Kho Dua Mus: Managing Diabetes in the Hmong Community
What can be done to help Hmong community members who live with diabetes manage their disease more effectively? That has been the question for University of Minnesota Associate Professor Katherine Montag Schafer, PharmD, BCACP, CDCES, and Assistant Professor Kathryn Brown, MD, MS, along with their research team.
With invaluable help from a Community Advisory Board, they have been working on a quality improvement project to inform Hmong individuals living with diabetes about diabetes care. Because the standard of care and available tools are insufficient for Hmong patients with diabetes, there is a need for culturally relevant educational resources tailored to the community.
Montag Schafer shares her experience kicking off the project, what her team is working on now, and their hopes for the work and its long-term impact. Lending her viewpoint as well is Munaa Liberta, a member of the Community Advisory Board who worked alongside the research team to help inform and drive the project.
The decision to focus on diabetes care disparities in the Hmong community
Every year, with the St. John’s Hospital Family Medicine Residency Program residents, the faculty engage in at least one quality improvement project. This came out of a quality improvement project in which they reviewed the quality metrics tracked by the system and reported to Minnesota Community Measures. That's the transparent platform that lets patients see the quality of care their clinic provides. Minnesota Community Measures goes a step further, spelling out how these quality metrics differ across communities and populations within Minnesota.
“I've been with the M Health Fairview Clinic - Phalen Village (Phalen clinic) since 2016,” said Montag Schafer. “This project started in 2019. By that point, we had seen that our Hmong community, which we predominantly serve at Phalen clinic in East St. Paul, was highlighted by the Minnesota Community Measures year after year as the community in Minnesota that has one of the lowest rates of optimal diabetes care.”
Montag Schafer points out that her quality improvement projects are determined by consensus. Someone sees data or a trend and proposes it to the group to dive deeper. “We were fortunate enough that the other people in the group that we were working with also showed interest in this. We had consensus, and we moved forward,” she said.
The simple thing about quality improvement projects is that they don't have to be a grandiose intervention to just learn more. The first thing the group did at the clinic was to survey patients. They had a medical student at the time who was interested in making this her medical school project. The team asked patients living with diabetes, “Is diabetes important to you?” and “What are the barriers?” Most people said it was important to them, and the reported barriers mostly concerned knowledge and education. That was what kicked off the research project.
Coming up with a study intervention design
Based on patient feedback, the team needed to find or create educational opportunities for Hmong community members with diabetes. The next step was to review the literature to determine which interventions are helpful for communities with multiple preferred languages.
The Hmong community is unique because, for many, the spoken Hmong language is preferred, while younger generations may prefer English. Given its unique history, the written Hmong language isn't as well-known as the spoken Hmong language.
“We needed to be creative in finding a way to develop a tool that could lean on spoken language rather than written language,” said Montag Schafer. “Many diabetes education materials are written. Patients take them home, digest them, and figure out how to apply them to their lives. But we couldn't rely on the tools that we had available to us because the written Hmong language just isn't as universally used.”
A group at the Mayo Clinic has done similar work with Spanish- and Somali-speaking communities. They found that video storytelling interventions can be helpful to communities with an oral language tradition rather than a written one. When the team began looking for existing literature, they found nothing that addressed the needs of the Hmong community. There weren't any studies that said, “This is the preferred way to deliver diabetes education to the Hmong community.”
That’s when it clicked: Video storytelling seemed like a reasonable thing to consider given the successes that other researchers had found.
“There's also some literature that says regardless of spoken language, regardless of culture, whatever education you're trying to deliver, it should be tailored to the community and to the culture," said Montag Schafer. “Many of our diabetes education materials are rooted in Western American culture and then translated. We could talk about a meat and potato meal, then translate into another language, but that's not relevant for many communities.”
The Hmong community is not a monolith; individual experiences in the United States are varied, including but not limited to their refugee and immigration journeys and generational gap. Despite this, the Hmong community has maintained a very strong cultural identity. She continued: “We needed to make sure that the educational content was tailored and relevant to the community strengths, traditions, culture and family structure. That was the second part of our framework. We know that teaching people how to change their eating habits to promote health is important for diabetes, but we needed to make sure that was translated. We had to add that cultural layer to that information.”
Working with a Community Advisory Board to help ensure community relevance and success
The Community Advisory Board comprises Hmong community members and other healthcare professionals who are genuinely interested in ensuring that the health of the Hmong community is well served. They want to see the community's health constantly improving.
Munaa Liberta, a community health worker at M Health Fairview and member of the Community Advisory Board, shares what makes their contribution so important.
“In addition to the MDs and the researchers, the community advisory boards are another critical component because they help make sure the project is shaped by the voices and experiences of the community,” she said. “Because for something like diabetes education, it's really important that the information we are trying to relate to the public, to patients, and community members needs to be accurate but also meaningful, relatable, and accessible.”
The board members all have different backgrounds, with some coming directly from the Hmong culture. Others work with a variety of communities. Liberta notes that having that broad, multicultural base of board members helped make the project that much stronger and more impactful. Montag Schafer agrees.
“We haven't made any decisions without our Community Advisory Board,” said Montag Schafer. “The Board has been instrumental, and we couldn't do this without them. For me, it's been truly enlightening to work with them and to hear their thoughts.”
She continued: “Board members have been helping us hone our messaging and connecting our messaging to what's most relevant to the community. We have based our educational framework on the Seven Self-Care Behaviors endorsed by the Association of Diabetes Care and Education Specialists. The Board members worked to embed Hmong community strengths, family structure, traditions and language into these evidence-based recommendations. These are the foundation for our video storytelling curriculum.”
Liberta illustrates just how important the board members’ input has been by relating a common situation:
“For instance, a patient might be told that their blood sugar is high at a doctor's visit. In some cultures, that's something people get as they grow older and eventually die from. A patient might be told to cut down on sugar, but in some cultures, starch is an important part of their diet. So, for this video project, instead of just saying ‘cut your sugar,’ we made sure to include cultural components.”
That means, instead of telling people to eliminate sugar, for example, the team honed their message to say it’s fine to keep eating rice but to try to limit portion sizes. It’s about meeting people where they are.
“Those are some things we talked about during our board meetings,” said Liberta. “We wanted to make sure that our videos relate to community members’ life needs and perspectives. The program will be more effective when we include those components.”
This project has been rewarding for board members as well, owing to the vast positive impact that the work is bound to have on the local community.
“The discussions around the meaningful contribution of both the health care and the community perspective was a highlight because it just made it a way that education is more accessible and that really made it a very rewarding experience.”
Positive feedback from members of the community
Before the current video series the team is creating, they created the diabetes education pilot video. With that pilot video, Montag Schafer and the team solicited feedback from patients living with diabetes.
“We had a research study where we showed patients the video and asked their feedback as an orally administered survey,” she said. “Patients told us they liked the video and they wanted to learn more. They also said it was reflective of themselves, their family and their community. It was from that pilot and that positive feedback that assured us we are doing this right and we are going to keep moving forward.”
Next steps for the team and their project
Right now, the team is focused on completing the video series. Then they will move on to the evaluation phase.
“Once we complete our seven-video series highlighting the seven self-care behaviors, we would love to study its effectiveness,” shared Montag Schafer. “We need to study whether it is helping to change diabetes outcomes like blood sugar levels, cholesterol, etc., which are the important things for long-term health for people with diabetes. That's the current work in progress.”
She acknowledges that the team needs to find funding to do that, noting it’s important to make it worth people's time to engage. The team is also interested in seeing how effective the videos are in different settings.
“Most of our work so far has been done at Phalen clinic,” she said. “We've recruited our patients at the clinic and solicited their feedback and their opinions. But not everyone seeks care from a clinic or has a clinic home that they go to often.”
The team is interested in looking at how this could be implemented in a community-like environment. That could be a community education class, for example, which would help them evaluate its effectiveness.
“It would also be valuable to see how that could be different than facilitating it in a clinic, where we have many patient visits and the ability to follow up with our patients along the way,” she noted.
In addition, she notes that their team has learned much from University of Minnesota Extension's long history of community-based education. A next step may be to implement this in other community settings, such as adult day facilities and churches.
Looking toward the positive outcomes from this work
Liberta shared: “I really hope that after the project is done, it will help people understand more about diabetes and feel confident at managing their health properly and managing their blood sugar.”
She and the rest of the Board and team members hope it will open greater access to education. That’s especially important because we all learn in different ways.
“Hopefully this video series feels approachable and empowering,” said Liberta. She also notes that another goal they all share is to increase health literacy, which is another barrier for many people.
“In some cultures, things get done together as a family, as a group. So by watching these videos, which are short and relatable, my hope is that they bring families together while improving the health of their loved ones.”
She adds that word of mouth can go a long way, so if one family watches and connects with the videos, it could naturally encourage others to watch as well. If the video series continues to
spread, it has the potential to reach many families and make a meaningful impact in the Hmong community.
Keeping the videos findable and relevant for years to come
Montag Schafer and her team want the work to be easy to find and timeless. There's been wonderful work done locally, such as Ramsey County's document, Healthy Hmong Lifestyles, published in 2015.
“That document was so inspirational for our group because it showed exactly what we are trying to do: layer in Hmong community traditions and practices into educational information,” she said. Montag Schafer notes that they are working to build a dissemination plan to keep the video series in the conversation and circulating, like the work of Ramsey County.
Community Board Member Cassandra Silveira, PhD, MPH, RD, program leader with the University of Minnesota Extension, has been a strong advocate for a robust, long-term dissemination plan. She has worked with the team to help create that.
Montag Schafer puts it this way: “We need to make sure that these live on, given how much work has gone into them and how much we truly believe in what they are. They're from the community, they're by the community.”
Ideally, the team would like to have the educational materials available in the electronic health record (EHR). Currently, if a patient's preferred language is Hmong, the computer pulls up available resources in that language from a database of educational materials. Building these new tools into the EHR will help make it as easy as possible for clinicians to access them and know about them.
Similarly, it’s vital that the resources remain easily accessible for members of the Hmong community. The Community Advisory Board has said that elders love YouTube and use it regularly. The younger generations also use social media. Knowing this, the team can include it in the dissemination plan. The ultimate goal is for the diabetes education videos to be among the top search results on Google.
“I'm so grateful to everyone who's been involved,” shared Montag Schafer. “There have been so many students, residents and staff at the clinic serving as a sounding board for this project. They're not official members of our Community Advisory Board, but they definitely have been involved along the way. They've given us feedback on what we're doing.”
She added: “I am also so grateful to our Community Advisory Board members, who have been so dedicated even though this work takes so long and there are lots of pauses between our meetings, and seeing progress. They keep showing up.”
Learn more about Kho Dua Mus - Keeping Diabetes Managed in the Hmong Community
