Chris Walker

Peer-Led Diabetes Education Programs in High-Risk Mexican Americans Improve Glycemic Control Compared With Standard Approaches: A Project Dulce promotora randomized trial

OBJECTIVE To evaluate the effect of a culturally sensitive diabetes self-management education program that uses a low-cost, peer-educator format (Project Dulce) on glucose control and metabolic parameters in low-income Mexican Americans with type 2 diabetes. RESEARCH DESIGN AND METHODS A total of 207 Mexican-American patients recruited from federally funded community health centers in San Diego County with HbA1c >8% were randomly assigned to the Project Dulce peer intervention or continuation of standard diabetes care. The primary outcome of interest was HbA1c. RESULTS The majority of subjects were born in Mexico, were female, were middle-aged, had less than an eighth-grade education, and had high baseline HbA1c levels. Significant time-by-group interaction effects for HbA1c (P = 0.02) and diastolic blood pressure (P = 0.04) indicated that the Project Dulce group exhibited greater improvement (i.e., decreases) across time. Within-group analyses showed that the intervention group exhibited significant improvements from baseline to month 4 in absolute levels of HbA1c (−1.7%, P = 0.001) and HDL cholesterol (+1.4 mg/dL, P = 0.01) and from baseline to month 10 in absolute levels of HbA1c (−1.5%, P = 0.01), total cholesterol (−7.2 mg/dL, P = 0.04), HDL cholesterol (+1.6 mg/dL, P = 0.01), and LDL cholesterol (−8.1 mg/dL, P = 0.02). No significant changes were noted in the control group. CONCLUSIONS This randomized trial, using the Project Dulce model of culturally sensitive, peer-led education, demonstrates improvement in glucose and metabolic control and suggests that this low-cost approach to self-management education for high-risk diabetic populations is effective.

Outcomes of Project Dulce: A Culturally Specific Diabetes Management Program

BACKGROUND: Diabetes mellitus is a common and costly chronic disease that increasingly affects minority populations; however, there is little evidence regarding the clinical effectiveness and costs of culturally appropriate disease management programs. OBJECTIVE: To determine the clinical outcomes and costs of Project Dulce, a combined stepped-care diabetes nurse case management program and culturally oriented peer-led self-empowerment training program. METHODS: Pre—post clinical outcome and cost analysis of Project Dulce participants were compared with a cohort of historical controls over a one-year period. Subjects included 348 persons with diabetes with coverage under County Medical Services who were receiving services in community health centers in San Diego, CA. Generalized regression models were used to estimate changes in clinical outcomes (hemoglobin [Hb] A1c, blood pressure, cholesterol level) and costs associated with participation in Project Dulce. RESULTS: Project Dulce participants had significant reductions in HbA1c (0.8%; p < 0.001), systolic (5.4 mm Hg; p = 0.001) and diastolic (8.0 mm Hg; p < 0.001) blood pressure, total cholesterol (28.1 mg/dL; p < 0.001), and low-density-lipoprotein cholesterol (15.6 mg/dL; p < 0.001). Expenditures for pharmacy (

Improved care for diabetes in underserved populations.

3157 Dulce vs

Improving Treatment of Depression Among Latinos With Diabetes Using Project Dulce and IMPACT

1618 control) and disease management (

Support for disease management, depression, self-care, and clinical indicators among Hispanics with type 2 diabetes in San Diego County, United States of America

507 Dulce) increased. Total costs were higher during the first year of disease management (

Outcomes From a Culturally Tailored Diabetes Prevention Program in Hispanic Families From a Low-Income School: Horton Hawks Stay Healthy (HHSH)

5711 Dulce vs

Community-Created Programs: Can They Be the Basis of Innovative Transformations in Our Health Care Practice? Implications from 15 Years of Testing, Translating, and Implementing Community-Based, Culturally Tailored Diabetes Management Programs

4365 control; p < 0.001). CONCLUSIONS: Project Dulce was effective in improving clinical outcomes for control of diabetes and related conditions in a medically indigent, culturally diverse population. Our finding of reduced hospital expenditures, although statistically insignificant, is clinically and economically important and suggests that intervention might provide an immediate benefit to a high-risk population.

Glycemic control with insulin glargine as part of an ethnically diverse, community-based diabetes management program.

UNLABELLED Diabetes mellitus (DM) is a common chronic health condition among the adult population in the United States. DM is more prevalent and complications higher in Latinos, possibly due to inadequate medical and self-care as well as inaccurate culture-bound beliefs. Project Dulce is a nurse-managed DM educational and treatment program designed to measure the effect on clinical outcomes, adherence to American Diabetes Association and American Heart Association standards of care, and cultural beliefs in 210 high risk (HbA1c > 9.5%) and 346 lower risk (HbA1c < 9.5%) indigent Latinos with DM. METHODS All patients were given a 12-week culturally sensitive educational program. Nurse manager/certified diabetes educators working together with primary care providers treated high-risk patients using protocols from Staged Diabetes Management. Physical exam and biochemical markers of DM were followed. Pre- and post-program questionnaires measured changes in diabetes knowledge, cultural beliefs practices, treatment satisfaction, and health locus of control. Chart reviews of Latinos with diabetes (n = 311) not enrolled in Project Dulce provided the case controls. RESULTS After 1 year, the high-risk group showed significant improvements in HbA1c (11.5% to 8.3%, p < 0.0001), total cholesterol (219 to 181 mg/dL, p < 0.00001), SBP (129 to 122 mmHg, p < 0.03), and DBP (79 to 75 mmHg, p < 0.006). Pre- and post-test evaluations showed improved diabetes knowledge (p = .024), treatment satisfaction (p = .001) and internal locus of control (p = 0.04), and fewer inaccurate culture-bound beliefs (p = 0.001). Compliance was 100% in the high-risk group in obtaining HbAlc, lipids, urine microalbumin, and foot exams and 47% in obtaining eye exams, while the case controls had 28%, 46%, 31%, 14%, and 6% respectively. Mean TC and LDL values improved in Project Dulce patients compared to case controls (181 vs 221 Img/dL, p < 0.0001 and 99 vs 1241 mg/dL, p < 0.0004). CONCLUSION Patients enrolled in Project Dulce had significantly improved clinical outcomes, adherence to standards of care, and culture bound beliefs. Nurse managed diabetes management programs that are culturally sensitive may decrease the incidence of complications of diabetes and improve health outcomes.

Improvement in Diabetes Care of Underinsured Patients Enrolled in Project Dulce A community-based, culturally appropriate, nurse case management and peer education diabetes care model

OBJECTIVE—To assess the feasibility and cost of integrating diabetes and depression care management in three community clinics serving a low-income and predominately Spanish-speaking Latino population. RESEARCH DESIGN AND METHODS—We screened diabetes patients for depression, and for those with depressive symptoms, we provided depression care management. We assessed changes in depressive symptoms using the Patient Health Questionnaire-9 (PHQ-9), diabetes self-care activities (nutrition, exercise, and medication adherence), and costs. RESULTS—Thirty-three percent of patients with diabetes had symptoms of major depression. Among 99 patients completing the study, PHQ-9 scores declined by an average of 7.5 points from 14.8 to 7.3 (P < 0.001). Clients averaged 6.7 visits with the care manager during the study period. Costs of depression care management were estimated to be

Teen Peer Educators and Diabetes Knowledge of Low-Income Fifth Grade Students

512 per participant. CONCLUSIONS—Adding a depression care manager to an existing diabetes management team was effective at reducing depressive symptoms at a reasonable cost.