Evaluation of the Program

                The intervention that will be used for the problem of diabetes in the African American community is basically providing residents with the opportunity to purchase healthy foods at grocery stores within. This will happen by use of different participation of certain institutions, mainly grocery stores, hospitals and clinics. In this intervention, patients can be referred to the program where they can trade in certain amounts of money for a certain amount of “healthy money” or vouchers that can be used in designated grocery stores that will participate in the program. In these stores, only certain items will be able to be purchased with the money, which will of course be healthier for the at risk or already diabetic patients. (Maybe patients can rack up points at the cash register that they report back to their doctors)

                To implement this intervention there would have to be cooperation of the hospitals, clinics and grocery stores that I plan to run the program in. For the beginning of the program there won’t be as many participant institutions until we have evaluated the program to ensure that it has been going as planned.  I suppose I would have to approach the heads of the hospitals in order to see if they are on board with the program and if they have to then ask their superiors. In addition to this, grocery stores would need to be approached as well. It would have to be taken into consideration whether the grocery store is public or privately owned. In addition to this, producers of the foods that are planned to be put on the list would have to be approached as well.

                Possible barriers, of course, include the fact that the stakeholders won’t agree to the plans. To overcome this, perhaps there could be incentives in place for the stakeholders so that they want to participate in the program. Also, there could be a barrier in exactly understanding how the regular currency will be traded in for representative money at grocery stores.

                A good way to communicate the program to stakeholders is to hand out pamphlets to residents in the communities to be targeted. It would be beneficial to actually get people who are at risk or already have diabetes within those communities to pass them out because others would be more persuaded rather than have outsiders handing them out. Putting up posters in common, popular spots would be helpful as well. In Baltimore, there are a variety of faiths and religions, so perhaps it would be helpful to hold information sessions or place posters inside of churches for example. To get other stakeholders like grocery stores and hospitals on board, data about the program and how we see the benefits of the program on patients, might persuade them, especially since these places are within the communities where these residents live.

Evaluating the program is next. One way to do this is to record the number of program participants and whether they are actually purchasing items using the vouchers and which items. Also there can be a count of the amount of patients that were recommended to the program and those that actually decided to enroll.  Some outcome measures that can be used are evaluating the patient’s attitude towards healthier food options and towards the program in general. There can also be a survey of patients and residents to see if they actually saw or heard about the program and that will show well the communication of the program’s existence is going. Also, doctors can track the patient’s health from the beginning of the program until a set amount of time enrolled in the program and see if the patient showed improvements over that time.

Interventions

A current intervention that addressed my problem that was tested focused on the idea that having one’s peers as a form of social support when dealing with chronic illness will actually improve and influence the behaviors of those who have the illness. For this study, they looked at background information about how this model worked in other situations and in other places, for example, for people with hypertension. The intervention that they implemented was used in west Baltimore city. Basically, they first recruited members of the community to become community health care case managers in their specific communities. They then trained these workers extensively about what the program entailed and about diabetes. These community healthcare workers made weekly in home visits and phone calls with patients. They did everything from helping the patients to keep their appointments to making sure they were taking their medications appropriately to monitoring for signs of complications. The key determinant they addressed was that there were increasing hospitalizations and emergency room visits for patients with diabetes who were on Medicaid.

                A possible strategy that identifies the issue of food deserts is to incorporate more farmers’ markets within these communities. By doing this, residents have more consistent access to quality, healthy foods. Perhaps these farmers markets should also be actively advertised within the communities and hold other attractions so that residents are more likely to attend. Maybe there’s something there for kids, which can then lead to the parent having to take the child to the event and indirectly will be susceptible to purchasing some of the produce.

                Another possible strategy is to provide incentives to patients who come in regularly for their checkups and for physicians who will agree to see these Medicaid patients. Such incentives could be pay bonuses for physicians and healthy meal vouchers at their local grocery store for the patients. This is just a way to get the diabetic patients in the hospital and seen by a professional that can track their progress and analyze if there are any potential complications in the future so that they can be reduced.  This addresses the issue of Baltimore residents being of low socioeconomic status and many are on some type of public health insurance.

                Lastly, because a large majority (over 70%) of residents in Baltimore are associated or affiliated with some type of religious group, perhaps it would be a good idea to get these institutions involved as well. For instances, churches can hold health fairs, sponsored screenings, or day-clinics to get their members to be aware of the statistics. Perhaps health professionals can enter these institutions and provide presentations on the epidemic that is present in the African American community. This is more of a primary method, aiming at educating Baltimoreans about diabetes and how to prevent the illness.

Options Decision Criteria	Intervention 1: Food deserts	Intervention 2: medicaid	Intervention 3: churches
Effectiveness	2	2.5	1.5
Feasibility	2.5	1	2.5
Sustainability	2	2.5	2
Cost	2	1	2
Cost effectiveness	2	2	2
Political acceptability	2.5	1.5	2
Social will	2.5	1.5	2.5
Potential for unintended risks	3	1.5	3
Potential for unintended benefits	3	3	3
Total/conclusion	21.5	16.5	20.5

The best intervention seems to be the first one based on the idea of food deserts. This scored the highest from the decision criteria, which all seemed appropriate for determining the best interventions. 

Possible Stakeholders...

There are several stakeholders that play a role within developing an intervention for diabetes in the African American community. It is important to recognize who the stakeholders are within the area that you plan to implement a program because those are the people who will have to be convinced or approached for support and resources in the event that the program you are implementing will affect them.

        Possible stakeholders include the population that obviously is going to be directly impacted: African Americans. Besides this, there are other organizations and persons to be considered. There can be food suppliers and grocery stores, local/state/government contracting and government budgets (fiscal analysts or those who control the budget of the area), health insurance companies, hospitals and physicians.

The beginnings of some possible interventions for this problem for example could be the development of more efficient grocery stores within urban areas to decrease the amount of food deserts. Stakeholders for this intervention include the local or state governments who have to make room in their budgets to build more grocery stores. They would also have to provide staff and training for these new stores. You would need the cooperation of those individuals who live in the area where the stores are planned to be built, especially in the case that residents might need to be displaced, unless the stores were built on vacant lots or other places. In this case, there may be opposition from the local governments, especially if there budget spending is limited and they would like to put the money they have towards other areas that they deem more necessary. This can be addressed by ensuring some type of payback towards the government for each grocery store that is established.

Another intervention is to provide more fresh and healthy foods for lower prices. Stakeholders in this intervention could be farmers and those who grow the produce, the companies who manufacture the produce, the stores that distribute and sell the produce, and even the government because of the decrease in profits (i.e. taxes) that will be incurred from the lower prices. There may be opposition from farmers because there income will be impacted by the lower costs. Perhaps there could be an incentive for farmers who participate in the intervention over a certain amount of time or how much of their products were purchased in consumer markets.

The stakeholders will obviously have many concerns about what the implementations might mean to them in the long run. For many of the stakeholders, the loss of money is a huge factor in whether they will comply or negotiate with the implementation plans. They may also be concerned about how their participation looks to other groups and organizations that they support. Even more important, they may be concerned about what they may gain from negotiating with the task force.

All About Key Determinants

There has been increased prevalence of Diabetes among African Americans 18 years and older in the United States between 2002 -2010. There are a variety of key determinants that factor into this diabetes epidemic on many levels. Biological determinants include race,  gender, physical activity, and previous health-related problems such as obesity and hypertension.  Social and Cultural factors are things such as ethnicity, socioeconomic status, group norms (soul food, curvy women), daily lifestyle habits (working multiple jobs, not enough time to cook), education (being aware of healthier options), media influence, and social support. In addition to these are environmental determinants such as the distance to grocery stores, access to gyms, and quality of neighborhoods. Economic factors include the price of foods, medication costs, and employment status. There are also political determinants such as access to healthcare/quality of healthcare and even medication costs.

To analyze these determinants and see how much they contributed to the development of diabetes, many studies were done. The Food, Identity, and African-American Women With Type 2 Diabetes: An Anthropological Perspective analyzed the importance of food in African American culture and relationships, predominantly among women. They found that food was sort of a way to welcome others, and to show gratitude those who the food was given too felt they had to eat plenty. One interviewee stated that, “The old people that I work around, they show me they love me and really care for me, they feed me. They feed me a lot. They feed me like five times a day, not thinking, well, this child needs a balanced nutrition meal so he won’t get fat.” Other research was done on another basis as noted in Social determinants of health among African Americans in a rural community in the Deep South: an ecological exploration. Researchers interviewed African Americans in a systematic way which included questions from several different categories of ecological levels such as individual, relational, and environmental. As a result of these interview responses, they put together possible determinants of health. This included lack of social capital, political cronyism, poverty, racism, and local economy. Although this study does not particularly identify diabetes determinants, they can also be applied to this disease. Another study, Healthy Eating and Exercising to Reduce Diabetes: Exploring the Potential of Social Determinants of Health Frameworks Within the Context of Community-Based Participatory Diabetes Prevention, focused on diabetes in the population of African Americans in Detroit, Michigan. Something they found was that the city had a higher rate of mortality from the disease than the state itself, (note: Detroit is predominantly African American).  They also identified that African American women were the least active and the most overweight among many groups and bridged a link between this and the development of type 2 diabetes. The researchers suggest that race-based residential segregation is one of the overarching issues that have a trickling effect down to the health disparities seen in the US.

There are many key determinants that contribute to the prevalence of diabetes among the African American community. I intend to identify those that relate to my problem definition through more research.

Liburd, Leandris C. "Diabetes Spectrum." Food, Identity, and African-American Women With Type 2 Diabetes: An Anthropological Perspective. American Diabetes Association, n.d. Web. 01 Apr. 2013.

Scott AJ, Wilson RF.  Social determinants of health among African Americans in a rural community in the Deep South: an ecological exploration. Rural and Remote Health 11: 1634. (Online) 2011.

Schulz, Amy J., Shannon Zenk, and Angela Odoms-Young. "Healthy Eating and Exercising to Reduce Diabetes: Exploring the Potential of Social Determinants of Health Frameworks Within the Context of Community-Based Participatory Diabetes Prevention." PMC. American Journal of Public Health, Apr. 2005. Web. 01 Apr. 2013.