Article Text

Original research
Role of cultural brokering in advancing holistic primary care for diabetes and obesity: a participatory qualitative study
  1. Thea Luig1,
  2. Nicole N Ofosu1,
  3. Yvonne Chiu2,
  4. Nancy Wang2,
  5. Nasreen Omar2,
  6. Lydia Yip2,
  7. Sarah Aleba2,
  8. Kiki Maragang2,
  9. Mulki Ali2,
  10. Irene Dormitorio2,
  11. Karen K Lee3,
  12. Roseanne O Yeung4,
  13. Denise Campbell-Scherer1,5
  1. 1 Physician Learning Program, University of Alberta Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada
  2. 2 Multicultural Health Brokers Cooperative, Edmonton, Alberta, Canada
  3. 3 Division of Preventive Medicine, Department of Medicine, University of Alberta Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada
  4. 4 Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada
  5. 5 Family Medicine, University of Alberta Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada
  1. Correspondence to Denise Campbell-Scherer; denise.campbell-scherer{at}ualberta.ca

Abstract

Objectives Diabetes and obesity care for ethnocultural migrant communities is hampered by a lack of understanding of premigration and postmigration stressors and their impact on social and clinical determinants of health within unique cultural contexts. We sought to understand the role of cultural brokering in primary healthcare to enhance chronic disease care for ethnocultural migrant communities.

Design and setting Participatory qualitative descriptive–interpretive study with the Multicultural Health Brokers Cooperative in a Canadian urban centre. Cultural brokers are linguistic and culturally diverse community health workers who bridge cultural distance, support relationships and understanding between providers and patients to improve care outcomes. From 2019 to 2021, we met 16 times to collaborate on research design, analysis and writing.

Participants Purposive sampling of 10 cultural brokers representing eight different major local ethnocultural communities. Data include 10 in-depth interviews and two observation sessions analysed deductively and inductively to collaboratively construct themes.

Results Findings highlight six thematic domains illustrating how cultural brokering enhances holistic primary healthcare. Through family-based relational supports and a trauma-informed care, brokering supports provider–patient interactions. This is achieved through brokers’ (1) embeddedness in community relationships with deep knowledge of culture and life realities of ethnocultural immigrant populations; (2) holistic, contextual knowledge; (3) navigation and support of access to care; (4) cultural interpretation to support health assessment and communication; (5) addressing psychosocial needs and social determinants of health and (6) dedication to follow-up and at-home management practices.

Conclusions Cultural brokers can be key partners in the primary care team to support people living with diabetes and/or obesity from ethnocultural immigrant and refugee communities. They enhance and support provider–patient relationships and communication and respond to the complex psychosocial and economic barriers to improve health. Consideration of how to better enable and expand cultural brokering to support chronic disease management in primary care is warranted.

  • Obesity
  • Primary Health Care
  • DIABETES & ENDOCRINOLOGY
  • QUALITATIVE RESEARCH

Data availability statement

Data are available upon reasonable request. No data are publicly available. Sharing of data will be considered on a case-by-case basis in collaboration with community partners.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

Statistics from Altmetric.com

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Strengths and limitations of this study

  • This study’s qualitative design provides in-depth insights in often invisible and under-researched care work cultural brokers do to support obesity and diabetes care in ethnocultural migrant communities.

  • Our participatory approach with engagement of cultural brokers in all stages of the research enhances trustworthiness of our findings.

  • The participatory and purposeful sampling ensured representation from all major local ethnocultural communities that expressed increasing concerns around obesity and diabetes.

  • Participant observation was hampered by cancellations of group programmes during the summer months when our data collection occurred.

  • This study’s sample is limited to participants from one local organisation, but lessons learnt are relevant for regional or national and other healthcare contexts where cultural distance and racial disparities present challenges to care.

Introduction

In diabetes and obesity prevention and management, clinical assessment must identify physiological and psychological root causes, determinants of health, constraints and values to inform cocreation of clinical intervention.1 2 Immigrants are disproportionally at risk for developing obesity and type 2 diabetes.3 Migration impacts every domain of social determinants of health and healthcare,4–7 adding complexity to care.8 Premigration trauma, postmigration stress and discrimination9 interact with poverty, loss of social roles and social support and the misalignment of familiar cultural practices with the new socioenvironmental context, leaving families without capacity to make their health a priority.10 Complex care needs for patients with migration backgrounds include food and housing insecurity, trauma and psychosocial stressors.6 Healthcare services must advance their practice to serve this growing portion of society.

Healthcare professionals are rarely trained in the unique needs of immigrants and newcomers11 and may perpetuate barriers based on cultural distance, language difficulties, prejudices and implicit racial bias, which negatively impacts care12–14 and provider–patient relationships affecting trust, access and continuity of care.7 15 Health system constraints, heavy workload for providers16 and variable knowledge and skills17 further complicate effective care delivery.

Community health workers (CHW) focus on addressing these gaps in ethnocultural migrant communities in vulnerable circumstances by supporting navigation of healthcare and social resources.18–21 While established in the USA,22 there has been scant attention to CHW’s in Canada.5 23–25 CHW’s work has been shown to be helpful, but their roles in health are little understood and largely invisible.26 27 Linguistic and culturally diverse CHWs often work as cultural brokers, embedded in community relationships with deep contextual awareness of the life-reality of immigrants. Cultural brokering aims to ‘bridge gaps in cultural meaning or gaps in understanding’ between health professionals, patients, their community and the broader social system28 to innovate solutions,29 improve cross-cultural delivery of social and healthcare services and mitigate racial and ethnic health disparities.30

To better inform health system change in primary care in Canada, we partnered with the Multicultural Health Brokers Cooperative (MCHB) to answer the question: what is the role of cultural brokers in supporting care outcomes and in filling the gaps in healthcare for immigrant and refugee patients with diabetes or obesity?

Methods

Setting and design

A team of interdisciplinary researchers and a cooperative of CHW of immigrant and refugee backgrounds (the MCHB) together designed, and obtained funding for, a larger participatory multimethod study10 to address clinical and social determinants of health to advance obesity and diabetes prevention and management in vulnerable ethnocultural communities. This article reports on one component of the study, a qualitative, descriptive–interpretive31 exploration of the role of cultural brokers in primary healthcare to enhance chronic disease care. Other components of the larger study investigated experiences and gaps in care from the perspective of newcomer and immigrant people living with obesity and diabetes10 as well as the perspective of primary care providers.32 The work builds on our previous work on personalised conversations about obesity in primary care.33

Patient and public involvement

Following principles of participatory34 and pragmatic research,35 a community advisory group (CAG), including eight brokers, met 16 times from 2019 to 2021 to codesign research questions, methods and interpret findings as a means of continual verification of methods, analytical thinking and findings to ensure credibility and trustworthiness.36 Cultural brokers from the CAG vetted all proposed methods to ensure minimal burden and time required to participate in the study. The CAG contributed to writing and revising the manuscript. Annually, we met with policy-makers from the provincial health organisation, the municipality and a primary care network representing over 300 local family physicians, to discuss findings, implications and potential policy or programme responses.

Theoretical considerations

Theoretically and methodologically, this work has been influenced by concepts in medical anthropology including syndemics,37 intersubjectivity and relationality,38 ecological approaches to health,39 salutogenesis40 and participatory community-based research34 (online supplemental file 1). We have a pragmatic orientation to using theoretical approaches and methods to obtain the best data possible to answer research questions that matter to community partners and provide contextually rich information for decision-making and policy work.35 We embrace participatory research,34 deeply valuing the expertise of community partners throughout the process and reflexivity as a continuous process of bringing to awareness and making transparent how our own position as researchers shapes the knowledge we are cocreating. In addition to our participatory approach and continuous iterative collaboration with community partners, other strategies to ensure trustworthiness included methodological coherence, theoretical grounding and thick description including participant voice.36

Supplemental material

Participants

The MCHB identified concerns about increasing diabetes and obesity rates in eight major ethnocultural communities in Edmonton, an urban centre in Alberta, Canada. We therefore purposefully invited as participants, cultural brokers embedded in these eight communities with longstanding experiences caring for community members with diabetes and/or obesity (table 1). Brokers had between 5 and 20 years of experience, and hence the breadth and depth of experiences needed to provide relevant, rich and diverse data.41

Table 1

Participant characteristics

Data collection and analysis

We codeveloped with the CAG, a semistructured interview guide (see online supplemental file 2). A PhD cultural anthropologist (TL) conducted all interviews in 2019, which lasted 60–90 min, were audio-recorded and transcribed verbatim. To enhance trustworthiness,42 we triangulated interview data with observation of group programmes, field notes from interviews and observations, and notes from collaborative interpretation during monthly advisory meetings. We recorded analytical and reflexive thinking throughout the project.

Supplemental material

Data were managed and coded in NVivo (QSR International Pty, V.12, 2018). Select interview transcripts were first cross-coded inductively and deductively by four researchers (TL, NNO, RY and DC-S). Codes were compared, discussed and synthesised into a coding manual at regular team and advisory meetings. TL applied the coding manual to all transcripts applying multiple codes to interview passages to maintain the entanglement of complex processes throughout analysis. Avoiding reduction of complexity is key to understanding lived experiences in its relationality within family, community, societal and global processes and an important means to enhance trustworthiness of the study. Over several levels of abstraction, TL constructed themes that illustrated relationships between patterns within and between codes discussing patterns and themes with the academic team and CAG in monthly meetings. Together with the CAG, we grouped themes into meaningful clusters to answer research questions. Within limits of this article, we provide thick description of context and setting, and rich quotes illustrating themes in the participants’ voice to demonstrate transferability of findings.

Results

Ten cultural brokers participated in interviews (table 1) and two brokers allowed researchers to observe their group-based parenting programmes. All study participants were women, reflecting the predominantly female membership of the MCHB cooperative.

We identified six thematic domains (figure 1) that describe the role of cultural brokers in interaction with primary care for patients with diabetes and/or obesity from ethnocultural migrant communities. We report the results using both past and present tenses.

Figure 1

Thematic domains that describe the roles of cultural brokers in interaction with primary care for people with diabetes and/or obesity from ethnocultural migrant communities.

Past tense indicates experiences and data examples shared by brokers with the researcher during an interview, while present tense is used for analytical, interpretive patterns in the data. Quotes are presented in tables 2–4 and are edited minimally for readability and to reduce length.

Table 2

Example quotes for thematic domains 1 and 2.

Table 3

Example quotes for thematic domains 3 and 4.

Table 4

Example quotes for thematic domains 5 and 6.

Cultural brokers are trusted intermediaries

Brokers agreed that trust relationships and deep contextual knowledge are foundational for brokering practice. Brokers share the experiences of premigration and postmigration realities with the communities they serve, and of impacts these experiences can have on relationships, ways of living, identity and health. They have embodied knowledge of the ways of being in diverse communities, the aspirations and traumas of migration and the hopes and challenges of building a new life. As community members, brokers’ relationships to clients include expectations and rights common in the respective community. Many brokers described these relationships as family-like implying trust, and obligation to help in a comprehensive manner. They adapt the modalities of their work, such as time, place and mode of communication, to honour these relationships and be available whenever clients may require support (see representative quotes in table 2).

Cultural brokers’ embeddedness in cultural ways of being and their relentless efforts cultivating relationships across diverse communities and institutional partners places them in a trusted and deeply knowledgeable intermediary position between patients and primary care. Brokers interpret meaning, mediate in conflict and facilitate the cocreation of contextually meaningful solutions for care. Brokers build trust between community members and providers through their high level of cultural competence, relational capital, skill and dedication.

Cultural brokers develop a holistic, contextual knowledge of their clients’ story

As trusted intermediaries, brokers know their client intimately and can culturally interpret practices, living conditions and social and emotional determinants of health for care providers to ensure a full understanding of people’s needs. Accumulating insights across different clients and communities, brokers observe patterns in health and illness entangled with premigration and postmigration realities that may be little understood in the larger society including research, healthcare or policy domains.

Brokers developed complex mental models of diabetes and obesity. They spoke about attending to root causes including premigration trauma, immigration route, poverty, stress around income, housing, food insecurity, poor sleep and the health impact of the drastic change in food and activity practices implicated in moving to the Canadian context. They paid attention to mental health concerns such as challenges to identity, social roles and self-worth, changes to relationships, parenting, social capital and their to the interaction with obesity or diabetes. Brokers illustrated how these root causes contribute weight gain and illness. For example, poverty is a barrier to accessing quality and familiar foods. Unfamiliar urban environments, the harsh climate and limited access to reliable transportation constrain people’s ability to incorporate physical activity and social connection into daily routines. Trauma and poverty keep families in ‘survival mode’, where basic needs must take priority over quality of food, exercise, activities or rest. Financial insecurity aggravates mental health challenges, further impacting families’ coping resources and capacity; families are often physically and mentally exhausted.

Brokers use their cultural competency to interpret and appropriately respond to diverse perceptions and concepts of aetiology and management of obesity and diabetes. For example, in one community fasting requirements affect diabetes management. In another community, large bodies are perceived as a sign of wealth. Brokers observed how dietary habits with little impact on health in the more physically demanding life in the country of origin, now negatively impact health because people cannot maintain that level of physical activity in the context of postmigration stresses, poverty and a car-oriented Canadian built environment. Brokers emphasised how this requires a tactful approach to have meaningful conversations about food, eating practices, weight and health.

Through their knowledge and relationships, brokers support identification of client’s complex root causes of diabetes and obesity and facilitate communication of sensitive information to the care provider (see representative quotes in table 2).

Facilitating access to care

Brokers play an essential role in mediating access to healthcare through navigation, sensemaking, cultural interpretation and practical support. Brokers mitigate access barriers by connecting families with bilingual physicians, connecting clients without immigration status with physicians willing to care for them, providing childminding for medical appointments, support cost and navigation of transportation and facilitating relationship-building with providers.

Brokers help clients understand Canadian primary care and its focus on prevention, which may differ from their experience. In some cultural contexts, having no symptoms equates to no illness, and people seek urgent care when symptoms are severe. Brokers familiarise clients with a preventive approach by identifying opportunities to connect them with stable primary care. Brokers emphasised how pregnancy is a time when people are open to prevention and regular interactions with physicians. They enhance care continuity by supporting follow-up and ongoing education.

Brokers observe that clients are often unable to benefit from chronic disease supports through interdisciplinary care available in the local primary care model.43 There is a mismatch between the design and delivery of programmes and immigrants’ complex realities. Examples include written materials that are inaccessible for people with language barriers; communication via phone messages in English, lack of access to and skills with technology; inflexible programme schedules and strict no-show policies and lack of programme personalisation for their specific needs. Brokers identified the need for primary care to proactively engage with ethnocultural communities through intermediaries to help familiarise the care model, build trust and relationships and cocreate tailored care delivery (see representative quotes in table 3).

Facilitating communication and patient–provider relationships

Communication in primary care is difficult and can fail, particularly when there is no prior relationship with a family physician. Brokers support communication beyond translation by providing bidirectional cultural interpretation to ensure the relationship is nurtured, and needed care is provided. They use examples and metaphors to frame messaging in a way that clients are open to hearing it and able to make sense of information.

Obesity and diabetes are ambiguous concepts for many clients. For some diabetes may be perceived as a disease of the wealthy, something that people believe would not happen to them. Brokers explained difficulties with speaking about obesity as a medical label that is both unfamiliar and carries negative meanings in many languages. In some communities, obesity is stigmatised and providers may not possess the knowledge to avoid harm to relationships when addressing obesity. Brokers navigate divergent narratives and stigma about obesity in the clients’ cultural contexts, and find messages reconciling contradictory perceptions of obesity, helping their clients understand why healthcare providers may be concerned about weight gain. Some brokers use descriptive phrases, such as ‘we are gaining and it’s not healthy’. Or, they model a shift in mindset around health, food and body in the care for children that aligns with parents’ values in prioritising their children’s needs. Brokers take on the challenges of framing the meaning of obesity in a culturally safe manner, and carefully introducing the medical usage of the word to their communities when appropriate, while supporting overall health and resilience over a focus on weight or body size.

Cultural brokers’ practice is trauma-informed, enhances the care relationship and makes health information and advice meaningful and manageable in patients’ lives. Brokers perceived that healthcare providers saw them as interpreters, not recognising their extensive role as cultural brokers. They highlight missed opportunities for partnership with providers to enhance care and improve outcomes (see representative quotes in table 3).

Addressing root causes

Cultural brokers practically address psychosocial and economic root causes of diabetes and obesity in clients’ lives. The MCHB’s position outside of the regulated healthcare organisations enables them to flexibly respond to whatever needs arise for clients, families or community. Brokers work holistically and longitudinally to stabilise families financially, socially and emotionally through mobilising resources and knowledge, navigating new environments, fostering social connection and agency.

Brokers navigate and support basic needs with income, housing, food, social connection and information. For families in ‘survival mode’, brokers respond with holistic support not constrained in scope or mandate. Brokers locate resources and ensure families receive supports through application support, advocacy and follow-up. Once families are settled and life is more ‘certain’, then topics of healthy living can be addressed.

Being aware of the interactions between mental health and lifestyle-related chronic disease, brokers work preventatively to support coping, encouraging clients to accept support and help. Many migrants go through an existential crisis of displacement from relationships, identities, gender roles and cultural ways of being. They struggle making sense of unfamiliar ways of organising daily life and relationships, experience discrimination and aggression and feel isolated. These stressors leave no capacity for health promotion. Brokers provide the security of a stable and responsive care relationship and work to ‘empower’ clients by strengthening their social network, capacity and competency in the new environment, and ultimately agency and autonomy. Brokers access the social capital of close-knit ethnocultural communities to step in where public services are lacking. This support of whole-person health while addressing social determinants of health is key for primary care prevention and management of obesity and diabetes (see representative quotes in table 4).

Long-term, hands-on at-home prevention and management

Brokers observe a gap in health and food literacy and management strategies that are realistic for their families’ context. They provide practical support to mitigate management challenges such as time, money and stigma. They take responsibility for following up on healthcare encounters to help clients understand medical information given and implement it in their lives.

Diabetes and obesity require many adjustments in people’s lives, particularly challenging in the context of poverty, stress, cultural distance, isolation, language barriers and culturally nuanced views of illness and care. For example, purchasing and taking medications is difficult with food insecurity, poverty and language barriers. Brokers support accessing and adhering to medication. Additionally, they work to help families adapt to new food environments while supporting cultural continuity. They help clients familiarise themselves with foods available in local stores, identify ethnic stores and support integration of new foods and cooking skills with cultural food knowledge and practices. Supporting cultural continuity strengthens identity, confidence and sense of agency about health within the new food environment.

In group programmes, brokers facilitate conversations on health information, foods and eating practices and how health advice can be made realistic, acceptable and manageable within the community and family context. Brokers carefully weigh when and how to provide information and welcomed involvement of healthcare professionals in providing education in the community setting (see representative quotes in table 4).

Discussion

Research on the role of community health workers (CHWs) in Canada is scarce. This study aimed to understand cultural brokers’ role in diabetes and obesity care. Findings contribute important insights relevant for enhancing chronic disease care for ethnocultural migrant communities.

Cultural brokers extend and enhance primary care for people living with diabetes or obesity from ethnocultural immigrant communities. We illustrate six domains where cultural brokering bridges communities and primary care by building relationships, mobilising and transforming knowledge bidirectionally to support context-informed and sustainable chronic disease management (figure 1). Cultural brokers act as trusted intermediaries between individuals, families and communities and primary care services and providers. Their deep knowledge of the client’s story contributes context information to support clinical assessment. Brokers’ work to navigate primary care services and enable individuals to attend appointments, getting medications filled, taking them, and to integrate changes needed for health into their lifeworld. During a clinical visit, cultural brokers facilitate optimal knowledge and meaning transfer by providing cultural translation in addition to linguistic translation. Brokers support individuals and families holistically in areas of life that are outside the scope of primary care, but important social determinants of health. Finally, cultural brokers’ long-term relationships and community embeddedness allows them to support health and food literacy tailored to each family’s and community’s unique circumstances and needs.

Recognising cultural brokers as vital partners in primary care has important implications for improving care, enhancing the Patient Medical Home Model of longitudinal, interdisciplinary, team-based care44 and addressing racial disparities in health. Through partnering with cultural brokers, providers can build better rapport with people living with diabetes or obesity; ameliorate cross-cultural communication; improve and destigmatise assessment, diagnosis and treatment; more effectively facilitate chronic disease management and better personalise treatment approaches.

Three principles that are key to cultural brokering success align with primary care to support such partnership. First, relationality as a core value in primary care45 46 entails contextually informed, non-judgemental, strengths-based communication to build trust for people to seek help, express concerns and ask questions about diagnosis and treatment.46 This is paramount in obesity care where understanding the individual’s story, strengths and values is vital to develop realistic, meaningful and whole-person options for healthy living.2 Cultural brokering realises this through relationship-centred and holistic wrap-around care that expands on the scope of regular practice. Relationship-centred care aligns with person-centred care but expands beyond the provider–patient relationship and includes allied health professionals, the health system, as well as families, communities and health and social resources.47 Primary care providers need awareness of the diversity of human perception of health and illness and associated practices to question assumptions and explore what is going on with the people they care for. Cultural brokers are essential intermediaries bridging the impact of cultural distance, premigration and postmigration trauma and stereotyping that can undermine a patient’s trust, sense of agency,48 and relationship with health professionals.

A second principle underlying cultural brokering is an ecological39 and syndemic37 perspective. Brokers recognise the entanglement of individual health with families, community, socioeconomic and political environments, and observe the interaction of illnesses in populations living with trauma experiences in the context of vulnerable socioeconomic circumstances.10 While there is growing recognition of these interactions, primary care that is responsive to the syndemic effects is difficult to realise without change in health and social policy, and medical training. Cultural brokers are advocates for change and key actors in the health ecosystem49 responding to multiple health concerns and contextual vulnerabilities holistically.50

Finally, cultural brokering focuses on strengthening individuals’, families’ and communities’ resources and capacities to health aligning with primary care’s orientation on prevention. Salutogenesis is a theoretical framework for health promotion40 that highlights meaningfulness, manageability and comprehensibility as components of ‘general resistance resources’ vital for better health outcomes in the face of challenges. Brokers strengthen resistance resources by assisting people in making sense of their health, care and new environment (comprehensibility); by fostering social connection, meaningful relationships and occupations and supporting the people they serve in realising their potential (meaningfulness) and by cultivating cultural continuity that helps clients meet basic and existential needs (manageability and meaningfulness).

Our findings expand on previous research highlighting the importance of brokering support for building patients’ competence and confidence in engaging with their health and healthcare, and building capacity for cultural safety for improving equitable access to health.20–22 26 Cultural brokers as partners to primary healthcare support the goals of patient-centred care, team-based, comprehensive and integrated care and care continuity.44 49

Despite their success in improving health and access to care, cultural brokering is largely invisible. Organisations struggle with precarious funding30 and chronic work overload, aggravated by disproportionate impacts of the COVID-19 pandemic on marginalised populations.51 A transformation in the healthcare system to recognise and support cultural brokers as partners in primary healthcare is long overdue. To realise this, there is a need to break down power differentials between providers, brokers and patients, to formally recognise the contributions of cultural brokers and support their care model with sustainable funding.

Involvement of cultural brokers in primary care creates safe spaces for mutual understanding, trust and practice cultural humility.52 Such a partnership can catalyse syndemic care50 through recognising the patient’s situation in its complexity and cocreating responsive care plans and support sustainable healthcare.53

Conclusion

Cultural brokers work in the gaps where social determinants of health and cultural distance hamper access to care, and the ability of families to move beyond survival to attain and navigate the means to prevent and manage diabetes, obesity and other chronic diseases. Cultural brokers enhance the ability of primary care to address health in a syndemic manner, and mitigate environmental or situational impacts exacerbating illness in ethnocultural migrant communities. Cultural brokering aligns with the relational, personalised and ecological approach of primary care highlighting the opportunities for partnership with cultural brokers. Findings are relevant nationally and for other healthcare contexts beyond primary care where cultural distance impacts care.

Data availability statement

Data are available upon reasonable request. No data are publicly available. Sharing of data will be considered on a case-by-case basis in collaboration with community partners.

Ethics statements

Patient consent for publication

Ethics approval

This study involves human participants. The study was approved by the University of Alberta Health Research Ethics Board (Pro00089571). Participants gave informed consent to participate in the study before taking part.

Acknowledgments

We thank Melanie Heatherington for her excellent and tireless support throughout this research and submission of this article. We express our gratitude for partnership of the Edmonton Southside Primary Care Network in support of this project and for Jessica Schaub’s commitment to this work, her thoughtful input and suggestions. We would like to acknowledge and thank the members of our Policy Advisory Committee, especially Lucenia Ortiz and Richard Lewanczuk for their dedication to this project. We acknowledge Yuriy Kyrzov for the excellent design work in figure 1.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • Contributors DC-S, YC, TL, RY and KKL conceptualised the study, obtained funding and cocreated research design. TL, YC, NNO, NW, NO, LY, SA, KM, MA and ID codesigned recruitment, interview guide and coding manual. TL conducted all interviews. TL coded and analysed the data supported by NNO, DC-S, RY. TL, YC, NO, NW, LY, SA, KM, MA and ID had significant input in data interpretation and constructing themes. TL wrote the first draft of this manuscript with significant intellectual contributions by NW and NO. All authors reviewed and approved the manuscript for submission. TL is the guarantor for the overall content of this article.

  • Funding This work was supported by NOVAD, a competitive peer-reviewed partnership grant of the Government of Alberta, Novo Nordisk and the University Hospital Foundation. The Physician Learning Program at the University of Alberta and the Edmonton Southside Primary Care Network supported in this research through in-kind support.

  • Competing interests DCS: personal fees from a Pfizer Advisory Board Meeting on Diabetes and Obesity. KKL: industry funding for other work from Christenson Group of Companies, UN Studio and Doubleday Canada. RY: consultation fees from Novo Nordisk.

  • Patient and public involvement Patients and/or the public were involved in the design, conduct, reporting and/or dissemination plans of our research. Refer to the Methods and analysis section for further details.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.