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Research paper
Best practices on Diabetes
education for people from Diverse
cultures with emphasis on south-
east Asians, Africans and Latin
Americans.
Presented by:
Dr Amina Chaudhary(M.B.B.S.)
Diabetes Educator.
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Executive Summary
The diabetes prevalence is on the rise in Canada at an alarming rate (1). A major
reason for increased prevalence of diabetes is the increased rates of immigration from
high-risk source countries (2). Furthermore, racialized groups such as South Asian,
Latin American, Caribbean, sub-Saharan African, North Africa and Middle East are at
greater risk for developing diabetes-related complications than the general population in
Ontario(3)
Diabetes education programs (DEPs) facilitated by multidisciplinary teams including
diabetes educators are highly effective at helping patients adhere to management
recommendations (4), but participation rates are often low(5-6) and attrition rates are
high (36). The literature suggests culture and gender-specific issues may affect DEP
attendance (7). Transportation costs to attend DEPs are a particular concern for low
income individuals with diabetes (8, 9).
Language and literacy issues also pose significant barriers (10). A U.K. study
involving South Asians revealed that health literacy was a more significant determinant
of access to education than language (11). Other issues that were of greater concern to
Asian women versus men were coping with health problems and self-management, and
some were uncomfortable discussing their problems with male physicians or
participating in mixed-gender education groups (12). In one study, both male and
female African American participants stated that DEPs should target women because
they are primarily responsible for food purchase and preparation (9). Current evidence
indicates diabetes care delivered in a structured program of continuous education and
comprehensive care is effective in improving health outcomes for individuals with
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diabetes. (12) The review of the international literature to identify diabetes education
practices that were evaluated and therefore could be classified as either ‘best’ or
‘promising’
Introduction
As research suggests, primary approaches to prevent diabetes include programs,
targeting high risk sub groups of population like high risk ethnic groups, such as those
designed to promote physical activity and healthy eating in adults and children
(13,14,15)
Adverse neighbourhoods and housing conditions may affect the development of DM
(Diabetes Mellitus )through their influence of development of other health conditions of
residents. These include obesity, hypertension and other co-morbid conditions.(16,17)
Primary prevention strategies like using best diabetes education practices will aim
to empower people to take charge of their own health by gaining control over the
determinants of health. Of interest for researchers is the possibility of prevention of DM.
Prevention in turn can improve the quality of life of an individual and reduce health care
costs. (18) Health promotion moves beyond prevention and management of chronic
disease to community development, health education, citizen participation and
advocacy of health (19)
Literature Review
It is believed that, type 2 diabetes has reached an alarming “epidemic” level; over 2
Million Canadians have diabetes. Diabetes has been ranked the 7th leading cause of
death in Canada due to high morbidity and mortality associated with its chronic
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complications (20). Research shows that certain ethno-cultural populations are at
increased risk developing diabetes such as Africans, Asians, Hispanic and aboriginal
populations (20). The Finnish DPS(Diabetes Prevention study) assessed lifestyle
changes, shows that living a healthier lifestyle can reduce the onset of type 2 Diabetes
mellitus (T2DM) by as much as 58%. T2DM has been associated with lifestyle factors
and the risk of developing this illness increases with being overweight, lack of physical
activity and aging. Although approaches to prevent and control this illness do exist,
most of these studies were designed to serve the mainstream population and to place in
clinical settings. Therefore, it is difficult to transport these models out of the clinics and
into the community. In addition, the needs and health beliefs of ethno-cultural groups
are not included in their designs or delivery. Fraser (21), Scott (22) and Stephenson
(23) argue that ethno-cultural have different health beliefs and attitudes towards eating
habits, the healthcare system and obesity. Therefore, the use of mainstream
preventative approaches may not be successful with these communities.
Wong (24) stated that the community’s buy-in or full participation is the key to
success for any education all and preventative health programs and that traditional
studies that only focus on “reduction of behavioural risk factors without enabling
changes in the social environment, produce only moderate effects”. Wong suggests that
the health prevention strategies that integrate social support and enabling mechanisms
towards changing social determinants, “tend to result in self-initiated behaviours”.
Dennis (25) believes that researchers and healthcare providers need to extend their
understanding beyond lifestyle impacts /changes and seek different explanations and
solutions. Dennis argues that service providers and researchers should take into
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consideration social determinants such as peoples’ social economic status and start
“asking different questions to the causes of its incidence and factors effecting its
management”. Dennis states that for many low- income people, there are other
pressuring societal issues such as poverty, unemployment etc. that makes the
recommended lifestyle change a difficult task to achieve. Knowler’s (26) research
shows that lifestyle change reduced the development of T2DM among those ethno-
cultural community members that took part in this study. Yet reports that societal factors
like poverty play a crucial role of development of T2DM. He writes that, “low income
levels were significantly associated with a higher prevalence of diabetes among
Hispanics. (27)
The development of T2DM can have very high costs to the health-care system
and the individual. The costs associated with primary care and expensive blood testing,
along with the fact that some people do not have access to primary care, has led to the
development of less expensive community and population-based approaches including
lifestyle interventions in the prevention of, and inexpensive tools for the screening of
T2DM. Numerous studies support the notion that community and lifestyle interventions
are in fact more cost-effective than the more expensive primary health-care
interventions. Lifestyle interventions that target diabetes may include group physical
activity, diet, and/or smoking cessation programs, and/or policy and advocacy efforts
directed toward increasing access to those programs or opportunities(28,29,30,31)
Standards for Diabetes Education in Canada developed by the Canadian Diabetes
Association’s Diabetes Educator Section (DES)(32) which were met by each practice.
The six DES Process Standards are:
1. Diabetes education is based on ongoing, client centred needs assessment of
individuals and or communities.
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2. Plans for diabetes education are client-centered and ongoing.
3. Implementation of diabetes education is client-centered and facilitates
learning.
4. Diabetes education services partner with other resources and services
required by individuals, support persons and/or communities affected by
diabetes.
5. Diabetes education is provided according to the practice standards of the
healthcare professionals involved.
6. The effectiveness and quality of diabetes education services are regularly
evaluation and revised, as needed.
Examples of the best practices identified by Canadian Diabetes Association
regarding diverse cultures of South-east Asians, Africans and Latin Americans(3)
1. Culturally Tailored Diabetes Intervention for Mexican Americans was carried
out in United States. The program consists of eight weekly two-hour sessions and
includes didactic content, cooking demonstrations and group support. Participants are
encouraged to bring a support person to the sessions. The content followed the
National Diabetes Education Program and American Diabetes Association (ADA)
guidelines. Discussions about self-monitoring of blood glucose and how to interpret
results are also included, and content on stress and stress management, heredity and
culture (including traditional Mexican American ideas of causes of diabetes). Promotora
(lay peer educator) support played a key role in success of this intervention.
2. Group-Based Counselling for Improved Coping was carried out in Norway.
The intervention occurs during nine group sessions and emphasizes patients’ active
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role and responsibility for the management of their diabetes. A nurse specialist in
diabetes care and experienced individuals with diabetes worked together as co-leaders
to facilitate the nine group sessions. Topics covered during the sessions were: self-
monitoring of blood glucose; stress, coping and self-care behaviour; coping profiles and
strategies; relationships (with healthcare professionals and with family, friends and
colleagues); stress management; goal setting; dietary and exercise self-care; and goal
attainment and relapse prevention.
3. Low Literacy (U.S.A.) The Program Goals was to supply information in form of
extensive audio and visual format to provide psychological support and promote
diabetes self management skills to individuals with low health literacy skills. The touch
screens were placed in waiting areas of public health clinics. Headphones were also
made available. The public clinic supported the program implementation through their
willingness to set up computer kiosks.
4. Pounds Off With Empowerment ( POWER)( U.S.A.)
This program was designed for African Americans and Latinos with type 2 Diabetes.
The project goal was to achieve and maintain a 10% weight loss over 12 months with
25% of calories from dietary fat, and a minimum of 150 minutes of physical activity per
week with an intensity similar to brisk walking.
5. Promotora DiabeteseIntervention for Mexican Americans(U.S.A.)
The Program Goals was to determine the effectiveness of an intervention led by
community lay workers (promotoras) on the glycemic control, diabetes knowledge and
diabetes health beliefs of Mexican Americans with type 2 diabetes living in a major city
on the Texas-Mexico border. The study found out that Promotoras are an effective way
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to deliver patient education that is culturally and linguistically competent. Moreover, the
spirituality of Hispanic clients needs to be addressed in all patient education programs
to enhance outcomes.
6. X-PERT Program (U.K.) designed for Urdu speaking South Asians
The Diabetes X-PERT program is a patient centred, group-based self-management
program delivered in six weekly two-hour sessions. The program is designed to develop
participant skills and build confidence to enable patients to make informed decisions
about their diabetes self-care. About 16 people participate with 4 to 8 carers in each six-
week cycle of the program. Community organizations provide meeting space for the six
weekly sessions.
7. Diabetes Prevention Program (DPP): The program was implemented among
low-income minority patients in urban America I.e., African Americans, Latinos
and south east Asians. A case management approach for high-risk, minority patients
with type 2 diabetes, which uses a seven-module participant handbook and provider
script (revised from the Diabetes Prevention Program Lifestyle Change). The program
combines face-to-face contact and telephone support with a nurse case manager.
The goals of the intervention were to achieve increased exercise levels, a weight loss of
7% and appropriate modification of the patient’s diet.
8. Picture Flashcard Health Education South Asians(U.K.)
To increase knowledge, self-caring skills and attitudes toward diabetes ten colour
photographs were produced with the help of a dietitian, link workers and a professional
photographer, enlarged to A3 size and laminated. Asian models, utensils and foods
were used. Each photograph was designed to cover one or more predetermined
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teaching objectives. A standardized interview questionnaire was developed to use with
the flash cards. The patients were shown the flash cards by the link worker together
with a structured education package. They were taught to test their urine for sugar if
they did not already do that. Patients received one on-one education in either a hospital
outpatient clinic or a diabetic clinic. Interviews could also take place at the participant’s
home. All interviews took place in the language the patient was most comfortable using.
9. Project Dulce (U.S.A.) is a diabetes care and education program that addresses
the specific needs of underserved, ethnically diverse populations. The program is
dedicated to “Diabetes Excellence Across Communities. With a mission of improving
the lives of people with diabetes through culturally appropriate, community-based
diabetes management, education and support programs. Project Dulce has conducted
extensive socio-cultural research to adapt its group education curriculum and approach
to address the needs of African American, Filipino and Vietnamese communities.
Peer educators from each of these cultural groups provide diabetes education and
support to respective communities. Patient handouts have been translated into
numerous languages and the handouts are available.
10. REACH Detroit Family Intervention to determine the effects of a community-
based, culturally tailored, diabetes lifestyle program. Family Health Advocates (FHAs)
were trained to work with the REACH families. REACH participants were referred to the
project by their personal physicians from one of three healthcare systems in Detroit. The
program was developed with Latino and African American cultures in mind. Latino
families participated in El Camino a la Salud and African American families participated
in The Journey to Health programs. REACH families also receive a new Internet
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computer and training that helped them get important information about diabetes and
community programs in their own home.
Program goals are to increase healthy eating and leisure-time physical
activity, enhance family-health provider relationships, increase access to quality health
care, improve client’s ability to control diabetes with self care and increase access to
community health promotion resources.
11. Soul Food Light to test the effects of a culturally competent dietary self-
management intervention on physiological outcomes and dietary behaviours for African
Americans with type 2 diabetes in rural South Carolina. Because of low literacy levels,
the focus was on one major dietary concept in order to improve the chances for success
by simplifying the intervention and behaviour change required.
The peer-professional approach with the discussion groups facilitates cultural
translation of content, culturally competent learning methods, and emotional support
from peers and family – it is the preferred group structure of southern African
Americans.
12. Empowering the African-American Community To Live Well “Meeting
People Where They are 6 weeks curriculum presenting physical activity and hands on
cooking classes with strategies presenting material 4 to 5 grade with free transportation
with reinforce and encourage. Impact of low literacy is significant. This community need
a trusted source of information.
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Best approaches applicable to diverse cultures of Saint James Town
Saint James town is the largest high rise community in Canada consisting of 19
towers with approximately 17,000 immigrants speaking more than 100 languages
comprising of Asians (east Asians and south Asians), Africans, South Americans and
Caribbeans. NDSS incidence data for SJT from 1995 to 1999: there is 29% increase in
20-34 years old, 35% increase in 35-49 years old, 23% in 50-64, 26% in 65-74,27% in
75 in female and 18%,24%, 26%, 27% and 28% respectively in males.
According to the WHO, over 90% of T2DM and 80% of coronary heart
disease could be avoided or postponed with good nutrition, regular physical activity,
the elimination of smoking and effective stress management (1)
Approaches which would work in this densely populated community are following:
Teaching of didactic content, cooking demonstrations and group support. Content on
stress and stress management, heredity and culture (including traditional Mexican’s
ideas of causes of diabetes). Promotora (lay peer educator) support played a key role in
success of this intervention.
To address the low literacy in the immigrant communities, there is a need to
develop information in form of extensive audio and visual format.
Psychological support and promotion of patient education material that is culturally
and linguistically competent should be make available . Moreover, the spirituality of
Hispanic clients needs to be addressed in all patient education programs to enhance
outcomes. Face-to-face contact and telephone support with a Diabetes educator proved
beneficial in many programs.
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Peer educators from each of these cultural groups should be encouraged to provide
diabetes education and support to respective communities. Handouts translated into
numerous languages should be available and handy.
6 weeks curriculum presenting physical activity and hands on cooking classes with
strategies presenting material 4 to 5 grade can be arranged for the black Africans in a
participating church and information brochures should be available in local barber
shops.
Conclusion:
It is clear that in order to most effectively prevent T2DM, we need to tailor both
screening tools and interventions to the specific populations we are working with. For
interventions, given the similarities between programs, this adjustment does not have to
be extremely expensive or time-consuming. For example, increasing the number of
physical activity opportunities in a neighbourhood, such as, building safe and accessible
trails within the neighbourhood of interest, offering cooking classes on traditional foods,
give information about Farmer’s market, offering classes on awareness and education
provided by individuals’ from the culture of interest, in the language of interest. Other
additions to interventions elements that have been found to be successful that could be
implemented into any large-scale prevention intervention could include setting specific
goals for changes, using a stages of change model, offering some level of individual
tailoring within the group setting, asking evaluation questions before programs and then
at follow-up.(30) In short, a culturally competent healthcare setting should include an
appropriate mix of the following(33)
1.Culturally diverse staff that reflects the community(ies) served,
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2. Providers or translators who speak the clients’ language(s),
3. Training for providers about the culture and language of the people they serve,
4. Signage and instructional literature in the clients’ language(s) and consistent with
their cultural norms,
5. culturally specific healthcare settings.
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References
(1) Ohinmaa A, Jacobs P, Simpson S, Johnson JA. The projection prevalence and
cost of diabetes in Canada: 2000 to 2016. Can J Diab 2004;28(1):116-23.
http://www.utoronto.ca/cuhi/seminars/supportingdocs/DEP%20Report%20-
April%208-FINAL%20COPY(2).pdf
(2) Statistics Canada. Canada’s Ethnocultural Portrait: The Changing
Mosaic.Ottawa, ON.: Statistics Canada; 2003.
(3) Creator, MI, Moineddin R, Booth G, Manuel DH, DesMeules M, McDermott S,
Glazier RH: Age and sex related prevalence of diabetes mellitus among
immigrants to Ontario, Canada. CMAJ 182: 781-789, 2010.
(4) Robbins JM, Vaccarino V, Zhang H, Kasl SV. Excess type 2 diabetes in African-
American women and men aged 40-74 and socioeconomic status: evidence from
the Third National Health and Nutrition Examination Survey. J Epidemiol
Community Health 2000;54(11):839-45.
(5) Coleman MT, Newton KS. Supporting self-management in patients with
chronic illness. Am Fam Physician 2005;72(8):1503-10. October 1, 2008
(6) IrvineAA, Mitchell CM. Impactof community-based diabetes education on
programattenders and nonattenders. Diabetes Educ 1992 Jan;18(1):29-33.
(7) Robson T, Blackwell D, Waine C, Kennedy RL. Factors affecting the use of
dietetic services by patients with diabetes mellitus. Diabet Med 2001
Apr;18(4):295-300.
(8) Skelly AH, Samuel-HodgeC, Elasy T, Ammerman AS, Headen SW, Keyserling TC.
Development and testing of culturally sensitiveinstruments for African American
women with type 2 diabetes. Diabetes Educ 2000 Sep;26(5):769-7.
(9) Brown SA, Hanis CL. Culturally competent diabetes education for Mexican
Americans: the Starr County Study. Diabetes Educ 1999 Mar;25(2):226-36.
(10) Skelly AH, Samuel-Hodge C, Elasy T, Ammerman AS, Headen SW, Keyserling
TC. Development and testing of culturally sensitiveinstruments for African
American women with type 2 diabetes. DiabetesEduc 2000 Sep;26(5):769-7.
15. 15
15
(11) James DC. Factors influencing food choices, dietary intake, and nutrition-
related attitudes among African Americans: application of a culturally sensitive
model. Ethn Health 2004 Nov;9(4):349-67
(12) Canadian DiabetesAssociation 2008 ClinicalPractice Guidelinesfor
thePrevention and Managementof Diabetesin Canada, 15.
(13) Micucci S, Thomas H, Vohra J. The effectiveness of school-based strategies
for the primary prevention of obesity and for promoting physicalactivities and /or
nutrition, the major modifiable risk factors for T2DM: a review of reviews
Hamilton, ON: Public Health Research, Education and Development Program,
Ministry of Health and long term care: 2002. Availableat:
http://old.hamilton.ca/phes/ephpp/Research/Full- Reviews/Diabetes-Review.pdf
.Accessed September 1, 2008.
(14) Daniel M, Green L.W., marion SA, et al. Community-directed diabetes
prevention and control in a ruralAboriginalpopulation in British Columbia,
Canada. Soc sci med. 1999; 48:815-832.
(15) Simmons D, VoyleJ, Swinburn B, et al. Community-based approaches for the
primary prevention of non-insulin-dependentdiabetes mellitus. DiabetMed.
1997;14:519-526.
(16) Kriska AM, Saremi A, Hanson RL, et al. physicalactivity , obesity and the
incidence of T2DM in high risk population. AM J Epidemiol (2003) 158:669-75.
(17) StrodlE, Icenardy J. Psychosocial and non- psychosocialrisk factors new
diagnosis of diabetes of elderly women. Diabetes Res clin Pract (2006) 74:57-65.
(18) Diabetes Educator GraduateCertificate Program-Module2-3,Prevention and
health Promotion.
(19) Wass A. Promoting Health: The primary careapproach. 2nd
ed.., Sydney:
HarcourtSaunders;2000.
(20) Health Canada. (1990). Diabetes in Canada: National statistics and
opportunities for improved surveillance, prevention, and control. Report cat. No.
H49-121.
16. 16
16
(21) Fraser, H.S. etal. The obesity epidemic of the Caribbean. WestIndian Medical
Journal1996 Vol. 45, No.1, pp. 1-2.
(22) Scott, Penelope and Lynda Rajan. (2000) Eating habits and reactions to
dietary advice among two generations of Caribbean people:A south London study,
part 1. Practical Guide international. Vol17, No 6,pp. 183-186.
(23) Stephenson, Peter H. (19950. VietnameseRefugees in Victoria, B.C.; An
overview of immigrant and Refugees Heath Care in a medium- sized Canadian
Urban Centre. Social Science Medicine. Vol.40, No. 12, pp.1631-1642.
(24) Wong. Sherley et al. (2002). A conceptualmodel for a culturally responsive
community-based diabetes prevention programme. InternationalJournalof
Health Care Quality Assurance. incorporating Leadership in Health Services. Vol..
(25) Dennis Rapheal, et al. (2003). Thesocialdeterminants of incidence and
management of T2DM:arewe prepareto rethink our questions and redirect our
research activities? InternationalJournalof Health Quality Assurance
incorporating Leadership in Health Services. Vol. 16, No.3, pp 10-20.
(26) Knowler, William. C. et al. (2002). Diabetes Prevention Research Group.
Reduction in the evidence of T2DM with lifestyle intervention or metformin. New
England journalof Medicine. Vol. 346,pp.393-403.
(27) Best Practices in Diabetes prevention-Working with Ethno-Cultural
Communities. Resourcemanual about projectof the West End Urban health
Alliance (WEUHA) Nutrition Steering committee.
(28) Herman, W.H., Thompson, W.J., Visscher, W., Aubert, R.E., Engelgau, M.M.,
Liburd, L. et al. (1998). Diabetes mellitus and its complications in an African-
American community: ProjectDIRECT. Journalof the National Medical
Association, 90:147-156.
(29) Jacobs-van der Bruggen, M.A.M, Bos, G, Bemelmans, W.J., Hoogenveen, R.T.,
Vijgen, S.M., & Baan, C.A. (2007). LifestyleInterventions AreCost-Effectivein
People With DifferentLevels of Diabetes Risk: Results froma modeling study.
Diabetes Care 30: 128-134.
(30) Roux L, Pratt M, Tengs TO, Yore MM, Yanagawa TL, Van Den Bos J, Rutt C,
Brownson RC, Powell KE, Heath G, Kohl HW 3rd
, Teutsch S, Cawley J, Lee IM, West
17. 17
17
L, Buchner DM. (2008). Costeffectiveness of community-based physicalactivity
interventions. American Journalof PreventiveMedicine, 35(6):578-88.
(31) (Ramachandaran A, Snehalatha C, Mary S, Mukesh B, Bhaskar AD, Vijay V.
(2006). TheIndian diabetes prevention programmeshows thatlifestyle
modification and metformin preventT2DM in Asian Indian subjects with impaired
glucosetolerance (IDPP-1). Diabetologia , 49:289-97.
(32)
http://www.diabetes.ca/documents/forprofessionals/Bestpractice-eng.pdf
(33)
http://www.camh.net/About_CAMH/Health_Promotion/Community_Health_Promotion/C
ulture_Counts_Guide/CultureCountsGuide8.pdf
