the public health approach to diabetes.14

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Diabetes was first identified as a publichealth problem in the 1970s.1 With dia-betes and prediabetes continuing togrow at unprecedented rates, addressingdiabetes as a public health concern is

even more important today. Yet the government,the media, and the general public have more read-ily accepted other diseases as public health issues2;for example AIDS, some forms of cancer, and thethreat of avian flu. In contrast, diabetes and otherchronic illnesses continue to be viewed as “clinical

diseases” and are more often managed by an acuteillness model. A clinical approach is inadequate tomeet the growing demand that diabetes is placingnot only on individuals but also on families, com-munities, and society. Diabetes treatment and pre-vention also require a population-based publichealth approach.

Glasgow and colleagues defined a public healthapproach to diabetes as “a broad, multidisciplinaryperspective that is concerned with improving out-comes in all people who have diabetes, with atten-tion to equity and the most efficient use of resources in ways that enhance patient and commu-nity quality of life.”2 For people with diabetes, med-ical issues are not the only area that requiresmanagement; lifestyle, family, psychosocial, cul-tural, and economic issues also need attention.

The Institute of Medicine (IOM) called for re-focusing attention on the three core functions of public health agencies3:

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The Public Health Approachto Diabetes

Community and system aspects.

By Ann Albright, PhD, RD

Ann Albright is director of the Division of Diabetes Translation,Centers for Disease Control and Prevention, Atlanta,and president of health care and education for the AmericanDiabetes Association. Contact author: [email protected] author of this article has no other significant ties, financial

or otherwise, to any company that might have an interest in the publication of this educational activity.

• assessment and monitoring of the health of com-munities and populations to identify healthproblems and priorities

• formulation of public policies designed to solveidentified local and national problems and prior-ities

• assurance that all populations have access toappropriate and cost-effective care, includinghealth promotion and disease prevention ser-vices, and evaluation of the effectiveness of thatcare

The IOM issued this call to action in 1988. Itremains as relevant today as it was almost twodecades ago.

The Ecological Model of Health Behavior (seeFigure 1, page 41) provides a framework for under-standing the multiple levels of influence on healthbehavior.4, 5 Its concentric rings describe four suchlevels; beginning at the core and moving outward,these are labeled: “individual,” “family, friends,small group,” “system, group culture,” and “com-munity and policy.” As one moves outwardthrough the rings, the influences upon healthbehavior become more complex, require more timeto change, and are more difficult to evaluate. Thisarticle examines diabetes care in terms of the twoouter levels of influence (system, group culture, andcommunity and policy) in terms of the three corefunctions named by the IOM.

ASSESSMENT AND MONITORING OF COMMUNITIES’

HEALTH

Assessment and monitoring of diabetes throughsurveillance data collected at the national, state,and county levels are necessary steps in definingand ultimately reducing the burden of diabetes.

Data sources for surveillance include vital statistics(for example, birth and death records), hospital

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records, health surveys, and registries (population-based and disease-specific).

A major source of surveillance data for monitor-ing diabetes prevalence and health care behaviorsis the Behavioral Risk Factor Surveillance Survey(BRFSS).6 This survey is administered annually inmost states, and the Centers for Disease Control andPrevention coordinates and monitors the survey andanalyzes the data. An additional surveillance tool,the California Health Interview Survey (CHIS), isadministered every two years to a larger, morediverse (both by ethnicity and by age) population inCalifornia.

The California Diabetes Program, part of theCalifornia Department of Health Services, recentlyproduced a report using CHIS data.7 The reportprovided information, organized by county, on dia-betes prevalence and the number of people withdiabetes who had had glycosylated hemoglobin(HbAIc) tests and foot exams. The report also pro-vided information on the number of people whowere overweight (body mass index of 25 or greater)or obese (body mass index of 30 or greater), whowere not physically active, and who did not eat therecommended five servings of fruits and vegetablesper day. Community organizations, local health

departments, and policymakers are using this infor-mation to set priorities for interventions.

Population-based survey tools such as the BRFSSand CHIS are vital for monitoring diabetes, but theyalso have limitations. Administered by telephone,they collect self-reported data, and they are expen-sive. Increasing the size and diversity of the sampleswould greatly improve the usefulness of the results.Adding more questions to the tools, particularlyconcerning diabetes prevention and family historyof diabetes, is also desirable. Advocacy and researchby nurses and other health care professionals canspur such improvements.

Diabetes is not a reportable disease, as cancerand AIDS are, so there is no national registry. Untilrecently, diabetes registries were disease-based andself-contained, used within health care systems tomonitor their own patient populations.

Recently, the New York City Department of Health and Mental Hygiene (NYCDOH) began torequire laboratories that serve patients within a des-ignated area of New York City to report all HbAIcdata (see AJN Reports, June 2006). The healthdepartment is collecting this information in a citygovernment–based registry. People can opt out of

this registry after they receive a letter informingthem of their results. Collected data also will be

shared with the patient’s physician. The NYCDOHbelieves the registry will help to monitor this popu-lation and improve outcomes.8 At the time of thiswriting, interventions that registry participants canaccess and use to improve their blood glucose con-trol were still under development. In various meet-ings, some people, especially those with diabetes,have expressed concerns about privacy issues andways the data will (or could) be used. The nursingprofession should closely follow this effort, in termsof both its potential to improve patient outcomesand issues regarding patient privacy.

FORMULATION OF PUBLIC POLICIES

Public policies on diabetes cover a broad range,from insurance coverage to school policies.Formulation of policies, which occurs at thenational, state, and local levels, brings in many dif-ferent perspectives. The challenge often lies in coor-dinating these perspectives to ensure that when apolicy is established, it is meaningful and useful.

Insurance coverage for diabetes supplies and edu-cation has improved during the last decade at thestate and national levels. Currently 46 states havesome coverage for diabetes supplies and education.9

The American Diabetes Association, the American

Association of Diabetes Educators, state diabetesprevention and control programs, and many inter-ested community constituents have contributed tosuccess in this area. But there are still gaps in cover-age. Nurses and other health care professionals needto work to obtain coverage for those without it, andthis must be accomplished without significantlyundermining current coverage. It is also importantto assess the level of diabetes self-managementtraining that actually results from state laws.

On the federal level, Medicare policies increasethe potential for more people to receive better cov-erage for diabetes testing supplies, diabetes self-management training, and medical nutritiontherapy. Continued evaluation of these policies willdetermine the extent to which Medicare recipientsare using benefits, what barriers exist (for example,lack of patient and provider awareness about thebenefits and reimbursement rates), and how best toovercome the barriers.

Policies that affect children with diabetes posegreat challenges for the nursing profession, espe-cially for school nurses. Technologies and medica-tions that enable better control of diabetes, alongwith clinical trial data that prove good diabetes

management prevents or diminishes chronic com-plications,6, 10 make it clear that children with dia-



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betes must be able to follow their treatment planssafely while in school or at school-related activities.School nurses are the most appropriate personnel tomonitor and supervise the health care of childrenwith diabetes at school.11 However, there is a short-age of school nurses in many communities nation-wide.12 Some states have passed legislation andothers are considering bills that provide for quali-fied health professionals to train lay volunteers inroutine and emergency diabetes care.11

IMPROVING ACCESS TO CARE THROUGH SYSTEM CHANGES

Over the last decade the public health perspective

on diabetes treatment and prevention has focusedon changing health care delivery systems and con-necting them to communities, especially through theChronic Care Model (see Figure 1, “The ChronicCare Model,” in “Diabetes Care: The Need forChange,” page 14). This model summarizes thebasic elements for improving care in health systemsat the community, organization, practice, andpatient levels.13 Health systems that are adopting theChronic Care Model are making significant contri-butions to the way care is delivered.

One of the best examples is the HealthDisparities Collaboratives, which includes a dia-

betes collaborative, organized by the Bureau of Primary Health Care (BPHC). A division of the U.S.Department of Health and Human Services, theBPHC oversees programs that, as of 2004, offeredhealth care to 13.1 million underinsured and unin-sured people through more than 1,000 BPHC-funded health centers.14 Eighty-eight health centersjoined the diabetes collaborative in the first phase,and another 115 joined in the second phase. Thiscollaborative is using three different models: a learn-ing model, the Chronic Care Model (referred to bythe collaborative as the planned care model), and animprovement model.15 One goal of the diabetes col-laborative is to increase the number of patients whohave two HbAIc tests per year. Early results indicatethat the overall percentage of patients meeting thisgoal, for all models combined, was 300% greaterthan before the collaborative began.16

Renders and colleagues conducted a systematicreview of interventions to improve diabetes man-agement in primary care, outpatient, and commu-nity settings.17 A total of 41 studies met the inclusioncriteria; 12 used interventions targeting health careprofessionals, 9 targeted organizations of care, and20 targeted both. Organizational interventions that

used a computerized database and follow-upreminders improved processes of care. Interventions

that added patient education or that gave nurses agreater role in diabetes management led to improve-ments in patient outcomes and processes of care.

A study comparing nurse-directed care and usualcare in blacks and Hispanics at three clinics in LosAngeles found significant improvements in HbAIclevels in the groups that received nurse-directedcare.18 In addition, nurse-directed care resulted inmore frequent performance of most process meas-ures, including measurement of HbAIc every sixmonths, eye exams at least annually, and foot examsat least biannually. Other work in high-risk ethnicpopulations and underinsured groups also showedimproved process and outcome measures forpatients with diabetes when community healthworkers teamed with nurses.19

The use of the Chronic Care Model and theimplementation of interventions, led either bynurses or by nurses and community health workersin tandem, are part of progressive changes by healthcare systems to improve the care and outcomes of patients with diabetes. Such projects require com-mitment from many people within health care sys-tems, who must be willing to work collaboratively

and devote time to learning sessions. Data collectionand reporting pose additional challenges.

FIGURE 1. Ecological Model of HealthBehavior

Community and policy

System,group culture

Family, friends,

small group

Individual(biological,

psychological)

Copyright © 2002 American Diabetes Association, from Fisher EB, et al.Diabetes Care 2002;25(3):599-606. Reprinted with permission from TheAmerican Diabetes Association.



42 AJN June 2007 Vol. 107, No. 6 Supplement http://www.nursingcenter.com/ajndiabetes

REFERENCES

1.Vinicor F. Is diabetes a public-health disorder? Diabetes Care1994;17 Suppl 1:22-7.

2.Glasgow RE, et al. If diabetes is a public health problem,why not treat it as one? A population-based approach tochronic illness. Ann Behav Med 1999;21(2):159-70.

3. Institute of Medicine: Committee for the Study of the Futureof Public Health. The future of public health. WashingtonDC: National Academies Press; 1988.

4.Stokols D. Translating social ecological theory into guidelinesfor community health promotion. Am J Health Promot 1996;10(4):282-98.

5.Fisher EB, et al. Behavioral science research in the preventionof diabetes. Diabetes Care 2002;25(3):599-606. http:// care.diabetesjournals.org/cgi/reprint/25/3/599.

6.UCLA Center for Health Policy Research. California Health

Interview Survey. The Regents of the University of California. http://www.chis.ucla.edu/about.html.

7.Gary HE, et al. Diabetes in California counties: prevalence,risk factors and resources: California Department of HealthServices: California Diabetes Program; 2005.

8.Steinbrook R. Facing the diabetes epidemic—mandatoryreporting of glycosylated hemoglobin values in New YorkCity. N Engl J Med 2006;354(6):545-8.

9. American Diabetes Association. Expanding health coverage and fighting rollbacks. The Association. http://www.diabetes.org/ advocacy-and-legalresources/state-legislation/healthinsurance.jsp.

10.Nathan DM, et al. Intensive diabetes treatment andcardiovascular disease in patients with type 1 diabetes.N Engl J Med 2005;353(25):2643-53.

11.American Diabetes Association. Safe at school statement

of principles. The Association. http://www.diabetes.org/ advocacy-and-legalresources/discrimination/ safeatschoolprinciples.jsp.

12.National Association of School Nurses. HANDS: helping administer to the needs of the student with diabetes inschool. The Association. http://www.nasn.org.

13.Wagner EH. Chronic disease management: what will it taketo improve care for chronic illness? Eff Clin Pract 1998;1(1):2-4.

14.Health Resources and Services Administration. Bureau of Primary Health Care Home page. U.S. Department of Healthand Human Services. http://bphc.hrsa.gov.

15. Health Resources and Services Administration. HealthDisparities. Collaborative Models for changing practice.http://www.healthdisparities.net/hdc/html/about.hdcModels.aspx.

16.Health Resources and Services Administration. HealthDisparities Collaborative Home page. http://www.healthdisparities.net.

17.Renders CM, et al. Interventions to improve the manage-ment of diabetes in primary care, outpatient, and communitysettings: a systematic review. Diabetes Care 2001;24(10):1821-33.

18.Davidson MB. Effect of nurse-directed diabetes care in aminority population. Diabetes Care 2003;26(8):2281-7.

19.Philis-Tsimikas A, et al. Improvement in diabetes careof underinsured patients enrolled in Project Dulce: acommunity-based, culturally appropriate, nurse case manage-ment and peer education diabetes care model. Diabetes Care2004;27(1):110-5.

The Public Health Approach to Diabetes

LEARNING OBJECTIVES: After reading this article and taking this test (answercoupon on page 75), you will be able to• outline the issue of diabetes as a public health problem.• identify the various initiatives that have led to improvements in diabetes

care.

1. Diabetes was not recognized as a public health problem until the

a. 1950s. c. 1970s.b. 1960s. d. 1980s.

2.Today, diabetes is more often managed by a (an)a. managed-care model.b. public health approach.c. population-based approach.d. acute illness model.

3. In the Ecological Model of Health Behavior, which of the followinginfluences health behavior?

a. the culturalb. the individualc. the economicd. the psychosocial

4.The Behavioral Risk Factor Surveillance Survey (BRFSS) monitorsdiabetes surveillancea. in addition to health care behaviors.b. in the state of California primarily.c. based on data collected biannually.d. by local public health agencies.

5.What is a limitation of population-based tools like the BRFSS?a. They’re administered by mail.b. They’re difficult to analyze.c. They collect self-reported data.d. They have too many questions.

6.There is no national diabetes registry because the disease is nota. controllable.b. communicable.c. terminal.d. reportable.

7. In addition to the Chronic Care Model, the Health DisparitiesCollaboratives uses 2 other models, one of them based on

a. processes.b. improvement.c. analysis.d. complications.

8. One goal of the diabetes collaborative is to increase the number ofpatients who have

a. 2 glycosylated hemoglobin tests per year.b. 1 foot exam per year.c. 2 eye exams per year.d. 1 complete physical per year.

TEST CODE: AJND5

TEST

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