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research-article2015
TDEXXX10.1177/0145721714567233Diabetes Prevention in the WorkplaceBrown et al
Diabetes Prevention in the Workplace 175
Culturally Tailored Diabetes Prevention in the Workplace Focus Group Interviews With Hispanic Employees
Purpose
Sharon A. Brown, PhD, RN, FAAN Alexandra A. García, PhD, RN, FAAN
The purpose was to conduct focus groups with Hispanic employees to obtain input into adaptation of previous DSME interventions for use as a workplace diabetes prevention program.
Mary A. Steinhardt, EdD, LPC Henry Guevara, PhD, MPH, APRN, FNP-C Claire Moore, MPH Adama Brown, PhD
Methods
Mary A. Winter, MSN, RN
From a list of interested Hispanic employees who attended a local health fair (n = 68), 36 were randomly selected to participate in focus groups held during supper mealtime breaks. An experienced bilingual moderator directed the sessions, using interview guidelines developed by the research team.
Results Participants’ ages ranged from 22 to 65 years (mean = 50.4, n = 36, SD = 10.7), 7 males and 29 females attended, and 53% had type 2 diabetes mellitus (T2DM). Employees expressed a keen interest in diabetes classes and recommended a focus on preparing healthier Hispanic foods. Primary barriers to promoting healthier lifestyles were work schedules; many employees worked 2 part-time or full-time jobs. Administrators and direct supervisors of the employees were highly supportive of a workplace diabetes prevention program.
From School of Nursing, The University of Texas at Austin, Austin, Texas (Dr Brown, Dr Garcia, Dr Brown, Ms Winter); Department of Kinesiology and Health Education, College of Education, The University of Texas at Austin, Austin, Texas (Dr Steinhardt); and The University of Texas at Austin, Austin, Texas (Dr Guevara, Ms Moore). Correspondence to Sharon A. Brown, The University of Texas at Austin School of Nursing, 1710 Red River Street, Austin, TX 78701, USA ([email protected]). Funding: This study was supported by an Expedited Proposal-Enhancement Grant, The University of Texas at Austin’s St. David’s Center for Health Promotion/Disease Prevention Research, School of Nursing; a Special Research Grant from the Office of the Vice President for Research; and the Joseph H. Blades Centennial Memorial Professorship awarded to the first author. DOI: 10.1177/0145721714567233 © 2015 The Author(s)
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Conclusions The consistent message was that a workplace program would be the ideal solution for Hispanic employees to learn about diabetes and healthy behaviors, given their busy schedules, family responsibilities, and limited resources. If found to be effective, such a workplace program would be generalizable to other service employees who have disproportionate diabetes rates.
T
ype 2 diabetes mellitus (T2DM) has emerged as the foremost epidemic of the twenty-first century,1 affecting 29.1 million people nationwide and costing $245 billion annually,2 primarily due to the costs of complications and lost productivity.3 T2DM affects Hispanics and other racial/ethnic minority populations disproportionately, with higher rates of risk factors for T2DM, prevalence of diagnosed T2DM, and diabetes-related deaths.4 In previous Starr County studies with Mexican Americans, the largest Hispanic subgroup, who resided on the Texas-Mexico border, mean baseline A1C levels were consistently at 12%, with some individuals having A1C levels as high as 18%.5,6 A1C levels ≥10% are associated with 3-year health care costs that are 11% higher than A1C levels ≤6%.7 Native American genetic admixture combined with environmental risk factors—low socioeconomic status, barriers to accessing health care, underutilization of health care resources, lower rates of insurance coverage, and lack of health education—have been implicated as causal factors for T2DM, particularly in Hispanics.8-11 The major precursor to T2DM is abdominal obesity, which is associated with the most dangerous risk factors for cardiovascular events and premature deaths, for example, insulin resistance, high cholesterol, and hypertension (HTN).12-15 In the Diabetes Prevention Program (DPP),16 moderate physical activity, namely, ≥150 minutes per week of activity similar in intensity to brisk walking, and losing a minimum of 7% of body weight through reduced caloric intake resulted in the largest reduction in diabetes risk (58%) in persons with impaired glucose tolerance (IGT). These findings were consistent across all populations, both genders, and all age groups. Thus, small weight reductions (7%-10%) enhance insulin
sensitivity and glycemic control and: (1) may reduce the need for medications in those diagnosed with T2DM or (2) delay diabetes onset in those who are at high risk but not yet diagnosed.17-19 However, higher obesity rates and lower physical activity levels have been documented in minorities compared to non-Hispanic whites.20 Since the initial findings of the DPP study were reported, follow-up studies have been conducted on the DPP cohort to evaluate longitudinal effects of the program. These follow-up studies have documented that the health improvements experienced by this cohort of individuals at high risk for diabetes continued for at least 10 years. Long-term benefits included a 34% reduction in the rate of developing T2DM, a delay of T2DM by about 4 years, and a reduction in A1C levels and cardiovascular risk factors. So it is clear that modest reductions in caloric intake and weight and increases in physical activity have long-term health benefits.21 Accessible diabetes interventions are effective in improving the health of individuals diagnosed with or at risk for developing T2DM. Workplace health programs are more accessible than traditional programs; employees are present at these sites on a daily basis and thus are able to avoid the challenges of finding additional personal time and transportation resources to attend programs held at other locations. Further, such employee wellness programs have been found to have cost-benefits by reducing absences due to illness.22 However, few diabetes studies have been conducted in workplace settings, particularly with minority groups who would benefit from interventions adapted to account for varying health beliefs present across different communities and cultures.23 Aldana et al24-26 demonstrated in a series of pilot studies that a workplace lifestyle intervention provided for prediabetic and diabetic employees and also for individuals with other chronic illnesses such as cardiovascular disease (CVD) improved nutrition, physical activity, and physiological indicators of health, such as glucose tolerance, cholesterol, and body weight/BMI. Some of the positive effects were maintained at the 2-year followup measurement period.26 Giese and Cook27 translated the DPP curriculum to a worksite setting, with weight loss as the primary target for 35 overweight and obese employees. Using a 1-group pretest-posttest design, individuals achieved statistically significant reductions in body weight (P < .001) and body mass index (P < .001). Program attendance correlated with weight loss (r = 0.51; P = .002).27
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In many workplace settings, Hispanics hold 40% to 50% of the positions in service departments, for example, custodial services, landscaping, and repairs/maintenance (according to Workforce Analyst, University of Texas at Austin Human Resources). In studies conducted by this research team over the past 20+ years in Starr County, Texas, community-based diabetes self-management education (DSME) interventions, culturally tailored for Mexican Americans, were designed and tested. Clinically and statistically significant improvements in key health indicators suggested that this intervention holds promise for implementation in workplace settings. Postintervention reductions in A1C ranged from 1.4 to 1.7 percentage points. Individuals who attended ≥50% of intervention sessions achieved a 6% point reduction in A1C.5,6 It is logical to posit that with minor modifications, the intervention could be an effective workplace program by eliminating many of the documented barriers to DSME program participation, such as lack of transportation, need for babysitting services, conflicting family responsibilities, and lack of access to exercise facilities. The purpose of this paper is to present the results of focus group interviews held in November 2013 with Hispanics employed by 1 of the larger employers in the local area. Interviews were designed to obtain input into the adaptation of previous DSME interventions for use as a workplace diabetes prevention program, both primary prevention (prevention or delay of onset of T2DM) and secondary prevention (prevention or delay of diabetesrelated complications in individuals already diagnosed with T2DM). Research questions that guided the focus group study were: Research Question 1: What are the characteristics (intervention setting, time of day, number of sessions, program leaders, degree of family involvement, language preference) recommended by Hispanic employees for development and provision of a workplace diabetes prevention and self-management program? Research Question 2: What are the potential obstacles for individuals to participate in a workplace diabetes prevention and self-management program?
Ultimately, a culturally tailored workplace intervention is expected to closely approximate the Starr County DSME interventions, which emphasized culturally congruent, yet healthy, dietary practices and physical activity as well as enhancing group and family support. Diet, for example, preparing Hispanic-preferred foods in a
healthier manner, and physical activity are both appropriate strategies for preventing diabetes as well as for effective diabetes self-management.
Methods Study Design
Focus groups were held with Hispanic employees, individuals who had been diagnosed with diabetes or, due to their Hispanic ethnic heritage, were at high risk for developing diabetes in the future. Members of the research team have conducted many similar focus groups with Hispanics, beginning in the early 1990s, to inform initial development and subsequent refinement of diabetes self-management interventions.28 The focus group interview approach, as opposed to conducting individual interviews, is consistent with Hispanic cultural preferences that value social interactions and generates more rich information since subjects are enabled to react to and build on responses of others in the group.29 Participant Recruitment
In June 2013, the employer held an annual employee health fair. Prior Institutional Review Board (IRB) approval was obtained to solicit contact information from Hispanic health fair attendees who expressed an interest in participating in future focus groups and who, due to their Hispanic heritage, either had diabetes or were at high risk for developing it. After obtaining full IRB approval for the focus group study, names were randomly selected from a list of 68 Hispanic employees collected at the health fair and telephone screening was conducted according to the following inclusion criteria: 1. English- or Spanish-speaking Hispanic employees, employed either full-time or part-time; 2. diagnosed with T2DM or, by virtue of being Hispanic, were at risk for developing the disease; 3. willing to participate in a 1-hour focus group during their work schedule, at mealtime.
There was no restriction on whether individuals had participated in previous diabetes self-management programs. Family members of Hispanic employees were encouraged to attend, if available and desirous of participating. The goal was to have at least 10 individuals present at each focus group session in order to foster conversation and diverse opinions; also each person
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would have an opportunity to express his or her opinions. To adjust for possible attrition, 12 individuals who met inclusion criteria were invited to a session; all 12 invitees attended their session, which resulted in a total sample of 36 persons. Procedures
Procedures for conducting focus groups followed established guidelines.30,31 Individuals who met the aforementioned inclusion criteria were invited to a focus group session held during their shift mealtime at a central location and the common site of employee health and wellness programs. Verbal consent was obtained by telephone prior to holding the interview sessions, and copies of the consent information sheet were distributed at the beginning of each session. The most efficient time period for conducting focus group interviews with employees was during their supper mealtime break (8 pm), as most of these employees worked the evening shift (beginning at 5:30 pm). In addition to the meal, a $20 gift card was provided. The moderator used a structured interview guide, and at least 1 member of the research team attended the interview sessions (see Table 1). Each individual focus group session involved a discussion of the purpose of the meeting, justification for the initial focus on Hispanic employees, concept of diabetes self-management for prevention and treatment of T2DM, current barriers to recommended health behaviors, and groups’ recommendations for a workplace diabetes prevention and selfmanagement program. Groups were asked to designate the preferred language for the interviews, Spanish and/or English. Data Analysis
Interview sessions were audiotaped, and the moderator and the research team member noted nonverbal cues. Within 30 days of completing the focus groups, a local research office employed to conduct the focus group interviews provided us with the Spanish transcription and a summary English translation of each focus group session. Interview questions were highly structured so analysis of the data was facilitated, allowing researchers to identify specific recommendations for revising/adapting the Starr County interventions for a workplace program. The moderator and research team member in attendance were debriefed regarding their perceptions of the issues raised by the focus group participants.
Results Characteristics of Focus Group Participants
Participants’ ages ranged from 22 to 65 years with a mean age of 50.4 years (SD = 10.7); 7 males and 29 females attended 1 of the focus group sessions. Approximately 53% had been diagnosed with T2DM; the rest did not have T2DM but indicated that they had family members (eg, a spouse) who had been diagnosed with the disease. Five of the 36 participants reported attending some type of previous diabetes self-management education program. Consistent with previous experiences of the research team with Mexican Americans in South Texas, only 1 of the 36 individuals preferred that the discussion be offered in English; all others preferred Spanish. Recommendations for a Workplace Diabetes Program
The employees expressed a keen interest in diabetes classes and recommended a focus primarily on food preparation, nutrition principles, portion sizes, and diabetes home remedies (see Table 2): A program that teaches you how to cook. Like us Mexicans . . . how to cook to make it more healthy the way I prepare it today. That’s a program I would like, with what I already have in my kitchen. I don’t want to go buy something from the store that I won’t use. Any kind of food that isn’t too gourmet. To make gourmet food, you need to buy lots of products to prepare the meal. So use what I already have in my kitchen— beans, rice, fideo [pasta], and ground beef. How can I make it different and more healthy? That’s what I would like.
Most had access to DVD players in the home, as opposed to computers or smartphones, and suggested that DVDs could be used for diabetes-specific as well as other health education purposes. They also expressed an interest in accessing local exercise gyms but stated that they could not afford the costs. They preferred group programs so they could learn from each other and share experiences, both for their own personal benefit as well as for the benefit of their family members. They recommended Spanish-language classes with approaches that integrated respect for their cultural views and values, including differing food preferences and views on
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Table 1
Interview Questions/Guide Restate the purpose of the meeting: To obtain input into the design of a program on how to prevent and manage diabetes in the workplace, specifically targeting Hispanics. Explain reason for the focus on Hispanics: T2DM has become epidemic in Hispanic populations so we will begin with a specific program for Hispanics and then add programs for other groups. Introduce the concept of diabetes self-management education for prevention and treatment of T2DM: Indicate 4 major health behaviors (ie, diet, physical activity, medications, glucose self-monitoring), 2 of which are important for diabetes prevention (diet, physical activity). We desire input into a program, offered in either Spanish or English, that would be useful for managing diabetes in individuals already diagnosed with T2DM AND preventing diabetes in individuals who have not yet been diagnosed. To begin the dialogue, ask about current barriers to: (1) eating healthy (2) getting recommended physical activity and for those with diabetes, (3) taking their medication(s) (4) monitoring their blood glucose at home Spend the majority of time discussing the following questions and probes: (1) What are the activities or characteristics of a workplace diabetes program that would be helpful to individuals who either have been diagnosed with diabetes or who are concerned about developing diabetes in the future? Probes: (a) Have you ever received a referral from your physician or other health care provider to attend diabetes education classes in the past? If so, did you attend, and why or why not? (b) What types of activities would be most helpful to individuals in supporting them with: • increasing physical activity • improving dietary habits • accessing health resources in the community • increasing attendance at the intervention sessions that will be offered • for individuals already diagnosed with diabetes, taking medications correctly and monitoring own glucose levels at home (c) How often should program sessions occur? Would you be willing to do “homework” in between sessions (eg, watch an educational DVD/video)? (d) For how many weeks would you be willing to attend meetings? (e) Where and what time of day would be the best place and time to hold such educational sessions on diabetes treatment/ prevention? (f) What would be the most important things you’d like to learn from this program about preventing or managing diabetes? (g) Would access to a mentor who has successfully completed our program be of help to future participants in the program? What role would you like to see them play? (h) Would you like to have your family members involved in the program? How? Anyone else? (i) Should the sessions be offered in English or Spanish? (j) Should the sessions include all Hispanics, or should there be separate sessions for Mexican Americans, Cuban Americans, and so on? (2) What other information could you provide that would be helpful to us in designing this program?
traditional gender roles. The overall consistent message was that a workplace diabetes prevention and selfmanagement program would be the ideal solution to learning about diabetes and healthy behaviors, given busy schedules, family responsibilities, and limited resources:
I would like a program, most of us work at night or during the day and there is no opportunity for a program to support us and that we don’t use up our time. . . . A program where they are firm about the number of hours and how much time we can dedicate to it.
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Table 2
Overview of Focus Group Results Diabetes
Physical activity: barriers
Diet: barriers
Medication: barriers
Home glucose monitoring: barriers
Suggestions for diabetes programs
Freely discussed among most family members Participants want to share knowledge with family members and neighbors Google and YouTube are sources of information on the Internet Response to being referred previously to other diabetes classes was mixed; those who refused had time constraints or needed more sleep Work is tiring Lack of time with 2 jobs; home demands; need for family time Lazy; refusal to exercise Lack of education Lack of family support Lack of habit More difficult for women because demands are higher: family, work, home Culture: women serve the men Cost of gym Fast food is readily available Work schedule that can’t be controlled—work nights and sleep days “Mexican food is always bad” Not wanting to be educated Lack of family support and knowledge Lack of time to cook healthier Cost; fruit is expensive Culture: learning different when growing up, fiesta foods, cooking with lard Forgetting to take medications; a calendar is needed Work starting too early (failure to eat) and being too busy Cost Feeling worse after taking the medication Cost; reluctance to ask family for financial help Lack of medical insurance Fear of the results Lack of education Relying on how one feels rather than the results Pain Continuous monthly meetings for 30-45 minutes at start time, before or at lunch Endorsement of supervisor to use work time regularly without reprimand Information about prevention to new hires English and Spanish language Men and women together Family participation desired; some family members are not local, children are resistant Support group, entertainment, give ideas and opinions, increase motivation Healthy eating taught by a nutritionist: cooking method and length of time, portions, types of bread, eating schedules, foods to avoid, natural remedies, recipes, samples, using ingredients already on hand, multicultural classes with foods appropriate for each culture—to divide cultures into different classes would be racist Exercise taught by someone from a gym: demonstration of exercises that are different from work motions, group walking 30 minutes 2 to 3 times a week or 2 or 3 miles, using stairs rather than the elevator, chair exercises Education by a physician: prevention, signs and symptoms, cause, types, keeping diabetes under control, combining food with exercise, creating a schedule for medications How to manage stress; pressures from being short-staffed Show the consequences of diabetes to increase motivation: amputations, dialysis Include homework: watch DVDs, read a pamphlet, smartphone, Internet (availability of these electronic options varied by participant)
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Potential Obstacles to Participating in a Workplace Diabetes Program
The primary barriers to promoting healthy lifestyles in this population were work schedules (see Table 2). Some of the participants reported working 2 part-time or fulltime jobs, arriving home at 3 am from their night job and arising early the next day (some as early as 6 am) to begin their day job. We forget. . . I start at 5 in the morning and I’m not hungry. If I don’t eat I can’t take the pills. Then I get to the office and I get busy with work. Then I start to feel bad and wonder why and I realize I’ve not taken my medicine. I’m too busy doing things I shouldn’t be doing.
In terms of barriers to incorporating healthier lifestyle behaviors, the groups consistently emphasized the importance of and challenges associated with obtaining and preparing healthy foods, citing the need for help in addressing the high costs, combined with the challenge of balancing work outside the home with providing healthy food for themselves and their family members. Thus, they had little time for grocery shopping and food preparation; fast food was their practical solution. The fast food that is sold . . . for someone who works, it’s easy to go buy fast food. I think one of the barriers is our refusal and we don’t educate ourselves on what we need to do. There is time, if we have time to watch an hour of television, then we have time to exercise. And the same goes with food. [The grocery store] has packages of salads and chicken ready. It comes down to not wanting to be educated. And the family at home doesn’t help because they ask me, “make flour tortillas, honey.” So they are eating tortillas and wanting to know what’s for dinner. Some beans with chorizo and flour tortillas. That’s another barrier.
Similar barriers were identified for being able to initiate any planned exercise program, although most individuals indicated they got plenty of physical activity at work through the extensive amount of walking that was associated with their jobs. There’s no time left to exercise . . . work . . . it is very tiring and I leave work late and tired. It’s hard to find time to exercise for those of us who have 2 jobs.
They indicated fewer barriers to obtaining medications, but diabetes test strips were too expensive to use on a regular basis, and some individuals didn’t want to know the results. Honestly, I don’t like checking my sugar. Because I don’t want to see if it is low or high . . . I don’t want to know the results. I just don’t want to know because I can’t find a reason to prick myself to find out my numbers. I know my body. Well, I’m not a doctor but I know my body. I feel if I need something. So I say, OK, my sugar is high. What am I going to do? Nothing. Why? Why should I take the medicines? In any case I have to make an appointment with my doctor. . . . Or sometimes I have an infection in my body and that makes the medicine not work like it is supposed to. And your sugar is high until it is not.
Additional Findings
Members of the research team who attended the sessions noted the significant support from supervisors, who in some cases volunteered to transport their employees to the session in an employer van. Researchers met with the departmental director to explain the goals of the program; he expressed full support, gave permission for individuals to attend a focus group session, and notified supervisors to permit attendance of their employees. Additionally, the director suggested that members of the research team provide diabetes information at safety meetings, which are required for employees and held at regular intervals. Further, when the information regarding the planned focus groups spread among the employees, numerous phone calls were received from other employees requesting to participate; a wait-list was developed. Focus group study participants volunteered (actually requested) to participate in any future pilot intervention projects, building on the groups that were constructed for the focus group sessions.
Discussion and Conclusion Discussion
Focus groups are the first phase in developing a workplace diabetes prevention program. Promoting lifestyle change in individuals is a challenge, but it is extremely difficult when persons lack personal resources, have limited access to medications and health care providers for
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treatment and medical oversight, and work long shifts and/or multiple jobs. Some of the informants interviewed in these focus groups held 2 part-time or full-time jobs, 1 from 8 am to 5 pm and the second that began at 5:30 pm and lasted until well after midnight. These work schedules serve as major barriers to participating in any type of health program, including those designed to prevent or treat diabetes as well as to making recommended healthy lifestyle changes. It was clear that there were a number of significant and complex issues that would need to be taken into account when designing any future program. Focus group participants were clear. Any program needs to consider Hispanic values and beliefs, that is, to be “culturally tailored,” as well as to be offered in Spanish. But typically, diabetes interventions for Hispanics have often been, and frequently continue to be, provided solely in English and based on incorrect and/or insensitive assumptions about the cultural characteristics of the population. Hispanics in particular have been labeled “noncompliant” and have received different, inadequate, or inappropriate diabetes treatments.4,32-35 Health care providers continue to misadvise Hispanics by recommending that they discard cultural lifestyles, food preferences for example, for a “healthier Anglo lifestyle.”33 This recommendation is not only culturally insensitive, but it is factually wrong. Culturally competent interventions: (1) match the “superficial” cultural characteristics, for example, using the same language and incorporating cultural music and food, and (2) integrate the “deep structure” of the culture, such as the social, environmental, and psychological forces of a culture that influence health behavior.34 Many Hispanics rely on family and friends for health advice, lack transportation to health care facilities, are isolated from mainstream culture, consider family needs as more important than their own, and may speak, or at least prefer, a different language than health care workers.35 Current approaches ignore important cultural values of individuals from Hispanic heritage—a strong interdependence with family members; traditional gender roles; a value for mutual respect and conformity, particularly with strangers perceived to have authority; flexible time orientation; and a belief among older, less acculturated Hispanics that illness results from wrongdoing.36 A culturally tailored workplace diabetes program has the potential to be clinically effective, as well as cost-effective, because it bypasses many of the current personal and environmental challenges that many of the “working poor” encounter.
The major recommendation for a workplace diabetes prevention program that emerged from these interviews was to focus on improving individuals’ diets. General, vague recommendations, such as “eat less,” “cut back on eating fat,” “cut back on your calories,” and “count your carbs,” are not welcomed nor are they effective, particularly over the long term. Participants clearly wanted detailed instructions and demonstrations on how to improve their diets, considering the cultural food preferences of both them and their families and involving foods that were already readily available in their kitchens. Conclusion
A number of significant challenges were identified in the focus groups reported here. However, both potential participants as well as their work supervisors expressed considerable support for such a workplace diabetes program, particularly one that focused on practical guidance for preparing healthier Hispanic foods. The next step is to adapt previously successful diabetes programs for the workplace, integrating information gleaned from the focus groups, and conduct pilot tests of interventions in order to establish feasibility and refine approaches. Future clinical trials will be designed to establish efficacy and cost-effectiveness. Practice Implications
The future work that will build on the proposed focus group interviews is aimed at developing work-based interventions for the treatment and prevention of T2DM in high-risk populations. The overall goal is to enhance the health of individuals who are employed, some fulltime, many part-time, but who tend to remain underserved from a health care access perspective, that is, the “working poor.” This line of work that focuses on designing a workplace diabetes intervention: (1) expands a productive line of research designed to prevent or delay diabetes in high-risk populations; (2) examines an occupational health approach, a relatively unstudied area in diabetes care, especially in minority groups; and (3) targets a population that has exceedingly high rates of T2DM, rates that have doubled over the recent past.37 Such approaches, if found to be effective, would be generalizable to other medically underserved populations who also have a disproportionate diabetes burden and tend to hold service jobs, such as African Americans.
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19. Mau MK, Sinclair K, Saito EP, Baumhofer KN, Kaholokula JK. Cardiometabolic health disparities in native Hawaiians and other Pacific Islanders. Epidemiol Rev. 2009;31:113-129. 20. Beaton SJ, Robinson SB, Von Worley A, et al. Cardiometabolic risk and health care utilization and cost for Hispanic and nonHispanic women. Popul Health Manag. 2009;12:177-183. 21. NIDDK Central Repository, The National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health. Diabetes Prevention Program outcomes study. https://www.nidd krepository.org/studies/dppos/. Accessed December 10, 2014. 22. Braun T, Bambra C, Booth M, Adetayo K, Milne E. Better health at work? An evaluation of the effects and cost-benefits of a structured workplace health improvement programme in reducing sickness absence [published online July 6, 2014]. J Public Health (Oxf). pii: fdu043. 23. Ho LS, Gittelsohn J, Harris SB, Ford E. Development of an integrated diabetes prevention program with First Nations in Canada. Health Promot Int. 2006;21:88-97. 24. Aldana SG, Barlow M, Smith R, et al. The Diabetes Prevention Program: a worksite experience. AAOHN J. 2005;53:499-505. 25. Aldana SG, Greenlaw RL, Diehl HA, Salberg A, Merrill RM, Ohmine S. The effects of a worksite chronic disease prevention program. JOEM. 2005;47:558-564. 26. Aldana SG, Barlow M, Smith R, et al. A worksite diabetes prevention program: two-year impact on employee health. AAOHN J. 2006;54:389-395. 27. Giese KK, Cook PF. Reducing obesity among employees of a manufacturing plant: translating the Diabetes Prevention Program to the workplace. Workplace Health Saf. 2014;62:136-141. 28. Benavides-Vaello S, García AA, Brown SA, Winchell M. Using focus groups to plan and evaluate diabetes self-management interventions for Mexican Americans. Diabetes Educ. 2004;238:242244, 247-250. 29. Stewart DW, Shamdasani PN. Focus Groups: Theory and Practice. 2nd ed. Thousand Oaks, CA: SAGE Publications; 2007. 30. Witkin BR, Altschuld JW. Planning and Conducting Needs Assessments: A Practical Guide. Thousand Oaks, CA: SAGE Publications; 1995. 31. Krueger RA. Focus Groups: A Practical Guide for Applied Research. Thousand Oaks, CA: SAGE Publications; 1994. 32. Haffner SM, Fong D, Stern MP, et al. Diabetic retinopathy in Mexican Americans and non-Hispanic Whites. Diabetes. 1988;37:878-884. 33. Alcozer F. Secondary analysis of perceptions and meanings of type 2 diabetes among Mexican American women. Diabetes Educ. 2000;26:785-795. 34. Resnicow K, Baranowski T, Ahluwalia JS, Braithwaite RL. Cultural sensitivity in public health: defined and demystified. Ethn Dis. 1999;9:10-21. 35. Lipton RB, Lee ML, Giachello A, Mendez J, Girotti MH. Attitudes and issues in treating Latino patients with type 2 diabetes: views of healthcare providers. Diabetes Educ. 1998;24:67-71. 36. Marín G, Marín BV. Research with Hispanic Populations. Newbury Park, CA: SAGE Publications; 1991. 37. Centers for Disease Control. Rates of diabetes doubles in 10 years: CDC. http://health.usnews.com/health-news/diet-fitness/ diabetes/articles/2008/10/30/rate-of-diabetes-cases-doubles-in10-years-cdc. Accessed October 31, 2014.
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research-article2015
TDEXXX10.1177/0145721714567233Diabetes Prevention in the WorkplaceBrown et al
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Culturally Tailored Diabetes Prevention in the Workplace Focus Group Interviews With Hispanic Employees
Purpose
Sharon A. Brown, PhD, RN, FAAN Alexandra A. García, PhD, RN, FAAN
The purpose was to conduct focus groups with Hispanic employees to obtain input into adaptation of previous DSME interventions for use as a workplace diabetes prevention program.
Mary A. Steinhardt, EdD, LPC Henry Guevara, PhD, MPH, APRN, FNP-C Claire Moore, MPH Adama Brown, PhD
Methods
Mary A. Winter, MSN, RN
From a list of interested Hispanic employees who attended a local health fair (n = 68), 36 were randomly selected to participate in focus groups held during supper mealtime breaks. An experienced bilingual moderator directed the sessions, using interview guidelines developed by the research team.
Results Participants’ ages ranged from 22 to 65 years (mean = 50.4, n = 36, SD = 10.7), 7 males and 29 females attended, and 53% had type 2 diabetes mellitus (T2DM). Employees expressed a keen interest in diabetes classes and recommended a focus on preparing healthier Hispanic foods. Primary barriers to promoting healthier lifestyles were work schedules; many employees worked 2 part-time or full-time jobs. Administrators and direct supervisors of the employees were highly supportive of a workplace diabetes prevention program.
From School of Nursing, The University of Texas at Austin, Austin, Texas (Dr Brown, Dr Garcia, Dr Brown, Ms Winter); Department of Kinesiology and Health Education, College of Education, The University of Texas at Austin, Austin, Texas (Dr Steinhardt); and The University of Texas at Austin, Austin, Texas (Dr Guevara, Ms Moore). Correspondence to Sharon A. Brown, The University of Texas at Austin School of Nursing, 1710 Red River Street, Austin, TX 78701, USA ([email protected]). Funding: This study was supported by an Expedited Proposal-Enhancement Grant, The University of Texas at Austin’s St. David’s Center for Health Promotion/Disease Prevention Research, School of Nursing; a Special Research Grant from the Office of the Vice President for Research; and the Joseph H. Blades Centennial Memorial Professorship awarded to the first author. DOI: 10.1177/0145721714567233 © 2015 The Author(s)
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Conclusions The consistent message was that a workplace program would be the ideal solution for Hispanic employees to learn about diabetes and healthy behaviors, given their busy schedules, family responsibilities, and limited resources. If found to be effective, such a workplace program would be generalizable to other service employees who have disproportionate diabetes rates.
T
ype 2 diabetes mellitus (T2DM) has emerged as the foremost epidemic of the twenty-first century,1 affecting 29.1 million people nationwide and costing $245 billion annually,2 primarily due to the costs of complications and lost productivity.3 T2DM affects Hispanics and other racial/ethnic minority populations disproportionately, with higher rates of risk factors for T2DM, prevalence of diagnosed T2DM, and diabetes-related deaths.4 In previous Starr County studies with Mexican Americans, the largest Hispanic subgroup, who resided on the Texas-Mexico border, mean baseline A1C levels were consistently at 12%, with some individuals having A1C levels as high as 18%.5,6 A1C levels ≥10% are associated with 3-year health care costs that are 11% higher than A1C levels ≤6%.7 Native American genetic admixture combined with environmental risk factors—low socioeconomic status, barriers to accessing health care, underutilization of health care resources, lower rates of insurance coverage, and lack of health education—have been implicated as causal factors for T2DM, particularly in Hispanics.8-11 The major precursor to T2DM is abdominal obesity, which is associated with the most dangerous risk factors for cardiovascular events and premature deaths, for example, insulin resistance, high cholesterol, and hypertension (HTN).12-15 In the Diabetes Prevention Program (DPP),16 moderate physical activity, namely, ≥150 minutes per week of activity similar in intensity to brisk walking, and losing a minimum of 7% of body weight through reduced caloric intake resulted in the largest reduction in diabetes risk (58%) in persons with impaired glucose tolerance (IGT). These findings were consistent across all populations, both genders, and all age groups. Thus, small weight reductions (7%-10%) enhance insulin
sensitivity and glycemic control and: (1) may reduce the need for medications in those diagnosed with T2DM or (2) delay diabetes onset in those who are at high risk but not yet diagnosed.17-19 However, higher obesity rates and lower physical activity levels have been documented in minorities compared to non-Hispanic whites.20 Since the initial findings of the DPP study were reported, follow-up studies have been conducted on the DPP cohort to evaluate longitudinal effects of the program. These follow-up studies have documented that the health improvements experienced by this cohort of individuals at high risk for diabetes continued for at least 10 years. Long-term benefits included a 34% reduction in the rate of developing T2DM, a delay of T2DM by about 4 years, and a reduction in A1C levels and cardiovascular risk factors. So it is clear that modest reductions in caloric intake and weight and increases in physical activity have long-term health benefits.21 Accessible diabetes interventions are effective in improving the health of individuals diagnosed with or at risk for developing T2DM. Workplace health programs are more accessible than traditional programs; employees are present at these sites on a daily basis and thus are able to avoid the challenges of finding additional personal time and transportation resources to attend programs held at other locations. Further, such employee wellness programs have been found to have cost-benefits by reducing absences due to illness.22 However, few diabetes studies have been conducted in workplace settings, particularly with minority groups who would benefit from interventions adapted to account for varying health beliefs present across different communities and cultures.23 Aldana et al24-26 demonstrated in a series of pilot studies that a workplace lifestyle intervention provided for prediabetic and diabetic employees and also for individuals with other chronic illnesses such as cardiovascular disease (CVD) improved nutrition, physical activity, and physiological indicators of health, such as glucose tolerance, cholesterol, and body weight/BMI. Some of the positive effects were maintained at the 2-year followup measurement period.26 Giese and Cook27 translated the DPP curriculum to a worksite setting, with weight loss as the primary target for 35 overweight and obese employees. Using a 1-group pretest-posttest design, individuals achieved statistically significant reductions in body weight (P < .001) and body mass index (P < .001). Program attendance correlated with weight loss (r = 0.51; P = .002).27
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In many workplace settings, Hispanics hold 40% to 50% of the positions in service departments, for example, custodial services, landscaping, and repairs/maintenance (according to Workforce Analyst, University of Texas at Austin Human Resources). In studies conducted by this research team over the past 20+ years in Starr County, Texas, community-based diabetes self-management education (DSME) interventions, culturally tailored for Mexican Americans, were designed and tested. Clinically and statistically significant improvements in key health indicators suggested that this intervention holds promise for implementation in workplace settings. Postintervention reductions in A1C ranged from 1.4 to 1.7 percentage points. Individuals who attended ≥50% of intervention sessions achieved a 6% point reduction in A1C.5,6 It is logical to posit that with minor modifications, the intervention could be an effective workplace program by eliminating many of the documented barriers to DSME program participation, such as lack of transportation, need for babysitting services, conflicting family responsibilities, and lack of access to exercise facilities. The purpose of this paper is to present the results of focus group interviews held in November 2013 with Hispanics employed by 1 of the larger employers in the local area. Interviews were designed to obtain input into the adaptation of previous DSME interventions for use as a workplace diabetes prevention program, both primary prevention (prevention or delay of onset of T2DM) and secondary prevention (prevention or delay of diabetesrelated complications in individuals already diagnosed with T2DM). Research questions that guided the focus group study were: Research Question 1: What are the characteristics (intervention setting, time of day, number of sessions, program leaders, degree of family involvement, language preference) recommended by Hispanic employees for development and provision of a workplace diabetes prevention and self-management program? Research Question 2: What are the potential obstacles for individuals to participate in a workplace diabetes prevention and self-management program?
Ultimately, a culturally tailored workplace intervention is expected to closely approximate the Starr County DSME interventions, which emphasized culturally congruent, yet healthy, dietary practices and physical activity as well as enhancing group and family support. Diet, for example, preparing Hispanic-preferred foods in a
healthier manner, and physical activity are both appropriate strategies for preventing diabetes as well as for effective diabetes self-management.
Methods Study Design
Focus groups were held with Hispanic employees, individuals who had been diagnosed with diabetes or, due to their Hispanic ethnic heritage, were at high risk for developing diabetes in the future. Members of the research team have conducted many similar focus groups with Hispanics, beginning in the early 1990s, to inform initial development and subsequent refinement of diabetes self-management interventions.28 The focus group interview approach, as opposed to conducting individual interviews, is consistent with Hispanic cultural preferences that value social interactions and generates more rich information since subjects are enabled to react to and build on responses of others in the group.29 Participant Recruitment
In June 2013, the employer held an annual employee health fair. Prior Institutional Review Board (IRB) approval was obtained to solicit contact information from Hispanic health fair attendees who expressed an interest in participating in future focus groups and who, due to their Hispanic heritage, either had diabetes or were at high risk for developing it. After obtaining full IRB approval for the focus group study, names were randomly selected from a list of 68 Hispanic employees collected at the health fair and telephone screening was conducted according to the following inclusion criteria: 1. English- or Spanish-speaking Hispanic employees, employed either full-time or part-time; 2. diagnosed with T2DM or, by virtue of being Hispanic, were at risk for developing the disease; 3. willing to participate in a 1-hour focus group during their work schedule, at mealtime.
There was no restriction on whether individuals had participated in previous diabetes self-management programs. Family members of Hispanic employees were encouraged to attend, if available and desirous of participating. The goal was to have at least 10 individuals present at each focus group session in order to foster conversation and diverse opinions; also each person
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would have an opportunity to express his or her opinions. To adjust for possible attrition, 12 individuals who met inclusion criteria were invited to a session; all 12 invitees attended their session, which resulted in a total sample of 36 persons. Procedures
Procedures for conducting focus groups followed established guidelines.30,31 Individuals who met the aforementioned inclusion criteria were invited to a focus group session held during their shift mealtime at a central location and the common site of employee health and wellness programs. Verbal consent was obtained by telephone prior to holding the interview sessions, and copies of the consent information sheet were distributed at the beginning of each session. The most efficient time period for conducting focus group interviews with employees was during their supper mealtime break (8 pm), as most of these employees worked the evening shift (beginning at 5:30 pm). In addition to the meal, a $20 gift card was provided. The moderator used a structured interview guide, and at least 1 member of the research team attended the interview sessions (see Table 1). Each individual focus group session involved a discussion of the purpose of the meeting, justification for the initial focus on Hispanic employees, concept of diabetes self-management for prevention and treatment of T2DM, current barriers to recommended health behaviors, and groups’ recommendations for a workplace diabetes prevention and selfmanagement program. Groups were asked to designate the preferred language for the interviews, Spanish and/or English. Data Analysis
Interview sessions were audiotaped, and the moderator and the research team member noted nonverbal cues. Within 30 days of completing the focus groups, a local research office employed to conduct the focus group interviews provided us with the Spanish transcription and a summary English translation of each focus group session. Interview questions were highly structured so analysis of the data was facilitated, allowing researchers to identify specific recommendations for revising/adapting the Starr County interventions for a workplace program. The moderator and research team member in attendance were debriefed regarding their perceptions of the issues raised by the focus group participants.
Results Characteristics of Focus Group Participants
Participants’ ages ranged from 22 to 65 years with a mean age of 50.4 years (SD = 10.7); 7 males and 29 females attended 1 of the focus group sessions. Approximately 53% had been diagnosed with T2DM; the rest did not have T2DM but indicated that they had family members (eg, a spouse) who had been diagnosed with the disease. Five of the 36 participants reported attending some type of previous diabetes self-management education program. Consistent with previous experiences of the research team with Mexican Americans in South Texas, only 1 of the 36 individuals preferred that the discussion be offered in English; all others preferred Spanish. Recommendations for a Workplace Diabetes Program
The employees expressed a keen interest in diabetes classes and recommended a focus primarily on food preparation, nutrition principles, portion sizes, and diabetes home remedies (see Table 2): A program that teaches you how to cook. Like us Mexicans . . . how to cook to make it more healthy the way I prepare it today. That’s a program I would like, with what I already have in my kitchen. I don’t want to go buy something from the store that I won’t use. Any kind of food that isn’t too gourmet. To make gourmet food, you need to buy lots of products to prepare the meal. So use what I already have in my kitchen— beans, rice, fideo [pasta], and ground beef. How can I make it different and more healthy? That’s what I would like.
Most had access to DVD players in the home, as opposed to computers or smartphones, and suggested that DVDs could be used for diabetes-specific as well as other health education purposes. They also expressed an interest in accessing local exercise gyms but stated that they could not afford the costs. They preferred group programs so they could learn from each other and share experiences, both for their own personal benefit as well as for the benefit of their family members. They recommended Spanish-language classes with approaches that integrated respect for their cultural views and values, including differing food preferences and views on
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Table 1
Interview Questions/Guide Restate the purpose of the meeting: To obtain input into the design of a program on how to prevent and manage diabetes in the workplace, specifically targeting Hispanics. Explain reason for the focus on Hispanics: T2DM has become epidemic in Hispanic populations so we will begin with a specific program for Hispanics and then add programs for other groups. Introduce the concept of diabetes self-management education for prevention and treatment of T2DM: Indicate 4 major health behaviors (ie, diet, physical activity, medications, glucose self-monitoring), 2 of which are important for diabetes prevention (diet, physical activity). We desire input into a program, offered in either Spanish or English, that would be useful for managing diabetes in individuals already diagnosed with T2DM AND preventing diabetes in individuals who have not yet been diagnosed. To begin the dialogue, ask about current barriers to: (1) eating healthy (2) getting recommended physical activity and for those with diabetes, (3) taking their medication(s) (4) monitoring their blood glucose at home Spend the majority of time discussing the following questions and probes: (1) What are the activities or characteristics of a workplace diabetes program that would be helpful to individuals who either have been diagnosed with diabetes or who are concerned about developing diabetes in the future? Probes: (a) Have you ever received a referral from your physician or other health care provider to attend diabetes education classes in the past? If so, did you attend, and why or why not? (b) What types of activities would be most helpful to individuals in supporting them with: • increasing physical activity • improving dietary habits • accessing health resources in the community • increasing attendance at the intervention sessions that will be offered • for individuals already diagnosed with diabetes, taking medications correctly and monitoring own glucose levels at home (c) How often should program sessions occur? Would you be willing to do “homework” in between sessions (eg, watch an educational DVD/video)? (d) For how many weeks would you be willing to attend meetings? (e) Where and what time of day would be the best place and time to hold such educational sessions on diabetes treatment/ prevention? (f) What would be the most important things you’d like to learn from this program about preventing or managing diabetes? (g) Would access to a mentor who has successfully completed our program be of help to future participants in the program? What role would you like to see them play? (h) Would you like to have your family members involved in the program? How? Anyone else? (i) Should the sessions be offered in English or Spanish? (j) Should the sessions include all Hispanics, or should there be separate sessions for Mexican Americans, Cuban Americans, and so on? (2) What other information could you provide that would be helpful to us in designing this program?
traditional gender roles. The overall consistent message was that a workplace diabetes prevention and selfmanagement program would be the ideal solution to learning about diabetes and healthy behaviors, given busy schedules, family responsibilities, and limited resources:
I would like a program, most of us work at night or during the day and there is no opportunity for a program to support us and that we don’t use up our time. . . . A program where they are firm about the number of hours and how much time we can dedicate to it.
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Table 2
Overview of Focus Group Results Diabetes
Physical activity: barriers
Diet: barriers
Medication: barriers
Home glucose monitoring: barriers
Suggestions for diabetes programs
Freely discussed among most family members Participants want to share knowledge with family members and neighbors Google and YouTube are sources of information on the Internet Response to being referred previously to other diabetes classes was mixed; those who refused had time constraints or needed more sleep Work is tiring Lack of time with 2 jobs; home demands; need for family time Lazy; refusal to exercise Lack of education Lack of family support Lack of habit More difficult for women because demands are higher: family, work, home Culture: women serve the men Cost of gym Fast food is readily available Work schedule that can’t be controlled—work nights and sleep days “Mexican food is always bad” Not wanting to be educated Lack of family support and knowledge Lack of time to cook healthier Cost; fruit is expensive Culture: learning different when growing up, fiesta foods, cooking with lard Forgetting to take medications; a calendar is needed Work starting too early (failure to eat) and being too busy Cost Feeling worse after taking the medication Cost; reluctance to ask family for financial help Lack of medical insurance Fear of the results Lack of education Relying on how one feels rather than the results Pain Continuous monthly meetings for 30-45 minutes at start time, before or at lunch Endorsement of supervisor to use work time regularly without reprimand Information about prevention to new hires English and Spanish language Men and women together Family participation desired; some family members are not local, children are resistant Support group, entertainment, give ideas and opinions, increase motivation Healthy eating taught by a nutritionist: cooking method and length of time, portions, types of bread, eating schedules, foods to avoid, natural remedies, recipes, samples, using ingredients already on hand, multicultural classes with foods appropriate for each culture—to divide cultures into different classes would be racist Exercise taught by someone from a gym: demonstration of exercises that are different from work motions, group walking 30 minutes 2 to 3 times a week or 2 or 3 miles, using stairs rather than the elevator, chair exercises Education by a physician: prevention, signs and symptoms, cause, types, keeping diabetes under control, combining food with exercise, creating a schedule for medications How to manage stress; pressures from being short-staffed Show the consequences of diabetes to increase motivation: amputations, dialysis Include homework: watch DVDs, read a pamphlet, smartphone, Internet (availability of these electronic options varied by participant)
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Potential Obstacles to Participating in a Workplace Diabetes Program
The primary barriers to promoting healthy lifestyles in this population were work schedules (see Table 2). Some of the participants reported working 2 part-time or fulltime jobs, arriving home at 3 am from their night job and arising early the next day (some as early as 6 am) to begin their day job. We forget. . . I start at 5 in the morning and I’m not hungry. If I don’t eat I can’t take the pills. Then I get to the office and I get busy with work. Then I start to feel bad and wonder why and I realize I’ve not taken my medicine. I’m too busy doing things I shouldn’t be doing.
In terms of barriers to incorporating healthier lifestyle behaviors, the groups consistently emphasized the importance of and challenges associated with obtaining and preparing healthy foods, citing the need for help in addressing the high costs, combined with the challenge of balancing work outside the home with providing healthy food for themselves and their family members. Thus, they had little time for grocery shopping and food preparation; fast food was their practical solution. The fast food that is sold . . . for someone who works, it’s easy to go buy fast food. I think one of the barriers is our refusal and we don’t educate ourselves on what we need to do. There is time, if we have time to watch an hour of television, then we have time to exercise. And the same goes with food. [The grocery store] has packages of salads and chicken ready. It comes down to not wanting to be educated. And the family at home doesn’t help because they ask me, “make flour tortillas, honey.” So they are eating tortillas and wanting to know what’s for dinner. Some beans with chorizo and flour tortillas. That’s another barrier.
Similar barriers were identified for being able to initiate any planned exercise program, although most individuals indicated they got plenty of physical activity at work through the extensive amount of walking that was associated with their jobs. There’s no time left to exercise . . . work . . . it is very tiring and I leave work late and tired. It’s hard to find time to exercise for those of us who have 2 jobs.
They indicated fewer barriers to obtaining medications, but diabetes test strips were too expensive to use on a regular basis, and some individuals didn’t want to know the results. Honestly, I don’t like checking my sugar. Because I don’t want to see if it is low or high . . . I don’t want to know the results. I just don’t want to know because I can’t find a reason to prick myself to find out my numbers. I know my body. Well, I’m not a doctor but I know my body. I feel if I need something. So I say, OK, my sugar is high. What am I going to do? Nothing. Why? Why should I take the medicines? In any case I have to make an appointment with my doctor. . . . Or sometimes I have an infection in my body and that makes the medicine not work like it is supposed to. And your sugar is high until it is not.
Additional Findings
Members of the research team who attended the sessions noted the significant support from supervisors, who in some cases volunteered to transport their employees to the session in an employer van. Researchers met with the departmental director to explain the goals of the program; he expressed full support, gave permission for individuals to attend a focus group session, and notified supervisors to permit attendance of their employees. Additionally, the director suggested that members of the research team provide diabetes information at safety meetings, which are required for employees and held at regular intervals. Further, when the information regarding the planned focus groups spread among the employees, numerous phone calls were received from other employees requesting to participate; a wait-list was developed. Focus group study participants volunteered (actually requested) to participate in any future pilot intervention projects, building on the groups that were constructed for the focus group sessions.
Discussion and Conclusion Discussion
Focus groups are the first phase in developing a workplace diabetes prevention program. Promoting lifestyle change in individuals is a challenge, but it is extremely difficult when persons lack personal resources, have limited access to medications and health care providers for
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treatment and medical oversight, and work long shifts and/or multiple jobs. Some of the informants interviewed in these focus groups held 2 part-time or full-time jobs, 1 from 8 am to 5 pm and the second that began at 5:30 pm and lasted until well after midnight. These work schedules serve as major barriers to participating in any type of health program, including those designed to prevent or treat diabetes as well as to making recommended healthy lifestyle changes. It was clear that there were a number of significant and complex issues that would need to be taken into account when designing any future program. Focus group participants were clear. Any program needs to consider Hispanic values and beliefs, that is, to be “culturally tailored,” as well as to be offered in Spanish. But typically, diabetes interventions for Hispanics have often been, and frequently continue to be, provided solely in English and based on incorrect and/or insensitive assumptions about the cultural characteristics of the population. Hispanics in particular have been labeled “noncompliant” and have received different, inadequate, or inappropriate diabetes treatments.4,32-35 Health care providers continue to misadvise Hispanics by recommending that they discard cultural lifestyles, food preferences for example, for a “healthier Anglo lifestyle.”33 This recommendation is not only culturally insensitive, but it is factually wrong. Culturally competent interventions: (1) match the “superficial” cultural characteristics, for example, using the same language and incorporating cultural music and food, and (2) integrate the “deep structure” of the culture, such as the social, environmental, and psychological forces of a culture that influence health behavior.34 Many Hispanics rely on family and friends for health advice, lack transportation to health care facilities, are isolated from mainstream culture, consider family needs as more important than their own, and may speak, or at least prefer, a different language than health care workers.35 Current approaches ignore important cultural values of individuals from Hispanic heritage—a strong interdependence with family members; traditional gender roles; a value for mutual respect and conformity, particularly with strangers perceived to have authority; flexible time orientation; and a belief among older, less acculturated Hispanics that illness results from wrongdoing.36 A culturally tailored workplace diabetes program has the potential to be clinically effective, as well as cost-effective, because it bypasses many of the current personal and environmental challenges that many of the “working poor” encounter.
The major recommendation for a workplace diabetes prevention program that emerged from these interviews was to focus on improving individuals’ diets. General, vague recommendations, such as “eat less,” “cut back on eating fat,” “cut back on your calories,” and “count your carbs,” are not welcomed nor are they effective, particularly over the long term. Participants clearly wanted detailed instructions and demonstrations on how to improve their diets, considering the cultural food preferences of both them and their families and involving foods that were already readily available in their kitchens. Conclusion
A number of significant challenges were identified in the focus groups reported here. However, both potential participants as well as their work supervisors expressed considerable support for such a workplace diabetes program, particularly one that focused on practical guidance for preparing healthier Hispanic foods. The next step is to adapt previously successful diabetes programs for the workplace, integrating information gleaned from the focus groups, and conduct pilot tests of interventions in order to establish feasibility and refine approaches. Future clinical trials will be designed to establish efficacy and cost-effectiveness. Practice Implications
The future work that will build on the proposed focus group interviews is aimed at developing work-based interventions for the treatment and prevention of T2DM in high-risk populations. The overall goal is to enhance the health of individuals who are employed, some fulltime, many part-time, but who tend to remain underserved from a health care access perspective, that is, the “working poor.” This line of work that focuses on designing a workplace diabetes intervention: (1) expands a productive line of research designed to prevent or delay diabetes in high-risk populations; (2) examines an occupational health approach, a relatively unstudied area in diabetes care, especially in minority groups; and (3) targets a population that has exceedingly high rates of T2DM, rates that have doubled over the recent past.37 Such approaches, if found to be effective, would be generalizable to other medically underserved populations who also have a disproportionate diabetes burden and tend to hold service jobs, such as African Americans.
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