J Clin Med Res

Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc

Journal website http://www.jocmr.org

Original Article

Volume 12, Number 8, August 2020, pages 517-529

Impact of a Culturally Tailored Diabetes Education and Empowerment Program in a Mexican American Population Along the US/Mexico Border: A Pragmatic Study

Figure 1. Flowchart of the study participants. DEEP: Diabetes Education and Empowerment Program; EMR: electronic medical record; PAID: problem areas in diabetes; LDBQ: Latino Dietary Behaviors Questionnaire.

Figure 2. Effect of intervention by sessions attendance. All variables are presented with pre-post changes except for HDL, knowledge and LDBQ (post-pre changes). HDL: high-density lipoprotein; LDBQ: Latino Dietary Behaviors Questionnaire.

**Table 1.** Baseline Characteristics of Participants
Characteristics	All participants (N = 209), N (%) or mean (SD)	Completers* (N = 123)	Non-completers** (N = 86)	Pearson Chi-squared, P value^a
Attended ≥ 75. *Attended < 75. ^aCompleters vs. non-completers. ^bT-test.
Gender				0.726
Female	143 (68.4)	83 (67.5)	60 (69.8)
Male	66 (31.6)	40 (32.5)	26 (30.2)
Race				0.213
Hispanic	184 (91.1)	105 (89.0)	79 (94)
Non-Hispanic	18 (8.9)	13 (11)	5 (6)
Income				0.413
< $20,000	127 (74.3)	71 (73.2)	56 (75.7)
$20,000 - 30,000	27 (15.8)	18 (18.6)	9 (12.2)
> $30,000	17 (9.9)	8 (8.2)	9 (12.2)
Education				0.596
HS diploma	100 (57.1)	56 (55.4)	44 (59.5)
No HS diploma	75 (42.9)	45 (44.6)	30 (40.5)
Language				0.591
Spanish	122 (58.7)	68 (55.7)	54 (62.8)
English	81 (38.9)	51 (41.8)	30 (34.9)
Both	5 (2.4)	3 (2.5)	2 (2.3)
Self-reported health status				0.572
Fair/poor	104 (58.1)	58 (56.3)	46 (60.5)
Ex/VG/G	75 (41.9)	45 (43.7)	30 (39.5)
Acculturation				0.136
Low (mostly Spanish)	115 (72.3)	69 (68.3)	46 (79.3)
High (mostly English)	44 (27.7)	32 (31.7)	12 (20.7)
Insurance				0.278
Medicare	78 (43.8)	48 (47.1)	30 (39.5)
Medicaid	22 (12.4)	11 (10.8)	11 (14.5)
Private	30 (16.9)	20 (19.6)	10 (13.2)
None	48 (27.0)	23 (22.5)	25 (32.9)
Birth country				0.407
Mexico	99 (55.9)	53 (52)	46 (61.3)
USA	74 (41.8)	46 (45.1)	28 (37.3)
Other	4 (2.3)	3 (2.9)	1 (1.3)
Mean age (years)	58.92 (11.25)	56.68 (11.21)	59.06 (11.48)	0.812^b
Years with diabetes	8.30 (7.83)	7.78 (7.42)	8.91 (8.30)	0.374^b

Table 1. Baseline Characteristics of Participants

Characteristics

All participants (N = 209), N (%) or mean (SD)

Completers* (N = 123)

Non-completers** (N = 86)

Pearson Chi-squared, P value^a

*Attended ≥ 75. **Attended < 75. ^aCompleters vs. non-completers. ^bT-test.

Gender

0.726

Female

143 (68.4)

83 (67.5)

60 (69.8)

Male

66 (31.6)

40 (32.5)

26 (30.2)

Race

0.213

Hispanic

184 (91.1)

105 (89.0)

79 (94)

Non-Hispanic

18 (8.9)

13 (11)

5 (6)

Income

0.413

< $20,000

127 (74.3)

71 (73.2)

56 (75.7)

$20,000 - 30,000

27 (15.8)

18 (18.6)

9 (12.2)

> $30,000

17 (9.9)

8 (8.2)

9 (12.2)

Education

0.596

HS diploma

100 (57.1)

56 (55.4)

44 (59.5)

No HS diploma

75 (42.9)

45 (44.6)

30 (40.5)

Language

0.591

Spanish

122 (58.7)

68 (55.7)

54 (62.8)

English

81 (38.9)

51 (41.8)

30 (34.9)

Both

5 (2.4)

3 (2.5)

2 (2.3)

Self-reported health status

0.572

Fair/poor

104 (58.1)

58 (56.3)

46 (60.5)

Ex/VG/G

75 (41.9)

45 (43.7)

30 (39.5)

Acculturation

0.136

Low (mostly Spanish)

115 (72.3)

69 (68.3)

46 (79.3)

High (mostly English)

44 (27.7)

32 (31.7)

12 (20.7)

Insurance

0.278

Medicare

78 (43.8)

48 (47.1)

30 (39.5)

Medicaid

22 (12.4)

11 (10.8)

11 (14.5)

Private

30 (16.9)

20 (19.6)

10 (13.2)

None

48 (27.0)

23 (22.5)

25 (32.9)

Birth country

0.407

Mexico

99 (55.9)

53 (52)

46 (61.3)

USA

74 (41.8)

46 (45.1)

28 (37.3)

Other

4 (2.3)

3 (2.9)

1 (1.3)

Mean age (years)

58.92 (11.25)

56.68 (11.21)

59.06 (11.48)

0.812^b

Years with diabetes

8.30 (7.83)

7.78 (7.42)

8.91 (8.30)

0.374^b

**Table 2.** Self-Reported Baseline Clinical Characteristics of Participants
	All participants (N = 209), N (%) or mean (SD)	Completers (N = 123), N (%) or mean (SD)	Non-completers (N = 86), N (%) or mean (SD)	Pearson Chi-squared, P value
^aT-test.
Diabetes type	N = 203			0.340
Type 1	7 (3.3)	4 (57.1)	3 (42.9)
Type 2	155 (74.2)	85 (55.6)	68 (44.4)
Not known	41 (19.6)	28 (68.3)	13 (31.7)
Ever taken a diabetes class	N = 122			0.807
Yes	47 (38.5)	28 (39.4)	19 (37.3)
No	75 (61.5)	43 (60.6)	32 (62.7)
Self-monitored glucose (times per week)	N = 187			0.509
0	32 (17.1)	21 (18.6)	11 (14.9)
> 1 per week	155 (82.9)	92 (81.4)	63 (85.1)
How often do you check your feet? (times per week)	N = 183			0.445
0	38 (20.8)	21 (18.9)	17 (23.6)
> 1 per week	145 (79.2)	90 (81.1)	55 (76.4)
Sought diabetes care in the past 12 months	N = 185			0.811
0	15 (8.1)	10 (8.8)	5 (6.9)
1 - 3	100 (55.7)	61 (54)	42 (58.3)
> 4 per year	67 (36.2)	42 (37.2)	25 (34.7)
Awareness of A1c% value	N = 182			0.085
Self-reported A1c	52 (28.6)	24 (22)	12 (16.4)
Never heard	36 (19.8)	49 (45)	45 (61.7)
Not known	94 (51.6)	36 (33)	16 (21.9)
Self-reported A1c value	N = 52 8.40 (2.64)	8.22 (2.82)	8.81 (2.20)	0.639^a
Times doctor performed eye exam ever	N = 159			0.568
0	2 (1.3)	1 (1.1)	1 (1.1)
1	54 (34.0)	35 (37.2)	19 (29.2)
> 1	103 (64.80	58 (61.7)	45 (69.2)
Times doctor performed foot exam in the past 12 months	N = 164			0.023
0	61 (37.2)	28 (29.5)	33 (47.8)
1	42 (25.6)	24 (25.3)	18 (26.1)
> 1	61 (37.2)	43 (45.3)	18 (26.1)
Diagnosed with retinopathy ever	N = 193			0.678
Yes	52 (26.9)	86 (74.1)	55 (71.4)
No	141 (73.1)	30 (25.9)	22 (28.6)
Watching TV/videos (times/week)	N = 203			0.887
Less than 1	40 (19.7)	24 (19.7)	16 (19.8)
1 to 2	59 (29.1)	34 (27.9)	25 (30.9)
More than 2	104 (51.2)	64 (52.5)	40 (49.4)
Sports/exercise (times/week)	N = 199			0.282
More than 3	29 (15.2)	14 (12.3)	15 (19.5)
1 to 3	23 (12)	16 (14)	7 (9.1)
Less than 1	139 (72.8)	84 (73.7)	55 (71.4)

Table 2. Self-Reported Baseline Clinical Characteristics of Participants

All participants (N = 209), N (%) or mean (SD)

Completers (N = 123), N (%) or mean (SD)

Non-completers (N = 86), N (%) or mean (SD)

Pearson Chi-squared, P value

^aT-test.

Diabetes type

N = 203

0.340

Type 1

7 (3.3)

4 (57.1)

3 (42.9)

Type 2

155 (74.2)

85 (55.6)

68 (44.4)

Not known

41 (19.6)

28 (68.3)

13 (31.7)

Ever taken a diabetes class

N = 122

0.807

Yes

47 (38.5)

28 (39.4)

19 (37.3)

75 (61.5)

43 (60.6)

32 (62.7)

Self-monitored glucose (times per week)

N = 187

0.509

32 (17.1)

21 (18.6)

11 (14.9)

> 1 per week

155 (82.9)

92 (81.4)

63 (85.1)

How often do you check your feet? (times per week)

N = 183

0.445

38 (20.8)

21 (18.9)

17 (23.6)

> 1 per week

145 (79.2)

90 (81.1)

55 (76.4)

Sought diabetes care in the past 12 months

N = 185

0.811

15 (8.1)

10 (8.8)

5 (6.9)

1 - 3

100 (55.7)

61 (54)

42 (58.3)

> 4 per year

67 (36.2)

42 (37.2)

25 (34.7)

Awareness of A1c% value

N = 182

0.085

Self-reported A1c

52 (28.6)

24 (22)

12 (16.4)

Never heard

36 (19.8)

49 (45)

45 (61.7)

Not known

94 (51.6)

36 (33)

16 (21.9)

Self-reported A1c value

N = 52
8.40 (2.64)

8.22 (2.82)

8.81 (2.20)

0.639^a

Times doctor performed eye exam ever

N = 159

0.568

2 (1.3)

1 (1.1)

54 (34.0)

35 (37.2)

19 (29.2)

> 1

103 (64.80

58 (61.7)

45 (69.2)

Times doctor performed foot exam in the past 12 months

N = 164

0.023

61 (37.2)

28 (29.5)

33 (47.8)

42 (25.6)

24 (25.3)

18 (26.1)

> 1

61 (37.2)

43 (45.3)

18 (26.1)

Diagnosed with retinopathy ever

N = 193

0.678

Yes

52 (26.9)

86 (74.1)

55 (71.4)

141 (73.1)

30 (25.9)

22 (28.6)

Watching TV/videos (times/week)

N = 203

0.887

Less than 1

40 (19.7)

24 (19.7)

16 (19.8)

1 to 2

59 (29.1)

34 (27.9)

25 (30.9)

More than 2

104 (51.2)

64 (52.5)

40 (49.4)

Sports/exercise (times/week)

N = 199

0.282

More than 3

29 (15.2)

14 (12.3)

15 (19.5)

1 to 3

23 (12)

16 (14)

7 (9.1)

Less than 1

139 (72.8)

84 (73.7)

55 (71.4)

**Table 3.** Diabetes Clinical, Self-Management Behaviors and Psychosocial Variables Pre- and Post-Intervention
	Baseline	Post-intervention	Change scores^a	Percent change from baseline^b	Paired t-test, P value
*Participants that have pre- and post-values. ^aScore change from participants who completed pre- and post-surveys. ^bPercentage change on a variable was defined as the difference between its values in the final period and initial period, divided by the initial value, and multiplied by 100. A1c: glycated hemoglobin; BMI: body mass index; HDL: high-density lipoprotein; LDL: low-density lipoprotein; TG: triglyceride; PAID: problem areas in diabetes; LDBQ: Latino Dietary Behaviors Questionnaire.
Clinical outcomes
BMI (kg/m²)	130	32.44 (7.34)	130	32.40 (7.51)	130	-0.39 (-0.50 to 0.42)	1.20	0.866
Cholesterol (mg/dL)	63	188.25 (60.27)	63	171.07 (36.66)	63	-17.17 (-0.736 to -2.08)	9.12	0.041
HDL (mg/dL)	64	43.03 (11.91)	64	44.29 (14.28)	64	1.26 (-1.79 to 4.33)	2.92	0.412
LDL (mg/dL)	56	96.10 (39.71)	56	89.28 (34.12)	56	-6.82 (-19.81 to 6.16)	7.09	0.297
TG (mg/dL)	58	190.12 (95.32)	58	178.29 (108.19)	58	-11.82 (-36.80 to 13.53)	6.21	0.347
A1c (%)	79	8.92 (2.28)	79	7.82 (1.91)	79	-1.10 (-1.59 to -0.612)	12.33	< 0.001
Microalbumin (urine) (mg/dL)	9	169.07 (295.75)	9	154.90 (218.40)	9	-14.17 (-103.58 to 75.23)	8.38	0.724
Behavioral and psychological variables
Knowledge (range: 0 - 21)	202	13.45 (3.33)	141	15.45 (2.73)	141	1.83 (1.28-2.38)	13.43	< 0.001
PAID (range: 0 - 100)	158	39.22 (26.66)	115	32.78 (24.96)	111	-7.32 (-11.86 to-2.79)	-18.03	0.002
LDBQ (range: 1 - 47)	160	24.88 (6.92)	117	27.37 (6.90)	115	2.23 (1.20-3.26)	8.78	< 0.001
Fatalism (range: 12 - 72)	152	41.44 (12.28)	111	40.46 (12.09)	110	-1.22 (-4.06 -1.61)	-2.92	0.393
Glucose self-monitoring (times/week)	187	8.42 (7.31)	138	9.47 (8.10)	115	1.33 (0.209 to 2.46)	16.19	0.021
Exercise (times/week)	191		137		129			< 0.001
4 or more		29 (15.2)		38 (27.7)		18 (13.96) to 36 (27.9)	99.85
1 to 3		23 (12.0)		24 (17.5)		17 (13.17) to 22 (17.1)	29.84
Less than 1		139 (72.8)		75 (54.7)		94 (72.87) to 71 (55.0)	24.52

Table 3. Diabetes Clinical, Self-Management Behaviors and Psychosocial Variables Pre- and Post-Intervention

Baseline

Post-intervention

Change scores^a

Percent change from baseline^b

Paired t-test, P value

Mean (SD)

95% confidence interval

*Participants that have pre- and post-values. ^aScore change from participants who completed pre- and post-surveys. ^bPercentage change on a variable was defined as the difference between its values in the final period and initial period, divided by the initial value, and multiplied by 100. A1c: glycated hemoglobin; BMI: body mass index; HDL: high-density lipoprotein; LDL: low-density lipoprotein; TG: triglyceride; PAID: problem areas in diabetes; LDBQ: Latino Dietary Behaviors Questionnaire.

Clinical outcomes

BMI (kg/m²)

130

32.44 (7.34)

130

32.40 (7.51)

130

-0.39 (-0.50 to 0.42)

1.20

0.866

Cholesterol (mg/dL)

188.25 (60.27)

171.07 (36.66)

-17.17 (-0.736 to -2.08)

9.12

0.041

HDL (mg/dL)

43.03 (11.91)

44.29 (14.28)

1.26 (-1.79 to 4.33)

2.92

0.412

LDL (mg/dL)

96.10 (39.71)

89.28 (34.12)

-6.82 (-19.81 to 6.16)

7.09

0.297

TG (mg/dL)

190.12 (95.32)

178.29 (108.19)

-11.82 (-36.80 to 13.53)

6.21

0.347

A1c (%)

8.92 (2.28)

7.82 (1.91)

-1.10 (-1.59 to -0.612)

12.33

< 0.001

Microalbumin (urine) (mg/dL)

169.07 (295.75)

154.90 (218.40)

-14.17 (-103.58 to 75.23)

8.38

0.724

Behavioral and psychological variables

Knowledge (range: 0 - 21)

202

13.45 (3.33)

141

15.45 (2.73)

141

1.83 (1.28-2.38)

13.43

< 0.001

PAID (range: 0 - 100)

158

39.22 (26.66)

115

32.78 (24.96)

111

-7.32 (-11.86 to-2.79)

-18.03

0.002

LDBQ (range: 1 - 47)

160

24.88 (6.92)

117

27.37 (6.90)

115

2.23 (1.20-3.26)

8.78

< 0.001

Fatalism (range: 12 - 72)

152

41.44 (12.28)

111

40.46 (12.09)

110

-1.22 (-4.06 -1.61)

-2.92

0.393

Glucose self-monitoring (times/week)

187

8.42 (7.31)

138

9.47 (8.10)

115

1.33 (0.209 to 2.46)

16.19

0.021

Exercise (times/week)

191

137

129

< 0.001

4 or more

29 (15.2)

38 (27.7)

18 (13.96) to 36 (27.9)

99.85

1 to 3

23 (12.0)

24 (17.5)

17 (13.17) to 22 (17.1)

29.84

Less than 1

139 (72.8)

75 (54.7)

94 (72.87) to 71 (55.0)

24.52

**Table 4.** Unadjusted Associations Between Demographic and Behavioral Characteristics With Glycemic Control (A1c ≤ 8%)
Variables	Glycemic control (N = 105), N (%), (Mean, SD)	Odds ratio	95% confidence interval	P value
PAID: problem areas in diabetes; LDBQ: Latino Dietary Behaviors Questionnaire.
Age (years)	105 (58.3, 10.5)	1.00	0.968 - 1.04	0.825
Years with diabetes	82 (8.17, 8.41)	0.904	0.848 - 0.964	0.002
Preferred language				0.212
English	37 (36.6)	1.0
Spanish	64 (63.4)	1.68	0.742 - 3.84
Gender				0.932
Male	33 (31.4)	1.0
Female	72 (68.6)	0.964	0.415 - 2.23
Country of birth				0.509
USA	34 (38.6)	1.0
Mexico	54 (61.4)	1.34	0.560 - 3.21
Acculturation level				0.397
Low	63 (76.8)	1.0
High	19 (23.2)	0.639	0.227 - 1.80
Self-reported health status				0.054
Fair/poor	55 (59.1)	1.0
Ex/VG/G	38 (40.9)	2.36	0.984 - 5.69
Education				0.466
< High school	40 (44.0)	1.0
≥ High school	51 (56)	0.730	0.314 - 1.70
Retinopathy				0.002
No	38 (27)	1.0
Yes	58 (60.4)	0.227	0.087 - 0.590
Knowledge	75 (13.3, 3.3)	0.979	0.825 - 1.16	0.810
PAID - diabetes emotional distress	64 (39.6, 26.1)	1.00	0.987 - 1.02	0.527
LDBQ - dietary behaviors	66 (25.2, 6.9)	1.02	0.954 - 1.09	0.538
Fatalism	63 (39.9, 12.4)	1.02	0.982 - 1.06	0.275

Table 4. Unadjusted Associations Between Demographic and Behavioral Characteristics With Glycemic Control (A1c ≤ 8%)

Variables

Glycemic control (N = 105), N (%), (Mean, SD)

Odds ratio

95% confidence interval

P value

PAID: problem areas in diabetes; LDBQ: Latino Dietary Behaviors Questionnaire.

Age (years)

105 (58.3, 10.5)

1.00

0.968 - 1.04

0.825

Years with diabetes

82 (8.17, 8.41)

0.904

0.848 - 0.964

0.002

Preferred language

0.212

English

37 (36.6)

1.0

Spanish

64 (63.4)

1.68

0.742 - 3.84

Gender

0.932

Male

33 (31.4)

1.0

Female

72 (68.6)

0.964

0.415 - 2.23

Country of birth

0.509

USA

34 (38.6)

1.0

Mexico

54 (61.4)

1.34

0.560 - 3.21

Acculturation level

0.397

Low

63 (76.8)

1.0

High

19 (23.2)

0.639

0.227 - 1.80

Self-reported health status

0.054

Fair/poor

55 (59.1)

1.0

Ex/VG/G

38 (40.9)

2.36

0.984 - 5.69

Education

0.466

< High school

40 (44.0)

1.0

≥ High school

51 (56)

0.730

0.314 - 1.70

Retinopathy

0.002

38 (27)

1.0

Yes

58 (60.4)

0.227

0.087 - 0.590

Knowledge

75 (13.3, 3.3)

0.979

0.825 - 1.16

0.810

PAID - diabetes emotional distress

64 (39.6, 26.1)

1.00

0.987 - 1.02

0.527

LDBQ - dietary behaviors

66 (25.2, 6.9)

1.02

0.954 - 1.09

0.538

Fatalism

63 (39.9, 12.4)

1.02

0.982 - 1.06

0.275