Indian Journal of Public Health

REVIEW ARTICLE
Year
: 2019  |  Volume : 63  |  Issue : 1  |  Page : 65--72

Gender differences and barriers women face in relation to accessing type 2 diabetes care: A systematic review


Neethu Suresh1, Kavumpurathu Raman Thankappan2,  
1 PhD Scholar, Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
2 Professor Emeritus, Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India

Correspondence Address:
Dr. Kavumpurathu Raman Thankappan
Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala
India

Abstract

The objectives of this systematic review were to find out whether gender differences exist in the domain of access to type 2 diabetes care and to identify the barriers faced by women in accessing type 2 diabetes care. A PubMed search was conducted for English articles published between January 01, 2005, and April 30, 2017, that looked into the above-mentioned topics. The search showed 219 articles, which were scrutinized and 21 articles were chosen for final review. Five articles dealt with gender differences, 14 articles dealt with barriers faced by women in accessing type 2 diabetes care and two articles dealt with both aspects. To accomplish the first objective, major areas studied by articles dealing with gender differences in accessing type 2 diabetes care were identified. In each of those areas, articles which reported gender differences were noted. Six out of these seven articles which dealt with gender differences (87%) reported that gender differences were present in the areas of type 2 diabetes care they studied. These articles also reported that women faced more difficulty in accessing type 2 diabetes care. To accomplish the second objective, data from articles dealing with barriers faced by women in accessing type 2 diabetes care were carefully analyzed and potential themes and theme categories were identified. Results showed that women faced personal, sociocultural, health system, economic, psychological, and geographical barriers in accessing type 2 diabetes care. Since this systematic review could identify only limited studies, evidence from more studies would help to confirm and generalize our findings.



How to cite this article:
Suresh N, Thankappan KR. Gender differences and barriers women face in relation to accessing type 2 diabetes care: A systematic review.Indian J Public Health 2019;63:65-72


How to cite this URL:
Suresh N, Thankappan KR. Gender differences and barriers women face in relation to accessing type 2 diabetes care: A systematic review. Indian J Public Health [serial online] 2019 [cited 2019 Oct 14 ];63:65-72
Available from: http://www.ijph.in/text.asp?2019/63/1/65/253887


Full Text



 Introduction



Diabetes is one of the largest health emergencies of the 21st century.[1] In 2015, globally diabetes was the seventh leading cause of death.[2] Among noncommunicable diseases (NCDs), globally, diabetes was the fourth leading cause of death in 2011.[3] Diabetes was the sixth leading cause of death for women worldwide in 2011.[4] Access to health care depends on adequate supply of necessary services and affordability, physical accessibility, and acceptability of services.[5] Existing literature shows that gender differences prevail in diabetes process of care measures,[6] among those with diabetes women were less likely than men to receive the care recommended by guidelines,[7] women received less intense therapy [8],[9] and monitoring.[10] Access to health care plays an important role in determining diabetes-related morbidity and mortality. These gender differences can adversely affect women's quality of life, disease outcomes such as the development of diabetes-related complications and death.[7] Diabetes-related death is more among women than in men.[1] Socioeconomic barriers and cultural factors could play a role in limiting women's access to health care.[7] Our objectives were to consolidate the evidence from the previous studies to find out whether gender differences exist in access to type 2 diabetes care and to identify the barriers faced by women in accessing type 2 diabetes care.

 Materials and Methods



Data sources

A systematic review was planned based on Preferred Reporting Items for Systematic Review and Meta-Analyses statement,[11] for which a PubMed search was conducted for English articles published between 01.01.2005 and 30.04.2017. The search words and the combination used were the followings: ([gender] OR [women]) AND ([“access to Type 2 diabetes care”] OR [“differences in access to Type 2 diabetes care”] OR [“barriers to Type 2 diabetes care”] OR [“barriers to access to Type 2 diabetes care”]).

Study selection

The inclusion criteria were as follows: original research studies published in English, which dealt with gender differences in accessing type 2 diabetes care or barriers faced by women in accessing type 2 diabetes care. In order to get a wider perspective, it was decided to include quantitative and qualitative studies.

Data extraction

Data extraction was done by the first author, and then it was cross-checked, verified, and confirmed by the second author. Quality assessment of the selected studies was done to assess their methodological quality and to determine the extent to which studies have addressed the possibility of bias in their design, conduct, and analysis. Quality assessment for qualitative studies was done using the Critical Appraisal Skills Programme (CASP) qualitative checklist,[12] for quantitative cross-sectional studies quality assessment was done with the Joanna Briggs Institute checklist for analytical cross-sectional studies,[13] and that of the longitudinal analytical study was done with CASP cohort study checklist.[14]

To accomplish the first objective, major areas studied by articles dealing with gender differences in accessing type 2 diabetes care were identified. In each of those areas, articles which reported gender differences were noted. To accomplish the second objective, data from articles dealing with barriers faced by women in accessing type 2 diabetes care were carefully analyzed and potential themes and theme categories were identified and final decision was made by the authors.

 Results



The search showed 219 article results, out of which 62, which dealt with access to type 2 diabetes care, were selected for a full-text review. Only original research articles were included, reviews and editorials were excluded. After full-text review of 62 articles, 34 articles were excluded because they did not look into gender differences in access to type 2 diabetes care or barriers faced by women in accessing type 2 diabetes care. The quality assessment of the remaining 28 articles was done. The selected studies included quantitative and qualitative studies. Three out of 17 qualitative studies whose quality assessment was done using CASP checklist for qualitative studies [12] had poor quality and 14 had good quality. Four out of the 10 quantitative cross-sectional studies whose quality assessment was done using Joanna Briggs Institute checklist for analytical cross-sectional studies [13] had poor quality, and six had good quality. Studies which had poor quality were excluded. The only one longitudinal study whose quality assessment was done with CASP cohort study checklist [14] had good quality. Hence, our final review included 21 studies of good quality. [Figure 1] illustrates the details of study search and selection. [Table 1] describes in detail the characteristics of the articles selected for the final review.{Figure 1}{Table 1}

Gender differences in relation to accessing diabetes care

Out of the selected 21 articles, seven articles [15],[16],[17],[18],[19],[20],[21] dealt with gender differences in accessing type 2 diabetes care. The major areas studied by articles dealing with gender differences in accessing type 2 diabetes care were the mode of diagnosis, medicines prescribed, investigations done, hospitalizations, and visit to specialists. [Table 2] lists the major areas studied by articles dealing with gender differences in accessing type 2 diabetes care.{Table 2}

Six [16],[17],[18],[19],[20],[21] out of these seven articles (87%) reported that gender differences were present in the areas of type 2 diabetes care they studied. All these six studies also reported that women faced more difficulty in accessing the areas of type 2 diabetes care they studied.

Only one study which dealt with the mode of diagnosis of diabetes reported that among men 45% were diagnosed with diabetes after the onset of symptoms, but in women, only 35% were diagnosed in that way.[20] Women were mostly diagnosed with diabetes while being tested for some other illness, which could be a complication stemming from diabetes, but men were mostly diagnosed by testing after the onset of symptoms before complications developed.[20]

All the three studies [15],[18],[19] which dealt with medicines prescribed reported gender difference and two [18],[19] out of those three studies (67%) reported that women received less aggressive treatment for diabetes. Women were less likely to receive oral antidiabetic medications [18] and insulin [19] even when they had glycated hemoglobin levels higher than 9% or antihypertensive agents [19] when they had elevated blood pressure values. Even in the presence of micro/macroalbuminuria women were less likely to receive angiotensin-converting enzyme inhibitors.[19]

Both the studies [16],[19] which dealt with investigations reported that compared to men women underwent less number of diabetes-related investigations. Women were less likely to be monitored for diabetic complications.[16],[19]

The only one study which dealt with diabetes-related hospitalization did not report any gender difference.[15] All the three studies [15],[17],[21] which dealt with a visit to specialist reported that gender difference exists and two out of those three studies (67%) reported that compared to men, women were less likely to visit specialists for diabetic complications.[17],[21]

Our findings indicate that gender differences exist in accessing type 2 diabetes care and women face more difficulties than men in accessing type 2 diabetes care; but they cannot be generalized because six out of these seven studies (87%) which dealt with gender differences were from developed countries [15],[16],[17],[18],[19],[21] and one study was from a developing country.[20] There was variation in the study setting and sample size of these studies. We could identify only very limited studies dealing with gender differences in accessing various aspects of diabetes care. Therefore, evidence from more studies with large sample size is needed from different parts of the world to confirm our findings.

Barriers faced by women in accessing diabetes care

Out of the 21 selected articles, 16 articles [20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35] dealt with barriers faced by women in accessing type 2 diabetes care. The potential themes were identified, and they were grouped under six theme categories which were personal, sociocultural, health system, economic, psychological, and geographical barriers. [Table 3] lists the barriers faced by women in accessing diabetes care and number of articles reporting the barriers.{Table 3}

Personal barriers

A lack of time due to the caregiving role by women and the associated work schedule, women giving less priority to their own health, lack of education and other health problems were the personal barriers we identified.

Lack of time due to the caregiving role and the associated work schedule were reported as barriers by five out of 16 (31%) articles. Due to their caregiving role women found it difficult to take care of themselves.[25],[26],[27] In between family and work responsibilities, women had less time for themselves.[28],[29]

Women giving less priority to their own health was identified as a barrier by four out of 16 (25%) articles. Women felt that the need of family members was more important than their own health needs.[20],[26],[27]

The lack of education was reported as a barrier by two out of 16 (13%) articles. Uneducated women were not able to keep track of clinical appointments [28] and could not actively participate in consultations.[29]

One out of 16 (6%) articles identified other health problems as a barrier. Elderly women with co-morbidities such as vision problem and walking difficulties found it difficult to reach the health facilities.[27]

Sociocultural barriers

Lack of family and social support was the sociocultural barriers we identified.

Lack of family and social support was reported by four out of 16 (25%) articles. Family members were reluctant to take women to health care centers and to buy medicines for them.[22],[25] Alterations in diet after diagnosis of diabetes changed women's overall body condition, which affected their marital relationship.[32] Employers felt that women with diabetes would not be able to deliver productive work. Hence, women had to retire from work due to diabetes.[32]

Health system barriers

Failure to provide adequate health information, unsupportive nature of health professionals, lack of trained health professionals, improper communication with health professionals, inconvenience caused by medical encounters, inefficiency of public health-care systems, and lack of confidence in health professionals were the health system barriers we identified.

Six out of 16 (37%) articles reported failure to provide adequate health information as a barrier. Health-care professionals did not provide adequate information on diet,[27],[32] exercise,[31] self-management,[25] symptoms of hypoglycemia,[29] and diabetic complications.[21]

Unsupportive nature of health professionals was reported as a barrier by six out of 16 (37%) articles. Women were disheartened when health care providers were nonattentive to their worries,[21],[25],[29],[30] did not encourage them to adhere to treatment regimens [30],[34] and self-management advice.[31]

Lack of trained health professional was reported as a barrier by three out of 16 (19%) articles. Women hesitated to go to health centers because of lack of female doctors [22] and dietitians.[23]

Improper communication with health professionals was reported as a barrier by three out of 16 (19%) articles. Often the communication between provider and patient was vertical.[25],[29]

Three out of 16 (19%) articles reported inconvenience caused by medical encounters as a barrier. Women were frustrated by the lack of privacy during consultations,[29] glucose monitoring,[33] and while taking insulin injection.[26],[33]

The inefficiency of public health-care systems was reported as a barrier by two out of 16 (13%) articles. Public health centers did not have adequate medicine supply and laboratory services.[32] Hence, women had to depend on private health centers where the services were expensive.[27]

Lack of confidence in health care providers was reported as a barrier by two out of 16 (13%) studies. Women lost their trust in health-care providers' ability to treat them because of brief consultations, lack of proper communication, and infrequent physical examinations.[27],[30]

Economic barriers

Cost of treatment, medication, consultations, and tests, financial dependence of women, and lack of health insurance were the economic barriers we identified.

Three out of 16 (19%) articles reported the cost of treatment, medication, consultations, and tests as barriers. Due to high cost of medications,[27],[35] and test consumables [33] women could not afford diabetes care. Financial dependence of women was identified as a barrier by two out of 16 (13%) articles. Women who were financially dependent on their family members found it difficult to pay for their health care needs.[27],[35] One out of 16 (6%) articles reported that lack of health insurance was a barrier for women to access diabetes care.[24]

Psychological barriers

Denial of disease status and severity, negative outlook and superstitious believes were the psychological barriers we identified.

Denial of disease status was reported as a barrier by two out of 16 (13%) articles. Women who feared the consequences of diabetes [32] and those who hoped that diabetes will go away by its own [25] denied their disease status. One out of 16 (6%) articles identified negative outlook as a barrier. Women who believed that diabetes was an inevitable fate did not seek care.[33]

Geographical barriers

Fragmented health care system was identified as a barrier by one out of 16 (6%) articles. Due to fragmented health-care system women had to visit multiple locations to get care for a single medical encounter.[27]

Our findings on the barriers faced by women in accessing type 2 diabetes care cannot be generalized, because there was variation in the study setting and sample size of these studies. The sociocultural, economic, and educational background of the study populations was also different. Some barriers we identified were reported by only a few studies. Therefore, evidence from more studies are needed to confirm our findings.

 Discussion



This systematic review focused on articles dealing with only type 2 diabetes as it is the most common type of diabetes. We included quantitative and qualitative studies which helped us to get a comprehensive view regarding gender differences in relation to accessing type 2 diabetes care and the barriers faced by women in accessing type 2 diabetes care.

Our findings indicate that gender differences exist in accessing type 2 diabetes care and women faced more difficulties than men in accessing type 2 diabetes care.

Other studies on NCDs have also identified gender differences in accessing health care and reported that compared to men, women faced more difficulties in accessing health care. The differences in access to health care between men and women may be due to unequal power relations and gendered norms.[36] Bonita and Beaglehole [37] reported that there exists a strong gender bias which acts against equitable prevention and treatment of NCDs. Maina [38] reported that women had poor access to NCD care. Bonita and Beaglehole [37] identified that women faced more barriers than men for accessing cardiovascular care. Women were asked fewer questions, received fewer examinations, and had fewer diagnostic tests ordered compared to men.[37] Ng et al.[39] reported that compared to men women were more likely to experience delays in diabetes care.

We found that women faced personal, sociocultural, health system, economic, psychological, and geographical barriers in accessing type 2 diabetes care. The barriers we identified were similar to the barriers faced by women in accessing care for other NCDs such as cardiovascular diseases and cancer.[40] Maina [38] reported that women faced sociocultural, geographical, and economic barriers to access NCD care.

Lack of time due to caregiving role and work schedules were the main personal barriers we identified. The main sociocultural barrier we identified was lack of family and social support. The study by AbouZahr [36] also reported that due to household responsibilities and sociocultural restrictions women were not able to access health care. Encouraging men to play an active role in child-rearing and household work can increase the family support to women.[41] Organizing diabetes awareness programs might help to overcome the sociocultural barriers.[42]

Failure to provide adequate health information and unsupportive nature of health professionals were main health system barriers we identified. Maina [38] also reported that the accessibility, comprehensiveness, and responsiveness of the health-care system were less for women.[38] Training health-care providers to provide individually tailored and culturally acceptable health care advice [42] and encouraging them to adopt a caring and supportive approach [43] would help to overcome the health system barriers.

The cost of treatment, medication, consultations, and tests were the main economic barriers we identified. Studies on NCDs have also reported that women lack control over resources so they cannot afford treatment for NCDs.[38] Women's inability to pay for health care was a major barrier in the prevention and treatment of NCDs such as diabetes.[40] Introducing health insurance schemes for women [44] and increasing women's job opportunities would help to overcome the economic barriers.

The main psychological barrier identified by us was a denial of disease status and severity by women. Denial of disease status by women due to fear of stigmatization was also reported in relation to other NCDs.[40] Incorporating the service of a psychologist at diabetes care centers and forming diabetic women's networks can provide psychological support to women.[45]

Fragmented health-care system was the main geographical barrier identified by us. Sikder et al.[46] also reported that distance to health care facilities reduced women's access to health care.

Making all diabetes care facilities available under one roof, introducing telemedicine services,[47] organizing medical camps, and home visit programs [35] would help to overcome the geographical barriers.

A gender-sensitive approach, giving due importance to sociocultural context while planning and implementing diabetes care programs will help to reduce the gender differences in access to type 2 diabetes care and to overcome the barriers faced by women in accessing type 2 diabetes care.

Our systematic review had some limitations. We reviewed only English articles published in PubMed between January 01, 2005, and April 30, 2017. There was variation in the study setting, and sample size of these studies. The sociocultural, economic, and educational background of the study populations was also different. We could identify only very limited studies dealing with gender differences. Some barriers identified by our systematic review were reported by only a few studies. There was a lack of geopolitical contextualization as this systematic review included studies from both developed and developing countries. Geopolitical and economic issues can shape the nature and extent of gender differences. In developing countries, there is a shortage of available diabetes supplies, scarcity of medication, lack of diabetes education, and more stigma associated with diabetes; so gender differences in accessing diabetes care would be more severe in developing countries.[48] Economic issues like women having less control over resources and inadequacy of medical care coverage could also increase the gender difference.[49] Therefore, more studies are needed to confirm our findings.

 Conclusion



Gender differences exist in accessing type 2 diabetes care and women face more difficulties than men in accessing this care. Women face personal, sociocultural, health system, economic, psychological, and geographical barriers in accessing type 2 diabetes care. Evidence from more studies would help to confirm and generalize our findings.

Acknowledgment

We would like to acknowledge the experts and participants of the peridoctoral workshop conducted at the Centre for Social Medicine and Community Health, School of Social Sciences, Jawaharlal Nehru University, New Delhi, India in February 15–18, 2016, for their valuable suggestions that helped to improve this systematic review.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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