Presentation is loading. Please wait.

Presentation is loading. Please wait.

Building Bridges: Improving Health through Program Integration Ethnic Myths: Implications for Chronic Care Management Sharon A. Brown, PhD, RN, FAAN Professor.

Similar presentations


Presentation on theme: "Building Bridges: Improving Health through Program Integration Ethnic Myths: Implications for Chronic Care Management Sharon A. Brown, PhD, RN, FAAN Professor."— Presentation transcript:

1 Building Bridges: Improving Health through Program Integration Ethnic Myths: Implications for Chronic Care Management Sharon A. Brown, PhD, RN, FAAN Professor and Associate Dean for Research Director, Cain Center for Nursing Research The University of Texas at Austin School of Nursing

2 List 3 cultural myths related to racial, ethnic, or cultural norms about health… Describe 2 strategies for addressing these myths in chronic care management and their ethical implications Discuss 3 ethical principles of providing care that is culturally competent OBJECTIVES

3 MA: DSME interventions (ANF) RGV: Intervention development (focus groups, pilots) MA: DSME interventions revisited (DREF) RGV: Efficacy of culturally tailored DSME intervention in Mexican Americans (NIDDK) MA: Weight loss strategies in type 2 diabetes (NINR) RGV: Comparison of 2 culturally tailored DSME interventions in Mexican Americans (NIDDK) MA: Pilot testing of a predictive model of diabetes outcomes (Faculty Development Leave) MA: Biobehavioral determinants of health outcomes in type 2 diabetes (NINR, current) RGV: Feasibility of nurse case management in rural border communities (NIDDK) RESEARCH PATHWAYS Meta-analysisIntervention 3

4 Recruitment / Retention Genetic Predisposition / Fatalism Gender Roles Acculturation & Dietary Practices Breaking barriers with Promotoras (CHWs) CULTURAL MYTHS

5 RESPECT FOR PERSONS Individuals are autonomous Protect those with diminished autonomy BENEFICIENCE Do no harm Maximize possible benefits / minimize possible harms JUSTICE: to each person… an equal share according to individual need according to merit ETHICAL PRINCIPLES

6 RESEARCH MOTIVATION Growing diabetes epidemic Tight glucose control reduces complications by 25%-75% (DCCT, UKPDS) Glucose control > 6 years of additional life $174 billion spent annually Less than 30% achieve glycemic control

7 Predicted growth of the Hispanic population Source: Passel, J.S., & Cohn, D. (2008). U.S. population projections: 2005-2050. Washington, DC: Pew Research Center. U.S. 296 million (2005) population:438 million (2050, immigrants) Latinos: largest minority group (14%) will triple in size Whites:will become a minority (47%) Elderly: double in size

8 Prevalence per 100,000 Source: CDC Wonder (the Healthy People 2010 Database) Diabetes prevalence rates in the U.S.* GROUP Prevalence Rate (2008) American Indian or Alaskan Native109 Black / African American83 Hispanic / Latino81 Asian58 White55 Gender: Female Male 58 60 Education: < high school High school graduate At least some college 132 102 70 by racial group

9 Deaths per 100,000 (only 30% of diabetes death rates documented on death certificates) Source: CDC Wonder (the Healthy People 2010 Database) Diabetes-related death rates in the U.S.* Racial / Ethnic GroupDeath Rate (2006) Black / African American127 Hispanic: Cuban Mexican American Puerto Rican 52 104 108 American Indian98 White69 Asian / Pacific Islander55 Gender: Female Male 63 89 Education: < high school High school graduate At least some college 61 41 16 by racial group

10 20012004 Blacks113104 Hispanics6380 Whites2831 Amputations per 100,000 population Source: Agency for Healthcare Research and Quality, 2008 Diabetes-related amputation rates by race/ethnicity in the U.S.* ONLY 38% OF ADULT HISPANICS RECEIVED SCREENINGS (foot exams, eye exams, A1c) COMPARED TO 47% FOR WHITES AND 47% FOR BLACKS

11 Diabetes Prevention Program Group 1 Coaching in healthy lifestyle designed to promote weight loss (diet & physical activity) Group 2 Metformin Group 3 Placebo Diet and exercise Diet & physical activity (walking) reduced risk of diabetes by 58% Diabetes drug Reduced risk of diabetes by 31% Consistent across populations Highest reduction achieved by people over age 60 in diet & exercise group – a 71% reduction RESULTS

12 Promoting Weight Loss in Type 2 Diabetes (n=89) (Brown et al., 1996) -20# wt. loss-2.4%-age points

13 Glazier et al. (2006). A systematic review of interventions to improve diabetes care in socially disadvantaged populations. Diabetes Care, 29, 1675-1688. At least a 1.0%-age point reduction in HbA1c ( reduces death by 10%, microvascular end points by 25% ) Consistent positive effects in studies that included: Cultural tailoring Community educators / lay people One-on-one interventions w/ individualized assessment Treatment algorithms Behavior-related tasks Feedback High-intensity interventions (>10 contacts, 6 mos.) DSME EFFECTS

14 14 The Starr County Border Health Initiative

15 STARR COUNTY, TEXAS

16 SETTING: Starr County Population: 62,249 97.5% Hispanic Poorest county in Texas - 3rd poorest in U.S. Unemployment rate 11.9% (2008) Per capita income $10,716 (2008) Young population 10% > 65 years of age 2,200+ colonias on the border 400,000 people Diabetes affects 50% of adults over age of 35 (Hanis, 1983) 50% of health care obtained in Mexico Lower RGV has highest diabetes-related death rate Native American admixture contributes to risk/ethnic differences Hispanics labeled noncompliant more likely treated with insulin Population:MD = 7657:1 (3789:1 rest of TX) Population:RN = 851:1 (159:1 rest of TX) Source: Texas Secretary of State, http://www.sos.state.tx.us/border/colonias/faqs.shtml

17 SETTING: Starr County 17

18 SETTING: Starr County 18

19 COMMUNITY ASSESSMENT Understanding of diabetes: Blood sugar or blood glucose testing / results Gods will (fatalism but generational differences) Will get diabetes eventually (fatalism or reality?) Previous diabetes-related experiences: Told not to eat cultural food preferences Previous weight loss failures Feared insulin injections Diabetes care from both sides of the border Folk remedies (generational differences) Suggestions for a diabetes intervention: Interested in DSME No complicated exchange lists No brochures (low literacy rates among elderly) Involve family members (low levels of support) Reduce fat intake (lard)

20 health literacy a stronger predictor of health than age, income, employment status, education level, and race Source: Report of the Council of Scientific Affairs, Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association, JAMA, Feb 10, 1999

21 Populations Vulnerable to Poor Health Literacy Minority / immigrant populations Low income: 1/2 Medicare/Medicaid recipients read <5th grade level People w/ chronic health conditions Elderly: 2/3 have inadequate literacy Source: National Network of Libraries of Medicine (nnlm.gov) Williams, MV. JAMA, December 1995

22 Consequences of poor health literacy Take meds. on erratic schedules Miss follow-up appointments Do not understand instructions ( 81% of patients 60 years of age at public hospital could not read or understand basic materials such as prescription labels ) Source: IOM, Health Literacy: A Prescription to End Confusion Williams, MV. JAMA, December 1995

23 Diabetes-Related Knowledge (n=252) (% that identified the right answers across relevant items)

24 Consequences of poor health literacy in Starr County Self-prescribing of medications and other treatments Misinterpretation of symptoms did not perceive symptoms as serious Misinterpretation of HCP recommendations Misunderstanding of health experiences of family and friends Self-prescribing of medications and other treatments Misinterpretation of symptoms did not perceive symptoms as serious Misinterpretation of HCP recommendations Misunderstanding of health experiences of family and friends

25 Recruitment / Retention Genetic Predisposition / Fatalism Gender Roles Acculturation & Dietary Practices Breaking barriers with Promotoras (CHWs) CULTURAL MYTHS?

26 Language Family-centered Non-judgmental approach Transportation Flexible scheduling Reminders telephone, calendars Benefits feedback, intervention, monitoring, rewards Snacks of healthy Mexican American foods STARR COUNTY STUDIES Recruitment: 95% Retention: 81-90% CULTURAL COMPETENCE Matches superficial characteristics of the culture (e.g., food, music) Integrates deep structure of the culture (social, historical, environmental, psychological factors)

27 SAMPLE CHARACTERISTICS 64% female 54 years of age on average (range 35-70) 20% on insulin 38% use alternative remedies (garlic, chaya) 8 years average diabetes duration (range 1-25) Scored low (1.0) on acculturation scale (0-4) 90% preferred speaking Spanish

28 Recruitment / Retention Genetic Predisposition / Fatalism Gender Roles Acculturation & Dietary Practices Breaking barriers with Promotoras (CHWs) CULTURAL MYTHS?

29 INTERVENTIONS Culturally tailored education + group support: 52 contact hours (extended) 22 contact hours (compressed) Series of Spanish-language videotapes Instructors: RNs & RDs + promotoras Social support: family members, friends, groups Community-based settings ( churches, schools ) 1,100+ study participants

30 Diabetes y Su Salud

31 MEASURES HbA1cDemographics FBGHealth history BMIAcculturation Cholesterol Diabetes knowledge BPHealth beliefs LeptinFamily history TriglyceridesMedication history MicroalbuminuriaFat intake ComplicationsFood frequency Physical activity

32 Compressed vs. Extended Program (1999-2004) STUDYOUTCOME: HbA1c HbA1c MYTH Genetic Predisposition, Fatalism

33 Outcome: HbA1c Compressed vs. Extended Program 50% attendance (n=110) Outcome: HbA1c Compressed vs. Extended Program 50% attendance (n=110) MYTH Genetic Predisposition, Fatalism

34 Top 10% achievers in reducing HbA1c n=20 Attended 57% -6%-age pts Mean age: 54.8 Bottom 10% achievers in reducing HbA1c n=20 Attended 37% +3%-age pts Mean age: 53.9 Dosage Effects of Program Attendance

35 Recruitment / Retention Genetic Predisposition / Fatalism Gender Roles Acculturation & Dietary Practices Breaking barriers with Promotoras (CHWs) CULTURAL MYTHS?

36 MYTH: Gender Roles HEALTH BELIEFS Control over diabetes males (F=4.1, p=.05) Social support males (F=6.1, p=.01) HEALTH BELIEFS Control over diabetes males (F=4.1, p=.05) Social support males (F=6.1, p=.01) METABOLIC CONTROL HbA1c levels lower in males (t=3.11, p=.002) Males with greater attendance achieved greater improvements in HbA1c

37 Recruitment / Retention Genetic Predisposition / Fatalism Gender Roles Acculturation & Dietary Practices Breaking barriers with Promotoras (CHWs) CULTURAL MYTHS?

38 MYTH: Acculturation & Dietary Practices (weight & type 2 diabetes) Returning native cultures to traditional cultural diets significantly improves glucose intolerance and insulin resistance Recommendations: Walk 30 minutes per day Lose 5-7% body wt ( 500-1000 kcal)

39 Recruitment / Retention Genetic Predisposition / Fatalism Gender Roles Acculturation & Dietary Practices Breaking barriers with Promotoras (CHWs) CULTURAL MYTHS?

40 …a community health safety net and a natural extension of the health and human services agencies, improve health at the neighborhood level. Latin American program-type for underserved populations peer liaisons advocacy, interpersonal relations, capacity building, communication, knowledge, organization, teaching, service coordination beyond community health worker model: speak the same language come from the same neighborhood tend to be women [Nichols et al., Prev Chronic Dis, Nov 2005] MYTH Breaking barriers: Promotoras (CHW)

41 Promotoras: a cautionary tale Focus group input: promotoras not acceptable as group leaders Anecdotal evidence: individuals consider the use of the promotora model as racial Starr County promotora role: Data collection Recruitment Telephone contact / reminders Transportation Motivation Logistical support (intervention sites, materials) Grocery shopping / preparation of snacks

42 RESPECT FOR PERSONS Individuals are autonomous Protect those with diminished autonomy Best predictor of health health literacy Cultural myths fatalism, generational differences Promotora model Heterogeneity within cultures Use of focus groups Language issues ETHICAL PRINCIPLES

43 Community-based research takes place in community settings involves community members in the design and implementation of research projects Principles: Community involved at the earliest stages Community influences project Research processes & outcomes benefit community Community hired and trained whenever possible Community part of data interpretation; input into how results are distributed Partnerships should last beyond the project Community empowered to initiate their own projects Source: http://sph.washington.edu/research/community.asp

44 BENEFICIENCE Do no harm Maximize possible benefits / minimize possible harms Alarming self-management practices Integrate DSME into other aspects of treatment Family involvement / social support Home glucose self-monitoring Socioeconomic constraints Real environmental barriers Physiologic barriers to improved glycemia ETHICAL PRINCIPLES

45 JUSTICE: to each person… Mexican Americans / Hispanics least studied group Hispanic health disparities: lower rates of health screenings 38% vs. 47% for whites and blacks higher diabetes prevalence rates 1.5 x whites higher diabetes-related deaths 1.5 x whites Average HbA1c reduction with effective DSME interventions across all groups 2.4%-age points Average HbA1c reduction attained with DSME culturally tailored for socially disadvantaged groups 1.0%-age points Few minority health professionals ETHICAL PRINCIPLES

46 Estimated Intervention Costs Extended Care (RN, RD, & promotora) 26 sessions $384/person Compressed Care (RN or RD and promotora) 11 sessions $131/person

47 Craig Hanis, PhD, Co-PI (Professor, UT-Houston School of Public Health) Alexandra García, RN, PhD, Co-I (Associate Professor, UT Austin School of Nursing) Kamiar Kouzekanani, PhD, Co-I (Statistician, UT Austin [previously]) Philip Orlander, MD, Consultant / Co-I (Chair, Division of Endocrinology, UT-Houston Medical School) Research Associates Maria Winchell, MSMary Winter, MSN RESEARCH TEAM

48 Intervention Staff Evangelina Villagomez, MSN, RN Mario Segura, MSN, RN Lilia Fuentes, MSN, RN Lita Silva, MSN, RN, CDE Nora Morín Siller, RD, LD Maria Olivia Garza, RD, LD Ana Gonzalez, MS, RD, CDE Norma Cottrell, RD Mila Villareal, MSN, RN Juan Jesús Treviño, BS, LD Patricia Ramírez, RD, LD Rogelio Contreras, RN Celia Zuñiga, RN Emiliana Guerra, RD Sylvia Cardenas, RN, FNP Ventura Huerta, RN, BSN, MPH Starr County Field Office Hilda Guerra, Manager Sylvia Hinojosa Marie López Imelda Martínez Alma Martínez Jesusa L. Salmón Maricela Garza Maria Coder Umbelina Reyna Minerva Margo Elva Yolanda Morado Maria Garza Clara Treviño Elizabeth Peña RIO GRANDE VALLEY STAFF

49 Funded by... Office of Research in Minority Health State of Texas University of Texas at Austin University of Texas at Houston


Download ppt "Building Bridges: Improving Health through Program Integration Ethnic Myths: Implications for Chronic Care Management Sharon A. Brown, PhD, RN, FAAN Professor."

Similar presentations


Ads by Google