Cultural Group: African Americans, Research Paper Example

Diabetes Prevention and Education for African Americans

Introduction

The incidence of type 2 diabetes among African-Americans is a particularly unfortunate example of the health disparities faced by this historically marginalized community. Poverty and lack of healthcare contributes to a much higher incidence of diabetes among African-Americans than among European-Americans. In addition, there are a number of cultural factors that pose profound challenges to rectifying the health disparities. Fortunately, by developing culturally responsive and efficacious treatment plans, it is possible to ameliorate this disparity by educating those at risk, or who have diabetes.

Community Cultural Assessment

African-Americans are an at-risk population for diabetes, accounting for a disproportionate share of cases of type 2 diabetes in the U.S. Nationally representative samples have demonstrated that African-American men are two to five times as likely as their Euro-American counterparts to either have or develop diabetes. For African-American women, the figure is twice the likelihood of their Euro-American female counterparts (Baptiste-Roberts et al., 2007, p. 907). Cheng et al. (2012) found an association between African-American descent and higher rates of diabetes, even when controlling for environmental risk factors such as socioeconomic status (pp. 3-5). Specifically, they found an increase of 30% to 40% in “odds of type 2 diabetes among participants in the highest (>87.5%) vs. the lowest (<80.5%) tertile of African ancestry, even after adjustment for measures of SES and/or BMI (p. 4). Genome-wide scans identified loci suggestive of possible genetic variants that might affect these outcomes, notably 12p13.31 and 13q14.3. However, no single locus was identified as the major cause of the disparity (pp. 5-6).

In determining the variables of access, availability, and acceptability that govern a population’s engagement with health care, one good starting point is health literacy. Low literacy can be defined in terms of lower abilities to “read, write, speak, and to solve problems” (McCleary-Jones, 2011, pp. 25-26). Low health literacy pertains to the specific aspects of literacy that entail gathering and understanding information, and obtaining any necessary services, in order to be able to manage their health (pp. 25-26). Similarly, self-efficacy is important: if an individual is to be successful in managing their health, they must truly believe that they are capable of doing so (p. 26).In a study of African-Americans with diabetes, McCleary-Jones (2011) found important associations between both diabetes knowledge and self-efficacy and dietary self-care, foot self-care, and exercise (pp. 29-30). Health literacy was improved by diabetic teaching, although diabetes knowledge level was not improved. This demonstrates the importance of ongoing education. The fact that insured individuals had lower hemoglobin A1C scores also indicated the importance of access to health insurance (pp. 30-31).

Clearly, knowledge is very important to patients’ health outcomes, and it is an area in which many in the African-American community are at risk. In a study of African-American diabetics’ knowledge levels with regard to glycaemic index, Waller and Tzeng (2011) found that 50% of them had received information about the glycaemic index (GI). Those who had attended diabetes education classes were more likely to be knowledgeable about GI and the uses thereof. They were also much more likely to use the GI (pp. 1104-1106). This indicates the importance of diabetes education, and highlights a significant deficit that harms health outcomes for many African-American patients.

However, Baptiste-Roberts et al. (2007) found that African-Americans with family members who were diabetics were more likely to be aware of risk factors for diabetes. In particular, theywere most likely to be aware of the risk factors of “being overweight, having family members with diabetes, not exercising enough, and eating an energy-dense diet” (p. 909). They were also more likely to eat more healthily, and to have had themselves screened for diabetes (p. 909). This indicates an important area of knowledge strength: those who come from families with a history of diabetes are more likely to be aware. As such, this finding helps to frame the parameters of the challenge: extending awareness and knowledge to those who may be at risk but are not aware of it, or think that nothing can be done.

African-Americans are also disproportionately likely to be uninsured, and this has many ramifications for treatment. After all, it is expensive to manage a diabetic condition without insurance. Under the Affordable Care Act (ACA), this disparity is expected to improve, but whether or not this actually improves the health of many of the more at-risk segments of the African-American population, notably the most impoverished, depends on both how the market and the workplace adjust, and on how African-Americans themselves adjust (Leigh & Wheatley, 2010, p. 198). Availability of health insurance is not quite the same thing as access to health care, as cost containment measures may result in fewer Medicare and Medicaid enrollees being served. Since African-Americans are disproportionately uninsured and disproportionately eligible for the newly-expanded Medicaid than are whites, there are significant concerns about access to care (p. 198).

In addition to the socioeconomic and knowledge barriers that disproportionately affect African-Americans, there are cultural factors that increase risk and make it less likely that African-Americans will exercise preventive measures to avoid getting diabetes. Research has identified a strong tendency among many African-Americans of living in the present (Gavin & Wright, 2007, p. S15). In addition, there appears to be a widespread willingness to accept obesity as the norm among many African-Americans. Regarding type 2 diabetes mellitus (T2DM), many African-Americans hold to the view that it is hereditary, and as such cannot be prevented (p. S15). The mentality of living in the present, coupled with these specific health care beliefs, disproportionately puts African-Americans at risk for contracting T2DM.

Gavin and Wright (2007) recommend an individualized approach to caring for diabetes patients, whatever their ethnicity/race. Practitioners need to understand how their patients see the disease, and what their goals are. While every individual is different, there are cultural and social trends in the African-American community that practitioners need to take account of if they are to effectively serve their patients. A case in point is language and terminology barriers, which are quite common among some African-Americans, due to education deficits and/or preferences for vernaculars that tend to be distinct from ‘standard’ English. Practitioners need to take these linguistic issues into account in order to compassionately craft their presentations of information in ways that their patients will understand and find acceptable (pp. S15-S16).

An important aspect of communication in much of African-American culture is maintaining eye contact at an even level. Gavin and Wright (2007) recommend practitioners put themselves at eye level with the patient, for example by sitting if the patient has sat. Due to unfortunate historical realities of unethical medical experimentation on African-Americans, such as the Tuskegee Experiment, older African-Americans in particular may find it hard to trust medical personnel, even if said personnel are also African-American (p. S16). Like other patients, African-Americans may find it difficult to trust medical personnel due to personal negative experiences with medicine, or else negative experiences that friends and family members have had. Also like other patients, they may be mistrustful due to fear of receiving bad news; fear of embarrassment at their own lack of medical knowledge, or financial concerns (p. S16). Here, patience, kindness, and being transparent and straightforward with the patient will go a long way, just as they do for all patients.

Another area in which clinicians will need to tread lightly is religious faith. Many African-Americans are people of faith, and it is very common for them to believe in the power of faith over the power of medicine (Gavin & Wright, 2007, p. S16). Practitioners working with African-American patients are likely to find that some of them believe in the power of prayer and faith healing to cure them of T2DM, and that to acknowledge T2DM would be to undo the healing. Given the depth of importance of faith beliefs, it is vital that practitioners recognize them and be prepared to respond appropriately. As with patients from any other group, it is vital to not be seen as minimizing or in any way taking lightly religious concerns. In fact, here the most important thing is for practitioners to engage with churches. In fact, some African-American churches are responding to the problem of diabetes by entering into partnerships with practitioners for the purpose of providing their congregations with education on how to prevent or manage diabetes, and the consequences of not controlling one’s diabetes (p. S16). Joining patients in prayer can be an important exercise in building rapport and trust, but, just as with all patients, the practitioner should only do this if they are able to do so sincerely (pp. S16-S17).

Frank and Grubbs (2008) studied the implementation of just such a faith-based congregational program, designed to teach patients about reducing risk factors for diabetes, cardiovascular disease, and stroke. The population in question was a southern, rural African-American population, and over 120 participants from four congregations attended these educational programs. They were faith-based in that the pastors actually set aside time in the course of Bible study for the program, and preached on the subject of health prior to the program. The program produced some improvement in knowledge, but only a very slight improvement, evincing the importance of making it a repeat program. The feedback from participants was overwhelmingly positive, with the majority saying they learned something new (pp. 96-99). What this indicates is that this format of faith-based education and screening programs is effective in educating patients and helping them to engage with their condition. By incorporating faith and church community into the intervention, then, practitioners can increase the impact of the knowledge they offer.

From the above, it is possible to craft a prevention strategy with primary, secondary, and tertiary levels. Primary prevention for T2DM entails education of the population in question. As seen, this is an area in which many in the African-American community are at risk, especially those who do not have diabetic family members. Education for primary prevention should be conducted through churches as well as through all health clinics. The focus should be on helping people to understand the very real health risks posed by obesity, a major risk factor for diabetes but also a condition associated with other health complications (Tulchinsky&Varavikova, 2009, p. 199). Thus, to a great degree primary prevention should focus on preventing or reducing obesity, with physical exercise and healthy eating, especially the consumption of fruits and vegetables, important strategies to pursue (p. 199). The culturally sensitive factors have already been addressed, but are worth recapitulating: practitioners should make eye contact at patient’s level, be patient if patients are mistrustful, be prepared to overcome language and terminology barriers, and be ready to address common misconceptions about diabetes as well as obesity. As with any patients, practitioners should be compassionate, understanding, and respectful of patients’ deeply held religious beliefs.

Given the lack of efficacy of antidiabetic drugs against type 2 diabetes, physical exercise and proper diet to prevent or manage the condition are especially important (Bhowmik, Hjellset, &Hussain, 2013, p. 104). Secondary prevention, then, centers on healthy lifestyle much as primary prevention does, and can be taught and encouraged through church and community groups, as well as offered through community health clinics and the like. The key additional element is screening, which can also be addressed in education initiatives, and by nurses and doctors when they see patients who may be at risk. Patients who are at risk and should undergo screening include those who have a family history of the disease; those with cardiovascular, renal, and eye diseases; pregnant women; new mothers who had glucose intolerance in pregnancy, or delivered infants weighing more than 4000 grams, and obese persons (Tulchinsky&Varavikova, 2009, p. 199).

Instruction and monitoring can then be provided to those who have abnormally high blood glucose levels. In addition to proper diet and exercise, it is necessary to test urine and blood sugar regularly, and teach patients about appropriate hygiene and foot care. Although medication is less efficacious than lifestyle modification, in some cases it may still be necessary. Oral hypoglycemic agents are the most common (Tulchinsky&Varavikova, 2009, p. 199). As with any patients, again, practitioners should be compassionate, helpful, and sensitive to religious beliefs. It is very important that practitioners be prepared to overcome language or terminology issues, or trust barriers, with African-American patients, being that these are, again, some of the more salient issues that tend to arise with this population.

For tertiary prevention, the focus is on restoring lost functionality and preventing further deterioration of functionality (Tulchinsky&Varavikova, 2009, p. 199). Foot care is especially important here, since proper foot care can actually delay amputations in cases wherein a patient has peripheral vascular disease and potential gangrene. Ophthalmologists can provide important follow-up as well, preventing cases of diabetic retinopathy with photocoagulation treatment (p. 199). Again, diet and exercise are the best overall strategies for the prevention of reducing risk factors at this level. Patients need to be taught the importance of proper diet and exercise for managing their condition to the best of their ability. Medication may be necessary in many cases, in which case practitioners will need to educate patients on the importance of the medication, perhaps explaining a bit about how it works, in terms that are accessible and understandable to the patient (Vijgen, Hoogendoorn, Baan, de Wit, Limburg, &Feenstra, 2006, p. 434).

Teaching Plan

The objectives of the teaching plan should center on building up patient knowledge and self-efficacy. The first target should be inaccurate beliefs about diabetes, such as the idea that it cannot be avoided, and simply runs in families. Patients should be encouraged to think long-term about their health. Patients also need to understand the risk factors for, and complications associated with, diabetes. This is where an explanation of physical exercise and nutrition comes in. It is altogether easy to say to a patient, ‘You need to diet and exercise.’ This, however, is not likely to produce real change. On the other hand, a highly clinical and technical explanation is likely to be lost on patients who have no formal background in medicine. Because of this, it is essential for the clinician to educate patients about the importance of dieting and exercise in accessible terms, explaining to them what different foods do to the body—and what the accumulation of fat does to the body, and so on—and how exercise helps the body to stay healthy and either prevent, or manage, diabetes. By explaining this in accessible and informative terms, the practitioner can then empower the patients. Blood glucose levels are all-important in diabetes. Accordingly, the practitioner must teach the patients about them: what they are, how different foods and exercise affect them, etc. The practitioner can then teach the patients how to monitor blood glucose using a blood glucose meter. Only after the patients understand glycaemic index (GI) and the like will they be ready to learn the use of the blood glucose meter. The patients must then be taught proper care of feet and skin, and understand why these are important areas of concern for their condition. Before discharge, the patient will be provided with teaching materials, including times for diabetes education classes so that they can notify any friends or family who would wish to be present. Also before discharge, the patient should be provided with thorough instructions about hypoglycemia (“low blood sugar”) and hyperglycemia (“high blood sugar”). SUNY (2010) has a very helpful handout that contains much useful information for patients before they are discharged. The information matches a condition or imperative with an action. For example, for hyperglycemia, or “high blood sugar”: “Can occur if you eat too much food, are ill, under a lot of stress or do not take enough medicine” (SUNY). The item then gives signs: “tiredness, urinating often, feeling thirsty and having blurry vision” (SUNY). This in turn matches to a pair of actions that the patient should take: “Call your health care provider if you have unexplained blood sugar of 200 mg/dl or greater for 2 days”, and “Monitor your sugar level every 4 hours or as discussed with your doctor” (SUNY).

Similarly, for hypoglycemia, “low blood sugar”: “Can occur when food, exercise and diabetes medicine don’t balance” (SUNY, 2010). Examples given include “Too little food and delay in meals”; “Too much exercise”; “Too much medication” (SUNY). Symptoms are listed, and patients are then charged with actions: they should test their blood immediately; if they can’t, they should immediately treat themselves with fast acting sugar (SUNY). This excellent approach can easily be adapted for the plan under consideration here, and should be used as such. The nurse should vet all teaching materials with someone who has medical knowledge and knows relevant terminology and other language and cultural issues for the African-Americanpopulation in question (bearing in mind regional as well as individual differences), to ensure that it is appropriate and accessible.

By formulating a culturally sensitive plan for African-American patients, the nurse can avoid dual ethnocentrism. To a great degree, the imperatives are fundamentally the same as with all patients: communicate the information in a way that is accessible and acceptable to the patient, be respectful and compassionate, and be prepared to field questions and take time to establish trust. Specific considerations include the role of religious faith, especially beliefs in faith healing, that are prevalent among many (though by no means all) African-Americans, as well as terminology and language issues and preferred modes of communication. Finally, it is also necessary for the practitioner to be aware of the painful legacies of racism, if he or she is not already, which are responsible in no small measure for poorer socioeconomic status among many African-Americans, and the disproportionate burdens of health and education disparities that fall on them as a result. By so doing, they can ensure the success of the program.

Conclusion

Clearly, culture matters. Culture has a profound impact on what patients do, because it includes beliefs about what is normal and not normal in terms of health. Healthcare beliefs held by many African-Americans put them at risk of diabetes, including a tendency to live in the present and take little thought for health over the long run; a willingness to accept obesity as normal; a belief that type 2 diabetes cannot be prevented, and simply runs in families, and a high reliance on faith and prayer in lieu of medicine. By working within African-American culture and being respectful and compassionate, the practitioner can devise an efficacious plan for closing the gap between African-Americans and European-Americans, reducing both the overall incidence of diabetes through effective prevention, and complications of diabetes.

References

Baptiste-Roberts, et al. (2007). Family history of diabetes, awareness of risk factors, and health behaviors among African Americans. American Journal of Public Health, 97(5), pp. 907-912.

Bhowmik, B., Hjellset, V.T., & Hussain, A. (2013). Global migration and prevention of diabetes. In P. Schwartz & P. Reddy (Eds.), Prevention of diabetes (pp. 94-113). Chichester: John Wiley & Sons.

Cheng, C.-Y., et al. (2012). African ancestry and its correlation to type 2 diabetes in African Americans: A genetic admixture analysis in three U.S. population cohorts. PLoS ONE, 7(3), pp. 1-9.

Frank, D., & Grubbs, L. (2008). A faith-based screening/education program for diabetes, CVD, and stroke in rural African Americans. The ABNF Journal, pp. 96-10.

Gavin, J.R., & Wright, E.E. (2007). Building cultural competency for improved diabetes care: African Americans and diabetes. The Journal of Family Practice, pp. S14-S20.

Leigh, W., & Wheatley, A. (2010). U.S. healthcare reform, 2009-2010: Implications for African Americans. Review of Black Political Economy, 37(3), pp. 191-201.

McCleary-Jones, V. (2011). Health literacy and its association with diabetes knowledge, self-efficacy and disease self-management among African Americans with diabetes mellitus. The ABNF Journal, pp. 25-32.

SUNY. (2010). Diabetes discharge instructions. SUNY downstate medical centre. Retrieved from http://www.downstate.edu/nursing_dept/pdf/Diabetes-Discharge-Instructions-Brochure-July-2012-English-Revised.pdf

Tulchinsky, T.H., &Varavikova, E.A. (2009). The new public health (2^nd ed.). San Diego, CA: Elsevier Academic Press.

Vijgen, S., Hoogendoorn, M., de Wit, G., Limburg, W., &Feenstra, T. (2006). Cost effectiveness of preventive interventions in type 2 diabetes mellitus: A systematic literature review. PharmacoEconomics, 24(5), pp. 425-441.

Waller, B., & Tzeng, H.-M. (2011). Glycaemic index knowledge and use among African Americans with type 2 diabetes. Journal of Advanced Nursing, 67(5), pp. 1102-1108.