Reducing Diabetes Through Creative Community Building
By LUCI FERNANDES, SHAHNA ARPS, and RICARDO CONTRERAS
Luci Fernandes, Ph.D. is a cultural anthropologist whose research focus is on documenting daily life through audio/visual mediums. She documents life ways in both contemporary Cuban and in Eastern North Carolina, where she lives and teaches anthropology courses for East Carolina University. Luci is a regular contributor to Community Works Journal. Her aim in to highlight everyday people, their joys and struggles to connect people in their human experience. Along with her colleagues Shanhna Arps and Ricardo Contreras, she shared the following program with Community Works Journal.
Diabetes currently represents an urgent health problem among Latinos. The National Alliance for Hispanic Health estimates that one in ten Hispanics in the United States is living with diabetes, although only one in three may know he/she has the disease. Latinos in the US appear to be particularly vulnerable to diabetes. Their disproportionately high rates of this disease and other health problems appear to be related to insufficient access to education, information, and health services, as well as their lifestyle, which includes nutrition and physical activity. We must address diabetes awareness and prevention in Latino populations within the US. However, we have learned that we cannot design effective health programs that promote behavioral changes unless we understand their beliefs, values, customs, and constraints.
Creative community building offers, we believe, a means of helping individuals and communities look within at their strengths, assets and resources. It also provides strategies for developing the kinds of collaboration that can shape the vibrant and successful communities in which people want to live, work, and play. Accessible and relevant healthcare is essential to such communities.
Our goal was to build alliances that created bridges between the university and Hispanic communities, alliances that were mutually beneficial. Community organizers in eastern North Carolina have been prompted by the population of fairly recent Latino immigrants in Greenville to implement outreach programs disseminating information on healthy living practices. The local organization, AMEXCAN (Association of Mexicans in North Carolina), was interested in partnering with university researchers to design and carry out health and wellness programs. We worked closely with Juvencio Rocha Peralta, AMEXCAN President and Juan Pablo Servin Ramírez, AMEXCAN Coordinator. Our objective was to integrate the experiences, knowledge, and interests of community members, including AMEXCAN staff, into the design and implementation of health outreach projects. If organizations collaborate with community members, the diet and exercise programs they design together are more likely to fit into a particular lifestyle, be more familiar and enjoyable, and consequently are more likely to be adopted and successful overall (citation needed). Community members have to be part of the design and decision making process at all levels. One time implementation of a project, however, is not enough. Members of the community also need to be in charge of insuring that the program continues.
To learn about local perceptions of health, Shahna Arps, Luci Fernandes and Juan Pablo Servin conducted focus groups and preliminary interviews in local churches and community centers in and around Greenville. We conducted discussions in Spanish and the majority of the 23 participants were from Mexico. Through open-ended questions, we gathered information that can inform the design of healthy living programs in the United States. By understanding the ways in which lifestyle practices are altered through migration, community organizers can identify the needs associated with preventing and managing diabetes and other diseases. We wanted to design diet and exercise programs that are simple to follow and that are culturally appropriate. Expanding local knowledge of the condition is the first step in preventing and treating diabetes. The second step requires changes in lifestyle, which often prove difficult to maintain with consistency. We decided to focus on how to make lifestyle changes attainable given the social and economic context. For example, Latinos had to be able to accommodate dietary changes and exercise routines within their daily schedules. The diet, as well as the exercises, had to be culturally appropriate. We also realized that a community support system was necessary.
Nutrition and activity levels deserve special attention because of their impact on health status and diabetes risk. During group discussions, we focused on perceptions of diabetes, nutrition, and physical activity in order to examine the factors that contribute to obesity and physical inactivity. The Latinos we spoke with clearly understood that “diabetes is a terrible illness” that can be fatal. Interestingly, they also listed many of the causes: “bad nutrition”, “being overweight”, “not being physically active or exercising”, and “heredity”. We found the inclusion of physical inactivity particularly important given that in other studies of diabetes perceptions, Latino immigrants rarely report lack of exercise as a cause. Since they identified poor diet as a cause of diabetes, we wanted to know what they considered a poor diet. Their responses included “fast food”, “hamburgers”, “sweets”, “French fries”, “bread”, “high fat foods”, “fried foods”, and “pizza”. We were surprised that the Latino participants mentioned physical activity since in other studies of diabetes perceptions among Latino immigrants exercise has rarely been reported as a cause.
We also asked the Latino migrants about changes in their daily lives since migrating to the United States. “There is a huge change (bastante!)! It will ruin you!” They emphasized that they had had more nutritious diets and active lifestyles in Mexico. In the US, they eat less fresh food and more foods that are high in fat. They can’t find in North Carolina the fruits and vegetables they were accustomed to eating in their native countries. “Before we could grow many things, like corn, lettuce, tomatoes, cabbage, garlic, and peppers, on our own land.” “Food was from the country, not bought.” “We ate more grains and meat.” “Meat is old because it’s frozen and shipped.”” We saw the chickens grow up, free-ranging, saw them grow, saw what they ate, it took time. Here they inject the animal and the next day it’s big.” That gives the meat “a different taste.” “Here the food has more fat and grease.” The Latinos also rely on convenient foods, which were largely unavailable in their native countries. Often this reliance on convenient foods was related to the dietary preferences of their children, who had been brought up in the US on American foods. The kids don’t want traditional foods; they want pizza, macaroni and cheese, “dishes that have more flavor because they are full of ketchup, high in salt, and high in fat”! They like the fast food from McDonalds, and Taco Bell. And the mothers don’t want to have to prepare both traditional dishes and American ones. “It is our custom to spend a lot of time cooking and eating, but it is not possible because we do not have time.”
Also, the Latinos complain that they lead more sedentary lives. In their native countries, they used to walk daily, sometimes two hours each day to school, in the country (campo), to shops. In the US, they don’t walk much, “just to the refrigerator” one said. Since most of them live outside of town, they depend on cars. This is also true for those who live within the city of Greenville, since it is not pedestrian-friendly and doesn’t have a good public transportation system. “Here you don’t go anywhere; if you don’t have a car, you are stuck at home.” Instead of washing clothes by hand, as they had usually done in their native countries, they used washing machines. They also tended to use machines, such as vacuum cleaners, to do housework. And they didn’t do any yard work. Moreover, the colder climate of North Carolina, compared to their home countries, kept them inside during the winter. In fact, they had difficulty giving examples of physical activities or exercise that they did regularly.
Like typical Americans, their busy lives were often a barrier to physical activity and healthy diets. They work long hours and are typically too tired to exercise when they get home. At work, their short meal breaks encourage them to eat fast food. The schedules of Latinas were, in addition, complicated by childcare and their children’s school, leaving them little time for cooking traditional meals or physical activities, let alone exercising. The lifestyle changes that the Latinos described helped us understand what aspects of their life in the US promoted obesity and physical inactivity—the major risk factors for diabetes that even the Latinos themselves recognized.
Our challenge, and that of all community health initiatives for preventing diabetes in the Latino community, was to design culturally appropriate strategies for overcoming these barriers. What we discovered has implications for the design of diabetes education and prevention programs since we believe that community health initiatives need to use culturally appropriate strategies that address the specific problems that Latinos experience if they are to have any effect of the prevention and treatment of diabetes.
First, the Latinos said that they would like to have information about diabetes disseminated more widely. Although participants knew something about the causes and symptoms of diabetes, they were less clear about how to prevent the disease, and how it can be treated. In particular, they wanted information about how to eat a healthier diet, how to fit exercise into their busy schedules, how to reduce stress, and how to get access to appropriate healthcare. AMEXICAN, with the assistance of faculty from East Carolina University, implemented a community health advisor (CHA) program in Pitt County. The program, supported by a grant from Pitt Memorial Hospital Foundation, trained men and women residing in Pitt County to reach out, raise awareness, and educate the Hispanic community on Type 2 diabetes prevention, with an emphasis on culturally-appropriate nutrition and physical activity. The program built upon the diabetes awareness project AMEXCAN had already put into place with funding from the same foundation. People who participated in the diabetes awareness project were trained in diabetes prevention and methods of popular education. The people trained as community health advisors (promotoras/es de la salud) were the central piece of an outreach model whose purpose was to improve health in the Hispanic community. This prevention program targeted people where they live and socialize, such as neighborhoods, churches, parks, and schools. We also organized a “Feria de Salud Comunitaria” (community health fair) as part of our “Campaña de Prevención Sobre la Diabetes” (Campaign to Prevent Diabetes). Held at the local Boys and Girls Club, it included screening for diabetes, HIV/AIDS, as well as testing of blood pressure, glucose, cholesterol and much more. Music, authentic foods and recreational activities were included.
Disseminating information about diabetes as a disease, however, is only the first step. We knew that we also had to design culturally-appropriate programs to improve nutrition and increase physical activity within the Latino community. Since the Latinos, and especially the Latinas, indicated that they were less physically active in the US than they had been in their native countries, what kind of exercise program could we come up with that was culturally relevant to the Latino community? “We like to dance!” All twelve of the Latinas in one of our focus groups said that they were interested in dancing and would like to bring their kids. So, we developed an exercise program using Latin styles of music and dance: Ranchero, Salsa, Merengue, Bachata, Cumbia! However, not all Latino groups within the community felt comfortable with dancing. So we learned that one program does not fit all people in the Latino community. We had to find alternatives that were appropriate. The alternative idea that emerged was “El Dia del Campo,” whose activities including walking groups and soccer.
How could we get Latinos to eat a healthier diet? First we needed to know what foods they usually ate now that they live in North Carolina. In the focus groups, participants reporting eating the following foods frequently chicken, beef, corn tortillas, tamales, rice, beans, and soups. They often cooked with lard (manteca de Puerco), and sometimes vegetable oil. Cilantro was a commonly used herb, and participants reported eating the following fruits/vegetables: tomatoes, chilies, okra, cabbage; and nopal (prickly pear cactus). The Latinas explained to us that their families eat corn tortillas. In Mexican dishes, corn tortillas are traditional except in northern Mexico. In American dishes, Tex-Mex style food, or from Taco Bell, flour tortillas are common. Six corn tortillas as the equivalent of one flour tortilla. The Latinas told us that they were always interested in trying new recipes, especially for their children. We then looked for ways to modify traditional recipes with healthier options. We developed a recipe exchange and cooking contests.
Also, since participants had mentioned that they had difficulty finding the vegetables they were accustomed to and had grown in gardens in their native countries; we asked them about gardening in North Carolina. Some did have gardens here, but others said they have no space. One woman said that it depends on who you rent from, not all have permission to have a garden. They did indicate that they were interested in a community garden, and would have time to participate. They asked if they would have to pay to participate and whether they could grow whatever they wanted. So, we added to idea of community gardens to our program. We also decided to encourage them to raise their own chickens, even helping them build chicken coops.
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