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Service Delivery Innovation Profile

Clinics Offer Culturally Tailored Diabetes Education and Culturally Appropriate Care to Ethiopian Patients, Leading to More Engagement, Better Outcomes, and Reduction of Health Disparities


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Snapshot

Summary

As part of a broader initiative to address health disparities in underserved communities, HealthPartners (a large Minnesota-based health system) offered a diabetes outreach and education program to recent Ethiopian immigrants at two clinics that serve a large number of East African patients. Developed by staff with input from community members and others who have experience with Ethiopian culture, the 6-month program featured culturally tailored educational classes and materials and the integration of culturally sensitive approaches into everyday care. The program attracted high levels of participation and acceptance among patients, helped staff become more culturally sensitive, increased patient engagement, improved health outcomes, and contributed (along with other programs) to a decrease in racial disparities. Although the program as described below does not continue today, the two clinics still offer large group classes occasionally. The lessons from this project informed a second EBAN year-long collaborative focused on diabetes improvement efforts in East African populations and continue to impact culturally sensitive approaches to care.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of HbA1c levels and disparities in health outcomes among patients with diabetes, along with post-implementation data on patient participation in the program and post-implementation anecdotal reports on staff cultural sensitivity and patient engagement.
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Developing Organizations

HealthPartners; HealthPartners Institute for Education and Research
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Date First Implemented

2010
The program began in 2010, with the 6-month pilot test conducted the following year.begin pp

Patient Population

Vulnerable Populations > Immigrantsend pp

Problem Addressed

Like their peers in other areas, the many recent Ethiopian immigrants who live in Minnesota face an increased risk of diabetes. Because of language and cultural differences and other factors, these immigrants often do not receive timely medical care or effective support with ongoing management of the disease.
  • High rates of diabetes among Ethiopians: The prevalence of diabetes (both type 1 and type 2) are on the rise in Ethiopia and among Ethiopians who immigrate to other countries, including those who live in Minnesota (home to one of the largest populations of East African immigrants in the Nation).1,2 Immigrants from sub-Saharan Africa (which includes Ethiopia) have higher rates of diabetes than immigrants from Europe, the Middle East, or East Asia.1 A history of malnutrition and increasingly sedentary and urban lifestyles likely account for some of this disparity.
  • Failure to provide culturally appropriate care: Many Ethiopians do not receive timely medical care or effective ongoing support in managing diabetes, due in large part to cultural and linguistic barriers to accessing care. Recent Ethiopian immigrants may not understand how to make appointments or understand the various roles of members of the health care team. Diabetes self-management information may not be presented in a way that Ethiopian patients can relate to or understand. For example, these patients often require translators and may feel more comfortable in women- or men-only classes.

What They Did

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Description of the Innovative Activity

As part of the EBAN Experience™ initiative to address health disparities and reach out to underserved communities, HealthPartners offered a diabetes outreach and education program to recent Ethiopian immigrants at two clinics that serve a large number of East African patients. (EBAN is a symbol from the Asanti people of Ghana that represents security, safety, and trust.)3 The 6-month program featured culturally tailored educational classes and materials and the integration of culturally sensitive approaches into everyday care. Key program elements are detailed below:
  • Outreach to Ethiopian patients with diabetes: Staff identified Ethiopian patients who might benefit from the program through several means, including recommendations from nurses, physicians, and staff interpreters. The participating HealthPartner clinics, pharmacies, and laboratories also had flyers available describing the program. Interpreters or other familiar staff contacted patients by telephone to invite them to a class.
  • Culturally tailored educational classes: During the 6-month period, each clinic offered 3 large group classes cotaught by a dietician and diabetes nurse specialist, along with periodic small-group classes that formed based on individual needs. (Participants were invited, but not required, to attend all large-group classes.) The first 2 large-group classes were held 6 weeks apart (at the beginning of the program and 6 weeks later), with the last class offered at the end of the 6-month period. Between the second and third large-group class, participants periodically met in small groups. The classes were designed and structured in a culturally sensitive and tailored manner, integrating social time, storytelling, visual learning, and other elements that are in line with Ethiopian traditions. Adhering to cultural convention, the clinic offered separate classes for men and women and incorporated breaks during Muslim prayer times. Interpreters versed in two predominant Ethiopian languages attended each session to provide translation services.
    • Large-group classes: Led by a dietician and diabetes nurse specialist (with support from a pharmacist and physician who attended at least part of the class to answer questions from patients and reinforce the importance of the education), each large-group class lasted roughly 3 hours and consisted of the following:
      • Social time, including traditional meal: Staff greeted each participant on arrival and engaged in social time in a large classroom, including having participants share stories about their lives and living with diabetes. Because important occasions in Ethiopian culture include food, clinic staff and participants shared a typical Ethiopian meal prepared by a local restaurant in consultation with the clinic dietician. (Also during this period, laboratory staff collected blood samples to allow for measurement of the program's impact; staff took the samples in a room adjacent to the classroom, with vials having been prepared and labeled before the class began.)
      • Diabetes education geared to Ethiopian patients: After social time and the meal, the dietician and diabetes nurse specialist presented information on how diet and exercise can help control diabetes and prevent complications. The team approach ensured that participants who came to only one class still received both diet and lifestyle information and allowed participants to ask questions of both staff members. The presenters used Ethiopian foods to demonstrate appropriate portion size and covered exercise options consistent with Ethiopian beliefs about modesty and appropriate behavior for men and women. Because many Ethiopians believe that discussing possible complications amounts to a “curse,” staff instead talked about the importance of keeping feet and eyes "healthy" and mentioned possible problems only at the end of their presentation. Instead of using illustrations of body parts (which some Ethiopians find offensive), staff used other props, such as a glass of clear and cloudy water to demonstrate the function of healthy kidneys.
      • Storytelling: At each session, staff built in time for storytelling to reinforce key educational messages. For example, at holiday time, a staff member shared stories about how he or she maintained a healthy diet during family feasts. Participants would then share their stories as well.
    • Small-group classes: Between the second and last large-group class, participants periodically met in small groups that formed based on individual needs. For example, a diabetes educator worked with individuals using insulin, while a dietician led classes and discussions for those primarily in need of lifestyle interventions. The group for insulin-dependent participants met more frequently than did those focused on lifestyle changes. As with the large-group sessions, interpreters participated in the sessions. Although the actual content for these classes typically consisted of only 45 to 60 minutes of material, they often lasted for 2 or even 3 hours to give participants flexibility as to when they arrived. Outside of these classes, nurses sometimes offered one-on-one education to those unable to attend the small-group sessions.
  • Culturally sensitive educational handouts: All classes featured culturally sensitive educational handouts designed to reinforce the teaching. For example, illustrations of recommended exercises showed women with appropriate covering. Consistent with Ethiopian culture, information was presented in a positive light. For example, discussions of potential lifestyle-related kidney complications were phrased as “you have a 60 percent chance of having healthy kidneys if you follow this advice,” rather than “do this to avoid kidney complications.” Because many Ethiopian immigrants (especially women) cannot read in their native language, handouts featured simple, appropriate illustrations and text written in simple, plain English so that interpreters or family members who spoke English could translate the materials for the patients.
  • Integration of culturally sensitive approaches into daily practice: Clinic staff integrated culturally sensitive approaches into office visits with Ethiopian patients to help ensure their understanding of and adherence to recommendations for diabetes self-management. Some of these techniques include the following:
    • Shared visits with diabetes nurse and provider: Whenever possible, patients saw both the provider and the diabetes nurse in a shared visit. If this is not possible, the diabetes nurse reviews educational materials with the registered nurse assigned to that patient's provider, especially if the patient has missed a small group followup session. This allowed the nurse and physician to reinforce this learning with the patient and also helped teach nurses culturally appropriate approaches to care and education.
    • Storytelling: Clinicians routinely incorporated storytelling into their interactions with patients. For example, in encouraging a patient to get more exercise, the clinician might say, “I walk along the river each day to get exercise and stay healthy. What types of activities do you enjoy?” Patients are more likely to open up and share their customs and stories when clinicians do the same.
    • Seeing patients without an appointment: Many patients from Ethiopia are accustomed to walk-in clinics where they can see a physician without an appointment. In the past, reception staff at the clinics would tell walk-in patients that they must make an appointment. Under this program, when an Ethiopian patient arrived at the clinic with a question about their diabetes, front-desk staff found someone (usually a nurse, diabetes educator, or pharmacist familiar with Ethiopian culture) to talk to them. Although the patients did not get a full office visit that day, staff could usually address their immediate concerns. This approach helped to build a trusting relationship and to encourage patient engagement.
    • Presence or reinforcement of program message by physician: In Ethiopia, physicians provide most patient care. As a result, many Ethiopians are not used to receiving care from a nurse, dietician, or other clinician. Consequently, at every office visit, the physician encouraged patients to continue attending the group sessions. Also, as noted, physicians routinely stopped by the large-group classes to underscore the importance of the content of those sessions.

Context of the Innovation

A large integrated health care system headquartered in Bloomington, MN, HealthPartners operates 27 primary care clinics in the Minneapolis–St. Paul area, home to one of the nation’s largest communities of East African immigrants. In 2011, the HealthPartners Institute for Education and Research launched an initiative known as the EBAN Experience™ to address issues affecting the health of local communities and reduce health disparities among minority populations. As part of this initiative, two HealthPartners Clinics located in areas with a large, growing number of East African immigrants (including many from Ethiopia and Somalia) joined forces to design a program to reach out to patients with diabetes from these countries.

Did It Work?

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Results

The program attracted high levels of participation and acceptance among patients, helped make staff more culturally sensitive, increased patient engagement, improved health outcomes, and contributed (along with other programs) to a decrease in racial disparities.
  • High levels of participation and acceptance: Staff invited 38 patients to participate in the 6-month program. Nearly 85 percent (32 individuals) completed the course. Twenty-four individuals attended each large group meeting, and 10 participants attended at least one small-group session.
  • More culturally sensitive and communicative staff: Staff throughout the two clinics (including frontline clinicians and those at the front desk, business office, laboratory, and pharmacy) have become more welcoming and engaging to patients from Ethiopia and other East African countries. They have also increased their communications with each other about these patients. For example, clinicians now routinely inform diabetes educators and dieticians whenever a patient with diabetes comes to the clinic with another concern, thus giving them the opportunity to check in with these patients and reinforce self-management messages.
  • More engaged patients: Anecdotal reports from patients and staff suggest that patients from the Ethiopian community now feel a strong bond with the clinics and their staff, and consequently stay in touch with staff between clinic visits, even inviting them to significant events in the Ethiopian community.
  • Better outcomes: More than 80 percent of patients completing the program who had HbA1c levels above 8 percent reduced these levels by at least 0.3 percentage points during the 6-month program. Most with an HbA1c level below 8 percent maintained that level of control during the program. Lower HbA1c levels are associated with a reduced risk of diabetes complications.4
  • Decreasing diabetes outcomes disparities: At one of the two clinics (the only one where data are available), the program has, in conjunction with other programs, helped decrease racial and ethnic disparities in outcomes for diabetes patients. In January 2011, people of color (including East Africans and African Americans) with diabetes served by the clinic had overall health scores 10 percentage points below those of non-Hispanic whites seen at the clinic. By December 2012 (after completion of this program and the launch of other quality improvement projects, including a patient-centered medical home program), the overall diabetes scores for people of color increased by more than 11 percentage points, nearly erasing disparities in outcomes for diabetic patients at the clinic.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of HbA1c levels and disparities in health outcomes among patients with diabetes, along with post-implementation data on patient participation in the program and post-implementation anecdotal reports on staff cultural sensitivity and patient engagement.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Recognizing difficulties in reaching East Africans with diabetes: In the past decade, many recent East African immigrants moved into the neighborhoods in which the two clinics were located (the Cedars Riverside and Thomas-Dale neighborhoods of Minneapolis and St. Paul, respectively). Many of these new residents had undiagnosed or inadequately treated diabetes. However, clinic staff found that traditional methods of educating and treating them did not work well. In particular, they noticed that many East African immigrants did not show up for their appointments or adhere to recommended self-management strategies.
  • Forming committee, training key staff: When HealthPartners Institute for Education and Research launched the EBAN Experience™ initiative, staff at the two clinics decided to design a quality improvement project to address the difficulties encountered in reaching out to Ethiopians with diabetes. To that end, the clinics created a committee made up of key staff from the two clinics as well as community advisers. These individuals participated in a yearlong learning collaborative that held quarterly sessions focused on improving patient care and community health and reducing health disparities of minority populations through experiential learning, community dialogue, and health care systems improvement.
  • Designing specific intervention: The committee worked with two East African medical students and other community members who had experience with Ethiopian culture to design key elements of the program, including strategies and methods for outreach and the content and structure of the educational classes.
  • Ending formal education program (with continuation of other key elements): The two clinics no longer offer the full educational program, but occasionally host large-group classes. In addition, the culturally sensitive approaches used by staff in both clinics have become embedded into everyday clinic operations. The results from the program have informed other improvement efforts, including The EBAN Defeating Diabetes Disparities (3D) Collaborative launched in 2013.

Resources Used and Skills Needed

  • Staffing: No new staff were hired for this program; existing staff incorporated program-related responsibilities into their regular duties. During the 6-month program, the team leader (also the diabetes educator) spent at least 10 to 15 hours a week on the program. In addition, two diabetes educators, two dieticians, and a pharmacist spent time on the program, as did two interpreters (one for each of the two predominant Ethiopian dialects) who attended each large- and small-group learning session. As noted, a physician and laboratory technician also attended the beginning of each large-group session, and staff nurses sometimes conducted one-on-one education sessions with patients.
  • Cost: Implementation of the program required some shifting of staff duties away from clinical care (which is reimbursable) to administrative, educational, and planning tasks (which generally are not reimbursable). Other expenses included the catered meals, printing of handouts, and other tools and supplies used during the classes.
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Funding Sources

HealthPartners
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Tools and Other Resources

HealthPartners Institute for Education and Research has a Web site that explains the EBAN Experience™ initiative, available at: www.ebanexperience.com.

Adoption Considerations

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Getting Started with This Innovation

  • Include interpreters in program design and implementation: Interpreters who speak the patients’ dialects have a unique window into their culture and personality. They accompany patients throughout the clinic and get to know them on a different level than medical professionals. Consequently, including them in the design and implementation of the program helps ensure that it meets the needs of the targeted population. With this program, interpreters played an important role in identifying and reaching out to patients. For example, Ethiopian women often will not accept telephone calls from someone they do not know. But because the interpreters already knew many of the patients, they were often able to reach these individuals by telephone.
  • Train staff to adapt language to culture of target population: Words used in a medical environment may have different meanings when translated. For example, the term “office visit” denotes social time to Ethiopian patients. To clarify the purpose of the appointment, staff stopped using this term and instead started referring to “doctor time” or told patients that it was time for “your diabetes management.”
  • Incorporate large classes: Participants reported enjoying the large classes more than the smaller ones and even the office visits. They likened the large sessions to their English classes, and hence felt compelled to pay attention and take the content seriously. By contrast, they reported perceiving the small-group visits as more social in nature and hence less important and serious.
  • Combine dialects into one class: The original design called for separate large-group classes for each of the two major dialects. However, that proved too labor intensive, and consequently the two classes were merged into one, with an English-speaking staff member presenting first, followed by translations into each dialect.

Sustaining This Innovation

  • Consider merits of team-taught classes: Having a diabetes educator, dietician, pharmacist, physician, and interpreters on hand makes for more interesting and productive classes that will attract more interest than those involving fewer staff (such as the small-group sessions). Having the laboratory technicians come to class to draw samples increased compliance with the laboratory portion of the study. However, this approach can be expensive and, as a result, it may be difficult to get leaders to commit to it over the long term.
  • Consider paying for meal: Providing a welcoming meal helps attract and build trust with participants. Program staff originally thought they could save money by making the meal potluck, but local interpreters and community advisers explained that in Ethiopian culture the host provides the meal and hence inviting someone to a potluck dinner would be considered an insult. However, the high cost of providing these meals ultimately became a barrier to continuing the large-group classes. The clinic is now applying for a grant to cover the food costs, with the hope of hosting at least one large-group class a year for different ethnic groups.
  • Pack as much into a visit as possible: Because patients often have trouble making and keeping appointments, it makes sense to pack as much as possible into each clinical encounter. Under this program, if a diabetes patient makes an appointment for an acute illness or injury, front-desk staff notify those involved in diabetes management to make sure that any needed laboratory work and self-management education can take place at the same time.
  • Incorporate storytelling: The customary, reserved approach of medical professionals can be off-putting to Ethiopian patients, often making them feel unwelcome. To overcome this problem, staff should share personal stories while still remaining within professional boundaries (e.g., by not also sharing their contact information).

More Information

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Contact the Innovator

Debra Bryan
Director, Collaborative Learning
HealthPartners Institute for Education and Research
PO Box 1309, Mailstop 21101B
Minneapolis, MN 55440-1309
(952) 883-6904
E-mail: debra.j.bryan@healthpartners.com

Innovator Disclosures

Ms. Bryan reported that Pfizer Medical Education Group made an independent professional education grant to the organization to fund the Equitable Health Collaborative—Leading System Change Through PI-CME, which later was renamed the EBAN Experience™.

References/Related Articles

Engelhart C, Straub R, Newell T, et al. Connecting with patients of other cultures. AADE in Practice. Spring 2012.

Footnotes

1 Creatore MI, Moineddin R, Booth G, et al. Age- and sex-related prevalence of diabetes mellitus among immigrants to Ontario, Canada. CMAJ. 2010;182(8):781-9. [PubMed]
2 McGuigan CL. EthnoMED, Harborview Medical Center. Diabetes in the Eritrean and Ethiopian community: cultural information and recommendations for diabetes educators. 2010 Jun. Available at: http://ethnomed.org/clinical/diabetes
/diabetes-in-the-eritrean-and-ethiopian-community-cultural-information-and-recommendations-for-diabetes-educators
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3 HealthPartners Institute for Education and Research. The EBAN Experience Web site. Available at: http://www.ebanexperience.com/.
4 HealthPartners Institute for Education and Research. The EBAN Experience. Clinical outcomes. Available at: http://www.ebanexperience.com/uploads/5/6/8/7/5687864/outcomes_2011-12.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
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Original publication: January 29, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: January 29, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.