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PURPOSE: Large-scale effectiveness trials designed to translate evidence-based diabetes care to community settings are few. Studies describing these methods among high-risk minority populations are particularly limited. METHODS: The authors describe Project Sugar, a randomized controlled trial conducted in 2 phases: Project Sugar 1 (1994-1999), which piloted a 4-arm clinic and home-based intervention using nurse case management and community health workers in 186 urban African Americans with type 2 diabetes, and Project Sugar 2 (2000-2005), which examined effectiveness of this intervention among 542 diabetic, urban African Americans. Results and Conclusions Project Sugar had success with regard to recruitment and retention, both in phase 1 (80% rate at 24 months) and phase 2 (>90% at 24 months). Using the RE-AIM framework, planning and research design for Project Sugar 2 is described in detail for elements that contributed to the reach, effectiveness, adoption, implementation, and maintenance of this study within a minority community setting. In addition to successful strategies, challenges to conducting effectiveness trials in an inner-city African American community are identified. [ABSTRACT FROM AUTHOR]

Translation of research advances into clinical practice for at-risk communities is important to eliminate disease disparities. Adult type 2 diabetes prevalence in the US territory of American Samoa is 21.5%, but little intervention research has been carried out there. We discuss our experience with cultural translation, drawing on an emerging implementation science, which aims to build a knowledge base on adapting interventions to real-world settings. We offer examples from our behavioral intervention study, Diabetes Care in American Samoa, which was adapted from Project Sugar 2, a nurse and community health worker intervention to support diabetes self-management among urban African Americans. The challenges we experienced and solutions we used may inform adaptations of interventions in other settings.

Context: High diabetes prevalence among low-income and urban African American populations. OBJECTIVES & MAIN OUTCOME MEASURES: This study aimed to determine associations between neighborhood-level food sources and socioeconomic status (SES), and dietary patterns and body-mass index (BMI). The hypotheses were that the presence of food stores in neighborhoods would be associated with better dietary habits and BMI, and that the presence of convenience stores, and lower neighborhood SES, would be associated with poorer dietary habits and BMI. DESIGN, SETTING, & PATIENTS: Black adults (n = 132) with type 2 diabetes in Project Sugar 2 (Baltimore, Maryland) underwent the Ammerman dietary assessment: total dietary risk score and subscores for meat, dairy, starches, and added fat. Food source availability (food stores, convenience stores, other food stores, restaurants, and other food service places) and SES data from the 2000 US census at the tract-level were linked to individual-level data. Linear mixed-effects regression models with random intercepts were used to account for neighborhood clustering and for individual-level SES and potential confounders., Results: The presence of restaurants and other food service places in census tracts were associated with better dietary patterns (adjusted added fat subscore beta = -1.1, 95% confidence interval [CI] = -1.8, -0.4, and beta = -1.0, 95% CI = -1.7, -0.3, respectively). The presence of convenience stores and lower neighborhood SES was not significantly associated with worse dietary patterns or body-mass index, although trends were in the hypothesized direction., Conclusions: These findings provide some evidence for structural improvements to food environments in urban and low-income black neighborhoods.

Objective: The purpose of this study was to examine the association between parental history of type 2 diabetes and glycemic control among diabetic urban African Americans., Research Design and Methods: Study participants included 359 African Americans with type 2 diabetes from Baltimore, Maryland, enrolled in Project Sugar 2. Participants underwent an interview-administrated questionnaire that asked about family history, sociodemographics, clinical characteristics, and knowledge and perception of adequate glycemic control. Regression analysis was used to determine the association between parental history of diabetes and glycemic control, as measured by A1C., Results: In the comparisons between participants with and without a parental history of diabetes, those with a positive parental history tended to be younger, have higher glucose levels, and have higher blood glucose levels before calling a doctor (all P < 0.05). After adjustments for age, sex, and BMI, there was a significant association (P = 0.02) between A1C and parental history with the mean A1C difference between those with a positive and a negative parental history being 0.58%. However, after adjustment for duration of diabetes, the association was no longer significant (P = 0.11). However, there was a tendency for individuals with two diabetic parents to have higher A1C (P = 0.011)., Conclusions: From these results, we conclude that among the urban African American participants who were aware of their parental history of diabetes, a positive parental history was associated with worse glycemic control, partly due to longer duration of diabetes. Parental history did not appear to be associated with better knowledge or perception of adequate glycemic control.

Background: With growing use of Community Health Workers (CHWs) to reach underserved populations, there is a need for more information on training methods to prepare CHWs, particularly in a health educator role., Objectives: To describe procedures used to recruit, train, and evaluate CHWs in Project Sugar 2, a randomized controlled trial of a nurse case manager and CHW team intervention designed to improve diabetes care and control in a sample of 542 urban African Americans with type 2 diabetes., Methods: CHWs received a Core Training on guidelines and procedures, didactic diabetes self-management education, and research protocol training. However, barriers to CHW implementation of the intervention were encountered, including CHW attrition, job performance and satisfaction issues, low self-confidence in knowledge and skills as educators, difficulties with maintaining a large caseload, and inefficiencies experienced in conducting home visits. To address barriers, the initial training was modified and condensed. A supplemental training utilizing participatory methods was developed collaboratively by CHWs and trainers to facilitate CHWs' designing of intervention materials in their own words and contributing processes for intervention implementation and quality control., Results: The supplemental training resulted in CHW retention, satisfaction, confidence in skills, and feelings of ownership of the intervention. Participant satisfaction with care received from the CHWs and the Project Sugar 2 intervention was rated as high by 97% and 93% of responders, respectively., Conclusion: Core training in research intervention policies, procedures, and protocols, combined with an extended participatory training, led to effective preparation of laypersons to serve as CHWs.

Purpose: The purpose of this pilot study was to examine psychometric properties of the Diabetes Problem-Solving Scale (DPSS), which was designed to assess how adults with type 2 diabetes approach and manage problems encountered in diabetes self-management., Methods: Participants were 64 African American adults with type 2 diabetes. The 30-item DPSS and measures of social problem solving, diabetes self-management, and depressive symptoms were administered. Blood samples were collected to measure hemoglobin A1C level., Results: Cronbach alpha for the DPSS total scale was .77 and ranged from .72 to .78 for subscales. Correlations of the DPSS total score and subscale scores with a standardized social problem-solving scale ranged from 0.30 to 0.46 (all P < .01). Higher DPSS total scores, indicating better self-reported diabetes problem solving, were associated with higher medication adherence, more frequent self-monitoring of blood glucose, and lower hemoglobin A1C level. Of the DPSS subscales, Impulsive Style, Negative Transfer of Past Experience/Learning, and Negative Motivation were differentially associated with reduced self-management and disease control., Conclusion: The DPSS demonstrated acceptable total scale and subscale internal consistency, construct validity, and predictive validity in this pilot sample. The scale may have utility both in identifying associations between diabetes-related problem solving and self-management and in guiding problem solving interventions to improve self-management and control.

The Social Problem-Solving Inventory--Revised, Short Form, was administered to 65 urban African Americans with type 2 diabetes to examine association of generic problem-solving styles and orientation with hemoglobin A1C (A1C). Eighty-five percent of participants had total social problem-solving scores in the Average range or higher. In linear regression models adjusted for education, each interquartile increase in impulsive/careless score was associated with a 0.82 increase in A1C (%) (p = 0.01), and each interquartile increase in avoidant score was associated with a 1.62 increase in A1C (%) (p = 0.004). After adjusting for depressive symptoms, the association of impulsive/careless style with A1C was attenuated, while the association of avoidant problem solving with A1C remained significant (p = 0.01). Associations of rational problem-solving style, positive orientation, and negative orientation with A1C and health behaviors were not statistically significant. Ineffective problem-solving styles may prove to be important targets for intervention to improve glycemic control.

The aim of this study was to determine the relationship between patient satisfaction and diabetes- related preventive health care and emergency room (ER) use. We studied 542 urban African-Americans with type 2 diabetes aged > or =25 years who were enrolled in a primary carebased intervention trial to improve diabetes control and reduce adverse health events; 73% female, mean age 58 years, 35% had yearly household incomes of <$7500, and all participants had health insurance. All completed a baseline interview-administered questionnaire. Patient satisfaction was measured using a modified version (nine questions) of the Consumer Assessment of Health Plans Survey (CAHPS) and use of diabetes-related preventive health care and ER were assessed by self-report. We then followed participants for 12 months to determine ER use prospectively. In general, participants gave favorable ratings of their care; over 70% reported that they had no problem getting care, over 60% reported the highest ratings on the communication and courtesy domains, and mean ratings (0-10 scale) for personal doctor and overall health care were high (8.8 and 8.4, respectively). Using poisson regression models adjusted for age, education, and self-reported rating of health, several aspects of patient satisfaction were associated with subsequent ER use. Participants who reported that medical staff were usually helpful or that doctors and nurses usually spent enough time were 0.49 and 0.37 times, respectively, less likely to use the ER (all p < 0.05). However, few aspects of patient satisfaction were associated with better preventive services. These data suggest that greater patient satisfaction was associated with lower ER use in urban African-Americans. Whether measures to improve patient satisfaction would reduce ER use requires further prospective study.

The objective of the study was to determine the effectiveness and cost-effectiveness of primary care and community-oriented interventions in managing HbA1c, blood pressure, and lipids, and reducing hospitalizations and emergency room visits over 2 years. We describe an ongoing, randomized controlled trial of 542 urban African-Americans with type 2 diabetes ages 25 years and older who are members of a university-affiliated managed-care organization in Baltimore, MD. The participants are 74% female, have a mean age of 58 years, and 35% have yearly incomes greater than 7500 US dollars. Participants were randomized to one of two intervention groups for a period of 2 years: (1) usual medical care plus minimal telephone intervention implemented by a trained lay health educator (control group) or (2) usual medical care plus intensive intervention implemented by a nurse case manager (NCM)/community health worker (CHW) team. The intensive NCM/CHW team executes individual plans of care using evidence-based algorithms that focus on traditional diabetes self-management, screening and management of diabetes-related complications, and social issues surrounding diabetes care. Face-to-face NCM visits are conducted in the clinic once per year and CHW visits are conducted in the participant's home one to three times per year, both with additional follow-up contacts as needed. Written and verbal feedback (when necessary) is provided to the participant's primary care physician. All participants are expected to attend a 24-month follow-up visit where data are collected by interviewers blinded to intervention assignment. As of May 1, 2003, recruitment is complete, interventions are being fully implemented, and 24-month follow-up visits are beginning. Baseline sociodemographic characteristics, health-care utilization, health behaviors, and clinical characteristics of the study population are reported. This study is designed to test the hypothesis that a primary-care-based NCM plus CHW team approach is an effective, practical, and economically feasible strategy for translating current knowledge about type 2 diabetes into high-quality health care for urban African-Americans.