title: Improved care for diabetes in underserved populations.
abstract: Diabetes mellitus (DM) is a common chronic health condition among the adult population in the United States. DM is more prevalent and complications higher in Latinos, possibly due to inadequate medical and self-care as well as inaccurate culture-bound beliefs. Project Dulce is a nurse-managed DM educational and treatment program designed to measure the effect on clinical outcomes, adherence to American Diabetes Association and American Heart Association standards of care, and cultural beliefs in 210 high risk (HbA1c > 9.5%) and 346 lower risk (HbA1c < 9.5%) indigent Latinos with DM.
  
  
  METHODS
  All patients were given a 12-week culturally sensitive educational program. Nurse manager/certified diabetes educators working together with primary care providers treated high-risk patients using protocols from Staged Diabetes Management. Physical exam and biochemical markers of DM were followed. Pre- and post-program questionnaires measured changes in diabetes knowledge, cultural beliefs practices, treatment satisfaction, and health locus of control. Chart reviews of Latinos with diabetes (n = 311) not enrolled in Project Dulce provided the case controls.
  
  
  RESULTS
  After 1 year, the high-risk group showed significant improvements in HbA1c (11.5% to 8.3%, p < 0.0001), total cholesterol (219 to 181 mg/dL, p < 0.00001), SBP (129 to 122 mmHg, p < 0.03), and DBP (79 to 75 mmHg, p < 0.006). Pre- and post-test evaluations showed improved diabetes knowledge (p = .024), treatment satisfaction (p = .001) and internal locus of control (p = 0.04), and fewer inaccurate culture-bound beliefs (p = 0.001). Compliance was 100% in the high-risk group in obtaining HbAlc, lipids, urine microalbumin, and foot exams and 47% in obtaining eye exams, while the case controls had 28%, 46%, 31%, 14%, and 6% respectively. Mean TC and LDL values improved in Project Dulce patients compared to case controls (181 vs 221 Img/dL, p < 0.0001 and 99 vs 1241 mg/dL, p < 0.0004).
  
  
  CONCLUSIONS
  Patients enrolled in Project Dulce had significantly improved clinical outcomes, adherence to standards of care, and culture bound beliefs. Nurse managed diabetes management programs that are culturally sensitive may decrease the incidence of complications of diabetes and improve health outcomes.
authors.affiliation: Project Dulce, Whittier Institute for Diabetes, La Jolla, California, USA.
authors.forename: A
authors.initials: A
authors.lastname: Philis-Tsimikas
authors.forename: C
authors.initials: C
authors.lastname: Walker
mesh_terms: D002140:California; D019090:Case Management; D003191:Comprehensive Health Care / Q000458:organization & administration*; D003920:Diabetes Mellitus / Q000378:metabolism / Q000628:therapy*; D007722:Health Knowledge, Attitudes, Practice; D006630:Hispanic or Latino / Q000523:psychology*; D006801:Humans; D008507:Medically Underserved Area; D017063:Outcome Assessment, Health Care; D010349:Patient Compliance; D010353:Patient Education as Topic / Q000379:methods*; D010865:Pilot Projects; D011795:Surveys and Questionnaires; D016746:Transcultural Nursing / Q000458:organization & administration*