Diabetes Education for the Deaf: Unexplored Territory

Ramon E. Martinez, MD1, Marina Krimskaya, ANP/CDE1, Amy Lam, RN1, Gordon Burke1, and Leonid Poretsky, MD1 Maria Towe, CT2, and Bart Worthington, CI2
1

Department of Medicine Division of Endocrinology, Diabetes & Metabolism 2 Sign Language Interpreting Department Beth Israel Medical Center, New York City, NY

Abstract
Objective To describe the initiative for the development of a diabetes education curriculum for the deaf. Methodology Twenty deaf patients with diabetes to be enrolled in a Diabetes Self-Management Education Program (DSME) designed for the deaf by Certified Diabetes Educators (CDE) and sign language interpreters. Clinical outcomes will be measured before and after intervention. Results Diabetes education materials for the deaf have been developed. These include glucose self-monitoring logbook, hyperglycemia and hypoglycemia symptoms guides, and blood glucose ranges with actions to be taken. Additional materials are in development. 2 workshops have been held
An initial workshop with 13 deaf patients provided information about Self Monitored Blood Glucose (SMBG), and hypoglycemia and hyperglycemia symptoms A follow-up meeting with 11 of the initial 13 patients was held 6 weeks after. 2 new patients attended this meeting.

9 of 11 patients were able to perform SMBG, which they did not do before DSME first workshop Discussion Nine percent of the US population have a hearing impairment (the most common disability in the US) and approximately 5 million individuals are considered deaf. Twenty five percent of the deaf population have a second disability. The deaf community shares a common language (American Sign Language). The level of education differs from the rest of the US population: average education level for an 18 y/o deaf person is 3rd grade. Level of English literacy is low as well. There is no data regarding the prevalence or incidence of diabetes mellitus in this population. Available educational materials are not appropriate for deaf patients level of education and perception. Our search, including medical literature, printed and web-based material provided by national organizations (e.g. American Association of Diabetes Educators and American Diabetes Association) and internet at large, failed to identify diabetes education materials or programs for deaf individuals. Our pilot study seems to indicate that developing DSME materials, designed specifically for deaf people with diabetes, as well as a specific presentation of these materials might improve their control over the disease.
Conclusions Developing culturally sensitive educational techniques, methods and materials can help to reduce the gap in diabetes knowledge and glycemic control between the deaf and the hearing populations.

Introduction
Effective communication between patients and physicians is KEY! Approximately 9% of the US population have a hearing impairment
The most common chronic physical disability Roughly 4.8 million are deaf

Deaf individuals are those that share:

Common language (American Sign Language ASL) Experiences Set of beliefs that are different from hearing, middle class norm US society

1 in 1000 children is born with severe hearing loss 4 5 in 1000 children have a hearing disability significant enough to interfere with language acquisition 25% have an additional disability (i.e. learning)

Introduction (cont)
This population has:
Lower income Greater level of unemployment Less education 70% have 12 years of education More Blue Collar jobs Less insurance coverage Lower level of English literacy

They may find themselves learning different cultures at the same time Mean reading level for a deaf high school student (16 18 y/o) is between 3rd and 4th grade Unknown incidence and prevalence of Diabetes Mellitus among the deaf population Available educational materials are not appropriate for their level of education and perception

Methods
Twenty deaf patients with diabetes to be enrolled in a pilot Diabetes Self-Management Education Program (DSME) designed for the deaf by Certified Diabetes Educators (CDE) and sign language interpreters. Materials to accomplish the DSME were developed considering: That these patients have limited abstract thinking Level of education Learning disabilities Cultural differences See Figures 1, 2, and 3

Methods
Workshops were organized in order to educate approximately 20 patients in each group CDE and sign language interpreters were in charge of leading the instruction and available for questions Patients received general instructions regarding:
SMBG Hyperglycemia and hypoglycemia symptoms Actions to take according to BG levels

After oral and PowerPoint presentation, patients were asked to demonstrate what they were taught, and they were provided with supplies to have hands-on experience Materials developed were provided to patients to practice at home

Figure 1

NO

YES

Figure 2
Before Breakfast Before Lunch Before Dinner Before Bed

M T W T F S S

Figure 3
Blood Sugar Range

Below 80
Drink orange juice

Above 250
Contact doctor

Results
Diabetes education materials for the deaf have been developed, and tried in deaf people with diabetes These include:
Glucose self-monitoring logbook (Figure 2) Hyperglycemia and hypoglycemia symptoms guides BG level and actions to take (Figure 3)

2 workshops have taken place with a total of 15 patients, of which 11 individuals attended both
9 out of 11 patients were able to demonstrate proficiency in SMBG after the initial workshop

Discussion
Nine percent of the US population have a hearing impairment (the most common disability in the US) and approximately 5 million individuals are considered deaf. Twenty five percent of the deaf population have a second disability, which is precisely our study population. The deaf community shares a common language (American Sign Language). The level of education differs from the rest of the US population: average education level for an 18 y/o deaf person is 3rd grade. Level of English literacy is low as well. There is no data regarding the prevalence or incidence of diabetes mellitus in this population. Available educational materials are not appropriate for deaf patients level of education and perception. Our search, including medical literature, printed and web-based material provided by national organizations (e.g. American Association of Diabetes Educators and American Diabetes Association) and internet at large, failed to identify diabetes education materials or programs for deaf individuals.

Discussion
The initial result of the pilot program showed that deaf patients with diabetes can effectively learn SMBG with the appropriate educational techniques (didactics), and the materials specially developed for their level of education, and culture. Clinical outcomes in deaf patients with diabetes needs to be investigated in larger studies.
At the Gerald J. Friedman Diabetes Institute, we plan to start a large study on the effects of this program, specifically designed for the deaf with diabetes mellitus. We will evaluate hard clinical parameters (HbA1c, lipids, blood pressure, and BMI).

Conclusion
Developing culturally sensitive educational techniques, methods and materials can help to reduce the gap in diabetes knowledge and glycemic control between the deaf and the hearing populations.

References
Hamer, LM. Health Care Delivery and Deaf People: Practice, Problems, and Recommendations for change. Journal of Deaf Studies and Deaf Education. 4:2 Spring 1999