Culturally competent diabetes education for Mexican Americans: the Starr County Study.

PURPOSE: Few culturally competent health programs have been designed for Mexican Americans, a group that bears a disproportionate burden of Type 2 diabetes. In Starr County, a Texas-Mexico border community, investigators designed and tested a culturally competent intervention aimed at improving the health of this target population. The purpose of this article is to describe the development process of this diabetes education and support group intervention. METHODS: The development stages were (1) community assessment, (2) intervention design, (3) selection or development of outcomes, (4) pilot testing, and (5) a randomized clinical investigation. RESULTS: Focus group participants identified knowledge deficits regarding diabetes and self-management strategies, and suggested characteristics of an effective intervention for Mexican Americans. Outcome measures included metabolic control indicators, a newly developed knowledge instrument, and an existing health belief instrument. Preliminary analyses indicated that the intervention was successful in significantly improving metabolic control in the target population. CONCLUSIONS: Developing successful diabetes interventions for minority groups requires a number of stages, careful planning, assessment of cultural characteristics of the target population, and a systematic approach to implementation.     

Gender and treatment differences in knowledge, health beliefs, and metabolic control in Mexican Americans with type 2 diabetes

PURPOSE: The purpose of this project was to describe metabolic control, knowledge, and health beliefs of Mexican Americans with type 2 diabetes. METHODS: The study site was Starr County, Texas, a border community located on the Rio Grande River and bordering northern Mexico. Of the total sample of 360 persons, 252 agreed to participate in this intervention study and were randomized either to the treatment group or the control group that waited 1 year to begin the intervention. RESULTS: The majority of individuals were Spanish-speaking females with a mean age of 54 years and a mean diabetes duration of 8 years. For those treated with diet only, males exhibited higher fasting blood glucose levels than females. Gender effects were seen for cholesterol level, with females exhibiting higher levels than males. Males expressed stronger perceptions of control and social support for diet. Bivariate relationships were found between acculturation and diabetes knowledge. The health belief subscales of control and impact on job together explained 16% of the variance in HbA1c values. CONCLUSIONS: Males and females held differing beliefs about ability to control their diabetes and degree of social support for diet. The impact of gender differences on ability to integrate diabetes self-care and on effectiveness of diabetes programs has not been determined but should be considered in future research.     

Health communication with Chinese Americans about type 2 diabetes

PURPOSE: Chinese Americans are at high risk for type 2 diabetes and face some health disparities that can be attributed to language barriers, cultural differences, and access to care. The purpose of this article is to review current literature and establish best practices regarding health communication about type 2 diabetes for Chinese Americans. The authors reviewed clinical research literature from January 2000 to April 2011 to assess current knowledge about providing diabetes management guidance to Chinese Americans. CONCLUSIONS: To improve health communication and dissemination of health information to Chinese Americans regarding diabetes and diabetes management, research scholars, health care providers, and diabetes educators can analyze current health messages by source, message, audience, channel, and destination characteristics. Extensive research has led to clear guidelines focusing on language-appropriate materials, an understanding of Chinese food beliefs and family practices, and the importance of culturally competent health care providers. However, many Chinese Americans are using Chinese foods and medicinal herbs with little communication between patients and providers about these practices. Although Chinese Americans are not a homogenous group, this article points to a set of cultural considerations that health care providers should address when working with Chinese Americans. By attending to various qualities of health messages, efforts at diabetes prevention and management may be greatly enhanced.     

Family support, diet, and exercise among older Mexican Americans with type 2 diabetes

PURPOSE: The purpose of this study was to examine the relationship between diabetes-specific family support and other psychosocial factors with regard to diet and exercise self-care behavior among older Mexican Americans with type 2 diabetes. METHODS: Adults aged 55 years and older who presented for care in a primary care clinic for type 2 diabetes (N=138) completed a survey to assess family support specific to diabetes, barriers to self-management, self-efficacy, and diabetes self-care activities. Multivariate regression analyses were conducted to evaluate the relationship between family support and self-care activities for diet and exercise. RESULTS: Higher levels of perceived family support and greater self-efficacy were associated with higher reported levels of diet and exercise self-care. As the barriers to exercise increased, the levels of exercise self-care decreased. Living with family members (more than just a spouse or significant other) was associated with higher levels of diet self-care, as was older age. CONCLUSIONS: Family behavior is associated with diet and exercise self-care. Diabetes educators and healthcare providers should consider involving the entire family in the management of older patients with type 2 diabetes. Interventions designed to improve diabetes self-management should address family support specific to diabetes, self-efficacy, and barriers to self-care.     

Family interactions among African Americans diagnosed with type 2 diabetes

PURPOSE: The purpose of this study was to examine the impact of family and friends on the management of persons with diabetes and their willingness to be involved in a culturally tailored program. METHODS: This qualitative study was based within a larger quasi-experimental study that focused on the impact of a culturally tailored group intervention compared with individual standard diabetes education on the outcomes of self-management and glycemic control among rural African Americans with type 2 diabetes. Twenty-one participants were randomly assigned to an individual education group or a culturally tailored intervention group. Family members/peers (n = 6) attended invited group sessions to obtain information about diabetes and family/peer support. The facilitator of the invited group sessions used a guide to help with group discussions. The investigators used an iterative approach to enhance the examination of the responses from the discussion guide, thus identifying recurring themes within the participants' responses. RESULTS: The data revealed that family and friends made a difference in the diabetes management of individuals with diabetes. Although family and friends may have been helpful at times, they also created moments of problems and an environment that made it more difficult to care for diabetes. The data also revealed that diabetes is hard to manage and control. Participants reported that taking medications and being aware of types of foods to keep a well-maintained glucose level were often challenging. CONCLUSIONS: These findings confirm that family and peers greatly influence diabetes management among rural African Americans. The study's results will help health care providers understand the importance of involving family members and friends in the treatment and diabetes management of individuals with type 2 diabetes, particularly within rural African American communities where resources are limited.     

Texas-Mexico border intervention by promotores for patients with type 2 diabetes

PURPOSE: The purpose of this study is to evaluate the impact of a promotores-led diabetes self-management program by comparing the outcomes (knowledge, beliefs, and HbA1c level) of Mexican American patients with type 2 diabetes who received usual diabetic care in a wait-list control group to those who received self-management education and follow-up by promotores in consultation with clinic providers and staff. METHODS: This randomized control study compared the results of 63 patients who attended a promotores-led culturally sensitive diabetes self-management course at a community clinic with 68 patients in a wait-list, usual-care control group. Participants were Mexican Americans with type 2 diabetes who were patients at the clinic and at least 18 years of age. At baseline, 3 months, and 6 months, the Diabetes Knowledge Questionnaire (DKQ), Health Beliefs Questionnaire (HBQ), and HbA1c levels (drawn by the clinic laboratory) were collected. RESULTS: There was a significant improvement in the intervention group's DKQ scores over time and in treatment by time. The baseline HbA1c level was 7.49 and did not change over time in either group. The DKQ, HBQ, and HbA1c results were significantly affected by age; the DKQ and HbA1c were affected by years with diabetes. CONCLUSIONS: The promotores-led diabetes self-management course improved the knowledge of patients with diabetes. Participant baseline HbA1c level was close to therapeutic level (much lower than reported in previous studies), suggesting participants received good medical care within the community clinic.     

Culturally tailored intervention for rural African Americans with type 2 diabetes

PURPOSE: The purpose of this pilot study was to evaluate a culturally tailored intervention for rural African Americans. Social Cognitive Theory provided the framework for the study. METHODS: Twenty-two participants were recruited and randomly assigned to either Group or Individual diabetes self-management (DSME). Group DSME included story-telling, hands-on activities, and problem-solving exercises. Individual DSME sessions focused on goal-setting and problem-solving strategies. Sessions were offered in an accessible community center over a 10-week period. RESULTS: Outcomes included glycosylated hemoglobin (A1C), self-care actions, self-efficacy level, goal attainment, and satisfaction with DSME. Participants in both Group and Individual DSME improved slightly over the 3-month period in self-care activities, A1C level, and goal attainment. Although differences were not statistically significant, trends indicate improved scores on dietary actions, foot care, goal attainment, and empowerment for those experiencing Group DSME. CONCLUSIONS: The culturally tailored approach was well received by all participants. Improvements among those receiving Individual DSME may indicate that brief sessions usinga culturally tailored approach could enhance self-care and glycemic control. Additional testing among more participants over a longer time period is recommended.     

Health-related quality of life in urban African Americans with type 2 diabetes

OBJECTIVE: To examine the association of socioeconomic barriers, familial barriers, and clinical variables with health-related quality of life (HRQL). METHODS: A cross-sectional study was conducted of 186 African Americans with type 2 diabetes recruited from 2 primary care clinics in East Baltimore, Maryland. Physical functioning, social functioning, mental health, and general health were measured using the Medical Outcomes Study 36-item short form. Socioeconomic (money, housing, street crime) and familial (family problems, caretaker responsibilities) barriers were assessed by standardized interview. Insulin use, comorbid disease, and measured abnormalities in body mass index, hemoglobin A1c (HbA1c), blood pressure, lipids, and renal function were investigated. RESULTS: Mean HRQL scores were: physical functioning, 61 +/- 29; social functioning, 76 +/- 26; mental health, 69 +/- 21; and general health, 48 +/- 21. Linear regression analyses revealed that each barrier to care was significantly associated with lower scores in 1 or more HRQL domain. As number of socioeconomic and familial barriers increased from 0 to 5, HRQL scores decreased by 18 for social functioning, 21 for general health, 23 for physical functioning, and 28 for mental health (all P for trend <.01). Clinical variables significantly associated with reduced HRQL were obesity, impaired renal function, insulin use, and comorbid disease. Blood pressure, lipids, and HbA1c were not significantly associated with HRQL. CONCLUSIONS: An independent, graded relationship was found between socioeconomic and familial barriers to care and HRQL. This relationship was at least as strong as the association between HRQL and the clinical variables more likely to be perceived by participants as causing symptomatic distress or impacting lifestyle.     

Beliefs and attitudes of African Americans with type 2 diabetes toward depression

PURPOSE: This qualitative study was conducted with African Americans with type 2 diabetes to explore beliefs and attitudes about depression. METHODS: Twenty-five adults participated in 4 focus groups. The sessions were recorded, transcribed, and analyzed. The Health Belief Model was used as a theoretical framework for the design and analysis of the focus group data. RESULTS: Five themes pertinent to depression management emerged: (1) There were misconceptions about the etiology of depression and individual vulnerability to depression. (2) Depression was perceived as severe. (3) Treatment was perceived as beneficial. (4) Stigma was a significant barrier to seeking treatment. (5) Cues to action did not appear to change beliefs. CONCLUSIONS: Despite awareness about the severity of depression and benefits of treatment, several barriers and erroneous beliefs may interfere with the ability of African Americans with type 2 diabetes to seek and adhere to treatment for depression.     

Public health significance of upper body adiposity for non-insulin dependent diabetes mellitus in Mexican Americans.

An unfavourable body fat distribution has been associated with an increased prevalence and incidence of non-insulin dependent diabetes mellitus (NIDDM). The potential utility of assessing body fat distribution in diabetes screening, however, has not been assessed. We compared the impact of upper body fat distribution (assessed by the waist-to-hip ratio (WHR)) and body mass index (BMI) and NIDDM using the population attributable risk approach of Levin in 1965 Mexican Americans from the San Antonio Heart Study, a population-based study of diabetes and cardiovascular disease. The population attributable risk percentage (PAR%) was 52.0% for WHR compared to 43.4% for body mass index. After stratification by BMI, women with a high WHR had a PAR% of approximately 50% and men had a PAR% of 28-58%. For any given cutpoint (e.g. the 10th percentile, 20th percentile, etc.) of WHR used to screen for NIDDM, WHR had both a higher sensitivity and a lower false positive rate than the corresponding cutpoint of BMI. To evaluate the relative contribution of WHR in identifying prevalent cases of NIDDM, multiple logistic regression analyses were performed, and the number of subjects identified as being in the top 20% of the risk score distribution was compared using a model that included WHR and a model that included BMI. In men, BMI did not increase the sensitivity in detecting NIDDM subjects once age was accounted for; WHR increased the sensitivity only slightly. In women, sensitivity was enhanced modestly using both measures, although WHR again was the more sensitive method. These data suggest that WHR is a better single screening measure for NIDDM than BMI.     

Exercise preferences and barriers in urban African Americans with type 2 diabetes

PURPOSE: The purpose of this study was to determine physical activity preferences and barriers to exercise in an urban diabetes clinic population. METHODS: A survey was conducted of all patients attending the clinic for the first time. Evaluation measures were type and frequency of favorite leisure-time physical activity, prevalence and types of reported barriers to exercise, and analysis of patient characteristics associated with reporting an obstacle to exercise. RESULTS: For 605 patients (44% male, 89% African American, mean age = 50 years, mean duration of diabetes = 5.6 years), the average frequency of leisure activity was 3.5 days per week (mean time = 45 minutes per session). Walking outdoors was preferred, but 52% reported an exercise barrier (predominantly pain). Patients who cited an impediment to physical activity exercised fewer days per week and less time each session compared with persons without a barrier. Increasing age, body mass index, college education, and being a smoker increased the odds of reporting a barrier; being male decreased the chances. Men reported more leisure-time physical activity than women. Exercise preferences and types of barriers changed with age. CONCLUSIONS: Recognition of patient exercise preferences and barriers should help in developing exercise strategies for improving glycemic control.     

Predictors of health status in middle-aged and older Mexican Americans

Data from the Southwestern sample of the Hispanic Health and Nutrition Examination Survey (Hispanic HANES) were employed to investigate the association of socioeconomic variables with the health status of middle-aged (aged 45 to 59) and older (aged 60 and over) Mexican Americans. The most significant and consistent predictor of health status was employment. Less acculturated men had poorer self-assessed health; married men were more likely to have been hospitalized during the year prior to the interview, while less acculturated women were less likely to have been hospitalized (other things equal). Analysis involving interaction terms showed more significant associations in middle-aged than in older respondents, but only among men. Implications related to a selective survival thesis are discussed along with directions for future research.     

Anthropometric features and cardiovascular risk in young Latin Americans with type 2 diabetes mellitus

OBJECTIVE: The purpose of this study is to compare score systems used to estimate the risk for cardiovascular disease (CVD) in young patients with poorly controlled type 2 diabetes. METHODS: Fifty-seven Latin American patients with type 2 diabetes, between the ages 18 and 45 years, were screened to participate in a clinical research study evaluating the effects of intensive insulin therapy on both traditional and nontraditional CVD risk factors. All women were premenopausal and had regular menstrual periods. Baseline reviews of cardiovascular (CV) risk scores, personal history, physical examination, and laboratory screening were performed. The Framingham Study Score system and the presence of features of the metabolic syndrome (MSyn) were recorded and compared. RESULTS: Both genders had a comparable number of features of the MSyn, whereas according to the Framingham Score System, men had a slightly higher risk of CVD. CONCLUSIONS: The Framingham Score system is not an accurate device to estimate risk of CVD in premenopausal women with type 2 diabetes mellitus, who otherwise have a multiple features of the MSyn. If used to estimate risk of CVD, the Framingham score system could underestimate the risk of CVD in both young men and women with type 2 diabetes mellitus.     

Relationships between cerebral structure and cognitive function in African Americans with type 2 diabetes

Background

Relationships between cognitive function and brain structure remain poorly defined in African Americans with type 2 diabetes.

Protective neighborhoods: neighborhood proportion of Mexican Americans and depressive symptoms in very old Mexican Americans

Research indicates that neighborhood context can have a significant effect on the health of older adults. The evidence suggests that there may be physical health benefits afforded to Mexican Americans living in ethnically homogenous neighborhoods, despite the relatively high economic risk in such neighborhoods, but few studies have considered the effect of neighborhood ethnic density on mental health outcomes in older adults. This study evaluated the association between neighborhoods with a high proportion of Mexican Americans and depressive symptoms in very old Mexican Americans. Hierarchical linear modeling was used to examine data from Wave 5 (2004/05) of the Hispanic Established Populations for the Epidemiologic Study of the Elderly. Subjects included 1,875 community-dwelling Mexican Americans aged 75 and older living in 386 neighborhoods in five states in the southwestern United States (Arizona, California, Colorado, New Mexico, Texas). Depressive symptoms were measured using the Center for Epidemiologic Studies Depression Scale (α=0.88). Results showed that, in very old men, there was a significant negative association between percentage of Mexican Americans in the neighborhood and depressive symptoms (P=.01). In women, the direction of the association was the same, but the effect was not significant. These findings suggest that the proportion of Mexican Americans in the neighborhood matter more for very old Mexican American men than women. Further research may inform screening and treatment for depressive symptoms based on differences in neighborhood composition. Recommendations include culturally customized programs that offer older Mexican Americans greater mobility and access to programs and opportunities in culturally identifiable neighborhoods.