The National Institutes of Health (NIH) (2010) define disparities in health as “differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups” (para. 1). The Latino population is one group with known health disparities, especially in the area of diabetes. Extensive research in diabetes care has been conducted; however, there is a significant gap in the research literature related to factors that influence the achievement of glycemic control and self-management practices of the Latino population, in general, and migrant workers specifically.
Diabetes is a metabolism disorder (NIH, 2008). In those with diabetes, the pancreas will provide little or no insulin, or the cells will not react to the insulin produced (NIH, 2008). This results in a build up of glucose, which the body disposes of through the urine. Even if there was a build up of glucose, the body loses it main source of energy.
Diabetes among Latino population
Diabetes is one of the fastest growing disease classifications within the United States, especially among the Latino population (CDC, 2005). Nationally 2.5 million or 9.5% of all Latinos, 20 years of age or older, have diabetes. Latino individuals are 1.7 times as likely to have diabetes compared to non-Hispanic white individuals of similar age (CDC, 2005). These numbers are on a steady increase and only account for diagnosed cases of diabetes. Prevalence rates for the common complications of diabetes, obtained from the Centers for Disease Control and Prevention 2002 and 2005 data for the Latino population, clearly imply that developing strategies for preventing the complications from diabetes is a critical need. For example, 16.5 per 100 Latino adults with diabetes have visual impairments; 430.4 per 100,000 Latino adults with diabetes have end-stage renal disease; and 26.9 per 100 Latino adults age 35 years or older with diabetes have self reported cardiovascular disease (CDC, 2005). Comparable figures for non-Hispanic white adults are 19.5, 262.7, and 34.9 respectively. In addition, less than 60% of Latino adults with diabetes receive annual eye and foot exams, and participate in daily blood glucose monitoring (CDC, 2005).
Among Mexican-American adults, a subgroup of Latino adults, type 2 diabetes has reached epidemic proportions with concomitant devastating health complications, morbidity and mortality. Fortunately, many of these complications could be prevented through self-management techniques that promote tight glucose control. The costs, financial, physiologic and psychologic, associated with this disease and its complications are extreme. The need to explore culturally congruent, cost reducing and health promoting disease self-management strategies is imperative for this high risk population.
Vulnerability Among the Latino Migrant Population with Diabetes Within the diverse Latino population in the United States are those individuals who are long term residents of the United States and are well acculturated; individuals who have recently immigrated to the United States; and those who are migrant farm workers (individuals who relocate in order to work in agriculture and are unable to return to their permanent residence at the end of the work day) (Hakes et al., 2003). These characteristics have differential effects on cultural beliefs and practices, health outcomes and self-management practices.
Extensive research has been completed related to vulnerability and the identifying factors that produce the greatest risk for poor health outcomes which include ethnic/racial, economic, educational and health care related factors (Aday, 2001; Flaskerud & Winslow, 1998). Latino migrant workers meet all of these criteria. First, ethnic/racial factors, which include language barriers, apply because cultural norms of this group may not be well understood by health care providers and may clash with typical Anglo approaches to health. This group may experience a lack of support or feelings of isolation when migrating from region to region in search of work. Economic factors apply because they frequently have below minimum wage field work that does not provide for health coverage, experience increased financial burden related to migration from state to state, and from work area to work area, with periods of unemployment (US Census Bureau, 2003). Educational factors apply because few have a high school education (US Census Bureau). In addition to lack of education, they are confronted by a new society and legal system. Health care related factors apply because of inconsistency of health care caused by frequent moving. Many of these individuals move from provider to provider and often run out of medications in the process.
The consequences for diabetes control are monumental. Extended periods with elevated blood glucose levels increase the likelihood of retinopathy, cardiovascular disease and kidney failure. If and when these individuals seek medical assistance, often no records are available to the provider who must then start over (Hakes et al., 2003). This often leads to new medications and dosages that may have already proven ineffective, in turn extending the time frame of poor glucose control. The expense of repetitive laboratory work, medication changes, and office visits increases the financial burden for this population, leading to further delays in treatment and follow up. In addition, routine screening and evaluation is limited or omitted due to lack of continuity of care. Typically, only the acute management issues are addressed, leaving recommended annual exams (dental, dilated eye, urine protein and creatinine) incomplete, further leading to increased risk of complications from non-intervention (Clement, 1995; Hakes et al., 2003). Additionally, these individuals are at increased risk for work injuries due to the nature of fieldwork (Clement, 1995; Hakes et al., 2003). When the risk of unidentified injury secondary to peripheral neuropathy (resulting from prolonged blood glucose elevation) is added, these individuals are likely to become disabled and unfit to continue working. Unfortunately, these individuals do frequently continue to work, due to financial needs, often resulting in further injury that leads to lower extremity amputation (Clement, 1995).
Diabetes significantly increases the risk of serious debilitating and life threatening complications if not aggressively treated and tightly controlled. Many devastating disabilities can be minimized if the client has the knowledge and ability to follow through on self-management. All of these issues point toward the need for strong self-care management skills because the Latino migrant adults are the major directors of their own care (in relation to access and migrant status.)
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As a migrant population, issues of border and border crossing may also influence the health disparities and/or vulnerability of this population. Crossing borders, including the U.S.-Mexico border and state borders within the United States, influences access to health care. of particular concern with this migrant population is the issue of legal documentation to enter the United States. Although the majority of this population has entered the United States legally, some lack this legal documentation (NCFH, 2005). As a result, fear of exposure and identification as undocumented, resulting in deportation, may hinder efforts to seek out healthcare providers. Knowledge of where and from whom to access care becomes an ongoing challenge along the migration path. In addition, members of this population may avail themselves of healthcare on both sides of the border, United States and Mexico, further fragmenting care. Health care availability, funding, and access also vary across U.S. state borders as each state’s regulations and requirements for low income assistance vary. Additionally, these assistance programs are not transferable to neighboring states, further increasing the vulnerability of this migrant population. Border crossing can also result in separation from family and social networks; decreasing, abolishing, or at the very least disrupting resources of social support for health maintenance. Each of these border factors further heightens the risks for poor health. The issues that increase vulnerability of this population are further accentuated by and not separable from border health issues in general.
Promoting Self Management Practices
Self-management has also been described as caring about oneself, not harming oneself, and having relationships that motivated self-care practices (Leenerts & Magilvy, 2000).
A large knowledge gap related to self-management in the Latino population exists. This group has a high rate of diabetes complications (CDC, 2003) despite interventions extensively documented in the Anglo population to decrease complication rates. Perhaps the problem relates to a mismatch between the assumptions of self-management among the Latino migrant population (familism worldview) compared to Anglo American individuals (individualistic worldview). Culturally influenced self-management beliefs and practices must be explored and culturally congruent nursing interventions developed.
A paucity of available research, and the strong cultural ties to familism in the face of the sometimes disrupted family structures characteristic of migrant status, leaves much to conjecture regarding diabetes management practices in this population. The epidemic rate of diabetes in the Latino population, coupled with the vulnerabilities that arise as a result of migrant status, highlights the importance of cultural and social processes of diabetes self-management within the families/households of Latino migrant workers. Understanding gained from this research can guide development of interventions and education programs, utilizing culturally appropriate methods, to enhance the health of this population.
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