MPH 601 Week 5 Adapting Health Education for a Special Population Example

Not Just Translated: Culturally Adapting Diabetes Prevention Education for Spanish-Speaking Adults Over Sixty With Limited Health Literacy

[Student Name]

University of Phoenix

MPH/601: Public Health Promotion and Education

Week 5 Assignment

[Instructor Name]

[Date]

The county program, its participants, promotoras, adaptation steps and pilot results are composites written for a model paper; research findings come from the sources cited.

Six months into the redesigned diabetes prevention program, attendance in the Spanish-language groups was half that of the English groups, and the gap was widest among participants over 60. The program had translated its materials and hired a bilingual facilitator, but something was not working. The coordinator decided to adapt the program properly for this population. This paper describes the adaptation.

The Population

The population is Spanish-speaking adults over 60 on the county's east side with prediabetes. Many were born in Mexico or northern New Mexico, have lived in the county for decades and completed fewer than eight years of school. Many care for grandchildren, cook for extended families and manage other conditions, such as high blood pressure and arthritis. Many rely on adult children for transportation.

Why Literacy Matters Here

Limited health literacy was common in this group. A systematic review of 96 studies linked low health literacy to more hospitalizations and emergency care, lower use of some preventive services, poorer ability to take medications and interpret labels and, among older adults, poorer health and higher mortality (Berkman et al., 2011). Materials and teaching had to work for people who read little.

A Structured Adaptation Process

Adaptation followed a consensus model. Reviewers of cultural adaptation research agree that adaptation can be organized into five stages: information gathering, preliminary design, preliminary testing, refinement and final trial, and reviews across conditions, including diabetes, concluded that culturally enhanced interventions are generally more effective than usual care or other control conditions (Barrera et al., 2013).

Stage One: Information Gathering

The team interviewed 15 participants who had stopped attending, held two focus groups at churches and formed a community advisory group of eight older adults, two adult children, a pastor and a promotora. They learned that participants felt the young facilitator did not understand their lives, that sessions moved too fast, that family members were not included, that some believed diabetes was God's will or inevitable in their family and that evening sessions were hard for those who did not drive after dark.

Surface and Deep Adaptations

The team separated two kinds of change. Surface changes adjust language, images, foods and settings. Deep changes reflect values, family roles, beliefs and ways of learning. Both were needed. Translation alone had handled only part of the surface level, which explains why attendance lagged despite Spanish materials.

Stage Two: Preliminary Design, Messengers

The most important change was the messenger. Sessions would be co-led by promotoras, older community health workers from the same neighborhoods.

Evidence for Promotoras

Evidence supports this. In a randomized trial of 207 low-income Mexican American adults with type 2 diabetes recruited from community health centers, a culturally sensitive, peer-led education program lowered glycated hemoglobin by 1.7 points at four months and 1.5 points at ten months within the intervention group and improved diastolic blood pressure and cholesterol, while the control group showed no significant changes (Philis-Tsimikas et al., 2011). Participants listened to people who shared their language, their history and their kitchens.

Design: Pacing and Format

Sessions were slowed down, with fewer topics per session and more repetition. Sessions moved to late mornings at churches, with transportation help from volunteer drivers and adult children, who were invited to stay. Content was delivered through stories, demonstrations and discussion rather than written materials.

Design: Family and Values

Deep adaptations addressed family and values. Sessions welcomed a family member, framed healthy changes as a way to stay strong for grandchildren and discussed respectfully the belief that diabetes is inevitable, using stories of local elders who had prevented it. Recipes came from participants.

Design: Literacy and Age

Materials used large print, pictures and color coding. Numbers were replaced with objects and hand measures. Activity sessions included chair exercises, gentle stretching and walking options suited to arthritis.

Keeping the Core

The adaptation preserved the elements that make diabetes prevention programs effective: a weight loss goal, a physical activity goal of 150 minutes a week, self-monitoring and regular sessions over a year. Monitoring was adapted, using picture logs and weekly check-in calls instead of written food diaries.

Training the Promotoras

Four promotoras, aged 52 to 68, completed 40 hours of training covering prediabetes, the program's core goals, facilitation skills, teach-back, when to refer participants to clinicians and how to handle questions about medications. Each co-led two sessions with an experienced educator before leading on their own. They receive a stipend and monthly supervision, which recognizes their work and supports quality.

Respect in Practice

Participants valued being addressed formally, being asked about their experience and having their knowledge of food and family acknowledged. Sessions opened with time to share news, which the original program had treated as wasted time. The advisory group described this as the difference between being taught at and being welcomed.

Stage Three: Preliminary Testing

A pilot group of 14 participants completed eight sessions. Attendance averaged 85%, compared with about 45% in earlier Spanish-language groups. Participants rated sessions highly and suggested more time for questions and a session on managing high blood pressure alongside prediabetes. One participant said it was the first health class where she had understood everything, because the promotora explained it the way her own mother would have.

Stage Four: Refinement

The team added question time, a combined session on blood pressure and blood sugar and a reunion session for graduates. Promotoras requested more training on answering medication questions and on when to refer to clinicians.

Stage Five: Final Trial

The adapted program will be tested with 120 participants, comparing attendance, weight change and activity with the standard Spanish-language version in a staggered rollout across church sites.

Avoiding Drift

Adapted programs can drift from their core. To prevent this, the team created a fidelity checklist covering the weight and activity goals, self-monitoring and session structure. A supervisor observes one session per month at each site. Changes proposed by promotoras are reviewed by the advisory group and the program coordinator together, so that cultural fit and effectiveness are weighed at the same time.

Costs

The adaptation cost about $38,000 in its first year, including promotora stipends, training, transportation help, printing picture-based materials and the pilot. Because peer delivery costs less than clinician delivery, the adapted program's cost per participant is expected to be similar to the original once it reaches full enrollment.

Community Involvement Throughout

The advisory group met at every stage, reviewed every material before use and helped recruit. Its members presented the pilot results to the board of health.

Conclusion

Translating materials was not enough for Spanish-speaking older adults with limited health literacy. A structured adaptation, guided by a consensus model and community voices, changed messengers, pacing, settings, materials and family involvement while keeping the core elements. Evidence for promotora-led programs and on health literacy supported the changes, and a pilot showed attendance nearly doubling before a larger trial.

References

Barrera, M., Jr., Castro, F. G., Strycker, L. A., & Toobert, D. J. (2013). Cultural adaptations of behavioral health interventions: A progress report. Journal of Consulting and Clinical Psychology, 81(2), 196-205. https://doi.org/10.1037/a0027085

Berkman, N. D., Sheridan, S. L., Donahue, K. E., Halpern, D. J., & Crotty, K. (2011). Low health literacy and health outcomes: An updated systematic review. Annals of Internal Medicine, 155(2), 97-107. https://doi.org/10.7326/0003-4819-155-2-201107190-00005

Philis-Tsimikas, A., Fortmann, A., Lleva-Ocana, L., Walker, C., & Gallo, L. C. (2011). Peer-led diabetes education programs in high-risk Mexican Americans improve glycemic control compared with standard approaches: A Project Dulce promotora randomized trial. Diabetes Care, 34(9), 1926-1931. https://doi.org/10.2337/dc10-2081