Role of cultural brokering in advancing holistic primary care for diabetes and obesity: a participatory qualitative study.

OBJECTIVES: Diabetes and obesity care for ethnocultural migrant communities is hampered by a lack of understanding of premigration and postmigration stressors and their impact on social and clinical determinants of health within unique cultural contexts. We sought to understand the role of cultural brokering in primary healthcare to enhance chronic disease care for ethnocultural migrant communities. DESIGN AND SETTING: Participatory qualitative descriptive-interpretive study with the Multicultural Health Brokers Cooperative in a Canadian urban centre. Cultural brokers are linguistic and culturally diverse community health workers who bridge cultural distance, support relationships and understanding between providers and patients to improve care outcomes. From 2019 to 2021, we met 16 times to collaborate on research design, analysis and writing. PARTICIPANTS: Purposive sampling of 10 cultural brokers representing eight different major local ethnocultural communities. Data include 10 in-depth interviews and two observation sessions analysed deductively and inductively to collaboratively construct themes. RESULTS: Findings highlight six thematic domains illustrating how cultural brokering enhances holistic primary healthcare. Through family-based relational supports and a trauma-informed care, brokering supports provider-patient interactions. This is achieved through brokers' (1) embeddedness in community relationships with deep knowledge of culture and life realities of ethnocultural immigrant populations; (2) holistic, contextual knowledge; (3) navigation and support of access to care; (4) cultural interpretation to support health assessment and communication; (5) addressing psychosocial needs and social determinants of health and (6) dedication to follow-up and at-home management practices. CONCLUSIONS: Cultural brokers can be key partners in the primary care team to support people living with diabetes and/or obesity from ethnocultural immigrant and refugee communities. They enhance and support provider-patient relationships and communication and respond to the complex psychosocial and economic barriers to improve health. Consideration of how to better enable and expand cultural brokering to support chronic disease management in primary care is warranted.

Understanding the bigger picture: syndemic interactions of the immigrant and refugee context with the lived experience of diabetes and obesity.

BACKGROUND: Providing contextually appropriate care and interventions for people with diabetes and/or obesity in vulnerable situations within ethnocultural newcomer communities presents significant challenges. Because of the added complexities of the refugee and immigrant context, a deep understanding of their realities is needed. Syndemic theory sheds light on the synergistic nature of stressors, chronic diseases and environmental impact on immigrant and refugee populations living in vulnerable conditions. We used a syndemic perspective to examine how the migrant ethnocultural context impacts the experience of living with obesity and/or diabetes, to identify challenges in their experience with healthcare. METHODS: This qualitative participatory research collaborated with community health workers from the Multicultural Health Brokers Cooperative of Edmonton, Alberta. Study participants were people living with diabetes and/or obesity from diverse ethnocultural communities in Edmonton and the brokers who work with these communities. We conducted 3 focus groups (two groups of 8 and one of 13 participants) and 22 individual interviews (13 community members and 9 brokers). The majority of participants had type 2 diabetes and 4 had obesity. We conducted a thematic analysis to explore the interactions of people's living conditions with experiences of: 1) diabetes and obesity; and 2) healthcare and resources for well-being. RESULTS: The synergistic effects of pre- and post-immigration stressors, including lack of social network cultural distance, and poverty present an added burden to migrants' lived experience of diabetes/obesity. People need to first navigate the challenges of immigration and settling into a new environment in order to have capacity to manage their chronic diseases. Diabetes and obesity care is enhanced by the supportive role of the brokers, and healthcare providers who have an awareness of and consideration for the contextual influences on patients' health. CONCLUSIONS: The syndemic effects of the socio-cultural context of migrants creates an additional burden for managing the complexities of diabetes and obesity that can result in inadequate healthcare and worsened health outcomes. Consequently, care for people with diabetes and/or obesity from vulnerable immigrant and refugee situations should include a holistic approach where there is an awareness of and consideration for their context.