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General Approach

A patient with a chronic condition is responsible for much of his or her own care that determines outcomes in the long run. Understanding diversity and the factors that influence human behavior is essential to tailor a treatment plan that works at an individual level. Culture and ethnicity may determine certain beliefs, but there is enormous variation among individuals within any given cultural or ethnic population.

The following information provides a roadmap to build trust—the essential element in providing quality care.

  1. Communication skills and belief systems
    Assess a patient’s communication skills and belief systems prior to developing a treatment plan. Common areas to explore are the patient’s education level, duration in the United States, and familiarity with the health care system. Many cultures have a traditional healer. There may be a benefit in asking about prior treatment and whether the patient has sought help from a traditional healer or taken traditional home remedies.1

  2. Populations with limited English skills
    Patients with English as a second language or no significant English skills require translation. Untrained translators and/or family members may not have the skills to effectively translate complex medical concepts. Care for this population is best when the health care team has access to a trained medical translator who is also culturally competent. The quality of care requires effective communication. The Americans with Disabilities Act requires that translation services be provided at no cost to patients with limited English skills.2 In addition, the 2010 Patient Protection and Affordable Care Act requires information related to health plan benefits to be provided in the patient’s own language.3

  3. Tools You Can Use

    The National Diabetes Education Program (NDEP) has created materials that apply principles of plain language, health literacy, and numeracy to help people learn more about diabetes.

  4. Assess health literacy
    Education level partially defines health literacy, but does not define when there is a potential problem. The ability to read medication labels or understand simple disease concepts should be assessed initially and again if there is evidence of poor medication adherence or a lack of desirable behavioral changes. Patients with limited English skills may have poor health literacy in their own language, limiting the value of printed in-language health information. Included in health literacy is numeracy, the ability to understand mathematical concepts.4 The simple phrase “twice a day” may need to be restated as “two times a day.”

  5. Cultural and religious beliefs
    Most immigrant patients and their offspring in the United States have some degree of acculturation, but the degree that cultural beliefs influence health varies by individual and should be assessed. Fatalism, the acceptance of a disease condition as a person’s destiny, is a common belief that is a barrier to chronic medical therapy.5,6 The cultural role of family is often a critical element in managing diabetes.7

  6. Let the Evidence Guide You

    Changes in lifestyle and food can disrupt the harmony and cultural practices related to meals and specific foods in a Chinese family.

    Chesla CA, Chun KM, Kwan CML. Cultural and family challenges to managing type 2 diabetes in immigrant Chinese Americans. Diabetes Care. 2009;32(10):1812-16.

  7. Sensory and physical limitations
    Hearing and sight are critical for communication. Older adults are particularly prone to physical problems, but they may exist in other populations and go unnoticed due to factors such as language barriers and health literacy.

  8. Alternative approaches to communication and access to care
    The team approach to managing specific populations is often a critical component to delivering effective care. Expanding the role of the medical translator to a community health worker is an effective approach for a population with limited English skills.8 Educational material may need to be adapted to forms of verbal communication such as storytelling.9
Tools You Can Use

Everyone with Diabetes Counts is an independent organization that has contracted with the Centers for Medicare & Medicaid Services Quality Improvement Organizations. The organization’s sole focus is to address patients with diabetes through the lens of their socioeconomic class, culture, race, and gender in an effort to produce Diabetes Self-Management Education to address health disparities. Watch an overview of this program here: Everyone with Diabetes Counts: A QIO-Led Project to Affect Behavioral Changes and Improve Outcomes.



1. Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Report. Hyattsville, MD: National Center for Health Statistics. 2008.
2. United States Department of Justice, Civil Rights Division. http://www.ada.gov/index.html
3. Translation Requirements Pursuant to Obamacare. Legal Language Services. 2013. Available at: https://www.cms.gov/cciio/resources/regulations-and-guidance/
4. Understanding Literacy and Numeracy. Centers for Disease Control and Prevention. 2015. Available at: http://www.cdc.gov/healthliteracy/learn/understandingliteracy.html
5. Drew EM, Schoenberg NE. Deconstructing fatalism: ethnographic perspectives on women’s decision making about cancer prevention and treatment. Med Anthropol Q. 2011;25(2):164-82.
6. Walker RJ, Smalls BL, Hernandez-Tejada MA, Campbell JA, Davis KS, Egede LE. Effect of diabetes fatalism on medication adherence and self-care behaviors in adults with diabetes. Gen Hosp Psychiatry. 2012;34(6):598-603.
7. Chesla CA, Chun KM, Kwan CM. Cultural and family challenges to managing type 2 diabetes in immigrant Chinese Americans. Diabetes Care. 2009;32(10):1812-6.
8. National Center for Chronic Disease Prevention and Health Promotion, Division for Heart Disease and Stroke Prevention. Addressing Chronic Disease Through Community Health Workers: A Policy and Systems-Level Approach: A Policy Brief on Community Health Workers. 2011. Available at: http://www.cdc.gov/dhdsp/docs/chw_brief.pdf (PDF, 1.1 MB).
9. Promoting Health Literacy Through Storytelling. Online Journal of Issues in Nursing. 2009;14(3). http://www.medscape.com/viewarticle/717470

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