Stress and diabetes in socioeconomic context: A qualitative study of urban Indians

Abstract

Type 2 diabetes has escalated in urban India in the past two decades. Historically a disease of the affluent, recent epidemiological evidence indicates rising diabetes incidence and prevalence in urban India's middle class and working poor. Although there is substantial qualitative data about people with diabetes from high-income countries, scant resources provide insight into diabetes experiences among those in India, and lower-income groups specifically. In this article, we use individual-level analysis of illness narratives to understand how people experience and understand diabetes across income groups in Delhi, India. We conducted in-depth qualitative interviews and administered the Hopkins Symptoms Check-List (HSCL-25) to evaluate depression among 59 people with diabetes in northeast Delhi between December 2011 and February 2012. We analyzed their responses to: 1) what caused your diabetes?; 2) what do you find most stressful in your daily life?; and 3) where do you seek diabetes care? We found few people held diabetes beliefs that were congruent with socio-spiritual or biomedical explanatory models, and higher income participants commonly cited “tension” as a contributor to diabetes. Stress associated with children's futures, financial security, and family dynamics were most commonly reported, but how these subjective stresses were realized in people's lives varied across income groups. Depression was most common among the poorest income group (55%) but was also reported among middle- (38%) and high-income (29%) participants. One-quarter of respondents reported diabetes distress, but only those from the low-income community reported co-occurring depression and these respondents often revealed poor access to diabetes care. These data suggest that lower-income populations not only have higher rates of depression but also may be more likely to delay health care and therefore develop diabetes complications. This research has many implications for public health care in India as diabetes prevalence shifts to affect lower income groups who concurrently experience higher rates of depression and poorer access to medical care.

Introduction

Originally from Punjab, Kamala moved to Delhi to settle with her husband's family soon after marriage. In her late 50s, Kamala reflected on the chronic stress of the past thirty years spurred by tensions of joint-family conflicts, worries about the success and economic mobility of her children, and diabetes. She reported mild depression in addition to poor diabetes control. Kamala often would forgo medical treatment because of overcrowding in government hospitals and the expense of private hospitals. Therefore, she managed diabetes with her diet and relied on friends for social support, a television show for information, and Ayurvedic medicines to manage her glucose. Rarely did she find time or opportunities for physical activity, as the only physical work she once did was housework, and these tasks had been taken over by her daughter-in-law.

Historically type 2 diabetes (hereafter, “diabetes”) in India was considered a disease of the elite. But in tandem with escalating diabetes incidence in India, diabetes is shifting to afflict people like Kamala who represent the growing urban middle class and working poor (Popkin, Adair, & Ng, 2012). With an estimated 11–16% diabetes prevalence within mega-cities, such as Delhi and Chennai, these increases are significant (Ajay et al., 2008; Ebrahim et al., 2010; Gupta & Misra, 2007; Patel, Chatterji, et al., 2011) and a documented socioeconomic reversal of diabetes distribution (Deepa, Anjana, Manjula, Narayan, & Mohan, 2011; Reddy et al., 2007) produces new public health challenges. Specifically, as diabetes increases among lower income groups, the stress–diabetes interface will become a central part of the diabetes problem as a result of increased exposure to stressful experiences, economic insecurity, co-morbid depression, and poor access to health care.

Heretofore, a small body of research attends to the social and cultural factors that shape diabetes onset and management in India (Sarkar & Mukhopadhyay, 2008; Shobhana et al., 2003; Sridhar et al., 2000, 2007; Sridhar & Madhu, 2002; Weaver & Hadley, 2011). Weaver and Hadley (2011) published an extensive list of tensions reported by women with diabetes and discussed how these stressors result from and contribute to social roles and mental distress. Sridhar and Madhu (2002) found that men more commonly than women relied on their spouses to manage their diets and were less likely to seek their support with regard to emotional states or medication adherence. Others suggest that men's reliance on women was one reason for men having fewer diabetes complications than women (Shobhana et al., 2003; Sridhar et al., 2007) and that women's feelings of stress and guilt associated with diabetes might be a contributor to diabetes problems (Sridhar et al., 2007). Few studies have considered the role of economic security in the social experiences or psychological burden of urban Indians with diabetes.

In addition to everyday stresses that may facilitate diabetes onset or impede one's ability to manage their disease, co-morbid depression plays an important role in diabetes management among people with diabetes. Studies from high-income countries identify depression as both a cause and consequence of diabetes and a growing body of research emphasizes bi-directionality between the two chronic conditions (Egede & Ellis, 2010; Golden et al., 2007, 2008; Knol et al., 2006; Mezuk, Eaton, Albrecht, & Golden, 2008). A recent population-based study in metropolitan India found 20% of people with newly diagnosed diabetes had co-occurring depression (Poongothai et al., 2010). Another study of a clinical population of urban Indians with diabetes found that depression was estimated at 41% (Raval, Dhanaraj, Bhansali, Grover, & Tiwari, 2010). Indeed, the urgency for understanding the role of social and psychological distress in diabetes, particularly among poorer Indians with limited health care access, is underscored by the strong association of depression with poor self-care practices and poor glycemic control (Katon et al., 2010), which, in turn, can increase the likelihood of diabetes-related complications and consequently mortality (de Groot, Anderson, Freedland, Clouse, & Lustman, 2001; Lin et al., 2009).

In this article, we use individual-level analyses of illness narratives to understand how people across income groups experience and understand diabetes in Delhi, India. This article is the first in depth qualitative study to examine socioeconomic variation in knowledge about diabetes, common stressors that people with diabetes report, and problems regarding health care access that lower income groups face in diabetes care in the urban Indian context. In addition, we use a mixed-methods approach to inventory depression in order to explore psychological morbidity across socioeconomic groups. We differentiate study participants by income group to evaluate how social and economic resources may shape knowledge about and experiences with diabetes, social stress, and access to health care.