MILESTONE #3 LITERATURE REVIEW 1

Milestone #3 Literature Review

Angel Alvarez & Lou Luis

School of Occupational Therapy, Pacific Northwest University of Health Sciences

OTH 540: Foundations of Injury II

Dr. Malcolm Cutchin, PhD

February 27, 2024

Milestone #3 Literature Review

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The Problem

The number of older adults, defined as those over 65 and older, continues to increase

rapidly, experiencing a 38.6% increase between 2010-2020 alone (United States Census Bureau,

2023). The average life expectancy of individuals 70 and older has also increased worldwide

(Global Burdan of Disease 2019 Ageing Collaborators., 2022). While there are more older adults

alive and those older adults are living longer, they are not necessarily enjoying optimum health

in later life. The burden of disability due to chronic diseases among older adults has remained

constant despite improvements in lifespan, suggesting a need to improve public health and

intervention programs to enhance well-being (Global Burden of Disease 2019 Ageing

Collaborators., 2022).

The burden of disability due to chronic disease among Mexican American older adults

(MAOA) is particularly concerning. Mexican Americans (MA) are the fastest growing and aging

population (Garcia et al., 2017). Conditions such as diabetes, osteoarthritis, hypertension, stroke,

obesity, and cognitive decline are notably more prevalent among MAOAs (Collins et al., 2018;

Samper-Ternent et al., 2012). National Diabetes Statistics Report 2020, Hispanics are diagnosed

with diabetes in 10.3% of cases, undiagnosed diabetes percentage is 3.5%, and the total diabetes

percentage is 14.7% (CDC, 2020). In addition, arthritis has increased in prevalence among some

MAOA populations between 1994 and 2005 from 40.8% to 59.3% (Nam et al., 2017). Moreover,

the Centers for Disease and Prevention (CDC) further highlights disparities in MAOA health

outcomes and underscores the impact of multiple chronic conditions on MA. Age-related risk

factors associated with pain, such as diabetes, obesity, and disability, are particularly prevalent

among older Mexican American adults. As a result, they are also more likely to have low levels

of health literacy and poor access to medical care. While many factors contribute to the current

health crisis among MAOA, older MAs also tend to experience a lower socioeconomic status
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and are more likely to be uninsured or underinsured. They express less satisfaction with their

health care, all of which contributes to a higher likelihood of MAOA suffering from various

chronic health issues and experiencing worse health outcomes compared to non-Hispanic whites

(CDC, 2021; Delgado et al., 2012; Garcia et al., 2017). For example, non-Hispanic whites had an

average out-of-pocket expense of $1,463, while non-Hispanic blacks and Hispanics averaged

$781 and $710, respectively (MEPS., 2017). These figures highlight the financial burden of

healthcare on these populations and underscore the urgent need for policy interventions to

address these disparities. Furthermore, correlation has been found between diabetes and early

retirement affecting individual income (Scholfield et al., 2014).

The Significance

The impact of a chronic disease burden among older MA is significant. Multimorbidity

due to chronic disease is associated with functional limitations for activities of daily living

(ADLs) and instrumental activities of daily living (IADLs) (Klinedinst et al., 2021; Nam et al.,

2021; Prasad., 2023). These conditions, along with difficulties with IADLs, are the driving force

pushing these older adults into early retirement (Yuan et al., 2022). Additionally, complications

associated with diabetes and an extended period of diabetes have been linked to a more

significant decline in ADL and IADL functions for aging Hispanics (Wu et al., 2003). Thus, the

significant impact of chronic conditions on the functional abilities and quality of life of older

Mexican American adults emphasizes the urgent need for comprehensive healthcare strategies.

As the retirement age increases, more older adults continue to work. However, the positive

association between chronic conditions and retirement-aged adults pushing them to work with

poor health conditions prolongs inadequate self-management of their conditions (Yuan et al.,

2022). The substantial number of older MAs who want and need to continue working in later life

suggests a need to find ways to assist MAOA in managing chronic conditions and disease
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burdens (Albu et al., 2024). Existing research suggests occupational therapy could play a

significant role in self-management. While not explicitly focused on MAOA, prior research

suggests occupational therapy is beneficial for helping those with chronic conditions (American

Occupational Therapy Association., 2020; Donnelly et al., 2023; Leland et al., 2017; Manasha et

al., 2020; Pyatak et al., 2019). Significant disparities in income and healthcare eligibility exist

among Medicare beneficiaries, particularly between Hispanic and non-Hispanic white

individuals. These disparities underscore the financial challenges faced by older adults and those

with disabilities, especially within Hispanic populations. The National Center for Health

Statistics reported that half of Medicare beneficiaries in 2019 had an income close to $30,000,

contrasting the $14,000 average for Hispanics (National Center for Chronic Disease and Health

Promotion, 2022). Furthermore, the financial burden becomes even more evident for those with

multiple chronic conditions across all race/ethnicity categories.

The Scientific Knowledge of the Problem

In today’s primary healthcare, the focus has shifted towards preventative care and health

management due to the high prevalence of multimorbidity of chronic conditions. Simultaneously,

there has been a significant increase in research highlighting the role of occupational therapists

(OTs) in primary care, particularly for the older adult population. Chronic disease management

and self-management are the two most common interventions (Donnelly et al., 2023). Building

on this, OTs bring a proactive approach to supporting older adults with multiple chronic

conditions (MCC) by promoting engagement in occupation (American Occupational Therapy

Association., 2020; Berger et al., 2018; Donnelly et al., 2023; Leland et al., 2017; Manasha et al.,

2020; Pyatak et al., 2019). Moreover, research supports the utilization of OTs in primary care

when addressing diabetes, with high satisfaction rates reported among practitioners and clients

(Pyatak et al., 2019). Generally, communication with MA adults about medication adherence by
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providers facilitated its proper use, while poor communication was a barrier preventing adequate

care (Baghikar et al., 2019). An OT could direct a patient themselves in this endeavor by

understanding their barriers to providing actionable solutions (Pyatak et al., 2019). Regarding the

redesign of primary care, the American Association of Occupational Therapy (2020) has

concluded that the role of an OT can be molded into what the specific interprofessional team

needs. The flexible OT could fill the part of a direct care provider, consultant, educator, case

manager, or advocate. Furthermore, an effective interprofessional team utilizing OTs in primary

care has been stated to define clear roles, primary care provider education, and an

interdisciplinary care model (Grant et al., 2024; Leland et al., 2017; Li et al., 2024). Managing

chronic conditions has become a significant role for OTs. Furthermore, OTs take a client-

centered approach to adaptations to their specific lifestyles and medicine, highlighting their

routines in the contextual environment. In the context of a chronic care management framework

addressing the social determinants of health for MA adults, community health workers observed

a 69% improvement in diabetes self-management. Occupational therapy would fit into this

framework, playing the role of patient navigator and behavioral professional in primary care

(Zolezzi et al., 2022; Dahl-Popolizio et al., 2021).

The Key Gaps in Evidence

Research has shown the importance of developing and informing workers about optimal

retirement strategies, including when and how to retire, what to expect, and how to maintain

cognitive function post-retirement (Chaffee et al., 2017) in similar instances, enhancing

healthcare outcomes necessities more systematic reviews and empirical studies. These studies

have not fully recognized the insightful information provided by the participants in a primary

care environment (Allory et al., 2024). Future research should aim to determine the optimal

dosage of culturally tailored interventions. These should aim to determine the optimal dosage of

culturally tailored interventions. Future research should define ‘usual care’ and elucidate how
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culturally tailored interventions improve health outcomes—identifying the key components that

make these interventions effective (Joo & Liu., 2021). Moreover, it is essential to identify the

number of cultural elements used in addressing multimorbidity for MAOAs (Joo & Liu., 2021).

Finally, a pertinent question comes into question: How we can best achieve intrinsic motivation

for better health outcomes in MAOA populations for self-management (Manusov et al., 2022).

The Key Gaps this Study will Address

This research article aims to address the critical gaps in our current understanding of how

older Mexican American workers manage their chronic conditions. We will delve into the

multimorbidity of conditions, an area often overlooked in previous studies. Most research will

define what ‘culturally appropriate’ means regarding chronic disease management in primary

care. We will draw on the work of Knight et al. (2010), which identifies cultural values

associated with Mexican American culture. Our examination will encompass multiple cultural

dimensions, including familism, respect, religion, and traditional gender roles. We aim to

understand and explain the behavior of MAOAs and how they self-manage their conditions. We

hypothesize that one’s culture significantly influences these behaviors. This study will explore

the necessary modifications in the routines and habits of our MAOA population and the nature of

support they receive from both clinical and familial perspectives. We will focus on understanding

the strategies employed by OTs in aiding the self-management of health conditions among

MAOAs in primary care. Additionally, we will look at their work environments to understand the

impact on their health management strategies. By addressing these gaps, we hope to enhance our

understanding and contribute to improving the self-management of chronic conditions among

MAOAs in primary care and provide insights that could lead to more effective, personalized, and

culturally appropriate interventions. These insights could improve the quality of care of MAOAs
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and inform occupational therapy training programs, equipping future therapists with the skills to

support diverse older adult populations in managing their chronic conditions.

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