Self-Management and Glycemic Targets in Adult Haitian Immigrants With Type 2 Diabetes: Research Protocol.

BACKGROUND: Type 2 diabetes (T2D) is a chronic condition affecting more than 34.2 million U.S. adults, and people of African descent have a disproportionate burden. Haitian immigrants' unique cultural and biological factors put them at elevated risk for T2D-related complications. Despite prior research highlighting the success of multimethod approaches to T2D self-management behaviors on glycemic targets, a dearth of studies have used these methods to improve diabetes self-management in this marginalized population. OBJECTIVES: This article describes a repeated-measures design protocol of a going study about self-management behaviors among adult Haitian immigrants with T2D and characterizing their barriers to T2D self-management. METHODS: We will enroll 100 Haitian immigrants aged 18-64 years who have lived with T2D for at least 1 year. Using multiple recruitment methods and Research Electronic Data Capture, subjective and objective data on T2D self-management practices, glucose variability via continuous glucose monitor, and a comprehensive view of physical activity via actigraphy are collected. RESULTS: Data analysis will follow a two-part approach mirroring the two primary study objectives. DISCUSSION: Findings from the study will guide the development and testing of a culturally tailored diabetes self-management education program that will contribute essential information about best practices for this population and break barriers that may impede research on unique individuals and subsequent effective self-management.

Barriers to Type 2 Diabetes Management Among Older Adult Haitian Immigrants.

PURPOSE: The purpose of this study was to describe the experiences of older adult Haitian immigrants in managing type 2 diabetes mellitus (T2DM). METHODS: A descriptive qualitative approach using semistructured interviews was conducted with 20 older adult Haitian immigrants with T2DM. Interviews were transcribed verbatim and categorized using NVivo. An iterative descriptive data analysis method was used to examine the data, compare codes, challenge interpretations, and develop themes inductively. RESULTS: Older adult Haitian immigrants reported that T2DM affected every aspect of their lives. Financial hardship and social isolation were described as the major barriers to T2DM management, which forced them to choose between basic needs and health care, and at times, they had to forgo medications or avoid seeking medical care. They recognized that creating and maintaining good community support was the key to self-management of T2DM. CONCLUSIONS: Financial hardship and social isolation have a tremendous impact on the ability of older Haitian immigrants to manage T2DM effectively. It is challenging to modify these barriers through individual efforts, and clinical, research, and public efforts may be necessary to address these concerns.

¡Sí, Yo Puedo Vivir Sano con Diabetes! A Self-Management Randomized Controlled Pilot Trial for Low-Income Adults with Type 2 Diabetes in Mexico City.

BACKGROUND: Type 2 diabetes (T2D) is a worldwide epidemic and a leading cause of death in Mexico, with a prevalence of 15.9%, and >70% of diagnosed adults have poor glycemic control [glycated hemoglobin (HbA1c) >7.5%]. We developed a diabetes self-management education program contextualized to the study population, including dietary preferences, health literacy, and health system. OBJECTIVES: We aimed to evaluate the efficacy of a self-management + text message program (¡Sí, Yo Puedo Vivir Sano con Diabetes!) on primary (HbA1c), and secondary behavioral (self-management), clinical, and psychosocial outcomes in adults with T2D in Mexico City. METHODS: Participants were recruited at public primary healthcare centers (Seguro Popular), and randomly allocated to treatment (n = 26) or wait-list control groups (n = 21) with data collected at 3 and 6 mo. The program included 7 weekly sessions and 6 mo of daily text/picture messages. Descriptive statistics and a generalized linear mixed model with intent-to-treat analysis were calculated. RESULTS: Participants were 55.5 ± 8.8 y of age (mean ± SD), 68% female, 88.6% overweight/obese, and 57% lived in food-insecure households. Mean ± SD T2D duration was 11.9 ± 7.8 y and HbA1c was 9.2% ± 1.5%. There was 89% attendance at sessions and 6.4% attrition across both groups at 6 mo. Group-by-time effects were seen in self-monitoring of blood glucose (P < 0.01) and diabetes self-efficacy (P < 0.04); and a trend for lower HbA1c was seen in the intervention group at 6 mo (P = 0.11). Significant improvements in dietary behavior (P < 0.01) were demonstrated in the intervention group over time, but this did not reach statistical significance compared with the control group. CONCLUSIONS: The program was associated with clinically significant improvements in T2D self-management, self-efficacy, and HbA1c over time. Thus, T2D self-management skills, including diet, were improved in a vulnerable metropolitan population.This trial was registered at clinicaltrials.gov as NCT03159299.

Development of a diabetes self-management + mHealth program: tailoring the intervention for a pilot study in a low-income setting in Mexico.

BACKGROUND: Type 2 diabetes (T2D) is a public health pandemic disproportionately affecting low- and middle-income countries. The purpose of this formative research was to adapt evidence-based diabetes self-management education programs to the context of Seguro Popular clinics in Mexico. A theory-based mHealth (pictorial text messaging) component was developed. METHOD: Our formative research and development of the program protocol consisted of six phases: (1) interviews and focus groups with stakeholders on the challenges to T2D management, curriculum content needs, and the use of mHealth as a supplement to a DSME program; (2) review of the theoretical underpinning, curriculum, and interactive strategies of four evidence-based DSME programs and modification to meet the needs of adults with T2D and systems of care in Mexico City; (3) development of theory-based illustrated text messages; (4) evaluation of text messaging acceptability and access in adults with T2D via focus groups; (5) development of program manual; and (6) development of a training program for health care providers. RESULTS: The ¡Sí, Yo Puedo Vivir Sano Con Diabetes! included 7 group-based weekly lessons; simple, interactive content; weekly empowerment messages; video novellas; group activities; and goal setting. Adaptations to the cultural context of Mexico included content/activities on diabetes etiology (addressing cultural misconceptions), nutrition (indigenous foods and plate method), self-blood glucose monitoring, and diabetes-related stress/coping. We used the Health Action Process Approach to guide the text message development, which posits that adoption, initiation, and maintenance of health behaviors require the development of intentions, plans, coping, and self-efficacy. Our final text message bank consisted of 181 messages. There were approximately 20-30 messages for each process of behavior change (e.g., action planning, maintenance self-efficacy) and 30 messages for each content topic (e.g., eating healthy, physical activity). There were 96 messages that were illustrated. Training materials were also developed. DISCUSSION: We used a systematic approach, collaboration with stakeholders, and a well-established behavior change theory to develop an evidence-based intervention to an international context and system of care. Collectively, this process has the potential to enhance the feasibility, acceptability, and efficacy of the program.

Haitian Immigrants and Type 2 Diabetes: An Integrative Review.

Type 2 diabetes (T2D) is a complex, lifelong condition that is disproportionately prevalent among minority populations. Haitian immigrants (HIs) living in the US with T2D have unique factors that influence diagnosis, treatment, and self-management. The purpose of this integrative review was to provide a synthesis of the research on T2D in the HI population. In a systematic literature search, 14 studies met the inclusion criteria. Three themes were identified: risk factors for less self-management and/or worse metabolic control; protective factors for better self-management and/or metabolic control; and mixed results. HIs had higher HbA1c, yet better self-management, different genetic profiles, and lower levels of vitamin D and hemoglobin concentration compared to other ethnic groups. HIs also reported better dietary quality, less healthcare utilization, and higher perceived emotional/psychological stress compared to other ethnic groups. This study has implications for practice for integrating the unique cultural factors when assessing and intervening with HIs.

Challenges to diabetes self-management for adults with type 2 diabetes in low-resource settings in Mexico City: a qualitative descriptive study.

BACKGROUND: The prevalence of type 2 diabetes (T2D) in Mexico is one of the highest in the world, with high morbidity and mortality, and difficulty meeting glycemic targets. The purpose of this study was to identify the challenges for T2D self-management as perceived by both adults with T2D and health care providers in primary health clinics from Seguro Popular in Mexico City. METHODS: This was a qualitative descriptive study conducted in three Seguro Popular primary care clinics in Mexico City using convenience sampling. Semi-structured interviews were conducted with participants and data were analyzed using a content analysis approach. RESULTS: The sample included 20 adults with T2D [52.5 years old (SD = 9.9), diagnosed with T2D for 12.3 years (SD = 6.3), mean A1C of 9.8% (SD = 2.4), 80% female, 90% with financial insecurity] and 19 providers [primarily female (78.9%), mean age of 41.6 years old (SD = 11.4), 12.3 mean years in practice (SD = 8.50)]. Personal challenges included cultural beliefs, lack of resources, challenges to lifestyle modification, lack of family support/competing demands, and mental health issues. System level challenges included lack of resources, perceived quality of care, and patient engagement barriers. CONCLUSIONS: Evidence-based diabetes self-management programs need to become more accessible, taking into consideration the social determinants of health and building upon current initiatives to improve early diagnosis and treatment of T2D. Cultural beliefs, personal control, and low health literacy influence diabetes self-management in adults with T2D with limited resources. Mental health and financial challenges of adults with T2D will require multidisciplinary team-based care. Future research on best practices to implement and scale-up evidence-based patient-centered T2D prevention and DSME programs for the poor and underserved is warranted in Mexico and world-wide.

Cultural influences on causal beliefs about depression among Latino immigrants.

PURPOSE: This study describes causal beliefs about depression among Dominican, Colombian, and Ecuadorian immigrants. The authors describe participants' narratives about how particular supernatural or religious beliefs may contribute to or alleviate depression. METHOD: Latino primary care patients (n = 177) were interviewed with the Beliefs About Causes of Depression Scale, a list of 35 items rated from not at all important to extremely important. Participants had the option of expanding on responses using an informal conversational approach. Underlying themes of these explanatory comments were derived from narrative and content analysis. RESULTS: Major themes that emerged were Psychosocial and Religious and Supernatural causal beliefs. A third theme emerged that represented the integration of these categories in the context of the immigrant experience. DISCUSSION AND CONCLUSIONS: This article adds to the understanding of cross-cultural beliefs about depression. Psychosocial stressors related to the immigrant experience and adverse life events were highly endorsed, but the meaning of these stressors was construed in terms of religious and cultural values. To provide culturally appropriate services, nurses should be aware of and discuss the patient's belief systems, illness interpretations, and expectations of treatment.