Use of Culturally Sensitive Nutritional Diabetes Education for Hispanic Adults with Type 2 Diabetes

Use of Culturally Sensitive Nutritional Diabetes Education
for Hispanic Adults with Type 2 Diabetes

ACKNOWLEDGEMENTS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ABSTRACT

Use of Culturally Sensitive Nutritional Diabetes Education
for Hispanic Adults with Type 2 Diabetes

by

Type 2 diabetes mellitus (T2DM) and its complications are having a massive impact globally and are the seventh leading cause of death (U.S.) (Rowley, Bezold, Arikan, Byrne, & Krohe, 2017; Centers for Disease Control and Prevention [CDC], 2017). The disease is a significant public health issue affecting approximately 415 million individuals and prepared to increase to 642 million by the year 2040 and 700 million by 2045 (Al-Lawati, 2017; International Diabetes Federation, 2017).

Individuals of certain racial and ethnic groups are most likely to develop prediabetes and T2DM (CDC, 2019). The groups include African Americans, Hispanic/Latino Americans, and

compared to 7.4% in non-Hispanic white individuals (American Diabetes Association, 2015).

Culturally sensitive education is essential in addressing the prevalence of diabetes within communities. The Hispanics/Latino communities, as with others, have unique genetics, foods, and lifestyle choices. As factors that influence the prevalence of diabetes, educative systems must cater to the uniqueness of the culture to enact successful change. This paper also showcases the benefits of culturally sensitive education and the impact it can have on reporting, diagnoses, and self-care for the prevention and management of the disease.

 

 

Chapter 1

Introduction

Type 2 Diabetes Mellitus (T2DM) is a metabolic condition that requires patients to continually regulate and monitor their lifestyles to maintain healthy blood sugar levels.  Four hundred twenty-five million, (one out of 11) people have diabetes globally (International Diabetes Federation [IDF] Diabetes Atlas, 2018). Diabetes has increasingly plagued the well- being of Americans, affecting over 30 million people (ADA, 2015).  Bullard et al. (2018) reported there are 23 million U.S. adults who have been diagnosed with diabetes. The most prevalent form of the disease is type 1 and type 2. For this project, we will focus on type 2 diabetes mellitus (T2DM). Type 2 diabetes is primarily caused by a combination of insulin resistance and deficiency (Bullard et al., 2018). A study conducted by the National Health Interview Survey used in 2016 highlighted the frequency of diagnosed diabetes among adults. Roughly 8.6% of adults were diagnosed with type 2 diabetes, which represented 21.0 million adults (Bullard et al., 2018). The most recent United States statistics list diabetes as the cause of 80,000 deaths annually (ADA, 2015).  According to the Centers for Disease Control and Prevention [CDC] (2017), diabetes is still the seventh leading cause of death.

The diseases affect people from all cultures thus introducing a need to develop special intervention programs for individual cultures. The differences in genetics, foods, literacy, and lifestyle choices that separate cultures are significant influencers on the prevalence and management of the disease (Aguayo-Mazzucato et al., 2018). Developing an education program considering these factors should improve its results. The Hispanic community showcase a high prevalence of T2DM with rates of 12.1% compared to non-Hispanic whites’ 7.4% in the United States (ADA, 2015). The following chapters focus on T2DM addressing the importance of cultural sensitivity in the development of nutrition education programs.

T2DM, Hispanic Adults, and Culturally Sensitive Education

In 2016, the prevalence of diagnosed T2DM was 8.6% (approximately 21.0 million U.S. adults) (Bullard et al., 2018). Roughly ten percent of Americans of all ages currently live with the disease (ADA, 2015), while the statistics are expected to worsen with 21% expected to receive a diagnosis of T2DM by 2050 (IDF Diabetes Atlas, 2015). For Hispanic/Latino adults, they are 1.7 times more likely to be diagnosed with diabetes by a doctor (Office of Minority Health, 2019). Other statistics showed that in 2016, Hispanics were 2.6 more likely to be hospitalized for treatment of end-stage renal disease and 1.4 times probable to dies from diabetes (Office of Minority Health, 2019).

Diabetes is a disease that affects insulin production, the role of insulin, and in turn, how the body manages blood glucose (Bullard et al., 2018).  Type 2 Diabetes mellitus (T2DM) is most prevalent in individuals who are overweight, inactive, or who consistently partake in unhealthy eating habits. Also, genetic predispositions may play a role in developing the disorder (Mercader, & Florez, 2017).  T2DM is described by a cellular insulin resistance, which emphasizes a breakdown of the response loop between the pancreas cells and insulin-sensitive tissues (Skyler, Bakris, Bonifacio, Darson, Eckel, Groop, & Ratner, 2017). This breakdown eventually leads to the loss of β-cells, low insulin-making, which causes reduced glucose control (Skyler et al., 2017). Genetics play a significant role in the increased occurrence of T2DM in the Hispanic/Latino population (Aguayo-Mazzucato et al., 2018). Other factors include cultural, environmental, lifestyle, and food choices, and obesity (Aguayo-Mazzucato et al., 2018; Moreira et al., 2017). Additionally, the increased prevalence of the disease among this population indicated that they are undertreated and underdiagnosed, hence less likely to control their glucose levels, blood pressure, and lipid levels (Cheng et al., 2019). In the Hispanic community, approximately one-third of the individuals with the disease are not aware they have it (Juarez et al., 2018).

The significance of the topic is that as of 2015, 84.1 million more adults are pre-diabetic and at higher risk for developing the disease (ADA, 2015).  Individuals diagnosed with T2DM are more susceptible to kidney failure, lower-limb amputations, and adult-onset blindness. These same patients are 1.8 times more likely than non-diabetics to succumb to a heart attack (Healthy People, 2020). The study will contribute by advancing scientific knowledge and improving the clinic’s current practices to delivering patient-centered care to the Latino population. The findings from the project can add to the previous literature regarding teaching self-management skills for Hispanic/Latino populations.

Assessment of the Phenomena

Diabetes is a global public health problem that affects individuals of all ages and ethnic groups. The Latino population is one of the rapidly growing ethnic groups in the United States and are affected by T2DM (Mier, Smith, & Wang, 2017).  A few reasons for the disparities include the lack of physical exercise, socioeconomic status, minimal and/or unavailable education, poor dietary habits and intake, lack of health insurance, and obesity (Mier et al., 2017). There is a clinical challenge for healthcare providers to help this population because of their patients’ internal conflict with social and personal beliefs related to the recommended regimen.  Although there is an abundance of research studies on T2DM, the incidence and prevalence continue to rise, particularly in the Hispanic population. In the private clinic where the project was conducted, nutrition education was provided as part of the discharge instructions (English and Spanish) via a language interpreter.

Many Hispanic adults, require more education regarding nutrition and self-management skills to lower their glucose levels. Hu et al. (2016) emphasized that nutritional education was an essential tool in assisting this population to control their glucose levels. Healthcare providers must understand the Hispanic patient’s personal, family, and supporting factors that affect their lifestyles and food choices (Moreira et al., 2017; Hu et al., 2016). Furthermore, healthcare professionals must create action plans that include the collectivistic culture point of view (Moreira et al., 2017). The emphasis for this population consists of group activities (family) and shared responsibility, which means more attention is focused on how a situation will affect the group (Moreira et al., 2017; Hu et al., 2016). This is critical for improving the patient’s self-management of the disease. It is not known if or to what degree the implementation of a culturally sensitive nutrition educational intervention will impact the HgbA1c levels by two points in Hispanic adults with T2DM post three months.

Historical and Societal Perspective

In 1500 BC, the earliest documentation and conversation that occurred related to diabetic symptoms and treatment was written by an Egyptian Papyrus Ebers. The term diabetes was developed by Aretaeus of Cappodocia (81-133AD) (Karamanou et al., 2016). In 1675, Thomas Willis added the term Mellitus to describe the sweet smell of the patient blood and urine (Karamanou et al., 2016). By 1776, Matthew Dodson proved validated the presence of extra sugar in the urine created sweetness (Karamanou et al., 2016). In 1857, Claude Bernard of France established the role of the liver in glycogenesis and the concept of excessive glucose production (Karamanou et al., 2016). The role of the pancreas was discovered by Mering and Minkowski in 1889 (Karamanou et al., 2016). By 1921, Fredrick Banting, and Charles Best developed insulin preparation and clinical usage procedures (Karamanou et al., 2016). Lily Pharmaceutical company would, in 1923, partner with these scientists to make insulin commercially available as Iletin (Karamanou et al., 2016). Over the next few years, diabetes treatment procedures made significant advancements with more developments in insulin types and delivery mechanisms (Karamanou et al., 2016).

In 1997 and 2003, the American Diabetes Association (ADA) updated and revised the guidelines, which are the standards used by health care providers today.

Studies show that societal perspectives regarding the disease are predominately negative (Kugbey, Asante, & Adulai, 2017). Diabetes’ nature as a non-curable disease causes significant strain on personal relationships which can significantly influence patients’ help-seeking behavior and reduce their tendency to seek treatment (Low, Tong, & Low, 2015). Cultural beliefs are a crucial concern regarding diabetes treatment with cultures (Park, Nam, & Whittemore, 2015). East Asian Immigrants for instance neglect the severity of diabetes due to subtle symptoms, and further beliefs concerning medicine, food, and medical check-ups (Park, Nam, & Whittemore, 2015). Cultural factors influence diabetes prevalence across the population. In a study conducted by Moreira et al. (2017) with Hispanics regarding diabetes showed their belief system stated the disease was caused by having a family history, eating high amounts of fat and sugar, and little physical exercise. The participants experienced fright, anger, sadness, and depression in contracting the disease. For many Hispanic patients, they attribute the onset of diabetes to an event that triggers the disease such as (trauma from a breakup or divorce, stress) (Moreira et al., 2016). The current data shows that minority groups as more susceptible to the disease, particularly Hispanic/Latinos (CDC, 2017). Healthcare providers must understand the Hispanic culture regarding food and cultural habits on the individual, which can affect the likelihood of success or failure in self-management of the disease.

Incidence and Prevalence

In the United States, the Latino community is one of the fastest-growing and is becoming the nation’s largest ethnic group.  As of 2015, the United States Census Bureau reported that there are 56.6 million Hispanics in the country, representing 18.3 % of the population.

The prediction is that by 2060, the Hispanic-American community will grow to 119 million [28.6%] (United States Census Bureau, 2016).  According to the CDC (2017), diabetes mellitus is the seventh leading cause of death in the United States for this population.  The rates of diagnosed diabetes range from 7.4% in non-Hispanic whites to 15.1% in American Indian/Alaskan Native populations.  Recent literature showed a breakdown of the data that 13.8% of Hispanic Americans struggle with the disease daily (ADA, 2015).

The level of diagnostic disparity between non-Hispanic whites and Hispanics indicates a critical need to rectify the underlying causes.  In 2017 the State of California noted 3.1 million diagnoses of diabetes in adults; of these 2.6 million (83%) have Type 2 diabetes (Taylor, Downie, & Mercado, 2019).  Minority ethnicities make up most of the diabetic population with prevalence rates ranging from 7.7% (Non-Hispanic Asian/Pacific Islander) to 9.8% (American Indian/Alaskan Native) (Taylor et al., 2019). Hispanics and Non-Hispanic African Americans are responsible for the second-highest percentage of T2DM cases (9.7%) in the State (Taylor et al., 2019).

Healthcare Cost

In reviewing the financial costs of T2DM, one must evaluate the monthly and annual expenses. The ADA (2018) reported that in 2012, the estimated total cost of diagnosed diabetes rose from $245 billion to $327 billion in 2017. The costs of all types of diabetes in the United States was $327 billion, which included direct ($237 billion) and indirect ($90 billion) costs (ADA, 2017). The economic costs of T2DM have increased by 26% in the past five years (ADA 2018). For many diabetic patients, their yearly expenses associated with the disease is $16,750, with over $9,600 related to the disease (ADA, 2018). Diabetes-related disability affects the workforce, as shown in 2017, costing $37.5 billion and absenteeism $3.3 billion (ADA, 2018). The Hispanic patient faces $8,051 related to diabetic healthcare costs and 66% of its population is more likely to receive the diagnosis (ADA, 2018).

Introduction of PICOt Foundation

Diabetes is a global concern for people of all ages, races, and genders. Healthcare providers must learn and understand the cultural belief system of the Hispanic/Latino population to decrease the clinical challenges that these patients encounter (Moreira et al., 2017).  Despite the research studies on T2DM, the incidence and prevalence of the disease continue to increase, especially in the Hispanic population (CDC, 2019). Evidence showcases an over 50% chance for Hispanics to developing T2DM with about 17% of the population living with the disease (CDC, 2019). In comparison, all US adults have a 40% chance of developing T2DM and the non-Hispanic white population’s 8% of diabetics showcase the severity of the disparity (CDC, 2019). Along with the higher development rates so are the rates of complications, morbidity, and mortality (CDC, 2019).

            Research articles have proven that physical inactivity, poor dietary choices, and lack of understanding of the disease are contributing factors to exacerbating T2DM. These factors are exacerbated in demographics for diabetes but specifically affect the Hispanic population. Medications have been the main form of regulating diabetes symptoms, but research has shown that dietary control and consistent physical activity are vital to improving patient health (Sami et al., 2017). Certain dietary changes such as decreasing fat intake, increasing vegetable, fruit, and grain consumption, and eliminating sugary beverages influence the reduction of blood sugar levels which could improve management and prevention of the disease (CDC, 2019). The evidence supports the use of culturally sensitive education programs to improve self-care, and management practices among diabetic patients from minority communities.

 

 

 

 

 

 

 

 

 

 

Chapter 2

Literature Review

Introduction of PICOt Question

The PICOt format is used for summarizing one’s research questions, which evaluate the effects of an intervention (Kumari, Sinha, Ranjan, 2017). Without an elaborate question, it would be difficult to identify the variables, resources, and significance of the evidence. The PICOt question is used for developing answerable and researchable questions. De and Singh (2019) emphasized that the PICOt clarifies the questions asked making it easier to find the answer. The (P) refers to the population (participants) recruited for the study, (I) refers to the intervention given to the participants enrolled in the study, (C) refers to the comparison identifying the plan (reference group compared with intervention), (O) refers to the outcome or outcomes measured to evaluate the effectiveness of the intervention, (t) describes the time the study is conducted for data collection (Kumari, Sinha, Ranjan, 2017). For this project, the PICOt that will guide the project is (P) adult Hispanic patients with T2DM, (I) culturally sensitive nutrition educational intervention, (C) compared to current nursing practice, (O) weight loss by five pounds and reduction in HgbA1c levels by two points, (t) three months. Q1. To what extent did the culturally nutritional education intervention impact the T2DM Hispanic participants’ weight loss and reduction in HgbA1c levels post three months?

The databases used to search for scholarly and peer-reviewed articles regarding Hispanics and T2DM were CINAHL, EBSCOhost, PubMed, Cochrane Library, Google Scholar, Med Sci, and Brandman University Library, and University of Phoenix (online library).  A total of 100 studies were found and 25 of them were used in the literature review.  The inclusion criteria consisted of articles written in English, within the past six years, and involved Hispanic participants. The exclusion criteria consisted of articles not written in English, over ten years, and involved in other ethnic groups. Keywords searched: attitudes and beliefs of Hispanics regarding diabetes, culturally sensitive nutrition education for Hispanics, Hispanics or Latinos and diabetes mellitus, self-management skills and nutrition for diabetics, type 2 diabetes mellitus, and Hispanics.

T2DM, Hispanic Adults and Culturally Sensitive Education in Literature

Diabetes is remaining a global challenge within the health sector, where some groups are at higher risks than others. For example, in the U.S., one of the groups to acquire the disease are Hispanics who have an increased risk of developing the condition. Hispanic adults are 50% likely to die from this condition compared to whites (Tang et al., 2015). Other studies, such as Mercader and Florez (2017) emphasized the Hispanic population has several genetic variants that have a strong association with the condition. Healthcare providers must understand and learn culturally appropriate interventions to help this population develop stronger self-management skills in managing their weight and HgbA1c levels. This section briefly discussed topics researched with an explanation of the major themes that emerged from the literature. This analysis of literature on T2DM, Hispanic adults, and culturally sensitive education should showcase their relationship with disease complications, risk factors, and interventions specific to the Hispanic population.

 

Review elements:

Population – number studied, characteristics…gender, race, urban v rural, study setting

Methodology – inclusion, exclusion, education intervention….

Intervention

Outcomes

p-value – “outcomes were statistically significant (p<.05)”

Statement of how the research supported your study…

 

Type 2 Diabetes

            CDC (2019) stated there was a prevalence of T2DM noted in racial/ethnic groups such as (Hispanics/Latinos) in comparison to non-Hispanic whites (Cheng et al., 2019). Furthermore, the CDC emphasized the growth rate among Hispanics/Latinos has increased, which suggested that the population is frequently undertreated and underreported. This leads them to be less likely to achieve or maintain glucose, weight, and cholesterol control levels (Cheng et al., 2019). Hispanics/Latinos with T2DM have a two to four increased risk of developing cardiovascular disease (Aguayo-Mazzucato et al., 2018). The complications of the disease are greater because of the factors affecting the care, such as (environment, socioeconomic, language, and access to health services).

Hispanic Adults and Chronic Disease

Diabetes and its complications is an emerging disease that has impacted countries, age groups, and the world’s economy (Papatheodorou, Banach, Bekiari, Rizzo, & Edmonds, 2018). In 2015, the International Diabetes Federation stated that roughly 415 million individuals had diabetes, with the number expected to increase over 640 million by 2040 (Papatheodorou et al., 2018). Many people who have the disease are not aware they have it furthering the development of diabetic complications. The chronic diabetic complications are common among T2DM divided into subgroups of micro and macrovascular problems (Papatheodorou et al., 2018). Microvascular conditions include neuropathy, nephropathy, and retinopathy, whereas macrovascular complications include cardiovascular disease, cerebral vascular accident, and peripheral artery disease (Papatheodorou et al., 2018).

            Diabetic retinopathy.  In a prospective, cross-sectional case-control study conducted by Nittala, Keane, Zhang, and Sadda (2014) evaluated the personal and demographic risk factors for Latinos in Los Angeles county related to diabetic retinopathy. Seven hundred and twenty-nine participants (n=729) from the University of Southern California who were enrolled in the study completed HgbA1c, creatinine, and cholesterol levels. The results showed the mean age of the participants with diabetic retinopathy was 57.43 years of age. The findings demonstrated that men using insulin, history of hypertension, and diabetes for 10 to five

The Los Angeles Latino Eye Study (LALES) was a longitudinal, quantitative study regarding 6000 (N=6000) Latino participants over the age of 40 years of age. The participants underwent medical assessments and physical examinations and were evaluated regarding the risk factors for eye disease and diabetic retinopathy. The results demonstrated that out of all the ethnic groups, Latinos developed visual impairment and blindness at an increased rate than others in the county. For older Latinos age 80 years and higher, 19.4% were visually impaired, 3.8% had bilateral blindness. One in five patients with T2DM with the new diagnosis, 25% showed signs of retinopathy during their first exam. The study showed participants between the ages of 40 to 59 had the highest rates of developing the eye condition.

The study validated the findings from the previous study Nittala et al. (2014) and West, Klein, Rodriguez, Munoz, and Broman (2001) Proyecto Vision Evaluation and Research study that emphasized the prevalence of diabetic retinopathy in Hispanics over the age of 40 (living in Arizona). The similarities in the studies showed the risk factors noted for this population in developing the disease. The participants that developed the disease had comorbidities of hypertension, socioeconomic problems, and lack of access to health care. All the studies concluded that early detection, screening, and treatment was a need for preserving the eyesight of diabetic Latino patients. The preservation of an individual’s eyesight is a financial benefit to the healthcare system and the global economy (Barsegian, Kotlyar, Lee, Salifu, & McFarlane, 2017). An annual eye examination for diabetic patient saves $2,162 of vision gained (Barsegian et al., 2017). All health care providers must concentrate and educate Spanish patients regarding the risk factors while encouraging annual diabetic retinopathy screenings. Minority populations are more susceptible to macro and microvascular diabetic complications (Barsegian et al., 2017). The Hispanic patient’s weakness and poor eye screening increase this population’s vision for threatening complications (Barsegian et al., 2017). Increasing the awareness with frequent patient reminders for these patients would help to diminish the disease.

 End-stage renal disease.  According to Desai, Lora, Lash, and Ricardo (2019), Hispanics are the largest ethnic group in the U.S. have the highest prevalence of kidney and end-stage disease. The prevalence of end-stage renal disease is approximately 50% higher in Hispanics in comparison with non-Hispanic whites. Poor management of the disease and its other health factors lead to increased prevalence and impact of the disease (McCurley, Guttierez, & Gallo, 2016). The data collected from Kaiser Permanente in Northern California showed that patients in stage 3 and 4 of chronic kidney disease (CKD) were Hispanic and associated with 1.3-fold for risk for progression to end-stage renal disease (ESRD).

A cross-sectional, quantitative study conducted by Ricardo et al. (2015) on Hispanic/Latino adults 16, 415 (N=16415) that included (Cuba, Dominican Republic, Mexican, Puerto Rico, Central, and South America) regarding the prevalence and correlation of ESRD in this population. The participants were between the ages of 18-74 years recruited from densely populated Hispanic cities throughout the U.S. The pre-examination consisted of clinical assessments, questionnaires, and laboratory values (venous (complete blood count and creatinine) and urine specimens). Demographic factors were also collected, which were (socioeconomic, acculturation, smoking, and medical history). The participants had their glomerular filtration rate (GFR) evaluated by three different methods: (a) chronic kidney disease epidemiology collaboration creatinine, (b) CKD-EPI cystatin C, and (c) CKD-EPI creatinine-cystatin C. The CKD was described by a low eGFR (< 60ml/min per 1.73) or the occurrence of albuminuria on the spot urine samples.

The results from Ricardo et al. (2015) study showed 9032 women and 6129 men (N=16415) for the participants. Two hundred and fifty-three (n=253) participants were excluded because of missing data or not being of the Hispanic/Latino group. The findings confirmed the prevalence of CKD and elevated levels of albumin in the population, p-value <0.001. The results magnified the highest prevalence of the disease found in women from Puerto Rico (16.6%) and South America (7.4%). Eighteen percent of the participants who partook in the study reported an increase in CKD awareness. The study concluded the increase of albuminuria was the main contributing factor of CKD in participants between the ages of 18-44 years, and low eGFR was commonly found in participants of the ages of 55-74 years.

The study conducted by the authors Ricardo et al. (2015) was significant because the last study concerning this topic took place ten years ago. The study could not confirm if the increased prevalence of earlier phases of CKD or fast progression remained for this population. The study found that there was a different rate of progression of CKD among the varied Latino groups. There was an association of CKD with a decrease in lower socioeconomic income, history of hypertension and T2DM, cardiac disease, and male gender. The strengths of the study were the participation of varied Latino subgroups from a diverse population. The second strength was the large population sample used for the study, which provides a greater generalization of the findings. The findings emphasized the grave implications for public health that by not improving this population’s understanding, screening, and educating the disease will continue to increase. More research studies are required to examine the modifiable risk factors for CKD progressing in the Hispanic/Latino population.

Risk Factors

            The Hispanic/Latino population is more likely than any other ethnicity to develop diabetes. Approximately 2.5 million or 10.4% of Hispanic/Latino Americans ages 20 and older will acquire the disease. Roughly half of the children born in the year 2000 will develop diabetes within their life span. The risk factors for this population include being overweight, history of the disease from siblings and parents, over the age of 45, and gestational diabetes. The next three sections will discuss the risk factors to include biological and cultural beliefs.

            There are three reasons for healthcare providers to understand how T2DM affects the Hispanic/Latino population. The reasons include the rapid growth of the people, the frequency and development of T2DM (an increase of obesity and chronic complications that lead to mortality rates), and their lag within the healthcare system (Aguayo-Mazzucato et al., 2018). For this population to heal and move forward, healthcare providers must be aware of the risk factors specific to the culture in dealing with T2DM (Moreira et al., 2017). Certain aspects of the culture could become barriers in the management of T2DM, using the cultural characteristics allows for teaching opportunities, prevention, and improvement of care (Aguayo-Mazzucato et al., 2018; Moreira et al., 2017).

            Obesity. A study conducted by Sorkin, Biegler, and Billimek (2015) discussed the lack of physical activity (such as walking) or other vigorous physical exercises among Hispanic adults versus non-Hispanic adults. The National Health and Nutrition Examination Survey taken during 2001-2006 reported this population at less than five servings of fruit and vegetables per day (less than 30%) (Mier et al., 2017). For many Hispanic adults, the prevalence of increased body mass index (BMI) above 30 ranges from 28.1% to 47.6% (Mier et al., 2017). Individuals with T2DM who are obese are at a higher risk of uncontrolled glucose control, reduction in quality of life, increased diabetic complications (such as hypertension, cardiovascular disease, strokes, and end-stage renal disease (Mier et al., 2017).

            Socioeconomic factors. Aguayo-Mazzucato et al. (2019) stated that from an income viewpoint the Hispanic/Latino population has a lower income of typically around $20,000. This financial issue is prevalent in this population coping with the disease, which leads them to have a difficult time with medications, follow-up visits, health insurance (24.4% are not insured), and self-care management. In individuals whose income is higher than $75,000 annually (12.8% for males and 8.3% for women), there are lower rates of the disease and better self-care management (Aguayo-Mazzucato et al., 2019). The average income for Hispanics/Latinos is $47,000 per year (Aguayo-Mazzucato et al., 2019). Hence, the Hispanic/Latino population have higher rates and risk in diabetes prevention and complications on time (Aguayo-Mazzucato et al., 2019). Lower economic communities hamper one’s desire for proper self-care management due to the limited access to quality foods (fresh fruit and vegetables), lack of exercise (no safe places) to participate in physical exercise (Aguayo-Mazzucato et al., 2019).

Interventions

            One of the most productive interventions that should be utilized with the Hispanic/Latino population is enhancing the culturally competent clinical skills of healthcare providers (Concha, Mayer, Mezuk, & Avula, 2016). Developing cross-cultural skills is essential because healthcare providers are the primary sources of diabetes information (Concha et al., 2016). Culturally competent communication between the healthcare provider and patient increases patient satisfaction, knowledge, compliance to medical regimen, and higher participation in self-care behaviors/management (Concha et al., 2016).

Culturally Specific Programs.

The main approach for achieving a culturally specific program is for the healthcare provider to understand the disease process is understood within a culture (Concha et al., 2016). This approach influences the patient’s beliefs and assumptions regarding the disease, prognosis, and outcome (Concha et al., 2016). This approach for dealing with diverse populations is called culture centered where Hispanics/Latinos believe that strong or negative feelings (such as stress) cause diabetes (Concha et al., 2016). The belief is known as susto (fright sickness), which influences and impacts how this population copes with diabetes self-management regimen. Bridging the perspectives of the healthcare providers (biomedical) and susto (Hispanic cultural belief) is a way to advance cultural competence (Concha et al., 2016).

Diabetes Education There is a vast amount of literature that supports the practice of diabetic self-management educational (DSME) intervention in varied subgroups and populations. Studies such as Azami et al. (2018), Chrvala et al. (2015), and Zandiyeh, Hedayati, and Zare (2015) showed a common finding, which was the groups that participated in the DSME intervention glucose levels resulted in lower readings. Two studies Azami et al. (2018) and Chrvala et al. (2015) studies illuminated that DSME is considered the gold standard for enhancing positive outcomes for T2DM patients.

Theoretical Framework

The Health Behavior Model (HBM) was the framework chosen for the project because it applied to an individual’s attitudes, beliefs, and barriers that impact one’s health behaviors. The model defines the concepts that guided the student researcher to provide a nutritional education intertwined with the patient’s culture and beliefs. The model was developed in the late 1950s by a team of social psychologists Hochbaum and Rosenstock, who worked in the public health service that explained an individual’s failure to participate in programs that detected and prevented disease (Rosenstock, 1974).

The model has six constructs that advocate a person’s belief in the danger of the disease in combination with their acceptance leads to adopting the recommended health behavior (Rosenstock, 1974). The sections include perceived susceptibility, severity, benefits, costs, motivation, and self-efficacy (see Figure 1) (Jones et al., 2015). The perceived susceptibility describes one’s perception of the health condition or disease if it is relevant to them (Rosenstock, 1974). The perceived severity refers to one recognizing the illness, the behavior does not change unless the person believes the seriousness of the condition or issue and its social complications (Rosenstock, 1974). Perceived benefits refer to one’s belief that the treatment or intervention will alleviate or prevent illness (Rosenstock, 1974). The perceived costs are associated with the disease’s complications, duration of the illness, and accessibility to the treatment (Jones et al., 2015). Motivation refers to the individual’s need to comply with the treatment regimen (Jones et al., 2015). Self-efficacy refers to one’s personality variables, satisfaction, and socio-demographic factors (Jones et al., 2015).

The clinical question is in alignment with the HBM model because it helped the student researcher to explain the disparities among the Hispanic sample size related to implementing the nutritional intervention. The theory is the foundation for a healthcare provider to learn how to present material using greater communication skills (Jones et al., 2015). This theoretical framework allowed the student researcher to assess nutritional education among the Hispanic participants. Although the cross-sectional project had a short time frame, significant improvements were noted after the implementation of the nutrition education intervention. Analysis occurred at the baseline, two weeks, and post-implementation of the intervention regarding the six constructs.

There are many complications associated with diabetes that impose an enormous burden on today’s health care. Many of the causes of T2DM originate from people’s lifestyles, such as lack of exercise, poor planning of meal choices, and overweight. As the model advances through the six stages, motivation for lifestyle changes becomes an easy task. For example, through perceived susceptibility, it would be easy for one to increase awareness of the risks and complications linked to T2DM. Additionally, the need for one to change lifestyle behaviors would also be included in this stage. Through perceived benefits, the patient understands the various merits that are associated with adjusting lifestyle choices, which plays into the motivation factor. Lastly, the creation of awareness on how to deal with perceived barriers such as lack of support from friends or family and stress aids one in their fight against T2DM.

In summary, T2DM among the Hispanic/Latino population continues to increase. Many factors influence the compliance and adherence to a regimen such as cultural and familial beliefs, socioeconomics, and lack of knowledge about the disease. Healthcare providers must assess all the varied reasons and integrate an action plan that is individually based. Stereotyping the Hispanic/Latino patients provides a false safety that healthcare professionals cannot use because it increases difficulties related to medical decision-making and communicating with them. These are a few steps that can be successfully implemented to prevent, treat, and manage the Hispanic/Latino populations (Moreira, 2017).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chapter 3

Methodology

Rowley et al. (2017) emphasized that T2DM and its complications are globally affecting individuals and are the seventh cause of death in the U.S. The rate of the disease is increasing at a rapid rate and is expected to affect 642 million people by 2040 (Al-Lawati, 2017). The problem is significant because approximately 193 million individuals will have diabetes and remain undiagnosed because of symptoms being mild or asymptomatic (Al-Lawati, 2017). Certain ethnic groups are most likely to develop T2DM (CDC, 2019). The groups comprise of African Americans and Hispanic/Latino Americans (CDC, 2019).

One of the significant challenges care providers face in their attempt to improve diabetes outcomes in the United States is the difference in ethnicity (Heisler, 2019). According to Heisler (2019), the prevention of diabetes requires individuals to embrace several healthy practices that are influenced by beliefs and cultures. Thus, any strategy or measures to reduce the condition ought to incorporate the aspect of culture. A study indicated that the use of culture-sensitive education was effective in advocating for weight loss in African American setup (Metghalchi et al., 2014). Additionally, a study by Mark (2016), revealed that culturally sensitive education could be used to reduce workers’ risk of metabolic syndrome among the Hispanic group. This article deploys the same approach in dealing with T2DM among the Hispanic group.

Compelling scientific evidence indicates that changes in lifestyle could act as a remedy for the disease (Sami et al., 2017). Several studies indicate that adopting a healthy lifestyle could aid in managing the disease (Chong et al., 2017). Examples of lifestyle changes that a person with diabetes ought to incorporate include physical exercises, managing weight, and eating healthy (Chong et al., 2017). Evidence showcases that lifestyle changes are as essential in preventing diabetes as it is in its management (McCurley et al., 2016). As such it is vital to reinforce lifestyle interventions through health literacy programs. According to Borrell, Dallo, and White (2015), educational attainment levels has a direct relationship with the prevalence of the condition among whites and Hispanic.

Additionally, attaining education may aid in the promotion of the embracement of practices such as proper nutrition, and observing medication may help reduce the risks of diabetes. The Hispanic population is at higher risk of obtaining the condition as opposed to other groups, and thus, educating them on the need for exercising healthy behaviors is essential. Proper nutrition may also act as a remedy for the diabetes condition. The incorporation of proper nutrition education programs such as ones involving family-based glycemic control would help to decrease the rate of diabetes among the Hispanic population (Hu et al., 2016). Lastly, waist circumference can be used as a measure for predicting diabetes risk (Smith, 2015). According to Smith (2015), size acts as an indicator of abdominal fat. Scherer and Hill (2016) recommend the reduction of waist circumference as an effective intervention for dealing with the condition, especially among the young adults in the Hispanic Population. For this project, it will concentrate on adult Hispanic/Latinos because they receive the diagnosis of T2DM greater than other groups.

Purpose Statement

           This project aims to determine the benefits of a nutrition education program on reducing hemoglobin A1c scores among the Hispanic adult in a family healthcare clinic. The goal of this project is to assess dietary behaviors among Hispanic and how they contribute to a diabetic condition. The project aims at improving clinical outcomes through encouraging changes in lifestyle, promoting the use of nutrition education, and self-management guidelines based on the American Diabetes Association (ADA) guidelines for educational intervention for the reduction of hemoglobin A1c level among adult Hispanics with T2DM.  Moreover, this project targets to provide a standard and sustainable approach to dealing with diabetes among the Hispanic population. Will culture-specific diet education and diet change reduce in hemoglobin A1c level by 2% among Hispanic adults diagnosed with T2DM within ninety days?

Population and Sample

Los Angeles County, which is situated south of California, is the second-most populous city in the US. As of 2018, the estimated population in the county was estimated to be 10,105,518 (United States Census Bureau, 2019). The county comprises of people from over 140 countries and is thus racially and ethnically diverse. In this case, as of July 1, 2018, approximately 48.6% are Hispanic, 26.1 % are White, 9% are Black, and other races 3.1% (United States Census Bureau, 2019). California population is expected to grow more slowly in the future because of the decline of immigration (World population Review, 2019). According to the United States Census Bureau (2019), 14.9% of families in Los Angeles live in poverty. Moreover, 6.2% of the population between 2013 and 2017 under the age of 65 have a disability condition. The population of participants chosen for this project consisted of adult Hispanic diagnosed with T2DM from a family health care clinic and the plan was to recruit at least 40 participants who live in the City of Los Angeles.

A convenience sampling of forty adults Hispanic who volunteered to participate, which is described as a non-probability sampling method was used for the project. The convenience sample size was recruited when the participants arrived at the family healthcare clinic on the recruitment dates period that was posted on the clinic notice board. The recruitment procedures used to capture the participants began after IRB approval from the university. The student researcher used flyers, which were posted in the patient waiting room, check-in windows, patient exam rooms, bathrooms, exit from the clinic, and distributed to patients in the reception area. All the participants were informed that their participation in the project was voluntary and they could withdraw without discussion regarding the reason for their non-participation. Participants were informed of the project’s objectives, purpose, timeline, and educational intervention. The medical assistant collected the names of participants who were interested in participating in the project.

The inclusion criteria for the participants included Hispanic/Latino adults aged 18 years or older,  male or female, can read and write English or Spanish, diagnosis with T2DM for three years or more, HgbA1c greater than 7.0 percent, no neurological or mental conditions, willing to participate in the study, and willing to provide informed consent. The exclusion criteria included participants with a major chronic illness other than diabetes and those with major impairments that would prevent them from engaging in questionnaires and surveys. After three days of recruiting participants, twenty-five participants met the criteria. On the last day of the recruitment period, five participants decided to opt-out because they had no means to attend the educational sessions. The twenty participants who met the criteria were informed about the project, purpose, and educational program. Participants verbalized understanding of the project and informed consent was obtained and participants were informed of their privacy and rights.

Study Design

The purpose of this quantitative, quasi-experimental design was to determine if the implementation of a culturally sensitive nutrition educational intervention will affect the HgA1c levels by two points in Hispanic adults with T2DM post-three months. In this project, a quantitative methodology was used since it can provide a decisive answer to the proposed clinical question (Salvador, 2016). According to Goertzen (2017), a quantitative methodology allows numerical data to be collected and evaluated creating trustworthy findings. For this project, the numerical data was compared to the pre-intervention and post-intervention data. The findings of the project were shown in statistical form and analysis to determine the success of the nutrition educational intervention.

A qualitative methodology was considered for this project because of its in-depth analytical characteristics (Quieros, Faira, & Almeida, 2017). Qualitative methodology is utilized to explore and identify the underlying reasons, feelings, and motives of the participants (Teherani, Martimianakis, Hayes, Wadhwa, & Varpio, 2015). In a qualitative research project, it uses unstructured and semi-structured interviews, discussions, or observations (Teherani et al., 2015).  Another characteristic of a qualitative study is that they typically have a smaller sample size, which makes it complicated to generalize the findings (Teherani et al., 2015).

A quantitative methodology is the best method considered for this quality improvement project because it is in alignment with the clinical questions being asked to understand the problem. The methodology helped evaluate and access the effect of the educational intervention on the participants’ glucose levels. According to Salvador (2016) and Queiros et al. (2017), these techniques offer better platforms for data collection and analysis as well as reducing bias in the study’s conclusions (Queiros et al., 2017).

To be more exact, this project’s pre-test and post-test intervention were used to answer the clinical question. This design was used to measure the self-reported questionnaires of twenty adult Hispanic participants with T2DM and the difference in blood glucose levels before and after the implementation of the intervention. A pre-test and post-test one-group design are dependent on three factors, pre-intervention assessment, administered intervention, and post-intervention assessment (Leedy & Ormrod, 2016).  The participants reported their pre-intervention blood glucose levels, and knowledge during the six weeks of the educational intervention for the t-test. The clinical conference room was utilized to provide educational classes for participants. The use of Powerpoint presentation and printed pamphlets were utilized to convey the teaching. The educational intervention included but not limited to the definition of diabetes, subtypes of diabetes, (focus mainly on Type 2 diabetes), causes, symptoms, treatment of hyperglycemia and hypoglycemia, the complications of diabetes, nutritional benefits, medication adherence, self-management of diabetes, and daily physical activity. The educational program was conducted in a group of five for each class session which lasted for one and a half hours for the first two consecutive weeks. Questionnaire on diabetes and knowledge of diabetes self-care management were presented to participants to evaluate participants’ knowledge about diabetes and how well they monitor their blood glucose level.

The study design was appropriate for the project because it measures the changes in the participants’ behavior and knowledge levels after the educational intervention. The self-reported questionnaire and initial glucose level were reported one-week before and one-week post-implementation.

Hispanics with type 2 diabetes were able to control their glycemic level and had a

reduction in HbgA1c levels by 0.5 to 1 point in three to twelve months (Rotberg, et al.,

2016; Perez-Escamilla, et al., 2014; & Wang, et al., 2013). In a paired-sample t-test

comparing the hemoglobin A1c levels before and after three months of dietary education

intervention, patients should have a significant reduction in their Hbg A1c levels

(Rotberg, et al., 2016; & Wang, et al., 2013).

Purpose Statement

This project examined the effect of a diet education program on reducing hemoglobin A1c

scores in Hispanic adults from a primary care clinic. The study focused on Hispanic

American patients who had a diagnosis of type 2 diabetes. The purpose was to assess the

impact of diet education program and compare the hemoglobin A1c level before and after

the intervention. The medical records on the hemoglobin A1c levels were retrieved from

2018 and 2019.  Will culture-specific diet education and diet change reduce in

hemoglobin A1c level by 2% among Hispanic adults diagnosed with Type 2 diabetes

within ninety days

Hispanics with type 2 diabetes were able to control their glycemic level and had a

reduction in HbgA1c levels by 0.5 to 1 point in three to twelve months (Rotberg, et al.,

2016; Perez-Escamilla, et al., 2014; & Wang, et al., 2013). In a paired-sample t-test

comparing the hemoglobin A1c levels before and after three months of dietary education

intervention, patients should have a significant reduction in their Hbg A1c levels

(Rotberg, et al., 2016; & Wang, et al., 2013).

Purpose Statement

This project examined the effect of a diet education program on reducing hemoglobin A1c

scores in Hispanic adults from a primary care clinic. The study focused on Hispanic

American patients who had a diagnosis of type 2 diabetes. The purpose was to assess the

impact of diet education program and compare the hemoglobin A1c level before and after

the intervention. The medical records on the hemoglobin A1c levels were retrieved from

2018 and 2019.  Will culture-specific diet education and diet change reduce in

hemoglobin A1c level by 2% among Hispanic adults diagnosed with Type 2 diabetes

within ninety da

Instrumentation

The instrument used for the project was the Diabetes Self-Management Questionnaire (DSMQ). It is a 16-item questionnaire that evaluates self-care activities linked with glucose control. The questionnaire was developed and based on the theoretical considerations and process of empirical improvements at the Research Institute of the Diabetes Academy Mergentheim (Schmitt et al., 2013). The Four subscales include glucose management (items 1, 4, 6, 10, 12), dietary control (items 2, 5, 9, 13), physical activity (items 8, 11, 15), and healthcare use (items 3, 7, 14) (Schmitt et al., 2013). Item 16 provides an overall rating of the individual’s self-care and is included in the sum scale. The scoring of the questionnaire includes reversing negatively worded items that have higher values, which are suggestive of effective self-care (Schmitt et al., 2013). Scale scores are calculated as sums of item scores and then converted to a scale ranging from 0 to 10. For example, a raw score *10 with a glucose management raw score of 12 equals 12/15*10=8). The score often demonstrated the highest self-rating of the individual’s behavior.

Data Collection

The step-by-step procedures conducted by the investigator did not begin until permission was received from Brandman University Institutional Review Board (IRB) and all project related materials were also approved by Brandman University IRB. Two to three weeks before the recruitment period, the medical assistance in the family clinic posted the recruitment flyers at the clinic notice board, windows at the check-in station, and on the wall visible to everyone at the waiting lounge. The medical assistance was able to recruit participants during the time of check-in. Selected participants were provided details of the project related to the risks, benefits, and confidentiality. Participants were instructed that participation in the project was voluntary and that they could withdraw from the project at any time without disclosure. The Research Participant’s Bill of Rights, the date and time for the class sessions, and behavioral health questionnaire were explained to the participants. All selected participants signed informed consent. The Diabetes Self-Management Questionnaire (DSMQ) questionnaires and Behavioral Health questionnaire were collected at the end of the meeting.

Participants’ pre-hemoglobin A1c were retrieved from the clinic’s database EMR software. At the initial meeting, participants’ height, weight, blood sugar, vital signs were obtained. The lesion outlined the definition of diabetes, types of diabetes, risk factors associated with diabetes, causes, of T2DM, signs, and symptoms of hypoglycemia and hyperglycemia, complications associated with the disease, benefits of regular blood sugar monitoring, and importance of nutrition education and the use of MyPlate, and daily physical activity. The United States Department of Agriculture (USDA) established MyPlate dietary guidelines. The aim of creating MyPlate was to create awareness on the consumption of a nutritional based diet. MyPlate is a tool implemented to promote a well-balanced plate and guide individuals to develop a healthy eating pattern (ADA, 2019). The use of this tool is to assist participants to gain more knowledge about diabetes, and how to create a healthy eating plan, regulate their carbohydrate intake, and improve their diabetes self-management care. Powerpoint presentations, an educational handout from the American Diabetes Association (ADA)

Data Analysis

 The DNP student used descriptive statistics that described the basic features of the sample population. The descriptive statistics will be displayed using tables and figures (mean, median, and mode). The clinical question was answered using a paired sample t-test to determine the participants’ weight loss and decrease of HgA1c. The question was answered by analyzing the mean scores of the pre-intervention and post-intervention from the developed questionnaire. The purpose of using the paired t-test was to evaluate the statistical significance (p-value <.05). The information was entered from the Microsoft Excel Spreadsheet (2016) codebook, then exported into Statistical Package for the Social Sciences (SPSS) 26.

Summary

The impact of diabetes self-management education is essential for the Hispanic/Latino population in managing their disease. A greater need should be placed on healthcare providers to become culturally competent to offer patient-centered strategies.  The chapter discussed the methodology, instrumentation, data collection, and analysis used in the study.

Chapter 4

Findings

Group	Sample	Mean Weight	Std. Error	Std. Dev.	[95% Conf. Interval]
Without Prior Diabetes Education	8	214.5875	11.05426	30.11903	31.26616	240.7267
With Prior Diabetes Education	12	180.8333	8.055286	27.90433	163.1038	198.5629
Combined	20	194.335	7.412121	33.14801	178.8213	209.8487
diff		33.75417	13.35423		5.697978	61.81036

Table 1: Paired T Test Result for Patients’ Weight with and without Prior Diabetes Education

diff = mean(0) – mean(1)

t =   2.5276

Ho: diff = 0

Degrees of freedom =       18

Ha: diff < 0……………………….. Pr(T < t) = 0.9895

Ha: diff != 0………………………. Pr(|T| > |t|) = 0.0211

Ha: diff > 0…………………………Pr(T > t) = 0.0105

A paired t-test showcased a mean weight difference of 33.7 lbs. between the two patient groups. Furthermore, the data also provides a 0.0211 and 0.0105 as p-values to assert a difference between the means. These values prove that nutritional education will impact the patient’s weight.

Group	Sample	Mean HgbA1c	Std. Error	Std. Dev.	[95% Conf. Interval]
Without Prior Diabetes Education	8	8.8625	.4048534	1.145098	7.905174	9.819826
With Prior Diabetes Education	12	8.158333	.3246113	1.124486	7.443869	8.872798
Combined	20	8.44	.2588842	1.157766	7.898149	8.981851
Diff		.7041667	.5169345		-.3818724	1.790206

Table 2: Paired T-Test Results for Patients’ HgbA1C with and without Prior Diabetes Education

diff = mean(0) – mean(1)

t =   1.3622

Ho: diff = 0

Degrees of freedom =       18

Ha: diff < 0……………………………  Pr(T < t) = 0.9050

Ha: diff != 0……………………………  Pr(|T| > |t|) = 0.1899

Ha: diff > 0……………………………. Pr(T > t) = 0.0950

This paired t-test compares the HgbA1c results of the patients in the two groups. The test results showcase p-values of 0.1899 and 0.0950 that highlight the little difference between the HgbA1c means. The test proves there is no significance in the difference in HgbA1c levels between the two groups.

Chapter 5

Discussion

Implication

Concha et al. (2016) emphasized that the health status of American Hispanics/Latinos continue to face considerable disparities in type 2 DM management, prevalence, and outcomes. The increased incidence of the disease among this population ranges from 14% to 16% in comparison to 6% for non-white Hispanics (Concha et al., 2016). Furthermore, this ethnic group is nearly three times more likely to experience complications from the disease, such as disability and mortality (Concha et al., 2016). For many of these individuals, they are less prone to obtain clinical information, examinations (eye and foot exams, A1c tests), and follow-up care. These factors and healthcare disparities add to the non-compliance, delay in care, and overuse of the emergency department (Aguayo-Mazzucato, 2018). The research illuminates that the Hispanic/Latino population is one of the fastest and leading growing minority groups that need more culturally and linguistically competent healthcare providers and services to improve the healthcare outcomes (Moreira et al., 2017).

Future Implications

            The project showed the need for healthcare providers to become culturally and preferably linguistically competent in providing care to this population. Furthermore, the project demonstrated that the participants’ compliance rates increased because of nutritional education utilizing evidence-based nursing guidelines. The project was successful in assisting the participants in developing personalized self-management strategies to maintain their weight. The student researcher believes that future implications should involve additional research related to marketing methods specific to Hispanic/Latino diabetic adults using newer technology. Another future suggestion is related to integrating nutritional/self-management teaching into church programs since this is an avenue that has limited health programs related to one’s health (Baig et al., 2014).

The results of the project indicated statistical changes in the participants’ education and weight. Although the results were not significantly statistical, it is still important to note that the participants were responsive and compliant in accomplishing the requested goals. The pretest/posttest of the HgbA1c results showed a decrease of .52, not the expected drop of two points in the three months (t (20) =6.30, p<0.5). These results suggested that perhaps the results would have shown significant changes if it were a longitudinal study (one year) versus cross-sectional (three months). As for the participants’ weight loss, there was a change by 33.75 lbs., which meets the study’s requirements of a five-pound loss in three months. The findings did show that the participants were interested in their health and complied when the evidence-based program was centered on patient needs. The participants learned varied food choices, which considered the patient’s financial status since many of the participants (85.72%) of them worked part-time. For most of the participants, they stated that eating healthy food was expensive, making fast food more accessible.

The results of the quality improvement project supported the previous and current body of evidence such as Concha et al. (2016) and McCurley et al. (2016) in a call for change in healthcare provider’s methods, attitudes, and behaviors in caring for this population.  Healthcare practitioners need to become culturally and linguistically competent to provide care and educate this population. The education should be patient-centered according to their cultural beliefs, mores, values, and health literacy levels. The implications noted in the project showed that the findings from the project could be used in other home healthcare settings for adult Hispanic/Latino patients related to developing new strategies.

Supporting Evidence for Advanced Practice Registered Nursing (APRN)

For APRNs, direct clinical practice is the core competency for providing care according to the Hispanic/Latino population. The nursing practice for APRNs states that they are prepared to assume the responsibility and accountability for health promotion, assessment, diagnosis, and management of their patients (O’Grady, 2008). Three factors could be used regarding the key role of APRNs participating in the improvement of practice related to Hispanic/Latino T2DM patients. The three factors include dealing with their personal biases regarding this population, identify barriers that could prevent the patient from being compliant with the recommended regimen, and provide greater support and resources. Interventions should involve culturally appropriate resources and patient-centered strategies in the self-management of diabetes.

Limitations

Limitations are described as restrictions, flaws, or shortcomings that are beyond the researcher’s control while conducting the project (Grimes, 2020). Two limitations involved with the project were the small sample size (n=21) and the restricted time frame. Leedy and Ormrod (2016) emphasized that a small sample size could lead to potential biases, such as a participant’s non-response, which is not a truthful representation of the population. This possibility may lead to voluntary response biases when a small number of non-representative participants had the opportunity to partake in the study. To minimize this occurrence, the student researcher included individuals who were related to the project’s subject (Gentles et al., 2015).

The second limitation was related to the time frame (cross-sectional versus longitudinal) in conducting the project. The time frame to lead the project was completed in three months, which could have decreased the significance of the findings. In the project, the results demonstrated that the participants did lose weight and lowered their HgbA1c, but perhaps it could have decreased significantly if a longitudinal study were conducted. Hence, the student researcher could have used repeated measurements to follow the participants over a more extended period (one year) (Leedy & Ormrod, 2016). Longitudinal studies are conducive for evaluating the outcomes and changes of treatment over time, providing more robust findings and validity for cause-and-effect relationships (Leedy & Ormrod, 2016).  A cross-sectional study provides a snapshot of the outcome of measured variables at a specific time.

Dissemination

The findings of the project will be disseminated with the nursing management, stakeholders, and medical director of the home health care facility. A PowerPoint presentation will be presented at a luncheon for the nurses, nurse leaders, patients, and physicians to convey the project and its outcomes. The results could also be disclosed with nurses during their morning huddles using a poster board and a five-minute video presentation. By establishing efficient and appropriate dissemination procedures researchers can instigate significant change in the professional and academic community and also receive substantial financial benefits (Gonzalez et al., 2017).

On a personal level, the student researcher’s eventual goal is to share the findings in oral and written formats via journals such The Journal of the National Black Nurses Association, National Coalition of Ethnic Minority Nurses Association, National Association of Rural Health Clinics, and National Association of Nigerian Nurses in North America. This would provide the student researcher a forum to provide an updated discussion of issues related to the care of minorities in the healthcare-related to Black and Brown communities. These arenas are a vehicle for the student researcher to exchange ideas of scholarly works, disseminating knowledge learned about critical practice and research affecting this population. Although the findings were specific to the Hispanic/Latino population, they could be used for other minority populations.

Application to the DNP Essentials

In 2006, the American Association of College of Nursing (ACCN) distributed The Essentials of Doctoral Education for Advanced Nursing Practice. The essentials detailed the curriculum components and competencies required by all doctoral nursing programs. The essentials validate and work in conjunction with the Institute of Medicine report findings that addressed nursing education and the need to focus on the complexity of the healthcare system. In the DNP Essentials, there are eight competencies required of all APRNs graduates regardless of their specialty. Three essentials applied to this project, which will be described and met while conducting this project. The essentials are listed below:

The DNP Essential II: Organizational and Systems Leadership

The nursing environment is multi-dimensional regarding addressing their patient’s cultural beliefs, mores, personal opinions, and other aspects. In this environment where APRNs are providing care for diverse populations, it requires leadership, control, and knowledge to achieve the best health care outcomes for the patients, as well as the organizations.  In organizational and systems leadership, the top leaders of the organization are the ones that implement the best practices and decision-making process to occur at varying stages of patient care. According to AACN (2006), Doctor of Nursing Practice has a unique role in contributing to nursing practice by evaluating research, translating research findings, and disseminating the research findings into practice. This essential provided the rationale for the student researcher’s choice in using MyPlate Nutritional Guide as one of the strategies that can be used to manage diabetes among Hispanic participants. Moreover, this essential guided the project on whether a culturally appropriate educational program could provide additional and essential guidelines for reducing the Hemoglobin A1c and weight loss in this population.

The DNP Essential III: Clinical Scholarship and Analytical Methods for Evidence-Based Practice

Evidence-based practice (EBP) is a critical element of modern nursing and health care practice. It can be defined as the conscientious, explicit, and judicious utilization of the best available evidence in deciding patient care (Dang & Dearholt, 2017). Clinical scholarship raises the level of the nursing profession through the participation of integrating new knowledge based on scientific and social exchange (Ahmed, Andrist, Davis, & Fuller, 2018). These views echo those provided by Leung, Trevena, & Waters (2016) asserting the importance of the procedure in developing clinical proficiency among nurses.

Evidence-based practice is not only about using the best evidence in one’s clinical practice but the ability to generating research findings that can be used as a guide for future practice (Leung et al., 2016). Basic research is a requirement for any scholarly activity. However, the discovery of new perspectives is now a crucial element of scholarships, primarily due to the integration of new knowledge. This essential was met by the student researcher analyzing and evaluating previous and current literature related to the Hispanic/Latino T2DM population. The student researcher was able to critically analyze the quality of the current findings regarding the participants’ condition, values, and circumstances surrounding the health issue (Fisher et al., 2016). This critical analysis provided the opportunity for conscientious decision-making during the process of the plan of care.

The DNP Essential VI: Inter-Professional Collaboration for Improving Patient and Population Health

Collaboration with other healthcare professionals with expertise from various professions such as pharmacists, dietitians, and behavioral psychologists is essential in addressing minorities’ health issues. This essential goal was accomplished by the student researcher seeking guidance for safe, timely, efficient, effective, equitable, ideas to implement patient-centered care (AACN, 2006). To further meet the requirements of this essential, the student researcher will have Zoom of Microsoft meetings with the stakeholders to present and discuss an implementation plan that will assist the patients in improving their glucose levels. The writer will collaborate with the physicians, patients, nurses, medical assistants, and dietitian at the Family Health Care Clinic in southern California. As part of the healthcare team, the student researcher will share knowledge, ideas, and clinical skills used during the research process related to current literature and explore strategies that can improve this populations’ HgbA1c levels and prevent diabetes complications. During this period, the student researcher noted communication skills and leadership role was improved.

 

 

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