Edith C. Kieffer

Effectiveness of a Community Health Worker Intervention Among African American and Latino Adults With Type 2 Diabetes: A Randomized Controlled Trial

OBJECTIVES We tested the effectiveness of a culturally tailored, behavioral theory-based community health worker intervention for improving glycemic control. METHODS We used a randomized, 6-month delayed control group design among 164 African American and Latino adult participants recruited from 2 health systems in Detroit, Michigan. Our study was guided by the principles of community-based participatory research. Hemoglobin A1c (HbA1c) level was the primary outcome measure. Using an empowerment-based approach, community health workers provided participants with diabetes self-management education and regular home visits, and accompanied them to a clinic visit during the 6-month intervention period. RESULTS Participants in the intervention group had a mean HbA1c value of 8.6% at baseline, which improved to a value of 7.8% at 6 months, for an adjusted change of -0.8 percentage points (P < .01). There was no change in mean HbA1c among the control group (8.5%). Intervention participants also had significantly greater improvements in self-reported diabetes understanding compared with the control group. CONCLUSIONS This study contributes to the growing evidence for the effectiveness of community health workers and their role in multidisciplinary teams engaged in culturally appropriate health care delivery.

Racial and Ethnic Approaches to Community Health (REACH) Detroit Partnership: Improving Diabetes-Related Outcomes Among African American and Latino Adults

OBJECTIVES We sought to determine the effects of a community-based, culturally tailored diabetes lifestyle intervention on risk factors for diabetes complications among African Americans and Latinos with type 2 diabetes. METHODS One hundred fifty-one African American and Latino adults with diabetes were recruited from 3 health care systems in Detroit, Michigan, to participate in the Racial and Ethnic Approaches to Community Health (REACH) Detroit Partnership diabetes lifestyle intervention. The curriculum, delivered by trained community residents, was aimed at improving dietary, physical activity, and diabetes self-care behaviors. Baseline and postintervention levels of diabetes-specific quality-of-life, diet, physical activity, self-care knowledge and behaviors, and hemoglobin A1C were assessed. RESULTS There were statistically significant improvements in postintervention dietary knowledge and behaviors and physical activity knowledge. A statistically significant improvement in A1C level was achieved among REACH Detroit program participants (P<.0001) compared with a group of patients with diabetes in the same health care system in which no significant changes were observed (P=.160). CONCLUSIONS A culturally tailored diabetes lifestyle intervention delivered by trained community residents produced significant improvement in dietary and diabetes self-care related knowledge and behaviors as well as important metabolic improvements.

When Is Social Support Important? The Association of Family Support and Professional Support with Specific Diabetes Self-management Behaviors

BACKGROUNDSocial support is associated with better diabetes self-management behavior (SMB), yet interventions to increase family and friend support (FF support) have had inconsistent effects on SMB.OBJECTIVETo test whether FF support differentially affects specific SMBs and compare the influence of support from health professionals and psychological factors on specific SMBs to that of FF support.DESIGNCross-sectional survey of people with diabetes recruited for a self-management interventionPARTICIPANTS AND SETTINGOne hundred sixty-four African-American and Latino adults with diabetes living in inner-city DetroitMEASUREMENTS AND MAIN RESULTSFor every unit increase in FF support for glucose monitoring, the adjusted odds ratio (AOR) of completing testing as recommended was 1.77 (95% CI 1.21–2.58). FF support was not associated with four other SMBs (taking medicines, following a meal plan, physical activity, checking feet). Support from non-physician health professionals was associated with checking feet [AOR 1.72 (1.07–2.78)] and meal plan adherence [AOR = 1.61 (1.11–2.34)]. Diabetes self-efficacy was associated with testing sugar, meal plan adherence, and checking feet. Additional analyses suggested that self-efficacy was mediating the effect of FF support on diet and checking feet, but not the FF support effect on glucose monitoring.CONCLUSIONSThe association between FF support and SMB performance was stronger for glucose monitoring than for other SMBs. Professional support and diabetes self-efficacy were each independently associated with performance of different SMBs. SMB interventions may need to differentially emphasize FF support, self-efficacy, or professional support depending on the SMB targeted for improvement.

Perspectives of pregnant and postpartum Latino women on diabetes, physical activity, and health

Impaired glucose tolerance and diabetes are prevalent among Latino women of childbearing age. Physical activity during and after pregnancy may contribute to weight control and improved metabolic status, but recommended activities may not be perceived as appropriate or feasible. To plan realistic and acceptable interventions, pregnant and postpartum Latino women in Detroit met in a focus group series to discuss their beliefs about diabetes and factors influencing their participation in regular physical activity during pregnancy and postpartum. Women believed that diabetes was primarily related to heredity and diet but not to physical activity. Exercise was believed to reduce stress and improve general health. Women suggested an organized group intervention, in a respected location, that offered safe physical activities within the context of a variety of activities for women and children. This strategy reduced concerns about safety and social acceptability while addressing their primary interest in social support.

Comparative Effectiveness of Peer Leaders and Community Health Workers in Diabetes Self-management Support: Results of a Randomized Controlled Trial

OBJECTIVE To compare a peer leader (PL) versus a community health worker (CHW) telephone outreach intervention in sustaining improvements in HbA1c over 12 months after a 6-month diabetes self-management education (DSME) program. RESEARCH DESIGN AND METHODS One hundred and sixteen Latino adults with type 2 diabetes were recruited from a federally qualified health center and randomized to 1) a 6-month DSME program followed by 12 months of weekly group sessions delivered by PLs with telephone outreach to those unable to attend or 2) a 6-month DSME program followed by 12 months of monthly telephone outreach delivered by CHWs. The primary outcome was HbA1c. Secondary outcomes were cardiovascular disease risk factors, diabetes distress, and diabetes social support. Assessments were conducted at baseline, 6, 12, and 18 months. RESULTS After DSME, the PL group achieved a reduction in mean HbA1c (8.2–7.5% or 66–58 mmol/mol, P < 0.0001) that was maintained at 18 months (−0.6% or −6.6 mmol/mol from baseline [P = 0.009]). The CHW group also showed a reduction in HbA1c (7.8 vs. 7.3% or 62 vs. 56 mmol/mol, P = 0.0004) post–6 month DSME; however, it was attenuated at 18 months (−0.3% or −3.3 mmol/mol from baseline, within-group P = 0.234). Only the PL group maintained improvements achieved in blood pressure at 18 months. At the 18-month follow-up, both groups maintained improvements in waist circumference, diabetes support, and diabetes distress, with no significant differences between groups. CONCLUSIONS Both low-cost maintenance programs led by either a PL or a CHW maintained improvements in key patient-reported diabetes outcomes, but the PL intervention may have additional benefit in sustaining clinical improvements beyond 12 months.

The Development, Implementation, and Process Evaluation of the REACH Detroit Partnership's Diabetes Lifestyle Intervention

PURPOSE The purpose of this article was to describe the development, implementation, and process evaluation findings of a culturally tailored diabetes lifestyle intervention for African Americans and Latinos. METHODS African American and Latino adults with type 2 diabetes from 3 health care systems in Detroit, Michigan, participated in diabetes lifestyle intervention of the Racial and Ethnic Approaches to Community Health Detroit Partnership. The intervention curricula were culturally and linguistically tailored for each population. Trained community residents delivered the curricula in 5 group meetings aimed at improving dietary, physical activity, and diabetes self-care behaviors of study participants. The aims of the process evaluation were to assess participant satisfaction with the intervention, utility, and applicability of information and cultural relevance of intervention materials. Content analysis was used to analyze qualitative data. Matrices were developed along thematic lines, and common themes were determined by grouping responses by question. RESULTS Ninety-eight percent of participants attended 1 or more intervention classes; 41% attended all 5 meetings. Attendance rates ranged from 59% to 88% for individual meetings. Participants reported that program information and activities were useful, culturally relevant, and applicable to diabetes self-management. Participants also appreciated the convenient community location for meetings and the social support received from other participants. CONCLUSIONS A community-based, culturally tailored diabetes lifestyle intervention delivered by trained community residents was associated with high participant satisfaction and retention.

Self-Efficacy, Social Support, and Associations With Physical Activity and Body Mass Index Among Women With Histories of Gestational Diabetes Mellitus

PURPOSE To examine the associations between 2 potential facilitators of healthy behaviors (self-efficacy and social support), and both physical activity and body mass index (BMI) among women with histories of gestational diabetes mellitus (GDM). METHODS Two hundred and twenty-eight women with histories of GDM who were enrolled in a managed care plan were surveyed. A cross-sectional analysis was used to assess the association between womens social support from family and friends for physical activity and self-efficacy for physical activity with womens physical activity levels. The association between womens social support from family and friends for healthy diet and self-efficacy for not overeating and their dietary habits also were examined. Finally, the association between all of these psychosocial constructs and body mass index (BMI) were assessed before and after adjustment for covariates. RESULTS Participants reported low to moderate social support and self-efficacy scores, suboptimal performance of physical activity, suboptimal dietary scores, and high BMIs. Self-efficacy and social support from family and friends for physical activity were associated with physical activity. Social support from family and friends for a healthy diet was associated with better dietary scores, and the association between self-efficacy for not overeating and healthy diet bordered on significance. No significant associations existed between psychosocial constructs and BMI. CONCLUSIONS Psychosocial constructs such as social support and self-efficacy are associated with physical activity and dietary habits. However, associations with BMI are weak. Further exploration of constructs associated with BMI may be needed to design effective weight-loss interventions in this population.

Diabetes-Specific Emotional Distress among African Americans and Hispanics with Type 2 Diabetes

This study examines baseline levels and correlates of diabetes-related emotional distress among inner-city African Americans and Hispanics with type 2 diabetes. The Problem Areas in Diabetes (PAID) scale, which measures diabetes-related emotional distress, was administered to 180 African American and Hispanic adults participating in the REACH Detroit Partnership. We examined bivariate and multivariate associations between emotional distress and biological, psychosocial, and quality of health care variables for African Americans and Hispanics. Scores were significantly higher among Hispanics than African Americans. Demographic factors were stronger predictors of emotional distress for Hispanics than for African Americans. Daily hassles, physician support, and perceived seriousness and understanding of diabetes were significant for African Americans. Understanding the personal, family and community context of living with diabetes and conducting interventions that provide support and coping strategies for self-management have important implications for reducing health disparities among disadvantaged racial and ethnic groups.

Pregnancy outcomes of US-born and foreign-born Japanese Americans.

OBJECTIVES This study investigated the birth outcomes of Japanese Americans, focusing on the role of the mothers place of birth. METHODS Single live births to US-resident Japanese American mothers (n = 37,941) were selected from the 1983 through 1987 US linked live birth-infant death files. RESULTS US-born mothers were more likely than foreign-born mothers to be less than 18 years old and not married, to start prenatal care early, and to more adequately use prenatal care. Infants of foreign-born Japanese Americans had a slightly lower risk of low birthweight.No significant differences were found between nativity groups for very low birthweight or neonatal, postneonatal, and infant mortality. The mortality rates of infants of US-born (6.2) and foreign-born (5.4) Japanese American women were below the US Year 2000 objective but still exceeded Japans 1990 rate (4.6). However, low-birthweight percentages of the US-born group (5.7%) and the foreign-born group (5.0%) were similar to that of Japan (5.5%). CONCLUSIONS The infants of foreign-born Japanese-American women exhibited modestly better low-birthweight percentages than those of US-born Japanese Americans. This finding supports theories of the healthy immigrant.

The Influence of Maternal Weight and Glucose Tolerance on Infant Birthweight in Latino Mother-Infant Pairs

OBJECTIVES We assessed the influence of maternal anthropometric and metabolic variables, including glucose tolerance, on infant birthweight. METHODS In our prospective, population-based cohort study of 1041 Latino mother-infant pairs, we used standardized interviews, anthropometry, metabolic assays, and medical record reviews. We assessed relationships among maternal sociodemographic, prenatal care, anthropometric, and metabolic characteristics and birthweight with analysis of variance and bivariate and multivariate linear regression analyses. RESULTS Forty-two percent of women in this study entered pregnancy overweight or obese; at least 36% exceeded weight-gain recommendations. Twenty-seven percent of the women had at least some degree of glucose abnormality, including 6.8% who had gestational diabetes. Maternal multiparity, height, weight, weight gain, and 1-hour screening glucose levels were significant independent predictors of infant birthweight after adjustment for gestational age. CONCLUSION Studies of birthweight should account for maternal glucose level. Given the increased risk of adverse maternal and infant outcomes associated with excessive maternal weight, weight gain, and glucose intolerance, and the high prevalence of these conditions and type 2 diabetes among Latinas, public health professionals have unique opportunities for prevention through prenatal and postpartum interventions.