Effectiveness of Culture-Specific Diabetes Care for Surinam South Asian Patients in the Hague

Abstract

A n extremely high prevalence of dia-betes has been found among South Asians, especially among immi-grants living in a western society (1). In the Hague, we found a high prevalence of diabetes among South Asians from Suri-nam (2). Because usual diabetes care had insufficient affinity with the cultural and culinary traditions of this population, a new culture-specific type of care was de-veloped. We investigated whether this in-tervention led to a decrease in HbA 1c level, an improvement in lipid profile, or a decrease in BMI. The intervention consisted of the re-ferral of South Asian patients by their at-tending physician to a specialist diabetes nurse and a dietitian. These care provid-ers received training to improve their knowledge of the South Asian cultural and culinary traditions. They made use of newly developed educational materials consisting of an audio-cassette containing general diabetes information recorded in the Surinam-Hindi language and two booklets, one containing general informa-tion on nutrition and another containing a carbohydrate variation list; both were based on South Asian cooking. It was ex-pected that the advice from the dietitian would be more applicable, among other things, because of the information con-cerning calorie-equivalent dishes con-tained in the carbohydrate variation list. It was also expected that the interaction be-tween patients and care providers would improve, resulting in improved compli-ance with therapy. The diabetes educa-tion provided by the nurses and dieticians consisted of intensive guidance (ϳ4 –7 vis-its) for 3 months, after which the patients continued to receive guidance from these care providers but with longer intervals. The intervention study was carried out in three general practices (eight gen-eral practitioners) and an outpatient clinic. All Surinam South Asian patients known to have type 2 diabetes, with no comorbidity interfering with the interpre-tation of metabolic control (e.g., recent myocardial infarction or dementia), and who visited their attending physician dur-ing the first half of 1998, were included in the study. The first part of the study was a ran-domized controlled trial (RCT), in which the patients were randomized based on date of birth: odd numbers (intervention patients, n ϭ 53) and even numbers (waiting-list control patients, n ϭ 60). The only parameter of the RCT was the difference in the change in the HbA 1c level immediately after the intensive guidance of the intervention patients. After 6 months, the control patients were also given the opportunity to benefit from the new type of care. Of these 60 patients, 28 who were no longer under the control of the same physician or who could only be sent a written invitation did not participate. Together with the remain-ing 32 waiting-list control patients and the 53 intervention patients, 4 other pa-tients were included in the second part of the study. This was a controlled before-and-after study (CBA), thus including 89 patients. The CBA study consisted of a pretest measurement of HbA 1c , BMI, and lipid profile; a measurement of HbA 1c and BMI immediately after the period of inten-sive guidance; and a second post test mea-surement of HbA 1c , BMI, and lipid profile (values known from 53–76%) 1 year later. The t test was used to answer the research questions. In the RCT, the average age was 51.7 vs. 54.8 years, the male-to-female ratio was 26 of 27 vs. 31 of 29, and the initial HbA 1c level was 8.4 vs. 8.2% for interven-tion vs. control patients, respectively. A difference of 0.42% (P ϭ 0.02) was found in the average change in HbA 1c level, in favor of the intervention patients. After controlling for differences in age, sex, and initial HbA 1c , the difference between groups was 0.50% (P ϭ 0.004). The change was greatest in the subgroup of patients who had never previously re-ceived diabetes education. When consid-ering only those patients with an initial HbA 1c level Ͼ7.5%, the difference was 0.69% (35 intervention and 35 control patients; P ϭ 0.003). In the CBA, the change in HbA 1c level was smaller (0.29%) because of a more modest result among the waiting-list con-trol patients who started their participa-tion after the completion of the RCT. BMI decreased by only 0.04 kg/m 2 . One year later, this had not essentially changed. No relation was found between changes in BMI and HbA 1c . After 1 year, the lipid profile improved significantly; total cho-lesterol decreased by 0.56 mmol/l (P Ͻ 0.0005), total cholesterol–to–HDL ratio decreased by 0.54 mmol/l (P ϭ 0.001), and triglycerides decreased by 0.34 mmol/l (P ϭ 0.002). In one general practice, for financial reasons, there was no continuity in the new type of care. Considering the data of the 19 patients of this practice with a known HbA 1c level 1 year later, the im-provement had disappeared almost en-tirely. In contrast, improvement was maintained in the other three practices. This study has shown that the devel-opment of culture-specific diabetes care can have a beneficial effect on metabolic control. It is probable that this effect is partially caused by the fact that contact was made with a group of patients that had not been contacted before. Continu-ity in the provision of this care appears to be crucial for a lasting effect. With respect to the two above-mentioned possible active mechanisms, improvement in the applicability of nutri-tional advice should, in particular, be re-flected in calorie intake. However, little improvement was found in BMI, and no relation between changes in BMI and HbA 1c was found. Therefore, the results suggest that the improvements in HbA 1c and lipid profile were mainly achieved by better interaction between care providers and patients, which may have led to better compliance, not only with regard to med-ication, but possibly with regard to phys-ical activity and nutrition (e.g., a better distribution of meal times). Effects of the intervention program are described as being particularly favor-able if an important role is attributed to the nursing staff and if considerable em-phasis is put on patient education (3). Both of these characteristics apply to the present intervention. Research was restricted to only a few practice settings and a small number of care providers. 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