Hea610 Masters Project For Therapeutic Assessment Answers

Answer:

Introduction

Type 2 diabetes can be defined as a chronic metabolic disorder that is primarily characterised by an increase in the level of sugar in the bloodstream, in addition to insulin resistance and an absence or deficiency of insulin hormone. Type 2 diabetes is generally caused due to a combination of different environmental and genetic factors that eventually result in an impairment in the secretion of insulin hormone. In other words, T2D is defined as a multifactorial disease that involves the actin of several genes and certain environmental triggers in different extent (DeFronzo et al., 2015). T2D is increasing at an alarming rate in the global context. Reports postulated by the International Disease Foundation state that there will be an estimated 438 million individuals affected by the metabolic disorder by the year 2030, which in turn would account for approximately 4.5% of the projected world population (Dabelea et al., 2014). T2D was formerly referred to as non-insulin dependent diabetes and was historically diagnosed during middle age and later years. However, recent epidemiological studies have shown its increasing prevalence in children and young adults as well. However, poorly controlled repercussions of the metabolic disease and its un-treated form often imposes great personal burden on the affected person and economic burden on the society. This burden generally manifests in the form of comorbid conditions and early mortality (Akter, Rahman, Abe & Sultana, 2014).

Some of the major complications that are associated with type 2 diabetes are kidney disease that might lead up to end stage renal disorder, visual impairment and blindness, stroke, cardiovascular problems, erectile dysfunction and amputation of the lower limbs (Gregg et al., 2014). Insulin resistance is most commonly attributed to an increase or elevation in the levels of pro-inflammatory cytokines and free fatty acids in the blood plasma, thereby accounting for a reduction in the amount of glucose that is transported to the muscle cells (Kahn, Cooper & Del Prato. 2014).

The prevalence of diabetes has doubled in the past two decades in Australia, owing to an increase in population. According to data projected by the health department, an estimated 6% or 1.2 million Australian aged 18 years or above were found to report symptoms that were related to diabetes in 2014-2015. This proportion of diabetic individuals comprised of people suffering from both type 1 and type 2 diabetes. Furthermore, based on accounts of self-reported data, diabetes prevalence has increased thrice from 1990 to 2015 (Aihw.gov.au, 2018). This can be validated by the increase in the proportion of diabetic individuals from 1.5% to an approximate 4.7%. In addition, data reports suggest that diabetes occurs in more than 280 Australians each day and there are an estimated 500,000 people with undiagnosed T2D (Diabetesaustralia.com.au, 2018). Conversely, according to reports projected by the 8^th edition of the IDF Diabetes Atlas, approximately 15.5 million adult individuals aged between 20-79 years were found to live with the metabolic disorder in 2017, in the African IDF region. This represented a 3.3% prevalence and T2D was found highest among people aged 55-64 years (Idf.org, 2018). Furthermore, the region was also found to report highest undiagnosed diabetes prevalence. Thus, the aforementioned data helps in identifying the alarming rates with which T2D is affecting people in Australia and Africa.

Exercise and diet are not the only two components that need to be addressed for the prevention and management of T2D. Experts hold the opinion that appropriate consideration must be given to the cultural influences as well that predispose and individual to increased genetic-geographical risk of diabetes onset. Several studies have attempted to provide an explanation for the cultural influences on risk of diabetes development (Schabert, Browne, Mosely & Speight, 2013). Highest prevalence of diabetes is found in North Africa (Bos & Agyemang, 2013). However, some of the gaps in research are attributed to high rates of non-participation in the studies. Furthermore, individuals with known levels of abnormal glucose in bloodstream might show an increased interest in participation in those studies, thereby increasing the risks of bias in the results. Additionally, gaps also exist between practices and knowledge of type 2 diabetes mellitus among the affected individuals (Ali, Bullard, Gregg & del Rio, 2014). Asians when compared to their Caucasian counterparts often report poor control of blood glucose levels which in turn is influenced by their dietary habits, an essential aspect of their culture (Gujral, Pradeepa, Weber, Narayan & Mohan, 2013). Furthermore, low participation of women suffering from diabetes mellitus in observational studies also reflect a lack of awareness regarding the prevalence and management of T2D (Moin et al., 2015). Presence of language barriers among people of different cultural backgrounds also contributes to a reduced awareness on the metabolic disorder. Moreover, the healthcare policies and services existing in different regions of Australia and Africa differ largely in terms of the way by which they address delivery of care services and associated financing. Although much research has been conducted to identify the role of cultural beliefs, faith, prayers, economic background and employment status on diabetes prevalence in Australians and Africans, there exists a wide variance in the way by which people belonging to these two regions perceive illnesses. Presence of weak national healthcare system in Australia is often considered as a major contributor to inequity and poverty among African people. Thus, person having poor health status move down the social ladder, when compared to their healthy counterparts, residing in other developed countries. Furthermore, poor infrastructure and conventional beliefs also create issues in the access of curative and preventive health management services. Furthermore, people of African origin also fail to gain access to these services due to their low economic background, thus not getting appropriate chance to utilise curative interventions, which focus on social determinants of health (De Maeseneer & Flinkenflögel, 2010). However, the primary healthcare system of Australia is quite advanced and generally acts as the entry level where a resident obtains the initial access to healthcare facilities. These existing disparities in the way health and illness are perceived by people belonging to the two population also contributes to differences in disease prevalence (Duckett & Willcox, 2015). In other words, the potential differences that contribute to the process of disease development makes it necessary to study the role of socio-cultural determinants in increasing susceptibility of Asians and Africans for T2D onset.

Research aim

The research aims to identify the prevalence of type 2 diabetes among Australians and Africans and the primary determinants (including culture) on the risk of predisposition to the condition.  

Research objective

• To determine the prevalence of T2D among Africans and Australians
• To explore the major factors that increase likelihood of the target population getting affected by the metabolic disorder
• To assess the role of culture in predisposing Australians and Africans to T2D 

Methodology

Search terms

Methodology forms an important part of a literature review since it assists the researchers to select or chose the steps that need to be adhered to, while addressing the research question. A review of literature on the selected topic began with the search of appropriate research articles in an operational and systematic way. This approach acts useful in highlighting authentic and relevant articles (McGowan et al., 2016). Identification of search terms and key phrases are of utmost priority in a literature review. Before beginning the conduction if a research, the key phrases need to be described in a manner that covers all essential aspects of the research aims and objectives. The search terms used for the literature review were ‘diabetes’ ‘type 2’ ‘prevalence’ ‘presence’ ‘factors’ ‘culture’ ‘Australia’ ‘Africa’ and ‘determinants’. 

Inclusion and Exclusion criteria

Time and again it has been stated that there must be a comprehensive plan for conducting search of literary sources that adhere to a certain search protocol. The formulation of specific criteria for including and excluding relevant articles helps in narrowing down the retrieved hits and reduce wastage of time. While inclusion criteria refer to characteristics that must be present in prospective articles if they are to be incorporated in the review, exclusion criteria are those that help in disqualifying potential articles from inclusion in a review. The inclusion criteria for this review were as follows:

• Articles should be methodologically sound
• Must be published in English
• Must be published between January 2008 to August 2018
• Should not focus on pediatric population
• Should elucidate on type 2 diabetes
• Must measure prevalence and/or determinants as one of the major outcomes
• Should not discuss about any other population, apart from Africans and Australians
• Research method should be either qualitative or quantitative (McGowan et al., 2016)

The exclusion criteria were as follows:

• Publications in foreign languages
• Publication date prior to 2008
• Articles addressing pediatric population
• Articles that discuss on type 1 diabetes
• Articles elucidating on the prevalence of diabetes in any other geographical population
• Clinical guidelines
• Case studies
• Unpublished manuscripts

Databases used

Electronic databases namely PubMed, CINAHL, and MEDLINE were used for extracting pertinent articles. With the aim of increasing sensitivity of the literature review and enabling a larger choice of scholarly sources that could be extracted from the databases, the bibliography were also evaluated. Initially PubMed was used for obtaining an exhaustive insight into the total number of research papers that were available for an analysis (McGowan et al., 2016).

Following addition of filters for the publication year (2008-2018), an estimated 69 articles were obtained for prevalence of type 2 diabetes in Africans, and 75 for prevalence in Australians. This huge number of search hits provided an indication of the fact that there is an array of scholarly articles for answering the research objectives. With the aim of finding adequate articles for the review, the other two databases were used for defining the literature results. This approach helped to refine the search results. Limiters were also applied with the help of Boolean operators that helped to combine the different key phrases together. ‘AND’ and “OR” were the Boolean operators used in this context that assisted permutation and combination of the different search terms (Hart, 2018). 

The initial level of screening involved reading the title and abstracts of the prospective articles, in order to make a decision regarding the inclusion and exclusion of studies, from the review. Having excluded articles that failed to meet the inclusion criteria, a smaller number of possibly pertinent articles were obtained that were read, followed by a critical analysis of the full texts in order to determine their relevance to the research aims and objectives. Some of the major questions that helped in evaluating the articles were as follows:

• Does the article address a well-focused or problem?
• Were valid methods used for addressing the research questions?
• Are the research findings valid and important enough?
• Are the findings relevant to the target population?
• Can they be applied to the local context?

Duplicate articles were also eliminated from the extracted results after reviewing the abstract, title, author names, year of publication, and journal name.

Quality assessment

Following the identification of articles that were found relevant in terms of their content and the title, with regards to the research aim, their quality was evaluated with the use of two different appraisal tools. The quality of qualitative articles was assessed by a 32-item checklist, commonly referred to as the ‘COREQ’, which covers reporting of studies that utilise focus groups and interviews as data collection methods. The primary reason for use of this checklist can be attributed to the fact that it is the only reporting tool that has obtained isolated endorsement (Booth, Hannes, Harden, Noyes & Harris, 2014). Some of the major domains that were taken into consideration while using this checklist are given below:

1. Research items and reflexivity
2. Study design
3. Findings and analysis

Hence, use of this COREQ checklist provided the opportunity to conduct a comprehensive and succinct reporting of qualitative articles that covered all important components of a study design. Quantitative articles were assessed with the help of the PRISMA tool or Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The PRISMA encompasses a checklist comprising of 27 items (Stewart et al., 2015). The major features of quantitative articles that were evaluated using this checklist are the title, abstract, introduction, methods, results, discussion, and funding.

Data extraction

Data relevant to each of the retrieved articles were extracted based on the title of the research, the names of the corresponding authors, publication year, setting of the research, sample size, prevalence of type 2 diabetes by age, and gender in the pre-specified geographical region. This process usually refers to the act of retrieving appropriate data out of sources for processing of information. Data extraction forms were used for creating a summary table of the major study characteristics that were finally assessed (Te Morenga, Mallard & Mann, 2013). The following were the characteristics of the articles that were evaluated:

Table 1- Summary of the nine scholarly papers retrieved from electronic database

Data analysis

Data analysis is considered as one of the most crucial parts of a study. This analysis helps in drawing a summary of the data that has been collected in from a set of scholarly resources that matched the research question. In this research, the data analysis was done based on the interpretation and critical evaluation of data in a logical way to determine the existing relationships and trends in the findings. Data analysis was conducted following the Creswell’s data analysis spiral that encompasses several stages namely, (1) organisation, (2) perusal, (3) classification, and (4) synthesis, following which the final report was obtained (Taylor, 2014). After reading through the entire data from the nine articles, they were coded on the basis of description and themes, following by making an interrelation between the different themes. There exist two different research approaches, namely inductive and deductive. This review was based on the inductive research approach where the primary focus was laid on generation of a new theory from the collected evidences and data. This is in clear contrast with the deductive approach that primarily focuses on testing an already existing theory (Gioia, Corley & Hamilton, 2013). This approach will facilitate identifying the determinants and factors related to onset and management of type 2 diabetes among Australians and Africans.   

Results

This section of the review will analyse the data collected from the different articles into specific themes or sets and present the findings in a way that draws a correlation between them with the research question being investigated. Although diabetes has been an illness of major concern since several years, the cultural barriers or beliefs that impeded diabetes care have gained attention in recent years. Thus, an analysis of the articles discussed above suggested that all forms of ethnic and racial disparities and their subsequent complications are a direct manifestation of the culture.

Prevalence

The responses obtained from Sub-Saharan migrants in Australia suggested that showing consistency with the theories of social identity, pre-migration experiences often predisposed the African patients to T2D during the process of integration in the new environment. Integration was defined as one of the primary coping contrivances of acculturation. Though food environment before migration was characterised by scarcity of food, the post-migration environment showed an abundance in take-away food products (Issaka, Lamaro & Renzaho, 2016). In another study, diabetes was diagnosed among 23 female and 18 male participants. Furthermore, 29.3% of them showed an inability to work due to prevailing disability or pain. The fact that only 14.6% of the recruited patients displayed an association with either informal or formal employment means, established the correlation between the metabolic condition and poor socio-economic status. Furthermore, a large proportion of the participants were older adults (39%) and the females were homemakers (17.1%) (Foley & BeLue, 2017).

An analysis of the socio-demographic characteristics among at risk Congolese migrants suggested that most of them belonged to the mean age of 43.7 and 44.7 years, respectively for males and females. Furthermore, only 20% of the males and 50% of the females had attended high schools. The risk of diabetes among the Congolese participants was further elaborated by the 30% and 20% rates of unemployment among men and women, respectively (Ilunga Tshiswaka, Ibe-Lamberts, Mulunda & Iwelunmor, 2017). Comparable demographic characters were found among diabetic patients of coastal Kenya that comprised of 46.7% males and 53.3% females. This provided evidence for the larger prevalence of metabolic disorder among women. Additionally, the mean age group for diabetes was 52.9 years and 53.4% of the patients had never attended secular schools. Only 3.3% of the patients has completed secondary schools, thereby establishing a correlation between educational attainment and diabetes management. The fact that 63.3% of them had first degree relatives afflicted with diabetes mellitus increased their vulnerability to T2D manifold (Abdulrehman, Woith, Jenkins, Kossman & Hunter, 2016). A study conducted in Australia showed a diabetes prevalence among 186,279 Victorian residents, of whom 53% were men. Highest prevalence was found among people who were born in Australia (1754144 people). Regional variation was also observed among the number of males (9.7%) and females (12.1%) aged over 50 years of age (Abouzeid, Philpot, Janus, Coates & Dunbar, 2013).

High prevalence of T2D was found among Indigenous Australians in another study. Some of the most conspicuous features of the metabolic condition comprised of increased prevalence among people who resided in remote settings and had a premature age of onset of the condition. Furthermore, T2D also exhibited an increased incidence among the Indigenous adolescents and children. Thus, the perceived burden of the condition was much larger than those experienced by their non-indigenous counterparts. Presence of a familial history of diabetes in addition to being obese or overweight also made the indigenous Australians more predisposed to the condition (Azzopardi et al., 2012). Another study conducted by Renzaho et al. (2011) showed a correlation between diabetes and insulin resistance among 2% and 46.9% people, respectively, which did not show any difference in terms of length of residence of the African migrants in Australia or age. Additionally, the study also established a strong association between age and fasting glucose levels ((r=0.53, p<0.00).

Religious factors

The article by Abdulrehman, Woith, Jenkins, Kossman and Hunter (2016) stressed on the importance of religious rituals and their association with diabetes among people in coastal Kenya. Religious practices such as, fasting was found to create a large impact on diabetes self-management. Reports from the study suggested that since most of the members of the population being investigated were practised Islam, during the month of Ramzan, they participated in an obligatory fasting practice. Although the findings suggested that fasting helped in a good control of the diabetes by making the respondents adhere to specific dietary restrictions, it was also responsible for consumption of high-calorie speciality diet. Moreover, the authors also elaborated on the fact that fasting is considered imperative for promoting purity of the cultural group. Additionally, the respondents also elaborated on the range of difficulties that dehydration and binge-eating create in diabetes management. Similar findings were presented by another study that elaborated on the role of religious practices and psychological support in diabetes management among African Americans (Chlebowy, Hood & LaJoie, 2010). The findings suggested that religion and participation in religious communities among the Africans are often considered essential components while coping with any disorder or illness. The authors elaborated on the fact that most African Americans prayed to their God for better management of blood sugar levels and did not seek appropriate healthcare services for the same. This prevents them from adequately accessing healthcare facilities for preventing onset of diabetes, thus impeding the process of keeping a check on the blood sugar levels.

In the words of Issaka, Lamaro and Renzaho (2016) who determined the role of religion on the prevalence of diabetes among Sub-Saharan African migrants residing in Melbourne. The authors illustrated the fact that there existed a robust sense of religion and its impact among all the African respondents belonging to a range of faiths and religious backgrounds. They were found to hold the belief and assumption that onset or the event of acquiring type 2 diabetes is the direct result of Allah or God’s will. Furthermore, the respondents also emphasised on the fact that optimal health of person is completely under God’s will. This made them believe that inset of diabetes was due to the wish of the supreme protector. Additionally, as a part of the traditional acculturation coping pathway, recruited participants who practiced Islam also stated that they would often use traditional prayers during the healing process, if they found themselves diagnosed with type 2 diabetes.

However, those African respondents who were of the Christian community assumed that miracles and prayers were capable of curing the metabolic condition. This emphasised their belief in the fat that the religion they practiced was the primary medicine for any form of health ailment. In addition, participants were also found to state that bad luck and/or several supernatural forces were responsible for the onset of diabetes among members of their community. However, these conventional beliefs were found to be more widespread among African migrants who were traditional-oriented, compared to those who had assimilated. These findings were consistent with results presented in another study that illustrated the importance of religion and faith. An estimated 90% English speaking, Afro-Caribbean participants thought that religious prayers were a major form of matching treatment that could regulate type 2 diabetes. They held the assumption that faith and prayer complemented all forms of traditional and biomedical Caribbean medicine for managing diabetes and its associated health complications. The belief in God was also found among participants who had expressed their frustration in relation to the disease. They hoped that their God would assist in easy recovery from the condition that would gradually become tolerable with time (Smith, 2012).

Perceptions

Foley and BeLue. (2017) stated that few of the participants recruited in the study mentioned the fact that some of their family members failed to understand the actual course of progress and the symptomatic pathophysiology of type 2 diabetes. In most cases this lack of understanding of the metabolic disorder resulted in difficulty of the affected people tom follow an appropriate therapeutic diet. Besides, the participants also stated that this lack of awareness and less perception about the disease in their culture often made them follow a diet similar to that of the other family members, thereby making it difficult to manage the blood sugar levels. Results from another study suggested that Congolese immigrants often perceived American junk foods as a crucial factors that exerted a negative impact on their poor health status and made them more predisposed to type 2 diabetes. Furthermore, they also held the view that consumption of traditional Congolese food products protected from the disease owing to the fact that food items that were encompassed in a Congolese diet were healthy and did not incorporate dietary acculturation. The responses of the participants also suggested that they strongly believed in the correlation between specific foods and diabetes risks among the ethnic community (Ilunga Tshiswaka, Ibe-Lamberts, Mulunda & Iwelunmor, 2017). Cultural perceptions that governed the presence and management of type 2 diabetes among the Swahili community encompassed the use non-biomedical interventions, mistrust and fear of medical therapies. This made the ethnic people adopt a defeatist approach toward diabetes management. Furthermore, people belonging to coastal Kenya also supposed that herbal medicines were much affordable, when compared to the already established pharmacological products that target T2D.

Furthermore, most of the participants were also of the view that adhering to anti-diabetic medicines for a prolonged period of time would make them highly dependent on them. This led to a sense of mistrust and fear. Furthermore, negative perceptions were also related to the consideration of diabetes as a death warrant (Abdulrehman, Woith, Jenkins, Kossman & Hunter, 2016). Thus, the cultural beliefs and values were responsible for governing the opinions that the African community held. In the words of Smith (2012) Afro-Caribbean female participants thought that old Caribbean medications were more operative for the management of type 2 diabetes, in addition to a plethora of other medical ailments such as, hypertension. 57% participants gave responses that illustrated the widespread use of traditional Caribbean medications such as, noni/ cerasse/bitter/caraili melon (Momordica charantia), mauby bark (Colubrina arborescens), Aloe vera, cinnamon (Cinnamomum verum), celery (Apium graveolens), and bush tea. Moreover, 76% Afro-Caribbean patients were also of the opinion that the traditional Caribbean food patterns were not adequate for keeping a check on the blood glucose levels. The fact that conventional Caribbean diet contains high content of sugar, starches, and fat, makes the ethnic group more vulnerable to T2D development.

Food insecurity and restricted contact with appropriate healthcare services among the indigenous Australian population were some of the commonly perceived barriers to diabetes management and prevention. The way by which the Aboriginals perceived their disease and health as an integral part of their life often prevented them from accessing proper healthcare facilities, in spite of the significant rates of morbidity associated with diabetes. This acted as a major barrier in the path in the management of T2D (Azzopardi et al., 2012). Furthermore, people belonging to the African migrant community often perceived diabetes as a rare condition. They had the opinion that such diseases usually affect one or two people in the entire community and are not of much significance. This observation was related to ‘lived experiences’, where they had met some people with T2DM. Further perceptions were also related to the fact that the African community often interprets T2D as a disease that affects the wealthy people. This belief was largely responsible for the low priority that African migrants attributed to diabetes (Issaka, Lamaro & Renzaho, 2016).

Enablers

One of the major challenges that were reported by participants residing in Senegal was poor finances. Most of the affected people were retired older adults. Although vegetables, lean meat and fresh fruits were easily available, they were perceived to be costly. This made most of the patients run out of adequate food products, before sufficient money could be arranged for. Moreover, people belonging to poor economic status often skipped their meals and depended largely on social services for food procurement. Furthermore, poor economic background was also found top contribute to failure in buying adequate medications and diet. These factors are largely responsible for failure of the ethnic community to show compliance to a diabetic diet (Foley & BeLue, 2017). In another study, Congolese participants suggested that grocery stores and other establishments primarily comprised of sweetened and unhealthy food products and fail to provide help to people suffering from diabetes. Additionally, lack of appropriate information between risks for T2D development and dietary consumption was also recognised as a major factor that governed the high prevalence of the disorder in the African community (Ilunga Tshiswaka, Ibe-Lamberts, Mulunda & Iwelunmor, 2017).

Similar factors were also stated by the costal Kenyan population who identified the impact of poverty, and biomedical costs on their health status. Poverty was cited as the primary reason for not getting adequate nutritional intake and resulted in failure of the patients to consume food on a regular basis. Furthermore, the high costs of diabetes medications most often made them stay without the drugs for many days. Poor socio-economic background directly governed the rate of attending appointments with diabetes specialists (Abdulrehman, Woith, Jenkins, Kossman & Hunter, 2016). These results were consistent with the factors identified among the indigenous Australian population in another study. Remoteness of the indigenous diabetic patients resulted in a limitation of the telecommunication facilities that could be cited as a major barrier to the appropriate management of diabetes.

In addition, poor socio-economic status of the ethnic Australian population also prevented them from proper educational attainment, thereby contributing to a lack of awareness on health and wellbeing. This was in direct correlation with restricted resources associated with lifestyle modifications, and inaccessibility of healthcare facilities (Azzopardi et al., 2012). Concerns over the time consuming nature of diabetes prevention and management strategies were identified as potential barriers in another article. This factor was found to directly contribute to their incapacities to successfully self-manage type 2 diabetes symptoms. Participants also specified that it was problematic to uphold daily or recreational activities and frequently exercise T2D self-management actions. Lack of self-control in terms of dietary adherence, and pain relate to use blood-glucose monitor were other barriers to the process of diabetes prevention and supervision (Chlebowy, Hood & LaJoie, 2010).

Discussion

Most of the studies included in the review were able to identify different factors that acted as barriers or facilitators in the prevention and/or management of type 2 diabetes in the Australian and African population. Four of the studies were able to draw a correlation between religion and spirituality with diabetes among the patients, or those at risk. The findings were consistent with those presented in a separate article that elaborated on the fact that religion and spiritualty were significantly related to glycemic control (GC) among Black women diagnosed with T2D. The RWB was related to different aspects of a supportive, personal and direct relationship with God. Findings from the study indicated that an increased dependence on God, in relation to acute illness such as, diabetes, attenuated concomitant emotional distress and/or anxiety. Therefore, women who demonstrated suboptimal levels of GC, accompanied by symptoms of neuropathic pain and vision changes had an amplified reliance on God for reducing their emotional suffering. Women with increased perception of the meaning, purpose and satisfaction of their lives had a better optimal GC, signifying that religiousness may endorse effective management of diabetes (Newlin, Melkus, Tappen, Chyun & Koenig, 2008).

These statements were in accordance to those mentioned by Iranian diabetic individuals who endorsed the fact that religious beliefs significantly strengthened the patients to tolerate diabetes. They look upon the datum they had developed diabetes by the willpower of their God, the creator. Acceptance of diabetes was largely governed by their belief in God. Their reliance was a custom of acceptance that offered them the internal forte to accept life with diabetes. Additionally, eight participants considered that their connexion with God encompassed different aspects of spirituality, and provided them vital support (Abdoli, Ashktorab, Ahmadi, Parvizy & Dunning, 2011).

Similar findings were elaborated by Lundberg and Thrakul (2013) who illustrated the fact that in order to cope with the stress and anxiety that are associated with diagnosis most Muslim and Buddhist women sought help from religious practices. Some Buddhist women stated that their religion promoted their psychological wellbeing and also held the belief that these Buddhism helped in management of diabetes, if they followed the Buddhist principles. Such patients were of the view that diabetes was a result of their past actions (karma) and accepted the disease as a part of their life. Similar statements were given by Muslim women as well, who suggested that practicing their religion would help them recuperate from the disease and what had happened to them was under the supreme control of their God. This was further established by the fact that the religious practice of fasting during the month of Ramadan often helped them in controlling their elevated blood sugar levels. The role of spirituality in coping with diabetes and its management was also highlighted in another article that established a strong correlation of spirituality with the female gender. The findings of the articles suggested that both males and females showed compliance to different paths of spiritual journey, based on their psychological and biological characteristics. Furthermore, people being diagnosed with type 2 diabetes for a shorter duration showed an increased spirituality scores. The authors were also able to establish a direct association between coping spirituality and HbA1c levels. Therefore, the findings of the article and statements of the researchers suggested the need of addressing the role of spirituality in self management of diabetes among different communities (Parsian & Dunning, 2009).

Six articles included in the review elaborated on the link between diabetes and perceptions, among people belonging to the Australian and African community. Food insecurity was identified as a major contributing factor that is generally defined in the form of limitations and/or restrictions in the consistent access to appropriate food products, due to lack of resources and money at a particular time of the year. In the words of Seligman, Jacobs, López, Tschann and Fernandez (2011) food insecurity was identified as a major causal factor to poor glycemic control. Results of the study made it clear that people diagnosed with type 2 diabetes having food insecurity showed an increased difficulty in showing adherence to a diabetic diet that generally comprises of fibre rich food, that have low sugar or fat content. The authors elaborated on the fact that most people who belonged to poor socio-economic status or older adults not having proper access to adequate nutritional components start getting out of food at the end of the month, and fall sick. Some of the compensatory strategies that were used by such patients, during conditions when food products are scare, were related to eating anything that they could find, which in turn increased their risks of hyperglycemia. The cyclical phenomenon of food insecurity with recurrent episodes of food scarcity that were usually followed by events of relative adequacy of food materials predisposed person, already diagnosed with type 2 diabetes to hypoglycemic conditions. These findings were consistent with the results presented by researchers in another article that examined the association between clinical evidence of diabetes, hyperlipidemia, and hypertension with food insecurity (Seligman, Laraia & Kushel, 2009). The authors illustrated the presence of noteworthy food insecurity in Latino households when compared to their white counterparts (p<0.001). Additionally, household food insecurity was also related with low family income, low educational attainment, use of tobacco, and absence of adequate health Insurance. Furthermore, the researchers were also able to establish a relationship between higher BMI among females, with food insecurity. Clinical evidence for type 2 diabetes was presented by 7.4 % of the poor adults, who lived in food secure families, when compared to 10.2% of those who lived in food insecure houses. Moreover, adults who had been diagnosed with type 2 diabetes showed a direct link between food insecurity and inadequate management of the metabolic condition (ARR 1.35; 95% CI, 1.05–1.74).

According to Hu, Amirehsani, Wallace and Letvak (2013) frustration in association with taking diabetes medications that were inconvenient, and dietary constraints caused major difficulty in self-management of the disorder. Several participants enrolled for the study suggested on their liking towards junk food and soda that were rich in sugar and fat content, which acted as barriers in self-management. Furthermore, absence of family support, particularly in relation with dietary changes and a lack of awareness and/or understanding among family members regarding diabetes mellitus, directly impeded the process of recovery. Dietary constraints were also found responsible in creating a sense of conflict over dietary issues, which made it difficult for diabetic patients to adhere to restricted nutritional intake. Belief on traditional herbal medicines over pharmacological medications for T2D treatment was also emphasized in another study where Senegalese diabetics showed their faith in the effectiveness of medicinal plants, in treatment of the metabolic disorder. Results published in this study suggested that all people diagnosed with diabetes belonging to Senegal, often relied on the use of Moringa oleifera and Sclerocarya birrea. More than 50% of these patients were illiterate and only 29% of them had the opportunity to attend secondary schools. They were of the belief that these two herbal plants were capable of reducing blood glucose levels. They explained their decision to use these herbal medications owing to the fact that the traditional treatments did not create any adverse effects on their health, and were in accordance to their beliefs. Apart from efficacy of these traditional treatments, low cost of herbal plants were cited as another major reason that prevented people belonging to this cultural group to access the costly therapeutic medications for T2D (Dièye et al., 2013).

These findings were further endorsed by Kolling, Winkley and von Deden (2010) who confirmed the fact that the primary reason that made people diagnosed with diabetes in Tanzania use ethnomedicine was associated with their less expensive nature and increased affordability, when compared with the high price of medicines, available at biomedical pharmacies. Another probable reason that made ethnic diabetics use traditional medicine was allied with the claims made on their efficacy by herbalist healers or spiritual leaders. Taking into consideration the fact that herbal medicine created profound positive impact on diabetes treatment in some people, others cited this as an opportunity for self-management of the condition. Dissatisfaction with the adverse effects, high cost of oral tablets, financial constraints and residence in remote location prevented them from attending healthcare facilities. Thus, most of the people belonging to these ethnic communities resorted to the use of cost-effective herbal medicines.

The different barriers and enablers to type 2 diabetes care provision among the Australian and African community were identified by five studies included in the review.  These findings were in unity with the results presented by authors who conducted a similar study amidst people residing in regions of social disadvantage. According to the responses given by young adults recruited by the authors, high costs of diabetes care, difficulties with transport, residence in remote location, and time constraints prevented them from appropriately accessing healthcare services for management of diabetes. Low average income of all of these respondents acted as a significant barrier and was directly related with increased levels of anxiety and depressive symptoms, in addition to diabetes related distress. Likewise, previous unsatisfactory experiences of diabetes health care were also cited as the major motive that prevented people belonging to poor socio-economic background from attending appointments at diabetes clinic, consequently reducing the likelihood of proper diabetes management (Kibbey, Speight, Wong, Smith & Teede, 2013).

Elder and Tubb (2014) also established the connection between homelessness and diabetes care. Homeless people diagnosed with diabetes were usually found to prioritise needs related to their shelter, employment, and food procurement, above all other requirements of obtaining medical care and self-management of type 2 diabetes. Besides, homeless people did not receive any education or support about the supervision of the chronic disorder from social service providers, which in turn made them perceive their poor socio-economic background as the primary reason for deprived health status. The role of racial disparities in diabetes management within integrated communities were also concomitant with the hypothesis stated in another research that differences in relation to risk exposures that happen due to isolation in the society directly obscure the consciousness of health disparities. Likely environmental and socio-economic factors that were accounted for in the study were identified to precipitate the disproportion in incidence and prevalence of diabetes. These factors most commonly included the allowance of precautionary healthcare resources, food quality and security, parks, exercise facilities, and apparent self-efficacy in illness deterrence (LaVeist, Thorpe, Galarraga, Bower & Gary-Webb, 2009).

Implications

A diabetic nurse has the role of providing help to all patients who have been diagnosed with diabetes mellitus, the disease that prevents the adequate production of insulin or its sufficient absorption from the blood. Owing to the fact that most nurses spend majority of their time in relaying essential information tom the doctors, patients and their family members, taking into consideration the role of culture, family awareness, socio-economic status, religious views and food insecurity will prove beneficial in diabetes management (Garcia & Brown, 2011). Nurses should display a cultural competence in terms of their ability and knowledge in working with people belonging to culturally diverse population, regardless of their customs, language, beliefs, communication, values and preferences, according to their ethnicity and race. An essential element in overcoming the ethnic barriers during a nurse-patient relationship is the utilization of effective communication. This approach must always be considered while working with the indigenous population of Australia or the African residents, who have low rates of literacy, limited proficiency in the English language and are non-English speakers. While communicating with people having poor educational attainment, the nurses must take efforts to formulate educational materials that meets the preferences and values of their culture (Dunning, 2013).

Furthermore, using teach back methods would also prove effective in confirming patient understanding of the health scenario they are currently in. The ability of nursing professionals to foster cross-cultural communication is indispensable to providing tutoring to dissimilar population, as it empowers the usage of appropriate spoken and non-verbal communication styles. In addition, the patient education that will be provided must comprise of culturally profound material that might be dispersed to augment patient understanding on controlling diabetes. Hence, nurses will be entitled with the duty of acting as diabetes educators where they will need to display a mindfulness of the religious customs, faiths and cultural traditions of patients belonging to varied ethnic groups, in addition to recognising the plethora of socio-economic challenges that they generally face in everyday life (Nam, Chesla. Stotts, Kroon & Janson, 2011). Considering the motivational spurs of persons from varied backgrounds will allow diabetes educators to improve operative programs, instruction strategies, and customised care plans for alleviating the influence of diabetes (Hawthorne, Robles, Cannings?John & Edwards, 2010). Assimilating the discrete cultures within diabetes training and education is another major nursing implication. Diabetes management can be enhanced among people belonging to culturally diverse backgrounds by acknowledging that the cultural perceptions linked to health are discrete and unique for each person (Guo et al., 2012).

According to the traditional religious beliefs held by all individuals, most diseases are considered as an action of God and accepted as a part of the life. Awareness is the key to maintain proper diabetic health. Thus, nurses should be able to meet the religious preferences and demands of the diabetic patients, while providing them care services, in the form of provisions of interaction with spiritual leaders or access to holy books. When combined with therapeutic care approaches, these religious aspects will largely make the affected people cope up with their illness (Betancourt, Green, Carrillo & Owusu Ananeh-Firempong, 2016). Owing to the fact that when people become physically unfit they usually rely on religious practices and beliefs for relieving their emotional and physical distress, regaining a sense of control, and maintaining a hope in their lives (Namageyo-Funa, Muilenburg & Wilson, 2015). Thus, nurses should take into consideration that religion is an essential philosophical orientation that is responsible for influencing the understanding of the patient for the outer world, and make their sufferings bearable and understandable. Hence, nursing staff should allow the diabetics being provided care, to adhere to their religious practices like praying, which in turn will promote a sense of wellbeing and help to cope with stressful conditions (Haas et al., 2012).

Providing diabetes self-management support will also effectively help in enhancing behaviour related to self-care among people who are food-insecure. Diabetes patients residing in food-insecure households will greatly benefit from diabetes learning that concentrates on low-budget self-management policies such as, dietary constraints and modifications. Lack of nutrition knowledge has also been allied with an augmented probability of household food insecurity (Laraia, 2013). Hence, nurses should adopt education programs to increase nutritional knowledge among the culturally diverse patients. Application of the chronic care model would also be imperative in management of diabetes. Interventions that target patient enablement by accentuating the role of service users in handling their personal health, the usage of care strategies for self-care, objective setting, preparing a plan of care and monitoring health status would be another major nursing implication (Dancer & Courtney, 2010). Establishing a partnership with community programs and healthcare organisations would also enable in increasing access to health services among the culturally diverse patients residing in remote locations. 

Conclusion

Culture usually encompasses the beliefs, knowledge, habits and customs that are shared by a group of people. T2D has also been recognised as the major reason that contributes to non-traumatic amputation among patients in Australian and has also recently been identified as the primary cause of renal dialysis commencement in affected people. When compared to non-diabetic individuals, those suffering from T2D are at a 2-4 times increased likelihood of suffering from cardiovascular disorders. To all intent and purpose, individuals suffering from this form of diabetes are able to lead a successful and meaningful life. An analysis of the articles included in the review suggested that type 2 diabetes is an insidious disease that induces a cascade of psychological reactions during the entire course.

Hence, management of diabetes requires maintaining balance between different factors such as, diabetes knowledge, family support, religious views, cultural beliefs, traditional diet, educational levels, food insecurity and poor economic background. Spiritualty and religion are commonly used as major coping mechanisms. The primary reason for high prevalence of diabetes among Australians and Africans could be attributed to the fact that those who belonged to poorer economic strata usually considered diabetes as a will of God and resorted to the adoption of prayers to cope up with the illness. Moreover, acculturation in new environment and/or adherence to traditional medicines were also found among the ethnic communities. The high costs of pharmaceutical diabetes management products, reduced access to adequate nutrients, low literacy and lack of awareness among family members on diabetic diet were some of the major aspects that contributed to the increased prevalence of diabetes among Africans and Australians.

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