Some challenges were noted during implementation of the DCCP and addressed as part of a quality improvement process. First, Diabetes Health Ambassadors originally went door to door and had difficulty recruiting participants. Holding screening events in public spaces within housing units addressed this problem. Second, the WSHC team found that women needed more behavioral health support than was being provided, with some of the women reporting to their case managers that it was difficult for them to handle the stresses of life and at the same time manage their diabetes. In response, an integrated behavioral health specialist was hired to provide guidance on how to manage life stressors and how to increase health behaviors despite physical, social, and financial barriers.
Third, women reported a lack of access to fresh fruits and vegetables. In response, WSHC implemented a formal collaboration with a mobile food truck (June 2012) that sold subsidized fresh food 3 days a week to public housing residents. Fourth, participants reported some barriers related to transportation for scheduled appointments at the WSHC. The team addressed this issue by providing taxi vouchers for those who lacked adequate access to transportation. Finally, the coordinated team noticed that medication adherence was a barrier to care for many program participants. Consequently, they developed a medication management support group led by the clinical pharmacist to address barriers related to medication adherence.
There were several methodological challenges confronted in carrying out this study. First, the dose of services that were provided for each individual participant was difficult to ascertain. For example, some of those enrolled in the DCCP earlier may not have had the full set of services that were available towards the end of the program. Second, although group data were available, data on individual level outcomes were not ; this made it difficult to assess whether there was change in behavior on the part of particular individuals. Third, a case study design, without a comparison group, does not control for threats to internal validity (eg, history, maturation, and attrition) that might have accounted for improvements in clinical outcomes. Finally, despite the comprehensive documentation, there could have been program elements that were implemented but not documented. Despite these methodological limitations, the case study design facilitated learning about associations between program implementation and changes in clinical health outcomes in a context of health disparities [20].
A particular strength of the program was use of Diabetes Health Ambassadors as mediators for DCCP service delivery. Ambassadors increased diabetes awareness within the community and also played a key role in building rapport and trust in the diabetes program among community members.
Lessons Learned
As part of a qualitative component, key informant interviews with WSHC staff were used to examine lessons learned during project implementation. First, an identified positive outcome was that the Ambassadors gained new insights into the management of their own diabetes and adopted additional lifestyle changes along with program participants. Second, the WSHC team affirmed that African-American women act as gatekeepers for their families, and that teaching and serving one woman allowed for teaching and serving the entire family. Program participants reported that their own lifestyle changes had an impact on other family members. For example, one participant reported she stopped purchasing soda beverages for her family. Another participant began using healthier cooking strategies, such as using olive oil instead of butter. Third, consistent with another study, the coordinated care model helped to assure comprehensive diabetes care [21]. Staff noted that “it takes a village” (a coordinated team) to address the diverse array of clinical issues needed for diabetes control. Fourth, self-management education was helpful, especially when coupled with social support from peers and family members. Fifth, working collaboratively with partners in non-health sectors was helpful in achieving the conditions needed for improved diabetes care [22].