Cultural competency in dietetic diabetes care—A qualitative study of the dietician’s perspective

Abstract Introduction Diabetes type 2 is more prevalent in ethnic minorities in the Netherlands, and outcomes of health care in general are worse compared to other Dutch patients. The purpose of this study is to explore the experiences of dieticians and the knowledge, skills and attitudes they consider to be important for effective dietetic care in migrant patients. Methods Semi‐structured interviews were held with 12 dieticians, of various ages, ethnic backgrounds and experience. The interview guide was based on Seeleman's cultural competence model and the Dutch dietetic consultation model. Interviews were transcribed, coded and thematically analysed, revealing 7 main themes. Results Dieticians were uncertain whether their care fulfilled their migrant patients’ needs. They experienced language differences as a major barrier for retrieving information and tailoring advice to the patient's needs. Furthermore, dieticians feel they lack cultural knowledge. An open and respectful attitude was considered important for effective care. The communication barrier hindered building a trusting relationship; however, few dieticians mentioned a need for communication training. They expressed a need for cultural competence training, specifically to acquire cultural knowledge. Conclusion Dieticians struggle with providing dietetic care for migrant diabetes patients due to communication barriers and difficulty in building a trusting relationship. They are conscious of their lack of cultural knowledge, and acknowledge the need for an open and respectful attitude and essential communication skills in order to collect and convey information. They seem unaware of the impact of low (health) literacy. Cultural competence training is needed for effective dietetic care for migrants.


| INTRODUC TI ON
In the Netherlands, at least 22% of the population has an ethnic minority background, half of whom are migrants. 1 The largest groups originate from Turkey, Morocco, Surinam and the Dutch Antilles. 1 Type 2 diabetes mellitus is highly prevalent within Europe, and two to four times more prevalent in ethnic minority populations in this region. 2 Additionally, amongst ethnic minorities, higher blood glucose and lipid levels are observed and severe complications occur more often 3 compared to native Dutch diabetic patients. 4 These health disparities relate to patients' poor health literacy 5,6 and lower self-efficacy 7 resulting in poor self-management. Unhealthy dietary patterns, for example consumption of high amounts of sugar-rich beverages as well as small amounts of whole-grain products, 8 and low physical activity 7,9 may be rooted in cultural habits with an emphasis on elaborate cooking, joint meals, and health beliefs. [10][11][12][13] Language differences and a lack of cultural competences as well as prejudices of health-care professionals interfere with effective communication and care. [14][15][16] Moreover, trained professional interpreters are hardly used due to the lack of reimbursement within the Netherlands. Diabetes care in the Netherlands is multi-disciplinary, concentrated in primary health care. Dutch multi-disciplinary guidelines 17 instruct dieticians to focus on promoting self-management, adherence to dietary advice and engaging in regular exercise.
Previous studies revealed that dieticians' counselling does not always fit the needs of migrant patients. 10 Migrants experience difficulties within their community when adhering to dietary advice 10,11,14 and often expect a more rigorous, directive approach of dietetic advice, based on medical tests. 10 To be able to cope well with the needs of migrants and to provide a good quality of care, dieticians should obtain the necessary knowledge, attitude and skills that are defined by Seeleman 5 as "cultural competence": knowledge about epidemiology of diseases and differential treatment effects in various ethnic groups, awareness of how culture shapes individual behaviour, social contexts and one's own prejudices and skills to transfer information in a way the patient can understand, to know when external help with communication is needed and to adapt to new situations creatively. Embedding cultural competence in health-care systems enables systems to provide appropriate care to patients with diverse values, beliefs and behaviours, and it would meet patients' social, cultural and linguistic needs. 12 This improves access and equity for all groups in the population, consumer "health literacy," communication and mutual understanding and it reduces delays in seeking health care and treatment. 13 Previous work on cultural competency in dietetic care focused on the views and experiences of migrant diabetes patients. 10 However, little is known about the experiences of dieticians caring for migrant patients nor which knowledge, skills and attitudes they consider important. Therefore, the research question of this explorative study was what are the experiences of dieticians with dietetic care in migrant patients and which knowledge, skills and attitudes do they consider important for effective dietetic care in migrant patients.

| Design
The study has an explorative, qualitative design using semi-structured in-depth interviews with dieticians involved in diabetes care.

| Study population
A purposive sampling strategy was followed, aiming at a maximum variation amongst dieticians regarding age, ethnic background, experience in dietetic care in general and in caring for migrants. The practice registry of the Dutch Dietetic Association for primary care dietetic practices was screened in areas with a high density of migrant residents. Dieticians were approached by e-mail explaining the purpose and procedure of the study and were asked for participation. After signing informed consent, an interview was planned. Recruitment continued until theoretical data saturation was reached. 18 Participating dieticians were offered a free training in cultural competence.

| Data collection
The interview guide was developed by the research team based on Seeleman's cultural competence model 5 and the Dutch dietetic consultation model. 19 It addressed topics such as the dieticians' experiences with migrant diabetes patients, the barriers and facilitators for good dietetic care, the knowledge, skills and attitudes that the dieticians considered important, and training needs. The preliminary interview guide was tested in a pilot interview for comprehensibility. The length of the interviews was between 45 and 90 minutes. Interviews were conducted by MJ (dietician) at the practice location of the dietician. All interviews were audiotaped and transcribed verbatim.

| Data processing and analysis
The interviews were anonymized and entered in the computer software program Atlas.ti 8. A framework approach based on Seeleman's cultural competence model 5 and the Dutch dietetic consultation model 19 was used to analyse the transcripts. The researchers (MJ and AdB) familiarized themselves with the data by reading, re-reading and summarizing the interview transcripts. Then a coding scheme based on the framework was developed. Additionally, other codes that emerged from the data were added for more specific aspects. To ensure reliability, both MJ and AdB independently coded and analysed the first three interview transcripts. Differences were discussed until a consensus was reached.
Finally, in an iterative process, related themes were identified to structure the results section. The citations were translated from Dutch into English by MJ.

| RE SULTS
Twelve dieticians, aged 22 to 61 years, all female, participated in the study. Ten were of Dutch, one was of Bulgarian origin, and one was of Turkish origin (see Table 1). All participants were professionally trained in the Netherlands. Their dietetic working experience ranged from 5 months to 38 years. Their experience working with migrants varied from only a few patients in total to over 10 years of experience working with many migrant patients.

| General experience: working with migrants is difficult
All dieticians from Dutch origin regarded a consultation with a migrant patient as challenging or even difficult. Many of them felt insecure or felt that their advice was inadequate. All dieticians strove for good care and were very willing to help their patients to the best of their ability. However, communication problems and insecurity with migrant patients made some dieticians feel uncomfortable with the consultation and left them feeling unsatisfied. D5: 'With mister X (..) it was the most difficult conversation I've had in this entire period. That was solely due to the language problem and the fact that he did not like being counselled.
But it was also nice, because he was a very nice man. (…) I thought it was very frustrating that I could not quite figure out what he was doing wrong. I could not reach him, so I could do very little. That is very frustrating'. D7: 'And with these groups it does not always work as well as when you understand each other's language well. I struggle with that. (…) It is a very unsatisfactory feeling that one can't improve that. A kind of powerlessness in a way.
The two dieticians from non-Dutch origin seemed less insecure and regarded the difficulties more as an exciting challenge.
As a consequence of the difficulties they experienced, some dieticians expected their dietetic counselling in migrant diabetes patients to be less effective. D2: 'Not all of course, but I do notice, that many, it comes across like that to me, that it doesn't interest them much'.
Helping patients to make long-term behavioural change was seen as challenging in many patients, irrespective of their cultural background, but to really understand the motivation and the behavioural patterns of their migrant patients was found particularly difficult.

| Skills: achieving shared decision-making
Many dieticians were trained in shared decision-making and used motivational interviewing techniques to help their patients change their lifestyle. However, they mentioned that these techniques did not always seem to fit to the expectations of migrant patients.
Dieticians said that migrants expect them to take on a more directive role described as 'telling patients what to eat and what not to eat', or to give patients a list with daily menus. Although dieticians were willing to take on this role, they often felt uncomfortable with this approach.

| Skills: communication in case of a language barrier
Language differences between dietician and patient were experienced as the major barrier to good care. Dieticians said it hindered information retrieval, explaining the relationship between diabetes and diet, and discussing treatment options. Furthermore, many dieticians found it more difficult to gather information on culturally influenced ideas about health and health-care expectations and might not ask their patients about the questions they have. Retrieving information about portion sizes was often mentioned as a challenge. One dietician mentioned: D12: 'They often can't read or write Dutch, so a food diary isn't an option then'.
All dieticians had experience with informal interpreters, like family members, and most had experience with professional interpreting services. However, none of the dieticians recently used these interpreting services, as they are no longer reimbursed.
Some dieticians were aware of the problems that may arise while using informal interpreters.

| Skills: communication strategies and solutions
Dieticians felt that much creativity and effort is necessary for overcoming a language barrier. A few solutions to this were mentioned, such as asking the interpreter if they understood the information and

| Attitude and skills: importance of building a trusting relationship
Trust was mentioned often as an important factor in the relationship between patient and dietician. Dieticians were aware that a trusting relationship facilitates the sharing of information.
D12: 'Yes, creating that safe feeling that they feel like they can be themselves and that they can just communicate on an equal level. That you do not say "I am a caregiver," but that you can talk to each other on an equal level and relax, so that they have the feeling that it is not a big barrier to go to you'.

| Cultural competence training needs
None of the dieticians had received any training on cultural competence and many mentioned that they really wanted a course to be developed to this end. A few visited a mosque with a group of colleagues. Some dieticians wanted to know a few words in their patient's language. A few also mentioned skills they wanted to learn, for example how to build a trusting relationship and how to convey information.
Although language was mentioned as a major barrier during the consultation, only a few mentioned that they wanted to learn how to handle language differences.
The participants would prefer training methods that include role-

| D ISCUSS I ON
This study reveals that dieticians struggle with their care for migrant patients and are not sure whether their care fulfils the migrant patients' needs. Language differences were experienced as a major barrier hindering the necessary information retrieval and adjusting dietary advice to their needs. In particular, dieticians' expectations on cultural differences in food habits complicated giving dietary advice. The language and communication barrier also hindered the building of a trusting relationship which they deemed essential for effective care. Dieticians expressed a need for training on culturally competent care, which they never received.
Specifically, they would like to acquire cultural knowledge. In contrast, despite their experience of the importance of language barriers, many dieticians did not mention a need for communication training.
There is a large body of knowledge on the central role of language concordance in providing good quality of care. Language differences often lead to miscommunication, frustration and impede shared decision-making. 15 It also complicates talking about emotional matters 20 and building a trusting and warm relationship, which is known to improve the quality and outcome of medical encounters. 21 Although the use of trained professional interpreters positively affects patients' satisfaction, quality of care and health outcomes, 22 The experience of the respondents that food diaries were not returned, and food intake assessment was found difficult is not surprising, as written methods for food intake assessment, such as a food diary, are not suitable for people with low literacy.
Verbal food intake assessment methods, such as a 24-hour recall method or a dietary history method probably is a better fit for these patients. With respect to portion sizes, the use of visual aids is critical in migrant populations as the concept of individual servings may not exist for certain cultures, particularly those who eat from a communal serving dish. Food photographs or food models appear to be more effective than only using common household measures. 33,34 A previous study about the experiences of migrant patients with dietetic care showed that some patients were dissatisfied with their dietician because they expected a more rigorous and directive approach. 10 This is in line with the experience of the dieticians in this study who felt that migrant patients often prefer a more directive approach and seem to be less interested in shared decision-making. Although the concept of shared decision-making may indeed be uncommon to migrant patients who are used to a more physician-lead decision-making health-care system, 35 recent studies in the Netherlands indicate that migrant patients also want to participate actively in consultations with their general practitioner.
However, making an informed decision will be more difficult in case of a language barrier and low health literacy. 36 For example, knowledge that in some food cultures, rice may be prepared with large amounts of fats, which is uncommon in Dutch food culture, helps to improve skills to collect food intake information.
The feeling of uncertainty our respondents experienced due to the communication difficulties and lack of "cultural" knowledge was also observed in other studies in physicians and nurses. [44][45][46] Training in cultural competences can diminish this uncertainty. 47 The

| Strengths and limitations
To our knowledge, this is the first study to explore the experiences of dieticians caring for migrant patients with diabetes and the knowledge, attitude and skills they consider important for good quality dietetic care for these patients.

| Recommendations
Training in cultural competences should be developed and implemented for dieticians. Recommendations are provided in Table 2. The use of professional interpreters in dieticians consultations should be encouraged and reimbursed.

CO N FLI C T O F I NTE R E S T
None declared.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.