Involving men and families in reducing cardiovascular disease risk ...

Involving Men and Families in Reducing Cardiovascular Disease Risk in Chiapas, Mexico Meredith Fort, Maricruz Castro, Liz Peña, Manuel RamírezZea, Homero Martínez 14 November, 2013

Background  INCAP Comprehensive Center for the Prevention of Chronic Diseases (CIIPEC), Guatemala City, Guatemala

 School of Nutrition, University of Arts and Sciences of Chiapas, Mexico

 RAND Corporation, Santa Monica, CA  Funding from the Heart Lung and Blood Institute of the National Institutes of Health

 Fogarty International Clinical Research Fellows Program, Vanderbilt University

Primary health and community-based support model to lower the risk of cardiovascular disease in individuals with type 2 diabetes mellitus and/or arterial hypertension in urban health centers in San José, Costa Rica and Tuxtla Gutiérrez, Chiapas

Goal of the Study  The main goal of this project is to adapt a health education intervention that can be delivered at the primary care level in the two settings.  Phase 1: Formative research: focus groups and interviews.  Phase 2: Adaptation and validation of educational materials.  Phase 3: Intervention (Nov. 2011 – Dec. 2012).  Phase 4: Qualitative study: interviews with men, families, and practitioners in Tuxtla Gutiérrez (ongoing through February 2014).

Education Sessions Corazón Sano y Fuerte. México  Quiero que mi corazón esté sano y fuerte.

 Comiendo sanamente en familia.

 Yo controlo mi presión.  Yo controlo la diabetes.  Pasos para tener un corazón sano y fuerte.

 Diga sí a la actividad física y al Autocuidado.

Pura Vida Costa Rica  Quiero que mi corazón este pura vida.

 Comiendo sanamente en familia.

 Yo controlo mi presión.  Yo controlo la diabetes.  Pasos para tener un corazón pura vida.

 Diga sí a la actividad física y al Autocuidado.

Variables  Variables measured: age, sex, years of education, body mass index, blood pressure, glucose, presence of type 2 diabetes and/or hypertension, medication use, smoking status, self-efficacy, and stages of change.

 Patient information gathered at baseline, 4 months and 8 months.

 Data captured in REDCap and analyzed in Stata version 12.



Conceptual Model to Evaluate Core Study 3: Primary health and community‐based support model to lower the risk of cardiovascular diseases in San José, Costa Rica and Chiapas, México

Ongoing Primary Care: Risk Classification Clinic visits Advice on Diet and Exercise Available Medication

Patient Characteristics: Age, Sex Predisposing: Education, work, marital status, Enabling: distance, transportation Need: absolute cardiovascular risk level

Site implementation factors: Infrastructure Human resources at the health center Other health promotion programs/policies Health Promotion Intervention Education Sessions Telephone follow‐up Home visits

Intermediate Outcomes

Increased Knowledge

Final Outcomes

Improved Self‐efficacy

Clinical Measures: Blood glucose Blood pressure Waist circumference Body mass index

Stage of change Behavior change: Diet Physical activity Smoking

(Prochaska, Bandura)

Baseline Socio-demographic characteristics Variable

Chiapas Compar. n=90

Age, years

57.4 ± 12.3 (34-80)

51.7 ±11.7* (29-88)

62.6 ± 9.7 (31-85)

64.0 ±8.9 (33-80)

69 (77%)

87 (92%)*

59 (68.6%

34 (40.5%)

21 (23%)

8 (8%)

27 (31.4%)

50 (59.5%)

4.2 ± 4.6 (1-18)

4.7 ± 3.9 (1-21)

8.6 ± 4.6 (0-20)

9.7 ± 4.0 (1-17)

34.4

31.6

9.4

18.3

an ± s.d. (min-max)

x (%) Femenine Masculine Years of study,

an ± s.d. (min-max)

Working(%)

Chiapas Costa Rica Costa Rica Intervention Compar. Intervention n=95 n=86 n=84

Defining phase 4 of our study Intervention study underway (Nov.2011 Dec. 2012) In Chiapas, 92% of the enrolled participants were women. In San José, CR – 60% and in Guatemala – 69%.

Individual orientation of the intervention could be missing a key group: family members.

Questions: 1) Why do so few men participate? 2) What is the family members’ experience and what

Gender “You take care of your husband but you don’t take care of yourself!...” (Chiapas, Female, paraphrasing her doctor) “... and men are so negative about going to the doctor, right, a few of them are accessible but most are not, most of them don’t want to go ... and it was a question of me having to tell him every day: take them, take them! I want to see you taking your pills.” (San José, CR, Female) Source: Barriers and facilitating factors for disease self-management: a qualitative analysis of perceptions of patients receiving care for type 2 diabetes and/or hypertension in San Jose, Costa Rica and Tuxtla Gutierrez, Mexico. BMC Family Practice 2013, 14:131

Family Support and How the Family is Affected “Look, when you were sick – I tell him – you had somebody to help you, now it is both of us by ourselves, we do not have anybody else to help us, so we have to help one another…” “You have to learn to be healthfully selfish and put limits or what should I say... with food I do not have problems because I cook without salt and if they want to add salt to their food then they can add it but they didn’t understand and ... but yes it (the family) helps a lot it has to help a lot because what if it is only causing you problems? To my two eldest kids, I stopped talking to them I don’t remember how many months so they wouldn’t say anything to me to avoid stress. Now they understand it...”

Specific Aims

) To understand reasons why there is limited participation from men with hypertension and/or type 2 diabetes in cardiovascular ealth promotion activities.

) To investigate how family members are affected by and ngaged in management and cardiovascular disease risk eduction when somebody in the family has hypertension nd/or type 2 diabetes.

3) Characterize providers’ recommendations for involving men n cardiovascular health promotion activities and in involving amily members in disease management and prevention.

Methods Qualitative study employs interviews with:  10-14 men receiving care at health centers,  6-8 families, and  8-10 Secretary of Health providers. Genograms and eco-maps are also being used to diagram family relationships, composition, and resources.

Methodology July to December of 2013. Analysis workshop in February 2014. Definition of who to include:  4-6 men who do participate in group education sessions.  6-8 men who do not participate in group education sessions.  8-10 health care providers who work with patients with chronic conditions.  6-8 families where at least one adult family member has type 2 diabetes and/or hypertension for which they receive clinical care from a Health Center in Tuxtla Gutiérrez.

For families, 1-2 interviews with a minimum of 3 adult family members.

Genorams

Goldrick, nica, Randy rson and Sueli ry (2008). nograms: sessment and ervention, d edition.

Analysis All interviews are transcribed into Word documents and will be coded by 3-person research team based on a defined codebook, with the support of Atlas.ti. Updates to the codebook during the process and discussion of discrepancies between the 3 researchers. Definition of themes, emerging from the data, using a grounded theory approach.

An example from Chiapas

EcoMaps

Mapping External Resources

Community ontext and esources that re external to he nuclear amily.

Complementary nformation to what may be btained in a enogram.

Other Example: Ficha Familiar in Perú

Preliminary Results (1) Ideas about why men do not participate:

Preliminary Results (2) Ideas for involving family members:  A) As care providers to support those who are diagnosed.  B) With the aim of preventing diabetes and hypertension in a family member not already diagnosed.

Primary References McGoldrick, Monica, Randy Gerson and Sueli Petry. Genograms: Assessment and Intervention, third edition. New York: WW Norton & Company, Inc. 2008. Gwen Rempel, Anne Neufeld, Kaysi Eastlick Kushner. Interactive Use of Genograms and Ecomaps in Family Caregiving Research. Journal of Family Nursing Vol. 13, No. 4. 2007: 403-419.