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Journal of Nursing

The Reality of Diabetes in Rural Mexico: A Nursing Student Perspective

Hillary E. Handler Suzanne M. Le Markita A. Balfour Maria de la Luz Bonilla Sebastiana del Rosario Gargantua Aguila Karen A. Monsen [email protected]


Abstract


Students from six universities in Canada, Mexico, and the USA participated in a service learning exchange. In order to understand the needs of diabetes patients in rural Mexico three students from Canada and the USA trudged in the heat through the rough terrain to their homes.  We used Omaha System signs/symptoms to collect interview data. The standardized language of the questionnaire allowed us to be aware of the interaction between traditional medical beliefs and the western medical model. Some of these challenges include maintaining the traditional family roles, controlling blood glucose levels without the appropriate medical equipment, and economic barriers. One patient was responsible for both caring for her eight young children and working in the fields to put food on the table. Additionally, she was in a constant hypoglycemic state causing her to faint in the fields. We also visited a visually impaired man that was distraught because he needed to rely on others for help in a machismo society.  He said “While living in New York City, I was a victim of a robbery. I was so afraid because I thought I was going to die and as a result I got diabetes.” Though some may find this comment strange, it is a common theory among the rural population in Mexico. We will always remember the many Mexican speculate that eating bread absorbs the scare and thus prevents diabetes. This experience gave us a glimpse of the harsh reality that these people face everyday coping with diabetes.


 


 


           


 


 


 


The Reality of Diabetes in Rural Mexico: A Nursing Student Perspective


            Nursing students from six universities in Canada, Mexico, and the United States participated in “Cultural Immersion and Service Learning in Public Health Nursing,” a North American Mobility Project funded by governmental grants from the three countries between 2010 and 2012.  The nursing schools involved in the exchange include Dalhousie University, the University of Prince Edward Island (Canada), Benemerita Universidad Autonoma de Puebla, and Universidad Autonoma del Estados de Morelos (Mexico), the University of Minnesota (lead institution), and St. Louis University (United States).  The North American Mobility project prepared baccalaureate nursing students to personally experience international public health issues through service learning activities. The objectives of these activities are to educate the students about the host country’s health care system as well as enhance their understanding of how the communities address and care for adults with chronic illnesses, specifically Type II diabetes mellitus.  Diabetes was chosen as a focus for the student exchange because it has become an international crisis, with the number of deaths related to diabetes in North America expected to double between 2005 and 2030 (WHO, 2011).


During a semester course, students from all universities participated together in interactive online discussions in English and Spanish to meet the course objectives and develop language and communication skills. After the semester, a funded student exchange enabled students and faculty to travel between counties and experience cultural differences.  During the student exchange they interacted with diabetic persons in the host countries, providing further opportunities for the students to develop culturally sensitive nursing skills and an appreciation for the beliefs and values that affect how an individual manages their illness. Every component of the North American Mobility Project offered valuable information concerning the treatment and management of diabetes mellitus.


            During the exchange, faculty participating in the North American Mobility Project determined that a standardized approach to interview data collection was needed. The desired tool would need to not only assess and evaluate the outcome of care in the diabetic population but it would also need to be standardized across settings and populations (Monsen et al., 2011).  It was also preferred that the tool would be amenable to use in an electronic documentation system (Monsen et al,, 2011).  For this reason and for the past success in public health research using the Omaha System, it was selected to create the interview tool that would be tested by students participating in the North American Mobility Project in Canada, Mexico and the United States (Monsen et al., 2011).  By using the standardized terminology of the Omaha System, data were gathered through interviews in two rural towns and one urban clinic. The first three authors were students who participated in the service learning exchange. We present this experience to share the benefits and challenges of an international service-learning exchange from our perspective as students


Methods


The case study survey project was exempted from review by the University of Minnesota International Review Board and was approved by all participating universities. Faculty accompanied students to the homes and health care centers of persons with diabetes and obtained verbal consent for student interviews. Faculty, students, and translators recorded the data and reviewed the interview notes. A follow-up meeting with faculty and students enabled further reflection on student learning, cultural sensitivity, and the experience of persons with diabetes in rural Mexico (see Figure 1).



Instrument


The Omaha System is a research-based classification system that helps with the documentation of client care (Fig.1) (Martin, 2005; Omaha System, 2011).  This tool was designed to help the care provider diagnose and follow the progress of clients from admission to discharge (Omaha System, 2011).  The difference with this system is that not only does it permit the user to identify problems and appropriate interventions but it is also able to provide actual measurable outcomes by using a rating scale (Martin, 1999).  The use of the Omaha System is gaining popularity nationally and internationally in diverse practice settings (Martin, Monsen & Bowles, 2011).
            Since the beginning of the development of the Omaha System in the 1970s, its use in education, practice and research has grown exponentially (Martin, 1999).  The use of the Omaha System has been proven to be very helpful in many nursing sectors including public health nursing (Erci, 2011, Correll & Martin, 2009 and Monsen et al., 2011).   The diabetes interview data collection tool was created by using selected signs and symptoms of the Omaha System that relate to diabetes. Then, it was formulated into both the English and Spanish language (Monsen et al., 2011).  The interview tool is intended to be a guide for data collection, and the interviewer has the freedom to make the process more personalized as well as enter into a conversation with the interviewee, rather than simply following the question and answer format.   


Data collection


Together with nursing faculty and a translator from Mexico, three students from Canada and the United States trudged in the heat through the rough terrain to the homes of patients with diabetes. First, we visited village San Andrés Azumiatla. The two-day voyage began with a hike through the mountainous countryside to the homes of three persons with diabetes. Each student initiated a relationship with a person. We interviewed our patients using personal, informal conversation, which strengthened our findings in regards to the person’s needs. While the questionnaire assisted in data collection, the setting, the person’s home, provided an even greater insight into their daily lives and struggles. On the following day, the students returned to the homes in order to obtain the person’s height, weight, and waist circumference. These measurements further identified the client’s risk, as well as determined whether the patients were complying with the lifestyle changes recommended by the clinics.
            This interview and data collection process was also completed in the village of Santa Ana Coatepec, another small town outside of Puebla.  At General Regional Hospital No. 36 IMSS, an urban hospital located in the heart of Puebla, the students conducted similar interviews following a diabetes education session that diabetic individuals were required to attend monthly.  


Results


            We provide examples in narrative form to share the richness of our student exchange experience. The analysis of the Omaha System signs/symptoms data were described elsewhere (Monsen et al., in press).


San Andrés Azumiatla


 


Señora AB was a 60 year old, stay-at-home “ama de casa” (house wife). She has been living with diabetes for 15 years.  During the interview, she seemed distressed about her current health situation, yet happy to have the opportunity to share her story with me.  She is well-known in the community as the cook, and relies on this as her main source of income.  Interestingly enough, she refuses to buy an oven.  Instead, she spends her days cooking with coal and fire under a blue tarp, thus inhaling the hazardous smoke and fumes.  When I brought up the possible health risk with this set-up, she simply said that the food taste better and she is not willing to change her age-old habit.  She also stipulated that her customers would probably not appreciate the change.  While I stayed at her home for only an hour, I could feel the smoke obstructing my airways and felt the need for fresh air even though we had been outside. Thus, I cannot begin to imagine what it is like to stay in those conditions day after day.  Since AB does not make enough money, she relies on social services for most of her medical expenses.  Unfortunately, while the community center offers free services and is only a fifteen minute walk down a steep hill, she must attend a clinic farther away or social services will refuse to pay her monthly allowance. Now, she suffers from kidney complications and is in dire need of surgery. But, with a cost so great, she will forego treatment.  While she is begging her daughter in another country to help out, she has not yet received any word on that front.  Although, she is happy that her daughter was able to leave Mexico and have a better life, she feels abandoned by her own child and a lack of support to take care of her family there in Mexico (A.B., personal communication, June 12, 2012).
            Señora C.S. was diagnosed with type II diabetes two years ago.   Despite having the shortest diagnosis and being the youngest individual interviewed with diabetes, her condition appeared to be the worst.  In addition to the responsibility of taking care of her health, C.S. cares for her eight young children and works daily in the fields under the Mexican heat to provide food for her family.  She has little time to care for herself. Very often neighbors have found her after she fainted in the fields while working.  Since her diagnosis, she has lost 20 kilograms in weight, barely putting her in the healthy weight category.  Other complications that C.S. experiences are excessive dry skin, slow healing, and pain in her lower legs and arms.  The most prevalent complication associated with her diabetes is how her mood has changed since her diagnosis.  C.S. expressed how irritated and upset she gets, and how she has no patience with her children.  When she feels like this she takes one of her prescribed medications and goes to bed; which when you have eight children to take care of is very difficult.  The interview gave C.S. awareness of the services provided at the community clinic since she was unaware of the services they provided, such as foot care, dental care, and prescriptions.  The nursing students were very hopeful when they saw C.S. arrive at the community clinic the following day for treatment.  Taking her medications every day and eating a fairly healthy diet, (though she does not have the resources to eat as advised), showed that C.S. has a good understanding of her condition. However, it was evident that further counseling and education on how to control her blood glucose could benefit her.  (C.S., personal communication, June 12, 2012).


Santa Ana Coatepec


            Señor JJ was a 74 year old who has been living with diabetes for 30 years.  He was very sociable and quite the jokester.  He enjoyed talking and was happy to have visitors at his home.  JJ traveled many times to the United States for work.  JJ was diagnosed with diabetes while working on the docks in New York City and living with his son.  He said, “While living in New York City, I was a victim of a robbery. I was so afraid because I thought I was going to die and as a result I got diabetes.” Though some may find this comment strange, “susto” or “scare” is a common theory among the rural population in Mexico. Although, JJ follows the plan of care, he has been unable to avoid complications.  Now, he is almost completely blind; he is able to discern shapes and some shadows but only if they are within a few feet of him.  During the interview, JJ expressed a desire to return to the United States but since he developed an ulcer on his left foot, he must stay in Mexico in order to receive treatment.  His daughter has recently moved in with him since mobility has become an issue due to the ulcer and vision impairment.  Even though he has been blind for years, until his daughter moved in with him, he still attempted to cook for himself. But, he burned himself more often than not.  JJ informed me that he is currently looking for a wife (number four) because he needs someone to look after him. Although, he has trouble accepting the fact that he cannot care for himself anymore, a common issue among men living in a Machismo society, he has realized that he must put his pride aside. (J.J, personal communication, June 14, 2012)  
            Señor H.L. was diagnosed with diabetes 38-years ago and has been battling this chronic illness for over half of his life, although this is anything but apparent in H.L.’s appearance.  Although he works outside all day, his skin has not taken a toll. He only complained of slight pain in his extremities and vision impairment. Although his vision loss has made it extremely difficult to maintain his role in the household, he receives continuous support from his family. Talking with H.L., it is apparent that he has a solid understanding of his diagnosis.  Upon receiving his initial diagnosis, he was very worried and thought that there was no cure, but has since put those worries aside.  He expressed how hard it has been to change his diet, but has begun to eat in moderation, incorporating more vegetables and eliminating meat from his daily meals. Ultimately, he expresses satisfaction with the services the community clinic provides and finds few barriers in his health care (H.L., personal communication, June 14, 2012).


General Regional Hospital No. 36 IMSS


            Señora M.M. was diagnosed with type II diabetes mellitus 11 years ago. Since then, she has learned a great deal about her disease through services provided by the hospital. M.M. must utilize these services in order to receive compensation and care at the hospital. Thus, M.M. attends an educational session every month conducted by a diabetic nurse specialist at the hospital. During these sessions, she has learned valuable information about the importance of following the plan of care in all aspects of her life. In addition, she seeks medical attention every month in order to prevent further diabetes’ complications. She has completely changed her diet to include more fruits and vegetables and limits herself to only three tortillas each day. Likewise, M.M. follows a strict medication regimen that was indicated by her doctor. These interventions have resulted in positive outcomes. For example, she has lost 6 kilograms in total. Although, M.M. is following some of the recommended treatments, she does not engage in exercise. M.M. is currently taking care of a sick family member and states this as the reason to why she does not follow the indicated exercise regimen of 30 minutes of exercise per day. This patient seems to have an excellent understanding of her condition and received support to take charge of her illness (M.M., personal communication, June 19, 2012).


Discussion


A North American Mobility service learning and cultural immersion project enabled three nursing students from Canada and the United States to visit a nursing program in Mexico. During the exchange, we witnessed lifestyles utterly different than our own. The student exchange provided us with insight into the harsh reality that individuals who are managing a chronic illness in rural Mexico face on a day to day basis. Living in Mexico for a month and being immersed in the culture made us aware of profound differences in daily living and their perspective on health.


Participating in diabetes education classes at General Regional Hospital No. 36 IMSS and observing public health nurses out in the community enabled us to understand that there are many similarities in the diabetes education content in Mexico and that in Canada and the United States. All countries emphasize the importance of thirty minutes of moderate exercise each day, a healthy diet, and blood glucose control (2011 National Diabetes Fact Sheet, 2011).


The majority of diabetics we interviewed in Mexico were unable to monitor their blood glucose because they do not own or have access to a glucometer regularly. Therefore, the only time their blood glucose levels can be verified is at a clinic, making it extremely difficult for them to manage their condition and avoid a hypoglycemic or hyperglycemic episode  (JEG et al, 2006).  Additionally, crowded streets, unsafe neighborhoods, large families to care for and economic barriers make it difficult for individuals to achieve the 30 minutes of needed exercise (Valenzuela et al., 2003).  The people we met knew how to control their diabetes; however they lacked the proper tools to do so.


We will always remember the cultural belief that eating bread after a scare will absorb a scare, thus preventing diabetes.  Likewise, though establishing a diabetic diet involving more fruits and vegetables is difficult for many, all persons understood that they should not eat more than five tortillas a day, a foundational part of the Mexican diet.  These learning experiences have made us more culturally sensitive and have provided us with a better understanding of how to better serve the Latino population in our home countries (McCloskey & Flenniken, 2010).


            We learned to enter situations with an open-mind, since having a judgmental approach can deter the nurse-patient relationship, thus hindering information we hoped to obtain. Although we did not agree with every treatment method or their beliefs, we learned a great deal from them. We understand more deeply that although we have our own beliefs and opinions, as health care providers we cannot impose them on our patients, but rather empathetically listen to their wants and needs, and educate them so that they can make an informed decision. Though difficult at times, it is important to refrain from imposing our western views and instead maintain a culturally sensitive approach.


The Omaha System provided common terminology that enhanced data collection and reflection on the interview content.  We became aware of the interaction between traditional medical beliefs and the western medical model. Some of these challenges include maintaining the traditional family roles, controlling blood glucose levels without the appropriate medical equipment, and economic barriers.  Using the Omaha System enhanced our learning and understanding of the lived experience of diabetes in rural Mexico.


Further research is needed to evaluate the long term benefits of the cultural immersion experience in nursing education. Funds for the North American Mobility project have been eliminated. The participating universities hope to continue the valuable collaboration despite lack of funding because of the great benefits to students and faculty alike. The interviews are examples of individual experiences in rural Mexico and are not generalizable.


Conclusion


            This experience gave nursing students a glimpse of the harsh reality that rural Mexican people face every day coping with diabetes.  By participating in this experience, our cultural sensitivity grew and we are now more aware of the role culture plays in the management and treatment of chronic illnesses. With the trust of these individuals, we were able to understand how difficult it is to manage their illness. This is not only because of the lack of resources available to them, but also because of their beliefs and knowledge regarding diabetes.  By interviewing patients in both community and clinical settings, we were able to contrast the cultural beliefs among these individuals and thus understand how these beliefs influence their management and treatment of diabetes.


 


 


Figure 1. Improving the Cultural Sensitivity and Understanding of Diabetes Management of Nursing Students through Cultural Exchange


 


 


 


References


2011 National Diabetes Fact Sheet. (2011). Centers for Disease Control and Prevention. Retrieved July 29th, 2012 from http://www.cdc.gov/diabetes/pubs/general11.htm#gen_c .


Correll, P., & Martin, K. (2009). The Omaha System helps a public health nursing


            organization find its voice. CIN: Computers, Informatics, Nursing, 27(1), 12-16. doi:10.1097/01.NCN.0000336470.10187.47


Diabetes. (2011). World Health Organization. Retrieved July 26th, 2012 from http://www.who.int/mediacentre/factsheets/fs312/en/index.html


Erci, B. (2012). The effectiveness of the Omaha System intervention on the women's health          promotion lifestyle profile and quality of life. Journal of Advanced Nursing, 68(4),        898-907. doi:10.1111/j.1365-  2648.2011.05794.x


JEG, Dallo, F., Salcedo Rocha, A., Rodriguez, C., Perez, N., Baer, R., & Weller, S. (2006). The relative effect of self-management practices on glycaemic control in type 2 diabetic patients in Mexico. Chronic Illness, 2(2), 77-85


Martin, KS, (2005). The Omaha System: A key to practice, documentation, and information management (Reprinted 2nd ed.). Omaha, NE: Health Connections Press.


Martin, K. S., Monsen, K. A., & Bowles, K. H (2011). The Omaha System and meaningful use:    applications for practice, education, and research. CIN: Computers, Informatics, Nursing,    29(1), 52-58. doi:10.1097/NCN.0b013e3131f9ddc6


Martin, K. S. (1999).  The Omaha System: Past, Present and Future. On-Line Journal of Nursing Informatics, 3(1).  Retrieved from: http://ojni.org/3_1/index.htm


McCloskey, J., & Flenniken, D. (2010). Overcoming cultural barriers to diabetes control: a            qualitative study of southwestern New Mexico Hispanics.       Journal Of Cultural Diversity,            17(3), 110-115.


Monsen, K. A., de la Luz Bonilla Luis, M., Pérez Garcés, A. M. del Rosario Gargantúa Aguila, S., Hayward, K. L., Swartz, K., Darst, E., & Krichbaum, K. E. (in press). Development and pilot test of a standardized diabetes interview data collection tool in Spanish and English. Studies in Health Technology and Informatics.


Omaha System. (2012). The Omaha System: Solving the clinical data-information puzzle. Retrieved from: http://www.omahasystem.org/


Valenzuela, G., Mata, J., Mata, A., Gabali, C., Gaona, E., Thom, D., & LeBaron, S. (2003).           Knowledge and beliefs regarding type 2 diabetes mellitus in rural Mexico.    Ethnicity & Health, 8(4), 353-360.

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