Cultural domain of the causes of diabetes in three generations of popular stratum in Guadalajara, Mexico

In somatometry, height was greater in the younger generations (F = 5.29, p = 0.006); body mass index (BMI) was of overweight-obesity in all cases (F = 3.31, p = 0.04); waist was at-risk for grandparents and parents (F = 1.14, p = 0.02); also, in some metabolic parameters such as glucose, the average was definitely high in grandparents (F = 4.82, p = 0.009). The average diastolic blood pressure was higher in parents (F = 5.31, p = 0.006).

In addition, participants did not show statistical differences in sex ratio (chi-squared = 3.42, p = 0.18), maternal history (chi-squared = 5.89, p = 0.20), weight (F = 1.43, p = 0.24), systolic blood pressure (F = 2.35, p = 0.10) and pulse (F = 2.38, p = 0.09) (Table I).

Cultural consensus model

Table II shows the semantic models of grandparents, parents and children about the causes of diabetes

1. They basically share the same items for causes (with statistically insignificant differences).
2. The younger the group studied, the more the model incorporates causal items of a biomedical nature.
3. The model of shared knowledge presents for componential analysis a ratio of variances greater than 3.0, which covers over 90% of the total variability of the causes indicated, which shows significantly that the cultural agreement of the group is mostly in consensus regarding the structure of the semantic model 
4. All groups showed an average level of group knowledge of the model greater than 0.70.

Discussion

The sample is representative of the upper-low and middle-low strata of the Libertad sector of the city of Guadalajara, and although it has the causal constraints of a quantitative cross-sectional study, it should be noted that its internal validity and cultural approach encourages the need to deepen the theme studied, given the demographic importance of the lower classes in urban areas of the country, in order to understand their perspective on the genesis of diabetes and improve health promotion.

Moreover, in the results reported, the differences are mainly explained by the socio-biological characteristics of the three groups studied.

In contrast, semantic models found in the three groups express generational agreement as similarities in their semantic elements (p = 0.42), which we believe are mediated by the culture that the informants share and control.¹¹

We think that the items or elements that make up the semantic model of each generation are the cultural result of generational dynamics, related to the process of socialization and the experience of disease.²¹

In the structures of the generations we found that three major cognitive dimensions coexist:

• The traditional, which is related to emotional elements: shock, anger, mortification, and joy, which show the affect based in ancestral folk knowledge.

• The everyday, which is related to components of the lifestyle of lower-class groups: poor diet, foods with sugar and fat, lack of exercise,

• The emerging, which is built based on modern biomedicine and is gradually shared by the generations studied: genetics, obesity, overweight, and stress.

This three-dimensional model, in the three generations studied, presents high rates of shared knowledge (> 0.80), results that are consistent with other studies,^6,22 but conducted in populations that do not differentiate generational groups, so our results show not only the existence and permanence of a lay cultural model, but also suggest the movement of shared cultural knowledge, in this case three generation groups from the lower classes, urban area inhabitants, for the causes of diabetes.

This leads us to suggest that the model found lies in a process of generational cultural transmission that works to, first, maintain the tradition that survives in Mexico to attribute loss of health to "strong" emotions (such as shock),²³ causes that come before biomedical disease etiology and embody illness in the experience of people, to reconfigure their identity and to make sense of current stress and psychological distress,²⁴ especially if we consider that the lower classes historically suffer structural violence, whether social, gender, or family. Hence their mentioning causes such as shock, anger, rage, and even redefining paradoxical emotions such as joy. 

Secondly, this process of cultural transmission serves to express priorities within the daily life of the lower classes, in which the satisfaction of the daily requirement of feeding oneself⁷ makes the food component occupy a prominent place, ranging from 43, 38 and 45% (p = 0.58) for generations of grandparents, parents and children, and thus the health and functionality of the individual is maintained.

Thirdly, this process serves to incorporate and adapt to its existence the impact of contemporary biomedicine, as it adds new items from this discipline: 25% in the generation of parents and 45% in the children.

According to Segall and Goldstein,²⁵ similarities and differences found between and within the semantic models described, include and express, at first, the way people link health and disease patterns to wealth and poverty. For example, until the twentieth century, obesity was a marker of wealth, and malnutrition a marker of poverty. However, the development of a consumer economy paradoxically fostered obesity in poverty,¹¹ which produced a high prevalence of overweight-obesity (> 70%)³ in the lower classes.

In a second stage, these similarities and differences explain for Segall et al. the incorporation of critical attitudes of dissatisfaction or recognition of the limits of biomedicine, as well as some traditions related to care practices, such as: the main causes have an external locus of control,²⁶ such as those of emotion and food, which are issues that involve tensions with health professionals (as they favor the culture of reprimand, prohibition, and enforcement), a situation that requires understanding to facilitate self-care and care; otherwise, educational activities might seem like coercion by the health team.

In a third stage, these similarities and differences explain for Segall and Goldstein lay or specialized knowledge on the effects of lifestyle on health and the desire to exercise or not their personal responsibility for health. For example, it is said that the idea of ​​chronic disease is not well digested by the community, which sees many of its causes as reversible, causing treatment failures in the lay population, which believes that simply by no longer eating sweets, resting, or drastically reducing daily intake, their health will improve; however, by proposing this in a communication context of care, though formalistic, it may be defective, because of failure to use indirect communication for bad news, highly respected in lower classes, for whom conversational customs involve ritual presentation, demonstrations of respect, tranquility in the topic (not hurried) and relative proximity (a situation that is sometimes left out when communicating the diagnosis of diabetes).

The intergenerational transmission of knowledge and health behaviors is given by mechanisms such as values, socialization, assigned roles (whose extent depends on the presence of parents), quality of the relationship, similarity of gender, inherited status, exposure to similar structures of opportunity and, in the case of young adults, the propensity to use cultural stereotypes disseminated by the media, and religion.²⁷ For example: socialization in the family makes its members learn what disease is and how it is treated; that is, as a mechanism for selection, it also homogenizes the cultural capital of its members, the experience of the disease. Especially if it is chronic.²⁸

Thus the cultural dominance of the causes of diabetes evidences a complex process in which the dimensions are dynamically constructed and reconstructed: traditional, which maintains folk significance and meanings; everyday, product of domestic praxis for meeting basic needs; and the emerging, harmonizing this knowledge with modern biomedical care.

For this last reason it is necessary, among other things, to take into account the generational aspect to provide culturally comprehensive care when implementing specific adjustments to programs for prevention and control of diabetes.

Cultural studies formalize what appears obvious, as in the case studies of generational knowledge of the causes of diabetes mellitus, which can help create alternative programs^29,30 that take into account the three dimensions of lay causality for diabetes mellitus, adapting these programs to group subculture, whether they are applied individually or in groups, both for healthy individuals and patients with type 2 diabetes mellitus, during institutional opportunities, being attended by the health team, situations in which it is possible to influence not only by increasing their knowledge, as is traditionally done, but also to develop skills and practices that generate self-confidence in the patient and consciousness in the health team.

Conclusion

A representative sample of grandparents, parents, and children belonging to the upper-low and middle-low strata in the sector Libertad in Guadalajara presented a model of lay causes of diabetes mellitus, similar in shared semantic elements, for three dimensions: traditional, everyday, and emerging. This structure can be a useful means of establishing culturally comprehensive educational programs for both patients and the health team.

Funding

The project received INN03D support from the Programa de Investigación en Migración y Salud (PIMSA), the Initiative for the Americas, and California Program on Access to Care to Berkeley School of Public Health.

Acknowledgements

We thank PIMSA for their support (INN03D) for the development of this work.

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