Cultural aspects influencing diabetes care

What is culture?

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

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 patient’s culture; and adaptation of skills.

– American Medical Association

What is Cultural Competence?

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.

Projected Resident Population of the United States,

1998-2030

Source: Collins, Hall, and Neuhaus, U.S. Minority Health: A Chart Book, 1999

1998 2030

Mexicans 66.9% Central and South

Americans 14.3%

Puerto Ricans 8.6%

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.

The US Hispanic/Latino Population

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.

Men and Women, Age 45-74 Years

Harris et al. Diabetes. 1987;36:523.Flegal et al. Diabetes Care. 1991;14(suppl 3):628. Knowler et al. Diabetes Care. 1993;16(suppl 1):216. Fujimoto et al. Diabetes Res Clin Pract. 1991;13:119. Fujimoto et al. Diabetes. 1987;36:721.

% w

ith

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tes

0

10

20

30

40

50

PimaPuerto Rican

MexicanAmerican

AfricanAmerican

JapaneseAmerican

CubanAmerican

European

US Diabetes Prevalence US Diabetes Prevalence by Ethnic Group by Ethnic Group

Insulin Resistance andAbdominal Obesity

Socio-economic andCultural factors

Beta Cell Dysfunction

Thrifty Genes +

Inadequate Lifestyle

Other defectsIncretin function?

Type 2 Diabetes

Frequent Chronic Complications

Increased Mortality rates

Socio-economic andCultural factors Biological

Factors

Genes, Environment and Social/Cultural Factorsin the development and course of Diabetes in Latinos

Caballero AE. Current Opinion in Diabetes, Endocrinology and Obesity 2007. In press

0

1

2

3

4

5

6

7

8

Insulin Sensitivity Differs among Ethnic Groups in Healthy Subjects

n=34 n=9 n=18 n=16

6.87 5.04 4.17 3.74

Insu

lin S

ensi

tivi

ty In

dex

(m

ol•

L-1•

m-2•

min

-1•

pm

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• L

-1)†

Non-HispanicWhite

AfricanAmerican

AsianAmerican

MexicanAmerican

*P =0.002 vs. Caucasians. †Data are geometric means. Adapted from: Chiu KC, et al. Diabetes Care. 2000;23:1353-1358.

**

*

Age 23-26BMI – 23-26.5

• 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: Joslin’s Diabetes Mellitus. LW & W; 2005. 14th Ed. p 505-524.

Type 2 Diabetes and its Complications in Minorities

*Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Institute of Medicine. The National Academies Press. Washington, D.C. 2004.

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

7.3

7.4

7.5

7.6

7.7

7.8

7.9

8

8.1

8.2

NH White NH Black Hispanics

NH White

NH Black

Hispanics

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

%

A1c levels by ethnicity/race

NHANES 1999-2000

37.8 39.3

60.5

0

10

20

30

40

50

60

70

NH White NH Black Hispanics

NH White

NH Black

Hispanics

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

%

Percentage of participants with undiagnosed diabetes with an A1c above 7% by ethnicity/race

NHANES 1999-2000

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 Rosa’s 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.

The Patient:Medical, Socio-economic,

Cultural factors

The Health Care Provider:Lack of cultural competence

The Health Care System:Insufficient:

Culturally Oriented ProgramsProfessional education

Cultural diversityHealth care access

Time and support with patients

Caballero AE. Current Diabetes and Endocrinology Reports 2007. In press

The Basic Triad in Diabetes Care

U.S. Census Bureau. Health Insurance Coverage: 2000. September, 2001.

Harris MI. Diabetes Care. 2001;24:454-459.

0 20 40 60 80 100

Percentage with health insurance

Non-Latino White

African American

All Latino

U.S. Born Mexican American

Foreign Born Mexican American

Health Insurance Coverage

SPIRITUASPIRITUALL

MENTALMENTAL

PHYSICAPHYSICALL

EMOTIONALEMOTIONAL

A few definitions

• Ethnocentrism – The conviction that one’s own culture is superior

• Stereotyping – Mistaken assumption that everyone in a given culture is alike

• Generalization – Awareness of cultural norms

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

A true story:

64 y/o Hispanic womanPatient does not speak EnglishTreated for Hypertension

Received a prescription for :

Lisinopril 10 mg.Once/d.

Patient rushed to the ER due to severe hypotension

Language Barrier

• Bilingual/bicultural professional staff

• Interpreters

• Language skills training for existing staff

• Internal language bank

• Phone-based interpreter services

• Written translations

The National Alliance for Hispanic Health. A Primer for Cultural Proficiency: Towards Quality Health Services for Hispanics. 2001:16.

Photo credit: US Census Bureau.

Approaches to BridgingLanguage Barriers

05

1 01 52 02 53 03 54 04 55 0

T o tal U S W hite A fricanA m erican

L atino

U ninsured C on tin uous ly Insured

Collins, et al, Collins, et al, Diverse Communities, Common Concerns: Assessing Health Care Quality for Minority Diverse Communities, Common Concerns: Assessing Health Care Quality for Minority

AmericansAmericans, The Commonwealth Fund, March 2002., The Commonwealth Fund, March 2002.

Percentage of Adults Reporting Communication

Problems

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.

Elicit Factors

Negotiate Models

Awarenessof Culturaland Social

Factors

ImplementManagement

Strategies

Model for Cross-Cultural Care:A Patient-Based Approach

Tools and skills necessary to provide quality care to any patient we see, regardless of race, ethnicity, culture, class or language proficiency.

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

The ESFT Model

• Explanatory Model

• Social Barriers

• Fears/Concerns about Medication

• Therapeutic Contracting/Playback

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

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; 2:80-91

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

The Latino Diabetes Initiative

www.joslin.org/latino

The Latino Diabetes Initiative

PatientCare and Education

ResearchProvider

Education

CommunityOutreach

Visit us at www.joslin.org/latino

THANK YOU