indigenous Reserve Qualitative Grounded theory using the emergent fit model used
for inquiry, theory of
integration used as the framework
10 Theoretical sampling
Interviews on two separate occasions,
at the location of their choice;
questions were open-
ended
-
34
Author, Year
Purpose Ethnic Group Setting Study Design Theoretical Background
Number of Participants
Sampling Data Collection
Sherifali et al., 2012
To understand the lived experience of First Nation adults living with or caring for someone with type 2 diabetes in an urban setting
Indigenous Urban Qualitative Descriptive approach, naturalistic
inquiry, thematic
analysis, no a priori
commitment to any theoretical
viewpoint
Mean attendance of 24 participants
per sharing circle
Convenience sampling
Four sequential
sharing circles (focus groups), over four weeks
Jacklin et al., 2017
To examine opportunities that
inspire and empower patients in their care, journey, as well as moments
that disarm and disengage
indigenous patients from formal health
care systems
Indigenous Reserve, rural, urban
Qualitative Phenomenological thematic
analysis model
32 A combination of purposive, convenience, and snowball
sampling
Sequential focus groups
and interviews:
Focus groups occurred over 5 sessions at
4 sites; 3 participants
were interviewed at
a 5th site Oster et al.,
2009 To describe the state of diabetes
care among Alberta First Nations
individuals with diabetes
living on reserves
Indigenous Reserve Quantitative Descriptive statistics
743 Convenience and snowball
sampling
Clinical measures,
clinical history, surveys
-
35
Author, Year
Purpose Ethnic Group Setting Study Design Theoretical Background
Number of Participants
Sampling Data Collection
Daniel et al., 2001
To test the psychosocial correlates of
dyslipidemia in Indigenous persons with and at risk for
type 2 diabetes
Indigenous Reserve Quantitative Linear regression
model
198 Not provided Blood samples, clinical
measures, and
psychosocial standardized
tests Daniel & Messer,
2002
To examine the capacity of the
health belief model in longitudinal prediction of
glycemic control while allowing for
the potential influence of
behavior in a sample of Indigenous
Canadians from a population at high
risk for diabetes and its complications
Indigenous Reserve Quantitative Linear regression models for each belief
34 Not provided Clinical measures,
blood samples,
Pima Indian physical
activity scale, diabetes
knowledge test, self-
reported logs of foods and drinks, health belief model
diabetes scale
-
36
Author, Year
Purpose Ethnic Group Setting Study Design Theoretical Background
Number of Participants
Sampling Data Collection
Rose et al., 2008
To evaluate treatment outcomes
in patients with diabetic foot ulcers
in a multidisciplinary, tertiary care clinic, and to determine
risk factors predictive of a poor
clinical outcome
Indigenous Reserve, rural, urban
Quantitative Chi-square, odds ratio, Cox
proportional hazard model
325 Included all those who
attended the clinic in a two-year timeframe
Medical records
Chuback et al., 2007
To determine the profile of foot
abnormalities in Canadian
Indigenous adolescents with
Type 2 diabetes and the risk factors associated with
these abnormalities
Indigenous Reserve, rural, urban
Quantitative Chi-square analysis and
two-tailed student’s t-test
110 Included all adolescents
(12– 17 years) of self-declared Indigenous
ancestry who were patients of
the Pediatric Type 2
Diabetes Clinic at the
Children’s Hospital
Medical record review and interview,
physical examination,
laboratory studies
-
37
Author, Year
Purpose Ethnic Group Setting Study Design Theoretical Background
Number of Participants
Sampling Data Collection
Allan et al., 2008
To compare youth and parent-proxy
perceptions of youth quality of life
Indigenous Reserve, urban
Quantitative Compared the scale scores
between child self-report and parent proxy-report within and between the generic
and diabetes tools using paired t-
tests
28 youth and parents
All youth who attended the clinic for the
first time after being
diagnosed with type 2 diabetes
Blood sample,
questionnaire, PedsQL
standardized survey
Ho & James, 2006
To determine some of the cultural
barriers to initiating insulin therapy
among Chinese individuals with type 2 diabetes living in
Canada
East Asian Urban Qualitative framework analysis for emergent concepts
and themes
5 Convenience and snowball
sampling
intensive semi-
structured interviews
Mian & Brauer, 2009
To examine perceived needs
and preferences for diet counselling
resources based on the Canadian
Diabetes Association meal planning guide
South Asian Urban Qualitative Discussions were
summarized and compared across groups
53 Convenience and snowball
sampling
Focus group discussions
-
38
Author, Year
Purpose Ethnic Group Setting Study Design Theoretical Background
Number of Participants
Sampling Data Collection
Gucciardi et al., 2013
To examine the views and current practice of SMBG
among Black Caribbean and
South Asian individuals with non-insulin treated type 2 diabetes mellitus
South Asian Urban Qualitative Thematic networks analysis
12 Purposive and snowball sampling
Semi-structured interviews
guided by the health belief
model
Uppal et al., 2016
To describe the ethnocultural
influences associated with
managing diabetes in a small sample of
older Sikh immigrants in
Toronto
South Asian Urban Qualitative Constant comparative methods – Themes emerged
9 Purposive and snowball sampling
Semi-structured interviews
Tang et al., 2014
To examine the feasibility and
potential health impact of a diabetes
self-management education and
support intervention involving peer
support on glycemic control and diabetes
distress
South Asian Urban Quantitative Attendance rate,
correlations, t-test, content
analysis
41 Not reported Clinical measures,
blood samples, diabetes distress scale,
surveys, post-intervention feedback session
-
39
Author, Year
Purpose Ethnic Group Setting Study Design Theoretical Background
Number of Participants
Sampling Data Collection
Ekong et al., 2013
To investigate how African Canadians experience type 2
diabetes
Black Urban Qualitative hermeneutic phenomenolog
y
11 Purposive sampling
1 to 2-hour interviews
Hyman et al., 2014
To investigate how African Canadians experience type 2
diabetes
Black Urban Quantitative Linear regression Bivariate
analyses (t-test, chi square
test, Fisher’s exact test)
102 Convenient sampling
Questionnaire
Indigenous includes Aboriginal, First Nation, Metis, Inuit, and Indian; East Asian includes Chinese, Japanese, Korean, Mongolian, and Taiwanese; South East Asian includes Thai, Filipino, Vietnamese, Cambodian, Singaporean, Indonesian, Malaysian, Lao, Burmese, Myanmarese, Bruneian, and East Timorese; South Asian includes Afghani, Bangladeshi, Bhutanese, Indian, Nepalese, Pakistani, Sri Lankan, Maldivian, and Dhivehin.
-
40
2.8. Supplementary Material
Supplementary I: Table 2-7 Areas of content covered in eligible papers categorized by ethnicity
Indigenous (N = 15)
Black (N = 2)
East Asian (N = 1)
South Asian (N = 4)
Southeast Asian (N = 0)
Total (N = 22)
Social Factors Financial Constraints 2 0 1 1 0 4
Time Constraints 0 0 0 0 0 0 Resource Constraints 8 2 1 3 0 14
Geographical Constraints
5 0 0 1 0 6
Total unique counts 11 0 1 3 0 15 Cultural Factors
Agency and Opportunity
2 0 0 2 0 4
Traditions and Conventions
2 0 0 3 0 5
Health and Illness 6 1 1 0 0 8 Self and Other 6 0 1 3 0 10
Change and Transition 6 0 1 3 0 10 Total unique counts 13 0 1 5 0 19
Indigenous includes Aboriginal, First Nation, Metis, Inuit, and Indian; East Asian includes Chinese, Japanese, Korean, Mongolian, and Taiwanese; South East Asian includes Thai, Filipino, Vietnamese, Cambodian, Singaporean, Indonesian, Malaysian, Lao, Burmese, Myanmarese, Bruneian, and East Timorese; South Asian includes Afghani, Bangladeshi, Bhutanese, Indian, Nepalese, Pakistani, Sri Lankan, Maldivian, and Dhivehin.
-
41
Supplementary II: Table 2-8 Data extracted from each eligible paper Author, Year
Huynh et al., 2015 Key themes identified The intensive lifestyle intervention did not elicit any changes in any of the
anthropometric or cardiometabolic risk factors Living with diabetes: (1) The negative emotions (Isolating, Feelings of guilt,
hopelessness, and defeat); (2) Difficulties in managing the illness (participants felt that diet was something that they were individually
responsible for managing, being in a group as being a significant motivator for participating in physical activity); (3) Positive experiences (support from other participants and staff as significant motivators for them to attend and participate, participating in the intervention provided a sense of hope); (4)
Relationships (The program helped participants develop and maintain close friendships, These relations were important for their holistic health, Some
described a feeling of intimacy as a result of participating) Unique aspects of the program that differed from traditional models of behavior change: (1) Timing and availability of programming (Benefits in
continuing programming into the summer months); (2) Inclusive environment (dislikes of the competitive nature of gym classes and feelings of judgement
when participating in physical activity in school)
Author’s interpretations Intensive lifestyle therapy alone may not be sufficient for risk reduction in youth.
Perceptions of guilt and lack of control are consistent challenges facing youth and their parents.
Social and familial support is considered a critical determinant. Youth and parents felt that activities that empowered youth (shopping tours
and cooking classes) were beneficial for youth. Non-competitive games that were equitable were critical aspects of
participation. Group-based lifestyle interventions delivered during the after-school period are feasible and are well received by some youth living with type 2 diabetes
in an urban setting, however, changes in cardiometabolic risk factors are variable.
Recommendations The need for novel approaches to behavior modification for youth living with type 2 diabetes
It is possible that different models of behavior change perhaps culturally tailored are more appropriate for indigenous youth living in the inner city of an
urban center Kulhawy‑Wibe et al., 2018
Key themes identified Geography: (1) Physical barrier to accessing care services; (2) Transportation to access specialist and allied health care is a challenge
(Transportation only offered for seeing a physician, Transportation related expenses are significant barriers); (3) Difficulties in diet adherence
(Significant difficulties accessing appropriate healthy foods, Easier to stock up processed food)
Finances and Health Insurance: (1) Obtaining diabetes supplies such as blood glucose testing strips, was financially difficult for most participants despite partial public funding through NIHB; (2) All reported a prohibitive financial barrier to accessing at least one of dental, vision, or foot care
related to NIHB policies and limited coverage (3) Significant financial cost associated with healthy food
-
42
Author, Year Lack of Diabetes Education: (1) Several participants were not aware of or
were unsatisfied with diabetes education offered in the community; (2) Some participants turned to the internet; (3) Many reported diabetes as completely
unfamiliar; (4) Knowledge gaps limited patients’ ability to manage their condition; (5) Knowledge gaps created stress that weighted heavily on the
minds of participants; (6) Some voiced a degree of fatalism that poor outcomes were inevitable; (7) Many had a hard time admitting or accepting
that they were diabetic or felt embarrassed; (8) There was an element of guilt and shame
Author’s interpretations Barriers to optimal care are complex and inextricably intertwined with culture, values, history, and geography.
Finances were a major concern in one way or another. Geographic isolation is a significant contributor when coupled with low
socioeconomic status. Quality diabetes education was lacking which hinders diabetes
management and promotes disease stigma. Generations of mistreatment and multigenerational trauma contribute
significantly to difficulties. Ongoing racism and exclusion lead to considerable mistrust of healthcare
providers which limits the quality of care that can be provided. Recommendations Care providers should practice cultural humility with openness to
indigenous ways of understanding health that incorporate patient centered interventions
Acknowledging the failed historical past of the healthcare system’s interactions with FN communities could be incorporated into educational
programs to breakdown the legacy of mistrust Barton et al., 2005
Key themes identified Western and traditional medicines: (1) How medications control diabetes is less understood; (2) Weekly pill box for medications beneficial; (3) Traditional
foods and medicinal plants used to manage diabetes; (4) Ceremonial practices used to share experiences
Diet, exercise and weight: (1) Smaller food portion sizes, less salt and sugar consumed; (2) Felt the need to ‘cheat’ on prescribed diet; (3)
Exercising viewed as most challenging Difficult to exercise repeatedly; (4) Weight loss successes, frustrating
fluctuations experienced Cultural communication: (1) others with diabetes sought for their wisdom;
(2) Need for professionals to understand Indigenous culture emphasized; (3) Desire for diabetic clinic and workshops in community expressed (4)
Inclusion of Indigenous perspectives into programs desired Choice and responsibility: (1) Diabetes is influenced by personal choice; (2)
Following professional advice is important; (3) Responsibility for own decisions acknowledged
Living day by day: (1) A sense of wellbeing promoted by living day by day; (2) Some life cycles may need to be broken; (3) Family and community
connections enhanced Author’s interpretations Not provided
Recommendations Consultative meetings with community members The use of a cultural awareness program for health professionals
The involvement of Indigenous people in the development of their own diet, exercise, and prevention strategies
-
43
Author, Year Barton, 2008
Key themes identified Cultural differentiations and diabetes experiences: How an Indigenous person living with diabetes experiences the world: (1) Indigenous
experiences