Case Study:
Mrs. Gomez & Gestational Diabetes

---

What unique cultural barriers to therapy might you encounter with Mrs. Gomez?

Fast Fact Over 20% of continuously insured Latinos report communication problems with their health care providers. Over 45% of uninsured Latinos report similar problems.17

Cultural issues that influence diabetes care in the Hispanic/Latino population:¹⁶

• Family Orientation -- traditional female roles
• Personalismo (personal friendliness)
• Fatalismo -- a sense of fate, nothing can be done
• Faith, Religion -- an act of God, punishment
• Body Image -- attitudes towards obesity
• Lifestyle (nutrition, physical activity)
• Acculturation -- or social isolation
• Language difficulties, as well as lack of knowledge
• Strong family dynamics

The traditional role of the mother may make her reluctant to spend money or resources toward her medical care. She may not think her diabetes is serious and would rather save these resources for the family's needs. She might also feel that she is punishing her family by following a meal plan specific to her needs. Also, she might not have access to educational materials (such as meal plans or recipes) in her own language.

The provider-patient relationship as well as compliance would probably improve if some of these issues were explored and openly discussed in a nonthreatening manner. Reinforce the positive and the importance of managing her diabetes to minimize any complications. Explain that these complications could make her family suffer if she were to develop them (increased cost of medications and care, loss of vision and function resulting from retinopathy and neuropathy, greater risk for hospitalization and mortality, for example), and would detract from her role and function as mother.¹⁸

How can strong family dynamics help or hinder Mrs. Gomez's treatment?

Positive -- Families often come as a group to the office visit, which can enhance adherence to regimen.

Negative -- For women, family obligations can inhibit effective self-care; woman's needs are often considered secondary to the good of the family.

What strategies should be considered in addressing these unique cultural barriers?

• Invite family to office visits to enhance compliance.
• Use English-speaking family members as interpreters at office visits.
• Acquire and use Spanish-language educational materials appropriate to various literacy levels.
• Hire bilingual/bicultural professional staff or interpreters.
• Encourage language skills training for existing staff.
• Use internal language banks, use phone-based interpreter services, or written translations.
• Refer patient to appropriate social services if warranted and available.

In your treatment plan, consider the following:

• The progression and seriousness of diabetes, especially in women who have had gestational diabetes
• Other members of the health care team and the responsibilities of each of them
• Important points to discuss with the patient
• Other factors that may prevent or hinder the patient from following their treatment regimen

What do your colleagues think about this case?

Visit the message board for this case and read what others have expressed about Mrs. Gomez; ask and answer questions regarding her case, and determine appropriate treatment strategies with assistance from your colleagues.

References

1. Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). JAMA 2003 May 21; 289(19):2560-2572
2. Diabetes Care 2004; 27: Sup 1. S19
3. Morb Mortal Wkly Rep1999 Jan 15; 48(1):8-12
4. American Diabetes Association. Facts and Figures. Mokdad et al. Diabetes Care 2000 23:1278
5. Kjos, SL, et al. Diabetes 1995 May; 44(5):586-591
6. Diabetes Care 2004; 27: Sup. 1. S19
7. Klein, R. Diabetes Care 1995; 18:258-268
8. Diabetes Care 2004; 27: Sup. 1. S19
9. Nathan, D. N Engl J Med Oct 2002; 347(17)
10. American Association of Clinical Endocrinologists. ACE Guidelines August 21, 2001
11. Creutzfeldt W, Ebert R. Diabetologia 1985; 28:5645.
12. Fineman MS, et al. Diabetes Care 2003; 26:2370-2377; Taylor K, et al. Diabetes Metab 2003; 29:4S265; Buse J, et al. Diabetes 2004; 53(suppl 2):A82 [352-OR]; Kendall DM, et al. 64th Scientific Sessions of the American Diabetes Association 2004, 02 D. Abstract 10- LB
13. DeFronzo R, et al. 64th Scientific Sessions of the American Diabetes Association 2004. Late-breaking abstract 6
14. Diabetes Care 2004; 27: Sup 1. S19
15. American Association of Clinical Endocrinologists. ACE Guidelines August 21, 2001
16. Collins, et al, Diverse Communities, Common Concerns: Assessing Health Care Quality for Minority Americans, The Commonwealth Fund, March 2002.
17. AE, Caballero. Current Diabetes Reports 2005; 5: 217-225
18. A primer for cultural proficiency: Towards quality health services for Hispanic. NAFHH-Estella press, 2001

Page 1 | 2 | 3 | 4 | 5