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Moving Beyond the Color of Skin—Providing Culturally Appropriate Diabetes Care and Education

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Published Online: Jun 6th 2011 US Endocrinology, 2008;4(1):27-8 DOI:
Authors: Amparo Gonzalez
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Cultural sensitivity and competence have been hot topics in diabetes care for several years. Ethnic and racial disparities in healthcare have been reported in numerous studies, and the gaps in access to care, quality of care, and health status continue to widen. The fact remains that the American health system fails to provide consistent, high-quality care to minority patients.

Healthcare providers can help to decrease the quality gap by becoming aware of the barriers to care and developing culturally sensitive and competent practices.

Cultural sensitivity and competence have been hot topics in diabetes care for several years. Ethnic and racial disparities in healthcare have been reported in numerous studies, and the gaps in access to care, quality of care, and health status continue to widen. The fact remains that the American health system fails to provide consistent, high-quality care to minority patients.

Healthcare providers can help to decrease the quality gap by becoming aware of the barriers to care and developing culturally sensitive and competent practices.

The argument for providing culturally appropriate care bears repeating, and every individual who provides healthcare to a patient who belongs to a minority ethnic group must take steps to eliminate these unnecessary and disturbing discrepancies.

The Case for Culturally Appropriate Care
Minorities currently account for one-third of the US population.1 By 2050, Hispanic, African-American, Asian, Native American/Alaska Native, and other groups will make up nearly 50% of the population.2 This demographic shift will have a considerable impact on the American healthcare system as these racial groups experience a higher incidence of chronic diseases and report significantly poorer health outcomes than non-Hispanic whites.

There are many factors that can contribute to these inequalities, some of which include genetic predisposition, socioeconomic status, limited education, geographical location, or a lack of health insurance; however, even when these access-related barriers are controlled, racial and ethnic minorities are still at a disadvantage when it comes to quality of healthcare.3

The 2002 Institute of Medicine (IOM) report ‘Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care’ created shockwaves among many healthcare providers by asserting that the discrepancies in minority care were not wholly attributed to the patient’s socioeconomic status, cultural differences, attitudes toward healthcare, or treatment preferences. In fact, the study found that “bias, prejudice, and stereotyping on the part of healthcare providers may contribute to differences in care.”

In examining the sources of healthcare disparities, the IOM identified two sets of contributing factors. The first set relates to the operation of healthcare systems and the legal and regulatory climate in which they exist. These factors relate to cultural or linguistic barriers, financial restrictions on services offered, and the type of setting in which minorities receive care.

Three specific provider-related mechanisms related to the ‘clinical encounter’ make up the second set of factors that influence inequalities in care: bias (or prejudice) against minority patients, clinical uncertainty when interacting with minority patients, and beliefs (or stereotypes) held by the provider about the behavior or health of minorities.

Based on these findings, the IOM made several recommendations for addressing the identified discrepancies. One such recommendation was that cross-cultural education be integrated into the training of all current and future health professionals. The IOM asserts that training programs will enhance healthcare providers’ awareness of how cultural and social factors influence the health status, treatment, and outcomes of minority patients.

The report states: “Cross-cultural education can be divided into three conceptual approaches focusing on attitudes (cultural sensitivity/ awareness approach), knowledge (multicultural/categorical approach), and skills (cross-cultural approach), and has been taught using a variety of interactive and experiential methodologies. Research to date demonstrates that training is effective in improving provider knowledge of cultural and behavioral aspects of healthcare and building effective communication strategies.”
How Healthcare Providers Can Supply Culturally Appropriate Care to People with Diabetes
Diabetes disproportionately affects minorities. Healthcare providers must take responsibility for educating themselves about the culture, beliefs, and preferences of their patient population.

For healthcare providers who deal with minority patients, it is important to objectively judge one’s own bias, prejudice, and stereotypes and see how they influence one’s treatment recommendations. This is exactly what must happen for the US healthcare system to bridge the gaps in quality of care and ensure that all patients receive the treatment they need, regardless of their ethnic or racial heritage.

Diabetes requires patients to make significant changes to their lifestyles, which are heavily influenced by their social norms and cultural identities. In a 2002 position statement entitled ‘Cultural Sensitivity: Definition, Application, and Recommendations for Diabetes Educators,’ the American Association of Diabetes Educators (AADE) recommends that: “Health professionals should develop and deliver diabetes education in a context that recognizes how groups of people self-identify their culture and express their beliefs, a perspective that underscores the importance of moving beyond simple associations of cultural identity with race or ethnicity.”

The position statement reinforces the idea that “Cultural identity is based on any combination of collectively shared historical, linguistic, and psychological lineage; these sets of factors influence the social and spiritual perspectives of ethnic groups, particularly in establishing priorities for daily living.”

As the successful self-management of diabetes depends on the patient’s understanding, acceptance, and implementation of healthy self-care behaviors, it is essential that every member of the care team takes the time to learn how to diminish or eliminate their conscious or unconscious biases toward minorities and standardize the quality of care delivered.

Bennett’s Developmental Model of Intercultural Sensitivity outlines the different stages of cultural sensitivity an individual has reached. The model has six stages. The first three show an ethnocentric approach, where one’s own culture is experienced as central to reality:

  1. denial: does not recognize cultural differences;
  2. defense: recognizes some differences, but sees them as negative; and
  3. minimization: unaware of projection of own cultural values; sees own values as superior.

    The next three stages reveal an ethno-relative approach, in which one’s own culture is experienced in the context of other cultures:

  4. acceptance: shifts perspectives to understand that the same ‘ordinary’ behavior can have different meanings in different cultures;
  5. adaptation: can evaluate the behavior of others from their frame of reference and can adapt behavior to fit the norms of a different culture; and
  6. integration: can shift frame of reference and also deal with resulting identity issues.

If you care for patients from minority populations in your practice, it is important that you achieve cultural acceptance, adaptation, or integration and that your practice reflects this.

The Office of Minority Health and the Department of Health and Human Services document ‘Assessing Cultural Competence in Health Care: Recommendations for National Standards and an Outcome-Focused Research Agenda’ makes specific recommendations for culturally effective healthcare. It highlights the importance of working with culturally competent administrative, clinical, and support staff and the necessity of examining the provider’s supporting attitudes, behavior, knowledge, and skills. Healthcare professionals are encouraged to work respectfully and effectively with patients and each other in a culturally diverse environment, and to employ strategies to address culturally and linguistically appropriate services.

The complexity of cultures should be used as a framework, and healthcare providers should individualize care after a detailed assessment around culture, background, degree of acculturation, socioeconomic level, country of origin, language, and legal status.

It is a good idea to view every patient encounter that takes place as a cross-cultural interaction, even if the patient’s skin is the same color as yours. People are an amalgamation of their experiences, family heritage, socioeconomic status, gender, sexual preferences, and lifestyle choices. To address the diverse needs of each patient, healthcare professionals must increase their cultural awareness and learn techniques and strategies that make patients feel understood, respected, and cared for. Ultimately, this will translate into better health outcomes for minority patients and help close the gaps in quality of care that they experience.

To become culturally competent, one must begin with a self-assessment and then work to acquire knowledge about other cultures and develop and maintain cross-cultural skills through coursework and informal interaction with people from this culture.

The IOM reports that implementing these skills will contribute to a decrease in the bias and stereotyping of patients and will increase equality in healthcare. Improving cultural competency in healthcare providers is a solution that you can implement and that will improve our health system.■


  1. National Center for Health Statistics. Health US, Chartbook on Trends in the Health of Americans, 2006.
  2. US Census Bureau, US Interim Projections by Age, Sex, Race and Hispanic Origin, 2004.
  3. Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, 2002.
  4. National Standards for Culturally and Linguistically Appropriate Services in Health Care, US Department of Health and Human Services, Office of Minority Health, 2001; available at: and

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