Viv BYEN ak Maladi Dyabet (Living Well with Diabetes)

Transcription

1 Viv BYEN ak Maladi Dyabet (Living Well with Diabetes) Adapting and Testing a Standardized Self- Management Program To Improve Outcomes for Haitian Seniors with Diabetes Lisa Montuori Trimble, RN MSN MPH

2 Cambridge Health Alliance Overview Integrated network of three community hospitals, twelve neighborhood health centers, four school based health clinics, and many community based programs Service area: Seven cities north and west of Boston, MA Patients also travel to Cambridge Health Alliance from more than 230 communities in Massachusetts Mission: To improve the health of our communities

3 Cambridge Health Alliance Overview Culturally and linguistically diverse community and patient population Large % of low income residents and patients CHA is largest proportional provider of care to low income individuals in MA Medicine/Family Practice Outpatients English 58% Portuguese 17% Spanish 10% Haitian Creole 5% Other 8% N = 82,900 patients (398,077 visits)

4 Haitian Community in MA ~70,000 in Greater Boston area Older Haitians often first generation immigrants Many are socially isolated, speak only Haitian Creole Often no literacy in any language Tend to hold traditional beliefs about health and illness Limited number of Haitian health care clinicians

5 Cambridge Health Alliance Overview Use of Planned Care Model of Chronic Disease to improve outcomes for patients with diabetes 4,856 adult patients in our diabetes registry (~6.9% of adult primary care patients in 12/10) Wagner EH (1998). Effective Clinical Practice (1) 2-4

6 Diabetes disparities across groups 5% of adult primary care patients speak Haitian Creole 11% of adult patients in diabetes registry speak HC ~12% of adult primary care patients aged 65+ speak HC 17% of patients aged 65+ in diabetes registry speak HC

7 Percent of patients with A1c > 9.0 by language 40.0% 30.0% 20.0% 10.0% 0.0% Eng Port Span Haitian Other Creole 7/08-6/09; N = 1,146; p =

8 Volunteer Health Advisor (VHA) Program Engaging our communities to understand and influence health behaviors Community Health Worker staff, longstanding community partnerships, network of multilingual community volunteers

9 Background to the project Latino Center for Excellence in Elimination Disparities grant (needs assessment of Spanish-speaking diabetics) Tufts Health Plan Foundation grant to improve long-term work with Haitian seniors with diabetes Question: How to use available evidence-based self-management support programs with very low literacy, non-english-speaking populations? Need to address: 1. Culturally-based understandings of health and illness, along with class, and language barriers 2. Low or no-literacy in any language 3. Effective strategies to assess outcomes

10 Diabetes Conversation Maps Strong reliance on visuals to tell a story Conversation oriented, very interactive Comprehensive, focus on basic knowledge, skills, and attitudes Flexible, but structured enough to be led by community health workers Tested in English & Spanish Tools and training readily available

11 Adaptation into Haitian Creole Project Team including CHW staff Line by line through curriculum and concepts Created additional low literacy images and models reflective of Haitian culture Added healthy eating and physical activity content with support from RD and PT staff Demographic form and pre/post tests and methods developed for low literacy group

12 Program Overview Eight session program in HC, led by two experienced Community Health Workers with support from Haitian VHA, PT/RD and clinical staff, local Haitian restaurant Three 8-week series in 2010, participants per group Sessions included: 1. Intro and Pre-test evaluation 2. Overview of Diabetes 3. Monitoring and Addressing Blood Glucose Levels Introduction to Physical Activity 4. Medications, Herbal supplements, Falls Prevention 5. Diabetes Complications, Let s Move! 6. Nutrition and Diabetes, Let s Move! 7. Healthy Eating and Cooking 8. Celebration and Post-test evaluation

13 Evaluation Project designed low literacy demographic form and pre/post-tests of knowledge, skills, attitudes, functional status, and behaviors 26 questions: Knowledge (8), Skills (4), Attitudes (4), Behavior (6), Functional Status (4) Administered by HC-speaking staff and volunteers (VHAs) in sessions 1 and 8 Data aggregated and pre/post tests analyzed for significance

14 Results - Demographics N=32, 29 patients, 3 caregivers Age range: 59-90; 28% men All spoke HC at home 70% reported <7 th grade education > 60 % uncomfortable with reading in English or HC 50% had never attended a DM group; all had seen MD/NP in past 6 months

15 Results Pre/post tests Statistically significant positive changes in: - 6 out of 8 Knowledge questions 7. Having diabetes means: My body cannot make or use insulin properly There is a problem with my liver I eat too much sugar I m not sure Pre Post My body cannot make or use insulin properly Incorrect answers or Not sure 21% (6) 89% (25) 79% (22) 11% (3) McNemar s Test p = <0.0001

16 Results Pre/post tests Statistically significant positive changes in: 3 out of 4 Skill questions 14. It is okay to cut my diabetes pills in half if I am running low on my medicines. Yes No I m not sure Pre Post No 71% (20) 96% (27) Yes or Not sure 29% (8) 4% (1) McNemar s Test p = 0.008

17 Results Pre/post tests Statistically significant positive changes in: - 1 out of 2 Attitude questions 18. Which of the following statements are true for you (pick all that apply): I feel hopeful that I can manage my diabetes I feel sad that I have to live with diabetes I feel scared that I may become blind, get and amputation or die from diabetes I feel depressed because it s hard to enjoy things when you have diabetes I d rather not think about the fact that I have diabetes Pre Post I d rather not think that I have diabetes 46% (13) 14% (4) Other choices: McNemar s Test p = I feel hopeful 75% (21) 79% (22) I feel scared, sad, or depressed 32% (9) 22% (6)

18 Results Pre/post tests Statistically significant positive changes in: - 1 out of 3 Behavior questions 24. Do you eat 5 or more servings of vegetables and fruits every day? No, and I have no plans to eat more No, but I have been thinking about eating more I try, but I usually eat less than 5 servings per day Yes, I eat 5 or more servings every day or almost every day Pre Post Yes, I eat 5 or more servings every day or almost every day or I try, but usually eat less than 5 servings a day Incorrect answers or Not sure 75% (21) 89% (25) 25% (7) 11% (3) McNemar s Test p = 0.046

19 Lessons Learned Conversation Maps curriculum useful tool for non-literate populations, including those with cognitive impairments Requires thoughtful adaptation into another cultural context CHWs were very effective group leaders Possible to evaluate outcomes in low literacy population with appropriate methodology For lasting clinical results, need to tie to clinical practice Some important concepts still lost in translation: Goal Setting, Action Planning

20 Plans for the future New groups with follow-up sessions on: Communicating with primary care provider Medication management Nutrition and physical activity Partner program with feedback to clinicians and review of the clinical management of patients with high A1c levels Cultural translation of Action Planning Replicate with low literacy Spanish speakers

21 DEPARTMENT OF COMMUNITY AFFAIRS Project Team: Lamos Paul, Kareen Alabre-Ribourg, Yadira Ramos, Anu Rao, Lisa Brukilacchio, Yele Adjognon, Emily Chiaison, Lisa Montuori Trimble Special thanks to: Tufts Health Plan Foundation, Latino CEED New England, Naomi Casimir (VHA Program), Joan Connors RD (CHA Elder Service Plan), Amy Lynch PT and Shelia Crusco (CHA Rehabilitation Services), Reem Jabr RD MS (CHA Ambulatory Nutrition), Meghan Ostrander RD (Community Servings, Boston MA) For more information, contact: Lisa Montuori Trimble RN MSN MPH Director, Health Promotion and Community Outreach