Culturally appropriate health education for type 2 diabetes mellitus in ethnic minority groups

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Hawthorne, Kamila and Robles, Yolanda and Cannings-John, Rebecca and Edwards, Adrian G.K. (2008) Culturally appropriate health education for type 2 diabetes mellitus in ethnic minority groups. Cochrane Database of Systematic Reviews, 3. pp. 1-354.


Background Ethnic minority groups in upper-middle and high income countries tend to be socio-economically disadvantaged and to have higher prevalence of type 2 diabetes than the majority population. Objectives To assess the effectiveness of culturally appropriate diabetes health education on important outcome measures in type 2 diabetes. Search strategy We searched the The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, ERIC, SIGLE and reference lists of articles. We also contacted authors in the field and handsearched commonly encountered journals. Selection criteria RCTs of culturally appropriate diabetes health education for people over 16 years with type 2 diabetes mellitus from named ethnic minority groups resident in upper-middle or high income countries. Data collection and analysis Two authors independently assessed trial quality and extracted data. Where there were disagreements in selection of papers for inclusion, all four authors discussed the studies. We contacted study authors for additional information when data appeared to be missing or needed clarification. Main results Eleven trials involving 1603 people were included, with ten trials providing suitable data for entry into meta-analysis. Glycaemic control (HbA1c), showed an improvement following culturally appropriate health education at three months (weight mean difference (WMD) - 0.3%, 95% CI -0.6 to -0.01), and at six months (WMD -0.6%, 95% CI -0.9 to -0.4), compared with control groups who received 'usual care'. This effect was not significat at 12 months post intervention (WMD -0.1%, 95% CI -0.4 to 0.2). Knowledge scores also improved in the intervention groups at three months (standardised mean difference (SMD) 0.6, 95% CI 0.4 to 0.7), six months (SMD 0.5, 95% CI 0.3 to 0.7) and twelve months (SMD 0.4, 95% CI 0.1 to 0.6) post intervention. Other outcome measures both clinical (such as lipid levels, and blood pressure) and patient centred (quality of life measures, attitude scores and measures of patient empowerment and self-efficacy) showed no significant improvement compared with control groups. Authors' conclusions Culturally appropriate diabetes health education appears to have short term effects on glycaemic control and knowledge of diabetes and healthy lifestyles. None of the studies were long-term, and so clinically important long-term outcomes could not be studied. No studies included an economic analysis. The heterogeneity of studies made subgroup comparisons difficult to interpret with confidence. There is a need for long-term, standardised multi-centre RCTs that compare different types and intensities of culturally appropriate health education within defined ethnic minority groups. -------------------------------------------------------------------------------- Plain language summary Culturally appropriate health education for type 2 diabetes mellitus in ethnic minority groups In upper-middle income and high income countries, minority ethnic groups often suffer a higher prevalence of type 2 diabetes mellitus than the local population. They also tend to come from lower socio-economic backgrounds, with attendant difficulties in accessing good quality health care. In some cases, cultural and communication barriers increase the problems minority ethnic communities experience in accessing good quality diabetes health education, a vital aspect contributing towards patient understanding, use of services, empowerment and behaviour change towards healthier lifestyles. In this review, 'culturally appropriate' health education is taken to mean any type of diabetes health education which has been specifically tailored to the cultural needs of a target minority group. The review found eleven randomised controlled trials (RCTs) of culturally appropriate diabetes health education in the world literature that met the selection criteria (participants from a defined ethnic minority group living in a middle income or high income country, over 16 years in age, with type 2 diabetes mellitus, and receiving a culturally tailored health education intervention). Culturally appropriate health education improved blood sugar control in participants, compared with those receiving 'usual' care, at three and six months post-intervention, to be of potential clinical importance if sustained. Knowledge about diabetes, and healthy lifestyles also improved. None of the other clinical outcome measures such as cholesterol, blood pressure or weight showed any improvement, nor were there any improvements in quality of life outcomes for patients. Studies tended to be of short duration, so longer term outcomes could not be measured. In addition, some outcomes selected by the review were not measured, such as the development of diabetic complications, death rates, or costs of the education programmes. The variation between studies, in terms of the cultural aspects of the populations being studied, the types and duration of the health education being offered to participants, the variety of different outcomes being measured and differences in the timings of these measurements after the health education intervention make interpretation of the findings limited. Although it appears that culturally appropriate health education is potentially more effective than 'usual care' in improving blood sugar control and knowledge of diabetes, with probable attendant benefits to patients, standardised RCTs of longer duration (using the same outcome measures and timings of these measures), are needed with full evaluation of costs.