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Improving Outcomes for Diabetes in African Americans: Lessons Learned for REACH Charleston and Georgetown Diabetes Coalition. Carolyn Jenkins, DrPH , APRN-BC, RD, FAAN Ann Darlington Edwards Chair and Professor Medical University of South Carolina phone: 843-792-4625

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Improving Outcomes for Diabetes in African Americans: Lessons Learned for REACH Charleston and Georgetown Diabetes Coalition

Carolyn Jenkins, DrPH, APRN-BC, RD, FAAN

Ann Darlington Edwards Chair and Professor

Medical University of South Carolina

phone: 843-792-4625


goals for today
Goals for Today

Review diabetes statistics.

Share some processes and outcomes from community-based participatory research and service learning.

Review an expanded chronic care model for improving outcomes in African American communities.

Explore needed community changes.

diabetes is the fifth deadliest disease in the u s and its prevalence is increasing




Diabetes is the Fifth Deadliest Disease in the U.S. and Its Prevalence is Increasing




7 to 9.6%


U.S. Prevalence

(% of population)

Lifetime Risk if Born in 2000








African Americans:




Sources: American Diabetes Association: Economic Costs of Diabetes in the U.S. in 2002. Diabetes Care. 2003;26:917-932.

Venkat Narayan KM, Boyle JP, Thompson TJ, Sorensen SW, Williamson DF. Lifetime risk of diabetes mellitus in the United States. JAMA. 2003;290:1884-1890.

American Diabetes Association: Diabetes Statistics for African Americans. Available at: Accessed March 14, 2005.

American Diabetes Association: Diabetes Statistics for Latinos. Available at: Accessed March 14, 2005.

how serious is diabetes



How Serious Is Diabetes?

It predictably affects both lifespan and quality of life



Age at diagnosis:

11 - 13

12 - 17

Lost # of life years:

Lost # of quality-adjusted life years:

21 - 24

18- 20

Source: Venkat Narayan KM, Boyle JP, Thompson TJ, Sorensen SW, Williamson DF. Lifetime risk of diabetes mellitus in the United States. JAMA. 2003;290:1884-1890.

the burden of diabetes is greater for minority populations in the united states
The Burden of Diabetes Is Greater for Minority Populations in the United States

Diabetes affects:

10.8% of African Americans

10.6% of Hispanics

6.2% of Whites

Diabetes in African Americans

Sources: American Diabetes Association: Diabetes Statistics for African Americans. Available at: Accessed March 14, 2005.

American Diabetes Association: Diabetes Statistics for Latinos. Available at: Accessed March 14, 2005.

Mokdad AH, Ford ES, Bowman BA, et al. Diabetes trends in the U.S.: 1990-1998. Diabetes Care. 2000;23:1278-1283.

  • 2.7 million (11.4%) over age 20
    • 60% higher than in whites
  • Higher complication rates
    • 2X as likely to suffer lower-limb amputations
    • 2X as likely to suffer from diabetes-related blindness
the financial impact of diabetes is staggering
The Financial Impact of Diabetes Is Staggering

Total Health Care Costs in 2007

Per capital costs averaged $11,744

Diabetes: $132B

Direct Expenditures: $92B

Indirect Expenditures: $58B

  • Lost workdays
  • Restricted activity days
  • Mortality
  • Permanent disability




Diabetes Care

Related Complications

OtherMedical Care

Source: American Diabetes Association: Economic Costs of Diabetes in the U.S. in 2007. Diabetes Care. 2008;31,1-20.

diabetes costs
Diabetes Costs
  • Annual health care costs for people with diabetes: $11,744.
  • One of every 5 health care $ spent caring for person with diabetes.
  • One of every 10 health care $ is attributed to diabetes.
    • Costs for people with diabetes 2.3 X higher than those without diabetes.

Diabetes Care 2008

south carolina statistics
South Carolina Statistics
  • In 2005 BRFSS:
    • 10.3% reported they had diabetes
      • African Americans (15.4%)
      • Non-Hispanic Whites (8.4%)
    • Insulin treated (29.5%)
    • “Pills” (72.9%)
    • A1C test in past year (77%)
    • Never had A1c (23%)
    • Diabetic eye disease (21.7%)
    • No insurance and/or no doctor (~18%)
      • African Americans (26.6%)
      • Non-Hispanic whites (15.1%)

Risk Factors Among African Americans in SC

Current Overweight Sedentary HBP Diabetes High

Smoker Obesity Lifestyle Cholesterol

  • Diabetes in SC:
  • Two-thirds of people with diabetes
  • die of heart disease and stroke
  • 1 of every 7 African-Americans has
  • diabetes, which is 80% higher than
  • rate for non-Hispanic whites.
diabetes in african americans in south carolina
Diabetes in African Americans in South Carolina
  • In Charleston and Georgetown Counties, 21% of African Americans reported having diabetes (2005 RRFS)
  • Rural African Americans with diabetes:
    • 60.6 % have inadequate control versus 42.5% of urban whites (SC BRFSS)

Disease risk, diagnosis, progression of disease, response to treatment, caregiving, and overall quality of life are all affected by a number of variables including race, ethnicity, gender, socioeconomic status, age, education, occupation, country of origin, and perhaps other lifetime and lifestyle differences.


DIABETES-ATLAS Conceptual Model

National Minority Health Month Foundation (2007)


Percentage of the 2005 Population

Diagnosed with diabetes

1994 present

CBPAR Activities and Diabetes Management

enterprise neighborhood health program 1994 1998
Enterprise Neighborhood Health Program (1994 – 1998)

HUD Grant with Charleston’s Enterprise Community to

a) recruit and train community leaders to become Community Health Advocates;

b) conduct needs assessment.

Needs assessment identified diabetes and HTN as priority issues.

61 community health advisors trained.

Video documenting needs and assets using community voices

AKA Summer Enrichment Program for children

diabetes initiative of south carolina
Diabetes Initiative of South Carolina
  • 1994—Report to SC Legislature on “Scope and Problems of Diabetes in SC”
  • Funding by State Legislature to create Center to address diabetes in SC
    • Center of Excellence at MUSC
      • Professional Council
      • Outreach Council
      • Surveillance Council
  • Annual Report on activities and outcomes to South Carolina Legislature and Governor

Enterprise Health Center

1995 - 2001

Donation of Lot

Building Completed

Opened November 2001

Now a FQHC site (FCFFHC)



  • An educational methodology based on a community-campus partnership which combines student community service with explicit learning objectives.  Students participating in service-learning are not only expected to provided direct community service but also to learn about the context in which the service is provided, and to understand the connection between the service and their academic coursework.

Seifer 1998

service learning with students
Service Learning with Students

>700 students (MUSC, Clemson,

Howard, USC, Rhode Island, UNC)

7 Doctoral Candidates/Graduates

6 Certified Diabetes Educators

7 doctoral dissertations

3 masters thesis

20 regional or national presentations

10 peer-reviewed publications

healthy south carolina hypertension and diabetes management and education program had me
Healthy South Carolina Hypertension and Diabetes Management and Education Program (HAD-ME)

Health care team conducted weekly screening, management, and education clinics (with linkages to primary care) in inner-city neighborhoods (1997-2001)

> 900 community residents with diabetes and/or hypertension participated.

> 1,100 referrals to primary care

Significant decreases in BP, blood glucose, and weight


REACH 2010: Charleston And Georgetown Diabetes Coalition’s Efforts to Decrease Disparities for Diabetes

Arlene Case-The Lesson


A heath disparity population is “a population where there is significant disparity in the overall rate of disease incidence, prevalence, morbidity, mortality, or survival rates in the population as compared to the health status of the general population”1.

Minority Health and Health Disparities Research and Education Act of 2000


REACH 2010: Charleston and Georgetown

Diabetes Coalition



Region 6





  • Statewide REACH home-based
  • in Columbia:
  • Communicare
  • Carolina Center for Medical Excellence




CORE Group

East Cooper Community Outreach

S. Santee

St. James

Senior Center

Enterprise Health


Enterprise Community





St. James

Santee Health


TriCounty Family


Trident United


Alpha Kappa

Alpha Sorority


Region 7

Franklin C. Fetter


Health Center






Diabetes Initiative

College of Nursing

methods and interventions
Methods and Interventions

Community skill-building and neighborhood clinics

175 lay educators trained

Diabetes self management education

Foot care training

Wise Woman for AA women 40-70 years old

Community health professional training

145 RNs with advanced foot/wound education

27 physicians with foot care education

Outreach by professional and lay educators

30 minute TV program aired 34 times on cable

Library program/Internet use

Weekly diabetes management classes in 8 sites

Health systems change

Registry and reminder system

CQI teams

Coalition building and policy change


Community and Media Activities reached >40,000 African Americans

Neighborhood Walk and Talk


Community Screening and Education

Skill-Building for

CHAs and Volunteers

Individual and Group Education Sessions


Percent with > Annual A1c by Race

(increased from 76.8% in 1999 to 97.1% in 2006)


Percent with > Annual Lipid Profile by Race

(increased from 47.3% in 1999 to 87.2% in 2006)


Percent with Kidney Testing

(microalbuminuria) by Race

(increase from 13.4% in 1999 to 56% in 2006)


Percent with > Annual Foot Exam

by Race (increased from 64.1% in 1999

to 97.3% in 2006)


Percent with BP < 130/80 by Race

(increased from 24% in 1999 to 38.2% in 2006)


Percent of Visits with Teaching by Race

(increased from 41% in 1999 to 93% in 2006)

Although studies documenting disparities are not in short supply, findings about what works to reduce disparities are. A 3-year, $6-million program called Finding Answers: Disparities Research for Change, sponsored by the Robert Wood Johnson Foundation, seeks to identify effective interventions to eliminate disparities.

Under the direction of Marshall Chin, MD, MPH, an associate professor of medicine at the University of Chicago Pritzker School of Medicine, the program reviewed more than 200 journal articles on disparity reduction interventions in cardiovascular disease, depression, diabetes, and breast cancer. The results appeared in October 2007 in a supplement to Medical Care Research and Review.

One of the few studies in the review that showed a reduction in racial disparities was part of the Racial and Ethnic Approaches to Community Health (REACH 2010) program, sponsored by the US Centers for Disease Control and Prevention in Atlanta, Ga. The demonstration program, which took place in Charleston and Georgetown counties in South Carolina, brought together 28 community partners, from health professionals to college sororities and local media, that set goals to improve diabetes care for blacks as well as eliminate health care disparities between black and white patients with diabetes.

The partners documented disparities in care for 12,000 black patients with diabetes in the 2-county community. The intervention included such community activities as health fairs, support groups, grocery store tours, community clinics, and church-based educational programs. After 24 months, the partners audited medical charts for 158 black patients and 112 patients who were white or of other racial or ethnic groups. They found that differences between black and white patients in rates of hemoglobin A1c testing, lipid and kidney testing, eye examinations, and blood pressure control that had ranged from 11% to 28% at baseline had been eliminated (Jenkins C et al. Public Health Rep. 2004;119[3]:322-330).

Chin is optimistic that other communities will develop their own, similar

programs in the future. "There are a lot of promising models," he says.

"But you may have to revise as you go along, just like in patient care."

Quote from R. Voelker in JAMA  2008;299(12):1411-1413.


REACH US:SouthEastern African American Center of Excellence for Eliminating Disparities for Diabetes


reach us center of excellence
REACH US Center of Excellence

A coordinated multi-system, multi-media, intergenerational approach to prevention and control of diabetes and its cardiovascular complications to eliminate health disparities in African Americans at risk and with diabetes.


Geographical Areas: African Americans with Diabetes and Stroke in

North Carolina,

South Carolina


what is needed to improve diabetes care and outcomes in african americans in south carolina

What is needed to improve diabetes care and outcomes in African Americans in South Carolina?

iom s 8 competency areas
IOM’s 8 Competency Areas



Cultural competence


Community based participatory research


Policy and law

Global health

Gebbie et al. (2001)

evidence based practice
Evidence-Based Practice
  • Practice supported by research findings and/or demonstrated as being effective through a critical examination and review of current and past practices. EBP integrates patient preferences with research evidence, to determine best course of action to improve health.

Listen to the StoriesWhile the stories are being told, don’t offer solutions too early!! Work together to identify the issues and develop the solutions.


Go to the people.Live among the people.Learn from the people.Work with the people.Start with what the people know.Build on what the people have.Teach by showing, learn by doing.Not a showcase but a pattern.Not odds and ends, but a system.Not piece meal, but an integrated approach.


Determinants of Health

from National Academy of Sciences, Epidemiology Review 2004;26:124-125

Life Course

Social & Economic Policies



Living Conditions

Social Relationships

Individual Risk Factors

Genetic/Constitutional Factors

Pathophysiologic Pathways

Individual and Population Health



Chronic Care Model


Health System

Health Care Organization

Resources and Policies


Self-Management Support







Practice Team






Improved Outcomes

Wagner, E. H. (1998). Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice(1), 2-4.


Care man. roles

Practice team

Care coordination

Proactive follow-up

Planned visit

Visit system changes

Leadership support

Provider participation

Coherent system QI


Provider education

Expert support

Patient education

Patient activation

Self-management assessment

Self-management resources

Collaboration on decisions

Guidelines to patients

For patients

For community


Info for care management

Performance data

A Model for Chronic Illness Care

Health System Organization








Clinical InformationSystems

Links to Community Resources

Adapted from: Wagner, E. H. (1998). Chronic disease management: What will it take to

improve care for chronic illness? Effective Clinical Practice(1), 2-4.


World Health Organization Social Ecology Adaptation of Wagner’s Chronic Care Model

  • Notice the added community involvement
  • Still low on patient, family & social network participation or accounting for sociocultural variations
  • Taken from Epping-Jordan, J., Pruitt, S., Bengoa, R., and Wagner, E. (2004). Improving the quality of health care for chronic conditions. Quality and Safety in Health Care, 13, 200-305. doi:10.1136/qshc.2004.010744

External Environment,1 Resources, and Dissemination influences:

Health Care Provider Systems

Community Resource Systems2

Prepared, Proactive Health


Prepared, Proactive Community


Community Information System


Information System

Informed, Activated Persons

Community & Service System Design

Delivery System Design



Policies & Actions Social,

Health, &


Community Decision Support

Clinical Decision Support

Patient Self-Management Support

Self-Management Support

Improved Community-Wide Health Outcomes and Elimination of Health Disparities

Conceptual Model for REACH US:

Charleston and Georgetown Diabetes Coalition

(adapted from Jenkins et al., Barr et al. , Wagner)

1 Environment is viewed through an ecological framework and includes social, political, and economical aspects.

2 To categorize the various community resource systems, we use the Community Systems Wheel (Anderson and McFarland, 2006). The systems include: Health and Social Services, Politics and Government, Safety & Transportation, Education, Communication, Economics, Recreation, and Physical Environment. We added Faith-based Services.

community based participatory action research
Community-Based Participatory Action Research
  • A collaborative approach to research that equitably involves all partners in the research process and recognizes the unique strengths that each brings. CBPR begins with a research topic of importance to the community, has the aim of combining knowledge with action and achieving social change.

WK Kellogg Foundation Community Health Scholars Program

fundamental characteristics of cbpar
Fundamental Characteristics of CBPAR
  • It is:
    • participatory.
    • cooperative, engaging community members and researcher(s) in a joint process with both contributing equally.
    • a co-learning process.
    • an empowerment process through which participants can increase control over their lives.
fundamental characteristics of cbpar1
Fundamental Characteristics of CBPAR
  • It involves systems development and local community capacity building.
  • It achieves a balance between research and action.

(Israel et al. 1998)

  • It involves sharing of funding among partners (usually equally).

Identified Challenges for Communities and Academic Institutions

  • Understanding cultures
    • Community culture
    • Academic and institutional culture
  • Differing philosophies.
  • Sharing of budgets in an equitable way.
  • Clearly defining and continuously implementing our principles for the partnership in a fair and equitable way.
instructions for community for partnering with academic institutions look for people that
Instructions for Community for Partnering with Academic Institutions--Look For People that:
  • Begin their discussions with you by asking questions, rather than offering solutions.
  • Recognize the gap between measuring differences and making differences.
  • Demonstrate a willingness to help you measure the differences you make.
  • Share control over financial resources and decisions with community representatives.
  • Express commitment to a working relationship built on trust and equity.

Prev Chronic Dis. 2004 January; 1(1): A12.

common characteristics of successful community institutional partnerships
Common Characteristics of Successful Community-Institutional Partnerships
  • Trusting relationships
  • Equitable processes and procedures
  • Diverse membership
  • Tangible benefits to all partners
  • Balance between partnership process, activities, and outcomes
  • Significant community involvement in scientifically sound research (Continued on next slide)

Seifer, 2006

common characteristics of successful community institutional partnerships1
Common Characteristics of Successful Community-Institutional Partnerships
  • Supportive organizational policies/reward structure
  • Leadership at multiple levels
  • Culturally competent and appropriately skilled staff and researchers
  • Collaborative dissemination
  • Ongoing partnership assessment, improvement and celebration
  • Sustainable impact

Seifer, 2006

recommendations for emerging and established partnerships
Recommendations for Emerging and Established Partnerships
  • Pay close attention to membership issues
  • Build on prior history of positive working relationships
  • Obtain support and involvement of both top leadership and “front line” staff of partner organizations
  • Embrace diversity in the partnership
  • Decide who the “community” is and who “represents” the community.

Seifer, 2006

recommendations for emerging and established partnerships continued
Recommendations for Emerging and Established Partnerships (continued)
  • Develop rationale, criteria and procedures for adding new partners
  • Develop structures and processes that facilitate the development of trust and sharing of influence and control among partners
  • Jointly develop partnership principles and operating procedures
  • Jointly create mission, vision, and priorities for the partnership

Seifer, 2006

recommendations for emerging and established partnerships continued1
Recommendations for Emerging and Established Partnerships (continued)
  • Strive to achieve an equitable distribution of costs, benefits, and resources among the partners
  • Conduct ongoing evaluation of partnership process
  • Build the capacity of all partners
  • Plan ahead for sustainability
  • Pay close attention to the balance of activities within the partnership
  • Be strategic about dissemination

Seifer, 2006

build capacity of all partners
Build Capacity of All Partners
  • Facilitate partner training, technical assistance and continuing education
  • Invest partnership resources in local community
  • Establish and maintain partnership infrastructure

Seifer, 2006

cultural humility
“A life long commitment to self evaluation and self critique” to redress power imbalances and “develop and maintain respectful and dynamic partnerships with communities”

Tervalon & Garcia, 1998

Cultural Humility:

Assets in Community

From: Kretzmann & McKnight. (1993) Building Communities from the Inside Out


Identifying Natural Community Leaders

  • When you have a problem, who do you go to for advice?
  • Who do others go to?
  • When people in the neighborhood have come together around a problem in the past, did a particular individual or group play a key role?
  • What things do people tell you you’re good at?

Eng et al, 1990; Israel, 1985; Sharpe, 2000

insider outsider tensions
Insider-Outsider Tensions
  • Power dynamics; the “power of authority” of the outsider’s often multiple sources of unspoken privilege (Wallerstein, 1999)
  • Conflicting time tables & demands
  • Differential reward structures (Minkler, 2006)

“We want to know how much you care, before we know how much you know.”

Alma Joseph Flores

Enterprise Community

  • A strategic combining of resources that create power far beyond the capabilities of individual players working alone.
thanks to our team and to you
Thanks to Our Team (and to you)!

REACH Community Partners and Staff

Gayenell Magwood, Barbara Carlson, Jane Zapka, Martina Mueller, Leonard Egede, Marilyn Laken, Montrese Edwards, Virginia Thomas, Joyce Linnen, Lee Moultrie, Sonja Smalls, Syndia Moultrie, Karen Hill, George Bush

REACH Partners Coaltion

Charleston Diabetes Coalition

Georgetown Diabetes CORE Group

Diabetes Initiative of South Carolina

Dr.John Colwell

Dr. Kathie Hermayer

Dr. Dan Lackland

Dr. Brent Egan

Pamela Arnold

SC Diabetes Prevention and Control Program

Centers for Disease Control and Prevention

National Institutes of Health-NIDDK

American Diabetes Association