The impact of culturally competent diabetes care interventions for improving diabetes-related outcomes in ethnic minority groups: a systematic review

Diabet. Med. 29, 1237-1252 (2012) ABSTRACT: Aim To examine the evidence on culturally competent interventions tailored to the needs of people with diabetes from ethnic minority groups. Methods MEDLINE (NHS Evidence), CINAHL and reference lists of retrieved papers were searched from inception to September 2011; two National Health Service specialist libraries were also searched. Google, Cochrane and DARE databases were interrogated and experts consulted. Studies were included if they reported primary research on the impact of culturally competent interventions on outcome measures of any ethnic minority group with diabetes. Paper selection and appraisal were conducted independently by two reviewers. The heterogeneity of the studies required narrative analysis. A novel culturally competent assessment tool was used to systematically assess the cultural competency of each intervention. Results Three hundred and twenty papers were retrieved and 11 included. Study designs varied with a diverse range of service providers. Of the interventions, 64% were found to be highly culturally competent (scoring 90-100%) and 36% moderately culturally competent (70-89%). Data were collected from 2616 participants on 22 patient-reported outcome measures. A consistent finding from 10 of the studies was that any structured intervention, tailored to ethnic minority groups by integrating elements of culture, language, religion and health literacy skills, produced a positive impact on a range of patient-important outcomes. Conclusions Benefits in using culturally competent interventions with ethnic minority groups with diabetes were identified. The majority of interventions described as culturally competent were confirmed as so, when assessed using the culturally competent assessment tool. Further good quality research is required to determine effectiveness and cost-effectiveness of culturally competent interventions to influence diabetes service commissioners.     

The Ethical Self-Fashioning of Physicians and Health Care Systems in Culturally Appropriate Health Care

Diverse advocacy groups have pushed for the recognition of cultural differences in health care as a means to redress inequalities in the U.S., elaborating a form of biocitizenship that draws on evidence of racial and ethnic health disparities to make claims on both the state and health care providers. These efforts led to federal regulations developed by the U.S. Office of Minority Health requiring health care organizations to provide Culturally and Linguistically Appropriate Services. Based on ethnographic research at workshops and conferences, in-depth interviews with cultural competence trainers, and an analysis of postings to a moderated listserv with 2,000 members, we explore cultural competence trainings as a new type of social technology in which health care providers and institutions are urged to engage in ethical self-fashioning to eliminate prejudice and embody the values of cultural relativism. Health care providers are called on to re-orient their practice (such as habits of gaze, touch, and decision-making) and to act on their own subjectivities to develop an orientation toward Others that is “culturally competent.” We explore the diverse methods that cultural competence trainings use to foster a health care provider’s ability to be self-reflexive, including face-to-face workshops and classes and self-guided on-line modules. We argue that the hybrid formation of culturally appropriate health care is becoming detached from its social justice origins as it becomes rationalized by and more firmly embedded in the operations of the health care marketplace.     

Ethics and cultural diversity--a framework for decision-making

Believing that healthcare outcomes will be more satisfying if the patients' cultural knowledge and values are understood and integrated appropriately in care planning, the author proposes a culturally competent ethical decision making model based on human rights--the fundamental right of individuals, families, groups, and populations to healthcare that is meaningful, supportive, and beneficial--and a reconceptualization of ethical principles to include the values and assumptions of clients. The ideal result is culturally congruent healthcare in which practitioners learn about their clients' lifeways and work with them to find satisfying ways to resolve clinical and ethical issues.     

A Survey of Canine Heartworm Awareness in Grenada,West Indies

Heartworm is a common parasite of dogs in Grenada, West Indies, due to the tropical climate and large number of mosquitoes. Because Grenada is a developing country and a small island, resources and education on heartworm are limited. In an effort to raise awareness of canine heartworm and the preventive measures available, observations and surveys were performed to determine the following: (a) heartworm knowledge among Grenadian dog caregivers seeking veterinary care at the Grenada Society for the Prevention of Cruelty to Animals (GSPCA), (b) dissemination of heartworm information by GSPCA staff to Grenadian dog caregivers, and (c) reasons Grenadians are not administering heartworm prevention to their dogs. Results indicated a marked deficiency in both heartworm knowledge among Grenadian dog caregivers and heartworm knowledge acquisition and dissemination. Lack of knowledge was also cited as a major reason Grenadian dog caregivers were not using heartworm prevention. These results are currently being utilized to modify heartworm education practices at the GSPCA by incorporating Grenada-specific educational tools, with the ultimate goal of reducing illness and death by canine heartworm.     

Diving into the Rio Grande Valley: Meaningful experiences in arts educator preparation

As the Texas Education Agency implements new standards for arts teachers and U.S. arts education policy stakeholders articulate a need for culturally competent educators, teacher preparation programs must respond and consider methods to prepare developing teachers to meet such standards. Preservice arts educators need exposure to a variety of art forms and opportunities to practice teaching in diverse settings in order to explore and exercise culturally responsive arts education. This research project examines the impact of a university program that places preservice teachers in the Rio Grande Valley near the Mexico/U.S. border in South Texas. The group surveyed includes 10 student teachers, two thirds of the total program participants. The research specifically examines the value of the experience for student teachers through surveys and follow-up interviews. The study concludes that student teaching in the Rio Grande Valley helps prepare participants to teach across identity markers and offers them important experience that helps prepare them to meet these new standards set by state policy makers. The article recommends offering more support and reflexive opportunities for these student teachers.     

Virtue,foible, and practice--medicine's arduous moral triad

Moral distress is often discussed as a response to the moral dilemmas that professional and other caregivers encounter in their effort to balance competing moral principles, or to provide care in difficult cases, to difficult patients, in spite of difficult institutional requirements or policy. In this essay, a reforming ER clinician and teaching physician, offers a personal approach to moral distress. Assuming that a clinician's own foibles may sometimes contribute to another's distress, and that attempting to rationalize or subvert these foibles causes moral fatigue, he offers personal guidelines for healthcare providers--four strategies that less-than-perfect practitioners may use while striving to attain the ideal of the competent, compassionate, altruistic, calm, and wise clinician.     

Tensions in Communication between Children on Antiretroviral Therapy and Their Caregivers: A Qualitative Study in Jinja District,Uganda

Introduction

HIV treatment and disclosure guidelines emphasize the importance of communicating diagnosis and treatment to infected children in ways that are appropriate to children’s developmental stage and age. Minimal attention, however, has been given to communication challenges confronted by HIV-infected children and their caregivers. This study examined the tensions between children and their caregivers arising from differing perspectives regarding when and what to communicate about antiretroviral therapy (ART).

Methods

This qualitative study was conducted between November 2011 and December 2012 and involved 29 HIV-infected children aged 8–17 years on ART and their caregivers. Data were collected through observations and in-depth interviews, which took place in homes, treatment centres and post-test clubs. Children and caregivers were sampled from among the 394 HIV-infected children and (their) 393 caregivers who participated in the cross-sectional survey that preceded the qualitative study. ATLAS.ti. Version 7 was used in the management of the qualitative data and in the coding of the emerging themes. The data were then analyzed using content thematic analysis.

Results

While the children felt that they were mature enough to know what they were suffering and what the medications were for, the caregivers wanted to delay discussions relating to the children’s HIV diagnosis and medication until they felt that the children were mature enough to deal with the information and keep it a secret and this caused a lot of tension. The children employed different tactics including refusing to take the medicines, to find out what they were suffering from and what the medications were for. Children also had their own ideas about when, where and with whom to discuss their HIV condition, ideas that did not necessarily coincide with those of their caregivers, resulting in tensions.

Conclusions

Guidelines should take into consideration differing perceptions of maturity when recommending ages at which caregivers should communicate with their children about diagnosis and ART. Health care providers should also encourage caregivers to recognize and respect children’s efforts to learn about and manage their condition. Children’s questions and expressions of feelings should be treated as openings for communication on these issues.     

Treatment engagement of individuals experiencing mental illness: review and update

Individuals living with serious mental illness are often difficult to engage in ongoing treatment, with high dropout rates. Poor engagement may lead to worse clinical outcomes, with symptom relapse and rehospitalization. Numerous variables may affect level of treatment engagement, including therapeutic alliance, accessibility of care, and a client's trust that the treatment will address his/her own unique goals. As such, we have found that the concept of recovery‐oriented care, which prioritizes autonomy, empowerment and respect for the person receiving services, is a helpful framework in which to view tools and techniques to enhance treatment engagement. Specifically, person‐centered care, including shared decision making, is a treatment approach that focuses on an individual's unique goals and life circumstances. Use of person‐centered care in mental health treatment models has promising outcomes for engagement. Particular populations of people have historically been difficult to engage, such as young adults experiencing a first episode of psychosis, individuals with coexisting psychotic and substance use disorders, and those who are homeless. We review these populations and outline how various evidence‐based, recovery‐oriented treatment techniques have been shown to enhance engagement. Our review then turns to emerging treatment strategies that may improve engagement. We focus on use of electronics and Internet, involvement of peer providers in mental health treatment, and incorporation of the Cultural Formulation Interview to provide culturally competent, person‐centered care. Treatment engagement is complex and multifaceted, but optimizing recovery‐oriented skills and attitudes is essential in delivery of services to those with serious mental illness.     

Mindreading, Mindshaping, and Evolution

I present and apply some powerful tools for studying humanevolution and the impact of cultural resourceson it. The tools in question are a theory ofniche construction and a theory about theevolutionary significance of extragenetic (and,in particular, of psychological and social)inheritance. These tools are used to show howculturally transmitted resources can berecruited by development and becomegeneratively entrenched. The case study isconstituted by those culturally transmitteditems that social psychologists call`expectancies'. Expectancy effects aremindshaping effects of our mindreadingdispositions. I show how expectancies may havebeen recruited by important human developmentalprocesses (like those involved in languageacquisition and those responsible for genderdifferences) and how they may have becomeentrenched. If the hypothesis is correct, therelation between mindreading and humanevolution is more intricate than usuallythought.     

Managing Ethical Challenges to Mental Health Research in Post‐Conflict Settings

Recently the World Health Organization (WHO) has highlighted the need to strengthen mental health systems following emergencies, including natural and manmade disasters. Mental health services need to be informed by culturally attuned evidence that is developed through research. Therefore, there is an urgent need to establish rigorous ethical research practice to underpin the evidence‐base for mental health services delivered during and following emergencies.     

Relationships and burden: An empirical‐ethical investigation of lived experience in home nursing arrangements

Quantitative research has called attention to the burden associated with informal caregiving in home nursing arrangements. Less emphasis has been placed, however, on care recipients’ subjective feelings of being a burden and on caregivers’ willingness to carry the burden in home care. This article uses empirical material from semi‐structured interviews conducted with older people affected by multiple chronic conditions and in need of long‐term home care, and with informal and professional caregivers, as two groups of relevant others. The high burden of home‐care arrangements is unanimously stressed by all three groups involved in the triangle of care. An empirical‐ethical investigation of what can be legitimately expected from family members and informal caregivers, informed by Frith's symbiotic empirical ethics approach, was undertaken. Key tenets from the special goods theory and nursing professionalism are used as analytical tools. The study concludes that the current situation may hinder professional development and can reinforce feelings of being a burden to relevant others.     

‘VAGUE OVIEDO’: AUTONOMY,CULTURE AND THE CASE OF PREVIOUSLY COMPETENT PATIENTS

The paper examines the ethical and legal challenges of making decisions for previously competent patients and the role of advance directives and legal representatives in light of the Oviedo Convention. The paper identifies gaps in the Convention that result in conflicting instructions in cases of a disagreement between the expressed prior wishes of a patient, and the legal representative. The authors also examine the legal and moral status of informally expressed prior wishes of patients unable to consent. The authors argue that positivist legal reasoning is insufficient for a consistent interpretation of the relevant provisions of the Convention and argue that ethical argumentation is needed to provide guidance in such cases. Based on the ethical arguments, the authors propose a way of reconciling the apparent inconsistencies in the Oviedo Convention. They advance a culturally sensitive approach to the application of the Convention at the national level. This approach understands autonomy as a broader, relational consent and emphasizes the social and cultural embeddedness of the individual. Based on their approach, the authors argue that there exists a moral obligation to respect the prior wishes of the patient even in countries without advance directives. Yet it should be left to the national legislations to determine the extent of this obligation and its concrete forms.     

Medicine for the City: Perspective and Solidarity as Tools for Making Urban Health

The United States has pursued policies of urban upheaval that have undermined social organization, dispersed people, particularly African Americans, and increased rates of disease and disorder. Healthcare institutions have been, and can be, a part of this problem or a part of the solution. This essay addresses two tools that healthcare providers can use to repair the urban ecosystem—perspective and solidarity. Perspective addresses both our ability to envision solutions and our ability to see in the space in which we move. Solidarity is our ability to appreciate our fellowship with other people, a mindset that is at the heart of medical practice. These two tools lay the foundation for structurally competent healthcare providers to act in a restorative manner to create a health-giving built environment.     

Evaluation of race and gender sensitivity in the American Heart Association materials for Advanced Cardiac Life Support

Background: Given the race and gender disparities in cardiac care for women and minorities, it is important to evaluate how we teach in this content area, because it may influence this bias.Objective: We assessed the American Heart Association's Advanced Cardiac Life Support (ACLS) materials, published in 2006, for examples of race and gender sensitivity that depicted culturally competent health education.Methods: Precourse materials, manuals, illustrations, case vignettes, compact discs (CDs), algorithms, and tests were evaluated for culturally competent opportunities. An opportunity was defined as each question or scenario that could have been edited to reflect race or gender. Minority status was interpreted as skin color other than white. Each individual component was counted separately. After the quantitative tally, an analysis was performed using simple percentile comparisons. Interpretations were based on these percentages.Results: The majority of teaching opportunities (54%) did not reflect race or gender. Of 149 patient opportunities to adequately represent those at risk, none clearly represented a minority female. In the simulated cases on the provider CD, all patients were white males. The mannequin had a male haircut and an open shirt. No mannequin had female characteristics (eg, earrings, breasts, or women's clothing). None of the provider CD cases illustrated patients or mannequins with skin color other than white.Conclusions: The current ACLS provider and instructor materials do not maximize opportunities to illustrate vulnerable segments of the population. Future studies designed to evaluate the effect of improved representation of women and minorities in teaching models should be considered.     

Locations of Remorse and Homelands of Resilience: Notes on Grief and Sense of Loss of Place of Latino and Irish-American Caregivers of Demented Elders

In this essay, based on qualitative research with Latino and Irish-American caregivers of demented elders, we argue that spatially and culturally constituted definitions of personhood, the moral life, and justice shape perceptions of normative aging, the agency of the demented persons and their place in the community, the appropriate care of the aged and demented, as well as partially determine the concrete resources which will be available to elders and their families. We review how ties to homelands and neighborhood institutions act as mediators and shapers of anticipatory grief, caregiver burdens, and caregiver resources, serving as a buffer against exhaustion and despair for some families (primarily the Irish-American sample), and as an additional site of loss or stress for others (primarily the Latino sample).     

Healthcare narratives from diverse communities--a self-assessment tool for healthcare providers

Research examining cultural diversity in the healthcare context has produced general themes about particular patient populations, and tools based on this research vary in their approach to improving cultural sensitivity and competency. Some tools pose questions that providers may ask patients to help them become better informed about their culture; others name areas of sensitivity that providers ought to be aware of in caring for culturally diverse patients. This tool is different. It focuses on the provider and its goal is to raise the provider's consciousness through self-reflection and examination. It consists of three parts: stories from interviews with actual patients followed by thought-provoking questions; commentaries on four of the narratives to help you measure your assessment of the ethical issues contained in each one; and a decision-making analysis grid to help you use the tool more effectively. It concludes with a bibliography for additional reading.     

Legal and regulatory concerns about transgenic plants in Brazil

Brazil has a biosafety law that was approved in 1995. This law provides for a horizontal type of regulation that coordinates other existing regulatory frameworks in the areas of agriculture, health and environment. Various federal government departments are responsible for implementing the law. The National Technical Biosafety Commission is the national competent authority on biosafety with overall responsibility. In the case of Bt plants or any insecticidal organism, the Agrochemical Law also applies and authorization for laboratory, greenhouse and field studies must be obtained from the Plant Protection Secretariat, the Brazilian Institute of Environment and the National Agency of Health. Furthermore, the National Environmental Council must issue a license for commercialization of any GMO. There is pressure needed for capacity building and to harmonize the regulatory and administrative frameworks among the different federal departments involved. Some perspectives and challenges for the commercial registration of transgenic crops are discussed.     

Race and ethnicity are not primary determinants in utilizing veterinary services in underserved communities in the United States

A retrospective database analysis (2011–2015) evaluated associations between race and ethnicity and veterinary service utilization by sampling 83,260 companion animals whose guardians (owners) self-identified as White, Black, or Latino/a from 39 Humane Society of the United States Pets for Life (PFL) sites across the United States. Controlling for socioeconomic status, the percentage of nonhuman animals sterilized through PFL whose owners were Latino/a or Black was substantially higher than in previously reported findings. While Latinos/as had the highest mean number of days from first contact with the program to consent, they also had the highest percentage of owners accepting the voucher during initial contact. Logistic regression models suggested that although meaningful, race and ethnicity were not primary determinants of veterinary service utilization. When veterinary and animal welfare organizations deliberately remove structural barriers embedded with racial inequalities, individuals, regardless of race and ethnicity, proceed with companion-animal sterilization. Therefore, service providers must use unbiased, informed, and culturally competent practices to improve companion-animal welfare through the optimization of veterinary services, including spay and neuter.     

Expression vectors for Acinetobacter baylyi ADP1

Acinetobacter baylyi ADP1 is naturally competent and proficient at homologous recombination, so it can be transformed without restriction digests or ligation reactions. Expression vectors for this system, however, are not yet widely available. Here we describe the construction and characterization of inducible expression vectors that replicate as plasmids in A. baylyi or integrate into a nonessential part of its chromosome. These tools will facilitate the engineering of genes and genomes in this promising model organism.     

Differentiation and cancer

Summary Cancer is discussed from a standpoint of a postembryonic differentiation. A differentiation requires the interaction of an exogenous inductive stimulus with competent precursor cell, which then evolve a new tissue with unique, stable heritable properties distinguishable from the progenitor. Evidence is cited pinpointing the normal stem cells of tissues as the competent target precursor cells in carcinogenesis. The resultant phenotype differs from its progenitor and has stable and unique characteristics. All of the characteristics associated with malignancy are expressed during some stage of development, suggesting that the normal genome contains the information necessary for malignant expression, and that the mechanism of malignancy is probably an alteration of control of genomic expression. Malignant tissue, like normal tissue, maintains itself by proliferation and differentiation of its stem cells; at least, that is what was observed in two tumors examined. In each of these tumors the differentiated progeny of the malignant stem cells proved to be benign. A third tumor was adapted to growth in vitro and under the conditions of the experiments could be modulated by altering the in vitro conditions. These data suggest that direction of the naturally occurring differentiation that occurs in tumors may be a suitable therapeutic alternative to cytotoxic chemotherapy. Presented in the Symposium on Regulation in Tumor Cells at the 22nd Annual Meeting of the Tissue Culture Association, Lake Placid, New York. Supported in part by Grant E105 from the American Cancer Society and Grant AM 13112 from the United States Public Health Service. Supported by a Traineeship from National Institutes of Health Training Grant GM 00977.