Gloria Palmisano

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.

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.

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.

Chronic Disease – Related Behaviors and Health Among African Americans and Hispanics in the REACH Detroit 2010 Communities, Michigan, and the United States

Objectives: To compare chronic disease risk factors and their correlates for African American and Hispanic residents of REACH Detroit, Michigan, and the United States. Method: Behavioral Risk Factor Survey data from 2001-2003 were used for comparisons and regression models. Results: Several chronic disease risk factors were more prevalent among REACH Detroit residents than their Michigan and U.S. counterparts. In REACH Detroit, greater fruit and vegetable consumption was associated with more than high school education and older age among Hispanics, and meeting exercise guidelines and older age among African Americans. Less than high school education, smoking, and male gender were associated with lower consumption among African Americans. Greater physical activity was associated with younger age, male gender, and more fruit and vegetable consumption among African Americans, and unemployment among Hispanics. Conclusions: Surveillance of health behaviors in high-risk communities contributes to planning interventions and policies for reducing racial and ethnic disparities.

Do pre-existing diabetes social support or depressive symptoms influence the effectiveness of a diabetes management intervention?

OBJECTIVE Examine influences of diabetes-specific social support (D-SS) and depressive symptoms on glycemic control over time, among adults randomized to a diabetes self-management education and support (DSME/S) intervention or usual care. METHODS Data were from 108 African-American and Latino participants in a 6-month intervention trial. Multivariable linear regression models assessed associations between baseline D-SS from family and friends and depressive symptoms with changes in HbA1c. We then examined whether baseline D-SS or depression moderated intervention-associated effects on HbA1c. RESULTS Higher baseline D-SS was associated with larger improvements in HbA1c (adjusted ΔHbA1c -0.39% for each +1-point D-SS, p=0.02), independent of intervention-associated HbA1c decreases. Baseline depressive symptoms had no significant association with subsequent HbA1c change. Neither D-SS nor depression moderated intervention-associated effects on HbA1c. CONCLUSIONS AND PRACTICE IMPLICATIONS Diabetes self-management education and support programs have potential to improve glycemic control for participants starting with varying levels of social support and depressive symptoms. Participants starting with more support for diabetes management from family and friends improved HbA1c significantly more over 6 months than those with less support, independent of additional significant DSME/S intervention-associated HbA1c improvements. Social support from family and friends may improve glycemic control in ways additive to DSME/S.

Correlates of Interpersonal Ethnoracial Discrimination Among Latino Adults with Diabetes: Findings from the REACH Detroit Study

ABSTRACT The purpose of this study is to identify the social and economic correlates of reported experiences of interpersonal ethnoracial discrimination among Latino adults in Detroit. We examine whether the correlates of interpersonal ethnoracial discrimination vary according to the domain of discrimination and compare findings for individual domains of discrimination to a composite measure of experiences of discrimination. This study suggests that the frequency of reported discrimination is moderately high, and relatively common among Latinos with diabetes who live in Detroit. The findings demonstrate that immigration and ethnicity-related factors, such as greater comfort speaking Spanish and being born in the United States, were persistent correlates of more frequent encounters of interpersonal ethnoracial discrimination. Implications for social work research and practice are presented.

An Exploratory Study of the Impact of Gender on Health Behavior Among African American and Latino Men With Type 2 Diabetes

This study explores gender values and beliefs among Latino and African American men with diabetes and examines how these values and beliefs may influence their health behaviors. Participants were recruited from individuals who participated in one of three Racial and Ethnic Approaches to Community Health Detroit Partnership diabetes self-management interventions. One focus group was conducted with African American men (n = 10) and two focus groups were conducted with Latino men (n = 12) over a 3-month period. Sessions lasted 90 minutes, were audiotaped, and analyzed using thematic content analysis techniques. Two themes emerged that characterize gender identity and its relationship to health behavior in men: (a) men’s beliefs about being men (i.e., key aspects of being a man including having respect for themselves, authority figures, and peers; fulfilling the role as breadwinner; being responsible for serving as the leader of the family; and maintaining a sense of chivalry) and (b) influence of gender values and beliefs on health behavior (i.e., the need to maintain a strong image to the outside world, and the need to maintain control of themselves served as barriers to seeking out and engaging in diabetes self-management behaviors). Results suggest that gender values and beliefs may have implications for how health behaviors among men with diabetes. Future research should study the direct impact masculine identity has on health behaviors among men with diabetes.