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Service Delivery Innovation Profile

Community-Based, Culturally Tailored Diabetes Education Program Helps Low-Income South Korean Immigrants Improve Self-Management Behaviors, Disease Control, and Other Health Markers


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Snapshot

Summary

The University of California, Irvine, used a bilingual nurse practitioner to deliver a low-cost, community-based, culturally tailored education program to low-income, predominantly elderly Korean immigrants with type 2 diabetes, with the goal of improving their ability to self-manage the disease. The nurse practitioner led two educational sessions (conducted in Korean) to review the basic pathology of diabetes, common complications and medical treatments, and culturally tailored self-management strategies. The program improved self-management behaviors and some of the key biological outcomes of diabetes: better blood glucose control, higher levels of "good" cholesterol, and reductions in waist circumference. Most participants completed all aspects of the program and reported high levels of satisfaction with it.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of various self-management behaviors, blood glucose levels, high-density lipoprotein levels, and waist circumference. As noted, post-implementation data were collected in a group meeting held 3 months after the initial classes.
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Developing Organizations

University of California, Irvine - Program in Nursing Science
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Date First Implemented

2011
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Patient Population

Program participants tended to be elderly (with an average age of 70 years, ranging from 30 to 87 years), and more than 75 percent had incomes below $20,000. Many did not speak English proficiently.Race and Ethnicity > Asian; Vulnerable Populations > Immigrants; Impoverishedend pp

Problem Addressed

Like some other communities, Orange County, CA, has a large, rapidly growing population of Korean immigrants with diabetes. Multiple barriers, including language, poverty, and lack of insurance, make it difficult for these individuals to access and benefit from traditional diabetes education programs.
  • Large, growing number of Korean immigrants with diabetes: Orange County is home to nearly 90,000 individuals of Korean descent, giving the county the second largest Korean population in the country (behind Los Angeles County). The Korean population in Orange County has increased rapidly in the last several decades, with average annual growth of 4.18 percent between 1990 and 2000 and 6.18 percent between 2000 and 2006.1 Koreans in Orange County face a disproportionate risk of diabetes, with prevalence rates of 9.7 percent, well above the 6.1 percent rate for whites.1
  • Multiple barriers to accessing, benefiting from traditional education programs: Korean immigrants face multiple barriers to accessing and benefiting from traditional diabetes education programs; in fact, before implementation of this program, only 24 percent of participants had received any diabetes education. Key barriers include the following:
    • Language: In Orange County, 87.7 percent of Koreans speak Korean in their homes, and 56.2 percent report speaking English less than "very well," suggesting a language barrier that would make it difficult for them to benefit from an English-language diabetes education program.1
    • Poverty: More than 1 in 10 elderly Koreans (10.3 percent) live below the Federal poverty level, well above the 6.2-percent rate among their peers in the county. Median per-capita income for all Koreans in Orange County averages $25,700.1
    • Lack of health insurance: Nearly one-fourth of Korean seniors (23.8 percent) in Orange County do not have health insurance, well above the 1.3 percent uninsured rate for all Orange County seniors. Overall, one-third of Koreans in the county do not have health insurance.1

What They Did

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Description of the Innovative Activity

The University of California, Irvine, used a bilingual nurse practitioner to deliver a low-cost, community-based, culturally tailored education program to low-income, predominantly elderly Korean immigrants with type 2 diabetes, with the goal of improving their ability to self-manage the disease. The nurse practitioner led two educational sessions (conducted in Korean) to review the basic pathology of diabetes, common complications and medical treatments, and culturally tailored self-management strategies. Key program elements are detailed below:
  • Marketing to patients: To recruit interested individuals with diabetes, the program leader distributed fliers at the Korean community center where the education program would take place and ran notices in the center's newsletter and a small advertisement in a local Korean newspaper.
  • Easily accessible, community-based location: The program took place at the volunteer-run Orange County Korean American Health Information & Education Center, which is located in a Korean shopping district.
  • Two sessions conducted in Korean by bilingual nurse practitioner: Based on content developed by the American Diabetes Association and the National Diabetes Education Program, a bilingual nurse practitioner led two group classes in Korean. During the initial trial, 53 patients attended the initial session, and 51 of those also attended the second one. Held 2 weeks apart on Friday mornings and lasting 1.5 and 2.5 hours, respectively, the sessions covered the following topics:
    • Disease pathology and treatments: The nurse practitioner reviewed the basic pathology of diabetes, potential medical complications, and medical treatments.
    • Culturally tailored self-management strategies: The nurse practitioner discussed various self-management strategies, such as how to monitor glucose levels, care for feet and skin, follow a healthy diet, and exercise regularly. During these discussions, she emphasized culturally appropriate strategies and concerns, as outlined below:
      • Culturally appropriate diet: The nurse practitioner explained how to adapt the traditional Korean diet (which is high in carbohydrates) and read labels of common Korean food items. She brought in traditional Korean dishes and explained how they can be altered, such as by substituting a mixture of brown rice and other grains for white rice and reducing the amount of sugar and oil used.
      • Discussion about Oriental medicine: The curriculum included an open discussion about traditional Oriental medicine and the potential harm associated with replacing or supplementing prescription medications with herbal remedies commonly used in the Korean culture.
      • Spouse attendance: Although spouses were not required to attend, several did attend. Dr. Sarah Choi, the innovator, encourages spouses to attend classes that she offers because they can be a valuable source of support for diabetic patients who may struggle to adhere to a time-consuming and complicated self-care regimen.

    Context of the Innovation

    Located in Orange County, the University of California, Irvine, has nearly 28,000 undergraduate and graduate students and 1,100 faculty. Launched in 2005, the university's program in nursing science includes undergraduate and graduate degree programs.

    The impetus for this program came from Dr. Sarah Choi, an assistant professor of nursing science who immigrated from South Korea to California in 1989. After her arrival, she worked as a family nurse practitioner for approximately 10 years with minority immigrant populations and became aware of the high prevalence of diabetes among low-income Koreans. She wanted to develop a program to help them improve self-management of the condition, recognizing that various barriers (as discussed earlier) often prevented them from attending traditional diabetes education classes. After earning a doctorate in nursing, she decided to develop an accessible program to provide practical, culturally relevant information about living with type 2 diabetes to low-income Korean immigrants.

    Did It Work?

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    Results

    The program improved self-management behaviors and some of the key biological outcomes of diabetes: better blood glucose control, higher levels of "good" cholesterol, and reductions in waist circumference. Most participants completed all aspects of the program and reported high levels of satisfaction with it.
    • Better self-management behaviors: Based on questionnaires that participants completed at each session, participants reported increasing the number of times they checked their feet each week from 1.7 at the first session to 2.8 at the second session to 3.1 at a third session, which was held 3 months later and was strictly for data collection. They also reported being more likely to follow dietary recommendations and they checked their blood glucose more frequently, although the mean change was not statistically significant for either of these self-management activities.
    • Improvement in blood glucose, "good" cholesterol, and waist circumference: During the 3-month period after attending classes, the typical participant experienced a decline in hemoglobin A1c levels (from 7.3 to 6.8 percent) and waist circumference (from 38.5 to 37.3 inches), and an increase in high-density lipoprotein (HDL) levels (from 44.1 to 47.8 mg/dL).
    • High retention and satisfaction: As noted, 51 out of 53 individuals (96 percent) who attended the initial session also attended the second group class. In addition, 41 of the original 53 (80 percent) came back 3 months later for a group session to collect data to inform program evaluation. The vast majority (88.7 percent) of participants reported being satisfied or very satisfied with the program, and 96.2 percent said they would recommend it to a friend. Seven participants who completed all aspects of the program traveled more than 100 miles to attend the sessions. After the program ended, several participants called the study team to inquire about future education programs.

    Evidence Rating (What is this?)

    Moderate: The evidence consists of pre- and post-implementation comparisons of various self-management behaviors, blood glucose levels, high-density lipoprotein levels, and waist circumference. As noted, post-implementation data were collected in a group meeting held 3 months after the initial classes.

    How They Did It

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    Planning and Development Process

    Keys steps included the following:
    • Developing course content: Dr. Choi, who is fluent in Korean and an experienced clinician, trimmed the standard curriculum from the National Diabetes Education Program and the American Diabetes Association to fit within 4 hours of classroom instruction and then translated it into Korean. She also translated standard research questionnaires and created a take-home handout for participants, including a description of the food pyramid.
    • Identifying potential partners: Dr. Choi identified individuals within the Korean community who were willing to help with the program, including the volunteer president of the Orange County Korean American Health Information & Education Center and several local Korean providers. They reviewed and commented on the translated course materials and research questionnaires. The community center's president connected Dr. Choi with several local providers (including the bilingual nurse practitioner who taught the program) and provided background information about the Korean community in Orange County.
    • Planning for more rigorous evaluation: Dr. Choi hopes that the results from this pilot study will convince potential funders to support a followup randomized controlled study to evaluate the program more rigorously and to test the value of adding a spousal support component to the program.

    Resources Used and Skills Needed

    • Staffing: The program requires a bilingual nurse practitioner and two clerical assistants to run the courses and conduct the followup data collection.
    • Costs: The program cost $829 to serve 53 individuals, or $15.64 per participant. This cost includes educational materials, food served during the sessions, and payments to the nurse practitioner and two assistants for their work on the program.
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      Funding Sources

      National Center for Research Resources, National Institutes of Health; National Center for Advancing Translational Sciences, National Institutes of Health
      The Orange County Korean American Health Information & Education Center provided the classroom space.end fs

      Tools and Other Resources

      National Diabetes Education Program. Guiding principles for diabetes care, 2009. Bethesda (MD): National Institutes of Health. 2009 Apr. NIH Publication No. 09-4343. Available at: http://www.ndep.nih.gov/media/GuidPrin_HC_Eng.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

      American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care. 2011;34(supp 1):S11-S61. [PubMed]

      Adoption Considerations

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      Getting Started with This Innovation

      • Develop good relationships with key people in community: Seek out community leaders and medical providers willing to support the program with their expertise, influence, community connections, and other resources, such as donated classroom space. These partners can also assist with development of a culturally appropriate curriculum and with marketing to and recruitment of participants.
      • Tailor program to generational differences: A program designed for older immigrants who have limited English proficiency and who cling to a more traditional lifestyle may not appeal to younger immigrants who have graduated from American schools and adopted American habits and attitudes.

      Sustaining This Innovation

      • Create a reason for participants to attend followup data collection: Some participants may not want to attend a followup session designed only to collect data for program evaluation. To encourage them to do so, consider providing new educational content along with a nominal payment to those who come.
      • Encourage spouses to attend: Spouses can be an important source of support once they understand the importance of controlling diabetes, including encouraging their loved ones to follow their prescribed self-care regimen.

      More Information

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      Contact the Innovator

      Sarah Choi, PhD, RN, FNP
      Assistant Professor of Nursing Science, College of Health Sciences
      University of California, Irvine
      100B Berk Hall
      Irvine, CA 92697-3939
      (949) 824-2043
      E-mail: sechoi@uci.edu

      Innovator Disclosures

      Dr. Choi reported having no financial interests or business/professional affiliations relevant to the work described in this profile other than the funders listed in the Funding Sources section.

      References/Related Articles

      Choi S, Rush E. Effect of a short-duration, culturally tailored, community-based diabetes self-management intervention for Korean immigrants: a pilot study. Diabetes Educ. 2012;38(3):377-85. [PubMed]

      Choi S. Diet-specific family support and glucose control among Korean immigrants with type 2 diabetes. Diabetes Educ. 2009;35(6):978-85. [PubMed]

      Choi S, Rankin S, Stewart A, et al. Perceptions of coronary heart disease risk in Korean immigrants with type 2 diabetes. The Diabetes Educ. 2008;34(3):484-92. [PubMed]

      Footnotes

      1 Kim-Goh M. Profiles of the Korean-American community in Orange County. Fullerton: California State University; 2008. Available at: http://www.koreancommunity.org/downloads/Executive_Summary.pdf.
      Comment on this Innovation

      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: August 14, 2013.
      Original publication indicates the date the profile was first posted to the Innovations Exchange.

      Last updated: June 04, 2014.
      Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

      Date verified by innovator: June 01, 2014.
      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.