TYPE 2 DIABETES, one of the most serious health problems in southern New Jersey, affects a growing number of older African-Americans and Mexican-Americans. Although attending diabetes education classes can help clients take control of this condition, few programs were culturally appropriate for these minority-group members.
Southern Jersey Family Medical Centers collaborated with a national health care provider that serves people with diabetes to initiate a project to increase the proportion of older African-Americans and Mexican-Americans who attend diabetes education classes in the Atlantic City, N.J., area. The main goal of this project was to motivate and educate people with diabetes to engage in healthy behaviors. Another goal was to encourage family members and friends to participate in this program to support their family member with diabetes.
In this article, I'll tell you what we learned about these groups and how we developed an innovative program to address their need for diabetes education.
Population at risk
We found that people living in the five-county southern New Jersey area are at higher risk for diabetes than people living in other parts of the state. This may be due to the large migrant populations and extreme poverty in three of the five counties.1 We also learned that diabetes education classes have been poorly attended by both African-Americans and Mexican-Americans. By providing culturally acceptable diabetes education programs, we hoped to reduce their health risks and promote diabetes control.
Our community assessment of African-Americans and Mexican-Americans living and working in this area suggested that both groups regard food as important in their culture. However, poor nutritional choices, overeating, and lack of exercise put them at risk for type 2 diabetes.
Following Green and Kreuter's PRECEDE-PROCEED health promotion planning framework, we found that people with diabetes seem to be motivated to learn more about living a healthy lifestyle.2 (See What's PRECEDE and PROCEED about?) Most clients in the general population read diabetes health information and often question their health care providers about risk factors and preventive measures.
In both ethnic groups, family support provides important reinforcement. For example, clients keeping an appointment at family health centers are often accompanied by several family members. In many African-American families, women make most health care decisions. Both African-Americans and Mexican-Americans rely on advice and home remedies from family members before they seek professional medical care.
Planning for success
To create a suitable teaching program, we needed to incorporate appropriate cultural considerations we'd learned about the targeted groups. We decided to offer the program in a community setting instead of a medical facility to make it more relevant to clients' lives and to include family members in the program.3 We also considered these elements to be indispensable for success:
- Blood glucose monitors must be available and clients need to know how to use them.
- Clients need education about reducing their risks by controlling their blood glucose levels, making better dietary choices, and managing their weight.
- Clients need better access to health care and culturally acceptable educational programs.
To reach older adults, we planned to hold classes in the community room of a senior residence on three Tuesday mornings in a row. We included one team member who spoke both Spanish and English. Our team included a physical therapist, a nutritionist, a certified diabetes educator, diabetes product representatives, supervisors of senior residences, and the director and the program coordinator of the Diabetes Outreach Education System.
Promoting our classes
About 6 weeks before classes began, I distributed information and flyers to three senior residences, an adult day care center, a rescue mission, a Spanish community center, and many local health care providers.
I encouraged social workers at the senior residences to offer our free diabetes classes to their residents. I also sent a press release to the local newspaper.
A few weeks before classes started, I mailed a flyer and a personal letter to over 200 clients who had diabetes and who used Southern Jersey Family Medical Centers, Atlantic City, as their primary health care facility. I told them about the free classes and provided a phone number to register or get more information.
One week after the mailing, I called each client to discuss the importance of diabetes control. One day before each of the three scheduled classes, I called everyone who'd registered for the class to remind them to attend.
Although most of our participants were African-Americans and Mexican-Americans, we also had participants who were Egyptian-Americans, East Indians, Asian-Americans, and white Americans.
Covering the basics
The first of our 2-hour classes included a basic description of diabetes, advice for maintaining normal blood glucose levels, and a discussion of signs and symptoms of hypoglycemia and hyperglycemia. A certified diabetes educator discussed risk factors for diabetes and how poor blood glucose control could cause complications. The certified diabetes educator also covered preventive practices such as:
- monitoring blood glucose daily
- performing daily foot exams
- using medication schedules
- visiting a health care provider regularly
- having two or more hemoglobin A1C blood levels tested per year
- having annual eye exams.
I provided many handouts tailored for minority populations.
At the second class, held 1 week later, topics included increasing exercise and regular physical activity. A physical therapist demonstrated exercises and provided a written exercise plan. We added literature about exercise and health to our collection of culturally and linguistically appropriate handouts.
The final class covered making healthy food choices, measuring food, reading food labels, eating meals on time, and dining out. A nutritionist demonstrated healthy cooking, including low-cholesterol, low-fat, and nutrient-dense entrees especially tailored for people with diabetes. Handouts included information about American diet pyramids, Mexican-American diet pyramids, and dairy products. Several recipes from African-American and Mexican-American diabetic cookbooks rounded out the collection.
After each lecture, I demonstrated a blood glucose monitor and distributed free glucose monitor kits provided by the national health provider serving diabetes patients. We provided easy-to-read illustrated handouts, some in Spanish. At the end of each program, we had a free drawing for a gift basket containing a diabetes calendar, food scale, diabetic cookbook, diabetes nutritional supplements, and other products.
Evaluating our results
Our evaluation survey gathered data for future programs targeted to minority populations. To address the needs of patients with vision problems, we used an 18- or 22-point boldface font for all demographic and evaluation forms as well as class schedules.
Thirty demographic forms were returned at the last class. Each class had 28 to 39 clients. Participants for these three sessions generally ranged in age from 35 to 73 years, but one 10-year-old girl who had type 1 diabetes also participated with her mother.
Information collected suggested that all participants had diabetes and all but two had family members with diabetes. Out of 30 participants, 6 didn't walk or exercise regularly, 8 didn't test their blood glucose levels, and 12 didn't follow a healthy diet. Four people had previously attended diabetes education classes.
All participants indicated the classes were helpful. When asked if they'd recommend these classes to a friend, all responded positively.
Meeting our goals
By bringing the two health care groups together and assembling a team of professionals, we shared information in simple and interesting terms geared to the communities we'd targeted. We found that delivering patient education through a diabetes health care team approach was an effective way to teach our clients to control risk factors, reduce complications from diabetes, and make healthy lifestyle choices.
What's PRECEDE and PROCEED about?
This educational framework is used for planning health education programs for communities.
- PRECEDE stands for
- Reinforcing, and
- Constructs in
- Diagnosis and
- PROCEED stands for
- Regulation or Resources
- Constructs for
- Educational and
Source: Green LW, Kreuter MW, Health Promotion Planning: An Educational and Environmental Approach, 2005.