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Service Delivery Innovation Profile

Culturally Competent Self-Management Program Increases Confidence and Knowledge for African Americans With or at Risk for Diabetes


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Snapshot

Summary

The Center for African American Health (CAAH) Focus on Diabetes project offered a culturally competent, 6-week diabetes self-management course, followup support, and a series of annual classes to people with or at risk for diabetes and their caregivers in the Denver metropolitan area. Geared toward the African-American community, Focus on Diabetes utilized CAAH partnerships with area churches and African-American health professionals to offer culturally appropriate education and services in a comfortable, welcoming environment, with the goal of improving the health and health-related quality of life for program participants. A majority of participants reported high levels of satisfaction with the program, as well as increased confidence and knowledge in diabetes self-management. In 2011, CAAH transitioned to an evidence-based model of diabetes self-management (developed by the Stanford School of Medicine) in an effort to increase scalability and sustainability of the program. The new model retains many of the core aspects of the original program, including the 6-week course taught by culturally proficient coaches, a community focus, and partnerships with church host sites.

Evidence Rating (What is this?)

Suggestive: The evidence consists of data from post-implementation surveys of a sample of participants, along with anecdotal reports from participants.
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Developing Organizations

Center for African American Health
The Center for African American Health was formerly known as the Metro Denver Black Church Initiative.end do

Date First Implemented

2001
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Patient Population

Race and Ethnicity > Black or african american; Vulnerable Populations > Racial minoritiesend pp

Problem Addressed

African Americans are almost two times more likely than whites to have diabetes, leading to increased risk of diabetes-related complications such as cardiovascular disease, kidney disease, amputations, blindness, and early death. Many African Americans with diabetes lack the skills and knowledge needed to effectively manage diabetes on their own.
  • African Americans disproportionately at risk: In the United States, African Americans are 1.8 times more likely to have diabetes than are non-Latino whites. One-fourth of African Americans between the ages of 65 and 74 years have diabetes; a similar percentage of African-American women older than 55 years suffer from the disease as well.1
  • More health complications, leading to premature death: Diabetes can cause a whole host of complications that increase the risk of early death, including cardiovascular disease, kidney disease, amputations, and blindness. For example, heart disease strikes people with diabetes more than twice as often as it does people without diabetes.1 African Americans are particularly susceptible to these complications. Among people with diabetes, African Americans are 1.5 to 2.5 times more likely to have a lower limb amputated, twice as likely to suffer from blindness, and 2.6 to 5.6 times more likely to get kidney disease. In Colorado, the death rate for African Americans with diabetes is more than twice that of whites who have the disease (36 per 100,000 vs. 15.8 per 100,000).2
  • Inadequate knowledge and skills to self-manage condition: Diabetic complications can often be reduced or delayed by monitoring blood pressure and glucose levels, taking medications, exercising, and maintaining a healthy diet. However, focus groups conducted by the Center for African American Health (CAAH) revealed that many African Americans with diabetes have difficulty accepting that they have the disease, do not understand its potential consequences, and are not aware of steps they can take to better manage their health.

What They Did

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Description of the Innovative Activity

Focus on Diabetes educated and helped build self-management skills for African Americans with or at risk for diabetes and their caregivers in the Denver metropolitan area. The program included a culturally competent, 6-week self-management course, followup support, and a series of annual events offered in a comfortable, community-based setting. The goal was to improve the health and health-related quality of life of these individuals. Key program elements included the following:
  • Diabetes self-management course: The core component of the program was a free, 6-week diabetes self-management course, offered five times per year. Each interactive, 2-hour weekly session focused on building skills, sharing experiences, and providing support. Topics covered included understanding diabetes and its associated health complications, proper nutrition and physical activity, use of medication, communicating with health providers, and dealing with the emotions and depression that individuals with chronic diseases often face. Key elements of the course are described below:
    • Culturally competent, volunteer faculty: Classes were taught by an all-volunteer faculty consisting of African-American health professionals and others from partner agencies.
    • Wide variety of topics covered: Each course covered a wide variety of topics. Medical professionals and students from the University of Colorado School of Pharmacy and School of Dentistry offered personalized, hands-on, skill-building sessions focusing on the proper use of diabetes medications and the importance of maintaining good dental hygiene. A physician and a certified diabetes educator from Kaiser Permanente taught an interactive session on self-management. Through partnership with the Association of Black Psychologists, a psychologist provided a session on depression and managing emotions. In addition, the program manager, a registered dietitian, offered a hands-on cooking session in which participants prepare a healthful meal and learn menu-planning skills. Finally, registered nurses taught a session on health complications that can arise as a result of diabetes.
    • Meals and exercise: During each class, participants ate a healthful meal and took a 15-minute exercise break. The meal served as a learning experience, giving participants the opportunity to talk about healthy food choices, portion control, and counting carbohydrates. The exercise break was led by a volunteer aerobics instructor who taught participants simple movements and stretches they can use to increase their level of physical activity.
    • Personalized health screenings: Class members received free, personalized blood pressure screenings and glycated hemoglobin (HbA1c) testing as a part of their participation in the course.
  • Telephone and inperson followup support: Participants who completed the 6-week course could choose to participate in a followup support group. Four trained counselors (who received a stipend for participating) conducted counseling sessions over the phone based on principles of motivational interviewing, a client-centered approach that uses techniques of reflective listening and agenda setting to change health behavior. Each participant received three phone calls, one each on nutrition, exercise, and using and understanding medications. In addition, all participants and counselors met as a group on a quarterly basis to discuss any issues or concerns around self-management; participants also received HbA1c testing at these meetings.
  • Annual, standalone events: Focus on Diabetes offered several annual events that were tailored to meet the needs of the African-American community (although they were open to all individuals with or at risk for diabetes and their caretakers). These events included a Thanksgiving and a holiday cooking class (held in December), both of which offered diabetes-friendly cooking techniques and strategies for remaining healthy during the holiday season. In addition, the program offered a well-attended class in mid-December on handling depression, because the holiday season can trigger feelings of sadness in people living with chronic diseases such as diabetes.

Context of the Innovation

Launched in 2005, CAAH developed out of the health programs of the Metro Denver Black Church Initiative, a grant-making program designed to build the capacity of Denver’s black churches as social service providers. After years of funding and collaborating with black churches on programs addressing a variety of issues, the Black Church Initiative determined that its unique competence was in addressing health disparities facing African Americans in their community. As such, the organization changed its name to CAAH, with a new mission of improving the health and well-being of African Americans. Focus groups conducted by CAAH revealed that many African Americans with diabetes had difficulty accepting their diagnosis and understanding how to manage the disease. To address this, CAAH applied for and received a 5-year grant through the Robert Wood Johnson Foundation (RWJF) Diabetes Initiative to design and implement the Focus on Diabetes program.

In 2011, CAAH transitioned to a standardized, evidence-based model of diabetes self-management (developed by the Stanford School of Medicine) in an effort to increase scalability and sustainability of the program. The new model retains many of the core aspects of the original program, including the 6-week course taught by culturally proficient coaches, a community focus, and partnerships with church host sites.

Did It Work?

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Results

Between 2003 and 2011, Focus on Diabetes served nearly 510 community members. Post-implementation surveys of participants show that a majority reported increased levels of confidence and knowledge in various areas of diabetes self-management. Anecdotal reports suggest high levels of participant satisfaction.
  • Increased confidence: Post-implementation surveys of a sample of 2007 program participants found that 60 percent reported being more confident in their ability to make appropriate food choices, 61 percent reported increased confidence in knowing what to do in response to high or low blood sugar levels, and 57 percent became more confident in their ability to manage their diabetes on a regular basis.
  • More knowledgeable: Responses to the surveys described above indicate that a majority of participants reported being more knowledgeable about managing the disease, including 70 percent who reported a better understanding of how to prevent and treat low blood sugar (the comparable figure for high blood sugar was 65 percent), 65 percent who reported improved understanding of the effects of physical activity and medications on their diabetes, 60 percent who reported improved understanding of how to prevent the potential long-term complications of diabetes, and 63 percent who reported improved understanding of meal plans that help to control blood sugar.
  • Highly satisfied participants: Participants in both the 6-week self-management course and the standalone sessions anecdotally reported high levels of satisfaction with the program. Many participants elected to repeat the course, stating that they learned more through Focus on Diabetes than they had in diabetes education programs offered through other sources.

Evidence Rating (What is this?)

Suggestive: The evidence consists of data from post-implementation surveys of a sample of participants, along with anecdotal reports from participants.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Recruiting participants through partnerships: Through its Faith and Health Ministries program, CAAH partnered with more than 80 black churches in the Denver area to promote healthy lives and lifestyles and to prevent disease. These partnerships were and continue to be vital in identifying and recruiting participants for the Focus on Diabetes initiative. In addition, during the second year of the RWJF grant, CAAH partnered with Eastside Health Center (a clinic site of Denver Health), putting a part-time staff member in the clinic to conduct outreach to the more than 850 African Americans listed in Denver Health’s diabetes registry.
  • Finding classroom space: To establish a community presence and to gain the trust of participants, Focus on Diabetes began by hosting classes in various black churches throughout Denver on a rotating basis. As the course gained momentum and popularity, logistics required that the class sessions move to CAAH’s conference room.
  • Developing culturally competent curriculum: CAAH began running Focus on Diabetes classes using a standardized, nutrition-centered curriculum called “Dining with Diabetes.” However, it became clear that this curriculum did not address all of the information and education needs of participants. Through a process of trial and error, program staff began building a culturally competent curriculum targeted toward the African-American community, incorporating a wide spectrum of topics to help African Americans understand and feel confident managing their disease.
  • Adapting phone counseling model for cultural appropriateness: To ensure cultural appropriateness, program staff reviewed and edited the questions included in a computer-assisted telephone interviewing software program used by counselors to guide their phone sessions.
  • Counselor training: CAAH contracted with a motivational interviewing trainer to provide an intensive 14-hour training program to all telephone counselors.
  • Transition to spread the program: In 2011, the program transitioned to Stanford’s evidence-based diabetes self-management model to address the challenge of sustainability. This model still uses a 6-week educational course with similar modules taught by culturally competent trainers. Now, two specially trained coaches (certified by Stanford) are required for each module; CAAH has more than 20 certified trainers as of May 2012. With smaller class sizes, the program has gone back to its roots by holding class sessions in local churches and community sites, where the participants feel welcome and comfortable. However, the new program no longer offers followup support groups or annual standalone events that were integral to the original model.

Resources Used and Skills Needed

  • Staffing: Two CAAH staff members worked on the program, including a part-time project manager and a full-time outreach coordinator. In addition, the program utilized a large pool of volunteers, including faculty for the self-management course and health outreach liaisons from each of CAAH’s partner black churches. (The new version of the program uses two specially trained coaches for each module taught.)
  • Costs: The annual operating expenses were $184,000, which covered the salaries of the program’s two staff members and other costs, such as meals and materials.
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Funding Sources

Robert Wood Johnson Foundation; Kaiser Permanente; Caring for Colorado Foundation; Colorado Trust
The program's development and initial operations were funded by a 5-year RWJF Diabetes Initiative grant. Ongoing operations were supported by grants from the Caring for Colorado Foundation and the Colorado Trust. As part of the transition to the Stanford evidence-based model in 2011, the program is now funded with a 3-year grant from Kaiser Permanente (updated May 2012).end fs

Adoption Considerations

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Getting Started with This Innovation

  • Seek funding: Identify and seek funding from foundations and other organizations that share an interest in and commitment to the health priorities of the target community.
  • Cultivate partnerships: Relationships are needed with local churches, clinics, and other health-related organizations that can help to build a base of participants and/or conduct outreach.
  • Strive for cultural proficiency: Using African-American health and medical professionals to deliver culturally appropriate course content helps to encourage participation and increase understanding among participants.
  • Hold sessions in a welcoming, safe setting: Health education is often delivered in a clinic or hospital setting, an environment commonly associated with sickness and discomfort. Offering classes in a welcoming, community-based setting can help to boost attendance, as participants look forward to the sessions.

Sustaining This Innovation

  • Be comprehensive: Many diabetes education programs focus on only one aspect of self-management, such as nutrition or exercise. Keep participants interested by providing education and skill-building opportunities related to a variety of topics.
  • Elicit user feedback: As participants complete the program, listen to their views on what elements were particularly successful and what else should be added.
  • Build personal relationships with participants: Encourage faculty to establish sensitive and caring relationships with participants, which not only encourages them to complete the course, but also to attend standalone events and to invite others to take advantage of program services.
  • Consider fee for service: Charging a fee to participants sent through health plans or other referring agencies is one possible strategy for obtaining a sustainable source of funding.

More Information

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Contact the Innovator

Grant Jones
Executive Director
Center for African American Health
3601 Martin Luther King Blvd
Denver, CO 80205
Phone: (303) 355-3423
Fax: (303) 355-1807
E-mail: grant@caahealth.org

Innovator Disclosures

Mr. Jones has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

More information on the 6-week Focus on Diabetes course and other diabetes management programs now used by CAAH is available at http://www.caahealth.org/index.cfm/ID/3/iNewsID/151/.

Footnotes

1 African Americans & Complications Web site. American Diabetes Association. Available at: http://www.diabetes.org/living-with-diabetes/complications/african-americans-and-complications.html.
2 Hunsaker J, Krause EMS, Carrington JM, et al. Racial and Ethnic Health Disparities in Colorado 2005. Colorado Department of Public Health and Environment Office of Health Disparities. 2005.
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: March 16, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: January 15, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: May 30, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.