Outreach crucial to effective cross-cultural diabetes care of Asian-Americans

Physicians and educators must stay sensitive to cultural beliefs, language of Asian-American patients.

Merging the concepts of life force and blood glucose level is just one challenge for diabetes health care workers within the Chinese-American community. Those who serve Asian-Americans, however, are still seeking new ways to increase diabetes awareness in a culturally sensitive manner.

Currently, no data are available for prevalence rates of both diagnosed and undiagnosed diabetes among Asian-Americans and Pacific Islanders in the United States. According to the National Diabetes Clearing House, in Hawaii, Asians, Native Hawaiians and other Pacific Islanders are two times more likely to have diagnosed diabetes as whites after adjusting for population age differences. The National Diabetes Information Clearinghouse does not differentiate between Asian-American and foreign-born Asians. In California, Asians were 1.5 times more likely to have diagnosed diabetes as non-Hispanic whites.

In March 2002 (the most recent date for which census information was available), Asians and Pacific Islanders constituted 4% or 12.5 million of the civilian, noninstitutionalized population.

These groups likely suffer higher rates of diabetes than other groups for a number of reasons, according to Thomas Tsang, MD, MPH, medical director of New York City’s Charles B. Wang Community Health Center.

“There must be a genetic component for us to process sugars,” Tsang said. “In Asia, you don’t eat a whole lot of starches and you don’t eat a whole lot of processed foods. You’re eating rice and you’re eating vegetables.”

This factor, combined with “environmental interaction” when groups emigrate from Asia to the United States, is likely causing higher rates of diabetes in Asian immigrants, Tsang said. This is particularly true of the Japanese, he noted, whose prevalence rate for diabetes is 10% among second- and third-generation immigrants.

“When they shift their diet, somehow it’s causing this increase in diabetes,” Tsang said.

High Diabetes Rates for Minorities Different studies found that African Americans are from 1.4 to 2.2 times more likely to have diabetes than whites. Hispanic Americans have a higher prevalence of diabetes than non-Hispanic people, with the highest rates for type 2 diabetes among Puerto Ricans and Hispanic people living in the Southwest and the lowest rate among Cubans. The prevalence of diabetes among American Indians is 2.8 times the overall rate. Major groups within the Asian and Pacific Islander communities (Japanese Americans, Chinese Americans, Filipino Americans, and Korean Americans) had higher prevalence rates than whites. Source: Agency for Healthcare Research and Quality

Community involvement

For Tsang and other health care providers at the Wang Community Healthcare Center, building awareness of diabetes starts with a routine physical, but it doesn’t end there.

If a patient’s BMI is over 25, it is addressed, Tsang said. Each patient who gets a physical gets fats and sugars tested as well.

The center’s community involvement also helps bring about diabetes awareness, Tsang said. The center, which began a diabetes education program with three certified diabetes educators at the end of 2004, holds diabetes workshops for both patients and community members at their Canal Street location. Workshops cover a general overview of diabetes, chronic complications, medicine, physical activity and blood glucose monitoring.

Outside the center, annual community events are sometimes held in a park closed off specifically for their use. About 5,000 people usually attend, Tsang said, and can receive screening for cholesterol and sugar, among other services.

Still, the notion of health screening is not always familiar to the immigrants he treats.

“When your priorities are just putting bread on the table or making enough money to pay the rent, the idea of going for an annual physical and drawing blood is contrary to your notion of practicing good health,” Tsang said. “In Chinese cultures, most people don’t want to give blood or have their blood drawn because that’s like taking life forces away from your body.”

Health literacy

Helping patients who have limited reading and writing skills in their own language, let alone in English, is another treatment challenge, said Abby Toa, RN, CDE, assistant head nurse of internal medicine at Wang Community Healthcare Center.

“Health literacy is a main problem in our community right now,” said Toa, who added that some older immigrants might not have had formal education in their country of origin. Others are new immigrants who may be uninsured and can’t afford health services.

According to Tsang, the health center population reads at a 3rd grade level in their native Chinese dialect. To better reach this segment of the population, the center works with Chinese media to produce informative radio programs.

For Toa, explaining diabetes to patients consequently requires using symbols familiar to them. She will describe a cell as a house and uses a key to represent insulin. When she describes how cells use glucose, she will explain the key is needed to open the door and let the sugar in.

While the Wang Community Center caters to both immigrant and non-immigrant Asians, a population who may be underserved due to financial reasons, diabetes affects other Asians regardless of income, Toa said.

The difference is that those with higher incomes are likely to be more educated and have more resources available to them when it comes to managing the disease.

Educating doctors, nurses

Gloria Yee

Outreach programs within the Asian-American community are not just geared toward patients these days, according to Gloria Yee, RN, CDE, business coordinator at the University of California San Francisco Diabetes Teaching Center.

“We are getting more referrals from primary care,” said Yee, explaining UCSF’s efforts to reach out to physicians.

For the past year, UCSF has been targeting primary care doctors in both health clinics and private practice who work in high diabetes risk areas. Monthly, the group distributes flyers detailing the services they provide for patients with diabetes. The diabetes team at UCSF includes pharmacists and nutritionists, as well as doctors, dentists and nurses who specialize in diabetes treatment.

Yee said that patients at the UCSF are primarily Chinese, Southeast Asian and Pacific Islander or of that heritage. She also has type 1 diabetes herself and has been a diabetes educator for the last 10 years. The Asian patients she sees are mainly those with type 2 diabetes, although a large group is also treated for type 1.

Patient and doctor response to the referral program has been positive, and the center is still brainstorming for new outreach methods. Center staff members already meet with clinic directors to spread word of the center’s services. The diabetes classes they offer are approved for continuing education units and nurses are encouraged to attend, she said. – by Rachel Eskenazi

For more information:

• Services provided by the Charles B. Wang Community Healthcare Center may be viewed at www.cbwchc.org/cbwchc.asp. Services offered by the Diabetes Center, University of California, San Francisco may be viewed at www.diabetes.ucsf.edu