• unlimited access with print and download
    $ 37 00
  • read full document, no print or download, expires after 72 hours
    $ 4 99
More info
Unlimited access including download and printing, plus availability for reading and annotating in your in your Udini library.
  • Access to this article in your Udini library for 72 hours from purchase.
  • The article will not be available for download or print.
  • Upgrade to the full version of this document at a reduced price.
  • Your trial access payment is credited when purchasing the full version.
Buy
Continue searching

Living with sugar: Socioeconomic status and cultural beliefs about type 2 diabetes among Afro-Caribbean women

ProQuest Dissertations and Theses, 2009
Dissertation
Author: Chrystal A. S Smith
Abstract:
In the U.S., individuals of Afro-Caribbean and Latino descent are two to three times more likely to develop type 2 diabetes than non-Hispanic whites. Caribbean and Latin America migrants, particularly minority women bear a disproportionate burden of type 2 diabetes and its risk factors. The purpose of this research is to investigate if Afro-Caribbean women share a cultural belief model about type 2 diabetes and how this belief model, along with structural barriers to health care, influence disease risk and management. A sample of 40 women, primarily Jamaican and Trinidadian, 35 to 90 years of age previously diagnosed with type 2 diabetes were recruited in southwest Florida. Socio-demographic, medical history, and self-reported height and weight data were collected from women. A 53 item yes/no cultural beliefs questionnaire about type 2 diabetes' etiology, treatment, and symptoms was administered to 30 women. Semi-structured interviews about diet and lifestyle type 2 diabetes management were conducted with 38 women, 24 interviews were conducted over the telephone. The cultural consensus analysis used to analyze the cultural beliefs questionnaire found that the women shared a single cultural belief model (.72 ±.081 SD) about type 2 diabetes. Body mass index was calculated from self-reported height and weight data, and correlated with socio-demographic and cultural belief variables. The age-adjusted prevalence of obesity was 40.39 percent. The Spearman correlation found that women with higher BMI ( rs = -0.42993, p = .0125) and individual cultural knowledge scores (rs = -0.41730, p = .0218) were significantly younger at age of type 2 diabetes diagnosis than women with lower BMI and individual cultural knowledge scores. The women's cultural belief model about type 2 diabetes was similar to the biomedical model. Women struggled to modify their traditional Caribbean diet and failed to engage in regular leisure physical activity which may have contributed to their high BMI. Inadequate health insurance and transnational migration prevented women from accessing regular medical care and effectively managing the disease. Afro-Caribbean women face an ongoing struggle to control their glucose levels and BMI to prevent the onset of type 2 diabetes complications.

Table of Contents

List of Tables ..................................................................................................................... iv

List of Figures .................................................................................................................... vi

ABSTRACT ...................................................................................................................... vii

Chapter I - Introduction ...................................................................................................... 1 Statement of Problem .............................................................................................. 2 Purpose and Significance of this Research ............................................................. 4 Research Questions, Hypotheses, and Objectives .................................................. 6

Chapter II – Conceptual Framework and Literature Review .............................................. 9 Conceptual Framework ........................................................................................... 9 Political Economy of Health ..................................................................... 11 Acculturation............................................................................................. 15 Cultural Consensus Analysis .................................................................... 18 Literature Review.................................................................................................. 21 Etiology of Type 2 Diabetes ..................................................................... 21 Treatment of Type 2 Diabetes ................................................................... 30 Pathogenesis of Type 2 Diabetes .............................................................. 31 Thrifty Genotype Hypothesis ........................................................ 31 Thrifty Phenotype Hypothesis ...................................................... 38 Microevolution and the English-speaking Caribbean ............................... 43 Epidemiological Transition Theory .......................................................... 48 Epidemiological History of the Caribbean ............................................... 52 Health and the English-speaking Caribbean ............................................. 57 Health and English-speaking Caribbean Migrants ................................... 65 Type 2 Diabetes in the English-Speaking Caribbean ............................... 68 English-Speaking Caribbean Attitudes about Type 2 Diabetes ................ 80 Traditional Caribbean Diet and Nutrition ................................................. 86 Health and Migration: Acculturation and Weight Gain ............................ 90 Migration and Identity: Afro-Caribbean Migrants in the U.S. ................. 94

Chapter III – Methodology ............................................................................................... 99 First Phase of Research ....................................................................................... 101 Second Phase of Research .................................................................................. 102

ii

Research Setting.................................................................................................. 103 Sampling and Recruitment .................................................................................. 105 Telephone Interviews .............................................................................. 109 Materials ............................................................................................................. 111 Socio-Demographic Questionnaire ......................................................... 111 Semi-structured Interview Protocol ........................................................ 112 Free List Exercise ................................................................................... 114 Cultural Beliefs about Type 2 Diabetes Questionnaire ........................... 115 Analysis............................................................................................................... 118 Cultural Consensus Analysis .................................................................. 119 Analysis of Individual Cultural Knowledge Scores................................ 121 Analysis of Cultural Belief Themes ........................................................ 122 Analysis of Self-Reported Measurements .............................................. 123

Chapter IV – Results ....................................................................................................... 128 Free List Data ...................................................................................................... 128 Socio-demographic Data ..................................................................................... 134 Medical Data ....................................................................................................... 140 Beliefs and Behavioral Characteristics ............................................................... 143 Characteristics of Study Participants without Type 2 Diabetes .......................... 144 Research Question 1 ........................................................................................... 144 Cultural Consensus Analysis .................................................................. 145 Cultural Belief Model about Type 2 Diabetes ........................................ 153 Research Question 2 ........................................................................................... 158 Efficaciousness of Traditional/Alternative Remedies ............................ 158 Modification of Traditional Caribbean Diet and Lifestyle ..................... 168 Prayer and Faith ...................................................................................... 174 Research Question 3 ........................................................................................... 180 Inadequate Health Insurance Coverage .................................................. 181 Cost of Medicines and Physician Visits.................................................. 183 Cost of Glucometer Testing Strips .......................................................... 185 Transnational Migration.......................................................................... 188 Research Question 4 ........................................................................................... 191 Anthropometric Findings ........................................................................ 191

Chapter V – Discussion .................................................................................................. 207 Cultural Consensus Analysis .............................................................................. 209 Cultural Beliefs and Practices about Type 2 Diabetes ............................ 216 Efficaciousness of Traditional/Alternative Remedies ............................ 217 Modified Caribbean Diet and Lifestyle .................................................. 224 Prayer and Faith ...................................................................................... 230 Structural Barriers to Type 2 Diabetes Care ....................................................... 232 Inadequate Health Insurance Coverage .................................................. 233

iii

Transnational Migration.......................................................................... 238 Obesity and Overweight ......................................................................... 242 Limitations .......................................................................................................... 253 Researcher as Native Anthropologist...................................................... 253 Selection Bias.......................................................................................... 257 Information Bias: Misclassification ........................................................ 258 External Validity ..................................................................................... 261 Sample Size ............................................................................................. 262 No Access to Medical Records ............................................................... 264 Lack of Detailed Physical Activity and Environment Data .................... 264 No Data on Severity of Sequelae ............................................................ 265

Chapter VI – Conclusion ................................................................................................ 266 Recommendations ............................................................................................... 270 Contributions to Biocultural Anthropology Framework..................................... 275 Contributions to Applied Anthropology ............................................................. 277 Further Research ................................................................................................. 278

References ....................................................................................................................... 281

Appendices ...................................................................................................................... 326 Appendix A: IRB Approval ................................................................................ 299 Appendix B: Research Flyer ............................................................................... 300 Appendix C: Recruitment Script ......................................................................... 301 Appendix D: Informed Consent Form ................................................................ 302 Appendix E: Socio-Demographic Questionnaire................................................ 306 Appendix F: Semi-Structural Interview Protocol ............................................... 310 Appendix G: Revised Semi-Structural Interview Protocol ................................. 311 Appendix H: Free List Questionnaire ................................................................. 312 Appendix I: Cultural Beliefs About Type 2 Diabetes Questionnaire ................. 314

About the Author …………………………………………………………….. End of Page

iv

List of Tables Table 1. Criteria for the Diagnosis of Diabetes Mellitus .................................................. 28

Table 2. Overview of 38 Semi-structured Interviews ..................................................... 110

Table 3. Free list Analysis: Prevention of Type 2 Diabetes ........................................... 129

Table 4. Free list Analysis: Causes of Type 2 Diabetes ................................................. 130

Table 5. Free list Analysis: Symptoms of Type 2 Diabetes ............................................ 131

Table 6. Free list Analysis: Complications of Type 2 Diabetes ..................................... 133

Table 7. Free list Analysis: Treatments of Type 2 Diabetes ........................................... 134

Table 8. Characteristics of Study Particpants ................................................................ 135

Table 9. Socio-Demographic Characteristics of Study Participants ............................... 137

Table 10. Medical Conditions of 40 Study Participants Diagnosed ............................... 143

Table 11. Results of Cultural Consensus Analysis ......................................................... 147

Table 12. Spearman Correlation Analysis Results ......................................................... 148

Table 13. Shared Cultural Beliefs of 30 Afro-Caribbean Women .................................. 157

Table 14. Fisher Exact Test Results: Traditional/Alternative Remedies ........................ 160

Table 15. Study Participants who used Traditional/Alternative Remedies .................... 162

Table 16. Frequently Used Traditional/Alternative Caribbean Remedies ...................... 163

Table 17. Fisher Exact Test Results: Traditional Caribbean Diets ................................. 169

Table 18. Study Participants Recommendations to Modify Caribbean Diet .................. 170

v

Table 19. Fisher Exact Test Results of Afro-Caribbean Women Beliefs ....................... 175

Table 20. Beliefs about 40 Study Participants‘ Prayer and Faith ................................... 178

Table 21. Overview of 40 Study Participants‘ Structural Barriers ................................. 180

Table 22. Self-Reported Weight/Height of 33 Study Participants .................................. 191

Table 23. BMI (kg/m 2 ) of 33 Study Participants ............................................................ 192

Table 24. Hypertension and BMI in 33 Study Participants ............................................ 193

Table 25. Spearman Correlation Results of 33 Study Participants‘ BMI ....................... 194

Table 26. BMI of 33 Study Participants by Mean Age................................................... 202

Table 27. Mann-Whitney U Test Results of 33 Study Participants by BMI .................. 204

Table 28. Fisher Exact Test Results: BMI and Belief Variables .................................... 206

vi

List of Figures Figure 1. English-speaking Caribbean Food Groups ........................................................ 87

Figure 2. Overview of the Research Design ................................................................... 100

Figure 3. Overview of the Research Sample and Instruments ........................................ 103

Figure 4. Age at Type 2 Diabetes Diagnosis and Cultural Knowledge Scores .............. 149

Figure 5. Age and Individual Cultural Knowledge Scores ............................................. 150

Figure 6. Years of Type 2 Diabetes Duration and Cultural Knowledge Scores ............. 151

Figure 7. Years Living in the U.S. and Cultural Knowledge Scores .............................. 152

Figure 8. Years of Education and Individual Cultural Knowledge Scores ..................... 153

Figure 9. Study Participant‘s Age of Type 2 Diabetes Diagnosis and BMI ................... 195

Figure 10. Study Participants‘ Age and BMI.................................................................. 196

Figure 11. BMI and Individual Cutural Knowledge Scores ........................................... 197

Figure 12. BMI and Years of Type 2 Diabetes Duration ................................................ 198

Figure 13. BMI and Years Living in the U.S. ................................................................. 199

Figure 14. BMI and Years of Education ......................................................................... 200

Figure 15. Modified Caribbean Diet Described by Afro-Caribbean Women…………..175

vii

Living with Sugar: Socioeconomic Status and Cultural Beliefs About

Type 2 Diabetes Among Afro-Caribbean Women

Chrystal A.S. Smith

ABSTRACT In the U.S., individuals of Afro-Caribbean and Latino descent are two to three times more likely to develop type 2 diabetes than non-Hispanic whites. Caribbean and Latin America migrants, particularly minority women bear a disproportionate burden of type 2 diabetes and its risk factors. The purpose of this research is to investigate if Afro- Caribbean women share a cultural belief model about type 2 diabetes and how this belief model, along with structural barriers to health care, influence disease risk and management. A sample of 40 women, primarily Jamaican and Trinidadian, 35 to 90 years of age previously diagnosed with type 2 diabetes were recruited in southwest Florida. Socio- demographic, medical history, and self-reported height and weight data were collected from women. A 53 item yes/no cultural beliefs questionnaire about type 2 diabetes‘ etiology, treatment, and symptoms was administered to 30 women. Semi-structured interviews about diet and lifestyle type 2 diabetes management were conducted with 38 women, 24 interviews were conducted over the telephone.

viii

The cultural consensus analysis used to analyze the cultural beliefs questionnaire found that the women shared a single cultural belief model (.72 ±.081 SD) about type 2 diabetes. Body mass index was calculated from self-reported height and weight data, and correlated with socio-demographic and cultural belief variables. The age-adjusted prevalence of obesity was 40.39 percent. The spearman correlation found that women with higher BMI (r s = -0.42993, p = .0125) and individual cultural knowledge scores (r s = -0.41730, p = .0218) were significantly younger at age of type 2 diabetes diagnosis than women with lower BMI and individual cultural knowledge scores. The women‘s cultural belief model about type 2 diabetes was similar to the biomedical model. Women struggled to modify their traditional Caribbean diet and failed to engage in regular leisure physical activity which may have contributed to their high BMI. Inadequate health insurance and transnational migration prevented women from accessing regular medical care and effectively managing the disease. Afro-Caribbean women face an ongoing struggle to control their glucose levels and BMI to prevent the onset of type 2 diabetes complications.

1

Chapter I - Introduction Type 2 diabetes accounts for approximately 90 percent of all cases of diabetes diagnosed in older individuals worldwide. Type 2 diabetes is a global epidemic and one of the major public health challenges of the 21st century. The World Health Organization (WHO) deems the prevention, diagnosis, and treatment of type 2 diabetes a priority (World Health Organization 2008). An estimate of the global increase in the number of people who develop diabetes suggests that the number will double from 151 million in 2000 to 300 million by 2025 (Zimmet et al. 2003). While the numbers of type 2 diabetes cases are expected to rise in every country worldwide, the greatest increases are expected in developing countries (Zimmet et al. 2003). In the U.S., 20.8 million people (7 percent of the population) are estimated to have diabetes (14.6 million diagnosed) (Centers for Disease Control and Prevention 2007). Diabetes is estimated to be the sixth leading cause of death (Heron and 2007; Roglic et al. 2005). Approximately, 90 to 95 percent of all diagnosed cases of diabetes in the U.S. are type 2 diabetes (Centers for Disease Control and Prevention 2007). The increasing prevalence of type 2 diabetes has placed enormous financial demands on the U.S. health care system (Centers for Disease Control and Prevention 2007). Individuals with type 2 diabetes face a decline in quality of life as well as the economic costs of managing this incurable disease.

2

This dissertation research investigates if Afro-Caribbean women, primarily from Jamaica and Trinidad and Tobago share cultural beliefs about type 2 diabetes‘ etiology, treatment, and symptoms and how this belief model along with their socioeconomic status influence their type 2 diabetes risk and their management of the disease. In addition, the presence of obesity and overweight in the study population was analyzed using self-reported height and weight data and correlated with socio-demographic and cultural belief variables. Statement of Problem In the U.S., migrants from the Caribbean and Latin America, particularly minority women bear a disproportionate burden of type 2 diabetes and its risk factors (Beckles and Thompson-Reid 2001; U.S. Census Bureau 2000; Centers for Disease Control and Prevention 2008; Smith and Barnett 2005; Roglic et al. 2005). Type 2 diabetes is characterized by hyperglycemia

(high blood glucose levels) which is caused by the insufficient production of insulin or the cells‘ inability to absorb insulin, a hormone produced by the pancreas (American Diabetes Association 2002). As women, immigrants, ethnic minorities, and mostly low income or working class, Afro-Caribbean women occupy the lower levels of the class and power structure in the U.S. For over half a century, the Afro-Caribbean immigrant community has constituted substantial presence in the U.S. Their numbers are particularly high throughout Florida including the Tampa Bay region (U.S. Census Bureau 2000).

3

Despite the long history of an English-speaking Afro-Caribbean immigrant community in the U.S. as well as the continuing and increasing migration from this region, there is a dearth of literature on the health of this community. Informal discussions with members of this community reveal a wide-spread awareness about type 2 diabetes. In these discussions, individuals often shake their heads and voice concern about friends and close relatives struggling to live with the disease. This dissertation research proposed a medical anthropological approach to bolster and expand the literature on the health of the English-speaking Afro-Caribbean immigrants in the U.S. The study population was drawn from southwest Florida where the largest English-speaking Afro-Caribbean community comprised of primarily Jamaicans and Trinidadians reside (U.S. Census Bureau 2000). Afro-Caribbean women between the ages of 35 and 90 years who self-reported type 2 diabetes diagnosis were eligible to participate in this research. Data on socio-demographic, medical history, and cultural beliefs were collected from study participants. Qualitative and quantitative methods were used to study cultural beliefs about type 2 diabetes management and how socioeconomic status influenced the health care decisions of these women struggling to cope with the disease in their daily lives. Self- reported height and weight data were to calculate and categorize the body mass index (BMI) so as to determine the prevalence of overweight and obesity among study participants. Also, analyzed were the relationships of study participants‘ BMI with socio- demographic, socioeconomic, and cultural belief variables.

4

Purpose and Significance of this Research The purpose of this dissertation research is to investigate how socioeconomic status, cultural beliefs, and obesity are related to type 2 diabetes risk among primarily Jamaican and Trinidadian women of African descent in southwest Florida. This dissertation research uses a medical anthropology approach and methods of inquiry within the framework of the political economy theory of health and culture theory. Proponents of political economy theory of health argue that in addition to considering the biological causes of disease, health disparities should be contextualized within the class and power structure of a capitalistic society. Biocultural anthropology also recognizes that cultural beliefs and practices about health also play a pivotal role in the decisions that individuals make on a daily basis. To measure cultural beliefs and explanatory models of disease, biocultural anthropology has borrowed cultural consensus theory which is also a statistical method from cognitive anthropology. This dissertation research examines if primarily Jamaican and Trinidadian women of African descent share cultural beliefs about type 2 diabetes‘ etiology, treatment and symptoms and how this belief model, along with their socioeconomic status, influences their type 2 diabetes status and their management of the disease and health care decisions. This dissertation research contextualizes the experiences of primarily Jamaican and Trinidadian women previously diagnosed with type 2 diabetes within the capitalist U.S. health care system. The structural barriers to accessing health care related to socioeconomic status are analyzed to determine how they constrain the choices that these

5

women make about managing the disease. Cultural consensus analysis was used to measure if there was a common cultural belief model about type 2 diabetes among primarily Jamaican and Trinidadian women. The cultural consensus analysis calculated study participants‘ individual cultural knowledge scores which were correlated with socio-demographic variables to determine if there was a significant relationship. Qualitative methods were used to explore the meanings of cultural beliefs and to determine how they were translated into practices and behaviors that influenced the decisions that these women make about managing their condition. To examine the biological component of the study population‘s type 2 diabetes risk, self-reported anthropometric measurements of height and weight were used to calculate body mass index (BMI). BMI was used to determine the proportion of overweight and obesity in the study population. Overweight and obesity increase the risk for CVD, coronary heart disease, myocardial infarction, and cerebrovascular incident (Alberti, Zimmet, Shaw 2006; Groop 1999). The analysis of the cultural beliefs, structural barriers, and overweight and obesity prevalence identified by this dissertation research contributes to the anthropological literature on political economy theory of health and Afro-Caribbean populations. This dissertation research also validates the use of the cultural consensus model to measure cultural beliefs about disease as proposed in biocultural anthropology. The results of this research will provide investigative and intervention models which can be applied to other

6

ethnic minority and marginalized groups at risk for type 2 diabetes and other chronic diseases such as hypertension and cardiovascular disease. The purpose of the applied aspect of this dissertation research is to inform public health officials and medical professionals about their patients‘ cultural beliefs and practices about type 2 diabetes and the structural barriers that prevent their patients from accessing adequate health care. Scholarly articles will be published in professional journals targeting health officials and medical professionals who provide services to Afro-Caribbean communities. This dissertation research will also make specific recommendations about how to ameliorate the current health care services provided to primarily Jamaican and Trinidadian women diagnosed with type 2 diabetes. This dissertation research will be presented to the English-speaking Caribbean organizations such as the Caribbean Community Association in Tampa. These presentations will elucidate the challenges confronting individuals suffering with type 2 diabetes and suggest strategies that support and meet the needs of these individuals. Research Questions, Hypotheses, and Objectives Research Questions

This dissertation research was guided by the following research questions:

1. Do study participants (primarily Jamaican and Trinidadian women) share a cultural belief model about type 2 diabetes?

2. What, if any, cultural beliefs about type 2 diabetes influence how study participants make lifestyle and health care decisions?

7

3. How do structural barriers to health care created by socioeconomic status influence how study participants manage type 2 diabetes?

4. Are type 2 diabetes risk factors, overweight, and obesity present in this study population?

Research Objectives

The research objectives of this dissertation study were:

To describe Jamaican and Trinidadian women‘s cultural belief model about type 2 diabetes.

To investigate the cultural beliefs about type 2 diabetes that influence Jamaican and Trinidadian women‘s health care decisions.

To identify the structural barriers that prevent Jamaican and Trinidadian women from managing type 2 diabetes effectively.

To gather anthropometric data on height and weight (to calculate body mass index) so as to determine the prevalence of overweight and obesity, risk factors for type 2 diabetes in the study population.

To provide practical, tactical, and actionable recommendations to the appropriate public health officials and Caribbean organizations about how to provide effective health services and communal support to Jamaican and Trinidadian women diagnosed with type 2 diabetes.

Research Hypotheses

The hypotheses tested in this dissertation research included:

H1. Jamaican and Trinidadian women with higher individual cultural knowledge scores are younger at age of type 2 diabetes diagnosis than Jamaican and Trinidadian women with lower individual cultural knowledge scores.

H 0 : There is no significant relationship between Jamaican and Trinidadian women‘s age at type 2 diabetes diagnosis and their individual cultural knowledge scores.

8

H2. Jamaican and Trinidadian women diagnosed with type 2 diabetes with higher individual cultural knowledge scores had more years of type 2 diabetes duration than Jamaican and Trinidadian women with lower individual cultural knowledge scores.

H 0 : There is no significant relationship between years of type 2 diabetes duration of Jamaican and Trinidadian women and their individual cultural knowledge scores.

H3. Jamaican and Trinidadian women diagnosed with type 2 diabetes with higher individual cultural knowledge scores had more years of education than Jamaican and Trinidadian women with lower individual cultural knowledge scores.

H 0 : There is no significant relationship between the years of education of Jamaican and Trinidadian women diagnosed with type 2 diabetes and their individual cultural knowledge scores.

H4. Jamaican and Trinidadian women diagnosed with type 2 diabetes with higher individual cultural knowledge scores have lived in the U.S. longer than Jamaican and Trinidadian women with lower individual cultural knowledge scores.

H 0 : There is no significant relationship between the length of time that Jamaican and Trinidadian women have lived in the U.S. and their individual cultural knowledge scores.

H5: Jamaican and Trinidadian women with higher BMI were younger at age of type 2 diabetes diagnosis than Jamaican and Trinidadian women with lower BMI.

H 0 : There is no significant relationship between Jamaican and Trinidadian women‘s age at type 2 diabetes diagnosis and their BMI.

H6: Jamaican and Trinidadian women with lower individual cultural knowledge scores had higher BMI than Jamaican and Trinidadian women with higher individual cultural knowledge scores.

H 0 : There is no significant relationship between the Jamaican and Trinidadian women‘s individual cultural knowledge scores and their BMI.

9

Chapter II – Conceptual Framework and Literature Review This chapter will discuss the conceptual frameworks of political economy of health theory and cultural consensus theory which were used to guide this dissertation research. The chapter will also review the literature on research conducted on the etiology of type 2 diabetes, the epidemiological distribution of type 2 diabetes in the U.S. and the Caribbean, and the cultural and migration experiences of Afro-Caribbean peoples throughout the Caribbean Diaspora. Conceptual Framework The conceptual framework used to guide this dissertation research is drawn from biocultural anthropology, often referred to as the biocultural synthesis (Armelagos, Leatherman, Ryan, and Sibley 1992; Goodman and Leatherman 1998; Singer 1995). Within the discipline of medical anthropology, Armelagos and colleagues (1992) and Goodman and Leatherman (1998) argue that there have developed two distinctive approaches to studying disease and ill health of populations. Sociocultural anthropologists study the socio-cultural aspects of disease and ill health. Biological anthropologists study the biological, physiological, and ecological components of disease and ill health. While both sociocultural and biological anthropological approaches to disease and ill health have their strengths, they are inconsistent with anthropology‘s holistic approach to understanding the human condition. Sociocultural anthropologists

10

fail to consider the biological consequences of changing cultural beliefs and practices within the capitalistic global system. Biological anthropologists often ignore the socio- cultural and political economic factors that influence human biology. The biocultural synthesis seeks to bridge the chasm between sociocultural and biological anthropological study of disease and ill health so that human biological conditions can be understood through the processes of history and the environment (Armelagos et al. 1992; Goodman and Leatherman 1998; Singer 1998). Integrating biological and cultural anthropological perspectives of disease and ill health has been challenging for anthropologists (Armelagos et al. 1992). One challenge to the biocultural perspective is that most anthropologists are not trained in the skills necessary to conduct biological and cultural anthropological research and have do not have in depth understanding of theoretical frameworks in each others‘ disciplines (Goodman and Leatherman 1998). Sociocultural anthropologists who usually study small population sizes have extensive experience with qualitative methods and analysis, but little or no experience with quantitative methods and analysis or training in collecting biological data. Additionally, many sociocultural anthropologists have a bias against using quantitative methods and argue that the biomedical model is not applicable to the study of traditional populations globally (Goodman and Leatherman 1998; Armelagos et al. 1992). Biological anthropologists have been trained in quantitative methods and analysis, but have limited experience with qualitative methodology and analysis. Additionally, biological anthropologists do not know how to systematically study cultural

11

phenomena and have concerns about the validity and reliability of cultural studies. As a result, there has been a struggle to identify areas of anthropological research and methodologies where both sociocultural and biological perspectives can find common ground (Goodman and Leatherman 1998). Despite the challenges confronting the biocultural synthesis, the discussion continues and biocultural research has an increasing presence and visibility in the anthropological literature (Goodman and Leatherman 1998). Political Economy of Health Originally, the concept of political economy was used to describe how the means of production and consumption were organized within the laws, customs, and government regulations of a capitalistic society. Friedrich Engels, Thomas Maltus, Karl Marx, David Ricardo, and Adam Smith wrote extensively about political economy. Engels (1843:1) offered ―political economy came into being as a natural result of the expansion of trade, and with its appearance elementary, unscientific huckstering was replaced by a developed system of licensed fraud, an entire science of enrichment.‖ Political economy formed the basis of modern economics and has been the foundation of schools of thought in the disciplines of anthropology, ecology, geography, history, political science, and sociology (Baer 1982). The first linkages between political economy and ill health were made by Marx and Engels (Morgan 1987). Both Marx and Engels observed that the health of British workers had declined due to the poor working conditions. In ―Das Kapital,‖ Marx (1887) examined the medical reports of British factory workers and noted the negative impact

12

that the long work days had on the workers, particularly the children who were under thirteen. These reports stated that the children had numerous physical deformities and suffered from asthma, consumption and other diseases related to the factory pollutants and demanding work. Marx (1887:380-381) stated, ―après moi le déluge! is the watchword of every capitalist and of every capitalist nation. Hence capital is reckless of the health or length of life of the labourer, unless under compulsion from society.‖ In his seminal work, ―The Condition of the Working Class in England,‖ Engels (1845) argued that the workers were healthier and enjoyed better quality of life prior to the industrial revolution. As an example, he noted that the health of the men, women and child who were employed in British mines significantly declined due to pollution and the hard labor they were required to perform on a daily basis. Women and children who had worked in the mines for extended duration suffered deformities in their spines, pelvises and lower extremities. Along with their male counterparts, workers suffered from digestive and heart diseases that caused them to age prematurely. Consequently, by the time they reached their 40s, many were unable to work. Using medical testimony Engels (1845) stated that the miners often died in their late 40s from consumption and asthma which he attributed to the pollution to which they had been exposed in the mines (Engels 1845). In the discipline of anthropology, the political economy of health has been defined as ―a critical endeavor which attempts to understand health-related issues within the context of the class and imperialist relations inherent in the capitalist world system‖

13

(Baer 1982). Proponents of political economy of health argue that disease and ill health is a ―struggle‖ for individuals who are subjected to the forces dictated by the capitalist world system (Baer, Singer, and Johnsen 1986). These macro-level social, political and economic forces create structural barriers and inequalities such as socioeconomic class and racism that are the primary explanations for the health disparities found among ethnic minorities and marginalized populations (Baer 1996; Singer 1995; Schoenberg et al. 2005). An example of the political economy of health perspective is the study of poverty as a social condition that individuals experience due to their low socioeconomic status; which is in turn, caused by the socio-political forces in a capitalist society. Yet poverty is more than a social condition; it causes diseases and physical conditions that severely debilitate individuals (Leatherman 2005; Thomas 1998). Consequently, the proponents of the biocultural synthesis use the political economy of health framework to argue that societal forces like power and the lack of access to resources, that are at the root of hunger cause and limit food intake, should be studied along with the physiological adaptations of malnourished individuals (Leatherman 2005; Thomas 1998). Political economy of health as a conceptual framework has gained widespread acceptance in medical anthropology since the 1970s (Baer 1982; Singer 93). Morgan (1987) argued that the political economy of health in anthropology consists of three major perspectives: Classical Marxist analysis, cultural critiques of medicine and the dependency/world system theory. Classical or orthodox Marxists examine how tenets of

14

capitalism (e.g. the accumulation of wealth), exploitation of workers, power, and class structure lead to health disparities and ill health in general. Proponents of the cultural critiques of medicine argue that biomedicine can have a negative impact on an individual‘s health and reproduce the low class status of women and minorities. However, biomedicine ignores the macro-level social, political and economic forces operating in a capitalist society. Dependency/world system theory analyzes the impact that capitalism, imperialism and colonialism has had on the health of populations in the developing world. Proponents of political economy of health do not fit neatly placed into one of these perspectives; instead anthropologists may fall along a range. For example, some anthropologists may strongly advocate the classic Marx approach, but they also incorporate dependency/world system theory into their research (Morgan 1987). Critics of the political economy of health theory argue that the three perspectives fail to address the ―cultural dimension‖ of socioeconomic inequalities and dismiss the interactions between biobehavioral responses and the environment (Dressler et al. 1998; Leatherman et al. 1993). For example, even within a capitalist society with a biomedical system, indigenous medical systems continue to exist and individuals make choices about how to serve their health by using both systems (Morgan 1987). Cultural beliefs and practices about disease and ill health also play a role in how individuals negotiate their formal and informal health care systems and/or integrate two systems (Baer 1982). Dressler and colleagues (1998) argue that most biocultural studies using the political economy of health framework measure proxies for socioeconomic status such as income

Full document contains 357 pages
Abstract: In the U.S., individuals of Afro-Caribbean and Latino descent are two to three times more likely to develop type 2 diabetes than non-Hispanic whites. Caribbean and Latin America migrants, particularly minority women bear a disproportionate burden of type 2 diabetes and its risk factors. The purpose of this research is to investigate if Afro-Caribbean women share a cultural belief model about type 2 diabetes and how this belief model, along with structural barriers to health care, influence disease risk and management. A sample of 40 women, primarily Jamaican and Trinidadian, 35 to 90 years of age previously diagnosed with type 2 diabetes were recruited in southwest Florida. Socio-demographic, medical history, and self-reported height and weight data were collected from women. A 53 item yes/no cultural beliefs questionnaire about type 2 diabetes' etiology, treatment, and symptoms was administered to 30 women. Semi-structured interviews about diet and lifestyle type 2 diabetes management were conducted with 38 women, 24 interviews were conducted over the telephone. The cultural consensus analysis used to analyze the cultural beliefs questionnaire found that the women shared a single cultural belief model (.72 ±.081 SD) about type 2 diabetes. Body mass index was calculated from self-reported height and weight data, and correlated with socio-demographic and cultural belief variables. The age-adjusted prevalence of obesity was 40.39 percent. The Spearman correlation found that women with higher BMI ( rs = -0.42993, p = .0125) and individual cultural knowledge scores (rs = -0.41730, p = .0218) were significantly younger at age of type 2 diabetes diagnosis than women with lower BMI and individual cultural knowledge scores. The women's cultural belief model about type 2 diabetes was similar to the biomedical model. Women struggled to modify their traditional Caribbean diet and failed to engage in regular leisure physical activity which may have contributed to their high BMI. Inadequate health insurance and transnational migration prevented women from accessing regular medical care and effectively managing the disease. Afro-Caribbean women face an ongoing struggle to control their glucose levels and BMI to prevent the onset of type 2 diabetes complications.