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Results of the Lothian ethnic diabetes project

In previous issues of NiP we've reported on the Lothian ethnic minority diabetes project that examined the effect of culturally-sensitive education on the diabetic control of patients from a South Asian background. Here are the results …

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

Teresa Torrance
RN RM HV cert BSc Nursing MSc Health studies
Diabetes Nurse Specialist
NovoNordisk

Movement of people has led to a greater diversity of ethnicity in almost every developed country in the world. Over two million people from South Asia have settled in the UK, making them one of the largest ethnic groups.(1)
In the last decade Scotland has become a multicultural society. It is estimated that over 180,000 people in Scotland have a diagnosis of diabetes, which is increasing rapidly and set to double by 2010.(2) The increased rates of diabetes within this group have been reported to be five times higher than that of the general population.(3) It is also estimated that 40% of diabetes remains undiagnosed within this group, with the mean age for myocardial infarction being approximately five years earlier than their British counterparts.(4) The National Service Framework (NSF) for diabetes recognises that inequalities exist for minority groups when accessing diabetes care, suggesting that planned services should consider ethnicity, language, culture and religion.(5)
The Lothian minority ethnic diabetes project was set up to develop culturally-sensitive diabetes care to a South Asian group of people within a general practice. The project also looked at patients who were at "high risk" of developing diabetes. Rates of ischaemic heart disease (IHD) are estimated to be 40% higher in South Asian men than in the UK population.(6)
The aims of the project were:

  • To improve diabetes care.
  • To provide interpreters/link workers skilled in diabetes education.
  • To try to identify and address barriers to healthcare.
  • To identify ways of improving overall healthcare results, in the short and longer term.

Education
Culturally-sensitive education about diabetes was delivered to the patients relating to disease, medication, diet and review of lifestyle. An initial health assessment and satisfaction survey was conducted.(7) Bhattacharya et al suggests that the satisfaction of the individual is vital.(8) It is also an easy way to identify specific problems, eg, understanding of treatments and waiting times. Language barriers are described as a "primary barrier" to receiving effective care, resulting in ineffective treatment and understanding.(9) Mello estimated that over two million people in UK speak very little English.(10) 
A total of 26 patients with type 2 diabetes, cardiovascular disease and impaired glucose tolerance were identified. Each patient was contacted by letter, followed up with a telephone call before the appointment (where possible in their preferred language) in an attempt to reduce failure-to-attend rates (FTA). Two patients were abroad long term and two were housebound. The average FTA rate was between 30 and 50%. 
The most common language was Urdu, but most patients also spoke English. A number of them benefited from communicating in their own language, which was demonstrated through better medical history taking, clearer knowledge and understanding of medications and the disease process.

Medication review
Not surprisingly this group of patients were taking a number of drugs. There did not appear to be any standardisation, with over four different ACE inhibitors and statins being prescribed. Approximately 50% had a good understanding of medication and could identify their tablets. Approximately 40% were unable to identify medication, admitted to not taking them as prescribed, or were taking the wrong medication at the wrong time. Ten percent of patients had no understanding of their medication and relied on a relative to help them. This was seen in two of the very elderly patients who spoke little or no English. One patient was unaware that his statin had been stopped due to side-effects.

Specific problems reported with medication
A small number of patients reported making mistakes with their medication, resulting in hypo- or hyperglycaemia. Further problems were reported with antihypertensive agents, poor follow-up of patients who commenced on insulin in secondary care, and a small number of glucose meter problems. Banerjee et al suggest that the increased lack of knowledge, poor use of health services and different attitudes to chronic disease in people from South Asia may lead to the increased incidence and prevalence of chronic diabetes complications.(11)

Lifestyle issues
The data collection looked at lifestyle issues including activity, diet, smoking, alcohol, stress and anxiety. Only one clinic was held during Ramadan (the final week) as traditionally patients often do not attend. All Muslim patients said that they would be fasting over this period. They all knew that they were exempt on health grounds. Medication and changes that were required were discussed using recognised guidelines.(12)
Lifestyle factors were discussed. Very few patients reported any regular activity and none reported vigorous activity. Thirty percent of the patients reported moderate activity regularly, either walking to work or a daily routine. Older female patients were more likely to stay at home and be inactive. A small number of patients smoked (20%). Most patients did not drink alcohol.
The use of salt in cooking and added to food on a daily basis was reported in 75% of patients. Sixty percent used oil for cooking and 15% ate fatty fried meats more than four times per week. Stress and anxiety were common - 40% experienced anxiety regularly. Thirty-five percent felt "low" or "down" regularly. Depression was reported in 25%. Stress and anxiety were attributed to work and home pressures.

Satisfaction survey
The questionnaire was delivered by the link worker in the patient's preferred language. Dissatisfaction was reported by a very small number of patients.

Conclusion
Patients were much more expressive when speaking in their preferred language. Medical history, both past and present, daily lifestyle and interactions appeared to be discussed in much more detail. Baradaran and Knill-Jones suggest that people's attitudes to health and their uptake of healthcare is very strongly related to knowledge, culture and beliefs, which are embedded in language.(13)
Activity levels were generally low with very few patients reaching the recommended levels. The British Heart Foundation reported similar findings suggesting that South Asian women were less likely to participate in physical activity, more likely to have central obesity and have low levels of high-density lipoproteins (LDL), and eat less fruit and vegetables.(14)
Many of the problems experienced within this group are culturally driven and require specialist resources to inform and bring about change. Vanterpool suggests that culture is a complex concept that can result in mis-interpretations of diabetes management.(15) Greenhalgh et al described a number of commonly held health beliefs that may influence care.(16) These include: belief that diabetes weakens the body; the use of herbs and self-medication; and external factors, eg, "the will of Allah".
Medication issues, compliance and polypharmacy were a significant problem in this group, requiring further study, particularly with understanding and concordance.
There were a number of important issues highlighted in the diet, specifically the high levels of salt and fat consumed. Activity levels were poor and there would appear to be degrees of social isolation, especially within the more elderly population. FTA rates were high at 50%, but 30% of patients responded to a second appointment. Two patients were abroad long term, which is not uncommon with this group. This does, however, raise concerns for follow-up and continuity of care.
There is little doubt that the use of a link worker trained in diabetes with the ability to speak to a patient in their own language can enhance not only the consultation and information, but also improve the quality of the service being delivered.

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References

  1. Office for National Statistics Census. People and migration. Ethnicity. London: ONS; 2005. Available from: http://www.statistics.gov.uk
  2. Diabetes UK Scotland. Focus on diabetes: a guide to working with black and ethnic communities in Scotland with long term conditions. Glasgow: Health Scotland; 2007.
  3. Nazroo JY. The health of Britain's ethnic minorities: Findings from a national survey. London. Policies Studies Institute; 1997.
  4. Hughes IO, Raval U, Rafhery ER. First myocardial infarction in Asian and white men. BMJ 1989;298:1345-50.
  5. Department of Health. National Service Framework for diabetes: standards. London: The Stationary Office; 2001.
  6. DH. Health service for England: the health of minority ethnic groups. London: The Stationary Office; 2001.
  7. Bradley C. Diabetes clinic satisfaction questionnaire. Health psychology research. Surrey: Department of Psychology, University of London; 2000.
  8. Bhattacharya B, Pickering S, McCulloch A, et al. The nurse-led clinic: a care satisfaction survey. J Diabetes Nurse 2007;11:228-32.
  9. NovoNordisk. Dealing with difference. NovoNordisk; 2006.
  10. Mello M. Plugging the gap. NT 1992;88:34-6.
  11. Banerjee M, Vyas A, Cruickshank JK. Ethnicity and its implications in diabetes management. Pract Diabet Int 2004;21:135-6.
  12. Ben Darif AT, Al-Sunni A, Mojaddidi M, et al. Tailoring diabetes care delivering appropriate care. Pract Diab Int 2006. Supplement.
  13. Baradaran H, Knill-Jones R. Assessing the knowledge, attitudes and understanding of type 2 diabetes amongst ethnic groups in Glasgow, Scotland. Pract Diabet Int 2004;21:143-7.
  14. British Heart Foundation. Coronary heart disease statistics diabetes supplement statistics survey. London: British Heart Foundation; 2001.
  15. Vanterpool G. Addressing the ethnic barriers to diabetes care provision. Diabetes and Primary Care 2006;8:(Suppl)152-4.
  16. Greenhalgh T, Helman C, Chowdhury AM. Health beliefs and folk models of diabetes in British Bangladeshis: a qualitative study. BMJ 1998;316:978-83.