1. AAFP 2014 Family Medicine Global Health Workshop
El Medicamento Es Lo Mejor:  Health Beliefs of Hypertension in a Resource Poor Community in the Dominican Republic
We didn’t analyze the diabetes data so we should should probably take out diabetes

2. Mark Ryan, MD Jasmine Abrams, MS Bryan Castro
Dept of Family Medicine and Population Health
Jasmine Abrams, MS
Prevention Specialist, Center for Cultural Experiences in Prevention
Doctoral Candidate, Health Psychology
Bryan Castro
Master in Public Health Student

3. Activity Disclaimer ACTIVITY DISCLAIMER
It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.
Mark Ryan, Jasmine Abrams, and Bryan Castro have indicated they have no relevant financial relationships to disclose.

4. Objectives
Describe the importance of NCDs in the developing world and the prevalence of NCDs in Esfuerzo, Paraíso.
Identify the importance of culturally appropriate medical interventions, and list characteristics of such interventions.
Outline an IRB-approved qualitative study to assess community residents’ needs and beliefs regarding NCDs.
Analyze the results of interview data and plan culturally appropriate community-based interventions based on results.

5. Non-communicable diseases
In 2008, 36 out of 57 million (63%) deaths in the world were due to NCDs, of which 29 million (80%) occurred in low-/middle-income countries
In 2010, almost 15,000 out 29,000 (50%<) deaths in the DR were attributed to NCDs
Prevalence of hypertension is 40% worldwide and 37% in DR
Prevalence of diabetes is 10% for both worldwide and DR
In 2008, 36 out of 57 million (63%) deaths in the world were due to NCDs, of which 29 million (80%) occurred in low-/middle-income countries
In 2010, almost 15,000 out 29,000 (50%<) deaths in the DR were attributed to NCDs
Prevalence of hypertension is 40% worldwide (age 25+) and 37% in DR (age 18-75)
Prevalence of diabetes is 10% for both worldwide (age 25+) and DR (age 18-75)

6. Culturally-Relevant Interventions
Para que sirve la ciencia, si no nos ayuda?
Need for culturally relevant programming in marginalized communities
Culturally tailored interventions are more effective than non-tailored interventions
Considering the lived experiences of individuals is essential to creating effective programs that will be embraced
I think these slides would be better placed at the end of the presentation before the slide where you ask about presentation ideas
This slide –Interventions can be a great cost efficient way to reduce or prevent health disparities however (transition into first bullet) – what good is science, if it doesn’t help us
Second bullet – the need is great for these programs to avoid a top down approach where the “helpers” develop programming without community input – the best prevention science emphasizes the need for culturally tailored programming that considers the needs and practical concerns of communities
Third bullet – numerous studies have found this to be true; also endorsed by WHO
Examples – Hypertension Improvement Project (HIP) Latino; Physical Activity Interventions in Hispanic Adults _-> behavioral interventions (multisession programs that target diet and exercise behaviors to improve health)
Fourth bullet – to maximize effectiveness its important to consider the lived experiences of individuals, recognize and respect their beliefs and work collaboratively to create sustainable interventions

7. Esfuerzo

8. Esfuerzo

9. Esfuerzo
Barrio located on the northwest margin of the urbanization of Santo Domingo (Norte).
Esfuerzo is a sub-community of Paraíso, within the barrio of Villa Mella.
Residents’ experiences defined by low income, lack infrastructure/support, little formal employment, low levels of education.

10. Esfuerzo
Approximately 90 homes (approximately 85 occupied), population approximately 450 people.
Ongoing work with short-term medical trips and community organization and development since 2006.
Medically, we have noted an increasing burden of NCDs with in the community.

11. Esfuerzo
Internal project evaluations have demonstrated a high prevalence of chronic disease (specifically hypertension), as well as low levels of treatment adherence.
As a short-term medical relief project, we are working to better address NCDs both via our efforts, and in collaboration with the community and with local healthcare providers.

12. The project
In June 2013, student researchers working with the Dominican Aid Society of Virginia and VCU’s HOMBRE organization undertook a research project to evaluate hypertension-related beliefs and perceptions.
The long-term goal is to use this information to enhance care for NCDs within the community of Esfuerzo.

13. The project Interview Questions:
Have you or anyone in your household or family been diagnosed with high blood pressure?
How did you/they learn you/they had this illness?
How was the diagnosis made?
What do you think/how do you feel about high blood pressure?

14. The project Interview Questions:
What do you think provokes (or produces) high blood pressure?
Why do people get high blood pressure?
What impact, if any, do these illnesses have on your life (daily activities like work, things to do, house chores, etc.)?

15. The project Interview Questions:
What can be done/what are you/they doing to control these illnesses?
What makes it difficult to control these illnesses?
What is the best way to treat chronic diseases like blood pressure?  

16. Participants 20 participants: 8 men, 12 women 50% employed
55% living with their partner, 30% married
95% either somewhat or strongly religious

17. Participants 85% identified as non-smokers
15 (75%) had hypertension, 5 (25%) had diabetes, and 4 (20%) had both conditions; total of 19 had hypertension.
Participants identified by community health committee, community health screenings, and other interviewees.

18. Results
Qualitative analysis of participant responses revealed four primary themes:
Knowledge of hypertension
Barriers to treatment of hypertension
Impact on life
Diagnosis

19. Results: Knowledge
All interviewees noted some knowledge of hypertension, mostly related to consequences, causes, and control/treatment of hypertension.

20. Results: Knowledge
Consequences of hypertension: patients attributed both short term symptoms (dizziness, fatigue, etc) as well as long-term risks (including stroke, cardiovascular disease, and death) to hypertension.

21. Results: Knowledge
Causes of hypertension: Psychological distress (47%) and lifestyle habits (32%) were listed as primary causes of hypertension.
Stress and interpersonal relationship struggles were blamed for hypertension, including by “heating up the blood”.

22. Results: Knowledge
Control and treatment of hypertension: 15 (75%) participants noted that medications were useful in controlling hypertension, and 11 (58%) believed that lifestyle changes such as increased exercise, healthier eating habits, and rest could help hypertension.
Keeping regularly-scheduled appointments and taking medications as prescribed were considered essential by most participants.
32% indicated dislike/distrust of home remedies.

23. Results: Barriers
Barriers to the treatment of hypertension: 84% of respondents indicated they experienced barriers to obtaining treatment.
63% indicated difficulty in accessing healthcare services, with most citing money as an obstacle
16% discussed lack of stable employment limited access to treatment, both due to income and insurance considerations

24. Results: Barriers
Resources to help overcome barriers included utilizing networks of social connections and supports, but nearly 1/3 of respondents noted they lacked such support.

25. Results: Barriers
26% noted barriers to care in the form of the healthcare system, including apathy from providers, busy hospitals, and the lack of available medications.
21% noted physical difficulties (including transportation) as barriers to care.

26. Results: Impact on life
Impact of hypertension on life:
21% reported no impact
32% reported an impact in that they felt unable to go outside in the sun, complete chores, or engage in strenuous activities
26% noted emotional changes from hypertension, including feeling sad and overwhelmed, and needing to take things slow

27. Results: Diagnosis
Diagnosis of hypertension: 21% had been diagnosed via international medical projects, and 58% were diagnosed by Dominican healthcare providers.

28. Results: Member Checking
Member checking of the results of the survey confirmed the validity of the results.
Finances and availability of medications continued to be noted as barriers to care, while perceived causes of hypertension and methods of hypertension management were largely reinforced.
Member checking – we went back and re-interviewed many of the original participants to determine if our analyses were in line with community beliefs

29. Summary of results
Patients had an understanding of the medical importance of hypertension.
Patient beliefs regarding the causes of hypertension did not necessarily align with recognized medical causes of hypertension.
Lifestyle changes, regular attendance of medical visits, and adherence to prescribed medical care were listed as important factors in treating hypertension.

30. Summary of results
Barriers to accessing healthcare services were common, and included patient finances and physical challenges, as well as health system issues such as available supplies, physician apathy, etc.
Many patients noted a lack of social support that might facilitate access to care.

31. Next steps
Given this information, what do you feel would be appropriate and productive interventions to propose to the community?
It may be useful to include the first two interventions I proposed from last year (given that an objective of the presentation states that we would create an intervention) and ask for feedback on those and then include this slide

32. Next steps
Subsequent research has indicated that insurance may cover the cost of doctor visits, but not medications, and cost and transportation/time were limits to accessing ongoing care.
Given this information, what do you feel would be appropriate and productive interventions to propose to the community?
It may be useful to include the first two interventions I proposed from last year (given that an objective of the presentation states that we would create an intervention) and ask for feedback on those and then include this slide

33. Culturally-Relevant Interventions
Para que sirve la ciencia, si no nos ayuda?
Need for culturally relevant programming in marginalized communities
Culturally tailored interventions are more effective than non-tailored interventions
Considering the lived experiences of individuals is essential to creating effective programs that will be embraced
I think these slides would be better placed at the end of the presentation before the slide where you ask about presentation ideas
This slide –Interventions can be a great cost efficient way to reduce or prevent health disparities however (transition into first bullet) – what good is science, if it doesn’t help us
Second bullet – the need is great for these programs to avoid a top down approach where the “helpers” develop programming without community input – the best prevention science emphasizes the need for culturally tailored programming that considers the needs and practical concerns of communities
Third bullet – numerous studies have found this to be true; also endorsed by WHO
Examples – Hypertension Improvement Project (HIP) Latino; Physical Activity Interventions in Hispanic Adults _-> behavioral interventions (multisession programs that target diet and exercise behaviors to improve health)
Fourth bullet – to maximize effectiveness its important to consider the lived experiences of individuals, recognize and respect their beliefs and work collaboratively to create sustainable interventions

34. Proposed Interventions
What would this group suggest would be proper interventions?

35. Proposed Interventions
Add a more robust health education component to HOMBRE winter and summer clinics?

36. Proposed Interventions
Add a more robust health education component to HOMBRE winter and summer clinics?
Disseminate free and low cost health service information to community members?

37. Proposed Interventions
Add a more robust health education component to HOMBRE winter and summer clinics.
Disseminate free and low cost health service information to community members.
Establish a community clinic and/or pharmacy project to provide basic health services to community members?

38. Proposed Interventions
Other ideas?

39. Cautions
Ensure that the proposed intervention will be useful to the community and sustainable for the long term.
Use available data from ongoing projects to assess proposals and community buy-in.

40. Thank you!
Mark Ryan: