Auburn Speaks
Office of the Vice President for Research and Economic Development

Reaching and Teaching

Written By Jan Kavookjian

Auburn and Tuskegee Universities, Local Hospital Collaborate on Diabetes Education Project

No Southern celebration is complete without food, from holiday parties with hundreds of people to families simply celebrating the end of a long day by gathering around the dinner table. However, when that food includes Southern staples like fried chicken, vegetables swimming in butter, and sugar-laden desserts, health problems such as diabetes can cast a shadow over fun traditions.

Obesity_Article_ADiabetes is a growing health problem in the United States, particularly in certain regions where diabetes is more prevalent among minority segments of the population. In particular, type 2 diabetes (T2D) is consistently problematic in the Deep South, with Alabama rating among the top three states for diabetes prevalence every year for the past several years. Current estimated diagnosed T2D prevalence in Alabama is at 11.1 percent of the population (compared with an 8.3 percent national average). Blacks make up a significant portion of Alabama’s population and are at greater risk for T2D. Alabama’s T2D problem is exacerbated by the prevalence of rural, underserved areas where patient access to diabetes self-management education and training (DSME/T) may be challenging.

Longstanding Southern traditions of cooking and eating clash with the somewhat complex dietary demands required to manage diabetes. Lack of access to culturally appropriate, simple instructions about how to make healthy eating choices can contribute to negative health and quality-of-life outcomes for those with diabetes.

Reaching Out for Better Health

The American Association of Diabetes Educators (AADE) is funding a project called “Reaching Out for Better Health.” The goals of the initiative are to extend the reach of established, accredited diabetes self-management education and training programs into rural and underserved areas by bringing diabetes education classes directly into the community. It is hoped that this will help disseminate evidence-based knowledge by meeting diabetes patients “where they are” while also considering the potential for literacy limitations.

More than 40 proposals were received by AADE for this program, and only 10 were funded. One of the funded proposals was submitted through a collaboration between a local accredited diabetes education program at the East Alabama Medical Center (EAMC) and an Auburn University Harrison School of Pharmacy faculty member, and subsequently, in collaboration with faculty members at Tuskegee University.

EAMC in Opelika, Alabama, is a 340-plus-bed regional hospital with a diabetes education center, known as the Diabetes and Nutrition Center (DANC). The center is an American Diabetes Association (ADA)-accredited diabetes selfmanagement education/training program that has served urban and rural areas in Lee County, where Opelika is located, as well as surrounding rural counties (Macon, Chambers, Tallapoosa, Russell, and Randolph) for the past 14 years.

Macon County, just to the west of Lee County, has a population of more than 24,000–85 percent black and 32.8 percent living below the poverty line. The median household income is $21,180.

Diabetes is the sixth leading cause of death in Macon County (nationally, it is seventh), and the Alabama Bureau of Public Health reports a 14.2 percent diabetes prevalence rate. The city of Tuskegee is the county seat and draw area for goods and services from surrounding rural counties; it is located approximately 25 miles from EAMC. The hospital and DANC have considered Tuskegee an important expansion area to help an underserved, high-risk section of the region learn how to prevent complications from uncontrolled diabetes.

The Auburn University faculty member on the Reaching Out team is Dr. Jan Kavookjian, associate professor of Health Outcomes Research & Policy in the Harrison School of Pharmacy. Dr. Kavookjian identified the funding opportunity and led the team in writing the proposal and preparing for the research aspects of the project. She has been faculty at Auburn for seven years with a focus on health psychology and behavior sciences applied to chronic disease management, particularly medication adherence and the lifestyle changes needed to prevent or manage diabetes and obesity.

She has also developed collaborations for this project with Tuskegee University faculty, including Dr. Fay Hall Jackson, assistant professor in the Tuskegee University College of Business, and Alveta Reese, assistant professor in the Tuskegee University School of Nursing.

Objectives of the Project

The Reaching Out program’s primary objective is to increase access to diabetes self-management education and training for people considered at high risk for diabetes and underserved. This project targeted the community of Tuskegee and surrounding rural areas with the goal of increasing the number of physician referrals/participants to the EAMC Diabetes and Nutrition Center for DSME/T and increasing patient retention for completion of the full set of DSME/T classes. The second objective is to measure impact of the program on self-management knowledge and behavior changes and on clinical outcomes of participants in Tuskegee-based DSME/T classes.Obesity_Article_C

To meet these objectives, Kavookjian’s coprinciple investigator and manager of DANC, Amie Hardin, planned and coordinated two separate 10-week series of DSME/T classes in Tuskegee, with the intention of measuring the impact of the classes. Their intent was to look at intermediate outcomes such as knowledge and self-management behavior change as well as clinical outcomes such as blood sugar control, blood pressure, and other health indicators. They would also look at quality of life outcomes.

Participants graduated in the summer of 2013; a follow-up “reunion” event is planned for March 2014 where longitudinal outcomes will be assessed. A follow-up newsletter was to go out as the holidays approached, including tips for taking care of diabetes during holiday festivities. Harrison School of Pharmacy students would participate in a health fair, and there would be a presentation on talking with family members about healthy behaviors.

DANC and the Reaching Out team networked directly with acquaintances who are recognized members of the Tuskegee community and held the meetings at familiar facilities in the Tuskegee area rather than requiring patients to make the 25-mile drive to EAMC. The two separate classes started in April 2013 and were conducted nearly simultaneously to allow for cross-attendance if needed.

Running the classes at the same time made it convenient for participants and promoted retention, encouraging participants to complete the classes.

The classes were held at locations that were familiar and accessible in the community, generating support and increasing access by increasing physician referrals of participants. The familiar local locations also helped with patient retention by removing potential barriers such as transportation.

The first DSME/T class location was an established diabetes support group that had been meeting for more than two years at the Greenwood Missionary Baptist Church in Tuskegee. A retired registered nurse, Lilly Hall, started the group informally when she faced her own acceptance of a T2D diagnosis. She is a well-known, respected member of the Tuskegee community, and the support group she started soon attracted a regular following of people with diabetes and pre-diabetes as well as their family members.

Obesity_Article_CThe group meets every fourth Friday for one hour during the day and did not include any lunch or food enticements, yet grew to include between 30 and 65 at every meeting. Most of them were older black adults, many of whom were retired and available to attend a class during the day. Lilly Hall embraced the invitation to collaborate with the Reaching Out team to champion a DSME/T class associated with the support group. The class was held at the same location as the support group to attract members who needed this kind of education.

The second DSME/T class location was within the medical practice of Dr. Thomas Holt, a family practice physician whose Tuskegee office includes a community hospitality room made available to organizations free of charge. This location was ideal because of its convenience and accessibility and its proximity to the county health department–right next door. In addition, Dr. Holt made clear his commitment to serving as a champion for the Tuskegee DSME/T class, agreeing to help promote the opportunity to his own patients and to his primary care colleagues in the community.

The 10-Week Curriculum

Content for the classes across the 10 weeks was derived from the accredited AADE self-care behavior targets, including the “AADE7 Self-Care Behaviors.” These behaviors are: Healthy eating, being active, taking medication, monitoring, healthy coping, problem solving, and reducing risks. Three of the 10 weekly classes covered diet and nutrition topics since healthy eating is among the most problematic, challenging, and complex of diabetes-management behaviors–particularly in the South, where fried foods reign supreme.

The first of these three healthy eating classes covered carbohydrate counting and how to read packaged food labels. The second class taught the importance of incremental changes in eating habits, with a focus on portion sizes, the basic food groups, and meal planning. The third class covered knowledge and strategies for decreasing fat and salt intake to reduce cardiovascular risk and planning ahead for good eating decisions during holiday events and parties.

Cultural and Accessibility Sensitivity

Concern for cultural sensitivity and for rural minorities in the Tuskegee community was key to achieving Reaching Out objectives. Partnering with local, trusted members of the community and organizations has been important for acceptance of the program. Community Advocates (CAs) were enlisted as part of the Reaching Out team to support the attendance and retention of participants in the classes, particularly people who might have access or transportation challenges.

The CAs were recruited by Lilly Hall and her daughter, Faye Hall-Jackson, a faculty member at Tuskegee University, and by case managers assigned to Macon County by the Alabama Medicaid Care Network.

The Tuskegee Community Advocates on the Reaching Out team were a key to overcoming barriers to acceptance. In addition to providing encouragement and transportation for participations, they provided social support. Five Tuskegee residents joined the Reaching Out team as CAs; three are retired health care providers, one is a faculty member from the Tuskegee University School of Nursing, and one is a Macon County Extension agent. They are known in the community and share characteristics with class participants, since they are also self-managing diabetes.

Partnerships with Local Businesses

Reaching Out team champions Dr. Holt and Lilly Hall worked with the EAMC Diabetes and Nutrition Center team to engage local businesses in “co-marketing” and building goodwill. The businesses provided prizes and incentives for the enrollment launch event, for the end-of-program graduation event, and for the reunion (when follow-up data was to be collected).

Local businesses and grocery stores provided coupons and gift cards specifically for purchasing fresh fruits and vegetables, and each participant received a printed canvas tote bag. The tote bags included several useful items, such as free bloodglucose monitors and strips for the duration of the Reaching Out classes, a refrigerator magnet that reminded participants about course dates, healthy reminders, a T-shirt including the participant as part of the Reaching Out team, and course/ education materials.

Goals and Incentives

For each of the two classes offered in the Reaching Out program, AADE asked that 20 adult participants with diabetes or pre-diabetes (40 total) be included. The program was so well received in the community that 49 participants signed up for the classes, including a few community leaders. Most had type 2 diabetes, and a few were either persons with blood sugars in the pre-diabetic range or had family members with diabetes.

Several strategies and incentives were used to encourage participants to join and remain involved.

In addition to receiving coupons, gift cards, and tote bags, participants who did not have transportation were offered rides to classes by CAs.

Participants were monitored regularly for their knowledge, behavior change goals and accomplishments, clinical outcomes, and self-reported quality of life and satisfaction. They also got on-the-spot “report cards” of their progress toward AADE7 self-management behavior goals and clinical indicators as the information was collected.

These outcomes also were periodically shared with participants’ physicians, if the participant desired. The Greenwood Baptist Missionary Church support group participants were encouraged to continue with their group for post-class support; the second group was encouraged to start and participate monthly in a support group after graduation. The Reaching Out team identified a motivated CA who could be trained to serve as a lead facilitator for a new post-class support group for the second class.

The CAs also received incentives for retaining their participants in the program and in the followup data collection. In addition, they received titles, professionally produced nametags, and recognition in the program and in the community for their roles (including publicity copy for the local radio and newspaper).

Current Results and Expected Outcomes

When this article was written, it was hoped and expected that a majority of the 49 participants would complete the Reaching Out program and that marketing efforts to establish a familiar and approachable presence in the Tuskegee community would result in additional participation. Thus far, both classes are taking place with near 100 percent participation. Classes were to continue through August 2013, and measurable target outcomes were to be evaluated at that time and compared with those reported at the beginning to look at the impact of learning diabetes self-management strategies.

The overall goal of the Reaching Out for Better Health program is to help people with diabetes achieve positive outcomes across measurable targets, including the outcomes of knowledge gain and establishing good self-management behaviors.

In addition, positive outcomes are hoped for across the targeted clinical outcomes. These outcomes include blood sugar control and prevention of weight gain, as well as considerations such as quality of life and satisfaction.

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