Improving Diabetes Self-Care among Low-income Puerto Rican Adults

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1 Improving Diabetes Self-Care among Low-income Puerto Rican Adults Chandra Y. Osborn, PhD, MPH Assistant Professor of Medicine Division of General Internal Medicine & Public Health Vanderbilt University Medical Center C.Y.O conducted this research under a National Research Service Award (NIDDK F31 DK067022), and is currently supported by a Diversity Supplement Award (NIDDK P60 DK020593). The study was supported by an American Psychological Association dissertation award and a pilot grant from the Center for Health Intervention and Prevention at the University of Connecticut, Storrs, CT.

2 Background & Purpose Traditional diabetes self-care programs have been met with limited success in ethnic minority populations. Culturally-targeted group-based interventions have become increasingly popular. However, few have been theory-based and tailored to the needs of individuals within an ethnic group. Puerto Rican Americans have the highest prevalence of diabetes, are twice as likely to have a diabetes-related hospitalizations relative to to other Hispanic groups, and yet few intervention studies have been published on this population. PURPOSE: To develop and assess a theory-based, culturally-tailored diet and exercise intervention for Puerto Ricans with T2DM. 1

3 Theoretical Approach Benefits of a theoretical approach: More likely to change behavior Can specify and test the theoretical elements to determine whether, and why, an intervention had its intended effect The Information-Motivation-Behavioral skills (IMB) model has many of the active ingredients needed for developing culturally-tailored interventions that result in behavior change. Information Behavioral Skills Behavior Health Outcomes Motivation 2

4 IMB model of diabetes self-care Information about self-care, correct utilization, and adequate performance about the importance of performing self-care to prevent acute and chronic complications about heuristics and implicit theories concerning the performance of self-care Behavioral Skills Objective and perceived abilities (selfefficacy) for performing self-care behaviors Behaviors Performance of self-care behaviors Health Outcome Glycemic Control Motivation Personal Motivation: attitudes about the outcomes of performing and not performing self-care and the evaluation of these outcomes Social Motivation: perceptions of significant others wants/desires for patient-performance of self-care and motivation to comply with these; and practical, instrumental support for performing self-care 3

5 Culturally-tailored Content Most culturally-sensitive interventions use a group-based approach. Interventions should be adapted to both the culture and the individual within it. Individually-tailored, IMB model-based interventions have been effective in other disease contexts. We developed a culturally-tailored, IMB model-based, diet and exercise intervention for Puerto Rican Americans with T2DM and used an RCT to evaluate this intervention. 4

6 Hypotheses Primary: Compared to controls, participants in the IMB modelbased intervention would experience greater improvements on: Food label reading Diet adherence Exercise Glycemic control Secondary: Does the IMB model predict diabetes diet and exercise behaviors and, in turn, glycemic control in this sample? Structural equation models estimated the predicted pathways IMB model of diabetes self-care (diet behavior) IMB model of diabetes self-care (exercise behavior) 5

7 Intervention Design Barriers Communication w/providers Irrelevant info Language Literacy IMB barriers IMB Intervention Population-specific Medical assistant from community Culturally-sensitive info Native language Person-specific Worked at each patient s pace Enhanced IMB elements 90 Minute Single Session 6

8 IMB Intervention (Information) DIET What foods raise blood glucose The importance of: monitoring carbohydrates controlling portion sizes eating throughout the day EXERCISE Inactivity leads to complications Benefits of exercising Lifestyle activity is exercise 8

9 IMB Intervention (Motivation) Motivational interviewing (MI) was used to deliver all intervention content and enhance patient s positive attitudes and subjective normative support towards improving diet and exercise behaviors. The interventionist used the following MI strategies: Providing personal feedback Asking open-ended questions Engaging in reflective listening Affirming desirable behaviors Working at a patient s pace Negotiating realistic & attainable goals 9

10 IMB Intervention (Motivation) 7

11 IMB Intervention (Behavioral Skills) DIET Identify foods w/carbohydrates Read food labels Use portion control techniques EXERCISE Be active in an unsafe neighborhoods Add speed & additional movement to everyday behaviors 10

12 Hartford, CT 11

13 Measures Self-report: Demographics Food Label Reading Diet Adherence Exercise IMB Diet IMB Exercise Health outcomes: HbA1c 12

14 Analyses Baseline group equivalence: Categorical variables: Pearson s χ 2 Continuous variables: Student s t-test What was the intervention s effect on: Food label reading? ANCOVA Diet adherence? ANCOVA Exercise? ANCOVA Glycemic control? ANOVA w/interaction term Do the IMB elements predict behavior and, in turn, glycemic control? Structural equation models 13

15 Participation Flow Baseline N = 118 April 2005 Random Assignment 3 Months Intervention n = 59 Control n = 59 Follow-up n = 48 Follow-up n = 43 July

16 Randomization Group of Completers Baseline Characteristics Intervention n = 48 Control n = 43 Age, years Female, n (%) 38 (79) 30 (70) Education, n (%) 8 th grade 26 (54) 28 (65) 9 th -high school or GED 17 (36) 11 (26) high school or GED 5 (10) 4 (9) Employment, n (%) Employed 2 (5) 2 (5) Unemployed 17 (35) 16 (37) Disabled, unable to work 29 (60) 25 (58) Years lived in the United States Speaks only Spanish at home, n (%) 42 (81) 37 (79) English proficiency, 0=poor to 5=excellent

17 Randomization Group of Completers Baseline Characteristics Intervention n = 48 Control n = 43 Health insurance, n (%) 42 (96) 39 (91) Years diagnosed with diabetes Diabetes support/education group, n (%) Never 13 (27) 7 (16) <3 months ago 12 (25) 9 (21) 4-6 months ago 6 (13) 9 (21) 7-9 months ago 3 (6) 2 (5) months ago 4 (8) 3 (7) 1-2 years ago 7 (15) 7 (16) >2 years ago 3 (6) 6 (14) Perceived health status, 0=poor to 5=excellent Body mass index, n (%) HbA1c

18 Group Means Diabetes Self-Care Behaviors 4.5 ANCOVA Outcomes Adj. M F (1,88) Food Label Reading ** 2.86 Diet Adherence * 3.65 Exercise Food label- TX Arm Food Label- Ctrl Arm Diet Adh- Tx Arm Diet Adh- Ctrl Arm Physical Activity-Tx Arm Physical Activity-Ctrl Arm 2 Baseline Follow-up Assessment Interval 17

19 Glycemic Control 8.0 Cov x Grp: F(1, 87) = 4.42, p < t(42) = 2.05, p = Intervention Control t(47) = 2.76, p = Baseline Intervention Follow-up Control 18

20 Intervention Findings a trend towards increased physical activity What s needed? A longer intervention, or multiple follow-up sessions More exercise intervention content Compared to the control group, patients in the IMB intervention group were more likely to report reading food labels adhering to diet recommendations 19

21 Glycemic Control There was no statistically significant difference between the intervention and control groups. However, the intervention group s mean HbA1c decreased significantly. Reasons? Baseline HbA1c levels were near normal. Studies with normal pre-hba1c lack statistical power. Group differences are observed when pre- HbA1c is > 10%. Intervention impact appears to have varied according to baseline HbA1c levels. 20

22 IMB Model of Diabetes Self-Care (Diet Behavior) SELF-CARE Information χ2 (14, N = 118) = 25.83, p = 0.03 CFI = 0.90 RMSEA = 0.08 (90% CI: ).30*.19*.39** SELF-CARE Behavioral Skills Perceived easiness of performing self-care SELF-CARE Behavioral Skills Perceived effectiveness of performing self-care.42**.32* SELF-CARE Behavior * Glycemic Control (HbA1c) Attitudes.87*** SELF-CARE Motivation.39**.04.63***.56***.21 Subj. Norms.46*** Food Label Reading Diet Self-Care

23 IMB Model of Diabetes Self-Care (Exercise Behavior) SELF-CARE Information.07 χ2 (6, N = 118) = 2.56, p = 0.86 CFI = 1.00 RMSEA = 0.00 (90% CI: ).36* **.65 SELF-CARE Behavioral Skills Perceived easiness of performing self-care Perceived effectiveness of performing self-care.42 t.23 SELF-CARE Behavior Glycemic Control (HbA1c) Attitudes Subj. Norms.71***.36*** SELF-CARE Motivation.05 22

24 Exploratory IMB Model of Diabetes Self-Care (Exercise Behavior) SELF-CARE Information.06.21*.24**.06.53*** SELF-CARE Behavioral Skills Perceived easiness of performing self-care Perceived effectiveness of performing self-care.45*** SELF-CARE Behavior Glycemic Control (HbA1c) Attitudes.09.25** Subj. Norms 23

25 Model Testing - Findings IMB model: 46% of diet and 23% of exercise behaviors DIET: Information and motivation predicted behavioral skills, and behavioral skills predicted behavior. Only behavior predicted HbA1c. EXERCISE: Attitudes predicted behavioral skills, and behavioral skills predicted behavior. Behavior did not predict HbA1c. Model Testing - Future Directions Longitudinal research Account for moderators Health literacy Depression Acculturation Focus on certain IMB elements, or modify the model 24

26 Study Strengths Applied a new health behavior change model to diabetes self-care behaviors Developed an intervention for an understudied, high risk group that was implemented it in a clinic widely accessed by the target population Trained a medical assistant to deliver culturally-tailored content Developed new culturally-tailored materials Used a carve out approach that required limited resources, fit well within the ecology of the clinic and its procedures, and could be easily replicated elsewhere 25

27 Improving Intervention Efficacy Include a carve in approach Extend the contact time to > 90 minutes Offer more time, follow-up sessions, and/or phone calls Expand the content Allocate more time to exercise content Include SMBG and medication adherence Evaluate effectiveness for > 3 months Include a detailed assessment of diabetes co-morbidities Include family and peers 26

28 Collaborators Jeffrey D. Fisher, PhD K. Rivet Amico, PhD Noemi Cruz, RD, CDE Ann A O Connell, EdD Rafael Perez-Escamilla, PhD Seth Kalichman, PhD William A. Fisher, PhD Leonard E. Egede, MD, MS Scott Wolf, DO, MPH Volunteers Demetria Cain, MPH Matt Dudley, MA Research Staff Rosemary Perez Charlene Aponte Luis Casillas Andrew Dudley Ilira Ibrahimi Chariunis Perez Dietetic Internists Melissa Johnson, RD Jane Quale, RD 27

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