Cities provide tremendous opportunity for studying and understanding the drivers behind type 2 diabetes. Cities are highly complex and dynamic and differ considerably in relation to urbanisation rate, and population size and density. Furthermore, most cities consist of both wealthy and poor and deprived areas. These vital differences between and within cities make it challenging to generalise on how city life implement health. Specific city characteristics may affect certain diseases adversely, while other characteristics may offer protection and a complex interrelationship between the characteristics makes it extremely difficult to predict the exact impact and generalise on how city life implement health.
Extensive research has been performed in five cities from 2014 to 2016: Mexico City, Copenhagen, Houston, Tianjin and Shanghai. Research has been initiated in 2016 in Johannesburg and Vancouver, and Rome started research in 2017.
These are cities with a combined population of almost 70 million people. They represent the characteristics of rapidly growing cities of emerging economies and more mature cities of the developed world: all of them faced with the challenge of a growing number of people with diabetes resulting in a growing economic burden for society.
RULE OF HALVES
The aim of the quantitative research is to estimate the extent of the diabetes burden in each city and define where the greatest challenges are in relation to diagnosis and/or treatment. We use the so-called “Rule of Halves” (RoH). 1 2
RoH is a framework used in various chronic diseases and it originally states that half the people with a chronic disease are not diagnosed, half of those diagnosed are not receiving care, half of those receiving care are not controlled.1 The first term of the rule of halves was suggested in the USA in 1947 for non-insulin dependent diabetes3 and in 1964 confirmed in the UK.4 The second term of the rule of halves for diabetes was added in 19765 and in 1980, the third term was established.6
The rule of halves still largely holds true for most chronic diseases.7 For this programme the RoH is adapted and two additional terms are included: half the people with diabetes are not diagnosed, half of those diagnosed are not receiving care, half of those receiving care are not achieving treatment targets, and half of those achieving treatment targets are not achieving the desired outcome (no complications).
The aim of the qualitative research is to understand what makes certain people vulnerable to type 2 diabetes and its complications. This makes it possible to go beyond the Rule of Halves results by exploring the socio-cultural drivers of type 2 diabetes in cities.
To serve this aim a Diabetes Vulnerability Assessment (D-VA) was designed based on an established Vulnerability Assessment (VA) tool developed previously by the academic lead at University College London in collaboration with the Unites Nations.1
The D-VA is tailored to each city to accommodate local circumstances and local language. Each local academic partner carries out data collection and performs analyses to identify relevant local factors that impact how health and wellbeing are experienced amongst individuals at local levels. Global analyses are conducted by the global academic lead at UCL to identify globally salient themes and develop a global set of social factors and cultural determinants based on the locally conducted D-VA.
In total, 740 interviews have been conducted in the first five cities.
To expand and further strengthen the global research platform, the Cities Changing Diabetes (CCD) programme is in the process of developing a new research tool. The Diabetes Q-Study Tool (D-Q) will enable new cities to better understand local specific social and cultural factors related to health, well-being and diabetes.
The D-Q tool utilizes Q-methodology2 3 and builds on the findings of the Diabetes Vulnerability Assessment (D-VA).
The D-Q tool principally answers two overall questions:
The D-Q tool enables cities to establish local research platform that can inform interventions and policies, at the same time contributing to further strengthen the global research platform.
The D-Q tool will be pilot-tested in Vancouver in the beginning of 2017.