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Together on Diabetes Project: A Diabetes Prevention and Management Program for
American Indian Youth
International Meeting on Indigenous Child Health, March 2017Presenters: Marissa Begay, Nicole Neault
Faculty/Presenter Disclosure
Marissa Begay has no relevant financial relationships with the manufacturer of commercial services discussed in this CME activity
Nicole Neault has no relevant financial relationships with the manufacturer of commercial services discussed in this CME activity
The faculty do not intend to discuss an unapproved/investigative use of a commercial product/device in this presentation
Johns Hopkins Center for American Indian Health at the Bloomberg School of Public Health
Founded in 1991 by Dr. Mathu Santosham, following research since 1980 with Southwestern tribes
Mission: To work in partnership with American Indian and Alaska Native communities to raise AI/AN health status, self-sufficiency and health leadership of AI/AN people to the highest possible level
Center focused on employing Native staff who are doing outreach and health research in their
communities, and Native faculty to assist with training of AI/AN scholars at JHU
Building local work force capacity
Changing the Future: Working Across the Lifespan
Birth
Early Childhood
Middle Childhood
Adolescence
Adulthood
“Family Spirit” 0-3:Parenting/Healthy Start
“Arrowhead” Youth Entrepreneurship
“Together on Diabetes”Family Health Coach Model
“Native Vision”Health and Education Promotion
Higher EdScholarships
“Celebrating Life” Suicide Prevention
“Respecting the Circle of Life”Teen Pregnancy/STI prevention
Maternal and Child Immunization
“EMPWR” Risk Reduction & Counseling
Pneumonia Prevention
Together on Diabetes (TOD) Program Sites
Navajo NationChinle, AZShiprock, NMTuba City, AZ
White MountainApache
Whiteriver, AZ
Location of Program SitesNavajo Nation: 3 sitesWhite Mountain Apache
1
UTAH COLORADO
NEW MEXICO
ARIZONAAlbuquerque
Tucson
Phoenix
TOD Target PopulationPrimary Target Population: Youth (ages 10 -19)Secondary Target Population: Support Person (>18 years)
TOD Inclusion Criteria1) American Indian youth aged 10-19 years old at study
enrollment.
2) Resides within ~ 1-hour transportation range of the health facility in Chinle, Shiprock, Tuba City, or Whiteriver.
3) Referral from a hospital provider indicating a diagnosis of pre-diabetes or type 2 diabetes by qualifying lab test OR considered at-risk for type 2 diabetes based on BMI ≥ 85th percentile and qualifying lab test.
TOD Intervention Overview• Intervention Components
– Home-based, delivered by Family Health Coach
– Youth Sessions• Intervention Phase:
12 Biweekly lessons (0-6 months)• Maintenance Phase:
6 Monthly lessons (7-12 months)• Provider visits to IHS, with
youth/parent permission
– Support Person Sessions• 4 Lessons (0-12 months)
– Community Wide Activities• Community Advisory Board Meetings• Partnerships with health promotion activities / events
TOD Evaluation MeasuresEvaluation Measures collected at:Baseline, 3 months, 6 months, 12months Youth
Support Person
Demographic Questionnaire (Baseline only) X X
Knowledge Quiz X
PsychosocialPatient Health Questionnaire-9Pediatric Quality of Life Inventory
XX
BehavioralPhysical Activity RecallFood Frequency Questionnaire Diabetes Screening Self Report
XXX X
Medical Home, Family Responsibility and Communication MeasuresCommunity Mastery-Family Scale Diabetes Family Responsibility Questionnaire Medical Home Assessment
XXX
XX
PhysiologicalBMIHbA1cBlood PressureWaist Circumference Medical Chart Review (at 12 months only – review of prior 24 months)
XXXXX
X
XX
Satisfaction Questionnaire (6 and 12 months only) X X
TOD Pilot Trial EnrollmentFinal Enrollment = 256 Youth Participants
= 225 Support Persons
TOD Retention - Youth
% Completed: Baseline: 100%6- Month: 81.6%12-Month: 84.8%
# of
Par
ticip
ants
Lessons Completed (max=12)12 Month Follow-up
Mean (SD)% of Total Lessons
9.95 (3.38)82.9%
%(n) Participants Completed ≥8 Lessons 73.4% (188)
Lesson Completion - Youth
TOD Trial Outcomes: Youth KnowledgeN= 254
***p-value<.0001 compared to baselineAdjusted for age at baseline and total number of lessons completed
Pediatric Quality of Life MeasuresN=255
BaselineMean (SD)
6 monthsMean (SD)
12 monthsMean (SD)
PQL Total 75.23 (0.98) 82.41 (0.97)*** 83.42 (0.85)***
PQL Physical Health 79.15 ( 1.09) 84.37 (1.07)*** 86.23 (0.96)***
PQL Psychosocial Health 73.12 (1.07) 81.33 (1.08)*** 81.88 (0.96)***
PQL Emotional Health 73.02 (1.33) 80.42 (1.31)*** 82.14 (1.39)***
PQL Social Health 77.97 ( 1.38) 83.15 (1.50)** 84.93 (1.28)***
PQL School Health 68.27 (1.30) 80.03 (1.31)*** 78.85 (1.23)*****p-value<0.01, ***p-value<0.001 compared to baseline.Adjusted for age at baseline and gender
TOD Trial Outcomes: Pediatric Quality of LifeN=255
Healthy ChildrenPQL Total Score: 831
Varni JW, Seid M, Kurtin PS. PedsQL 4.0: reliability and validity of the Pediatric Quality of Life Inventory version 4.0 generic core scales in healthy and patient populations. Med Care 2001; 39:800–812.
Positive Depression ScreeningN=255
***All p-values ≤ 0.001 compared to baseline.
1http://www.nimh.nih.gov/health/statistics/prevalence/major-depression-among-adolescents.shtml
US Prevalence of Depression Among Adolescents (2013)1
10.7%
TOD Trial Outcomes: Depression Screening
TOD Trial Outcomes: Physical ActivityN=256
Days Physically Active ≥30 min in the Last Week
Baseline %(n)
6 months%(n)
12 months %(n)
0 days 68.1% (172) 61.2% (126) 51.0% (105)***
1 day 22.1% (56) 22.9% (47) 21.2% (44)
2 days 4.3% (11) 8.3% (17) 16.4% (34)***
3 days 5.5% (14) 7.5% (15) 11.5% (24)*
*p-value <0.05 **p-value<0.01 ***p-value<0.001
TOD Trial Outcomes: Physiologic Measures
Physiologic Outcomes Baseline 6 Months p-value 12 Months p-value
zBMI (N=255)Overall: Mean(SD) 2.19 (0.03) 2.17 (0.03) 0.027 2.16 (0.04) 0.018
Hypertensive (N=255) n (%) (systolic and/or diastolic>90th) 35.0% (90) 25.8% (54) 0.013 28.5% (63) 0.094HbA1cAll: (N=251)
Mean HbA1c (SD)
Baseline>6.5%: (N=29)Mean HbA1c (SD)
6.09 (0.09)
8.72 (0.46)
6.02 (0.08)
7.87 (0.51)
0.328
0.039
6.07 (0.09)
7.91 (0.48)
0.812
0.036
***NOTE: HbA1c decreased from baseline values in 32.3% of Participants at 12month follow-up (Range: -7.4 - -0.1).
Youth: Program Satisfaction at 12 monthsI have learned a lot
AgreeDisagreeUndecided
200 (92.6%)2 (0.9%)
14 (6.5%)
The program was helpfulAgreeDisagreeUndecided
199 (92.1%)1 (0.5%)16 (7.4%)
I would recommend this program to othersAgreeDisagreeUndecided
185 (86.5%)5 (2.3%)
24 (11.2%)I feel that I am healthier
AgreeDisagreeUndecided
184 (86.0%)6 (2.81%)
24 (11.2%)I feel that I am happier
AgreeDisagreeUndecided
184 (85.6%)3 (1.4%)
28 (13 0%)
Impact of the Program on a Subset of Support Persons
Physiologic Outcomes Timepoint 1* 12 Months p-value
Weight, lbs (N=37)Mean(SD) 216.4 (8.77) 210.5 (8.72) 0.0043**
BMI (N=35)Mean(SD) 38.12 (1.57) 37.28 (1.53) 0.020*
Waist Circumference, cms (N=35)Mean(SD) 122.14 (3.06) 120.48 (3.04) 0.152
*NOTE: Due to the small number of SP with baseline data, we averaged baseline and 3 month measures for all outcomes.
*p-value <0.05 **p-value<0.01
Summary of Results – Youth Participants
• Increased knowledge• Increased quality of life• Decreased depression• Increased physical activity• Decreased BMI• Decreased hypertension• Decreased A1C in high-risk youth (HbA1c>6.5%)• High program satisfaction
Key Next Steps
• Analyze medical chart review data and share findings– Youth outcomes– Cost effectiveness study using matched controls
• Potential intervention improvements:– More support person lessons– Connect graduates (including support persons) to
new participants– Integrate more traditional knowledge and practices– Integrate more social media supports
• Identify partners and funders to scale and continue to improve and evaluate TOD
Acknowledgements Thank you to Tribal and University review boards for thoughtful review and approval processes
Navajo Nation IRB # 11.346Phoenix Area IHS IRB # 12.16Johns Hopkins IRB # 4505
Thank you to all field staff, community partners, and participants who made this project possible
Navajo Nation field-based faculty and staff:Dr. Raymond Reid, Leonela Nelson, Thomasina Blackwater, Gerilene Tsosie, Lisa Cohoe, Marissa Begay, Kendrea Begay, Nicole Watson, Ryan Grass, Jenny Richards, Kathy Charley, Stacie Tsinigine
White Mountain Apache field-based faculty and staff:Owen Laluk, Tashaya Massey, Sean Parker, Keoni Hill
THANK YOU
CONTACT:Johns Hopkins Center for American Indian Healthwww.caih/jhu.edu
415 N. Washington St., 4th FloorBaltimore, MD 21231410-955-6931
Marissa Begay mbegay5@jhu.edu
Nicole Neaultnneault@jhu.edu