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Culturally Competent Care of Diabetes

Of all the forms of inequality, injustice in health

care is the most shocking and inhuman(e. — Dr. Martin Luther King, Jr.

Objectives • Review demographic and epidemiologic

statistics relating to cultural diversity and health disparities in the United States, with a focus on diabetes

• Define the concept and rationale for culturally competent health care

• Identify strategies and resources that can facilitate the delivery of culturally and linguistically appropriate services

Changing Demographics

0

10

20

30

40

50

60

70

80

1990 1996 2005 2030

White

African American

Hispanic

Asian/Pacific Islander

American Indian/Alaskan Native

Diabetes Fast Facts • 29.1 million people or 9.3% of

the U.S. population have diabetes.

• Diagnosed: 21.0 million people • Undiagnosed: 8.1 million

people (27.8% of people with diabetes are undiagnosed).

Age-adjusted* percentage of people aged 20 years or older with diagnosed diabetes, by race/ethnicity U.S., 2010–2012

*Based on the 2000 U.S. standard population. Source: 2010–2012 National Health Interview Survey and 2012 Indian Health Service’s National Patient Information Reporting System.

Rate of new cases of type 1 and type 2 diabetes among people younger than 20 years, by age and race/ethnicity, 2008–2009

Source: SEARCH for Diabetes in Youth Study. NHW=non-Hispanic whites; NHB=non-Hispanic blacks; H=Hispanics; API=Asians/Pacific Islanders; AIAN=American Indians/Alaska Natives. *The American Indian/Alaska Native (AI/AN) youth who participated in the SEARCH study are not representative of all AI/AN youth in the United States. Thus, these rates cannot be generalized to all AI/AN youth nationwide.

<10 years 10–19 years

Cost of Diabetes • $245 billion: Total costs of diagnosed diabetes in

the United States in 2012 • $176 billion for direct medical costs • $69 billion in reduced productivity After adjusting for population age and sex, average medical expenditures among people with diagnosed diabetes were 2.3 times higher than what expenditures would be in the absence of diabetes. See more at: http://www.diabetes.org/diabetes-basics/statistics/#sthash.S4w1r5F1.dpuf

What is Cultural Competence? It is the demonstrated awareness and integration of three population-specific issues: health-related beliefs and cultural values, disease incidence and prevalence, and treatment efficacy. But perhaps the most significant aspect of this concept is the inclusion and integration of three areas that are usually considered separately when they are considered at all.

Why is it important? It has been estimated that the combined cost of health disparities and subsequent deaths due to inadequate and/or inequitable care is $1.24 trillion. Culturally and linguistically appropriate services are increasingly recognized as effective in improving the quality of care and services. By providing a structure to implement culturally and linguistically appropriate services, the enhanced National CLAS Standards will improve an organization’s ability to address health care disparities.

The Evidence shows results

Culturally sensitive diabetes education to promote lifestyle changes can work with: • Mexican Americans • African Americans • South Asians from India • Brazilians • Arabs • Cambodians

What does culture impact?

• Communication • Language • Art • Religion • Diet • Environment • Customs • Family role • Illness & Death

• Preventative Medicine • Gender role • Social Groups • Sexual Orientation • Physical Capacity • Mental status Culture may change.

Cultural Competency?

• It begins with an honest desire to not allow bias to keep us from treating each patient with respect

• It continues with learning to evaluate our own level of cultural competence and it must be an ongoing effort to provide better health care.

Benefits

• Reduced health disparities • Improved health communications • Improved dietary choices • Improved Glycemic Control • Improved Self-Management of Diabetes • Potential prevention of Diabetes type 2

No Stereotyping

• Culture is expressed through the individual • Not all members of a cultural group will

believe the same thing • Variation within cultural groups.

Preferred Foods Based on Country/Area of Origin

Mexico

Corn, beans, chiles, hearty stews, moles,

chocolate

Central America

Rice, beans, corn, chiles, chocolate

Rice, beans, starchy root Vegetables,

coconut, adobo sofrito

Caribbean

South America

Potato, corn, rice, Annato,

coriander, onions,

Beef

Culture & Health Communication

• Patients may choose not to seek needed services • Providers may make errors in diagnosis because of

miscommunication • Patients may not follow medical advice for lack of

trust or understanding • Providers may order fewer (or more) tests because

they may not understand or believe the patient’s description of symptoms

HRSA

Basic Strategies • Speak clearly and slowly without raising your

voice, avoiding slang, jargon, humor, idioms. • Use Mrs., Miss, Mr. Avoid first names, which may

be considered discourteous in some cultures. • Avoid gestures – they may have a negative

connotation. • Many carry or wear religious symbols – Sacred

threads worn by Hindus, native Americans-medicine bundles. DO not touch them.

Cultural Competence Framework

Concepts • Communication of cultural understanding and respect

is essential for establishing rapport and confidence • Culture-related stresses and tensions can induce illness • Culture-related behaviors (e.g. religion, diet) affect a

patient’s acceptance of and adherence to prescribed therapy

• Nonverbal and verbal communication may differ from culture to culture

Framework (Continued)

Skills (specific for each culture represented and include the following) • Communicate an understanding of the patient’s culture • Elicit patient’s understanding of his or her culture • Recognize culture-related health problems • Negotiate a culturally relevant care plan with patient as

partner

Framework, Continued Attitudes • Recognize the importance of the patient’s cultural

background and environment when constructing an approach to an illness

• Acknowledge the patient’s role as an active participant in his or her care

• Accept responsibility for the patient who has few support systems; avoid the “what can I do?” attitude when facing a patient in abject poverty or with language barriers

Framework, continued Knowledge (specific for each culture represented and include the following)

• Common dietary habits, foods, and their nutritional

components • Predominant cultural values, health practices, traditional

health beliefs • Family structure—patriarchal vs. matriarchal; nuclear vs.

extended; role of individual members • Effect of religion on health beliefs and practices • Customs and attitudes surrounding death

Culturally Competent Care

• Treat people uniquely • Listen respectfully • Gender sensitivity • Educate yourself

• Know your comfort level • Establish trust • Be aware of different

cultures

The 4 C’s • What do you call your problem? • What do you think caused your problem? • What have you done to cope with your

problem? • What concerns do you have about your

problem, about my recommendations?

Kleinman’s 8 Questions 1. What do you think caused the problem? 2. Why do you think it started when it did? 3. What does your sickness do and how does it work? 4. How severe is your sickness/ How long do you expect

it to last? 5. What problems has the sickness caused you? 6. What do you fear about your sickness? 7. What type of treatment do you think you should

receive? 8. What are the most important results you hope to

achieve from this treatment?

Guidelines for Health Practitioners: LEARN

Listen with sympathy and understanding to the patient’s perception of the problem. Explain your perceptions of the problem. Acknowledge & discuss the differences and similarities. Recommend treatment. Negotiate agreement.

Benefits

• Greater patient compliance • Fewer harmful drug interactions • More appropriate testing and screenings • Increased likelihood that minorities will seek

health care • More successful patient education

Developing Cultural Competence

Attitude/skill-centered approach • Recognize your own biases; understand how

race, ethnicity, gender, etc. play a role in healthcare delivery and perception of health care. https://implicit.harvard.edu/implicit/

• Acquire and apply culturally competent skills.

Resources

• www.ThinkCulturalHealth.hhs.gov • http://www.agingwithdignity.org/ • http://www.state.gov/misc/list/index.htm • http://www.un.org/en/members/index.shtml • http://culturalmeded.stanford.edu/teaching/c

ulturalcompetency.html • http://diversityrx.org/topic-areas/culturally-

competent-care

Thank you Gracias

Obrigada Merci

Dank U 谢谢

ありがとう شكرا

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