Source: TEXAS COOPERATIVE EXTENSION submitted to NRP
DO WELL, BE WELL CON DIABETES: A PILOT STUDY OF A TYPE 2 DIABETES SELF-MANAGEMENT EDUCATION PROGRAM FOR HISPANIC/LATINO RURAL OLDER ADULTS
Sponsoring Institution
National Institute of Food and Agriculture
Project Status
COMPLETE
Funding Source
Reporting Frequency
Annual
Accession No.
0219795
Grant No.
2009-46100-05910
Cumulative Award Amt.
(N/A)
Proposal No.
2009-05120
Multistate No.
(N/A)
Project Start Date
Sep 1, 2009
Project End Date
Aug 31, 2010
Grant Year
2009
Program Code
[LX]- Rural Health & Safety Education
Recipient Organization
TEXAS COOPERATIVE EXTENSION
(N/A)
COLLEGE STATION,TX 77843
Performing Department
Family Development and Resource Management
Non Technical Summary
Growth in Texas' 60-plus population is projected to escalate from its current 2.7 million to 8.1 million by 2040. Eighteen percent of the elder population is Hispanic/Latino. Along the Texas-Mexico border region, Hispanic elders will continue to outnumber other races and ethnicities. Starr County, pilot site, is located on the Texas-Mexico border in the lower Rio Grande River Valley. Texas Hispanic/Latinos over the age of 65 are disproportionately affected by diabetes prevalence (34.4 percent) than their White counterparts (17.5 percent). Across all racial/ethnic groups, prevalence rates of diagnosed diabetes dramatically increase with advancing age. For Hispanic/Latinos over the age of 65, these rates escalate from 6.8 percent for those 18 to 29 years to 34.4 percent. Coupled with higher prevalence rates, in 2005 Texas Hispanic/Latino mortality rates (52 per 100,000) were more than double Whites (21 per 100,000). Diabetes can significantly impact the quality of life of any elderly person with the disease, including Hispanics/Latinos. Older Hispanic/Latinos with diabetes are at an increased risk for co-morbidity and complications, and these conditions have a disabling effect on these individuals. Compared to nondiabetic elderly, Hispanic/Latino older adults are at an increased risk of disability in activities of daily living, the development of lower body disability, and major cognitive decline. Further, increased rates of comorbidity, disability, and health care use are greater in this cohort than the general elderly population. Proper management is critical to minimize the potential adverse effects of diabetes. Self-management education is the cornerstone for diabetic care and vital for glycemic or blood glucose control. Two measures of effective diabetes management - regular glucose self-monitoring and maintaining the recommended levels of hemoglobin A1c at less than 7 percent A1c - have been shown to reduce risks for disease-related complications. Literature documents lower blood glucose control among Mexican-Americans compared to Whites. Poor diabetes management is greatest among those with no insurance coverage, lower literacy, poor or no English skills, lower educational and income levels, and limited access to transportation. Identifying strategies and resources to provide diabetes education for vulnerable populations can help mitigate this problem. Developed in 2002, the English DWBW version has been cited by the Texas Department of State Health Services as a recommended community-based resource. In 2008, the English DWBW version was offered in 84 Texas counties with 1,527 persons attending the program. Success of the English DWBW version has set the stage for the development of the culturally adapted Spanish DWBW sequel. Similar to its counterpart, the Spanish DWBW version has the potential to offer the following benefits: better blood glucose management, social support by program staff and attendees, increased nutrition and diabetes self-care knowledge, and improved self-efficacy. Collectively, these enhancements will greatly contribute to positive health outcomes, especially among Texas elderly with diabetes.
Animal Health Component
100%
Research Effort Categories
Basic
(N/A)
Applied
100%
Developmental
(N/A)
Classification

Knowledge Area (KA)Subject of Investigation (SOI)Field of Science (FOS)Percent
72460203020100%
Knowledge Area
724 - Healthy Lifestyle;

Subject Of Investigation
6020 - The family and its members;

Field Of Science
3020 - Education;
Goals / Objectives
Below are the goals and objectives that will guide the proposed project: Goal 1: Pilot the Spanish DWBW version focused on older adults and their families who reside in a rural area of Texas. Objective 1:1: Organize a Starr County Diabetes Coalition consisting of health professionals and community stakeholders to help plan, market, and deliver the class series. Objective 1:2: Conduct a marketing campaign to recruit persons over the age of 60 who are diagnosed with type 2 diabetes. Objective 1:3: Train county agents and contracted registered nurses and dieticians to deliver DWBW. Objective 1:3: Implement DWBW at two pilot sites. Goal 2: Evaluate response to the intervention. Objective 2:1: Assess participants' pre- and post-A1c levels. Objective 2:2: Assess participants' pre- and post-knowledge, diabetes self-care behaviors, and self-efficacy using a previously developed, validated instrument. Objective 2:3: Develop a tool to evaluate facilitator instruction. Objective 2:4: Assess facilitators' program delivery. Objective 2:5: Modify the intervention based on evaluation results. Objective 2:6: Publish (post-project year) pilot test results. Goal 3: Ensure availability of the Spanish DWBW version to Texas AgriLife Extension Service county agents, the Cooperative Extension community, and stakeholders. Objective 3:1: Include the Spanish DWBW version as a program available for county agent adoption. Objective 3:2: Develop a Model Plan of Work for the program. Objective 3:3: Provide a link to the program on AgriLife Extension's Family and Consumer Sciences public website. Objective 3:4: Make available Spanish DWBW promotional resources on the eXtension Health Community of Practice
Project Methods
Methods The goal of Spanish Do Well, Be Well con Diabetes (DWBW) is to improve participants' diabetes self-care behaviors. Contracted registered nurses and dieticians, with volunteer assistance, facilitate the delivery of the program. The five weekly educational session topics and novela series are listed below: Cual es diabetes (What is diabetes) . Novela episode #1: Los mitos de la diabetes (Diabetes Myths) Coma sano con diabetes (Eat healthy with diabetes). Novela episode #2: Controlando la cantidad de comida (Portion Control) Sea activo con diabetes (Be active with diabetes). Novela episode #3: Saliendo a comer (Eating Out) Medicinas y diabetes (Medicines and diabetes). Novela episode #4: Hablando con su doctor (Talking to Your Doctor) Prevencion de problemas de la diabetes (Preventing diabetes problems). Novela episode #5: Controlando la diabetes (Taking Control of Diabetes) The group intervention is tailored for low-literacy needs and is communicated through culturally relevant experiences. Eight diabetes self-care practices are taught to promote blood glucose management: eating healthy, regularly checking blood glucose levels, engaging in physical activity, taking medicines, visiting the doctor, having vision exams, taking care of their feet, and having their teeth checked. To encourage social support, family members or friends are invited to attend. Guided by the social learning and self-regulation theories, this intervention focuses on several principals: self-efficacy, social support, role modeling, goal-setting, and self-monitoring. Instructional activities were developed to support these concepts. These strategies include skill-building activities, maintaining a weekly behavioral log, cognitive reframing, and viewing video novelas (soap opera) for role-modeling and reflection. As part of the development process, a team of nutrition and diabetes education experts conducted a content review of the curriculum. Evaluation and Methodologies The two-fold purpose of the pilot project is to evaluate the program's impact on A1c levels, diabetes knowledge, diabetes self-care behaviors, and self-efficacy; and assess the facilitators' delivery of the classes. A prospective, quasi-experimental, repeated-measure design will be used to evaluate the Spanish DWBW version. Hispanic/Latinos over the age of 60 with type 2 diabetes will be assigned to either an intervention or wait-list (control) group. Using county of residence as the assignment criterion, participants residing in Starr County, Texas, will form the intervention group; those living in Hidalgo County, Texas, will form the wait-list (control) group. Because of ethical considerations, those in the wait-list or delayed intervention group will receive their usual and customary diabetes care from their physician during the study period. The intervention will be offered to this cohort after the completion of the project. Clinical assessments (A1c) will be performed at Guajira Family Clinic and Diabetes Care in Rio Grande City and Edinburg, Texas. Institutional Review Board approval will be obtained from Texas A&M University.

Progress 09/01/09 to 08/31/10

Outputs
OUTPUTS: Below are the outputs specific to each of the project's objectives: Objective 1:1-1:4 a) Starr County DWBW Coalition formed and had its first meeting on Wednesday, November 18, 2009. b) Hidalgo County DWBW Coalition formed and had its first meeting Wednesday, December 9. Goal 2: Evaluate response to the intervention. Objective 2:1 Pre-A1c tests were conducted during a three-week period beginning the week of January 25, 2010 and ending February 5, 2010. Objective 2:2 Completed pre-assessment surveys for intervention and control groups the week of January 25th. Objective 2:3 Facilitator evaluation tool developed. Objective 2:4 The PI assessed facilitators Week 5 of the program. Objective 2:5 Based on facilitator's weekly evaluations and a program debriefing session program revisions have been made and curriculum finalized. Objectives 2:6 Publish (post-project year) pilot test results. The article reporting on quantitative analysis has been completed and is ready for submission. A second paper on the qualitative findings of the focus groups in development. Goal 3: Ensure availability of the Spanish DWBW version to Texas AgriLife Extension Service county agents, the Cooperative Extension community, and stakeholders. Objectives 3:1 A Spanish DWBW online training introducing the curriculum was conducted on November 12, 2009 for Family and Consumer Sciences county agents interested in offering the program after the pilot test. A second, comprehensive 7-hour training was held August 25. Objectives 3:2 A Model Plan was developed for the program and is available for adoption among Texas AgriLife Extension FCS county agents. Objectives 3:3 Provide a link to the program on AgriLife Extension's Family and Consumer Sciences public website. Plans are underway create an informational webpage about the Spanish DWBW program on the Family and Consumer Sciences (FCS) website. Objectives 3:4 Make available Spanish DWBW promotional resources on the eXtension Community of Practice site. The P.I. is serving on the CoP Community Health planning team. The CoP has received a $50,000 start-up grant. The Spanish DWBW promotional material will be posted during the final funding quarter. Dissemination of Yo Puedo (formerly Do Well, Be Well con Diabetes) a) P.I.'s poster presentation, Do Well, Be Well Con Diabetes: A Pilot Study Targeting Hispanic/ Latino Older Adults in South Texas, was a first prize recipient for the American Association of Diabetes Educators' Annual Meeting August 4 -7, 2010 in San Antonio, Texas. b) A state-wide training in Yo Puedo curriculum was held on Wednesday, August 25th for Texas AgriLife Extension FCS county agents. c) P.I. conducted a state-wide Yo Puedo training for Methodist Healthcare Ministry Wesley nurses on Thursday, September 23. A Memo of Understanding agreement was made with MHM to adopt Yo Puedo d) The P.I.'s abstract, Do Well, BeWell con Diabetes: A pilot study of a type 2 diabetes self-management education program for Hispanic/Latino rural older adults, conducted a podium presentation at the Society of Public Health Education's Annual Meeting in Denver, Colorado. The presentation will be conducted on November 6, 2010. PARTICIPANTS: Several targeted individuals and organizations collaborated on this project: 1) Family and Consumer Science (FCS) County extension agents were responsible for participant recruitment, program operation oversight, and were an Extension liaison in their respective communities. 2) A partnership was established with the Methodist Healthcare Ministries Wesley Nurses (San Antonio, Tx) to utilize local registered nurses to deliver classes. 3) A registered nurse with the Hidalgo County Women, Infant, and Child (WIC) program was contracted to be a class instructor. 4) In Starr County, we a registered dietitian with the Rio Grande City Independent School district was contracted to teach classes. 5) A partnership was established with Project Arise, a community-based organization that promotes empowerment of women and their families. Classes were conducted at their community center in the Las Milpas colonias (Hidalgo County). 6) The Starr County Commissioners Court partnered with Extension to allow classes to be held at their community center in Roma, Texas. 7) Three churches, Our Lady of Refuge Catholic Church, Immaculate Conception Catholic Church and Pharr First United Methodist Church, partnered with Extension to provide a site to conduct classes. Professional Training opportunities: 1) Interviewers Training to conduct pre- and post-test assessments. 2) Class leader training to deliver the diabetes self-management course. TARGET AUDIENCES: Efforts to influence change in knowledge, action, or conditions: 1) A 5-week program diabetes self-management education targeting low literate, Spanish-speaking Hispanic/Latinos. Objectives were to increase diabetes knowledge, improve self-management skills, and positively impact attitudes relevant to diabetes self-care. 2) Created an infrastructure of sustainability that included community empowerment through the training of health professionals to deliver Yo Puedo (formerly Do Well, Be Well con Diabetes). Additionally,partnerships that were established that facilitated securing community buy-in. PROJECT MODIFICATIONS: Nothing significant to report during this reporting period.

Impacts
Several products were developed as the result of the project that contributed to project outcomes: An Interviewers Manual was developed to trained persons to administer pre- and post-test assessments. 1) Facilitator's Evaluation tool was created to evaluate class leaders' delivery of the curriculum 2) Marketing material including brochures and flyers were developed to promote the program. 3) A summary brief was written that is used for marketing the program to potential community stake-holders and public officials. Evaluation summary: Intervention and control groups were similar in demographic characteristics: 75% were female,average was 60 years, 70% living at $20,000 or less, and 97% were Hispanic and speaking Spanish at home. Both groups were minimally acculturated: more than half the sample had a score of 0 out of 20, where a total score of 20 indicated highly acculturated. Overall, 50% of participants in both groups reported not having insurance. One difference between the groups was that 40% of the control group had more than a high school education compared to 20% in the intervention group. Baseline median HbA1c for both groups was below 8. At post-test, the intervention group reported significantly higher self-care and self-efficacy scores than the controls. Post-test HbA1c (collected at an average of 3 months) revealed a median 0.3% reduction from baseline among the intervention group. Conversely, median HbA1c for the control group increased by 0.1% between pre- and post-test.

Publications

  • An Empowerment-based Diabetes Self-Management Education for Hispanic/Latinos: A Pilot Study (2011)
  • The following paper has been written and will be submitted to the Diabetes Care journal on or before January 31, 2011: