August 2009
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Culturally Sensitive Education May Improve Outcomes for Type 2 Diabetes Patients
Language and cultural barriers can hinder the delivery of quality diabetes health education to ethnic minorities.
By Conni Bergmann Koury, Editor-in-Chief
In upper-middle and high-income countries, minority ethnic groups often suffer a higher prevalence of type 2 diabetes than the local population, according to background information in a review from the Cochrane Database of Systematic Reviews.1 These patients with diabetes also tend to come from lower socioeconomic backgrounds, with the associated difficulties in accessing quality health care, wrote Yolanda Robles, PhD, of the Department of General Practice, Cardiff University, Centre for Health Sciences Research, School of Medicine, Cardiff, UK, and colleagues.
"In some cases, cultural and communication barriers increase the problems minority ethnic communities experience in accessing good quality diabetes health education, a vital aspect contributing towards patient understanding, use of services, empowerment and behavior change toward healthier lifestyles," Dr. Robles said.
In this review, the investigators use the term "culturally appropriate" health education to mean any type of diabetes health education that has been specifically tailored to the cultural needs of a target minority group.
Dr. Robles and colleagues found 11 randomized controlled trials (RCTs) of culturally appropriate diabetes health education in the literature. These trials found that culturally appropriate health education improved blood glucose control in included patients versus those receiving usual care, at 3 and 6 months postintervention. They noted that this would potentially be clinically important if the improvements were sustained. The review found that knowledge about diabetes and healthy lifestyles also improved among included patients. No improvements in clinical outcome measures such as cholesterol, blood pressure, or weight were seen, and neither were improvements in quality-of-life outcomes for patients.
The studies reviewed tended to be short in duration, so the investigators noted that longer-term outcomes could not be measured. "In addition, some outcomes selected by the review were not measured, such as the development of diabetic complications, death rates, or costs of the education programs," they wrote. Additionally, interpretation of the findings is somewhat limited due to the variation among the studies in terms of the cultural aspects of the populations being looked at, the types and duration of the health education being offered to participants, the variety of outcomes being measured, and differences in the timings of these measurements after the health education intervention happened.
It appears that culturally appropriate health education is potentially more effective than usual care in improving blood sugar control and knowledge of diabetes and therefore would likely benefit patients. Standardized RCTs of longer duration (using the same outcome measures and timings of these measures), are needed with full evaluation of costs, Dr. Robles and colleagues concluded.
MAIN RESULTS
Included in the review were 11 trials involving 1,603 patients—10 trials provided data included in the meta-analysis. A1C showed an improvement following culturally appropriate health education at 3 months (weight mean difference [WMD], -0.3%; 95% confidence interval [CI], -0.6 to -0.01) and at 6 months (WMD, -0.6%; 95% CI, -0.9 to -0.4) compared with usual-care control groups. This effect was not significant at 12 months postintervention (WMD, -0.1%; 95% CI, -0.4 to 0.2). The review showed that knowledge scores improved in the intervention groups at 3 months (standardized mean difference (SMD), 0.6; 95% CI, 0.4 to 0.7), 6 months (SMD, 0.5; 95% CI, 0.3 to 0.7) and 12 months (SMD, 0.4; 95% CI, 0.1 to 0.6) postintervention. Other outcome measures such as lipid levels, bloood pressure, quality of life, attitude scores, and measures of patient empowerment and self-efficacy showed no significant improvement compared with control groups.
AUTHORS' CONCLUSIONS
Dr. Robles and colleagues concluded that culturally appropriate diabetes health education appears to have short-term effects on glycemic control and knowledge of diabetes and healthy lifestyles. "None of the studies were long term, and so clinically important long-term outcomes could not be studied," they wrote. "No studies included an economic analysis. The heterogeneity of studies made subgroup comparisons difficult to interpret with confidence. There is a need for long-term, standardized multicenter RCTs that compare different types and intensities of culturally appropriate health education within defined ethnic minority groups."
IMPLICATIONS FOR PRACTICE
The investigators note that culturally appropriate health education should be the gold standard for health education programs targeted at ethnic minority communities. They added that it has been known some time that diabetes health education improves knowledge about diabetes as well as blood glucose control,2-6 but this review has shown that culturally appropriate health education is better than usual practice for minority communities. Specifically, teaching and learning methods must be adapted to suit cultural and community needs as well as the content of the education itself (for example in dietary programs).7 They wrote that these results strengthen the belief, based on educational theory,8,9 that health education should be couched in a learner-centered manner that respects their religious, social, and cultural values in order to have the most impact.
"We cannot yet identify which aspects of the culturally tailored health education make the difference," they wrote, "although it appears from our subgroup analyses that a combination of one-to-one and group education is better than either used on its own and that intensity of exposure to the health education may positively affect outcomes.".
IMPLICATIONS FOR RESEARCH
The authors said that their findings should stimulate further research to answer some of the questions raised by these data. More randomized controlled trials with clear designs and links to theoretical models of health education are needed.10 Trials should evaluate long-term clinical outcome measures, the effects of different approaches, intensity of approach and duration of follow-up, and reinforcement of culturally appropriate health education on the incidence of diabetic complications and mortality figures, Dr. Robles and colleagues wrote.11 Additionally, more work with different minority communities is needed, and very few studies measured patient-centered outcomes such as acceptability, empowerment, and satisfaction. Reliable and valid measurement tools need to be developed, as well as the consensus to use them consistently in studies. The sustainability of health education programs and their cost-effectiveness also needs further investigation, Dr. Robles and her team said.
FINAL COMMENTS
There are few high-quality data on the effectiveness of culturally appropriate diabetic health education programs for ethnic minority groups, the investigators noted, and what exists are difficult to standardize and compare in a formal meta-analysis. This type of intervention, however, appears to be effective in improving glycemic control and knowledge about diabetes in the short to mid-term, and may contribute to improvement in total cholesterol levels.
Well-designed, long-term, multicenter RCTs that examine different types of educational interventions in different ethnic minority groups are needed. Outcome measures should include clinical and patient-centered outcomes, according to Dr. Robles, and cost-effectiveness of interventions should be evaluated.
Yolanda Robles, PhD, is in the Department of General Practice, Cardiff University, Centre for Health Sciences Research, School of Medicine, Cardiff, UK. She may be reached at roblesy@cf.ac.uk.
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