Effectiveness of Community-Based Multifaceted Intervention (STOP-DM) Designed for Korean-Americans with Type 2 DM

Purpose: The primary objective of this translational study was to conduct an effectiveness trial of a community-based glucose control intervention program for Korean American immigrants (KAI) with type-2 DM. The self-help intervention program for Korean Americans (SHIP-DM) focuses on the self-help aspect of DM control by empowering patients through enhanced knowledge of DM and diet, utilizing available technology to develop the ability to self –monitor their glucose control status, facilitating better communication with their health care providers, and enhancing health literacy and general problem-solving skills.  Background: Type 2 diabetes mellitus (DM) is a serious health problem in Asian-American communities, including the Korean American immigrant (KAI) community. KAI, one of the most underserved and understudied minority populations in the US, are at particularly high risk of developing type 2DM, a problem that is compounded by the fact that Asians who have emigrated to the West tend to gain weight after immigration. Our previous community research experience has indicated that an overwhelming number of KAI suffer not only from uncontrolled DM but also from a loss of self-confidence and social isolation stemming from language and cultural barriers. Like other immigrant ethnic minorities, they often have limited access to health care and information.  Also, more than 50% of KAI have no health insurance and rarely receive routine checkups. As a result, KAI with asymptomatic chronic diseases, such as DM, go undiagnosed and inadequately treated. These health risks are further compounded by low health literacy levels: 90% of first-generation KAI adults are monolingual (Korean only), and more than 70% report having trouble understanding medical terminology, even when using materials that have been translated into Korean. These factors lead to high rates of undetected, undertreated, or poorly managed chronic illnesses, often with costly and tragic consequences. KAIs with type 2 DM urgently need effective interventions that help them achieve better glycemic control and restore their self-confidence with regard to diabetic management. To address this critical need within the KAI community, we designed a community-based clinical trial to test the effectiveness of a multifaceted DM management program (STOP-DM) that was designed to address the cultural and social needs of KAI with type 2 DM.

Methods: Using a community-based randomized control design with delayed intervention, we have recruited and enrolled 250 KAI (130 in intervention group, 120 in control group) with following eligibility criteria: (a) Age between 35 and 80; (b) having the type 2 DM, (c)  being able to read Korean; (d) being at high risk of DM as measured by hemoglobin A1c at 7.0 or above; and (e) being able to stay in the program for at least a year.  By providing our intervention to every participant (with different timeframes), we can be sensitive to the community’s reasonable concern: not to use vulnerable immigrants with limited resources as research subjects without giving them any direct benefit. The 3 interventions were 6 week-long education on DM management focusing on comprehensive self-care skills including health literacy, followed by telephone counseling and home glucose monitoring for 12 months. Main outcomes were measured at baseline, 3, 6, 9, 12 months.

Results: Among 250 enrolled, 209 (mean age, 58.9 ± 8.4 years) completed the 12 month–long follow-up data collection; 105 in the intervention and 104 in the control group. The majority of these participants were married (89%); the average length of stay in US was 23 years, and the majority had at least high school education at their home land. The average monthly income was $4,269 and 52% did not have any access to health care.

Evaluation of the primary end point, the level of HgA1c reveled significant between differences at each measurement point.  (Table 1).

GroupPeriod	Baseline	Month 3	Month 6	Month 9	Month 12
Intervention  (A)	8.9 (1.95)	7.9 (1.50)	7.7 (1.44)	7.7 (1.46)	7.6 (1.17)
Usual Care (B)	8.7 (1.58)	8.4 (1.55)	8.3 (1.49)	8.2 (1.48)	8.1 (1.41)
Diff (A-B)	0.2	-0.5	-0.6	-0.5	-0.5
Prob(A-B) ≠ 0	0.31	0.01	0.00	0.02	0.01

Significant changes were observed over time in some psycho-behavioral outcomes, including self-efficacy for DM control, medication adherence behavior, DM related health literacy, diet pattern (p < 0.05). In addition, the intervention and control group showed a significant difference in DM knowledge and the level of depression.

Conclusion:  The study findings highlighted the importance of placing systematic efforts to developing tailored intervention to address the unique need of a target cultural group. While the methodological discussion regarding the effectiveness of the intervention of this kind is limited, especially in ethnic minority groups, we strongly believe that the systematic strategies and methodologies we used in this study are transferrable to other underserved communities. More importantly, lessons learned from our community-based trial using CBPR principles and community partners will be shared in the context of addressing the sustainability issue of this kind of program.