Facilitators and Barriers to Diabetes Education in Hmong Immigrants Living in the United States

Purpose:

Diabetes is a complex chronic disease with an increasing disparity in glycemic control and outcomes for racial and ethnic minorities. Hmong Americans are at high risk for developing diabetes and evidence suggests that the prevalence of diabetes in this population is increasing.  There is no study that addresses diabetes education in the Hmong Americans.

Because of the chronic nature of diabetes, diabetic education is essential to increase quality of life and positive outcomes for all people living with the disease.  To be successful, diabetes education must be tailored to meet the needs of a specific ethnic minority group. The purpose of this study is to explore barriers and facilitators related to the diabetes education experience of Hmong Americans with type 2 diabetes, living in central California in the United States.

Methods:

This qualitative study used an analytic method that employed both an inductive and deductive approach to identify themes in participants’ explanations of their diabetic education experience.  In the inductive approach, the Grounded Theory was used to formulate constructions of knowledge from the experiences and meanings attached to diabetes education by the research participants.  Themes were identified that emerged from descriptions of their diabetes education experience.  Using the deductive approach the Framework for the Study of Access to Medical Care (FSAMC) was used in the deductive approach. Selected apriori constructs applied to this study are health policy, characteristics of the health delivery system, characteristics of the population at risk, utilization of health services and consumer satisfaction. These constructs were utilized to operationalize access to health care among Hmong Americans with diabetes. Specifically to this study, the coding categories included consumer satisfaction (sub-constructs: cost and quality) and health care delivery system (sub-constructs: resource and organization). A Hmong community partner was used to assist in recruitment of the participants.  Using a convenience sample, two focus group interviews were conducted among 16 Hmong participants with type II diabetes living in Fresno, California.  Focus groups interviews were used for data collection.  Two Hmong interpreters facilitated the focus group procedures. Two Hmong individuals independently translated the transcripts directly from Hmong to English and two investigators reviewed and coded the transcripts to confirm the findings.

Results:

The results of this study are conceptualized into a framework that identifies three major points in the diabetes education experience of a population of Hmong Americans with diabetes:  health care access, health care experience, and output.  The points in the model are  (1) the health care access category, this is the input into the system from two a priori constructs of the FSAMC framework, consumer satisfaction (sub constructs are cost and quality) and the health care delivery system (sub constructs are resources and organization).  The deductive approach affirmed the relevance of apriori elements of the  FSAMC   (2) the health care experience category describes the diabetes education experience of the Hmong and is divided into three perceived barriers (language barrier, self-management barrier, stressors) and two perceived facilitators (focused culturally specific education and peer support group). The intervention target in this model addressed the perceived barriers and facilitators which leads to (3) the outputcategory that reflects the end products of the health care experience and health policy regarding access to care.  

The barriers and facilitators are exemplified in the following quotes from participants:

Language barrier-“If a lot of English is spoken at one time, then it’s hard to understand.  Yes, I just know the easy (English) words to get by.”

“Yes, for me, my doctor has given me a pamphlet in English about diabetes. But I cannot read it, I have it at home in a paper bag.”

Self-management barrier-“The reason I do not take medications prescribed by the doctor is because some does help you and some may just attack your system and causes other health concerns like kidney failure and blurred vision.” “I don't take the medication my doctor prescribed for me much. Maybe just two in one day just to help relieve the symptoms.”

Stressors-“There won’t be a medication that can help you heal from it, so those medicines are what you will have to take for the rest of your life.” “If they can't find anything to help cure diabetes, then for sure, our lives would be "poor."

The facilitators to diabetes education is exemplified in the quotes below:

Culturally specific education-“There should be a program focused on diabetes education and offered in Hmong too, so that we can understand it better. “I would like you (researcher) to take pictures of fruits, grains, or any foods, that way I see it, because I cannot read it.  This is better than a paper in English that I cannot read.” -

Peer support-. “We need to meet in a group with the same health condition that comes together to help encourage each other and to give advice about what they have done to help themselves fight diabetes. It's like learning from each other and using each other's ideas.” 

Conclusion:

This is the first study to address diabetes education in Hmong Americans. Because of the complexity of diabetes, education is key to management and good outcomes.  In promoting positive health outcomes for Hmong Americans with diabetes, the barriers and facilitators of diabetes education must be used to build health policies that will improve access to care.   When barriers and facilitators to diabetes education are addressed, it is hoped that Hmong Americans will have better health outcomes, increase in self-management skills, decreased complications, better disease management, and improved receipt of preventative services.