Cultural aspects influencing diabetes care. What is culture? The beliefs and attitudes that are...
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Transcript of Cultural aspects influencing diabetes care. What is culture? The beliefs and attitudes that are...
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
dia
be
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
ol-1
• 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
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