Cultural competence in diabetes management: why is it important?

Summary

Our culture influences our beliefs and world view, which influences our relationships. And nowhere are relationships more important than in the management of chronic diseases, where a network of people interact daily to improve the health of the person living with the disease. Successful diabetes care relies on a positive and trusting relationship between a patient and their care team. There is, however, no doubt that forming relationships with people different from us can be a challenge, especially when we don’t have a good understanding of their background. In an increasingly culturally diverse world, where everyone needs to access effective healthcare, how do we ensure that we interact respectfully? or knowledgeably? — with people whose norms may differ from ours? The answer: by being culturally competent.

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Key points

What is cultural competence?

A culturally competent person is someone who effectively interacts with, and understands people from other cultures. In healthcare, cultural competence refers to the ability of health providers, systems and policy to meet a patient’s social, cultural and language needs. This is particularly useful in the management of chronic diseases like diabetes or hypertension.  

To be culturally competent, you must: 

  • be willing to understand and accommodate different worldviews. 
  • not look down on another culture as inferior to yours.  
  • understand your culture as it helps in understanding others. 
  • appreciate cultural differences and similarities between and among similar ethnic groups. 

Why is cultural competence important? ​

According to Dr. Natalie Darko, associate professor at De Montfort University (U.K.), cultural competence improves treatment outcomes for ethnic minorities, particularly those of African and Caribbean descent.  

A culturally competent system not only improves health outcomes but also eliminates racial biases and increases the quality of care. Healthcare professionals who are able to see past their own cultural lense can establish a stronger, more meaningful and productive bond with their patients.  

“When discussing cultural competence, we need to separate race from ethnicity,” Dr. Darko says. “Race refers to skin colour or tone. And ethnicity focuses on the cultural aspects — behaviours, thoughts, communication, beliefs — of different groups,” she adds.  

Dr. Darko believes that understanding this difference will move us closer to achieving cultural competency. And ultimately, result in a better healthcare experience for affected groups. 

For Dr. Sam Seidu, Head of Research at Primary Care Diabetes Europe and a general practitioner in the U.K., cultural competence gives clinicians the tools to adapt their approach to their patients. For example, religion is often an important part of the culture for people from ethnic minorities. Understanding how religious beliefs may guide their perspective and influence their decisions is key to a more productive conversation about their health.  

Dr. Seidu recollects a recent exchange with one of his patients, who had decided to leave his condition “in the hands of God.”. “When such patients decline care and turn to God,” explains Dr Seidu “it’s the job of the provider to tailor care while accounting for the patient’s belief system.” “And this involves understanding that there are sensitivities and differences involved in treatment,” he adds.  

There are different ways in which beliefs can be brought up and addressed during a consultation. For Dr. Seidu, this might include involving God in a patient’s medication therapy or negotiating a reasonable middle ground. After all, ‘God’ may be putting qualified professionals on a person’s path.  

In cases where language barriers exist, Dr. Seidu encourages health providers not to label patient’s culture, but to instead encourage them. This can be done by either using an interpreter or exercising more patience. All these are done to remove stigma and improve understanding.  

Dr. Seidu and Dr Darko agree that cultural competence is important in changing the narrative, especially about minority groups being difficult to reach when managing chronic conditions.  

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Importance of cultural competency in diabetes management ​

Healthcare providers may want to become culturally competent for a list of reasons, not least because they care for their patients and wish to improve outcomes. Seeing people get better makes them happy.  

There is also an urgent need to improve outcomes for patients from ethnic minority communities. In the UK, Data shows that the incidence of Type 2 diabetes is three to five times higher in this group than in the white British population. For people living in these communities, the higher incidence of Type 2 results in higher stress levels and reduced quality of life. This also means a higher cost for the healthcare system.   

In the management of chronic illnesses like diabetes, cultural competence can help: 

  • Understand and address barriers that prevent uptake of treatment.  
  • Reduce disparities and inequality of access to diabetes care.  
  • Overcome culture blindness and offer a more nuanced approach to culture. For ex. not categorizing different ethnic groups — African and African Caribbean groups — into one, i.e. ‘black people’.  
  • Change some of the treatment outcomes and help in understanding differences in diagnosis and medication.  
  • Move towards health equity. 

Sadly, current diabetes management practices do not always up to date with culture competence.  

For Hindy Korah, a black nurse living with diabetes in the UK, cultural awareness and competency in diabetes care leave a lot to desire. “The closest I’ve come to having a conversation about culture is talking about Asian food and curry. I know we’ve got our spices in African food, but it’s not the same”. 

In her experience, a lot of the advice focuses rightly on eating vegetables, “but in our culture, starch and carbohydrate plays a huge role in the diet”. Because some care providers don’t have this context, she says they haven’t been able to help her properly. 

She says discussing culture would have made it easier to open up about her diet and overcome a fear of stigma. Or being judged for her food choices. Hindy is originally from Ghana and giving up her banku, a type of corn and cassava dough ball, has been difficult.  

Unsurprisingly, Hindy is very thorough when attending to ethnic minority patients like herself. In her practice, she asks a lot of questions and she is relatable. As a result, patients are more willing to talk to her and hear advice.  

According to Hindy, healthcare professionals need to accept that cultures are neither good nor bad; they’re just different. And removing labels encourages patients in minority groups to discuss their choices and habits. This is particularly important in bringing down mortality and morbidity rates. 

The following tips can assist healthcare professionals to open up a discussion:  

  • Establish a connection where patients can share the happenings of their life. This can be achieved by taking a genuine interest in the patient’s life and well-being.  
  • Don’t just ask questions, but try to understand the patient’s perspective. Doing this involves a lot of listening.  
  • Recognise how a person’s background and culture is linked to their identity.  
  • Encourage feedback by asking how you can do better as a provider, or what treatment option works best for a patient. E.g Does this medication adapt to the food you eat? Do you mind adapting your food to this medication? etc. 

All these can make a world of difference for people of ethnic minority background living with diabetes and other chronic illnesses.  

How to improve cultural competence

Cultural competency is an ongoing journey. After becoming culturally competent, we then become proficient. Cultural proficiency requires constantly updating our knowledge because culture is not static, and the needs of a group change regularly.

Cultural competence in diabetes management: why is it important?
an illustration of the cultural competence continuum, including cultural destructiveness, cultural incapacity, cultural blindness, cultural pre-competence, cultural competence, cultural proficiency

Image: The continuum of cultural competence Illustration by Diabetes Africa, adapted from Cross et al. (1989) and eCALD 

As healthcare professionals develop through each stage of ‘cultural competency’ or competence, they begin to appreciate their patient’s journey more. And ultimately, this leads to improved quality of care.  

Dr. Darko remarks that there are a few ways to kickstart the competence journey. They include: 

Humility

When was the last time you spoke with someone you had nothing in common with? or disagreed over a big issue?  

Did you truly listen in that conversation or did you just listen to just reply? Did you go away learning something new?  

Cultural humility involves listening. Truly listening to a person. By doing this, we become aware of our biases and the limitations of our knowledge. As a result, we start to make lesser assumptions about people. When we genuinely listen to people, they’re encouraged to share why they believe what they do. This then presents an avenue to learn more about their beliefs, realities and perspectives.  

This skill is very important in healthcare where so many diverse people interact on a daily basis. 

Sensitivity

To be culturally sensitive means to be aware of the differences and similarities that exist between people. And to not assign a value — whether positive nor negative. Right or wrong. Good or bad — to it. 

Cultural sensitivity allows us to learn what values and behaviour are important to people from different backgrounds. Examples include bowing to greet or addressing elders with reverence.

Appropriateness

Short form: cultural appropriateness means putting cultural sensitivity in action. 

Long-form: cultural appropriateness means tailoring interventions to specific groups. In health, it means that health services, behaviour, interventions, changes, and empowerment are adapted according to the population they’ll be applied to.  

It may involve adjusting health communication material to the language of a minority group, or paying attention to the role of religion in a patient’s behaviour. It may also involve determining the specific role of the family in a treatment regimen.  

The overall goal of cultural appropriateness is to ensure that interventions are holistic.  

How to improve cultural competence in health care

A culturally competent system provides quality care to all patients irrespective of race, ethnicity, English proficiency, or background. The following can be useful in improving cultural competence in the health system:  

  1. recruitment of ethnic minority staff in patient care. Hindy showed us that patients respond better when they see people who look like them. They open up more and this leads to better treatment outcomes. 
  2. arranging for interpreter services. This can help to overcome the language barrier or accent challenges that may occur during patient care. 
  3. inclusion of family members in health outcomes. For cultures where family influence is huge, bringing them on board can significantly improve treatment outcomes. 
  4. provision of regular cultural awareness training. Through constant training and regular updates, the provider’s knowledge keeps increasing.
  5. employment of various communication options. In addition to written leaflets, video and audio communication may also be employed. It also involves not assuming that every patient that comes seeking care can read and write. 
  6. locating health facilities in easily accessible areas. That way it’s accessible to all types of people.  

 

The importance of cultural competence in healthcare can’t be overstated, especially in chronic illnesses. Recently, Diabetes Africa hosted a virtual event on this topic. The event featured a physician, an academic researcher and a patient who shared her story. The aim of the episode was to understand how cultural competence affects treatment outcomes in diabetes. How these outcomes affect ethnic minority groups of African and Caribbean descent. And the necessary steps healthcare professionals could take in achieving cultural competence.  

 

*Novo Nordisk provided sponsorship to Diabetes Africa to support the costs of running the virtual event series. Novo Nordisk did not have any input into selection of speakers, programme content or agendas.

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