Health Inequities in the Latino/Hispanic community

Transcription

1 Health Inequities in the Latino/Hispanic community Enrique Caballero MD Endocrinologist/Clinical Investigator Director of the Latino Diabetes Initiative Director, International Professional Education Joslin Diabetes Center Harvard Medical School Boston, MA

2 Challenges The Latino/Hispanic population is the largest minority group in the country ( 50.5 million 16% of total population census ) The prevalence of type 2 diabetes is at least twice as high as that in the White population Diabetes care disparities worse glycemic control, high rates of chronic complications Social and cultural barriers Limited cultural awareness and skills among providers Significant limitations in clinical practice time, resources, support Limited comprehensive culturally oriented programs that address patient, provider and health system issues

3 Race and Ethnicity: Definitions Race Usually biological White, Black, American Indian (Native American)/ Alaska Native (Eskimo, Aleut), Asian/Pacific Islander Often overlapping Ethnicity Primarily social Independent of race Hispanic or Latino? Caballero AE. Diabetes in minority populations. In: Joslin s Diabetes Mellitus. LW & W; th Ed. p

4 The US Hispanic/Latino Population Puerto Ricans 9.2% Central Americans 7.9% Mexicans 63% South Americans 7.9% Others 6.8% Cubans 3.5% Dominicans 2.8% Spaniards 1.3% US Census Bureau The Hispanic Population in the United States. Available at: Accessed Sept 13th, 2013

5 *Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Institute of Medicine. The National Academies Press. Washington, D.C

6 Genes, Environment and Social/Cultural Factors in Type 2 Diabetes in Racial/Ethnic Minorities Appetite and Satiety? Thrifty Genes + Lifestyle Insulin Resistance and Abdominal Obesity Beta and Alpha Cell Dysfunction Type 2 Diabetes Incretin dysfunction? Socio-economic and Cultural factors Renal glucose handling? Frequent Chronic Complications Increased Mortality rates Caballero AE. Modified from Curr Diab and Endocrinology Reports :

7 Type 2 Diabetes and its Complications in Minorities Disparate and Disproportionate prevalence of long-term complications of type 2 diabetes in minorities Vs NH Whites lower leg amputations 2-4x retinopathy and blindness 2-4x stroke 2x ESRD 4-6x Caballero AE. Diabetes in minority populations. In: Joslin s Diabetes Mellitus. LW & W; th Ed. p

8 Metabolic control in the US Percentage of patients achieving an A1c<7% NHANES NHANES NHANES P=0.001 P= Patients (%) P= P= N= Total White African American Mexican American Ford E et al. Diabetes Care. 2008;31:

9 Boltri JM, et al. Ethn Dis 2005; 15 (4): A1c levels by ethnicity/race NHANES % NH White NH Black Hispanics NH White NH Black Hispanics

10 Boltri JM, et al. Ethn Dis 2005; 15 (4): Percentage of participants with diagnosed diabetes with an A1c 11% by ethnicity/race NHANES % NH White NH Black Hispanics 0 NH White NH Black Hispanics

11 Estimated lifetime risk of developing diabetes for individuals born in the United States in Total Non-Hispanic Black Non-Hispanic White Hispanic Percent Men Women Narayan et al, JAMA, 2003

12 Prevalence of major CVRF in Latinos Daviglus ML, et al. JAMA 2012: 308(17):

13 Prevalence of major CVRF in Latinos Daviglus ML, et al. JAMA 2012: 308(17):

14 Prevalence of major CVRF in Latinos Daviglus ML, et al. JAMA 2012: 308(17):

15 Obesity and Endothelial Dysfunction in Hispanic Children Variable Controls At risk P value (n=17) (n=21) Age Waist/hip ratio Total % fat < Trunk fat < Systolic BP < Diastolic BP Total cholesterol Triglycerides HDL LDL Demographic and clinical characteristics between both groups, comparisons were Done with t test in case of continuous variables and x 2 in case of dichotomous variables

16 Obesity and Endothelial Dysfunction in Hispanic Children Caballero AE. Diabetes Care. 2008; 31:576-82

17 ng/ml 1,00 svcam ng/ml 400 sicam * μg/ml Adiponectin * pg/ml TNF-α * 10 PAI-1 10 tpa * ng/ml ng/ml * mg/ml hs-crp * * White Cells (zx10-3) White Blood Cell Count * pg/ml IL-6 Control Group Overweight Group Caballero AE. Diabetes Care. 2008; 31:576-82

18 The Latino Diabetes Initiative at Joslin A comprehensive strategy that involves clinical care, patient education, community outreach, research and provider education

19 Current structure of LDI Clinical Program Research Program Community Based Activities Professional Education

20 What Causes Disparities in Healthcare? Patient Socio-economic status Education/Health literacy Health seeking behavior Cultural factors Mistrust Provider System Lack of cultural awareness Stereotyping or biases Language barrier Lack of resources Lack of culturally oriented programs Inadequate interpreter services Time pressures and resource constraints Lack of adequate training Limited Access

21 Ecological Model Community and policy System, group, culture Family, friends, small group Individual The health of individuals is inseparable from the health of communities (Healthy People 2010)

22 Primary Factors That May Influence Diabetes Development and Care in Culturally Diverse Populations Acculturation Body image Cultural competence Depression Educational level Fears General family integration and support Health literacy Individual and social interaction Judgment about disease Caballero AE. Am J Med 2011; 124, S10-S15

23 Primary Factors That May Influence Diabetes Development and Care in Culturally Diverse Populations Knowledge about the disease Language Myths Nutritional preferences Other forms of medicine (alternative) Physical activity preferences Quality of life Religion Socioeconomic status Caballero AE. Am J Med 2011; 124, S10-S15

24 Language Barrier A true story: 64 y/o Hispanic woman Patient does not speak English Treated for Hypertension Received a prescription for : Lisinopril 10 mg. Once/d. Patient rushed to the ER due to severe hypotension

25 Prevalent Racial/Ethnic Differences Related to Diabetes Medications Caucasian (n=230) African American (n=279) Latino (n=167) If my doctor told me that I would benefit from taking more medications, I would be willing to take more } P= If my doctor asked me to change my medication regimen, it would make me worry more about my health } P< I worry about the expense of my medications or glucosemonitoring supplies } P< I worry about becoming dependent on my medications } P< I worry about side effects from my medications } P< Patients responding affirmatively (%) Huang ES et al. Diabetes Care. 2009;32:

26 Education Level by Race/Ethnicity, and older only 100% 80% 60% 40% 20% 0% White, NH Black, NH Hispanic Asian, NH Less than high school College graduate US Census 2010 Data

27 How common is Low Health Literacy? 30 million Americans (14%) scored below basic on health literacy Grasp of no more than the simplest, most concrete literacy skills 47 million (22% or 1 in 5) of the population at basic health literacy Basic is defined as skills needed to perform simplest everyday literacy activities White S. Assessing the Nation s Health Literacy. Accessed at on August 28, 2009: p. 45.

28 Assessing Literacy: The Newest Vital Sign Validated tool Correlates with TOFHLA English and Spanish version Screening tool Score 0 1: High likelihood of limited literacy Score 2 3: Possible limited literacy Score 4 6: Almost always adequate Weiss BD, Mays MZ, Martz W, et al. Ann Fam Med. 2005;(6):

29 Evaluation of health literacy can guide education efforts A1C < 7% Intervention Control Rothman et al. JAMA. 2004;292(14):

30 Rosa s Story Provider Manual English Patient Booklet Spanish

31 Culturally Appropriate Translations

32 Practice Listening! And observing! Patients are interrupted by the healthcare provider after an average of 23 seconds In only 28% of visits did patients completely express concerns In 25% of visits, the healthcare provider never asked about patient s concerns Marvel MK et al. JAMA. 1999;281:

33 Goal setting S - Specific M - Measurable A - Attainable R - Realistic T Time

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35 Current structure of LDI Clinical Program Research Program Community Based Activities Professional Education

36 Time spent for a patient with diabetes Health Care Team 1.3 Work 80 Family 285 Person with diabetes 365

37 Esto es mejor: Improving food purchasing selection among low-income Spanish-speaking Latinos through social marketing messages Baseline Evaluation: Analysis of the Grocery Receipt: 930 Calories per dollar 29 gr of Fat per dollar 150 gr of Carbs per dollar 5 gr of Fiber per dollar 21 gr of Protein per dollar cal 50 USD Other activities: Home Visits Supermarket tours Photovoice Rosa s Story Salud America - RWJ Foundation Cortés D. et al. Am J Prev Med April 2013.

38 Esto es mejor: Improving Food Purchasing Selection Among Low-income Spanish-speaking Latinos Calories per receipt 1st supermarket 2nd supermarket Total Fat - gr Total Carbs - gr Each dollar bought: 1 st Supermarket 2 nd Supermarket 1st supermarket Fiber - gr 2nd supermarket Protein - gr 1320 Calories 583 Calories 84 grams of fat 28 grams of fat 135 grams of carbs 56 grams of carbs 10 grams of fiber 4 grams of fiber 9 grams of protein 18 grams of protein

39 Esto es mejor: Improving Food Purchasing Selection Among Low-income Spanish-speaking Latinos - RWJ Project Before After

40 Patient Care and Education

41 Health Care Professionals Education Joslin CME programs Community Health Centers Medical Students Visitors Program National and International Meetings Publications Health Coach training program

42 What is Cultural Competence? The knowledge and interpersonal skills that allow providers to understand, appreciate, and work with individuals from cultures other than their own. It involves an awareness and acceptance of cultural differences; self-awareness; knowledge of patient s culture; and adaptation of skills. American Medical Association

43 Cultural Competence Purnell s Model: Person, Family, Community, Society Unconsciously incompetent Consciously incompetent Consciously competent Unconsciously competent

44 The ESFT Model Explanatory Model Social Risk for Noncompliance Fears/Concerns about the Medication Therapeutic Contracting/Playback

45 Model for Cross-Cultural Care: A Patient-Based Approach Awareness of Cultural and Social Factors Elicit Factors Negotiate Models Implement Management Strategies Tools and skills necessary to provide quality care to any patient we see, regardless of race, ethnicity, culture, class or language proficiency.

46 Resources Cultural Awareness

47 Resources Latinos with Diabetes diabetes.org ndep.nih.gov diabetes.niddk.nih.gov

48 THANK YOU