Public Health Nursing Vol. 31 No. 4, pp. 317–326 0737-1209/© 2013 Wiley Periodicals, Inc. doi: 10.1111/phn.12093






Implementation of a Diabetes Prevention Program in Public Housing Communities Robin Whittemore, Ph.D., A.P.R.N., F.A.A.N.,1 Alana Rosenberg, M.P.H.,2 Lisa Gilmore, R.N., M.S.N.,3 Mary Withey, M.S.N., A.P.R.N., C.I.C.,4 and Allison Breault, R.N., M.S.4 1

Yale School of Nursing, New Haven, CT; 2Yale School of Public Health, New Haven, CT; 3William M. Backus Hospital, Norwich, CT; and VNAEast, Mansfield, CT


Correspondence to: Robin Whittemore, Associate Professor, Yale School of Nursing, New Haven, CT 06536. E-mail: [email protected]

ABSTRACT Objective: The purpose of this study was to describe the process of implementing a diabetes prevention program provided by homecare nurses to residents of public housing communities. Design and Sample: A cluster randomization pilot study was conducted comparing enhanced standard care (2 interactive classes on diabetes prevention) to a diabetes prevention program (7 interactive classes and behavioral support). The sample (n = 67) was primarily female (79%), nonwhite (76%), unpartnered (83%), with a mean age of 40 years, and an average of 3 children. Mixed methods were used to evaluate the implementation process. Measures: Data were collected on attendance, attrition, and protocol implementation. Interviews were conducted with nurses and community health workers who assisted with program implementation. Results: Homecare nurses were able to implement a diabetes prevention program in public housing communities, with a protocol implementation of 83% across classes and groups. Attendance was suboptimal with 60% for the enhanced standard care group and 54% for the diabetes prevention group. Nurses and community health workers were resourceful and positive about program implementation. Conclusion: Linking existing resources, such as a homecare agency with a public housing community, is one approach to disseminate diabetes prevention programs. Key words: type 2 diabetes prevention, health promotion, public health nursing practice, underserved populations.

The prevalence of type 2 diabetes (T2D) has increased dramatically in the past two decades. In the United States, the annual number of new cases for T2D has almost tripled from 1990 to 2010 (Geiss & Cowie, 2011). T2D disproportionately affects racial and ethnic minorities. The prevalence of T2D is greater in Hispanics (10.4%), non-Hispanic blacks (11.8%), and American Indian/Alaskan Natives (16.5%) compared with non-Hispanic whites (6.6%; Centers for Disease Control and Prevention, 2011). The increasing prevalence of T2D is concerning due the debilitating and costly complications associated with the disease (American Diabetes Association, 2013).

T2D prevention has become a national priority. Numerous studies have convincingly established that T2D can be prevented or delayed in at-risk adults by lifestyle programs promoting modest weight loss, healthy eating, and physical activity. The Diabetes Prevention Program (DPP), a large clinical trial in the United States with a racially and ethnically diverse sample of adults, demonstrated a 58% reduction in T2D with lifestyle change compared with a 31% reduction with metformin at 2.8year follow-up (Knowler et al., 2002). The 16-week DPP included interactive education with worksheets, behavioral support (i.e., goal setting, problem solving), and motivational interviewing



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provided individually to at-risk adults by trained health coaches, followed by monthly group meetings for 1 year (Diabetes Prevention Program Research Group, 1999). While cost-effective (Diabetes Prevention Program Research Group, 2012), the program had considerable incentives for participants, which limits wide-spread dissemination (i.e., free sneakers for participants having difficulty meeting physical activity goals). Since the completion of the DPP in 2002, numerous studies have been conducted translating the program to different settings to reach adults atrisk for T2D who are of low socioeconomic status and diverse race and ethnicity. These modified programs often include different components, providers, mode of delivery, length, targeted population, and outcomes. Attendance and attrition have also varied (Ali, Echouffo-Tcheugui, & Williamson, 2012; Whittemore, 2012). Group-based diabetes prevention programs have been tested across a number of settings and demonstrate modest improvement in health behaviors and weight loss (Whittemore, 2012). One successful group-based modified DPP was provided in the YMCA, a community-based organization that has a mission to promote the health of the community. The modified DPP was provided by trained health coaches (i.e., YMCA staff) and adults at-risk for T2D who participated in the program demonstrated a 6% weight loss compared with 2% in a wait-list control group (Ackerman, Finch, Brizendine, Zhou, & Marrero, 2008). Currently, this program has been disseminated to 46 communities in 23 states to over 2000 adults at-risk for T2D (Vojta, Koehler, Longjohn, Lever, & Caputo, 2013). While this program has been promising with respect to outcomes and dissemination, not all communities have a YMCA nor do many adults have access to the program. There is a continued need for health promotion programs that reach adults of diverse race and ethnicity and of low socioeconomic status, given the disproportionate burden of T2D in this population. Residents of public housing communities are often underserved with respect to health promotion programs. Public housing communities provide housing at reduced rental cost for individuals or families whose income is less than fifty percent of the median income for the county. Public housing communities may also provide housing to adults of

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diverse race and ethnicity. Public health nurses provide community health interventions as part of their mission to improve health outcomes and are known and trusted health professionals. In rural areas, nurses employed by local homecare agencies may function as public health nurses as the local public health infrastructure does not have a nursing presence. Thus, our research team conducted a study that evaluated a modified DPP (mDPP) provided by homecare nurses to adults of public housing communities at-risk for T2D compared to an enhanced standard care control condition over 6-month follow-up. Community health workers (CHWs) assisted with recruitment and implementation. A cluster randomized pilot study was conducted comparing the mDPP (6 classes) to an enhanced standard care control condition (2 classes). Repeated measure mixed model analysis controlling for gender, race/ethnicity, and site demonstrated no difference between groups on clinical (BMI, blood pressure, insulin resistance, lipid profile), behavioral (healthy eating, physical activity, sedentary behavior), or psychosocial outcomes (stress, depressive symptoms) (Whittemore, Rosenberg, & Jeon, 2013). However, participants of both groups improved significantly with respect to healthy eating, physical activity, stress management, depressive symptoms, and triglycerides. Attendance at classes was suboptimal, particularly with the mDPP after 3 months. The improvements seen in both the mDPP and the enhanced standard care group are encouraging as change in health behaviors, psychosocial adjustment, and select clinical outcomes occurred with a brief health promotion program. To improve implementation of health promotion programs in public housing communities, better understanding of factors that influence implementation is needed. The purpose of this secondary analysis is to describe the process of implementing an mDPP provided by homecare nurses to residents of public housing communities. Barriers and facilitators to program implementation will also be explored.

Methods Design and sample A mixed-method embedded design was utilized (n = 67) to complete the study aims of the primary

Whittemore et al.: Implementation of a Diabetes Prevention Program study (Whittemore et al., 2013) and this secondary analysis. Approval for the study was obtained from the Yale University Institutional Review Board and informed consent from participants was obtained. A partnership with a homecare agency was established and a participatory approach was used with stakeholders in the community and residents of public housing community to modify a diabetes prevention protocol for implementation in this setting. The program was implemented by homecare nurses in four geographically discrete public housing communities in a rural area of the northeast that had a community center and an adequate number of residents (>75 residents). The four housing units were randomized using a cluster randomization procedure to the enhanced standard care control group or the modified diabetes prevention group (mDPP). Residents of housing communities that randomized to the control group received a standard care program provided by study personnel. Participants received written information and two interactive education classes on nutrition and exercise to prevent T2D. Specifically, participants were encouraged to follow a healthy eating plan with reduced calories, to lose 5–10% of their initial weight through diet and exercise; to increase their exercise gradually with a goal of at least 30 min of exercise (i.e., walking) 5 days per week. The mDPP was based on the protocol for the DPP (Diabetes Prevention Program, 2004; Diabetes Prevention Program Research Group, 1999) and was modified after focus groups with stakeholders and residents of the community. The mDPP provided seven interactive education classes on nutrition and exercise to prevent T2D as well as content on low fat eating, adjusting recipes, and overcoming barriers to exercise. The first two classes were identical to the enhanced standard care control group classes. Behavioral support in goal setting, self-monitoring, and problem-solving barriers to change was also provided. Thus, the difference between the two programs was the additional content of the mDPP and the behavioral support provided over the 6-month duration of the program. Residents indicated that it would be helpful to have incentives to attend classes. Thus, a $5.00 gift card to a local supermarket was raffled at each class and a $25.00 gift card was raffled at the end of the program. All content and educational materials


were written in simplified language, included information on common racial/ethnic foods and social events, addressed lifestyle change within the context of limited financial resources, and were available in English or Spanish. Classes were taught in English with Spanish translation available, family members were invited to attend, and child care was provided. A convenience sample of adults at-risk for T2D was recruited from the public housing communities. To be included, adults needed to be >21 years of age, at-risk for T2D (2 or more risk factors, such as overweight, age, family history of T2D), and live in the housing community. Adults with T2D were not eligible for the study. Two homecare nurses were hired to implement the program and provide classes to residents. One nurse had been employed for >5 years as a homecare nurse in the community; the other nurse had homecare nursing experience and expertise in diabetes education. A community health worker from each housing community was hired to assist with recruitment, class setup, and follow-up. Nurses received approximately 8 hr of training on study procedures, the protocol for the enhanced standard care group, and the protocol for the mDPP. Nurses also completed select readings on T2D prevention, behavior change strategies, and group-based health promotion education. The nurses were responsible for program implementation at each public housing community. The primary investigator met with nurses approximately every 2 weeks to discuss study implementation. Community health workers received approximately 4 hr of training and ongoing supervision by nurses and the principal investigator of the study. Community health workers were responsible for recruitment, reminding participants about classes, coordinating walking groups, and translation as needed during data collection or classes. Nurses created a master schedule of classes provided at each community health center. Classes were provided every other week for the first month and monthly thereafter. Each class was offered at several different times to encourage participation. Participants were provided a schedule of classes offered at their community center and community health workers reminded participants about upcoming classes and encouraged attendance. If a participant missed a class, class handouts were delivered


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to participants’ home or mail and follow-up phone calls or handwritten notes were delivered to encourage attendance at the next class.

Measures Data were collected on attendance, attrition, and protocol implementation. The target for program attendance was that participants would attend 75% of classes. Protocol implementation consisted of nurse documentation of each session on attendance, the length of the session, content of the session, protocol implementation, and any deviation from protocol implementation. Protocol implementation included a checklist of general procedures and content specific to each class. Protocol implementation was calculated by dividing the number of items completed per class by the total number of possible items per class. Lastly, nurses and community health workers were interviewed at approximately 3 months after study implementation and at completion of the study to identify the barriers and facilitators of implementation by a coinvestigator with expertise in the conduct of interviews. Analytic strategy Quantitative data were entered into databases (Microsoft Excel, 2010, Redmond, WA, USA) by trained research assistants. Descriptive statistics were calculated using frequency distributions and summary statistics (SPSS, Inc., version 19, Chicago, IL, USA). Qualitative data were obtained from transcribed interviews and written notes, which were analyzed using content analysis procedures (Miles & Huberman, 1994). The following steps were completed: (a) transcribing the taped interviews, (b) developing coding categories, (c) coding transcribed interviews using coding categories with appropriate checks, and (d) categorizing coded data to identify themes.

Results Sixty-seven participants were enrolled between May 2010 and January 2011, which was below the recruitment goal for the study of 100 participants. The recruitment process was initiated by community health workers and completed by research assistants as well as the nurses. The sample was primarily female (79%), with a mean age of 40 years (Table 1). Participants were of diverse

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race/ethnicity, 76% were non-White (14% multirace, 15% Black, 47% Hispanic). The majority had a high school education (72%), were unemployed (73%), and of low-income (67% with less than $20,000 annual income). The majority of participants were single, divorced, or widowed (83%) with an average of three children.

Implementation of the program Homecare nurses were able to implement the program in public housing community centers, with a protocol implementation of 83% across classes and groups. Protocol implementation of the first two classes was slightly higher in the enhanced standard care control group (84%) compared with the mDPP group (80%). In the mDPP group, protocol implementation was greater than 70% across all TABLE 1. Demographic Characteristics by Group Standard care N = 33 N (%) Gender Male 3 (9.1) Female 30 (90.9) Race White, Non-Hispanic/ 5 (15.6) Non-Latino White, Hispanic/Latino 25 (75.8) Black 1 (3.0) Multirace or other 2 (6.1) Marital status Single/Divorce/Widow 27 (87.1) Married/Partner 4 (12.9) Education Less than High school 10 (31.3) High school level 14 (43.7) College level or higher 8 (25.0) Income No answer 8 (24.2) Less than $20,000 22 (66.7) $20,000 + 3 (9.1) Employed status Yes 10 (32.3) No 21 (67.7)

Age Comorbid conditions

Diabetes prevention N = 34 N (%)


10 (29.4) 24 (70.6)


11 (32.3)

Implementation of a diabetes prevention program in public housing communities.

The purpose of this study was to describe the process of implementing a diabetes prevention program provided by homecare nurses to residents of public...
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