Latinos with Diabetes The Stanford Self Management Model and Reflections from the Field

1. Latinos with Diabetes The Stanford Self Management Model and Reflections from the Field Sonia Alvarez, MA, MPH Training Director Stanford Patient Education Research Center March 3, 2011 Stanford Geriatric Education Center – 2011 Webinar Series Care of Diverse Elders and their Families in Primary Care

2. Latinos with Diabetes • Topics for this presentation: • Stanford’s “Manejo Personal de la Diabetes” Program • Stanford programs: Main Features • The Evidence: Randomized Trial Outcomes • Latinos and Diabetes: Spiced up cultural competence • Final Comments

3. Latinos with Diabetes • Stanford’s “Manejo Personal de la Diabetes” Program • Six session (2.5 hour each week) community based Diabetes self management workshop • Led by trained and certified Peer Leaders • Training materials created and written in Spanish • Meets content standards of the American Diabetes Association and the American Association of Diabetes Educators • Topics: Monitoring, Healthy eating, exercise, stress management, difficult emotions, communication, prevention of complications, working with the healthcare professionals, etc • (Patient Education Research Center. Programa de Manejo Personal de la Diabetes Manual de Instructores (Revised) Palo Alto, CA: Stanford University; 2009)

4. Stanford programs: Main Features • Start from systematic inquiry into the needs of patients • Seek expert knowledge of doctors, nurses, health educators, nutritionists and other health care professionals • Highly structured training protocols and carefully scripted manuals • Evaluated in randomized trials for long term outcomes • Interactive teaching techniques • Techniques to increase “self-efficacy”

5. Stanford programs: Core Principles • Theoretical foundation: Albert Bandura’s Social Learning Theory and “self’efficacy” construct • People with diabetes share concerns and problems • Must deal not only with the disease but also with the emotional impact it has on their lives. • Lay people with diabetes when given a detailed manual can facilitate the program as effectively, if not more effectively than health professionals • The process is often more important than the subject • Bandura A. Self-Efficacy: The Exercise of Control. New York: WH Freeman; 1997.

6. Where is the Evidence? • 2002-2007 N= 533 • National Institute of Nursing Research • Intervention group versus usual care group improved health status, health behavior, self-efficacy, as well as fewer emergency room visits • At one year, the improvements were maintained • Lorig K, Ritter PL, Villa F, Piette JD. Spanish diabetes self-management with and without automated telephone reinforcement. Diabetes Care. 2008; 31 (3)

7. Implications for clinicians • Patients more engaged in management of their disease • Less symptomatic • Less distress • More confident in own ability • Less dependent – opportunity for partnership between provider and patient • Potentially, savings in healthcare costs

8. Working with the Latino Population: Spiced up Cultural Sensitivity • The need to contextualize participants’ behaviors, preferences and characteristics • Immigration issues: political / economic • Immigration issues: psycho-social • Multiculturalism: Social / economic, political, cultural realities • Culture and Class • Trust and “Personalismo” - the quintessential element

9. Spiced up Cultural Sensitivity • The need to contextualize participants’ behaviors, preferences and characteristics • Immigration issues: political / economic

10. Spiced up Cultural Sensitivity • The need to contextualize participants’ behaviors, preferences and characteristics • Immigration issues: psychosocial

11. Spiced up Cultural Sensitivity • The need to contextualize participants’ behaviors, preferences and characteristics • Multiculturalism: Social / economic, political, cultural realities

12. Spiced up Cultural Sensitivity • The need to contextualize participants’ behaviors, preferences and characteristics • Culture and Class

13. Spiced up Cultural Sensitivity • The need to contextualize participants’ behaviors, preferences and characteristics • Trust and “Personalismo” - the quintessential element

14. Spiced up Cultural Sensitivity • Closing Comments • What is strictly clinical? Socio-cultural nature of clinical encounters • Information is not enough • The process takes priority - Awareness • The process takes priority - Communication: Language and linguistics • The unique contributions of Promotoras de Salud (Peer Health Promoters, Community Health Workers) • Bilingual & Bicultural Personnel • Kleinman A. Eisenberg L Good B. Culture, Illness, and Care: Clinical lessons from anthropologic and cross-cultural research. 2006 IV (1)

15. Spiced up Cultural Sensitivity • Closing Comments • What is strictly clinical? Socio-cultural nature of clinical encounters • Corbin J, & Strauss A. Understanding work and care: managing chronic illness at home. San Francisco, CA: Jossey-Bass; 1988.

16. Spiced up Cultural Sensitivity • Closing Comments • Information is not enough

17. Spiced up Cultural Sensitivity • Closing Comments • The process takes priority - Awareness

18. Spiced up Cultural Sensitivity • Closing Comments • The process takes priority - Communication: Language and linguistics

19. Spiced up Cultural Sensitivity • Closing Comments • The unique contributions of Promotoras de Salud (Peer Health Promoters, Community Health Workers)

20. Spiced up Cultural Sensitivity • Closing Comments • Bilingual & Bicultural Personnel

21. Spiced up Cultural Sensitivity Thank You! Patient Education Research Center http://patienteducation.stanford.edu