Cultural aspects influencing diabetes care

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Cultural aspects influencing diabetes care
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What is culture?

• The beliefs and attitudes that are learned and
  shared by members of a group

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What is Cultural Competence?

• The knowledge and interpersonal skills that allow
  providers to understand, appreciate, and work
  with individuals from cultures other than their
  own.  It involves an awareness and acceptance of
  cultural differences self-awareness knowledge
  of patients culture and adaptation of skills.
• American Medical Association

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Case

• Rosa is a 58 y/o Hispanic or Latino woman who has
  lived in the US for 20 years. She is married.
  Her husband is also Latino. They have two sons
  and two daughters and 6 grandchildren. She is a
  housewife. Her husband is a construction worker.
  She completed 6 years of school education. She
  speaks very little English.

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Projected Resident Population of the United
States, 1998-2030
1998
2030
Source Collins, Hall, and Neuhaus, U.S. Minority
Health A Chart Book, 1999
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The US Hispanic/Latino Population
Puerto Ricans 8.6
Mexicans 66.9
Central and South Americans 14.3
Cubans 3.7
Others 6.5
US Census Bureau. The Hispanic Population in the
United States March 2002. Available at
www.census.gov. Accessed June 28, 2004.
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Case

• Rosa has had no significant past medical history,
  except for continuous weight gain over the last
  20 years. Her father and maternal grandmother
  died of diabetes related complications. Her
  husband, children and grandchildren are
  overweight. Her meals are usually rich in CHOs
  and fats and does not exercise. Since she has
  felt well and has no health insurance, she has
  not had a medical visit in many years. During
  the last 6 months, she has felt very tired, with
  increasing polyuria and polydipsia.

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US Diabetes Prevalence by Ethnic Group
Men and Women, Age 45-74 Years
50
40
30
with diabetes
20
10
0
Pima
Puerto Rican
Mexican American
African American
Japanese American
Cuban American
European
Harris et al. Diabetes. 198736523. Flegal et
al. Diabetes Care. 199114(suppl 3)628. Knowler
et al. Diabetes Care. 199316(suppl 1)216.
Fujimoto et al. Diabetes Res Clin Pract.
199113119. Fujimoto et al. Diabetes.
198736721.
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Genes, Environment and Social/Cultural Factors in
the development and course of Diabetes in Latinos
Socio-economic and Cultural factors
Thrifty Genes
Inadequate Lifestyle
Insulin Resistance and Abdominal Obesity
Beta Cell Dysfunction
Other defects Incretin function?
Type 2 Diabetes
Socio-economic and Cultural factors
Biological Factors
Frequent Chronic Complications
Increased Mortality rates
Caballero AE. Current Opinion in Diabetes,
Endocrinology and Obesity 2007. In press
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Insulin Sensitivity Differs among Ethnic Groups
in Healthy Subjects
Age 23-26 BMI 23-26.5
n34
n9
n18
n16



Insulin Sensitivity Index (mmol L-1 m-2
min-1 pmol-1 L-1)
4.17
5.04
6.87
3.74
Mexican American
Non-Hispanic White
African American
Asian American
P 0.002 vs. Caucasians. Data are geometric
means.
Adapted from Chiu KC, et al. Diabetes Care.
2000231353-1358.
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Type 2 Diabetes and its Complications in
Minorities

• Disparate and Disproportionate prevalence of
  longterm complications of type 2 diabetes in
  minorities vs Whites
• lower leg amputations 2-4x
• retinopathy and blindness 2-4x
• stroke 2x
• ESRD 4-6x

Caballero AE. Diabetes in minority populations.
In Joslins Diabetes Mellitus. LW W 2005.
14th Ed. p 505-524.
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Unequal Treatment Confronting Racial and Ethnic
Disparities in Health Care. Institute of
Medicine. The National Academies Press.
Washington, D.C. 2004.
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Unequal Treatment major findings

• Racial/ethnic disparities consistently found
  across a wide range of
• health care settings (managed care,
  public/private hospitals, teaching/community,
  etc.)
• disease areas, and
• clinical services,
• even when various confounders are controlled for
  (i.e. socioeconomic status, insurance, stage of
  presentation, comorbidities)

www.nap.edu
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A1c levels by ethnicity/race NHANES 1999-2000

Boltri JM, et al. Ethn Dis 2005 15 (4) 562-7
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Percentage of participants with undiagnosed
diabetes with an A1c above 7 by
ethnicity/race NHANES 1999-2000

Boltri JM, et al. Ethn Dis 2005 15 (4) 562-7
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Case

• Rosa is followed by a non-Spanish speaking
  physician. Most of the time, a professional
  interpreter is present in the clinical encounter,
  but sometimes, it is one of Rosas children who
  helps with translation.
• Rosa usually forgets to take her oral medications
  well and has not made significant changes in her
  meal plan and physical activity.
• She frequently receives patient education
  brochures in Spanish. Most of these materials
  have been translated from an original English
  version.

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The Basic Triad in Diabetes Care
The Patient Medical, Socio-economic, Cultural
factors
The Health Care Provider Lack of cultural
competence
The Health Care System Insufficient Culturally
Oriented Programs Professional education Cultural
diversity Health care access Time and support
with patients
Caballero AE. Current Diabetes and Endocrinology
Reports 2007. In press
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Health Insurance Coverage
Non-Latino White African American All
Latino U.S. Born Mexican
American Foreign Born Mexican American
0 20 40 60
80 100 Percentage with health
insurance
U.S. Census Bureau. Health Insurance Coverage
2000. September, 2001. Harris MI. Diabetes Care.
200124454-459.
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MENTAL
SPIRITUAL
PHYSICAL
EMOTIONAL
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A few definitions

• Ethnocentrism The conviction that ones own
  culture is superior
• Stereotyping Mistaken assumption that everyone
  in a given culture is alike
• Generalization Awareness of cultural norms

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47 Million U.S. residents speak a non-English
language at home

• 18 of U.S. population
• Up from 14 in 1990
• 1/2 have difficulty speaking English

United States Census 2000
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Language Barrier

• A true story
• 64 y/o Hispanic woman
• Patient does not speak English
• Treated for Hypertension
• Received a prescription for
• Lisinopril 10 mg.
• Once/d.
• Patient rushed to the ER due to severe
  hypotension

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Approaches to BridgingLanguage Barriers

• Bilingual/bicultural professional staff
• Interpreters
• Language skills training for existing staff
• Internal language bank
• Phone-based interpreter services
• Written translations

Photo credit US Census Bureau.
The National Alliance for Hispanic Health. A
Primer for Cultural Proficiency Towards Quality
Health Services for Hispanics. 200116.
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Percentage of Adults Reporting Communication
Problems
Collins, et al, Diverse Communities, Common
Concerns Assessing Health Care Quality for
Minority Americans, The Commonwealth Fund, March
2002.
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51 of Americans have limited functional health
literacy

• Health literacy is the ability to
• understand basic medical terms about symptoms and
  illness
• follow directions for diagnostic procedures and
  therapies
• Engage in a dialogue about medical issues
• Highest number with low literacy are white and
  many are elderly

Health Literacy A Prescription to End
Confusion. Institute of Medicine. The National
Academies Press. Washington, D.C. 2004.
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Cultural Competence

• Purnells Model
• Person, Family, Community, Society
• Unconsciously incompetent
• Consciously incompetent
• Consciously competent
• Unconsciously competent

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Model for Cross-Cultural Care A Patient-Based
Approach
Elicit Factors
Negotiate Models
Awareness of Cultural and Social Factors
Implement Management Strategies
Tools and skills necessary to provide quality
care to any patient we see, regardless of race,
ethnicity, culture, class or language proficiency.
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Models

• LEARN Listen, Explain, Acknowledge, Recommend,
  Negotiate
• BATHE - Background, Affect, Trouble, Handling,
  Empathy
• ETHNIC Explain, Treatment, Healers,
  Negotiation, Intervention, Collaboration
• ESFT Explanatory model, Social risk, Fears,
  Treatment

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The ESFT Model

• Explanatory Model
• Social Barriers
• Fears/Concerns about Medication
• Therapeutic Contracting/Playback

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Main factors that may influence diabetes
development and care in Culturally Diverse
Populations

• Acculturation
• Body Image
• Cultural Competence
• Depression
• Educational Level
• Fears
• General Family Integration and Support
• Health Literacy
• Individual and Social Interaction
• Judgment about disease

Caballero AE. Insulin 2007 2 80-91
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Main factors that may influence diabetes
development and care in Culturally Diverse
Populations

• Knowledge about the disease
• Language
• Myths
• Nutritional Preferences
• Other forms of Medicine ( Alternative )
• Physical Activity Preferences
• Quality of Life
• Religion
• Socio-economic status

Caballero AE. Insulin 2007 280-91
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The Latino Diabetes Initiative

• The overall goal of the Initiative is to improve
  
• the lives of Latinos affected by diabetes or
• at risk for the disease through culturally
  oriented patient care, education and research

www.joslin.org/latino
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The Latino Diabetes Initiative
Visit us at www.joslin.org/latino
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