This paper will discuss diabetes mellitus, which is a chronic medical condition that worsens over time. The levels of glucose in the blood become too high because the body cannot use it properly. The pancreas fails to produce enough of the hormone insulin which controls the levels of glucose (WHO, 2002a). If diabetes is not treated, it can lead to heart disease, stroke, blindness, kidney failure, lower limb amputation, sexual dysfunction, and pregnancy complications in women (Diabetes UK, 2009).
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The paper will review health inequalities in people with diabetes living in the UK from the ethnic minority of the south Asian community (SAC). The focus will be on the most common preventable type 2 diabetes (T2D) in this community. This community is at higher risk of developing T2D, and cultural practices, for instance fasting if not managed appropriately makes their condition to become worsened. The community comprises a heterogeneous group of people of Afghanistan, Bangladeshi, Pakistani, and Sri Lankan origin that have different language, religion, culture and rates of diabetes especially T2D and live in all areas of the UK (Qiao, et al, 2003; Mohan, 2006; Katulanda, 2006, 2008). Their clustering in certain areas reflect the migration patterns such as a high intensity of Indians in the East and West Midlands as well as in Greater London, fairly low proportion of Pakistanis in Greater London and a high intensity in West Yorkshire and West Midlands (Raymond, 2009). Those of Bangladeshi origin are established mostly in Greater London particularly in Tower Hamlets with growing numbers in the West Midlands (Grace, 2008).
The condition is not equally impacted upon every person in our society and considerable inequalities are present in the risk of disease development, access to health services and service quality, and in health outcomes in particular those with T2D. Since health is unequally distributed within and between populations, a health inequality arises where variations in health status exist or in the allocation of health determinants amongst various population groups. Also it can be from unjust or unfair differences in health determinants or outcomes within or between defined populations.
An increased risk of developing diabetes is witnessed in those who are overweight, physically inactive or got a family history of diabetes. The UK is facing a huge increase in the number of people with diabetes from 1.4 million in 1996 to 2.5 million people diagnosed with T2D (Diabetes UK, 2009) and up to 500,000 undiagnosed cases (Department of Health, 2008). By 2025, it is estimated that more than four million people will have the condition. Also Department of Health states that understanding of diabetes in people differs significantly which further increase the complications of controlling and preventing the disease.
Although there has been a lot of literature on social circumstances affecting health, a lot more needs to be done in facing challenges that will fully address health inequalities in this group of people with studies that are more inclusive of this group rather than of a focus of a single ethnic group.
Epidemiology of Variations in Type 2 Diabetes
Incidence and prevalence
Type 2 diabetes continues to be one of the top public health challenges for the National Health Service (NHS, n.d.). Incidence of T2D is swiftly increasing globally, mostly for south Asian people living in urban areas (Qiao, et al, 2003; Riste, 2001). Although enormous steps have been made in detecting those with diabetes, there is yet a lot to be done to boost prevention and enhance services for the diagnosed, in addition to progressing with identifying new cases (Mayor, 2005). A four-fold to six-fold risk of developing T2D is bigger in south Asian individuals who get the disease at an earlier age, and have higher rates of renal and cardiovascular problems than do other ethnic groups (Burden, 1992; Mather, 1998).
The completed local ethnic profiling in Liverpool (Lee, et al, 2000) established that people from ethnic groups (aged 40 years and over) were more likely to self report diabetes compared to white British in the same age group, indicating a greater occurrence of diabetes within ethnic groups.
As reported in the Health Survey for England (2004), diabetes diagnosed by a doctor is nearly four times as common in Bangladeshi men, and nearly three times as common in Pakistani and Indian men in contrast to men in the general population. Also amongst women, the condition is more than five times as likely among Pakistani women, at least three times as likely in Bangladeshi women, and two-and-a-half times as likely in Indian women, compared with women in the general population. In the same survey, diabetes was highest among Indian men (2 per cent), Black African men (1.7 per cent) and Irish women (1.7 per cent) (Diabetes UK, 2009) (Table 1).
Table 1: Showing the prevalence of self-reported, doctor-diagnosed diabetes in England by minority ethnic group and sex (Diabetes UK 2009).
Source: Adapted from Diabetes UK 2009: Key statistics on diabetes.
Diabetes complications and control
The SAC has been identified of significantly having higher rates of diabetes-related complications (Chowdhury, 2002; Chandie and Shaw, 2006) such as diabetic reinopathy (Pradeepa, 2008), worse control of hypertension as shown in a study by Lanting, et al (2005), and according to Centre for Disease Control and Prevention (2005). The above contributes to SAC suffering more from health problems than the majority population of the country they live in as they bear an unequal burden of the diabetes epidemic (Mohanty, 2005). There is need for studies from the SAC to examine effects of renal disease on mortality. Also improved ethnicity data would help to understand the incidence of end-stage renal disease complications in order to plan for effective control of the disease.
Variations in quality of care and health service
Similarly in any community, there are a variety of opinions and views over health and this is also witnessed amongst the SAC who live in the UK. In reviewing the research evidence, there is substantial data that ethnic minorities have a higher diabetes disease burden (Mohan, 2004; Muhopadhyay, 2005) and encounter variations in the quality of care they get (Howthorne, 2001). However, reports of problems in obtaining health care have emerged to be different among ethnic groups and the remainder of the UK population.
It has to be noted that this community frequently needs to be dealt with in different ways from that of the White British community, but concurrently, age, gender, language and faith variations within the SAC should be valued when conveying health messages. Health care interventions that seek out to enhance diabetes care are likely to enhance health outcomes and bring down health variations amongst this community of people. This review also assimilates the available evidence regarding the effectiveness of such interventions.
Ethnicity data collection in the UK has occurred twice, in 1991 and 2001 giving the ethnic composition of the English population where the Asian community comprised of 6.6% (UK census, 2001) forming a special population subgroup. In addition to largely belonging to the groups with lower socioeconomic position (Connolly, et al, 2000), their health status is also affected by their cultural practices and behaviour, circumstances of life before arrival to the host country, stress of migration, and adjustment to the new lifestyle in the UK (Mackenbach, 1997; Fischbacher, 2004; Greenhalgh, 2001). Although their need of health care is often heightened due to a poorer health status, utilisation of health services by the SAC is often held back by lack of understanding of the system and inadequate language skills.
Evidence for inequalities in health among migrant populations in different host countries is as abundant as evidence for socioeconomic inequalities in health. This community faces a substantial amount of barriers to accessing care as already been noted. Stress has been another suggested factor where belonging to a minority group has been linked with accelerated stress levels (Abate and Chandalia, 2003) and the chances of T2D development has also been linked with stress (Mooy, et al, 2000).
Abate and Chandalia’s (2003) study shows the effect of lifestyle factors on obesity and diabetes to be predominantly common within ethnic groups. This might be due to environmental changes from host country that promotes obesity and also predisposition to T2D in the SAC. A reduction in fibre consumption and increased intake of animal fats and processed carbohydrates are the major adjustments in dietary behaviours adopted by SAC. Diet and exercise are very important determinants of the variation in T2D in the SAC.
While the main concern in public health is preventing diabetes, averting complications in those patients with confirmed diabetes is similarly imperative. The study by Gaede, etal (2003) shows evidence from randomised trials that this precedence can be accomplished by multi-factorial interventions, decreasing cardiovascular risk problems by up to 50%. The challenge remains on how to apply such interventions cost-effectively, particularly in high-risk ethnic groups such as south Asian patients, to minimise health inequalities that exist between SAC and the indigenous UK population (Barnett, 2006; Hanif, 2008). Despite the public health domain operating in addressing national patterns of health inequalities that bring about drawbacks among ethnic minority groups, significant recognition exist that regional, socioeconomic, and personal factors affect intra-group variations in risk (Alberti, 2007).
The SAC requires those responsible for planning and delivering diabetes services to write policies that address their specific needs, extremes of age, hard to reach groups (such as the housebound, young adults), people living in institutions, the socially excluded, and taking account of the different needs of both genders. Issues of health inequalities have been a central focus within the health-related research community since the publication of the Black Report more than twenty years ago (Black, 1988). The deep-rooted and extensive temperament of health inequalities proposes that policy interventions will face meticulously difficult issues in formulating and putting into practice policy at national and local levels. To shed light precisely on those issues referred to above, i.e. the connections relating to health inequalities evidence, policy and implementation. In England, the government has asked for the primary care trusts (PCTs) to be at the fore front of the responsibility at a local level for dealing with inequalities in health. From 1997 the PCT and its previous organisations have sought to react to and apply government policies to deal with inequalities in health.
Although there has been dedication and support for action on inequalities at Board level and together with senior management team, various barriers to local execution of policy on health inequalities have been met. A significant contextual factor has been the huge and re-emerging financial shortfall taken over by the PCT from its predecessor health authority. This has accentuated the priority given to attaining financial balance and access targets within NHS performance management. The SAC from the above evidence is likely to be served less well by the health services.
The barriers to accessing care and health service
Further to the concerns already raised in variations to quality of care and health service, barriers to accessing care by the SAC still exist. The issue of how places have an impact on health was addressed in studies by Picket and Pearl (2001); Macintyre, et al (2002) and Tunstall, et al (2004). As a result they showed an understanding of place-specific factors, cultures, and societies which are also required at the level of policy making in order to address health inequalities. Individuals from SAC who are excluded socially also comprise of prisoners, refugees and asylum seekers, and those with learning or mental health problems may be given poorer quality care. More than one of these risk factors may apply to some individuals in this community. There is a range of evidence that ethnic minorities have different health outcomes to those of the general population of the society in which they are living (Jenum, 2005; Britten, 2007; McElduff, 2005; Sahu, 2007). Furthermore, their diabetes is generally less well “controlled” in that it gets more serious more quickly and there are added health problems (Millett, 2007).
The reasons for the rise in occurrence is not fully known though various factors might appear to contribute such as different levels of inactivity and physical fitness; social deprivation, a lack of education and/or employment (Diabetes UK, 2001). A number of barriers (consisting of language barriers, cultural differences, transport problems, poor knowledge of services) with regard to their motivation to try to find medical aid deter them from accessing the services required in managing their condition. Also limitations in speaking English makes it difficult to target the largest part of this risk-group with lifestyle interventions as SAC is relatively isolated from mainstream society and has variable knowledge of and motivation to make use of conventional services (Greenhalgh, 2005).
The above still poses a lot of challenges in the elimination of the prevailing health inequalities. It is however, believed that the main barriers to physical activity (p.a.) in this group is lack of time due to extended working hours and household tasks. Furthermore, access to leisure and sporting facilities determined by their availability, costs and times they are open; the fear for individual safety in public open spaces; the absence of other persons from their community accessing the facilities, and, actual, or potential experiences of racism also contributes to barriers in accessing health services. Also dress codes for the women, absence of privacy in changing areas as well as lack of distinct gender provision possibly prevents the access to p.a. Since physical fitness and management of weight are very important with regard to preventing the onset of diabetes, these are also very important issues for this ethnic community.
Type 2 diabetes is also most common among those subjected to socioeconomic deprivation which is linked with elevated levels of obesity and overweight, sedentary lifestyles, poor blood pressure control and smoking. However, other factors prevail that include reduced glucose control, referral bias, poor access to services and limited education with those subjected to social exclusion feeling a sense of despair that may put them off from developing a belief in themselves to control their diabetes successfully (BMA, 2004).
Evaluation of strategies or measures in tackling T2D in the UK south Asian community
Ever since the 1980s a lot of research has been gathered on the strong positive associations between inequalities and ill-health, including some showing that the health gap between the affluent and deprived is widening. The health of the nation strategy for England, cited that successful strategies for improving health have to be responsive to differences in health, and guidance was made available to health authorities (HAs) on decreasing such differences. However, there was no target on inequalities in the health strategy and not considerable known facts had been gathered on effective interventions. However, the emergent body of data on the relationship between socioeconomic inequalities and ill health has revitalized the drive to tackle inequalities. Increased evidence also resulted in the establishment of a Chief Medical Officer working group to advise the Department of Health and the National Health Service on what it should be doing to tackle disparities in health. The findings of this group were published in 1995 in Variations in health: what can the Department of health do?
Recommendations followed from it that HAs ought to have an inclusive plan that identifies and tackles differences, making it an important aspect in public health. The issue of inequalities in health is continuously felt to be extremely important within the department of health authorities as evidenced by the extensive analyses and completed and continuing projects in many HAs. The findings of the Black Report in the UK were no different in showing the disparities in health.
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However, health-care delivery in the SAC is more challenging because of cultural, communication, and comprehension difficulties, which along with social deprivation further complicate the achievement of defined targets (Stone, 2005). Shekelle’s (2003) study shows that payments for UK general practices based on their achievement of quality (Quality and Outcomes Framework) targets do not distinguish different ethnic groups. Shortfalls still exist in the quality of care available for those in hospital and various activities are taking place by the Joint British Diabetes Society. Diabetes UK as a member of the society created a tool being used by adults with diabetes to know what care to anticipate throughout a hospital stay.
Furthermore, enhanced care packages based in the community have been associated with improved metabolic outcomes in some ethnic groups but have not been fully assessed in large randomised controlled trials. Such trials are scarce in people of south Asian ethnic origin (Gammon, 2008). Appropriate standards of care, tailored patient education and ease of access to services must be provided when needed (Diabetes UK, 2001). The United Kingdom Asian Diabetes Study (UKADS) assessed a community-based complex intervention that aimed to reduce cardiovascular risk in south Asian people with T2D (Davis, 2001; O’Hare, 2004). The intervention package was tailored to the needs of the south Asian community and consisted of additional time with a practice nurse, Asian link workers, and input from diabetes-specialist nurses, who were working to protocols to achieve clearly defined targets. The UKADS study hypothesis was that an enhanced care package for diabetes would improve cardiovascular risk profile in patients of south Asian origin, with established T2D.
Tackling health inequalities is important because inequality is widespread and in many cases this has widened over the last two decades. Unless concerted action is taken, most policies inadvertently widen health inequalities. The two national goals are specifically focused on health inequalities by following the National Service Framework for Diabetes (NSFD) that aims in the long term, up to and beyond 2010 to reduce health inequalities by tackling the wider determinants of health such as poverty, poor housing and education (DH, 2001).
The integration of care plans for those with complex diabetes requirements should be put into service and for them to be effective, a dedicated budget is required. It should be noted that alleviating diabetes health inequalities is expensive and thus requires the government to encourage PCTs to channel their funding to their environment accordingly (deprived areas, diverse communities, e.t.c.). Although it has been widely accepted in the public health field that many cases of T2D could be slowed down or stopped with lifestyle interventions, there still exists challenges in the government acting to restrict advertising of foods high in salt, sugar, and/or fat as well as ensuring that Food Standards Agency guidelines are adhered to by food manufacturers. This will assist consumers to be more aware of the contents of processed foods thus contributing to reducing the burden of the disease.
However, the NHS and government can gain knowledge from other programmes of work in the SAC (The Equal Access to Diabetes Healthcare Pilot Study established in Wolverhampton) on how improved care can be offered to all those not currently receiving adequate care. While the SAC is relatively concentrated in certain areas, others are more widely scattered and services must not ignore these groups because there are not large enough to warrant prioritisation. In 2004, Lewisham PCT undertook its own research that focussed on diabetes and hypertension for its ethnic minority populations with findings of service inadequacy consisting of cultural barriers. This resulted in a recommendation of a community based diabetes awareness education that addressed cultural beliefs and socioeconomic factors. In addition, cultural awareness was introduced to staff.
Improvement in the field of health inequalities will eventually be revealed by complete decrease in preventable morbidity and mortality among those in this most at-risk group. Factors such as the dedication of HAs staff to the inequalities schema, the setting of priorities, increasing awareness, thorough and enlightening analyses, execution of interventions and alliance working are evidently significant in accomplishing this goal. It is to be hoped that recent national initiatives for talking socioeconomic differentials in health will allow and urge HAs and new local partners to completely take on their role and act to eliminate these present health inequalities in this community and others. Nevertheless, as brought to light by Acheson, a more strategic approach is needed and will be an essential marker of HAs seriously dealing with this issue. However, authorities on health inequalities at the international level have recommended that measuring health inequalities is a requirement to developing strategies and programmes to deal with them (Wagstaff, 2000; Houweling, 2003).
Research has shown that there are individual differences in susceptibility to disease. Geofrey Rose taught us that the causes of population rates of disease may vary from the causes of personal cases (Rose, 1992; WHO, 2001). In Britain, the short-hand term “inequalities in health” refers to differences between social groups (Black, et al, 1988; The Stationery Office, 1998).
The Black Report on Inequalities in Health was seen as putting forward an opposition between an approach to an account that concentrated on health behaviours and one that focussed on the material forms of life (Blane, 1985). Following Black’s report, one ought to think of health inequalities as coming from material situations of life not psychosocial factors (Lynch, 2000). However, health inequalities are not limited to those living in absolute deprivation but are witnessed in those living at a material level above the threshold required for good health (Morris, 2000). Material conditions and psychosocial factors are closely related (Marmot, 2001) which the association was also made in the Black Report. A component of the difficulty of inequalities in health has to do with education with circumstances at work, with job uncertainty and joblessness and the nature of the neighbourhoods. Subsequent to Black’s and a lot of the work prior to and ever since demonstrates that inequalities in health show inequalities in society.
However, up till now a small amount of UK studies have included south Asians (Bartlett, 2003; Sheikh, 2004; Jolly, 2004). Hussain-Gambles (2006) explored on the causes for their abstention in clinical trials, including motivation (e.g. helping society, improving one’s health); and constraints (e.g. busy lifestyles, prior experiences and language difficulties). Professional views comprised of a lack of time and resources and insufficient sustainability. It has also been brought to light that south Asians are frequently explicitly left out due to the supposed cultural and communication problems (Greenhalgh, 1998; Erens, 2001; Rhodes, 2003; Baradaran, 2004; Vyas, 2003; Lawton, 2006), as well as studies where there might be language/literacy problems in getting informed permission. In addition, Choudhury (2008) shows that a lot of people from south Asian upbringing are reluctant to take part because they acknowledge their illness as an irreversible punishment from God or have a fear of what research actually entails.
It is widely accepted that people with low socioeconomic positions have in general poorer self-rated health than persons with high socioeconomic status (kawachi, 1999; Lantz, 2001). Several theories have been put forward to explain observed social gradients in health (Elstad, 2000). The materialist or structural theory suggests an important role of the physical environment e.g. working conditions, material conditions, and housing environment. These theories further suggest that differences in the material environment of the social classes are the key determinants of health inequalities and inequalities in the use of health services which may operate directly (physically) or psycho-socially. However, in this review it is noted that the south Asian community might feel alienated from the wider society as a whole and having very little or no support at a local level for their needs. In some parts of the UK, the level of care that people get varies in accordance to place of residence and this means the non existence of a devoted service framework in place, service tumbles well under NICE suggested standards.
Since individuals with diabetes require educational access, psychological and emotional help and care and care planning so that they deal with their own condition. Diabetes UK keep on prioritising collaborated self-management in its policy and campaigning activities, and request the government and the NHS to invest in improving services and infrastructure that assist in enhancing people’s lives and produces future benefits.
The behavioural or lifestyles theory came to sight when individual risk factors for instance unhealthy eating, physical inactivity, smoking, and alcohol use were recognized as health determinants. As already evidenced in this review on behavioural and cultural problems experienced within the SAC, this theory is relevant. The theory states that, social dissimilarity in beliefs towards health and actions are accounted for by an unhealthier lifestyle amongst those with deprived positions. Various social classes’ lifestyles are perceived as contributors to health that is excellent or poor which is considered to be actively chosen and thus open to transformation by way of promoting health. However, critics have argued that it can lead to a tactic of victim-blaming which contributes to widening of health variations as already cited in this review.
The psychosocial theory proposes that unhealthy habits are a reaction to stress and a way to alleviate frustration and that social capital, social support, and autonomy represent key elements for good health (Marmot and Wilkinson, 1999; Marmot and Wilkinson, 2001). However, none of these theories have been able to completely explain social differences in health.
It is important to separate the roles played by lifestyle, material factors, and psychosocial factors in health disparities. This will enable us to understand whether interventions should be aimed mainly at changes in lifestyle, in material conditions, or in the psychosocial environment.
A view held by many sociologists is that explanations of health inequalities need to take into account both material inequalities and cultural/behavioural differences. Behaviours regarded as individual ‘choices’ are ‘chosen’ from within unequal social locations. Some privileged social locations facilitate or enable healthy lifestyles, whilst other deprived material locations prevent, hinder or militate against healthy choices. For instance, if an individual from the SAC is in an unskilled job that provides barely enough wages which in turn provides a small chance to make choices as a consumer. In circumstances like that certain irrational behaviours (e.g. smoking, fatty foods) may arise as rational coping strategies.
Socioeconomic variations in health continue to be debatable as to whether they are by way of economic and material conditions or psychosocial factors like social support and employment control (Marmot and Wilkinson, 1999; Marmot and Wilkinson, 2001; WHO, 1997; Lynch, et al, 2000, Lynch, 2001). In addition, Denton (1999) and Alvarez-Dardet (2001) also highlighted the significance of lifestyle factors. The various opinions are focused on deviating theories that are also evidenced in this south Asian community on the causes of ill health (material/psychosocial factors) and whether ill health burden rests upon the individuals (lifestyle) or on society (structural factors). Van Lenthe (2004) suggested that in clarifying socioeconomic variations in health, all these factors play a role.
Strategies or measures in tackling the health variations in UK’s south Asians
The government, NHS and partner organisations continue implementing strategies and policies to help tackle T2D variations in the SAC. Public policy development is a multifaceted and iterative process which in turn has to tackle the multiple causes of health inequalities. While we ought to be concerned with health inequality, health is a fundamental component of well-being, whether or not it is associated with inequality in other dimensions of well-being. Utilization of evidence is a vital part of this process if knowledge is provided that is significant to policy questions (on costs, effectiveness, etc.), if it fits in with the overall political vision, and has distinct potential for practical implementation.
Presently in the UK, policy on health inequalities is perceived as evidence-informed and is a national priority as reflected in key targets. There is however, restrictions of the evidence base for effective interventions. Despite all efforts made in the past decade to gather substantial evidence to tackle the present T2D health inequalities, one would ask why we still have an increase in the prevalence of T2D in this community. However, the report presented by Diabetes UK and the South Asian Health Foundation (2009) promotes a correlation of work in partnerships and vibrant partnerships to thrive among researchers and organisations alike, to operate towards accomplishing major improvements in the understanding of diabetes and its impacts on this community living the UK. The same strong information basis is necessary for any health policy or health programme on tackling health variations thus calling for reliable research (i.e. valid, timely with relevant information) on the extent and causes of health inequality presented in the SAC.
The health equity audits (HEAs) identify how fairly services or other resources are distributed in relation to the health needs of different groups. They use evidence on inequalities to inform decisions on investment, service planning, commissioning and delivery, health equity audits should help organisations address inequalities in access to services and in health outcomes, such as the inequalities experienced by these minority ethnic groups.
The Audit Commission Patient Survey previously highlighted significant gaps in patient knowledge, understanding and confidence in managing diabetes, which were substantially more pronounced for ethnic minorities than the white population. The 2001 Census revealed that from 10 ethnic minority households, six did not have English as their main language. Facilities accessible are often unsuitable such as where language and cultural barriers between healthcare and patients has often resulted in misunderstanding or even no information given at all.
The PCTs and their partner organisations are required to consider the particular needs of their population, taking into account various needs and priorities within each community as per the 2005-2008 NHS Planning Guidance. Health inequalities have been retained as a key priority for the NHS, as set out in the NHS Operating
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