Culturally Competent Diabetes Self-Management Education for Mexican Americans: The Starr County Border Health Initiative (original) (raw)

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Diabetes Care. Author manuscript; available in PMC 2007 Dec 12.

Published in final edited form as:

PMCID: PMC2134805

NIHMSID: NIHMS33707

Alexandra A. Garcia, RN, MSN, Doctoral Candidate, Graduate Research Assistant, Kamiar Kouzekanani, PhD, Quantitative Methodologist, and Craig L. Hanis, PhD, Professor

Alexandra A. Garcia, School of Nursing The University of Texas at Austin;

Alexandra A. Garcia

School of Nursing The University of Texas at Austin

Kamiar Kouzekanani

School of Nursing The University of Texas at Austin

Craig L. Hanis

Center for Population Genetics, School of Public Health The University of Texas Health Science Center at Houston

Send correspondence to: Sharon A. Brown The University of Texas at Austin P.O. Box 7996 Austin, Texas 787012−1111 telephone: 512/471−2877 fax: 512/471−2827 e-mail: ude.saxetu.liam@nworbas

Abstract

Objective

To determine in Mexican Americans with type 2 diabetes the effects of a culturally competent diabetes self-management intervention.

Research Design and Methods

A prospective, randomized, repeated measures study was conducted on the Texas-Mexico border in Starr County. 256 randomly selected persons with type 2 diabetes were: (1) between 35 and 70 years of age; (2) diagnosed with type 2 diabetes after the age of 35 years; and (3) accompanied by a family member or friend. The intervention consisted of 52 contact hours over 12 months and was provided by bilingual Mexican American nurses, dietitians, and community workers. The intervention involved : (1) 3 months of weekly instructional sessions on nutrition, self-monitoring of blood glucose, exercise, and other self-care topics; and (2) 6 months of biweekly support group sessions to promote behavior changes. The approach was culturally competent in terms of language, diet, social emphasis, family participation, and incorporation of cultural health beliefs. Indicators of metabolic control (HbA1c and FBS), diabetes knowledge, and diabetes-related health beliefs.

Results

Experimental groups showed significantly lower levels of HbA1c and FBS at 6 months and at 12 months and higher diabetes knowledge scores. At 6 months, the mean HbA1c of the experimental subjects was 1.4% below the mean of the control group; however, the mean level of the experimental subjects was still high (over 10%).

Conclusions

This study confirms the effectiveness of culturally competent diabetes self-management education on improving health outcomes of Mexican Americans, particularly for those individuals with HbA1c levels above 10%.

Keywords: type 2 diabetes, metabolic control, diabetes self-care, diabetes self-management education

The four Texas-Mexico border counties located in the Lower Rio Grande Valley (LRGV) are predominantly populated by Mexican Americans and have the highest diabetes-related death rates in Texas (1). In some areas of the LRGV, type 2 diabetes affects as much as 50% of the Hispanic population over 35 years of age (2). Mexican Americans tend to be diagnosed with diabetes at younger ages and exhibit higher fasting glucose levels, decreased insulin sensitivity and increased insulin response, and more severe forms of diabetes complications (3-5). Native American genetic admixture has been linked to type 2 diabetes in Mexican Americans, perhaps contributing to ethnic differences in rates of energy expenditure and obesity and in patterns of body fat distribution (6,7).

In addition to genetic influences, evidence of the importance of environmental factors in the development and treatment of type 2 diabetes has been mounting for years. While it is estimated that approximately 40% of the “variability in BMI is related to genetic factors involved in the regulation of food intake and/or volitional activity”..., the “most likely successful therapy for obesity may target pathways of the regulation of food intake and an environment favouring engagement in physical activity...” (8). Physical activity is thought to play a significant role in the prevention of obesity, and perhaps diabetes, in genetically susceptible populations, such as Native Americans, Mexican Americans, and African Americans (9). Other environmental factors, some of which are modifiable and amenable to intervention, also have been implicated—low socioeconomic status, access barriers to health care, diet, and lack of education about health and using healthcare systems (9).

Lifestyle self-management and medical treatment resulting in tight glucose control has been shown to delay the onset of or reduce diabetes complications by 50% to 75% (10,11). Lifestyle self-management is most effective when augmented with careful medical supervision and a patient well educated in lifestyle behaviors (12). For Mexican Americans, the largest Hispanic subgroup, achieving glucose control reportedly has been difficult, because they are more likely to rely on family and curanderos (folk healers) for health advice; to lack transportation to health care facilities; to be isolated from mainstream culture; to consider family needs as more important than their own personal needs; and to experience language differences with health care workers (13). Culturally competent approaches, however, rarely have been investigated or employed in clinical or community settings; and traditional interventions have been ineffective. As a result, Hispanics in some locales have been labeled “noncompliant” and have been treated with insulin more often than persons from other cultures (4).

For 10 years, we have tested culturally competent diabetes self-management education interventions that meet national standards for diabetes care and that address specific cultural characteristics of Mexican Americans. This paper describes the Starr County Border Health Initiative (1994−1998) and the effects of the intervention on metabolic control and other health outcomes. The primary null hypothesis that was tested in this study was: There will be no significant differences in metabolic control, diabetes knowledge, or diabetes-related health beliefs at 3, 6, and 12 months between subjects in experimental groups compared to subjects in one-year wait-listed control groups.

RESEARCH DESIGN AND METHODS

Design

Effectiveness of the intervention was examined with a prospective, randomized, repeated measures design. The design of the investigation was nested; that is, longitudinal observations were nested within subjects, and these subjects were nested within experimental or one-year wait-listed control groups who received usual care provided by their private physicians or local clinics. Because investigators deemed it unethical to withhold the diabetes self-management education from the control subjects, all participants, regardless of whether they were randomly assigned to experimental or wait-listed control condition, ultimately received the intervention. An important advantage of this approach is that we were better able to retain control group subjects because of their expectations of eventually receiving the intervention. The disadvantages were the costs in terms of money and time that were involved in providing the intervention to every study participant and delay in providing the intervention to the control subjects.

Setting — Starr County, Texas

Located on the Texas-Mexico border approximately halfway between Brownsville and Laredo, Starr County has a population of 52,618; 97.7% of the residents is Mexican American (14). The Texas border area is characterized by the presence of many colonias, which are unincorporated settlements on either side of the border distinguished by extreme poverty, pollution, and deprivation. Starr County is the poorest county in Texas and one of the poorest in the U.S. and is characterized by the highest unemployment rate in the State (24.4% compared to 4.6% for the State) and the lowest personal income. In 1998, estimated per capita income for Starr County residents was 8,225,comparedto8,225, compared to 8,225,comparedto25,369 for the rest of the State. In January 2000, all of Starr County was designated as a Health Professional Shortage Area and as a Medically Underserved Area (14).

Subject Selection and Characteristics

A total of 256 persons with type 2 diabetes were randomly selected for the intervention study from rosters of previous Starr County research studies; 128 were allocated to the experimental group and 128 were allocated to the one-year wait-listed (control) group. Previous research involvement of these individuals had been limited to annual blood sampling; none had participated in any intervention studies, neither pharmacological nor behavioral, so we did not consider them to be a contaminated sample. Approximately 64 subjects were recruited quarterly during 1994 through 1995 to constitute four cohorts; in each cohort 32 entered treatment groups and 32 entered wait-listed groups. Groups then were randomly assigned to experimental or control-conditions.

Subjects were required to be: (1) between 35 and 70 years of age; (2) diagnosed with type 2 diabetes after the age of 35 years ([a] two verifiable FBS test results of 140 mg/dl or above or [b] taking or have taken insulin or hypoglycemic agents for at least one year in the past); and (3) willing to participate. To capitalize on the importance that the Mexican American culture places on family and social relationships, each subject identified a family member, preferably a spouse or first-degree relative, who agreed to participate as a support person. If a family member was not available, a close friend substituted. Subjects were excluded if they were pregnant or had medical conditions for which changes in diet and exercise levels would be contraindicated.

Procedures

Experienced bilingual research office staff telephoned each potential subject. Willing subjects were grouped by area of the county in which they lived, thereby controlling for within-group differences in socioeconomic status. Written informed consent was obtained prior to collecting baseline data according to procedures approved by the two relevant University Institutional Review Boards. At all data collection sessions, 79% or more of the subjects returned for their examinations; overall average data collection retention rate was 90%. A mutually convenient time for the intervention sessions was negotiated with each group at completion of baseline data collection. For all data collection and intervention sessions, field office staff provided transportation when necessary.

Community physicians and other healthcare providers in Texas and in Mexico were contacted to gain support and to enlist approval for dietary and exercise recommendations for their patients who were participating. Data collection occurred as cohorts reached 3-month, 6-month, 12-month, and annual examination dates. Questionnaires were read aloud in Spanish to each subject in one-to-one interviews, thus avoiding subject embarrassment about reading ability. Many spoke a blend of Spanish and English, easily changing between both languages; so, questionnaires were stated in both languages (15). Data collectors were instructed to: (1) create a comfortable environment; (2) read questions aloud without leading subjects to desired answers; and (3) communicate non-judgmentally about perceived negative health practices (e.g., use of unusual folk remedies). Practice and random observations insured consistency in data collection.

Description of the Culturally Competent Intervention

The intervention has been described in greater detail elsewhere (16). An overview of the intervention is provided in Table 1. The primary emphasis was on providing an intervention in accessible community-based sites and offering activities that reflected cultural characteristics and preferences of Mexican American participants. The intensive instructional and support group intervention of 52 contact hours over 12 months was provided in the preferred language, predominantly Spanish with a blend of English, by bilingual Mexican American nurses, dietitians, and community workers from Starr County. Key elements included: (1) three months of weekly two-hour instructional sessions on nutrition, self-monitoring of blood glucose, exercise, and other self-care topics; and (2) six months of biweekly plus three months of monthly two-hour support group sessions to promote behavior changes through problem-solving and food preparation demonstrations. The approach was culturally competent in terms of language, diet, social emphasis, family participation, and incorporation of cultural health beliefs. For example, typical Mexican American dietary preferences were incorporated into dietary recommendations and food demonstrations were provided at each session, based on healthy adaptations of favorite Mexican American recipes. Dietitians led visits to the local grocery store to help individuals apply dietary information they had learned. Social support was fostered through support from family members and friends, group participants, the intervention team, and community workers.

Table 1

Characteristics of the Intervention

Note: Reprinted with permission from The Diabetes Educator.

The biweekly support group sessions provided opportunities for patients and family members/friends to meet in an informal atmosphere to discuss their problems in managing diabetes, express feelings about the impact of diabetes on the family, ask questions in a non-threatening environment, review previously-learned information and skills, and participate in cooking demonstrations. Also, group leaders emphasized support from family members and encouraged support persons to improve their health habits. Individual participants discussed their concerns and problems, and members of the group, facilitated by the nurse or dietitian, assisted each other in solving problems. For the final three months, group meetings decreased from biweekly to monthly in order to gradually “wean” individuals.

Groups received the yearlong intervention offered in schools, churches, county agricultural extension offices, adult day care centers, and health clinics located in Starr County. Eight trained community workers with type 2 diabetes from Starr County managed preparations for group sessions associated with intervention studies (arranged location, contacted patients and their families weekly, organized equipment/supplies, provided transportation when necessary, assisted dietitians with food preparation, etc.). Community workers assisted the nurses and dietitians and provided important linkages with the local Mexican American community.

Measures

Low literacy rates in this community may be compounded by vision changes caused by diabetes, so investigators minimized written materials. Primary outcomes were diabetes-related knowledge (reliability, _r_=.88) and health beliefs, glycosylated hemoglobin (HbA1c), fasting blood glucose (FBS), lipids, and body mass index (BMI) (17-19). Language-based acculturation was determined at baseline, primarily to explore the language history and language preferences of the subjects (20). Body weights were measured with a balance beam scale with individuals in street clothing and without shoes. Heights were obtained using a secured stadiometer. Body mass index (BMI) was calculated, weight [(kg)/height(meters)2]. Ten ml. of blood were drawn at baseline and at post-intervention intervals. FBS (10 hours fasting) was assessed with a desktop glucose analyzer (YSI Model 2300 STAT PLUS Glucose Analyzer). HbA1c was analyzed at The University of Texas-Houston (Glyc-Affin Ghb, Isolab Inc., Akron, Ohio). FBS and cholesterol testing was performed on-site in the field office; and, at each data collection session, results were reviewed with individuals before the end of their exam. Pre-breakfast and supper blood glucoses were measured by subjects three days per week with home monitoring devices provided by the project.

Data Analysis

Descriptive statistics were used to characterize the sample and to summarize outcome measures before, during, and after the intervention. Hierarchical Linear and Nonlinear Modeling software, HLM 5, was employed to perform individual growth curve (IGC) analysis, using multilevel models (MLM). The MLM consists of two stages: 1) a within-subject analysis to estimate the parameters of the IGC, and 2) a between-subject analysis to predict differences in the growth parameters (21,22). One of the major advantages of multilevel modeling is that it uses all of the available data for a given subject to estimate a growth curve for that subject (23). Thus, subjects with missing data were not eliminated from the investigation.

Since the primary purpose of the investigation was to examine the effects of the diabetes self-management education and support group intervention on a series of outcome measures, conditional models were tested. Specifically, the general two-level models were estimated by means of restricted maximum likelihood. The time variable, coded as 0 (baseline), 3, 6, and 12 months, was entered at level one. The intervention variable, coded as 1 for the experimental group and 0 for the control group, was entered at level two. The HLM 5 tested the intervention effect at baseline and over time.

To better understand the nature of the outcome measures which were significantly affected by the intervention (i.e., HbA1c, FBS, and diabetes knowledge), a series of univariate analyses of covariance (ANCOVA) was performed. Although random assignment of subjects had been implemented and there were no statistically significant baseline differences between experimental and control groups on the above variables, the baseline measures were treated as covariates to reduce systematic bias and error variance. Effect sizes were also computed, using eta squared, and .01, .l6, and .14 were used to indicate small, medium, and large associations, respectively (24). All analyses were conducted at the .05 level of significance.

RESULTS

The majority of subjects were female, obese, and, on average, in their mid-fifties. (See Table 2.) Individuals had elevated FBS and HbA1c levels, indicating poor metabolic control. Language-based acculturation scores were low, on average, indicating that the language of preference was Spanish; 90% of the subjects preferred Spanish and 78% spoke Spanish at home. Approximately 25% of subjects were on insulin alone or on insulin in combination with oral hypoglycemic agents. One-third reported using home remedies, such as herbal teas (e.g., teas from the chaya plant), garlic, aloe vera, etc., to lower blood glucoses (25).

Table 2

A Profile of Subjects upon Admission to the Study*

There were no statistically significant differences at baseline between the experimental and control groups on any of the outcome measures (Tables 3 and ​4). Over time, there were statistically significant differences between the two groups on HbA1c, FBS, and diabetes knowledge.

Table 3

Means and Standard Deviations for Outcome Measures

HbA1c = Glycosylated Hemoglobin

Table 4

Growth Curve Analysis of Outcome Measures

The series of univariate analyses of covariance (ANCOVA) indicated that the experimental group showed statistically significant lower measures of HbA1c and FBS at 6 months and at 12 months and higher diabetes knowledge scores at 3 months and 12 months, than did the control group. (Knowledge was not measured at 6 months.) (See Table 5 and Figures 2 through 4.)

Table 5

Trend Analysis of Significant Intervention Effects; ANCOVA Analyses Controlling for Baseline Measures

For a clearer understanding of the clinical significance of the changes that occurred in HbA1c, FBS, and knowledge, average improvements in each of these variables were explored. In the experimental group, the level of HbA1c was decreased by 1.2%-age points at 3 months compared to the baseline level; increased by .19%-age points and .09%-age points from the 3-month follow-up to the 6-month follow-up, and the 6-month follow-up to the 12-month follow-up, respectively. In the control group, the level of HbA1c decreased by .58%-age points from the baseline to the 3-month follow-up; increased by .98%-age points from the 3-month follow-up to the 6-month follow-up; and decreased by .56%-age points from the 6-month follow-up to the 12-month follow-up.

In the experimental group, the level of FBS was decreased on average by 23.4 mg/dl and 4.4 mg/dl from the baseline to the 3-month follow-up and the 3-month follow-up to the 6-month follow-up, respectively, and increased by 9.7 mg/dl from the 6-month follow-up to the 12-month follow-up. In the control group, there was a 6.1 mg/dl decrease from baseline to the 3-month follow-up, followed by a 14.0 mg/dl increase from the 3-month follow-up to the 6-month follow-up, and a 4.5 mg/dl decrease from the 6-month follow-up to the 12-month follow-up. Compared to the baseline, at the 6-month follow-up, the experimental group showed a 27.8 mg/dl decrease in fasting blood sugar level, while the control group showed an increase of 7.9 mg/dl. The same comparison at the 12-month follow-up showed an 18.1 mg/dl decrease in the experimental group and a 3.4 mg/dl increase in the control group.

In the experimental group, diabetes knowledge was increased by 5.2 items (14.4%) correct and 1.5 items (3.6%) correct from the baseline to the 3-month follow-up and the 3-month follow-up to the 12-month follow-up, respectively. In the control group, increases of 1.8 items (4.8%) correct were observed from the baseline to the 3-month follow-up and from the 3-month follow-up to the 12-month follow-up. One year after the initiation of the intervention, diabetes knowledge of the experimental and control groups increased by 6.7 items (18%) correct and 3.6 items (9.7%) correct on the diabetes knowledge scale, respectively.

No other variables besides HbA1c, FBS, and diabetes knowledge were shown to respond to the self-management educational intervention. Additionally, the influence of age and gender on the above outcome measures was investigated. Specifically, age and gender were treated as random and fixed variables, respectively, and were included in a number of multilevel models. Results were not statistically significant; therefore, it was concluded that the age and gender of study participants had not affected the outcome measures. In addition, we found no differences in rates of home glucose monitoring between subjects who were successful in reducing their HbA1c and those who were not.

DISCUSSION

The Starr County diabetes self-management education study demonstrated that, comparing experimental to wait-listed control groups, statistically significant changes were achieved in three health outcomes: 1) diabetes knowledge; 2) FBS; and 3) HbA1c. It has been known for some time that diabetes knowledge is a prerequisite to, but not sufficient for, achieving improved metabolic control. A 60-item instrument was developed specifically for Spanish-speaking border populations, such as the residents of Starr County. The data demonstrated that both experimental and control group subjects increased their diabetes knowledge during the one-year intervention. We believe that the increased knowledge of control group subjects might have resulted from the 4 data collection points (baseline and 3, 6, and 12 months). During data collection sessions, subjects' questions were answered honestly, regardless of whether subjects were treatment or control group participants. Investigators believed that it was not ethical to withhold information from the control group subjects during data collection. In addition, as each subject completed a data collection session, he/she was required to participate in an exit interview. The interview provided immediate feedback by reviewing results of each person's laboratory tests and other outcome data (e.g., weight, blood pressure). Results were interpreted, trends in individual outcomes were reviewed, questions were answered, and a written report of individual results was provided. These efforts to provide ethical treatment both of experimental and control group subjects likely resulted in increased knowledge of subjects in both groups. However, experimental subjects achieved statistically higher diabetes knowledge levels both at 3 months and at 12 months.

FBS and HbA1c showed statistically significant changes as a result of the self-management education intervention, particularly at the 6-month measurement period. Benefits of the intervention on FBS peaked at 6 months with an average differential between experimental and control group subjects of 29.8 mg/dl. For HbA1c, the baseline to 6-month change in the experimental group reflected a decrease by 1.0%-age points, while the control group's HbA1c increased by .4%-age points. In other words, there was a 1.4%-age point differential between experimental and control groups at 6 months. It should be noted that the mean HbA1c of both experimental and control group subjects began at baseline near 12% and remained above 10% throughout the study period.

The DCCT demonstrated that a reduction of 0.5%-age points in HbA1c resulted in a significant reduction in diabetes complications (10). With intensive therapy, a reduction of approximately 2%-age points in HbA1c was achieved in persons with type 1 diabetes, while the Starr County study demonstrated a 1.4%-age point decrease in type 2 diabetes with self-management strategies alone. The DCCT baseline HbA1c values were much lower (8.8% to 9.0% by cohort), compared to Starr County (11.8%). It is not clear how the advantages of reducing HbA1c from 9 to 7, as reported in the DCCT, translate to reducing HbA1c levels from 12 to 10, as reported in Starr County; but, these reductions may indeed be clinically significant from the perspective of reducing the risk of diabetes-related complications.

We currently are refining and testing our intervention to achieve more favorable outcomes. It should also be noted that the baseline to 12-month follow-up decrease in the experimental group was .92%-age points, and only .16%-age points in the control group, reflecting a slight abatement in the effects of the intervention as time passed. This is not an unexpected finding and perhaps suggests the need for booster self-management sessions and motivation strengthening strategies, though an optimal strategy has yet to be developed.

Initial improvements in BMI were seen in experimental subjects but, by 12 months, levels returned to baseline levels. This failure to maintain weight loss is typically seen in weight loss clinical trials (26); but improved metabolic control can be attained with a modest weight loss of 5% (27). Baseline levels of cholesterol and triglycerides were not that much above recommended levels, in spite of the levels of obesity in this population. Initial focus groups conducted in Starr County indicated that individuals had had numerous prior weight loss failures and advised us that they would not participate in a study focusing on weight. They were more interested in learning about diabetes and how to improve blood glucose levels. Thus, we designed a program that focused on dietary principles, self-monitoring, and other activities that targeted reducing blood glucose levels, with the expectation that some weight loss would occur naturally.

We identified numerous barriers to participating in exercise, some of which were the existence of complications from diabetes, co-morbid conditions, a history of sedentary lifestyles, and decreased mobility associated with aging. Environmental barriers included no access to exercise facilities, cultural factors (such as the inappropriateness of women walking alone in the neighborhoods), and few areas in the community with sidewalks or paved streets. In addition, with the high temperatures that are common in the South Texas area – sometimes reaching over 110 degrees – and no enclosed malls available for walking, individuals find it difficult to exercise on a regular basis. Further, investigators have had concerns about the safety of unsupervised exercise in a community setting such as this, particularly in individuals with longstanding diabetes. However, stretching and walking for 20 to 30 minutes three times per week were recommended for individuals who were safely able to do it.

The intent of this project was to determine, from a population perspective, whether a culturally competent diabetes self-management intervention that focused primarily on diet and self-monitoring education would improve metabolic status, independent of the medical care that these individuals were receiving. Consequently, pharmacological treatment was not adjusted by project staff but was managed by each participant's regular physician. We provided physicians with copies of their patients' laboratory reports, progress letters, and diet and exercise recommendations of the study dietitians and nurses for each participant, and we periodically notified physicians by phone of particular health problems of their patients that needed physician attention.

One of the major questions that we have been asked is whether the one-year intervention tested in this study can be incorporated realistically into clinical practice settings. First, this question is less often asked of other treatment modalities, such as pharmaceuticals. If the effective “dosage” of the self-management educational intervention requires one year, or more with booster sessions, then this is what needs to be provided and reimbursed by third party payers. Second, although an extensive cost analysis was not proposed in the original project, basic costs of providing the one-year intervention were estimated and are modest. Subjects' Medicaid or other third party insurance could cover monitors and strips, educational materials would be a one-time purchase at the outset of the project, and free community-based sites are available. (During the current intervention, numerous sites in the community were provided at no cost to the project. Also, overhead charges that would be added to patient costs by organizations that might offer such an intervention are not included, but current local programs report charging an overhead of 50% or more.) Remaining costs of the intervention are personnel and food necessary for meal preparation. A nurse, dietitian, and community worker attended sessions 1 through 12; a nurse or dietitian and community worker attended sessions 13 through 26. Based on this scenario, a cost of $384 per person can be estimated as the cost of providing the intervention as described here, assuming monitoring supplies are paid by third party reimbursement (16). So, we have concluded that the cost of the intervention is not a reasonable obstacle to providing the one-year intervention described here.

There is, however, a more serious obstacle to providing this intervention and that is the availability of bilingual Hispanic nurses, dietitians, and community workers. [For example, in Starr County the ratio of population per registered nurse is 822 to 1, compared to 169 to 1 for the rest of the State (14).] Because of the low numbers of Hispanic health professionals, some communities use community lay workers for purposes of diabetes self-management education (28). Our initial plan was to have the nurses and dietitians provide the educational component of the intervention, followed by support groups directed by trained community lay workers. However, early in the project, subjects expressed their preference to have health professionals available throughout the one-year intervention. So, we modified the role of the community workers to one of providing support through telephone calls to subjects reminding them of the sessions, providing travel for subjects to intervention and data collection sessions, preparing food for demonstrations, and keeping attendance logs. Even though the role of the community workers changed, their logistical support was key to the success of the intervention. The efficacy of using community workers in other capacities could be tested in future studies.

The targeted population of this study had few personal resources, some had limited literacy, some had limited access to health care providers, and many had longstanding diabetes as well as longstanding lifestyle habits that negatively impact health. Barriers, such as the low socioeconomic status of the residents of the border area, were only partially addressed by the study. For example, free home glucose monitors and strips were provided for all study participants; but, individuals sometimes expressed difficulties with the costs of purchasing the foods that were recommended for achieving dietary goals. In addition, although monitoring supplies were provided, due to the budget limitations of the project, self-monitoring recommendations were limited to 2 times a day on 3 days each week. It seems logical to suggest that, given the improvements that were attained in the study, removing other possible barriers (some yet to be identified), increasing the frequency of home glucose monitoring, and providing more intensive medical/pharmacological therapy would result in greater improvements in metabolic control.

Culturally competent behavioral interventions should be the focus of major national initiatives. Future research should be aimed at developing culturally appropriate outcome measures, addressing translation issues for non-English speaking populations, and exploring motivating factors and strategies for diabetes self-management. If scientific advances in behavioral strategies are not supported and encouraged as a national imperative, other recent medical advances in diabetes treatment, such as pharmaceutical agents, will be diminished in importance or be found to be irrelevant. No medication or other therapeutic discovery currently available is likely to completely overcome unhealthy lifestyles or a lack of knowledge of self-management in persons with diabetes.

Acknowledgments

This study was funded by the National Institute for Diabetes and Digestive and Kidney Diseases and the Office of Research on Minority Health, National Institutes of Health, and the State of Texas. The authors thank subjects and their family members and friends who participated in the study and gratefully acknowledge the contributions of nurses, dietitians, and community workers, all residents of Starr County, Texas, and the surrounding Texas-Mexico border areas: Evangelina Villagomez, MSN, RN, CDE; Mario Segura, MSN, RN; Lilia Fuentes, BSN, RN; Nora Morín, RD; Maria Olivia (Nena) Garza, RD; Ana Jackson, MS, RD; Norma Cottrell, RD; Lita Silva, MSN, RN, CDE; and community worker Sylvia Hinojosa. Staff of the Starr County Health Studies office in Rio Grande City, managed by Hilda Guerra, has provided valuable assistance with subject recruitment and data collection.

Footnotes

Publisher's Disclaimer: This is an author-created, uncopyedited electronic version of an article accepted for publication in Diabetes (http://diabetes.diabetesjournals.org). The American Diabetes Association (ADA), publisher of Diabetes, is not responsible for any errors or omissions in this version of the manuscript or any version derived from it by third parties. The definitive publisher-authenticated version is available online at http://care.diabetesjournals.org/cgi/content/abstract/25/2/259.

Contributor Information

Alexandra A. Garcia, School of Nursing The University of Texas at Austin.

Kamiar Kouzekanani, School of Nursing The University of Texas at Austin.

Craig L. Hanis, Center for Population Genetics, School of Public Health The University of Texas Health Science Center at Houston.

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