Abstract
Background: In light of health disparities and the growing prevalence of chronic disease, there is a need for community-based interventions that improve health behaviors and health status. These interventions should be based on existing theory.
Objective: This study aimed to evaluate the health and utilization outcomes of a 6-week community-based program for Spanish speakers with heart disease, lung disease, or type 2 diabetes.
Method: The treatment participants in this study (n = 327) took a 6-week peer-led program. At 4 months, they were compared with randomized wait-list control subjects (n = 224) using analyses of covariance. The outcomes for all the treatment participants were assessed at 1 year, as compared with baseline scores (n = 271) using t-tests.
Results: At 4 months, the participants, as compared with usual-care control subjects, demonstrated improved health status, health behavior, and self-efficacy, as well as fewer emergency room visits (p < .05). At 1 year, the improvements were maintained and remained significantly different from baseline condition.
Conclusions: This community-based program has the potential to improve the lives of Hispanics with chronic illness while reducing emergency room use.
Tomando Control de su Salud (Taking Control of Your Health), a community-based program for Spanish-speaking Hispanics with chronic diseases, resulted from the convergence of three trends. The first trend is the growing health disparity between Hispanics and non-Hispanics. For example, studies indicate that the prevalence of diabetes is nearly two times greater among Hispanics than in non-Hispanic groups (National Diabetes Information Clearinghouse, 2002). Diabetes also is medically more severe among Hispanics (Harris, Klein, Cowie, Rowland, & Byrd-Holt, 1998). In studies of respiratory diseases, data indicate that although the prevalence of these diseases is variable among different Hispanic subgroups, Hispanics tend to be hospitalized more frequently for asthma than either African Americans or Whites (Carr, Zeitel, & Weiss, 1992;De Palo, Mayo, Friedman, & Rosen, 1994;Schulman & Glaxo Wellcome Inc., 1998). In Los Angeles, Hispanics have the second highest mortality for cardiovascular disease of the four major ethnic minority groups in Los Angeles County (Centers for Disease Control, 1999;Haywood, 1990). Cardiovascular disease, the leading cause of death for Hispanics, is declining at a slower rate in this group than in the remaining populations (Council of Scientific Affairs, 1991;Furino & Munoz, 1991;Hayes-Bautista, Baezconde-Garbanati, Schink, & Hayes-Bautista, 1994).
The second trend is the increasing prevalence of chronic diseases accompanied by comorbid conditions (Wu & Green, 2000). One in five Americans has a chronic condition (Wu & Green, 2000). This increases to 84% for people 65 years of age or older. Among older Americans, 62% have comorbid conditions (Wu & Green, 2000). It is not unreasonable to believe that the data are similar for the U.S. Hispanic populations.
These factors become especially important considering the third trend, that one third of Hispanics are without any form of health insurance (Eberhardt et al., 2001). Approximately 32.8 million Hispanics live in the United States (Therrien & Ramirez, 2000).
During the past decade, chronic disease self-management education programs have demonstrated their impact on health behaviors, health status, and healthcare utilization (Brown et al., 2000; Lorig, Gonzalez, & Ritter, 1999; Lorig, Sobel et al., 1999;Clark et al., 1992;Glasgow et al., 1997;Lorig et al., 2001). For example, a 6-week arthritis self-management program in a 4-month randomized trial demonstrated that participants increased their practice of exercise while reducing their pain (Lorig, Lubeck, Kraines, Seleznick, & Holman, 1985). In a 4-year longitudinal study, this same intervention resulted in a 19% reduction in pain and a 42% reduction in outpatient visits to physicians (Lorig, Mazonson, & Holman, 1993). When the 6-week arthritis program was culturally adapted and offered to Spanish speakers in a randomized trial, the 4-month results were similar to those for the English speakers. No significant deteriorations occurred between 4 months and 1 year (Lorig, Gonzales & Ritter, 1999b. To identify the mechanisms through which these programs achieved effects, the relations among gains in knowledge, adoption of self-management behaviors, and health outcomes were examined (Lorig, Seleznick et al., 1989). Correlations were either weak or absent (Pearson's r, 0.0-0.15). Semistructured interviews with English-speaking program participants followed by theme analyses showed that those whose health status improved believed they had some control over their symptoms, whereas those who did poorly believed that they could exert very little control (Lenker, Lorig, & Gallagher, 1984). This suggestive finding led to an exploration of psychological determinants of health and the possibility that the participants' perceived self-efficacy in coping with arthritis was an important mediator. An instrument was designed to measure perceived self-efficacy, and in two subsequent studies, a positive correlation with health status was found (Lorig, Chastain, Ung, Shoor, & Holman, 1989). On the basis of these findings, the program was revised to emphasize the efficacy-enhancing strategies of skills mastery, modeling, reinterpretation of symptoms, and social persuasion (Bandura, 1997, 2000;Lorig & Gonzalez, 1992). Participants in the revised program demonstrated greater improvements than participants in the original program.
More recently, a chronic disease self-management program based on self-efficacy theory was evaluated for nearly 1,000 subjects with heart disease, lung disease, stroke, or arthritis (Lorig et al., 1999c). Outcomes of the 6-month randomized trial and the 2-year longitudinal follow-up evaluation demonstrated that participants had significant increases in health behaviors and health status as well as reduced healthcare use (Lorig et al., 2001;Lorig et al., 1999c). Self-efficacy also increased and was the one factor that best predicted health status outcomes.
The qualitative work of Hunt, Valenzuela, and Pugh (1998) is of special interest. These researchers found that for Latino patients with non-insulin-dependent diabetes, the relation between behavior and illness is not so much determined by self-care attitudes as by the experience Latinos have trying to gain control over their disease. This finding supported theory grounded in control beliefs, which proposes that health behavior is strongly influenced by the belief that one can exercise some measure of control over one's health condition. The findings of Hunt et al. (1998) suggested that behavior may be determined by a reciprocal interaction between behaviors and a person's experience with these behaviors. The self-efficacy theory, which proposes such a reciprocal interaction, may offer a strong theoretical framework for building Latino diabetes self-management programs. This finding is supported by Abraido-Lanza (1997), who found that self-efficacy contributes to psychological well-being among Latinas with chronic illness.
Based on the needs of the Spanish-speaking community, especially the growing prevalence of comorbid conditions, and on the aforementioned theoretical work, Tomando Control de su Salud was developed as one step toward bringing chronic disease self-management education to the Spanish-speaking community. Individuals with serious diseases of both high and growing prevalence in the Spanish-speaking community were chosen for the study. The aims of this study were
* to develop a 6-week Spanish language self-management program for individuals with chronic disease (coronary artery disease, chronic obstructive pulmonary disease including asthma and chronic bronchitis, or type 2 diabetes) and to evaluate its effects on self-management behaviors, symptoms, health status, healthcare utilization, and self-efficacy.
* to evaluate the extent to which beneficial outcomes are maintained in a 1-year cohort study.