Effectiveness of Culturally Tailored Diabetes Education among Asian Americans

Introduction
There are various risk factors that have been associated with the development of type 2 diabetes. These include, but they are not limited to, ethnicity and lifestyle. With regard to ethnicity, it is important to note that people of Asian descent have a higher predisposition to type 2 diabetes, in comparison to persons of European ancestry. Some of the complications associated with type 2 diabetes include cardiovascular disease, kidney damage, and nerve damage. It therefore follows that the relevance of proper control and management of type 2 diabetes cannot be overstated. For most persons with type 2 diabetes, the optimal control of the same tends to be a challenge. In that regard, therefore, there is need to assess how effective patient-specific dietary and lifestyle modifications are towards the control and management of type 2 diabetes. Towards this end, this study will chart pre-education and post-education glucose levels of 5-10 Asian Americans with an aim of assessing the effectiveness of culturally tailored diabetes education among this group, in comparison to a control group that has no access to such education.
Background of the Problem
Like any other chronic disease, diabetes calls for the active involvement of the patient in its management and treatment. This effectively means that interventions ought to be cognizant of the relevance of self-management. According to Nguyen, Nguyen, Fischer, and Tran (2015), “type 2 diabetes mellitus (T2DM) is a growing problem among Asian Americans.” The need to address this problem calls for the implementation of valid and effective intervention measures. Culturally tailored diabetes education could come in handy in seeking to halt this worrying trend. This is more so the case given that in the recent past, the cultural practices and beliefs of Asian Americans regarding diabetes and its treatment have not been sufficiently explored or probed.
Theoretical Foundations
The theoretical framework of the present study will be based on health belief model (HBM). In essence, the HBM “highlights the cognitive processes that act as barriers to taking preventive action through an emphasis on the role of subjective beliefs or expectations…” (Cousins, 1998, p. 145). This model is of great relevance to the present study as in the words of Jones, Jensen, Scherr, Brown, Christy, and Weaver (2015), it “posits that messages will achieve optimal behavior change if they successfully target perceived barriers, beliefs, self-efficacy, and threat” (566). The proper control and management of diabetes is often hampered by challenges that have a cultural bearing. As a matter of fact, various studies have in the past pointed out that the relevance of the social context of disease management cannot be overstated in seeking to improve outcomes (Chesla, Chun, and Kwan, 2009).
Review of Literature
Being a chronic condition, the optimal outcome of treatment and management of diabetes largely relies on self-management education that is ideally designed to enhance the quality of life via the promotion of certain behaviors and habits (Jake, 2007). For this reason, diabetic patient education ought to be personalized so as to achieve the desired outcomes. It is, however, important to note that the ability of persons to acquire, process, retain, and recall information and skills is affected by a wide variety of factors. Some of the more prominent factors on this end include cultural background and life experiences. According to Nguyen, Nguyen, Fischer, and Tran (2015), the very first step in seeking to ensure that diabetes education has the desired impact is cultural sensitivity. Cultural sensitivity has got to do with the awareness of not only the customs and beliefs of a certain people, but also their actions and though processes (Nguyen, Nguyen, Fischer, and Tran, 2015). This is the definition of cultural sensitivity that will be adopted in this text. According to Lopez, Ruiz, and Pattern (2017), “a record 20 million Asian Americans trace their roots to more than 20 countries in East and Southeast Asia and the Indian subcontinent, each with unique histories, cultures, languages and other characteristics.” Type 2 diabetes, as Nguyen, Nguyen, Fischer, and Tran (2015) observe, is increasingly becoming a concern in this demographic group. This effectively underlines the need for the personalization of diabetes education for the same to be deemed effective.
As Shabibi et al. (2017) acknowledge, being a chronic disease, diabetes calls for the enhancement of the appropriate self-care habits and behaviors of patients. In a study seeking to chart how educational intervention founded the Health Belief Model affects the self-care habits of patients having type 2 diabetes, Shabibi et al. (2017) came to the conclusion that “health education through HBM promotes the self-care behaviors of patients with type 2 diabetes” (5967). In basic terms, this particular model, according to Cousins (1998) “highlights the cognitive processes that act as barriers to taking preventive action through an emphasis on the role of subjective beliefs or expectations…” (145). This effectively means that when applied in this context, HBM addresses the long-standing behaviors via the adaptation of individual cognitions so as to eliminate or improve behaviors deemed as being counterproductive to the wellbeing of an individual. This is more so the case given that HBM is constructed on the basis that it is possible to avoid health conditions deemed negative; that the adoption of a recommended course of action could be of great relevance in seeking to avoid adverse health conditions; and that people can indeed embrace or adopt health behaviors that reinforce their health and wellbeing (Jones, et al., 2015). The relevance of reining in diabetes via the effective management of the same cannot be overstated – and towards this end, HBM comes in handy in seeking to further enhance our understanding and grasp of health behaviors and how to positively influence them via the application of culturally-relevant diabetes education.
Chesla, Chun, and Kwan (2009) are of the opinion that for health interventions to be appropriate among various demographic groups having strong cultural bearings; cultural humility is of great relevance. While there are many approaches that could be embraced in seeking to overcome cultural barriers in the treatment and management of diabetes amongst Asian Americans, culturally tailored diabetes education appears to be the most effective given the level of involvement of diabetes patients in their treatment and management plan. Shabibi et al. (2017) are of the opinion that diabetic educators ought to be well-versed on the customs and traditions of the ethnic formations they interact with. This means that they should also be aware of the beliefs, preferences, as well as learned behaviors of those diabetic patients so as to be able to ensure that culturally appropriate methods are utilized in the delivery of diabetes education.
Problem Statement
It is not known how effective culturally tailored diabetes education, founded on current evidence-based findings, is in the management and control of diabetes among Asian Americans. Given that type 2 diabetes is a chronic disease, self-management education remains one of the most important interventions for improved outcomes. Towards this end, there is significant evidence to suggest that patient education ought to be tailored to the specific circumstances of the diabetes patient. However, learning is often influenced by a wide range of factors including, but not limited to, an individual’s support networks and life experiences – both of which are largely controlled or governed by culture. There is need, therefore, to determine how culturally tailored diabetes education impacts the management and control of diabetes.
Purpose of the Project
The purpose of this project is to determine whether patients who receive culturally tailored diabetes education report a reduction in A1C levels, in comparison to patients who receive standard education. It was hypothesized that participants who receive diabetes education would report improved A1C levels, in comparison to participants who receive standard education. For this project, a total of 10 participants of Asian American extraction will be selected. Findings will come in handy in seeking to not only map the efficacy of culturally tailored diabetes education programs for Asian Americans, but to also inform the appropriate design and implementation modes for such programs.
Clinical Questions and Variables
Research Questions
1. Amongst Asian Americans with type 2 diabetes, does culturally tailored diabetes education to implement patient-specific dietary and lifestyle modifications reduce their A1C levels after 3 weeks?
2. What unique practices and beliefs do Asian Americans exhibit regarding diabetes treatment and management?
H1: Amongst Asian Americans with type 2 diabetes, culturally tailored diabetes education to implement patient-specific dietary and lifestyle modifications results in statistically significant reductions in their A1C levels after 3 weeks.
H0: Amongst Asian Americans with type 2 diabetes, culturally tailored diabetes education to implement patient-specific dietary and lifestyle modifications has no significant impact on their A1C levels after 3 weeks.
Significance of the Project
The present study will add to the existing body of knowledge on the relevance of culturally appropriate diabetes interventions. There are several studies that have been conducted on this particular topic in the past in relation to diverse demographic groupings. For instance, Metghalchi et al. (2008) sought to assess whether making use of culturally sensitive diabetes education programs could lead to improved outcomes among the Hispanic population. In essence, most of the studies that have been conducted in this area are largely obsolete. No recent study assessing how effective culturally appropriate diabetic education (founded on current evidence-based practices) is, has been presented in recent times. In seeking to “assess the feasibility and acceptability of a culturally appropriate diabetes management program tailored to Chinese Americans with type 2 diabetes”, Wang and Chan (2005) came to the conclusion that “culturally tailored diabetes management may be effective in Chinese Americans with type 2 diabetes” (352). In addition to zeroing in on a specific demographic category i.e. Asian Americans, the present study will be founded on current approaches to the design and presentation of culturally appropriate diabetes education in an attempt to assess how such interventions impact pre-education and post-education glucose levels amongst Asian Americans with type 2 diabetes.
Rationale for Methodology
A quantitative methodology will be adopted for the present research. This methodology has been adopted because the study ought to be understood from the perspective of the demographic group under consideration, i.e. Asian Americans. Further, this research methodology provides both detail and depth. In that regard, therefore, it will be possible to have a detailed view of the issue under consideration.
Nature of the Project Design
For this particular study, I settled on a prospective cohort design. Jekel (2007) defines a prospective cohort study as where “the investigator assembles the study groups in the present time, collects baseline data on them, and continues to collect data for a period that can last many years” (p. 80). I settled on a cohort study due to the fact that it would permit me to not only control, but also standardize the collection of data as the process continues, and meanwhile be able to also assess or observe the outcome events.
Instrumentation or Sources of Data
The study will make use of pre and post-questionnaires as one source of data. In a research of this nature, questionnaires tend to be most appropriate. This is more so the case given that it would permit for follow-up on responses and clarification of misconceptions, if any. Glycemic control will be the primary outcome measure of efficacy.
Data Collection Procedures
A total of 10 persons of Asian American extraction and having type 2 diabetes will be selected. The said selection will be random and it will make use of recent related study roasters. Of the 10 persons selected, a total of 5 will be assigned to the control group, while the remaining five will be assigned to the experimental group. It is important to note that the past studies in which selected participants were involved must not be intervention related. This will eliminate the possibility of a contaminated sample. In essence, standards for participation will be: a) participant must be of age 25 – 60, b) participant has been taking insulin for a period of more than 12 months, or participant has been taking a hypoglycemic agent for a period of more than 12 months and c) participant is willing to participate in the investigation. Those who have certain medical conditions that contraindicate some diet change or lifestyle modifications will be excluded. Those who are pregnant will also be excluded from the study. Ethical approval will be sought and participants will be required to give a formal written consent of their willingness to participate. Participants will be provided with a journal in which they will record and document both their weight and sugar levels at intervals that will be predetermined. The journals will be returned after a week. Thereafter, this group will be provided with culturally appropriate diabetic education. The same group will them be asked to record their blood sugars in a similar format as that adopted during the baseline week. The pre-education and post-education glucose levels will then be compared
Data Analysis Procedures
Descriptive statistics will be utilized in not only the characterization of the sample, but also the summarization of outcome measures throughout the undertaking, i.e. before the intervention, during the intervention, and after the intervention. In seeking to conduct or complete the ICG analysis, the researcher will make use of the Hierarchical Linear and Nonlinear Modeling software (HLM). Towards this end, multilevel models will be utilized due to its ability to evaluate/approximate the subject’s growth curve using all the data available for the specified subject. Given that this investigation seeks to determine whether patients who receive culturally tailored diabetes education report a reduction in A1C levels, in comparison to patients who receive standard education, conditional models will be tested. In an attempt to enhance grasp of the outcome measures impacted upon by culturally tailored diabetes education (the intervention), there will be need to undertake a series of covariance univariate analyses (ANCOVA).
Ethical Considerations
To ensure that all those who participate in the study do so without coercion and elect to participate knowingly, informed consent will be sought. This will be in seeking to protect the autonomy of participants. Further, measures will be taken to respect the confidentiality and anonymity of participants. This is more so the case given that by its very nature, this study will involve the collection of the private information of participants. Such information includes, but it is not limited to, the medical records of participants, opinions and attitudes of participants, and participant beliefs.
References
Cousins, S.O. (1998). Exercise, Aging, and Health: Overcoming Barriers to an Active Old Age. Philadelphia, PA: Taylor & Francis.
Chesla, C.A., Chun, K.M. & Kwan, C.M. (2009). Cultural and Family Challenges to Managing Type 2 Diabetes in Immigrant Chinese Americans. Diabetes Care, 32(10), 1812–1816.
Jekel, J.F. (2007). Epidemiology, Biostatistics, and Preventive Medicine. Philadelphia, PA: Elsevier Health Sciences.
Jones, C.L., Jensen, J.D., Scherr, C.L., Brown, N.R., Christy, K. & Weaver, J. (2015). The Health Belief Model as an Explanatory Framework in Communication Research: Exploring Parallel, Serial, and Moderated Mediation. Health Communication, 30(6), 566-576.
Lopez, G., Ruiz, N.G. & Pattern, E. (2017). Key Facts about Asian Americans, a Diverse and Growing Population. Retrieved from http://www.pewresearch.org/fact-tank/2017/09/08/key-facts-about-asian-americans/
Metghalchi, S., Rivera, M., Beeson, L., Firek, A., Leon, M.D., Maclntyre, Z.R. & Balcazar, H. (2008). Improved Clinical Outcomes Using a Culturally Sensitive Diabetes Education Program in a Hispanic Population. Diabetes Education, 34(4), 698 – 706.
Nguyen, T.H., Nguyen, T., Fischer, T. & Tran, T.V. (2015). Type 2 Diabetes among Asian Americans: Prevalence and Prevention. World Journal of Diabetes, 6(4), 543–547.
Shabibi, P., Zavareh, M.S., Sayehmiri, K., Qorbani, M., Safari, O., Rastegarimehr, B. & Mansourian, M. (2017). Effect of Educational Intervention Based on the Health Belief Model on Promoting Self-Care Behaviors of Type-2 Diabetes Patients. Electronic Physician, 9(12), 5960–5968.
Wang, P.Y. & Chan, S.M. (2005). Culturally Tailored Diabetes Education Program for Chinese Americans: A Pilot Study. Nursing Research, 54(5), 347-53.
Appendices
10 Strategic Points Table
10 Strategic Points
Comments/Feedback
Broad Topic Area
1. Broad Topic Area:
Assessment of the Effectiveness of Culturally Tailored Diabetes Education among Asian Americans
Literature Review
2. Literature Review:
a. Background of the Problem/Gap:
· Being a chronic condition, the optimal outcome of treatment and management of diabetes is founded on self-management education (Jake, 2007)
· Diabetic patient education ought to be personalized so as to achieve the desired outcomes.
· Cultural background and life experiences affect how people acquire, process, retain, and recall information.
· The first step in seeking to ensure that diabetes education has the desired impact is cultural sensitivity (Nguyen, Nguyen, Fischer, and Tran, 2015)
b. Theoretical Foundations (models and theories to be foundation for study):
· The Health Belief Model (HBM) could help in the enhancement of the understanding and grasp of health behaviors and how to positively influence them via the application of culturally-relevant diabetes education.
· HBM “highlights the cognitive processes that act as barriers to taking preventive action through an emphasis on the role of subjective beliefs or expectations…” (Cousins, 1998, p. 145).
c. Review of Literature Topics With Key Organizing Concepts or Topics for Each One
Diabetes Prevalence in Asian Americans
“Type 2 diabetes mellitus (T2DM) is a growing problem among Asian Americans” (Nguyen, Nguyen, Fischer, and Tran, 2015)
Cultural Relevance
“A record 20 million Asian Americans trace their roots to more than 20 countries in East and Southeast Asia and the Indian subcontinent, each with unique histories, cultures, languages and other characteristics” (Lopez, Ruiz, and Pattern, 2017).
The Need for Culturally Tailored Diabetes Interventions
For health interventions to be appropriate among various demographic groups having strong cultural bearings; cultural humility is of great relevance (Chesla, Chun, and Kwan, 2009).
d. Summary
· Gap/Problem: There is need to determine how culturally tailored diabetes education impacts the management and control of diabetes
· Prior studies: There is significant evidence to suggest that patient education ought to be tailored to the specific circumstances of the diabetes patient.
· Quantitative application: Morbidity and mortality analysis and application of appropriate interventions.
· Significance: Will add to the existing body of knowledge on the relevance of culturally appropriate diabetes interventions
Problem Statement
3. Problem Statement
While there is significant evidence to suggest that patient education ought to be tailored to the specific circumstances of the diabetes patient, it is not known how effective culturally tailored diabetes education, founded on current evidence-based findings, is in the management and control of diabetes among Asian Americans
Clinical/PICO Questions
4. Clinical/PICOT Questions
P- (Population) Among Asian Americans diagnosed with type 2 diabetes
I- (Intervention) Does health education to implement patient-specific dietary and lifestyle modifications
C- (Comparison) Among patients who receive culturally tailored diabetes education, against patients who just receive standard education
O- (Outcome) Lead to a reduction of mean blood sugar levels
T- (Time frame) within a period of 2-3 weeks after education is provided?
Sample
5. Sample (and Location):
Location:
Population:
Sample: 10 participants
Define Variables
6. Define Variables:
Independent Variable: Culturally appropriate diabetic education
Dependent Variable: A1C levels
Methodology and Design
7. Methodology and Design:
This project will use a qualitative methodology with a prospective cohort design.
Purpose Statement
8. Purpose Statement:
The purpose of this project is to determine whether patients who receive culturally tailored diabetes education report a reduction in A1C levels, in comparison to patients who receive standard education.
Data Collection Approach
9. Data Collection Approach:
· 10 persons of Asian American extraction and having type 2 diabetes will be selected.
· The selection will be random and it will make use of recent related study roasters
· 5 persons will be assigned to the control group, while the remaining 5 will be assigned to the experimental group
· Participants will be provided with a journal in which they will record and document both their weight and sugar levels at intervals that will be predetermined
· Journals will be returned after a week.
· Experiment group will be provided with culturally appropriate diabetic education. The same group will them be asked to record their blood sugars in a similar format as that adopted during the baseline week.
· Pre-education and post-education glucose levels will then be compared
Data Analysis Approach
10. Data Analysis Approach:
· Descriptive statistics will be utilized in not only the characterization of the sample, but also the summarization of outcome measures throughout the undertaking
· To complete the ICG analysis, the Hierarchical Linear and Nonlinear Modeling software (HLM) will be utilized
· To enhance grasp of the outcome measures impacted upon by culturally tailored diabetes education (the intervention), there will be need to undertake a series of covariance univariate analyses (ANCOVA)