Progress 09/15/23 to 09/14/24

Outputs
Target Audience:As proposed, the target audience is the AI/AN community newly diagnosed with type 2 diabetes, either deemed food insecure in the baseline survey or SNAP recipients receiving treatment at the Oyate Health Center (OHC) and residing within a 15-mile radius of the OHC. Between September 2022 (project start date) and September 2023, tasks such as getting IRB approval, CITI training, etc., were completed. These are elaborated in the previous progress report. The active phase of the project began upon hiring a Project Coordinator (PC) in August 2023 at the OHC and a produce delivery person in September 2023 at the SDSMT. The PC and the PD met to discuss screening the type 2 diabetes Special Diabetes Program for Indians (SDPI) registry and selecting 80-100 eligible candidates. The PC reported that only a few fulfilled the criteria of " newly diagnosed" (defined as those who have not previously received treatment or medications for diabetes and have hemoglobin A1c >8%). Therefore, the PD advised going back 6 months-1 year or more if necessary. Rather than having a small cohort of newly diagnosed patients, the PD preferred to include patients diagnosed much earlier and reach the proposed minimum number of 80 participants. This helped the program start, and at least 80 participants began receiving produce intervention on the same date. More candidates (16) were found to fulfill eligibility criteria and were included in the program, bringing the total to 96. Currently, the produce intervention efforts under the SD-PPP is reaching an audience of 96 participants. Changes/Problems:The following are major deviations from the proposed scheme. To the best of the PDs understanding, these changes will not affect the project goals and were made merely for the convenience or safety of the program participants or to increase the efficiency of the PD/PC to fulfill SD-PPP goals.Prior permission from the National Program Leader was obtained when major changes were made. i]. Enrolling patients who were already on diabetes medication. The PC screened the SDPI registry to find newly diagnosed type 2 diabetes patients. There were not many newly diagnosed who also fulfilled the other criteria for eligibility, such as being food insecure/SNAP recipients, residing within a 15-mile radius of the OHC, and not having reliable transportation. Therefore, type 2 diabetics receiving treatment at OHC and on medication for many years were enrolled in SD-PPP to bring the total number of enrolled participants to 96.This change was narrated to the NPL, who understood the need to make this change but encouraged to seek newly diagnosed to replace a program non-completer. ii]. The PD had proposed home delivery mode for produce distribution because many AI/AN do not have reliable transport. However, the PCD found many employees at the OHC were type 2 diabetics and fulfilled the eligibility criteria such as being food-insecure/SNAP recipient. Therefore, they were added to the program. This set of program participants chose to pick their produce bags at the OHC partially eliminating the proposed home delivery mode. iii]. The proposal mentions distributing produce prescription vouchers (PPV) each month; instead, signatures are obtained on receipt of produce by the program participant. The PD decided that this mode of recording produce receipt is more reliable and convenient for the elderly as it eliminated the need for the participant to visit OHC to collect the PPVs. iv]. Phone calls and in-person meetings were used instead of social media platforms such as Facebook or WhatsApp. An iPad was purchased from the grant to collect digital produce receipt signature from participant and to create a WhatsApp/Facebook account. However, the previous produce delivery personnel was proficient in using these social media platforms resigned to take a new job at OHC. The replacement hire is not as skilled in managing social media. v]. Fork Real Community Cafe was the proposed site to unload and bag produce. The PD attempted to use their facility. Since the proposal was submitted in 2022, the café has expanded its business. The PD realized they no longer had sufficient space to accommodate produce unloading and bagging. Instead, a clean and less busy space in V-Lab of the SDSMT is currently used to unload and bag produce. vi] Incentives to keep appointments with primary physicians at the OHC. The proposal mentions incentives for the participants to keep appointments with their primary physician and provide blood pressure and weight. This could not be achieved because the finance department at SDSMT does not have prior experience in generating or accounting incentives in the form of gift cards for gas purchase or extra produce. This is the first project of its kind at the SDSMT. The finance department is familiar with managing grants awarded for scientific research and education, which almost never includes managing food items or tangible incentives. The PCD was able to gather data on weight and blood pressure without needing incentives and therefore the PD did not pursue providing incentives. The monies were instead diverted to provide ingredients for recipe demonstration and towards meals offered at the two workshops. vi] Separate Healthy Eating Index Surveys and Food insecurity surveys were not conducted because of the significant overlap of questions between them and the baseline and post-surveys provided by the NTAE. The Diabetes Distress Surveys were conducted as proposed. vii] The collaboration with the proposed external evaluator at the University of Georgia-Athens (UGA) failed to progress due to i] inability of the UGA to accept all the conditions (in the MOU and Business agreement) put forth by the OHC and SDSMT and ii] concerns about compliance with HIPAA requirements.The NPL grant writer at the OHC was informed of the decision to eliminate external evaluation by UGA. What opportunities for training and professional development has the project provided?Interaction with participants: The PCD interacted with the program participants via phone calls daily and narrated these interactions to the PD. The PD/PCD learned that continuous communication with the participants helped build trust, increase compliance, and gather feedback. These interactions have enabled the PD/PCD to learn about the community needs and how the SD-PPP can be tailored to improve program outcomes. Qualtrics software: The project offered PCD/PD experience gathering surveys, uploading them to Qualtrics, and analyzing the data. HIPAA: Neither the PD nor PCD have received formal training in HIPAA policies. The project provided an opportunity for self-learningand making commonsensical judgments. Improved knowledge of produce: Nutritional value of produce, storage, and recipes: Since the first produce delivery in December 2023, PCD/PD has handled more than 5,000 pounds of produce. They have gained valuable experience in handling, checking produce quality, storage, and selecting recipes appealing to the taste buds while retaining the nutritional value of the produce. How have the results been disseminated to communities of interest?The team is not yet ready to disseminate the results to the communities of interest. AS of today, the surveys have been uploaded into Qualtrics and data analysis is in progress. What do you plan to do during the next reporting period to accomplish the goals?The produce delivery will continue for 52 weeks and if budget permits a few more weeks thereafter. The participants will complete post-surveys and diabetes distress surveys. The participants will be on an " off-produce" period. During this time, the PCD will continue communicatingwith the participants. The participants will complete one more survey at the end of 6-month "off-produce" period. The surveys will be entered and analyzed in Qualtrics, More data analysis will be performed. A more detailed final report on the project outcomes will be prepared and submitted to NTAE and the granting agency,

Impacts
What was accomplished under these goals? Enrolling eligible participants: Screening the Special Diabetes Program for Indians (SDPI)registry and enrolling eligible participants began concurrently after the PCD was hired in August 2023. Streamlining produce purchase and distribution: For all produce deliveries, the program had 96 participants enrolled and receiving fresh produce each Wednesday or Thursday. Breadroot Natural Co-operative supplied proposed fresh and USDA-certified organic produce at a bulk discount. The produce was made available by weight or count. Breadroot supplied a weekly list of available produce and prices. The PD selected produce from the list. A scheme of 3 vegetables and 3 fruits was followed with a target of at least 1 pound/produce/person. The scheme was developed following discussions with the nutritionist and dietitian employed at the OHC. Synergistic produce varieties that could be combined in nutritious and flavorful dishes were thoughtfully selected--for example, avocado and tomatoes or spring salad and cucumber. The shelf life and need for refrigeration were also taken into consideration. Most of the time, the PD could select at least three of the six produce items that remained fresh for at least 2-3 days without refrigeration. Produce quality was checked before bagging and door-step deliveries or deliveries at the OHC were accomplished each week by delivery personnel hired at the SDSMT. Instead of prescription vouchers, which would have been difficult to supply/collect, the produce delivery personnel gathered signatures from the participant or a family member on produce receipt. Originals of weekly signed sheets are available with the PD. The PCD maintains copies of these sheets. Produce was delivered on Wednesday to participants employed at the OHC and those residing on the South Side of Rapid City, while those residing on the North Side received produce on Thursday. Those unable to collect produce called to schedule a time for produce pick up at the OHC or the SDSMT. The produce was held at the recommended temperature until pick up. At times when Breadroot supplied more produce than was ordered, the surplus was added to the bags for participants who had large families. Slightly excess produce (~5-10 pounds) was often received when ordered: "by weight." This could be due to an error in weighing or a difference in the scales of the Breadroot and SDSMT. There were 2 occasions when the PD had to supplement produce from Safeway Incorporation. The PD expected at least 90-95 cabbages in 100 pounds of cabbage order. Instead, only about 40 cabbages, each weighing between 2-3 pounds, were delivered. The PD and produce delivery personnel decided it would be unwise to slice the cabbages to distribute in 96 bags equally. Additional cabbages were purchased from Safeway using a corporate card supplied by SDSMT. On another occasion, Breadroot received less supply, and Safeway supplemented it to complete our requirement. Produce delivery at Breadroot was timely, barring one occasion when the delivery trucks were late due to highway road closure. Invoices from purchases are emailed by the produce manager at Breadroot to the Chemical and Biological Engineering department secretary, who processes the invoices and forwards them to the finance department. The payment checks are issued by SDSMT and sent directly to Breadroot. SDSMT has been successful in paying invoices within 7 days of produce purchase. Breadroot had a special request to process payments within 7 days of purchase. The PD wishes to point out that produce purchase, pick up, and delivery took 3-4 weeks to streamline. Seemingly simple tasks such as produce bag materials (plastic, paper, or cardboard boxes), produce pick-up days, delivery routes, days and times, arranging state vehiclefor produce delivery, etc. were optimized after several trial and error. Surveys: At enrollment, the participants completed baseline paper surveys. The PD advised PCD to replace the participants' names with participant IDs and use these to upload their baseline surveys. This was done to protect the participants' identities and comply with HIPAA policies. Neither SDSMT nor OHC had access to the Qualtrics account and were unable to upload these surveys until an account was created in January 2024. The account was linked to the PD's SDSMT email and shared with the PCD at the OHC. Post surveys were conducted at mid-program on May 7th, 2024. Data from these surveys will provideinsights into the trajectory of food security, healthy eating, and diabetes management. Weight and blood pressure: Depending on the participant's availability, the PCD recorded blood pressure and weight monthly or at least once every three months, either at the OHC or by making house calls. The data is recorded in Exceland maintained by the PCD at OHC. Following HIPAA guidelines, the patient names will be replaced with an identity number. The " deidentified" will be shared with the PD at SDSMT.

Publications

Progress 09/15/22 to 09/14/23

Outputs
Target Audience:Between Sept 2022 and Sept 2023, I have been in contact with the Oyate Health Center (OHC), Breadroot Natural Co-operative, and Fork Real Community Cafe. I was contacted by Safeway representatives who have expressedinterest in supporting the SD-PPP. The OHC and SDSMT had several meetings to create the sub-award documents for OHC and get approval from the Indian Health Services IRB. The OHC started a search for a project coordinator after they received the sub-award. The SDSMT and OHC also completed a MOU during this period. Changes/Problems:The major change to the project is the delay in starting the project. We are delayed by 1 year because the following steps had to be completed: 1. SDSMT had to process sub-award documents for OHC 2. OHC had to hire a project coordinator 3. MOU signed between SDSMT, OHC, and the University of Georgia-Athens 4. A positon for produce delivery personnel was created and advertised. What opportunities for training and professional development has the project provided? Nothing Reported How have the results been disseminated to communities of interest? Nothing Reported What do you plan to do during the next reporting period to accomplish the goals?The project took off only after the project co-ordinator was hired at the OHC on August 28, 2023. We plan to accomplish the following major goals in the next reporting period. 1. Enroll 80 participants in the SD-PPP . 2. Collect baseline core metrics 3. Provide fresh produce to the participants for 52 weeks 4. Collect data on food insecurity, diabetes management, and healthy eating 5. Have 1 workshop.

Impacts
What was accomplished under these goals? Only administrative and management goals were achieved in the past 1 year: 1. A memorandum of understanding was signed between the South Dakota School of Mines and Technology (SDSMT), Oyate Health Center (OHC) and the University of Georgia-Athens 2. SDSMT prepared sub-awards documents for theOHC and signed MOU and consultant documents with University of Georgia-Athens 3. SDSMt created a position for the produce delivery personnel after all efforts by the project director to recruit a AI/AL student at SDSMT failed. 4. The position was advertised and 1 person who applied, was not hired because of failed background check. The position will be advertised. 5. A position for project co-ordinator was advertised and 11 candidates were interviewed. On August 28th, 2023 a project coordinator was hired by the OHC. 6. The project coordinator Dianne Seidel and I have communicated via emails and in person. 7. We have identified at least 45 type 2 diabetics. We will continue until Oct 15th to identify and enroll participants or until we reach the 80-participant target; whichever comes first. 8. I have introduced Dianne to the managers of Breadroot Natural Cooperative and Fork Real Cafe. 9. I had meetings with the Dietician and Nutrition educationalists at the OHC to discuss the patient's diet and what fruits and vegetables should be included in the SD-PPP. 10. A tentative date of Oct 25th was set for the first workshop on diabetes management.

Publications