CULTURALLY COMPETENT DIABETES SELFMANAGEMENT EDUCATION IMPROVES HBA 1

CULTURALLY COMPETENT DIABETES SELF-MANAGEMENT EDUCATION IMPROVES HBA 1 C LEVELS IN HISPANIC PATIENTS WITH TYPE 2 DIABETES Capstone Project, MPAS 218 Spring 2020 Sirena Sechslingloff April 3, 2020

Disclosures ■ No financial interests or other relationships with manufactures of commercial products, suppliers of commercial services, or commercial supporters, if any, are presented in this course content. ■ No commercial support was received for this activity. ■ No animals or people were harmed during this production.

PICOT Question In Hispanic patients with type 2 diabetes, how does culturally competent diabetes self-management education affect A 1 c within 1 year?

Key Points ■ Describe Diabetes Self-Management Education (DSME). ■ Illustrate techniques used to create a culturally tailored DSME program. ■ Discuss the role of the Community Health Worker and how this profession aids in making DSME programs cost effective and culturally tailored. ■ Discuss how these techniques have lowered A 1 c levels in the Hispanic population within a 1 -year timeframe. ■ Address limitations to the published research articles on this topic. ■ Discuss recommendations for future studies.

Introduction ■ Diabetes is the seventh leading cause of death worldwide and prevalence is rising. ■ In 2016, 1. 6 million people died from diabetes related complications. ■ 1 in 3 people will develop type 2 diabetes by 2050. ■ Hispanics are third most affected ethnicity and make up 12. 1% of people diagnosed with diabetes. ■ Diabetes education is effective for improving clinical outcomes and quality of life at least in the short term. ■ Many Hispanic communities lack the resources, access to care and health literacy to effectively make lifestyle changes.

What is Diabetes Self-Management Education? ■ Ongoing facilitation of knowledge, skill, and ability needed for diabetes self-care. ■ Guided by evidence-based standards. ■ Supports informed decision making, self-care behaviors, problem solving and collaboration with the healthcare team to improve clinical outcomes and quality of life.

Benefits of Diabetes Education ■ According to the ADA, diabetes self-management education has reduced hospital admissions and re-admissions. ■ Reduced complications ■ Overall reduced costs ■ 1% A 1 c improvement ■ Psychosocial improvements – Self-efficacy and empowerment – Healthier coping mechanisms ■ Behavioral aspects – Healthful eating and regular exercise

The National Standards for Diabetes Self-Management Education Curriculum ■ Describing the diabetes disease process and treatment options ■ Incorporating nutritional management into lifestyle ■ Incorporating physical activity into lifestyle ■ Using medications safely and for maximum therapeutic effectiveness ■ Monitoring blood glucose and other parameters and interpreting and using results for self-management decision making ■ Preventing, detecting, and treating acute and chronic complications ■ Developing personal strategies to address psychosocial issues and concerns ■ Developing personal strategies to promote health and behavioral change

Who instructs Diabetes Self. Management Education? ■ Nurses ■ Registered dietitians ■ Pharmacists ■ Multidisciplinary team includes: – Physicians, PAs, nurse practitioners, psychologists, other mental health specialists, physical activity specialist, optometrists, podiatrists – Health educators(Certified Health Education Specialists), case managers, community health workers

Organization of Diabetes Self. Management Education ■ Individualized diabetes education assisted by a bilingual community health worker ■ Individualized nurse case management combined with monthly education sessions with a community health worker ■ Monthly support group sessions ■ 2 -hour group class weekly over 4 -6 weeks ■ 4 -hour class followed by support group meetings

Diabetes Education should be culturally tailored ■ Education participation rates are significantly lower for Hispanics with Diabetes than for non-Hispanic Whites. ■ Language and cultural barriers can contribute to underutilization of health care.

Culturally Relevant Strategies ■ Educational sessions in the native language of participants ■ Participation of family members ■ Bilingual professional staff of the same culture ■ Lay community health worker of the same culture ■ Providing classes in a community center ■ Cultural emphasis in class content (foods, health beliefs, music) ■ Addressing health literacy and literacy in general

What is a Community Health Worker? ■ Many diabetes education programs are utilizing community health workers (CHWs) to strengthen the healthcare team and serve as a liaison between healthcare providers and patients. ■ Members of the community who serve as a bridge between the healthcare system and the patient. ■ Represent ethnic, cultural, or geographic communities. ■ They don’t often have formal training or education, but they provide cultural appropriate health education, advocate for individual and community needs, and increase access to care.

American Association of Diabetes Educators ■ Community health workers may participate in diabetes selfmanagement education instruction if they have received training in diabetes management, teaching self-management skills, group facilitation, and emotional support. ■ They are a Level 1 Diabetes Paraprofessional according to the Diabetes Educator Practice Guidelines. ■ Services must be supervised by a diabetes educator or licensed health care provider. ■ Must receive training from a certified diabetes educator.

Latinos en Control ■ 2011 randomized control trial to test whether culturally tailored techniques improved glycemic control among low-income Latinos with type 2 diabetes. ■ Techniques utilized: courses held in community center, encouraged family participation, and educated on healthier meals based on a traditional Hispanic diet. ■ Latino adults with documented A 1 c of 7. 5% or above within last 7 months. ■ Year long program including home visit, weekly sessions, followed by monthly sessions. Courses led by diabetes educators, health educators, nutritionists, and “trained lay workers”. ■ Statistically significant decrease in Hb A 1 c at four months, this significance decreased at 12 months. ■ Strengths: First large RCT to test a culturally tailored literacy-sensitive diabetes selfmanagement intervention for low-income Spanish speaking Latinos. ■ Limitations: Self-reported nature of the behavioral data collected including diet and blood glucose self-monitoring.

Starr County Study ■ 2007 RCT on the Texas-Mexico border in Starr County. ■ Techniques utilized: Education delivered in Spanish, emphasis placed on the traditional Mexican diet, and encouragement of family participation. ■ Latinos between age 35 to 70 with type two diabetes and accompanied by a family member or close friend. ■ Classes were delivered by bilingual Mexican American nurses, registered dieticians, and community health workers. ■ Cooking demonstrations with healthier versions of typical Mexican food recipes. ■ Education on reading your food label and picking the right foods while at grocery store by registered dietician. ■ Significantly lower A 1 c levels at 6 months and 12 months, however less of a difference at the 12 -month mark when compared to baseline ■ Strengths: Consistency with the variable of bilingual diabetes educators of the same culture as patients involved. ■ Limitations: The average A 1 c for this population was 12 with an average reduction to 10, however the author noted at that point it was not known if that reduction was comparable in reducing diabetes complications to a reduction of A 1 c from 9 to 7.

Outcomes at 18 Months From a Community Health Worker and Peer Leader Diabetes Self-Management Program for Latino Adults. ■ This 2018 study investigated whether community health workers can provide effective culturally competent DSME to the Latino population by measuring A 1 c improvements over 18 months. ■ Participants: Latino, greater than 21 years old diagnosed with diabetes, no physical or psychiatric illness preventing participation and no self-reported illicit drug or excessive alcohol use. ■ Participants randomly assigned to 6 months of CHW led program or usual care. After 6 months the CHW group was further randomized to 12 months of CHW-delivered monthly phone outreach or 12 months of weekly group sessions led by peer leader. ■ Statistically significant improvement in A 1 c with CHW led DSME group compared to usual care at 6 months. Improvements were maintained by 18 months in group that continued weekly sessions with a peer leader. ■ Strengths: measures outcomes beyond the end of 6 mo. DSME program. ■ Limitations: Limited generalizability due to recruitment from one FQHC in Detroit.

Evidence Summary Slide ■ Latinos en Control – Statistically significant reduction in A 1 c levels at 4 mo. , still significant but not statistically at 12 months. ■ Starr County – Statistically significant lower measures of Hb. A 1 c and FBS at 6 months and at 12 months. ■ 18 -month CHW led DSME study – At 6 months, statistically significant reduction in A 1 c in CHW led DSME group compared to control group. – Statistically significant reduced A 1 c 12 months post DSME program with continued weekly peer led group sessions.

Conclusion ■ Diabetes education programs that are culturally tailored by involving the utilization of a bilingual community health worker of the same ethnicity, that encourage family involvement, that include curriculum based on Hispanic cultural beliefs and traditions, and that involve home visits, improves glycemic control among Hispanic communities with type 2 diabetes. ■ Utilizing a Community Health Worker decreases cultural barriers that may be experienced by the patient, better addresses literacy levels and allows for classes to be taught in the same language as the patient. ■ Employing a CHW also allows for greater access to care by having the ability and time to make home visits and hold group classes at a community location

Practice Implications ■ The techniques used to make DSME culturally tailored as mentioned, should be considered when creating and utilizing DSME programs for Latino populations. ■ Utilizing a Community Health Worker is potentially the culturally tailoring technique with the greatest yield. ■ Using a CHW is also cost effective due to the ability for on the job training, which can lead to increased numbers of CHWs and therefore greater access to diabetes education related services for patients in underserved communities. ■ Education from a patient’s primary care provider is great reinforcement, however, practitioners should consider referral to a culturally tailored DSME program.

Gaps in Knowledge ■ Based on the articles reviewed in my Capstone and other articles available on this subject matter, there is a reoccurring theme of studies being limited to a short time frame. ■ It was also noticed in a few of the interventions that there was more of a statistically significant reduction in A 1 c among participants at the 6 -month measurement when compared to the 12 -month measurement. ■ Higher attrition rate as the study lengthens. ■ Limited information regarding patients progress after completion of culturally tailored DSME programs.

Future Research Suggestions ■ Further studies assessing A 1 c levels in addition to other markers on a yearly basis after patients complete a year long intensive culturally tailored DSME program while offering continued peer led support groups. ■ Additional research regarding the attrition rate and investigating techniques that are most successful in reducing this rate within the Hispanic population. ■ Further research regarding the effectiveness of home visits may aid in addressing the high attrition rates.

Reference Slide 1. The top 10 causes of death. World Health Organization. http: //www. who. int/news-room/fact-sheets/detail/thetop-10 -causes-of-death. Accessed July 19, 2018. 2. Statistics About Diabetes. American Diabetes Association. http: //www. diabetes. org/diabetes-basics/statistics/. Accessed July 19, 2018. 3. Diabetes. World Health Organization. http: //www. who. int/news-room/fact-sheets/detail/diabetes. Accessed July 19, 2018 4. Powers MA, Bardsley J, Cypress M, et al. Diabetes Self-management Education and Support in Type 2 Diabetes: A Joint Position Statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Diabetes Care. 2015; 38(7): 1372 -1382. doi: 10. 2337/dc 15 -0730. 5. Brunisholz KD, Briot P, Hamilton S, et al. Diabetes self-management education improves quality of care and clinical outcomes determined by a diabetes bundle measure. Journal of Multidisciplinary Healthcare. 2014; 7: 533 -542. doi: 10. 2147/JMDH. S 69000. 6. Rosal MC, Ockene IS, Restrepo A, et al. Randomized Trial of a Literacy-Sensitive, Culturally Tailored Diabetes Self-Management Intervention for Low-Income Latinos: Latinos en Control. Diabetes Care. 2011; 34(4): 838 -844. doi: 10. 2337/dc 10 -1981. 7. Brown SA, Dougherty JR, Garcia AA, Kouzekanani K, Hanis CL. Culturally Competent Diabetes Self. Management Education for Mexican Americans: The Starr County Border Health Initiative. Diabetes care. 2002; 25(2): 259 -268. Aponte J. Diabetes Training for Community Health Workers. J Community Med Health Educ. 2015; 5(6): 378.

Reference Slide 9. American Association of Diabetes Educators. A Sustainable Model of Diabetes Self. Management Education/Training Involves a Multi-Level Team That Can Include Community Health Workers. 2010. Available at: http: //www. diabeteseducator. org/export/sites/aade/_resources/pdf/research/Community_Heal th_ Workers_White_Paper. pdf. 10. American Association of Diabetes Educators. Diabetes Educator Practice Levels. 2014. Available at: http: //www. diabeteseducator. org/export/sites/aade/_resources/pdf/general/Prac. Lev 2014. pdf. 11. Spencer MS, Kieffer EC, Sinco B, et al. Outcomes at 18 Months From a Community Health Worker and Peer Leader Diabetes Self-Management Program for Latino Adults. Diabetes Care. 2018; 41(7): 1414– 1422. doi: 10. 2337/dc 17 -0978 12. Egbujie, B. A. , Delobelle, P. A. , Levitt, N. , Puoane, T. , Sanders, D. , & van Wyk, B. (2018). Role of community health workers in type 2 diabetes mellitus self-management: A scoping review. Plos One, 13(6), e 0198424. https: //0 doi. org. pacificatclassic. pacific. edu/10. 1371/journal. pone. 0198424 13. Funnell, M. M. , Brown, T. L. , Childs, B. P. , Haas, L. B. , Hosey, G. M. , Jensen, B. , … Weiss, M. A. (2010). National standards for diabetes self-management education. Diabetes care, 33 Suppl 1(Suppl 1), S 89–S 96. doi: 10. 2337/dc 10 -S 089

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