Factors influencing the acceptance or rejection of dietary and body norm systems favorable to the prevention and control of type 2 diabetes among Sub-Saharan Africa migrants: A scoping review protocol

doi:10.21203/rs.3.rs-2574407/v1

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Factors influencing the acceptance or rejection of dietary and body norm systems favorable to the prevention and control of type 2 diabetes among Sub-Saharan Africa migrants: A scoping review protocol

https://doi.org/10.21203/rs.3.rs-2574407/v1

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Background: The number of people living with type 2 diabetes (T2D) is increasing worldwide. The prevalence rate of this disease is generally higher in the migrant population compared to the general population. However significant inequalities in the prevalence of T2D are notable between and within migrant populations. Among them, migrants from sub-Saharan Africa, South America and South Asia are more affected than those of European origin. The act of eating and the corporality play an essential role in the development of this disease. Dietary and body norms systems favorable to the prevention and control of type 2 go against what is vital for most of these people, exposing them to conflicts of norms that are difficult to reconcile.

Objectif: to identify factors that may influence the acceptance or rejection of dietary and body norm systems favorable to the prevention and control of T2D by Sub-Saharan Africa migrants living with T2D.

Materials and methods: Scoping review according to the steps described by Arksey and O'Malley (2005) will be conducted. An electronic search of studies from 2011 to 2022, published English, Italian, French or in Portuguese will be conducted in eight databases (CINAHL, Cochrane library, Embase, Google Scholar, PsycInfo, PubMed, Scopus, and Web of Sciences). The grey literature including publication in Open Grey database and Website of non-governmental organizations working on migrant from Sub-Saharan Africa will be searched. All articles related to body norms, dietary behaviors, or determinants of body behaviors and dietary of migrants from Sub-Saharan Africa and those related to factors that influence acceptance or rejection of dietary and body norms systems favorable to the prevention and control of T2D among the migrants from Sub-Saharan Africa living with T2D or at risk to develop this disease will be included. This scoping review will be reported following the Standard Protocol Items: Recommendations for interventional Trials (SPIRIT) and Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines.

Results: The results will focus on factors influencing the acceptance or rejection of dietary and body norms systems favorable to the prevention and control of T2D among the migrants from Sub-Saharan Africa living with T2D or at risk to develop it.

Corporality

Dietary

DT2

Factors

Obesity

Sub-Saharan Africa migrant

The number of people living with type 2 diabetes (T2D) is increasing worldwide[1, 2] and is qualified as an epidemic by the World Health Organization (WHO). An epidemic that in this 21st century affects about 371 million people, and could reach 552 million by 2030 [2, 3]. In developed countries such as Canada, this disease affects populations unequally [1, 2, 4, 5]. The literature shows that the prevalence rate is higher in the migrant population than in the general population [5–8]. In Canada, for example, migrants from Sub-Saharan Africa (SSA), South America, and South Asia are more affected than those of European origin [5, 6, 9, 10]. For example, Creatore, Moineddin [5] found in their study on the prevalence of diabetes among migrants in Toronto that the prevalence rates of diabetes among migrants from Eastern Europe and Central Asia were 4.6 among men and 4.8 among women, while among migrants from SSA the prevalence rates of diabetes were 7.9 among women and 8.9 among men.

Factors associated with T2D are multiple [11, 12]. The scientific literature on T2D generally explains the emergence of this disease based on risk factors such as lack of physical activity, the acquisition of poor eating habits and, consequently, the development of obesity [1, 2, 6]. Promotion, prevention, control, and monitoring programs arise from these explanations[13–15]. The alimentation and corporality, two social dimensions anchored in a system of socio-cultural representations [16–19] play an essential role in the development of this disease [6, 20]. These are the social dimensions most targeted by health workers in their practices aimed at the prevention and control of T2D [6, 20, 21]. Individuals living with T2D or at risk of developing this disease are invited to carefully choose the dietary they include in their daily diet, while respecting dietary and body norms that are favourable to the prevention and control of this disease [6, 22].

In the case of migrants from SSA, the systems of dietary and body norms conveyed in health care settings generally run counter what is vital for most of these people [23–25], thus exposing them to conflicts of norms that are difficult to reconcile [24, 26]. For example, for some people in SSA, overweight is a valued social norm. It is associated with opulence, social success, wealth [27, 28], beauty and fertility [24, 25, 29]. It is also an indicator of health and happiness within the couple [24, 25, 29]. However, in the host society such as Canada, overweight generally has a negative connotation. As mentioned by Ntanda [24] and Pillarella [23], most migrants from SSA remain loyal to the systems of dietary and body norms of their country of origin. The refusal or acceptance of the host society's systems of dietary and body norms may express, for some people, a will, a desire not to die as Worms [30] would say. This is not death in biological terms, but rather in terms of identity, community, family, relationships, and politics among others [24]. For some of these people, the acceptance of dietary and body norms systems favorable to the prevention or control of T2D is part of the desire to be accepted, considered or valued in the host society (by colleagues and friends), so as not to suffer social exclusion [23, 24]. For others, the refusal of these systems of norms may appear as a means of resistance, of asserting themselves in the face of a certain historical and/or subjectively experienced domination [24].

Although there is considerable evidence on the deteriorating epidemiological profile of migrants [22, 31, 32], little is known about factors that may influence the acceptance or rejection of dietary and body norm systems among migrants from SSA living with or at risk of developing T2D. To our knowledge, studies on migrants living with T2D in Canada have mostly concerned migrants from Asia, Latin America or migrants in general [6] and have mainly focused on individual dimensions (attitudes, behaviors, values) [4, 6, 13, 33–41]. These studies are in most cases carried out according to naturalist approaches. These approaches are dominant in health circles [42]. They essentialize biological life and often obscure the social, identity, historical and political dimensions of the act of eating and of corporality. This is a reductive way of understanding this pathology in which the individual component is more important than the environmental, family, community, and identity components. By focusing their efforts on individuals, these approaches tend to make people living with T2D feel guilty or even blame them [21]. This position implies that individuals are somehow without social ties, without family, community, social or identity belonging. They are totally free to choose their health-related behaviours. Yet, this is not always the case, as individuals may be aware of what is beneficial for their health, but they do not have all the means to make the consequent choice [43–45] or they choose otherwise to be in harmony with the people who matter to them [24]. For example, behaviors deemed good such as healthy eating, regular physical activity, and maintaining a healthy weight are recommended to prevent T2D and associated complications [3, 46]. However, if in a neighborhood there is a lack of healthy dietary products (reduced or absent availability) or these products are expensive (affordability), people are unlikely to choose these products [43, 44]. Similarly, if in the neighborhood, higher fat products such as fast dietary are more available and accessible than "healthy" products, the likelihood of choosing these products is higher[43, 44]. Similarly, in neighborhoods without supportive structures or sidewalks that do not provide communities with opportunities for regular physical activity, or where people are less tolerant of diversity, the rate of frequent sport participation is likely to be very low. Environmental conditions strongly influence individual/community well-being [43, 44].

A scoping review on factors that influence the acceptance or rejection of dietary and body norm systems favorable to the prevention and control of T2D among migrants from SSA living with or at risk of developing T2D will allow us to synthesise them and update knowledge on this topic as suggested by Arksey and O'Malley [47] and Levac, Colquhoun [48]. It could provide a better understanding of these factors, further for the development effective public health interventions to help alleviate this health concern [22, 24]. It will contribute to fill gaps in the literature to guide future research.

Methodological framework

As scoping review generally aims to explore a research question by mapping key concepts, types of scientific evidence and research gaps related to a domain or field of research [47, 48], the framework of Arksey and O'Malley [47] will be used according to the following steps: (1) define the research questions, (2) select the relevant articles, (3) selection of studies, (4) data extraction (5) analysis and aggregation of results; and (6) consultation exercise. This Scoping Review will be reported following the Standard Protocol Items: Recommendations for interventional Trials (SPIRIT) and Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for scoping reviews (PRISMA-ScR) guideline [49, 50], see additional files 1 and 2.

Research questions

The purpose of this scoping review is to identify factors that contribute to acceptance or rejection of dietary and body norm systems favorable to the prevention and control of T2D among Sub-Saharan African migrants. It will answer to the following questions:

what are factors that influence acceptance or rejection of dietary and body norms systems favorable to the prevention and control of type 2 diabetes among migrants from Sub-Saharan Africa living with T2D or at risk to develop it settled in low middle- or high-income countries?

What recommendations for health system managers, community organizations, for sub-Saharan Africa migrants could be made based on the factors identified?

Eligibility criteria

Eligibility criteria will be based on Population, Interventions (Interest), Comparators and Design and outcomes or Anticipated Outcomes, summarized in Table 1.

Population

In this Scoping Review, the population under study is the migrants. According to the glossary of International Organization for Migration (IOM), the term “migrant” refers to “any person who has voluntarily moved or is forced to move, whether within a country or across an international border, temporarily or permanently, and for a variety of reasons, to improve his or her material and social conditions, his or her future prospects or those of his or her family”[51]. As the migrants are a heterogeneous population [51], this review focus on those from Sub-Saharan Africa. It will include articles that focus on migrants from Sub-Saharan Africa, settled in low middle- or high-income countries. Articles that focus on migrants from north Africa and all those from other continents will be excluded.

Table 1

PICO
Population (P)	Immigrant from Sub-Saharan Africa; male and female; 18 years and older (settled in low middle- or high-income countries)
Intervention/ Interest (I) or exposure	Factors related to body behaviors, factors related to dietary behaviors; factors related to body norm systems, factors related to dietary norm systems
Comparator and design (C)	All empirical studies published in English, Italian, French or Portuguese, regardless of design, will be included except editorial articles and comments
Outcomes or intended result (O)	Factors that influence Sub-Saharan Africa migrants’ acceptance or rejection of dietary and body norm systems favorable to the prevention and control of type 2 diabetes

Intervention (Interest)

The focus of this scoping review is on factors that may influence the acceptance or rejection of dietary and body standards systems favorable to the prevention and control of T2D among migrants from Sub-Saharan Africa living with or at risk to develop T2D. Factors refer to a set element that can have beneficial or harmful effects on the health and well-being of individuals. Several factors influence the health and well-being of people. These factors are commonly referred to as determinants of health, grouped into four categories of factors: those related to the global context, structures, living environments and individual characteristics [52, 53]. Global context factors are related to a set of macroscopic elements that strongly influence life in society. These elements can ultimately have beneficial effects, such as increased well-being, or, on the contrary, harmful effects, such as increased inequality or intolerance. Taking them into account is useful for assessing their effects on other health determinants, which affect individuals more directly [52]. Systems factors include the education and childcare systems, the health and social services system, land use planning, employment support and social solidarity programs, and other systems and programs. The factors related to living environments are grouped into five categories: family environment, childcare and school environment, work environment, housing environment, local community, and neighbourhood. Factors related to individual characteristics are grouped in four categories: biological and genetic characteristics genetic characteristics, personal and social skills, and behaviours, and socio-economic characteristics [52, 53].These factors influence behaviour and actions of individuals [54] and they can influence dietary choices and consumption [24, 32, 43–45, 55, 56]. They can also influence the acceptance or rejection of dietary and body norm systems [24, 25].

The term system refers to a set of complex elements that are interrelated (or interacting) with each other and with their environment [57]. In this Scoping Review, the systems of dietary and body norms favorable to the prevention and control of T2D refer here to the WHO recommendations for the prevention or control of T2D[1]. Indeed, according to the WHO, having a healthy diet, a normal weight, practicing regular physical activity and avoiding tobacco consumption are all ways to prevent or delay the onset of T2D. Similarly, a healthy diet, physical activity, medication, regular screening, and treatment of complications can help treat diabetes and avoid or delay its consequences [1].

In the 19th century Adolphe Quetelet created the index which is at the origin of the body mass index (BMI) [58]. This index has been recognised since 1997 by the WHO and is now an integral part of the discourse in health circles on what constitutes a healthy body. A BMI below 18.5 is associated with thinness, while a BMI above 25 is associated with overweight. Obesity starting with a BMI of 30 is classified as moderate, severe from 35 and morbid from 40. Normal weight is between 18.5 and 25 [25, 59]. There is evidence that dietary behaviours vary widely among and within different populations compared to host populations [55]. This indicates that factors influencing dietary behaviour may differ in populations from other countries like migrants from Sub-Saharan Africa as compared to the majority population [56].This scoping review will consider all articles related to dietary behaviors, determinants of dietary behaviors, social representations of food, meanings associated with the act of eating, social representations of the body, perceptions of the thin body, the normal body, the overweight body among Sub-Saharan Africa migrants living with T2D or at risk to develop T2D. It will exclude studies focus only on descriptive information about diet and those examining beliefs and practices around breastfeeding and weaning.

Comparator and design (C)

The review will include all empirical studies published between 2011 and 2022 in English, Italian, French or Portuguese. The year 2011 was the launch year of the Global Diabetes Plan [2]. A landmark year in which world leaders met at the United Nations to agree on measures and actions to combat diabetes and other non-communicable diseases. We would like to document the studies that have been conducted from the launch of the Global Diabetes Plan until 2022 [2].

Outcomes or intended results (O)

Factors that influence acceptance or rejection of dietary and body standards systems favorable to the prevention and control of T2D will be reported among the migrants from Africa living with T2D or at risk to develop T2D.

Selection of relevant articles

Information sources

The identification of the relevant articles and documents will be performed in three steps. First, an electronic search of eight databases including CINAHL, Cochrane library, Embase, Google Scholar, PsycInfo, PubMed, Scopus, and Web of Sciences will be conducted and validate by an information specialist (CS). These databases are selected because they list a wide range of scientific papers addressing the topics of interest. In a second step, the grey literature by querying Open Grey database, and Websites of non-governmental organizations working on migrant from Sub-Saharan Africa will be consulted. A Google search will also be undertaken, using adjusted keywords used for searching electronic databases. Articles will be selected through its title and abstracts. Finally, pertinent references list of selected articles will be tracked.

Search and study selection

With the support of information specialist of the Université du Québec en Outaouais (CS), three team members (GMN, IB and DS) initially developed a search strategy using altogether free and controlled vocabularies with the logical operators "AND" and "OR", through PubMed with the aim of assessing the amount of available literature and identifying appropriate search terms to be used in the main searches. This search strategy has been reviewed by other team members (ET, AB) and presented in Table 2. The string of the research strategy will be pilot tested to improve the robustness before final query.

Table 2

Search strategy in PubMed to be adjusted as necessary for other databases
Number	Queries
1	TI/AB ("dietary" OR "food" OR "nutrition" OR "eating" OR "feeding" OR "aliment")
2	TI/AB ("body norms" OR "obesity" OR "Rotundity" OR "fat body" OR " thin body" OR "thinness" OR " healthy weight " OR "slimming" OR "Body Mass index" OR "BMI")
3	1 or 2
4	TI/AB ("migrant" OR "immigrant" OR "emigrant" OR "foreign" OR "black")
5	TI/AB ("Gambia" OR "Niger" OR "Benin" OR "Guinea" OR "Rwanda" OR "Burkina Faso" OR "Sierra Leone" OR "Burundi" OR "Somalia" OR "Sudan" OR "central Africa*" OR "Liberia" OR "Tanzania" OR "Chad" OR "Madagascar" OR "Togo" OR "Malawi" OR "Uganda" OR "Comore" OR "Congo" OR "RDC" OR "Mali" OR "Zimbabwe" OR "Eritrea" OR "Eswatini" OR "Mozambique" OR "Ethiopia" OR "Kenya" OR "Sao Tome and Principe" OR "Sao Tome" OR "Senegal" OR "Cabo Verde" OR "Cape Verde" OR "Cameroon" OR "Lesotho" OR "Swaziland" OR "Cote d'Ivoire" OR "Ivory coast" OR "Mauritania" OR "Djibouti" OR "Ghana" OR "Nigeria" OR "Zambia" OR "Namibia" OR "Gabon" OR "Angola" OR "Botswana" OR "Tchad" OR ("subsaharan africa" OR "sub-sahara africa", "black Africa", "dark Africa"))
6	3 and 4 and 5
7	TI/AB ("DM2" OR " types 2 diabetes" OR "diabetes mellitus" OR "T2D")
8	6 and 7
9	TI/AB ("factor" OR " determinant" OR "element")
10	8 and 9

Consistent with the methodology of the scoping reviews, more sensitive than specific keywords will be used to cover as many articles as possible [47, 48]. The search strategy in the example exhibits in Table 1 was based on the combination of the following keywords: (i) Migrant (emigrant, immigrant, foreign), (ii) Sub-Saharan Africa ( black Africa, dark Africa, Gambia, Niger, Benin, Guinea, Rwanda, Burkina Faso, Sierra Leone, Burundi, Somalia, Sudan, central Africa, Liberia, Tanzania, Chad, Madagascar, Togo, Malawi, Uganda, Comore, Congo, RDC, Mali, Zimbabwe, Eritrea, Eswatini, Mozambique, Ethiopia, Kenya, Sao Tome and Principe, Sao Tome, Senegal, Cabo Verde, Cape Verde, Cameroon, Lesotho, Swaziland, Cote d'Ivoire, Ivory coast, Mauritania, Djibouti, Ghana, Nigeria, Zambia, Namibia, Gabon, Angola, Botswana, Tchad); (iii) Type 2 diabetes (DM2, diabetes mellitus, T2D); (iv) Dietary (food, nutrition, eating, feeding, aliment); (v) Body norms (body mass index, BMI, obesity, rotundity, fat body, thin body, thinness, healthy weight, slimming and (vi) factors (determinant, element, component).

The search strategy will be modified as necessary to fit with different electronic databases. Articles will be exported in EndNote software where duplicates will be removed before exporting to Rayyan platform. The selection of records will be done independently and blindly by two team members (GMN and DS) in accordance with the inclusion and exclusion criteria defined by the PICO. The selection will be conducted with the support of a selection algorithm developed by the research team and implemented elsewhere [60] (Fig. 1). Conflicts will be resolve through discussion, a third coauthor (IB) will finally act as judge in case of lack of consensus.

Data extraction

Data extraction grid will be adapted from Osei-Kwasi, Nicolaou [32] grid used in their systematic scoping on the factors influencing dietary behavior in ethnic minority groups living in Europe. Data extraction will be performed by all team members according to the following study characteristics (see appendix): study design, sampling population (i.e.: country of origin), sample characteristics (i.e.: age, male, female), number of participants, country where the study was conducted, sampling method (qualitative, quantitative, mixed method, case study), body norms, dietary behavior measured, tools used to measure dietary behaviour, factors reported to influence dietary behavior and factors reported to influence body norms. This process will be iterative allowing the team to adapt the data extraction grid if necessary. Two researchers (GMN and DS) will individually extract data from the first five articles, any disagreement will be discussed and consensually resolved by the team members.

Data analysis

The data analysis will be done in three stages. 1) Studies will be organized according to the factors influencing dietary behavior and body norms identified in the selected papers and their association described with the different dietary behaviors and body norms observed. 2) Like Osei-Kwasi, Nicolaou [32], factors will be sorted and organized into clusters, during which, the list of factors emerging from the review will be regroup according to how they relate to each other, in a data mapping approach [32, 61]. As mentioned by Osei-Kwasi, Nicolaou [32], “ the concept mapping approach is guided by systems thinking, which can simply be defined as” “looking at things in terms of the bigger picture” [61]. This concept mapping approach will include “steps on generating a list of factors, and sorting and structuring these factors into clusters by consensus based on how they relate to each other”[32]. This clustering step will allow the development of a systems-based framework of factors that influence acceptance or rejection of dietary and body norms systems favorable to the prevention and control of type 2 diabetes among the migrants from Africa living with T2D. 3) Results will be reported by intended objective. In addition, a narrative summary will describe how the results are related to the research question. The results that will be obtained, i.e., the factors that influence acceptance or rejection of dietary and body standards systems favorable to the prevention and control of T2D, will be submitted for expert review as described in the following section.

Expert consultation

The mapped data will first be synthesized in the form of a briefing note and then presented at a meeting with 10–15 knowledge users working with migrants from Sub-Saharan Africa to deepen the result [48]. Their comments will be incorporated into the final document. We will invite by email to participate in a workshop: (i) Tree health system users; (ii) two health system managers; (iii) three health professionals; (iv) two community organizations; (v) two students. Upon their agreement, written informed consent will be obtained prior to the start of the workshop. Deliberative workshop will be conducted lasting approximately two-three hours virtual via a Zoom platform or face to face at the UQO. It will address the following questions: (i) Which are the factors that influence acceptance or rejection of dietary and body norms systems favorable to the prevention and control of type 2 diabetes among the migrants from Africa living with T2D? (ii) What recommendations for health system managers, community organizations, for sub-Saharan Africa migrants could be made based on the factors identified? It will be conducted in four stages: (1) The first thirty minutes will be dedicated to the presentation of the results of the scoping by the research team to the knowledge users. (2) Secondly, questions will be discussed in depth into subgroups of 5–6 people for forty-five minutes. (3) The third stage during the last sixty minutes and will be dedicated to the sharing of each group. Each sub-group will share the result of their group work in plenary. (3) Finally, in the last step, the research team will present in plenary the main recommendations for validation for thirty minutes.

High-income countries regularly receive many migrants, some of whom are from sub-Saharan Africa. Factors that influence the acceptance or rejection of dietary and body norm systems favorable to the prevention and control of T2D among these individuals need to be understood to better guide interventions for the prevention and control of T2D. Given the high prevalence of T2D in these populations [6, 9, 10], there is a need to understand these factors in order to better assess their needs and develop effective public health interventions that also affect them. The purpose of this review is to identify factors that contribute to acceptance or rejection of dietary and body norm systems favorable to the prevention and control of T2D among Sub-Saharan African migrants and gaps in the literature to guide future research. This scoping review will contribute to filling the current gap in the literature by aiming to identify structural factors that influence the acceptance or rejection of dietary and body norm systems that are conducive to the prevention and control of T2D among migrants from Sub-Saharan Africa living with or at risk of developing T2D.

To our knowledge, this scoping review is the first to identify structural factors that may influence the acceptance or rejection of dietary and body norm systems favorable to the prevention and control of T2D among Sub-Saharan African migrants. The method proposed for this review is better suited to the purpose of this study, allowing to better capture the complexity of the factors influencing social practices related to T2D, particularly in eating and body.

Beyond its strengths, this review has some inerrant limitations to its methods that are important to mention. It offers a description of what is already known rather than providing new knowledge. However, the results of this scoping will allow for what to develop a framework for the study of factors influencing social practices related to T2D, particularly act of eating and corporality.

Ethics approval and consent to participate: This protocol is part of a research project that has received ethical approval from the ethics committee of the Université du Québec en Outaouais in October 2022.
Consent for publication: Written informed consent will be required from the experts who will join the consultation session As part of the written informed consent, all participants will be asked to give.
Availability of data and materials: The datasets used and/or analyzed during the current study will be available from the corresponding author on reasonable request.
Competing interests: The authors declare that they have no competing interests.
Funding: The study was funded by Sherpa University Institute (Sherpa postdoctoral fellowship competition 2022-2023). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Registration: This scoping review has been registered in Research Registry (8433; https://www.researchregistry.com/browse-the-registry#home/)

Authors' contributions
- Conceptualization: Gisèle Mandiangu Ntanda, Drissa Sia
- Funding acquisition: Gisèle Mandiangu Ntanda
- Investigation: Gisèle Mandiangu Ntanda, Drissa Sia, Idrissa Beogo, Aurélie Baillot, Eric Nguemeleu Tchouaket
- Methodology: Gisèle Mandiangu Ntanda, Drissa Sia, Idrissa Beogo
- Project administration: Gisèle Mandiangu Ntanda
- Validation: Gisèle Mandiangu Ntand, Drissa Sia, Idrissa Beogo, Aurélie Baillot, Eric Nguemeleu Tchouaket
- Writing – original draft: Gisèle Mandiangu Ntanda.
- Writing – review & editing: Gisèle Mandiangu Ntanda, Drissa Sia, Idrissa Beogo, Aurélie Baillot, Eric Nguemeleu Tchouaket.

All authors approved the final revised manuscript.

Acknowledgements: Special thanks to Sherpa University Institute for funding

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No competing interests reported.

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Factors influencing the acceptance or rejection of dietary and body norm systems favorable to the prevention and control of type 2 diabetes among Sub-Saharan Africa migrants: A scoping review protocol

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