Catherine Chesla, Professor & Shobe Endowed Chair University of California, San Francisco

1. Developing Diabetes Interventions for Chinese Immigrants using Community Based Participatory Research Catherine Chesla, Professor & Shobe Endowed Chair University of California, San Francisco

2. Background Research Families caring for person with schizophrenia– NRSA Pre-doc Families caring for person with Alzheimer’s Disease– NRSA Post-Doc Interpretive Study of Clinical Expertise in Intensive Care Nursing, Helene FuldHealth Trust, Benner, PI 2-R01’s NIDDK Model-testing & interpretive study of T2DM in Whites, Latinos, African and Asian Americans Fisher PI Chesla Co-PI 1 R01 NINR– Comparative interpretive study of Foreign-born and US born Chinese Americans with T2DM Chesla PI Skaff, Mullan & Fisher Benner

3. Common Themes in Past Research • Multidisciplinary • Multi-method work • Interpretive • Model testing + Interpretive • CBPR + Clinical Trial • Team science • Directed to diverse populations • Family focused

4. Chinese Family Diabetes Education Project • Overview • Develop and test a culturally-adapted cognitive behavioral intervention to improve type 2 diabetes management among Chinese American immigrants. • Utilized community-based participatory research (CBPR) methods. • Timeline: June 2008-March 2012 NCE 2013 • Funding: National Institute of Nursing Research, National Institutes of Health (1R01NR010693)

5. Chinese Family Diabetes Education Project • Specific Aims • Strengthen academic-community partnerships with the Chinese American immigrant community in SF to improve diabetes management. • Adapt and test a cognitive-behavioral diabetes management intervention to address family and cultural issues in Chinese American immigrant patients with type 2 diabetes • Disseminate study findings via the community-academic partnership to the Chinese American immigrant community.

6. Academic Partners Community • Donaldina Cameron House • Historically significant social service agency in SF Chinatown, Est. 1874 • North East Medical Services • Largest CHC in US to serve immigrant Asians • Community Advisory Board • School of Nursing –University of California, San Francisco • Psychology Department- University of San Francisco

7. Academic & Community Partners • University of California, San Francisco • Catherine Chesla, RN, PhD, PI • Catherine Waters, PhD; Joe Mullan, PhD, Co-I • Christine Kwan, PhD, Project Director • University of San Francisco • Kevin Chun, PhD, Co-PI • Donaldina Cameron House • Yulanda Kwong, MSW, Clinical Supervisor • Diana To, LMFT; Tina Shum, BSW, Interventionists • North East Medical Services • Lydia Hsu, RN, Supervisor Rudy Kao, LCSW • Peggy Huang, RN, CDE, Consultant

8. Chinese Family Diabetes Education Project • Rationale • Asian Americans are one of the fastest growing ethnic groups in the U.S. (U.S. Census, 2010) • Asian Americans represent over 33% of San Francisco’s populace. • Chinese Americans are the largest Asian American group. • Chinese Americans’ risk for type 2 diabetes is 1.5-2x higher than for European Americans. • Risk for type 2 diabetes arises at lower BMI’s. • Chinese American immigrants face multiple cultural and family challenges in their diabetes management

9. Barriers to Health in Asians • Ethnic minority status (sometimes associated with) • economic hardship, perceived discrimination and prejudice, lack of transportation, low community awareness of health care services and resources • Cultural issues • Health conceptions, unfamiliar treatment prescriptions, alternative help-seeking pathways, loss of face and social stigma • Health agency characteristics • limited hours of operation, inconvenient location, and lack of bilingual, culturally competent and ethnically similar providers • Acculturation Status

10. Acculturation • Definition: contact between independent cultural systems, leading to adaptation involving value systems, relationships and behaviors • Multidimensional and dynamic • Acculturation modes: • Biculturalism Separation • Assimilation Marginalization

11. Bicultural Skills • Skills of working between two (or more) worlds • Evidence –minimal- that these skills can be fostered with direct interventions • Latino families (Bacallao & Smokowski, 2005) • Chinese immigrant parents and teens (Ying, 2009) • Our effort: To use cognitive-behavioral approaches to teach family and bicultural skills for managing type 2 diabetes in complex social settings.

12. Conceptual Model of Treatment

13. Principles of Community Based Participatory Research • Conducted by, for ,or with community • Collaboration, equal power sharing • Social justice over objectivity • Locally generated, locally responsive • Community involved in all phases of work

14. Roles and Relationships

15. The Chinese Family Diabetes Education Project • What are “best practices” for culturally-adapting a standardized intervention protocol? • Current study relied on: • Published clinical guidelines for work with Chinese Americans • Prior interpretive study of this population regarding personal and family challenges to living with type 2 diabetes. • Extensive clinical knowledge of Chinese American immigrant groups.

16. Chinese Cultural Norms and Values Chinese Cultural Worldviews & Values Guiding Cultural Adaptation

17. Cultural Adaptation Process • All partners were trained in original protocol by Dr. Margaret Grey’s team. • Partners systematically reviewed each session for cultural-appropriateness and family-centeredness. • Partners generated cultural metaphors for teaching didactic materials. • Partners adapted skill building processes to be culturally appropriate. Emphasized “bicultural skills”, “Chinese-Western Combined” (中西合璧)

18. Chinese Family Diabetes Education Project Time 1  Time 2  Time 3  Chinese Coping  Time 4  Time 5 Skills Training Participation timeline (Week) wk 1 wk 8 wk 16 wk 17-22 wk 24 wk 32

19. Chinese Family Diabetes Education Project • Chinese Coping Skills Training (CCST) • Six weekly group sessions (6-10 members per group) • Primary goal:To strengthen immigrants’ abilities to address family and cultural challenges in managing their diabetes and health in different cultural settings.

20. Cultural Adaptation in the Course Introduction Group leaders use Chinese-specific forms of joining and establishing rapport: Establishing credibility of the leader, her experience and knowledge about what is to be covered. Careful explanations about social learning skills versus exclusive focus on disease management skills. To encourage openness to learning new skills in older age —cultural saying, “one continues to learn as one grows older.” ( 活到老 ，學到老。) Added a session regarding diabetes management after the pilot study

21. “Chinese-Western Combined” • Emphasize the bicultural features of CCST training • Health care, and life involve Chinese background and U.S. cultural background • Toolbox of skills for both cultural environs • Examples of celebrities: Yao Min, YoYo Ma, Ang Lee, who have combined old and new • Goal is to improve health care and overall quality of life • 中西合璧

22. Chinese Protocol Examples of Cultural AdaptationProblem Solving Original Protocol • 7-9 Problem solving steps • Most examples were diabetes related • Role play scenes were of diabetes management • Steps simplified to 6 • Many examples family related • Role plays were of family roles Examples • Responding to MD • Types of rice for dinner

23. Chinese Protocol Example of Cultural Adaptation: Communication Skills Original Protocol Types of Communication • Aggressive • Assertive • Indirect • Passive Types of Communication • Aggressive • Assertive • Passive

25. Communication Handout --

27. Sample Description

28. Analysis • Multilevel regression models (hierarchical linear models) • Piecewise time segments were fit to examine within-person change over time; assessed immediate change from pre to post treatment (T3-T4) and maintenance of change post treatment (T4-T5), adjusting for T1-T3 change • Unconditional models and models adjusted for controls were essentially unchanged. Controls: Age, gender, educational level, number of years in US, acculturation level, disease duration, disease treatment type

29. Analysis Piecewise models were specified in 2 ways for each outcome: • Deviation-slope model: to determine the extent to which T3-T4 and T4-T5 slopes were deflected from T1-T3 slope • 3-consecutive-slope model: separate slopes were modeled for the 3 consecutive time periods (T1-T3, T3-T4, and T4-T5) to determine whether slopes were different from zero at each time span.

30. Family Emotional Support

31. Diabetes Self-Efficacy

32. Results: Deviation-slope Model aDiabetes Knowledge was assessed at T1, T3, and T4 only. bHemoglobin A1c was assessed at T1, T3, and T5 only. The estimates reported here correspond to a T3-T5 time segment.

33. Results: 3-consecutive-slope model aDiabetes Knowledge was assessed at T1, T3, and T4 only. bHemoglobin A1c was assessed at T1, T3, and T5 only. The estimates reported here correspond to a T3-T5 time segment.

34. Satisfaction and Acceptability • Chinese Coping Skills Training – Overall Satisfaction Retention rate: 81.5%; 100% retention once treatment began.

35. Dissemination-- Community

36. Discussion • First behavioral diabetes management intervention developed for Chinese in the US. • Our approach can be a model for using CBPR for cultural adaptation of evidence based practices with other ethnic groups • Satisfaction and retention suggest processes of cultural adaptation were successful. • Community response to dissemination activities has been very positive. New partnerships proposed with other researchers and other community agencies.

37. Discussion • Did the culturally adapted intervention make a difference? • Intervention was effective in personal and family realms • Positive & (short term) stable change for personal and most family constructs examined • Diabetes psychosocial outcomes were also positively affected, particularly diabetes distress, and DQOL • Sample had reasonably good HbA1c on intake (mean was ~7) thus limiting possible change

38. QUESTIONS