Q&A: Culturally inclusive diabetes care requires 'nuanced approach'
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Key takeaways:
- Balancing norms and evidence-based practices with sensitivity is key to culturally competent diabetes care.
- Physicians can establish trust by listening, tailoring education and respecting individual autonomy.
Diabetes has emerged as a worldwide health crisis, affecting a diverse set of demographically distinct patients with varying levels of severity. In an interview with Healio, Jay Shubrook, DO, professor and a primary care diabetologist at Touro University California College of Osteopathic Medicine, said this chronic condition holds a particular gravity among specific demographics, such as African American, Hispanic and Native American populations. The prevalence of diabetes and its complications within these communities underscores the urgent need for a nuanced approach to patient care, Shubrook said. This approach must recognize the cultural differences in the disease’s manifestation and the complex interplay of habits, preferences and beliefs that patients with diabetes encompass.
Though diabetes may be extremely common, the experience of diabetes can be deeply personal and contextual, Shubrook said, noting that approximately 90% to 95% of diabetes care relies on self-management. The challenges posed by cross-cultural dietary management further accentuate the significance of understanding and respecting the unique dietary habits and preferences rooted in diverse traditions. For this reason, the value of cultural competency in diabetes care has become exceedingly evident as a means of empowering doctors to effectively care for patients.
Healio: Can you share an example of a successful interaction where you addressed cultural beliefs about health and medicine to improve a patient’s diabetes management?
Shubrook: Often when I’m interacting with patients, I’ll ask them what are their goals for the visit? What are the things that are important to them? And what are their biggest challenges? Having that framework really helps me then to navigate the space where we can make differences. When we ask about, for example, a dietary history, I will usually ask them to walk me through a typical day. When do you wake up? What do you do? When do you eat? Who do you eat with? You get a much richer history about what that looks like. For example, I eat breakfast alone because I’m the only one awake. To make a change at breakfast might be easier because it doesn’t affect other people, or it might be harder because I don’t have other people to help me. When you say, let’s talk about modifications and let the person pick which things to be modified, it’s way more likely to be successful.
Healio: In your experience, what are some common misconceptions or cultural beliefs about diabetes that you’ve encountered? And how do you navigate conversations about this?
Shubrook: Every culture, every community has a set of myths, and it can make management harder. I hear people say commonly, “Well, I can’t have diabetes. I don’t feel it.” Many people are used to feeling sick when they are sick. That’s one thing to really highlight; that yes, you can have diabetes and you can have problems even if you don’t feel it. There are some cultures that attribute diabetes very heavily to stress, and, absolutely, stress can be a trigger, but rarely does stress cause it in its entirely. There’s genetic susceptibility; there’s, of course, lifestyle components; stress would make it worse, but it’s not like you can get rid of stress and you can get rid of diabetes. Some people, and this is somewhat cultural but also somewhat lived, feel very fatalistic about diabetes. If I get diabetes, I’m going to have kidney failure. While that may be what people have seen, we really haven’t created the space to say, “Well, actually there’s an alternative pathway.” You could identify this earlier, treat it earlier and get ahead of it to prevent kidney failure, but what happens is they think, “Everyone in my family gets diabetes, and if I get diabetes, I’ll get kidney failure. So, I’m going to wait as long as possible to admit I have diabetes,” which then kind of sets us up for failure.
The last myth is that insulin is bad. There’s a number of cultural groups that really resist insulin, and I think that’s partially due to the way we’ve been using insulin. It’s about knowing what that person’s individual and or cultural challenges are and trying to address those myths. You can do that by starting the visit by saying, “Tell me what you know about diabetes and how you got this diabetes.” I think you can learn a lot if you have these open-ended questions.
Healio: What strategies do you employ to ensure that diabetes care is inclusive and sensitive to LGBTQI+ patients unique concerns?
Shubrook: That’s a really important question and certainly a place where we could be doing better than we do as a group, as health care professionals. First of all, it is important to recognize that many people in the LGBTQI community actually are more likely to have complications, not because of their treatments, but because of the lack of treatments that are being provided for their diabetes because of considerations of their other health care needs. That is important to recognize. Just like anything else, we should be treating that person as an entire person and recognizing the pathophysiologic processes, which really have nothing to do with gender expression or identity. They are separate, it has nothing to do with it. We also need to be more sensitive in every aspect of the patient care visit, from answering the telephone, to the MA who brings the person in, to the health care clinician that sees them, to the diabetes care and education specialist. If you feel disrespected, you are probably not going to want to get care there or you are probably not going to be as trusting of care. We have to find a way to have the system be more inclusive so that when we get to the work of health care, it’s a nonfactor.
Healio: How do you approach discussing self-monitoring, insulin injections, other diabetes management techniques with patients who may have cultural taboos or sensitivities around certain bodily practices?
Shubrook: That’s an important and common concern. First of all, it’s good to know what those are; it’s good to recognize them. We had mentioned insulin earlier. I would say, “It sounds like insulin is really kind of a hard stop for you, I respect that, we’ll talk about other options. I will share with you why this would be important, but you are the captain of your ship and we will respect your wishes.” And I think that goes a long way. Letting people know they have a voice and that you’re not going to force your will on them.
I also think it’s good to be curious. I’m going to talk about, maybe, herbal things and come back to the glucose monitoring, but there are a lot of different people from different cultures that bring in their herbal and supplemental treatments. I think it’s great to say, “Tell me more about it. What do you know about it? How did you learn? I say, “Would you like me to look it up and I could give you an opinion?” I think that respects the person; like they did homework, right? Surely, they’ve checked it out, they have some experience.
Now, back to glucose monitoring. A lot of people feel like they are checking their sugars, which is maybe one of the most painful parts of diabetes, but they don’t know why they’re doing it and there’s no action plan. I will often say, “I’d like you to consider checking your sugars first thing in the morning and this is what we’re doing with it. And if you’re high or you’re low, this is how you can respond.” When people know that it’s part of a plan and they have action items they can do, they may be more willing to do it. I also think we should not assume that everybody must check their sugars. We now have sensors. I like to ask, “Is it the information that you’re worried about or is it the pricking of your finger?” Using continuous glucose sensors, even if it’s intermittently, could be another option.
Healio: How do you balance cultural considerations with evidence-based guidelines, especially when they might conflict?
Shubrook: I wouldn’t assume the cultural norms are not evidence-based, some might be. We have to be curious about all of it. I certainly want to give accurate information. I want to be a resource for my patients; but I also want to recognize that diabetes is largely self-managed. If you said, “Today, I would really like to use cinnamon to manage my diabetes, I feel strongly about this, my grandparents have recommended it.” I’ll say, “OK, well, let’s consider that. Would you be willing to check your glucose for a week before you start cinnamon? And then for the 2 weeks while you’re taking cinnamon, so we can see if it works for you? And if it works for you, great. If it doesn’t work for you, can we revisit some other options?” By doing that, you are respecting the person’s autonomy, you’re respecting their norms, and then you’re giving them an opportunity to test that theory, just like we would do with a medication.
Healio: What advice would you have regarding building trust and rapport with patients from culturally diverse backgrounds?
Shubrook: We have to listen; that’s the first place to start. Two, I think you want to make sure that the person and their family are comfortable in the medical setting. That often means building in extra time for those visits; it means having a certified translator if you don’t have the ability to communicate in multiple, which I don’t. Also, taking the time to know their norms and their experience as the starting point would be a critical part to building a long-term productive relationship; pointing out areas where there may be inconsistencies with medicine and cultural norms, but presenting that information in a nonjudgmental way.
Knowing what’s most important for the patient is also key. I have a number of patients that have very strong family values; that’s the focus of their lives. Then my recommendation will need to focus on the family. If I asked them to take care of themselves by making changes, it might be hard for them philosophically to do because they feel like they have other responsibilities. But if I could share that managing their diabetes could benefit their children, that’s a whole different conversation because they would do anything for their children.
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