Understanding the bigger picture: syndemic interactions of the immigrant and refugee context with the lived experience of diabetes and obesity

Acquisition, application, and distribution of health literacy from culturally sensitive type 2 diabetes education among Arabic-Speaking migrants in Denmark: A longitudinal qualitative analysis

BACKGROUND

Effective self-management of type 2 diabetes requires adequate health literacy (HL) and a supportive network. Diabetes self-management education and support programmes play a crucial role in improving these factors. However, limited research exists on how such programmes can support health literacy among migrants and facilitate the dissemination of knowledge within their social networks.

AIM

This study aimed to investigate the perspectives of Arabic-speaking informants with a migrant background in relation to how their type 2 diabetes-related health literacy was acquired, applied and distributed within social networks through participation in a culturally sensitive diabetes self-management education and support (DSMES) programme.

METHODS

Semi-structured interviews were conducted with 12 informants during the programme and three to 7 months later, from September 2019 to May 2020. Abductive analysis was applied using HL and distributed health literacy (DHL) theory as frameworks.

RESULTS

The analysis generated three themes: (1) sources of health information and the development of health literacy; (2) changes towards active self-management; and (3) distributed health literacy. Prior to programme participation, informants faced challenges in navigating conflicting information from family, friends and social media. After participating in the programme, they reported improvements in HL, particularly in knowledge acquisition. Many became more actively engaged in decision-making and exhibited improved health behaviours, such as dietary choices. Nonetheless, some informants continued to struggle with choosing appropriate prevention and treatment strategies. Notably, certain informants acted as HL mediators, sharing their newly acquired knowledge within their social networks in Denmark and abroad.

CONCLUSION

Culturally sensitive diabetes self-management education programmes have the potential to enhance HL among migrants, leading to the distribution of relevant diabetes knowledge within their social networks. Future studies should explore how members of migrants' social networks perceive their supportive role in type 2 diabetes management. Programmes can benefit from emphasising critical HL and exploring how participant-informants effectively communicate diabetes-related knowledge within their networks to address misinformation and conflicting information.

Health Problems of Increasing Man-Made and Climate-Related Disasters on Forcibly Displaced populations: A Scoping Review on Global Evidence

Forcibly displaced populations are among the most vulnerable groups in disasters. They experience poorer health conditions compared with nondisplaced individuals. However, a clear picture is lacking regarding the overall health problems encountered by disaster-induced mid- to long-term displaced people. This study investigated these disorders prevalence and identified their correlates among long-settled displaced populations worldwide. The current scoping review follows the PRISMA-ScR guidelines; a systematic search was conducted on PubMed, Web of Science, and CINAHL and included original peer-reviewed studies, commentary, reviews, and grey literature published in English between January 1990 to June 2022. In the thematic and content analysis, the authors applied the narrative review approach to identify themes and sub-themes. Forty-eight documents were identified as fully relevant to this study. The largest number of published papers were from Asia, followed by the Middle East, the United States, and Europe. IDPs in developed countries were the most researched populations. Human-made disasters were addressed by 89% of the included studies. The four main thematic categories included were "physical health," "mental health," "inadequate facilities," and "lack of healthy behaviour." The worsening of noncommunicable diseases had the highest prevalence, followed by communicable diseases. Due to their condition, forcibly displaced migrants face a triple burden of communicable diseases and noncommunicable diseases such as mental health issues. Health-related research and policy need to consider the links among disasters, health problems, and forced migration as a determinant of health in the new era of climate change-driven displacements.

Role of cultural brokering in advancing holistic primary care for diabetes and obesity: a participatory qualitative study

OBJECTIVES

Diabetes and obesity care for ethnocultural migrant communities is hampered by a lack of understanding of premigration and postmigration stressors and their impact on social and clinical determinants of health within unique cultural contexts. We sought to understand the role of cultural brokering in primary healthcare to enhance chronic disease care for ethnocultural migrant communities.

DESIGN AND SETTING

Participatory qualitative descriptive-interpretive study with the Multicultural Health Brokers Cooperative in a Canadian urban centre. Cultural brokers are linguistic and culturally diverse community health workers who bridge cultural distance, support relationships and understanding between providers and patients to improve care outcomes. From 2019 to 2021, we met 16 times to collaborate on research design, analysis and writing.

PARTICIPANTS

Purposive sampling of 10 cultural brokers representing eight different major local ethnocultural communities. Data include 10 in-depth interviews and two observation sessions analysed deductively and inductively to collaboratively construct themes.

RESULTS

Findings highlight six thematic domains illustrating how cultural brokering enhances holistic primary healthcare. Through family-based relational supports and a trauma-informed care, brokering supports provider-patient interactions. This is achieved through brokers' (1) embeddedness in community relationships with deep knowledge of culture and life realities of ethnocultural immigrant populations; (2) holistic, contextual knowledge; (3) navigation and support of access to care; (4) cultural interpretation to support health assessment and communication; (5) addressing psychosocial needs and social determinants of health and (6) dedication to follow-up and at-home management practices.

CONCLUSIONS

Cultural brokers can be key partners in the primary care team to support people living with diabetes and/or obesity from ethnocultural immigrant and refugee communities. They enhance and support provider-patient relationships and communication and respond to the complex psychosocial and economic barriers to improve health. Consideration of how to better enable and expand cultural brokering to support chronic disease management in primary care is warranted.

Double burden of vulnerability for refugees: conceptualization and policy solutions for financial protection in Iran using systems thinking approach

INTRODUCTION

Iran is host to one of the world's largest and longest-standing refugee populations. Although Iran has initiated a basic health insurance scheme for refugees throughout the country since September 2015, the population coverage of this scheme is very low, and various factors have caused a significant percentage of refugees to still lack insurance coverage and often face financial hardships when receiving health services. In response, this study aimed to understand barriers to insurance coverage among refugees in Iran and propose effective policies that can address persistent gaps in financial protection.

METHODS

This qualitative study was conducted in two phases. First, a review of policy documents and interviews with participants were conducted to investigate the common barriers and facilitators of effective insurance coverage for refugees in Iran. Then, a systems thinking approach was applied to visualize the common variables and interactions on the path to achieving financial protection for refugees.

RESULTS

Findings showed that various factors, such as (1) household-based premium for refugees, (2) considering a waiting time to be eligible for insurance benefits, (3) determining high premiums for non-vulnerable groups and (4) a deep difference between the health services tariffs of the public and private service delivery sectors in Iran, have caused the coverage of health insurance for non-vulnerable refugees to be challenging. Furthermore, some policy solutions were found to improve the health insurance coverage of refugees in Iran. These included removing household size from premium calculations, lowering current premium rates and getting monthly premiums from non-vulnerable refugees.

CONCLUSIONS

A number of factors have caused health insurance coverage to be inaccessible for refugees, especially non-vulnerable refugees in Iran. Therefore, it is necessary to adopt effective policies to improve the health financing for the refugee with the aim of ensuring financial protection, taking into account the different actors and the interactions between them.

Health care providers' perspectives on challenges and opportunities of intercultural health care in diabetes and obesity management: a qualitative study

BACKGROUND

Migrants often face worse health outcomes in countries of transit and destination because of challenges such as financial constraints, employment problems, lack of a network of social support, language and cultural differences, and difficulties accessing health services. As understanding how the migrant context affects patient-provider engagement is critical to the provision of contextually appropriate care, this study aimed at understanding primary health care provider perspectives on challenges and opportunities of the intercultural care process for migrant patients with diabetes and obesity.

METHODS

This qualitative study within a multimethod, participatory research project involved primary care providers in clinics and primary care networks in Edmonton, Alberta, between September 2019 and February 2020. We explored health care providers' approaches to diabetes and obesity management, and experiences of and challenges with intercultural care. We conducted a thematic analysis using an interpretive qualitative approach.

RESULTS

We conducted 9 interviews and 4 focus groups and identified 3 themes: a shift from traditional weight loss-centred approaches; relationships and navigating cultural distance; and importance of and limitations in identifying and addressing root causes and barriers. Health care providers encounter considerable nonmedical challenges when supporting immigrant patients, such as navigating cultural distance and working with patients' financial constraints.

INTERPRETATION

The nonmedical challenges we identified can hinder the process of chronic disease management. Thus, in addition to educational programs and trainings to enhance the cultural competency of health care providers, incorporating avenues for cultural brokering in health care can provide invaluable support in patient-provider engagements to mitigate these challenges.

Can We Deliver Person-Centred Obesity Care Across the Globe?

PURPOSE OF REVIEW

This article discusses what person-centred care is; why it is critically important in providing effective care of a chronic, complex disease like obesity; and what can be learnt from international best practice to inform global implementation.

RECENT FINDINGS

There are four key principles to providing person-centred obesity care: providing care that is coordinated, personalised, enabling and delivered with dignity, compassion and respect. The Canadian 5AsT framework provides a co-developed person-centred obesity care approach that addresses complexity and is being tested internationally. Embedding person-centred obesity care across the globe will require a complex system approach to provide a framework for healthcare system redesign, advances in people-driven discovery and advocacy for policy change. Additional training, tools and resources are required to support local implementation, delivery and evaluation. Delivering high-quality, effective person-centred care across the globe will be critical in addressing the current obesity epidemic.

Type 2 diabetes and depressive symptoms in the adult population in Mexico: a syndemic approach based on National Health and Nutrition Survey

BACKGROUND

The syndemic approach allows the analysis of clusters of diseases that affect a population in contexts of geographic, social and economic inequalities at the same moment and time. This study aims to analyze, from a syndemic perspective, the relationship between type 2 diabetes (T2D) and depressive symptoms in Mexican adults and its association with individual, contextual and structural factors.

METHODS

Observational, cross-sectional study based on secondary data from Mexico's National Health and Nutrition Survey 2018-19. The sample of this study consisted of 16 835 adults, which represented a total of 78 463 734 persons aged ≥ 20 years. Bivariate descriptive analyses were performed and logistic regression models were estimated to analyze the association between T2D and depressive symptoms with various co-variables. In addition, interactions between T2D and depressive symptoms with obesity, educational level, and socioeconomic status were tested.

RESULTS

In the study population, 12.2% of adults aged 20 years and older self-reported having T2D, 14.7% had depressive symptoms and 2.8% had both diseases. There was a statistically significant relationship between T2D and depressive symptoms. The prevalence of T2D and depressive symptoms was higher compared to people who did not have these two conditions. Obesity increased the probability of having T2D, while violence was statistically associated with people having depressive symptoms. A low level of education increased the odds ratio of having T2D and depressive symptoms.

CONCLUSION

The availability of analytical frameworks such as the syndemic perspective could help to identify areas of opportunity for decision making and actions for population groups that-because of their individual, contextual and structural disadvantages-are at greater risk of experiencing poorer health outcomes due to the presence of T2D and depressive symptoms.