Ethnic Myths and Chronic Care

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

• 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

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

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

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

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

•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 Native 109
Black / African American 83
Hispanic / Latino 81
Asian 58
White 55
Gender:
Female
Male
58
60
Education:
< high school
High school graduate
At least some college
132
102
70
byracial
group

•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 Group Death Rate (2006)
Black / African American 127
Hispanic:
Cuban
Mexican American
Puerto Rican
52
104
108
American Indian 98
White 69
Asian / Pacific Islander 55
Gender:
Female
Male
63
89
Education:
< high school
High school graduate
At least some college
61
41
16
byracial
group

2001 2004
Blacks 113 104
Hispanics 63 80
Whites 28 31
• 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

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

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

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
The Starr County
Border Health Initiative

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

COMMUNITY ASSESSMENT
Understanding of diabetes:
“Blood sugar” or blood glucose testing / results
“God’s 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)

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

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

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

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

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

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

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)

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

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

MEASURES
HbA1c Demographics
FBG Health history
BMI Acculturation
Cholesterol Diabetes knowledge
BP Health beliefs
Leptin Family history
Triglycerides Medication history
Microalbuminuria Fat intake
Complications Food frequency
Physical activity

Compressed vs. Extended
Program (1999-2004)
STUDYSTUDY
OUTCOME:OUTCOME:
HbA1cHbA1c
11.9
10.8
10.9
11.7
11.3
10.6
10.4
10.5
10.0
10.5
11.0
11.5
12.0
Baseline 3 Mos. 6 Mos. 12 Mos.
Compressed Extended
MYTH
Genetic Predisposition, “Fatalism”

Outcome:
HbA1c
Compressed
vs.
Extended
Program
≥50% attendance
(n=110)
Outcome:
HbA1c
Compressed
vs.
Extended
Program
≥50% attendance
(n=110)
11.6
10.5 10.5
11.010.9
9.9
9.6
9.2
9.0
9.5
10.0
10.5
11.0
11.5
12.0
Baseline 3 Mos. 6 Mos. 12 Mos.
Compressed Extended
MYTH
Genetic Predisposition, “Fatalism”

Dosage Effects of
Program Attendance
Dosage Effects of
Program Attendance

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
METABOLIC
CONTROL
 HbA1c levels lower in
males (t=3.11, p=.002)
 Males with greater
attendance achieved
greater improvements
in HbA1c

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)

“…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)

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

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

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

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

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

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, MS Mary Winter, MSN
RESEARCH TEAM

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

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

Ethnic Myths and Chronic Care

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Ethnic Myths and Chronic Care

Similar to Ethnic Myths and Chronic Care (20)

Recently uploaded

Recently uploaded (20)

Ethnic Myths and Chronic Care