This document discusses the importance of culturally-responsive healthcare, especially for immigrant populations dealing with diabetes. It outlines two approaches - the cultural competence model and cultural safety model. The cultural safety model is preferred as it considers how social, economic, and political factors influence health and recognizes diversity within cultural groups. The document also examines culturally-responsive diabetes care, including different conceptions of health, treatment approaches, expectations of professionals, and the influence of social determinants. It provides examples of best practices for developing culturally-appropriate services and resources.

1. Immigrants, Diabetes and
Culturally-Responsive Healthcare
Sylvia Reitmanova, MD, PhD
University of Ottawa
sreitman@uottawa.ca

2. The lack of culturally-responsive care
Misunderstanding and miscommunication
Patient general dissatisfaction
Poor adherence to therapy and care
Poor health outcomes
Health and care disparities
Rationale for the provision of
culturally-responsive health services

3. • Association of Faculties of Medicine of Canada:
the Social Accountability Initiative to address and advocate the
changing needs of the communities
• Liaison Committee on Medical Education:
“… demonstrate an understanding of the manner in which people
of diverse cultures and belief systems perceive health and illness
and respond to various symptoms, diseases, and treatments.”
“… to recognize and appropriately address gender and cultural
biases in themselves and others, and in the process of health care
delivery.”
Socially responsible healthcare

4. Ottawa (Census 2006):
Population 835,470
Immigrants 187,945
men 85,920
women 94,120
visible minorities 109,080
(Black, Chinese, South Asian, Arab)
no knowledge of English/French 10,325
Changing population demographics

5. Two approaches to developing
culturally-responsive care
Cultural competence model
culture = fixed patterns of learned beliefs, values, practices,
ways of interacting and communicating shared among groups
and passed between generations
• all patients in one cultural group present the same health beliefs
and behaviours
• eliciting patients’ health beliefs, concepts of time, space and
physical contact, communication styles, the role of family and
gender, social expectations, and decision-making preferences
• a list of “do’s and don’ts”
• tolerance, inclusion, and appreciation
Reinforces homogenizing, stereotyping and “othering”

6. Cultural safety model
culture = flexible system of values and world views that people
live by and recreate continuously depending on larger social,
economic and political circumstances
• the role of the social, economic, political and historical context in
health outcomes and healthcare delivery (variations in
socioeconomic status, employment, and housing patterns, the
effects of war, torture, and abuse)
• intersectionality of culture, ethnicity, skin colour, gender, class,
ability, age or sexual orientation in production of health
• exploration of personal biases, fears, emotional reflexes, and
psychological defences
Two approaches to developing
culturally-responsive care

7. Culturally-responsive diabetes care
• Conceptions of health and disease
• Variations in treatment approaches
and responses
• Expectations from health professionals
• Social determinants of health

8. Conceptions of health and disease
“People are enmeshed within kinship structures and political,
economic and religious systems which define who and what they
are” (Lawton, 2007, p.901)
Diabetes
Externalising responsibility = diabetes “happened to us” rather than
“we brought it on ourselves”
• Running in the family
• All-pervading in the community (impossible escaping)
• God’s will
• Stress due to social roles and obligations
• Stress due to unfamiliar lifestyles and values
• Lack of control over one’s lifestyle
• Medication

9. Variations in treatment approaches
and responses
• Psychological therapy (meditation, imagining, problem solving)
• Social therapy (family involvement, social re-integration)
• Physiological therapy (massage, acupuncture)
• Supernatural therapy (prayers - traditional folk healers or religious
authorities)
• Own herbal and healing remedies
• Drug therapy
Some patients (e.g. Hispanics and Nigerians) are more likely to
have low levels of Cytochrome P450 isoenzymes involved in the
oxidation of many drugs resulting in poor metabolism of drugs

10. Expectations from healthcare
professionals
“For decades we understood the professions as a conventional
nuclear family, with doctor-father, nurse-mother, and patient-
child. But our hope for total wisdom and protection from father is
forlorn, our wish for total comfort and protection from mother
unachievable, and the patient has grown up. A new three way
partnership should displace this vanishing family.”
(Salvage & Smith, 2000, p.1019)
Ontario’s Family Health Teams
The roles and authority Compliance

11. Social determinants of health
Racialization
poor health outcomes, undesired health behaviours and health
choices are often blamed on differences in biology, ethnicity,
culture or religion
Social determinants of health
gender, income and social status, employment and working
conditions, social support networks, education, physical and
social environment, healthy childhood development, health
services

12. The Starr County culturally-competent
diabetes self-management education
Community assessment
• Understanding of diabetes
• Previous experiences
• Suggestions for intervention
Intervention
• Language
• Cultural beliefs
• Diet
• Family
• Social emphasis

13. Practical tips for developing culturally-
responsive health services
• Physical environment, materials & resources
• Communication styles
• Social interaction
• Cultural conceptions of health, illness, and end of life
• Cultural assumptions, attitudes and values

14. Canadian Diabetes Association:
Diabetes GPS
• an interactive microsite developed to help people with diabetes
from the Chinese, South Asian and African Caribbean communities
access culturally appropriate information in their own language
http://www.diabetesgps.ca
Resources

15. References
• Brown SA & Hanis CL. Culturally competent diabetes education
for Mexican Americans: the Starr County Study. The Diabetes
Educator, 1999; 25(2):226-36
• Lawton J et al. Contextualising accounts of illness: notions of
responsibility and blame in white and South Asian respondents'
accounts of diabetes causation. Sociology of Health and Illness,
2007; 29(6):891-906
• Nova Scotia Department of Health. A Cultural Competence Guide
for Primary Health Care Professionals in Nova Scotia. Halifax, NS:
Nova Scotia Department of Health, 2005
• Salvage J & Smith R. Doctors and nurses: doing it differently. BMJ,
2000; 320:1019-20