Socioecological Framework and Cultural Barriers Assessment Answer

1. Public health problem and evaluation of socioecological framework to address the problem

Public health problems include medical or health concerns that affect a major portion of the population. Some examples of these public health problems include type 2 diabetes, mental health issues and HIV. For this report, the public health problem of focus will be diabetes. Diabetes is one of the largest global health emergencies and India accounts for a greater portion of the global burden. The disease burden or DALY rate was four-fold for diabetes in 2016 and the prevalence was found to be 8.9% in 2019 (Pradeepa & Mohan, 2021).

The socio-ecological framework is a multilevel conceptualization of health by considering different factors such as intrapersonal, interpersonal, organizational, environmental and public policy factors influencing the health of the population. It implies that health behaviour is affected by multiple contexts. Depending on different types of public health problems, the influence of the five factors could be different for different population groups (Scarneo et al., 2019). In the context of diabetes, the socio-ecological model can be used to identify risky behaviour and the different contextual factors that influence those behaviours. Depending on that, different health promotion programs can be implemented. In social science research, socio-ecological frameworks have been widely used to control and prevent diabetes. The study by Bamuya et al. (2021) used the socioecological model to explore the implementation of a diabetes education program in Malawi. Through this model, multifaceted personal and environmental factors that determine change were considered. The individual and interpersonal factors influencing health behaviour included cultural beliefs, traditional medicine and healers. These were important for the management of diabetes in Malawi and Mozambique health care. However, these cultural factors conflicted with modern medicine and the self-management of the disease. In addition, negative beliefs and stigma related to diabetes management and the use of insulin were found. The community influences were the lack of sophisticated facilities for diabetes treatment. Informed by the above barriers, appropriate and tailor-made educational programs can be delivered for the population group.

2. Key Terminologies

The key terminologies that are often used to synonymous with a public health problem are minority stress, structural bias, discrimination and social equity racism.

Minority stress: This model is based on the assumption that sexual minorities face unique and hostile pressure due to their sexual minority identity. It may include lesbian and bisexual individuals and challenges faced due to their identities. In the context of public health problems like diabetes, it has been found that minority stress is associated with greater engagement in maladaptive behaviours such as excessive eating or cigarette smoking (Corliss et al., 2018).

Structural bias: It refers to the ways in which societies foster discrimination by mutually enforcing inequitable systems that in turn contribute to discriminatory values and dissemination of resources. For instance, racial and ethnic disparities are seen in diabetes prevalence among ethnic groups and it is reflective of structure bias. Asians, African Americans, Hispanic and non-Hispanic whites are more likely to have a diagnosis of diabetes.

Social inequity racism: It relates to discrimination existing in society due to social inequality in the management of a condition. In the context of diabetes, social inequalities in the management of diabetes have been found. For instance, impaired glucose regulation is higher among people with low income and less education and those with greater deprivation. Similarly, the opportunity for physical activity is lesser in people from low socioeconomic groups compared to those with high socioeconomic status (Barnard-Kelly & Cherñavvsky, 2020).

Discrimination: It is defined as the prejudiced treatment of an individual or group of the individual based on their age, sex, ethnicity and disability. In India, diabetes is plagued with different issues such as gender bias against females, lack of disease awareness, poor quality of health services and lack of diabetes prevention programmes in the community (Gutch et al., 2014).

3. Role of structural bias, social inequities and racism on health equity

The issues such as structural racism, social inequities and racism challenge the equal distribution of resources and make certain groups certain people more vulnerable to diabetes and adverse outcomes compared to other groups. Social inequities may contribute to a lack of access to health services for the management of diabetes in ethnic minority groups and the community. Evidence shows that people living in low-income countries face challenges due to poor knowledge of the disease, difficulty in accessing the health care system and challenges in achieving optimal glucose levels. For people living in remote areas, transportation costs kept them away from accessing mainstream services and the incidence of poor glycaemic control was high in such groups. Thus, because of social inequities related to income and socioeconomic factors, some individuals are prone to risk compared to other groups. Equal health status in the area of diabetes prevention cannot be maintained in such communities (Karachaliou, Simatos & Simatou, 2020).

Structural barriers relates to the lack of culturally appropriate or age-appropriate services for diabetes in a healthcare organization. A study investigating the facilitators and barriers to diabetes management in South Asians identified a lack of cultural adaptation to diabetes as a major barrier to achieving health equity. Most of the time, healthcare workers lacked understanding regarding the economic, social and cultural factors shaping the health behaviour of diabetic patients. Individual motivation towards behaviour change was also a concern. South Asians had a lack of motivation towards healthy eating and misconceptions about physical activity. They also had fatal beliefs regarding their ability to prevent diabetes complications. For some cultures, exercise had little meaning according to their cultural context. In contrast, there were some groups, where exercise and living healthy were the common norm. Similarly, healthcare professionals failed to consider cultural values while preparing diet charts for different patients (Sohal et al., 2015). The study gives the implication for designing culturally appropriate programs that improve communication and respects the cultural beliefs of diverse population group while planning diabetes prevention intervention.

4. The social determinants of health (SDOH) factors such as housing, education, unemployment, individual habits, and social and cultural values are important factors contributing to health and well-being in individuals. Income status, education, job insecurity, workplace condition, food insecurity, social inclusion and structural conflict can influence people and the community in a both positive and negative way (World Health Organization, 2021). Many studies have explored the relationship between the SDOH factor and diabetes. Socioeconomic status (SES) is a multidimensional construct that involves education, occupational and economic status. It is a strong predictor of disease onset and progression of disease in the community. The SES factors can influence access to nutritious food, physical activity, transportation and health care services. Similarly, diabetes outcome is found to be influenced by the level of education in people. The study linked housing instability with the incidence of diabetes too. It revealed that around 37% of individuals report experiencing housing instability. In addition, for people with a diagnosis of diabetes and housing instability, the likelihood of emergency department visits or hospitalization was high (Sohal et al., 2015).

In addition, cultural factors influence self-management strategies for people with diabetes. Culture often leads to fatalistic beliefs about diabetes and reliance on traditional medicines instead of modern medicine to treat the disease. In addition, cultural gaps affected adherence to diabetes treatment plans because a lack of consideration of cultural values linked to diet affects engaging in healthy eating habits among diabetes patients. While engaging with a culturally diverse population, it is important to include nutritional preferences and develop a plan of care considering the social and cultural background of patients (Caballero, 2018).

5. Empirical findings have revealed a different association between race, sex and orientation with health status on diabetes management. For instance, the study by Huebschmann et al. (2019) shows that the minority population have a high burden of diabetes-related complications. Non-Hispanic Black and Hispanic adults have been found to have a high rate of albuminuria, retinopathy and poor glycaemic outcome compared to Whites. Similarly, in India, sex differences in the burden of T2D were found. Globally more number of males are diagnosed with diabetes and male predominance has been reported in many countries. For instance, the UK Biobank study referred to male predominance but no sex difference was reported in the US. In addition, studies done in sub-Saharan Africa also revealed no sex differences in diabetes prevalence.
6. In response to the identification of various structural and sociocultural barriers to the management of diabetes, it has been proposed to implement a culturally appropriate diabetes education program to address the public health problem. The main rationale for choosing this intervention is that it is likely to address the knowledge gap and allow all individuals irrespective of race or sexuality to engage in healthy behaviour. In addition, intervention is likely to improve motivation levels, promote adherence to treatment plans and increase access to health services. It can address structural barriers such as stigma and taboos surrounding diabetes treatment. The study by Goff et al. (2022) shows that culturally sensitive diabetes self-management education can balance the tension between structural and responsive care needs, the challenge posed by cultural beliefs and building relationships with healthcare professionals. It can address gaps in structural education for diabetes.

References

Bamuya, C., Correia, J. C., Brady, E. M., Beran, D., Harrington, D., Damasceno, A., ... & Hadjiconstantinou, M. (2021). Use of the socio-ecological model to explore factors that influence the implementation of a diabetes structured education programme (EXTEND project) inLilongwe, Malawi and Maputo, Mozambique: a qualitative study. BMC public health, 21, 1-11.

Barnard-Kelly, K. D., & Cherñavvsky, D. (2020). Social inequality and diabetes: a commentary. Diabetes Therapy, 11, 803-811.

Caballero, A. E. (2018). The “A to Z” of managing type 2 diabetes in culturally diverse populations. Frontiers in endocrinology, 9, 479.

Corliss, H. L., VanKim, N. A., Jun, H. J., Austin, S. B., Hong, B., Wang, M., & Hu, F. B. (2018). Risk of type 2 diabetes among lesbian, bisexual, and heterosexual women: Findings from the Nurses’ Health Study II. Diabetes care, 41(7), 1448-1454.

Goff, L. M., Moore, A., Harding, S., & Rivas, C. (2020). Providing culturally sensitive diabetes self-management education and support for black African and Caribbean communities: a qualitative exploration of the challenges experienced by healthcare practitioners in inner London. BMJ Open Diabetes Research and Care, 8(2), e001818.

Gutch, M., Razi, S. M., Kumar, S., & Gupta, K. K. (2014). Diabetes mellitus: Trends in northern India. Indian journal of endocrinology and metabolism, 18(5), 731.

Huebschmann, A. G., Huxley, R. R., Kohrt, W. M., Zeitler, P., Regensteiner, J. G., & Reusch, J. E. (2019). Sex differences in the burden of type 2 diabetes and cardiovascular risk across the life course. Diabetologia, 62, 1761-1772.

Karachaliou, F., Simatos, G., & Simatou, A. (2020). The challenges in the development of diabetes prevention and care models in low-income settings. Frontiers in Endocrinology, 11, 518.

Pradeepa, R., & Mohan, V. (2021). Epidemiology of type 2 diabetes in India. Indian journal of ophthalmology, 69(11), 2932.

Rodríguez, J. E., & Campbell, K. M. (2017). Racial and ethnic disparities in prevalence and care of patients with type 2 diabetes. Clinical Diabetes, 35(1), 66-70.

Scarneo, S. E., Kerr, Z. Y., Kroshus, E., Register-Mihalik, J. K., Hosokawa, Y., Stearns, R. L., ... & Casa, D. J. (2019). The socio-ecological framework: a multifaceted approach to preventing sport-related deaths in high school sports. Journal of athletic training, 54(4), 356-360.

Sohal, T., Sohal, P., King-Shier, K. M., & Khan, N. A. (2015). Barriers and facilitators for type-2 diabetes management in South Asians: a systematic review. PloS one, 10(9), e0136202.

World Health Organization (2021). Social determinants of health. Retrieved from: https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1

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