Asian Americans With Type 2 Diabetes

Epidemiology Paper Part Three: Implementation and Evaluation - Asian Americans with type 2 diabetes
1. Identify a public health theory you will use to support the implementation of your prevention and health promotion activities. Provide evidence that supports the use of this theory within the program you designed.
Efficient initiatives in the areas of health promotion, chronic illness management, and public health decrease disease risks and facilitate the maintenance and improvement of public health and chronic ailment management. They have the potential to improve individual, familial, community and organizational self-sufficiency and wellness. Typically, this sort of success necessitates behavioral modification at several levels including individual, community, and organizational (US Department of Health and Human Services, 2014). But every initiative doesn’t enjoy equal success. Initiatives with the greatest likelihood of achieving required results are founded on an explicit grasp of health behavior targets, and their environmental context of occurrence. Providers employ strategic planning theories for developing and managing such initiatives, constantly using meaningful assessment for bringing about improvements. Health behavioral theory may be a crucial factor throughout the process of initiative planning.
The interactive, multilevel ecological perspective has been recommended in relation to diabetes mellitus type 2 health improvement and prevention strategy implementation within the Asian-American population. According to this strategy, health promotion today entails more than mere societal education on healthy practices. Rather, it incorporates attempts at modifying organizational behavior, in addition to communities’ social and physical environments. Further, it deals with development and advocacy of health promotion policies (e.g., economic incentives). Such initiatives which aim at addressing health issues across the aforementioned spectrum operate on different levels and adopt various strategies (US Department of Health and Human Services, 2014).
The ecological standpoint stresses the inter-reliance and interaction between factors across and within each health-issue level. It focuses on individual interface with their respective sociocultural and physical environments. The following two main ecological perspective principles assist with the identification of health promotion intervention points: 1) Several levels of influence impact, and, in turn, are impacted by, behavior; 2) Individuals’ social setting influences, and, in turn, is influenced by, individual behavior (reciprocal causation). For explaining the first principle, McLeroy et al. (1988) cited the following 5 levels of influence with regard to health-related conditions and behaviors: (1) Individual or intrapersonal factors; (2) Organizational or institutional factors; (3) interpersonal factors; (4) public policy factors; and (5) community factors.
To practically address the level of the community necessitates considering public policy and organizational factors, besides societal norms and networks.
Intrapersonal factors
The most fundamental level is that of the individual; hence, planners need to effectively account for and guide individual behavior. Several healthcare providers dedicate the major part of their time at the workplace to face-to-face patient education or counseling. Further, individuals typically form the main target audience of health educational matter. As individual behavior constitutes the basic group behavior unit, individual-level behavioral modification models frequently integrate broader-level group, community, institutional and national behavioral models (Trickett, 2009). As individuals form groups, manage institutions, engage in policy-making and implementation, and vote for and appoint their political and institutional leaders, accomplishing institutional and policy modification necessitates influencing individuals. Besides exploring behavior, such individual-level models emphasize intrapersonal factors (that occur or exist within a person’s mind or self), which include beliefs, attitudes, knowledge, skills, motivation, prior experience, self-concept, and developmental history.
Interpersonal factors
Interpersonal-level health behavioral models maintain the assumption that people exist within their respective social environments, and are shaped by them. A person’s social environment comprises of family members, friends, colleagues, healthcare providers, etc. People’s behavior and feelings are shaped by the views, beliefs, conduct, guidance, and assistance of these persons surrounding them, and vice versa. Besides impacting behavior, those surrounding an individual influence their health as well. Several interpersonal-level theories exist, with the SCT (Social Cognitive Theory) (Trickett, 2009; US Department of Health and Human Services, 2014) being one among the most widely adopted and soundest health behavioral theories. It examines reciprocal individual and environmental interactions, and psychosocial factors governing health behavior.
Organizational/community factors
Group and community focused programs form the core of disease prevention- and control- linked public health strategies. Community-level theories examine the functioning and transformation of social systems, as well as how institutions and community members may be mobilized. They provide approaches which are effective in diverse settings including healthcare organizations, worksites, governmental organizations, schools, and community groups. These models embody the ecological perspective, effectively tackling individual, group, community and organizational problems. Communities are typically understood in terms of their geography; however, it is possible to define them based on other criteria as well (e.g., based on collective identity (such as Asian-Americans) or based on common interests (such as the scientific community)) (US Department of Health and Human Services, 2014). The planning of community-level initiatives necessitates familiarizing oneself with the distinctive traits of that community. This proves especially true when tackling health issues within culturally or ethnically diverse communities.
2. Design evidenced-based prevention and health promotion activities that can be implemented to decrease the health risk among your previously identified population.
The Community Guide or Guide to Community Preventive Services represents an evidence-based repository on what proves effective when it comes to public health. It presents various strategies for reducing diabetes mellitus type 2 (T2D) risks among the Asian-American community (Task Force on Community Preventive Services, 2005). This data may be utilized for selecting and designing an initiative corresponding to the ecological perspective and addressing the specific factors linked to T2D in the Asian-American population.
· Put combined physical activity and diet promotion initiatives into action for T2D prevention within the high-risk population. The initiatives may encompass coaching, counseling, or both combined.
· Come up with case management initiatives for coordinating and providing healthcare to all diabetics.
· Engage health workers from the community in prevention initiatives for better weight-related results and glycemic control within the high-risk community.
· Come up with intensive lifestyle programs for T2D-diagnosed persons for supporting diet change, better glycemic control, weight management, and consistent physical activity.
· Come up with team-based initiatives for facilitating T2D management and improvement in lipid, blood glucose, and blood pressure levels.
A combination of physical activity and diet promotion initiatives facilitate the reduction of new-onset T2D. Moreover, they improve cardiovascular and diabetes risk factors, such as obesity, elevated blood pressure, and elevated blood sugar. They aim at T2D prevention within the high-risk population. Lastly, they actively motivate individuals to engage in more physical activity and adopt a healthy dietary regime.
Team-based patient care represents an institutional, systems-level intervention assigning a multidisciplinary professional team for facilitating T2D self-management by patients. Individual teams comprise of patients, primary care practitioner (not a doctor, in all cases), and at least one other health professional. This team assists the patient with getting the right medical exams done, using medication for risk factor management, treatment adherence, and making healthy lifestyle and behavioral choices.
Interventions that engage health workers from the community for preventing diabetes improve weight-related results and blood glucose control among the high T2D-risk group. Community workers form the frontline workers in the public health arena functioning as the bridge between health systems and underserved populations. Initiatives can include lifestyle modification and diabetes prevention related education and counseling for high-risk individuals.
Rigorous lifestyle interventions aid T2D-diagnosed individuals in achieving improved glycemic control, in addition to decreasing cardiovascular disease risk factors. T2D patients receive guidance and advice for making physical activity and diet related modifications. Initiatives offer continuous coaching, counseling, or personalized advice on regular exercise or diet changes or both. However, this requires multiple patient-staff meetings for at least 6 months.
Proposed implementation strategy
The large-scale multicenter randomized control trial (RCT), titled the ‘Diabetes Prevention Program’ (n = 3234) represents the most robust evidence available at present for guiding T2D prevention within the US (Knowler et al., 2002). This initiative focuses on pre-diabetics and incorporates a sixteen-session curriculum dealing with the following lifestyle aspects: exercise, diet and behavioral modification. All sessions are conducted individually and face-to-face by the case manager who is qualified in motivational interview tactics (Nguyen et al., 2015). Further, 6 monthly follow-up sittings are conducted for reinforcing behavioral modification. The intervention’s chief objective is: at least 150 minutes of moderate weekly physical activity and 5-7 percent weight loss. Research results indicate the intervention decreased diabetes development by 58 percent (Knowler et al., 2002), with decade-long protective advantages.
The intervention would commence with educating primary healthcare workers on established prevention approaches potentially effective in case of Asian-Americans. The system will incorporate ‘immediate action’ for enhancing risk stratification and identification, risk reduction counseling, pharmacotherapy, and referrals to established community prevention initiatives. These improvements may be augmented through improved compliance with practice guidelines, preventive service reimbursement-related changes, and the promotion of ongoing diabetes prevention- connected medical education (Sallis et al., 2006; Green et al., 2012). ‘Strategic action’ may encompass more extensive preventive service reimbursement-related changes including reimbursement to community-based institutions and healthcare providers for referrals and urging state governmental undertaking and evaluation of broad prevention approaches for entire populations in the form of ‘natural experiments’. Relevant ‘research’ may concentrate on IT (information technology) targeted at identifying at-risk persons, facilitating economical evaluations and behavioral counseling, besides better linking clinics with community settings (Green et al., 2012; Whittemore, Melkus & Grey, 2004; Kegler et al., 2014).
Asian Americans’ diabetes prevalence rates and the role of risk factors common to a number of other chronic ailments necessitates interventions for addressing policy and environmental factors determining diet and physical activity (e.g., community design, recreation and park financing and policy, transport policy, laws on physical education at schools and nutritious foods’ prices) (Sallis et al., 2006). Strategic action may encompass multi-sector collaborations for advocating and evaluation environmental and policy changes. Studies in this domain may include cost-effectiveness research, public and lawmaker focused opinion polls regarding support for possible policy transformations, natural experiments for determining most practicable environmental and policy change intervention areas and systematic community intervention appraisal.
Attempts at improving care quality in diverse jurisdictions stress evidence-based care process and outcome measurements as the foremost step in externally as well as internally driven attempts at achieving quality improvement (Green et al., 2012). To healthcare practitioners and institutions, this information facilitates self-evaluation and focusing on areas requiring quality improvement. On the external level, this information has public reporting utility that can theoretically improve care through enabling healthcare consumers and purchasers to opt for top providers and providing providers the incentive to provider better quality care. Additionally, increasing efforts by American private payers and, of late, the CMS (Centers for Medicare and Medicaid Services) for rewarding superior-quality care through increased reimbursement (or ‘pay for performance) offers providers further financial incentive.
Hence, preventing and controlling ailments such as T2D appears to require the integration of care process and outcome related performance measures within private and governmental attempts at quality improvement for gauging care quality (e.g., the US NCQA’s (National Committee on Quality Assurance) HEDIS measures which evaluate managed care institutions’ care quality) (Green et al., 2012; Kegler et al., 2014). Evaluation would, logically, firstly be associated with patient counseling and screening with regard to risk factors that predict future diabetes onset. Individuals belonging to minority communities exhibit elevated diabetes risk, occasionally receive poor-quality care, and have worse outcomes. Thus, quality improvement attempts must especially ensure there aren’t any incentives for unintentional consequences. For instance, reforms ought not to pay smaller sums to institutions that provide care to especially challenging patients (e.g., patients with multiple comorbidities or advanced disease) (Kegler et al., 2014).
3. Identify the evaluation program you will use to determine the efficacy of your health promotion activities and in meeting the expected outcomes.
Efficient initiative assessment represents a systematic means of explaining and improving public health action to reduce T2D risks among the Asian-American community through involving practicable, valuable, appropriate and ethical procedures. The framework proposed was formulated for guiding public health practitioners in the use of initiative assessment. The non-prescriptive, practical tool aims at summarizing and organizing key initiative assessment elements (Linnan & Steckler, 2002). It is composed of effective evaluation practice steps and standards.

The framework constitutes 6 steps vital to all evaluations. They form the basis to tailor assessment to any given public health intervention at any given time. Owing to their interdependence, the steps may be encountered nonlinearly. But one can find an order for completing each steps; preceding steps offer the basis for advancement to the next step. Hence, decisions pertaining to step execution are iterative; they ought not to be finalized before comprehensively addressing preceding steps (Milstein & Wetterhall, 1999). The 6 steps mentioned above are:
Step 1: Stakeholder engagement
Step 2: Program description
Step 3: Assessment design focus
Step 4: Collection of credible proofs
Step 5: Conclusion justification
Step 6: Ensuring application and sharing of lessons learned
Compliance with the steps improves insights into initiative context (including its history, organization and setting) and how the majority of assessments are planned and implemented. The framework’s next aspect is a collection of thirty evaluation quality assessment standards grouped into the following categories:
Standard 1: utility,
Standard 2: feasibility,
Standard 3: propriety, and
Standard 4: accuracy.
The above Joint Committee on Standards for Educational Evaluation-based standards (Sanders, 1994) determine whether or not the evaluation will be effective. They are proposed as criteria to judge public health initiative evaluation quality.
Steps in Program Evaluation
1. Stakeholder engagement: A valid, accurate assessment forms the key objective for evaluators. Nevertheless, in the end, the soundest assessment will be one which helps beget action. Results must be relevant; they must facilitate future programming improvements. To achieve this, a key step is taking into consideration stakeholders or the audience for the evaluation (Milstein & Wetterhall, 1999). Identification of individuals invested in assessment questions and outcomes and their participation as assessment allies and resources is required.
2. Program description: The initiative’s cause-effect theory must be described and explored with initiative goals delineated and accepted, and measurable, concentrated evaluation questions formulated.
3. Assessment design focus: Assessment design may be decided upon by taking into account questions and resources on hand (including, human resources, funds, time, and data options). This step ought to involve weighing of multiple design alternatives for better understanding their advantages and drawbacks (particularly external and internal validity threats).
4. Collection of credible proofs: Information acquisition is crucial to supporting assessment recommendations and conclusions. Information acquisition technique and the information itself affects views on findings’ credibility and quality.
5. Conclusion justification: Evidence gathered and the ensuing data analyses may be used to aid in answering key research questions, besides creating recommendations and conclusions on the basis of findings.
6. Ensuring application and sharing of lessons learned: An assessment should primarily aim at being helpful, which necessitates communication and sharing of evaluation results. Stakeholders ought to be familiarized with the research process and findings, with efforts made towards ensuring results are integrated into initiative-related decisions (Milstein & Wetterhall, 1999).


References
Green, L. W., Brancati, F. L., Albright, A., & Primary Prevention of Diabetes Working Group. (2012). Primary prevention of type 2 diabetes: integrative public health and primary care opportunities, challenges and strategies. Family practice, 29(suppl_1), i13-i23.
Kegler, M. C., Swan, D. W., Alcantara, I., Feldman, L., & Glanz, K. (2014). The influence of rural home and neighborhood environments on healthy eating, physical activity, and weight. Prevention science, 15(1), 1-11.
Knowler, W.C., Barrett-Connor, E., Fowler, S.E., Hamman, R.F., Lachin, J.M., Walker, E.A. & Nathan, D.M. (2002). Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 346:393–403
Linnan, L., & Steckler, A. (2002). Process evaluation for public health interventions and research (pp. 1-23). San Francisco: Jossey-Bass.
McLeroy, K. R., Bibeau, D., Steckler, A., & Glanz, K. (1988). An ecological perspective on health promotion programs. Health education quarterly, 15(4), 351-377.
Milstein, B., & Wetterhall, S. F. (1999). Framework for program evaluation in public health. Center for Disease Control.
Nguyen, T. H., Nguyen, T. N., Taylor Fischer, W. H., & Tran, T. V. (2015). Type 2 diabetes among Asian Americans: Prevalence and prevention. World journal of diabetes, 6(4), 543.
Sallis, J. F., Cervero, R. B., Ascher, W., Henderson, K. A., Kraft, M. K., & Kerr, J. (2006). An ecological approach to creating active living communities. Annu. Rev. Public Health, 27, 297-322.
Sanders, J. R. (1994). The program evaluation standards: how to assess evaluations of educational programs. Sage.
Task Force on Community Preventive Services. (2005). The guide to community preventive services: what works to promote health?. Oxford University Press.
Trickett, E. J. (2009). Multilevel community?based culturally situated interventions and community impact: An ecological perspective. American Journal of Community Psychology, 43(3-4), 257-266.
US Department of Health and Human Services. (2014). Theory at a glance: A guide for health promotion practice. 2005. Washington: US Department of Health and Human Services Google Scholar.
Whittemore, R., Melkus, G. D. E., & Grey, M. (2004). Applying the social ecological theory to type 2 diabetes prevention and management. Journal of Community Health Nursing, 21(2), 87-99.