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Diabetes and the South Asian population

Lubna Kerr
BSc(Hons) MPharm PhD
Metabolic Unit
Western General Hospital

My interest in diabetes originates from anecdotal knowledge I acquired owing to the effects diabetes had on my family - my mum developed diabetes at the age of 39 due, she thought, to the shock of my father's death at the age of 45. So when I was given the opportunity to do a research project as part of my master's degree in clinical pharmacy education, I felt compelled to do something around diabetes, education and my own South Asian community.
Initially I found a plethora of diabetes education resources available to people with diabetes living in Lothian. People could be referred to the hospital for their diabetes education, or could access community education sessions run by practice nurses, pharmacists and dietitians; education was available in group sessions or on a one-to-one basis. However, there was one big problem. Diabetes resources were only available in English; if you didn't speak English your choices were very limited.
It is no secret that diabetes is best managed by the patient themselves, but to do this they must have the relevant knowledge and education.(1)

Culturally sensitive approaches
I set about looking for relevant, culturally appropriate information that could be delivered to people with diabetes who came from a different cultural background and perhaps did not have English as their first language.
Research has shown that if you come from a South Asian background you are four to six times more likely than the indigenous population to get type 2 diabetes, and at an earlier age.(2-4)
Research has also shown that culturally sensitive approaches are vital for effective and appropriate communication with this population.(5)
However, evidence shows that this population is less likely to access the health service due to language, culture and religious reasons, and often do not have accurate knowledge on what services are available.(6)

Religious differences
When dealing with South Asian patients it is very important to know where they come from, and what their main language and religion is, as this will impact on what their beliefs are around their condition or disease. "South Asian" is made up of three main sections of people - Pakistani, Indian and Bengali - but within this there are many different sects, religions and languages, not to mention dialects and ways of cooking. To ensure that a good practitioner-patient relationship is established, finding out where exactly your patient is from, how long they have lived here, what members of their family live near them, and how they spend their day is very beneficial.

Language difficulties
However, communication can still be a problem, especially if English is not the mother tongue. Interpreters are one option, but unless they have been given training in diabetes there is no guarantee that they can understand the clinical terms being used. Using trained bilingual link workers is a better option as shown by Curtis et al.(7)
Many of the older generation of South Asians may have problems with communicating in English. As arranged marriages are still the norm in some cultures, spouses are sought from back home and their grasp of English can be quite poor. For the women, whose role primarily revolves around the family and extended family, there is little opportunity to improve their spoken or written English. The men have more opportunity to improve their spoken English due to contacts through work; however, they might not have the written skills and will very often not admit their inability to read English. This is very important to remember when prescribing medicines, eg, if they can't read a label that states "This is one of two boxes" they could end up taking twice the dose of their medicine.

Education and awareness
Education is very important if a patient is to properly manage their condition; however, awareness of the condition is crucial too. In order to provide effective education all patients need to be empowered as a group to take responsibility for their own health. To do this successfully they need to have a basic knowledge of the disease process. However, the lack of awareness among South Asians of the prevalence of type 2 diabetes in this population is also a barrier and can delay presentation and diagnosis.(8)
A study by Hawthorne and Tomlinson found that Pakistani women who could not read were more likely to have poor glycaemic control and found it more difficult to learn how to apply their knowledge to daily life.(9) The researchers used flashcards to communicate and deliver their diabetes education effectively to the Pakistani women. They recommended that this subgroup of Pakistani women needed more intensive, culturally appropriate diabetes education and support.
These results concur with previous research where cultural beliefs and customs influencing diet, weight patterns and behaviour were examined in relation to diabetes.(10)
Researchers found that patients complied with dietary advice when it was tailored to suit the patient's culture and personal preferences.(11) The lack of culturally sensitive education material and programmes deter patients from attending education programmes that focus on diet, body weight and exercise. Diabetes UK provides very useful information on diabetes care for patients from different ethnic backgrounds, which can be accessed from their website -
Weight loss and exercise
Weight loss is an important factor in good diabetes management - up to 80% of patients with type 2 diabetes are overweight and obesity has been shown to be a major risk factor in developing diabetes and its complications.(12)
However, many South Asians see a larger physique as a sign of prosperity and health. This was reflected in a study where patients from Bangladesh were asked to pick out the "healthy" people from photographs showing a range of different body shapes.(13) They picked the larger individuals. Subsequent focus group discussions highlighted the belief that the larger person is perceived to be a healthier person.
The Health Education Authority (HEA) in England has commissioned several studies that examined the degree of exercise participation and the barriers for the low participation rates of the ethnic minority population.(14) Results showed that barriers to exercise come from a variety of sources, with cultural, ethnic and religious barriers the most quoted reasons. Within this population there are three main religions - Islam, Hinduism and Sikhism - that have different attitudes to dress and mixing with the opposite sex. The Hindu religion is the most liberal in its views of dress and does not mind women baring their legs in public, while in Islam it is prohibited for women to bare their legs and participate in mixed sporting activities. Therefore a large number of cultural issues need to be addressed before these services could be offered, including appropriate separate exercise locations for men and women, which are not open to the public, suitable Asian music and modest attire.
HEA studies that asked members of ethnic minority populations their personal reasons for not exercising, reported a variety of answers. Not having enough time was one of the main reasons given, particularly for Pakistani and Bangladeshi women who cited childcare responsibilities and family pressures as issues. Caring for elderly relatives was another reason given, particularly for women. When personal feelings were examined women claimed that they needed rest and were twice as likely to say they lacked energy.(14)
For ethnic minority men the barriers to exercise included time off from work and balancing their family commitments.(15) This is not surprising as from my own experience it is well known that men from South Asian families have a strong work ethic, work long hours with limited time off to participate in any activities, including attending hospital appointments.
It is vital that health professionals are able to identify, overcome and understand barriers to communication such as language and cultural and religious issues. Patients likewise must have the knowledge and understanding of their diseases to be able to make informed choices about treatment options and to be able to communicate effectively with healthcare professional in order to receive optimum care.

It is clear that South Asians are at high risk of developing type 2 diabetes, which, if uncontrolled, leads to many complications such as retinopathy, kidney failure, peripheral vascular disease, heart disease and stroke.(16,17) These complications are highly prevalent in this community, but cultural and language difficulties prevent individuals from accessing effective healthcare support.(5,6) Information about their diabetic condition, their medication and health-promoting lifestyle changes needs to be delivered in a culturally sensitive environment and in an appropriate language, which will empower patients to take control of their own disease.
In Edinburgh we have set up an award-winning culturally sensitive ethnic minority diabetes education service. More information will be available in a future article.



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