Culture Clash

In many populations, successfully treating diabetes and other ailments is often secondary to understanding the patient’s culture and traditions.

In the fall of 2010, the Centers for Medicare & Medicaid Services (CMS) awarded Austin, Texas–based TMF Health Quality Institute — the Medicare Quality Improvement Organization for Texas — a contract to launch the Salud por Vida/Health for Life (SPV) initiative that focuses on diabetes education classes. The target audience for SPV includes Native American and Hispanic Medicare beneficiaries with diabetes, as these two groups experience a higher incidence and prevalence of diabetes, as well as related complications such as heart disease, kidney failure, and amputations.

That same year, 1,700 miles away, the Indian Health Center of Santa Clara Valley (IHC), in San Jose, Calif., contracted with a public health sector insurance plan to expand its already extremely successful Diabetes Prevention Program (DPP), a 17-week lifestyle change program taught by a wide range of healthcare professionals.

Diabetes in the Native American and Alaskan indigenous communities is unfortunately, deemed as “an inevitable fate”, according to IHC community outreach and wellness director, Ramin Naderi.

Engagement and Empowerment

“The Health Disparities team at TMF understood that engaging the targeted audience would require a thorough understanding of the Hispanic and Native American communities in our state — their history, their culture and preferences, and their views about disease and prevention,” says Brenda Ortiz, program manager for TMF.

In Texas, many Native American people are also Hispanic Americans since a large proportion of these groups are native to the region, with their roots predating modern U.S. /Texas history. “For example,” Ortiz says, “the Kickapoo nation in Texas is a tribal group that has members in Texas and Mexico, but originated from the northern United States in the 1600s. This group travels between both countries at various times of the year and is fluent in Spanish, English, and other Algonquian dialects.”

To engage the Kickapoo nation, TMF needed to partner with the health center on the Kickapoo reservation and receive approval from the Council of Elders before any progress could be made in this community. “They were very open,” says Ardis Reed, MPH, RD, LD, CDE, diabetes educator at TMF. “They were very engaged and happy to have the tools to train their community.”

In 2003, the IHC applied for a grant to “change the face of diabetes in the community,” and the next year implemented the DPP. The program follows a curriculum based on a study by the National Institutes of Health that “found that an intensive lifestyle intervention can lower the risk of diabetes by 58%.” The mission of the DPP was to take that research and translate it to community settings.

The urban Native American community had already requested a gym at the IHC, one of 30 Native American urban health clinics across the country, a result of the Relocation Act, which enticed many Native American to leave their tribes and move to urban cities, with many settling in California.

“The story of American Indians in America is about disempowerment,” Naderi says, and so it is important to “do projects that empower the community.”

TMF staff also understood the need to develop a community outreach approach to promote their project, to establish strong relationships in new regions, and strengthen existing partnerships among Hispanic and Native American groups.

TMF pursued partnerships with community health workers and groups that already had an established relationship with the target communities to deliver the diabetes classes. Classes were held in locations that were well-known and easy to access for the community. The group took the “Tupperware approach,” says Reed, making house calls and holding classes in patients’ homes.

“This was especially important,” Ortiz says, “as early discussions with patients revealed that many of them avoided classes held at clinics and hospitals because they felt that the environment was too impersonal. Bringing the classes to their neighborhood or reservation, to be delivered by community health workers or members of the community, made the patients feel more comfortable and was a very important aspect of the project.”

TMF developed a strong marketing strategy, including community kickoff events in five regions in the state that had large numbers of targeted patients, which served to announce the start of the project to community members, clinicians, and partners. To boost the marketing campaign, TMF counted on the support of a celebrity spokesperson for the SPV project, “Little Joe” Hernandez, a Grammy Award–winning Texan musician and entertainer — a well known artist among Hispanic and Native American communities — who also has diabetes.

One of the first steps in undertaking a project this big and daunting, explains Naderi, was getting the entire community on board, because once the community is behind you, the barriers come down. “It all comes back to empowerment,” he says.

“Waste of Time”

Indeed, there were barriers. The first obstacle for the DPP was overcoming the fact that the community felt that the program was a “waste of time,” because the community had “lost hope in overcoming diabetes,” says Naderi. It also became a struggle to find candidates and participants for the program, as the Native American community is a “hidden” population from registries.

Even once participants qualify for the program, retention becomes an issue. Many communities have less education, higher stress levels, little or no income, no insurance, have more comorbidities, and experience more substance abuse problems. “Diabetes is often not the top of the list of priorities,” Naderi says.

With these barriers, “it takes more time to stabilize,” Naderi says. “We had to be proven by staying in practice for years, and now the same folks who doubted us have graduated from the program and also refer family and friends to the program. Hope is restored in the community.”

TMF faced obstacles that included participants’ lack of transportation, childcare issues, and having to attend weekly meetings for six weeks. The team had to be creative, so it engaged the support of many groups in each region, not only those that helped lead the classes, but local Area Agencies on Aging or groups that could provide transportation services. They encouraged the start of new classes in ZIP codes where the Medicare patients resided and provided this guidance to educators, so the classes were in the heart of the targeted communities. The team engaged experienced community health workers as educators, who could effectively build rapport with the patients. “This was crucial to maintaining a good retention rate for the six-week program,” Ortiz says. “The interpersonal communication skills of the educators made the most difference when measuring the success of the classes.”

“So Simple, but So Important”

By the end of the SPV program in July 2012, the initiative had enrolled more than 10,000 people affected by diabetes in the Diabetes Self-Management Education (DSME) classes.

The TMF team collected a small sample set of clinical data. Results for those patients that completed the six-week class showed that:

• The percentage of participants with an A1C (a three-month measure of blood glucose) <6.5 improved by 73%, within three months after completion of the class. Even a 1% reduction in A1C level is associated with a 37% reduction in microvascular complications, a 14% decrease in myocardial infarction (heart attacks), and 21% reduction in the risk of any diabetesrelated complication or death.

• The percentage of participants with LDL (low-density lipoprotein) < 100 improved by 45%, within three months after completion of the class.

The IHC expanded in 2010 to provide its diabetes program to include participants with pre-diabetes with a fasting blood glucose (FBG) of 100 – 125 or (A1c) of 5.7- 6.4 ) and patients with non-complicated type 2 diabetes referred by their primary care physicians. They shared impressive pilot program results at the Endocrine Society’s 2013 Reducing Health Disparities Summit. Of the 32 participants, 18 had diabetes, and follow-up labs showed that 44% of those patients saw a drop in their FBG from diabetic range to pre-diabetic range (<125).

• Five percent of the diabetic patients saw a decrease to normal glycemic range (<100).

• Patients even saw results beyond the numbers. DSME class participants showed improvement in their ability to cope with diabetes and improved skills to self-manage their disease, as evidenced from a preand post-patient survey.

“The patients build relationships; they make friends,” Reed says. “They learn problem solving skills. They share with family members [who learn to help them].”

For example, Reed continues, a young lady went to check on her uncle. He didn’t answer the door, so she climbed through a window and found her uncle on the floor, obviously in distress. She tried to help, but he shrugged her off , saying all he needed was water, but, thanks to the DSME classes, the young lady recognized the symptoms of high blood sugar. She called 911, despite her uncle’s protest. The EMT arrived and found that the uncle’s blood sugar was over 800. The EMT told the lady that she called just in time. The uncle recovered in the hospital in five days.

“This isn’t just about free strips and glucose meters. It’s about quality of life.”

— Ardis Reed, MPH, RD, LD, CDE, diabetes educator, TMF Health Quality Institute, Austin, Texas

Another patient — an elderly woman — learned in class about carrying her glucose tablets with her. One day, she was babysitting her grandson, making lunch, and began to feel ill — she was in a hypoglycemic episode and collapsed. She didn’t have the strength to make it to her purse, so she instructed her grandson to bring her pills to her. She took her glucose tablet and then had enough strength to make it to the hospital. “So simple, but so important,” Reed says.

Naderi also saw how the DPP affected the families of the participants. During the last graduation ceremony, he says, a young mother approached him with her young daughter in tow. The mother said, “My whole family has problems with complications of diabetes,” and then, while looking at her daughter, said, “I don’t want her to end up like that.” “She now has power” Naderi says.

“This isn’t just about free strips and glucose meters,” Reed says. “It’s about quality of life.”

Next Steps

More than half of the participants who attended the DSME classes had diabetes for an average of nine to 12 years, and roughly half of these participants had never had diabetes education. Reed says that the glaring gap from diabetes diagnosis to education is unacceptable and stresses that it must begin with the practitioner. “I don’t know if practitioners know about the time gap [from diagnosis to education],” she says.

The DPP is not very well known in most of the provider communities, according to Naderi. “In our clinic, the pre-diabetics would literally just wait until they became diabetic,” he says, “then they take medication.”

Still, with the successes both programs have enjoyed over the past couple of years, they’re each eyeing expansions and other projects. The TMF Health Disparities team is currently working on a similar initiative to SVP, called Health for Life/Everyone with Diabetes Counts, aimed at engaging African American Medicare patients with diabetes.

Naderi says that they must constantly develop different strategies for other at-risk groups, such as the Latino community, and provide pre-natal care in the clinic. “Once our efforts paid off ,” he continues, “we saw it as a worthy cause, not just for the American Indian community, but for the world.

— Bagley is the associate editor of Endocrine News. He wrote about the new Endocrine Society offices in the February issue.