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.