Cultural Competency in Diabetes Care, Focused in the Hispanic/Mexican Community

1

Cultural Competency in Diabetes Care, focused in the Hispanic/Mexican Community

by

Bertha (LILY) Gonzalez

Concordia University

October, 2016

Thesis Submitted in Partial Fulfillment

of the Requirements for the

Master's Degree in Public Health

Concordia University

Spring quarter, 2017

Abstract

Diabetes is a public health concern that is growing fast, especiallyin minority populations. Hispanic/Latinos have a high prevalence of type 2 diabetes and diabetes complications. Cultural barriers and social factors influence the way Latinos encounter and manage diabetes, consequently, the lack of cultural competency and Limited language proficiency from health care providers and workers exacerbate the negative diabetes outcomes. This systematic review will utilize a qualitative method to explore the cultural beliefs, expectation, social factors and barriers that influencediabetes management in Hispanics. And it will apply the ecological and health belief model as the theoretical foundation to better understand how these cultural beliefs and social factors influence their healthcare expectations and health behaviors.Lastly, considering that Mexicans are the largest Hispanic subgroup living in this country, I willattempt to focused my review in the Mexican group.

Introduction

Problem Statement

Hispanic/Latinos are experiencing the fastest increase in the rates of diabetes, they are also the fastest growing population of the United States and that alarms many public health officials (McQuilland 2014).

Minority populations like Hispanic/Latinos do not always receive adequate diabetes care because of barriers such as linguistic differences, limited educational backgrounds, religious and illness beliefs and different healthcare expectations that are not familiar with majority populations (Zeh, Sandhu, Cannaby & Sturt 2012). Cultural and language barriers can cause poor communication and poor adherence to medical care and medication therapy Caballero (2013). Poor communication is also responsible for poor outcomes and unnecessary readmissions, which are very expensive to the healthcare system (nso40th). Consequently, ethnic minority groups recurrently experience higher diabetes morbidity and mortality than majority populations. (Zeh et al., 2016).

Some studies suggest that Latinos with type 2 diabetes appear to be more likely to develop microvascular complications thannon-Hispanic whites (Caballero 2006). For instance, their risk for developing retinopathy is twice more than non-Hispanics Whites (Caballero 2006). And in 2010 Hispanics were three times more likely to start treatment for end - stage renal disease -related to diabetes as compared to non-Hispanic Whites. The Center for Disease control and Preventions stated that Hispanics have 51% higher death rate than Caucasians (AADE 2015).

The overall cost of diabetes in 2012 was $245 billion and theaverage medical expenditures among people with diagnosed diabetes was 2.3 times higher than the expenditures among people without diabetes. (ADA 2016).

Some experts argue that providing appropriate intervention by culturally and linguistically competent healthcare professionals can confer important benefits, not only to people with diabetes and their families, but also bring cost savings in every nation’s health care system (Zeh et al., 2012).

There is an abundance of literature related to cultural competency and the importance of its integration into all levels of health care to reduce health care outcomes. But there is a scarce amount of studies that have examined specific conditions like cultural competency in diabetes care, specially diabetes care in Latinos. Therefore, the purpose of this systematic review is to explore the needs and cultural expectations of the Latinos with diabetes and study the existing cultural competency strategies to increase positive diabetes outcomes.

Purpose Statement

According to the AADE 2015 the first step towards providing sensitive and competent diabetes education is the awareness of the need for culturally sensitive diabetes services, the need to gain relevant insight necessitates and the need to develop a certain amount of cultural humility. This recognition helps to develop a mutually respectful and positive relationship among patients and health care providers. (AADE 2016). The AADE highlights that the more engaged individuals with diabetes and their support members are involved in healthcare, the more likely they are to achieve desired outcomes and improve their quality of life. There are several articles related to cultural competency and the importance of its integration into all levels of health care to reduce health care outcomes. However, there is a scarce amount of studies focused on culturally and linguistically competent interventions concentrated in diabetes and specifically on diabetes in Hispanic/Mexican. therefore, the purpose of this systematic review is to explore and learn the needs, barriers, and cultural expectations of the Hispanic/Mexican individuals with diabetes, promote the personal necessity of gaining cultural awareness within clinicians and healthcare workers and identify culturally and linguistically sensitive interventions that increase positive diabetes outcomes.

Research Questions:

What are the healthcare and cultural expectations, perceptions and barriers of the Hispanics/Mexican with diabetes?

What cultural competency strategies are there that increase positive diabetes outcomes? Is there an association between culturally and linguistically competent interventions and an increase in positive diabetes outcomes?

Potential Significance

This review will have important contributions because it is going to provide an overall view of the cultural background of the Hispanic/Mexican group and promote cultural awareness within clinicians and healthcare workers. Additionally, it will affect the ways in which providers and other health care workers interpret patient’s experiences, influence the types of recommendations or interventions the clinicians propose, increase positive diabetes outcomes and save money on diabetes complications.

Chapter 2: Literature Review

Theoretical Foundation

Theories are an important element in research both qualitative and quantitative, as they provide the structure and rationale for the research.(MPH 530).The implemented theories in this review are the ecological and health belief model. The ecological model postulates that: psychological and social dimensions of human development are important aspects of the holistic health, and highlights that these are influenced by four important system levels of the ecological model: microsystem, mesosytem, exosystem and macrosystem (DiClemente, Salazar and Crosby 2013). Additionally, this model suggests that effective interventions influence multiple levels in the ecological model: interpersonal, community, institutional and policy level (Riverside community health foundation n.d.). In short; health is influence by culture and Culture is shaped by the ecological model including family, community, workplace, beliefs, traditions, and legal status and socioeconomic status. (Riverside community health foundation n.d.). Here is an example, some Mexican individuals may want to control their diabetes, but they may not have access to medical care, neither money to buy medication. Therefore, it is essential for the clinician to understand the environmental and cultural factors and barriers of the Latinos to tailor the treatment and /or interventions to their needs, wants and boundaries.

The second theory is the health belief model HBM, this model assumes that people may decide not to take action to control their diabetes because their perceived threat of the disease is smaller than their perceived barriers, in part because of the silent manifestation of the disease in the early stages, and because their perceived barriers is bigger than the perceive threat, for instance: Pedro’s perceptions of vulnerability and severity of diabetes is low, because he does not feel anything, even though his HbA1C is 14.5 and because he has no access to medical care, no primary care provider, no money, no time to go to the provider, no transportation, he is new in this country and do not know the healthcare system, do not trust the physicians and his is concern about seeking health because of his lack of legal status. (high perceived barriers). This model assumes that for the individual to take actions and/or adopt the recommended healthy behavior; the perceived threat and its severity must outweigh the perceived barriers. (Riverside community health foundation n.d.).

Table 1

Descriptions of included studies

To support my qualitative systematic review I included the description of eight articles:

Author(s) and Year / Type of review / Purpose / Main argument / Who participate / Results/ outcomes
1) Caban, A. and Walker, E. A (2006) / Systematic review qualitative data / Provide a description of current research on culturally relevant issues among Hispanic subgroups with diabetes through the United States. / “Clinicians and educators would benefit from exploring cultural belief systems with patients, as they may enhance the patient- provider relationship and serve as tools in identifying appropriate treatment strategies” / 5997 participants
Majority of them of Mexican American heritage. / personal models of illness varied across groups and are influenced by acculturation.
Clinicians and educators would benefit from exploring cultural belief systems with patients, as they may enhance the patient- provider relationships and serve as tools in identifying appropriate treatment strategies.
2) Hawthorne, K., Robles, Y., Cannings, J., and Edwards, A. G. K.
(appraisal and quality evaluation was done) / Systematic and narrative review – only randomized controlled trial (RCT) were included, eight of the 11 studies based their interventions on qualitative work and 3 on quantitative work. they utilized theoretical models of behavior change, soap dramas, storytelling, and lay workers to deliver health messages, some studies used repeated interventions/classes / To determine if culturally appropriate health education is more effective than “usual” health education for people with diabetes from ethnic minority groups living in high and upper middle income countries. / People from ethnic minority groups living in high income or upper -middle income have higher prevalence of type two diabetes, their problems are exacerbated by migrant status, relative deprivation and low socioeconomic status and limited English. / 1603 participants
Majority of them Spanish speaking and/or Mexican American
African American
Pakistani
British
South Asian
Surinam Asian / Culturally appropriate health education was more effective than “usual” health education in improving HbA1c and knowledge in the short to medium term.
3)Zeh, P., Sandhu, H. K., Cannaby, A. M., and Sturt, J. A.
(Appraisal assessment- interventions were assess for cultural competency as well) / Systematic review
11 studies included five RCT, two qualitative action, two retrospective cohorts, one quasi-experimental design, one qualitative study with focus groups
(This review included all ethnic minority groups and all types of diabetes) / To examine the evidence on culturally competent interventions, tailored to the needs of people with diabetes from ethnic minority groups. / Minority groups do not always receive adequate diabetes care as a result of barriers such as linguistic differences, limited educational backgrounds and religious, health and illness beliefs that are not familiar to the majority population. These cultural characteristics can make minority groups vulnerable within their host country healthcare system.
Culturally and linguistically competent health care professional can confer important benefits, not only to people with diabetes and their families but also for cost saving in every nations’ health care system. / 2616 participants
South Asian
African American
Indian Pakistani
Muslim
Bangladeshis
(Mediterranean
Turkish and
Caucasian with gestational diabetes)
Hispanics. / A consistent finding from 10 of the 11studies was that any structured interventions, tailored to ethnic minority groups by integrating elements of culture, language, religion and health literacy skills produced a positive impact on a range of patient important outcomes.
Authors identified benefits in using culturally competent interventions.
4) Pottie, K., Hadi, A., Chen, J., Welch, V., and Hawthorne, K. (2013) / A quasi-randomized controlled trial focused on diabetes education intervention for high risk minority population was used. Qualitative methods were conducted to design culturally appropriate interventions. Soap dramas, storytelling, and soap operas were utilized to reach target population / Determining how, when and why culturally appropriate interventions work is important for health systems faced with minority populations / The total number of participants from all the studies was 1603. / Minority patients with language barriers and limited access to diabetes programs responded to interventions using health workers from the same ethnic group, and interventions promoting culturally acceptable and financially affordable food choices using local ingredients.
Program incentives improved retention and this improved HbA1C levels at least in the short term.
Adopting a positive learning environment, a flexible and less intensive approach, one to one teaching informal setting compared with a group approach in clinics led to improved retention rates.
5)Hu, Jie., Amirehsani, K. A., Wallace, D. C., McCoy, T. P., and Silva, Z. (2016) / A quasi experimental design was used to examine the effects of the 8-week intervention group which was compared to a group who do not receive the intervention / Test efficacy of a family based, culturally tailored intervention for Hispanics with T2DM / Family value plays an important role in Hispanic culture, thus focusing on family involvement and family centeredness may be important in intervention for Hispanics with diabetes and may improve patients’ adherence to diabetes self-management regimes. (Hu et al., 2016) / Most of the patients in this study were females (186 Hispanics with type 2 diabetes), almost all of them immigrants. / A1C decreased by 4.9 % on average among patient from pre-interventions to 1-month post intervention.
Patients showed significant improvements in systolic blood pressure, diabetes self-efficacy, diabetes knowledge, and physical and mental components of heath related quality of life. Higher levels of intake of healthy foods and performance of blood glucose test and foot inspections were reported. Family members significantly lowered body mass index and improved diabetes knowledge from pre-interventions to immediately post intervention. No significant changes in levels of physical activity were found among patients with diabetes or family members. Findings suggest that including family members in educational interventions may provide emotional and psychological support to patients with diabetes, help develop healthy family behaviors and promote diabetes self-management.
6) Concha, J. B., Mayer, S. D., Mezuk, B. R., and Avula, D. (2015 / Mixed method approach (quantitative and qualitative methodologies) was used to capture numeric observations or participant’s diabetes causations beliefs and contextualize this data with participant’s words and insights into why and how these beliefs may be useful for health professionals Semi structured focus groups, demographic survey of the illness perception questionnaire -revised / Explore how cultural diabetes causation beliefs can improve Hispanic/Latino patient Self-management / Cultural competence training among health professionals is one of the strategies used for reducing health disparities and ensuring that marginalized racial /ethnic populations receive equitable effective and culturally appropriate clinical care. (Concha et al., 2015) / Total of 13 participants participated in the interventions / The top 5 diabetes causation items from the participants included stress or worry, behavior hereditary, diet/eating habits and family problems/worries. Work stress was specifically identified as contributor of unhealthy eating and diabetes. Most participants were aware of and believed in susto and referred to it as (coraje/anger).
Participants mentioned that; asking patients about their diabetes causation belief and emotional status can help health professionals better understand the patient and identify and prioritize diabetes treatment.
7) Cadzow, R.B., Craig, M., Rowe, J., and Kahn, L. (2013) / Qualitative and quantitative survey methodology. analysis of demographic and evaluation data included descriptive statistics (frequencies and means) and qualitative analysis of open ended response questions. / A community based diabetes education pilot project aimed to train and implement cultural health brokers can improve the community members’ diabetes knowledge and diabetes self-management skills, and can stablish a diabetes resource library at various locations (churches, community centers). / The effectiveness of community health workers program in linking patients to community resources has been demonstrated. Neighborhood health talker (NHT) was design to brand this health workers initiative. / 12 women and 1 man participated in the training to become cultural brokers. (Mostly African American) they provided community conversations and developed resource libraries.
The cultural brokers reached 700 people in the community interventions. / Twelve women and 1 man completed the training, alone or in pairs each held at least 5 community conversation, they reached 700 community members (all ages) over 3 months and established 8 diabetes resource libraries in the community. All trainees increased their diabetes knowledge and confidence as well as their abilities to perform task of a cultural broker. All the goals were met.
8) Caballero, E.
(2006) / Literature search
By using Pub Med/National Center for Biotechnology information. / Explore the implications of increasing prevalence of type 2 diabetes in Latinos, defined cultural values and differences that may affected acceptance on insulin therapy and reviewed available strategies that may facilitated initiation of insulin. / Latino patients are more resistant to insulin therapy that non-Hispanic whites, the challenges of the physicians are not knowing how to address the negative perception about insulin therapy from the patient, which is aggravated by cultural and language barriers / Latino population / cultural awareness and cultural competence among healthcare providers and increase the use of Spanish -speaking diabetes educators from the same ethnicities to understand the expectations of the different Latino subgroups and prevent poor diabetes outcomes.

Table 3 provides a description of each study included in my systematic review. Eight articles were included, two were systematic reviews, one of these was evaluated by two appraisals and the test score of reliability was high. One more was a narrative review, this was also evaluated by two appraisals and had a quality assessment as well, one was a realistic review. Two of the articles used a quasi- randomized control trial and quasi experimental design, the rest of the articles were not systematic reviews. I had qualitative and quantitative studies in most of the reviews, but qualitative was the most prevalent method in the systematic reviews and in the quasi experimental designs. In conclusion, only few of the systematic reviews included information of appraisal evaluation. This fact for sure is going to affect the validity of this systematic review.