Dr Hasina Visram: Cultural Barriers to Diabetes Management
Dr. Hasina Visram, MD, MSc
To review Ottawa’s cultural demographics To highlight the impact of culture on diabetesmanagement To review strategies to improve cross culturaldiabetes care
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.
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.
Qualitative interview based studies UK, United States South Asian, Hispanic, Chinese and AfricanAmerican populations
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
InterpretersPreferred professional translators over family Power dynamic of having parents depend onchildren to translate Translation of medical terms Same gender interpreter preferred
Not the only player Only providing advice in an Asianlanguage was ineffective as aneducational intervention toencourage dietary modification inSouth Asian patients with diabetesin Leicester.
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 . . .’
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.”
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
How confident are you filling out medical forms by yourself?How would you rate your ability to read medical forms?
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.
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
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
Incorporation in to a way of life◦ Travel◦ Visiting family◦ Shared meals
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).
Similar barriers in South Asian and Somalipopulations Added cost of culturally comfortable food (ie.Bangladeshi vegetables)
Disease states are an action by God◦ Individuals have little control over the course
Social stigma of illness Effects diet in group settings Deterrent to insulin treatment
Infancy of western medicine Concerns regarding side effects Beliefs about efficacy
Culturally sensitive and relevant programs Location Timing Program development Presenters Participants
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