The Contexts of SMART2D
Context is crucial for the management of a global disease such as T2DM. Factors and behaviors that affect the onset and risk of T2DM, such as exercise habits, food intake, or cultural perceptions of body size, are different in different settings. A "one size fits all" approach to interventions does not suit the realities of the settings. What may work in a high-income setting will not necessarily work in a low-income or middle-income context. Furthermore, the practicalities of implementing an intervention will also differ between environments.
By setting the study in three different contexts - a rural area in a low-income country (Uganda), an urban township in a middle-income country (South Africa), and vulnerable immigrant populations in a high-income country (Sweden) - it will be possible to develop evidence-based interventions that are relevant and adaptable to each context.
One would be hard-pressed to find another country to match the wealth of diversity found in Uganda. The country has nine indigenous communities and at least 56 tribes, each with its unique way of life - cultural norms, dietary habits, and means of livelihood - which may have a bearing on the prevention and management of type 2 diabetes and other non-communicable diseases (NCDs).
Subsistence farming is practiced across the country along a spectrum that spans pastoralism on one end, and crop cultivation on the other. Historically, these communities have survived on the crops that they had either raised or gathered, sourcing meat protein from both the domestic animals that they kept and the wild animals that they had hunted.
The country is home to one of the fastes growing and youngest populations: more than two-thirds of the people are below 25 years of age. Although more than 80% of the population is rural, socioeconomic pressures are driving young people from their ancestral homes to the burgeoning urban and peri-urban centres where the old ways have been discarded, giving way to new lifestyles.
Wide dietary choices are giving way to less nutritious, calorie-dense, prepackaged fare, and intense physical extertion, to the more sedentary pursuits characteristic of a suburban existence; as a consequence, waistlines are expanding inexorably and so is the prevalences of NCDs like type 2 diabetes.
The study site
The SMART2D Uganda study site is situated in Iganga and Mayuge districts, eastern Uganda, approximately 120 kilometres from Kampala, the national capital.
About two-thirds of the communities in the two districts are rural, thriving on subsistence farming supplemented by petty trading, in peri-urban areas and fishing, by the lakeshore. The majority of the population are Basoga, a Bantu-speaking community.
Recent studies in this population have fuond that 16.9% of the adult females and 7.5% of the adult males are overweight, and at least 1 in 20 of the adults are diabetic. Yet, just like the prevailing situation in the rest of the country, NCD services at the primary care level are few and far between - minimal NCD services are usually found at secondary care facilities. For instance, in Iganga district, blood glucose monitoring is available only once a week to the patients receiving care at the district hospital's weekly Diabetic Clinic.
The SMART2D intervention is charged with finding innovative models of diabetic prevention and care in this community.
In South Africa, the number of people with type 2 diabetes has grown hugely in the last few decards, and is associated with a sharp rise in the incidence of overweight and obesity. Obesity is a complex disease with genetic and environmental determinants, such as high-fat diets and physical inactivity, and is a well-established risk factor for diabetes and other chronic diseases. South Africa has the highest prevalence of obesity in sub-Saharan Africa, especially in urban African women, and nine percent of the population aged 33 years and above is thought to have type 2 diabetes, which represents approximately 2 million cases.
The increase in diabetes is fuelled by urbanization and changing lifestyles, associated with changes in diet, away from a traditional diet high in legumes and low in processed and refined carbohydrates, to a Western diet high in fat, sugar, and salt. Sales of packaged foods have increased rapidly. The sale of ready-made meals, for example, has increased 43% between 2005 and 2010. Likewise, the consumption of cola averages 254 liters per person per year, which is nearly three times the global average.
The changing good environment, with the increased penetration of supermarkets into rural areas, plays a major role. The increasing market share captured by large supermarket retailers and fast-food outlets has catalysed a shift in dietary patterns, whereby healthier food is often higher priced and out of reach for many South African families.
The study site
The SMART2D study site is located in the peri-urban Langa community, one of the oldest townships in the Cape Town Metropole. Its population is relatively homogenous and consists of 99.1% black Africans; in 2011, nearly half (46%) were less than 25 years old and 60% had not attained a secondary education. The area is characterized by underdevelopment, a poor infrastructure, and a lack of adequate civil services, although government has recently started investing in improved infrastructure. Two health facilities serve and estimated population of 52 400 residents: the Vanguard community health centre and the Washington clinic. The former offers obstetric services, 24-hour emergency services, chronic care, and care for minor ailments, whereas the latter offers TB and HIV care and maternal and child health services.
Migration has shaped Sweden for a long time. In the late nineteenth century, 1.5 million Swedes migrated to America, mainly due to poverty and religious and political repression. During 1887 alone, as many as 50,000 Swedes left Sweden. This record number was only broken in 2011, when 51,000 Swedes emigrated to other countries in Europe, America, and China.
Currently, immigration to Sweden involves two parallel processes: labor immigration and refugee immigration. An increase in political instability around the world has led to large groups of people fleeing their home countries, and immigration to Sweden has grown significantly. During 2014, the total population of Sweden increased by around 100,000 people, mainly due to refugees from Syria, Iraq, Afghanistan, Eritrea, and Somalia, seeking asylum in Sweden. Political unrest in Latin America and the Balkans in the 1970's and 80's led to immigration waves from those areas. About 21 percent of the population in Stockholm was born outside Sweden, and about 16 percent of the nation's population have parents who were born outside of Sweden.
Stockholm is a capital city characterized by a strong urbanization with more than 2 million inhabitants, out of a population of 10 million total. The popularity of Stockholm is positive, even though it brings challenges such as competativeness in the housing and job markets, pressure on schools and healthcare provision, and on traffic. Segregation and the development of an increasing number of neighborhoods with high immigrant density have emerged as a political issue during the last 20 years. These neighborhoods are composed of residents of many nationalities, in comse cases from more than 100 countries. There are no neighborhoods where one single ethnic group composes more than 10 percent of the population.
The study site
The SMART2D study site is in two such neighborhoods. The neighborhoods are geographically located in the suburbs of Stockholm, in areas built during the 1960's as part of a "Million Homes" program that built a million apartments over a short period of time. Rental housing dominates in these areas, in addition to condominiums (bostadsrätt). The neighborhoods are considered to be socially vulnerable, with low income levels and high unemployment rates. The mobility in these neighborhoods is higher than in areas where residents are mainly born in Sweden. The dynamics of mobility within a segregated area is a relatively new field of research in Sweden and findings from one recent study suggests that the residents born in Sweden are less inclined tha most migrant groups to move into migrant dense areas (1).
Healthcare in Sweden is publically financed and primary health care is the point of entry for persons seeking preventative or curative services. The primary healthcare centers provide the main part of the services for persons with diabetes and other chronic conditions. Diabetes rates are increasing in Stockholm. The share of persons diagnosed with diabetes was 4.6% in 2010, compared to 2.8% in 1990. Increasing overweight and obesity problems in the population are likely the main reason for this trend. Socially disadvantaged neighborhoods have higher rates of disease, in particular diabetes. The prevalence of diabetes in women in areas with poor socioeconomic conditions is two to three times higher than in women in the rest of Stockholm county.
1. Andersson, R. (2013). Reproducing and reshaping ethnic residential segregation in Stockholm: the role of selective migration moves. Geografiska Annaler. Series B, Human Geography. 95(2):163-187.