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THE ROLE OF EDUCATION IN IMPROVED SELF-MANAGEMENT 1

The Role of Education in Improved Self-Management of Type II Diabetes in Hispanics

Presented in Partial Fulfillment of the Requirements for the

Doctor of Nursing Practice

Catherine McCauley School of Nursing

College of Health Professions at Maryville University

By

Kristin Washington

Graduate Program in Nursing

Maryville University

December 2018

DNP Scholarly Project Committee:

Capstone Chair: Dr. Cathy Hogan

Capstone Committee Member: Dr. Michele Libman


Table of Contents

AbstractSetting and Resources ....................................................................................................... 3

Introduction and Background .......................................................................................................... 4

Problem Statement ........................................................................................................................... 6

Objectives and Aims ........................................................................................................................ 7

Significance …………………………………………………………………………………….…7

Benefit to Practice …………………………………………………………………………….... 10

Literature Search ……………………………………………………………………………...…11

Review of Literature ...................................................................................................................... 12

Theoretical Model ......................................................................................................................... 12

Project and Study Design .............................................................................................................. 23

Needs Assessment ...................................................................................................................... 24

Setting and Resources ............................................................................................................... 25

Study Population ........................................................................................................................ 26

Sources of Data .......................................................................................................................... 27

Data Analysis ............................................................................................................................. 28

Quality ....................................................................................................................................... 29

Ethics and Human Subjects Protection ...................................................................................... 33

Timeframes or Timeline ............................................................................................................ 34

Budget ........................................................................................................................................ 35

Risks and Benefits …………………………………………………………………………….36

Strengths and Weaknesses of the Study…………………………………………………….….36

Conclusion ..................................................................................................................................... 39

References ..................................................................................................................................... 41

Appendix ....................................................................................................................................... 45

Basic APA, 6th ed., Citation Styles ............................................................................................ 45


Abstract

Diabetes Mellitus Type 2 is an identified healthcare epidemic across our world today

which is growing at an alarming rate each year. Diabetes Mellitus Type 2 is a chronic and

progressive illness which affects a significant number of our adult populations, and

unfortunately, a rising number of children and adolescents. The incidence of Diabetes Mellitus

Type 2 in the Latino and Hispanic culture is common due to a diet which is high in refined

carbohydrates. There is typically little emphasis placed on the importance of daily exercise or

obesity prevention methods. Many factors, including lifestyle, socioeconomic status, access to

care, and cultural beliefs, contribute to these high percentages of people living with this chronic

health condition. Increased self-management of Diabetes Mellitus Type 2 is critical to help fight

this growing health epidemic, and a rigorous teaching initiative is required to help fight the

spread of this illness.

An identified area of need for the prevention of further disease progression and the

related health complications associated with Diabetes Mellitus Type 2 in the Hispanic

community was to address the lack of education within this cultural group. Many Hispanic

Americans are unaware of the severity of this illness, and often, are not provided with any useful

literature or teaching tools to help promote their successful self-management of this disease. The

purpose of my scholarly project was to examine the effectiveness of a health clinic-based

diabetes self-management education program for Hispanic Americans, which is grounded in

culturally adaptive care strategies and which attempted to show significant improvement in

glycemic control and Hemoglobin A1c levels within a six-weeks.

Keywords: Diabetes Mellitus Type 2, Hispanic, Education, Self-management


Introduction

Diabetes Mellitus Type 2 is a growing global healthcare epidemic which is affecting a

significant amount of our adult populations, and unfortunately, a rising number of children

across the world. Diabetes is a chronic illness which is increasing in incidence among the

general population and is increasing at an even higher rate among ethnic and racial minorities

with predisposing risk factors such as obesity, family history, insulin resistance, glucose

intolerance, and gestational diabetes (Cruz, Hernandez-Lane, Cohello & Bautista (2013).

Diabetes, considered by many as the public health crisis of the century, affects nearly 9%

of U.S. adults and the prevalence of diabetes has increased more than 60% from 2005 to 2015

(Center for Disease Control [CDC], 2015). Latinos, the fastest-growing minority group in the

United States, are among the hardest hit by the diabetes epidemic with the prevalence of diabetes

in Latinos at approximately 10% (Vincent, 2009). Among people of Hispanic ethnicity,

Mexicans had the highest prevalence (13.8%), followed by Puerto Ricans (12.0%), Cubans

(9.0%), and Central/South Americans (8.5%) (CDC, 2015).

Diabetes Mellitus Type 2 was the sixth leading cause of death in the United States in

2015 (CDC, 2015). Diabetes is a chronic, metabolic disease characterized by macrovascular and

microvascular complications along with the dysfunction of fat and protein metabolisms because

of the complete or partial deficiency of insulin secretion or insulin resistance at different levels

(American Diabetes Association [ADA], 2012). Uncontrolled blood glucose levels are the

underlying problem in individuals with Diabetes Mellitus Type 2 and elevated sugar levels

correlate directly to more significant risks for the development of cardiovascular diseases,

nephropathy, neuropathy, lower extremity diseases, amputations and visual impairment (World

Health Organization [WHO], 2011).


The incidence of acquired Diabetes Mellitus Type 2 is enhanced by an individual’s poor

weight management, lack of cardiovascular exercise, and poor dietary habits, which exists

mainly in Latin American culture. Many factors, including lifestyle, socioeconomic status,

access to care, and cultural beliefs, contribute to these high percentages of people living with this

chronic health condition. The increasing prevalence of diabetes and the growing focus on its

prevention require strategies for providing people with knowledge, skills, and strategies they

need and can use (Burke, Sherr & Lipman, 2014).

Diabetes Mellitus Type 2 is a chronic and progressive illness which can lead to many

long-term health conditions if it is not addressed and corrected promptly. Health guidelines

recommend that individuals learn strategies to self-manage their diabetes but getting people to

adopt required lifestyle changes is challenging, and many people are not able to prevent their

diabetes from escalating, nor are they capable of controlling their glucose levels (Page-Reeves et

al., 2017). Increased self-management of Diabetes Mellitus Type 2 is critical to help fight the

growing health crisis and will require a substantial teaching initiative to help progress the

knowledge of the identified high-risk populations (Page-Reeves et al., 2017).

Culturally competent self-management programs can significantly improve diabetes

outcomes, and different models for culturally relevant programming have been developed to

guide the Hispanic culture group towards enhanced wellness (Page-Reeves et al., 2017).

Considering the observed links between support resources for disease management and diabetes

self-management and the well-established connection between self-management and glycemic

control illustrates that the relationship between social-environmental support resources for

disease management and glycemic control may be explained by an indirect effect via diabetes

self-management (Fortmann, Gallo & Philis-Tsimikas, 2011). The significance of this project is


for the Advanced Practice Nurse to work towards improving overall Diabetes Mellitus Type 2

education, awareness, lifestyle choices, and improved self-management for the enhanced health

and well-being of the Hispanic population.

Problem Statement

Diabetes Mellitus Type 2 in the Hispanic and Latin-based communities is becoming a

rapidly growing health condition which is further perpetuated by a lack of knowledge

surrounding the importance of self-management, as well as the associated health risks which

could develop because of poorly controlled diabetes. Many Hispanic Americans are unaware of

the severity of this illness and often are not provided with any useful literature or education tools

to help promote their successful self-management of this disease. The incorporation of socio-

cultural based diet and lifestyle behaviors, as well as increasing physical activity and improving

weight loss for individuals living with Diabetes Mellitus Type 2, is of critical importance to the

Latino community.

The purpose of this scholarly project was to examine the effectiveness of a health clinic-

based diabetes self-management education program for Hispanic Americans, which is grounded

in culturally adaptive care strategies for the identified population group. Investigating Diabetes

Mellitus Type 2 in the Hispanic population can address the potential benefits of incorporating a

culturally based educational program into the daily practice of healthcare providers to promote

autonomy and improved knowledge for Hispanic Americans living with this condition. The

research question associated with this scholarly project asks: In a selected group of Type II

Diabetics from a predominantly Hispanic and Latino-based community, what is the effect of a

diabetes education program for participants chosen on their overall glycemic control and related

self-management behaviors within a six weeks?


Objectives and Aims

An identified area of need for the prevention of further disease progression and related

health complications from Diabetes Mellitus Type 2 in the Hispanic community is to address the

lack of education within this cultural group. Many Hispanic Americans are unaware of the

severity of this illness, and often, are not provided with any useful literature or teaching tools to

help promote their successful self-management of this disease. The purpose of my scholarly

project is to examine the effectiveness of a health clinic-based diabetes self-management

education program for Hispanic Americans, which is grounded in culturally adaptive care

strategies which will attempt to show significant improvement in glycemic control and

Hemoglobin A1c levels within a six-weeks.

Significance

Nursing

The significance of nursing care in the management of Diabetes Mellitus Type 2 displays

profound importance for patient education which may help to prevent diabetes-related

complications. Aghakhani, Nia, Ranjbar, Rahbar, and Beheshti (2012) suggest patient education

is an essential nursing practice standard that meaningfully impacts a patient's health and quality

of life. A holistic-based approach to patient teaching in the prevention of Diabetes Mellitus Type

2 will allow for recognition of ethnic, religious and gender-specific beliefs as it pertains to

dietary changes, meal planning for the family, weight loss recommendations, and overall

lifestyle choices.

Nurses embody an unspoken sense of self which allows for the growth of interpersonal

relationships and trust which can ultimately motivate and inspire change in a population. The

pattern of knowing for ethical knowledge draws upon the moral compass of nursing practice and


the duty of doing the right thing for humankind. It the responsibility of a healthcare provider to

reach the underserved and minority population within my community the dangers and health

risks associated with the development of Diabetes Mellitus Type 2. Although this disease can

often be prevented by improved lifestyle choices, it remains an obligation to provide education

regarding both the risk factors for developing Diabetes Mellitus Type 2, as well as the risks to

your body long-term once you have been diagnosed. Nurses have a profound role in the care of

Latin Americans diagnosed with Diabetes Mellitus Type 2 as they can teach their patients the

proper behaviors to follow which can help to advance their awareness.

Healthcare

The significance of a culturally appropriate Diabetes Mellitus Type 2 education program

which can enhance the ability of patients to take action in their health management is imperative

to create change in the Latin American community. As the Mexican American population

increases, the number of Mexican American patients seen in primary care practices will also

increase (Vincent, 2009). The integration of critical aspects of the Latin American culture in

diabetes teaching programs can assist in successful diabetes self-management interventions

which may positively impact self-management behaviors (Vincent, 2009). The focus of the

teaching initiative in healthcare must remain centered upon the well-being of patients. The

paradigm of diabetes management has shifted to focus on empowering the person with diabetes

to manage the disease successfully and to improve their quality of life (Burke et al., 2014). In the

aspect of nursing, patient teaching is an efficient and direct method for all members of the

healthcare team to begin making changes towards reducing the growing epidemic of Diabetes

Mellitus Type 2 patients within our society.


Advanced Practice Nursing

The significance of this scholarly project in advanced nursing practice is to identify the

role of culturally appropriate education within the Hispanic population towards the improvement

of self-management behaviors and improved glycemic control for Type II Diabetic individuals.

While there is substantial evidence to support the positive effect of diabetes self-management on

glycemic control, achieving and maintaining adequate self-management behaviors may be

challenging for Mexican Americans due to low literacy, inadequate levels of health literacy,

poverty, language barriers, and barriers to culturally relevant patient care (Vincent, 2009).

The goal of improved health status for the Latin American community is derived from a

recognized need for culturally sensitive patient education which may bridge the knowledge gap

and guide individuals towards improved lifestyle choices. This teaching initiative is significant

to advanced practice nursing as the effects of strengthening knowledge for this chronic health

condition may help to prevent illness, improve quality of life, and prolong the average lifespan

for Hispanic patients living with Diabetes Mellitus Type 2. Teaching individuals about the

prevention, development, and treatment of Diabetes Mellitus Type 2 includes educating about

multiple components of the disease process. Involved in the education process is the necessity of

following a well-balanced diet, the need for regular cardiovascular exercise, the importance of

maintaining a healthy Body Mass Index, certain foods and behaviors to avoid, and of course,

treatment goals for living with Diabetes Mellitus Type 2 if this condition is to develop

throughout the lifespan.

Practice Support for Project

The practice setting is a community health clinic which provides Internal and Family

Medicine for all local county employees and their dependents. Primary Care providers diagnose


and medically manage a lot of pre-diabetes and Diabetes Mellitus Type 2 in our country.

Utilizing this type of practice environment supported the scholarly project by providing the

context upon which the proposed research was built. This research consisted of a voluntary

subject study with participants who are Hispanic and have a diagnosis of Diabetes Mellitus Type

2 with the intent of evaluating the effectiveness of a culturally appropriate educational program

on patient’s overall glycemic control through increased self-management of their illness.

Participants were recruited from the current patient population, and implied consent was

obtained for permission from prospective subjects, before starting the research initiative. A pre-

test and post-test survey was conducted using the Diabetes Self-Management Questionnaire to

evaluate the participants’ levels of self-awareness and accountability for their health and

diabetes management, along with a pre-test Fasting Blood Glucose level and a Hemoglobin A1c

checked at the clinic. Once the survey was completed during the initial visit, an IRB approved

diabetes education packet was reviewed during our appointment. Participants were given a copy

of this packet with culturally appropriate literature, and meal planning for home review and

weekly email updates were sent directly to the subject’s work email portals to share recipe ideas

and weekly strategies for success. Participants were given eight weeks to work on their

improved self-management using the educational tools and then were brought in to the clinic for

follow up. At the post-intervention follow up, the Diabetes Self-Management Questionnaire was

re-administered and Fasting Blood Glucose levels, along with Hemoglobin A1c levels, were re-

checked for evaluation. Through the research conducted in this practice setting, the benefits of

culturally appropriate education on the improvement in self-management and glycemic control

for Hispanic Americans with Diabetes Mellitus Type 2 was analyzed for significance to future

practice.


The Benefit of Project to Practice

This scholarly project will benefit my current practice setting by providing our clinic with

an established educational tool for current and future patients who are in need of diabetes

education. Many Hispanic patients who come into the clinic for diabetes management are in

need of patient teaching which is customized for their cultural beliefs and practices. As a

healthcare provider, the benefits of having an available literature packet for use during office

visits can help to guide patients towards improving their diabetes self-management by making

positive therapeutic lifestyle changes. Patients can utilize this literature at home to share their

knowledge with their family members and to encourage diet changes through the use of dietary

education on carbohydrates and sugars in the diet. One of the most significant obstacles for

minorities with chronic illness is the availability of culturally sensitive and adaptive educational

resources to help guide their self-management behaviors. Advanced practice nurses have a

responsibility to provide education and awareness to our patient population regarding illness

prevention, health maintenance and illness management which can will promote improved

wellness and quality of life throughout the lifespan.

Literature Search

To find relevant evidence which supported and strengthened my literature review,

I conducted an advanced search utilizing the CINAHL database through the Maryville Student

Library. I performed this search looking for available, full-text PDF articles only. Filters were

used to restrict my research criteria such as specifically peer-reviewed sources, current articles

from the past five years, scholarly journals published in academic literature sources, and English

language only articles for ease of reading and reference. A search was performed using the


essential terms of diabetes education, self-management, Hispanic culture, cultural diabetes care,

Diabetes Mellitus Type 2, and diabetes teaching. This search yielded 127 articles in the database

from the selected criteria. Inclusion criteria for the review included chosen publications which

featured diabetes education initiatives for a Hispanic population group. Articles that were

focused on other culture groups, such as African Americans, Asians, or Native Americans were

excluded from the selected literature. Publications that focused solely on diabetes complications,

medications, or diabetes prevention were not considered for this literature review. After

reviewing the inclusion criteria, thirty-eight articles were selected for further analysis and

possible inclusion in this project.

Review of Literature

Diabetes Mellitus Type 2 in the Hispanic and Latin-based communities is becoming a

rapidly increasing health condition which is further perpetuated by a lack of knowledge

surrounding the importance of self-management and the associated health risks. This literature

review is focused upon the synthesis of related evidence to my research question: In a selected

group of Type II Diabetics from a predominantly Hispanic and Latino-based community, what is

the effect of a diabetes education program for participants chosen on their overall glycemic

control and related self-management behaviors within a defined period. The incorporation of

culturally relevant strategies which will encourage accessible patient education and teaching to

facilitate improved self-management of Diabetes Mellitus Type 2 is the core foundation of my

DNP capstone. Three themes which have emerged naturally from the analysis of the

incorporated literature include cultural beliefs and awareness regarding lifestyle choices, obesity

and lack of physical activity, and low literacy and income levels within the Hispanic community.

These three themes will be utilized as supporting evidence to enhance and guide the development


of this Literature Review and to emphasize further the overall purpose of improving support for

diabetes awareness and self-management in the targeted population.

Cultural Beliefs and Awareness

The cultural beliefs and practices which exist within the Hispanic community play a

predominant role in the development of Diabetes Mellitus Type 2 for this ethnic population.

Nurse Practitioners working with the Hispanic community must consider the importance of

critical cultural concepts and tailor messages to fit the culture to more effectively assist those

with diabetes in improving self-management behaviors (Vincent, 2009). Efforts to reduce

cultural and linguistic barriers in health care are necessary to increase the likelihood that

Hispanic adults will perceive and experience quality health care services in the United States (De

Jesus & Xiao, 2013).

Taking time to understand and respect cultural beliefs of the Latin American community

may assist the practitioner in managing the fear by working in tandem with a patient’s value

system and a healthcare practitioner’s biomedical experience (Heuman, Scholl, & Wilkinson,

2013). Health care practitioners can explore ways to educate Hispanic communities on healthier

alternatives within culturally based diets to assure communities that they can be healthy while

maintaining cultural practices and traditions (Heuman et al., 2013). By using cultural-based

education in promoting improved self-management of Diabetes Mellitus Type 2, the outcomes

for patient’s health and the improvement in overall glycemic control cannot be overlooked.

The relevant literature for this scholarly project is focused on the use of education to

increase self-management strategies in Diabetes Mellitus Type 2 care, which will ultimately

function to improve glycemic control and advance health outcomes for the Hispanic population.

Self-management strategies are developed, shaped and influenced by sociocultural environments,


as well as by knowledge of how one’s body responds to behavioral changes (Benavides-Vaello,

Brown, & Vandermause, 2017). Family and children are central components in most Hispanic

cultures including Mexican Americans, in which, familial support and the inclusion of family in

diabetes education and self-management programs result in better health outcome (Benavides-

Vaello et al., 2017).

The Mexican American culture places a strong emphasis on the family unit, and any

lifestyle adjustments will often require the commitment of the entire family to keep each other

following a healthier lifestyle plan together. Unfortunately, much of the Hispanic culture places

a great deal of attention on food and gathering together for large, traditional meals which can be

predominantly rice, beans, tortillas, and corn. These traditions can be hard to get away from for

many Type II Diabetics, and when teaching the Mexican American community, the healthcare

provider must be sensitive to cultural practices. Diabetes self-management education (DSME) is

a clinical practice intended to improve preventive practices and behaviors with a focus on

decision-making, problem-solving, and self-care (Rutledge, Masalovich, Blacher, & Saunders,

2017).

A series of educational materials were created for promoters to teach a group of

Hispanics about diabetes and healthy eating habits (Cruz et al., 2013). The teaching projects

included a training manual, a flip chart, a diabetes brochure, a bingo game, cups and spoons, and

a health basket which was designed to facilitate practical community talks, targeting Hispanics

and their families (Cruz et al., 2013). With the help of community workshops and increased

education, these targeted populations can get the information they need to make appropriate

lifestyle choices. Culturally relevant strategies were also found to be an essential part of

successful interventions which Hispanic bilingual community health workers delivered diabetes


self-management programs within (Valen, Narayan & Wedeking,2012). At the conclusion of

these studies, the findings suggest there was a significant improvement in diabetes knowledge

among diabetic participants through a culturally sensitive and linguistically appropriate program

which serves as an effective instructional approach to delivering diabetes education in the

Hispanic population (Valen et al., 2012).

Kline et al. (2016) used traditional cultural methods for treating illness and provided

diabetes counseling which resonated with Hispanic audiences and ultimately fostered perceived

self-efficacy related to following recommendations given about healthy lifestyle changes for

diabetes self-management. Clients commonly cite diet, exercise, and medication as a treatment

for diabetes (Lopez, 2006). Others mentioned the combination of traditional therapy and western

medical strategies effective treatments with traditional remedies such as nopal (cactus), sabila

(aloe vera), Espina de pochette (silk cotton tree), Chaya (tree spinach), arnica (arnica), and

aguade violeta (violet water). The biomedical system and folk beliefs influence beliefs about

diabetes, and the authors suggest that intervention programs should acknowledge and reinforce

aspects of both biomedical and folk beliefs to improve adherence to health recommendations

(Lopez, 2006).

The core of participant’s cultural understanding of diabetes is based on personally

relevant events and behaviors rather than emphasizing biomedical-based construction (Lopez,

2006). The goal of health practitioners is to negotiate various ways to increase self-efficacy

while also respecting patient responses that might be interwoven with their cultural beliefs,

practices, and values (Heuman et al., 2013). By using these associated findings, there is a

significant amount of literature to support the role of self-management strategies towards

improvement in health outcomes for Type II Diabetics within the Latin American community.


Obesity and Lack of Physical Activity

Diabetes is the leading cause of death among Mexican-Americans, Puerto Ricans, and

Cuban-Americans with only half of the actual diabetes cases clinically diagnosed in Latino

Americans due to cultural, educational, linguistic, financial and institutional barriers (Cruz et al.,

2013). According to the 2009–2010 National Health and Nutrition Examination Survey, 37.9 %

of Hispanics and 39.6 % of Mexican-American are obese (Cruz et al., 2013). Obesity-related

diseases are leading sources of health care expenditures in the United States; simple obesity

significantly increases a person’s risk for developing diabetes, and higher incidence rates among

Hispanic populations leads to a high percentage of Hispanic people who are obese that will

develop diabetes during their lifetime (Heuman et al., 2013). After reviewing relevant

population data, a three-tiered predisposition or vulnerability to diabetes can be identified—

heredity; preferences for unhealthy, culturally based food; and temptations from U.S. mainstream

fast food culture (Heuman et al., 2013).

Because of the overwhelming obesity rates in the Latin American community, strategies

have been created to help address the issues surrounding Diabetes Mellitus Type 2 and other

related co-morbid health concerns. One of the most promising, evidence-based methods for

disease education at the community level is an outreach model with community workers to

improve self-efficacy (Cruz et al., 2013). The community outreach programs highlighted in the

associated literature all emphasized increasing diabetes self-management through appropriate

teaching initiatives. To promote self-management of diabetes, all participants developed a

personal action plan including AlC, weight, and physical activity goals (Valen et al., 2012). The

interventions incorporated in the research to target obesity and the need for increased activity and

exercise were tailored appropriately for the Hispanic patient population.


Dancing is an integral part of Hispanic culture. Therefore, physical activity was promoted

through dancing, walking, and using ethnic music (Valen et al., 2012). The Hispanic culture

often incorporates dance into family events and parties, which is an excellent opportunity to

involve the family unit into diabetes education and self-management teaching strategies. The

family–disease management relationship is further influenced by patient education, social class,

and acculturation. Programs that incorporate aspects of the patient’s family in the design and

implementation of intervention programs need to be considered for practical outcomes (Fisher et

al., 2000).

Increasing cardiovascular exercise is an essential area of focus for diabetes education

programs which can attempt to foster improved self-management behaviors. In Vincent’s (2009)

study, activity levels were measured with a pedometer, as walking is a no-cost method of

exercising that can be done anytime and anywhere. Because a primary focus of the intervention

was to increase physical activity and to walk, all intervention participants were given a

pedometer and taught how to use it and record the number of steps walked each day (Vincent,

2009). Participants were given tips on increasing activity through low-cost activities that can be

performed within the home. Inexpensive activities included engaging in household chores, chair

exercises, they were given demonstrations on stretching and shown how to use soup cans for

strength training, as all of these are low-cost activities, and most can be performed within the

home (Vincent, 2009). These exercise initiatives were presented to the Type II Diabetic

participants as methods of losing weight, getting cardiovascular exercise and helping to reduce

blood sugar through natural means. Study results showed the mean number of participants steps

increased from 4175 to 7238 per day, which proves the significance of the intervention (Vincent,


2009). The implementation of culturally sensitive methods to increase physical activity and to

promote weight loss can help to reduce obesity and improve overall diabetes control.

Cultural dietary factors pose real barriers to Hispanics living with Diabetes Mellitus Type

2. Patient-centered diabetes intervention programs using strategies of empowerment and

improved self-efficacy can enable beneficial lifestyle changes (McCloskey & Flenniken, 2010).

Self-management strategies that reflect the cognitive, emotive, and behavioral areas of the

Mexican-American culture include the categories of (a) environmental controls, (b) avoiding

overeating, (c) lifestyle changes, (d) cooking tips, and (e) active self-management (Benavides-

Vaello et al., 2017).

Programs aiming to improve diabetes self-management and health outcomes in Hispanics

with Diabetes Mellitus Type 2 should consider multilevel, social, and environmental influences

on health, behavior, and emotional well-being (Fortmann, Gallo, & Philis-Tsimikas, 2011).

Participants claimed that they had been ignorant of the poor nutritional value of the Hispanic

diet, which includes a preponderance of tortillas, beans, and meat, rather than fruits and

vegetables (Heuman et al., 2013). Environmental controls were associated with managing food

challenges in the home and social environment, such as the grocery store. These approaches

included making burgers and tacos at home versus buying them from a restaurant (fast food or

local eatery), going to the grocery store alone and avoiding aisles with unhealthy food sale items,

and removing temptations from home (Benavides-Vaello et al., 2017).

Traditional family gatherings and family traditions serve as barriers to improving

Diabetes Mellitus Type 2 management for culture-sensitive individuals, and alternative strategies

must be developed for success in self-efficacy. Rather than insisting that traditional foods be


eliminated, alternative methods of preparation emphasized portion sizes, and suggestions for the

addition of fruits and vegetables to the diet may prove helpful (McCloskey & Flenniken, 2010).

Patients should start small and gradually increase daily or weekly behavior targets regarding

healthier eating, increased physical activity, and the development of related behavior skills

(Koenigsberg & Corliss, 2017). The opportunity to educate the Latin American community on

proper diabetes approved diet choices, the role of healthy weight management, and the need for

awareness surrounding Diabetes Mellitus Type 2 lifestyle behaviors must not be overlooked.

Action to improve education and self-management behaviors surrounding Diabetes Mellitus

Type 2 can achieve positive health outcomes for the identified culture group living with this

chronic illness.

Low Literacy and Self-Efficacy

The cultural beliefs and lifestyle practices which exist within the Hispanic community

play a predominant role in the development of Diabetes Mellitus Type 2 for this ethnic

population. The growing economic and social burden of diabetes among Hispanics calls

attention to the need for alternative approaches in how self-management guidance can influence

diabetes outcomes (Benavides-Vaello et al., 2017). Nurse Practitioners working with the

Hispanic community must consider the importance of critical cultural concepts and tailor

messages to fit the culture to more effectively assist those with diabetes in improving self-

management behaviors (Vincent, 2009). Extensive cross-cultural provider training in medical

schools to overcome provider-patient cultural barriers, and an increase in the number of Spanish-

speaking health professionals to overcome communication barriers, are important

recommendations to increase the perceived quality of health care for Hispanic adults (De Jesus &

Xiao, 2013).


Providing culturally sensitive education to the Hispanic population is a critical

component when considering the need for teaching strategies to encourage self-efficacy in

diabetic patients. The self-management education program applies the principles of the Diabetes

Empowerment Education Program (DEEP), which seeks to train community health workers to

provide diabetes education to members of their community by using interactive activities and

learning (Cruz et al., 2013). Training health workers on the importance of cultural sensitivity is

necessary before addressing a possible community group with lower literacy rates and the

potential for communication barriers.

With the help of community workshops and increased education, targeted populations

can get the information they need to make significant lifestyle choices. Culturally relevant

strategies were also found to be an essential part of successful interventions which Hispanic

bilingual community health workers delivered diabetes self-management programs within (Valen

et al., 2012). There was a significant improvement in diabetes knowledge among diabetic

participants through a culturally sensitive and linguistically appropriate program which serves as

a useful instructional approach to delivering diabetes education in the Hispanic population

(Valen et al., 2012).

Much of the Latin American population within the United States today consists of

individuals who may live at or below the poverty line, possibly with combined low literacy or

advanced education. Hispanic immigrants face critical access gaps to health care in the United

States (De Jesus & Xiao, 2013). Low-wage workers are less likely to be offered health benefits

or to be able to afford the employee’s share of premiums when they are provided coverage and

lack of continuous health insurance. Perceived lack of quality health care and low English


proficiency increased the likelihood of not seeking health care in Mexico or any other Latin

American country among US Hispanic adults (De Jesus & Xiao, 2013).

The lack of health insurance coverage has been associated with higher rates of

microvascular complications among Hispanics with Type 2 Diabetes and limited access to

healthcare, and medical insurance can lead to fewer preventive interventions and less screening

for complications (Valencia et al., 2014). Limited income and financial resources in many Latin

American communities require healthcare providers to develop self-management strategies

which will address Diabetes Mellitus Type 2 as a disease which can be managed on a limited

budget. Culturally sensitive diabetes care, by economic terms, has important implications for

medicine and health care, for families and patients with diabetes and society (Arredondo, 2014).

Given the positive effect of health literacy-sensitive interventions on glycemic control,

healthcare providers should actively incorporate strategies for accommodating patients with low

health literacy in diabetes self-management interventions (Kim & Lee, 2016). With the help of

community workshops and increased education, targeted populations can get the information

they need to make essential lifestyle choices.

Financial options to keep costs low within the Latin American communities are pivotal

for successful diabetes management through a formal education program. For example, a

Mexican diet might include processed cheeses or grains, Hispanic patients and clients can be

encouraged to use budget-friendly ingredients with less saturated fat and incorporate more

whole, unpackaged foods that are used in traditional Mexican dishes. Additionally, health

advocates can help community members to seek out locally available fruits and vegetables,

which should be lower in cost than conventional fruits and vegetables, and therefore partially

address the concern of cost as a deterrent (Heuman et al., 2013). The appropriate use of diabetes


preventive care practices and adherence to self-management behaviors, such as routine medical

visits, blood glucose and lipid tests, glucose self-monitoring, foot and eye examinations, and

healthy dietary and physical activity, can prevent or delay costly complications (Rutledge et al.,

2017).

Theoretical Model

Orem's Self-Care Deficit Theory involves the practice of activities that an individual

initiate and perform on his or her behalf to maintain life, health, and well-being, based upon the

self-care agency, which is a human ability to “engage in self-care” (Petiprin, 2016). Universal

self-care requisites are associated with life processes; Orem identifies these requisites as a

balance between activities and rest, as well as between solitude and social interaction, the

prevention of hazards to human life and well-being, and the promotion of human functioning

(Petiprin, 2016).

Assumptions of Orem's Self-Care Deficit Theory are people should be self-reliant and

responsible for their care, a person's knowledge of potential health problems is needed for

promoting self-care behaviors, and self-care behaviors are learned within a socio-cultural context

(Petiprin, 2016). Orem's approach to the self-care process involves modifying self-concepts to

accept oneself as being in a particular state of health and includes learning to live with the effects

of pathologic conditions through improving lifestyle behaviors (Petiprin, 2016). This self-care

process effectively displays the profound importance of improving diabetes management for this

culture group by inspiring self-management of illness. This self-care theory lends itself most

naturally to the intention of this scholarly project, which is to improve outcomes for Type II

Diabetic patients within the Hispanic and Latin American communities.


Orem's Self-Care Deficit Theory displays the need for patients to be self-reliant and

responsible for their care. The person with diabetes must learn how to evaluate themselves,

decide what actions need to be taken to attend to their needs, and perform those actions; and

these actions will become possible with cultural education regarding Diabetes Mellitus Type 2,

based on Orem’s Self-Care Deficit Theory (Sürücü & Kizilci, 2012). Orem’s Self Care theory

accurately identifies how a person's knowledge of a potential health problem is needed to

promote self-care behaviors, which can be learned and understood through a socio-cultural based

foundation (see Figure 1 in Appendix).

The Self-Care Deficit Theory lends itself naturally to my topic of the need for education

and enhanced self-management for Hispanic Americans with Diabetes Mellitus Type 2.

According to Sürücü & Kizilci (2012), based on Orem’s theory, the person with diabetes must

learn how to evaluate themselves, decide what actions need to be taken to attend to their needs,

and perform those actions; and these actions will become possible with education about diabetes.

The use of this theory as my theoretical framework will allow me to address the importance of

education and teaching initiatives in the Hispanic population to encourage improved lifestyle

choices and help to guide patients towards better individual diabetes control which will improve

their long-term health status.

Project and Study Design

A well-designed research study is required for further evaluation and an analysis of

outcomes to address the proposed research question on the effects of a culturally based self-

management education program on Diabetes Mellitus Type 2 in the Latin American community.

The research for this study will be conducted at a local community health clinic which allows for

increased exposure to the Hispanic American population, with a high occurrence of Diabetes


Mellitus Type 2. The research study will include a longitudinal study design which focuses on

data collection at two points in time, specifically addressing the effects of an education program

on glycemic control and the capacity for improved self-care. This study will include the use of

the Diabetes Self-Management Questionnaire (DSMQ) (BioMed Central, 2013), which will

evaluate pre and post-test measurements from all included participants to assess the effectiveness

of the proposed study intervention. The results of this study will be analyzed for any potential

statistical significance which can substantiate the overall purpose of the research, which

addresses the role of education in improving Diabetes Mellitus Type 2 outcomes for patients.

Needs Assessment

The incidence of acquired Diabetes Mellitus Type 2 within the Hispanic American

community is growing by rapid proportions due to the escalating rates of obesity, lack of

cardiovascular exercise, and the poor dietary habits which are prevalent within this cultural

group. Diabetes Mellitus Type 2 is a progressive illness which can lead to many long-term

health conditions if it is not addressed and corrected promptly. Due to this reality, it is critical to

put forth a self-management teaching effort to increase awareness and prevent disease within the

Hispanic communities. Through the development of a culturally sensitive education program,

proposed to be launched with volunteer participants in a local community health clinic, the need

for increased self-management within the Latin American community will be brought to the

forefront of primary care medicine. The goal of improved health status for the local community

begins with the identification of Diabetes Mellitus Type 2 patients who are willing to participate

in a culturally founded diabetes education program which will focus on healthier lifestyle

behaviors and proper meal choices to improve glycemic control and lower blood glucose levels.

This self-management initiative will not only improve patient outcomes in regards to disease


management, but it may also prevent future illness from occurring, or improve quality of life,

and prolong the average lifespan for Latin Americans in the community health clinic. Culturally

tailored diabetes self-management interventions can positively impact self-management

behaviors. Therefore, Nurse Practitioners must consider the importance of critical cultural

concepts and tailor patient care to fit the culture, to more effectively assist those with diabetes in

improving self-management behaviors (Vincent, 2009). Teaching individuals about the

prevention, development and treatment of Diabetes Mellitus Type 2 includes the necessity of

following a well-balanced diet, the need for regular cardiovascular exercise, the importance of

maintaining normal Body Mass Index, certain foods and behaviors to avoid, and of course,

treatment goals for living with diabetes if this condition is to develop throughout the lifespan.

This education is required in the local Hispanic communities to motivate individuals towards

improved personal health status and self-management of illness to prevent additional co-morbid

conditions or complications.

Setting and Resources

The environment for this study was a local community health clinic in a town outside of

West Palm Beach, Florida. This community health office offers free healthcare to the county

employees with no co-pays or costs associated with regular office visits. A large percentage of

the clinic’s demographics include middle-aged, Latin American patients. The clinic will need a

fasting blood glucose level at the initial visit, along with a Hemoglobin A1c measurement, and a

Urinalysis. The exclusion criteria included Gestational Diabetes or any pregnant women, any

severe neurologic or speech deficits which could prevent a patient from participating in self-

management education, any patient who is not proficient in the English language, and any patient


who is blind or unable to read education handouts or emails, as this would prevent patient

success in this self-management education program.

Recruitment for the project will be done on a volunteer basis. The healthcare provider

will inquire with every patient who fits the inclusion criteria if they are interested in participating

in the study. For all interested participants, implied consent will be reviewed for privacy

protection and safety. Participants will first be screened for baseline labs and will be given the

Diabetes Self-Management Questionnaire (DSMQ) to be completed in the office. During the

initial visit, the provider will explain and educate participants on the included education

materials. Patients will go home with the educational tools and will be sent weekly email blasts

to provide additional information and teaching. At the end of eight weeks, participants will

return for final lab testing and will repeat the DSMQ scale. These answers were scored, and the

results were analyzed, along with the baseline and final lab values, to detect any statistically

significant changes in patient’s Diabetes Mellitus Type 2 management following the

intervention. Participants will be asked during the eight week period to review and follow the

education discussed in the handouts and to read the weekly email blasts for content.

Study Population

The Community Health Clinic is an established medical practice, through Martin County Board

of County Commissioners (BOCC), known as Employee Wellness, LLC, which is my current place of

primary care practice as a Family Nurse Practitioner. Our clinic serves approximately 600 employees and

their dependents, and we operate free of charge to our patients as part of their benefits package. The

subjects for this project will be comprised of employees of BOCC, which are county workers and patients

of our clinic. The potential clients included county landscapers, building crews, park attendants, county

office employees, and Utilities or Waste Management workers. The anticipated number of participants to

be involved in this study is 20-30 patients, all with active Diabetes Mellitus Type II. The characteristics


of participants include Latin American or Hispanic ethnicity with a diagnosis of Diabetes

Mellitus Type 2, all participants must be 18 years of age or older, and they can be male or

female. The upper age limit for this study will be 60 years of age. Inclusion criteria will require a

diagnosis of Diabetes Mellitus Type 2 and current treatment being managed by the health clinic, in which

a large percentage of the clinic’s demographics include middle-aged, Latin American patients. The

patients needed to be able to speak, read, and write in English, or they will need to be agreeable to

assistance by a translator to participate. As this is a culturally adaptive program, we will have a clinical

staff member available at all times to assist any patient who is not capable of writing, speaking, or reading

English. The exclusion criterion for this study included any patient under the age of 18 and over the age

of 60. Exclusion criteria also included Gestational Diabetes or any pregnant women, any severe

neurologic or speech deficits which could prevent a patient from participating in self-management

education, as this would prevent patient success in this self-management education program.

Sources of Data

For the collection of data in this study, the Diabetes Self-Management Questionnaire

(DSMQ) will be utilized, which is a questionnaire designed to help distinguish the amount a

person is aware of their diagnosis of Diabetes Mellitus Type 2 and what lifestyle behaviors the

diabetic person may possess, especially in regards to health and wellness. This scale contains 16

questions to be answered by a choice of four different categories of self-awareness for this

illness. Participants can respond with either highly applies to me, considerably applies to me,

somewhat applies to me, and does not apply to me. This tool is useful to understand what level

of diabetes education a patient may possess and how self-driven one may be in regards to taking

care of themselves when living with the diagnosis of diabetes.


Data Analysis

This research study was a longitudinal study with pre and post-test data being collected

from participants. This research data was computed for the quantitative analysis of findings,

which led to the evaluation of any possible statistical significance. Descriptive statistics were

used to summarize the data collected for the 22 actual participants who completed the education

program. The mean fasting blood glucose (FBG) and Hemoglobin A1c (A1c) levels were lower

following the education, and the scores on the Diabetes Self-Management Questionnaire

(DSMQ) increased following the instruction (Table 1). Urinalysis revealed that in the pretest

group 40% of the participants had traces of glucose in their urine and 10% had moderate glucose

in their urine. Following the education program, only 22% of the participants had traces of

glucose in their urine, and 0% had moderate glucose in their urine, indicating an overall

improvement in their health status.

Paired Samples t-Tests were calculated to compare pre/post-test data for (a) fasting blood

glucose (FBG), (b) Hemoglobin A1c levels (A1c), and (c) Diabetes Self-Management

Questionnaire scores (DSMQ). A significant decrease in fasting blood glucose (t(21) = 3.680, p

= .001) and a significant decrease in A1c levels (t(21) = 4.183, p = .000) indicates an overall

improvement in the participants’ diabetic status. A significant increase in the DSMQ scores

(t(21) -10.949, p = .000) indicates patients perceived that they were better able to manage their

diabetes following the education intervention (See Table 2).

A Wilcoxon Signed Rank Test was calculated to determine if urinalysis results were

significantly different following the education intervention. For 8 of the participants, the

urinalysis demonstrated a decrease in glucose levels, there was no change for 14 of the

participants, and there were no cases where the level of glucose increased following the


education intervention. A statistically significant improvement in urinalysis glucose levels was

found (Z = -2.828, p = .005) (See Table 3).

Quality

Several mechanisms were implemented for participant safety, privacy, and the safety and

accuracy of the collected data to assure the quality of the study. The first quality measure was

the protection of the relationship between the healthcare provider conducting the study, and their

participants. The relationship between the researcher and potential participants is a provider to patient

relationship. The participants are patients within the current practice setting; these are established

patients in the community health clinic. Participation in this study was on a volunteer basis. There was

no attempt to entice or pressure any patient into participation in this study.

The research was solely for interested and willing participants from within the clinic. Verbalized

consent before participation was performed and a front desk employee was in charge of recruitment

details to prevent possible coercion from occurring. There was a small script placed at the front desk, to

be reviewed with the patients at their time of volunteering for participation. This script was

straightforward and was read aloud by the staff, in either English or Spanish. This script was attached

under Appendix A. Strict HIPAA guidelines were adhered to, as there was no personal data

retained in the data collection. Only age and inclusion criteria, blood glucose readings, self-

management questionnaire scores (pre and post), and A1c measurements w collected for research

purposes. Patients’ anonymity was protected to the highest level possible with the use of a

voluntary study that can be exited at any time, for any reason, and without question. Although it

was requested that participants check in via the patient portal email system and follow up in

office after six weeks, any participant data could have been chosen by the research participants

not to be included in the study, and they were able to exit the study at any time.


For patient privacy, all patients who chose to participate in this research study signed the

HIPAA privacy statement, attached to the application. HIPAA was protected by avoiding any

personal information for patient’s privacy protection). Patients signed a HIPAA form in office,

in English only, but this could have been read aloud in Spanish to our participants if needed. The

HIPAA forms were stored in a locked file cabinet, in an office which is locked. Only the use of

in-office lab results, which were collected in-house and stored in a locked office, in a specific file

which is password protected and questionnaire scores, were required in this research. Minimal

patient demographics were collected in an attempt to minimize risk of a breach in confidentiality

or violation of HIPAA. Only basic lab results and the scores of patient questionnaires were

obtained. All of the data was de-identified.

All patient education was conducted in a private, secure exam room, and participants

could leave at any time if they felt uncomfortable with the questionnaire. They were allowed to

cease to answer any question if they chose. Data was recorded and stored during the research study

on a computer that was located within a locked office, within the identified health clinic. No one else had

access to the patient data, as the computer is password protected. The results of this project were

presented to the Maryville University community as part of the requirements for the DNP program. Data

collected from participants were identified as “Hispanic American Patients” with a number assigned to

their data for proper organization of findings. No personal identifiers were used. The data was presented

as an aggregate. All collected data will be deleted from the hard drive six months after the project has

concluded, and any printed materials will be shredded. All participant data will be stored on a password-

protected electronic devices. There are two levels of security protection for the recorded data. The data

will be stored on a password-protected computer that is maintained in a locked office within our clinic.

All signed informed consent forms must be kept for three years after the conclusion of the study and will

remain locked in a secure filing cabinet.


Interpretation of Findings

This study did encounter certain limitations which may have affected the research

outcomes. The most significant limitation of this study was the small sample size, with only 22

participants completing the research study. Due to the small sample size, the validity of this

study cannot be concluded without further research. The study’s potential validity is threatened

mainly by the small number of included participants. The limited sample size prevented the

ability to predict a confidence interval, causing an inability to generalize the findings. Evidence

was found to support statistical significance, as p values were found to be less than p= .05. The

results of this study were mixed. With this small sample size, further research with larger sample

sizes would be needed. The included literature review for this study did provide some related

evidence from other studies which can be utilized to support the interpretation of findings

further. No additional analysis was undertaken to facilitate understanding. Supplementary

analysis is not required in a research study of this size. No unwarranted causal inferences can be

made based on the study’s findings; the results are inconclusive due to the limits of the sample

size. No alternative explanations for the participants’ outcomes were considered in regards to

the findings.

Further studies would be required to evaluate the magnitude of effects. The precision of

the results are accurate using the data collection and the statistical analysis procedures, and these

were computed with accuracy for significant findings to support the research study. Due to the

limited sample size, generalizability is not possible and further research is required to generalize

these findings.


Implications of Findings

Reflection on the data analysis and findings for this study will show statistical evidence

to support the benefits of incorporating a culturally based educational program for Hispanic

patients living with Diabetes Mellitus Type 2 into daily clinical practice. The implications of

this study, as it relates to clinical nursing practice, include the need for further research in regards

to culturally sensitive diabetes education and awareness. To validate this effectiveness of this

self-management education program, the findings support the need for future studies with larger

patient sample sizes to generalize these results. Overall, the limitation of a small sample size

does not support the magnitude of the effects necessary to complete the implication of the

findings. Consideration may also be given towards lengthening the amount of time allotted for

the educational program, to allow for more time in which participants could improve upon their

self-management of illness.

Clinical Significance

Healthcare providers can take this gained insight on self-management and health

behaviors within targeted cultural groups to promote patient autonomy and to improve the

knowledge of illness for Hispanic Americans living with Diabetes Mellitus Type 2. Advanced

practice nurses have a responsibility to provide education and awareness to our patient

population regarding illness prevention, health maintenance and illness management which can

will promote improved wellness and quality of life throughout the lifespan. As discovered

through the data collection process, one of the most significant obstacles for minorities with

chronic illness is the availability of culturally sensitive and adaptive educational resources to

help guide their self-management behaviors. Statistical significance is clearly shown in the data

analysis and is reflected in all categories of results. There was improvement found in


Hemoglobin A1c values, urinalysis results, and in fasting blood glucose readings, which all

function to support a statistically relevant outcome for the self-management education program.

The Diabetes Self-Management Questionnaire (DSMQ) also showed statistical significance

which further supports the benefits of initiating a self-management Diabetes Mellitus Type II

education program in Hispanic patients. Clinical significance for this study cannot be interpreted

at the group-level, due to the limited sample size. Individual-level results are the appropriate

choice for this research study, given the small number of actual research participants. Clinical

significance can be operationalized on the foundation of proven statistical data from within the

study. This significance can be applied and utilized clinically to enhance nursing practice and to

outline improved health outcomes for diabetic patients. This study is significant to the future of

advanced practice nursing as the effects of strengthening knowledge for this chronic health

condition may help to prevent illness, improve quality of life, and prolong the average lifespan

for Hispanic patients living with Diabetes Mellitus Type 2. It is imperative for healthcare

providers to recognize the need in their daily practice for culturally appropriate educational

resources which can guide their Hispanic patients towards improved diabetes control through

enhanced self-management strategies.

Ethics and Human Subjects Protection

Nursing has a distinguished history of concern for the welfare of sick, injured, and

Vulnerable populations (Code of Ethics for Nurses, 2001). As with any study that contains

human beings, due diligence must be taken to protect all subjects of a research project during all

aspects of the study. This diligence and security for study participants follow the ethical

principle of beneficence, which means that all people should be treated fairly and endure no

harm during any portion of the research study. Another principle of ethics which must be


conducted during any research study is the right for participant’s to maintain autonomy. All

subjects entered the study willingly, made all of their own choices and decisions during the

study, and they retained their personal right to exit the research study at any given time,

regardless of completion and without the need for permission from the researcher.

As with any research study, potential risks always could occur during the conduction of

the project. The researcher paid careful attention when working with human participants to keep

all personal information protected and to avoid the risk of a breach in confidentiality. Protecting

the privacy of research subjects is an obligation for all those who are involved in the research, all

human subjects have a right to expect that their personal information will not be divulged when

the results of a study are published or when data sets from a research project are shared with

other investigators (American Speech-Language-Hearing Association (ASHA), 2013). There is

also the risk of non-secured participant data being compromised during a research study. Data

and the personal identities of individual participants in research studies must be kept

confidential. There should always be careful supervision of staff to make sure that they are

adhering to best practices in protecting the confidentiality of all participant data (ASHA,

2013). These risks were managed in this study by keeping participants identity

anonymous and by preventing any identifiable data from being released publicly.

Timeframes or Timeline

In order to develop this proposed research study, a certain amount of time was be

required for adequate preparation, recruitment of total participants, the collection of initial data,

time for the education program to be conducted, and finally, the follow up office visit where the

data is re-collected and the final survey to be undertaken. Once the approval was granted for the

project by the IRB, implementation of this research study was underway as soon as possible.


During the two weeks sign-up period, the healthcare provider informed and attempted to obtain

volunteers for the proposed research study by asking any patient who met the inclusion criteria if

they would like to join the research study. This research was voluntary and was offered to all

Hispanic American patients with Diabetes Mellitus Type 2, who did not have any of the

excluding factors. Once the two week enrollment period was over, the participants were brought

into the office for the initial visit and data collection. During this visit, the Diabetes Self-

Management Questionnaire (DSMQ) administered, a fasting blood glucose level was obtained, a

Urinalysis was performed in-house, and a baseline Hemoglobin A1c measurement was taken.

Patients then sat with the healthcare provider for a 40-minute education session which included a

review of all of the literature dispensed in the approved handout, and any questions were

answered. After this, the patients were sent home to begin the self-management education

process, and the healthcare provider checked in once weekly via email blasts, also education

updates were sent via email and any questions were addressed. After six weeks, the participants

were brought back in for follow up lab testing to repeat the Hemoglobin A1c and fasting glucose

reading via glucometer; they also repeated the DSMQ scale with the healthcare provider. After

this follow-up visit, all data was gathered and analyzed to identify any possible statistical

significance from this study. Once the statistical analysis was complete, all final reports were

completed.

Budget

The resources required for this research study were very minimal. The setting of the

study was a free community health clinic. Participants had no co-pay or office visit fees and

received all testing in-office at no out of pocket cost. Materials included handouts on Diabetes

Mellitus Type 2, which were printed at the facility and dispersed during office visits. No dollar


amount was attached to this study as the materials were minimal and the health clinic operates on

a no fee for service policy. Participants all had work emails set up through the county, as this

project was conducted in a local county employee wellness based clinic, which offers no-cost

healthcare to all county employees. Weekly email blasts went directly to work email accounts of

all participants to check in and evaluate for potential progress, also to answer any questions from

participants. There were no additional costs associated with the teaching initiative.

Risks and Benefits of the Study

Through the development of a culturally sensitive education program, launched using volunteer

participants in a local community health clinic, the need for increased self-management within the Latin

American community was brought to the forefront of primary care medicine. The goal of improved

health status for the local community began with the identification of Diabetes Mellitus Type 2 patients

who were willing to participate in a culturally founded diabetes education program which focused on

healthier lifestyle behaviors and proper meal choices to improve glycemic control and lower blood

glucose levels. This self-management initiative not only improved patient outcomes in regards to disease

management, but it may also help to prevent future illness from occurring, or improve quality of life, and

prolong the average lifespan for Latin Americans in the community health clinic. The potential benefits

of improved self-management of illness and better glycemic control for diabetic patients certainly

outweighed any possible risks for violation of privacy or feeling uncomfortable with the questionnaire,

which were avoided at all costs. Privacy was of the utmost concern during the research and data collection

process. The risks in this study were very minimal and were mediated fairly easily by ensuring HIPAA

was followed closely and privacy was monitored at all times. The potential benefits to the Hispanic

community through an improvement in self-management of Type II Diabetes more than offset any

possible risks involved in this study.


Strengths and Weaknesses of the Study

Healthcare providers can take this gained insight on self-management and health

behaviors within targeted cultural groups to promote patient autonomy and to improve the

knowledge of illness for Hispanic Americans living with Diabetes Mellitus Type 2. Advanced

practice nurses have a responsibility to provide education and awareness to our patient

population regarding illness prevention, health maintenance and illness management which can

will promote improved wellness and quality of life throughout the lifespan. As discovered

through the data collection process, one of the most significant obstacles for minorities with

chronic illness is the availability of culturally sensitive and adaptive educational resources to

help guide their self-management behaviors.

Strength in this study is represented through statistical significance, which is clearly

shown through the data analysis and is reflected in all categories of results. There was

improvement found in Hemoglobin A1c values, urinalysis results, and in fasting blood glucose

readings, which all function to support a statistically relevant outcome for the self-management

education program. The Diabetes Self-Management Questionnaire (DSMQ) also showed

statistical significance which further supports the benefits of initiating a self-management

Diabetes Mellitus Type II education program in Hispanic patients. Individual-level results are

the appropriate choice for this research study, given the small number of actual research

participants. Clinical significance can be operationalized on the foundation of proven statistical

data from within the study. This significance can be applied and utilized clinically to enhance

nursing practice and to outline improved health outcomes for diabetic patients. This study is

significant to the future of advanced practice nursing as the effects of strengthening knowledge


for this chronic health condition may help to prevent illness, improve quality of life, and prolong

the average lifespan for Hispanic patients living with Diabetes Mellitus Type 2. It is imperative

for healthcare providers to recognize where culturally appropriate educational resources are

lacking, as this can inspire Hispanic patients to improve their diabetes control through enhanced

self-management strategies.

This research study did encounter certain limitations which may have affected the data

outcome. The most significant limitation of this study was the small sample size, with only 22

participants completing the research study. Due to the small sample size, the validity of this

study could not be concluded, without further research. The study’s potential validity was

threatened mostly by the small number of included participants. The limited sample size

prevented the ability to predict a confidence interval causing an inability to generalize the

findings. Evidence was found to support statistical significance, as p values were found to be

less than p= .05. The results of this study were mixed, and with this small sample size, further

research with larger sample sizes would be needed.

The included literature review for this study did provide some related evidence from

other studies which can be utilized to support the interpretation of findings further. No

unwarranted causal inferences can be made based on the study’s findings; the results are

inconclusive due to the limits of the sample size. No alternative explanations for the

participants’ outcomes were considered in regards to the findings. Further studies would be

required to eliminate the limitations, based on the given sample size. In regards to limitations,

generalizability is not possible in this study and further research would be required to generalize

the findings.


Advanced practice nurses have a responsibility to provide education and awareness to our

patient population regarding illness prevention, health maintenance and illness management

which can will promote improved wellness and quality of life throughout the lifespan. Nurse

Practitioners can take this gained insight on self-management and health behaviors, within

targeted cultural groups, to promote patient autonomy and to improve the knowledge of illness

for Hispanic Americans living with Diabetes Mellitus Type 2. Healthcare providers must

recognize the need for culturally appropriate educational resources which can guide their

Hispanic patients towards improved diabetes control through enhanced self-management

strategies and improved lifestyle choices.

Conclusion

This scholarly project functions to support the growth of Diabetes Mellitus Type 2 education,

increased risk awareness for high-risk ethnic or social groups, and real-life diabetes management

counseling for a targeted cultural community. Based on the educational need which exists within the

Latin American community, the incorporation of a socio-cultural based diet and culturally

sensitive lifestyle behaviors for individuals living with Diabetes Mellitus Type 2 is of critical

importance. The purpose of this project was to examine the effectiveness of a health clinic-based

diabetes self-management education program for Hispanic Americans, which was grounded in

culturally adaptive care strategies. As a result of investigating this particular practice problem,

the benefits of incorporating a culturally based educational program into the daily practice of

healthcare providers to promote autonomy and improve knowledge for Hispanic Americans

living with Diabetes Mellitus Type 2 is significantly displayed.

The research conducted within this study was centered upon the need for increased

patient teaching, through self-management behaviors, which will potentially improve future


health outcomes for Hispanic Americans living with Diabetes Mellitus Type 2. The focus of all

the included interventions within this quantitative study was the potential for improvement in

glycemic control through a culturally sensitive health education program, which focuses directly

on the improvement of self-efficacy for the Hispanic population. The themes of profound

importance when addressing the Hispanic population are highlighted most evidently in the areas

of cultural beliefs and awareness, obesity and limited physical activity, and limited self-efficacy

with low literacy rates.

After completion of a thorough literature analysis on multiple intervention-based research

studies, it can be concluded that the use of education has a profound impact on improved

glycemic control for the Hispanic community. Success was demonstrated most readily through

the use of enhanced self-efficacy to encourage Type II Diabetic patients to take a more active

role in theiroverallhealthandwellness.Implications for future practice should consider the use

of interventions that will be targeted towards respect in all observed cultural beliefs of Hispanic

patients to enhance the likelihood that Type II Diabetic individuals will stay committed to

lifestyle changes. Nurse practitioners can facilitate improved glycemic control for their Type II

Diabetic patients of Hispanic origin by implementing a culturally based self-efficacy initiative to

inspire changes in lifestyle. The need for continued research on the benefits of a health

education program to enhance Diabetes Mellitus Type 2 self-management for the Hispanic

population is of the utmost importance to gain a tighter control on this rapidly growing health

epidemic.


References

American Diabetes Association (ADA) (2012). Standards of Medical Care in Diabetes. Diabetes

Care, 35 (Suppl.1),11-61.

Arredondo, A. (2014). Type 2 diabetes and health care costs in Latin America: exploring the

need for greater preventive medicine. BMC Medicine, 12(1), 136. doi:10.1186/s12916-

014-0136-z

Benavides-Vaello, S., Brown, S. A., & Vandermause, R. (2017). "Can you keep it real?" :

Practical, and culturally tailored lifestyle recommendations by Mexican American

women diagnosed with type 2 diabetes: A qualitative study. BMC Nursing, 161-7.

doi:10.1186/s12912-017-0232-4

Burke, S. D., Sherr, D., & Lipman, R. D. (2014). Partnering with diabetes educators to improve

patient outcomes. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, 7,

45–53. http://doi.org/10.2147/DMSO.S40036

Center for Disease Control (CDC) (2015). Diabetes: Deadly, disabling and on the rise. Retrieved

from http://www.cdc.gov/nccdphp/aag/aag_ddt.htm

Cruz, Y., Hernandez-Lane, M., Cohello, J., & Bautista, C. (2013). The Effectiveness of a

Community Health Program in Improving Diabetes Knowledge in the Hispanic

Population:Saludy Bienestar (Health and Wellness). Journal of Community Health, 38(6),

1124-1131. https://doi.org/10.1007/s10900-013-9722-9


De Jesus, M., & Xiao, C. (2013). Cross-border health care utilization among the Hispanic

population in the United States: implications for closing the health care access gap.

Ethnicity & Health, 18(3), 297-314. doi:10.1080/13557858.2012.730610

Fisher, L., Chesla, C., Skaff, M., Gilliss, C., Mullan, J., Bartz, R., & ... Lutz, C. (2000). The

family and disease management in Hispanic and European-American patients with type 2

diabetes. Diabetes Care, 23(3), 267-272.

Fortmann, A. L., Gallo, L. C., & Philis-Tsimikas, A. (2011). Glycemic Control Among Latinos

With Type 2 Diabetes: The Role of Social-Environmental Support Resources. Health

Psychology, 30(3), 251-258. doi:10.1037/a0022850

Fortmann, A., Gallo, L., Walker, C., & Philis-Tsimikas, A. (2010). Support for disease

management, depression, self-care, and clinical indicators among Hispanics with type 2

diabetes in San Diego County, United States of America. Revista Panamericana De

Salud Publica, 28(3), 230-234. doi:dx.doi.org/S1020-49892010000900014

Heuman, A. N., Scholl, J. C., & Wilkinson, K. (2013). Rural Hispanic Populations at Risk in

Developing Diabetes: Sociocultural and Familial Challenges in Promoting a Healthy

Diet. Health Communication, 28(3), 260-274. doi:10.1080/10410236.2012.680947

Kim, S. H., & Lee, A. (2016). Health-Literacy-Sensitive Diabetes Self-Management

Interventions: A Systematic Review and Meta-Analysis. Worldviews on Evidence-Based

Nursing, 13(4), 324-333. doi:10.1111/wvn.12157

Kline, K. N., Montealegre, J. R., Rustveld, L. O., Glover, T. L., Chauca, G., Reed, B. C., &

Jibaja-Weiss, M. L. (2016). Incorporating Cultural Sensitivity into Interactive

Entertainment-Education for Diabetes Self-Management Designed for Hispanic


Audiences. Journal Of Health Communication, 21(6), 658-668.

doi:10.1080/10810730.2016.1153758

Koenigsberg, M. R., & Corliss, J. (2017). Diabetes Self-Management: Facilitating Lifestyle

Change. American Family Physician, 96(6), 362-370.

Lopez, O. (2006). Self-care practices and Hispanic women with diabetes. Journal of Human

Behavior In The Social Environment, 14(1/2), 183-200.

McCloskey, J., & Flenniken, D. (2010). Overcoming cultural barriers to diabetes control: a

qualitative study of southwestern New Mexico Hispanics. Journal of Cultural Diversity,

17(3), 110-115.

Moreno, G., Morales, L., Nuñez de Jaimes, F., Tseng, C., Isiordia, M., Noguera, C., &

Mangione, C. (2014). Neighborhood Perceptions and Health-Related Outcomes Among

Latinos with Diabetes from a Rural Agricultural Community. Journal of Community

Health, 39(6), 1077-1084. doi:10.1007/s10900-014-9854-6

Page-Reeves, J., Regino, L., Murray-Krezan, C., Bleecker, M., Erhardt, E., Burge, M., & Mishra,

S. (2017). A comparative effectiveness study of two culturally competent models of

diabetes self-management programming for Latinos from low-income households. BMC

Endocrine Disorders, 171-8. doi:10.1186/S12902-017-0192-4

Petiprin, A. (2016). Self-care deficit theory. Retrieved from http://www.nursing-

theory.org/theories-and-models/orem-self-care-deficit-theory.php

Rutledge, S. A., Masalovich, S., Blacher, R. J., & Saunders, M. M. (2017). Diabetes Self-

Management Education Programs in Nonmetropolitan Counties -- United States, 2016.

MMWR Surveillance Summaries, 66(10), 1-6.


Sürücü, H. A., & Kizilci, S. (2012). Use of Orem's Self-Care Deficit Nursing Theory in the Self-

Management Education of Patients with Type 2: A Case Study. Self-Care, Dependent-

Care & Nursing, 19(1), 53-59.

Valen, M. S., Narayan, S., & Wedeking, L. (2012). An innovative approach to diabetes education

for a Hispanic population utilizing Community health workers. Journal Of Cultural

Diversity, 19(1), 10-17.

Valencia, W. M., Oropesa-Gonzalez, L., Hogue, C., & Florez, H. J. (2014). Diabetes in Older

Hispanic/Latino Americans: Understanding Who Is at Greatest Risk. Generations, 38(4),

33-40.

Vincent, D. (2009). Culturally tailored education to promote lifestyle change in Mexican

Americans with type 2 diabetes. Journal of The American Academy Of Nurse

Practitioners, 21(9), 520-527. https://doi.org/10.1111/j.1745-7599.2009.00439.x

World Health Organization (WHO) (2011). Diabetes Access: 19 March 2011,

http://www.who.int/mediacentre/factsheets/fs312/en/index.html


Appendix A: Subject Recruitment Script

Appendix B: Diabetes Self-Management Questionnaire Scale (DSMQ)

Appendix C: Permission letter needed to conduct research off-site

Appendix D: Copy of Informed Consent

Appendix E: HIPAA Authorization Form

Appendix F: Diabetes Education for Patients

Appendix G: Copyright Permission statements

Appendix H: Table 1- Descriptive Statistics

Appendix I: Table 2- Paired Samples t-Test Results

Appendix J: Table 3- Wilcoxon Signed Rank Test Ranks


Appendix A: Participant Recruitment Script

“Excuse me, sir/madam, may I speak to you before coming back for your scheduled appointment today?” (Front desk staff will complete this recruitment with patients, in Spanish if needed).

“Your appointment today is for Diabetes follow up and we are currently searching for willing participants to be involved in a research study to examine the effectiveness of a health clinic based diabetes self-management education program for Hispanic Americans with Diabetes Mellitus Type II. Specifically, we are looking for participants who are 18-60 years of age, have a diagnosis of Diabetes Mellitus Type 2, and seek current treatment at this health care facility.”

“Due to this qualifying criterion, would you be willing to review additional information about this study? Is it OK for me to continue?”

If individual says “no, not interested” = The front desk will stop, say thank you, and not continue.

If he/she says yes, then we will continue to have the patient come back into the clinic with the medical assistant for consent signatures, urinalysis, and a glucometer reading. The medical assistant will be bilingual, and will have a short script to review with the participants prior to completing their questionnaires.

This script for the medical assistant to review with the participant will proceed as follows:

“You have willingly consented to participate in this research study. At this time, we will bring you back to get your appointment started.” “I will provide a copy of the informed consent with you today, and will read it aloud in English or Spanish. You will be given the opportunity to review this and to ask any questions as needed”. “This is an informed consent to participate and your safety rights are outlined clearly, as well as ensuring your privacy will be protected. You may exit study at any time. We will collect urine, blood for an in-house blood sugar reading via glucometer, and we will provide you with a brief 16 question survey to gauge your self-care behaviors”. “I will sit with you during the survey and help you with any assistance you may need, including language translation, reading, and/or writing”.


Appendix B: Diabetes Self-Management Questionnaire

DiabetesSelf-ManagementQuestionnaire(DSMQ)

Thefollowingstatementsdescribeself-careactivitiesrelatedtoyourdiabetes.Thinkingaboutyourself-careoverthelast8weeks,pleasespecifytheextenttowhicheachstatementappliestoyou.

appliestomeverymuch

appliestometoaconsider-

abledegree

appliestometosomedegree

doesnotapplytome

1. Icheckmybloodsugarlevelswithcareandattention.

Bloodsugarmeasurementisnotrequiredasapartofmytreatment.3 2 1 0

2. ThefoodIchoosetoeatmakesiteasytoachieveoptimalbloodsugarlevels.

3 2 1 0

3. Ikeepalldoctors’appointments(appointmentswithhealthprofessionals)recommendedformydiabetestreatment.

3 2 1 0

4. Itakemydiabetesmedication(e.g.insulin,tablets)asprescribed.

Diabetesmedication/insulinisnotrequiredasapartofmytreatment.

3 2 1 0

5. OccasionallyIeatlotsofsweetsorotherfoodsrichincarbohydrates.

3 2 1 0

6. Irecordmybloodsugarlevelsregularly(oranalysethevaluechartwithmybloodglucosemeter).

Bloodsugarmeasurementisnotrequiredasapartofmytreatment.

3 2 1 0

7. Itendtoavoiddiabetes-relateddoctors’appointments(appointmentswithhealthprofessionals).

3 2 1 0

8. Iamregularlyphysicallyactivetoimprovemydiabetestreatment.

3 2 1 0

9. Istrictlyfollowthedietaryrecommendationsgivenbymy 3 2 1 0


doctorordiabetesspecialist.

10. Idonotcheckmybloodsugarlevelsfrequentlyenoughtoachievegoodbloodglucosecontrol.

Bloodsugarmeasurementisnotrequiredasapartofmytreatment.

3 2 1 0

11. Iavoidphysicalactivity,althoughitcouldimprovemydiabetes. 3 2 1 0

12. Itendtoforgettotakeorskipmydiabetesmedication(e.g.insulin,tablets).

Diabetesmedication/insulinisnotrequiredasapartofmytreatment.

3 2 1 0

13. SometimesIhavereal‘foodbinges’(nottriggeredbyhypoglycaemia).

3 2 1 0

14. Regardingmydiabetescare,Ishouldseemymedicalpractitioner(s)moreoften.

3 2 1 0

15. Iamlessphysicallyactivethanwouldbeoptimalformydiabetes.

3 2 1 0

16. Mydiabetesself-careispoor. 3 2 1 0

For the use of this questionnaire I reached out to BioMed Central and I was given the right to use the survey and was told as long as I change nothing about the survey, I would not need any further permission. I will attach permission email to this application, under Appendix H- Copyright Permission.


Appendix C: Permission Letter for Research Off-Site

Employee Wellness, P.A. 1050 SE Monterey Road Suite 101 Stuart, Florida 34994 To Whom This May Concern: Kristin Washington, FNP-C, ARNP is a Family Nurse Practitioner who has been working full time in my medical practice for the past five years. She has expressed the intention to conduct a research study within our community clinic on Type II Diabetes self-management education in our Latino/Hispanic population. She has asked to conduct this research as a student through Maryville University for her Doctor of Nursing Scholarly Capstone Project. She has expressed her intention of conducting interviews with any willing patients within our practice who fit her inclusion criteria. Kristin provided our clinic with a detailed plan regarding her data collection methods- i.e.: a diabetes self-management questionnaire she will complete with her patients, a copy of her Diabetes education packet of literature for her participants, and she has decided to use in house lab work and fasting glucose levels as her diagnostic criteria for participant outcomes. Kristin has expressed to our clinic that her University requires everyone who agrees to participate in this project to have consent to do so, she is planning on utilizing implied consent to preserve the anonymous status of her patients. As the medical director, I am aware her overall purpose of this research is to evaluate the effectiveness of a self-management education program for Type II Diabetic patients who are Hispanic. Subject participation will involve the initial questionnaire and baseline labs, follow up which Kristin will conduct via patient portal and a weekly email education update sent to participants, and an eight-twelve week follow up with fasting glucose check/A1c measurement and a repeat of questionnaire. The amount of time for participation will be a 1 hour initial visit, weekly email education updates sent to participants and a 1 hour follow-up visit with the patient to re-evaluate their education levels. This research study will not include any risks or discomfort and there will be no potential breach of confidentiality or privacy in this research. To minimize risks, researcher will employ the following safeguards: implied consent, patient communication via private patient portal, and protection of HIPAA during office visits. The possible benefits for


our patients from this research would be an opportunity for culturally based diabetes education which could improve outcomes in health management. Kristin has a well-developed plan for her research and I am giving her authorization to begin her data collection. She has full permission for the use of our clinic and patients for the development of her research and we will assist her in any way we can. Any questions, please feel free to call the office at (772)-872-7304. Sincerely, Michele Libman, MD

Appendix D: Informed Consent

Improvement of Self-Management in Hispanic Americans with Diabetes

To Whom This May Concern:

You are being asked to participate in a project conducted through Maryville University and Employee Wellness by Kristin Washington, Family Nurse Practitioner and Doctor of Nursing Practice student, working under the direction of my faculty advisor, Dr. Cathy Hogan PhD, Assistant Professor of Nursing. The University requires everyone who agrees to participate in this project to provide consent to do so.

The overall purpose of this research is to examine the effectiveness of a health clinic based diabetes self-management education program for Hispanic Americans, which is grounded in culturally adaptive care which will attempt to show significant improvement in Diabetes control within a twelve week period. Your participation will involve in office lab testing and completion of a questionnaire at the first, and follow up visits. You will also be encouraged to make lifestyle changes during the 12 week time frame to improve your lifestyle choices while living with Diabetes Mellitus Type II. The amount of your time will be an hour long initial visit and an hour long follow up visit at 12 weeks. To minimize risks and to protect your safety, all personal data, test results, and medical records are strictly confidential and will not be released. Participation is voluntary and you may exit study at any time. We do not promise you will receive benefits from this study. No incentives are being offered. There are no alternative treatments except not to participate. The results of this study will not be shared; they may be presented as a part of my DNP Scholarly Project with fellow students and instructors.

If you have any questions regarding this study, or if any problems arise, you may call the researcher, (name) at (phone number) (or the researcher’s faculty advisor [name] at [phone number]). You may also ask questions, state concerns regarding your rights as a research subject, or express any feelings of pressure to participate by contacting: Dr. Robert Bertolino, Chair of the Institutional Review Board at Maryville University, (314) 529-9659.

Maryville University recognizes its federally mandated responsibility to ensure that research be conducted in an ethical and scholarly manner, respecting the rights and welfare of all the human participants. Any research misconduct including but not limited to fabrication, falsification, or plagiarism in proposing,


performing and reviewing research, or in reporting research results, should be reported to Dr. Tammy Gocial, the Research Integrity Officer at Maryville University at (314) 529-6893.

Maryville University investigators, and their colleagues who are conducting research, recognize the importance of your contribution to the research studies which are designed to improve (therapeutic care; educational learning environments – insert whatever is appropriate given the purpose of your study). Maryville University investigators and their staffs will make every effort to minimize, control, and treat any complication that may arise as a result of this research. Research involving physical tasks or other health-related treatments need to add, if applicable: If you believe you are injured solely as a result of the research question being asked in this study, please contact the principal investigator or the Chair of the Institutional Review Board. Maryville reserves the right to make decisions concerning payment for medical treatments for injuries solely and directly related to your participation in the research.

By signing this form, you acknowledge that you are at least 18 years of age, that you have read and understand this form, and that you have had an opportunity to ask questions about the research project. You are voluntarily agreeing to participate in a study based on the information presented to you. You may choose to withdraw at any time without prejudice or penalty. You will receive a copy of this form, which will include the name and phone number of the researcher and the IRB at Maryville University, should you have any questions.

Subject / participant’s signature

_______________________________________ Date _________

_______________________________________ __________________ ______________

Researcher’s signature Date Phone Number


Appendix E: HIPPA Authorization

RESEARCHSUBJECT’SAUTHORIZATIONFORRELEASEOFHEALTHINFORMATIONFORRESEARCHPURPOSES

NameofResearchStudy:

IRBNumber:____________________PrincipalInvestigator:_________________________

Subject’sName:____________________________BirthDate:_____________________

We want to use your private health information in this research study. This will include both information we

collect about you as part of this study as well as health information about you that is stored in your medical

record. The law requires us to get your authorization (permission) before we can use your information or

share it with others for research purposes. You can choose to sign or not to sign this authorization. However,

if you choose not to sign this authorization, you will not be able to take part in the research study. Whatever

decision you make about this research study will not affect your access to medical care.


Section A: I authorize the use or sharing of my health information as described below: Who will be asked to give us your health information:

Kristin Washington, ARNP at Employee Wellness Clinic

Who will be able to use your health information for research: Kristin Washington, ARNP

Section B: Description of information:

(1) If you choose to be in this study, the research team needs to collect information about you and your health. This will include information collected during the study as well as information from your existing medical records from May 2018 through August 2018

Your health information will be used and shared with others for the following study-related purpose(s):

• Find out study eligibility (screening) • Data analysis of results • Study audit and oversight

(2) Specific description of information we will collect: indicate the health information you will collect during the research and from medical records. Delete the items that do not pertain.

• medication list • most recent history • lab results Urinalysis, Hemoglobin A1c measurement, Fasting Glucose by glucometer

(3) We will also request the following specific items- N/A

Section C: General

(1) Expiration:


This authorization expires on September 2018, at end of study.

Right To Revoke:

You may revoke (take back) this authorization at any time. To do this, you must ask us Kristin Washington ARNP for the names of the Privacy Officers at the institutions where we got your health information. You must then notify those Privacy Officers in writing that you want to take back your Authorization. If you do, we will still be permitted to use and share the information that we obtained before you revoked your authorization but we will only use and share your information the way the Informed Consent Form says.

1. If you revoke this authorization, we may still need to share your health information if you have a bad effect (adverse event) during the research.

(2) Your Access to the Information: You have the right to see your medical records, but you will not be allowed to review medical records in your research records until after the study is completed.

………………………………………………………………………………………………….. I have read this information, and I will receive a signed copy of this form.

___________________________________________ _________________

Signature of research subject or personal representative Date

If appropriate, printed name of personal representative: ____________________________

Relationship to research subject: _______________________________________________

Please describe the personal representative’s authority to act on behalf of the participant:

______________________________________________________________________________


Appendix F: Diabetes Education Handouts for Patients

Hispanic Health: Preventing Type 2 Diabetes- Centers for Disease Control and Prevention (CDC)

During National Hispanic Heritage Month, September 15–October 15, we celebrate the culture of US residents who trace their roots to Spain, Mexico, and the Spanish-speaking nations of Central America, South America, and the Caribbean. And while recognizing their many contributions and achievements, let’s also acknowledge Hispanic and Latino people’s greater risk for type 2 diabetes and take action to prevent it.

Greater Diabetes Risk

Over their lifetimes, 40% of US adults are expected to develop type 2 diabetes. That number is even higher for Hispanic men and women—more than 50%.

Hispanic people are about 50% more likely to die from diabetes than whites.

More than 1 in 3 US adults have prediabetes (see below), and Hispanic people are at greater risk than non-Hispanics.

Diabetes is associated with serious health complications, including chronic kidney disease,[1.08 MB] or CKD. CKD can lead to kidney failure. A person with kidney failure will need regular dialysis (a treatment that filters the blood) or a kidney transplant to survive. Hispanics are about one and a half times more likely to develop kidney failure than non-Hispanics.

Diabetes & Prediabetes Basics

Diabetes is a disease in which blood sugar levels are above normal. Most of the food we eat is turned into blood sugar for our bodies to use for energy. The pancreas makes a hormone called insulin to help blood sugar get into the body’s cells. When you have diabetes, your body either doesn’t make enough insulin or can’t use its own insulin as well as it should. This causes sugar to build up in the blood, which over time can cause serious health problems, such as heart


disease, vision loss, and nerve damage leading to amputation of a foot or leg. Currently, more than 30 million Americans have diabetes, and 1 in 4 of them don’t know they have it.

There are three main types of diabetes: type 1, type 2, and gestational diabetes. Type 1 diabetes is caused by an autoimmune reaction (the body attacks itself by mistake) and can’t yet be prevented. It’s usually diagnosed in children and young adults. Type 2 diabetes develops over many years and is usually diagnosed in adults (though increasingly in children, teens, and young adults). It often can be prevented by following a healthy lifestyle including physical activity, healthy eating, and weight loss. Gestational diabetes occurs during pregnancy and is a risk factor for developing type 2 diabetes later in life.

With prediabetes, blood sugar levels are higher than normal, but not high enough yet to be diagnosed as diabetes. A person with prediabetes is at higher risk for developing type 2 diabetes and other serious health problems, including heart disease and stroke. You may have prediabetes and be at risk for type 2 diabetes if you:

Are 45 years of age or older

Are overweight

Have a family history of type 2 diabetes

Have high blood pressure

Are physically active fewer than three times a week

Ever had gestational diabetes or gave birth to a baby who weighed more than 9 pounds

Hispanic people are more likely to develop prediabetes and type 2 diabetes than non-Hispanics. There often are no clear symptoms, so it’s important to talk to your doctor about getting your blood sugar tested if you have any risk factors.

Type 2 Diabetes: Getting Started

Research shows that modest weight loss and regular physical activity can help prevent or delay type 2 diabetes by up to 58% in people with prediabetes (71% for people 60 or older). Modest weight loss means 5% to 7% of body weight, which is 10 to 14 pounds for a 200-pound person. Getting at least 150 minutes of physical activity each week, such as brisk walking, also is important. That’s just 30 minutes of movement for five days of the week.

You may have heard that type 2 diabetes runs in families, but it’s not only because people are related. Sometimes families share certain habits that can increase risk. A family history of diabetes doesn’t have to be your heritage. Make healthy choices part of the celebration during National Hispanic Heritage Month and throughout the year, and you’ll start a great new family tradition that can keep growing stronger.


More Information

Diabetes Self-Management Education and Support (DSMES) services help people with diabetes learn how to take the best care of themselves. Ask your doctor for a referral to DSMES services to help you manage your diabetes.

How will DSMES help me?

When you learn that you have diabetes, your first question might be, “What can I eat?” DSMES will answer this question and many others. Your first step should be ask your doctor to refer you for DSMES. If your doctor does not talk to you about these services, bring it up during your visit.

DSMES services include a health care team who will teach you how to stay healthy and how to make what you learn a regular part of your life.

DSMES services will help you:

Make better decisions about your diabetes.

Work with your health care team to get the support you need.

Understand how to take care of yourself and learn the skills to:

Eat healthy.

Be active.

Check your blood sugar (glucose).

Take your medicine.

Solve problems.

Cope with the emotional side of diabetes.

Reduce your risk of other health problems.

Why is DSMES important?

People who have the knowledge and support to manage their diabetes are healthier than those who do not. Learning how to control your diabetes will save money and time, and help you have fewer emergency and hospital visits. Knowing how and when to take your medication, how to monitor your blood sugar (glucose), and how to take care of yourself, helps you manage your diabetes better. Managing your diabetes will help you avoid or delay serious health complications. The skills you learn will help you take better care of yourself. Diabetes management starts with you. It’s important to go for DSMES services when you first find out


you have diabetes so you can learn how to take care of yourself. However, there are three other times DSMES can help you. Read about them in the table below.

When Do You Need DSMES?

When you first find out that you have diabetes, when you’re first diagnosed, you may not know where to begin. DSMES can give you the information and support to start managing your diabetes.

DSME is reviewed during yearly follow-up visits with your doctor and is helpful when new situations affect the way you take care of yourself. New events or conditions in your life can affect your diabetes. Examples include diagnosis of a new health condition, a change in your mobility, depression, or money problems. When other life changes occur that affect the way you take care of yourself. Major life changes can affect your diabetes. Examples of life changes include a change in your living situation, your doctors or insurance plan, or your job.

DIET GUIDELINES IN DIABETES

The recommendations for the primary prevention of diabetes, so we know that not only do we have diagnosed cases of diabetes, but we also have a large percentage of individuals that might be in this pre-diabetes zone, meaning that they are at risk of developing diabetes. So the studies have shown that a moderate weight-loss -- so we're talking about 7%, sometimes even up to 10%, of their body weight -- might impact positively on an individual's risk of preventing diabetes.

When it comes to different kinds of diets, whether it's a low carbohydrate diet, a low fat calorie restricted, a Mediterranean, and even a vegetarian diet, as long as the calories are kept to sustain the person's bodyweight or achieve the weight-loss have been equally affected; of course adding physical activity, about 150 minutes per week, also increasing dietary fiber 14 grams for every 1000 calories.

The consumption of whole grains is also very important. At least half of the grains that are consumed by persons at risk of developing diabetes, and I should say almost every individual, should come from whole grains, and to limit the intake of sugar sweetened beverages -- and that has been a epidemic in the nation is the use of sugar sweetened beverages. And what we see is that there is a 26% greater risk of developing diabetes where individuals consumed sugar sweetened beverages consistently.

Data suggests that consuming a high-fiber diet ( 50 g fiber/day) reduces glycemia in subjects with type 2 diabetes. Encourage fiber intake goals set for the general population of 25-30 grams daily.


Examples of what foods contain soluble fiber: 1-1/2 cup oats, 1 cup of cooked kidney beans, 1 cup of ochre, an apple, strawberries, and a cup of cooked broccoli -- all these foods contain soluble fiber.

We talked about carbohydrates and we talked about fruits, vegetables, beans, legumes in general, and whole grains. That's where most of the carbohydrates should be coming from, your fruits and vegetables. The protein and the fat should come from lean, and also the good and the healthy fat.

While the saturated fat might need to be decreased, there are other types of fats that are considered to be healthy. But above all, the total number of calories does matter regardless of that macro-nutrient mix. And the number of calories should be appropriate for a person's age, height, weight, physical activity, medication and their blood glucose levels.

Making healthy food choices involves eating smaller portions, learning what a serving size is for

different foods and how many servings you need in a meal. In general, when you have diabetes you need to eat less fat, choose fewer high-fat foods and use less fat for cooking. You especially want to limit foods that are high in saturated fats or trans fat, such as: Fatty cuts of meat. Whole milk and dairy products made from whole milk. Cakes, candy, cookies, crackers, and pies. Fried foods. Salad dressings. Lard, shortening, stick margarine, and nondairy creamers.

Eat more whole-grain foods. Whole grains can be found in:

Breakfast cereals made with 100% whole grains, oatmeal, whole grain rice, whole wheat bread, pita bread, and some tortillas. Eat a variety of fruits and vegetables every day. Choose fresh, frozen, canned, or dried fruit and 100% fruit juices most of the time. Eat plenty of veggies like these: dark green veggies (e.g., broccoli, spinach, brussel sprouts). Orange veggies (e.g., carrots, sweet potatoes, pumpkin, winter squash). Beans and peas (e.g., black beans*, garbanzo beans*, kidney beans*, pinto beans, split peas, lentils).

Eat fewer foods that are high in sugar, such as: Fruit-flavored drinks. Sodas. Tea or coffee sweetened with sugar. Use less salt in cooking and at the table. Eat fewer foods that are high in salt, such as: Canned and package soups. Canned vegetables. Pickles. Processed meats.

Never skip meals. Stick to your meal plan as best you can. Limit the amount of alcohol you drink. Make changes slowly. It takes time to achieve lasting goals.

The management of diabetes involves the need for weight loss and an overall reduction of calories to meet that goal. Research has shown that about a 5% weight loss is associated with a decrease of insulin resistance. So again, the message should be, "Any kind of weight loss is beneficial for person with diabetes."

RECIPIES:

Spanish omelet:


Tortilla Española- This tasty dish provides a healthy array of vegetables and can be used for breakfast, brunch, or any meal! Serve with fresh fruit salad and a whole grain dinner roll.

Ingredients:

5 small potatoes, peeled and sliced

Vegetable cooking spray

½ medium onion, minced

1 small zucchini, sliced 1½ cups green/red peppers, sliced thin

5 medium mushrooms, sliced

3 whole eggs, beaten

5 egg whites, beaten

Pepper and garlic salt with herbs, to taste

2 ounces shredded part-skim mozzarella cheese 1 Tbsp. low-fat parmesan cheese

Directions:

• Preheat oven to 375 °F.

• Cook potatoes in boiling water until tender.

• In a nonstick pan, add vegetable spray and warm at medium heat.

• Add onion and sauté until brown. Add vegetables and sauté until tender but not brown

• In a medium mixing bowl, slightly beat eggs and egg whites, pepper, garlic salt, and low-fat mozzarella cheese. Stir egg-cheese mixture into the cooked vegetables.

• In a 10-inch pie pan or ovenproof skillet, add vegetable spray and transfer potatoes and egg mixture to pan. Sprinkle with low-fat parmesan cheese and bake until firm and brown on top, about 20–30 minutes.

• Remove omelet from oven, cool for 10 minutes, and cut into five pieces.

Beef or Turkey Stew / Carne de res o de pavo guisada This dish goes nicely with a green leaf lettuce and cucumber salad and a dinner roll. Plantains or corn can be used in place of the potatoes.


Ingredients:

1 pound lean beef or turkey breast, cut into cubes

2 Tbsp. whole wheat flour

¼ tsp. salt (optional)

¼ tsp. pepper

¼ tsp. cumin

1½ Tbsp. olive oil

2 cloves garlic, minced

2 medium onions, sliced

2 stalks celery, sliced

1 medium red/green bell pepper, sliced

1 medium tomato, finely minced

5 cups beef or turkey broth, fat removed

5 small potatoes, peeled and cubed

12 small carrots, cut into large chunks

Directions:

• Preheat oven to 375 °F.

• Mix the whole wheat flour with salt, pepper, and cumin. Roll the beef or turkey cubes in the mixture. Shake off excess flour.

• In a large skillet, heat olive oil over medium-high heat. Add beef or turkey cubes and sauté until nicely brown, about 7–10 minutes.

1¼ cups green peas

Place beef or turkey in an ovenproof casserole dish.

• Add minced garlic, onions, celery, and peppers to skillet and cook until vegetables are tender, about 5 minutes.

• Stir in tomato and broth. Bring to a boil and pour over turkey or beef in casserole dish. Cover dish tightly and bake for 1 hour at 375 °F.


• Remove from oven and stir in potatoes, carrots, and peas. Bake for another 20–25 minutes or until tender.

Rice with Chicken, Spanish Style / Arroz con pollo This is a good way to get vegetables into the meal plan. Serve with a mixed green salad and some whole wheat bread.

Ingredients:

2 Tbsp. olive oil 2 medium onions, chopped 6 cloves garlic, minced 2 stalks celery, diced 2 medium red/green peppers, cut into strips 1 cup mushrooms, chopped 2 cups uncooked whole grain rice 3 pounds boneless chicken breast, cut into bite-sized pieces, skin removed 1½ tsp. salt (optional) 2½ cups low-fat chicken broth Saffron or SazónTM for color 3 medium tomatoes, chopped 1 cup frozen peas 1 cup frozen corn 1 cup frozen green beans Olives or capers for garnish (optional)

Directions:

• Heat olive oil over medium heat in a non-stick pot. Add onion, garlic, celery, red/green pepper, and mushrooms. Cook over medium heat, stirring often, for 3 minutes or until tender.

• Add whole grain rice and sauté for 2–3 minutes, stirring constantly to mix all ingredients.

Add chicken, salt, chicken broth, water, Saffron/SazónTM, and tomatoes. Bring water to a boil.

• Reduce heat to medium-low, cover, and let the casserole simmer until water is absorbed and rice is tender, about 20 minutes.

• Stir in peas, corn, and beans and cook for 8–10 minutes. When everything is hot, the casserole is ready to serve. Garnish with olives or capers, if desired

Avocado Tacos/Tacos de aguacate These fresh tasting tacos are great for a light meal!

Ingredients: 1 medium onion, cut into thin strips 2 large green peppers, cut into thin strips 2 large red peppers, cut into thin strips 1 cup fresh cilantro, finely chopped 1 ripe avocado, peeled and seeded, cut into 12 slices 1½ cups fresh tomato salsa (see ingredients below) 12 flour tortillas Vegetable cooking spray

Fresh Tomato Salsa Ingredients: 1 cup tomatoes, diced cup onions, diced ½ clove garlic, minced 2 tsp. cilantro tsp. jalapeño peppers, chopped ½ tsp. lime juice Pinch of cumin

Exchanges: Bread 3 Vegetable Fat 1 1 ½ Note: Diabetic exchanges are calculated based on the American Diabetes Association Exchange System.

Directions:


• Mix together all salsa ingredients and refrigerate in advance.

• Coat skillet with vegetable spray.

• Lightly sauté onion and green and red peppers.

• Warm tortillas in oven and fill with peppers, onions, avocado, and salsa. Fold tortillas and serve. Top with cilantro.

References

Centers for Disease Control and Prevention. (2018). Family health and diabetes. Retrieved from

https://www.cdc.gov/diabetes/ndep/communities/hispanic-latino-american/resources.html

Centers for Disease Control and Prevention. (2018).Diabetes and Hispanic Recipes. Retrieved

from https://www.cdc.gov/healthyweight/healthy_eating/recipes.html

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK): 4 Steps to Manage Your Diabetes for Life

• Step 1: Learn about diabetes.

• Step 2: Know your diabetes ABCs

• Step 3: Learn how to live with diabetes

• Step 4: Get routine care to stay healthy

• Things to remember

Actions you can take

The marks in this booklet show actions you can take to manage your diabetes.

• Help your health care team make a diabetes care plan that will work for you.

• Learn to make wise choices for your diabetes care each day.

________________________________________

Step 1: Learn about diabetes.

What is diabetes?


There are three main types of diabetes:

• Type 1 diabetes – Your body does not make insulin. This is a problem because you need insulin to take the sugar (glucose) from the foods you eat and turn it into energy for your body. You need to take insulin every day to live.

• Type 2 diabetes – Your body does not make or use insulin well. You may need to take pills or insulin to help control your diabetes. Type 2 is the most common type of diabetes.

• Gestational (jest-TAY-shun-al) diabetes – Some women get this kind of diabetes when they are pregnant. Most of the time, it goes away after the baby is born. But even if it goes away, these women and their children have a greater chance of getting diabetes later in life.

You are the most important member of your health care team.

You are the one who manages your diabetes day by day. Talk to your doctor about how you can best care for your diabetes to stay healthy. Some others who can help are:

• dentist

• diabetes doctor

• diabetes educator

• dietitian

• eye doctor

• foot doctor

• friends and family

• mental health counselor

• nurse

• nurse practitioner

• pharmacist

• social worker

How to learn more about diabetes.

• Take classes to learn more about living with diabetes. To find a class, check with your health care team, hospital, or area health clinic. You can also search online.


• Join a support group — in-person or online — to get peer support with managing your diabetes.

• Read about diabetes online. Go to National Diabetes Education Program.

Take diabetes seriously.

You may have heard people say they have “a touch of diabetes” or that their “sugar is a little high.” These words suggest that diabetes is not a serious disease. That is not correct. Diabetes is serious, but you can learn to manage it.

People with diabetes need to make healthy food choices, stay at a healthy weight, move more every day, and take their medicine even when they feel good. It’s a lot to do. It’s not easy, but it’s worth it!

Why take care of your diabetes?

Taking care of yourself and your diabetes can help you feel good today and in the future. When your blood sugar (glucose) is close to normal, you are likely to:

• have more energy

• be less tired and thirsty

• need to pass urine less often

• heal better

• have fewer skin or bladder infections

You will also have less chance of having health problems caused by diabetes such as:

• heart attack or stroke

• eye problems that can lead to trouble seeing or going blind

• pain, tingling, or numbness in your hands and feet, also called nerve damage

• kidney problems that can cause your kidneys to stop working

• teeth and gum problems


• Ask your health care team what type of diabetes you have.

• Learn where you can go for support.


• Learn how caring for your diabetes helps you feel good today and in the future.

________________________________________

Step 2: Know your diabetes ABCs.

Talk to your health care team about how to manage your A1C, Blood pressure, and Cholesterol. This can help lower your chances of having a heart attack, stroke, or other diabetes problems.

A for the A1C test (A-one-C).

What is it?

The A1C is a blood test that measures your average blood sugar level over the past three months. It is different from the blood sugar checks you do each day.

Why is it important?

You need to know your blood sugar levels over time. You don’t want those numbers to get too high. High levels of blood sugar can harm your heart, blood vessels, kidneys, feet, and eyes.

What is the A1C goal?

The A1C goal for many people with diabetes is below 7. It may be different for you. Ask what your goal should be.

B for Blood pressure.

What is it?

Blood pressure is the force of your blood against the wall of your blood vessels.

Why is it important?

If your blood pressure gets too high, it makes your heart work too hard. It can cause a heart attack, stroke, and damage your kidneys and eyes.

What is the blood pressure goal?

The blood pressure goal for most people with diabetes is below 140/90. It may be different for you. Ask what your goal should be.

C for Cholesterol (ko-LESS-tuh-ruhl).

What is it?

There are two kinds of cholesterol in your blood: LDL and HDL.


LDL or “bad” cholesterol can build up and clog your blood vessels. It can cause a heart attack or stroke.

HDL or “good” cholesterol helps remove the “bad” cholesterol from your blood vessels.

What are the LDL and HDL goals?

Ask what your cholesterol numbers should be. Your goals may be different from other people. If you are over 40 years of age, you may need to take a statin drug for heart health.


• Ask your health care team:

o what your A1C, blood pressure, and cholesterol numbers are and what they should be. Your ABC goals will depend on how long you have had diabetes, other health problems, and how hard your diabetes is to manage.

o what you can do to reach your ABC goals

• Write down your numbers on the record at the back of this booklet to track your progress.

________________________________________

Step 3: Learn how to live with diabetes.

It is common to feel overwhelmed, sad, or angry when you are living with diabetes. You may know the steps you should take to stay healthy, but have trouble sticking with your plan over time. This section has tips on how to cope with your diabetes, eat well, and be active.

Cope with your diabetes.

• Stress can raise your blood sugar. Learn ways to lower your stress. Try deep breathing, gardening, taking a walk, meditating, working on your hobby, or listening to your favorite music.

• Ask for help if you feel down. A mental health counselor, support group, member of the clergy, friend, or family member who will listen to your concerns may help you feel better.

Eat well.

• Make a diabetes meal plan with help from your health care team.

• Choose foods that are lower in calories, saturated fat, trans fat, sugar, and salt.

• Eat foods with more fiber, such as whole grain cereals, breads, crackers, rice, or pasta.


• Choose foods such as fruits, vegetables, whole grains, bread and cereals, and low-fat or skim milk and cheese.

• Drink water instead of juice and regular soda.

•

• When eating a meal, fill half of your plate with fruits and vegetables, one quarter with a lean protein, such as beans, or chicken or turkey without the skin, and one quarter with a whole grain, such as brown rice or whole wheat pasta.

Be active.

• Set a goal to be more active most days of the week. Start slow by taking 10 minute walks, 3 times a day.

• Twice a week, work to increase your muscle strength. Use stretch bands, do yoga, heavy gardening (digging and planting with tools), or try push-ups.

• Stay at or get to a healthy weight by using your meal plan and moving more.

Know what to do every day.

• Take your medicines for diabetes and any other health problems even when you feel good. Ask your doctor if you need aspirin to prevent a heart attack or stroke. Tell your doctor if you cannot afford your medicines or if you have any side effects.

• Check your feet every day for cuts, blisters, red spots, and swelling. Call your health care team right away about any sores that do not go away.

• Brush your teeth and floss every day to keep your mouth, teeth, and gums healthy.

• Stop smoking. Ask for help to quit. Call 1-800-QUITNOW (1-800-784-8669).

• Keep track of your blood sugar. You may want to check it one or more times a day. Use the card at the back of this booklet to keep a record of your blood sugar numbers. Be sure to talk about it with your health care team.

• Check your blood pressure if your doctor advises and keep a record of it.

Talk to your health care team.

• Ask your doctor if you have any questions about your diabetes.

• Report any changes in your health.



• Ask for a healthy meal plan.

• Ask about ways to be more active.

• Ask how and when to test your blood sugar and how to use the results to manage your diabetes.

• Use these tips to help with your self-care.

• Discuss how your diabetes plan is working for you each time you visit your health care team.

________________________________________

Step 4: Get routine care to stay healthy.

See your health care team at least twice a year to find and treat any problems early.

At each visit, be sure you have a:

• blood pressure check

• foot check

• weight check

• review of your self-care plan

Two times each year, have an:

• A1C test. It may be checked more often if it is over 7.

Once each year, be sure you have a:

• cholesterol test

• complete foot exam

• dental exam to check teeth and gums

• dilated eye exam to check for eye problems

• flu shot

• urine and a blood test to check for kidney problems

At least once in your lifetime, get a:

• pneumonia (nu-mo-nya) shot


• hepatitis B (HEP-uh-TY-tiss) shot

References

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Diabetes Education

for Hispanic Americans. (2018). Retrieved from https://www.niddk.nih.gov/

Appendix G: Copyright Consent/Permission

Copyright for NIDDK-

Reproducing Content, Logos, and Graphics

The majority of information on this site is copyright free and can be freely downloaded and reproduced. Content reproduced without changes should acknowledge the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) as the source.

There are a few exceptions: NIDDK logos should not be used without explicit review and approval by the NIDDK.

Generally, copyrighted materials will include a copyright statement

Editing Content: NIDDK and National Institutes of Health (NIH) logos must be removed from edited content. NIDDK content must not be used to imply endorsement of any companies, organizations, commercial products, processes, or services; or to recommend specific medical advice, treatments, or referrals.

Copyright for Center for Disease Control & Prevention (CDC)- CDC reports information on web reported by the Centers for Disease Control and Prevention, a U.S. Government agency, is public information. Therefore, all materials published including text, figures, tables, and photographs are in the public domain and can be reprinted or used without permission with proper citation.

Road to Health Toolkit in Spanish (Kit El camino hacia la buena salud) will be given to every patient; I ordered 50 copies from CDC that we have available in office. This toolkit covered under CDC copyright policy- Center for Disease Control & Prevention (CDC).

https://www.cdc.gov/diabetes/ndep/pdfs/toolkits/camino-buena-salud/road-to-health-toolkit-flipchart-spanish.pdf


Email from Bio-Medical with Permission to use Diabetes Self-Management Questionnaire:

Email in entirety:

"Dang Abadiano" <[email protected]> ([email protected])

To:you Details

Dear Kristin,

Thank you for contacting Springer Nature.

Reproduction of figures or tables from any article is permitted free of charge and without formal written permission from the publisher or the copyright holder, provided that the figure/table is original, BioMed Central is duly identified as the original publisher, and that proper attribution of authorship and the correct citation details are given as acknowledgment. Citation as follows: Schmitt et al.; licensee BioMed Central Ltd. 2013.

If you have any questions, please do not hesitate to contact me.

With kind regards,

Dang Abadiano

Global Open Research Support Executive

Global Open Research Support

Springer Nature

T +44 (0)203 192 2009

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Appendix H:

Table 1- Descriptive Statistics

N Minimum Maximum Mean Std. Deviation

Pre-test FBG 22 127 164 143.8 8.907

Post-test FBG 22 125 162 137.8 11.816

Pre-test A1c 22 6.5 8.3 7.0 .442

Post-test A1c 22 6.5 8.2 6.9 .396

Pre-test DSMQ 22 14 25 18.6 3.218

Post-test DSMQ 22 19 30 24.7 3.120

Valid N (listwise) 22


Appendix I:

Table 2- Paired Samples t-Test Results

Mean Std.

Deviation

Std. Error Mean

95% Confidence Interval of the

Difference

t

df

Sig Lower Upper

Pre-test FBG - Post-test FBG

6.00 7.647 1.630 2.61 9.39 3.680 21 .001

Pre-test A1c - Post-test A1c

.09 .10193 .022 .05 .14 4.183 21 .000

Pre-test DSMQ - Post-test DSMQ

-6.18 2.648 .565 -7.36 -5.01 -10.949

21 .000


Appendix J:

Table 3- Wilcoxon Signed Rank Test Ranks

N Mean Rank Sum of Ranks

Post-test U/A - Pre-test U/A Negative Ranks 8a 4.50 36.00

Positive Ranks 0b .00 .00

Ties 14c

Total 22

a. Post-test U/A < Pre-test U/A

b. Post-test U/A > Pre-test U/A

c. Post-test U/A = Pre-test U/A

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