Type 2 Diabetes Self‐Management Social Support Intervention at the U.S.‐Mexico Border

The objectives of this study were to pilot test efficacy of a culturally-tailored diabetes self-management social support intervention for Mexican American adults with type 2 diabetes (T2DM) in the Arizona-Mexico border region and to test the feasibility of recruiting and training promotoras to participate in intervention delivery. Background Type 2 diabetes is devastating for the 700,000 predominantly Hispanic adults living just north of the United States (U.S.)-Mexico border (Pan American Health Organization, 2008). Hispanics are at greater risk than non-Hispanic whites for T2DM and its complications, including premature death from diabetes-related cardiovascular events (National Institute of Diabetes, Digestive and Kidney Diseases [NIDDK], 2007). The 2004–2006 National Health Interview Survey indicated that 11.9 percent of Mexican Americans, the largest Hispanic subgroup in the border region, have been diagnosed with diabetes, primarily T2DM, as compared with 6.6 percent of non-Hispanic whites (NIDDK, 2007). In the border state of Arizona, the site of this study, one-third of the population is Hispanic, 9.2% of which has diabetes, compared to 7.8% of non-Hispanic whites (Arizona Department of Health Services, 2008). Diabetes self-management education (DSME) is the cornerstone of diabetes care (Mensing et al., 2007). Several studies demonstrated an association between DSME and improved diabetes knowledge and self-management behaviors and improved clinical outcomes (Norris, Engelgau & Venkat Narayan, 2001; Philis-Tsimikas et al., 2004). However, authors of a meta-analysis of diabetes self-management programs reported sharp declines in benefits within one month post intervention (Norris et al., 2001) suggesting that self-management interventions alone do not enable individuals to maintain behavior changes. Better outcomes were reported when DSME was of longer duration, community based (Centers for Disease Control and Prevention [CDC], 2001), included follow-up support (Norris et al., 2001), provided culturally sensitive interventions (Philis-Tsimikas et al., 2004; Brown et al., 2005), and addressed psychosocial issues (Mauldon, Melkus & Cagganello, 2006; Norris et al., 2001). In the U.S.-Mexico border region the complexity of T2DM self-management (American Diabetes Association [ADA], 2009) and the limited availability of effective and culturally-tailored diabetes programs continue to limit the successful management of T2DM in Mexican Americans (Ingram, Gallegos & Elenes, 2005; Brown, Garcia, Kouzekanani & Hanis, 2002). Social support is instrumental in affecting diabetes self-management and clinical outcomes (Van Dam et al., 2005; Ingram, Torres, Redondo, Bradford & O’Toole, 2007). Findings from six controlled intervention trials suggested that social support interventions affect self-management and diabetes outcomes (Van Dam et al., 2005); but only two of the studies were community-based interventions, and none included Hispanics. Carranza and LeBaron (2004) reported a relationship between social support and self-reported adherence to self-management behaviors among Mexican Americans with T2DM (N=78). However, Gleeson-Kreig and colleagues (2002) reported that for Puerto Rican adults with insulin-dependent diabetes (n=95), social support was not strongly related to diabetes self-management. These authors suggested this finding could be attributed to measurement issues and recommended that the interaction of social support and diabetes management be further examined with Hispanic populations. In this study social support, specifically the dimensions of informational, emotional, and appraisal support, provided the conceptual foundation for the intervention. Informational support is the provision of knowledge that is useful for self-evaluation and likely enhances perceptions of control by reducing confusion and providing strategies for responding to stressors. Emotional support is defined as verbal and nonverbal expressions of empathy, trust, and caring, and is believed to reduce stress through restoring self-esteem. Appraisal support affirms the appropriateness of acts or statements that serve to reinforce the recipient’s views and behaviors (Israel, 1982). The link between diabetes self-management, social support, and community health workers, termed promotoras in the U.S.-Mexico border region, has been recognized by the National Center for Chronic Disease Prevention and Health Promotion Division of Diabetes Translation (2005) and the American Association of Diabetes Educators [AADE] (2003). Promotoras understand how nuances of culture affect self-management and draw from this understanding when providing culturally and linguistically appropriate social support (McEwen, Baird, Pasvogel & Gallegos, 2007). Diabetes self-management interventions for Mexican Americans in the border region have been tested (Lujan, Ostwald & Ortiz, 2007; Brown, Blozis, et al., 2005; Sixta & Ostwald, 2008); however, only two studies reported promotoras as a social support intervention source for improving T2DM self-management behaviors. In the first study (Ingram et al., 2007) promotoras delivered a 1-year intervention for rural Mexican farmworkers with T2DM. The number of promotora support groups attended and the number of advocacy contacts were significantly correlated with improved glycemic control. In the second study (McEwen et al., 2007) promotoras delivered group and individual-level social support in a 6-month intervention for rural Mexican immigrant women with T2DM. From pre- to post-intervention there were significant increases in diabetes knowledge and self-management behaviors. This current study builds on these studies by testing the efficacy of a culturally-tailored diabetes self-management social support intervention for Mexican American adults with T2DM who reside in an urban border community and testing the feasibility of recruiting and training promotoras to deliver intervention components. Although promotoras in rural areas have participated in prior studies, the feasibility of recruiting and training them in an urban U.S.-Mexico border community was unknown.