Transcript The Short and Long Term Effect of a Non

Cultural aspects influencing
diabetes care
What is culture?
• The beliefs and attitudes that are learned
and shared by members of a group
What is Cultural Competence?
The knowledge and interpersonal skills
that allow providers to understand,
appreciate, and work with individuals
from cultures other than their own. It
involves an awareness and acceptance
of cultural differences; self-awareness;
knowledge of patient’s culture; and
adaptation of skills.
– American Medical Association
Case
• Rosa is a 58 y/o Hispanic or Latino woman
who has lived in the US for 20 years. She
is married. Her husband is also Latino.
They have two sons and two daughters and
6 grandchildren. She is a housewife. Her
husband is a construction worker. She
completed 6 years of school education. She
speaks very little English.
Projected Resident Population of the United States,
1998-2030
1998
2030
Source: Collins, Hall, and Neuhaus, U.S. Minority Health: A Chart Book, 1999
The US Hispanic/Latino Population
Puerto Ricans 8.6%
Mexicans
66.9%
Central and South
Americans 14.3%
Cubans 3.7%
Others 6.5%
US Census Bureau. The Hispanic Population in the United States: March 2002. Available at:
www.census.gov. Accessed June 28, 2004.
Case
• Rosa has had no significant past medical history,
except for continuous weight gain over the last 20
years. Her father and maternal grandmother died
of diabetes related complications. Her husband,
children and grandchildren are overweight. Her
meals are usually rich in CHOs and fats and does
not exercise. Since she has felt well and has no
health insurance, she has not had a medical visit in
many years. During the last 6 months, she has felt
very tired, with increasing polyuria and
polydipsia.
US Diabetes Prevalence
by Ethnic Group
Men and Women, Age 45-74 Years
% with diabetes
50
40
30
20
10
0
European
Cuban
Japanese African
Mexican
American American American American
Harris et al. Diabetes. 1987;36:523.
Flegal et al. Diabetes Care. 1991;14(suppl 3):628.
Knowler et al. Diabetes Care. 1993;16(suppl 1):216.
Fujimoto et al. Diabetes Res Clin Pract. 1991;13:119.
Fujimoto et al. Diabetes. 1987;36:721.
Puerto
Rican
Pima
Genes, Environment and Social/Cultural Factors
in the development and course of Diabetes in Latinos
Socio-economic and
Cultural factors
Thrifty Genes
+
Inadequate Lifestyle
Insulin Resistance and
Abdominal Obesity
Beta Cell Dysfunction
Other defects
Incretin function?
Type 2 Diabetes
Socio-economic and
Cultural factors
Frequent Chronic Complications
Biological
Factors
Increased Mortality rates
Caballero AE. Current Opinion in Diabetes, Endocrinology and Obesity 2007. In press
Insulin Sensitivity Differs among Ethnic
Groups in Healthy Subjects
Age 23-26
BMI – 23-26.5
Insulin Sensitivity Index
(mmol• L-1• m-2• min-1• pmol-1• L-1)†
8
n=34
n=9
n=18
n=16
7
6
*
5
*
4
*
3
6.87
2
5.04
4.17
3.74
1
0
Non-Hispanic
White
*P =0.002 vs. Caucasians.
†Data are geometric means.
African
American
Asian
American
Mexican
American
Adapted from: Chiu KC, et al. Diabetes Care. 2000;23:1353-1358.
Type 2 Diabetes and its
Complications in Minorities
• Disparate and Disproportionate prevalence
of longterm complications of type 2
diabetes in minorities vs Whites
– lower leg amputations 2-4x
– retinopathy and blindness 2-4x
– stroke 2x
– ESRD 4-6x
Caballero AE. Diabetes in minority populations.
In: Joslin’s Diabetes Mellitus. LW & W; 2005. 14th Ed. p 505-524.
*Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.
Institute of Medicine. The National Academies Press. Washington, D.C. 2004.
Unequal Treatment: major findings
Racial/ethnic disparities consistently found across a
wide range of
– health care settings (managed care, public/private hospitals,
teaching/community, etc.)
– disease areas, and
– clinical services,
even when various confounders are controlled for (i.e.
socioeconomic status, insurance, stage of
presentation, comorbidities)
www.nap.edu
A1c levels by ethnicity/race
NHANES 1999-2000
8 .2
8 .1
8
%
7 .9
7 .8
N H W h it e
7 .7
N H B la c k
7 .6
H is p a n ic s
7 .5
7 .4
7 .3
N H W hite
N H B la c k
H is p a n ic s
Boltri JM, et al. Ethn Dis 2005; 15 (4): 562-7
Percentage of participants with undiagnosed diabetes with an A1c
above 7% by ethnicity/race
NHANES 1999-2000
70
60.5
60
%
50
37.8
3 9 .3
40
N H W h it e
N H B la c k
30
H is p a n ic s
20
10
0
N H W h ite
N H B la c k
H is p a n ic s
Boltri JM, et al. Ethn Dis 2005; 15 (4): 562-7
Case
• Rosa is followed by a non-Spanish speaking
physician. Most of the time, a professional
interpreter is present in the clinical encounter, but
sometimes, it is one of Rosa’s children who helps
with translation.
• Rosa usually forgets to take her oral medications
well and has not made significant changes in her
meal plan and physical activity.
• She frequently receives patient education
brochures in Spanish. Most of these materials
have been translated from an original English
version.
The Basic Triad in Diabetes Care
The Patient:
Medical, Socio-economic,
Cultural factors
The Health Care Provider:
Lack of cultural competence
The Health Care System:
Insufficient:
Culturally Oriented Programs
Professional education
Cultural diversity
Health care access
Time and support with patients
Caballero AE. Current Diabetes and Endocrinology Reports 2007. In press
Health Insurance Coverage
Non-Latino White
African American
All Latino
U.S. Born
Mexican American
Foreign Born
Mexican American
0
20
40
60
80
Percentage with health insurance
U.S. Census Bureau. Health Insurance Coverage: 2000. September, 2001.
Harris MI. Diabetes Care. 2001;24:454-459.
100
MENTAL
PHYSICAL
SPIRITUAL
EMOTIONAL
A few definitions
• Ethnocentrism – The conviction that one’s
own culture is superior
• Stereotyping – Mistaken assumption that
everyone in a given culture is alike
• Generalization – Awareness of cultural
norms
47 Million U.S. residents speak a
non-English language at home*
• 18% of U.S. population
• Up from 14% in 1990
• 1/2 have difficulty speaking English
* United States Census 2000
Language Barrier
A true story:
64 y/o Hispanic woman
Patient does not speak English
Treated for Hypertension
Received a prescription for :
Lisinopril 10 mg.
Once/d.
Patient rushed to the ER due to severe hypotension
Approaches to Bridging
Language Barriers
•
•
•
•
•
•
Bilingual/bicultural professional staff
Interpreters
Language skills training for existing staff
Internal language bank
Phone-based interpreter services
Written translations
Photo credit: US Census Bureau.
The National Alliance for Hispanic Health. A Primer for Cultural Proficiency: Towards Quality
Health Services for Hispanics. 2001:16.
Percentage of Adults Reporting Communication
Problems
50
45
40
35
30
25
20
15
10
5
0
To tal U S
White
African
Latino
A m erican
U ninsured
C on tin uously Insured
Collins, et al, Diverse Communities, Common Concerns: Assessing Health Care Quality for Minority
Americans, The Commonwealth Fund, March 2002.
51% of Americans have limited
functional health literacy*
• Health literacy is the ability to:
– understand basic medical terms about symptoms
and illness
– follow directions for diagnostic procedures and
therapies
– Engage in a dialogue about medical issues
• Highest number with low literacy are white
and many are elderly
*Health Literacy: A Prescription to End Confusion. Institute of Medicine.
The National Academies Press. Washington, D.C. 2004.
Model for Cross-Cultural Care:
A Patient-Based Approach
Awareness
of Cultural
and Social
Factors
Elicit
Factors
Negotiate
Models
Implement
Management
Strategies
Tools and skills necessary to provide quality care to any
patient we see, regardless of race, ethnicity, culture,
class or language proficiency.
Models
LEARN – Listen, Explain, Acknowledge,
Recommend, Negotiate
BATHE - Background, Affect, Trouble,
Handling, Empathy
ETHNIC – Explain, Treatment, Healers,
Negotiation, Intervention, Collaboration
ESFT – Explanatory model, Social risk, Fears,
Treatment
The ESFT Model
• Explanatory Model
• Social Barriers
• Fears/Concerns about Medication
• Therapeutic Contracting/Playback
Main factors that may influence diabetes development
and care in Culturally Diverse Populations
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Acculturation
Body Image
Cultural Competence
Depression
Educational Level
Fears
General Family Integration and Support
Health Literacy
Individual and Social Interaction
Judgment about disease
Caballero AE. Insulin 2007; 2: 80-91
Main factors that may influence diabetes development
and care in Culturally Diverse Populations
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Knowledge about the disease
Language
Myths
Nutritional Preferences
Other forms of Medicine ( Alternative )
Physical Activity Preferences
Quality of Life
Religion
Socio-economic status
Caballero AE. Insulin 2007; 2:80-91
The Latino Diabetes Initiative
The overall goal of the Initiative is to improve
the lives of Latinos affected by diabetes or
at risk for the disease through culturally oriented
patient care, education and research
www.joslin.org/latino
The Latino Diabetes Initiative
Patient
Care and
Education
Community
Outreach
Provider
Education
Research
Visit us at www.joslin.org/latino
THANK YOU