Challenging Dogma - Fall 2008

Friday, December 12, 2008

The Un-fulfilled Goals Of National Diabetes Education Program Towards Limiting Racial Disparities In Diabetes Prevention- Monica Gupta

Introduction to Diabetes and NDEP

In the last twenty years, diabetes has rapidly become global problem for all races and all types of people. There are approximately 117 million people who are suffering from and living with diabetes making it a world wide epidemic (1). Of this, 8% of the American population has diabetes (2). Although the cause of diabetes is still unknown, certain environmental and behavioral factors have been linked to diabetes. The general population’s increase of obesity is though to be a principal explanation behind the cause of rising prevalence. While non-Hispanic white Americans, age 20 or older, have a prevalence of 8.7%, racial minorities have higher prevalence’s, with 13.3% among non-Hispanic blacks and 12.8% among American Indians. The prevalence of Hispanic/Latinos populations is not known, but with Mexican Americans there is about a 9.5% prevalence among adults 20 years of age or older. The prevalence among other minorities is unknown but there are signs that groups such as Asian Americans and Pacific Islanders have twice the risk of developing diabetes when compared to non-Hispanic whites(2).

Albeit its origins are still medically unknown, there are many ways to control and limit the effects of diabetes on individuals. To help spread the knowledge, there is the federally funded National Diabetes Education Program (3). This organizations works to continue to promote public awareness and educate people about diabetes symptoms, facts, treatment, and general lifestyle changes that can be made to help reduce the risk of illness (21). One of the fundamental purposes is to reduce racial health disparities in groups that are heavily burdened by diabetes. However, even with its good intentions, the program lacks cultural integration and chooses to ignore social outlets that would help spread the public health message much more effectively. If there were changes made, and money and time directed to a more wide spread reach, there ability to change communities would become promising.

Argument 1: Not as culturally friendly as intended.

NDEP is part of a large national movement to educate the public on who may be at risk for diabetes and about the threat to their health. This means addressing people of all races, whose origins span all the 195 countries (4). Therefore, NDEP has made a strong effort to connect itself with as many multi-racial organizations possible, such as Association of American Indian Physicians, Black Women’s Health Imperative, and National Alliance of Hispanic Health (3). However, even with these partnerships, there are inherent problems. One of the initial issues is that this organization hopes to encourage awareness among Asian Americans and Pacific Islander, and yet there is no sufficient data about their prevalence (5). What is reported are estimates based on incomplete data. If the goal is to promote change, there is a primary necessity to have done the surveillance and find out how much of the each groups are affected. Increased research is needed on minorities so that NDEP may build better programs for the groups in question (22). There is a barrier to health care services that women and men of color face on a daily bases and to help emphasize the importance of risk of diabetes among minorities to health care workers, the data is needed to share with them as well (6). Without a strong base on the problems and issues of where diabetes stems from in minorities, it will be difficult to make behavioral changes in individuals, much less groups.

While many ethnic minorities are under-educated, there is also significantly large group who are very educated and take censuses and statistics into consideration before making behavioral changes (5). The program tries to grasp for attention with its facts and statistics, however it is incomplete. It is imperative that the data is gathered and reported so that minorities may have an accurate view of how their environmental and behavioral factors affect their risk of developing diabetes. Many minorities are also mistrustful of the health care system and need more support to make changes in their lives (24). They are biased and have fear for the health care system which has not always been kind to them and their needs, may it be here in the US or in other countries. This data will help gather information on not only who to target, but what practices are best for each of the different groups and help bring a strong, more cohesive prevention plan into action

The website does try to include many minority groups by translating a handful of its most important brochures’ in to various languages such as Spanish, Tagalog, Hindi, Chinese, and a dozen more so that they may be read by all people (8). However, information that is provided is not adjusted accordingly. They are straight translations from the English version, which does not adjust for the different cultural understandings that is necessary when translation for medical purposes (9). Cross-cultural testing requires translations that adapt to different communities mentalities and linguistics. The multiple language versions are not fitted for their target population, which is an important step in translation that has been skipped (9). Factors such as educational background have not been taken into consideration, and can lead to brochures that are unhelpful to the population being targeted (10). It is evident that the website was created to help physicians assist their patients with brochures in their native language; however these ill translated texts could instead further hamper the care patients receive (24). This translation issue is a failure that undermines the programs goals to reduce racial barriers to better health care.

Argument 2: Lack of knowledge of history of woman and ethnic food

Along with the lack of data and sufficient translations, NDEP fails to help reach out to the many racial communities by failing to be sensitive to the history of the various groups and how it now affects the way people act towards their health. Although these minorities currently reside in the United States and therefore have some differences in health outcomes than from their counterparts in their native countries, there are a lot of traditions that do not change (23). NDEP fails to educate caregivers about the difference’s that will be seen depending on if they woman is a Hmong from China, a Black refugee, an illegal Hispanic, Catholic, Hindu, or Muslim. The mental status of each of these women will differ and therefore require different types of interventions, even within each group (11). Their health care outlook is affected by their ability to seek help and their responsibilities to primarily care for their family and then themselves (12). NDEP needs to provide more information so that these women, who may not be internet savvy and unable to find additional information online, are able to receive the information from caregivers and community outreach programs that depend on NDEP for adequate information.

One of the key features to reducing diabetes is with weight loss and prevention of obesity. Along with exercise, the NDEP promotes eating well which relies on many changes for patients such as decreasing sugar intake, decreasing carbohydrates, and increasing fruits and vegetables (7). The list and information is a positive starting point, however, it completely fails to consider the ethnic differences in food choices. Because of the heavy dependency on self-management among diabetes interventions, it is essential that all the information is provided so there are options on how to change to manage the disease (13.) The recipe and meal planner provided by NDEP lacks ethnic specific plans. It offers very generic advice with recipes that are not adjusted for minorities whose main meals are very different from an ‘American’ meal and who are not familiar with the options given. Groups may become fearful of what is recommended if they believe that the caregivers are forcing them to choice between a way of life and tradition and a living longer (24, 25). What is needed is, at the very least, links to sites that do offer more information. If patients do not have this information, they are more likely to fail making changes and unable to save themselves from future problems.

Argument 3: Do not use media to full potential

Minority children in America are at a higher risk of becoming obese and this extra weight could put them at an increased risk of developing diabetes. The change in weight is mainly due to the decrease of exercise, and the increase of sedentary activates such as watching television (15). Both the adults and children of minorities spend more time in front of the television than non-Hispanic white’s do, putting them at risk to be more prone to behavioral factors that affect their health. They are also highly influenced to make unhealthy choices based on the norms shown through the regular programming and advertisements (16.) One resource NDEP has not used is the media, targeting specific minorities according to different broadcasting stations. There are stations such as Zee TV, TvAsia, CTV, TV Japan, and Telemundo which are watched by thousands of minorities’ nation wide and where there is an automatic large community that can be communicated with ease. Some of these people are also part of a hard to reach community that lack health insurance and are not well connected with a primary physician who would help care for the diabetes (26). Many of these channels are watched so that the audience may continue to have a connection with their culture, and therefore watch many different types of shows. The media is a strong influence for all types of SES, where norms are represented through news, soap operas, shows, and advertisements (16). It instead could be used to help promote health lifestyle and bring awareness through well made advertisements, documentaries, and enjoyable programs that bring diabetes to greater attention (17). With the help of social marketing, the media can support positive health outcomes and change the prevalence for the future (26).

Along with using media and creating PSA’s for international channels, there is a need to present information efficiently. Currently NDEP’s method of choice is to be sent out the same material repeat, and ‘blasting’ the target population with paper and emails (18). However, this has been shown to not be helpful in the long run, and instead the over exposure can lead to indifference to the topic (19). This was observed among a younger, new generation of homosexual men, who have become immune to the threat of HIV and AID’s, thanks to the past twenty years of injecting fear into their minds. Their new attitude is very much que sera sera and they are indifferent to HIV. While the facts are important, it is also important to not preach, instead somehow draw attention to the benefits of changing behavior in general (20). Changes need to be made to increase the effectiveness of each outreach program and spend more time tailoring them specifically to the type of technology being used. The NDEP site is currently also difficult to get around, and has room for improvement. Programs which are heavily depended on websites should be easier to maneuver around than this one is. This website is not user friendly and takes to much time and knowledge to search for and download relevant information in various languages and for different groups (18). While it is on the agenda for future plans, for now it is difficult for minorities to initial get on the internet, and then to maneuver the website is beyond some of their capabilities. In the future, if technology is going to be used as the primary location for interventions, the communities being targeted should be taken into greater consideration.

Alterations to NDEP:

Even with all of the problems that plague NDEP’s website, the ability to fix it self is possible. As mentioned earlier, there are a couple of options to start off with. One of the easier routes is to add information to the site, and to make it easier to search for. The first change has to be to the “Recipe and Meal Planner Guide” (7). The plan needs to include other ethnicities recipes, and adjust their staples of different types of carbohydrates, meats, vegetables, and drinks into consideration. A link to American Association of Physicians of Indian Origins website is a must (14). AAPI has a very detailed diabetics guide to food that is not only specifically made for patients of Indian origin, but it is also specific to the many different regions and cultures of India who have different daily traditions for food and cooking. It will add to the database so diabetics have more than seven meal options. It has everything from breakfast, lunch, and dinner, but also snacks and restaurant food. It evaluates the different choices, the nutritional pros and cons, and gives advice on how to change each and every meal so that people now have incredibly specific information that fits their needs. The snack replacements for traditional Indian snacks and sweets show how high in carbohydrates and calories these mini meals are. This very detailed and lengthy AAPI Nutrition book is a must that needs to be distributed by doctors or diabetes organizations to patients of South Asian descent. It clarifies misconceptions that stem from hundreds of years of cooking with the inability to find healthier ingredients. These are adjustments that few nutritionists would know to recommend; hence making patients visit’s frustrating.

There is also a list of meal planning for various other Asian groups, such as Chinese, Khmer, Korean, and Vietnamese, which can be found on the King County, Washington Public Health website (27). This site has the different Asian regions split by culture, and offers meal planning and recipes, written and translated in the language of each group. This, like the AAPI guide, is useful to individuals from specific regions as well as could be beneficial to all diabetics who are put onto new diets and who might need help learning to cook for meals 365 days a year. The seven recipes currently offered by NDEP is a ridiculously small list that needs to be updated immediately with the information presented. And none of this involves new work of developing the material. The information is ready to be distributed. However, NDEP does need to put it directly on their site, with easy access. NDEP should make an effort to make these meal planners and others like it one of the central points on their homepage so that the risk of diabetes due to obesity and high glucose levels may decrease. If people are not able to find the information through their doctors or online, there is no use of it even existing. Nutrition is an essential for diabetes control, and any education program should recognize advice on meals should not be hidden deep into the website, but easy to find and pleasing to the eye, as well as the stomach.

Along with meal planner, which is change that can be made with out great difficulty, there is the bigger problem of the lack of sufficient data on minorities and diabetes. This is a surveillance and reporting problem that may be beyond NDEP’s reach, however they should encourage the CDC and Department of Health and Health Services to start the collecting the information. Any data that is collected will be helpful compared to what is currently available (22). Data on prevalence, age of incidence, gender differences, and obesity rates among minorities who have diabetes is needed. Much of this information can come from records that physicians already have. Although this requires a large scale reporting, it is necessary. This could be done through the physicians and hospitals, but it could also be done through the patients themselves. NDEP officials could use the community centers such as churches, temples, local minority organizations to compile the data.

Once this initial information is available, the CDC and NDEP will be able to provide it on their websites, to doctors and other caregivers as a solid mathematical evidence of risk to different individuals. Of course, further information would be beneficial, to compare the different SES, cultural differences among minority groups, and what other underlying factors may affect different types of groups’ risk (5-11). There are a lot of possibilities, and while many hours of work and money need to be invested in this project, it is feasible, It will help educate and save thousands of people who are currently sitting in a gray zone, where they know they are at risk, but not really how much or why.

If these two previous issues are resolved, and NDEP has made progress towards achieving some sort of racial equality on diabetes education, the next big step could be to help with outreach through the multinational radio and television channels. Some of mentioned programs are based in the US and some are not. More advertisement needs to be made, based on who is at risk and what steps should be taken to help individuals and families with diabetes (17). Advertisements will have actors based on the race/ethnicity being targeted, speaking the various languages spoken, with representation in traditional and western clothes, as well of the multiple religions that may come from each country. A PSA message on Telemundo would have to target native Mexicans new to America, Mexican Americans born in America, Indigenous Mexicans in America, Catholics, and the rest of the diverse Latin Americans that watch those programs. The same goes with other channels such as TV Japan. It would target older Japanese who may be very traditional, all the way to young Japanese who may be much more western but still watch TV Japan. This could result in many different variations of the same message, but it is will help bring out the message that Diabetes is problem for the community and people need to acknowledge and address the disease.

Program Overview:

Even though diabetes is a chronic disease that affects millions of people worldwide, in the United States there are not enough high quality preventions being done for minorities. Health disparities will continue to be a problem due to not enough data being collected on the affected groups, the lack to knowledge of different cultures and their preferences due to different backgrounds, and the inability for public health to use all of the resources present. For diabetes to be controlled any time in the future there needs to be mass culturally sensitive public health measures put into place that go beyond the doctor’s office. People need to be educated about the risk from childhood and encouraged to have healthier lifestyles that can not only help prevent diabetes, but various other aliments as well. While there is a lot of work that needs to be done, large steps have been taken with the start of organizations such as the NDEP. The CDC is on the right track to change the faces of diabetes. The alterations that have been discussed are all steps in the right directions to help reduce health disparities as well as help educate minorities. If now only the issues of lack of health care and financial woes could be removed, great changes could happen.


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