This document discusses cultural factors that impact diabetes management among immigrant populations in Ottawa, Canada. It begins by providing demographic information on cultural communities in Ottawa and then reviews qualitative studies that identified key cultural barriers to diabetes care, including language barriers, financial constraints, differences in diet and food practices, and certain cultural beliefs. The document concludes by discussing strategies for providing more culturally sensitive care, such as using interpreters and developing culturally tailored education programs.

1. Dr. Hasina Visram, MD, MSc

2.  To review Ottawa’s cultural demographics
 To highlight the impact of culture on diabetes
management
 To review strategies to improve cross cultural
diabetes care

4.  Canadian immigrants tend to settle in big cities.
 Compared to other cities, immigrants who settle in
Ottawa are typically more educated, earn higher
wages, and have higher levels of employment.
 Ottawa receives the highest percentage of refugees
and family-related immigration of any major
Canadian centre.
 Recent immigrants (settled within 10 years) - make
up 6.8% of the population.
 18% of Ottawa’s population was born outside of
Canada.

5.  Third-largest West Indian community, and
the second-fastest growing after Toronto.
 Fourth- largest African community, and the
second-fastest growing after Calgary.
 Chinese community is the smallest of
Canada's five largest centres, but the
country's fastest-growing.
 Fourth-largest Middle Eastern community.
 Our European community is the smallest of
Canada's five largest cities.

11.  Qualitative interview based studies
 UK, United States
 South Asian, Hispanic, Chinese and African
American populations

12.  Language
 Finances
 Diet
 Belief Systems

14.  Effects first generation immigrants more
 Poor fluency in English has been identified by
patients as a major barrier to accessing and
understanding basic health information
 Poor English also limited people’s willingness to
travel beyond the immediate neighborhood
 Impact on food shopping, exercise, daily living

15. Interpreters
Preferred professional translators over family
 Power dynamic of having parents depend on
children to translate
 Translation of medical terms
 Same gender interpreter preferred

16.  Not the only player
 Only providing advice in an Asian
language was ineffective as an
educational intervention to
encourage dietary modification in
South Asian patients with diabetes
in Leicester.

17.  UK Study interview based study
 Caucasian British patients as well as South
Asians suggested that information offered
about their condition could be difficult to
understand.
 White male, interview no. 20: ‘‘If they talked in layman’s I
would, knowing what they say what these tablets are for.
It’s when they start using the technical terms . . .’

18. Health literacy is distinct from language fluency
and refers to “an individual’s ability to read,
understand, and use healthcare information to
make effective healthcare decisions and follow
instructions for treatment.”

19.  Low health literacy is more prevalent among
marginalized populations
◦ A study of 408 patients with type 2 diabetes identified that
52% of Hispanic patients versus 15% of non-Hispanic white
patients had inadequate health literacy, as assessed with
the English or Spanish version of the short-form Test of
Functional Health Literacy in Adults.
◦ In a survey of 22 Hispanic patients with diabetes, 91% were
unfamiliar with the term A1c.
◦ A crosssectional survey of 30 Puerto Rican adults with type
2 diabetes found that only 37% were able to identify a
normal blood glucose level, and 33% could not identify
long-term complications related to diabetes.
 Strong English skills in the immigrant population
do not ensure strong health literacy

20. How confident are you filling out medical forms by yourself?
How would you rate your ability to read medical forms?

22.  Almost 60% of Hispanic adults with diabetes have
an annual income below $20,000 compared with
approximately 28% of non-Hispanic whites with
diabetes.
 In a survey of 44 low-income Mexican-Americans
with type 2 diabetes, cost was identified as a
reason some patients reduced their dosage or
frequency of insulin therapy.
 Cost cited as a barrier to treatment in 24% of
Hispanic patients with diabetes versus 8% of non-
Hispanic whites.

23.  General diabetic population in South
Auckland surveyed.
◦ Covered by government programs
◦ Annual out of pocket costs ranged from $191 -
$329
◦ 18-49% reported costs led to less blood glucose
monitoring
◦ 11-47% said finances impacted use of oral
medications
◦ 8-52% said that cost impacted insulin therapy

29.  Diet specific concerns
◦ High fat content of some Indian curries
◦ High sugar/calorie Indian desserts
◦ Role of rice in Chinese cuisine
◦ Role of balance in Chinese cuisine

30.  Incorporation in to a way of life
◦ Travel
◦ Visiting family
◦ Shared meals

31.  45 African American patients through
discussion groups:
◦ Four areas impacting diet – habitual (meal plans
lacking in taste), economic (cost of low fat, low
sugar, fresh items), social (lack of family support,
family pressure to cook preferred meals),
conceptual (understanding food labels).

32.  Similar barriers in South Asian and Somali
populations
 Added cost of culturally comfortable food (ie.
Bangladeshi vegetables)

34.  Disease states are an action by God
◦ Individuals have little control over the course

35. Social stigma of illness
 Effects diet in group settings
 Deterrent to insulin treatment

36. Infancy of western medicine
 Concerns regarding side effects
 Beliefs about efficacy

38. Culturally Oriented Clinical Encounter

40. Culturally sensitive and relevant programs
 Location
 Timing
 Program development
 Presenters
 Participants

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