The Problem We Face Our Approach

Use of Fotonovelas as a Culturally and Linguistically Appropriate Tool in a Diabetes Disease Management Program

There is a clear knowledge disconnect about diabetes in our Latino focus groups, and the cultural relevance of the story in the fotonovela really helped participants connect more with the issue, as the storyline was comfortable and familiar to them.

The positive reception of the Sweet Temptations fotonovela

also prompted WellPoint to support the development of a fotonovela on medication adherence and safety that is now in production. Inappropriate medication use is increasing in the Latino population and there is an urgent need to communicate effectively with Latinos about this chronic issue. The diabetes health equities pilot highlighted the need to increase participants’

awareness of medication-

related issues and appropriate medication use.

About WellPoint, Inc.

Creating Health Care Value. One of every nine Americans

is a member of a WellPoint affiliated health plan. For us, that's a tremendous privilege and responsibility. We believe that health care is personal. We ask ourselves each day what we can do to improve health, improve care and improve value for our customers by:•Creating innovative products that make health care more

accessible and affordable •Improving the health of our communities by promoting

wellness and preventative care •Collaborating with health care professionals to improve

the quality of care

Persistent racial/ethnic disparities exist in health care, even after controlling for socioeconomic confounders, such as income, education and access to health insurance.1

African

Americans and Hispanics experience higher prevalence of diabetes, worse quality of care, and a higher illness burden than whites.2-3

Among the modifiable factors hypothesized

to contribute to the disparities are environmental factors and specific health behaviors.4

Culturally relevant approaches have been linked to increased knowledge and understanding for self-care in diabetes.5

Traditional health industry and health plan practices for addressing health education needs of patients/members of ethnically diverse backgrounds or those with limited English proficiencies include offering access to a language translation line and printed materials in alternate languages. These materials are often pure translations of the source educational content in English.

Health-related fotonovelas take full advantage of the popular culture approach to message development and content presentation for Latino audiences. A specific aim of the health-related fotonovela is to address the problem of health literacy, which has gained the attention of professionals throughout the health field, especially in regard to the culturally diverse population. Prior research has shown that it is not sufficient to provide health information in the language of the target population. One must also adapt educational materials for different levels of overall literacy, but more specifically for health literacy itself.1.Smedley BD, Stith AY, Nelson AR., eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academy Press, 2002.

2.Brown AF, Gregg EW, Stevens MR, et al. Race, ethnicity, socioeconomic position, and quality of care for adults with diabetes enrolled in managed care: the Translating Research Into

Action for Diabetes (TRIAD) study. Diabetes Care. Dec 2005;28(12):2864-2870.

3.Heisler M, Smith DM, Hayward RA, Krein SL, Kerr EA. Racial disparities in diabetes care processes, outcomes, and treatment intensity. Med Care. Nov 2003;41(11):1221-1232.

4.U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: U.S. Government Printing Office, November 2000.

5.Robert Wood Johnson Foundation, Finding Answers: Disparities Research for Change program. Review of interventions to reduce racial and ethnic disparities in health care. (n.d.). Retrieved from www.solvingdisparities.org

Terri Amano1; Melvin F. Baron, PharmD,MPA2; Greg Molina2; Grace H. Ting, MHA1

1WellPoint, Inc. –

Thousand Oaks, CA; 2University of Southern California –

Los Angeles, CA

Objective

To test the acceptance and relevance of various culturally and linguistically appropriate health education resources and different information channels, WellPoint launched a diabetes disease management health equities pilot, which was offered to select employer groups in California and Georgia with Hispanic insurance members with diabetes

The outreach comprised a wide variety of traditional and electronic educational mediums, including web-based resources, videos, print education brochures and the Sweet Temptations

fotonovela.

The Sweet Temptations/Tentaciones Dulces fotonovela is a

24-page photographic “comic book” that follows the story of

the Mendoza’s family’s struggles with diabetes and healthful living challenges. Sweet Temptations

is developed and

produced by the University of Southern California’s School of Pharmacy (USC).

The fotonovela also allowed customized pages to be inserted at the end of the fotonovela story. To support our disease management education efforts, we designed a brief guide to diabetes-related self-management tips, including symptoms of low and high blood sugar and suggested self-care treatments, information on key diabetes health screening –

what they tests and how to interpret the lab results, and questions to ask the physicians.

Evaluation Methodology

The study involved two phases of focus groups held 2008 – 2009 by an independent market research firm. The focus

groups were facilitated by a Hispanic moderator and conducted in Spanish. Sessions with Hispanic participants (n=37) were held in Los Angeles, California. The first set of focus groups tested prototypes of culturally optimized health education materials with members with diabetes, and the second set of focus groups evaluated responses to final pilot materials for efficacy and potential abrasions.

All subjects were commercially insured adults living with diabetes between the ages of 20 and 62. Each set had 8 to 15 participants that had been diagnosed with diabetes between less than 1 year and as many as 16 years prior.

Focus Group ResultsParticipants in the Hispanic groups said that the fotonovela is a particularly appropriate way to approach the Hispanic community.

The effectiveness of the fotonovela was validated through a focus group evaluation of the pilot materials. The fotonovela proved to be a significant educational tool. Among both male and female Latino focus groups, participants were very enthusiastic about the fotonovela: “This is about life and how to avoid having your diabetes get worse.”

They said it really brings up family memories.

They would read it and keep it. “This is something you should keep in mind because it is very important.”

Almost all of participants said that the fotonovela was the single most important piece of material they were shown: “It’s about real life.”

Participants also appreciated the

thoughtful way sensitive topics are addressed, like fatigue and sexual dysfunctions, “and a lot of people don’t want to talk about sexual dysfunction, but that’s real.”

Indeed, the entertainment nature of the fotonovela was particularly inviting and encouraged the Hispanic readers to finish the educational materials. One of the younger participants who normally reads English said that she wanted the photo novella in Spanish because she watches Spanish television. Other comments included:

D i v e r s i t y R x C o n f e r e n c eOct. 18 –

21, 2010

B a l t i m o r e , M a r y l a n d

Impact

•This is an easy way to read it (information about diabetes). Not so serious…

•The photos made it more interesting.

•This is a great medium to attract the Hispanic population, because any store we go into, there’s lots of little novellas.

•If you’re really looking specifically for the Latino community, it’s this, the comic book, that will attract them.

Contacts: mbaron@pharmacy.usc.edu or grace.ting@wellpoint.com