Significant health disparities exist in the Hispanic community compared with their non-Hispanic counterparts in the United States. In terms of diabetes, specifically, recent data from the CDC indicate that Hispanics are 65% more likely to have diabetes, 55% more likely to be diagnosed with end-stage renal disease and 45% more likely to die of diabetes.
The health care challenge posed by these statistics becomes even more alarming because Hispanics are one of the fastest growing ethnic groups in the United States and may constitute 30% of the population by 2060.
Besides these disparities around diabetes diagnoses and outcomes, the Hispanic population is also at greater risk for prediabetes. Based on fasting glucose or HbA1c levels, it is estimated that nearly 38% of Hispanics aged 20 years or older have prediabetes.
It seems as if a Hispanic diabetes time bomb is waiting to explode unless culturally sensitive and targeted interventions are developed and implemented in this community to improve diabetes awareness and emphasize its prevention.
Culturally tailored programs
The National Institute of Diabetes and Digestive and Kidney Diseases was working with a budget of nearly $2 billion for fiscal year 2016, and a large portion of this amount generally funds development of community-based diabetes programs targeting diabetes prevention and/or improving diabetes-related outcomes in underserved communities. However, it is disappointing that these funds fail to translate into significant improvements in diabetes-related health outcomes in high-risk communities.
So, what might we be missing?
Although there is no denying the role of biological and lifestyle factors in the growing numbers of prediabetes cases in this community, we are probably discounting the role of a few other important factors. As health care providers and policymakers, it is tempting to invest our energies into “one-size-fits-all” interventions that we believe would be efficient and benefit all patients equally. However, we now know that such solutions are not effective in the long run because they do not address the unique needs of patients from minority but high-risk groups. Socioeconomic, cultural and behavioral factors in any population are important determinants of health outcomes, and programs that fail to evaluate or address issues related to these factors are less likely to be sustainable and effective in the long run.
Specific needs
Before developing a program targeting diabetes prevention in high-risk Hispanic communities in Southern California, we undertook two pilot studies to improve our understanding of the community needs around diabetes prevention and the baseline status of our underserved Hispanic communities regarding diabetes. In fact, both studies were hosted as community events open to anyone seeking additional health resources. However, nearly all participants in both events were Hispanic, which underlines the high need in this under-resourced population. In terms of clinical parameters, 75% of all participants fit in overweight or obese BMI categories, and finger-prick HbA1c measurements showed that about 40% of the sample overall had prediabetes and was at risk for progression to diabetes.
Most participants in both studies were women (study 1: n = 80; 75 women; study 2: n = 81; 59 women). This was not entirely unexpected because we know from previous research that, due to a variety of socioeconomic and cultural factors, engaging Hispanic men in health research is challenging. This gender tilt, however, limits the quality and quantity of health-based interventions that can be implemented in this community. In terms of education, 42% to 50% of participants from both studies had completed only junior high with approximately 10% reporting no formal education.
Health literacy also was low, with most participants (about 51%) emphasizing a high need for resources to help them better understand health information, including completing any medical forms at clinics and other facilities. Again, although not a surprising finding, this stresses the need for us as health care professionals to account for our target population’s basic understanding of health and related concepts while developing or disseminating interventions or health promotion materials. High education skills may not always translate into high health literacy, especially in a patient population with language barriers.
Regarding annual income, nearly 80% of the participants were earning less than $30,000, and about 40% of all participants did not have health insurance. These numbers have significant consequences for these individuals’ abilities to access and, ultimately, benefit from any health resources that are made available to them. Most of the participants were managing two jobs to be able to survive and reported not having the time, motivation or the financial resources to cook, as recommended for better health outcomes.
Food insecurity also was highly prevalent in the studies, and nearly 60% of the sample reported that they worry that food will run out before they get money to buy more; nearly 50% of participants reported that the food they bought did not last and that they did not have money to buy more groceries.
Using the Patient Health Questionnaire, we also identified a high risk for depression (35%-36% of all participants).
Future interventions for Hispanic communities
Developing and implementing diabetes prevention interventions without evaluating and addressing these issues will result in only short-term solutions, with patients falling back to their routines once the study and incentives are over. We may be able to make studies and their positive impact more sustainable by ensuring that patient empowerment is a strong component of our community-based research efforts, whereby study participants take an active role to improve their health, are well-informed about their rights as patients, and understand the community resources available to them. Offering psychosocial support to high-need participants in community programs may help lay a stronger foundation for our health promotion interventions.
Of course, we cannot develop health interventions that would check off all problem areas for our high-risk population. However, it would be worth our efforts to spend a bit more time planning around these prominent socioeconomic, cultural and psychosocial issues prevalent in these communities. Recommendations for improved health that are made in the context of patients’ psychological and socioeconomic status are more likely to improve patient engagement, adherence and translate to long-term health behavior changes.
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- Harsimran Singh, PhD, is a health psychologist and a clinical research scientist at the Mary & Dick Allen Diabetes Center at Hoag Memorial Hospital Presbyterian in Newport Beach, California. The center specializes in offering patient-centered clinical care, education services and psychosocial support for people with diabetes. The studies were undertaken in collaboration with Michaell Rose, LCSW, director of operations for community health at the Melinda Hoag Smith Center for Healthy Living, Hoag Memorial Hospital Presbyterian.
Disclosure: Rose and Singh report no relevant financial disclosures.
