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Preventing type 2 diabetes among Hispanic Americans: opportunities for optimizing mobile phone technology

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Preventing type 2 diabetes among Hispanic Americans: opportunities for optimizing mobile phone technology

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Content PREVENTING TYPE 2 DIABETES AMONG HISPANIC AMERICANS:
OPPORTUNITIES FOR OPTIMIZING MOBILE PHONE TECHNOLOGY

by

Stephanie Magdalena Lavayen

A Thesis Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF ARTS
(STRATEGIC PUBLIC RELATIONS)

May 2012

Copyright 2012 Stephanie Magdalena Lavayen

ii
Table of Contents

Abstract iii

Preface iv

Introduction 1

Chapter One: Type 1 and Type 2 Diabetes Classification 4

Chapter Two: Hispanic Americans and Risk for Type 2 Diabetes 6
Figure 2.1: Percent Distribution of the Hispanic Population 7
In the United States By Country of Origin

Chapter Three: Hispanic American Culture and Health Behaviors 9

Chapter Four: The “Small Steps, Big Rewards” and “Thunder and 15
Lightning and Rain” Type 2 Diabetes Prevention Campaigns

Chapter Five: Hispanic Americans and the Mobile Revolution 23

Chapter Six: Mobile Health and Type 2 Diabetes Prevention 25
and Management

Chapter Seven: The Strategic Implications of Hispanic American 30
Culture On Type 2 Diabetes Prevention

Chapter Eight: Implementing a Type 2 Diabetes mHealth Initiative 37
Targeting Hispanic Americans

Chapter Nine: The Challenges of Implementing a Type 2 Diabetes 45
mHealth Campaign Targeting Hispanic Americans

Conclusion 47

Bibliography 50

iii

Abstract

The number of Americans diagnosed with diabetes is projected to double over the
next fifty years (qtd. in Geiss and Cowie 25). The Centers for Disease Control (CDC)
estimates that 90-95% of all diabetes cases are type 2. Ethnic populations, particularly
Hispanic Americans, are disproportionately affected by diabetes. Numerous clinical trials
have proven that the onset of type 2 diabetes can be prevented through moderate exercise
and a balanced diet (qtd. in Dabelea et al. 39). Culturally relevant prevention strategies
can improve the effectiveness of type 2 diabetes prevention campaigns attempting to
reach Hispanic Americans.
In 2010, 87% of English-speaking Hispanic Americans (Smith), 78% of bilingual
Hispanic Americans and 68% of Spanish dominant Hispanic Americans reported having
a cell phone (Livingston). Hispanic Americans have widely adopted mobile phone
technology to access the Internet, SMS text messaging, videos, email and social networks
(Smith). Mobile health communication strategies have the potential reach Hispanic
Americans through a platform they have widely adopted for other communication
purposes and provide them with information to make smart lifestyle decisions and
hopefully prevent the onset of type 2 diabetes.

iv
Preface
Research Methodology
Qualitative primary research consisted of a series of interviews with public
relations professionals, specializing in the healthcare public relations or public health.
Interviewees included Kristina Martel, Director of Corporate Communications for the
American Cancer Society, Jackie Quintanilla, Senior Vice President at Edelman Health,
Laura Jackson, Consultant at Communications and Leadership Coaching, Peter Clarke,
co-director of From the Wholesaler to the Hungry and co-author of Surviving Modern
Medicine, and Matthew LeVeque, Senior Vice President and Director of Digital
Strategies Group at Ruder Finn. These interviews provided professional insight on the
current landscape of the healthcare public relations industry, opportunities for mobile
health and how to engage with minority populations.
Mobile Health and Public Relations
Public health campaigns have often relied on traditional media outlets, such as
TV, print news and radio, to deliver key messages and reach desired audiences. However,
the role of traditional media has been redefined with the onset of new digital platforms
and channels. Brian Solis, world-renowned digital expert, believes “the socialization of
the Web and content publishing disrupted the balance and is now forcing a media
renaissance that is transforming information distribution, human interaction, and

v
everything that orbits this nascent ecosystem.” The mobile phone, as a singular platform,
puts most of the information living in digital neighborhoods at consumer’s fingertips
through a variety of channels, such as SMS text messaging, email, social networks, web-
based applications and videos.
The healthcare industry has been impacted by the digital renaissance because the
advent of new channels and platforms has created new opportunities for patients and
doctors to exchange health information. Recent advances in mHealth or mobile health
technology leverage the capabilities of mobile phones to connect doctors, patients and
healthcare providers. For public relations practitioners, the challenge lies in integrating
multiple channels and platforms to construct a relevant and effective health prevention
campaign.
1
Introduction
In 1958, the Centers for Disease Control (CDC) estimated that 1.6 million
Americans suffered from diabetes (qtd. in Geiss and Cowie 18). In 2011, the CDC
reported that 25.8 million Americans were diagnosed with diabetes, which is about 8.3%
of the US population (“National Diabetes Fact Sheet, 2011”). By 2050, the number of
Americans with diabetes is projected to be around 48.3 million or 12% of the US
population (qtd. in Geiss and Cowie 25). The exponential growth of diabetes in the
United States over the last 50 years is alarming and it will continue to increase if effective
prevention strategies are not implemented.
According to the CDC, 90-95% of diabetes cases in the United States are type 2.
Numerous clinical trials have proven that lifestyle interventions involving moderate
exercise and modified eating habits, which lead to weight loss, can reduce the risk of type
2 diabetes by up to 58% (qtd. in Dabelea et al. 39). Type 2 diabetes disproportionately
affects ethnic populations, particularly Hispanic Americans. The CDC reported in 2011
that 11.8% of Hispanic Americans 20 years and older have been diagnosed with diabetes
(“National Diabetes Fact Sheet 2011”). The rising number of type 2 diabetes cases among
Hispanic Americans is an important health initiative for public relations practitioners and
medical professionals to address and develop effective prevention strategies.
Interestingly, a digital and technological revolution paralleled the spawn of the
diabetes epidemic in the United States. The 2011 Nielsen report, “Building Brands in a
Cross Platform World” indicated that the average Hispanic American spends 28 hours
and 32 minutes watching TV and another three hours on a computer searching the
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Internet. An additional hour and a half is spent watching time shifted TV, which means
viewers are streaming content on multiple devices at the same time (“Building Brands in
a Cross-Platform World”). Hours spent watching TV, on the Internet, or doing both, is
time not spent exercising or being active. Many health professionals associate a sedentary
lifestyle, as well as an unhealthy diet, with the rise of type 2 diabetes in the United States.
Fortunately, vice can become the virtue. Health care and communication
professionals can use the very tools that disrupt healthy lifestyles to educate Hispanic
Americans about type 2 diabetes. The question becomes, which digital channel or
platform should be used to most effectively communicate with Hispanic Americans
regarding type 2 diabetes prevention? According to the Pew Research Center study
“Mobile Access 2010,” “more than 87% of English-speaking US Hispanics owned a cell
phone vs. 80 percent of non-Hispanic whites” (Smith). Pew Research Center also
reported that 68% of Spanish dominant Hispanics and 78% of bilingual Hispanics have
cell phones (Livingston).
Hispanic Americans who speak Spanish, English, or both, appear to be widely
adopting mobile technology. They not only use cell phones, but 44% of Hispanic
Americans reported using a smartphone, giving them greater access to the Internet, email,
text messaging, videos or mobile applications (Smith). Mobile phones platforms arm
Hispanic Americans with multiple channels to consume information creating new
communication opportunities in mobile health.

3
Mobile health, or mHealth, involves “the use of mobile and wireless technologies
to support the achievement of health objectives” (“mHealth: New Horizons for Health
Through Mobile Technologies”). mHealth initiatives have been implemented around the
world and numerous cases have proven to be successful in providing care to underserved
populations. The opportunity to integrate mobile communication into type 2 diabetes
prevention campaigns targeting Hispanic American populations has never been greater
than it is today. According to “Hispanics and Health Care in the United States: Access,
Information and Knowledge,” 83% of Hispanic Americans credit the media as a source of
health information (Cohn, Livingston, and Minuskin).
Public health campaigns often leverage the reach of traditional media, such as TV,
radio and print newspaper. These traditional media sources have taken digital form and
can be accessed through mobile devices. The adoption of mobile phones and demand for
digital media can facilitate the exchange of type 2 diabetes information between health
professionals and Hispanic Americans by using mobile phone channels, such as SMS text
messaging, web-based applications, social networks and the Internet.
Before determining effective mobile phone strategies, it is necessary to answer:
what is diabetes? What are Hispanic American cultural norms and how do they influence
health behaviors? How does this effect prevention campaign strategies? What is being
done to prevent type 2 diabetes today, especially in Hispanic American communities? Is
it effective? What is the role of the mobile phone in health communication? And
ultimately, how could the mobile phone play a role in preventing type 2 diabetes among
the Hispanic Americans?
4
Chapter One: Type 1 and Type 2 Diabetes Classification
Diabetes is classified as type 1, type 2 or gestational. (For the purposes of this
paper, type 1 and type 2 diabetes will be explained). The Centers for Disease Control
(CDC) reported in 2011 that type 1 diabetes cases account for approximately 5% of all
diagnosed cases. Type 1 diabetes is an autoimmune and idiopathic disease, which means
the body destroys its own pancreatic beta cells and disables the self-production of insulin
(Bennett 9). According to the American Diabetes Association (ADA), “insulin is a
hormone that is needed to convert sugar, starches and other food into energy needed for
daily life.” Without insulin, a person’s body is unable to maintain healthy levels of
glucose (the result of dietary intake of sugar, starches and other food) in the bloodstream.
Fortunately, type 1 diabetics are able to monitor their blood glucose levels using
specialized monitoring devices. Insulin therapy allows patients to receive injections of
insulin through syringes and/or an insulin pump. Typically, type 1 diabetes is diagnosed
in children and young adults and is often congenital (“Diabetes Basics: Type 1”). The top
five symptoms of type 1 diabetes are: “frequent urination, unusual thirst, extreme hunger,
unusual weight loss and extreme fatigue and irritability” (“Diabetes Basics: Symptoms”).
Sadly, there is no cure for type 1 diabetes.
Type 2 diabetes, as the CDC reported, accounted for 90-95% of diagnosed
diabetes cases in 2011 in the United States but can be managed or prevented with
moderate exercise and a balanced diet (“National Diabetes Fact Sheet, 2011”). The ADA
described patients with type 2 diabetes as insulin resistant (versus type 1 diabetics who
are insulin deficient) or having a pancreas that cannot secrete a sufficient amount of
5
insulin to maintain healthy levels of glucose in the bloodstream (“Diabetes Basics: Type
2”). In type 2 cases, pancreatic beta cells experience decreased function causing an
insulin deficiency (Bennett 9). The ADA reports that there are often no symptoms for
patients to recognize if they have type 2 diabetes. Although they do advise people to look
for “any of type 1 symptoms such as frequent infections, blurred vision, cuts/bruises that
are slow to heal, tingling/numbness in hands/feet and recurring skin, gum or bladder
infections” (“Diabetes Basics: Symptoms”).
There are multiple risk factors scientifically linked to causing the onset of type 2
diabetes, including family history, ethnicity and age (“Diabetes Basics: Your Risk”).
Studies have also shown that the risk of developing type 2 diabetes increases as a
person’s body mass index (BMI) increases. The rise in BMI causes an increase in the
amount of insulin needed to overcome the body’s resistance to insulin. Eventually the
body can’t produce enough insulin to counteract its inability to tolerate glucose resistance
(Idrogo and Mazze). Lifestyle interventions involving moderate exercise, modified eating
habits and weight loss can reduce the risk of developing type 2 diabetes by up to 58%
(Davis et al. 39). Another treatment option the CDC suggests is the prescription
medication Metformin, which can reduce the risk of type 2 diabetes by 31% (“National
Diabetes Fact Sheet, 2011”). Type 2 diabetes is an important disease for public health
professionals to raises awareness about because it can be prevented.

6
Chapter Two: Hispanic American Risk for Type 2 Diabetes
The CDC reported in 2011 that compared to non-Hispanics, Hispanic Americans
have a 66% greater risk for developing type 2 diabetes and are among the top three
affected populations in the US along with non-Hispanic blacks, American Indians and
Alaska Natives (“National Diabetes Fact Sheet, 2011”). The Hispanic American
population is an important audience to target for a prevention campaign not only because
it is disproportionately affected by type 2 diabetes but because it is growing quickly,
culturally diverse and geographically concentrated in the Southwest region of the United
States.
According to the 2010 US Census population report, there were 50.5 million
Hispanics in the United States, which is about 16% of the total population (Albert, Ennis,
and Rios-Vargas 2). From 2000 to 2010 half the growth in total US population came from
Hispanic Americans (Ibid). In 2011, 11.8% of Hispanic Americans were diagnosed with
diabetes (“National Diabetes Fact Sheet, 2011”). The high rate of type 2 diabetes among
Hispanic Americans is of particular significance because they are considered to be the
fastest growing population group in the US and will be the nation’s largest population
segment by 2050 (Morton 46).
According to “The Hispanic Population: 2010” census report, the term “Hispanic
or Latino refers to a person of Cuban, Mexican, Puerto Rican, South or Central American
or other Spanish culture or origin regardless of race” (Albert, Ennis, and Vargas 2). (For
purposes of this paper the author uses the term Hispanic American to refer to peoples of
the above-mentioned origins). As illustrated in Figure 2.1, 71% of the total Hispanic
7
population originates from Central America and of that 63% from Mexico (Albert et al.
5). Identifying the unique cultural characteristics of various Hispanic origins can aid in
the development of culturally specific and relevant public health campaigns within the
greater Hispanic American population.

Figure 2.1: Percent Distribution of the Hispanic Population in the United States
by Origin, Source: Nora G. Albert et al. ; “The Hispanic Population: 2010” ; US Census
Bureau ; May 2011 ; Web ; 19 January 2012.

8
In addition to its tremendous growth and diverse cultural backgrounds, the
Hispanic American population at-large is geographically concentrated in Southern and
Western regions of the United States. In 2010, 37.6% of the total California population
was Hispanic and in 97% of the total population of East Los Angeles was Hispanic
American (Albert et al. 11). Locating the geographic regions with a high density of
Hispanic Americans can help prioritize where to invest campaign efforts. Not only is the
Hispanic American population at greater risk for developing type 2 diabetes, but it is also
projected to be the largest ethnic population in the US. Place of origin and geographic
location of Hispanic Americans are two factors that can help develop effective prevention
strategies.

9
Chapter Three: Hispanic American Culture and Health Behaviors
The understanding of Hispanic American cultural characteristics can contribute to
the development of relevant campaign strategies, messages, channels and tactics. In fact,
the high rate of type 2 diabetes among Hispanic Americans is linked to cultural norms,
socioeconomic status, geography and genetics (Geiss and Cowie 18). The Hispanic
American population continues to grow as a greater part of the total US population and
carry on years of rich cultural traditions.
Kristina Martel, Director of Communications at the American Cancer Society,
emphasized that identifying important cultural norms of the Hispanic American
population is a critical step in crafting public health campaigns because it helps develop a
better understanding of one’s audience (Martel). Martel advised paying attention to place
of origin, because Puerto Ricans, Colombians, Mexicans, and others of Hispanic heritage,
all have individual cultural norms, values and traditions within the broader context of the
Hispanic American culture. (While the author recognizes the importance of Martel’s
advice, this paper will undertake a broad cultural exploration of the Hispanic American
population as whole).
The Role of Family

The family plays an influential role in Hispanic American life, especially
throughout child rearing and treatment of the sick. Parents and children experience high
degrees of interdependence (qtd. in Abreu, Consoli, and Cypers 191). Raising children is
mainly done by mothers and grandmothers, however, males have overall household
influence (Ibid, 191). This is referred to as machismo (qtd. in “Cultural Insights:
10
Communicating with Hispanics/Latinos” 3). The value of family applies not only to the
“nuclear family but also the extended family. […], which plays a pivotal role in
influencing the raising of the children” (Centrella-Nigro 353). The cooperation among
multiple generations is often more important than fulfilling individual responsibility (qtd.
in “Cultural Insights: Communicating With Hispanics/Latinos” 2). In fact, the household
size of Hispanic Americans is larger when compared to the broader US population. In
2008, the average Hispanic American household size was 3.92 family members versus
3.22 of the total American population (Ibid 2).
The collectivist culture thriving in Hispanic American communities results in
shared experiences, values and norms between immediate family members and extends
into the local community. These tight-knit communities can play a vital role in providing
support for the sick. A study conducted in 2010, “Navigating a New Health Culture:
Experiences of Immigrant Hispanic Women,” examined the health behaviors of Hispanic
immigrants in the United States. The results confirmed that family or close friends were
called on for support before medical professionals (Sanchez-Birkhead et al. 1170).
The Hispanic American Diet

Food is a central component to Hispanic American family and community
gatherings (Abrue, Consili, and Cypers 187). A traditional Hispanic American diet is
high in fats, carbohydrates, fast food and sugary drinks. They typically have lower intake
of leafy greens, vegetables and meats (Salimbene 32). These dietary patterns put Hispanic
Americans at greater risk for developing type 2 diabetes. However, they are often
reinforced because food is an important part of community and family gatherings.
11
Type 2 diabetes prevention campaigns must approach the topic of diet with
caution, as it can be a sensitive topic among Hispanic Americans. A qualitative study
involving seven focus groups in the Bronx, N.Y., revealed the sentiment that “it feels like
home when you eat rice and beans…and when it’s not in the house its cold…it’s a cold
feeling” (Caban et al. 123). Traditional Hispanic American dietary choices, such as rice
and beans, often possess a greater emotional value than a nutritional one. Interestingly,
focus group participants viewed these traditional foods as forbidden in managing type 2
diabetes or lowering their risk for the disease (Ibid 123).
Rice and beans are not entirely forbidden from a healthy diet. But when they are
consumed alongside other unhealthy foods they can put Hispanic Americans at greater
risk for being overweight or developing obesity, two leading risk factors for developing
type 2 diabetes. Contrary to a more mainstream view that being overweight is unhealthy,
among Hispanic Americans “there is a widely held cultural belief that healthy babies and
children are ‘chubby’ or overweight” (Centrella-Nigro 353). The Hispanic American
definition of “healthy” versus a Western definition could potentially create a
communication barrier in how to appropriately and effectively address the topic of diet
and nutrition.
Non-Western Medical Traditions

Hispanic Americans also appear to apply different reasoning as to why people
develop a disease, including diabetes. The study, “The Role and Meaning of Susto in
Hispanic Americans’ Explanatory Model of Type 2 Diabetes,” discovered that a majority
of Hispanic American subjects interviewed believed their diabetes was a result of susto or
12
a profound episode of fright in their life. Susto was also described as an event that
triggered the manifestation of diabetes in their body, although they acknowledged there
could be other causes of diabetes, such as genetics (Poss).

Susto is just one example of
non-Western medical thoughts and practices that may be held by Hispanic Americans and
influence their health behaviors.
Many Hispanic Americans continue to treat illnesses with homemade remedies
that have been passed down from generation to generation. They believe “home or herbal
remedies were more ‘natural’ than synthetic prescription drugs and would protect the
body from the possible harmful effects of the strong medicines prescribed by their
doctors” (Callister et al. 1171). Older generations apparently pass down the traditions of
herbs, teas and other home remedies to their offspring. In instances where these traditions
are not passed down, the younger generation relies on the elders to take care of them
when they are sick, reinforcing the role of family in Hispanic American health support.
The proliferation of non-Western medicinal practices among Hispanic Americans
may also be tied to an absence of health insurance. According to the Pew Hispanic
Research Center, 32% of Hispanics are uninsured, which is the highest rate of any racial
or ethnic group in the United States (qtd. in “Cultural Insights: Communicating With
Hispanics/Latinos” 11). Lack of health insurance or inadequate coverage may deter
Hispanic Americans from relying on professional medical care in the United States.

13
Jackie Quintanilla, Senior Vice President at Edelman Health, emphasized the important
role promotoras de salud (health trainers) can have in communicating health issues to
members of Hispanic American communities and introducing them to health tools and
information.
Promotoras and Hispanic American Health Information
Promotoras are Hispanic ‘community health coaches’ who are typically trained to
work within local communities and share health information with low-income individuals
or those with limited access to health care. Promotoras may even work on behalf of
prevention campaigns and can play an instrumental role in educating Hispanic Americans
about type 2 diabetes, providing support and giving access to campaign tools and
materials. Quintanilla stated that promotoras have been shown to be effective in working
with Hispanic Americans because they understand sociocultural norms, the local
communities they work in, and often have relationships with local medical clinics.
Promotoras can also help to bridge the language gap that may exist in certain
communities. In 2010, Pew Hispanic Research Center published that 50% of native-born
Hispanics reported speaking English very well, while 71% of foreign-born Hispanics
reported speaking English less than well (Cohn and Hakimzadeh). It can be beneficial to
leverage promotoras who are bilingual to deliver campaign messages in Spanish and
English and ensure that audiences of all language levels can be reached.

14
The rich cultural traditions of family, cuisine, non-Western medicine and differing
English language comprehension levels makes developing type 2 diabetes prevention or
awareness campaigns particularly challenging. Evaluating previous communications
campaigns can offer insight into effective channels, messages and strategies for targeting
Hispanic Americans at-risk for type 2 diabetes.
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Chapter Four: The “Small Steps Big Rewards” and “Thunder and Lightning and
Rain” Type 2 Diabetes Prevention Campaigns

Evaluating diabetes prevention campaigns can help identify what types of
messages and strategies have been or are currently being used to target the Hispanic
American audiences. The National Diabetes Education Program (NDEP), founded in
1997 as a partnership with the US Department of Health and Human Services National
Institutes of Health and the Center for Disease Control and Prevention, developed the
“Small Steps, Big Rewards” campaign to reach the millions of Americans suffering from
type 2 diabetes.
The main supporting data for this campaign originated from the Diabetes
Prevention Program (DPP). The DPP demonstrated the overall effectiveness modest
weight loss could have, through increased physical activity and a lower calorie and fat
diet, on delaying or preventing the onset of type 2 diabetes. The two main messages of
the campaign were:
1. “Small steps: If you have pre-diabetes (higher than normal blood glucose
levels but not yet diabetic levels) losing a modest amount of weight-for
example 10 to 15 pounds for a 200 pound person- can help you prevent or
delay type 2 diabetes. You can do it by building up to 30 minutes of
physical activity a day 5 days a week and following a low-calorie, low-fat
eating plan.

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2. “Big Rewards: Preventing type 2 diabetes can mean a healthier and longer
life without serious complications from the disease such as heart disease,
stroke, blindness, kidney failure, and amputations” (“Small Steps. Big
Rewards. Prevent Type 2 Diabetes. Campaign”).
Messaging and Health Literacy

Both messages from the “Small Steps, Big Rewards” campaign provide important
facts about the risk of type 2 diabetes and how to prevent it, but they assume that
audiences already know what type 2 diabetes is. The use of medical terms such as
“glucose” may polarize audiences that are not already familiar with diabetes. For
example, if someone unfamiliar with type 2 diabetes were to be exposed to the first
message they may ask themselves: “what does it mean to be pre-diabetes?,” “what is a
normal blood glucose level?” or even “what is glucose?”
Health literacy explores how well populations in the US process health
information. The topic of “health literacy” is defined by the CDC as “the degree to which
individuals have the capacity to obtain, process and understand basic health information
and services needed to make appropriate health decisions” (“What We Know About
Health Literacy”). People who have low health literacy rates may not understand medical
terms such as ‘glucose’ or ‘insulin.’
In 2002, the study “Association of Health Literacy With Diabetes Outcomes,”
pointed out that a lack of health literacy skills, including reading and comprehension, can
significantly inhibit a patient’s ability to manage their health, thus raising their risk of
developing type 2 diabetes (Bindman et al., 475). The results also demonstrated that low
17
health literacy among ethnic populations could inhibit the efforts of public health
campaigns (Ibid, 480). Messages for type 2 diabetes prevention can be developed with
the health literacy rate of Hispanic Americans in mind to improve the chances of
understanding and retention of information presented in them.
Messaging and Cultural Relevance
In addition to assessing the health literacy rates, the unique cultural characteristics
of the Hispanic American population may affect message identification and
comprehension. The NDEP’s two messages for the “Small Steps, Big Rewards”
campaign do not appear to identify with any significant cultural norms of the Hispanic
American population. They seem to speak to a broad audience of at-risk diabetics.
Articulating an association between cultural norms and their influence on health
behaviors could contribute to credible messaging among Hispanic American populations.
In the first message, the topic of weight loss may not resonate with certain
Hispanic American audiences because weight is often believed to be a sign of health,
especially among young children. One resource on the NDEP website titled “Ten Ways
Hispanics/Latinos Can Prevent Type 2 Diabetes” is clearly directed towards Hispanic
American audiences at risk for type 2 diabetes. It offers general type 2 diabetes
prevention tactics, such as “cut down on food portion sizes” or “aim to lose at least 5 to 7
percent of your current weight.” If some Hispanic Americans view chubbiness as a sign
of health, telling them to lose weight may not make sense to them in the context of
18
diabetes prevention. Messaging on the subject of diet and nutrition could explain why it
is unhealthy to be overweight and ways to modify their diet without suggesting to
eliminate foods that hold cultural importance, such as rice and beans.
Language is another consideration for ensuring cultural relevance. Some words
may have different meanings when translated from English to Spanish and vice versa. It
is important to create messages in both English and Spanish in order to reach English and
non-English speaking Hispanic American populations. In 2007, Pew Hispanic Research
Center published “English Usage Among Hispanics in the United States” indicating that
52% of foreign-born Hispanic Americans report they speak only Spanish at home.
However, 88% of second generation and 94% of third generation and higher Hispanics
report fluency in English (Cohn and Hakimzadeh).
Kristina Martel, of the American Cancer Association, confirmed in a 2011
interview the importance of developing messages in Spanish and English. Simply
translating an English message into Spanish may lose meaning or create an unintended
meaning since there are words that do not directly translate from one language to the
other. Additionally, she noted that linguistic relevance does not imply cultural relevance;
it is never enough to take a message, translate it into Spanish and expect Hispanic
American audiences to react to it.

19
Hispanic Americans, Health Information and the Media

Determining appropriate communication channels to deliver campaign messages
requires understanding how and where Hispanic Americans consume information. In
2008, 83% of Hispanic Americans cited the media as a source of health information
(Cohn, Livingston, and Minuskin). The “Small Steps, Big Rewards” campaign messages
were prepared for print, radio and television, in addition to living on the NDEP website.
All three of these channels are still very important sources of information, especially
Spanish media outlets. In fact, the CDC reported “49% of Hispanic Americans who
watch prime time TV tune into Spanish language stations” (qtd. in “Cultural Insights:
Communicating with Hispanics/Latinos” 7).
In 2004, a public health campaign “Thunder and Lightning and Rain” was
implemented in Washington State and focused on generating awareness about diabetes
among Hispanic Americans. One major strength of this campaign was its recognition that
cultural and linguistic differences must be taken into consideration to effectively
communicate with various ethnic populations (Almendarez, Boysun, and Clark 115). The
campaign utilized traditional media channels such as radio, print and TV to reach
Hispanic Americans about diabetes prevention.
For Hispanic Americans, TV was listed second to doctors or medical
professionals as a source of health information (Cohn, Livingston, and Minushkin 27).
Behind TV were radio, newspapers and magazines, with 40% and 51% citing these
channels as sources of information, respectively (Ibid). These traditional media outlets
are still relevant channels of health information consumption among Hispanic American
20
audiences. The “Thunder and Lightning and Rain” campaign used messages from the
NDEP’s national campaign, “Small Steps. Big Rewards.” Messages also used were:
“diabetes is a serious illness, you can control your diabetes, and it is essential to see and
be treated by a doctor” (Almendarez, Boysun, and Clark 116). The use of NDEP
messages created consistency in type 2 diabetes communication, but these messages
appeared to lack direct cultural relevance to Hispanic American populations.
The “Thunder and Lightning and Rain” campaign discovered that Hispanic
Americans were more likely to take action towards preventing or managing their diabetes
if they heard the campaign messages over the radio (Ibid 120). This suggests that radio
could be used alongside TV as a top channel for communicating health information to
Hispanic Americans. Even though traditional media is still hugely influential, it is not
apparent that the “Thunder and Lightning and Rain” campaign tested the potential of
digital or mobile platforms as effective channels of health communication in targeting
Hispanic American audiences. Hispanic American populations continue to increase
consumption of information through digital platforms and channels. In fact, 64% of
Hispanic Americans “reported the they used the Internet because it was a good source of
information” (qtd. in “Cultural Insights: Communicating With Hispanic Latinos” 8).
Potential of Online Channels in Hispanic American Health Prevention

The NDEP website hosts a wealth of information on the subject of type 2
diabetes. The site offers visitors the option of using a detailed search engine to help filter
information based on if they: have diabetes, have pre-diabetes, are at risk, don’t know or
not applicable, as well as by ethnicity/race, language or age. Despite the amount and
21
quality of information on the NDEP website, its circulation among relevant audiences
depends on people being aware of the NDEP website. For audiences that may not have
knowledge about the NDEP or type 2 diabetes in general, they may never come in contact
with all of the resources on the NDEP website. A simple Google search of the phrase
‘type 2 diabetes’ did not even bring up NDEP or “Small Steps Big Rewards” in the top
20 results.
The Internet not only provides access to organizations websites, such as the
NDEP, but also to social networks, which can significantly help campaigns build
awareness among Hispanic Americans. In 2008, 70% of Hispanic Americans reported
having received health information from social networks, which is almost equal to the
71% that reported medical professionals as a source of health information (Cohn,
Livingston, and Minushkin ). The NDEP acknowledged the potential social media can
have in reaching these key audiences for diabetes prevention, noting one of their key
strategic initiatives by 2015 is to: “expand NDEP reach and visibility through
collaborations with public, private and non-traditional partners and use of national, state,
and local media, traditional and social media, and other relevant channels” (“About the
CDC’s Division of Diabetes Translation”).
This is an important initiative for the NDEP because of the potential social media
can have in generating national awareness of type 2 diabetes. A visit to the NDEP Twitter
handle profile, @NDEP, reveals a total of 8,968 followers to date (as of January 16,
2012). This is not even 1% of the total number of Americans who currently have diabetes
and would be an even lower percentage if valued against those at-risk for developing type
22
2 diabetes. The NDEP’s Facebook page involvement is lower than its Twitter account
with 2,167 “likers” as of January 16, 2012. The American Cancer Society boasts over
277,000 “likers” and features posts from its followers, which demonstrates its active
social media presence. The NDEP utilizes a “question and answer” tactic for Twitter and
Facebook but they are not garnering a significant amount of responses. On January 13,
2012, the NDEP issued the question: “Test Your Diabetes IQ: True or False. Only adults
can be diagnosed with diabetes” (National Diabetes Education Program). Only one
person responded to the Tweet.
Diabetes-centric social media sites have developed a significant following and
reputation in the diabetes community, especially the sites TuDiabetes and Juvenation.net.
As of March 13, 2012, TuDiabetes.net had approximately 24,000 members and
Juvenation.net (which targets type 1 diabetics) had approximately 400 members. A US
News Health article, “Diabetes Social Networks Vary in Quality,” published in 2011,
pointed out that the quality of these different diabetes social networks differ in what they
provide participants and in the actual audiences within the diabetes community they are
trying to reach (Gordon). There is an opportunity to develop and curate a social media
experience for Hispanic Americans at risk for developing type 2 diabetes and reinforce a
community support network. The exploration of social media as a channel to reach and
engage with Hispanic American audiences encourages a broader consideration of
developing prevention strategies for an entire platform, such as the mobile phone or
smartphone.

23
Chapter Five: Hispanic Americans and the Mobile Revolution

Review of the “Small Steps, Big Rewards” and “Thunder and Lightning”
campaigns reinforce the role traditional media outlets, such as TV and radio, can have in
communicating information to Hispanic Americans. They also highlight the opportunity
to invest in digital channels and platforms as top destinations for health information,
specifically the mobile phone. The mobile phone is a singular device patients could use
access to multiple information channels.
In 2010, the majority of American teens voted the mobile phone as their preferred
communication vehicle, with 75% of teens ages 12-17 owning a cell phone (Campbell et
al.) Hispanic Americans of all language levels have adopted the use of cell phones. In
2010, Pew indicated that 87% of English speaking Hispanic Americans report owning a
cell phone. In 2011, the “Latinos and Digital Technology” issued by Pew indicated that
68% of Spanish dominant Hispanics have a cell phone, while 78% of bilingual Hispanics
have one (Livingston). Language, English speaking versus Spanish speaking, does not
appear to impact Hispanic American cell phone adoption.
Smartphones provide access to other content channels, apart from mobile phones,
such as applications, videos, games and social networks. According to eMarketer’s “Top
Digital Trends in 2012,” 38% of people in the US were smartphone users in 2011; by
2015, it is projected smartphone users will be closer to 58% or 148.6 million people. The
same report published that smartphones have been outpacing phones, tablets and ereaders
and with the increase in the purchase of these products comes the “demand for apps,
streaming video and audio, games, ebooks and periodicals, social networking and other
24
marketer supported activities.” Just as the demand for new entertainment content to
stream on these platforms rises, so might the expectation that credible health information
will be made available.
Mobile and smart phones have the potential to transform prevention strategies for
type 2 diabetes, especially when communicating with Hispanic American audiences, who
are among the highest mobile phone users. In 2010, Pew issued a report “Teens and
Mobile Phones” that “cell phones help bridge the digital divide by providing Internet
access to less privileged teens” (Campbell et al.). In fact, 21% of teens that do not
typically access the Internet go online using their phone and 35% of Hispanic Americans
use their cell phones to go online (Ibid). They can surf the Internet at their convenience
and gather information on the go. A person can Google signs and symptoms of a disease
and try to self-diagnose their condition. Mobile phones are giving Hispanic Americans
greater Internet access and increasing their accessibility to web-based information.
In 2010, 58% of Hispanic Americans reported using their cell phones to access an
app, 27% to send and receive email, 55% to send and receive text messages and 34% to
send/receive instant messages (Livingston). The use of the mobile phone in health
communication is referred to as mHealth and it offers multiple channels, such as text
messaging, email and applications, to distribute health information. mHealth initiatives
are being implemented around the world. Exploring various mHealth strategies can
highlight opportunities for potential mHealth type 2 diabetes prevention campaigns
targeting Hispanic Americans.
25
Chapter Six: Mobile Health and Type 2 Diabetes Prevention and Management

The World Health Organization (WHO) classifies mobile health, or mHealth, as
“the use of mobile and wireless technologies to support the achievement of health
objectives” (“mHealth: New Horizons for Health Through Mobile Technologies”).
Mobile health is particularly valuable in allowing healthcare providers to reach patients in
geographic areas where primary care is scare. Aetna Health recently joined the
Consortium on Mobile Health Diabetes Prevention in India to provide support to
diabetics through mobile phones. The goal of this project is to reach 1 million people
over the next two years through mobile text messages. Aetna believes that “this mHealth
program will be instrumental in bringing about social change” (“Aetna Joins Consortium
on Mobile Health Diabetes Prevention”).
Countless mobile health programs, such as the ones mentioned above, are being
implemented overseas. There is not only an opportunity but also a need to develop
mHealth more fully in the United States, especially for type 2 diabetes prevention.
Hispanic Americans are the highest uninsured population in the United States (qtd. in
“Cultural Insights: Communicating With Hispanics/Latinos” 11). Once created and
implemented, mobile health could help provide cost effective access to health
information and treatment, a primary reason why mHealth is being utilized in other parts
of the world. It improves communication between patients, doctors and medical
professionals by leveraging a platform that most Americans use in their everyday lives.
The prevalence of diabetes currently burdens the American healthcare system. At
the present growth rate of diabetes, annual healthcare expenditures are upwards of $200
26
billion dollars a year (Bennett 3). Despite the high cost, it is argued that “the US
healthcare system is not meeting the needs of those with chronic illness such as diabetes,
as it focuses on outpatient visits for acute problems, rather than supporting patients in
their every day lives manage their health” (Britt et al. 563). In most cases, mHealth
initiatives are cost effective and can increase health care access, especially to those who
need it most. Hispanic Americans may have cell phones, but they might not have health
insurance or adequate coverage. The mobile phone is already a part of their everyday
lives with a majority voting it to be their preferred communication vehicle. Why not
make it their preferred platform for accessing health information?
There are multiple mobile phone channels that can be strategically used in type 2
diabetes prevention and management, including applications, the Internet, social media
and SMS text messaging. The 2010 study, “Mobile Phone-Based Self-Management
Tools for Type 2 Diabetes: The Few Touch Application,” tested a mobile-based
application, Few Touch, among 12 patients suffering from type 2 diabetes. The Few
Touch application included a blood glucose meter, step counter, software for recording
dietary intake and feedback on how users are performing related to personal goals they
set (Arsand et al. 328). The application was designed to include the most effective
management tools but also to limit the time needed to interact with the application
throughout the day.
The study found that the most important diabetes management tools are known to
be “healthy diet, blood glucose management (BG) and physical activity” (Ibid 330). It
also found that 58% of users reported an increase in their daily intake of fruits and
27
vegetables and confirmed the positive effect web-based applications can have on
encouraging patients to manage their diabetes on a daily basis by optimizing mobile tools
that are easy to use (Ibid 335).
In 2011, the study “Qualitative Evaluation of a Mobile Phone and Web-Based
Collaborative Care Intervention for Patients with Type 2 Diabetes,” tested the
effectiveness of seaming mobile phones with an online game web browser to provide
collaborative care for type 2 diabetics. The web-based application allowed patients to
“upload blood glucose values wirelessly through mobile phones, communicate through
email with a care manager (also through the mobile phone if desired) and access their
shared medical records from a game system at home” (Britt et al. 563). The difference
with this approach is that it not only gave patients tools to manage their diabetes, but also
the tools to reach out for care or support when they needed it. They did not have to wait
for their next appointment or be placed on hold when trying to reach their physician.
Instead, they were able to use their mobile phones to access what they were looking for
when they wanted or needed it. Participants reacted positively to the applications feature
of interacting with a clinician because it “reinforced their self-care behaviors, and they
reported increased health awareness from being enrolled in the program” (Britt et al.
566).
Using a mobile or web-based application can be important in helping patients
manage or prevent diabetes by putting the tools at their fingertips. It is not a disease that
allows patients to simply take a pill or injection of insulin and go on with their daily
28
routines but one that requires constant attention. Mobile phones are equipped with the
capabilities to help patients easily manage their disease daily.
Both of these studies provide excellent insights into how mHealth applications
can be used to manage diabetes. However, they are useful once patients are diagnosed or
have an awareness about type 2 diabetes. Also, users must have smartphone capabilities
to run the applications. Mobile applications are just one channel available for mobile
health initiatives. Other mobile phone capabilities, such as SMS text messages, may
prove to be successful prevention tactics, especially among Hispanic Americans where
smartphones may not be widely adopted yet.
SMS text messaging can ignite health prevention campaigns and capture
audiences. This is referred to as “community mobilization” and is “defined as the use of
text messaging for health promotion or to alert target groups of health campaigns”
(“mHealth: New Horizons for Health Through Mobile Technologies” 3.5). Community
mobilization can be instrumental in introducing a type 2 diabetes mHealth prevention
campaign among Hispanic Americans because it reinforces the community as a support
system, which can be important to Hispanic American audiences.
Besides enabling community mobilization, SMS text messaging can be used as a
channel to distribute key campaign messages. Dr. Joseph Kvedar, founder of the Center
for Connected Health, compared individuals who received text message reminders to put
on sunscreen versus a group who did not. Those who received the daily texts had twice
the level of adherence to putting on sunscreen compared to those who did not (Dolan).
Mobile phone users, especially Hispanic Americans, use texting as a primary channel of
29
communication. From a health prevention standpoint, texting allows campaign messages
to directly reach audiences and provide information to them through a channel they
frequently use.
As illustrated with the study on sunscreen use, SMS text messaging, has the
potential for improving adherence to preventative behaviors. Imagine a doctor being able
to send a text message to Hispanic Americans in a local community notifying them of
what fresh produce is in season and including a link for a recipe to make for dinner that
night?

30
Chapter Seven: The Strategic Implications of Hispanic American Culture On
Type 2 Diabetes Prevention

The relationship between Hispanic American cultural norms, health behaviors and
mobile phone habits creates a challenging but optimistic environment for harvesting a
type 2 diabetes prevention campaign. There are a few key strategic implications that
should be taken into consideration when developing campaign strategies for Hispanic
Americans including: the role of family, audience segmentation, message development
and the introduction of mobile health initiatives to key audiences. Understanding these
four areas of Hispanic American culture and health behavior can assist in the
development of relevant campaigns and optimize mHealth initiatives among at-risk
populations for type 2 diabetes.
The Importance of Family

The family is the nucleus of Hispanic American life, which may support why
Hispanic Americans often rely on each other for care when they are sick. Health
prevention strategies can reinforce the role of family in making healthy lifestyle changes
and leverage the power of community support to bring about positive health changes. In
developing mHealth initiatives, it could be beneficial to orchestrate a social network to
foster a sense of community and support system for those looking to make healthy
lifestyle choices and prevent type 2 diabetes.

31
Social networks reinforce the social nature of their family and community life and
can encourage an open dialogue about health topics. In the context of mHealth, a social
network can exist in the form of multiple channels, including a web-based portal or an
application, all with the goal of fostering a network of support and open dialogue about
type 2 diabetes and how to prevent it or manage it.
Key Hispanic American Audiences

A primary audience for a type 2 diabetes prevention campaign would be Hispanic
Americans who already suffer from type 2 diabetes. This audience most likely
understands the disease and how it can be managed through modified diet and increased
weight loss. For this audience, components of an mHealth initiative could involve daily
management tips and introducing tools to help them manage their disease, such as the
Few Touch mobile-based application. It also would be beneficial to encourage this
audience to share their experience with other Hispanic Americans who may be at-risk for
developing type 2 diabetes. This could be an extremely viable tactic since Hispanic
Americans are likely to listen to their peers for health information.
A second key audience could be to address Hispanic American mothers or
grandmothers because they are responsible for raising the children. Mothers and
grandmothers have the most control over what their children eat and how and if they
exercise. Messages explaining nutrition options or exercise tips would be appropriate, as
long as they comply with Hispanic American cultural norms and values. It may also be
helpful to develop various tactics that give mothers a sense of power by communicating
that they have the ability to teach their kids about a healthier lifestyle and lessen their risk
32
for developing type 2 diabetes in the future. If mothers and grandmothers adopt healthier
lifestyles that limit their risk of developing type 2 diabetes, it is likely it would be passed
on to future generations.
A third audience to target could be young children and adolescents. They are an
extremely important audience because they are early on in development and still forming
their lifestyle habits. Young children and adolescents are also often quick adopters of
mobile technology, which would ease the introduction of using mobile technology for
consuming health information. A potential barrier to communicating with adolescents
and children is that they may not have access to mobile technologies, control over their
food options or the freedom to exercise when or how they want. Children are often fed at
school and may be limited in the choices they have to eat each day. While some school
districts are working to improve healthier options for children, children may have no
choice: eat the unhealthier school food or go hungry. Mobile health initiatives can instead
aim to educate children about a healthy diet and help them make choices about food
when it is available to them.
A fourth audience could be Hispanic American adult males because they often
have ultimate authority over the household. Even though mothers and grandmothers are
responsible for raising the children, the traditional value of machismo may still be
important. Households may listen to males for information and look to them as examples
of how to behave. Influencing the adult men may have a positive effect on the entire
families.
33
Finally, insurance companies may be an important audience to communicate with
about mHealth strategies and initiatives because of the opportunity to gain their support
and investment in new health communication technologies. Aetna’s investment in an
mHealth initiative in India raised the question: why shouldn’t a health insurance provider
invest in an mHealth initiative to aid Hispanic Americans at-risk for type 2 diabetes in the
US? It might even become a service health insurance companies provide to all of its
members, in addition to those populations at-risk and most in need of health information.
Garnering the support of health insurance companies could open to the door to the
development of greater mobile health technologies and raise greater awareness of the
power mHealth approaches can have in increasing access to health information.
Culturally Relevant Messages

A second strategic implication is crafting culturally relevant messages. Messages
should be developed with Hispanic American cultural values and health-seeking
behaviors in mind, such as the role of family, the importance of food and proliferation of
non-Western medical practices. Authentic communication that resonates with Hispanic
American audiences may increase the likelihood of them taking action towards
preventing or managing type 2 diabetes.
One consideration when developing messages could be to reiterate the role of
family support in making healthy lifestyle choices and encourage family members to
make changes together. If messages isolate the individual, the risk is that Hispanic
Americans may not act on them. This is not to say that they don’t make individual
choices but their collectivist culture may influence changes in health behavior. Messages
34
related to nutrition and diet should be mindful of traditional Hispanic American dishes,
such as rice or beans, which can evoke emotional memories. Instead of trying to interfere
with Hispanic Americans’ relationships with traditional dishes, messages could
encourage the positive feelings that may result from integrating healthier menu options
and following a balanced diet.
A second consideration when developing messages for Hispanic American
audiences is being mindful of different language levels. Pew Research Center discovered
in 2010 that “more than 87% of English-speaking US Hispanics owned a cell phone.”
Then, in 2011, they reported that 68% of Spanish dominant Hispanics and 78% of
bilingual Hispanics have cell phones (Livingston). Hispanic Americans of all English and
Spanish speaking levels own and use mobile phones. However, this makes developing
messages challenging.
Audiences may have to be segmented by English, Bilingual or Spanish speaking
in order to make sure they are receiving messages they can understand. For Spanish-
speaking audiences, great care should be taken to make sure that the appropriate
messages are communicated. Kristina Martel, Director of Communications at the
American Cancer Society, noted that English messages can’t simply be translated into
Spanish because meaning may be lost in direct translation. Great care should be taken to
make sure that English and Spanish messages align in meaning.

35
A third consideration is addressing the health literacy rate of audiences. Not all
audiences have the same level of health knowledge or familiarity with health terms. For
example, using the term “healthy” connotes chubbiness and being slightly overweight
among some Hispanic American audiences. It can improve the clarity and understanding
of messages to consider word connotations among Hispanic Americans.

Introducing Mobile Health Initiatives

Another strategic consideration of a mobile type 2 diabetes prevention campaign
targeting Hispanic American audiences is that not all individuals may be familiar with
using mobile phones to access health information. Hispanic Americans do rely on
traditional media, such as TV and radio, for health information as demonstrated in the
“Thunder and Lightning and Rain” campaign. However, Hispanic Americans may not
realize that they can access health information through their mobile phone.
Hispanic Americans do use their mobile phone to access the Internet when they
otherwise may not have it. In fact, in 2010 Pew Internet Research reported that 21% of
teens that do not typically access the Internet go online using their phone (Campbell et
al.). The Internet is a top information destination for Hispanic Americans and more are
using their mobile phones to gain Internet access. However, public health professionals
must be aware that an initial campaign effort may be to raise awareness of how Hispanic
Americans can use these mobile capabilities to improve access to health information.
A challenge in introducing a mobile health campaign in the Hispanic American
community is that not every Hispanic American has access to a mobile phone or
smartphone. Those without mobile phones are still important audiences to reach
36
regarding a type 2 diabetes prevention campaign because they may still be at-risk.
Traditional media will still be an important source of health information for Hispanic
Americans even though digital technologies are facilitating new strategies for health
communication between health professionals and at-risk populations. To balance
outreach to those audiences without mobile phones, targeting traditional media channels
alongside a mobile initiative could help ensure that audience exposure is maximized.

37
Chapter Eight: Implementing a Type 2 Diabetes mHealth Initiative Targeting
Hispanic Americans

The mobile phone as a communication platform to reach Hispanic Americans
could revolutionize strategies for type 2 diabetes prevention. To completely leverage the
power of the mobile phone as a platform for health information, a three-phase mobile
prevention strategy could be introduced for type 2 diabetes prevention among Hispanic
American audiences. It begins by utilizing promotora’s and SMS text messaging for
community mobilization, followed by the introduction of a mobile application and finally
the creation of an online social health community.
8.1 Promotoras and SMS Text Messaging

The promotoras serve as a liaison between health professionals, public relations
practitioners and at-risk Hispanic American populations. Promotoras can be used to
introduce mobile health initiatives into their local Hispanic American communities
because of their ability to bring the community together. According to the World Health
Organization, for mobile health initiatives to be cost-effective, it “involves educating the
public about the benefits of mHealth” (“mHealth: New Horizons for Health Through
Mobile Technologies” 2). The promotoras traditional role in health prevention campaigns
has been to educate Hispanic Americans about different health topics. However, to ensure
that an mHealth initiative is understood among Hispanic American audiences and to
maximize its cost saving potential, promotoras could educate Hispanic Americans about
how to use their phone to access health information. Educating Hispanic American
communities about the specific mobile health initiative may increase its overall
effectiveness.
38
As part of the initial acculturation to mHealth, promotoras can collect mobile
phone numbers within local Hispanic American communities. They can explain to
Hispanic Americans why they are asking for the phone numbers and how mobile health
initiatives will help them learn more about diabetes and give greater access to health
information. Once the phone numbers are collected, the promotora becomes instrumental
in executing “community mobilization.” Catalyzing the launch of a health prevention
campaign in the local community can be done by sending out SMS text messages to those
who have signed up to receive them and welcoming them to the subscription service. The
value of sending text messages to at-risk Hispanic Americans is that this channel directly
reaches the intended audiences and has been proven to increase the likelihood of
changing health behaviors.
The promotoras understanding of Hispanic American culture and the specific
health behaviors of local communities can aid in message development. Jackie
Quintanilla of Edelman Health pointed out that promotoras can serve as members of
focus groups to test messages effectiveness among intended audiences. This helps ensure
that messages will be relevant and understood but also provides actionable health
information about type 2 diabetes.
The SMS text messages can developed with diabetes specialists. Similar to the
sunscreen study examined above, doctors could send text message updates to their
patients reminding them to check their blood glucose levels, take their prescribed
medications, exercise, schedule an appointment or come in for a check-up. Text messages
can also create closer relationships between Hispanic Americans and their local doctors
39
by using a channel that both parties are comfortable with. Hispanic Americans may have
felt disconnected from their health professionals or not understood how they could
benefit from working with a Western medical professional. The use of a communication
channel both parties are familiar with could increase the frequency and quality of
interaction between doctors and Hispanic Americans.
The World Health Organization indicates the challenges of using text messaging
in health communication include “SMS length restrictions (maximum of 160 characters),
language barriers, illiteracy and lack of technical support in rural areas” (“mHealth: New
Horizons for Health Through Mobile Technologies” 2). These can be taken into
consideration when working with promotoras at the local activation level. For instance,
when gathering phone numbers for the SMS text message subscription service, patients
could indicate whether they speak Spanish or English. Then, separate text messages can
be sent to English or Spanish speaking Hispanic Americans. Promotoras may also have
more knowledge of the health literacy rates in local communities and can help develop
messages about type 2 diabetes that will be understood.
8.2 Mobile Application and Convenient Diabetes Management or Prevention

Introducing mobile health initiatives through SMS text messaging could allow
campaign managers and their medical professional partners to evaluate how Hispanic
Americans are responding to mobile health communication tools. The second step in an
mHealth initiative would be to introduce a mobile or web-based application for managing
or learning about type 2 diabetes. This would likely require the promotoras to go out into
their local communities and introduce the mobile application with at-risk Hispanic
40
Americans. They would play a critical role in explaining the application, its functions and
ultimately how Hispanic Americans can benefit from integrating the application into their
daily lives.
There are a variety of components that can included in application to educate
audiences about type 2 diabetes and help them better manage the disease. The “Mobile –
Phone Based Self-Management Tools for Type 2 Diabetes: the Few Touch Application”
study found the value of a diet or nutrition track and blood glucose monitor in the mobile
health management of type 2 diabetes (Arsand et al. 328). The nutrition diary and
dictionary would allow users to not only track what they have been eating but also look
up foods and their nutritional information. It could complement the SMS text messaging
service of the campaign by providing a more expansive portal for users to explore
information they received texts about. For instance, if a text message offered a
educational tip on a certain food, users could use the application to look up a recipe with
that particular food as an ingredient.
Incorporating a Few Touch blood glucose monitor the application to sync with a
patient’s blood glucose monitor, allowing users to review their blood glucose levels and
adjust their diet and exercise in a timely and efficient manner. Those who are diagnosed
with type 2 diabetes can access the tools to manage their disease through a platform that
is already part of their everyday lives. The application could record information for users
to share with their doctor or nurse, which was found the be an effective management tool.
The exchange of health information between doctors and patients through digital
channels can allow for effective management outside of the physicians office.
41
A third important component of a mobile application could be including videos of
doctors or promotoras communicating information. In fact, an estimated 32% of
Americans with smartphones report streaming videos, with a reported increase in the
sharing of video content (“Top Digital Trends for 2012” 3). Receiving bits of information
from doctors may also motivate users to request more information or feel more
comfortable reaching out to doctors through the app for advice, thus helping lower the
barrier between Hispanic American traditions of non-Western practices and Western
diabetes care.
Social Networks in Providing Community Support

In addition to SMS text messaging and a web-based application, a third element
of a mobile type 2 diabetes prevention campaign could be the creation and curation of an
online social network. Social networks have the potential to provide Hispanic Americans
with valuable health information about type 2 diabetes and could preserve the role of
family and community support in health behavior. The use of social networks in health
seeking behaviors is often described as peer-to-peer healthcare.
Dr. Susannah Fox, a leading researcher on the intersection of technology and
healthcare, promotes the potential peer-to-peer health care has “to transform the pursuit
of health by allowing people to share advice and to share what they know about
themselves” (Comsti). Peer-to-peer healthcare lives in multiple forms and over the last
few years has began taking place on digital platforms and through digital channels. It
could play a particularly important role in offering Hispanic Americans a trusted
community to seek health information.
42
In 2008, 70% of Hispanic adults received health information from social
networks, which included family, friends, churches and community groups, while 83%
cited the media as a source of health information (Cohn, Livingston, and Minuskin).
Providing a digital support group would merge the effectiveness of social network, peer-
to-peer healthcare behavior and prominence of media as a trusted source of health
information. Hispanic Americans using online social networks as a resource on type 2
diabetes could access support from those dealing with the disease or making similar
lifestyle choices across the United States and outside their local communities. An
extensive support system could also help users continue making positive lifestyle changes
by being able to see that they are not the only ones having to make difficult adjustments.
However, online social networks may not appeal to all Hispanic American
audiences depending on language levels. Only 17% of Spanish-dominant Hispanic
Americans credit the Internet as a source of health information compared to 70% who
cited TV as the top source (Ibid). Bilingual and English-dominant Hispanic Americans
reported much higher rates, 40% and 53% respectively, in using the Internet as a source
of health information (Ibid). Hispanic Americans of all language levels may adopt the
Internet as a primary source of health information as mobile phones continue to provide
greater Internet access (Campbell et al.).
The Internet provides Hispanic Americans with access to online social networks,
such as Facebook and MySpace. In 2009, 33% of Spanish-speaking Hispanics and 58%
of English-speaking Hispanics 35 years or younger were likely to visit a social network
online at least three times a month (qtd. in “Cultural Insights: Communicating with
43
Hispanics/Latinos”). The rate of accessing the Internet and online social networks is
lower for Spanish dominant Hispanic American audiences indicating that there may be a
longer period of acculturation in introducing social networks as a source of health
information among Spanish-dominant audiences.
To increase the participation in an online social network among Spanish-speaking
audiences, a promotora could offer a demonstration of how to use it and moderate the
fora to make sure that Spanish-speaking audiences are engaged and understand the
information. The social network could create an environment similar to a community
meeting at a local clinic would but would not require their physical presence and allow
them to connect to the same information at their convenience. For bilingual and English-
dominant users, there is an opportunity to increase participation in health related social
networks, which can also be encouraged by a promotora.
There are many different features that can be integrated into the social network to
promote an open dialogue on the topic of type 2 diabetes prevention. Users could upload
content, such as pictures of their healthy meals or exercise outings, to the site. Pictures
and/or videos that are shared with other users could encourage others to try a new food or
exercise class. Users would be able to comment on these images, providing
encouragement and support. In addition to encouraging peer-to-peer healthcare in type 2
diabetes prevention, social networks also offer the opportunity to strengthen the
relationship between patients and doctors.
A health care concierge service known as Hello Health connects doctors and
patients through web-based social media. Patients have the ability to text doctors, email
44
them, request a face-to-face web call or even access their medical records through a
private and secured social network (Hawn). Patients pay a subscription fee and pay for
additional services they may need, such as prescriptions, an in-person visit or even a
house call (Ibid). Through Hello Health, doctors and patients can have open lines of
communication by leveraging technologies that have transformed other consumer
industries in the United States.
For Hispanic Americans who may not have access to primary care or can’t afford
frequent physician’s office visits, Hello Health or a similar web-based health care tool,
may help improve the rate of type 2 diabetes by providing them with more accessible
information. Whether it is an automated message sent through the application a few times
a day or users being able to ask a doctor a question through email, applications and
mobile services, like Hello Health, have the potential to increase information exchange
and could provide important and timely health care and information access to those in
need.

45
Chapter Nine: The Challenges of Implementing a Type 2 Diabetes mHealth
Campaign Targeting Hispanic Americans

Developing a useful mobile prevention campaign targeting Hispanic Americans at
risk for type 2 diabetes could open up communication between doctors, patients and at-
risk populations through a platform that is widely accessed for other types of information
and communication. Hispanic Americans use their mobile phone to connect with friends,
family, the Internet, social networks and to send emails. Why not maximize the potential
to be a valuable source of accurate health information?
Despite the opportunity that exists, there may be a few barriers inhibiting the
effectiveness of mHealth initiatives among Hispanic Americans. The first is that some
individuals may be reluctant to sign up for text message updates. Depending on their
mobile phone plan or familiarity with SMS text messaging, Hispanic American audiences
may not want to provide their phone number or sign up to receive text messages from
local clinics, campaign organizers or promotoras. It is important that campaign
organizers use promotoras in mobilizing the campaign in local communities in order to
acculturate audiences, especially Spanish-speaking Hispanic Americans that have higher
rates of accessing traditional media for health information instead of on their mobile
phones.
Second, it can be costly to not only develop mHealth initiatives but also to
institute them in communities across the US. As the World Health Organization
identified, a significant cost associated with mobile health programs is generating
awareness about them. Federally funded institutions, such as the NDEP, likely have the
financial resources to institute and support a large-scale awareness campaign about type 2
46
diabetes. Despite the cost of developing and launching mobile health initiatives, investing
in mobile health campaigns could help alleviate the current financial stresses diabetes
places on the US healthcare system, which are upwards of 200 billion dollars annually,
by preventing people from developing type 2 diabetes in the first place. New platforms
and channels offer the opportunity to integrate health communication tools into
consumer’s everyday lives, which is important in preventing and managing a disease
such as type 2 diabetes.
An exploration and analysis of the broad cultural norms embraced by the Hispanic
American population influenced the campaign recommendations. In order to maximize
relevancy among the Hispanic American population, specificity can be taken to address
particular subgroups within the Hispanic American population, depending on origin.
Jackie Quintanilla, of Edelman Health, noted that there are distinct differences between
the various sub-populations of Hispanic Americans that can require communicators to
take further considerations for how health information messages are developed and
communicated.
The blessing of an mHealth campaigns is the opportunity to test multiple channels
and determine the most effective in communicating with certain Hispanic American
audiences. SMS texting, smartphone applications and online social network possess
additional capabilities than those outlined here. The creative and flexible nature of mobile
channels provides a bright horizon for the future of public health campaigns and
prevention of type 2 diabetes among Hispanic Americans.
47
Conclusion
Today, about 8% of the United States population suffers from diabetes, but by
2050 the number of Americans with diabetes is projected to be around 12% of the US
population (qtd. in Geiss and Cowie 25). Also by 2050, Hispanic Americans are projected
to be the nation’s largest population segment (Morton 46). The fact that Hispanic
Americans are one of the most at-risk populations for developing type 2 diabetes and
believed to be the fast growing population in the US virtually determines the need for
effective type 2 diabetes prevention campaigns. The burden of diabetes on the American
population and the US healthcare system indicates that creative alternatives to prevention
campaigns, such as the use of mobile health, may just be the answer to increasing access
to health information, services and primary care among high-risk populations.
Traditional media, such as TV, print and radio, continue to provide Hispanic
Americans with health information. However, in the midst of a digital revolution, they
are adopting new technologies, such as mobile phones and smartphones, which provide
them with greater access to the Internet, social networks and applications, as well as new
channels to connect with their peers, such as SMS text messaging and email. The
dynamic capabilities of the mobile phone and smartphone can revolutionize health care
communication, especially among Hispanic American audiences at-risk for type 2
diabetes.
Cultural norms, such as the role of family and community in providing support for
the sick and the practice of non-Western medicine, influence Hispanic American health
behavior. Digital social networks accessed through mobile or smartphones can reinforce
48
the value of community and potentially enhance its role in preventing type 2 diabetes.
Additionally, the one-to-one nature of certain mobile phone functions, such as SMS text
messaging, can allow different messages to be sent to audiences depending on health
literacy rate or language.
Mobile health initiatives may also increase access to information for Hispanic
Americans of varying language levels. Spanish-speaking Hispanic Americans currently
access the Internet for health information at a lower rate than bilingual or English-
Speaking Hispanic Americans. The cell phone ownership is almost equal between
Hispanic Americans of all language levels, indicating the potential to generate awareness
about mHealth initiatives and increase mobile health information seeking behaviors. The
one-to-one communication capabilities of the mobile phone, via SMS text messaging or
email, can help deliver messages to audiences depending on whether they speak English,
Spanish or both. It also allows to campaign managers to develop messages for audiences
of different literacy rates to ensure they are understood and effective.
In March 2012, 40% of doctors believed “that mobile health technologies can
reduce the number of office visits” (Murphy). The cost-saving opportunity associated
with the investment in mHealth initiatives could alleviate not only the financial burden of
diabetes on the US healthcare system but also the social component by preventing at-risk
populations from ever developing type 2 diabetes. The opportunity to leverage mobile
phone and smartphone communication channels in type 2 diabetes prevention among
Hispanic Americans could revolutionize healthcare communication. When instituted
properly, mobile health initiatives could create a flourishing and expansive ecosystem,
49
cultivating a trusted network of health information and increasing access to health
information to those who lack primary health care access or adequate coverage. They are
already being used around the world to bring health information and care to populations
in need. People in the United States suffer from similar health limitations: limited access
to primary care and lack of health insurance. Mobile health initiatives could secure a
healthier future for Hispanic Americans and other at-risk populations and prevent the
proliferation of type 2 diabetes in the United States.

50
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Abstract (if available)

Abstract The number of Americans diagnosed with diabetes is projected to double over the next fifty years (qtd. in Geiss and Cowie 25). The Centers for Disease Control (CDC) estimates that 90-95% of all diabetes cases are type 2. Ethnic populations, particularly Hispanic Americans, are disproportionately affected by diabetes. Numerous clinical trials have proven that the onset of type 2 diabetes can be prevented through moderate exercise and a balanced diet (qtd. in Dabelea et al. 39). Culturally relevant prevention strategies can improve the effectiveness of type 2 diabetes prevention campaigns attempting to reach Hispanic Americans. ❧ In 2010, 87% of English-speaking Hispanic Americans (Smith), 78% of bilingual Hispanic Americans and 68% of Spanish dominant Hispanic Americans reported having a cell phone (Livingston). Hispanic Americans have widely adopted mobile phone technology to access the Internet, SMS text messaging, videos, email and social networks (Smith). Mobile health communication strategies have the potential reach Hispanic Americans through a platform they have widely adopted for other communication purposes and provide them with information to make smart lifestyle decisions and hopefully prevent the onset of type 2 diabetes.

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Asset Metadata

Creator Lavayen, Stephanie Magdalena (author)

Core Title Preventing type 2 diabetes among Hispanic Americans: opportunities for optimizing mobile phone technology

School Annenberg School for Communication

Degree Master of Arts

Degree Program Strategic Public Relations

Publication Date 05/04/2012

Defense Date 04/02/2012

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag health communication,health prevention,health public relations,Hispanic Americans,mHealth,mobile phones,OAI-PMH Harvest,Public Health,type 2 diabetes

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Floto, Jennifer D. (committee chair), Jackson, Laura Min (committee member), Le Veque, Matthew (committee member)

Creator Email slavayen@usc.edu,stephanie.lavayen@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c3-27886

Unique identifier UC11288369

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Legacy Identifier etd-LavayenSte-745.pdf

Dmrecord 27886

Document Type Thesis

Rights Lavayen, Stephanie Magdalena

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Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

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