Social Determinants Influencing the Non-Adoption of Norms Favorable to the Prevention and Control of Type 2 Diabetes: Qualitative Research

Abstract

Diet, physical activity, and body shape play an essential role in the development of type 2 diabetes (T2D) and are the social dimensions most targeted by health professionals in their practices or intervention aimed at preventing and controlling T2D. However, several interventions focus more on individual factors and less on social determinants likely to influence the adoption of dietary, body, and physical activity standards favorable to the prevention and control of T2D. This study aims to explore the social determinants influencing the rejection or adoption of dietary, bodily, and physical activity norms favorable to the prevention and control of T2D among migrants from sub-Saharan Africa. A qualitative exploratory design guided data collection and analysis. Semi-structured qualitative interviews and focus groups were conducted between October 2022 and March 2023 in Montreal and Quebec Cities. The cost of food, the difficulty of accessing certain foods, a reliable level of income, work schedules, the gazes of relatives or communities, migration policies, disappointment and stressful situations linked to migratory status, racial microaggressions, and the lack of food guides adapted to the realities of MASS were the main determinants identified by the participants. These determinants can influence the adoption of public health recommendations on diet for the prevention and control of T2D. People living with T2D obviously have an important role to play, but much of the work lies outside their control. Therefore, Preventive, clinical, or awareness-raising interventions should more consider the life and structural contexts in which these people navigate without ignoring their pre-migratory rules of dietary, body, and physical activity norms.

• What do we already know about this topic?

• Several factors contribute to the development of type 2 diabetes among migrants.

• How does your research contribute to the field?

• Preventive or clinical interventions must target more social determinants.

• What are your research’s implications toward theory, practice, or policy?

• This study also contributes to epistemic justice by supporting the participation of minorities.

Introduction

Type 2 diabetes (T2D) prevalence rates are increasing worldwide, and the disease affects populations unequally.^1,2 In Canada, the migrant population has very high rates compared to the general population.^3,4 According to data from the Canadian Health Measures Survey Cycle 4, 5 and 6 (2014-2019), the T2D prevalence rates are higher among long-term migrants (10.2%) than in the general population (7.5%). ⁵ However, migrant populations are unequally affected by this pathology.^3,4 In 2021, age-standardized diabetes prevalence rates were 14.4% among people of South Asian origin, 12.9% among those of African descent, 9.4% among those of Arab and West Asian origin, 8.2% among those of East and Southeast Asian origin, and 4.5% among those of Latin American origin. ⁶ Compared to European migrants, prevalence rates are particularly high among those from sub-Saharan Africa (SSA).^3,4

Many factors, such as poor diet, sedentary lifestyle, and obesity, contribute to the development of T2D.^4,7-9 In fact, diet, physical activity, and body shape play an essential role in the development of this chronic disease^4,10 and are the social dimensions most targeted by health professionals in their practices aimed at preventing and controlling T2D.^4,10,11 However, studies of migrant people living with T2D in Canada have focused mainly on individual dimensions (attitudes, behaviors, values). Additively, the interventions aimed at preventing and controlling T2D are, in most cases, directed at individual health determinants^2,4,12-21 and they do not take into account the social determinant, ¹¹ which are also the fundamental causes of chronic diseases such as T2D.

To help to fill this gap, research was conducted to explore the social determinants that influence the rejection or adoption of dietary, bodily, and physical activity norms favorable to the prevention and control of T2D among migrants from sub-Saharan Africa (MSSA).

The health social determinants refer to the contexts in which people are born, grow, live, work, and age. These contexts are determined by many forces, such as the economy and social policies, among others. ²²

The adoption of dietary, physical activity, and body standards refers to the acceptance and observance of these standards. Rejection of dietary, physical activity, and body standards refers to non-acceptance or non-adoption of these standards. In this study, dietary, physical activity, and body standards favorable to the prevention and control of T2D refer to the World Health Organization (WHO) recommendations for the prevention or control of T2D. ¹ According to the WHO, a healthy diet, a normal weight, moderate daily physical activity, and avoiding tobacco consumption are all ways of preventing or delaying the onset of T2D. ¹

Theoretical Perspective

The study was structured on 3 theoretical perspectives to construct the interview guide and structure the data analysis. The theoretical framework of social determinants of health^22,23 was used to identify the social determinants that influence the adoption or rejection of dietary, body, and physical activity norms by MSSA living with T2D. Intersectionality emphasizes the role of relationships and intersections between social and individual factors such as biology, socio-economic status, sex, gender, and race, at several levels of society, in social inequalities in health.^24,25 It was used to analyze how social factors interact with individual ones influence the adoption of dietary, body, and physical activity norms favorable to the prevention and control of T2D among MSSA. Social normativity is part of a critical vitalist posture as defined by Canguilhem. ²⁶ This theoretical perspective has enabled us to: (i) move away from a purely biomedical vision of health to conceive the concept of health differently, as well as that of the act of eating, physical activity, and corporality; (ii) consider migrant people living with T2D as social actors with the capacity to create their own norms of social life.

Materials and Methods

Research Design

A qualitative exploratory descriptive design guided data collection and analysis^27,28 in accordance with the COnsolidated criteria for REporting Qualitative research (COREQ) guideline. ²⁹ This approach was chosen because of its interpretative, spontaneous, and natural way of approaching, questioning, and understanding realities. ³⁰

Population

This study looked at MASS residing in Canada at risk of developing T2D or living with this disease. In this study, MASS at risk of developing T2D were those with a family history of T2D (having a close relative living with T2D).

By migrant, we mean any person born and raised in a SSA country, who has been granted permanent residency in Canada by immigration authorities. Also included in this category are people who have obtained Canadian nationality through naturalization process. On the other hand, foreign-born Canadians by birth, as well as temporary residents such as those with temporary work or study permits, are excluded. ³¹

Recruitment

Participants (n = 24) were recruited according to predefined criteria (see Table 1) and a purposive sampling technique. Since our study focuses on a population that is difficult to reach, several recruitment strategies were put in place, including: (1) posting the project description, including our contact details, on social networks (Facebook pages of organizations working with immigrants in Montreal and Quebec City), by e-mail or by posters at the head offices of other ethnocultural organizations and in many other locations (churches, universities, exotic grocery stores, festive events, etc.); (2) snowball recruitment, asking participants who had already been recruited to recommend other eligible participants. Above all, this study was approved by the Ethics Committee of the Université du Québec en Outaouais in October 2022 (No. 2023-2446). In addition, participants signed a consent form before taking part in the interviews.

Table 1.

Eligibility Criteria.

Inclusion criteria	Exclusion criteria
• Born and raised in sub-Saharan Africa	• Suffering from a severe mental disorder
• 18 years of age or older	• Temporary resident
• Living with DT2	• Refugees and asylum seekers
• Family history of T2D (a relative living with the disease)
• Permanent resident of Canada

Data Collection

Twenty-four semi-structured qualitative interviews lasting an average of 1-h were conducted by the main author (GMN) between October 2022 and March 2023 with MASS, including 11 men (8 DT2) and 13 (9 DT2) women. Ninety percent were employed at the time of the interview, 8% were on maternity leave and 2% were unemployed. The number of interviewees was adjusted according to the empirical saturation principle.^32-34 It was saturation that brought data collection to an end. An interview guide was developed to collect the data. This guide was adjusted after the first 3 individual interviews. Please note that this guide was not used as a rigid questionnaire, but rather as a flexible guide. Most of the interviews took place face-to-face, depending on the availability of our participants. Open-ended questions were addressed to the MASS interviewees with a view to obtaining their opinions on the factors influencing the food choices they frequently consume, the practice of physical activity and the adoption of the Public Health of Canada’s recommendations for the prevention or control of T2D. The interviews were mainly conducted remotely via Zoom. After preliminary analysis of the individual interviews, we completed data collection by conducting 3 focus groups, in December 2022, with 18 individual interview participants who agreed to be recontacted to participate in the focus groups. The interview guide was adjusted according to the main themes that emerged from the individual interviews. The 3 focus groups were conducted remotely. These exchanges made it possible to enrich, readjust, and deepen certain avenues of analysis. Participants were informed that their participation was completely voluntary and that they could withdraw from the study at any time without prejudice. In addition, prior to the interviews, all participants signed a consent form. The interviews were recorded in agreement with the participants in accordance with ethical guidelines. We kept a logbook throughout our immersion in the field to record the entire research process.

Data Processing and Analysis

Data was collected by a trained student. Information was subjected to a continuous and iterative process of thematic analysis. ³⁵ Collected data was recorded and transcribed in verbatim form for analysis using NVivo software^36,37 Version Release 14.23.1. ³⁸ The verbatim statements were coded by a researcher and validated by the others. The deductive and inductive approaches was used. Themes emerged from theories and improved from data from the field.

Results

The Sociodemographic Characteristics of the Participants

For the individual interviews, the 24 MASS recruited were aged between 26 and 65 at the time of the interview. Thirteen self-reported living with T2D. Fifteen lived in Montreal and 9 in Quebec City and were originally from the Democratic Republic of Congo (8), Cameroon (4), Rwanda (3), Senegal (4), Angola (2), Burkina Faso (2), and Togo (1). Sixteen had lived in Canada for more than 10 years. Fifteen had obtained Canadian citizenship and 9 were permanent residents. Only 3 declared themselves non-practicing, the others identifying themselves as Catholics (8), Muslims (6), or Evangelicals (7). Twenty-one had completed university studies. Twenty-two were employed, and 1 was on maternity leave.

Social Determinants of the Adoption or Rejection of Food Norms

The cost of food, the difficulty of accessing certain foods, a reliable level of income, work schedules, the gazes of relatives or communities, disappointment and stressful situations linked to migratory status, and the lack of food guides adapted to the realities of MASS were the main determinants identified by the participants. These determinants can influence the adoption of public health recommendations on diet for the prevention and control of T2D.

Cost of food

Although they are aware of the importance of adopting a healthy diet in their daily lives, most of the people interviewed mention that they are sometimes confronted with high food prices. For them, the cost of food is a major barrier to adopting public health recommendations on healthy eating.

Fruit is very expensive. [. . .]. I can eat them two or three times a week. I eat beans, fish, chicken, spinach. (P1-W-DT2)

Immigrants do not have enough money, especially when you’ve just arrived. We may be told to eat this or that, but when we come here, our concern is elsewhere. How to survive here and how to help our loved ones who live in our countries of origin. (P2-W)

Difficult access to certain foods

Some food products are not available in stores in certain neighborhoods, requiring extra time and transportation to purchase them. The lack of availability of certain foods can influence the adoption of certain foods considered healthy and necessary to prevent or control certain chronic diseases such as T2D.

Where I live, I find it hard to buy vegetables, even fresh fruit. We have to buy fruit and vegetables in cans. (P9-W-DT2).

We don’t have many stores to buy what we eat. Where I live, there are just two stores, so we’re limited. (Focus group)

Some MASS mentioned the low nutritional quality of the food they eat.

Here you can find food from our country, but it’s not fresh food. It’s food that has lasted a long time; it’s frozen. [. . .]. We eat to get rid of nostalgia. We take refuge in these foods. You find comfort. (Focus group)

I think there’s a connection to be made between food and lifestyle. The way people eat and the way they maintain their health. Fatty oil, lots of salt, additives. Draws people’s attention to excess. (P9-W-DT2)

Reliable level of income

The conditions in which most MASS live prevent them from adopting public health recommendations on diet. Income and type of employment were identified as the main barriers. Some highlighted the fact that their income is low, and they have many expenses to meet.

I eat according to my budget and not according to the food guide that says eat 5 fruits or eat this. I won’t make it to the end. With what I earn, I can’t make it to the end of each month. (P1-W-DT2)

It was difficult when I arrived. They don’t take diplomas into account. Conditions were difficult. The salary here is $500. I can’t make it. (P5-M-DT2)

For some MASS, working conditions (late or unfixed hours, type of work) are a major barrier to adopting public health recommendations on diet.

Immigrants find jobs that people here won’t take. This doesn’t help. So, we go and eat sandwiches, McDonald’s. [. . .]. They don’t have time to prepare. Life here is difficult. (Focus group)

I often don’t have time to cook. I eat what I can find. After work, I look at A&W or Tim Hortons or other places. It’s quick and cheaper too. I don’t waste too much time cooking. (P16-M-DT2)

Gazes of relatives or communities

The looks or comments of certain members of their communities can influence the adoption of a healthy diet.

[. . .] I get lots of invitations, and even if I don’t go, they bring the food home. People think we say no because she’s proud. It’s perceived in a negative way. (P22-M-DT2)

Food is part of everyday life, people eat, diabetic or not. People end up putting on a lot of weight. It’s really in our customs that we must place these elements. [. . .] I’ve realized that every summer, as soon as there’s a visit, we eat a lot. My daughter is a nursing assistant, and so are her friends. She knows I have diabetes, and when I say no, I don’t eat this or that, they tell me it won’t work, you’ll die. It’s so complicated. (P9-W-DT2)

The way others look at us hurts. They don’t encourage us. How difficult it is in our communities to make the right decision. A reality that exists. (FOCUS group)

Disappointment and stressful situations linked to migratory status

Some comments from MASS illustrate that certain circumstances linked to immigration lead them to adopt poor eating habits, putting them at risk of developing T2D.

I sent in my CV to look for work, but nothing worked. I didn’t go out and wait for the phone to ring, maybe for an employer. When they told me they’d received your application but had selected someone else, I’d dive into my food. In certain circumstances, we find comfort in these foods. (Focus group)

When you get here, you think you’re going to be fine, but you’re not. We start eating anything. We don’t have the money; we must survive. (P4-M-DT2)

Lack of food guides adapted to the realities of MASS

The lack of food guides adapted to the realities of MASS may influence the rejection of dietary norms recommended to prevent or control T2D. Some of these people feel that the food guide should reflect their realities by also incorporating the foods they frequently consume. When we asked them to share their views on public health recommendations for healthy eating, and to tell us about the Canadian and Quebec food guides with which they were familiar, most MASS interviewees recognized the importance of these recommendations and existing guides. However, they find that these recommendations and most of the information in the food guides they know about are often disconnected from their realities. According to these people, they do not consider the indications relating to the foods they frequently consume.

I’m followed by nutritionists. They take good care of me. But they don’t tell me what to eat. For example, I eat cassava, plantains, and yams almost every day. Cassava can be eaten in several ways. There are cassava leaves, cassava flour and chikwangue. What does all this represent in terms of the portion I have to eat. (P9-W-DT2)

It’s hard to eat things you don’t know about. Even if they tell you it’s good for your health. You can’t suddenly change what you eat. I’ve already looked at the food guide, there are foods I don’t know about, and I don’t eat them. (P3-M)

We add lots of spices and fish to the manioc leaves. We also eat amaranths. We mix them with meat and other things. How much should I eat? You won’t find this information in the guidebook. It’s complicated and complex. The guide adapted for us is necessary. (P9-W-DT2)

You must document when you take eggplants and add them to the eggs. I’m always hungry for the portion I get from my nutritionist. When I respect what I’m given, I can’t resist. Does the portion work when it’s cassava leaves or fish? The guide must tell us which corresponds to cassavas, to yams, to manioc carrot. This information is not found in the Canadian or Quebec food guide. (Focus group)

Social Determinants of the Adoption or Rejection of Body Norms

Contrasting body norms

The MASS interviewees perceive the importance and necessity of having a healthy weight. However, they find that the body norms conveyed in health-care circles are different from those shared within their communities.

Thin bodies have not been valued since childhood. It’s the fat that’s seen and valued. In my circle here, I hear parents from Africa say that children must be fat to defend themselves, to avoid bullying. In the playground, fat black children are feared. Some parents encourage them to eat and put on weight to get fatter. (P1-W-DT2)

In our country, even dancers must be big to move well. Fat bodies are valued by some people from Africa. (P9-W-DT2)

When a married woman becomes thin, people think she has an incurable disease like AIDS or cancer. With T2DM, you want to be like everyone else. (P17-W-DT2)

The comments of some of the MASS interviewees also illustrate the fact that there is a growing tendency to value a slim body to remain in good health.

There’s a certain culture that accompanies this representation. In Senegal, thin women mean that they don’t get all the care they need. In Gambia, where I’ve been, being overweight (is) a sign of quality of life, opulence. Thinness means that the woman who doesn’t treat her husband well, or vice versa. We see it here too, but it’s changing, at least in my circle. (P3-M)

Educated women are increasingly keen to take up sport. But there too, there’s a problem when it comes to doing it. We don’t have the time. (Focus group)

Gazes of relatives or communities

Although some of the MASS interviewees recognize the importance of having a slim body, the comments or gazes of their loved ones and communities are likely to prevent them from adopting this norm.

We don’t change overnight. Those born here do change. Fit means you’re physically fat. They say you’re starting to get used to white. (Focus group)

In my brother’s family, when his wife moved out, he lost weight when his wife came back. His wife got him back into his normal routine. (Focus group)

Social Determinants of Adoption or Rejection of Physical Activity Norms

Although most MASS interviewees recognize and understand the importance of physical activity, but several factors may prevent them from practicing it. The economic context (the cost associated with gym membership), living conditions (income, working hours, limited time), and limited social support networks (communities, relatives) are the main barriers to adopting physical activity as recommended in health circles to prevent or treat certain chronic diseases such as T2D.

Some say that when they were in Africa, physical activity was part of their daily routine. They did it almost every day, walking long distances to work or to run errands. This was not a programmed activity, but rather a very active way of carrying out their various daily activities.

The problem goes further. Black people don’t exercise. In my neighborhood, I don’t really see them. I’d say few women and more men on bicycles or on foot. In Africa, we don’t really practice programmed sports like we do here. It’s not a common habit, but people move around a lot. People walk long distances to work, to fetch water, to visit friends. (Focus group)

I walked a lot when I was in Senegal. Sometimes I walked long distances to work. Every day we’d go with friends to play soccer. Sport was natural. Coming here, it’s not the same rhythm. I take my car to go shopping. I don’t move around as much. Yes, you must move, but when? It’s important, but sometimes willpower isn’t enough Mrs. (P3-M)

High cost of gym memberships

Although most of the PMASS interviewees acknowledged that it is also possible to be physically active outdoors, the cost associated with gym membership was cited as one of the factors that can contribute to a sedentary lifestyle, especially in winter.

Memberships are very expensive. With the standard of living of people from Africa, especially at the beginning, it’s not feasible. [. . .]. If, for example, governments could provide incentives. Initiative to alleviate the costs associated with gyms. Initiative for childcare. (P3-M)

And then, when we talk about physical activity, we get the impression that it’s like something extra, but we know that it’s not extra, it’s necessary. If I take the example of winter, I don’t go out and to move, I must go to a gym. It’s expensive, can I afford it? What about other immigrants? (P24-W)

Busy work schedule

Work schedules and lack of time can prevent people from being physically active.

When you get here, it’s survival, you forget about your health. Physical activity is considered extra. (P2-W)

Imagine someone who must work hard and send money to Africa. He has no time. I moved around a lot when I was back home. To get to work, you must move. We move around a lot. Here we take the car for everything, to be quick and to avoid the cold. You end up putting on weight and it’s not automatic to lose it. (P5-M-T2D)

Limited social support network

Comments from some MASS, especially those with young children, illustrate that the limited social support network can be a barrier to physical activity.

For the child, someone from here, she can leave her child with her mother for at least 2 hours, but the person from elsewhere must pay for all these services. (P9-W-T2D)

You could say that if Canadians can do it, so can immigrants. It’s not the same thing. They have families, grandmothers, aunts, uncles, and sisters here. They’re often on their own. They must pay for everything, from childcare to repairs. It’s an expensive life. (P16-M)

Discussion

The aim of this study was to identify, through the words of MASS living with or at risk of developing T2D, the social determinants that influence the adoption or rejection of dietary and bodily norms favorable to the prevention and control of T2D. The results indicate that MASS living with or at risk of T2D live at the intersection of numerous social determinants that influence the adoption or rejection of dietary and bodily norms conducive to the prevention and control of T2D. Our results indicated that income, working conditions, living environment, social networks, level of health literacy and access to an adapted food guide were among the main factors favoring the adoption or rejection of dietary norms favourable to the prevention and control of T2D. These factors are interrelated and influence food choice and consumption. A MASS may find itself at the intersection of 2 or more factors, a reality that further complicates compliance with public health standards for healthy eating.

Our results revealed that food costs represent a major barrier to the adoption of a healthy diet by PMASS. Often, these people live in very precarious conditions to ensure their daily survival and turn to unhealthy and less expensive foods. These results concur with the findings of previous studies.^38-41 It is difficult for migrant families, especially the more modest ones, to maintain their traditional eating habits. Sometimes, fast food becomes an inexpensive and accessible food option for migrants living below the poverty line.^40,42 In addition, the living environment is seen as a key factor facilitating the accessibility or otherwise of quality food. Most of the participants in this study had no access to supermarkets selling fresh produce in their neighborhoods. Poor and disadvantaged neighborhoods often lack supermarkets, so many vulnerable populations experience difficulties in accessing healthy food, leading to food insecurity or perhaps a food desert.^43-45 A situation that encourages unhealthy eating habits among immigrants,^40,46 they face difficulties related to public transport to access healthy food in distant supermarkets.^41,47

MASS have non-professional, lower-paying jobs when they arrive, due to the non-recognition of their diploma in Canada. To meet their needs and those of their families back home, they hold several jobs. This work overload also coincides with a reduction in their time for other activities, including household chores. Unlike in their countries of origin, immigrants to Canada have a heavy workload and no access to support for household chores, which means less free time for cooking. ⁴⁸

According to our results, PMASS living with T2D do not have enough family and social support to help them respect public health recommendations relating to healthy eating. Despite their diabetes, most are encouraged to consume as before by members of their family or those in their community, particularly during friendly gatherings. These results are consistent with previous studies.^49,50 African migrants eat at the home of a member of their community 1 to 4 times a month and it is a time to savor the foods of their country. ⁵⁰

MASS living with T2D must eat at all costs to maintain their weight, because fat plays a role in constructing their identity and well-being. Indeed, the systems of food and body standards conveyed in health circles aimed at the prevention and control of T2D often go against what is vital for most migrant people from SSA^51-53 thus exposing them to conflicts of irreconcilable standards.^52,54

Most MASS living with T2D consume more foods from their country. The Quebec or Canadian food guide offered to participants ignores these foods. Most MASS believed it was important to be able to continue their original food traditions. ⁵⁵ The preparation and consumption of traditional foods is rooted in the conservation of the cultural identity or heritage of these migrants.^56,57 Maintaining their eating habits before migration offers these people a feeling of comfort and proximity to their country of origin. ⁵⁷ This study revealed the need to develop a Quebec and Canadian food guide adapted to the eating habits of PMASS living with T2D.

Furthermore, participants are less motivated to exercise to achieve a healthy weight. In general, daily physical activity is genetically and biologically regulated and humans always avoid moving more than necessary to preserve energy for times when it is better needed. ⁵⁸ Preference for body size and social expectations promote non-use of physical activities among African migrants. ⁵⁹ For MASS, their daily challenges in Canadian society break their momentum to practice physical activities. The feeling of lack of belonging to a society could hinder the practice of physical activities among migrants. ⁵⁸

Given that diet and physical activity play an important role in the prevention and control of T2D, the fact that most preventive programs targeting SSA migrants take little account of social determinants, the success of these programs remain limited by the fact that they target individual dimensions while most often neglecting cultural, economic, social, family, identical, and community dimensions. As an indication, behaviors considered good such as healthy eating are recommended to prevent T2D and its associated complications. ¹ However, if there is a lack of healthy food products in a neighborhood (reduced or absent availability) or if these products are expensive (economic accessibility), it is unlikely that people will choose these products. Likewise, if in the neighborhood, products with a higher fat content such as fast foods are more available and accessible than “healthy” products, the probability of choosing these products is higher. ⁶⁰

Importance for Practice and Research

Without wanting to disempower MASS for rejecting public health recommendations relating to healthy eating, most of these people are powerless. Food standards rejection could be caused by cultural, political, social, racial, environmental, and economic aspects which remains beyond the control of MASS. Therefore, it will be necessary to subsidize fresh foods such as fruits and vegetables, including those imported and consumed by MASS. Additionally, it is important for healthcare professionals to recognize that the dietary, physical activity, and body standards that migrants identify with or adhere to may be different from those conveyed in Canadian healthcare settings. Indeed, longitudinal studies and randomized trials will be able to shed light on the impact of the consumption of traditional foods in MASS living with T2D.

Limitations

One limitation concerns the external validity or transferability of our study. Indeed, for reasons of participant availability, despite our efforts to guarantee the internal diversity of the sample by trying to include people from several SSA countries, we were only able to interview migrants from 7 SSA countries (Angola, Burkina Faso, Cameroon, Democratic Republic of Congo, Rwanda, Senegal, and Togo) while the latter includes 48 countries. Given the diversity of countries, regions, and cultures that make up this part of the planet, the comments collected as well as the facts observed do not reflect all the realities of migrants from this region of the world, nor even of their native country. However, the triangulation of data (individual interviews-focus groups-literature) carried out as part of this study made it possible to obtain a global vision of the reality studied.

Furthermore, the data collection was carried out during the health crisis linked to the COVID-19 pandemic. The latter is carrying out significant economic and social transformations which have brought changes to the labor market, lifestyles, and social contacts. It is therefore difficult to know to what extent the crisis influenced our results. Other studies could be carried out documenting experiences before and after the health crisis.

Conclusion

T2D is an important indicator of social health inequalities. Considering the results of our study, we dare to believe that, with certain populations such as MASS, interventions should target more the social determinants, namely the living conditions and the structural contexts in which these people navigate.

People living with this disease obviously have an important role to play, but much of the work lies outside their control. As it illustrated in the previous paragraphs through some comments from MASS, income, unemployment, type of employment, working hours, social networks, and conditions linked to migration, between others, are important determinants for the adoption of dietary and body standards favorable to the prevention and control of T2D. These determinants lie beyond the control of these people. Therefore, preventive, clinical or awareness-raising interventions should take greater account of these different dimensions likely to influence healthy eating and the practice of physical activity. Furthermore, it is important not to underestimate or ignore the pre-migratory food culture of migrants. However, acting solely on social factors would be insufficient since they are interrelated with individual factors. However, by improving living conditions and structural contexts, it is easier to achieve improvements at the individual level. The opposite direction is more difficult.