Diabetic ulcers in Indigenous patients
Socioeconomic factors and a physician’s lack of cultural competency lead to worse outcomes and more complications (1,500 words, 7 minutes)
The Indigenous Canadian population is at elevated risk of diabetes and faces more skin complications and worse outcomes than the general population, Dr. Veronica McKinney said during the 7th annual Skin Spectrum Summit onNovember 66. Physicians lack understanding of these patients’ circumstances, and there is low trust between physicians and patients. This complicates care, she said.
Socioeconomic factors limit healthy food choices, access to quality clothing or housing, and treatment options, Dr. McKinney said. High costs or limited access can mean Indigenous patients with diabetes do not have optimal footwear or diet or may have reduced availability of cleaning supplies and soaps. Wet feet can lead to weakened skin, and dirty clothes raise infection risk, making skin problems worse, she said.
Dr. McKinney is an assistant professor of medicine at the University of Saskatchewan and director of Northern Medical Services.
She said that the rate of diabetes in the Indigenous population is up to five times higher than in the rest of Canada. She noted this rate is lower in more northern communities that still obtain food from traditional sources such as hunting and trapping. As those food sources change, though, diabetes rates are increasing.
“We know that in our communities, the negative outcomes of diabetes are much more common and much more severe,” said Dr. McKinney.
Another concern is that Indigenous people are developing Type 2 diabetes at a younger age, some as young as eight years old.
Access to medical care is also a challenge, potentially involving a day’s travel and a hotel stay, said Dr. McKinney.
Physicians may not understand the realities Indigenous patients face, Dr. McKinney said. Patients are often not being deliberately non-compliant but simply cannot afford to follow physicians’ recommendations, she said.
“We talk to them as if they are making poor choices or that they are not eating properly without considering what access they have to food or what financial means they have,” she said.
Other patients may have experience with family members who experienced diabetes-related amputations or other complications, making them reluctant to face the facts of their diabetes.
Dr. McKinney said physicians need to take time to help patients understand the complexities of diabetes. This may also mean adapting information to Indigenous traditions, which often involve more oral communication than written.
She said physicians also need to be sensitive to how diabetes can affect patients socially and spiritually. Diabetes may prevent patients from hunting or trapping. It may make them uneasy about social or family gatherings if they must worry about what foods will be there; it may make participating in sweat ceremonies or fasting more difficult.
A history of unethical medical experiments on Indigenous people, forced sterilization, and prominent news stories of racism by medical professionals toward Indigenous peoples contribute to the low trust of physicians as well, Dr. McKinney said. “That means that patients are less likely to come and access care, and it is even more likely that they will not necessarily follow [physicians'] recommendations.”
She said that treating Indigenous patients may take a larger investment of time and resources by a physician. It could include travelling to the patient’s home and advocating for them through letters or phone calls. Dr. McKinney said it is important to know what is available within the community and to help the patients access community workers or support groups if those are available.
Bottom Line: Indigenous people are more likely to develop diabetes than the general Canadian population, and their outcomes are likely to be more severe. It can be more challenging for Indigenous patients to trust the medical system, access or afford care or obtain proper food or clothing. Diabetes can lead to worse social isolation. Understanding cultural traditions and exploring and using whatever resources are available within local communities is important.
From the literature on diabetes in Indigenous communities
Development of an American Indian diabetes education cultural supplement: A qualitative approach
The authors of this paper consulted with Diné healers and cultural experts to develop an educational tool called Diné Health to aid in culturally-appropriate health education about diabetes for Diné Indigenous patients.
Key themes that emerged from the data included the importance of discipline, positivity and mindfulness in the context of Hózhó—a Diné concept often translated as “balance and beauty”.
Three specific Type 2 diabetes self-care behaviours were discussed. These included healthy eating, physical activity and healthy coping.
The authors write that engaging with cultural leaders in a safe and meaningful way can be key to developing tribe-specific diabetes education programs.
Traditional, complementary and integrative medicine use among Indigenous peoples with diabetes in Australia, Canada, New Zealand and the United States
This paper reviews 12 studies from Australia, Canada and theU.SS. The authors found that Indigenous peoples used traditional, complementary and integrative medicine (TCIM) alongside conventional diabetes treatment. TCIM was mostly chosen when conventional treatment did not meet Indigenous peoples’ holistic understandings of wellness. The authors write that while TCIM was often viewed as an effective treatment through bringing balance to the body, the reviewed articles lacked definitions of treatments that comprise safe and effective TCIM use.
Multi-level diabetes prevention and treatment interventions for Native people in the USA and Canada: A scoping review
This review of diabetes interventions that mobilize support through a combination of individual, interpersonal, organizational, community, and policy found little literature about these programs forU.S.. and Canada-based Native peoples. The authors identified 10 interventions. All focused on diabetes prevention. Most of these were primarily individual-, school-and community-based, with only three interventions including environmental or policy-level components.
Clinical and cost-effectiveness of telehealth for Indigenous and culturally and linguistically diverse (CALD) people: a scoping review
This is a review of peer-reviewed publications (2000-2021) on the effectiveness of telehealth interventions for Indigenous and culturally and linguistically diverse people. The 10 papers reviewed included participants from Canada, theU.S.., Australia and New Zealand, with sample sizes ranging from 19 to 1,665 people.
The authors say the findings suggest that telehealth shows some promise in diabetes, depression, neurological and cognitive assessment. Telehealth can also help with health program adherence, use of services, and cost of services.
However, mixed quality in the study designs and risks of bias means they are not fully confident in the findings, they write.
VIDEO: Managing Diabetic Foot Complications in the Indigenous Community
At the intersection of skin and society
Cindy Blackstock, member of the Gitxsan First Nation and Executive Director of the First Nations Child and Family Caring Society (FNCFCS) of Canada, has been named one ofCanada’ss Top 25 Women of Influence.
The annual list is compiled by the Women of Influence organization to““recognize the extraordinary accomplishments ofCanada’ss self-identified women and gender-diverse role models. The recipients have all left their mark over the past year: contributing to the greater good through their initiatives; using their influence to drive positive change; or reaching inspiring heights on a global stage””
In their announcement, the Women of Influence organization write that Blackstock, a professor at the School of Social Work at McGill University, has engaged in activism regarding the welfare and rights of Indigenous children for more than 30 years.
Most recently, Blackstock played a significant role on behalf of the FNCFCS in the $40 billion agreement reached on December 31, 2021, between the Canadian government and First Nations leaders—a deal that facilitates the compensation of First Nations children who were harmed by Canada’s discriminatory child welfare system.
Shear listening pleasure episode eight
The first episode for 2022 of Dr. Neil Shear’s Shear Listening Pleasure podcast has been released. In this episode, Dr. Shear speaks with guest Dr. ElizabethO’Brienn about her career journey, closing her practice to continue teaching, and chasing passion projects as a dermatologist.
This week
March 14-20 is Healthcare Science Week in theU.KK. March 166 is No Selfies Day in theU.SS. March 199 is Certified Nurses Day in theU.SS.
Something to think about in the week ahead…
Next week
Coming up onMarch 211 is our coverage of a special talk by Dr. Ncoza Dlova on cutaneous manifestations of HIV and the stigmatization of patients with HIV in South Africa. Dr. Dlova is Dean and Head of School of the University of KwaZulu-Natal’ss School of Clinical Medicine. She spoke at the 7th annual Skin Spectrum Summit.
Coming soon
OnApril 233, 2022, Chronicle Companies will be presenting the 2022 Summit on Atopic Dermatitis. This will be a one-day virtual medical educational event. The conference seeks to address an unmet need for education on the incidence of and latest therapies for atopic dermatitis A.D.D) among dermatologists and general practitioners. Presentations are planned to discuss the most current treatments for all disease severities. The conference will also emphasizeA.D.D diagnosis in skin of colour and will provide resources for patient and caregiver support.
Registration for the Summit on Atopic Dermatitis is open and available at this link.