Diabetes disproportionately affects minority populations in America. For example, a Native American is twice as likely and an African American is 1.5 times as likely to develop diabetes than a white American. Those minorities who develop diabetes are disproportionately affected by its complications as well, including retinopathy, nephropathy, and neuropathy. The prevalence of these complications is higher and the outcomes are worse.
In an effort to reduce the morbidity and mortality associated with diabetes, the Centers for Disease Control has established a Diabetes Task Force (DTF) to systematically review community-based interventions for patients at risk for diabetes and its complications. As part of this effort, special attention has been focused on those interventions targeting minority populations. The evidence-based reviews will be used to make recommendations for diabetes interventions in the Guide to Community Preventive Services.
A structured search of the CDC’s database yielded 7000 articles describing community-based interventions for diabetes prevention and management. The abstracts of these articles were reviewed individually for appropriateness of inclusion as per guidelines established by the DTF. Accepted articles, totaling approximately 1800, were then evaluated using a standardized abstraction form. The information obtained included study classification, descriptive information, study design, intervention, measurement information (exposure), and results. Statistical analysis and study quality were also assessed. Evidence tables were then created with subsequent determination of a quality score for each study.
Of 1800 articles reviewed, only 40 articles describing interventions designed and implemented in minority populations have been identified for further evaluation thus far. Sixteen of the 40 articles were of sufficient quality to allow meaningful policy recommendations. These articles described community-based programs targeted towards Asian American/Pacific Islanders (4), African Americans (6), and Native Americans (7). Successful programs incorporated either self-management training with emphasis on patient education or broad-based health care system interventions such as patient or provider reminder/recall systems and provider monitoring and feedback systems. Those interventions leading to modification in patient behavior (lifestyle) were often not successful in the long-term. The majority of studies integrated culturally sensitive, tailored elements or used health providers/community liaisons sharing the same racial/ethnic background as the target populations. Measurable improvements included enhanced diabetes knowledge and improved physiologic measurements such as hemoglobin A1c.
Interventions targeting minority populations are critically needed for improved diabetes prevention and management. Two interventions with demonstrated success utilized self-management training with emphasis on diabetes education and health care system modifications. Inclusion of culturally sensitive materials and use of health care providers or liaisons from the targeted minority community was an essential component. Further work is needed to elucidate more potential interventions, especially those associated with long-term behavioral change. Also, few quality studies in Latino communities could be identified, pointing to a need for more research in this population.
Susan Norris, MD, MPH, Division of Diabetes Translation, Centers for Disease Control, Medical Center
….Joan’s involvement with my career did not end when I completed the fellowship, though. She strongly encouraged all of us to explore nontraditional career paths, and provided the necessary guidance and support for us to do so. When I finished residency, I had planned on pursuing an academic medical career as a clinician-researcher. However, after the fellowship, I joined the Commonwealth Fund, and worked on quality of care issues for underserved populations for over 2 years. I then came to the U.S. Senate and served as deputy director for health for Senator Edward M. Kennedy, and now as health and education policy advisor for Senator Barack Obama. Three years later, I continue to depend heavily on the academic training, the leadership and networking that I acquired through the Commonwealth program, and personal guidance and advice from Joan. I am always impressed by the caliber and diversity of the career paths of my co-alumni fellows. Our health care system here in the U.S. is broken, and there are no easy solutions to the twin crises of health care access and health care quality. The breadth and the magnitude of these crises underscore the importance of the Commonwealth fellowship and its strong leadership. I give my congratulations and gratitude to Joan Reede, and look forward to the next 10 years of partnership!