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Type 2 Diabetes and Migrants: A Twelve Country Study

Author(s): Manuel Carballo1, Klea Faniko2, Alexandre Lefebvre1
Affilation(s): 1International Centre for Migration, Health and Development, Geneva, Switzerland, 2University of Geneva, Switzerland,
1st country of focus: Greece
Additional countries of focus: Austria, Canada, Germany, Ireland, Italy, Netherlands, Norway, Portugal, Spain, Switzerland, UK
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): This twelve country study (Austria, Canada, Greece, Germany, Ireland, Italy, Netherlands, Norway, Portugal, Spain, Switzerland, UK) addressed the prevalence of type 2 diabetes (T2DM) in migrant and non-migrant populations and responses to its diagnosis and management.  Respondents were recruited from health care facilities and they were interviewed using a standardized questionnaire in their language of choice.  Statistically significant differences emerged between migrants and non-migrants with respect to a number of health care indicators, and the study highlights the importance of reaching out to migrants with T2DM diagnostic and therapeutic services designed around their particular needs and sociocultural situation.
Background (max 200 words): Over the last two decades the number of people with diabetes mellitus (T2DM) has increased by almost 50 percent. While better diagnosis and reporting may in part account for this increase, there is growing evidence that the problem is in fact becoming more common in developing as well as developed countries, and that migrants and ethnic groups tend to have a higher risk of developing T2DM than other groups do.  Chronic psychological stress, poor nutritional acculturation, radical changes in lifestyle and difficulties with health care in general may be important factors in the development of T2DM in migrants and ethnic minorities. There is also evidence that migrants and ethnic minorities are not always able to benefit from diabetes-related programs as they are currently structured.  There is a growing understanding that the complex relationship of T2DM and migration must be better characterized and that more should be done to ensure that migrants and ethnic minorities are reached with timely prevention, diagnosis and care programs that take into account their risk factors and special needs.
Objectives (max 100 words): The overall aim of the project was to provide a body of socio-epidemiological data that could form the basis for national policies and programs, including training of healthcare personnel and development of guidelines that can be used in the day-to-day prevention, diagnosis, care and treatment of T2DM in migrants and ethnic minorities.  The specific objectives of the project were to: • define what is currently known about the link between migration and T2DM and its treatment/management in migrants;• determine the incidence/prevalence of T2DM among people meeting the study definition of “migrant”, and identify contributing factors;• describe how people meeting the study definition of “migrant” perceive T2DM and its care and treatment/management;• assess how healthcare personnel working with people who meet the study’s definition of “migrant” and are diagnosed with T2DM perceive their interaction with them;• assess how a control group of non-migrants with T2DM perceive the disease and its care and self-management;• develop a program to sensitize stakeholders, including migrants, their families, health care personnel and others, on the needs of migrants with respect to T2DM;• develop guidelines on the prevention, diagnosis, care and treatment of diabetes in migrants and ethnic minorities;• develop public information materials for migrants (and ethnic minorities) on T2DM prevention, diagnosis, care and treatment;• develop training materials and training programs for healthcare personnel on the theme of multi-cultural health care with special reference to diabetes;• evaluate the impact of these interventions by measuring changes of attitudes and knowledge among healthcare personnel and migrants (and ethnic minorities).
Methodology (max 400 words): The study focused on four groups of interest: migrants and non-migrants diagnosed with T2DM; healthcare staff working with migrants and others with T2DM.  Respondents were recruited from pre-selected public health care facilities in locations with a known high presence of migrants.  Respondents were recruited with the agreement of healthcare authorities and patients.  Contact with respondents was made by letter from the PIs in the countries concerned.  Healthcare personnel working with migrants with T2DM were also contacted directly by the PIs.  All migrants and non-migrants were aged between 35-59 years, and PIs were also asked to ideally involve healthcare providers within the same age-range as the patient/respondent group in order to minimize possible “time-cultural” differences.  Participating centers were asked to select and interview the following; between 50 and 100 migrants with T2DM; between 50 and 100 non-migrants with T2DM; at least 20 healthcare staff providing diabetes care to migrants and others.  Information about the study and its aim was disseminated through local healthcare facilities in each city and through associations, clubs and other facilities known to be frequented by migrants and non-migrants.  Potential participants in the study were given details on the purpose of the study, namely to improve the quality of care available to migrants and others with respect to diabetes, and were given an opportunity to ask questions about the study.  They were assured of confidentiality.  No incentives were offered, but in cases where the participant requested assistance with counseling or referral, this was provided.  Face-to-face interviews were conducted using structured questionnaires specially developed for the purpose of the study by interviewers who were capable of speaking the language of the respondents. If respondents chose not to participate in the project, this was recorded as a refusal.  If respondents started and then decided to discontinue the interview, it was recorded as a discontinued interview and the reason was recorded.  The interviews lasted approximately 40 minutes.  Focus groups were also organized to generate information from health care personnel using guidelines developed specially for the purpose of this study.  Data entry was done locally on an on-going basis using data entry sheets provided by ICMHD and sent to ICMHD and analyzed centrally.
Results (max 400 words): Statistically significant differences emerged between migrants and non-migrants in a number of areas, such as knowledge about T2DM, factors influencing its occurrence, its short and long-term implications, the ways in which it can and should be managed, and where help can be had if and when complications arise.  Attitudes to T2DM also differed; migrants were far more inclined to take a more fatalistic view of the disease than non-migrants were.  There were also significant differences with respect to the circumstances in which T2DM was diagnosed; data from all the countries suggested that migrants tend to be diagnosed with T2DM as a result of other health problems/complaints and not as a result of regular checkups; almost 60% of migrants with T2DM had been diagnosed during medical examinations for other problems including occupational injuries.  On the whole, migrants diagnosed with T2DM were much more likely to say that the diagnosis had been poorly explained to them, or that they had not understood what had been said. There was also a fairly widespread feeling that the people treating them were not interested in them as migrants or in their needs, even though the diagnostic setting was typically described as friendly. Migrants frequently expressed concern at not feeling sufficiently “in control” of their lives to manage their diabetes, and they had much more difficulty keeping appointments with healthcare providers.  They were also more likely to use emergency call numbers (hotlines) for diabetes related problems than non-migrants.  One of the background characteristics we believe may be important in the development of T2DM is the relatively large proportion of migrants who had been separated from their significant others by migration and who said they were chronically stressed.  There was a clear tendency for migrants to also have less economic/occupational security than their host population equivalents; contractual employment was less common among migrants and was also seen by them as a source of stress. There was also a tendency for migrants to work longer hours than non-migrants and have little time for personal activities including cooking, a fact that they said contributed to their use of pre-prepared foods. In accordance with what has been observed elsewhere, migrants were also more likely to be living in overcrowded dwellings and sharing accommodation with a number of people to whom they were not related.
Conclusion (max 400 words): The prevalence of T2DM is significantly higher among migrants than non-migrants in Europe and Canada. A number of factors may be linked to this, including chronic stress, rapid and often difficult changes in lifestyle, high dependence on ready-made foods and fast foods outlets, poor awareness of the factors contributing to T2DM and the importance of T2DM as a disease. It is also clear from the study that the diagnosis of T2DM in migrants often occurs incidentally to other complaints and not as part of any targeted regular checkups. Migrants also appear to have more difficulty coping with T2DM than non-migrants and in many cases do not have the level of personal control needed to make self-treatment easy or successful. On the whole communication between healthcare providers and migrants with respect to explaining the nature of the disease, the contributing factors and ways of dealing with it is also lacking, and many migrants tend to interpret this as a lack of interest on the part of healthcare providers in them as migrants and, in particular, as people with different medical and socio-cultural histories. In view of the growing problem of T2DM and the growing magnitude of migration it is clear that much more will have to be done to tailor national diabetes strategies in ways that address the specific needs of this new population. There is a need for more and better outreach to migrants, and there are grounds for promoting regular screening for T2DM in migrants.  Certainly more needs to be done to convey to migrants what the risks of developing T2DM are and what the main factors contributing to those risks are.  It is also clear that providing psychosocial support to migrants could well help them to manage their diabetes better and be less reliant on health care providers and emergency care in particular.  Although this type of intervention might at first seem costly, it is probably one of the more cost-effective investments that can be made once migrants have been diagnosed with T2DM.

One thought on “Type 2 Diabetes and Migrants: A Twelve Country Study

  1. Great study of an emerging and important problem worldwide. How did the authors measured and compared prevalences? Were there any difference in clinical outcome such as glycaemic control, complications, use of insulin?
    Yves Jackson

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