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A systematic literature search in Nelson and CINAHL database for primary studies published in English were used to obtained articles ensuring reliability, quality and relevance (Aveyard, 2010) reason why Google and Wikipedia were not used. Sequence of key words such as: diabetes type 2, socioeconomic class/group/position, risk factors in UK, type 2 diabetes quality of care in the UK, type 2 diabetes difference in care management, inequalities in UK type 2 diabetes treatments, differences in type 2 diabetes management globally, deprivations in type 2 diabetes in articles title (see appendix 1). Among the database mentioned Nelson was mainly used as it provided many articles which were relevant to the topic. The National Institute for Health and Care Excellence (NICE) guidelines for type 2 diabetes updated in 2017 was looked at as well as publications from the Department of Health (DOH), WHO, Diabetes UK, Government website (Gov.UK), Nurses and Midwifery Council (NMC), International Diabetes Federation (IDF) were used as well as a seminal piece from Newcastle University research.
The timeframe of this articles was restricted to the last 10 years to enable comparability between all the studies. As a result, only articles published between 2008 and 2018 were selected. This generated a great number of articles and as a result a suitable inclusions and exclusion criteria were adopted to narrow findings (see appendix 2). A range of peer-reviewed literature including both qualitative and quantitative were looked at. Qualitative research aims to understand, interpret the thought and reasons of people concerning a subject (Streubert and Rinaldi, 2011). This method adopts a systematic and explicit method of analysis which is reproducible. This research method may delineate preliminary questions which quantitative research can then address (Aveyard, 2014). On the other hand, a quantitative research method quantifies the problem developing a numerical data which can also generate statistics generalising it findings from a vast sample population (Streubert and Rinaldi, 2011). On first trial many of the key words were returning nothing useful therefore, they were disregarded and some words were altered to retain appropriate information. Hits were high with some keywords therefore the filters had a significant role in narrowing it down leading to a manageable number of articles to choose from. An abstract review was adopted to choose final articles relevant to the topic. Through this method 17 articles were chosen for the themes. Critical Appraisal Skills Programme (CASP) was adapted to critiques these articles. CASP is a NHS supported tool based on the importance of systematic review in evidence based practice, result interpretation and features of a high-quality review but also help to locate effectively systematic reviews. Through systematic review and critique of this literature the following themes were identified: socioeconomic inequalities, mortality, lifestyle.
SOCIOECONOMIC POSITION
Studies mentioned in the literature suggest there is a link between socioeconomic position and type 2 diabetes. According to Read et al., (2016) strong evidence of this was found in the Scottish diabetes survey produced by the Index of Multiple Deprivation which point out massive type 2 diabetes inequality prevalence as 77% of the people living in low quintile were more at risk compared to the 23% with a higher socioeconomic position living in non-deprived areas. Highlighting, that between 2004 and 2013 there were 180,290 people in Scotland diagnose type 2 diabetes which mostly involved young adult. Data collected from 350 General practices around the UK outlined doctor diagnose type 2 diabetes in men living in poor quintile was approximately 1.5 times higher compared to those living in privileged areas whilst the women were twice higher compared to people living in non-deprived areas (Read et al., 2016). Interestingly, further analysis proved that mortality prevalence of type 2 diabetes linked with socioeconomic position and age were 1.38 higher in men and 1.49 higher in women living in deprived areas. This proves young people living in more deprived areas have a high risk of developing type 2 diabetes leading to major health complications and premature death (Read et al., 2016). The study conducted by Read et al., (2016) presents two significant strengths. Firstly, this study was based on a large sample size as it used a big population register, which included 99% of type 2 diagnosis in Scotland and used national death registration data to analyse mortality trends. However, it could be argued this study cannot be generalised to all UK population, as ethnicity and food culture ware not considered. On the other hand, data collection accuracy could be argued as this was done routinely increasing the possibility that people diagnose with type 1 diabetes may have misclassified as type 2 diabetes and added to the figures.
Socioeconomic position is strongly linked with type 2 diabetes even when factors such as lifestyle and obesity are considered. An important finding was the study of the African American women conducted by Supriya Krishnan et al., (2010). This study examined the neighbourhoods in which African Americans women live based on their socioeconomic status and the prevalence of developing type 2 diabetes. Data was collected through a biennial follow up structured questionnaire sent by email to the 43.382 participants. This study started in in 1995 and lasted for twelve years and participants were aged between 30 to 69 years. And in other to assess neighbourhood socioeconomic status the US census block were use. Each census block containing approximately 1.500 people. There was a significant positive correlation between income and education in relation to indicators of socioeconomic position as well as individuals neighbourhood. Comparatively, the study found out people living in deprived neighbourhood had 20 to 25% higher risk of developing type 2 diabetes (Supriya Krishnan et al., 2010). Interestingly, they also point out the relation between neighbour socioeconomic position with type 2 diabetes prevalence was also present within the African American women who had better education and higher income. An advantage of this study is the large sample size and the fact that it focuses on a specific sample type: African American women. However, one limitation of this study is the reliability of the data as the questionnaires are completed electronically and participants self reported, this could present bias (Aveyard, 2014).
It is widely recognised individuals with higher socioeconomic position have a better health compared to individuals with low socioeconomic status who present in general poor self-rated health (Read et al., 2016). On the other hand, the evidence from Kivimaki et al., (2015) study aimed to find how long working hours of manual labour associated with low socioeconomic position is a risk of developing type 2 diabetes. The study through meta-analysis included 222,120 people of both gender from Europe, United State of America (US), Australia and Japan. The most interesting founding was that there is a higher incidence of type 2 diabetes in low socioeconomic population who work long hours considering other factors as physical activity, age, obesity and gender. As people with manual labour job that worked 55 hours a week due to their low socioeconomic position increased the risk of type 2 diabetes of 30% compared to those who work 35 to 45 hours per week. However, it could be argued the study conducted by Kivimäki et al., (2015) presented some limitation. Even though the meta analysis data used covered Australia, USA, Europe and Japan not all the research was population based, therefore this finding cannot be generalising to all countries (Aveyard, 2014). Another limitation is the fact that working hours was measured based on a single assessment and there was no specific definition of what long hours means as this might differ in the countries mention above. However, and advantage off this study was large sample size (Aveyard, 2014).
All studies mentioned above highlight socioeconomic inequalities as a risk factor of type 2 diabetes as treatment management, awareness of this disease, it complications as well as accessibility to health allied support services may differ base on patients groups neighbourhood or income. Meaning some health services are way below the NICE standards as theres no devoted service structure in place (NICE, 2017). These studies all have similar opinions and obtained significant result to clearly state socioeconomic deprivation raise inequalities among different patient groups.
MORTALITY
There is a large research on mortality within the field of type 2 diabetes and socioeconomic positions emerging as an important feature in the literature review. Else-Marie Dalsgaard et al., (2015) through a population base study examined 2.330.2006 participants aged 40 to 69 years who had no past medical histor of type 2 diabetes. The study lasted for 11 years. This study estimated mortality rate ratio and age standardised mortality rate of type 2 diabetes whilst taking into account participant home income, their neigbourhood base on socioeconomic status and their level of education. During this study 195.661 participant died and 19.959 of these was diagnosed with type 2 diabetes. The study conducted by Dalsgaard et al., (2015) suprisingly find out both socioeconomic position as well as type 2 diabetes were strongly connected to the mortality cases. There was a significant difference between higher income quintile individuals who had no type 2 diabetes the mortality rate was 2.8 higher for people with type 2 diabetes living in deprived quintile and type 2 diabetes itself increased mortality rate of 2.0. However, this study conducted by Dalsgaard et al., (2015) have some limitations as factors such as smoking status, bodi max index, physical activities, and clinical conditions were not taking into accont. On the other hand, data from this study included the Danish registers enabling reliable data colection which can be consedered as strenght (Aveyard, 2014).
Mortality is of key concern in the literature as outlined in the previous study. Walker, J.J. et al., (2011) similarly conducted a study to identify mortality rate in type 2 diabetes individuals. The Scotish eletronic database was used to obtain mortality records among people aged 35 to 84 years between 2001 and 2007. Quintiles 1 and quintiles 5 were adopted to measure low socioeconomic deprived neighbourhoods and the high socioeconomic priviladge areas. To measure the incidence of mortality rate and estimate it associated risks among those diagnose with type 2 diabetes and those who dont have this condition a poison regression was used and gender, age, socioeconomic position and the duration of type 2 diabetes were taken into account as variable factors. The study included 210.994 participant of which 33.842 deaths and results showed mortality significantly increased increased more for men compared to women as socioeconomic deprivation and age increased. Strenghts of Walker, J.J. et al., (2011) study, a part from the large sample size is the use of a population based eletronic database which includes data from five of the thousand primary care practices in Scotland. However, the area base quintiles adopted to measure socioeconomic position instead of an individual based measure can be seen as a limitation (Aveyard, 2014).
On the other hand, Smith, B.T. et al., (2011) examined the level of cumulative life course of socioeconomic position linked with type 2 diabetes prevalence in young adults vary by gender. And also to analised if low socioeconomic position increase type 2 diabetes incidents during adulthood or childhood. Data was collected through 1.893 male and female from Framingham Offspring study who have been folowed up for 30 years. Roughtly every four years partecipant were asked to complete a standardised questionaire and undertake a physical examination, a doctors check to keep medical hystory up to date. Both men and women cumulative socioeconomic position was straightly linked with smoking, body max index, hight and higher consumption of alcohol. Findings of this study revealed theres an
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