CULTURALLY INFLUENCED BARRIERS IN CHRONIC DISEASE MANAGEMENT

Objectives• To review Ottawa’s cultural demographics• To highlight the impact of culture on several common

barriers faced in the management of chronic diseases • To review strategies to improve cross cultural care

Ottawa

Ottawa• Canadian immigrants tend to settle in big cities. • Compared to other cities, immigrants who settle in Ottawa

are typically more educated, earn higher wages, and have higher levels of employment.

• Ottawa receives the highest percentage of refugees and family-related immigration of any major Canadian centre.

• Recent immigrants (settled within 10 years) - make up 6.8% of the population.

• 18% of Ottawa’s population was born outside of Canada.

Ottawa• Third-largest West Indian community, and the second-

fastest growing after Toronto. • Fourth- largest African community, and the second-

fastest growing after Calgary. • Chinese community is the smallest of Canada's five

largest centres, but the country's fastest-growing. • Fourth-largest Middle Eastern community. • Our European community is the smallest of Canada's five

largest cities.

Ottawa

Ottawa

Ottawa

Ottawa

Chronic Disease Management• Long term management plans• Long term health impact• Lifestyle changes form part of treatment plan

Data Sources• Qualitative interview based studies• UK, United States• South Asian, Hispanic, Chinese and African American

populations

Barriers• Language• Finances• Diet• Belief Systems

Language

Language• Effects first generation immigrants more• Poor fluency in English has been identified by patients as

a major barrier to accessing and understanding basic health information

• Poor English also limited people’s willingness to travel beyond the immediate neighborhood

• Impact on food shopping, exercise, daily living

Language

Interpreters

Preferred professional translators over family• Power dynamic of having parents depend on children to

translate• Translation of medical terms• Same gender interpreter preferred

Language

•Not the only player

•Only providing advice in an Asian language was ineffective as an educational intervention to encourage dietary modification in South Asian patients with diabetes in Leicester.

Language• UK Study interview based study

• Caucasian British patients as well as South Asians suggested that information offered about their condition could be difficult to understand.

• White male, interview no. 20: ‘‘If they talked in layman’s I would, knowing what they say what these tablets are for. It’s when they start using the technical terms . . .’

Language

Health literacy is distinct from language fluency and refers to “an individual’s ability to read, understand, and use healthcare information to make effective healthcare decisions and follow instructions for treatment.”

Language• Low health literacy is more prevalent among marginalized

populations• A study of 408 patients with type 2 diabetes identified that 52% of

Hispanic patients versus 15% of non-Hispanic white patients had inadequate health literacy, as assessed with the English or Spanish version of the short-form Test of Functional Health Literacy in Adults.

• In a survey of 22 Hispanic patients with diabetes, 91% were unfamiliar with the term A1c.

• A crosssectional survey of 30 Puerto Rican adults with type 2 diabetes found that only 37% were able to identify a normal blood glucose level, and 33% could not identify long-term complications related to diabetes.

• Strong English skills in the immigrant population do not ensure strong health literacy

Language

How confident are you filling out medical forms by yourself?

How would you rate your ability to read medical forms?

Finances

Finances• Almost 60% of Hispanic adults with diabetes have an

annual income below $20,000 compared with approximately 28% of non-Hispanic whites with diabetes.

• In a survey of 44 low-income Mexican-Americans with type 2 diabetes, cost was identified as a reason some patients reduced their dosage or frequency of insulin therapy.

• Cost cited as a barrier to treatment in 24% of Hispanic patients with diabetes versus 8% of non-Hispanic whites.

Finances• General diabetic population in South Auckland surveyed.

• Covered by government programs• Annual out of pocket costs ranged from $191 - $329• 18-49% reported costs led to less blood glucose monitoring• 11-47% said finances impacted use of oral medications• 8-52% said that cost impacted insulin therapy

Finances

Finances

Diet

Diet• Diet specific concerns

• High fat content of some Indian curries• High sugar/calorie Indian desserts• Role of rice in Chinese cuisine• Role of balance in Chinese cuisine

Diet• Incorporation in to a way of life

• Travel• Visiting family• Shared meals

Diet• 45 African American patients through discussion groups:

• Four areas impacting diet – habitual (meal plans lacking in taste), economic (cost of low fat, low sugar, fresh items), social (lack of family support, family pressure to cook preferred meals), conceptual (understanding food labels).

Diet• Similar barriers in South Asian and Somali populations• Added cost of culturally comfortable food (ie. Bangladeshi

vegetables)

Belief Systems

Belief Systems

• Disease states are an action by God• Individuals have little control over the course

Belief Systems

Social stigma of illnessEffects diet in group settingsDeterrent to insulin treatment

Belief Systems

Infancy of western medicineConcerns regarding side effectsBeliefs about efficacy

Culturally Oriented Clinical Encounter

Culturally Oriented Clinical Encounter

Community OutreachCulturally sensitive and relevant programsLocationTimingProgram developmentPresentersParticipants

Questions

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