Diabetes is one of the nation’s greatest challenges in health care. Direct and indirect costs from diabetes are also a great burden to the health care system. …
Primary Prevention of Diabetes in Hispanic Migrant Farmworkers
CHIC Project - Block 2
September, 2005
Project Partner: 835
Background/Literature Review:
Diabetes is one of the nations greatest challenges in health care
It is the 5th leading cause of death due to disease in the United States
and a major contributor to other medical morbidities such as heart disease,
end organ failure and extremity amputation Direct and indirect costs from
diabetes are also a great burden to the health care system Estimated
costs for 2002 were approximately 132 billion US dollars[i] More than
90 of the diabetic population are type 2 diabetics with a significant
portion being of Mexican and Puerto Rican descent This Hispanic sub-group
today represents a total of approximately 2 million people
Hispanic Americans are the largest growing minority group in the
United States, having reached 413 million people as of July 1st, 2004
This number reflects a 36 increase compared to a 1 increase in
the
Unites States total population[ii] Within this ethnic group diabetes has
been found to have caused 41 more years of potential life lost before age
75 per 100,000 people compared to non-Hispanic whites in 2001Table 1
[iii]
Table 1:
Mexican Americans in particular, the largest Latin American subgroup, are 2
times more likely to develop diabetes compared to non-Hispanic white
Americans[iv]
Despite the high prevalence of diabetes, as well as other subsequent
co-morbidities in the Hispanic population, this ethnic group continues to
be the largest group underserved by the health care system The percentage
of uninsured Hispanics continues to remain high at 327 in 2004, unchanged
from the year prior Absolute numbers of uninsured continues to rise
however, increasing to 137 million uninsured Hispanics in 2004 from 132
million in 2003[v],[vi]
Considering the natural history and initially silent effects of
diabetic pathophysiology, poor access to health care can clearly contribute
to increased morbidity and mortality In addition, major risk factors for
diabetes such as being of Hispanic ethnicity, being overweight BMI25,
and hypertension are largely characteristic of
the Latin American
population These risk factors combined with the highest incidence of
uninsured, places this population at the greatest risk of premature death
due to diabetes A specific population largely reflective of this
detrimental combination is the migrant farm worker population
Migrant farm workers are largely of ethnic minority descent
Approximately 83 are identified as Hispanic, 80 of which are of Mexican
descent[vii] This ethnic composition makes them an excellent community of
people to target for diabetes prevention education Migrant farm workers
are disadvantaged in multiple ways, placing them at a great risk of
morbidity and mortality from disease, not reserved to diabetes alone Farm
workers are among some of the most economically disadvantaged people in the
United States Approximately three-quarters of all workers earn less than
10,000 annually [viii] Often due to these economic conditions, farm
workers are very reluctant to seek health care services during work hours
for the fear of missing work or much worse - losing their jobs Farm
workers often feel obligated to use emergency services as their form of
health care, and only at times when illness
completely inhibits their work
All these circumstances undoubtedly contribute to prolonged periods of
minimal or no health care Initially silent diseases, like diabetes, are
then allowed to develop and go unnoticed until advanced symptomatic disease
has been established
Local Community[ix]:
Wayne County, being largely a rural community, has always struggles
with issues of access to health care Diabetics, largely Hispanic, often
face no access to preventive services despite results of a state census
demonstrating a higher prevalence of diabetes in Wayne County compared to
New York State as a whole Chart 9 below
In 1994, Wayne County Public Health joined the Finger Lakes Migrant Health
Care Coordination Project FLMHCP FLMHCP is a federally funded migrant
health program established to help provide special outreach services to the
migrant community including in-camp screening and primary care clinics
One of these primary care clinics called La Clinica is located in Sodus
where migrant workers often go to get medical services after-hours La
Clinica is open during the day as well as between 6 and 10pm daily Here
patients are able to get medical services without the need to
take any time
out of work
Project Description/Methods:
Our goal was to provide primary diabetes prevention to this high risk
population We contacted Dr Telva Olivares a physician at La Clinica and
URMC faculty member Upon discussing our thoughts for this project with
Dr Olivares it became evident that diabetes prevention education was
something of which the community was largely in need We decided it would
be best to focus our efforts toward the general migrant population in La
Clinica waiting room According to the staff, patients typically arrived
all at once to the clinic waiting room at approximately 6pm and waited to
be attended regardless of appointment time These dynamics provided for a
good setting to elicit patients attention and provide diabetes prevention
education
Implementation/Results:
In efforts to provide interactive teaching to a highly uneducated
population, some of which may have possibly been illiterate, we decided to
establish visual methods for relaying our major points We conducted the
weekly classroom style education sessions in Spanish, with occasional
translation to English for English-speaking Haitian patients sometimes
present Sessions were
started by asking what the patients knew about
diabetes and pre-diabetes We then tailored our teachings, depending on
the response received from the group Topics central to our teachings were
the major risk factors for diabetes and the methods of minimizing the
effects of these risk factors We discussed the importance of maintaining
regular physical activity and maintaining a healthy diet to prevent onset
of risk factors such as hypertension and obesity We were able to
demonstrate the added calories present in common drinks such as Coke, apple
juice, orange juice, Goya Pear Nectar juice, and Malta Malt drink by
placing zip-lock bags of different amounts of sugar randomly next to the
drinks and having the group guess which amount of sugar corresponded to
each drink We also demonstrated the saturated fat content in ground beef
versus chicken, regular cheddar cheese versus low-fat cheddar cheese, and
whole milk versus 1 milk by placing the appropriate weight of shortening
corresponding to each food item In the process of these demonstrations we
discussed the different cooking methods and food choices possible to
maintain a healthy diet The clinic also provided cookbooks to
patients
which described alternate methods of cooking and alternate ingredients for
typical ethnic recipes We also made a point of demonstrating somewhat
graphic pictures of potential complications of diabetes to emphasize the
importance of preventing the onset of this disease Much of the teaching
sessions were spent answering questions and giving examples of different
ways to maintain a healthy diet At the end of each session we provided an
easy to read handout on pre-diabetes, in Spanish and English[x]
During the fourth week the final plan was to hold a focus group
targeted toward diabetes patients to help Terry Yonkers, the diabetes
program coordinator, identify barriers to maintaining blood glucose control
in diabetics Unfortunately getting a hold of the diabetic patients
provided to us on a list proved to be much more difficult than expected due
to telephone numbers being out of service or patients indicating they felt
no need to attend a diabetes support group As a result the diabetes focus
group was not held We also continued a partnership with Sharon Morano of
the Diabetes Coalition We planned to attend the monthly diabetes support
group session at Rural
Opportunities, run by Sharon, Carlos Rodriguez and
Maria Parelta on the fourth Wednesday of each month The goal was to
observe group dynamics in the hopes of establishing a similar forum at La
Clinica for a diabetes prevention program and in light of the fact that we
were unable to provide our own focus group session Unfortunately at the
last minute we were informed of the group cancellation Apparently, due to
poor communication and the absence of Carlos Rodriguez, plans were not
established to meet at Rural Opportunities that day There are no further
plans to hold the meeting at a later date as of yet
Community reaction/feedback:
In observing the results of our pre-diabetes teachings in La Clinica
it seemed there was significant interest in learning more about this
disease Familiarity with diabetes at times was non-existent, and the
desire to learn more about preventing the risk factors was quite
significant An impact was evidently made at the time of each teaching
session, demonstrated by the questions and interactive nature of the
audience One of the patients in fact elicited my undivided attention and
wrote down, as best he could, the appropriate questions to ask
his doctor
regarding his risk of diabetes In speaking with Dr Telva Olivares, Terry
Yonkers, and Sharon Morano there was great enthusiasm about our project,
recognizing the need for primary diabetes prevention
There was also a great deal of enthusiasm by all personnel at La
Clinica on days I was there, simply for the mere fact that I speak fluent
Spanish The presence of language barriers to care and the need for
translators is so significant that any bit of help is useful to the staff
This reaction to me as a Spanish speaking individual supported the
significant presence of a true language barrier to care among this
population of people
Sustainability:
This project provides sustainability by maintaining the partnerships
established with La Clinica in Sodus, the Diabetes Coalition and Rural
Opportunities These continued partnerships will allow for future medical
students to continue providing care to this underserved community as well
possibly establishing further partnerships
Another potential project to allow for further impact on this
community is the establishment of a Diabetes Prevention Program at the
Sodus migrant clinic A diabetes prevention program
with specific handouts
and organized sessions has been established by the National Institute of
Health/ National Institute of Diabetes and Digestive and Kidney Diseases
NIDDK Further communication with the FLMHCP for possible funding as
well as further planning with La Clinica can help establish a formal
Diabetes Prevention Program to which high risk patients can be referred
Another project may be developing a specific system, such as an outline or
checklist to be included in patient charts, for diagnosing the presence of
pre-diabetes; perhaps a system the nursing staff may use to screen
patients, which the doctors can later discuss with the patients This can
then serve as a mechanism for patient referral to a Diabetes Prevention
Program or at least for specific counseling sessions on how to reverse the
development of pre-diabetes Other ideas might include providing the same
type of prevention education but at a particular chosen camp site which
perhaps may have an older population with more risk factors for diabetes
This would first require evaluation of different camp sites for
identification of the appropriate target group There are multiple ways to
maintain sustainability
and partnership with FLMHCP using our focus of
diabetes prevention
Impact of project on community:
Formal assessment of the impact of our teachings on the population was
difficult due to the short length of our project and the transient nature
of our audience In order to formally assess the impact of prevention
education one would have to continually provide teachings to a stable set
of individuals and assess factors such as BMI and blood pressure before and
after a continued set of teaching sessions Unfortunately this is not
something than cannot be accurately assessed in 3-4 weeks, much less with
teaching being provided to consistently different groups of people Our
ultimate attempts at assessing the diabetic community for barriers to
control of diabetes were unsuccessful due to poor patient cooperation as
well as difficult patient access Often inaccurate contact numbers are
provided by these patients for fear of immigration issues, especially by
those with illegal immigration status I do believe however, our goals of
providing diabetes prevention education were achieved and this knowledge
provided to this population will hopefully last much longer than our 4
weeks of
teaching I expect our sessions and handouts, combined with
continued preventive work by the clinic itself, will create a long-lasting
impact on this community
Impact of community and/or project on me:
Working with this community of migrant farm workers has been one of
the most enjoyable experiences I have had in medicine The population as a
whole is very humble and considerate, unlike any other population I have
ever seen The opportunity to work with such a pleasant group of people
instilled in me a great drive to help To also know that my skills are
truly needed makes me want to continue working with this group all the
more In fact, I plan to continue traveling out to Sodus to help eliminate
language barriers and continue to teach about preventable diseases of which
they are likely not aware
Before beginning this project I knew this population was largely
uneducated I was not aware however, of how uninformed they were of
medical illnesses Many times upon asking if anyone had heard of diabetes,
several people told me they had never heard of this disease which was
extremely surprising to me The need in this population for health
education made me realized how
gratifying it is to provide help and
education to those who are truly in need This experience not only helped
me learn about the needs and disadvantages of migrant farm workers but it
also helped re-emphasized the overall need for primary prevention services
Appendix:
Contacts:
Finger Lakes Migrant Health Care Project:
Contact: Telva Olivares, MD
Email: Telva_Olivares@urmcrochesteredu
Contact: Terry Yonkers, NP - Diabetes Program Coordinator
Phone: 315 483-1199
Contact: Terry Clark, RN
Phone: 315 483-1199
Contact: Beverly Sirvent, In-camp coordinator
Phone: 315 483-1199
Wayne County Diabetes Coalition:
Contact: Sharon Morano
Phone: 315 331-8415
Rural Opportunities Diabetes support group location:
Contact: Carlos Rodriguez
Phone: 315 483-9151
Patient Handout:
Spanish
Page 1
Page 2
Patient Handout:
English
Page 1
Page 2
Citations:
———————–
[i] Hogan P, Dall T, Nikolov P; American Diabetes Association Economic
Costs of Diabetes in the US in 2002 Diabetes Care
2003;263:917-932
[ii] wwwcensusgov
[iii] Center for Disease Control and Prevention Morbidity and Mortality
Weekly Report Health Disparities Experience by Hispanics - United States
2004;5340:935-937
[iv] Centers for Disease Control and Prevention National diabetes fact
sheet: general information and national estimates on diabetes in the United
States, 2003 Rev ed Atlanta, GA: US Department of Health and Human
Services, Centers for Disease Control and Prevention, 2004
[v] Guendelman S Wagner TH Health services utilization among Latinos and
white non-Latinos: results from a national survey Journal of Health Care
for the Poor Underserved 2000;112:179-94
[vi] DeNavas-Walt C, Proctor BD, Lee CH US Census Bureau, Current
Population Reports, P60-229, Income Poverty and Health Insurance in the
United States: 2004 US Government Printing Office, Washington, DC, 2005
[vii] United States Department of Labor National Agricultural Workers
Survey NAWS 2001-2002
[viii] United States Department of Labor National Agricultural Workers
Survey NAWS 2001-2002
[ix] New York State Department of Health Wayne County Local Health
Department Community Health Assessment 1999-2004
[x]
wwwdiabetesorg/for-health-professionals-and-scientists/CVDjsp
