Barriers to Healthcare for Diabetic Ethnic Minorities

Comparing Barriers to Healthcare in Diabetic Ethnic Minorities in Urban Versus Rural Settings

• Noreen Choudhary 

Issue/Problem

There has been abundant research done in the study of ethnic minorities and their access to healthcare. Attention has been paid to common barriers such as language, knowledge and communication, which are all culturally influenced. Most of this research has focused on general access to healthcare and not specific diseases. There is very little reserach on comparing barriers that exist depending on location. The issue I would be exploring in my study is determining the differences in potential barriers that exist in access to healthcare among ethnic minority diabetic individuals in urban versus rural settings. The potential barriers in access should differ depending on the location since the type and amount of resources present varies in both settings. This study hopes to contribute to the literature by focusing on diabetes and determining the differences in barriers that exist for ethnic minorities in the urban versus rural settings.

Background

The regions with the greatest incidence of diabetes are Africa and Asia, where the rates are expected to rise two or three times (Oldroyd, Banerjee, Heald & Cruickshank, 2005). The three countries with the highest prevalence of diabetes are USA, China and India (Oldroyd et al., 2005). The largest increases are expected in Brazil, Indonesia, Bangladesh , Pakistan and Japan (Oldroyd et al., 2005). Type 2 diabetes is most common among ethnic minority groups residing in developed countries (Oldroyd et al., 2005). Diabetes is a chronic illness that requires continuing medical attention as well as self-management education (American Diabetes Association, 2002).

Renfrew et al. (2013) reported on barriers to care present in a Cambodian population near Boston. The study highlighted the importance of a culturally sensitive healthcare system for Cambodians (Renfrew et al., 2013). The researchers found the following barriers in access to healthcare: patients’ views of chronic disease, diabetes management, communication, psycho-social factors, diabetes etiology and explanatory models and fears of interacting with the healthcare system (Renfrew et al., 2013). The researchers were advocating for a culturally sensitive approach to healthcare for this population because most of the barriers identified were culturally influenced. Some of these culturally influenced barriers were patients’ mistrust in the western model of health, replacement by alternative medicine, belief that western medicine is an ‘instant’ cure, and desire to please the practitioners (Renfrew et al., 2013). Researchers found these barriers among other which were influenced by cultural beliefs of the patients (Renfrew et al., 2013).

Smith, Garie, and Schmitz (2014) illustrated self-reported use of diabetes healthcare services in a Quebec community-based sample. The study found that people with major depression were more likely to be high users or non-users of diabetes healthcare services (Smith, Garie, & Schmitz, 2014). People with major depression reported more problems with accessing diabetes healthcare services (Smith, Garie, & Schmitz, 2014). People with major depression perceived more problems with the healthcare they received (Smith, Garie, & Schmitz, 2014). The results also showed that people with major depression perceived problems with the length of time they had to wait to see a doctor, that there is a lack of specialist care in their area and are more likely to report having problems getting to the doctor due to transportation and health problems (Smith, Garie, & Schmitz, 2014). The low service users represent a particularly vulnerable group who may need to be targeted by interventions in order to encourage them to visit a doctor (Smith, Garie, & Schmitz, 2014). The finding in this study was important because it showed that perceived problems with accessing healthcare services could impact utilization of healthcare.

Wagner et al. (2013) reports on the effects of trauma on the risk for disease development and access to healthcare. Mental health problems among Southeast Asian refugees are well known but the long term affects of mass violence as re-settled refugees age are less well described (Wagner et al., 2013). This study investigated any potential relationship that may exist between trauma symptoms, self-reported health outcomes, and barriers to healthcare among Cambodian and Vietnamese persons in Connecticut (Wagner et al., 2013). Healthcare access and occurrence were measured regarding patient-provider understanding, cost and access, and interpretive services (Wagner et al., 2013). Individuals with greater levels of trauma symptoms were associated with greater lack of understanding, cost and access problems, and the need for an interpreter (Wagner et al., 2013). Although these Southeast Asian immigrants arrived to United States as refugees more than 20 years ago, there continues to be high levels of trauma symptoms among this population which are associated with increased risk for disease and decreased access to healthcare services (Wagner et al., 2013). This article was interesting because it didn’t mention the usual barriers we talk about when it comes to access to healthcare (such as language).

The last article I found was titled, ‘Diabetes care quality is a question of location’ by The Press Association. The article talks about the standard of diabetes healthcare in England depending on a postcode lottery (The Press Association, 2013). The quality of care patients receive depends whether it’s provided by a GP or a hospital, it depends on the location (The Press Association, 2013). The report found big regional differences in patients’ access to quality, integrated care (The Press Association, 2013). Some areas were four times more likely to get annual checks needed to manage their conditions (The Press Association, 2013). This article is similar to my research project however instead of rural and urban settings, it focused on location in terms of where healthcare was sought, a clinic, hospital, or GP (The Press Association, 2013).

Purpose/Aim of your Project

The aim of my research proposal is to identify any potential barriers that may exist in access to healthcare among ethnic minority diabetics in rural versus urban settings. My original research proposal was investigating potential barriers in access to healthcare among ethnic minority diabetics without the location factor. When I started looking up literature, I found there was already enough information in this area and my research wouldn’t add anything distinctive to this field. I started reading more articles and doing a literature review, I didn’t find any studies comparing potential barriers in urban and rural settings. After reviewing the comments I received from the professor after the first assignment, I was actively looking for gaps in research when reading articles. Therefore, I decided to alter my original question after I found this gap. If there are differences in the types of barriers present in these two distinct settings, then hopefully my research would bring this to the forefront of healthcare providers and policymakers and would result in equitable care in urban and rural settings.

Rationale/justification

Canada is known for its multiculturalism with Ontario being the most ethnically diverse province [3]. Almost 13.4% of Canadians identified themselves as being a visible minority in the 2001 census [3]. Since diabetes is most prevalent in ethnic minorities and Canada is one of the most ethnically diverse countries, it’s understandable why there is an abundance of research in this field.

There is a currently a gap in research that my research would potentially fulfill. While reading articles present in my field of interest, I couldn’t find any that compared barriers in access to healthcare present in urban versus rural settings. This sort of information is necessary for policymakers to reduce or even eliminate these barriers to achieve high quality of care for diabetic individuals in the future. If the results conclude that the barriers present in the urban settings differ from the ones present in the rural setting, then there is work to be done. We must ensure health equity when it comes to access to healthcare and eliminate any geographical factors that come into play. We must ensure healthy places for all individuals but especially diabetics who require a lot of social and medical support. Also, the need for culturally appropriate health care to accommodate the unique needs of ethnic minorities. The other research gap I found was studies didn’t talk about information loss during translations, either during patient and practitioner interactions or researcher and patient interactions. I think it’s an important factor to consider in studies consisting of subjects who speak another language. For instance, in one study the researchers found that patients didn’t understand the concept of chronic disease and I believe that this was due to information loss during translation. Therefore, the purpose of this study is to provide healthcare professionals with information on the different barriers that exist among urban and rural settings in order to achieve health equity.

Researchable research question

The research question for my study is: What are potential barriers in access to health care among ethnic minorities with diabetes in the urban versus the rural settings?

Intellectual guideposts

Ontology is the theory of being or what reality fundamentally is, in social sciences it is closely linked with ethical implications (David & Sutton, 2011). The basic premise of phenomenological ontology is that for humans reality is not something separate from its appearance (David & Sutton, 2011). The way we think about ourselves is fundamental to what we are (David & Sutton, 2011). For me, I think that health is a fundamental aspect of being human, it’s a basic right and an underlying factor in our existence. All individuals should have access to healthcare and this access should be equitable, regardless of one’s location.

The particular ‘epistemological’ (theory of knowledge) stance (positivist, critical theoretical or interpretivist) will be grounded in assumptions about the basic character of being human (David & Sutton, 2011). My research project is rooted in the interpretivist paradigm because I believe that access to healthcare is an important aspect of being human. Health is an important part of being human and to achieve this health, we need a culturally sensitive and acceptable healthcare system for ethnic minorities.

Axiology is about the values each individual has and its influence on their research [print]. There are no value-free sociologies, values are foundational for knowledge-producing systems [print]. The topic of this study began with a personal experience I have with diabetes but eventually filtered out to form a researchable question that could add value to the field. Coming from a background in biology, we are taught that there is something wrong with the body and it needs to be fixed, that health is solely a biological factor. This was purely based in a positivist paradigm which is aligned with quantitative research. I believe that healthcare access regardless of ethnicity, location, age, sex, or gender is crucial for all humans. Coming from a country with a poor healthcare system also influences my view in terms of healthcare access. I believe that health has a strong social component which cannot be measured quantitatively and thus I adopted an interpretivist and qualitative approach for my study.

The best way to undergo my study would be by utilizing a qualitative approach, more specifically, open-ended interviews. I want to gain insight into the barriers that are present for each individual from these ethnically diverse backgrounds. I want to understand their perspective and beliefs, and how these influence their use of the healthcare system. After I understand these barriers, I will compare the difference in the types of barriers that are present among those living in the urban and rural settings. Since I am using open ended interviews, I believe the best rhetorical choice would be passive. I believe the participants in the study should have the freedom to talk in depth about the issue at hand. I don’t want to influence their answers in any way but at the same time they should have the opportunity to freely express themselves. Especially in my study which includes ethnic minorities, there may be language barriers present so this freedom to answer freely would be a plus for the participants.

Interpretive/theoretical frame

My research project will be embedded in the interpretive paradigm. More specifically, I will be adopting the constructionism theory. “Constructionists focus on how people create meaningful social reality for themselves through their interactions and thereby create a sense of order through shared beliefs… (David & Sutton, 2011).” Constructionists adopt qualitative approaches such as interviews and unstructured observation (David & Sutton, 2011). I believe that culture is important in defining health, it influences our behaviour in terms of how we access and utilize our healthcare system. For example, Renfrew et al. (2013) talked about how people’s perceptions on chronic illness affected their use of the healthcare system. One’s culture, beliefs, views and attitudes affects their behaviour in terms of healthcare use. This is relevant to my research project because I want to understand the barriers that exist for ethnic minorities with diabetes but with the added element of comparing these barriers in two settings: urban and rural.

References:

American Diabetes Association. (2002). Standards of medical care for patients with diabetes mellitus. Diabetes Care, 25, 533-549.

David, M., & Sutton, C. (2011). Social research: An introduction. London : Sage Publications.

Oldroyd, J., Banerjee, M., Heald, A., & Cruickshank, K. (2005). Diabetes and ethnic minorities. Postgrad Medical Journal, 81, 486-490.

Renfrew, M. R., Taing, E., Cohen, M. J., Betancourt, J. R., Pasinski, R., & Green, A. R. (2013). Barriers to care for Cambodian patients with diabetes: Results from a qualitative study. Journal of Health Care for the Poor and Undeserved, 24(1), 633-655.

Smith, Garie, & Schmitz (2014). Self-reported use of diabetes healthcare services in a Quebec community-based sample: impact of depression status. Public Health, 128, 63-69.

The Press Association. (2013, December 10). Diabetes care quality is question of location. Nursing Times. Retrieved from http://www.nursingtimes.net/home/clinical-zones/diabetes/diabetes-care-quality-is-question-of-location/5066307.article

Wagner et al. (2012). Trauma, healthcare access, and health outcomes among Southeast Asian refugees in Connecticut. Journal Immigrant Minority Health, 15, 1065–1072.

Peer Feedback Form

1. Is it clear what issue or problem the author will investigate through this study? Explain.

Yes, the author is studying healthcare access by immigrants from two different backgrounds: those from developed countries and those from underdeveloped countries. It is evident in the assignment what the researcher will be trying to determine and why they have chosen to do so. There is a gap in understanding barriers in access to healthcare that exist between immigrants from developing countries and those from developed countries.

2. Is the approach chosen, qualitative or quantitative a suitable choice, and will it bring insight into the research question? Explain.

The approach is qualitative and this is a suitable choice. Since the researcher wants to understand why people over or under use the healthcare system and wants their opinion/views, it’s best to use a qualitative approach. By using interviews, for example, they can gain insight into the factors that influence people to use or not use the healthcare system in their country.

3. Has the author explained connections to the literature, including what gaps exist in our knowledge about the topic? Explain.

Yes, the author has clearly explained why they want to do this research and what gap it will fill. They have mentioned that previous research has been done on immigrants and access to healthcare, however, none have focused on the differences in this access based on country of origin (developed/developing).

4. Are the aims of this project clear and well written? Explain.

Yes, the aims are quite clear. The author wants to understand the factors that prevent immigrants from using the healthcare system based on their country of origin, the Western or Eastern countries. They want to compare these factors and understand if any differences exist.

5. Is the research question clearly stated? Is it researchable? Does it fit well within approach the author has selected? Explain.

The question is clearly stated and is researchable. It will fit with the qualitative approach that the researcher has chosen because it will allow them to understand from the immigrants’ views why they chose or didn’t choose to utilize the healthcare system. They want to understand the barriers that exist for them individually and thus, the best approach is to use qualitative methods.

6. Has the author properly and convincingly used the intellectual guideposts for research, explaining her or his project and position relative to these? Explain.

Yes, the author used the intellectual guideposts to explain her position on each one. The use of the constructionism theory in this research proposal makes sense. They want to understand the barriers that exist for each individual and this is influenced by how people create and perceive their realities, the basis of constructionism.

7. Is it clear which paradigm and theoretical frame will be used in this study? Explain.

It is quite evident that this research is based on the interpretive paradigm. As she stated in this assignment, “The largest factor guarding our interpretations of the social world is culture.” This perfectly fits with this research study because I’m sure that most of the barriers that exist in access to healthcare are influenced by culture. This is especially true for most immigrants who come from countries that are different culturally.

8. What suggestions can you make or ideas can you bring to enhance the overall clarity of the proposal? Explain.

Overall the assignment was very well done, however, I’m just wondering if you are concentrating on new or long term immigrants. I think this would potentially affect the types of barriers that are present. For example, language or knowledge would be more of a barrier for newer immigrants. Maybe you could control for this aspect, as it could be a potential confounder. Good luck!

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