Diabetes in the Asian Indian Population of Plainsboro New Jersey

Windshield Survey of Diabetes in the Asian-Indian Community in Plainsboro, New Jersey: Planning, Implementation, and Evaluation

As the home to the second-largest population of Asian-Indians in the United States today (the first is another nearby small community, Edison, New Jersey) (Sahney, 2010). Out of a population of around 23,500, 16.97% of the residents of Plainsboro (or about 4,000) describe themselves as having Indian ancestry (Sahney, 2010). Although Plainsboro enjoys a high standard of living, a desirable community environment and state-of-the-art medical facilities, it is reasonable to suggest that some of the Asian-Indian population in this community remain marginalized due to an inability to afford these state-of-the-art health care services and the potential for cross-cultural differences in views about health care may further exacerbate this lack of access.

A growing body of evidence also indicates that Asian-Indians are among the highest-risk populations for developing diabetes, making this community an especially important target for public health interventions. To this end, this paper provides a windshield survey of the Township of Plainsboro, New Jersey to identify salient characteristics, including the demographic composition of the community, representative views of the community's attributes, and a description of a public health initiative that is designed to raise awareness among the Asian-Indian population of Plainsboro concerning the need for regular testing for diabetes and what changes in their lifestyle can help reduce the potential for their developing diabetes. Finally, a summary of the windshield survey and important findings concerning public health interventions for the Asian-Indian population in the United States in general and in Plainsboro, New Jersey in particular are presented in the conclusion.

Introduction

Established in 1919, the Township of Plainsboro, New Jersey (hereinafter alternatively "Plainsboro" or "the Township") has been transformed from a sleepy, rural community into a vibrant, upscale community today (Brooks, 2004). Originally called the "Borough of the Plains" or "The Plains," the first U.S. Post Office eventually changed the name to Plainsboro (Brooks, 2004). The Township was established following the selection of the site as the home for an innovative certified dairy farm in 1897, which produced some of the only available high quality infant formulas available at that time (Brooks, 2004). The Township's transformation into its modern suburban form began when this company ceased operations in 1971 (Brooks, 2004). Although transformed, Plainsboro remains a highly desirable place to live, work and recreate because of this heritage. In this regard, Brooks points out that, "Today, with Princeton University as its largest property owner, Plainsboro is a quality suburban community that retains much of its agricultural and open-space heritage" (2004, p. 8).

A windshield survey of this community confirms these observations, and there is a general consensus among civic leaders and residents alike that the Township is a bucolic oasis in a sea of urbanity. For instance, according to the township's Web site, "Plainsboro Township is a highly desirable community that has successfully balanced economic growth and open space preservation. Home to renowned corporations and award-winning schools, Plainsboro residents enjoy an exceptional quality of life" (About Plainsboro, 2015, para. 1). In fact, New Jersey Monthly magazine designated Plainsboro as "one of the top ten Best Places to Live" in New Jersey as [one of its] premier suburban communities" (About Plainsboro, 2015, para. 2).

Unlike many highly urbanized communities, Plainsboro enjoys an extensive public parks network, including the Plainsboro Preserve, a 1000-acre facility that features walking trails, healthy wetlands, a 50-acre lake, and large areas of forest that serve as a natural habitats for the region's flora and fauna (About Plainsboro, 2015). Other community resources include an expansive environmental education center operated by New Jersey Audubon, a world-class public library system, and a new recreation and cultural center for senior residents of Plainsobor (About Plainsboro, 2015). In addition, this community boasts some of the best public schools in the state (among the top five highest SAT scores in New Jersey) and nearly all (96%) of high school graduates enter college (About Plainsboro, 2015). In addition, Plainsboro enjoys an average family income of $163,415 (Plainsboro Village Center, 2015) and the Township's careful planning in the past has provided the community with a strong economic base today, open spaces that account for more than half of the Township's land, and a wide range of housing opportunities for budgets of all sizes (About Plainsboro, 2015).

Some representative views of Plainsboro that confirm its upscale qualities are presented in Figures 1 and 2 below.

Figure 1. Plainsboro Village Center

Source: http://sharbell.com/sites/default/files/plainsborovillagecenter.gif

Figure 2. Plainsboro Village Center Sidewalk View

Source: http://www.njfuture.org/wp-content/uploads/2011/05/Plainsboro_for_web.jpg

In addition, in 2011, a new $441 million hospital opened in Plainsboro on a 160-acre health care campus as depicted in Figure 3 below.

Figure 3. University Medical Center of Princeton at Plainsboro (part of the Bristol-Myers Squibb Community Health Center complex)

Source: http://blog.nj.com/ledgerupdates_impact/2008/10/large_UMCP1.JPG

Given its numerous aesthetic qualities and mature infrastructure, it is not surprising that many immigrants have made their home in Plainsboro, including about 4,000 residents who described themselves as having Indian ancestry (Sahney, 2010). According to Sahney, many Asian-Indians "prefer to live in Plainsboro because they point out that it has good schools" (2010, p. 40). This means that Plainsboro has the second largest community of people from India in United States, topped only by Edison, another town in New Jersey (Sahney, 2010). Moreover, the Indian-Asian population in Plainsboro has increased even further over the past decade or so due to expatriate assignments to the United States from information technology firms in India (Sahney, 2010).

The Asian-Indians living in Plainsboro are among more than 1.5 million individuals of Asian-Indian ancestry currently living in the United States, the majority of whom came to America within the last 50 years or so during the third wave of extensive immigration during the 1960s (Sheehan, 2001). On the one hand, many of the Asian-Indians that have relocated to the United States have prospered more than other demographic groups while on the other hand, they have still encountered the same types of racially and ethnic-based discrimination and hatred that linger in the American consciousness (Sheehan, 2001).

Moreover, despite their large numbers, Asian-Indians have frequently been ignored in the public health care research (Sheehan, 2001). According to Sheehan, though, "Two themes hold New Jersey's diverse Indian-American population -- together. As they strive for success, they struggle for acceptance. As they embrace America, they hold on to India. These thematic threads -- individual economic achievement coupled with American racism, cultural transition alongside Indian tradition" (2001, p. 118).

In support of these assertions, Sheehan cites the example of a "typical" Asian-Indian to underscore how these issues have impacted these individuals in their efforts to assimilate into mainstream America. In this regard, Sheehan (2001) reports that, "Changes in Indian culture in New Jersey occur among people who frequently see themselves as atypical, and they place the process of cultural assimilation in the United States within a larger context of personal and cultural transformation" (p. 118). The observations also suggest that there are some powerful cross-cultural issues involved in how these Asian-Indians view the available health care services in Plainsboro as well as their need for them.

These are important issues because Asian-Indians are among the highest risk group for contracting diabetes. A combination of the aforementioned cultural issues, lack of knowledge about diabetes, and lack of financial resources often cause Asian-Indians to ignore the health care system or not adhere to a prescribed medication or lifestyle regimen (Chandras & Eddy, 1999). Assuming receipt of a 3-year, $300,000 grant to address this problem, the following sections outline a feasible community collaborative intervention to address the gaps in care and services for this priority problem among the Asian-Indian population of Plainsboro.

Review and Analysis

Identification of a problem from the community diagnosis list and rationale for selection

Some demographic groups are more genetically susceptible to developing diabetes than others, and Asian-Indians appear to be at double the risk of the global population for diabetes (Pantalone & Hobbs, 2015). This inordinately high prevalence rate has been attributed to increasingly sedentary lifestyles combined with high intakes of fat, sugars and simple starches that are characteristic of Asian-Indian foods (Anderson, 2014). In fact, the prevalence of diabetes is also increasing rapidly in India (Anderson, 2014). Indeed, a growing body of evidence indicates that Asian Indians are at much higher risk of developing Type 2 diabetes compared to the general American population (Li, 2009). In this regard, Misra (2014) emphasizes that, "Asian Indians are markedly prone to developing diabetes" (p. 37).

In addition, the American Diabetes Association (ADA) reports that different body mass indexes (BMIs) should be used for Asian-Indians compared to their Caucasian counterparts in the United States, with a lower BMI cut-off of 23 (Mohan, 2014). This recommendation is based on "what researchers and experts have long been maintaining - that the Asian, and particularly south Asian, population comprising Indians, Bangladeshis and Pakistanis are more vulnerable to diabetes even with a lower BMI" (Mohan, 2014, p. 7). In fact, even a BMI cut-off score of 23 represents a danger sign of diabetes for Asian-Indians and physicians recommend the use of the BMI calculation approach set forth at Appendix A for this population (Mohan, 2014). Although additional research in this area is needed, what is known for certain today is that Asian-Indians require culturally appropriate diabetes testing regimens. In this regard, Mohan emphasizes that, "We have been working on BMI specifically for Asian Indians for nearly 15 years and on various international fora for diabetes and obesity it was agreed and accepted that there is a need for a lower BMI cut-off to prevent the diabetes epidemic" (2014, p. 7). The need for culturally sensitive public health interventions for Asian-Indians was also the focus of a study published by the American Diabetes Associates in January 2015 wherein it was recommended that:

Asians, as against their white counterparts, must screen for diabetes after reaching the BMI of 23. South Asian, Chinese, and black subjects developed diabetes at a higher rate, at an earlier age, and at lower ranges of BMI than their white counterparts. Our findings highlight the need for designing ethnically tailored prevention strategies and for lowering current targets for ideal body weight for non-white populations. (cited in Mohan, 2014, p. 7)

Likewise, a study by Fernandez and Everett (2015) found that ethnic-specific prevalence of diabetes ranged from 6-7% among the normal weight to 19-33% among the Asian-Indians who were obese versus non-Hispanic whites in the United States. Based on their findings, Fernandez and Everett concluded that Asian Indians are at increased risk and there is a need for culturally sensitive strategies that extend beyond the health sector should be developed to target lifestyle changes in this high risk population (Fernandez & Everett, 2015). The results of a study by Edwards (2014), though, indicate that many American clinicians are not using culturally sensitive communication approaches in diabetes management, making the need for improved cultural competencies among health care providers even more important as discussed further below.

Short-term and long-term goals and outcome objectives

The short-term goals of the diabetes initiatives envisioned herein will be as follows:

To identify, with specificity, the current prevalence level of diabetes among the Asian-Indian population of Plainsboro to establish the extent of the problem.

To raise public awareness of the fact that Asian-Indians are at high risk of developing diabetes to reinforce the need for timely testing and health care interventions when appropriate.

To educate health care providers in Plainsboro concerning the large percentage of Asian-Indian residents living there and the need for culturally sensitive communication approaches.

To provide a clearinghouse of information for Asian-Indian residents in Plainsboro concerning recent research into diabetes among this population and what community-based resources are available to them.

The long-term goal of this initiative will be to reduce the benchmarked prevalence rate of diabetes among the Asian-Indian population of Plainsboro by 50% within 3 years using the community-based approach described below.

Three-year community-based, community participatory interdisciplinary plan for Plainsboro, New Jersey

The following 3-year initiative draws on support from Plainsboro civic leaders, including the mayor, board of commissioners and business leaders. In addition, prominent members of the Asian-Indian community will also be recruited for their support.

Description of culturally-appropriate and age-appropriate programs. At present, the author is working with an age group of 45- to 64-year-old adults in the Plainsboro community. A culturally and age-appropriate program for this population would include a series of monthly community-based one-hour workshops sponsored by the Plainsboro branches of the Juvenile Diabetes Foundation and American Diabetes Association conducted in conferences rooms in the public library system would provide Asian-Indian residents with the opportunity to learn more about their high risk and what they should do for themselves and their families with respect to diabetes. Finally, a Diwali festival ("festival of lights") will be held each year in October or November to coincide with the celebration in India to promote public awareness of the diabetes problem among this population. Because this festival is intended to represent the triumph of good over evil, it is an especially appropriate venue to promote improved health care among the Asian-Indian residents of Plainsboro.

Incentives for attending programs. Authentic Indian cuisine will be offered at each event. In addition, attendees at the one-hour workshops will receive a free tee-shirt and coffee mug featuring a "Fight Diabetes" logo, and attendees at the Diwali festivals will receive free information packets about diabetes and what steps they should be taking to ensure optimal testing regimens are followed. Because many of the Asian-Indian adult residents in Plainsboro are on temporary expatriate assignment from the home firms in India, the incentives will remain the same from year to year since there will likely be a new group of attendees during the pendency of this initiative.

A media campaign that would work in your target community. With just $100,000 a year to cover all of the expenses of this initiative, it will be important to use cost-effective media campaign techniques. For this purpose, the initiative will provide information to the Asian-Indian residents of Plainsboro through a Web site, community newspaper, the Plainsboro Senior Spirit Newsletter (monthly), bulletin board flyers and other print and digital media including social media networks such as Facebook and Twitter concerning the need for glucose testing for diabetes for all Asian-Indian residents every 2 years based on recommendations from the American Diabetes Association (Perry, 2000). The social media networks will include an interactive feature that provides an ongoing survey concerning diabetes awareness and allows Asian-Indian residents of Plainsboro to self-report being tested for diabetes. This media campaign will also include a description of the planned events noted above, their dates, times and locations, as well as the incentives that will be offered for attendance.