Problem Statement
One of the major prevailing diseases in the United States is Type 2 diabetes. It affects millions of people and significantly burdens the healthcare system. However, racial and ethnic disparities in the prevalence and management of type 2 Diabetes are even more alarming. This paper addresses this issue, identifies stakeholders who provide solutions, proposes research methods, and discusses the limitations of the solutions.
Type 2 diabetes mellitus (T2DM) is prevalent worldwide, varying based on geographic and racial/ethnic groups (Golden et al., 2019). Racial and ethnic minorities in the United States experience type 2 diabetes disproportionately in terms of prevalence, functional disability, and poor health care compared with their white counterparts (Smalls et al., 2020). Studies have revealed that African Americans and Hispanics, including American Indians/Alaska Natives, are disproportionately affected by T2DM compared to non-Hispanic whites (Smalls et al., 2020). More specifically, African Americans and Mexican Americans have been found to develop T2DM and its complications at a higher rate than their non-Hispanic white counterparts (Smalls et al., 2020). Furthermore, older adults in the US life expectancy are longer, and they are more likely to suffer from a variety of co-morbidities that increase the burden of disease, healthcare costs, and the need for care (Smalls et al., 2020). According to the study by Golden et al. (2019), the number of people diagnosed with Diabetes in the US by self-reported race/ ethnicity at a specific age was 17.7% among older adults (75 years and older), 45.2% among non-Hispanic whites, and 45.2% among American Indians / Alaska Crown. This disparity creates a massive public health burden that calls for immediate response.
T2DM has a big impact on human lifestyles and the cost of health, and for that reason, imposing an extensive healthcare cost burden. Its effect on human performance and quality of life results in morbidity and mortality (Khan et al., 2019). Health costs associated with Diabetes are at least 3.2 more than per capita health care costs and 9.4 times more if there are complications (Khan et al., 2019). Diabetes often occurs in older human beings. Studies show that over a third of deaths due to Diabetes are among those 60 years old and above (Khan et al., 2019). In addition, an increase in unhealthy food intake and a sedentary lifestyle leads to increased body mass index (BMI) and fasting plasma glucose, leading to Diabetes (Khan et al., 2019). Individuals with a higher BMI are more likely to develop type 2 diabetes. In addition, more than 29 million people are currently uninsured in the United States, and there are significant disparities in access to health care across income, gender, race, and ethnicity (Glantz et al., 2019). Previous research has documented that racial and ethnic minorities also experience lower access to preventive health care compared to their white counterparts, a significant disparity that increases the public health burden (Glantz et al., 2019).
Racial/ ethnic disparities in type 2 diabetes present profound long-term implications. The growing burden of Diabetes strains minority communities and healthcare systems economically. The health disparities associated with it further widen the social inequalities due to the cycle of disadvantage and fewer opportunities(Hill-Briggs et al., 2020). Individually, those with poorly managed Diabetes suffer severe complications, which reduce their quality of life and contribute to early death. Various initiatives try to address Diabetes at a national level but fail to tackle racial and ethnic disparities effectively. Some of the current efforts are public health campaigns, programs for diabetes management, and increased healthcare access. However, they lack cultural competence, fail to consider social determinants of health, and fail to reach marginalized communities (Wasserman et al., 2019). Barriers such as limited healthcare access, socioeconomic factors, and cultural differences contribute to the persistence of disparities in diabetes outcomes.
Identifying Stakeholders
A multi-dimensional approach involving stakeholders is necessary for addressing the persistent disparities in type 2 diabetes. Importantly, the communities directly impacted by the problem are essential stakeholders. Their experiences, needs, and preferences are essential in tailoring interventions and evaluating their effectiveness (Ryan et al., 2021). They can participate in focus groups, pilot programs, and community advisory boards. The families and caregivers of the affected population are also important in their role of supporting diabetes management, and they can be involved in educational programs and support groups.
Health professionals such as physicians, nurses, diabetes educators, and others are stakeholders. They must be trained in culturally competent and appropriate care, considering language barriers and social determinants of health(Chauhan et al., 2020). Their role is to develop clinical guidelines, culturally relevant educational materials, and training programs to increase understanding of the needs of diverse populations. Hospitals and clinics can implement culturally appropriate diabetes care, address barriers to access, and collect data to track progress. While public health agencies address health disparities and promote public health, they are also accountable for resource allocation using evidence-based strategies to improve health outcomes (Brownson et al., 2021). They support research and projects and coordinate efforts in various areas. They play an important role in policy development and implementation.
Churches and other community-based organizations have a role in reaching out to underserved communities, providing them with culturally sensitive programs, and addressing the social determinants of health. Community health centers serve low-income and minority populations with access to diabetes care and broader cultural sensitivities (Saloner et al., 2019). Advocacy groups help raise awareness, advocate for policy change, and hold stakeholders accountable. Policymakers and payers, such as government agencies, can design policies that address the social determinants of health, increase access to affordable health care, and drive nutrition effectively (Horwitz et al., 2020). Health insurance companies can develop culturally appropriate policies, address disparities in access to medicines and technologies, and support research on interventions.
Researchers examine the root causes of disparities, design and evaluate culturally appropriate interventions, and share findings to inform policy and practice (McNulty et al., 2019). Academic institutions provide training and educational resources to health professionals and community members, collaborate on research, and support capacity building in small communities to engage stakeholders in the development, implementation, and research. Collaboration should also be considered one of the most important factors for the project to succeed.
Mission Statement, Goals, Objectives
The mission statement is to build empowered communities with culturally appropriate resources and support systems to prevent and manage type 2 diabetes, reduce disparities, and achieve health equity.
Goals/ Objectives
- To establish 10 Community Empowered Diabetes Action Network (CEDAN) hubs in underserved communities with high diabetes prevalence in one year.
- Train 50 community health workers (C.H.W.s) in cultural competency, diabetes education, and community mobilization within a year.
- Partner with 20 local healthcare providers to improve access to culturally competent diabetes care within a year
- Advocate for and secure policy changes promoting healthy food access and physical activity opportunities in target communities within two years.
- Improve self-reported diabetes management indicators (e.g., HbA1c levels) by 10% among program participants within three years.
Proposed Solution
The proposed solution is to establish a Community Empowered Diabetes Action Network (CEDAN). It is a multi-pronged intervention that aims to reduce racial/ethnic disparities in type 2 diabetes by focusing on community empowerment, providing culturally tailored resources and support systems, and advocating for policy changes to address the root causes of these disparities. It works by training community health workers in cultural competency and diabetes education to become trusted community anchors, build relationships, conduct outreach, and mobilize residents to participate in programs. Culturally tailored interventions improve engagement, adherence, and health outcomes (Joo & Liu, 2020).
Evidence-based diabetes prevention and management programs like self-management education curricula will be adapted to resonate with specific cultural beliefs, practices, and language preferences. A study by Wayne et al. (2022) examined stakeholder perceptions of a culturally adapted diabetes self-management program for African Americans (AA) called Peers EXCEL. 13 semi-structured interviews were conducted with seven health professionals and five organizational leaders. Health professionals and organizational leaders believed the Peer Excel program would support clinical care and could help reduce health disparities by providing peer support for barriers to Diabetes medication adherence, diet, and lifestyle management. A qualitative study by Alaofè et al. (2021) conducted in Berlin focused on adapting a diabetes self-management education program to the specific cultural context of Cotonou, Benin.Qualitative data were collected through focus group discussions (FDGs) involving 32 patients with T2D, 16 academic partners, and 12 community partners. Respondents encountered challenges like the high cost of healthy food, perceptions, stigmas surrounding the disease, and the financial burden of medical equipment and treatment. There was a need for more information about local food selections and recipes and social support for physical activity. They suggested incorporating gender dynamics and spirituality when adapting the curriculum.The study demonstrates the need for culturally sensitive interventions and a motivation-based health approach with spiritual and emotional support. It also lays the groundwork for addressing T2D in Benin and similar sub-Saharan African countries.
Collaboration with healthcare providers, social service agencies, faith-based organizations, and policymakers will ensure holistic care and address social determinants of health. Research states that synergistic partnerships yield better results than single approaches (Schroeder et al., 2022). In addition, addressing issues such as poverty and food insecurity is essential to reduce disparities as it focuses on eliminating the root causes of the problem. CEDAN will advocate programs to ensure food security, good, safe environments, equal access to physical activity, and health care, addressing systemic barriers. Research shows how community interventions effectively reach underserved populations and improve health outcomes (Nickel & Von dem Knesebeck, 2020).
These solutions align with stakeholders and the problem in question by addressing differences through community empowerment, providing culturally appropriate care, and consuming social determinants of life as the solution. It also brings together stakeholders such as community health workers, health care providers, community organizations, and policymakers. The solution also requires funding to establish and sustain CEDAN centers, train community health workers, implement programs, and conduct research. Policy support is also needed to advocate for policies that address social determinants, expand access to health care, and promote healthy environments. Communication/partnerships with community organizations and residents are also essential to program success in line with interventions.
Evaluation
It is crucial to measure the success of CEDAN in addressing racial/ethnic disparities in type 2 diabetes. Therefore, a comprehensive evaluation plan will be employed, encompassing both process and impact methods, guided by a clear model outlining program activities, expected outputs, and desired outcomes. The evaluation process will focus on how CEDAN was adhered to during implementation. It will assess reach, including the number of communities it served, participants, and diversity. Dosage, another measure, will be assessed regarding the interventions delivered, training effectiveness, and community mobilization. It will also assess the adaptability of the interventions to specific community needs and cultural preferences. The final measure will be satisfaction to gauge what the participants think about the program.
The impact evaluation will assess how CEDAN affects diabetes prevention, management, and health equity. For intermediate outcomes, we will track changes in knowledge, attitudes, and beliefs regarding Diabetes, healthy behaviors, healthcare access, self-reported behaviors such as physical activity, healthy eating, medication adherence, healthcare utilization, and clinical indicators like blood sugar control, blood pressure, and cholesterol. For the long term, we will monitor changes in diabetes prevalence and incidence, health disparities between target communities and others, and policy shifts advocating for healthy food access, physical activity, and equitable healthcare. Data will be collected through surveys, interviews, medical record reviews, program records, and community surveys. We will measure diet using food frequency questionnaires or 24-hour recalls, health behaviors using self-reported data, pharmacy records, medication adherence, and health outcomes like HbA1c, blood pressure, cholesterol, and diabetes-related complications.
A quasi-experimental design will compare changes in target communities to a comparison group without the program. We will employ a mixed-methods approach, combining quantitative and qualitative data for a comprehensive picture. Evaluation results will be reported in various formats, such as technical reports for funders and policymakers, summaries and infographics for stakeholders and community members, and presentations and publications to share findings with the broader public health community. Active collaboration among different stakeholders will be paramount to ensure the success of this proposed solution(Collins et al., 2019). Community health workers will participate in data collection and feedback sessions. Community advisory boards will provide input on evaluation design and interpret results, while policymakers will receive reports and be invited to discuss policy implications(Oliver et al., 2019). Its success will benefit all, including community health workers who will improve their skills and recognition and develop their careers for opportunities. There will be increased access to resources, improved health, and empowered residents within the community. Healthcare providers will enhance their ability to deliver culturally competent care, and policymakers will acquire evidence-based data to inform policy decisions on health equity.
Limitations
While CEDAN holds promise for addressing disparities in type 2 diabetes, it is important to acknowledge its limitations. Securing long-term funding for establishing and sustaining CEDAN hubs, training CHWs, and implementing programs can be challenging. However, this can be mitigated by diversifying funding sources such as grants, partnerships, and community fundraising and demonstrating program effectiveness through evaluation to secure continued support(Murphy et al., 2021). Also, it may be difficult to achieve sustained community engagement and participation, especially in underserved communities with distrust in healthcare systems. It is, therefore, essential to build trust through culturally competent outreach, involving community leaders and CHWs, and demonstrating program benefits through success stories and positive outcomes(Lansing et al., 2023).
Influencing policy changes, particularly at the systemic level, requires significant time, resources, and political will. Building strong partnerships with advocacy groups, policymakers, and community members, focusing on achievable policy goals with clear benefits for health equity, can go a long way toward achieving this goal(Campos & Reich, 2019). It may be challenging to tailor interventions to individual cultural needs and preferences due to the expertise and effort required. However, it can be reduced by recruiting and training CHWs from diverse backgrounds, ongoing cultural assessment, and community engagement in transitional interventions(Schleiff et al., 2021). Separating CEDAN effects from other diabetes outcomes is difficult and requires a strong analytical framework.
Despite these limitations, CEDAN is a valuable solution because it addresses various causes of inequality, including access to care, social determinants of health, barriers, and culture, by advocating for change and identifying with community members who ask for active involvement in their health. They are. Other communities can use this model as a guide for research and change. It builds on existing research on diabetes prevention and effective management strategies.
Racial/ethnic disparities in type 2 diabetes require prompt and effective intervention. The proposed CEDAN approach focuses on community empowerment, culturally appropriate interventions, and removing systemic barriers to address health equity. Through the collaboration of partners and stakeholders, the role of meaningful communication, and ongoing program evaluation and maintenance, the CEDAN diabetes care and outcome gap can be closed.
References
Alaofè, H., Yeo, S., Okechukwu, A., Magrath, P., Amoussa Hounkpatin, W., Ehiri, J., & Rosales, C. (2021). Cultural considerations for adapting a diabetes self-management education program in Cotonou, Benin: Lessons from a qualitative study. International Journal of Environmental Research and Public Health, 18(16), 8376. https://doi.org/10.3390/ijerph18168376
Brownson, R. C., Kumanyika, S. K., Kreuter, M. W., & Haire-Joshu, D. (2021). Implementation science should give higher priority to health equity. Implementation Science, 16(1). https://doi.org/10.1186/s13012-021-01097-0
Campos, P. A., & Reich, M. R. (2019). Political analysis for health policy implementation. Health Systems & Reform, 5(3), 224-235. https://doi.org/10.1080/23288604.2019.1625251
Chauhan, A., Walton, M., Manias, E., Walpola, R. L., Seale, H., Latanik, M., Leone, D., Mears, S., & Harrison, R. (2020). The safety of health care for ethnic minority patients: A systematic review. International Journal for Equity in Health, 19(1). https://doi.org/10.1186/s12939-020-01223-2
Collins, T., Mikkelsen, B., & Axelrod, S. (2019). Interact, engage, or partner? Working with the private sector for the prevention and control of noncommunicable diseases. Cardiovascular Diagnosis and Therapy, 9(2), 158-164. https://doi.org/10.21037/cdt.2018.08.04
Glantz, N. M., Duncan, I., Ahmed, T., Fan, L., Reed, B. L., Kalirai, S., & Kerr, D. (2019). Racial and ethnic disparities in the burden and cost of Diabetes for US Medicare beneficiaries. Health Equity, 3(1), 211–218. https://doi.org/10.1089/heq.2019.0004
Golden, S. H., Yajnik, C., Phatak, S., Hanson, R. L., & Knowler, W. C. (2019). Racial/ethnic differences in the burden of type 2 diabetes over the life course: A focus on the USA and India. Diabetologia, 62(10), 1751-1760. https://doi.org/10.1007/s00125-019-4968-0
Hill-Briggs, F., Adler, N. E., Berkowitz, S. A., Chin, M. H., Gary-Webb, T. L., Navas-Acien, A., Thornton, P. L., & Haire-Joshu, D. (2020). Social determinants of health and Diabetes: A scientific review. Diabetes Care, 44(1), 258–279. https://doi.org/10.2337/dci20-0053
Horwitz, L. I., Chang, C., Arcilla, H. N., & Knickman, J. R. (2020). Quantifying health systems’ investment in social determinants of health, by sector, 2017–19. Health Affairs, 39(2), 192-198. https://doi.org/10.1377/hlthaff.2019.01246
Joo, J. Y., & Liu, M. F. (2020). Culturally tailored interventions for ethnic minorities: A scoping review. Nursing Open, 8(5), 2078-2090. https://doi.org/10.1002/nop2.733
Khan, M. A., Hashim, M. J., King, J. K., Govender, R. D., Mustafa, H., & Al Kaabi, J. (2019). Epidemiology of type 2 diabetes – Global burden of disease and forecasted trends. Journal of Epidemiology and Global Health, 10(1), 107. https://doi.org/10.2991/jegh.k.191028.001
Lansing, A. E., Romero, N. J., Siantz, E., Silva, V., Center, K., Casteel, D., & Gilmer, T. (2023). Building trust: Leadership reflections on community empowerment and engagement in a large urban initiative. BMC Public Health, 23(1). https://doi.org/10.1186/s12889-023-15860-z
McNulty, M., Smith, J., Villamar, J., Burnett-Zeigler, I., Vermeer, W., Benbow, N., Gallo, C., Wilensky, U., Hjorth, A., Mustanski, B., Schneider, J., & Brown, C. H. (2019). Implementation of research methodologies for achieving scientific equity and health equity. Ethnicity & Disease, 29(Suppl 1), 83-92. https://doi.org/10.18865//ed.29.s1.83
Murphy, S. E., Farmer, G., Katz, L., Troëng, S., Henderson, S., Erdmann, M. V., Corrigan, C., Gold, B., Lavoie, C., Quesada, M., Díazgranados Cadelo, M. C., Guzmán Mora, A. G., Nunez, E., Montebon, A., Meo, S., Waqainabete‐Tuisese, S., Dutra, G., Pereira, R., Mongdong, M., … Putra, K. S. (2021). Fifteen years of lessons from the seascape approach: A framework for improving ocean management at scale. Conservation Science and Practice, 3(6). https://doi.org/10.1111/csp2.423
Nickel, S., & Von dem Knesebeck, O. (2020). Do multiple community-based interventions on health promotion tackle health inequalities? International Journal for Equity in Health, 19(1). https://doi.org/10.1186/s12939-020-01271-8
Oliver, K., Lorenc, T., Tinkler, J., & Bonell, C. (2019). Understanding the unintended consequences of public health policies: The views of policymakers and evaluators. BMC Public Health, 19(1). https://doi.org/10.1186/s12889-019-7389-6
Ryan, J. C., Wiggins, B., Edney, S., Brinkworth, G. D., Luscombe-March, N. D., Carson-Chahhoud, K. V., Taylor, P. J., Haveman-Nies, A. A., & Cox, D. N. (2021). Identifying critical features of type two diabetes prevention interventions: A Delphi study with key stakeholders. PLOS ONE, 16(8), e0255625. https://doi.org/10.1371/journal.pone.0255625
Saloner, B., Wilk, A. S., & Levin, J. (2019). Community health centers and access to care among underserved populations: A synthesis review. Medical Care Research and Review, 77(1), 3-18. https://doi.org/10.1177/1077558719848283
Schleiff, M. J., Aitken, I., Alam, M. A., Damtew, Z. A., & Perry, H. B. (2021). Community health workers at the dawn of a new era: 6. Recruitment, training, and continuing education. Health Research Policy and Systems, 19(S3). https://doi.org/10.1186/s12961-021-00757-3
Schroeder, K., Bertelsen, N., Scott, J., Deane, K., Dormer, L., Nair, D., Elliott, J., Krug, S., Sargeant, I., Chapman, H., & Brooke, N. (2022). Building from patient experiences to deliver patient-focused healthcare systems in collaboration with patients: A call to action. Therapeutic Innovation & Regulatory Science, 56(5), 848–858. https://doi.org/10.1007/s43441-022-00432-x
Smalls, B. L., Ritchwood, T. D., Bishu, K. G., & Egede, L. E. (2020). Racial/Ethnic differences in glycemic control in older adults with type 2 diabetes: United States 2003–2014. International Journal of Environmental Research and Public Health, 17(3), 950. https://doi.org/10.3390/ijerph17030950
Wasserman, J., Palmer, R. C., Gomez, M. M., Berzon, R., Ibrahim, S. A., & Ayanian, J. Z. (2019). Advancing health services research to eliminate health care disparities. American Journal of Public Health, 109(S1), S64-S69. https://doi.org/10.2105/ajph.2018.304922
Wen, M., Maurer, M., Schwerer, L., Sarkarati, N., Egbujor, U. M., Nordin, J., Williams, S. D., Liu, Y., & Shiyanbola, O. O. (2022). Perspectives on a novel culturally tailored diabetes self-management program for African Americans: A qualitative study of healthcare professionals and organizational leaders. International Journal of Environmental Research and Public Health, 19(19), 12814. https://doi.org/10.3390/ijerph191912814
write