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CULTURALLY INFLUENCED 
BARRIERS IN CHRONIC 
DISEASE MANAGEMENT
Objectives 
• To review Ottawa’s cultural demographics 
• To highlight the impact of culture on several common 
barriers f...
Ottawa
Ottawa 
• Canadian immigrants tend to settle in big cities. 
• Compared to other cities, immigrants who settle in Ottawa 
...
Ottawa 
• Third-largest West Indian community, and the second-fastest 
growing after Toronto. 
• Fourth- largest African c...
Ottawa
Ottawa
Ottawa
Ottawa
Chronic Disease Management 
• Long term management plans 
• Long term health impact 
• Lifestyle changes form part of trea...
Data Sources 
• Qualitative interview based studies 
• UK, United States 
• South Asian, Hispanic, Chinese and African Ame...
Barriers 
• Language 
• Finances 
• Diet 
• Belief Systems
Language
Language 
• Effects first generation immigrants more 
• Poor fluency in English has been identified by patients as 
a majo...
Language 
Interpreters 
Preferred professional translators over family 
• Power dynamic of having parents depend on childr...
Language 
•Not the only player 
•Only providing advice in an Asian 
language was ineffective as an 
educational interventi...
Language 
• UK Study interview based study 
• Caucasian British patients as well as South Asians 
suggested that informati...
Language 
Health literacy is distinct from language fluency and refers 
to “an individual’s ability to read, understand, a...
Language 
• Low health literacy is more prevalent among marginalized 
populations 
• A study of 408 patients with type 2 d...
Language 
How confident are you filling out medical forms by yourself? 
How would you rate your ability to read medical fo...
Finances
Finances 
• Almost 60% of Hispanic adults with diabetes have an 
annual income below $20,000 compared with 
approximately ...
Finances 
• General diabetic population in South Auckland surveyed. 
• Covered by government programs 
• Annual out of poc...
Finances
Finances
Diet
Diet 
• Diet specific concerns 
• High fat content of some Indian curries 
• High sugar/calorie Indian desserts 
• Role of...
Diet 
• Incorporation in to a way of life 
• Travel 
• Visiting family 
• Shared meals
Diet 
• 45 African American patients through discussion groups: 
• Four areas impacting diet – habitual (meal plans lackin...
Diet 
• Similar barriers in South Asian and Somali populations 
• Added cost of culturally comfortable food (ie. Banglades...
Belief Systems
Belief Systems 
• Disease states are an action by God 
• Individuals have little control over the course
Belief Systems 
Social stigma of illness 
Effects diet in group settings 
Deterrent to insulin treatment
Belief Systems 
Infancy of western medicine 
Concerns regarding side effects 
Beliefs about efficacy
Culturally Oriented Clinical Encounter
Culturally Oriented Clinical Encounter
Community Outreach 
Culturally sensitive and relevant programs 
Location 
Timing 
Program development 
Presenters 
Pa...
Questions
References 
1. Caballero A. Cultural Competence in Diabetes Mellitus Care: An Urgent Need. Insulin 2007; 2(2): 80-91. 
2. ...
Cultural barriers in chronic disease managment
Cultural barriers in chronic disease managment
Cultural barriers in chronic disease managment
Cultural barriers in chronic disease managment
Cultural barriers in chronic disease managment
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Cultural barriers in chronic disease managment

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Cultural barriers in chronic disease managment

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Cultural barriers in chronic disease managment

  1. 1. CULTURALLY INFLUENCED BARRIERS IN CHRONIC DISEASE MANAGEMENT
  2. 2. Objectives • To review Ottawa’s cultural demographics • To highlight the impact of culture on several common barriers faced in the management of chronic diseases • To review strategies to improve cross cultural care
  3. 3. Ottawa
  4. 4. Ottawa • 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. 5. Ottawa • 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.
  6. 6. Ottawa
  7. 7. Ottawa
  8. 8. Ottawa
  9. 9. Ottawa
  10. 10. Chronic Disease Management • Long term management plans • Long term health impact • Lifestyle changes form part of treatment plan
  11. 11. Data Sources • Qualitative interview based studies • UK, United States • South Asian, Hispanic, Chinese and African American populations
  12. 12. Barriers • Language • Finances • Diet • Belief Systems
  13. 13. Language
  14. 14. Language • 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. 15. Language 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. 16. Language •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. 17. Language • 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. 18. Language 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. 19. Language • 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. 20. Language How confident are you filling out medical forms by yourself? How would you rate your ability to read medical forms?
  21. 21. Finances
  22. 22. Finances • 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. 23. Finances • 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
  24. 24. Finances
  25. 25. Finances
  26. 26. Diet
  27. 27. Diet • 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
  28. 28. Diet • Incorporation in to a way of life • Travel • Visiting family • Shared meals
  29. 29. Diet • 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).
  30. 30. Diet • Similar barriers in South Asian and Somali populations • Added cost of culturally comfortable food (ie. Bangladeshi vegetables)
  31. 31. Belief Systems
  32. 32. Belief Systems • Disease states are an action by God • Individuals have little control over the course
  33. 33. Belief Systems Social stigma of illness Effects diet in group settings Deterrent to insulin treatment
  34. 34. Belief Systems Infancy of western medicine Concerns regarding side effects Beliefs about efficacy
  35. 35. Culturally Oriented Clinical Encounter
  36. 36. Culturally Oriented Clinical Encounter
  37. 37. Community Outreach Culturally sensitive and relevant programs Location Timing Program development Presenters Participants
  38. 38. Questions
  39. 39. References 1. Caballero A. Cultural Competence in Diabetes Mellitus Care: An Urgent Need. Insulin 2007; 2(2): 80-91. 2. Campos CMPH. Addressing Cultural Barriers to the Successful Use of Insulin in Hispanics with Type 2 Diabetes. South Med J 2007;100:812-20. 3. Chesla CADNSC, F.A.A.N., Chun KMPHD, Kwan CMLPHD. Cultural and Family Challenges to Managing Type 2 Diabetes in Immigrant Chinese Americans. Diabetes Care 2009;32:1812-6. 4. Dutton GR1, Johnson J, Whitehead D, Bodenlos JS1, Brantley PJP. Barriers to Physical Activity Among Predominantly Low-Income African- American Patients With Type 2 Diabetes. Diabetes Care 2005;28:1209-10. 5. Grace C, Begum R, Subhani S, Kopelman P, Greenhalgh T. Prevention of type 2 diabetes in British Bangladeshis: qualitative study of community, religious, and professional perspectives. BMJ 2008;337:1094-100. 6. Ho E, James J. Cultural Barriers to Initiating Insulin Therapy in Chinese People With Type 2 Diabetes Living in Canada. Canadian Journal of Diabetes. 2006;30(4):390-396. 7. Karter A, Stevens M, Herman W, Ettner S, Marrero D, Safford M, Engelgau M, Curb J, Brown A. Out-of-Pocket Costs and Diabetes Preventive Services. Diabetes Care 2003;26:2294–2299. 8. Law M, Cheng L, Dhalla I, Heard D, Morgan S. The effect of cost on adherence to prescription medications in Canada. CMAJ 2012. DOI:10.1503/cmaj.111270 9. Lawton J, Ahmad N, Hanna L, Douglas M, Hallowell N. 'I can't do any serious exercise': barriers to physical activity amongst people of Pakistani and Indian origin with Type 2 diabetes. Health Educ Res 2006;21:43-54. 10. Ngo-Metzger Q, Massagli MP, Clarridge BR, et al. Linguistic and cultural barriers to care. Journal of General Internal Medicine 2003;18:44-52. 11. Powers BJMHS, Trinh JV, Bosworth HB. Can This Patient Read and Understand Written Health Information? JAMA 2010;304:76-84. 12. Sriskantharajah J, Kai J. Promoting physical activity among South Asian women with coronary heart disease and diabetes: what might help?. Fam Pract 2007;24:71-6. 13. Stone M, Pound E, Pancholi A, Farooqi A, Khunti K. Empowering patients with diabetes: a qualitative primary care study focusing on South Asians in Leicester, UK. Fam Pract 2005;22:647-52. 14. Vijan S, Stuart NS, Fitzgerald JT, et al. Barriers to following dietary recommendations in Type 2 diabetes. Diabetic Med 2005;22:32-8. 15. Wallin, AnneMarie L, Monica A, Gerd RNT. Diabetes: a cross-cultural interview study of immigrants from Somalia. J Clin Nurs 2007;16:305-14.

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