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Developing Effective Diabetes Care Interventions in Rural Populations
Salem International University
Traci L French
May 20, 2013

Abstract: Diabetes mellitus wreaks a high toll on Americans in regards to shortened life expectancy, decreased quality of life and staggering health care expenses. Prevalence of this disease in some populations can reach nearly 30%, with 11.3% of the total population affected in 2010 (Texas Diabetes Institute, San Antonio, TX). In Arkansas, prevalence rates of the illness in some counties exceed 20% (Bradley, 2010). Recent statistics show that annual direct expenditures on diabetes care total $116 billion dollars per year with an additional $58 billion per year in indirect costs due to lost productivity and increased mortality (Texas Diabetes Institute, San Antonio, TX). The goal of this paper is to assess the development and implementation of current interventional strategies for diagnosing diabetes mellitus in affected populations in the southeastern United States. Outcomes of current programs will then be evaluated on a local, regional and national level. The final area of study will examine possible improvements to existing programs using culturally sensitive methodology to increase access to care within these populations and improve clinical outcomes while following evidence-based care guidelines.

Diabetes mellitus is a costly illness, both in the number of lives affected as well as actual expenditures on health care and lost wages. In 2007, 23.6 million people were diagnosed with diabetes in the US and an additional 57 million Americans were classified as pre-diabetic (Bradley, 2010). Diabetes is the sixth leading cause of death among all Americans (233,619 in 2007) and the fourth most common cause of death among African Americans (Bradley, 2010). It is believed that the actual mortality rate is under-reported in that only 40% of diabetic patients have the illness listed as a cause of death on his or her death certificate (Balamurugan, 2005). In Arkansas, my state of focus, 8.6% of the population is affected, with an incidence up to 30% in certain subgroups, with approximately 30% of cases believed to be undiagnosed (Balamurugan, 2005) and this number increases to nearly 80% in some international populations (International Diabetes Federation, 2012, p. 11). The incidence of diabetes has increased 28% over the past decade and disproportionately affects poor and minority groups. The prevalence of DM in the African American population is 37% higher than in White populations. The mortality rate for African Americans is triple that of the population at large and hospitalization rates are significantly higher as well (Balamurugan, 2005). Diabetes care and treatment accounts for 20% of all US health care expenditures and 956 million dollars was spent on this condition in Arkansas alone in 2007 (Bradley, 2010). The etiology of the illness is unknown, but it is believed that genetic predisposition along with lifestyle factors such as obesity and a lack of exercise contribute to illness development. There are three main types of diabetes: Type I - caused by a lack of insulin production, Type II (90-95% of cases) – results from a combination of insulin resistance and insulin deficiency. Gestational diabetes occurs in 2%-5% of pregnancies and occurs when insufficient insulin is produced to meet the extra demands of pregnancy. Affected individuals have a 35%-50% lifetime probability of progressing on to type II diabetes (Balamurugan, 2005). A great deal of focus in diabetes care programs centers around early diagnosis of the illness and disease prevention and risk factor reduction through lifestyle modification. The risk of developing diabetes is decreased by 58% through smoking cessation, weight loss and increased physical activity (Bradley, 2010). These outreach efforts are often hampered by disparities in race, income, health care access, and educational level. Patients in low income, minority populations as well as obese patients are less likely to receive recommended educational materials. Patients in low and middle-income groups as well as uninsured patients are less likely to receive recommended services as well (Balamurugan, 2005). This population can be very high in some areas (48% of Arkansas Hispanics, 27% of Marshallese) (Bradley, 2010) and are often the groups that would receive the greatest benefit from lifestyle intervention programs. The goals of most existing diabetes management plans aim to increase awareness of risk factors, educate patients on disease prevention strategies and consequences of uncontrolled illness, promote self-management techniques and integrated care models (J Gallivan, 2008). These programs work within a framework of public, patient and provider educational awareness campaigns, community action toolkits and evaluation models which provide both short-term and long-term process improvement. The methodology for establishing these programs is to engage stakeholders, define the program, gather evidence, analyze data, and use the findings for program improvement and development of future programs (J Gallivan, 2008). An example educational program is a diabetes education program in rural Arkansas. The objectives of this program are: 1) enable high-risk individuals to recognize diabetes warning symptoms, access available providers and receive proper diagnostic evaluation and treatment (Arkansas Department of Health, 2012). Current screening guidelines recommend fasting blood glucose testing in all overweight individuals over age 30, especially those in high-risk populations, positive family history of diabetes, symptoms of diabetes, history of gestational diabetes or a personal history of hypertension or hyperlipidemia. Testing should be performed at least every 3 years in all individuals over age 45 or yearly in high-risk individuals (American Diabetes Association, 2013). Diagnosis of the illness is made when Hgb A1c > 6.5%, fasting blood glucose is greater than 126 mg/dL, random blood glucose greater than 200 mg/dL or 2 hour glucose tolerance testing greater than or equal to 200 mg/dL 2) Facilitate attainment of successful clinical outcomes for patients currently diagnosed with diabetes by educating patients on important self-care measures, objective clinical measurement goals, and resources to enable compliance to treatment regimens. The learning outcomes for patient and provider populations are similar to overall program goals: providers receive education on patient education needs, preferred learning methods, cultural barriers, medication side effect issues hampering compliance to treatment regimens, financial issues that create difficulty with treatment regimen compliance and awareness of spiritual and psycho-social barriers to treatment (Balamurugan, 2005). The primary clinical goals addressed are blood pressure measurements, cholesterol management, glucose monitoring and Hemoglobin (Hgb) A1C monitoring (American Diabetes Association, 2012 ). Local and national standards recommend goal blood pressure readings below 140/80 for most diabetic patients, Hgb A1C< 7.0% at least two times yearly, and lipid readings below 100 LDL, triglycerides<150 and HDL>50. In addition, annual influenza immunizations are recommended along with pneumococcal vaccination (American Diabetes Association, 2013). Recommended screening tools include foot exams at each medical visit, bone density exams, hearing screenings, cognitive evaluations for depression and dementia, dental exam biannually, annual dilated retinal exam at least yearly, family planning referrals for women of child-bearing age, diabetic education counseling, hepatitis C screening as currently recommended in CDC guidelines, albuminuria screening through urinalysis yearly, and laboratory evaluation of Vitamin D, creatinine, hemoglobin, electrolytes, cholesterol, and thyroid/parathyroid function as recommended based on risk factors, age and population subgroup (American Diabetes Association, 2013). Medical exam criteria include discussion of eating habits, medication review, medication compliance and side effect review, discussion of diabetes complications and preventative self-care measures, review of blood glucose monitoring data with appropriate medication adjustment, and physical activity data review (American Diabetes Association, 2013). The physical exam should include BMI measurements, skin exam for acanthosis nigricans, and thyroid palpation along with the other measurements and screenings discussed above (American Diabetes Association, 2012). Dietary management includes limiting saturated fat intake, trans fat intake, moderate alcohol consumption, and an individualized diet plan that controls carbohydrate intake while providing adequate calories and nutrients. Diabetic patients are recommended to include 150 minutes of aerobic activity and two resistance training sessions into their weekly schedule. International diabetes quality measurement standards differ slightly from state and national diabetes guidelines. Diabetes diagnostic criteria are the same as US standards but screening should be limited to high-risk populations (International Diabetes Federation, 2012, p. 9) and the diagnosis may be made based on clinical criteria if diagnostic testing is unavailable. The HgbA1C test is the primary test of diabetes diagnosis and management but ancillary testing should be available to differentiate between Type I and Type 2 DM (International Diabetes Federation, 2012, p. 10). Medical care recommendations include developing an integrated, individualized, culturally sensitive care plan with comphrensive education, offer yearly examinations that include foot exams, dilated retinal exams, screening for neuropathy, renal disease, psychiatric illness and biannual monitoring of Hgb A1c, blood pressure and cholesterol (International Diabetes Federation, 2012, pp. 35-47). Target numbers are HgbA1c < 7.0%, blood pressure <130/80, and LDL<80 mg/dL, triglycerides<200 mg/dL. Glucose self-monitoring is only recommended in patients with insulin-dependent diabetes or diabetes that is uncontrolled with oral agents and the testing agents are readily available and affordable (International Diabetes Federation, 2012, p. 50). Lifestyle modifications differ only in that resistance training is suggested three times per week. When addressing the educational needs of the local diabetic population, I believe an integrated approach to evaluation design as discussed by Issel on p. 385 would be the most useful. Intake interviews detailing dietary habits, shopping venues, exercise habits, and electronic media usage of sample population representatives can help determine program needs and develop educational plan delivery methods. Observation of cooking habits and medication administration can determine barriers to overcome when creating educational curricula and will help bring hidden cultural patterns or biases to light. For example, Graber (1977), noted that patient observation “picked up” medication administration errors, medication compliance issues, foot care and daily hygiene issues, as well as dietary and nutrition concerns, all of which affected overall clinical outcome measures but not daily self-monitoring issues (A Graber, 1977, p. 62). “A day-long diabetic education program was instituted at Grady Memorial Hospital in Atlanta where patients administered insulin and monitored glucose under nursing supervision, ate two meals under the supervision of a dietician and received a physical exam and counseling by a medical professional along with individual and/or group counseling based on patient needs” (A Graber, 1977, p. 62).
Planning a comphrensive diabetes care model specifically for rural and other under-served populations would need to factor in transportation access, provider availability issues, lack of appropriate exercise facilities and opportunities, economic deprivation, “aging” of the rural population, lack of IT infrastructure in many areas and food scarcity in some cases. Benefits of working with these populations include strong social and community support networks, ample green space for spontaneous outdoor activity and food production and patient trust in medical authority figures and educational sources. When designing such a program, including transportation services or locating facilities near a transportation center will likely improve compliance, as will including prominent social figures within the community as a liaison or spokesperson for the program. Other ways to improve recruitment and retention to such programs include developing educational activities that involve local churches, schools or other community hubs, improving access to fruits, vegetables and lean protein, providing access to assistance for prescription medications and diabetic testing supplies and improving access to internet educational references, computers, and possibly developing a telemedicine program for outreach and support in under-served populations (Kreps, 2005). The example used in Kreps (2005), built health education programs around Head Start Centers in areas with low income, low health literacy and high risk factors to promote intervention programs using computer training both as an educational tool and as an incentive. A similar model was used in a nursing home where health education information was delivered in a “soap opera” type format to patients with few computer skills and low literacy scores. Both delivery models could be easily and inexpensively adapted to existing community settings in low-income and rural areas to provide information to populations typically considered “hard to reach” (Kreps, 2005, pp. 7-16). These models will work more effectively if local and state groups pool resources and outreach efforts to attract and retain members of these groups and offer ongoing support to maintain behavioral changes beyond the intervention period. Quantitative evaluations on nutrition and diabetes care can be given to clients in the pre-intervention and post-intervention phase to test baseline knowledge and intervention efficacy. Laboratory and other clinical data are also quantitative evaluation methods that will determine the benefit of behavior intervention. Using this data for program improvement is referred to as "formative evaluation". Patients receive education on disease etiology, natural disease progression with and without treatment, the importance of lifestyle modification in the overall treatment plan and the importance of a proactive, patient-centered care model in the clinical outcome of the illness. The next step is encouraging the patient to access multi-disciplinary resources for diabetes care with a focus on disease prevention and risk modification (Kreps, 2005) and development of an individualized patient care plan. Patients should be classified into separate groups for educational purposes. Educational needs differ for newly diagnosed diabetic patients versus patients who have chronic illness as do insulin-dependent diabetics versus diabetics requiring oral medications. Children and adults also have vastly different cultural, social, dietary and medication concerns (A Graber, 1977, p. 63). Care integration is the key element to success in planning a diabetes education and care project. The health care delivery team provides the necessary inputs and includes the primary care physician, subspecialty physicians, pharmacists, allied health providers of education and medical services, referral coordinators, HIT personnel who record data and track clinical outcomes, durable medical equipment providers, public health entities and hospitals. (American Diabetes Association, 2012 ). The information and services provided need to be presented in a consistent and cohesive manner. Data indicates that “knowledge retained from diabetic educational services is more closely related to the content and format of the program than the actual amount of time spent in educational sessions.” (A Graber, 1977, p. 62) All of these providers require support via grant funding, private funds and third-party insurers, facilities, support staff and cooperation/resources from patients and families before a program can commence. Funding is always a consideration when designing a health education program and qualitative data collection methods are typically more expensive and time-consuming than quantitative data collection methods. Many of the example population studies we have studied during this course combine both types of data collection methods in order to complete the project. Quantitative methods such as case studies or interviews provide a personal, intense view of a few selected subjects whereas qualitative collection methods generate large amounts of objective data quickly and the collection process may be automated (Kreps, 2005). Outcomes include data measurements (lab values, monofilament testing, etc.), depression screening information, medication refill compliance, complication rates, appointment compliance, referral processing, and hospitalization rates. Quality of care and desired patient outcomes depend on the ability of the care team to process the data inputs and utilize the information to improve care delivery. The other important factor in this equation is the ability of office staff to organize and track referral information and ensure patient compliance with scheduled appointments and referrals.
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Works Cited
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