Development of culturally sensitive dialog tools in diabetes education.

Person-centeredness is a goal in diabetes education, and cultural influences are important to consider in this regard. This report describes the use of a design-based research approach to develop culturally sensitive dialog tools to support person-centered dietary education targeting Pakistani immigrants in Denmark with type 2 diabetes. The approach appears to be a promising method to develop dialog tools for patient education that are culturally sensitive, thereby increasing their acceptability among ethnic minority groups. The process also emphasizes the importance of adequate training and competencies in the application of dialog tools and of alignment between researchers and health care professionals with regards to the educational philosophy underlying their use.

INTRODUCTION

Culturally sensitive dialog tools promoting patient-provider communication and healthy behaviors improve patient outcomes.[1] However, few studies explicate methods of achieving cultural sensitivity in interventions like diabetes education, including how and if members of the target population were involved.[2345] Cultural sensitivity can be considered with regards to two dimensions; “surface structure” (e.g. matching of materials and messages to the preferred by the target population) and “deep structure” (incorporating cultural, social, historical, environmental, and psychological factors that influence health behaviors of the target population).[2] This report describes the development of dialog tools targeting dietary education among Pakistani immigrants in Denmark with type 2 diabetes, a population with increased prevalence of both type 2 diabetes and multiple chronic conditions, a lower educational level, and less diabetes knowledge, compared to the majority population.[67]

DEVELOPING DIALOG TOOLS

To develop the dialog tools, we used a design-based research approach. Design-based research covers methodologies in education that are designed to bridge the gap between research and practice.[8] Design methods include ethnographic and observational techniques, visualization, prototyping, sketching, storytelling, brainstorming, and others. The processes in design-based approach are a continuous process of definition and redefinition of problems and design opportunities, as well as design and redesign of prototypes [Table 1].[9] Rather than designing an entire intervention only to discover at the end that it may not work, iterative design argues for quickly building prototypes, testing them, and re-designing while gradually evolving the intervention over time. In this study, we applied the methodology of design thinking, which is a humanistic approach developed by Brown and Wyatt.[10] Design thinking particularly focuses on the needs of the people who consume a product or service and the infrastructure that enables it.[10]

Table 1

Overview of activities in the design thinking process

The “consumers” of dietary education are health care professionals and patients, so both groups were highly involved in the development phase. The process of design thinking can be divided into three major phases: Inspiration, ideation, and implementation [Table 1]. Researchers with public health, behavioral and educational science backgrounds were drivers of all processes. In addition, four dieticians, an industrial designer, a nutritional scientist with managerial responsibility, and 18 patients with Pakistani background and type 2 diabetes were involved in the process. The nutritional scientist was also co-driver of the implementation phase. Patients were recruited within a specialist diabetes clinic in the Copenhagen area, using snowball sampling.

The iterative development process characterized as “research through mistake” required a great deal of dialog between researchers and dieticians.[9] Dieticians had a strong focus on the outcome, namely effective education, as opposed to the researchers’ strong focus on the process leading to effective education through designing, testing, and redesigning tools. The number of tools and their content such as the amount of text and pictures were modified throughout the entire process, based on data from observations and interviews with patients, dieticians, and health care professionals with the goal of increasing the surface and deep structure dimensions of cultural sensitivity.[2] A consistent developmental pattern was a movement toward less text and more pictures in the dialog tools.

Some dialog tools were rooted in existing education materials and converted into interactive and engaging tools. Others emerged as ideas from patients or as a combination of patients’ and dieticians’ ideas. For example, patients preferred that the dietary education addressed low blood sugar in relation to diet, whereas dieticians expressed a need to address high blood sugar. Consequently, researchers merged the two ideas into a dialog tool addressing the symptoms of high and low blood sugar, as well as possible solutions to address high or low blood sugar as described by patients and dieticians. Some tools were not well-received by patients. For instance, patients considered a food pyramid with familiar and commonly consumed food items irrelevant and difficult to interpret; it was consequently omitted early in the process.

In practice, how effective the tools were at activating and involved patients was highly dependent on the setting and the dieticians’ skills in social learning, a person-centered approach, and cultural competence. Dieticians considered it is challenging to choose the “right tools at the right time.” Knowledge and learning tools were chosen and tested more frequently by dieticians than were reflection tools. Barriers to applying reflection tools were that dieticians were less confident at using them and viewed them as time-consuming. In addition, dieticians were more familiar with applying knowledge-based materials in their usual patient counseling. Researchers perceived that dieticians’ application of the tools was not always consistent with the intended person-centered approach, which encompassed a strong focus on patient experiences and patient-identified problems and challenges. Furthermore, researchers and dieticians did not always reach consensus about the educational philosophy with regards to pedagogy and process of learning. For example, one learning and knowledge tool contained pictures of food items patients reported eating if they experienced low blood sugar. One dietician was concerned that the images depicted inappropriate food items and could cause confusion for patients. These differences were explored and sought solved through dialog between researchers and dieticians during workshops.

We observed differences in how the tools were received by patients in individual and group settings. One reflection tool intended to create awareness of the patient's role in the family regarding food (e.g. planning, grocery shopping, and social practices) was well-received when tested in family interviews but not in a group setting. Interviews with patients revealed that the tool was considered inappropriate in group settings due to cultural expectations about a family's role in practices around food. If the family pattern diverged from the expectations, it was considered inappropriate to share this information in a group setting. In this way, cultural sensitivity was also embedded in the application of dialog tools.

CONCLUSION

A design thinking approach appears to be a promising method to develop dialog tools for patient education that are culturally sensitive, thereby increasing their acceptability among the target population. Forthcoming interviews will explore the perspectives of the patients further. The process also emphasizes the importance of adequate training and competencies in the application of dialog tools and of alignment between researchers and health care professionals with regards to the educational philosophy underlying their use.