Delivering Diabetes Care to Ethnic Diversity (DEDICATED):
A systematic review of the impact of culturally-competent diabetes care
interventions for improving diabetes-related outcomes in ethnic minority
groups (EMGs)
P. Zeh¹ ², J. Sturt¹, H. Sandhu¹ & AM Cannaby²
,
1
University of Warwick
2
University Hospitals Coventry & Warwickshire NHS Trust
Research study background
• • • • • • • • Diabetes prevalence is rising at an alarming pace globally, affecting people of all ages especially ethnic groups
Approximately 285 million (6.6%) adults worldwide, age range 20-79 years, have diabetes, of which around 70% live in low- and middle-income countries
The cost of treating diabetes is approximately USD376 billion (11.6%) of the world’s total health
care expenditure in 2010
The number of diabetes cases is expected to rise to 438 million (7.8%) of the adult population by 2030, if preventive measures are not put in place
EMGs are the most vulnerable groups within their host country health care systems due to
cultural and linguistic problems
There is a paucity of culturally-competent health care service interventions on improving
diabetes health-related outcomes in EMGs
Culturally-appropriate interventions delivered by culturally and linguistically-competent
healthcare workers can confer important benefits to the person with diabetes, their families and bring about cost savings in every nation’s healthcare system
Improved responsiveness to the health beliefs, practices and cultural needs of patients with
diabetes is needed to ensure equitable access to diabetes care services, tailored to the
individual patient’s needs
Study aims
• • • • • • • • • • • Examine the effectiveness of culturally-competent interventions tailored to the needs of EMGs with diabetes globally
Study methods
• • • • • • • Medline (NHS Evidence), CINAHL and reference lists of retrieved papers were searched from inception to April 2010, with hand searching of three experts’ publications including two NHS specialist libraries for diabetes, and ethnicity and health
In addition, we searched the Warwick Medical School Research Publications, Cochrane and DARE databases
Paper selection and appraisal conducted independently by two reviewers
Inclusion criteria in the analysis were any study design which assessed effectiveness to any EMG within a majority population with diabetes
Only primary published studies were included
No language restriction, though all the full papers retrieved were in English
Data collection was on all reported outcome measures
• The review adheres to the NHS Centre for Reviews and Dissemination guidelines on Undertaking Systematic Reviews of Research on Effectiveness (2001)
Study Results
Figure 1: Flow chart of screening & included studies (Moher et al (2009) PRISMA)
Potentially relevant studies identified through
database searching and their titles & abstracts
independently screened by 2 reviewers (n=263)
Studies (full text) retrieved for
more details (n = 52)
Studies excluded with reasons as not interventions or
innovations aimed at improving cultural sensitive
service delivery to EMGs with diabetes (n=36)
Potentially relevant studies to be
included in the systematic review
for analysis (n=16)
Following detailed assessment against inclusion criteria, further
studies excluded (n=6):
Alexander et al (2008) – Findings reported in Utz et al (2008)
Collie-Akers et al (2007) – Not DM but prevention
Griffiths et al (2005) – Not only DM but also other chronic diseases
Hsu et al (2007) – Not primary study but a review
Peters & Jackson (2005) – EMGs without DM
Roy & Lloyd (2008) – Not EMGs
Appropriate RCTs and innovation
studies with adequate procedures
included for analysis (n=10)
Contact
For more information please contact; peter.zeh@uhcw.nhs.uk Included studies
Randomised controlled trials (n=4)
• Joshi et al (2010) - Improving ambulatory diabetes care in high-risk racial minorities (Hispanics & African American): use of culture-specific education and close follow-up (USA)
• Bellary et al (2008) – Enhanced diabetes care to patients of south Asian ethnic origin: a cluster randomised controlled trial (UK)
• Baradaran et al (2006) – A controlled trial of the effectiveness of a diabetes education
programme in a multi-ethnic community of South Asians in Glasgow (UK)
• O’Hare et al (2004) – Evaluation of delivery of enhanced diabetes care to patients of SA ethnicity
Action research (n=2)
• Povlsen et al (2005) – Educating families from 7 ethnic minorities in type 1 diabetes (Denmark)
• Greenhalgh et al (2005) - ) Sharing stories: complex intervention for diabetes education in
minority ethnic groups (Bangladeshis) who do not speak English (UK)
Retrospective cohort (n=2)
• Mehler et al (2004) – A community study of language concordance in Russian patients with
diabetes (USA)
• Hoppichler et al (2001) – Counselling programs and the outcome of gestational diabetes in
Austrian & Mediterranean Turkish women. Turkish women (Austria)
Quasi-experimental (n=1)
• Utz et al (2008) – Culturally tailored intervention for rural African Americans with T2DM (USA)
Qualitative involving group discussion / interview (n=1)
• Wilson et al (1993) – Diabetes Education: An Asian Perspective (UK)
Potentially relevant studies identified
through other sources & independently
screened by 2 reviewers (n=8)
Studies excluded with reasons; either duplicates or not
research or diabetes or EMGs or culturally-competent
related (n=219)
Ten out of 271 studies met the inclusion criteria (See Figure 1)
With the exception of two studies; one (10%) from Denmark and another (10%) from Austria, the rest of the studies (n=8) were either conducted in the UK (n=5) or USA (n=3)
The heterogeneity of these studies required narrative analysis
Participants were recruited from 3 settings (primary care, outpatients and community) and
varied greatly (African Americans (n=182), Asians (n=165), Bangladeshis (n=not given),
Hispanics (n=174), Turkish (n=39), Russians (n=55), SA (n=1865) and other 7 EMGs (n=37)
Study designs were varied and the interventions were provided by a diverse range of health workers namely: certified diabetes educators (often nurses), registered dieticians, podiatrist,
multilingual Asian link workers, expert diabetes patients from the same ethnic backgrounds,
diabetes specialist nurses, Diabetes specialist Health visitor, bilingual Russian internist in culture concordance, bilingual health advocates, and interpreters, where necessary
Apart from two studies (Mehler et al, 2004; Wilson et al, 1993), all the interventions reported a follow-up period which varied from 10 weeks to 7 years
Various outcomes reported: 7 were self-reported outcomes (e.g. satisfaction with diabetes
education programmes), 9 were assessed by someone other than the patient (e.g. eye checks) and 4 included objective validation (e.g. glycosylated haemoglobin)
No study formally set out to systematically assess the cost effectiveness of their culturallycompetent interventions
Two studies conducted in the USA with African-Americans (Utz et al, 2008; Joshi et al, 2010) used financial incentives to recruit and retain participants
The fundamental finding from these studies is that any diabetes-related intervention that was
tailored to EMGs by integrating the element of culture into that intervention, (cultural and
religious beliefs including linguistic and literacy skills), produced a positive impact. This was
consistent in all of the studies
Conclusions / recommendations
• • • • • • Diabetes is a serious and complicated disease which requires optimum glycaemic control to
minimise morbidity and mortality associated with it and its related complications
We identified benefits in using culturally-competent interventions with EMGs with diabetes
Due to the mixed methodologies and outcome measures in the review, the data did not allow for convincing comparisons across countries, EMGs, or the type of interventions
Further culturally-competent interventions are required and should include the cost-effectiveness evaluation which can easily influence diabetes service commissioners to decide on its
implementation
We recommend culturally-competent training to providers involved with diabetes care and
service delivery to EMGs to meet their specialised needs, which will ultimately improve their
outcomes
Finally, there is need for culturally-competent structured education programmes which should
include community leaders/companions of specific EMGs to instill motivation and commitments
Dissemination plan of findings
• • • • Review abstract submitted with Diabetes UK for poster competition
Findings to be presented at appropriate local MDT meetings
Review search to be updated and written up for Diabetes Medicine Journal or British Medical Journal publication once through with upgrade
Findings have led to a second systematic review on ‘cultural barriers to people with diabetes from EMG in accessing effective diabetes care and services’ whose data extraction is currently underway
We gratefully acknowledge the West Midlands Strategic Health Authority for funding this project
University Hospitals
Coventry and Warwickshire
NHS Trust