Cross-Cultural Work Health and Medicine

Nelly Hernandez, UT MD Anderson Cancer Research Center

Internship at University of Texas MD Anderson Cancer Research Center: Reaching Latino Families to increase Physical Activity and Healthy Eating

Nelly Hernandez

During the fall semester of 2016, I was part of the internship program at the University of Texas MD Anderson Cancer Center in Houston. I worked on a research project known as “Tu Salud Si Cuenta (TSSC),” which means “Your Health Matters.” This outreach program aims to improve the health of the local Hispanic Community. My first-hand experience led me to a broader understanding of the intense process necessary to develop an outreach program.

Location of the Research Program

The program’s roots go back to Brownsville, Texas through University of Texas and continues to be an active part of the lower Rio Grande Valley where it originated. The program is now administered by Dr. Larkin Strong as part of the Health Disparities Department at University of Texas MD Anderson Cancer Center in Houston concentrating predominately in Latino communities of the East end, Magnolia, Northside, Northline and Gulfton areas. University of Texas continues to expand its preventative research study through South Texas including Galveston and Austin prioritizing areas with higher populations of indigent inhabitants.

The objective for Tu Salud Si Cuenta is to adapt and evaluate the relevance and acceptability of a family-based intervention designed to enhance physical activity and healthy eating habits among adult Latino family dyads in Houston. Dyads consist of any two related adults within the household. Families consist of members connected through intertwining relationships; therefore, it is strongly believed that change in one family member influences change in other family members. TSSC uses this family based approach to engage multiple family members in the ongoing research to promote physical activity and healthy eating.

Diet and Physical Activity Statistics

According to the American Institute for Cancer Research, physical inactivity, a poor diet, and obesity are major risk factors for cardiovascular disease, certain cancers, diabetes, and stroke, and are important contributors to preventable morbidity and mortality in the U.S. (American Institute for Cancer Research 2007). Although most adults in the U.S fail to meet national physical activity and dietary recommendations, underserved populations such as Latinos are less likely to meet these recommendations than the non-Latino White population (Otero-Sabogal 1995: 73-82). Approximately one-third of non-Latino White populations report the recommended weekly leisure-time activity, compared to the 23% of Latinos, and over 78% of Latinos consume fewer than five servings of fruits and vegetables per day. These trends parallel disparities in overweight and obesity, with approximately 67% non-Latinos being overweight or obese, compared to approximately 79% of Latino adults (Protocol 2015). These behaviors are heavily correlated with the person’s social and cultural environment and have an impact on the two key lifestyle behaviors of physical activity and diet that TSSC targets.

Overview of the TSSC program

The program is delivered in-person by the bilingual MD Anderson research staff and community health workers, known as promotoras, who have the responsibility of aiding in the administration of the treatment plan. These plans include in-depth interviews or open-ended interviews conducted to explore attitudes, behaviors, barriers, facilitators, and social support related to healthy eating and physical activity. The information gathered from the in-depth interviews also serves to analyze the extent to which social and cultural environments play in each participant’s life. Keying the information gathered from the participants into REDCap enables researchers to pinpoint the areas with inconsistencies and allows researchers to develop proper strategies to target the social and cultural behaviors and better adapt the intervention to the study group. Six monthly home visits take place, during which the participants are instructed in standard behavioral skills such as self-monitoring, goal setting, problem solving and relapse prevention, as well as sharing motivational strategies that involve interactive hands-on learning techniques to achieve the desired positive change in the participant’s health.

U

sing REDCap to maintain assurance of the data

My responsibility was to register all the data gathered from the in-depth interviews into REDCap, including transcribing and translating every in-depth interview that was administered. REDCap is a secure web-based application with controlled access designed to support data capture for research studies and give access to the research staff.

From the REDCap database, the qualitative findings or underlying insights for diet and nutrition were gathered and divided into sections by Dr. Strong, explaining the quantitative results or the data measurements reported by the participants. From these qualitative findings I understood that many of the cultural barriers that impede Latinos from a healthier lifestyle come from within the home. For example, one participant reported not adopting healthier meals because her family already had meal preferences; therefore, that dictated the foods that were to be prepared in her household. Culture influences what we eat and for the quantitative results this means that the participants will not be meeting the recommended intake for fruits and vegetables because their typical meals do not consist of fruits and vegetables. Similar patterns are seen with physical activity. Although a participant may have a motivation for purposeful physical activity and realize the importance of physical activity, many admit that they engage in little or no exercise. The barriers listed are many, from lack of motivation to giving more importance to the household environment to not having an appropriate neighborhood environment to exercise in, but most importantly there is little to no social support from other family members. For example, one participant discussed how her mother was a procrastinator and because of that she was also a procrastinator and the only way that they would be able to get up and exercise was if someone else motivated them and pushed them to go. The basis of the research relies on the data measurements and results gathered; therefore, it must present correct information.

A crucial phase for the TSSC intervention is to review and edit the structure of each of the assessments given to the dyads during pilot testing before initiating the research. This step ensures that the questions being asked are receiving the answers that will ultimately answer the study question. Inconsistencies noted in the results are reviewed by the researchers and discussed during weekly meetings. At the conclusion of each meeting, each part in question is reviewed through REDCap. Whether it is editing the surveys, questionnaires or interview questions, it is necessary that these corrections are presented to Dr. Larkin. Once the corrections have been made, they must be approved before re-administering the assessment. Editing and reviewing each assessment is a tedious and time-consuming process that must be done to ensure a successful and effective approach for the intervention.

Home Visit Procedure

During my participation in a mock home visit, an event during which we collect several forms of research data, called the immersive assessment, all the health-workers that will be conducting future assessments were present for training. The home visit is an assessment that provides information about the study sample and data collection procedures, and the degree of correlation in behavioral measures between dyad members. The TSSC research team first, start with having each participant sign two consent forms each. Once the consent forms are signed the dyads are given a brief overview of what will be occurring over the next four hours. While I was at the home visit, it was decided by one research staff member that one dyad would begin with the surveys and questionnaires and the other participant would begin with the household food inventory.

Second,  to assess the usual dietary intake of the participants, each dyad has to complete a randomized dietary questionnaire designed to give more accurate quantitative results. Third, each participant is given a checklist and each item on the checklist is marked off only when that item is present , meaning that the participant had to physically see the food item in their household, along with recording whether the items are fresh, frozen, or canned. In a separate checklist the participant, also checked-off on kitchen appliances and food preparation supplies present in their household. The examination of the food within the household takes place to better enhance the understanding of the foods available for consumption that may yield insights important for informing interventions to promote healthy eating.

Once each participant had completed an area, they would rotate to the fourth step, the Anthropometry and blood pressure measurements. One of the research assistants and I set up the Anthropometry equipment beforehand. I was asked to help the research member take measurements. Our first dyad was asked to remove her waist trainer so that her hip and waist circumference could be measured as accurate as possible with a Gulick tape measure. Her height was then measured using a Stadiometer, her weight with a calibrated digital floor scale, and then her blood pressure was taken. Each of these measurements was administered twice or until the measurements were within the permitted variance.

After both dyads completed the required parts of the assessment, the last step required that each dyad wear an accelerometer during the day over a course of seven days. This accelerometer would be used to complete the objective physical activity section of the assessment. The accelerometer provides an objective measure of physical activity and sedentary behavior. It measures acceleration and captures body movement, intense activity and time. Each accelerometer is then sent elsewhere, where the data is put together and then inserted into the REDCap database for the research staff to access. Although, this  assessment was part of the pilot test, the majority of the strategies that targets the two key elements for TSSC of diet and physical activity, are implemented and shared with each dyad by the health workers by using the compiled results from each of the tools used during the home visits.

Conclusion

Working with the Tu Salud Si Cuenta team allowed me to understand that preventative research is part of an intense process. I witnessed first hand that research requires the collaboration of several personnel and outside resources. I listened to people’s real life stories of their struggle to obtain a decent meal, and I enjoyed seeing them smile when we gave each of them a $75 Walmart gift card and others were also given vouchers for the food bank. This experience allowed me to interact with physicians that work behind the scenes instead of direct-patient care. It was a privilege being at MD Anderson and being surrounded by medical personnel and being part of a research team that will benefit an infinite amount of people in the future. All of this research also benefits me, to know that I too can make an impact in my family toward healthy eating and physical activity.

References

Hiatt RA, Otero-Sabogal R., Perez-Stable EJ, Sabogal F. 1995. “Dietary practices, alcohol consumption, and smoking behavior: ethnic, sex, and acculturation differences.” Journal of the National Cancer Institute Monographs:73-82.

Christie Israel, Hoelscher Deanna, Lee MinJae, McNeill H. Lorna, Reininger Belinda, Schembre Susan, Stingo Francesco and Strong L. Larkin. 2015. “Tu Salud Si Cuenta: Reaching Latino Family Dyads to Increase Physical Activity and Healthy eating.” Protocol 2015:1-20.

World Cancer Research Fund/ American Institute for Cancer Research. 2007. “Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective.” World Cancer Research Fund/ American Institute for Cancer Research.

About the author

The Internship Coordinator

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