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Dr Hasina Visram: Cultural Barriers to Diabetes Management
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Dr Hasina Visram: Cultural Barriers to Diabetes Management


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Dr. Hasina Visram, MD, MSc Fellow in endocrinology and metabolism, University of Ottawa

Dr. Hasina Visram, MD, MSc Fellow in endocrinology and metabolism, University of Ottawa

Published in: Health & Medicine

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  • 1. Dr. Hasina Visram, MD, MSc
  • 2.  To review Ottawa’s cultural demographics To highlight the impact of culture on diabetesmanagement To review strategies to improve cross culturaldiabetes care
  • 3.  Canadian immigrants tend to settle in big cities. Compared to other cities, immigrants who settle inOttawa are typically more educated, earn higherwages, and have higher levels of employment. Ottawa receives the highest percentage of refugeesand family-related immigration of any majorCanadian centre. Recent immigrants (settled within 10 years) - makeup 6.8% of the population. 18% of Ottawa’s population was born outside ofCanada.
  • 4.  Third-largest West Indian community, andthe second-fastest growing after Toronto. Fourth- largest African community, and thesecond-fastest growing after Calgary. Chinese community is the smallest ofCanadas five largest centres, but thecountrys fastest-growing. Fourth-largest Middle Eastern community. Our European community is the smallest ofCanadas five largest cities.
  • 5.  Qualitative interview based studies UK, United States South Asian, Hispanic, Chinese and AfricanAmerican populations
  • 6.  Language Finances Diet Belief Systems
  • 7.  Effects first generation immigrants more Poor fluency in English has been identified bypatients as a major barrier to accessing andunderstanding basic health information Poor English also limited people’s willingness totravel beyond the immediate neighborhood Impact on food shopping, exercise, daily living
  • 8. InterpretersPreferred professional translators over family Power dynamic of having parents depend onchildren to translate Translation of medical terms Same gender interpreter preferred
  • 9.  Not the only player Only providing advice in an Asianlanguage was ineffective as aneducational intervention toencourage dietary modification inSouth Asian patients with diabetesin Leicester.
  • 10.  UK Study interview based study Caucasian British patients as well as SouthAsians suggested that information offeredabout their condition could be difficult tounderstand. White male, interview no. 20: ‘‘If they talked in layman’s Iwould, knowing what they say what these tablets are for.It’s when they start using the technical terms . . .’
  • 11. Health literacy is distinct from language fluencyand refers to “an individual’s ability to read,understand, and use healthcare information tomake effective healthcare decisions and followinstructions for treatment.”
  • 12.  Low health literacy is more prevalent amongmarginalized populations◦ A study of 408 patients with type 2 diabetes identified that52% of Hispanic patients versus 15% of non-Hispanic whitepatients had inadequate health literacy, as assessed withthe English or Spanish version of the short-form Test ofFunctional Health Literacy in Adults.◦ In a survey of 22 Hispanic patients with diabetes, 91% wereunfamiliar with the term A1c.◦ A crosssectional survey of 30 Puerto Rican adults with type2 diabetes found that only 37% were able to identify anormal blood glucose level, and 33% could not identifylong-term complications related to diabetes. Strong English skills in the immigrant populationdo not ensure strong health literacy
  • 13. How confident are you filling out medical forms by yourself?How would you rate your ability to read medical forms?
  • 14.  Almost 60% of Hispanic adults with diabetes havean annual income below $20,000 compared withapproximately 28% of non-Hispanic whites withdiabetes. In a survey of 44 low-income Mexican-Americanswith type 2 diabetes, cost was identified as areason some patients reduced their dosage orfrequency of insulin therapy. Cost cited as a barrier to treatment in 24% ofHispanic patients with diabetes versus 8% of non-Hispanic whites.
  • 15.  General diabetic population in SouthAuckland surveyed.◦ Covered by government programs◦ Annual out of pocket costs ranged from $191 -$329◦ 18-49% reported costs led to less blood glucosemonitoring◦ 11-47% said finances impacted use of oralmedications◦ 8-52% said that cost impacted insulin therapy
  • 16.  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
  • 17.  Incorporation in to a way of life◦ Travel◦ Visiting family◦ Shared meals
  • 18.  45 African American patients throughdiscussion groups:◦ Four areas impacting diet – habitual (meal planslacking in taste), economic (cost of low fat, lowsugar, fresh items), social (lack of family support,family pressure to cook preferred meals),conceptual (understanding food labels).
  • 19.  Similar barriers in South Asian and Somalipopulations Added cost of culturally comfortable food (ie.Bangladeshi vegetables)
  • 20.  Disease states are an action by God◦ Individuals have little control over the course
  • 21. Social stigma of illness Effects diet in group settings Deterrent to insulin treatment
  • 22. Infancy of western medicine Concerns regarding side effects Beliefs about efficacy
  • 23. Culturally Oriented Clinical Encounter
  • 24. Culturally sensitive and relevant programs Location Timing Program development Presenters Participants
  • 25. 1. Caballero A. Cultural Competence in Diabetes Mellitus Care: An Urgent Need. Insulin 2007; 2(2): 80-91.2. Campos CMPH. Addressing Cultural Barriers to the Successful Use of Insulin in Hispanics with Type 2 Diabetes. South Med J 2007;100:812-20.3. Chesla CADNSC, F.A.A.N., Chun KMPHD, Kwan CMLPHD. Cultural and Family Challenges to Managing Type 2 Diabetes in Immigrant ChineseAmericans. Diabetes Care 2009;32:1812-6.4. Dutton GR1, Johnson J, Whitehead D, Bodenlos JS1, Brantley PJP. Barriers to Physical Activity Among Predominantly Low-Income African-American Patients With Type 2 Diabetes. Diabetes Care 2005;28:1209-10.5. Grace C, Begum R, Subhani S, Kopelman P, Greenhalgh T. Prevention of type 2 diabetes in British Bangladeshis: qualitative study ofcommunity, religious, and professional perspectives. BMJ 2008;337:1094-100.6. Ho E, James J. Cultural Barriers to Initiating Insulin Therapy in Chinese People With Type 2 Diabetes Living in Canada. Canadian Journal ofDiabetes. 2006;30(4):390-396.7. Karter A, Stevens M, Herman W, Ettner S, Marrero D, Safford M, Engelgau M, Curb J, Brown A. Out-of-Pocket Costs and Diabetes PreventiveServices. Diabetes Care 2003;26:2294–2299.8. Law M, Cheng L, Dhalla I, Heard D, Morgan S. The effect of cost on adherence to prescription medications in Canada. CMAJ 2012.DOI:10.1503/cmaj.1112709. Lawton J, Ahmad N, Hanna L, Douglas M, Hallowell N. I cant do any serious exercise: barriers to physical activity amongst people ofPakistani and Indian origin with Type 2 diabetes. Health Educ Res 2006;21:43-54.10. Ngo-Metzger Q, Massagli MP, Clarridge BR, et al. Linguistic and cultural barriers to care. Journal of General Internal Medicine 2003;18:44-52.11. Powers BJMHS, Trinh JV, Bosworth HB. Can This Patient Read and Understand Written Health Information? JAMA 2010;304:76-84.12. Sriskantharajah J, Kai J. Promoting physical activity among South Asian women with coronary heart disease and diabetes: what might help?.Fam Pract 2007;24:71-6.13. Stone M, Pound E, Pancholi A, Farooqi A, Khunti K. Empowering patients with diabetes: a qualitative primary care study focusing on SouthAsians in Leicester, UK. Fam Pract 2005;22:647-52.14. Vijan S, Stuart NS, Fitzgerald JT, et al. Barriers to following dietary recommendations in Type 2 diabetes. Diabetic Med 2005;22:32-8.15. Wallin, AnneMarie L, Monica A, Gerd RNT. Diabetes: a cross-cultural interview study of immigrants from Somalia. J Clin Nurs2007;16:305-14.