Type 2 diabetes is emerging as a serious health problem, especially in high risk minority communities. The highest rates of type 2 diabetes are found among the African American, American Indian/Alaskan Native, and Latino populations (Diamant, 2007). Compared to non Latino white adults with diabetes, African American and Latino adults with diabetes are also more likely to have poorer control of their blood glucose levels and higher rates of complications (Mainous, King, Garr, & Pearson, 2004; Gonsalves, Gessey, Mainous, & Tilley, 2007; Marshall, 2005). More than 1.8 million California adults, or about 7% of the population 18 years and older, have been diagnosed with diabetes (Diamant, 2007). Individuals at high risk can benefit from efforts to prevent or delay the onset of type 2 diabetes with moderate physical activity, a low-fat diet, and modest weight loss (Williamson, Vinicor, & Bowman, 2004).
Low-income African American and Latinos face multiple and interrelated barriers to diabetes prevention and control, e.g., poverty, lack of access to health care, limited literacy, and cultural values and beliefs that are not considered adequately by the health care system (Rhee et al., 2005; Kieffer et al., 2004; Carlson, Neal, Magwood, Jenkins, King, & Hossler, 2006). Conventional diabetes education programs, including standard weight loss treatment, have limited impact on some African American adults (Wing & Anglin, 1996; Liburd, Anderson, Edgar, & Jack, 1999). Lack of cultural sensitivity and unrealistic weight loss goals of conventional programs may explain the higher dropout rates observed among black compared to white adults. Culturally sensitive diabetes education and support programs can improve outcomes, even in underserved, low income populations (Anderson Loftin, Barnett, Bunn, Sullivan, Hussey, & Tavakoli, 2005; D'Eramo Melkus et al., 2004; Williams, Auslander, de Groot, Robinson, Houston, & Haire Joshu, 2006).
Cooperative Extension has become increasingly involved in diabetes prevention programs (Corbin, Kiernan, & Getting, 2007; Williams, LeBlanc, & Christensen, 2004). The University of West Virginia Cooperative Extension offers a program, Dining with Diabetes . The University of Idaho Cooperative Extension program has used the Idaho Plate Method to teach principles of portion control, along with basic nutrition education, to people with diabetes and their families. Since 1999, the University of California Cooperative Extension (UCCE) has supported a health promotion workgroup that includes county based advisors and campus specialists and faculty. The goal of the workgroup is to reduce ethnic health disparities related to diabetes and other chronic diseases in California.
In the formative phase of our work, the workgroup conducted and published findings from seven focus groups, moderated by an African American advisor (UC Health Promotion workgroup, 2002). Participants included 60 African American adults in Santa Clara, San Mateo, San Bernardino, Los Angeles, San Joaquin, and Stanislaus counties. In San Joaquin and San Bernardino Counties, the African American participants commonly mentioned a lack of cultural sensitivity and respect among health care providers. Given the high rate of diabetes among African Americans, focus group participants in San Joaquin County were also very concerned about the overall lack of diabetes prevention information available in their community. They emphasized the need for client centered information to be presented through community based programs. Other barriers to change included the taste of foods and social pressures to eat less nutritious foods at family gatherings and in the workplace. Participants also stressed the need for using trained African Americans from the communities to take the message about diabetes and its complications to the people.
The workgroup also previously conducted four focus groups among 28 Latino adults with diabetes and a needs assessment survey among 120 Latino participants in UCCE classes (Kaiser et al., 2003). Although many of those surveyed in the UCCE classes were at high risk of developing diabetes, 44% had never been screened, and 37% did not know where to be screened. The belief that stressful or traumatic events play a role in onset of the disease was predominant among these adults. Individuals who cited more sources of social support had made more behavioral/lifestyle changes after they had been diagnosed than those with less social support.
Based on our research and building on programs in other states, our workgroup developed the Take Care of Your Health program. This article describes an approach that Cooperative Extension in California has used to develop this program to raise diabetes awareness and prevent diabetes and its complications in low income, high risk ethnic communities. Below, we provide details on the communities where we pilot tested the program, steps involved in its development, and participant response to the program.
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