Qualitative systematic review of the socioeconomic factors affecting type 2 diabetes management in Pakistan

Abstract

BACKGROUND

Type 2 diabetes mellitus (T2DM) is increasing rapidly in Pakistan, especially among socioeconomically disadvantaged populations. While clinical care remains central, social determinants such as poverty, gender norms, and mistrust in healthcare critically shape disease outcomes.

AIM

To synthesize qualitative evidence on how these factors influence the experience and management of T2DM in Pakistan.

METHODS

Following PRISMA guidelines, a systematic review of qualitative studies published between 2000 and 2025 was conducted on February 25, 2025 using PubMed, CINAHL, MEDLINE Plus, and PakMediNet. Eleven studies exploring socioeconomic influences on T2DM care and self-management in Pakistan were included. Thematic synthesis was used to identify key patterns. Quality was appraised using the Joanna Briggs Institute Checklist for Qualitative Research.

RESULTS

Three major themes were identified: (1) Economic insecurity. High cost of treatment, poor rural infrastructure, and food insecurity hinder access and adherence; (2) Sociocultural and gender norms. Restricted mobility of females, family control over health decisions, and fatalistic beliefs delay care; and (3) Knowledge gaps and mistrust. A lack of culturally appropriate education, reliance on traditional remedies, and distrust in public health systems reduce compliance. These intersecting barriers collectively impede effective diabetes management.

CONCLUSION

T2DM in Pakistan is driven by entrenched social and economic barriers. Addressing it requires culturally sensitive, equity-oriented strategies that go beyond biomedical models. Policy reforms should focus on affordability, rural outreach, and inclusive health education. Future research should engage marginalized voices through participatory methods.

Key Words: Type 2 diabetes mellitus; Socioeconomic determinants; Gender norms; Health-seeking behavior; Health equity; Cultural barriers; Health literacy

Core Tip: This article highlighted how socioeconomic and cultural barriers such as poverty, gender norms, and mistrust undermine diabetes care in Pakistan. Economic hardship limits access while sociocultural norms restrict health-seeking behavior, especially among females. Misinformation and distrust further exacerbate poor outcomes. Effective type 2 diabetes mellitus management demands equity-driven, culturally responsive health interventions.

INTRODUCTION

Type 2 diabetes mellitus (T2DM) has emerged as a critical public health issue in Pakistan with its prevalence escalating rapidly over the past two decades. The disease not only imposes a significant burden on the healthcare system but also deeply affects individuals’ quality of life, particularly in socioeconomically disadvantaged communities. The conventional biomedical focus on diet, exercise, and pharmacological interventions often overlooks the broader social determinants that drive the onset and progression of T2DM, especially in low-income and middle-income countries like Pakistan. These include poverty, low literacy, lack of access to healthcare, urban overcrowding, and gendered norms surrounding health behaviors and decision-making[1,2].

The rationale for this study lies in the urgent need to understand T2DM not just as a medical condition but as a socially constructed and influenced phenomenon. Pakistan’s unique cultural, economic, and healthcare landscape creates conditions in which prevention and management strategies often fail due to misalignment with patients’ everyday realities. Many individuals struggle to adhere to treatment regimens due to financial constraints, limited education about diabetes, or reliance on traditional beliefs and family influences. In such contexts socioeconomic status is not merely a background variable; it is central to understanding disparities in disease outcomes[3,4].

Despite numerous epidemiological studies outlining the rising incidence of T2DM in Pakistan, there is a notable research gap when it comes to understanding the lived experiences and social contexts that shape diabetes management and health-seeking behaviors. Existing literature has often relied on quantitative surveys or hospital-based data that fail to capture the nuanced barriers encountered by patients in their daily lives. This gap limits the development of holistic, patient-centered interventions that address not only clinical needs but also socioeconomic and cultural barriers[5].

Emerging qualitative studies have begun to shed light on how people in Pakistan experience and manage T2DM in settings marked by poverty, gender inequality, and limited healthcare resources. These studies reveal how deeply entrenched socioeconomic challenges influence access to care, dietary choices, mobility, and health literacy. For example, patients from low-income groups often prioritize immediate economic survival over long-term health planning while females may be constrained by familial roles or lack autonomy in health-related decisions. The literature also indicates that patients frequently rely on informal health networks and faith-based practices that complicate standard treatment pathways. However, most of these studies are fragmented or limited in scope, underscoring the need for comprehensive synthesis that collates and critically examines qualitative insights into how socioeconomic factors shape the experience of living with T2DM in Pakistan[5,6].

MATERIALS AND METHODS

Review design

This study employed a qualitative systematic review design using thematic synthesis to identify and synthesize patterns across qualitative research that explored the influence of socioeconomic factors on T2DM within the Pakistani population. The PRISMA framework was adhered to during search, selection, and documentation stages. No additional ethical approval was required for this secondary analysis of previously published data.

Eligibility criteria

Inclusion criteria: Studies were included if they met the following criteria: (1) Population. Human participants diagnosed with T2DM and residing in Pakistan; (2) Phenomenon of interest. Socioeconomic determinants impacting the prevalence, diagnosis, or self-management of T2DM; (3) Context. Community and healthcare settings across rural, peri-urban, and urban regions of Pakistan; (4) Study design. Original qualitative studies (e.g., interviews, focus groups, ethnographic research); and (5) Publication characteristics. Published between January 2000 and April 2025 in the English language in peer-reviewed journals due to unavailability of translated versions in open access.

Exclusion criteria: (1) Quantitative-only studies without any qualitative component; (2) Mixed-methods studies that did not present separately extractable qualitative data; and (3) Studies conducted outside of Pakistan or focused solely on other countries’ South Asian populations.

Search strategy

A comprehensive search strategy was developed in consultation with an academic librarian. The following databases were systematically searched: PubMed; CINAHL; MEDLINE Plus; and PakMediNet.

Search terms included a combination of free-text keywords and Medical Subject Headings. Boolean operators (AND, OR) were used to combine search terms. The PubMed search string used was: (“Type 2 Diabetes Mellitus” OR “T2DM”) AND (Pakistan) AND (“qualitative” OR “interviews” OR “focus group” OR “ethnography”) AND (“socioeconomic” OR “poverty” OR “education” OR “income” OR “social determinants” OR “barriers” OR “health inequality”).

Study selection

All retrieved citations were imported into Zotero for reference management and screening. Two independent reviewers screened titles and abstracts to assess eligibility. Full-text articles were retrieved for potentially relevant studies. Discrepancies in inclusion were resolved through discussion and when necessary adjudicated by a third reviewer. A PRISMA flow diagram was used to illustrate the screening and selection process.

Quality appraisal

The Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research was used to assess the methodological rigor and credibility of included studies. Each paper was independently appraised by two reviewers, and disagreements were resolved through consensus. No study was excluded based on quality alone; however, the appraisal informed the interpretation of findings during synthesis.

Data extraction

A predesigned data extraction form was developed and piloted to ensure consistency. Key data extracted included: Study; authors (year); study location; participants and sampling; methodology; and key findings/themes. Data were extracted independently by two reviewers and cross-verified for accuracy. The data were managed manually in MS Excel.

Synthesis method

A thematic synthesis approach was applied. This method involved three stages: (1) Line-by-line coding of findings from primary studies; (2) Development of descriptive themes; and (3) Generation of analytical themes that interpret how socioeconomic conditions influence T2DM prevalence and management in Pakistan.

The synthesis prioritized identifying cross-cutting patterns across diverse social, economic, and cultural contexts as experienced by patients in various regions of Pakistan.

RESULTS

Study selection

The PRISMA flowchart for the studies included in our systematic review is given below.

Study characteristics: Study characteristics are mentioned in Table 1.

Table 1 Study characteristics.

Ref.	Study	Study location	Participants and sampling	Methodology	Key findings/themes
Ansari et al[2], 2022	Experiences of diabetes self-management (study 1)	Rural Punjab	Middle-aged adults (n = 38) from low-income rural communities	Focus groups; thematic analysis	Low health literacy, poverty-induced dietary choices, strong reliance on family caregivers; fatalism and religious interpretations influenced self-care
Bukhsh et al[1], 2020	Perspectives and barriers of patients with T2DM (study 2)	Lahore and Multan	T2DM patients (n = 40), purposively selected from diabetes centers	Semi-structured interviews	Patients reported financial stress, limited awareness of glycemic control, dependence on informal care, and shame linked to insulin injections
Tariq et al[3], 2022	Living with diabetes: Role of culture and family (study 3)	Karachi	Urban females with T2DM (n = 25), recruited via clinics	Narrative interviews	Gender inequality limited female autonomy in diet/exercise. Family obligations, social restrictions on outdoor movement, and male gatekeeping were dominant themes
Ansari et al[13], 2019	Self-management in rural Pakistan (study 4)	Bahawalpur and Rahim Yar Khan	Patients (n = 22) from rural diabetes clinics	In-depth interviews	Accessibility challenges (distance, cost), low prioritization of diabetes, low self-efficacy, lack of culturally appropriate health messaging
Barolia et al[5], 2019	Motivators and deterrents to diet change (study 5)	Interior Sindh	Low-SES adults with T2DM (n = 15) with CVD	Ethnographic interviews	Religious motivation, fear of dependency, and family pride encouraged change; deterrents included food affordability, social gatherings, and denial
Bukhsh et al[1], 2020	CAM practices among patients with T2DM (study 6)	Urban Punjab	CAM users with T2DM (n = 35), interviewed from CAM clinics	Descriptive qualitative interviews	Patients chose CAM due to economic constraints, mistrust in biomedical systems, and beliefs in natural healing; affordability a critical driver
Ansari et al[12], 2021	Healthcare providers’ perspectives (study 7)	Dera Ghazi Khan	Rural HCPs (n = 18): Doctors, nurses, educators	Thematic framework analysis	HCPs cited lack of diabetes-specific training, poor community health-seeking behavior, and absence of referral systems; females more neglected
Gillani et al[8], 2018	KAP of diabetes in general population (study 8)	Nationwide Pakistan	Mixed community sample (n = 90) across provinces	Focus groups with diverse SES groups	Major knowledge gaps on diet/exercise; misconceptions about heredity and stigma; financial burden deterred routine monitoring
Othman et al[9], 2022	Perspectives of diabetes self-management (study 9)	Multan	Patients attending public clinic (n = 30)	Focus group interviews	Stress from unemployment, peer influence on noncompliance, lack of social support, and limited trust in primary care were noted
Siddique et al[10], 2021	Diabetes education in low-income Punjab (study 10)	Southern Punjab	Older adults (n = 20) in low-income diabetic households	Grounded theory approach	Participants faced conflicting medical advice, inadequate public health information, poor dietary infrastructure, and high food inflation
Jamil et al[11], 2025	Social determinants of diabetes in Pakistan (study 11)	National (urban and semi-urban)	Multi-level policy and community participants	Key informant interviews, stakeholders and patients	Diabetes risk embedded in systemic poverty, fragile health systems, and urban food deserts. Participants emphasized intergenerational cycle of poor education and disease

CVD: Cardiovascular diseases; CAM: Camera; T2DM: Type 2 diabetes mellitus; HCPs: Healthcare providers; KAP: Knowledge, attitude, and perception; SES: Socioeconomic status.

Quality appraisal results: All included studies were appraised using the JBI Checklist for Qualitative Research, and overall methodological quality was moderate to high across the sample. Most studies clearly articulated their philosophical stance and employed appropriate qualitative methodologies aligned with their objectives, such as thematic analysis (studies 1-11), narrative inquiry (study 3), ethnographic interviews (study 5), grounded theory (study 10), and thematic framework analysis (study 7). Credibility was established through member checking, triangulation, or peer debriefing in studies 1, 2, 4, and 10. However, not all studies consistently addressed key methodological criteria. Studies 1, 3, and 9 provided limited discussion on researcher reflexivity and the potential influence of positionality on data interpretation. Ethical considerations, including informed consent procedures or ethical approval, were underreported in studies 4, 6, and 9. Sampling strategies were clearly justified in most cases, but studies 5 and 8 did not sufficiently explain their sampling rationale or participant inclusion criteria. Additionally, thematic saturation was not clearly described in studies 6, 8, and 11. Studies conducted in rural or low-literacy contexts, specifically studies 1, 4, and 10, did not adequately describe strategies to address power imbalances, language barriers, or participant vulnerability.

Despite these methodological gaps, all studies were retained for synthesis due to their contextual depth, relevance, and contribution to understanding the social determinants of T2DM in Pakistan.

Synthesis of findings

Using thematic synthesis, findings from the 11 included studies were categorized into three main analytical themes with associated subthemes. These themes reflect shared social realities faced by Pakistani individuals living with T2DM and highlight how socioeconomic conditions shape diagnosis, care, and self-management.

Theme 1: Economic insecurity as a barrier to access and adherence. Subthemes: (1) Cost of medications and diagnostic tests; (2) Healthcare infrastructure gaps in rural areas; and (3) Food insecurity and dietary compromise.

“I can barely manage the bus fare to the clinic, let alone buy sugar-free food. Sometimes I just eat what’s available.” (participant, study 4). Many participants described a persistent inability to afford diabetes medications, glucose monitors, or specialist visits. Dietary adherence was particularly compromised by financial constraints with low-income households prioritizing quantity over quality of food. Several studies reported that economic pressures led patients to delay treatment or substitute formal care with herbal remedies.

Theme 2: Sociocultural and gender norms in health-seeking behavior. Subthemes: (1) Restricted mobility of females and autonomy; (2) Role of family and male decision-makers; and (3) Cultural misconceptions and fatalism.

“Even if I want to walk outside, my husband says it’s not safe or proper. So how can I exercise?” (female participant, study 3). Cultural expectations deeply influenced health behaviors, especially among females. Most female participants were dependent on male relatives for clinic visits and medical decisions. Misconceptions such as “sugar is a punishment from God” or “natural foods don’t need insulin” were prevalent in multiple studies, reinforcing delayed diagnosis and treatment resistance.

Theme 3: Knowledge gaps and mistrust in biomedical systems. Subthemes: (1) Lack of culturally sensitive health education; (2) Preference for complementary and alternative medicine (CAM); and (3) Distrust in public health systems

“I don’t trust what the hospital doctor says - he changes the medicine every time. The hakeem has treated me for years.” (participant using CAM, study 6). Participants reported major gaps in their understanding of T2DM and its complications. Several studies showed a strong preference for traditional healers due to familiarity, affordability, and perceived empathy. Mistrust in overburdened and under-resourced public hospitals contributed to noncompliance and fragmentation in care.

DISCUSSION

This qualitative systematic review synthesized findings from 11 studies exploring the impact of socioeconomic determinants on the management and lived experience of patients with T2DM in Pakistan. Three interrelated themes were identified: (1) Economic insecurity and its influence on treatment access and adherence; (2) Sociocultural and gender norms in health-seeking behavior; and (3) Knowledge gaps and mistrust in biomedical systems. These themes are not abstract observations; rather, they are grounded in lived realities across Pakistan’s diverse rural and urban populations and reveal significant implications for diabetes care, particularly for nursing professionals who often serve as the primary point of patient education, counseling, and care coordination.

Across studies economic constraints emerged as a persistent barrier to medication adherence, follow-up consultations, and dietary modifications. Nursing professionals, especially those working in primary or community-based settings, are uniquely positioned to mitigate these barriers through low-cost, community-centered educational programs that promote food substitution strategies and rational medication use tailored to patients’ financial realities. Nurses can also lead initiatives to screen for food insecurity and refer families to social support systems where available to improve dietary compliance[4,5].

The role of gender in diabetes management was a dominant thread throughout the reviewed studies. Mobility restrictions, lack of autonomy, and caregiving burdens of females deeply limited their ability to seek timely care or engage in lifestyle modifications[6-8]. Meanwhile, males often delayed seeking care due to stigma or economic responsibilities. These findings underscore the need for gender-sensitive nursing interventions, such as family-inclusive counseling sessions, and mobile outreach led by female community health nurses to engage females in their homes or safe community spaces. Nurses can also act as advocates for gender equity in clinical decision-making, involving both males and females in health discussions to reduce resistance and increase support for self-care efforts of females[9-11].

A striking theme across studies was the widespread mistrust in biomedical care and reliance on CAM, especially in low-literacy or rural contexts. Nurses, especially those working in community health or diabetic clinics, can lead trust-building efforts by delivering culturally respectful education that acknowledges CAM beliefs while reinforcing evidence-based self-management. Training nurses in narrative communication and motivational interviewing techniques could bridge the informational divide and empower patients to integrate biomedical advice with their belief systems in a non-threatening way[12,13].

These findings support the World Health Organization Social Determinants of Health framework that stresses how social, economic, and cultural contexts shape individual health behavior and system-level outcomes[14]. While previous quantitative studies in Pakistan have confirmed correlations between low income, rural residence, and poor glycemic control[1-4], this review deepened the understanding of those patterns by exposing the lived barriers and coping strategies shaped by socioeconomic status, gender norms, and informal care structures.

Importantly, this review presented actionable insights for nursing research and practice. There is a critical need for nurse-led research exploring innovative, locally adaptable models for diabetes education and family engagement. Examples include co-designing interventions with patients and caregivers, integrating faith leaders into health literacy programs, and piloting nurse-driven telehealth initiatives to reach remote or marginalized communities. Nurses are also well-positioned to advocate for structural reforms such as the inclusion of diabetes educators in primary care teams or the integration of diabetes screening into maternal and child health visits[15].

Globally, studies in South Asian and immigrant populations have mirrored these challenges by reporting cultural stigmas, male-dominated decision-making, and low health system trust as barriers to T2DM care[5,8]. Yet the Pakistani context introduces unique complexities, such as weak health infrastructure, high out-of-pocket costs, and fragmented public-private services. In this fragmented landscape nurses often serve as the linchpin of continuity and trust, especially in under-resourced settings where physicians are scarce or overburdened.

By capturing voices across gender, geographic, and socioeconomic divides, this review filled a critical gap in the literature. The findings move beyond abstract determinants and offer a contextualized, patient-centered perspective. More importantly, they highlighted the transformative potential of nursing leadership in addressing social barriers, promoting culturally appropriate care, and designing interventions that reflect patients’ lived realities.

Strengths and limitations

A major strength of this review was in its exclusive focus on qualitative studies within the Pakistani context, ensuring that findings were grounded in the sociocultural and economic fabric of the country. Thematic synthesis allowed for the integration of nuanced insights across diverse regions, participant types, and care settings. The review followed ENTREQ and PRISMA guidelines and included studies assessed with a standardized quality appraisal tool (JBI).

However, limitations must be acknowledged. At the review level the search was restricted to English-language, peer-reviewed publications, possibly excluding relevant Urdu-language or grey literature. Additionally, while selective databases were searched, qualitative research is often under indexed in bibliographic databases and may have limited retrieval scope.

At the study level most included studies had small, localized samples and limited reflexivity. Few authors discussed how their own position may have influenced data collection or interpretation. The heavy reliance on interviews with minimal triangulation and the absence of longitudinal or ethnographic perspectives may also restrict the depth of understanding regarding evolving diabetes experiences over time and the fact that most data came from certain regions of Pakistan.

Implications

The findings of this review have several implications for practice, policy, and future research. Clinically, healthcare providers must recognize that socioeconomic and cultural factors heavily shape patients’ capacities to follow medical advice. Routine diabetes care should include culturally sensitive counseling, involve family members in decision-making, and prioritize clear, non-technical communication, especially for patients with limited health literacy.

For health policy there is a pressing need to address financial barriers to diabetes management. This includes subsidizing essential medications, establishing rural outreach clinics, and integrating community health workers trained in culturally appropriate diabetes education. Moreover, policy frameworks must acknowledge that diabetes management is not merely an individual responsibility but one embedded in social structures and power dynamics, particularly those related to gender.

From a research perspective future studies should explore underrepresented regions of Pakistan and adopt longitudinal designs to track how patients’ experiences evolve over time. Community-based participatory research could also better capture the voices of marginalized groups and support co-designed interventions. Lastly, studies comparing Urdu-language media messaging or traditional healing practices with biomedical guidance would provide valuable insights into the cultural ecology of diabetes knowledge.

These insights are crucial not only for clinicians and policymakers but also for caregivers, patient advocates, and health educators aiming to reduce the burden of diabetes through socially responsive care.

CONCLUSION

This systematic review highlighted that socioeconomic determinants, particularly poverty, gender norms, and health literacy, significantly shaped the experience and management of T2DM in Pakistan. Economic hardship, cultural expectations, and mistrust in biomedical care were consistent barriers across diverse populations. Addressing these factors requires culturally tailored, equity-focused healthcare interventions. Policymakers must prioritize structural reforms to improve access, education, and support systems for vulnerable groups. Future research should adopt participatory and longitudinal methods to deepen understanding and drive sustainable change.