Now that you have considered the evidence and potential options to address the local site problem and project objectives, it is now time to describe the proposed design of your project, specific detai

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Implementation of Type 2 Diabetes Self-Management Education in an Impoverished Community

Leonne M. Reid

NGR 7911

Dr. Valerie Martinez

University of Central Florida

September 26, 2022

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Abstract 2

Table of Contents 3

Introduction 5

Background, Significance 5

Description of Organization 7

Mission 8

Organizational Structure 8

Organizational Needs Assessment 8

Organizational Data Indicating a Problem 8

Stakeholder Analysis 10

Patients 10

Professional Organizations 11

Interdisciplinary Colleagues 12

Project Management Tools 13

SWOT Analysis 13

Local Problem Statement 14

Literature Review 15

Description of Search Strategy 15

Inclusion Criteria 15

Search Strategy 16

Quality Appraisal 17

Synthesized Key Findings 17

Interventions Used to Improve the Problem and their Outcomes 17

Peer Support or Coaching or Peer Health Coaching 17

Patient Education 18

Lifestyle Modification Programs 19

Problem-solving or Problem-Solving Therapy 20

Facilitators and Barriers to Implementation of the Interventions Identified 21

Purpose and Project Goals 22

EBP Model 22

References 23

Appendices 29

Appendix A - Summary of Evidence Table 29

Appendix B - Project Management Tools 44

Appendix C - SWOT Analysis 45

Ethnic and racial minority groups in the US, particularly impoverished communities, bear a more significant load from the increasing incidence of Type 2 diabetes (T2D), making the disease a primary focus for disparities in healthcare research (Haw et al., 2021). T2D is a complicated, dire disease in which the weight of self-care is on the patient. In the United States, there are approximately 37.3 million people with diabetes (Centers for Disease Control and Prevention, 2022). Unfortunately, T2D is among the greatest difficult chronic health conditions to manage and control. The increased demand for disease management and the incorporation of complicated self-management routines in the day-to-day lives of diabetics has been proven to lead to increased stress, leaving individuals discouraged, frustrated, and overwhelmed. These demands could also cause depression, anxiety, and reduced well-being (Papelbaum et al., 2010). However, patient behaviors such as lifestyle modifications associated with exercise and diet, medication, record keeping, and daily blood glucose monitoring are crucial in effectively managing the disease (Shrivastava et al., 2013). These behaviors are often referred to as self-management.

Self-management is participating in self-care actions to enhance a person's well-being and behaviors . This considerable burden affects patients from impoverished communities that usually find it challenging to deal with self-management. This is mainly because of cultural, economic, and social barriers, inadequate access to diabetes self-care and self-management resources, and high survival demands among disadvantaged populations (Haw et al., 2021). Recent immigrants and refugees might also experience difficulties adhering to diabetes self-management practices due to various factors, including the absence of preventive care, leading to late treatment and diagnosis (Heerman & Wills, 2011). Cultural differences in how people perceive the origin and treatment of diabetes might also make it challenging to manage the disease among disadvantaged populations (Heerman & Willis, 2011).

Nonetheless, self-management is the most effective way of managing diabetes among populations that lack access to quality healthcare. Most of these practices require considerably less financial resources than frequent healthcare visits. For instance, self-management practices require patients to control and monitor their diet, engage in more physical activity, and monitor their glucose levels, which is more affordable than other management options . However, social support systems might address the effects of environmental and economic challenges that affect effective T2D management by increasing access to social capital, thus promoting self-efficacy behaviors. Nam et al. (2011) state that social support is essential since it is related to the hindrance and facilitation of self-care among patients suffering from chronic diseases like diabetes. Families are the key foundation of social support since they help patients manage their condition successfully.

Ideally, social support is multifaceted and correlates with several social networks (institutional, community-based, occupational, or familial) surrounding a patient (Nam et al. 2011). It has a high potential to exert either negative or positive influences on the person's capability to control the condition independently. A patient's capacity to use social capital to capitalize on established resources could play a significant responsibility in self-care. They could activate constructive social capital resources by seeking and getting help from substantial people in several social positions, such as family members that understand how to manage the disease, thus minimizing the challenges associated with their poverty status that limit them from addressing the condition effectively. In most cases, some attributes of the healthcare system affect effective disease self-care, especially among disadvantaged communities for whom the cost and access to healthcare might provide significant barriers to achieving effective self-management.

The professional organization that is both a stakeholder and a sponsor of this project is the American Diabetes Association (ADA). This organization is committed to printing innovative and timely information and publishing research for professionals specializing in diabetes care, treatment, research, and education (ADA, 2022). It is a non-profit membership organization that promotes the efforts of healthcare professionals to cure and prevent diabetes by enhancing the well-being of people with diabetes (ADA, 2022). ADA offers research grant awards, patient information programs or materials, and professional education programs and helps spread public awareness of diabetes. The organization's technology assessment activities are publishing review articles, creating position papers, and sponsoring and funding consensus conferences. ADA also sponsors conferences, research symposia, and annual postgraduate courses that intend to spread new diabetes information or discuss crucial topics related to the disease.

"To offer the public and healthcare professionals comprehensive and correct information on technologies (drugs, medical devices, surgical or medical procedures among others) that are relevant to diabetes" (ADA, 2022).

The board members, professional members, and officers of the American Diabetes Association (ADA) often request for research to be conducted. Formal written requests are then submitted to the senior staff or volunteer leadership, who then set the research topic priorities. Research is often performed by assessors or researchers that have expertise in areas related to diabetes, such as public health, law, nutrition, medicine, and exercise. The key methods used in the assessments include cost analyses, group judgment, expert opinion, and information synthesis (Council on Health Care Technology, 2008).

According to the National Diabetes Statistics Report, roughly 8.2% of the United States population (26.9 million individuals) were diagnosed with diabetes in 2018 (Center for Disease Control and Prevention, 2020). In 2016, around 12.6 % of US citizens in non-metropolitan regions were diagnosed with diabetes, a higher statistic than 9.9 % in metropolitan regions (Center for Disease Control and Prevention, 2020). In the 'diabetes belt', the incidence of diabetes was about 11.7 % of the entire US population. Over one-third of counties within the diabetic belt are located in the Appalachian Region. Many states within the belt are extremely rural compared to the United States average (Centers for Disease Control and Prevention, 2022). These statistics show that diabetes is a major concern within impoverished and rural communities because of limited access to healthcare services and a higher prevalence of risk factors (Misra et al., 2019). For instance, impoverished communities often comprise populations at a higher risk of T2D, such as ethnic and racial groups and older adults (Mendenhall et al., 2017).

Additionally, several barriers affect patient education and quality healthcare access in impoverished communities. First, fewer transport options in rural areas make it challenging for T2D patients to travel to doctor appointments (Stotz et al., 2021). Secondly, there are higher rates of uninsured patients in rural communities. Limited access to medical covers makes it difficult for impoverished populations to access medical supplies, medications, and cover medical appointments. Also, there are fewer healthcare providers in poor communities, making it difficult to offer patient education, replace retiring healthcare professionals, and retain nutritionists and dietitians. Workforce shortages in impoverished societies also limit access to specialized healthcare professionals, including endocrinologists (North et al., 2022).

These data indicate a major problem within impoverished communities since T2D patients would fail to access pharmacological interventions for managing the disease. However, with the introduction of self-management practices, individuals in rural communities could learn about some of the efficient lifestyle modifications they should make to control their weight and glycemic levels. Self-management is cheaper and less cumbersome because it only requires the efforts of a patient and their family to manage the disease .

The main stakeholders relevant to this research include patients, their families, the family advisory committee, professional organizations such as the American Diabetes Association (ADA), and interdisciplinary colleagues such as respiratory therapists, nutritionists, physicians, or occupational therapists (OT)/PT.

Patients are the main stakeholders in this project because the project will have a significant impact on them. This project will help patients understand how self-care and self-management could help manage T2D. Their families will also benefit from the project because they will be able to recognize effective strategies to incorporate self-management into their management regimen. Another major thing that patients, family advisory committees, and relatives need to understand from the project is examples of self-management interventions that have been proven effective in managing T2D. Patients and their families are also a great asset to the project because they will contribute by taking part in the project and having outcomes measured like HbA1c and glycemic levels, weight, and quality of life . Also, families of patients with the disease can contribute to the project by providing crucial information on the efficacy of the self-management interventions they have used on their relatives. However, patients might impede the project by providing false information on self-management efficiency and failing to commit to self-management interventions. Families can also affect the project by failing to give their relatives with type II diabetes the correct self-management interventions during the study period. The engagement of patients and their families in this project requires that self-care and self-management education be offered.

Utilizing professional organizations such as the American Diabetes Association (ADA) will help inform the project and have them approve whether the identified strategies are safe and effective in managing T2D. These organizations would contribute to the project by offering the study's respondents patient education . They could also fund the research since the American Diabetes Association (ADA) often funds studies to control, treat, and prevent diabetes (ADA, 2022). The main way that professional organizations could impede the project is by refusing to fund and contribute to the project . The best way to engage professional organizations is having them offer patient education on safe self-management practices for T2D.

In a healthcare setting, an interdisciplinary team consists of practitioners from different disciplines that work together to address a patient's psychological and physical needs ( Indeed, 2021 ). For instance, for a patient with T2D, the interdisciplinary team comprises respiratory therapists, nutritionists, occupational therapists, and other physicians. These stakeholders are crucial to the project because they will help inform the project and approve the self-management practices recommended at the end of the project. The main thing that this group of stakeholders is concerned with is whether self-management interventions are effective in managing T2D. This project will help them understand which patient education they need to provide to these patients and the self-management practices they would recommend to patients other than pharmacological interventions. Interdisciplinary colleagues could also contribute significantly to the project. For instance, nutritionists are well-equipped with the correct information on healthy diets for patients suffering from different diseases. Therefore, in this project, they will help recommend healthy lifestyles and dietary changes which would help control HbA1c and glycemic levels and weight. Additionally, occupational therapists (OT) are healthcare professionals that help injured, disabled, or sick patients improve, recover, or develop by maintaining the life skills needed for healthy living (Burson, Fette, & Kannenberg, 2017). Therefore, they could help T2D patients maintain, recover, and develop meaningful occupations or activities for communities, groups, and individuals.

The interdisciplinary team could affect or obstruct this project when they do not recommend and administer appropriate and efficient self-management interventions for the project participants . For instance, if a nutritionist recommends a diet that would not be effective in reducing glycemic levels in a patient with T2D, then the project findings will be a ffected . Similarly, suppose an occupational therapist does not help a patient to develop a healthy lifestyle to manage the disease adequately. Patient health outcomes will be affected in that case, impacting the project's findings.

Several factors would impede the efficient implementation of this study in the given practice setting (See Appendix C for the SWOT Analysis diagram of these factors).

Strengths

i. There is access to respondents who would help provide information on which strategies they have adopted and utilized in the effective management of T2D other than pharmaceutical interventions since the given setting is impoverished communities .

ii. There is the availability of experienced researchers and professionals (such as nutritionists and occupational therapists) to help recommend effective self-management interventions to the study 's respondents.

Weaknesses

i. Lack of funding because there are fewer financial resources in impoverished communities; hence project initiators must fund the project themselves or look for a professional organization willing to fund the research.

ii. Limiting beliefs among individuals , such as using cultural interventions like traditional herbs and ayurvedic medications, is the most effective way of preventing and treating T2D (Ahmad, 2021). These beliefs might impede the effective implementation of self-management interventions.

Opportunities

i. Increased interest among professional organizations and leading scientific institutions to research effective disease management strategies. For example, the American Diabetes Association has emerged to help fund research on effective T2D management, provide education on self-management practices that would help manage the disease and recommend healthy diets for the patients (ADA, 2022).

ii. The availability of professional organizations which help provide education to patients with T2D in impoverished communities.

Threats

i. Language and cultural barriers. Researcher s might find it difficult to communicate with T2D patients from impoverished communities.

T2D patients in impoverished communities have limited access to healthcare services due to different factors, such as geographical and financial barriers; this accounts for the high rates of T2D within these communities since patients lack professionals to guide them through pharmacological interventions. These high statistics could be mitigated through dietary and lifestyle modifications. Because treatments such as insulin and drugs are expensive and impoverished communities have fewer resources, it is important to prioritize prevention and manage the disease using self-management practices. It is also essential to spread awareness and educate patients on how lifestyle changes could be as effective as using drugs to manage and prevent T2D.

I screened this topic independently and then selected articles for quality appraisal and inclusion criteria. Once the pieces were screened, I developed a quality appraisal and inclusion criteria. For the articles to be included in the official review, they were analyzed using the following inclusion criteria. The article must have the following:

i. Provided quantitative and qualitative empirical (descriptive, cohort study, quasi-experimental, RCT, systematic review, or meta-analysis) evaluative support.

ii. Identified an intervention.

iii. Included an outcome variable of self-care and self-management.

iv. Included adult respondents with type II diabetes.

v. Operationalized as a psychosocial indicator (such as support, stage of change, depression, stress, or emotional adjustment), physiological indicator (such as cholesterol, HbA1c, weight, blood pressure, blood glucose level), self-management outcomes (such as SBGM pattern, medication, exercise, diet) and knowledge.

An all-inclusive search was performed through Ebscohost utilizing the following databases: PsycInfo, PsycArtiCLES, MEDLINE, Health Source: Nursing/Academic Edition, CINAHL, and Academic Search Complete. The search was conducted to establish best practices in self-management interventions for T2D. The top search terms used include randomized controlled trials, self-management, patient education, self-care, type 2 diabetes, and diabetes mellitus. Only peer-reviewed articles written in English between January 2015 to 2022 were selected. Additionally, the Cochrane Library was looked up for self-management review. The first search yielded 62 peer-reviewed articles abstracted for self-management intervention topics. Forty -six articles were excluded since they failed to meet the inclusion criteria because they focused on T1D rather than T2D. Duplicates were removed from search results. The themes of the remaining sixteen articles selected for review included patient education, lifestyle modification programs, peer support, and lifestyle adaptation. The reference lists of the selected articles were then analyzed to locate other relevant articles in the search. At the end of the reviews and search, 14 articles were chosen for synthesis. All articles chosen for review were critically appraised using the Johns Hopkins Evidence-Based Practice Model Heirchy of Evidence guide. The quality of the articles selected for this review could be summarized as high-quality randomized clinical trials (n=1), good-quality systematic reviews (n=2), good-quality meta-analysis (n=1), low-quality integrative review (n=1), high-quality qualitative descriptive study (n=11), and good quality literature reviews (n=4). See Appendix H for evidence table.

Peer support, peer coaching, and health coaching utilize volunteers or health care providers, often referred to as peer supporters or coaches, to offer self-management care to individuals with the same healthcare condition as them or those they consider their peers (Thom et al., 2013; Ghorob et al., 2011). These peers and coaches could include healthcare professionals, family members, educators, community health workers, and patients. Ideally, peer health coaching is done to connect a patient to other patients that have the same health issues. Regardless of peer support or coaching, the objective is to motivate and engage T2D patients in self-care and self-management. Peer support and coaching interventions have been adequately researched in disease education. Tang et al. (2011) explain that in diabetes self-management, peers and coaches play multiple roles, such as group facilitator, mentor, case manager, educator, cultural translator, and advocate. Peer support and coaching are often delivered by trained professionals and primarily emphasize self-management interventions based on documented curricula and time-limited. Based on efficiency, support and peer health coaching have effectively helped lower HbA1c levels and improve self-management (Powers et al., 2015; Moskowitz et al., 2013). Due to such favorable results, peer support and health coaching have received significant interest as effective interventions for disease self-care (Aschbrenner et al., 2015).

Diabetes self-management education (DSME) has been the most common and effective strategy for managing diabetes (Pamungkas, Chamroonsawasdi, & Vatanasomboon, 2017). This intervention program has evolved over the decades to include biopsychosocial treatment models and affective and behavioral tactics to deal with the psychosocial and medical requirements of individuals with T2D (Carpenter, DiChiacchio, & Barker, 2019). Patient education could be administered in different modalities, to groups or individuals, professionals or peers, in extended or short-term sessions. DSME entails various crucial components that should be maintained to prevent complications related to diabetes- monitoring checks, physical activity, adherence to diet, and treatments (Carpenter, DiChiacchio, & Barker, 2019). Powers et al. (2015) found that implementing self-management education effectively improves the quality of life for T2D .

Lifestyle modification programs are used to improve health outcomes through behavior and lifestyle changes. Lifestyle modification programs could comprise a variety of topics such as stress management, exercise, diet, and medications (Carpenter, DiChiacchio, & Barker, 2019). Lifestyle modification programs have had a long history in managing diabetes because it usually combines interventions targeting behavior modification, exercise, diet, and medication management. Lifestyle modification programs such as self-efficacy, healthy diets, and greater exercise have helped patients with T2D manage their weight and control their glycemic and HbA1c levels (Delahanty et al., 2013; Kerrison et al., 2017; Carpenter, DiChiacchio, & Barker, 2019).

Problem-solving therapy (PST) is a strategy for behavioral modification used to determine what needs to be done to attain a goal that is not apparent (Carpenter, DiChiacchio, & Barker, 2019). Problem-solving therapy aims to minimize adverse emotional reactions, change behavior, and improve positive emotional responses (Zhang et al., 2018). Problem-solving therapy entails teaching individuals suffering from a chronic disease how to deal with life issues by breaking them down into two different sections: utilizing problem-solving skills and employing problem-solving orientations to life. Additionally, problem-solving therapy mainly focuses on teaching a patient skills such as recognizing the health issue, defining the problems, comprehending them, setting health objectives associated with the health issue, identifying alternative strategies to solve the health issue, analyzing and selecting the best methods, implementing these alternatives, and analyzing their effort in solving the problem (Nezu et al., 2012).

Problem-solving therapy (PST) has had an extended history in counseling and clinical mindset to deal with substance abuse, coping skills and stress management, relational and family distress, and several mental health disorders. Additionally, problem-solving therapy has been constantly used within diabetes care and education and is recognized as a crucial skill, intervention, and process in diabetes self-management (Carpenter, DiChiacchio, & Barker, 2019).

Barriers to T2D self-management include lack of support, shortage of resources, inadequate behavioral beliefs and knowledge, and suffering from health issues (Shi et al., 2020). When patients lack support from their families (such as lack of emotional support, taking medications, and eating healthy) and professionals, it interferes with the efficacy of self-management interventions. Some health issues, such as insomnia, physical discomfort, and hyperglycemia, could also interfere with self-care (Shi et al., 2020). These issues reduce patient motivation to engage in self-management interventions. Moreover, the shortage of resources, such as limited access to patient education, lack of finances to buy healthy foods, little blood glucose monitoring, and unavailability of hypoglycemic medications.

Lastly, inadequate behavioral beliefs, knowledge, and confusion about taking diabetes medications interfere with the efficacy of diabetes self-management (Kulhawy-Wibe et al., 2018). Shi et al. (2020) found that many diabetic patients did not understand how to use hypoglycemic agents. Many were confused about the medications' side effects, usage, and names, which prevented them from efficiently managing diabetes. Recognizing these barriers is essential in creating effective strategies, including promoting successful self-management, implementing patient-centered care, reinforcing social and medical support, and creating favorable environments. Also, understanding these barriers will help patients understand how they will deal with them and educate their families and peers on how they can help them manage the disease on their own.

The project aims to answer the EBP question of whether self-management effectively manages T2D in impoverished communities . Self-management could be one of the best alternatives for managing T2D among communities with inadequate access to quality healthcare since fewer financial resources are required than pharmacological means (Whittemore et al. 2019). For example, because T2D is mainly developed from poor diet and lifestyle practices, modifications such as eating a cleaner diet, exercising more often, and tracking glucose levels could help manage the disease. However, factors such as limiting beliefs among rural residents and lack of support from family could impede the effective use of self-management to control T2D (Shi et al. 2020). Therefore, this research will examine how such barriers could be addressed to ensure that patients manage T2D effectively without experiencing dire health effects. It will also look at how patient education could be improved within impoverished communities so that people with diabetes could learn how to manage the disease independently without the intervention of healthcare professionals.

This project utilizes the Johns Hopkins Nursing Evidence-Based Practice Model (JHNEBP). This model is structured to satisfy EBP needs by employing a simple process known as Practice Question, Evidence, and Translation(PET; Christenberry , 2017). In the first step, the EBP question is created, followed by searching, appraising, describing, and rating the quality of evidence. In the last step, feasibility of the project is determined, an action plan for implementation is created, and evidence-based practice changes are implemented (Christenberry, 2017). Also, findings are presented to the larger nursing faculty and healthcare organizations.

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Figure 1: Driver Diagram

Table 2: SWOT Analysis