Designing Interventions to Reach Populations with Low Health Literacy: Diabetes Care in US-Mexico Border Communities as an Exemplar

Designing Interventions to Reach Populations with Low Health Literacy: Diabetes Care in US-Mexico Border Communities as an Exemplar

New World Syndrome Interaction of Amerindian genetic admixture + adoption of Westernized lifestyles Pima Indians: Starr County: 50% of adults have type 2 DM 50% of Mexican American adults are affected by type 2 DM <30% achieve good glucose control <10% achieve 3 major health goals: HbA1c <7% (6.5%) LDL<100 mg/dl (<70 mg/dl) blood pressure <130/80 mm Hg

THE SETTING: U.S.-Mexico Border 21% U.S. population live in border states Medically underserved communities Characterized by: extreme poverty few personal resources pollution low education / literacy high diabetes rates barriers to accessing health & social services

SETTING: Starr County

SETTING: Starr County 97.3% Mexican American Impoverished community: Poorest county in Texas - 3rd poorest in U.S. Unemployment rate 10.6% (2007) Per capita income $12,971 (2005) Low literacy 35% high school education Population:MD Population:RN 7657:1 (3789:1 rest of TX) 851:1 (159:1 rest of TX) Highest diabetes-related death rate (TDSHS)

SETTING: Starr County colonias 2200+ colonias along Texas-Mexico border 400,000 residents Began in the 1950s Agriculturally worthless land, floodplains Lack electricity, plumbing Source: Texas Secretary of State, http://www.sos.state.tx.us/border/ colonias/faqs.shtml Residents build homes (tin, cinder blocks, wood)

SETTING: Texas-Mexico Border

SETTING: Texas-Mexico Border

The Starr County Border Health Initiative 1988-2009 Rio Grande City

Stages of Intervention Design 5 YEARS Phase 1: COMMUNITY ASSESSMENT Phase 2: DESIGNING THE INTERVENTION & EDUCATIONAL MATERIALS Phase 3: MEASURES OF INTERVENTION EFFICACY / EFFECTIVENESS Phase 4: PILOT TESTING Phase 5: CLINICAL TRIAL(s) Brown, S.A., & Hanis, C.L. (1999). Culturally competent diabetes education. The Diabetes Educator, 25 (2), 226-236. DOI: 10.1177/014572179902500208

FOCUS GROUPS PHASE 1: Community Assessment Initial community assessment: health care providers (nurses, physicians, dietitians) community workers religious workers political leaders individuals with type 2 diabetes Informing intervention development Ongoing (refining & evaluating interventions, assessing cultural acceptability)

PHASE 1: Community Assessment FOCUS GROUPS FINDINGS Lack of understanding of diabetes Negative previous diabetes-related experiences Suggestions for a diabetes intervention

PHASE 2: Designing the intervention and educational materials Educational Spanish-language videotapes: pilot tested focus groups Major decisions: intervention teams intervention sites intervention plan (based on meta-analyses) intervention content and materials

PHASE 3: MEASURES HbA 1c Health history FBG Acculturation (4 items) BMI Physical activity Cholesterol Complications BP Family health history Leptin Medication history Triglycerides Fat intake Microalbuminuria Food frequency (new) Diabetes knowledge Health beliefs Demographics

PHASE 4: PILOT TESTING One year planning project funded by NIH Tested an 8-week version of the intervention Objectives: 1) determine feasibility 2) refine intervention 3) develop mechanisms for tracking measures Sample size: 8 Findings: HbA1c reduced by 2.4%-age points FBG reduced by 73 mg/dl

PHASE 5: CLINICAL TRIAL(s) For every 1%-age point reduction in HbA 1c, diabetes complication rates decreased by 30% to 75% ---DCCT, UKPDS Efficacy trial (4 years) findings: reduced HbA1c (-1.4%-age points) Comparison of 2 interventions (5 years) findings: dosage effect (HbA1c 10.9% to 9.2%) Feasibility study of NCM findings: analyses in progress Prevention trial in review

low health literacy. challenges Diabetes as a priority Alarming selfmanagement practices Misinterpretation of information Cultural myths:?fatalism?spousal support Learning trajectory: realistic program vs. cost

Estimated Intervention Costs Extended Care (RN, RD, & promotora): 26 sessions / 8 persons per group $ 384/person Compressed Care (RN or RD & promotora): 11 sessions / 8 persons per group $ 131/person

low health literacy. challenges Designing intervention strategies (e.g., grocery store visit) Limited access to other health care services Data collection Ethical challenges re to providing resources after the project Intervention innovation

RESEARCH TEAM acknowledgements Craig Hanis, PhD, Co-PI (geneticist, UT-Houston) Alexandra García, RN, PhD, Co-I (previous graduate student, UT Austin) 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

RIO GRANDE VALLEY STAFF acknowledgements 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

Funded by... acknowledgements State of Texas University of Texas at Austin University of Texas at Houston Office of Research in Minority Health Pilot and meta-analysis: National Institute of Nursing Research