“When I Don’t Have Money, I Don’t Eat”: A Critical Hermeneutic Study of Diabetes in Liberia





Diabetes, Critical Hermeneutics, Photovoice, Lived Experiences, Liberia


Diabetes is a growing public health concern in Liberia, where an estimated 2.1% of the population live with the disease. The challenges with diabetes in Liberia are enormous. Diabetes places immense socioeconomic pressure on individuals and their families and burdens an already overstretched health care system still recovering from the destructive effects of the 14-year civil war. While efforts towards rebuilding the health care system in Liberia are ongoing, people with diabetes experience significant challenges accessing social, economic, and health-care resources to manage their illness. Purpose: The goal of this critical hermeneutic study was to explore what is it like to live with diabetes in Liberia. Methods: Through purposeful sampling, 10 adults with diabetes were recruited from a publicly funded hospital in Monrovia, Liberia. Data were collected using a photovoice method, wherein participants photographed their everyday experiences of living with diabetes. Results: We identified three themes that answered the question of what is it like to live with diabetes in Liberia: living with diabetes means living with 1) food insecurity, 2) trying to access a health care system that was not built to respond to diabetes, and 3) using faith to cope and foster hope. Conclusion: The experiences of people living with diabetes in Liberia are under-researched, pointing to a gap in knowledge. The findings from this study address this gap in the literature by providing a clearer picture of the impact of diabetes on individuals and families. We provide tangible recommendations to local governments and policy makers on interventions that may improve health outcomes and quality of life for people living with diabetes in Liberia.


Abdoli, S., Ashktorab, T., Ahmadi, F., Parvizy, S., & Dunning, T. (2011). Religion, faith and the empowerment process: Stories of Iranian people with diabetes. International Journal of Nursing Practice, 17(3), 289-298. https://doi.org/10.1111/j.1440-172X.2011.01937.x

Adler, A. J., Trujillo, C., Schwartz, L., Drown, L., Pierre, J., Noble, C., Allison, T., Cook, R., Randolph, C., & Bukhman, G. (2021). Experience of living with type 1 diabetes in a low-income country: A qualitative study from Liberia. BMJ Open, 11(10), e049738. https://doi.org/10.1136/bmjopen-2021-049738

Alessi, J., & Yankiv, M. (2022). War in Ukraine and barriers to diabetes care. Lancet, 399(10334), 1465-1466. https://doi.org/10.1016/s0140-6736(22)00480-9

Ameyaw Korsah, K., & Ameyaw Domfeh, K. (2020). The realities of religious coping experiences of patients with diabetes mellitus: Implications for policy formulation in Ghana. International Journal of Africa Nursing Sciences, 13, 100245. https://doi.org/https://doi.org/10.1016/j.ijans.2020.100245

Atun, R., Davies, J. I., Gale, E. A. M., Bärnighausen, T., Beran, D., Kengne, A. P., Levitt, N. S., Mangugu, F. W., Nyirenda, M. J., Ogle, G. D., Ramaiya, K., Sewankambo, N. K., Sobngwi, E., Tesfaye, S., Yudkin, J. S., Basu, S., Bommer, C., Heesemann, E., Manne-Goehler, J., …Werfalli, M. (2017). Diabetes in sub-Saharan Africa: From clinical care to health policy. The Lancet Diabetes & Endocrinology, 5(8), 622-667. https://doi.org/10.1016/S2213-8587(17)30181-X

Capous-Desyllas, M., & Bromfield, N. F. (2018). Using an arts-informed eclectic approach to photovoice data analysis. International Journal of Qualitative Methods, 17(1). https://doi.org/10.1177/1609406917752189

Central Intelligence Agency. (2021, April 21). Liberia. https://www.cia.gov/the-world-factbook/countries/liberia/

Chatterjee, S., Khunti, K., & Davies, M. J. (2017). Type 2 diabetes. The Lancet, 389, 2239-2251. https://doi.org/doi:https://doi.org/10.1016/S0140-6736(17)30058-2

Ewald, W. (1985). Portraits and dreams: photographs and stories by children of the Appalachians Writes and Readers Publishing.

Fall, I. S. (2019). Ebola virus disease outbreak in Liberia: Application of lessons learnt to disease surveillance and control. The Pan African Medical Journal, 33(Suppl 2), 1. https://doi.org/10.11604/pamj.supp.2019.33.2.19074

Frankenberg, R. (1988). White women, race matters: The social construction of whiteness University of California.

Freire, P. (1970). Pedagogy of the oppressed. Herder and Herder.

Gadamer, H. G. (1990). Reply to my critics. In G. O. A. Schrift (Ed.), The hermeneutic tradition: From Ast to Ricouer. State University of New York Press.

Given, L. M. (2012). Critical theory. In The SAGE encyclopedia of research methods https://doi.org/doi: http://dx.doi.org/10.4135/9781412963909

Gucciardi, E., Vahabi, M., Norris, N., Del Monte, J. P., & Farnum, C. (2014). The Intersection between food insecurity and diabetes: A review. Current Nutrition Reports, 3(4), 324-332. https://doi.org/10.1007/s13668-014-0104-4

Habermas, J. (1984). The theory of communicative action. Beacon Press.

Hubbard, J. (1991). Shooting back: A photographic view of life by homeless children. Chronicle Books.

International Diabetes Federation. (2021). IDF diabetes atlas 10 edition. https://diabetesatlas.org/idfawp/resource-files/2021/07/IDF_Atlas_10th_Edition_2021.pdf

Jacobson, D., & Mustafa, N. (2019). Social identity map: A reflexivity tool for practicing explicit positionality in critical qualitative research. International Journal of Qualitative Methods, 18, 1–12. https://doi.org/10.1177/1609406919870075

Khan, M. A. B., Hashim, M. J., King, J. K., Govender, R. D., Mustafa, H., & Al Kaabi, J. (2020). Epidemiology of type 2 diabetes - Global burden of disease and forecasted trends. Journal of Epidemiology and Global Health, 10(1), 107-111. https://doi.org/10.2991/jegh.k.191028.001

Khan, Y., Albache, N., Almasri, I., & Gabbay, R. A. (2019, Aug). The management of diabetes in conflict ettings: Focus on the Syrian crisis. Diabetes Spectrum, 32(3), 264-269. https://doi.org/10.2337/ds18-0070

Lee, P. T., Kruse, G. R., Chan, B. T., Massaquoi, M. B. F., Panjabi, R. R., Dahn, B. T., & Gwenigale, W. T. (2011). An analysis of Liberia's 2007 national health policy: Lessons for health systems strengthening and chronic disease care in poor, post-conflict countries. Globalization and Health, 7(1), 37. https://doi.org/10.1186/1744-8603-7-37

Liu, J., Ren, Z.-H., Qiang, H., Wu, J., Shen, M., Zhang, L., & Lyu, J. (2020). Trends in the incidence of diabetes mellitus: results from the Global Burden of Disease Study 2017 and implications for diabetes mellitus prevention. BMC Public Health, 20(1), 1415. https://doi.org/10.1186/s12889-020-09502-x

Ministry of Health and Social Welfare Republic of Liberia. (2011). Liberia chronic disease risk factor surveillance. https://www.who.int/ncds/surveillance/steps/Liberia_2011_STEPS_Report.pdf

Ministry of Health Republic of Liberia. (2016). National Non-Communicable Diseases Policy and Strategic Plan (2017-2021). https://extranet.who.int/nutrition/gina/sites/default/filesstore/LBR%202017%20NCD%20Policy.pdf

NCDI Poverty Network. (2018). The Liberia noncommunicable diseases & injuries (NCDI) poverty commission report. https://static1.squarespace.com/static/55d4de6de4b011a1673a40a6/t/5be085804d7a9c6daef842ea/1541440897071/Liberia+NCDI+Poverty+Commission+Report+FINAL.pdf

Nsimbo, K. B. A., Erumeda, N., & Pretorius, D. (2021). Food insecurity and its impact on glycaemic control in diabetic patients attending Jabulani Dumani community health centre, Gauteng province, South Africa. African Journal of Primary Health Care & Family Medicine, 13, 1-6. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S2071-29362021000100029&nrm=iso

Onyishi, C. N., Eseadi, C., Ilechukwu, L. C., Okoro, K. N., Okolie, C. N., Egbule, E., & Asogwa, E. (2022). Potential influences of religiosity and religious coping strategies on people with diabetes. World Journal of Clinical Cases, 10(25), 8816-8826. https://doi.org/10.12998/wjcc.v10.i25.8816

Ricoeur, P. (1981). Hermeneutics and human science: Essays on language, action and interpretation (John Thompson Translation). Cambridge University Press.

Robbiati, C., Armando, A., da Conceição, N., Putoto, G., & Cavallin, F. (2022). Association between diabetes and food insecurity in an urban setting in Angola: A case–control study. Scientific Reports, 12(1), 1084. https://doi.org/10.1038/s41598-022-04888-7

Smith, D. E. (1897). The everyday world as problematic. Northeastern University Press. https://public.ebookcentral.proquest.com/choice/publicfullrecord.aspx?p=1085088

Song, K., & Lee, A. (2021). Factors influencing the effective management of diabetes during humanitarian crises in low- and middle-income countries: a systematic review. Public Health (London), 199, 110-117. https://doi.org/10.1016/j.puhe.2021.08.020

Tracy, S. J. (2010). Qualitative quality: Eight “big-tent” criteria for cxcellent qualitative research. Qualitative Inquiry, 16(10), 837-851. https://doi.org/10.1177/1077800410383121

van Manen, M. (2014). Phenomenology of practice?: Meaning-giving methods in phenomenological research and writing. Left Coast Press.

VanLeeuwen, C. A., Guo-Brennan, L., & Weeks, L. E. (2017). Conducting hermeneutic research in international settings: Philosophical, practical and ethical considerations. Journal of Applied Hermeneutics, Article 7.

anLeeuwen, C. A., Weeks, L. E., & Guo-Brennan, L. (2019). Critical pedagogy of discomfort in community-based learning: Kenyan students' experiences. Comparative and International Education, 48(1).

Wang, C., & Burris, M. A. (1997). Photovoice: Concept, methodology, and use for participatory needs assessment. Health Education & Behavior 24(3), 369-387. https://doi.org/10.1177/109019819702400309

World Health Organization. (2016). Diabetes country profile. https://www.who.int/diabetes/country-profiles/lbr_en.pdf

Zheng, Y., Ley, S. H., & Hu, F. B. (2018). Global aetiology and epidemiology of type 2 diabetes mellitus and its complications. Nature Reviews Endocrinology, 14(2), 88-98. https://doi.org/10.1038/nrendo.2017.151

Zimmermann, M., Bunn, C., Namadingo, H., Gray, C. M., & Lwanda, J. (2018). Experiences of type 2 diabetes in sub-Saharan Africa: a scoping review. Global Health Research and Policy, 3(1), 25. https://doi.org/10.1186/s41256-018-0082-y

Zimmet, P. Z. (2017). Diabetes and its drivers: The largest epidemic in human history? Clinical Diabetes and Endocrinology, 3(1). https://doi.org/10.1186/s40842-016-0039-3




How to Cite

Bleah, P., Rosemary Wilson, Danielle Macdonald, & Pilar Camargo-Plazas. (2023). “When I Don’t Have Money, I Don’t Eat”: A Critical Hermeneutic Study of Diabetes in Liberia. New Trends in Qualitative Research, 16, e785. https://doi.org/10.36367/ntqr.16.2023.e785