- Diabetes Treatments

The Diabetes Educator
http://tdesagepubcom Sir Insulin Monk Versus the Evil Diana Betes: A Program Addressing Type 2 Diabetes Education and Prevention in Youth
Jeanne Fenn, Cecilia Rosales and Claire Logue The Diabetes Educator 2007; 33; 455 DOI: 101177/0145721707301910 The online version of this article can be found at: http://tdesagepubcom/cgi/content/abstract/33/3/455

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American Association of Diabetes Educators

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Program Addressing Type 2 Diabetes Education
and Prevention in Youth
455

Sir Insulin Monk Versus the Evil Diana Betes
A Program Addressing Type 2 Diabetes Education and Prevention in Youth

Abstract
The purpose of this article is to share an innovative method of integrating community resources into a program designed to deliver age-appropriate and culturally appropriate diabetes education to youth The educational program involves an interactive dialogue that engages school-aged children in an active process of learning about diabetes School or community-based settings provide the best venue for presenting information to youth on diabetes In addition, peer education is an excellent method of creating interest among youth Many adults have received diabetes education simply by observing the program This program has become an appealing and interactive method of delivering type 2 diabetes prevention information to children of all ages
Jeanne Fenn, MEd, RN, BC, CDE Cecilia Rosales, MD, MS

tool chest

Claire Logue
From University Medical Center, Tucson, Arizona Ms Fenn; Mel and Enid Zuckerman College of Public Health, Division of Community, Environment, and Policy, University of Arizona, Tucson Dr Rosales; and the Sahuaro Girl
Scout Council, Inc, Tucson, Arizona Ms Logue

Correspondence to Jeanne Fenn, MEd, RN, BC, CDE, University Medical Center, PO Box 245116, Tucson, AZ 85724 jfenn@umcazedu

D
Fenn et al

iabetes is a family affair Not only is diabetes an epidemic in the adult population, it is also rapidly becoming a significant problem in youth1 Once considered a disease among adults, type 2 diabetes is now being diagnosed in patients as young as 9 years of age The rise in type 2 diabetes in youth has been shown to correlate with the rise in obesity in children2 The time has come to address prevention of type 2 diabetes in youth This article discusses an innovative method of integrating community resources into a program designed to deliver age- and culturally appropriate diabetes education to youth This educational program involves an interactive dialogue that engages school-aged children in an active process of

Acknowledgment: Funding to support this project and the development of the took kit was solicited and awarded through the Arizona Department of Health Services through a mini grant program established with resources received from the US Mexico Border Health Commission Commission funding for
these projects was required to address 1 or more of the Healthy Gente/Healthy Border 2010 objectives For a copy of the transcript and/or Train-the-Trainer: Dont Monkey Around With Diabetes tool kit, please contact Jeanne Fenn at 520 694-2475 or e-mail at jfenn@umcazedu

DOI: 101177/0145721707301910

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learning about diabetes During the development and implementation of the educational program, a number of questions were raised What approach best addresses the topic of diabetes in a school-aged population? What approach to delivering content associated with diabetes would have the greatest impact? How effective is youth theater in modeling healthful behavior? Implementation of the program has introduced a new model for engaging youth, families, and the community in prevention of type 2 diabetes According to the American Diabetes Association, 85 of children with type 2 diabetes are overweight or obese at diagnosis and present with
glycosuria, absent or mild polyuria, and polydipsia with little or no weight loss About 15 of children aged 6 to 19 years of age are seriously overweight, representing nearly 9 million American children3 Obesity and type 2 diabetes have become significant health care issues for children of all ages

Use of Community Resources
The Tucson-based Girl Scout program is a local grassroots organization that was approached in developing awareness of type 2 diabetes in youth A group of middle schoolaged Girl Scouts wanted to provide a community service as part of obtaining their Silver Award4 The Silver Award is the highest award an 11- to 14-year-old Cadette Girl Scout can achieve and requires a leadership and community service project that helps improve the lives of others Selecting diabetes as the topic for their community service project was not a difficult choice for these young girls Upon reflecting on their own lives, each member realized that a parent, grandparent, sibling, or friend was affected by diabetes Through guidance from their troop leaders and mentor, the group reviewed the local, national, and global data on diabetes The following questions were asked: Who is providing
educational services to this age group? What is the best approach to address the issue of diabetes? and How can we best engage the age group of 11- to 14-year-olds to increase their awareness and knowledge of diabetes? Moreover, as residents of a border state, it was likewise important to consider the unique needs of Mexican Americans The United StatesMexico border region is a rich, multicultural, multilingual area with many isolated rural communities including several sovereign tribal nations Three of the 5 members of the troop are Mexican American and have an understanding of how diabetes affects the Hispanic population

While many accept the importance of a culture match between learner and educator, an in-depth look at the literature on prevention education programs targeting youth indicated that there is a dearth of peer-led or youthdriven education and awareness programs related to type 2 diabetes and its risk factors In fact, most diabetes prevention literature is aimed at the adult population It is important to note that there are very few prevention programs that cater to the special needs of children in promoting healthy lifestyles and behaviors, especially along the
border region There are several programs identified in the literature when using keywords and phrases such as peer-led, youth prevention programs, youth-driven diabetes programs, and diabetes education using theater Youth Zone from the American Diabetes Association focuses on topics in diabetes as they relate to children and teens5,6 Get Kids in Action and VERB are examples of programs accessible via the Internet that focus on obesity prevention in youth7,8 There are peer-led educational programs that focus on teen issues such as sexually transmitted diseases, unwanted pregnancy, weight reduction, and healthy lifestyles9-11 The authors attempted to identify whether the diabetes prevention program developed by the Tucson Sahuaro Girl Scout Council Troop 509 was being used by other Girl Scout troops in other parts of the country None of the programs identified in the literature had a strong peer or cultural component, and none available used peer educators for developing type 2 diabetes messages

Methods
The Tucson Sahuaro Girl Scout Council Troop 509 decided on the best approach for teaching young children not yet affected but at risk for developing diabetes Their overarching goal
was to educate children not yet affected with type 2 diabetes who in turn would take these messages home to engage their families with discussions on type 2 diabetes This young troop set out to create an interactive program that would reach out to the children residing in the areas along the United StatesMexico border and also within the Native American nations of the Tohono Oodham, Pascua Yaqui, San Carlos Apache, and Pima Indians Their mission was to develop awareness and increase the knowledge base of all school-aged children about the chronic and disabling effects of type 2 diabetes

Volume 33, Number 3, May/June 2007
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Teaching Through Theater
A play was created by 2 members of the troop that incorporated diabetes facts, risk factors, and prevention tips in a lively, creative, and humorous fashion The play features Diana Betes, an evil, arrogant villain cloaked in a black robe draped with empty potato chip bags and pizza
boxes representing the disease of type 2 diabetes Her disheveled hair is adorned with old candy wrappers and a long chain of soda pop cans strung around her neck The Town of Glucose, where the play takes place, has just recently lost their king, King Beta Cell, to diabetes Diana Betes sluggishly withers away onstage as Sir Insulin Monk from the Town of Glucose defeats her and stops her villainous activities using exercise and healthy eating The Town of Glucose cheers their hero, Sir Insulin Monk This 30-minute program includes a lecture to introduce the content Each peer health educator presents 1 of the 5 mini topics including definition, prevalence, risk factors, signs and symptoms, and prevention tips of type 2 diabetes This is presented prior to the play in an informal didactic style To engage this age group in the learning process and reinforce learning, the interactive play is presented after the mini lecture After the play, presenters ask the audience questions about each of the content areas: What is diabetes? Name 2 risk factors for diabetes How many people have diabetes? and How do you prevent diabetes? The method of evaluation is provided in a supportive and humorous
manner Prizes are awarded for those who have participated in this program Group preparation involves approximately 5 to 6 weekly meetings The number of individuals who participate in the program varies from 5 to 15 Groups are encouraged to change the script to match the cultural issues surrounding obesity and diabetes An example is changing names to reflect their community and culture Valley of Glucose, Lady Insulin Warrior and to reference common snack foods The groups who have used this program have presented several times to groups or classes within their school or community The program encourages exchange of knowledge and creative presentation skills without the expectations of expert acting skills In addition, educational brochures were developed and are provided in a creative format with age-appropriate language, for example, Dont Monkey Around With Diabetes and Ask Me About the Big D The content includes signs and symptoms of diabetes and prevention tips Brochures have been translated into local languages

including Spanish and Tohono Oodham A coloring and activity workbook have also been developed and translated into Spanish To encourage educators to include this
presentation in their curriculum, the teaching objectives, content, and method are outlined and provided to the schools

Evaluation
How do you evaluate and ensure that you are having an impact? Evaluating effectiveness is based on goals and objectives of the program: to increase awareness and knowledge of type 2 diabetes The audience is questioned at the onset and at the end of the program with the same set of questions regarding the 5 mini topics: definition, prevalence, risk factors, signs and symptoms, and prevention tips of type 2 diabetes After the play, the Girls Scouts randomly select students and ask questions about the content of the lecture and play Small gifts are awarded to those students who participate in this portion of the program Their response and a show of hands have been successful and informal methods of evaluation This interactive evaluation method is integrated into the overall entertaining interaction with the children The age/attention span of the audience and the brief time with this group make the question-answer format the most effective form of evaluation For individuals, families, and societies to make behavioral change, there must be an awareness of
the need to change behavior Steps for behavioral change are reflected in the transtheoretical model12 Prior to making any preparation or action for change, a person needs to be aware of the reasons for change Approaching a person or population based on their readiness for change is the first step in behavioral modification

Outcomes
The group has delivered its message of awareness to numerous schools along the United StatesMexico border and various health organizations throughout the United States in the past 4 years These organizations include elementary schools on or near tribal reservations, binational and national conferences, and local and border health fairs To reach the thousands of children in the schools, the troop designed a Train-the-Trainer tool kit aptly named Dont Monkey Around With Diabetes This tool kit demonstrates what they have created and trains other

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Prevention in Youth
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peer groups to take this education and outreach program to their community schools This involved developing a curriculum, a DVD recording of the lecture and play, and an evaluation format This DVD is formatted to show how to present this program and play and is included in the tool kit The tool kit contains a script of the play and a diabetes prevention activity book both in English and Spanish A diabetes prevention poster, Frisbee, portion plate, and exercise guidelines are included to provide ideas and maintain interest in younger children A PowerPoint presentation, diabetes facts, school objectives, and methods of interfacing with the community are included to help guide production of the program All information is presented in a colorful, portable box Through the use of this tool kit, several regional community health programs and school districts have performed this play and incorporated it in their teaching programs Schools, youth groups, and diabetes prevention programs are now using this prevention program/play as a different model of education One other Girl Scout Troop is using the tool kit developed by Troop 509 The Oregon State Department of
Health in Salem is working collaboratively with a local troop Locally in Tucson, the University of Arizona Center for Health Equality, Project EXPORT, is also using the tool kit and working in a collaborative fashion with children and youth living in an urban community Students in Nogales, Arizona, located near the United StatesMexico border, and Tuba City, Arizona, located in the Navajo Nation, are in their second year of presenting the play to peers via telemedicine The Arizona Diabetes Virtual Center of Excellence program associated with the Arizona Telemedicine Program has supported this ongoing activity This program elicits a greater response of viewers not only because of its entertainment value but also because it provides a personal reason for attending: to view grandchildren, family members, and friends performing in a play Creating an awareness of the issues of diabetes through use of theater provides a successful teaching method

Implications/Relevance for Diabetes Educators
Peer education is a powerful tool in educating youth Involving youth in planning, presenting, and evaluating teaching programs can be very effective Not only does this project recognize and empower
the individual presenters, it also educates members at the community level When a collaborative approach is used with a youth organization dedicated to community service, it can be an effective method for promoting healthy behaviors
References
1 Rosenbloom AL, Joe JR, Young RS, Winter WE Emerging epidemic of type 2 diabetes in youth Diabetes Care 1999;22:345-354 2 Haire-Joshu D, Nanney M Prevention of overweight and obesity in children: influences on the food environment Diabetes Educ 2002;28:415-423 3 All about diabetes Available at: http://wwwdiabetesorg/aboutdiabetesjsp Accessed January 16, 2007 4 Girl Scout Silver Award Available at: http://wwwgirlscouts org/program/gs_central/insignia/highest_awards/silver_awardasp Accessed January 5, 2007 5 American Diabetes Association YouthZone: exercise and healthy weight Available at: http://wwwdiabetesorg/youthzone/activityhealthy-weightjsp Accessed January 10, 2007 6 American Diabetes Association For teens Available at: http://wwwdiabetesorg/for-parents-and-kids/for-teensjsp Accessed January 14, 2007 7 Get Kids in Action Available at: http://wwwgetkidsinactionorg/ newsphp Accessed January 10, 2007 8 Wong F, Hulman M, Hutzler C, et al
VERB–a social marketing campaign to increase physical activity among youth Prev Chronic Dis 2004;1:A10 9 Horizon International Images–theatre for young hearts and minds Available at: http://wwwsolutions-siteorg/artman/publish/article_52shtml Accessed January 10, 2007 10 Lethbridge College Be fit for life Available at: wwwlethbridge collegeabca/ Accessed January 10, 2007 11 McClain JP, McQuiston C Center for Innovation in Health Disparities, North Carolina Central University, Peer led adolescent weight reduction program Available at: http://wwwdisparityresearch org/ongoinghtmlweight Accessed January 15, 2007 12 Ruggiero L Helping people with diabetes change behavior: from theory to practice Diabetes Spectrum 2000;13:125-132

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