Attitudes and issues in treating Latino patients with type 2 diabetes: views of healthcare providers

Contributors to depression in Latino and European-American patients with type 2 diabetes

OBJECTIVE

To determine the independent and cumulative contributions of diabetes and other life stresses on depression and anxiety in Latino and European-American (EA) patients with diabetes.

RESEARCH DESIGN AND METHODS

A total of 75 Latino and 113 EA patients with type 2 diabetes, recruited from managed care settings, were assessed regarding three groups of potential stresses: demographics (age, sex, and education), disease status (functional impact, time since diagnosis, comorbidities, HbA(1c), and BMI), and family stress (financial stress, spouse conflict resolution, and family closeness). Dependent variables were depression (Center for Epidemiological Studies-Depression scale [CES-D]) and anxiety (Symptom Checklist [SCL-90]). Multiple regression equations assessed the independent contribution of each predictor on depression and anxiety.

RESULTS

For both ethnic groups, education, functional impact, and financial stress significantly and independently predicted depression; poor spouse conflict resolution was a fourth significant predictor for EA patients only. The equations accounted for a high percentage of variance (43- 55%). Excluding education, the same variables predicted anxiety for both ethnic groups. The disease status and family stress variable groups significantly predicted outcomes independently. The relationships among these variables and depression and anxiety generally occurred for all patients, not only for those classified as likely depressed.

CONCLUSIONS

The findings suggest the utility of considering many life stresses, not just diabetes alone, that combine to affect depression and anxiety. We suggest that these effects are experienced cumulatively as general psychological distress for all patients with diabetes, not just those classified as likely depressed. Taken together, the findings emphasize a life-centered, patient-focused approach to the treatment of depression, rather than an exclusive disease-related perspective.

Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model

This article develops a conceptual model of cultural competency's potential to reduce racial and ethnic health disparities, using the cultural competency and disparities literature to lay the foundation for the model and inform assessments of its validity. The authors identify nine major cultural competency techniques: interpreter services, recruitment and retention policies, training, coordinating with traditional healers, use of community health workers, culturally competent health promotion, including family/community members, immersion into another culture, and administrative and organizational accommodations. The conceptual model shows how these techniques could theoretically improve the ability of health systems and their clinicians to deliver appropriate services to diverse populations, thereby improving outcomes and reducing disparities. The authors conclude that while there is substantial research evidence to suggest that cultural competency should in fact work, health systems have little evidence about which cultural competency techniques are effective and less evidence on when and how to implement them properly.

Interpreting diabetes mellitus: differences between patient and provider models of disease and their implications for clinical practice

Current medical literature suggests that Type 2 diabetes mellitus can be controlled by diet and hypoglycemic agents or diet and insulin therapy. Nevertheless, adhering to a low glucose dietary regimen remains problematic for a majority of patients, and management of the disease is an ongoing source of frustration for physicians and other providers. While calling for more research on the physician's experience of treating chronic conditions like diabetes, the authors argue that much of the current frustration stems from the different frames or explanatory models that physicians and patients use to understand the disease. By comparing physician narratives collected in several clinical contexts (e.g., medical lectures, precepting sessions, patient care sessions and personal interviews) with patient stories obtained primarily through narrative interviews, the authors highlight crucial differences in the way physicians and patients experience and think about the disease. In particular, the authors highlight differences between physicians and patients across five dimensions: etiology, symptoms/signs, factors which affect blood sugar, ideal blood sugar, and future prospects. In concluding, the authors sketch out elements of a theory of clinical practice involving diabetes care. Data for the study was collected at two family practice training sites in Chicago.

Secondary analysis of perceptions and meanings of type 2 diabetes among Mexican American women

PURPOSE

The purpose of this study was to explore explanatory models of diabetes from the perspective of Mexican American women with type 2 diabetes.

METHODS

In-depth interviews were conducted in a secondary analysis of an interpretive interactionism study to investigate the meanings of diabetes from the perspectives of Mexican American women with type 2 diabetes. The sensitizing concept used was Kleinman's explanatory models of illness. The original study sample included 20 Mexican American women between the ages of 27 and 45 with varying lengths of time since diagnosis.

RESULTS

Data analysis was an interactive process. The data were collapsed into explanatory models of diabetes categorized as defining, getting, having, describing, or taking care of diabetes. The meaning of having diabetes was viewed as a life threat with complications and a shortened life.

CONCLUSIONS

Diabetes complications, viewed as symptoms, were structured in the explanatory models developed from the contextual arenas of family and community. Given the family and community history of diabetes, genetic predisposition to the disease, and perceived life threat, understanding Mexican American women's explanatory models about diabetes serves as a basis for negotiating therapeutic interventions.

Sexual prevention of HIV: a model for Latinos

Despite reductions in AIDS deaths in the general population, Latino AIDS deaths in the United States have been increasing. The underlying cause of the rising HIV infection rates in the U.S. Latino population is not fully understood. Focus groups among Mexicans in North Carolina revealed methods of prevention that were different from those recommended by the Centers for Disease Control and Prevention (CDC). A research-based Mexican model of HIV prevention is proposed and contrasted with a model deducted from CDC prevention strategies. Recently immigrated Mexicans may be unlikely to adopt the CDC model of HIV prevention due to their culturally specific views of prevention.

Attaining gender and ethnic diversity in health intervention research: cultural responsiveness versus resource provision

Despite the National Institutes of Health (NIH) mandate to include women and diverse ethnic groups in all NIH-funded research projects, these groups are still excluded as participants in health intervention research. This exclusion has denied them access to state-of-the-art treatments and prevention strategies. making them vulnerable to increased morbidity and mortality and decreased longevity. This article compares two conceptual approaches to inclusion: cultural responsiveness and resource provision. Several issues are raised as to why women and ethnic people of color are not involved in health intervention research. For each of these issues, an appraisal is made as to whether cultural responsiveness or resource provision would more successfully address the problem. It is concluded that cultural responsiveness facilitates participation in research but is not sufficient. An equally important, if not more important, approach may be the provision of resources to empower participants to address problems of access and burden.

Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model

This article develops a conceptual model of cultural competency's potential to reduce racial and ethnic health disparities, using the cultural competency and disparities literature to lay the foundation for the model and inform assessments of its validity. The authors identify nine major cultural competency techniques: interpreter services, recruitment and retention policies, training, coordinating with traditional healers, use of community health workers, culturally competent health promotion, including family/community members, immersion into another culture, and administrative and organizational accommodations. The conceptual model shows how these techniques could theoretically improve the ability of health systems and their clinicians to deliver appropriate services to diverse populations, thereby improving outcomes and reducing disparities. The authors conclude that while there is substantial research evidence to suggest that cultural competency should in fact work, health systems have little evidence about which cultural competency techniques are effective and less evidence on when and how to implement them properly.

Resolving disease management problems in European-American and Latino couples with type 2 diabetes: the effects of ethnicity and patient gender

The management of type 2 diabetes requires major life style changes. How patients and family members resolve disagreements about disease management affects how well the disease is managed over time. Our goal was to identify differences in how couples resolved disagreements about diabetes management based on ethnicity and patient gender. We recruited 65 Latino and 110 European-American (EA) couples in which one spouse had type 2 diabetes. Couples participated in a 10-minute videotaped, revealed differences interaction task that was evaluated with 7 reliable observer ratings: warm-engagement, hostility, avoidance, amount of conflict resolution, off-task behavior, patient dominance, and dialogue. A series of 2 x 2, Ethnicity x Sex ANOVAs indicated significant effects for Ethnicity and for the Ethnicity x Sex interaction, but not for Sex. Latino couples were rated as significantly more emotionally close, less avoidant, less hostile toward each other, and had less dominant patients than EA couples; however, Latino couples achieved significantly less problem resolution and were more frequently off-task than EA couples. These findings were qualified by patient gender. The findings highlight important differences

Development of a community-based diabetes management program for Pacific Islanders

PURPOSE

This study examined the perception of diabetes among a sample of Pacific Islanders in Honolulu, Hawaii. All 23 participants were diagnosed with type 2 diabetes, ranged in age from 21 to 70 years, and had glycosylated hemoglobin levels of 5.8% to 13.9%.

METHODS

Four focus groups were held in English and audiotaped. Outreach workers served as translators and comoderators. The content of transcripts was analyzed with Ethnograph software by investigators. The priority issues were confirmed by the comoderators and participants.

RESULTS

Participants perceived diabetes as full of complications, emotions, symptoms, and behavior changes. Responses to hyperglycemia were fear, frustration, and uncertainty. Barriers to staying on the prescribed diet were habit, cultural ritual, ideal body image, and limited budget.

CONCLUSIONS

Participants suggested that helpful activities would include walking/support group, cooking class, community healthy food store, translated material, and family participation. A community-based diabetes program has been developing as a result of the focus group findings.

Culture counts: why current treatment models fail Hispanic women with type 2 diabetes

PURPOSE

The purpose of this article is to evaluate whether current treatment models adequately address the cultural factors involved in treatment adherence in Hispanic females with Type 2 diabetes.

METHODS

A review of relevant professional literature was conducted.

RESULTS

Established health behavior models do not adequately address the unique needs of the female Hispanic population, especially those older women who hold traditional religious and cultural beliefs.

CONCLUSIONS

To decrease the devastating effects of Type 2 diabetes among Hispanic women, interventions must be based on a comprehensive, culturally sensitive model that works with cultural values, not against them.

Culturally competent diabetes education for Mexican Americans: the Starr County Study

PURPOSE

Few culturally competent health programs have been designed for Mexican Americans, a group that bears a disproportionate burden of Type 2 diabetes. In Starr County, a Texas-Mexico border community, investigators designed and tested a culturally competent intervention aimed at improving the health of this target population. The purpose of this article is to describe the development process of this diabetes education and support group intervention.

METHODS

The development stages were (1) community assessment, (2) intervention design, (3) selection or development of outcomes, (4) pilot testing, and (5) a randomized clinical investigation.

RESULTS

Focus group participants identified knowledge deficits regarding diabetes and self-management strategies, and suggested characteristics of an effective intervention for Mexican Americans. Outcome measures included metabolic control indicators, a newly developed knowledge instrument, and an existing health belief instrument. Preliminary analyses indicated that the intervention was successful in significantly improving metabolic control in the target population.

CONCLUSIONS

Developing successful diabetes interventions for minority groups requires a number of stages, careful planning, assessment of cultural characteristics of the target population, and a systematic approach to implementation.