This case study will focus on Tuscarora Native Americans living in WNY Niagara County. This population consists of a community that lives in a geographically isolated reservation, several miles from the nearest town. The main economic activity of this community is farming and majority of the community members are poor. A significant proportion of the community members are obese. Persons suffering from type 2 diabetes in the community are mainly in the 18-45 years age bracket. Majority of those who have had the condition for long periods have already started developing diabetes associated complications such as peripheral neuropathy, leg ulcers, poor vision, and retinopathy. Amputations are very common in the community. The predominant foods consumed in the community are high in fats, carbohydrates, and proteins. Very few of the community members consume vegetables and fruits. The community gets food aid from the government which consists mainly of canned foods. The literacy level of the community members is low because very few have completed high school. Most of the community members have no health insurance and can barely afford health care. Health services in the community are mainly provided by community health workers because the local hospital is several kilometers away. Most of the diabetic patients are on long-term insulin. There is no active diabetes prevention or management program for the community members.
Statistics on American Indians indicate that an estimated 30% of this population has pre-diabetes whilst 16.3% has already being diagnosed with diabetes. The percentage of American Indians with diabetes is slightly higher than that of non-Hispanic whites which stands at 8.7%.
The prevalence of diabetes amongst American Indians and Native Americans is on the rise. Between the years 1994 and 2004, the increase was 68% of which type 2 diabetes accounted for 95%. Diabetes associated mortality is also three times higher amongst American Natives than that of the general population. Estimates for the average annual cost for a diabetic patient is $13, 243 (Edwards & Patchell, 2009). Type 2 diabetes is much more expensive to manage than type 1 diabetes mainly because it has a higher prevalence rate (Timothy et al., 2009).
The community informant was of the opinion that there was a high incidence of type 2 diabetes in the community. He attributed the increased prevalence of the condition to genetics since the disease is found in certain families and feeding habits. He also noted that the community lacked a comprehensive diabetes prevention or management program and most of the community members were ignorant about the disease.
Community need
Based on the analysis of data collected through observation, from the community informant, and review of population statistics, the community has a need for a diabetes prevention program.
Review of literature
A number of community-based diabetes prevention programs targeting Native Americans have being conducted so far. They include a culturally sensitive low intensity lifestyle intervention program by Thompson et al. (2008 as cited in Edwards & Patchell, 2009).The program targeted females aged 18-40 years. The intervention in this study consisted of monthly group discussions that focused on physical activity, healthy eating, setting goals, and social support. The interventions were delivered for five months. The effectiveness of the program was evaluated via assessments of pre-and post eating habits, waist circumference, and total blood cholesterol levels. These parameters improved amongst those who received the intervention more than in the control group. The pros of this program include, it focused on lifestyle changes crucial to the prevention of diabetes, incorporated social support, the length of time was optimal, and it had an evaluation component. Its major weakness was that it focused on only one gender.
Another community-based diabetes prevention program was the Cherokee Choices program which targeted Cherokee Indians residing in the North Carolina. The program had three key components, an adult worksite wellness intervention, an elementary school mentoring intervention, and a health promotion program which was church-based. The following indicators were used to evaluate the effectiveness of the program dietary benchmarks, physical activity benchmarks, and body mass indexes. The pros of this program include, it targeted both adults and children and it had an evaluation component (Edwards & Patchell, 2009).
The Ho-Chunk Youth Fitness Program is another example of a community-based diabetes intervention program. This program by Carrel et al. (2005 as cited in Edwards & Patchell, 2009) was designed to evaluate the efficacy of an intervention consisting of supervised classes in nutrition and exercise which were delivered over 24 weeks. It was targeted at both natives and non-native Americans aged 6 to 18 years. The mean fasting plasma insulin levels was the indicator used to assess the effectiveness of the program in preventing type 2 diabetes. The pros of the program incorporate the facts that it emphasized on lifestyle changes which have been shown to be effective in preventing and delaying the onset of diabetes. The main demerits of the program include, it targeted only one age group and evaluation of the effectiveness of the program was based on a single parameter.
Another culturally competent diabetes prevention program is the 2005 study by Saksvig et al. (as cited in Edwards & Patchell, 2009) which was based at the Sandy Lake School. The study aimed at changing one, dietary intake behaviors and two, dietary self-efficacy. The following outcomes, measured before and after the study, were used to evaluate the effectiveness of the program, preference, knowledge, dietary intention and self-efficacy. The merit of this study is that it addressed dietary habits and food intake and it had an evaluation component. It, however, failed to address other important components of a diabetes prevention program such as stress management and exercise.
Community care plan
Goals
Objectives
Interventions
The proposed interventions will be primary, secondary, and tertiary. They will be four-pronged because they will target four groups, school-going children, youths, adults without diabetes, and known diabetic patients. The interventions for the school-going children and youths will entail nutrition and physical activity classes which will be delivered over a 24 week period. The interventions for the adults with and without diabetes will entail group and individual group discussions with a lifestyle coach. These discussions will be held once weekly over a period of 24 weeks. The period is optimal because it will permit repeated reinforcement of diabetes education. During these discussions, community members will be educated on strategies for preventing diabetes and its complications such as losing weight, eating healthy, and engaging in physical activity. Education on eating healthy will emphasize on the right type of foods, appropriate proportion of foods, and the importance of reading food labels. They will also be apprised of emotions and situations that can undermine their diabetes prevention efforts and ways of coping with them. The group discussions will also provide a forum for the provision of social support to the participants as they try to adjust their lifestyles (Edwards & Patchell, 2009).
Networking and Collaboration
Nurses and nutritionists will act as lifestyle coaches for the program. They will be enrolled from the local hospital and community organizations. The following organizations will be approached and requested to sponsor the program, insurance firms, the Indian Health Services, local universities, and community non-governmental organizations.
Evaluation
The effectiveness of the program will be evaluated using the following indicators which will be assessed before, immediately after, and six months after the program:
Body weight
Waist circumference
Body mass index
Total plasma cholesterol levels
Dietary benchmarks
Physical activity benchmarks
Knowledge levels on diabetes and its prevention
HBA1c levels for known diabetic patients
Blood glucose levels for known diabetics (Edwards & Patchell, 2009).
References
Dall, T. M., Mann, S.E., Zhang, Y., Quick, W.W., Seifert, R. F., Martin, J., Huang, E. A., &
Zhang, S. (2009). Distinguishing the economic costs associated with type 1 and type 2
diabetes. Population Health Management, 12(2), 103-110.
Edwards, K., & Patchell, B. (2009). State of the science: A cultural view of Native Americans
and diabetes prevention. Journal of Cultural Diversity, 16(1), 32-35.
Valeria, W. (2011). Economic change: A barrier to diabetes self-management. Primary Health
Care, 21(8), 27-30.
