2. Of all the forms of inequality, injustice in health
care is the most shocking and inhuman(e.
— Dr. Martin Luther King, Jr.
3. Objectives
• Review demographic and epidemiologic
statistics relating to cultural diversity and
health disparities in the United States, with a
focus on diabetes
• Define the concept and rationale for culturally
competent health care
• Identify strategies and resources that can
facilitate the delivery of culturally and
linguistically appropriate services
5. Diabetes Fast Facts
• 29.1 million people or 9.3% of
the U.S. population have
diabetes.
• Diagnosed: 21.0 million people
• Undiagnosed: 8.1 million
people
(27.8% of people with diabetes
are undiagnosed).
6. Age-adjusted* percentage of people aged 20 years or older
with diagnosed diabetes, by race/ethnicity U.S., 2010–2012
*Based on the 2000 U.S. standard population.
Source: 2010–2012 National Health Interview Survey and
2012 Indian Health Service’s National Patient Information Reporting System.
7. Rate of new cases of type 1 and type 2 diabetes among people
younger than 20 years, by age and race/ethnicity, 2008–2009
Source: SEARCH for Diabetes in Youth Study. NHW=non-Hispanic whites; NHB=non-Hispanic blacks; H=Hispanics;
API=Asians/Pacific Islanders; AIAN=American Indians/Alaska Natives.
*The American Indian/Alaska Native (AI/AN) youth who participated in the SEARCH study are not representative of all AI/AN youth
in the United States. Thus, these rates cannot be generalized to all AI/AN youth nationwide.
<10 years 10–19 years
8. Cost of Diabetes
• $245 billion: Total costs of diagnosed diabetes in
the United States in 2012
• $176 billion for direct medical costs
• $69 billion in reduced productivity
After adjusting for population age and sex, average
medical expenditures among people with diagnosed
diabetes were 2.3 times higher than what expenditures
would be in the absence of diabetes.
See more at: http://www.diabetes.org/diabetes-
basics/statistics/#sthash.S4w1r5F1.dpuf
9. What is Cultural Competence?
It is the demonstrated awareness and integration
of three population-specific issues: health-related
beliefs and cultural values, disease incidence
and prevalence, and treatment efficacy.
But perhaps the most significant aspect of this
concept is the inclusion and integration of three
areas that are usually considered separately when
they are considered at all.
10. Why is it important?
It has been estimated that the combined cost of health
disparities and subsequent deaths due to inadequate
and/or inequitable care is $1.24 trillion.
Culturally and linguistically appropriate services are
increasingly recognized as effective in improving the
quality of care and services.
By providing a structure to implement culturally and
linguistically appropriate services, the enhanced National
CLAS Standards will improve an organization’s ability to
address health care disparities.
11. The Evidence shows results
Culturally sensitive diabetes education to
promote lifestyle changes can work with:
• Mexican Americans
• African Americans
• South Asians from India
• Brazilians
• Arabs
• Cambodians
12. What does culture impact?
• Communication
• Language
• Art
• Religion
• Diet
• Environment
• Customs
• Family role
• Illness & Death
• Preventative Medicine
• Gender role
• Social Groups
• Sexual Orientation
• Physical Capacity
• Mental status
Culture may change.
13. Cultural Competency?
• It begins with an honest desire to not allow
bias to keep us from treating each patient
with respect
• It continues with learning to evaluate our
own level of cultural competence and it must
be an ongoing effort to provide better health
care.
14. Benefits
• Reduced health disparities
• Improved health communications
• Improved dietary choices
• Improved Glycemic Control
• Improved Self-Management of Diabetes
• Potential prevention of Diabetes type 2
15. No Stereotyping
• Culture is expressed through the individual
• Not all members of a cultural group will
believe the same thing
• Variation within cultural groups.
16. Preferred Foods Based on
Country/Area of Origin
Mexico
Corn, beans,
chiles, hearty
stews, moles,
chocolate
Central America
Rice, beans,
corn, chiles,
chocolate
Rice, beans,
starchy root
Vegetables,
coconut, adobo
sofrito
Caribbean
South America
Potato, corn,
rice, Annato,
coriander,
onions,
Beef
17. Culture & Health Communication
• Patients may choose not to seek needed services
• Providers may make errors in diagnosis because of
miscommunication
• Patients may not follow medical advice for lack of
trust or understanding
• Providers may order fewer (or more) tests because
they may not understand or believe the patient’s
description of symptoms
HRSA
18. Basic Strategies
• Speak clearly and slowly without raising your
voice, avoiding slang, jargon, humor, idioms.
• Use Mrs., Miss, Mr. Avoid first names, which may
be considered discourteous in some cultures.
• Avoid gestures – they may have a negative
connotation.
• Many carry or wear religious symbols – Sacred
threads worn by Hindus, native Americans-
medicine bundles. DO not touch them.
19.
20. Cultural Competence Framework
Concepts
• Communication of cultural understanding and respect
is essential for establishing rapport and confidence
• Culture-related stresses and tensions can induce illness
• Culture-related behaviors (e.g. religion, diet) affect a
patient’s acceptance of and adherence to prescribed
therapy
• Nonverbal and verbal communication may differ from culture
to culture
21. Framework (Continued)
Skills
(specific for each culture represented and include the
following)
• Communicate an understanding of the patient’s culture
• Elicit patient’s understanding of his or her culture
• Recognize culture-related health problems
• Negotiate a culturally relevant care plan with patient as
partner
22. Framework, Continued
Attitudes
• Recognize the importance of the patient’s cultural
background and environment when constructing
an approach to an illness
• Acknowledge the patient’s role as an active
participant in his or her care
• Accept responsibility for the patient who has few
support systems; avoid the “what can I do?”
attitude when facing a patient in abject poverty
or with language barriers
23. Framework, continued
Knowledge
(specific for each culture represented and include the
following)
• Common dietary habits, foods, and their nutritional
components
• Predominant cultural values, health practices, traditional
health beliefs
• Family structure—patriarchal vs. matriarchal; nuclear vs.
extended; role of individual members
• Effect of religion on health beliefs and practices
• Customs and attitudes surrounding death
24. Culturally Competent Care
• Treat people uniquely
• Listen respectfully
• Gender sensitivity
• Educate yourself
• Know your comfort level
• Establish trust
• Be aware of different
cultures
25. The 4 C’s
• What do you call your problem?
• What do you think caused your problem?
• What have you done to cope with your
problem?
• What concerns do you have about your
problem, about my recommendations?
26. Kleinman’s 8 Questions
1. What do you think caused the problem?
2. Why do you think it started when it did?
3. What does your sickness do and how does it work?
4. How severe is your sickness/ How long do you expect
it to last?
5. What problems has the sickness caused you?
6. What do you fear about your sickness?
7. What type of treatment do you think you should
receive?
8. What are the most important results you hope to
achieve from this treatment?
27. Guidelines for Health Practitioners:
LEARN
Listen with sympathy and understanding to the
patient’s perception of the problem.
Explain your perceptions of the problem.
Acknowledge & discuss the differences and
similarities.
Recommend treatment.
Negotiate agreement.
28. Benefits
• Greater patient compliance
• Fewer harmful drug interactions
• More appropriate testing and screenings
• Increased likelihood that minorities will seek
health care
• More successful patient education
29. Developing Cultural Competence
Attitude/skill-centered approach
• Recognize your own biases; understand how
race, ethnicity, gender, etc. play a role in
healthcare delivery and perception of health
care.
https://implicit.harvard.edu/implicit/
• Acquire and apply culturally competent skills.
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