LA COMUNIDAD SANA

DIABETES PROJECT

This project educates the community on the nature of diabetes and its control, and intends to increase the rate of early detection and effective management of diabetes in the Hispanic communities of the Mid-Columbia. It seeks to further the development and implementation of an integrated, customized, culturally appropriate program to address barriers to care for Mexican-American farmworkers. Nuestra Comunidad Sana's participation is funded through a generous grant from the Meyer Memorial Trust. Major partners are our Medical Advisory Group, a collection of 17 health professionals and Hispanic diabetes patients, Dr. Bryan Gallagher, Medical Director for the project, the Mid-Columbia Health Trust, Skyline Hospital, La Clinica del Carino Community Health Center and Providence Hood River Memorial Hospital. Exercise classes are supported with the generosity of the Hood River Aquatics Center, the Hood River Sports Club, and The Dalles Sports and Fitness Center.

Description of the Project

La Comunidad Sana utilizes a collaborative approach linking NCS Promotores de Salud with current programs of other community health agencies to create a continuum of care for diabetes in the Hispanic community.

Project goals are aligned with newly developed state and national goals:

• Widespread public education on the nature of diabetes and the importance of detecting it early-on;
• Widespread screening for actual detection of diabetes;
• Effective referral for further evaluation and care.
• Educational outreach to patients and their families to support them in managing their diabetes.

Need for the Project

The Hispanic community faces significant barriers to care, including language, economics, racial discrimination, cultural limitations, and a limited understanding of the American health care system's expectations for patient/doctor responsibilities. Of these, the last is perhaps the most formidable with regard to diabetes. The typical Mexican approach to health care is to "give" the disease to the doctor to cure. But there is no cure for diabetes. The patient must be able to take primary responsibility for managing the disease if s/he is to avoid great suffering.

According to the ADA, 10.6% of all Hispanics regardless of age have diabetes, which is twice the general rate. In adults over 45, the prevalence of diabetes is one out of every four persons, which is three times the general rate. Those Hispanics who know they have diabetes have limited success controlling it; for instance, only half as many Mexican-Americans with diabetes-related hypertension have their blood pressure under control as does the general population (14% vs. 29%).

For a variety of reasons, it is more difficult to reach the Hispanic community than the Anglo community. As diabetes can progressively damage various body organs during its early, "silent" years when there are no outward signs, it is important not to wait until symptoms show up prior to detecting diabetes. Simple denial also plays a role in aggravating the complications of diabetes in Hispanics.

Hispanics who know they have diabetes and desire treatment have a much more difficult time obtaining care than does the general community. For instance, almost twice the percentage of Hispanics in Oregon (29%) have no health care coverage whatsoever compared to the general community (17%).

Anticipated Benefits from the Project

• Increased access to medical care for diabetes for the Hispanic population of the Mid- Columbia;
• Reduced suffering from the complications of diabetes;
• Fewer early complications from diabetes;
• Increased capacity in Hispanic patients to manage their diabetes;
• More effective provision of medical care to Hispanics;
• Decreased costs of care over the long term from more appropriate utilization of resources.

Plan of Action

To implement the project, we took the following steps:

1. Provided training and guidance to Community Health Promoters through collaboration with the ADA, qualified trainers, and our local Medical Advisory Group;

2. Provided community education and screening to the Hispanic community through field clinics where the community lives, works, and congregates;

3. Provided counseling and facilitated referrals to those who screen positive, in order to make sure clients understand the importance of treatment, and to actually get to a doctor;

4. Guaranteed access to care regardless of ability to pay through referral agreements with La Clinica del Carino and area private providers;

5. Supplemented case management services with home visits involving the entire family; and

6. Conducted family support groups for clients and family members to support them all in helping to manage the client's diabetes.

Assessment

We assess the effectiveness of the project by:

• Process evaluation of activity goals and number minimums;
• Pre/post evaluations for attendees of nutrition/exercise education classes;
• Patient monitoring through medical providers;
• Tracking clients in the program for use of acute care facilities at Providence HR Memorial Hospital, Skyline Hospital, and the Mid-Columbia Medical Center.

Economic impact of diabetes

• A minimum of 15,000 Hispanic seasonal agricultural workers arrive each year in the Mid- Columbia; another 8000 + Hispanics are "settled out" in the Mid-Columbia.
• The average Hispanic per capita income in the Mid-Columbia in 1997 was $7,909.
• The actual average agricultural annual wage in 1997 for all workers regardless of ethnicity in the Mid-Columbia was $13,055. The estimated average agricultural annual wage for Hispanic workers was $10,444.
• The percentage of Hispanic adults in the 3 Mid-Columbia counties possessing a high school diploma (or equivalent) is: Hood River Co. 10%; Wasco Co. 11%; Klickitat Co. 6%.
• In the United States, approximately 5% of the total population has diabetes, but 15% of all health care expenditures are related directly to diabetes. A similar proportion of costs has been demonstrated in Oregon. *
• Nearly 30% of the Medicare budget is used in treating diabetes and its complications. *
• Each person with diabetes in the United States results in over $6000 annually on average in direct medical costs. **
• Each person with diabetes in the United States results in an estimated additional $3380 annually on average for indirect costs, such as disability payments, time lost from work, etc. **
• Compared to non-Hispanic whites, the death rate from diabetes is 1.7 times higher for persons of Hispanic origin (and 2.4 times higher for American Indians). **
• Diabetes is listed as an underlying cause of death in over 8% of Oregon deaths in 1994. *

* Diabetes in Oregon: An Assessment Report (March 1997), Oregon Health Division.

* * "Closing the Gap" (February/March 1999), Office of Minority Health.