Incorporating Cultural Perspectives into Diabetes Self-Management Programs for East Asian Immigrants: A Mixed-Study Review

Exploring Perspectives and Challenges to Type 2 Diabetes Self-management in Haitian American Immigrants in the COVID-19 Era: An Emic View

INTRODUCTION

Racial and ethnic minorities experience a disproportionate burden of the type 2 diabetes (T2D) and are at a 2 to 5 times higher risk of developing macrovascular disease. The purpose of the study was to describe the perspectives of Haitian American immigrants' challenges to effective T2D self-management.

METHODS

Utilizing a descriptive qualitative approach, purposive sampling was employed to recruit a subgroup of adult Haitian American immigrants from a parent cross-sectional study. Content analysis was used to identify themes describing participant perspectives. Lincoln and Guba's four criteria to assess the trustworthiness and ensure the rigor of the study were applied.

RESULTS

A total of 36 participants were enrolled, with 54% being male, and age ranged from 34 to 63 years. The majority were married, and 77% reported using metformin. Three facilitators and two barriers to their T2D self-management were found. Facilitators included (1) family and social support, (2) optimism and hope, and (3) novel devices. Barriers included (1) psychosocial and (2) environmental factors.

DISCUSSION

The facilitators underscore the pivotal role of close familial relationships, communal influence, and the potential utility of innovative devices like continuous glucose monitoring in enhancing T2D management, whereas the barriers delineate the unique challenges posed by discrimination, lack of provider/client decision-making and communication, the compounding effects of COVID-19, concerns about safety, mistrust in healthcare systems, and financial constraints, which collectively exacerbate the complexities of ineffective T2D management. Collaboration between clinicians, clients, and policymakers is imperative to emphasize the urgent necessity for a multifaceted approach in addressing the complex healthcare landscape of Haitian American immigrants managing T2D in the United States.

Health literacy and self-care among adult immigrants with type 2 diabetes: a scoping review

INTRODUCTION

There exists a gap in the health status of immigrants in comparison to the overall population, and health literacy has been shown to be a mediator for health outcomes and may predict their quality of life (QoL). We aimed to systematically map and synthesize research findings on adult immigrants' health literacy in terms of their health beliefs, understanding, and self-management of Type 2 Diabetes Mellitus.

METHODS

A scoping review guided by Arksey and O'Malley's framework was conducted, based on systematic searches in the Embase, Ovid MEDLINE, and APA PsycInfo databases in June 2023. The retrieved articles were screened and assessed by the two authors independently.

RESULTS

Of 568 identified studies, 16 (9 qualitative, 4 cross-sectional, 1 mixed-methods, and 2 experimental) were included in this review. Low/moderate health literacy levels with no sex-related differences were reported. Immigrants' access to health information was limited by language barriers and a lack of culturally adapted information, especially from their physicians. Among women, access to health information was limited by patriarchal norms. Knowledge gaps were primarily related to understanding the necessity of medication and the importance of a healthy lifestyle. Healthcare professionals played an important role in motivating immigrants to adhere to treatment.

CONCLUSION

Few studies were found on this topic, and additional research is needed to enhance health literacy among immigrants. Limited health information, language barriers, and a shortage of culturally sensitive knowledge appear to hinder immigrants' ability to access, understand, and apply health information. Cultural norms and personal factors further suppress these abilities, ultimately impacting their health outcomes. The findings of this study suggest that health literacy is a crucial component of healthcare professionals' curricula, equipping them with the skills to identify and assist patients with low health literacy.

Contextual factors for the successful implementation of self-management interventions for chronic diseases: A qualitative review of reviews

OBJECTIVES

To identify and describe the most relevant contextual factors (CFs) from the literature that influence the successful implementation of self-management interventions (SMIs) for patients living with type 2 diabetes mellitus, obesity, COPD and/or heart failure.

METHODS

We conducted a qualitative review of reviews. Four databases were searched, 929 reviews were identified, 460 screened and 61 reviews met the inclusion criteria. CFs in this paper are categorized according to the Tailored Implementation for Chronic Diseases framework.

RESULTS

A great variety of CFs was identified on several levels, across all four chronic diseases. Most CFs were on the level of the patient, the professional and the interaction level, while less CFs were obtained on the level of the intervention, organization, setting and national level. No differences in main themes of CFs across all four diseases were found.

DISCUSSION

For the successful implementation of SMIs, it is crucial to take CFs on several levels into account simultaneously. Person-centered care, by tailoring SMIs to patients' needs and circumstances, may increase the successful uptake, application and implementation of SMIs in real-life practice. The next step will be to identify the most important CFs according to various stakeholders through a group consensus process.

Ethiopian immigrants with diabetes in Israel: Oscillating between two narratives

AIM

The purpose of this project was to examine the role of cultural differences in shaping the management of diabetes among Ethiopian immigrants living in Israel.

METHODS

A qualitative, in-depth study involved semistructured interviews with 16 Ethiopian immigrants with diabetes living in Israel. The interviews were audio-recorded, transcribed and translated into Hebrew, if necessary. The authors each identified themes in the responses and then through discussion came to a consensus about the most significant ones and how to categorize them.

RESULTS

A main theme was revealed structuring the participants' perception of diabetes: an oscillation between a familiar narrative, associated with traditional life in Ethiopia, and a foreign one. Five additional subthemes were also identified as an oscillation about the causes of disease, between collectivism and individualism, between accessible food and a balanced diet, between relying on bodily sensations and prescribed treatment and between culturally oriented and translated knowledge.

CONCLUSION

The participants understood that they could be adversely affected both by the changes in lifestyle following their move and by adhering to the traditional norms. They agreed that professional liaisons and peers who have successfully managed their diabetes could help provide a bridge between the narratives.

Integrative Nutritional Counseling Combining Chinese Medicine and Biomedicine for Chinese Americans with Type 2 Diabetes: A Mixed-Methods Feasibility Study

Objectives: This study describes the development and feasibility of Integrative Nutritional Counseling (INC), a Chinese medicine (CM)+biomedicine-based nutrition curriculum for Chinese Americans with type 2 diabetes. Although Chinese Americans often incorporate CM principles into their diet, scant research has explored how to integrate CM with biomedical nutrition standards in a culturally appropriate manner or if such a program could improve diabetes self-management. Design: This is a 1-month pre-post study design including three points of contact: baseline, in-person class, and 1-month follow-up. Subjects: Participants (n = 15) were Cantonese-speaking/reading Chinese Americans diagnosed with type 2 diabetes who had used some form of CM/medicinal foods in the last 12 months. Interventions and Outcome Measures: The INC program included baseline surveys and a CM intake interview conducted by a licensed acupuncturist. The acupuncturist generated a CM diagnosis, which was shared with the participant, and used this diagnosis to tailor brief nutrition education. To bolster this brief education, a bilingual registered dietitian provided a 2-h group education class in Cantonese to all participants, during which time participants also received a Chinese/English INC booklet. Participants completed surveys immediately after the class and at 1-month follow-up, with qualitative exit interviews. Results: Participants reported improved attitudes and dietary habits aligning directly with INC, and improvement in biomedically valued measures of type 2 diabetes, such as weight loss, and CM-valued measures of digestion/elimination and hot/cold feeling. Satisfaction with INC was high, but challenges included confusion with some INC information, structural barriers, and comorbidities. Conclusions: Chinese Americans with type 2 diabetes and interventionists found integrative nutrition approaches acceptable and feasible. Future research should examine INC with a larger population and explore optimal delivery of INC given reported challenges.

Patients' and healthcare providers' perspectives on diabetes management: A systematic review of qualitative studies

BACKGROUND

Despite the availability of evidence-based guidance to deliver effective diabetes care, many patients do not achieve goals as recommendations. This systematic review was to synthesize useful insight perspectives by patients and providers to identify factors related to diabetes management using Chronic Care Model.

OBJECTIVE

This systematic review aimed to synthesize perspectives by patients and providers in order to identify factors related to diabetes management.

METHODS

Databases were searched including CINAHL, PubMed, Science Direct, and Web of Science from January 2001 to September 2017. Combination of search terms were used like 'qualitative,' 'diabetes management,' 'patients' perspective,' and 'provider's perspective.' All qualitative studies used were in English with available full text. Chronic Care Model framework was used to analyze the content and to organize the findings.

RESULTS

Of 108 articles used, only 23 of this met the inclusion criteria. Nine factors were identified including community linkage, health service system for diabetic patients, continuity of care, self-management, providers' support, referral system, patient-provider interaction, increasing competency of healthcare providers and family support. Community linkage was revealed to be an important factor to encourage diabetic patients to look after their disease while health service system showed the limit of accessibility due to location, medical service availability, finance, information, and time. Continuity of care has shown lack of coordination in referral system within a health care team and self-management was dependent on the knowledge, beliefs, attitude, and behavior of the patient. More so, providers' support through an effective plan and/or strategy has also indicated to help patients get their target goal. Poor interaction between patients and health providers was found to be largely attributed to language barrier and lack of communication skill. Improving competency for the health providers can be achieved through continuing professional education. Both perspectives supported a family involvement and community resources for diabetes patients.

CONCLUSION

Factors related to diabetes management from nine themes showed various gaps in both perspectives. Further research on new models for diabetes management is required.

Positive health beliefs are associated with improvement of glycated hemoglobin and lipid profiles in Mexican patients with type 2 diabetes mellitus: a cross-sectional study

BACKGROUND

Health beliefs are relevant to consider in patients with type 2 diabetes since disease control depends mainly on the patient's behaviour. The aim of this study was to assess the association between health beliefs and glycated hemoglobin levels in Mexican patients with type 2 diabetes.

METHODS

An analytical cross-sectional study was conducted, and 336 patients were included. Fasting blood levels of glycated hemoglobin, glucose, cholesterol; triglycerides, high-density lipoprotein cholesterol (HDL-c), and low-density lipoprotein cholesterol (LDL-c) were measured. Body fat percentage, weight, height; waist circumference, and systolic and diastolic blood pressures were also obtained. A previously validated self-administered questionnaire was used to assess the health beliefs with regards to non-pharmacological treatment. Health beliefs were classified as positive, neutral, and negative.

RESULTS

The average age of patients was 54.7 ± 8.5 years, with a higher proportion of females (69%). The questionnaire had a good internal consistency with a Cronbach's alpha score of 0.83. More than 90% of patients attributed a health benefit to diet and exercise, 30 to 40% experienced barriers, and more than 80% had a perception of complications associated to uncontrolled diabetes. Patients with positive health beliefs had lower HbA1c levels (8.2 ± 1.7%) compared to those with neutral (9.0 ± 2.3%), or negative (8.8 ± 1.8%; p = 0.042). The LDL-c levels were lower (p = 0.03), and HDL-c levels were higher (0.002) in patients with positive heath beliefs.

CONCLUSIONS

Positive health beliefs are associated with better metabolic control indicators in patients with type 2 diabetes.

Cultural Influences on Dietary Self-Management of Type 2 Diabetes in East Asian Americans: A Mixed-Methods Systematic Review

Purpose: Many East Asian Americans (EAAs) (populations originating from China, Korea, Japan, and Taiwan) with type 2 diabetes mellitus (T2DM) experience unique challenges in managing their disease, including language barriers and traditional cultural beliefs, particularly among first-generation immigrants.. The purpose of this mixed-methods systematic review was to examine cultural perspectives of EAAs that influence dietary self-management of T2DM and identify education interventions and their approaches to enhance EAAs' dietary self-management of diabetes. Methods: A mixed-methods systematic review was conducted to examine EAAs' perspectives from qualitative studies and to identify education interventions and their approaches from quantitative studies. A literature search was conducted using PubMed/MEDLINE, SCOPUS, CINAHL, and Web of Science from 1995 to 2018. Sixteen studies (10 qualitative and 6 quantitative) met criteria for analysis. Thematic synthesis of qualitative data was conducted using a line-by-line coding strategy. Extracted quantitative data were assessed for cultural approaches used in the interventions and diabetes-related outcomes. Results: In the qualitative studies, beliefs about food impacted EAAs' abilities to adopt appropriate dietary recommendations for diabetes management. Requiring a specialized diet disrupted social harmony and made EAAs feel burdensome to others. Having bilingual and bicultural resources eased the stress of making dietary modifications. The most commonly incorporated approaches in diabetes education interventions were bilingual education and culturally specific dietary recommendations. Social roles and harmony were not discussed. Significant reductions in hemoglobin A1c and increases in diabetes knowledge were reported post-intervention. Conclusions: Beliefs about food, beliefs about social roles, and access to culturally competent care play an important role in dietary self-management of T2DM among EAAs. Understanding the cultural influences on dietary self-management of T2DM and tailoring interventions to meet the needs of EAAs are essential in effort to address the growing epidemic and improve patient outcomes.

Haitian Immigrants and Type 2 Diabetes: An Integrative Review

Type 2 diabetes (T2D) is a complex, lifelong condition that is disproportionately prevalent among minority populations. Haitian immigrants (HIs) living in the US with T2D have unique factors that influence diagnosis, treatment, and self-management. The purpose of this integrative review was to provide a synthesis of the research on T2D in the HI population. In a systematic literature search, 14 studies met the inclusion criteria. Three themes were identified: risk factors for less self-management and/or worse metabolic control; protective factors for better self-management and/or metabolic control; and mixed results. HIs had higher HbA_1c, yet better self-management, different genetic profiles, and lower levels of vitamin D and hemoglobin concentration compared to other ethnic groups. HIs also reported better dietary quality, less healthcare utilization, and higher perceived emotional/psychological stress compared to other ethnic groups. This study has implications for practice for integrating the unique cultural factors when assessing and intervening with HIs.

Meaningful and culturally appropriate palliative care for Chinese immigrants with a terminal condition: a qualitative systematic review protocol

OBJECTIVE

This review aims to identify and synthesize the best qualitative evidence on the experiences of Chinese immigrants receiving palliative care in their country of residence where the culture is predominantly Western, and the experiences of their family carers.

INTRODUCTION

The recent increase in international immigration has led to challenges in providing culturally appropriate palliative care. Chinese populations have particular beliefs, values and practices surrounding death and filial piety. These differ considerably from those in Western cultures and have significant implications for palliative care service provision. This review will explore the experiences and perceptions of Chinese immigrants and how their cultural beliefs shape their acceptance and decision making related to palliative care.

INCLUSION CRITERIA

The review will include studies on the experiences of Chinese immigrants over 18 years of age with a terminal medical condition receiving palliative care in outpatient units, hospitals, hospices, specialist palliative care units, homes and community settings in their country of residence where the culture is predominantly Western.

METHODS

Eligible studies will be studies with qualitative data including designs such as phenomenology, grounded theory, ethnography, narrative research, qualitative description, action research and feminist research published in English and Chinese. CINAHL, PsycINFO, MEDLINE, Scopus and Web of Science Core Collection will be used and grey literature will be searched using ProQuest Dissertations and Theses, OpenGrey and Caresearch. Appraisal of selected studies will be done with the Joanna Briggs Institute Qualitative Assessment and Review tool. Findings will be synthesized through a meta-aggregative approach to produce a comprehensive set of synthesized findings that can be used as a basis for evidence-based practice.

Participation of Racial and Ethnic Minorities in Technology-Based Interventions to Self-Manage Type 2 Diabetes: A Scoping Review

PURPOSE

Strategies to decrease societal and cultural barriers for ethnic minorities to participate in health research are well established. However, limited data are available regarding participation of ethnic minorities in mobile and Internet technology-based interventions to self-manage type 2 diabetes where health disparities are predominant. Thus, the purpose was to understand the participation of ethnic minorities in technology-based intervention programs to manage type 2 diabetes.

DESIGN/METHOD

A scoping review was used to review a total of 21 intervention studies containing participant information about ethnic minorities and one qualitative study discussing participation of ethnic minorities.

FINDINGS

There was limited enrollment and participation of ethnic minorities. Technological barriers in addition to existing societal and cultural barriers were identified. Strategies to decrease the barriers were recommended.

CONCLUSIONS

Technological barriers were identified on top of the societal and cultural barriers in traditional interventions. Further research to reduce the barriers is warranted.