Patients often remain strongly influenced by their cultural background, even if they’ve been in the United States for many years. Because culture often impacts how health is perceived, healthcare providers need to be sensitive to these influences when treating patients with diabetes. Fortunately, several mnemonic tools can be used by diabetes educators to help healthcare providers enhance their encounters with patients with diabetes regardless of their cultural perspective. This can increase the likelihood of improving healthcare behaviors to manage diabetes.

Available Tools

Three tools are available to help healthcare providers overcome potential cultural barriers to care. These include:

1. ETHNIC: Explanation, Treatment, Healers, Negotiate, Intervention, Collaboration.
2. BATHE: Background, Affect, Trouble, Handling, Empathy.
3. LEARN: Listen, Explain, Acknowledge, Recommend, Negotiate.

While tactics of these tools vary, all of them focus on unearthing how patients perceive and respond to their condition and how their culture influences them. The purpose is to find mutually agreeable solutions. For example, as a diabetes educator, I often use ETHNIC. I start by having patients explain how they view diabetes and what treatments have been tried. I also ask if they have seen alternative health providers or healers. We then negotiate interventions to manage diabetes that are acceptable and can benefit patients. The last step is to collaborate with family members and healthcare professionals, including healers, to manage diabetes.

Understanding Patient Views

During patient encounters, I always ask about the foods and beverages that patients are eating more of to treat their condition as well as the ones that are being avoided. This information helps me understand patients’ perspective and behaviors. Misunderstandings about important health behaviors can come to light.

Tools like ETHNIC, BATHE, and LEARN can uncover many behaviors that may be aggravating diabetes. For example, patients may be taking herbs or supplements that actually cause harm. It’s important to understand that beliefs can be imbedded based on cultural backgrounds, highlighting the importance of collaboration with patients. Patients are more likely to follow diets that include familiar foods, but we may help them by recommending that they bake rather than fry some foods or switch to healthier alternative substitutes for foods they prefer. Another example is that some patients may not value exercise. However, we can recommend alternatives to typical exercise, such as dancing to culturally familiar music or going for after-dinner walks with the family.

The simple tools that have been developed to address cultural issues when managing patients can help healthcare providers treat patients with diabetes more competently. Diabetes educators can provide further support, helping patients follow good self-care plans that work for them.


Berlin E, Fowkes W. A teaching framework for cross-cultural health care: application in family practice. West J Med. 1983;139:934-938.

Health beliefs and compliance with prescribed medication for hypertension among black women–New Orleans, 1985-86. MMWR. 2012;39:701-704. Available at

Van Son C. Developing culturally targeted diabetes educational materials for older Russian-speaking immigrants. Diabetes Educ. 2014;40:418-426.

Brown S, Hanis C. Lessons learned from 20 years of diabetes self-management research with Mexican-Americans in Starr County, Texas. Diabetes Educ. 2014;40:476-487.

McEwen M, Murdaugh C. Partnering with families to refine and expand a diabetes intervention for Mexican Americans. Diabetes Educ. 2014;40:488-495.

Levin S, Like R, Gottlieb J. ETHNIC: a framework for culturally competent clinical practice. IN: Appendix; useful clinical interviewing mnemonics. Patient Care. 2000;34:188-189.