1. Population Health and Evidence-Based Practice
The leading chronic diseases that are causing death in the United States are heart disease, diabetes, and cancer [1]. The Centers for Disease Control and Prevention estimated that “Six in ten Americans live with at least one chronic disease, like heart disease, cancer, stroke, or diabetes. These and other chronic diseases are the leading causes of death and disability in America, and they are also a leading driver of health care costs” [1]. The United States has established numerous programs and health care organizations to manage and prevent these chronic diseases. There are numerous variables that contribute to the cause of chronic diseases including: gender, age, ethnicity, race, poor nutrition, physical inactivity, smoking, alcohol use, and other pre-existing diseases. These factors can be non-modifiable and modifiable. If you have a chronic condition, it’s important to eat well, stay active, and follow your treatment plan. These steps can help you feel well and avoid complications. The general measures are individualized per patient, per treatment plan, and per condition.
The Texas Institute of Diabetes has created a population heath improvement plan to tackle the issue of Type 2 Diabetes Mellitus (T2DM) in the Hispanic/Latino population in Texas. The initiatives that were implemented in the plan are based on the most up-to-date cultural evidence of the Hispanic population in that area, Mexicans. It is also based on evaluation of the demographic, epidemiological and environmental data in that area for that population. The plan also includes strategies for how to effectively communicate with Mexicans and health care professionals the health improvement goals in an ethical, culturally sensitive, and inclusive way.
2. Environmental and Epidemiological Data about Mexican
Communities
Diabetes is a life changing illness that can lead to death if not treated properly. In the United States, “Diabetes remains the 7th leading cause of death in the United States in 2015, with 79,535 death certificates listing it as the underlying cause of death, and a total of 252,806 death certificates listing diabetes as an underlying or contributing cause of death” [2]. This illness may lead to kidney failure, blindness, heart disease, and amputation of limbs. These patients are also more susceptible to infections. Most of the Hispanic population consists of migrants which are predominantly Mexicans. Statistics have shown that, “Texas’ Hispanic population increased from 9.7 million in 2010 to 11.1 million last year, according to new census population estimates” [3]. The data also shows that the Hispanic population has a prevalence of T2DM compared to their non-Hispanic counterparts. The factors that are affecting this odd distribution of Diabetes in Texas are biological characteristics, socioeconomic conditions, and cultural aspects.
The evaluation of the epidemiological and environmental data of T2DM in the Hispanic communities has shown that they have a lack of knowledge in regard to this illness. The CDC does not have an accurate count as to how many Mexican migrants there are since they are illegal aliens. Homeland security has estimated that, “there were 1.68 million undocumented immigrants living in Texas. The nation as a whole is said to have 10.8 million, according to the DHS; Texas has the second-highest number of all the states, after California” [4]. This makes evaluating the epidemiological data difficult to assess. The environmental data shows that Mexicans are exposed to harmful pollutants and fertilized chemicals in the fields. The jobs they often endure are those picking fruit and preparing the fields. They are inhaling the harmful chemicals that were designed to increase crop production and size. They have no knowledge of what these chemicals are composed of or what they could do to the human body.
The sociocultural and linguistic factors that are limiting Mexicans from accessing health care are their inability to understand or speak English, no health insurance, and the fear of being deported. The issue with accessing health care insurance is that, “undocumented immigrants aren’t eligible to buy Marketplace health coverage, or for premium tax credits and other saving on Marketplace plans. But they may apply for coverage on behalf of documented individuals” [5]. Also, many Mexicans also do not believe in Western medicine and continue to use their traditional herbal remedies. Most Mexicans also live below the poverty level, “In 2007, approximately 22% of Hispanics/Latinos were living below the poverty level compared with approximately 9% of non-Hispanic whites. Importantly, studies have shown that lower socioeconomic status is associated with an increased prevalence of type 2 diabetes, as well as amputation owing to the disease” [6]. This patient population also does not have transportation to health care services or education classes.
3. Health Improvement Plan to Address Diabetes among
Mexicans
The Texas Institute of Medicine has comprised a plan in the local clinics to help overcome the barriers this specific patient population is facing in regards to successfully managing their diabetes. The first step is to carefully evaluate the educational level of the patient, ability to speak English, and literacy level. The other factor that will be considered is the level and progression of the disease in the patient [3].
Education on cultural competency will be implemented in the health care system in Texas in regard to Mexican traditions, beliefs, practices, and attitudes toward healing specifically on diabetes. The reason behind encouraging and educating health care professionals on cultural competency is to avoid misunderstandings, limit barriers, and encourage compliance with treatment [3]. When the culture is understood, the physicians can implement a treatment plan that will be accepted and respect the Mexican culture.
The diet of the Mexican culture is primarily carbohydrates and sugars. After seeing what foods, they prepare the physicians can refer the patient to a dietician that can work with them to establish a diet that can control their diabetes. Educating the patient on what a proper diabetic diet is and how it can still comply with their culture will make the patient more acceptant and willing to follow it.
Overcoming the socioeconomic barriers will be done by educating and holding monthly free care in local clinics where the Mexican population is abundant. There will be volunteers and workers that are from the same culture so that the Mexicans will feel a bit at ease knowing that they have someone from their culture that understands. Diabetic education will be provided and those willing can be screened to see if they are at risk for diabetes. At the free care event, there will be stations that will be offered in Spanish that will show those who are diabetic on how to check their blood sugar at home along with the proper aseptic techniques to limit infection. The staff will also explain what range the blood sugar should stay within such as 60 - 100. They will also be informed on what to do if the blood sugar is above 100. Staff will also hold stations as to where the patients can practice giving themselves their insulin injections. Exercise stations will also be available to show the patients simple ways in which they can do physical activities at home.
Besides the free care every month the local clinics will partner up with the local buses and establish a company van that will allow for the Mexicans to have transportation to and from their medical appointments. This will improve healthcare access and give no excuse as to why they cannot receive care.
All the services will be offered in Spanish and the whole community is encouraged to participate. This will not only limit the barrier of language but also the cultural barrier of fear. By seeing that the staff are not looking to deport them but help them live healthier lives, the Mexicans will be more reluctant to accept and seek medical care.
All of these strategies of this plan will educate and inform the Mexican community of what diabetes is and how treating it will allow them to have a long and healthier life.
4. Value and Relevance of the Diabetic Plan
In a study done by the Texas Institute of Diabetes they found that, “of 676 patients with type 2 diabetes (25% Hispanics/Latinos, 34% non-Hispanic whites, and 41% non-Hispanic blacks), Hispanics/Latinos were significantly more likely than non-Hispanic whites to worry about medication side effects (66% vs. 39%, respectively) and report concerns about becoming dependent on medication (65% vs. 39%). As a result, a significantly greater proportion of Hispanic/Latino patients were unwilling to take more medications when recommended by their healthcare provider (12% vs. 7% for non-Hispanic whites)” [3]. This shows that the monthly free health care in the clinic will benefit the Mexican population tremendously. They will receive the proper education on what diabetes is and the reasoning behind taking diabetic medication. The patients will also be educated on that diabetes is a life-long disease and that insulin is not something that you become addicted to rather that it is something that is helping you to survive.
The study also showed that, “More than half of the patients (56%) thought that a high glucose level was 200 mg/dL [1 mg/dL 0.05551 mmol/L], and 54% believed they could feel when their glucose levels were high. Furthermore, 36% thought that they would not always have type 2 diabetes, 29% expected their healthcare provider to cure them, and 23% thought there was no need to take diabetes medications when glucose levels were normal” [3]. The education provided at the clinics will inform the patients of the values in which their blood sugars should be within. It will also inform them that insulin must always be taken regards of what the blood sugar is.
When health care providers use Spanish in describing care it allows for cultural competency and to, “improve overall care for patients with limited English proficiency by increasing patient comprehension and reducing errors in communication, resulting in better clinical outcomes and higher patient satisfaction” [2]. This shows that when we incorporate their language into educating about diabetes there will be better outcomes and better diabetic care.
The free care event in the clinic will also help with improving patient knowledge of the health care system. Studies have shown that, “health education programs for Hispanic/Latino patients with type 2 diabetes were successful at improving patient outcomes. It is crucial that patient education programs be culturally appropriate, address cultural barriers, and be written at a low literacy level, preferably in Spanish” [4]. Designing the event specifically for diabetes will help to promote awareness and proper treatments as well.
5. Criteria to Evaluate Achievement of Plan Outcomes
The plan will be evaluated monthly during the free clinic event. The clinic will check the patient’s blood sugar and compare it to last months, they will then be able to see if there is an improvement or if further education and treatment is needed. The clinic will also do weekly evaluations of how many new Mexican patients come into the clinic for diabetic care. Each Mexican patient at every visit will be asked to demonstrate on how to use the glucometer and how to give themselves insulin injections. Every three months the A1C will be check on each patient to see if the education and treatment has worked. The transportation crew will also keep track of how many people are using it to see if it is helping improve and encourage health care access. Each patient will be asked monthly about how they feel with having staff that speak Spanish and if they see an improvement in their health. The patients will be asked to keep a journal, if they are able to write, about their diet and what their blood sugars were each day to see if there is a trend. This will not only help them see their progress but to see what could be improved. The overall outcome of the plan that will be monitored and evaluated is the decrease in people developing diabetes. This will be evaluated monthly by screening the community to see if they are risk. The current patients without diabetes will also be monitored at each visit to see if they lower their risks of developing diabetes.
6. Culturally Competent Communication Strategies for the
Diabetic Plan
The health care system must provide culturally competent care for the plan to succeed. They must partner with people in the community to better understand the Mexican culture before they can implement a plan. After collaborating with community members, they can work with other health care professionals to establish a plan that will be respectful to the Mexican culture. Interpreters will be offered and available at each health care visit and via telephone. The clinic must also train their staff to give culturally competent care. They must first know what their own beliefs are before they can care for someone else of a different culture. Communication is key in giving proper care to any patient and the clinic will make this possible by meeting with Mexican elders or those in charge of the community to find strategies to improve care. When the Mexicans feel their culture is accepted and understood they will be reluctant to visit the clinic and speak about what is going on with them. Another thing that will be considered is the level of education in which information can be communicated. The clinic needs to provide clear instructions in the language and at a level that the Mexican culture can understand as well.
7. Conclusion
Diabetes is a life-long disease that can lead to death if not treated properly. The Texas Institute of Diabetes has established a plan with a series of strategies that will improve diabetic management in the Mexican population of Texas. Cultural competence and communication are all considered in the plan to improve the health of this patient population. Effective collaboration and cultural acceptance are all key factors that will help the plan succeed in managing diabetes in the Mexican culture. Diabetes can only be prevented and treated when everyone works together to form a solution.