Janette S. Carter

Participant Satisfaction With a Culturally Appropriate Diabetes Education Program: The Native American Diabetes Project

PURPOSE the purpose of this paper is to report on participant satisfaction with the Native American Diabetes Project diabetes education program. METHODS A questionnaire was designed to measure satisfaction among participants in the diabetes education program, which consisted of five sessions designed according to the Transtheoretical Model of Change and Social Action Theory with input from community members. Eight pueblo communities participated in the program. Sessions were taught by community mentors in three sites in New Mexico. One site taught sessions in a one-on-one format, and two sites taught sessions in a group format. RESULTS The results showed that participant satisfaction did not vary based on session delivery type or by session site. Overall, participants responded positively to sessions designed according to Social Action Theory and with cultural competency. Retention rates for the sessions were 81% for group sessions and 91% for one-on-one sessions. CONCLUSIONS Using a strong theoretical framework and community input to design diabetes education sessions may be important factors in participant satisfaction and retention in diabetes lifestyle education sessions.

Rapid HbA1c Testing in a Community Setting

OBJECTIVE To determine whether the DCA 2000 analyzer provides valid and reliable HbA1c results when used under field conditions and operated by nonmedical personnel. This study was part of a community diabetes education program, the Native American Diabetes Project, in which HbA1c was measured as an indicator of average glycemic control. RESEARCH DESIGN AND METHODS Two study samples were taken, the first in the spring of 1994 and the second in the spring of 1995. Seven community members in 1994 and six new community members in 1995 were trained over 2 days, using standard protocol, to operate the DCA 2000 HbA1c analyzer and to collect two capillary blood samples from participants in the Native American Diabetes Project. Duplicate DCA 2000 HbA1c measurements performed by the community workers were compared with measurements from a high-performance liquid chromatography (HPLC) system. Validity and reliability measures were calculated. RESULTS Of the participants, 43 were studied in 1994 and 14 in 1995. Comparison of the mean DCA 2000 results with those of HPLC showed high validity, with the absolute relative difference between the mean DCA 2000 and the external reference of HPLC (│ mean DCA 2000-HPLC │ /HPLC) as 4.0 and 2.0% for 1994 and 1995, respectively. The Pearson correlation coefficients (r) between these two measures were 0.968 and 0.996 for 1994 and 1995, respectively. While the 1994 data appeared to have less validity for values > 10%, they included only one value with a 60-min warm-up of the DCA analyzer. The 1995 data, all collected after a 60-min warm-up, had good correlation throughout the range of values. The within-run reliability was excellent, with an intraclass correlation coefficient of reliability of 0.959 and 0.975 for paired samples, for 1994 and 1995 respectively. The mean coefficient of variation for these paired measures was 3.0% in 1994 and 2.8% in 1995. Both validity and reliability were improved by changing the warm-up period of the DCA 2000 analyzer from 5 to 60 min. All correlation coefficients were statistically significant (P < 0.0001). CONCLUSIONS The DCA 2000 gave valid and reliable HbA1c results when operated in a community setting by nonmedical personnel. Extending the warm-up period of the device to 60 min slightly improved the validity and reliability of the test.

Challenges to Participating in a Lifestyle Intervention Program: The Native American Diabetes Project

PURPOSE This paper describes the factors that American Indian teachers in the Native American Diabetes Project (NADP) reported affected participation in the NADP lifestyle education sessions. METHODS A postsession exit interview was conducted with each of the 7 mentors (teachers) of the NADP sessions. Interview questions addressed general perceptions of the sessions, factors that kept participants from coming to the sessions, and attitudes toward diabetes and persons with diabetes. Interviews were transcribed and responses reflecting factors related to participation were marked and organized into topic areas. RESULTS Mentors reported a range of factors that affected participation in the sessions, such as conflicts with community activities and beliefs/attitudes about diabetes. The latter factor includes program knowledge, recruitment methods, attitudes toward the program, and beliefs about diabetes. CONCLUSIONS Asking community members what factors they believe affect participation is an important component of increasing participation in community-based programs. Community members can provide a valuable personal perspective of actual and potential conflicts in the community.

Diabetes mortality among New Mexico's American Indian, hispanic, and non-hispanic white populations, 1958-1987

OBJECTIVE— To determine the diabetes-related mortality rates among New Mexicos American Indians, Hispanics, and non-Hispanic whites over a 30-yr period. RESEARCH DESIGN AND METHODS— Death certificates were used to identify diabetes as an underlying cause of death by ethnic group in New Mexico during each 5-yr period from 1958 through 1987. The age-adjusted rates were calculated by ethnic group and sex, and temporal trends were examined. Comparison was made to U.S. white age-adjusted rates during the same time period. RESULTS— Age-adjusted diabetes mortality rates for American Indians and Hispanics increased throughout the 30-yr period, and far exceeded rates for New Mexico non-Hispanic whites and U.S. whites by the 1983–1987 time period. The rates increased most dramatically among the states American Indians, increasing 550% among women and 249% among men. Hispanic women and men experienced increases of 112 and 140%, respectively. CONCLUSIONS–New Mexicos American Indian and Hispanic populations have higher diabetes mortality rates than non-Hispanic whites, and American Indian mortality rates have risen dramatically over the 30-yr period included in our study. Although the high prevalence of diabetes in American Indians and Hispanics is a major contributor to these rates, other factors may also influence the reported mortality rates.

Native American Diabetes Project: Designing Culturally Relevant Education Materials

From the Veterans Affairs Medical Center (Dr Carter), University of New Mexico School of Medicine Department of Medicine (Dr Carter and Mss Gilliland and Perez) and Department of Pediatrics (Mss Levin and Cunningham-Sabo and Dr Davis), and the Diabetes Headquarters Office, Indian Health Service (Mss Broussard and Valdez), Albuquerque, New Mexico. This study was supported by the Veterans Administration; a grant from the National Institutes of Diabetes, Digestive, and Kidney Diseases, Grant No. DK 47096; and Dedicated Health Research Funds of the University of New Mexico School of Medicine. Correspondence to Janette S. Carter, MD, Surge Building, Room 251, University of New Mexico School of Medicine, Albuquerque NM 87131. Reprint requests to The Diabetes Educator, 367 West Chicago Avenue, Chicago, IL 60610-3025. In minority communities where diabetes is a major health problem, diet and exercise behaviors have cultural intlu-

Temporal Trends in Diabetes Mortality among American Indians and Hispanics in New Mexico: Birth Cohort and Period Effects

Rates of diabetes mortality are disproportionately high among ethnic minorities in the United States. To describe ethnic trends and cohort effects in diabetes mortality in New Mexico, the authors examined the trends in mortality rates for non-Hispanic whites. Hispanics, and American Indians in the state during the period 1958-1994. Age-specific rates were examined graphically to qualitatively describe the contribution of calendar period and birth cohort effects to changes in the rates. The authors also fit age-period-cohort models to these data. Age-adjusted diabetes mortality rates for American Indians and Hispanics surpassed rates for non-Hispanic whites for all but the earliest two time periods. In the 1993-1994 period, the age-adjusted mortality rate for American Indians was 3.8 times higher for men and 5.6 times higher for women than for their non-Hispanic white counterparts. Rates for American Indian men and women increased sharply over the 37-year period, by 565% and 1,105%, respectively. Mortality rates increased among Hispanics over the period of study but less rapidly than did rates among American Indians. Graphical analyses of age-specific rates were consistent with birth cohort effects among both American Indians and Hispanics and also with a period effect among American Indians. Results from age-period-cohort models indicate a birth cohort effect starting with the 1912 cohort in American Indians and the 1902 cohort in Hispanics. A period effect was present during the 1960s in American Indians. American Indians have experienced an epidemic rise in diabetes mortality in New Mexico; if current trends continue, diabetes may become the leading cause of mortality among American Indians in the state.

Communicating through stories: experience of the Native American Diabetes Project.

Stories appear to provide an indirect way of confronting the inherent conflict between the concepts of disease and wellness and assisting in the transition to a new concept of living well with the disease. This new concept may engender feelings of acceptance and hope that can facilitate application of knowledge and behavior change. In addition, culturally appropriate stories allow people to draw from their own personal beliefs and values to interpret and apply new information to their own lives. A good story takes listeners on a collective journey with many paths; each path is uniquely suited to the needs of the individual, with wisdom gained that is uniquely suited to their own life.

Adaptation of the Dartmouth COOP Charts for Use Among American Indian People With Diabetes

OBJECTIVE To adapt the Dartmouth COOP Charts for use among American Indians with diabetes and to evaluate the operating characteristics of the adapted charts because measures of health status have not been evaluated for use among American Indians with diabetes. RESEARCH DESIGN AND METHODS American Indian adults participated in focus group conferences to adapt and review the Dartmouth COOP Charts for use in American Indian communities. American Indian participants with diabetes were interviewed and administered the adapted charts. The operating characteristics of the charts were evaluated by measuring internal and external consistency, reliability, and acceptability. RESULTS Some of the wording and pictures were considered to be offensive and culturally inappropriate in American Indian communities. The adapted charts showed internal consistency in a comparison of interchart variables. CONCLUSIONS The adapted Dartmouth COOP Charts are more culturally acceptable than the original charts and appear to measure constructs adequately.