Anthropological insights on Diabetes-Cardiovascular Disease Care; a case study of Punjab, Pakistan

A pragmatic cluster randomized controlled trial – a pilot intervention was conducted to assess the effectiveness of a standardized care package of diabetes-cardiovascular disease delivered through rural primary healthcare facilities in District Sargodha, Punjab, Pakistan. Diabetes patients were recruited into intervention and control arms. The diabetes care package required a skill mix beyond medical knowledge i.e. the counselling tool for life style modification and drug regimen and follow-up adherence that needed to be refined and understood socio-culturally. Any effort to improve case management required more in-depth understanding of lay belief systems, cultural norms, access to information and products, social service context etc. The current study was designed by making an intervention site an entry point in the lives of the diabetics. The patients registered at the Rural Health Center (RHC) 104 Northbound health facility were studied in their local settings. The study adapted the patients’ explanatory model to explore the journey/episode of type 2 diabetes. The study used an interview guide along with observational checklist to conduct in-depth interviews with adherent (male and female) and non-adherent patients (male and female).

The adherence to the proposed treatment was found to be influenced by both direct and in-direct factors. The treatment was found to be two pronged (i.e. clinical treatment and lifestyle modification). The direct social factors towards adherence to the clinical treatment were the perception(s) towards public health care system, role of paramedic, opportunity cost and social identity of diabetic. The in-direct factors were also found to be cross cutting with the direct social factors. The in-direct factors were the overall environmental factors, education, health illiteracy and age. The adherence to the lifestyle modification was also found to be influenced by certain cultural factors (both directly and in-directly). The direct cultural factors that may affect adherence to the lifestyle change were the concept of diet, concept of physical activity, gender and perception towards the treatment of diabetes (especially desire for cure and maximum benefits). The in-direct cultural factors were also found to be cross cutting with direct cultural factors that may include perceived seriousness of diabetes, financial pressures, position status in the family and environmental factors. The overall adherence to the proposed treatment was majorly influenced by the gender (of the patient).

It may be concluded that adherence to the treatment (clinical treatment and lifestyle modification) was a strong socio-cultural construct. The adherence to the treatment may be improved with the help of understanding the patients’ perspective that may lead to develop culturally competent strategies to troubleshoot barriers at the important stages of the diabetes care. It may also be concluded that the range of health care providers may be considered as important stakeholders in the different stages of the disease. The incorporation of these health care providers in the general framework may help educate and refer the patients in case of emergency and complications to the RHC.

Keywords: Diabetes-cardiovascular disease care, lifestyle change, adherence, follow-up, socio-cultural factors