The number of people living with diabetes in UK is rising since 1996 and currently about 3.5 million people are estimated to be diagnosed with diabetes. As there might be many people who are living with undiagnosed diabetes, considering this the total number of people living with diabetes may be over 4 million (Diabetes Prevalence Numbers 2017). The studies on ethnicity and minority have revealed that ethnicity also has an impact on diabetes and it may increase or decrease the risk of developing diabetes. This link is mainly seen due to the differential access to health care and other socioeconomic factors in ethnic groups, however even with equal access, the prevalence of diabetes differs in different ethnic groups. For instance diabetes is 6 times more likely to be seen in South-Asian people (Diabetes and Ethnicity 2017). Research by Majeed?Ariss et al. (2015) shows that Black and ethnic minority groups are at higher risk of developing type-2 diabetes due to inadequate health and social care needs in relation to the needs of this people. The researcher was of the opinion that implementation of appropriate policy might help to reduce health inequality.
Majority of research regards differential access to health and socioeconomic factor in ethnic groups having an impact on the prevalence of diabetes. However, there is little awareness regarding range of other ethnicity factors that might be leading to high prevalence of diabetes in UK. Hence, the purpose of this systematic literature review is to analyze all UK research articles that gives new insight into the impact of ethnicity on diabetes prevalence in UK. The aim of the systematic review is-
The systematic review of relevant literature was carried out under the stage of setting exclusion and inclusion criteria, searching the literature, quality assessment of paper and data analysis to identify key themes.
Database search- Primary and secondary research articles related to the topic was searched from the Cochrane library database, CINAHL, Medline, PubMed, Embase, PsychINFO and other reports on UK policy related to diabetes.
Key terms- ‘Diabetes and ethnicity in UK’ was the key terms used to find related databases and five primary research articles was selected on that basis. Furthermore, secondary articles were searched with the term relation between ‘diabetes and ethnicity’, ‘impact of ethnicity and diabetes’ and other related terms.
Inclusion and exclusion criteria- The inclusion criteria to find relevant research article related to the diabetes and ethnicity in UK included selection of English language paper published within the year 2007 to 2017. The first stage of selecting the literature was to check if it had an abstract and whether it had substantial reference to ethnicity and diabetes and it was applicable to London setting. After selecting relevant articles based on scrutiny the abstract, the next stage was to grade paper on the basis of quality and key themes. There were also exclusion criteria at this stage to exclude all articles in which ethnicity was not a major focus and which was not related to UK setting.
Data analysis- After the final filter stage, a total of 30 articles was analyzed regarding study characteristics, key themes and main focus. Out of them, some were primary research articles, some published research, reviews and other grey literature. Out of this, finally 18 articles were critically analyzed to obtain the results.
Following the analysis of selected articles and reports, many clears themes related to impact of ethnicity on diabetes in UK emerged. The following are the key themes from the 18 literature searched-
Ethnic disparities in diabetes management-
The ethnic disparities in diabetes complication is observed by Winkley et al. (2013) who showed that prevalence of complication was lower in black and South Asians at the time of diagnosis however the onset of diabetes was 10 years earlier compared to white population reflecting prolonged disease morbidity for them.
The primary research by Millett et al. (2007) explored the disparities in management of diabetes within a multiethnic population in London through a population based longitudinal survey. Clinical outcome indicator related to diabetes revealed lesser improvement in glycaemic control among Black Caribbean group compared to White British group. It revealed that pay-for performance incentive in health care is not effective in addressing disparities in control of diabetes in ethnic groups. Hence, there is a need to put more emphasis on minority communities in UK to avoid prevalence and complications of diabetes.
Another primary research is influential under this themes as the cross-sectional study examined the prevalence of diabetic retinopathy in various ethnic group diagnosed with diabetes in UK. The main findings reflected that diabetes complications are higher in Afro-Caribbean and South Asian compared to White Europeans. Hence, ethnicity is a complex risk factor for diabetes. However, the rate depicted in this study might be an underestimation it used only those group who had attended diabetes screening and treatment (Sivaprasad et al. 2012).
Unique features of complications of diabetes in South Asians
Considering the high prevalence of diabetes complications among South Asians in UK, the review by Gupta and Misra (2016) gave the indication that phenotypic characteristics of South Asian such as excess body fat, abdominal adiposity, low muscle fat and hepatic fat make them prone to diabetes mellitus. Practices such as barefoot walking are common to South Asian and this contributes greatly to foot ulcerations in them. However, still robust epidemiological data is needed to improve health outcome in ethnic groups.
Another research study investigating the beliefs and experiences of diabetes management in British South Asian gave the indication that social networks and beliefs about diabetes among this group influence their disease management behavior. Migrant British South Asians have the tendency to alter or abandon medications. They also receive less support for diabetes management from social networks. Hence, the finding was significant as it revealed the role of social network in illness management and South Asians tend to change their health behavior when they travel East. Hence, there is an immediate need for South Asians to pay attention to self-care behavior and education might also influence the diabetes management practice in this group (Patel et al. 2015). The related diabetes complications in South Asian population is also seen from research study by Shah and Kanaya (2014) which presents they are most likely to develop diabetes due to biologic and lifestyle factors.
Association between ethnicity and diabetes distress
August and Sorkin (2011) gave the detail on frequency and dietary response to health-related social support in ethnically diverse sample population and social control is associated with better health behaviors. The randomized controlled trial study on diabetes patient highlight ethnic difference in health related social support and it form designing interventions for ethnic groups to incorporate social network members in their daily diabetes management.
As South Asians living in UK has high risk of type 2 diabetes, the purpose of a cross-sectional research study by Whincup et al. (2010) was to examine the whether the ethnic difference was apparent in childhood. The risk factors for South Indian includes high fat mass index and other adiposity markers, while high fasting insulin was a risk factor in Black Afro-Caribbeans. It revealed that ethnic difference in diabetes precursor following adult health behavior is also high in UK children and certain changes in adult life are necessary for early prevention of diabetes.
Impact of lifestyle intervention on ethnic groups with high risk of type 2 diabetes
As primary research articles have mainly established high susceptibility to type-2 diabetes in South Asian people, there was a need to impact of lifestyle interventions on this group in UK. The trial with impaired glucose tolerance among South Asians in UK revealed modest changes in their weight which acted as a positive factor to prevent risk of diabetes. Hence, simple information related to diet and lifestyle and tailor made intervention can significantly reduce risk of developing diabetes (Bhopal et al. 2014).
Barrier to prevention of diabetes in ethnic groups in UK
The secondary research article by Johnson et al. (2011) examines the barriers and facilitators to implementing lifestyle interventions among black and ethnic minority groups in UK. Major barriers identified included lack of understanding regarding cultural and religious needs among health care providers, health care accessibility issues for the target groups, influence of cultural and social norms and resistance to change in health behavior. The health behavior differed in different groups and contrasting practices was observed across generations.
Socio-cultural context of diabetes self-management in ethnic groups
Beliefs about diabetes is critical to diabetes self-management and investigation into socio-cultural context of illness beliefs in South Asians revealed fatalistic beliefs about diabetes among them with lack of personal control measures to improve their health outcome. Diabetes management was easier if any family members had the disease, otherwise the overall awareness was low. Hence, socio-cultural context had a dominant influence on interpretation of disease and self-management (Patel et al., 2015). The focus on South Asians was also seen in the research articles by Patel et al. (2015) which revealed the attitude towards insulin acceptance in ethnically diverse population in UK. The belief about the necessity of insulin was questioned and health providers role in critical in making patients understand the necessity of insulin.The relationship between adiposity and diabetes prevalence across ethnic groups in UK Biobank cohorts reveal different obesity cut-offs for South Asian and White population. It reflects lower obesity threshold should be used for ethnic groups (Ntuk et al. 2014). Ethnicity links to prevalence of diabetes is also seen from the literature by Mathur et al. (2017) which explains difference in screening delivery increasing risk of severe diabetes among ethnic groups.
Effectiveness of UK policy to prevent diabetes in ethnic groups
The current UK policy to prevent type to diabetes includes creating integrated strategy for non-communicable disease to convey healthier lifestyle message to population and encourage people to live a healthy diet (National strategy and policy to prevent type 2 diabetes 2017). The evaluation of National Programme in England revealed health coverage was lower than expected, however improvement was seen every year (Robson et al. 2016). A research study reviewing the effectiveness of self-management educational programs for racial ethnic minority groups revealed better results in face-to-face intervention (Ricci-Cabello et al. 2014). The study on effectiveness of screening and treatment policies indicated false screening may hamper the prevention process and this policy are unlikely to have impact on diabetes epidemic Barry, E., (Roberts et al. 2017).
The systematic review of 18 research articles after comprehensive analysis of relevant articles based on inclusion and exclusion criteria presented many new insights to determine the facilitators and barrier to diabetes prevention in ethnic groups in UK. Primary research revealed many data revealing the higher complication in South Asian and Afro-Caribbean compared to other groups. Furthermore, the classification of research articles on the basis of key themes revealed factors like lack of understanding about disease and healthy behavior, socio-cultural elements, beliefs and attitude as a common link significantly affecting the self-management of diabetes. The limitations in the approach may help to determine the factors that health care providers can take to reduce prevalence of diabetes in UK.
Conclusion and recommendation
The systematic review of relevant research article from different databases mainly points out to the high rate of complications in South Asians living in UK. Hence, it is necessary to understand the risk factor in this group to prevent the diabetes epidemic in UK. Several research studies also pointed to the barrier in promoting positive health behavior in ethnic group to prevent diabetes. As language barrier and access issues prevent full engagement in prevention of diabetes complication, there is a need to mitigate traditional belief regarding foods and lifestyle practices in vulnerable groups and promote awareness regarding factors leading to diabetes complication among ethnic group. Accessing the varied needs of this group may help to increase acceptability to intervention and reduce the prevalence of diabetes in UK (Johnson et al. 2011). The recommendation to reduce diabetes complication in ethnic groups in UK includes taking steps include educational element in prevention program so that cultural sensitivity are addressed and interventions are made specific to the needs of ethnic groups.
Reference
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