Description of the case
Berks Community Health Center serves communities of Berks County, Pennsylvania, which include urban, suburban, and rural areas with distinct populations and different needs. However, the population of the City of Reading is a group of particular concern. The racial and ethnic structure of the City population changed over the past two decades. The proportion of White residents decreased from 47.0% to 28.7%, and the share of Latino residents increased from 38.0% to 58.2% (Public Health Management Corporation, 2013). Today, Latino is the largest cultural group with specific healthcare needs in the area. According to the survey of the Public Health Management Corporation (2013), the members of the Hispanic community in the City of Reading, PA, identify diabetes as one of the most pressing health issues.
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Type 2 diabetes disproportionately affects Hispanic adults. They show a higher death rate from diabetes (51% higher) and higher prevalence of diabetes (133%) and obesity (23%) compared with Non-Hispanic Whites (Dominguez et al., 2015). Hispanics have demonstrated poorer glycemic control, higher rates of diabetes-related complications, and lower rates of self-management compared to Non-Hispanic Whites with type 2 diabetes (Hatcher & Whittemore, 2007). Considering Hispanic disparities in diabetic health outcomes, there is an urgent need for preventive measures to decrease the burden of diabetes in the local Hispanic community.
Several evidence-based and culturally tailored diabetes education interventions have been developed for Hispanic population. Examples include the Starr County Border Health Initiative, La Diabetes y la Unión Familiar, Project Dulce, and ¡Si! (Culica, Walton, Harker, & Prezio, 2008; Prezio et al., 2013). However, none of them are implemented in the City of Reading. The YMCA of Philadelphia Freedom Valley offers the CDC-recognized diabetes prevention program in Boyertown, the only place in Berks County (CDC, 2019). The program is unavailable to the majority of Hispanics due to costs and transportation barriers. To address these issues, Berks Community Health Center decided to form an alliance with other community organizations and develop a free-of-charge digital health program to prevent diabetes and its complications among low-income Hispanic patients.
Description of the facts of the case
Background and goals/objectives/mission of the new idea
To achieve optimal control of diabetes, patients should be proactively engaged in self-management practices that involve behavioral changes and execution of complex medical treatment regimens (Fontil et al, 2016). Practice-based interventions that provide support for self-management have become a foundation of various diabetes prevention programs. Overall structure of the diabetes prevention program includes a trained lifestyle coach that facilitates a small group of participants in learning about healthier eating, physical activity, and other behavior changes. Advancements in information technology (IT) have expanded the ability to engage patients in the healthcare process, motivate health behavior change, and offer the potential to disseminate lifestyle self-management programs like DPP on a large scale.
The overall goal of the digital health program is to reduce health disparities for local Hispanic population. It will be designed specifically for Hispanic population addressing issues, such as language barrier, low literacy, low acculturation level, limited preventive attitudes, poor knowledge about diabetes and health care system in the US, and low socio-economic status of many Latinos. It will be culturally appropriate in terms of diet, beliefs, barriers to exercise, limited access to health care, and personal preferences. Two primary objectives for the development team is (1) to adapt the literacy level and cultural relevance of the standard DPP content for the low-income, underserved Spanish-speaking population and (2) to develop a user-centered design.
Facts of the case
In its digital version, DPP includes online group support, personalized health coaching, and a weekly curriculum. The cornerstone of this program is a health coach figure who shares the same ethnicity, language, and geographic community with target population. Patients are more likely to trust a peer from a similar background who understands their culture. Therefore, health coaches will serve as a bridge between patients and providers. They will improve diabetes-specific behaviors by delivering educational sessions, helping patients navigate health care system, and providing referrals to health care providers if needed. The online platform would allow participants to asynchronously complete weekly lessons, send messages and call a health coach for individual counseling, and monitor weight loss progress and engagement in physical activity.
Currently, the Pennsylvania state legislation relating to diabetes does not mandate coverage for diabetes prevention programs, and Medicare and Medicaid programs do not provide reimbursement for such interventions, nor do they cover HbA1c testing for the diagnosis of prediabetes (Vojta, Koehler, Longjohn, Lever, & Caputo, 2013). Non-profit organizations and philanthropic groups will provide funding for this program. However, financial sustainability and potential issues related to integration of the program into the existing health care services are not a focus of this paper.
Analysis of the problem including key stakeholders and their perspectives
The list of key stakeholders includes two distinctive groups: those who would benefit from outcomes of the program and those who will be involved in development and implementation of the program. The community stakeholders who would benefit from outcomes of the program include Latino community of the City of Reading, Centro Hispano (the Latino community organization of the City of Reading), and local health care systems and community clinics, such as Berks Community Health Center and Penn State Health St. Joseph. Stakeholders who will be involved in development and implementation of the program include research and clinical groups including endocrinologists, certified diabetic educators, and public health nurses, software developers, health coaches, and volunteers from Latino community. Non-profit organizations and philanthropic groups, such as Berks County Community Foundation, the United Way of Berks County, and local churches, will provide funding (Holleran Community Engagement Research & Consulting, 2016).
The central problems derived from the stakeholders’ analysis include awareness and acceptability of the program by the Hispanic Community and adequacy and availability of culturally sensitive health care providers. Many may not understand concepts of Western medicine and have limited preventive attitudes. Many types of preventive care are not commonly available in the Latin culture, and many Hispanics do not realize the benefits of preventive services and do not seek health care unless they feel ill. They share a cultural belief that their lives and destiny, including illness, are not under their control, so seeking early preventive care is pointless (Abraido-Lanzo et al., 2007).
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Another area of concern is cultural competence of health care providers. Cultural competency goes much deeper than a language barrier and the routine use of translation services would not eliminate all possible mistakes and misunderstanding. In addition, the majority of programs on cultural competence focus on superficial cultural characteristics such as rituals and beliefs. This approach would do more harm than good because it leads to stereotyping, development of a very simplistic schema of a person as a member of a certain cultural group (Garneau & Pepin, 2015). The most immigrants are acutely aware of possible differences and do not expect that a health care provider would know everything about their culture. What they need is reliable means to communicate their needs.
Decision-making and implementation issues
The primary decision the team needs to make is how to incorporate the perspectives and experiences of Hispanic clients in developing and finalizing a culturally appropriate content and user-friendly digital platform with the ultimate goal of improving usability, acceptability, and value to end-users. The team considers two alternatives. First alternative is to develop a digital product based on Community Diabetes Education (CoDE) program. This program was developed in response to the local diabetic epidemic in Dallas, Texas, an area similar to the City of Reading in terms of high diabetes prevalence, a high percentage of Latino populations and residents without health insurance (Culica, Walton, Harker, & Prezio, 2008; Prezio et al., 2013). It was designed specifically for Hispanic population and involved bilingual and bicultural community health workers who served as a primary diabetes educator and as the “bridge” between patients and health care providers.
There are two disadvantages of this option. First, the content of the CoDE program was designed specifically for Hispanics of Mexican American origin, while the Latino majority in the City of Reading is Puerto-Ricans. Differences between these two cultural groups in terms of diet, beliefs, and attitudes are considerable. This raises concerns about appropriateness of the content of the CoDE program to the local context. In addition, this option does not offer ready-to-use technological solutions.
Second alternative is the Omada Health Program, an Internet- and mobile-phone-based educational solution program. It provides a ready-to-use technological solution that can be customized according to the needs of specific users (Fontil et al, 2016). This option is preferred because it addresses disadvantages of the CoDe program. To transform the standard content of the Omada Health Program into culturally appropriate material, the team plans to iterate a prototype through a series of Plan-Do-Study-Act (PDSA) cycles. In Plane phase, the team will conduct interviews with focus groups to understand the needs and perspectives of Hispanic clients. Then, based on this feedback, the team will translate and adapt the online curriculum. In the Study and Act phases, the team will test the modified program and develop recommendations for the next iteration.
Barriers and facilitators to implementation
The access to primary/preventive health care services is the big issue for the community. The significant barriers are a shortage of providers accepting Medicaid/Medical Assistance and financial issues. Only two not‐for‐profit community clinics, the Berks Community Health Center and Penn State St. Joseph Downtown Campus, provide many low-cost or free health care services (Public Health Management Corporation, 2013). However, these clinics have long waiting times due to insufficient capacity to satisfy the community needs and have a significant shortage of bilingual health care providers who potentially could participate in development and implementation of the program (Public Health Management Corporation, 2013). Literature sources cited the lack of trust in providers as a common barrier for DPP implementation (Culica et al, 2008). The area of particular concern is limited computer literacy of older Hispanic adults (Fontil et al, 2016). Many Hispanics may be illiterate and cannot read written information even in Spanish (Delmarva Foundation for Medical Care, 2014).
However, the local Latino community identified diabetes as one of the most pressing health needs (Public Health Management Corporation, 2013). Community leaders confirmed their readiness to provide funding and all necessary assistance, and many bilingual and bicultural members of Centro Hispano are willing to volunteer and help with content adaption and development. These factors can facilitate the implementation of the project.
Evaluation of the outcomes or future planning involved
The team will evaluate an enrollment rate and attrition rate because the goal of the program is to achieve better glycemic control in all out target population. The team will develop recommendations regarding a target enrollment rate based on data that will be collected during prototype testing. The enrollment rate will be calculated as a proportion of all eligible patients who will complete a sign-up process. Based on literature reviews, the expected target attrition rate is 14-22% (Culica et al, 2008; Prezio et al., 2013). The same studies found that patients who attended more education sessions achieved better glycemic control, and participation in the program was associated with frequency of patient contacts with a health coach. Thus, the team will evaluate the effectiveness of the program by monitoring the improvements in glycosylated hemoglobin level. According to Prezio et al. (2013), 1.14-1.6% decrease over 1 year is an achievable level. In addition, the team will monitor a frequency of signing in, a proportion of individuals who contact a health coach, a proportion of participants who contact a health coach by phone, and the proportion of individuals who prefer text messages or email.
- Centers for Disease Control and Prevention. (2019). National Diabetes Prevention Program. Retrieved February 21, 2019, from http://www.cdc.gov/diabetes/prevention/index.html
- Culica, D., Walton, J. W., Harker, K., & Prezio, E. A. (2008). Effectiveness of a community health worker as sole diabetes educator: Comparison of CoDE with similar culturally appropriate interventions. Journal of Health Care for the Poor and Underserved, 19(4), 1076-95. http://dx.doi.org/10.1353/hpu.0.0076
- Delmarva Foundation for Medical Care. (2014). Hispanic diabetes disparities learning network in community health centers (08-0044-EF). Retrieved from Agency for Healthcare Research and Quality website: http://www.ahrq.gov/research/findings/final-reports/diabetesnetwork/index.html
- Dominguez, K., Penman-Aguilar, A., Chang, M. H., Moonesingle, R., Castellanos, T., Rodriguez-Lainz, A., & Schieber, R. (2015). Vital signs: Leading causes of death, prevalence of diseases and risk factors, and use of health services among Hispanics in the United States — 2009–2013. Morbidity and Mortality Weekly Report (MMWR), 64(17), 469-478. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6417a5.htm
- Fontil, V., McDermott, K., Tieu, L., Rios, C., Gibson, E., Castro, S.,…R. Lyles, C. (2016). Adaptation and feasibility study of a digital health program to prevent diabetes among low-income patients: Results from a partnership between a digital health company and an academic research team. Journal of Diabetes Research, 2016(8), 1-10. doi:10.1155/2016/8472391.
- Hatcher, E., & Whittemore, R. (2007). Hispanic adults’ beliefs about type 2 diabetes: Clinical implications. Journal of the American Academy of Nurse Practitioners, 19(10), 536-45. doi: 10.1111/j.1745-7599.2007.00255.x
- Holleran Community Engagement Research & Consulting. (Ed.). (2016). Berks County health collaborative community health needs assessment. Retrieved from https://www.thefutureofhealthcare.org/assets/community-health-needs-assesment.pdf
- Prezio, E. A., Cheng, D., Balasubramanian, B. A., Shuval, K., Kendzor, D. E., & Culica, D. (2013). Community Diabetes Education (CoDE) for uninsured Mexican Americans: A randomized controlled trial of a culturally tailored diabetes education and management program led by a community health worker. Diabetes Research and Clinical Practic, 100(1), 19-28. http://dx.doi.org/10.1016/j.diabres.2013.01.027
- Public Health Management Corporation. (2013). Berks County, Pennsylvania. Community health needs assessment. Retrieved from https://www.readinghealth.org/~/media/Files/About/Community%20Health%20and%20Wellness%20County%20Health%20Needs%20Assessment.pdf
- Vojta, D., Koehler, T. B., Longjohn, M., Lever, J. A., & Caputo, N. F. (2013). A coordinated national model for diabetes prevention: Linking health systems to an evidence-based community program. American Journal of Preventive Medicine, 44(4), S301-S306. doi:10.1016/j.amepre.2012.12.018
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