Professor Lenore Manderson¹ and Renata Kokanovic²
¹ Faculty of Medicine, Nursing and Health Sciences, Monash University,
²Primary Care Research Unit, Department of General Practice at the University of Melbourne
Beyond Blue Victorian Centre of Excellence
Project completion year
With improved life expectancy, and changes in diet and levels of physical activity, chronic diseases are increasing in prevalence; concurrently the incidence and prevalence of depression has also increased. These conditions are prevalent in Australia today, among older immigrants as well as Australian-born men and women.
Although the reasons are not clear, people with chronic conditions such as diabetes are also more likely to suffer from depression and those with both, are at greater risk of complications and consequent disability, and have higher all-cause mortality.
The issues are complicated among immigrants. Cultural factors may influence understanding of depression and diabetes in terms of cause, symptom recognition, presentation for care and adherence to advice. People tend to be more comfortable dealing with physical conditions such as diabetes, than with mental health conditions such as depression - but cultural differences and social factors influence disclosure, treatment-seeking and adherence to treatments. Many immigrants also have poor access to services, in terms of affordability and appropriateness.
Our research was conducted in metropolitan Victoria, with men and women from several different immigrant, linguistic and cultural backgrounds (Chinese, Greek, Pacific Island and South Asian) among whom diabetes is prevalent.
The study aimed to identify the different patterns of understanding of chronic disease, its impact on mood, and how people understood changes in emotional and general well-being.
Participants were recruited through general practitioners and ethnic community organisations providing support to people living with diabetes.
The study used a qualitative approach, with open-ended interviews to explore relationships between mood, mood disorder and diabetes in these different cultural groups.
Relationships between doctors and their patients
Patients reported difficulty in absorbing all information provided to them at consultations related to diagnosis, and often experienced considerable difficulty in comprehending the practical aspects of management.
Some doctors minimised the seriousness of the condition: while this reduced patient anxiety, it also led to patients dismissing some of the advice because they did not regard their condition as serious: “It’s only a little bit of diabetes”.
Other doctors emphasised the seriousness of complications, contributing to anxiety in some patients as a result: “The anxiety is [because of] the constant scaring by my doctors of the diabetes…that, uh, you’re going to lose a leg, you’re going to lose your eyesight”.
The data highlights the complex task facing doctors who wish to encourage behavioural change and adherence, and the importance of maintaining a supportive relationship with patients.
Finding social support
Women in all groups selectively disclosed information about their health, and usually received support and practical assistance in return. In order to avoid causing others worry or anxiety, women limited the number of people to whom they turned. They also did this to avoid others interfering unnecessarily over their behaviour. They rarely discussed their personal feelings about their illness with family members, often felt alone, and that their experiences were not understood. Women also felt that people in their social networks underestimated the difficulties that they were experiencing.
Idioms of distress
People distinguish between worry and more serious anxiety and distress. While worry included concern about the implications and direct effects of the disease, their ability to manage it and the long-term prognosis, distress and particularly depression, were tied to other events, even when the person was aware – as occurred in one case – that people with diabetes did experience a higher incidence of depression.
The primary factors underlying depression and associated signs (poor sleep, weeping, inability to concentrate, lethargy, suicidality) included the death of significant others, breakdowns in family life and consequent loneliness, and poverty.
Implications for Policy and Practice
Understanding the social context of the management of diabetes, and the diagnosis and management of depression, may be important in addressing non-adherence to treatment, preventing complications of disease, and ensuring the well-being of people diagnosed with chronic disease. There is a continuing need to explore ways to support the well-being of those diagnosed with chronic disease and to meet the needs of people from diverse cultural and linguistic backgrounds, and people who have limited support because of social and economic background.
More research needs to consider the patient in context, to examine the various ways in which families and social networks affect, and are affected by, illness. Our next step is one in rural Victoria, in which we are gathering data again from Asian-background participants, people from Italian backgrounds and Australia-born. In this study, we are gathering further data of understanding of and management of mood, including anxiety, stress, distress and depression.
About the Researchers
The research commenced when Lenore Manderson was an ARC Federation Fellow in the Key Centre for Women’s Health in Society, and Renata Kokanovic, a Research Fellow with the Centre for International Mental Health at The University of Melbourne. Lenore, now at Monash University, is an anthropologist who, in conducting research on chronic disease, has been struck by the extensiveness of depression among those whom she has interviewed. Renata, with the Primary Care Research Unit, Department of General Practice at The University of Melbourne, is a medical sociologist.
Kokanovic, R. & Manderson, L., (2006) Care and control: immigrant women living with Type 2 diabetes in Australia, Chronic Illness, 2: 291-301.
Kokanovic, R. & Manderson, L., (2007) Exploring doctor-patient communication in immigrant Australians with type 2 diabetes. Journal of General Internal Medicine, Published on-line 10 February 2007 DOI 10.1007/s11606-007-0143-2.