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RESEARCH AND PRACTICE
Racial and Ethnic Approaches to Community Health REACH Detroit Partnership: Improving Diabetes-Related Outcomes Among African American and Latino Adults
| Jacqueline Two Feathers, MPH, PhD, Edith C Kieffer, PhD, Gloria Palmisano, MA, Mike Anderson, Brandy Sinco, MS, Nancy Janz, PhD,
Michele Heisler, MD, Mike Spencer, MSW, PhD, Ricardo Guzman, MPH, MSW, Janice Thompson, PhD, Kimberlydawn Wisdom, MD, MS, and Sherman A James, PhD
Although the overall health of the US population has improved over the last 2 decades, striking disparities continue in the burden of illness and death experienced by African Americans, Latinos, Native Americans/Alaska Natives, Asians, and Pacific Islanders1 Diabetes, in particular, presents a significant public health burden in terms of increased morbidity, mortality, and economic costs2,3 African Americans and Latinos experience a 50 to 100 higher burden of illness and mortality because of diabetes compared to White Americans46 The prevalence of blindness owing to diabetes is twice as high among African Americans as among Whites2 The incidence of kidney disease is 6 times higher in Native Americans, 4 to 6 times higher in Mexican
Americans, and 4 times higher in African Americans than in Whites7 African Americans with diabetes have a higher rate of lower-extremity amputations,7 and peripheral vascular disease is 80 more common in Mexican Americans than in non-Hispanic Whites with diabetes2 Two landmark clinical trials have demonstrated that tight control of blood glucose can greatly reduce the risk of diabetes complications Dietary and physical activity changes are among the principal strategies recommended for controlling blood glucose among individuals with type 2 diabetes2,8,9 A continuing question is how best to assist people in making the lifestyle changes necessary for optimal metabolic control Diabetes self-management education interventions hold the promise of improving metabolic control and promoting protective lifestyle behaviors that can reduce the risk of diabetes complications and improve quality of life8,10,11 Al-
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 diabetesspecific 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 Am J Public Health 2005;95:15521560
doi:102105/AJPH 2005066134 though diabetes education interventions have generally yielded positive results, few African Americans and Latinos have been included in these studies Even fewer studies have evaluated culturally appropriate, community health workerled interventions that may be more acceptable and costeffective than interventions led by health care professionals8,12,13 Racial and Ethnic Approaches to Community Health REACH 2010 is the Centers for Disease Control and Preventions CDCs effort to eliminate racial and ethnic disparities in 6 priority health areas, including diabetes14 The REACH Detroit partnership has used a community-based participatory approach at multiple levels to reduce risk factors for type 2 diabetes and its complications among African Americans and Latinos residing in low-resource neighborhoods of east and southwest Detroit We assessed whether the REACH Detroit community-based diabetes lifestyle intervention delivered by trained community residents to African Americans and Latinos with type 2 diabetes resulted in significant diabetes-related knowledge and behavioral changes and glycemic control
METHODS
Participants and Setting
REACH Detroit
participants were recruited through 2 hospitals with specialty clinics and 1 community-based health center Henry
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Ford, St John Riverview, and Community Health and Social Services [CHASS], respectively Participating physicians gave consent for REACH Detroit staff to contact a list of patients with diabetes identified through administrative data systems as living in the 3 target neighborhoods Participating physicians also agreed to provide clinical measures for patients who consented to participate in the REACH Detroit program All Latino adults were recruited from CHASS, and African American adults were recruited from all 3 sites From March to June 2002, 10 African American and Latino community residents who had completed a 10-week Family Health Advocate FHA training program, invited potential participants by mail and telephone to participate in the diabetes lifestyle intervention African American and Latino men and women were eligible if they had physician-diagnosed type 2 diabetes, were older than 18 years of age, had
insurance or received care from a federally qualified health center, were mentally able, and resided in 1 of the 6 REACH Detroit zip code areas Of the 600 patients identified, 300 met the eligibility criteria, and 151 agreed to participate, gave written informed consent, and completed a baseline survey administered in their home by an FHA Refusals most frequently cited no time or not interested as reasons for nonparticipation The study protocol was approved by the institutional review boards of the participating health systems and the University of Michigan
REACH Detroit participants were compared to A1C values abstracted from the medical charts of a random sample of insured nonREACH Detroit African American and Latino patients with type 2 diabetes receiving care in the same health care systems during the same period of time Age, gender, and ethnicity data also were abstracted
Intervention
Results from the focus group conducted with community residents during the REACH Detroit planning phase guided the content, format, and method of delivery of the diabetes lifestyle intervention15 A curriculum intervention, originally designed and evaluated for Native Americans, was adapted for
the REACH Detroit participants16 The FHAs and steering committee members contributed local and cultural knowledge during adaptation The curricula, The Journey to Health for African American participants and El Camino a la Salud for Latino participants, were designed to reduce risk factors associated with diabetes complications by increasing participants diabetes self-management understanding, self-efficacy, and autonomous motivation Building on culturally relevant knowledge and activities, the program sought to help participants gain knowledge and skills related to healthy eating, physical activity, and stress reduction through 5 2-hour group meetings delivered every 4 weeks by 10 FHAs in 2 community locations from June to October 2002 The FHAs were trained by research staff and experts in patient empowerment approaches17 to deliver the curriculum intervention Research staff observed 1 intervention meeting for each FHA to document fidelity to the curriculum, questions asked by participants, and general satisfaction Intervention classes were delivered in English and Spanish Participants were encouraged to bring a family member or friend The first meeting provided an overview of
diabetes; the relationship between diabetes, stress, and depression; and methods for stress reduction Subsequent meetings focused on increasing physical activity, encouraging consumption of fruits and vegetables, and encouraging decreased dietary fat and sugar intake, respectively The final meeting discussed maintenance of behavioral changes with so-
cial support as a key strategy Current recommendations from the American Diabetes Association and the CDC guided dietary and physical activity content of the intervention18,19 Social cognitive theory constructs20 were combined with selected cultural symbols and themes, cultural patterns and concepts, values, norms, and relationships to promote healthy eating, exercise, and stressreducing activities
Intervention Outcome Measures
A survey was administered to participants at baseline and postintervention to evaluate knowledge and behaviors related to diet, physical activity, diabetes self-care activities, and diabetes-specific quality of life Pre- and postintervention A1C values and other clinical measures were abstracted from participants medical charts within 1 month preceding and 1 month following the intervention The specific
measures were developed on the basis of the problems identified in the community focus groups as well as the theoretical underpinnings of the study15,21 Knowledge questions assessed participants understanding of the relationship between diet, exercise, and blood sugar control Dietand physical activityrelated questions were derived from the Behavioral Risk Factor Surveillance Survey BRFSS to facilitate comparison of REACH Detroit results with those of other REACH sites, as well as those of the local, state, and national BRFSS Diet-related questions from the BRFSS were asked to assess fruit and vegetable consumption Participants were asked the number of servings of fruits and vegetables they ate per day and per week Similarly framed questions were asked for consumption of fried and sweet foods, whole grains, and regular soda or fruit-flavored beverages Participants were also asked if they poured the fat off of meat after cooking it Quantity of food consumed was not assessed in this study The frequency of following a healthy eating plan and self-monitoring blood glucose were assessed through items from the Summary of Diabetes Self-Care Activities questionnaire22 To measure
diabetes-specific quality of life, we administered the revised Problem Areas in Diabetes23 scale A1C, blood pressure, total cholesterol, low-density
Design
The intervention was planned and implemented with guidance from the REACH Detroit steering committee, which is composed of community health leaders, clinical providers, researchers, and REACH Detroit staff Because of the legacy of distrust in the community about research, at the interventions inception, the committee recommended a nonrandomized study The effectiveness of the intervention was examined primarily through a nonrandomized, 1-group, before and after design Baseline and postintervention A1C values a measure of blood sugar control during the previous 3 months of
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lipoprotein, high-density lipoprotein, triglycerides, weight, height, duration of diabetes, and medications, collected by participants healthcare providers during baseline and postintervention clinic visits, were abstracted from participants medical records before and after intervention
cal software
package SPSS version 12 SPSS Inc, Chicago, Ill24
RESULTS
Participant Retention and Baseline Characteristics
Of the 151 baseline participants, 111 74 completed a postintervention survey, of which 91 had postintervention clinical measures 60 Therefore, all knowledge and behavior change analyses were based on the 111 participants with pre- and postintervention surveys To evaluate the effect of participation on the intervention on clinical measures, all analyses of clinical measures were based on the 91 participants with pre- and postintervention survey and clinical measures There were no significant differences in demographic characteristics, reported baseline knowledge, behaviors, or A1C between participants who completed a baseline survey n 151 compared to participants with n 111 and without n 40 postintervention data, except for the number of intervention classes attended Eighty-three percent of participants without postintervention data attended no classes; the mean for the group was 053 classes compared with 398 classes for participants with postintervention data P 001 Of 111 REACH Detroit participants, 64 were African American and 36 were Latino Table 1 The average age of
participants was 59 years, with African American participants significantly older than Latino participants Almost 80 of participants were female Latino participants were significantly more likely to have less education and to be uninsured than African American participants The mean A1C for all REACH Detroit participants at baseline was 84 There was no significant difference in mean baseline A1C owing to ethnicity There were, however, significantly more African American participants who were in the 7 or less A1C category compared with Latino participants Finally, African American participants had a significantly higher body mass index compared with Latino participants There were no other significant clinical or medication differences between African American and Latino participants There were also no significant differ-
Statistical Analyses
Summary statistics, including frequency distributions, means, and other descriptive analyses of variables, were calculated to provide an overview of the characteristics of REACH Detroit participants and the comparison group One-way analysis of variance ANOVA and 2 tests were used to test differences from baseline as well as differences between
groups among REACH Detroit racial/ethnic groups To test for pre- and postintervention changes, continuous variables were evaluated with the Wilcoxon signed-rank test For dichotomous outcomes, the McNemar test of symmetry was used to test the difference between proportions in the paired variables Independentsample Student t tests were used to assess differences between A1C for the comparison group and REACH Detroit participants at baseline and postintervention Multivariate procedures were used to identify predictors of outcomes that were shown to have significant pre- and postintervention changes during the previous analyses Predictors included were those with conceptual relevance and significant statistical association with at least 1 of the outcomes during the prior analyses Age, gender, ethnicity, and baseline scores on the dependent variable were entered into the regression models as covariates For A1C, additional covariates of health care system, duration of diabetes, and medication were included Outliers, multicollinearity, and the effect of interaction terms on the outcomes of interest also were investigated Because no participants formally withdrew from the REACH Detroit
program, 2 and 1-way ANOVA statistics were used to compare characteristics of participants with and without postintervention data For analyses, participants were grouped into 2 age categories, 18 to 59 and 60 years and older, with approximately equal numbers in both groups All analyses were conducted with the statisti-
ences in baseline knowledge, behaviors, or A1C between participants who had taken a diabetes course previously and those who had not In the baseline comparison of REACH Detroit participants and the health system comparison group, there were significant differences in ethnic and gender composition P 006 but not age Latino representation was smaller P 0001, and male representation was higher in the comparison group compared to REACH Detroit participants P 013 Baseline A1C values from the REACH Detroit participants and those from the comparison group were not significantly different P 751
Class Attendance
Of the 111 REACH Detroit participants with postintervention survey data, 98 attended at least 1 intervention meeting, and 41 attended all 5 intervention meetings Attendance at each meeting ranged from 60 to 87
Changes in Knowledge
After intervention, a
significant number of participants had a better understanding of the relationship between healthy eating and blood sugar control than at baseline P 013 Table 2 Females and participants who were aged 18 and to 59 years improved the most compared to other REACH Detroit subgroups Participants, overall, also improved significantly in their knowledge that exercise could improve blood sugar P 035
Behavioral Changes
Dietary behaviors improved after intervention for REACH Detroit participants, including a significant increase in mean vegetable consumption P 001 and in the numbers of participants who reported pouring fat off of meats after cooking fatty foods P 0001 Table 2 Women, African Americans, and participants aged 18 to 59 years improved the most compared to other REACH Detroit subgroups Table 3 There was also a significant increase in participants reporting eating whole grain bread P 004, particularly among women, African Americans, and both age groups All REACH Detroit subgroups reported a significant decrease in consumption of regular soda or fruit-flavored beverages
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TABLE 1–Baseline Characteristics of Racial and Ethnic Approaches to Community Health REACH Detroit Participants
Total African Americans Latinos
No Age,a mean years SD 1859, n 60, n Gender Female, n Language,a n English Spanish Community,a n East Side Southwest Education,a n Less than high school High school graduate Attended college Insurancea Yes, n Duration of diabetes, y Mean SD Range Previous diabetes class Yes, n Hemoglobin A1C Baseline,a mean SD 7, n 7, n Weight, lbs,a mean SD Overall Females Males Body mass index, n Normal 185249 Overweight 250299 Obese 30 Blood pressure, mean SD Systolic Diastolic Medications, n Insulin Oral Hypertension 26 missing
a
Sociodemographic Characteristics 111 71 640 585 145 609 139 58 523 34 479 53 477 37 521 88 790 76 650 34 290 59 530 52 470 48 430 22 200 26 230 86 760 12 98 139 54 490 Clinical Characteristics 84 23 26 286 65 714 2071 528 2058 483 2128 706 6 70 18 190 67 740 1373 198 783 90 38 420 69 760 51 560 55 775 71 1000 0 57 803 14 197 16 225 18 254 24 338 65 915 136 100 234 32 450
40 360 543 149 24 600 16 400 33 825 5 125 34 850 2 50 38 950 32 800 4 100 2 50 21
525 97 91 139 22 550
P 0001 The number of days participants reported following a healthy eating plan increased significantly P 004, particularly among women and participants who were aged 18 to 59 years All REACH Detroit participants improved significantly in the number of days they monitored their blood sugar as often as their doctor recommended P 0001 No significant changes were observed in other dietary behaviors, such as fried and sweet food consumption There was also no significant change observed in level of physical activity or diabetes-specific quality of life
Change in A1C
REACH Detroit participants experienced a significant improvement in A1C values P 0001 in contrast to the health system comparison group P 160 Table 2 A significant number of REACH Detroit participants moved out of the 7 or higher category and into the 7 or lower category P 035 Changes for African American and Latino adults were also assessed separately because of the underrepresentation of Latino adults in the comparison group The separate changes for REACH Detroit African Americans and Latinos were each statistically significant P 0001 and P 001, respectively Table 3 Other clinical measures of
cholesterol, blood pressure, and weight did not change significantly from baseline
82 25 21 389 33 611 2251 558 2239 479 2299 827 2 30 8 110 44 620 1406 180 793 89 25 470 38 700 28 519
86 20 5 135 32 865 1808 344 1806 367 1813 212 4 100 10 250 23 580 1329 214 771 93 13 350 31 840 23 622
Predictors of Outcomes
Table 4 shows the multivariate logistic and linear regression models for selected behavioral outcomes and A1C level for REACH Detroit participants adjusting for baseline values Latino participants were 84 more likely than African American participants to understand the relationship between healthy eating and blood sugar control This understanding was 4 times more likely among participants who attended class 3 Eat more fiber, fruits, and vegetables compared with those that did not Similarly, Latino adults were 89 more likely to follow a healthy eating plan than African American adults Additionally, participants who understood the relationship between healthy eating and blood sugar control were 4 times more likely to follow a healthy eating plan compared to participants who
Significantly different between African American and Latino participants P 05; P 01; P 001; P
values obtained with 2 test for education and body mass index; analysis of variance for age, duration, A1C, weight, and systolic and diastolic blood pressure; and with the Fisher exact test for gender, language, community, insurance, previous diabetes class, and medication
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TABLE 2–Pre- and Postintervention Changes in Knowledge, Behaviors, Quality of Life n 111, and A1C n 91 for Racial and Ethnic Approaches to Community Health REACH Detroit Participants
Outcome Preintervention Knowledge Dietary knowledge, n Not at all/somewhat Well/very well Exercise knowledge, n Agree Dont Know Vegetable consumption, mean SD Pour fat off meat, n Yes No Whole grain bread, n 01/wk 24/wk 57/wk Beverages times/week, n 01 27 Fruit consumption, mean SD Five per day, n Yes No Sweet foods times/week, n 01 27 Fried foods times/week, n 01 27 Physical activity, n None Some Meets recommendations Healthy eating plan days, n 01 23 46 7 Test blood sugar days, n 01 23 46 7 Quality of Life PAID-2 mean SD 26 300 62 700 96 880 13 120 Behavioral
Changes 202 131 67 604 24 216 35 315 24 216 50 450 43 390 67 610 190 14 28 250 83 750 59 530 49 440 68 610 40 360 34 310 37 330 39 350 20 180 26 240 28 250 36 330 30 270 22 200 9 80 49 450 Quality of Life 185 168 13 150 75 850 84 955 4 45 250 131 100 973 8 72 27 243 47 423 36 324 84 850 15 150 192 13 36 320 75 680 69 620 38 340 77 690 30 270 27 240 41 370 41 370 5 50 18 170 33 310 52 480 9 80 12 110 20 180 69 630 204 176 Postintervention Pa
013
035 001
0001
004
0001 880
did not Dietary knowledge was also a predictor of increased vegetable consumption Although many studies have found that knowledge of diabetes self-management does not necessarily translate into behavioral change,35 results indicated that dietary knowledge was a predictor of dietary behavior Statistically significant improvements in pre- and postglycemic control were associated with gender, self-monitoring blood glucose, and postintervention quality-of-life score Male participants had larger improvements in A1C than did female participants Participants who reported monitoring between 4 and 7 days during the preceding 7 days had a significant improvement in A1C compared to participants who reported monitoring on
only 0 to 3 days during the preceding 7 days Better postintervention quality-of-life scores were also associated with improved A1C Postintervention changes for all dependent variables were significantly related to their respective baseline levels Improving dietary knowledge and following a healthy eating plan were not predictors of the change in A1C
DISCUSSION
280
126
200
327
004
0001 088 Continued
These findings suggest that a culturally tailored, community-based healthy lifestyle intervention delivered by community residents over 5 sessions can significantly improve glycemic control and reduce risk factors associated with diabetes complications There were significant improvements in some areas of diabetes self-care knowledge and dietary behaviors, and participants had a statistically significant improvement in A1C 08 reduction A health system comparison group that did not receive the intervention did not e 
xperience a significant change in A1C over the same period The REACH Detroit findings are consistent with prior studies showing the efficacy of diabetes lifestyle interventions in improving knowledge, behaviors, and glycemic control10,16,2534 The REACH Detroit study was
unique in that 1 intervention materials were adapted for both African Americans and Latinos from a previously evaluated program for Native Americans; 2 trained community residents rather than health professionals delivered the program; and 3 urban African
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TABLE 2–Continued
Clinical Outcomes Hemoglobin A1C REACH DETROIT n 91, mean SD 7, n 7, n Comparison Group n 98, mean SD 84 23 26 286 65 714 84 20 76 19 35 385 56 615 86 20 0001 035 160
Note Actual questions were Dietary knowledge: How well do you understand the relationship between healthy eating and blood sugar control?; Exercise knowledge: Exercise helps to improve your blood sugar; Pour fat off meat: When you prepare foods or meals, do you pour the fat off meat after cooking?; Whole grain bread: How often do you eat whole grain bread?; Beverages: How many times per week do you drink regular soda and/or fruit-flavored drinks?; 5 per Day: 5 servings of fruit and vegetables per day?; Physical activity: None no physical activity; Some some moderate or vigorous
activity but not ideal; Meets recommendations 57 days of moderate exercise for at least 30 minutes, or 37 days vigorous for 20 minutes or longer; Healthy eating plan: On how many of the last 7 days did you follow a healthy eating plan?; Test blood sugar: On how many of the last 7 days did you test your blood sugar at least as often as your doctor has recommended? a P values obtained using the McNemar test for dichotomous variables and Wilcoxon signed-rank test for continuous variables
Americans and Latinos with significant impediments to healthy lifestyles were included, and both groups benefited from aspects of the intervention in a number of ways and to varying degrees10,13 This study reinforces the belief that interventions using community health workers can result in improved knowledge and health practices3539 Improvements in outcomes may be due, in part, to the commitment and persistence of the FHAs, the cultural tailoring of the intervention materials for both African Americans and Latinos English- and Spanishspeaking, and the frequency and community location of the intervention classes Adaptation of intervention materials is especially salient as there is minimal
documentation as to whether interventions successful for one group can be replicated or adapted and be successful for another group4042 This may be the first study to demonstrate that an intervention developed for and tested with Native Americans can be adapted for and effective among African Americans and Latinos Although various diabetes self-care behaviors are relatively independent of one another,4346 dietary aspects of the regimen are the most difficult to maintain,4749 followed by exercise REACH Detroit participants made significant positive improvements in several dietary behaviors Postintervention data indicated modest, but not statistically significant, positive improvements in level of physical activity Two factors may have affected the lack of significant change in physi-
cal activity First, there was only 1 intervention class devoted to physical activity compared to 2 classes for diet regulation Second, the physical activity intervention class presented walking as an inexpensive, easy method for increasing physical activity In the REACH communities, and elsewhere, environmental conditions, such as crime and lack of sidewalks, facilities, and programs have been reported
as hindrances to physical activity15,25,28,50 REACH Detroit community-level intervention is working to ameliorate identified environmental factors This and other programs may need to incorporate a stronger or more structured focus on ways to make physical activity a part of an everyday routine in various environmental contexts Postintervention data also indicated modest, but not statistically significant, positive improvements in diabetes-specific quality of life The intervention period may not have been long enough for participants to experience changes in quality of life Also, baseline responses indicated few participants reported high emotional distress related to their diabetes
Strengths and Limitations
It is more difficult to draw conclusions about causality from nonexperimental designs that may be subject to selection bias51 Nonexperimental designs, if methodologically sound, may, however, reveal important information about the effectiveness of interventions52 Randomized controlled trials are not
always feasible, or even desirable, particularly when examining community educational interventions53 These limitations are modified somewhat by the significant positive changes in
A1C, an objective measure, and by comparison of A1C with a health system comparison group followed during the same time period Although this study demonstrated improved glycemic control among intervention participants, only 1 behavioral variable, frequency of self-monitoring blood glucose, significantly predicted this outcome in the multivariate regression analyses Other investigators have had difficulty linking changes in knowledge and behaviors targeted by the intervention to changes in A1C16,28 Other factors, both measured and unmeasured, may have influenced outcomes of this study Improvements in physiological outcomes, such as A1C, may not be parallel to reported changes in knowledge, diet, or physical activity Measurement of knowledge and behaviors were based on self-report and may under- or overestimate actual knowledge and behavior changes Future studies should include objective measures of dietary change and physical activity Additional measures could also include medication adherence and changes in medication during the intervention period A longer intervention period may also be required to observe change in some outcomes Many of the participants in this study had few
personal resources; this factor, along with limited literacy and knowledge of diabetes self-management and longstanding lifestyle habits, negatively impacts health Impediments, such as the low socioeconomic status of some residents in Detroit and the lack of necessary community resources, were only partially discussed by the study During the planning phase, participants reported difficulties with the cost and lack of availability of the foods that were recommended for improving dietary habits, such as fruits and vegetables Overcoming such environmental barriers is a crucial component to the design of effective interventions to enhance health behaviors in low-resource communities
Conclusions
We have demonstrated that an appropriately designed, community-based program
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TABLE 3–Significant Pre- and Postintervention Changes for Racial and Ethnic Approaches to Community Health REACH Detroit, by Gender, Race/Ethnicity, and Age
Males n 23 Outcomes Dietary knowledge Well/very well Not at all/somewhat Exercise knowledge Agree Dont
know Vegetable consumption, mean SD Pour fat off meat Yes No Whole-grain bread times/wk 01/wk 24/wk 57/wk Beverages times/wk 01 27 Follow a healthy eating plan days 01 23 46 7 Test blood sugar days 01 23 46 7 A1C Pre Post Females n 88 Pre Post AA n 71 Pre Post Latinos n 40 Pre Post 1859 Years n 58 Pre Post 60 Years n 53 Pre Post
18 783 5 217
19 826 4 174
55 647 68 782 30 353 19 218
44 620 27 380
49 700 21 300
29 784 38 950 8 216 2 50
36 632 21 368
48 842 9 158
37 725 39 736 14 275 14 264
22 957 17 100 1 43 0 223 157 266 184
74 860 67 944 62 886 12 140 4 56 8 113 197 124 246 114 21 14
64 941 34 872 20 100 4 59 5 128 0 27 14 19 12 21 10
51 879 47 100 45 882 37 902 7 121 0 6 118 4 98 19 14 26 13 22 13 24 13
11 786 3 214
20 952 1 48
56 727 80 920 21 273 7 80
40 678 19 322
62 912 6 88
27 844 38 950 5 156 2 50
39 736 14 264
54 964 2 36
28 737 46 885 10 263 6 115
9 391 3 130 11 478 10 435 13 565
7 304 10 435 6 261
26 302 20 230 21 244 37 425 39 45 30 345
17 246 14 203 38 551 21 300 49 700
10 143 31 443 29 414
18 450 17 425 10 250 16 400 12 300 7 175
23 404 15 263 19 333 20 345 38 655
13 228 26 456 18 316
12 231 14 264 9 173 21 396 31 596 18 34
17 895
33 379 67 838 2 105 54 621 13 163
45 763 22 550 39 975 14 237 18 450 1 25
44 830 23 442 40 870 9 170 29 558 6 130
3 130 6 261 5 217 9 391 5 217 5 217 5 217 8 348 78 23
1 45 4 182 4 182 13 591
17 195 4 47 20 230 14 163 23 264 29 337 27 310 39 453
13 183 18 254 17 239 23 324 17 243 14 200 5 71 34 486 82 25
5 72 16 232 17 246 31 449 8 114 9 129 13 186 40 571
7 179 0 8 205 2 50 11 282 16 410 13 333 21 538
13 224 17 293 13 224 15 259
3 54 7 135 2 38 10 179 9 173 8 154 13 232 15 288 20 385 30 536 21 404 22 423 6 103 7 121 9 155 36 621 14 269 3 58 8 154 5 96 3 58 11 212 27 519 33 635 70 11
1 43 25 287 8 92 1 43 17 195 11 126 5 217 4 46 15 172 16 696 41 471 53 609 68 13 85 23 79 20
13 325 1 25 16 276 8 200 3 75 14 241 4 100 7 175 6 103 15 375 29 725 22 379 79 15 89 26
75 22 86 20
82 24 78 18
Note Actual questions were Dietary knowledge: How well do you understand the relationship between healthy eating and blood sugar control?; Exercise knowledge: Exercise helps to improve your blood sugar; Pour fat off meat: When you prepare foods or meals, do you pour the fat off meat after cooking?; Whole grain bread: How often do you eat whole grain bread?; Beverages: How many times per
week do you drink regular soda and/or fruit-flavored drinks?; Follow healthy eating plan: On how many of the last 7 days did you follow a healthy eating plan?; Test blood sugar: On how many of the last 7 days did you test your blood sugar at least as often as your doctor has recommended? P 005 P 001, P 0001
requiring little technology and few health care resources can have positive effects, such as improving knowledge, health behaviors, and glycemic control among urban African Americans and Latinos with type 2 diabetes If the significant improvement in A1C among REACH Detroit participants can be sustained, the Journey to Health and El Camino a la Salud interventions have the potential to substantially reduce microvascular complica-
tions, morbidity, and health care utilization costs5456 Future research efforts should be aimed at confirming, enhancing, and sustaining the effect of this type of intervention among populations in which health disparities exist Risk factors for preventing or delaying the onset of diabetes complications are complex and interdependent To attend to this complexity, the REACH Detroit inter-
vention combined community-based lifestyle education, social
support, and behavior change approaches Meta-analyses indicate that a combination of these approaches is associated with better outcomes compared with any single approach57 Diabetes self-care is influenced on multiple levels Further research is needed to investigate how best to design and implement multilevel, culturally tailored, community-based
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TABLE 4–Multivariate Logistic and Linear Regression Models for Selected Behavioral Outcomes and A1C for Racial and Ethnic Approaches to Community Health REACH Detroit Participants
Dietary Knowledge n 107 OR 95 CI Baseline response Age Gender Male Female Race/Ethnicity African American Latino Class 3 attendance Dietary knowledge Monitoring blood glucose 03 days/wk 47 days/wk PI QOL 437 119, 1282 976 94, 101 110 275, 436 Referent 162 034, 769 Referent 417 136, 127 Healthy Eating Plan n 106 OR 95 CI 348 115, 106 963 922, 101 962 251, 368 Referent 107 019, 594 Referent 107 189, 610 420 126, 141 Vegetable Servings/Day N 95 ß 584 095 028 Hemoglobin A1C n 90 ß 691 059
187
Acknowledgments
This study was supported by the Centers for Disease Control and Prevention grant U50/CCU51726401 We thank all of the family health advocates and participants for taking part in the REACH Detroit program We also thank Robert Anderson and Ken Resnicow for reviewing earlier drafts of this article
Human Participant Protection
The study protocol was approved by the institutional review boards of the participating health systems and the University of Michigan
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type of diabetes N Engl J Med 1989;321:10741079 6 Pugh J, Stern M, Haffner S, Eifler C, Zapata M Excess incidence of treatment of end-stage renal disease in Mexican Americans Am J Epidemiol 1988; 127:135144 7 Centers for Disease Control and Prevention National Diabetes Fact Sheet Atlanta, Ga: Centers for Disease Control and Prevention, Division of Diabetes Translation; April 2002 8 Clement S Diabetes self-management education Diabetes Care 1995;18:12041214 9 Nelson K, Reiber G, Boyko E Diet and exercise among adults with type 2 diabetes Diabetes Care 2002;25:17221728 10 Brown S Meta-analysis of diabetes patient education research: variations in intervention effects across subjects Res Nurs Health 1992;15:409419 11 Norris S, Engelgau M, Narayan V Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials Diabetes Care 2001;24:561587 12 Brown S Effects of educational interventions in diabetes care: A meta-analysis of findings Nurs Res 1988;37:223230 13 Norris S, Lau J, Smith S, Schmid C, Engelgau M Self-management education for adults with type 2 diabetes Diabetes Care 2002;25:11591171 14 Centers for Disease Control and
Prevention Racial and Ethnic Approaches to Community Health Atlanta, Ga: Centers for Disease Control and Prevention; 1999 15 Kieffer EC, Willis SK, Odoms-Young AM, Guzman JR, Allen AJ, Two Feathers J, Loveluck J Reducing disparities in diabetes among African American and Latino
Note OR odds ratio; CI confidence interval; ß standardized regression coefficient; PI QOL postintervention quality-of-life score Dietary knowledge participants understanding of the relationship between healthy eating and blood sugar control; healthy eating plan frequency with which the participant followed a healthy eating plan during the last 7 days; class 3 attendance eat more fiber, fruits, and vegetables; monitoring blood glucose frequency with which the participant monitored during the past 7 days as often as their doctor recommended A1C is the log-transformed pre- and postintervention change value; A1C model adjusted for all variables listed as well as for duration of diabetes, medication, and health care system P 05; P 01; P 001
behavior change interventions in greater depth We must determine what elements of interventions are most effective eg, skills training, problem solving, cognitive
techniques, for what outcomes, and in what context58 We need to continue to develop our understanding of the critical components of successful interventions that encourage and sustain healthy lifestyle behaviors among populations at high risk for diabetes and its complications
cine, University of Michigan Mike Spencer is with the School of Social Work, University of Michigan Ricardo Guzman, Gloria Palmisano, and Mike Anderson were with Community Health and Social Services, Detroit, Mich Janice Thompson is at the Office of Native American Diabetes Programs, University of New Mexico, Albuquerque At the time of the study, Kimberlydawn Wisdom was with the Henry Ford Health System, Detroit Requests for reprints should be sent to Jacqueline Two Feathers, 2723 Sierra Drive NE, Albuquerque, NM, 87110 e-mail: jtwofea@umichedu This article was accepted April 26, 2005
Contributors About the Authors
Jacqueline Two Feathers and Nancy Janz are with the Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor At the time of the study, Edith Kieffer, Brandy Sinco, and Sherman James were with the School of Public Health, University of
Michigan, Ann Arbor Edith Kieffer and Brandy Sinco were also with the School of Social Work, University of Michigan Sherman James was also with Duke University, Durham, NC Michele Heisler is with the Veterans Administration Ann Arbor Health System and the Department of Internal MediJ Two Feathers led the design and implementation of the study, led the writing of the article, and conducted the statistical analysis E Kieffer contributed to the study design and implementation R Guzman, G Palmisano, and M Anderson assisted with study design and interpretation B Sinco assisted with data management and statistical analysis M Spencer and J Thompson assisted with statistical analysis and helped conceptualize ideas N Janz, M Heisler, K Wisdom, and S James helped conceptualize ideas and reviewed drafts of the article All authors helped to conceptualize ideas, interpret findings, and review drafts of the article
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