The Social Determinants of Health and Type 2 Diabetes: what are the barriers towards a wider acceptance among key stakeholders? Shane O’Donnell Sociology PhD Candidate University College Dublin

Three points: SDH ContradictionPolicy 1.Increased acknowledgment of SDH 2.Lack of engagement with policy implications 3.Fatalistic attitude towards change at the structural level

Outline: Introduction/statement of problem Literature review Methodology Findings Conclusion

Introduction: Dominant understandings of type 2 diabetes Disease of lifestyle and poor personal choices Increasing acknowledgement of SDH in recent public, research and policy discourses However policies still focused on individual

Theoretical Framework Many different interpretations of SDH- Raphael et al. Importance of policies aimed at distribution of wealth and power– Marmot et al.

Poverty as “the elephant in the room” Chaufan et al; Raphael at el Conceptions of class historically influential in medical understandings of diabetes -O’Donnell Literature Review

Research Questions: How did key informants explain the causes of, and solutions to, inequalities in diabetes outcomes? How did key informants account for the lack of engagement with the policy implications associated with the SDH?

Methodology Semi-structured interviews with an international based sample of key informants (n=12): -consultants, GPs, researchers, NGOs Thematic based analysis

Diabetes among low income groups: Causes and solutions Emphasis on individual, as well as structural level explanations: -poverty, built environment, affordability of healthy foods, psychosocial stress Vast majority did not advocate for structural approaches to addressing SDH

Tensions and contradictions in accounts of key informants (I) Do you think the diabetes community has a role in highlighting that lack of income has the impact you describe? Well it’s low income. And that is an inequity in a lot of societies. But it's also helping people make the best use of the income they have.. So things like supermarket tours... Teaching them to cook...They don't have role models in a lot of these communities… I think we have done a silly thing in Australia by giving every new mother $3000. What do they do with it? They have another child and another child. Which they spend on drugs or cigarettes or rubbish so that hasn’t solved the problem. But if $3000 is put in the bank and is used to buy healthy things it might make more sense. That then engages the family and the parents… It's engaging the whole community with these kinds of changes. I think that's the kind of model if they haven't got much money. – Jenny (Nurse/Researcher/NGO)

Tensions and contradictions in accounts of key informants (II) Why isn’t there an adequate prevention program and adequate treatment program for obesity [and diabetes]? it’s because the medical policymakers and profession as a whole see it broadly as their own fault... they should have never have let themselves go; they are enormous...would you look at the size of her?...There is embedded discrimination against obese people. -Michael (consultant)

Tensions and contradictions in accounts of key informants (III) I think that also there’s a lot of ill feeling in society. If you are overweight …it’s your own fault or your parents fault-you can do things about it yourself. And I think the EU is leading this because the EU is full of intelligent people and they would love to have a handle on health in Europe because of national incompetence…And one of those things they’ve taken to recently is individual responsibility. They’re promoting that, and in getting countries to promote that, what it means is an excuse to do nothing about major public health problems that affects large numbers of the population. -David(GP, NGO)

Conclusion/Implications Taken for granted assumptions surrounding lower income groups may be leading to a depoliticized version of the SDH However, SDH can provide a solid evidence base to convince government to commit more resources to deal with epidemic

[The diabetic diet] may be comparatively easy to effect in private practice, but in the case of the poor especially the outpatient poor, who cannot be made to understand the necessity of abstaining from bread potatoes apples, etc., it becomes very difficult to teach them “what to drink, eat and avoid.” -C. M Durrant (consultant )