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Family-centred education for ethnic-minority diabetic patients

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

Traditional approaches to education in diabetes has centred around the concept that patients are empty pots to be filled with information from a variety of sources. However, it is now accepted that, to achieve the desired changes in behaviour, education must encourage self-motivation and self-determination.(1) Therefore education of the person with diabetes has to evolve from imparting knowledge to a more proactive self-management style.(2)
South Asian patients are four to six times more likely to develop type 2 diabetes than the indigenous population, and diabetes can develop 10 years earlier in this ethnic group.(3) In addition it has been noted that South Asian people with diabetes and their carers may have problems accessing healthcare due to cultural and language barriers.(4,5)

Research project
A research project in Edinburgh Scotland was designed to examine the effect of culturally sensitive education and intervention on the diabetic control of patients from a South Asian background.
South Asian patients living in the southeast of Edinburgh were treated as the study group and were given culturally appropriate diabetes education, medication review and healthy eating and living advice by a bilingual pharmacist. West Lothian South Asian patients were the control group and received standard treatment and support for their diabetes. Before the delivery of the diabetes education baseline biochemical measurements including: HbA1c (average blood sugar over a period of three months), weight, blood pressure, and cholesterol, were recorded for both sets of patients. These biochemical measurements were retaken after the six-month period for both sets of patients.

Educational package
The educational package developed for the intervention group consisted of a questionnaire designed to be conducted in a semistructured interview that recorded each patient's knowledge and understanding of their condition. It was delivered in the language preferred by the patients and the results were used to deliver tailored diabetes education to the patients in the study group. The questionnaire was conducted before and after the delivery of the rest of the education package, which consisted of medication review, Asian cookery classes to demonstrate healthy adaptations of traditional Asian cuisine, and culturally sensitive exercise classes.

Cookery and exercise
As we wanted to make this service more accessible and remove any possible barriers the patients were visited at home or their place of work. It was also very important to educate the whole family about diabetes. The South Asian community is very family oriented and we felt it would be beneficial to increase the family's understanding of diabetes rather than selectively educate the patient. It had been observed that often it wasn't the person with diabetes who did the food shopping or the cooking, and therefore it was important to educate the person buying the food and planning and cooking family meals. For these reasons, the cookery class was attended by not only the target patients, but also family members.
A dietitian and a diabetic liaison nurse delivered the first cookery class. As there is a culture of respect for the elderly in the South Asian community the approach used did not seek to teach participants how to cook, but rather how to adapt their own recipes into healthier styles of cooking; for example, they were encouraged to use less oil (and ghee) and salt in their traditional cooking.
In addition the patients and family members were given the opportunity to try gentle exercise during the cookery class. When the pots were simmering, lights were dimmed and on came an exercise video with Jan Leeming in a fluorescent leotard. It was funny for all of us but for very different reasons! The exercise video showed the women how to do exercise sitting down and for many present this was the first time they had experienced any form of exercise.
Separate exercise classes for men and women were organised in a city centre sports centre where the patients were able to use the gym, play badminton and take part in aerobic exercise. These classes are ongoing and are very well attended. We have worked very closely with Edinburgh Leisure and are very grateful to them for their support in continuing this class. 

Medical advice
Medication review was vital to the education service, and was carried out by the pharmacist with the patient following the questionnaire. The patient's medication list was obtained from their GP practice and the GP was asked if there were any questions they wanted us to ask the patients, to which the most common reply was: "Can you check what medication they patient is taking?"
During the medication review patients were asked what medication they were taking, what it was for and how long they had been taking it. The issues that arose were the same as most patients taking medication might have - not sure what each medication was for and that they had to take them for life (very important, especially if it was insulin). However, these problems are compounded when the patient does not have English as their first language and is less likely to question their GP - again a cultural quirk, to accept whatever is told to them by someone of the medical profession, especially a doctor.

Results
After six months of providing the full education package we revisited the biochemical and qualitative parameters. Results from the postintervention questionnaire showed an increase in patient's knowledge regarding the disease and the complications of poor diabetic control - with the largest difference being the increase in the patient's knowledge of the terms "hypoglycaemia" and "hyperglycaemia".
Results from biochemical measurements showed a reduction in HBA1c of 1% in the patients who received the education package, which was highly statistically significant. In the study group the HbA1c fell from an average of 9.1 to 8.2 whereas in the control the HbA1c remained the same at 8.8. A 1% decrease in HbA1c has been shown to reduce the risk of microvascular events by 37%.6 The control group had no difference in their HbA1c. The study group of patients also had a decrease in their cholesterol values from 5.5 mmol/l to 4.4 mmol/l, which was now less than 5 mmol/l - the desired value to prevent any cardiovascular events. It is difficult to state whether this reduction was due to the improved compliance following their medication review, where patients were asked if they knew what they were taking their medication for and if they were taking it, or if the whole package made the difference. Whatever the reason, the result was the desired one.
There was an average 2.5 kg weight loss in the study group and again no change in the control group.

Conclusion
Patients who received diabetes education in a language they understood found it was culturally sensitive and relevant. Their diabetic control improved and the education empowered patients to take control of their diabetes. It also improved their access to health services and leisure facilities, which had been previously denied to them. Patient understanding of the disease increased and there was improved compliance with medication.
The medical staff also benefited, not only from the increased knowledge regarding the prevalence of type 2 diabetes in the South Asian population, but also in terms of the GMS contract, as this education package would help practices reach targets for HbA1c, blood pressure and cholesterol.
The results of this research project suggest that delivery of a specially designed culturally sensitive intensive education package could improve the diabetes control and knowledge of patients of South Asian origin with type 2 diabetes. This fits in with research that has been done in other parts of the world such as Finland and the United States of America, which showed that intensive diabetes education could improve diabetic control.7,8
The challenge now lay in turning the research project into a service, which would be open to all ethnic minorities and for the whole of Lothian. It was essential to show that this service was required to provide equity of service. Currently when patients are diagnosed with diabetes they are given the opportunity to receive education in diabetes (essential if they are to be empowered to control their own disease), which is delivered in group sessions. However, these sessions are in English. As privacy is a big issue ethnic minority patients are less likely to join in on group sessions especially if they can't speak the language. Therefore there is a need for an education service that can address their diabetic and cultural needs.

References
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2. Clements S. Diabetes self-management education. Diabetes Care 1995;18;1204-14.
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6. United Kingdom Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes (UKPDS: 28). BMJ 1998;317:703-13.
7. Tuomilehto J, Lindström J Eriksson JG, Valle TT, Hämäläinen H, Ilanne- Parikka P, et al. Finnish Diabetes Prevention Study Group. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001; 344:1343-50.
8. Knowler W, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, et al; Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393-403.