Diabetes Management, Prevention and Control Program for African Americans in Ohio - Essay Example

? A project on Diabetes Management, Prevention and Control Program for African Americans in Ohio Introduction Health is one of the vital constituentsof development strategies across the world. Public health and welfare policies and schemes of government significantly contribute to its health equity across the socio-economic strata, especially the poor and the marginalized population. In America, various public health strategies are developed to promote better health for the community. In the recent times, increased cost of healthcare deliverables have become major concern for the public as well as for the government who is bearing the major cost through Medicare and Medicaid. Today, the rise of lifestyle diseases like diabetes, hypertension, obesity etc. have become hugely worrying aspects of healthcare programs. It has necessitated an in depth research for evolving effective mechanisms of control and prevention to curb this rapidly growing tendency amongst the population. The paper would be addressing the various issues of diabetes for developing health promotion project for effective diabetes management, prevention and control amongst Afro-American population in Ohio for better health and welfare of the society at large. In the contemporary times, diabetes has emerged as major health issue across America. 25.8 million people in America have diabetes and 7 million of those have undiagnosed diabetes (cdc, 2013). Moreover, 1.9 million new cases of diabetes were detected in 2010 and if this trend continues, one out of every three American adult would be diabetic by 2050! (ibid). It is a dangerous lifestyle disease because it not only reduces life expectancy but it is also the seventh most common cause of death. It also adversely impacts the quality of life and damages heart, kidney, eyes etc. with fatal outcome if not treated timely. Most importantly, being a lifestyle disease, it is preventable and can be managed if diagnosed early. Intervention techniques used in early stages can control diabetes and improve quality of life that would lead to higher life expectancy. Diabetes is marked by high level of sugar content or glucose in blood which is not utilized and which damages organs like heart, kidney etc. There are three main types of diabetes: type 1 diabetes; type 2 diabetes; and gestational diabetes mellitus or GDM. Type 1 diabetes is characterized by inability of pancreas to produce enough insulin to control glucose in sugar, In type 2 diabetes, cells resist insulin but can be activated through lifestyle changes and medication. Gestational diabetes is type 2 diabetes experienced by pregnant women in their third trimester and pose considerable risk to mother and unborn child. Most importantly, minority population is at disadvantage as there is inequity in health status across racial and ethnic population. African Americans are twice as likely to be diabetic and 2.2 times higher death rate than white adults (odh, 2012). As such, within the healthcare industry, leadership initiatives in the management of healthcare programs and projects become hugely critical issue for developing and implementing health projects successfully across the defined population. The paper would be looking at the various aspects of diabetes management and would exploit intervention mapping process as developed by Bartholomew et al. to develop new diabetes management project for Afro-Americans in Ohio. Profile of Afro Americans in Ohio and diabetes management In Ohio, 885,815 or 10% of adult population is affected by diabetes and 200,000 of these are either diagnosed with GDM with high probability of acquiring type 2 diabetes at later stage of their life. Marginalized population, especially Afro-American population in Ohio is at greater risk of getting diabetes. According to Ohio Department of Health factsheet (odh, 2012), 14.9% of black population and 6.3% of Hispanic population in Ohio has diabetes. The estimated statistics for Afro-Americans is alarming and needs to be addressed urgently. Reducing health disparities in health issues like diabetes is intrinsic part of development strategy as healthcare affects everyone equally and healthcare equity would promote higher productivity. The various programs and projects for diabetes management, control and prevention would be evaluated for developing effective diabetes management project for Afro Americans in Ohio. Healthcare management is different as it not only focuses on processes, policy and outcome of the healthcare projects but also considers the complexities of caring for patients and their families, as well as providing support to the staff involved directly with those patients. The myriad perspectives of managerial leadership in healthcare programs and healthcare settings are important linkages that influence human behavior for higher productive outcome, both in terms of patients’ outcome as well as organizational or project outcome. In diabetes management projects, various imperatives like leadership initiatives, decision making processes and mechanisms, social intervention theories, social dynamics and community support projects based on empowerment of the patients and others stakeholders become vital ingredients for successful outcome of the healthcare projects. Thus, evaluation and analysis of various processes and institutional and social change system greatly facilitate in understanding the target group and help evolve effective diabetes management project for the community. Leadership principles and skills for health promotion project Principles of leadership fundamentally rely on the vision, perseverance and abilities of leaders to inspires others for higher productive outcome (Grossman & Valiga, 2012). Effective managerial leadership encourages flexible approach that can incorporate the changing dynamics of the environment. The challenges of good leadership in healthcare takes into account the changing environmental factors and translate them into opportunities for greater healthcare delivery. Organizational leadership is highly motivating and promotes common goals and shared learning. It empowers its followers with knowledge and ensures that decisions are based on informed choices. It influences their behaviour, attitude and feelings towards important issues so that people are better prepared for changes and adopt flexible approach to tackle obstacles. The traits and styles of leaders within healthcare therefore become the key elements that are able to exploit new situations and instil a sense of stability amongst the followers. The many leadership theories endorse the varying views of leaders and how they impact the behaviour and attitude of others. Kouzes and Posner, (2007) assert that honesty; forward looking; inspiring; and competency are the four most important traits of effective leaders. Honest leaders have committed followers and they tend to set high standard of ethics and moral integrity. It promotes trust building and gives credence to their ideological perspectives of issues. The forward looking leaders is well equipped to anticipate changes and become better prepared to meet new challenges and turn them into opportunities for improving healthcare delivery. They have also strong communication skills and convey their vision and missions across people. Their ability to understand and read not only one’s emotions and but also others’ emotions and views greatly helps to guide their decision making processes (Ashkanasy et al., 2002: 317). The leadership skill relies on experience that equips the leaders with necessary knowledge to act appropriately under different situations. They understand the hidden dynamics of human relationship and use them to boost self-confidence of the patients and healthcare workers for enhanced healthcare outcome. Indeed, leadership traits can be acquired under different situations and therefore tends to limit the trait theory of leadership (Shaw, 2007). The situational contingency theory adopts varying leadership styles to tackle different situations (Bolden et al 2003). Situational leadership has flexible approach motivates the others and empowers them with information to meet new challenges with equanimity. Transformational leadership is stimulating and transforms followers into effective leaders (Burn, 1978). Participatory leadership is very popular and highly successful as it promotes collective goals and shared learning for improved outcome. Donaher et al., (2007) says that managerial leadership of nurse managers is vital constituent of healthcare delivery. In healthcare setting, nursing leadership thrives on participatory approach and shared learning that is supported by organizational structure (Pearson et al., 2007). It encourages high standard of legal, ethical and moral considerations within the broader framework of healthcare paradigms. The disparity in health status, especially amongst the Afro American population necessitates in-depth understanding of issues that influence their behavior and attitude towards diseases. Higher emotional intelligence tends to explore various aspects of the target population in order to deconstruct the complex human behavior and help evolve new mechanisms to influence their views and implement programs with higher success. Diabetes leadership initiatives are essential ingredients of diabetes management project primarily because it not only requires extensive interaction with community but also skills that can effectively communicate vital information to the people and influence their decision making and lifestyle imperatives. Managerial leadership in healthcare acknowledges human capital as major resource and promotes relationship building to enhance understanding of cross cultural values and exploits the same for higher healthcare outcome. Indeed, the participatory approach of managerial leadership, patients and other stakeholders in diabetes management projects encourages creativity and innovative practices to promote trust and mutual respect. In diabetes management, health worker-patient relationship is key aspect of effective healthcare outcome. It helps them to exploit their knowledge and use environment factors to evolve into empathetic and empowered individuals who can effectively manage their diabetes and other healthcare issues. Leadership initiative is also the most desirable factor for effective management of diabetes across minority population because it relies on developing better understanding and applying new knowledge for higher patient satisfaction and outcome. Developing leadership traits across healthcare professionals therefore, becomes intrinsic part of diabetes management project as it takes into consideration the transforming values and environmental issues. Most importantly, good leaders judiciously exploit paradoxical situations for new perspectives and help achieve project goals. Effective decision-making processes Effective decision making processes are based on participatory approach, using collective goals and shared knowledge using best practices in healthcare setting. The Baldrige criteria validates decision making mechanism that identifies and evaluates various operational processes, developmental issues and key factors that have significant impact on the outcome. It adopts them as best practice within their programs/ projects so as to meet the challenges with high efficiency (HCC, 1998). Within the healthcare system, Baldrige’s core values encompass innovative practices that promote proactive participation of all stakeholders to improve and improvise healthcare delivery. It comprises of visionary leadership and leadership initiatives; patient- focused excellence; organizational and personal learning; valuing workforce members and partners; societal responsibility; focus on etc. The health disparity status amongst African American in United States is major health concern. The health disparity can be broadly described as inequitable mortality and morbidity rates amongst minority population as against that of mainstream population and non-Hispanics (Fiscella et al., 2002). In the Healthy People 2010, health equity across age, gender, race, culture, income etc. was vital imperative to ensure participation in health programs for improving overall health of the nation. Thus, empowerment of individual was a critical issue that was designed to overcome the barriers of cultural beliefs and earn their trust. To make right decisions, it is important for health workers and other stakeholders to be culturally competent and be committed to meet the healthcare needs of all the individuals. The participatory approach highlights dissemination of information so that patients and other health workers can make decisions based on informed choices. Various models of decision making promote consensus and collective actions. The Rational Approach Model of decision making identifies the problem and critically analyses it for the root causes, looking at various perspectives to make decisions for improved outcome (Osland et al., 2007). In this model, the decision making is based on deciding the objectives, generating and evaluating several solutions and forming decisions for contextual situations. The rational approach takes into account the various environmental factors that impact the issues and critically evaluates the optimal solution. Most importantly, it also anticipates the problems and tries to seek solutions to improve outcome. In Satisficing Model, bounded rationality significantly restricts the options and therefore does not promote the best solution for the problems. Muddling through Model experiments with different options till hurdles come and then takes different course. Recognition Primed Decision Model or RPD uses pattern recognition cues to anticipate problems and solutions. They are mostly used to make quick decisions in complex situations which require immediate actions (Trout, 1999). The model is more focused on seeking solutions rather than looking at alternative for best decisions and primarily relies on past situations which were similar. The pattern helps to come to decisions, even though the individual may lack experience of handling the situation. It tends to identify the constraints to generate possible course of actions and decide on the best course based on previous events or situations. The decision makers compare situations and using priorities, adopt typical actions that would help achieve the desired goal. The best practices encourage decisions based on information and use critical thinking to identify and evaluate the best course of action. In healthcare setting, various imperatives of healthcare issues impact decision making processes because health concern of individuals become the key priority for the health workers. The diabetes management project for African American requires extensive knowledge about the target population in order to understand the behavioural determinants of illness perception. This is vital aspect of the project as the cultural beliefs is major barrier for effective management of the disease (Snow, 1983). The family and informal support system is observed to be one of the most important factors that influences decision making processes. Analysis of principle of community social change processes while planning HPP Collaborative effort between the community and health workers improves healthcare delivery. The cultural approach of the communities towards diseases and health has emerged as the major cause for the spread of those diseases (Geary et al., 2005). It is important to change the perception of disease and create knowledge based understanding of the same to facilitate better health related results in the identified community. Diseases like diabetes are mainly lifestyle diseases which can be prevented and controlled trough external interventions. The principle of community social change fundamentally uses socio-environmental approach to identify external factors and create awareness across the target community to influence their views and attitude towards the diseases. The socio-economic conditions of the people have the capacity to aggravate or delay the chances of diseases like diabetes and other age related diseases. As such, environmental factors can be better controlled through change in social attitude towards issues and imperatives that have adverse impact on health. Engaging in productive dialogue with health advocates and community workers helps in creating and optimizing interpersonal relationships, promoting better understanding of issues. It empowers people to make decisions that promote their welfare and wellbeing. Community projects have evolved as vital facilitators that meet the growing demands of healthcare issues of people. According to Bandura (2004), health promotion paradigms are assessed on the basis of social cognitive theory. The theory posits that environment factors are responsible for the diseases and therefore, good health can be maintained by adopting preventive measures through change of lifestyle and behavior. The community change processes are critical factors that facilitate conscious efforts for self-efficacy of keeping fit. Bandura emphasizes that disease based models of healthcare is being supplanted by health and well-being model that exploits individual’s beliefs in the social perspectives of the disease. The external factors vis-a-vis environmental pollution, fast food, smoking, sedentary lifestyle etc. considerably contribute to the diseases like diabetes, cardiovascular diseases, high blood pressure, etc. Consequently, quality of life is impacted by lifestyle choices and habits developed over a period. This distinctly suggests that if people make effort to change attitude and habits, they would be better prepared to prevent diseases and maintain good health. Health promotion therefore, needs to be started with goals and not means as it would widen the scope of interventional techniques. The escalating cost of healthcare delivery and the long waiting list tend to delay the treatment that worsens the conditions of the patients. Increased life expectancy tends to delay the treatment of minor illness that often turns them into chronic ones. Thus, the psycho-social factors have emerged as crucial elements that define the choices that individuals may undertake to maintain quality of life. Social cognitive theory is highly pertinent in the current times as it looks at various determinants and mechanisms that can be translated into effective healthcare practices. The five key determinants are used for improved health outcome: knowledge or information empowers individuals with regard to health risks and benefits of different ways of keeping fit; self-efficacy encourages self-management of the disease through control over habits and behavior; outcome expectations show the benefits of changed habits; setting of short term and long term goals are essential part of strategies and implementation projects; and perceived facilitators help create awareness of socially constructed hurdles that can adversely impact the goal of the program. Health behavior is hugely impacted by the consequences expected by people. Various issues like reaction of people, the loss of favorite activities and most importantly the self-evaluation of the change become pertinent ingredients of change process. Indeed, when changes are observed and positive results are seen, people are motivated to adopt different behavioral pattern. At the same time, collaborative efforts include proactive participation in the change processes and promote healthy living across the community. The self-management of the disease endorses strong belief system in self-efficacy. Indeed, attitude towards the behavior and social norms decide the overall behavior or change. The success of the project and positive outcome largely depends on the importance placed on the outcome and perceived social obligations as well as on the extent of motivation to continue with the program. The community support and awareness drives are integral part of social model of health. The information dissemination reinforces one’s belief in the program that helps to turns into a major motivating factor. Moreover, awareness creation must highlight successful cases to motivate people in order so that they are encouraged to embrace alternative methods of keeping fit. In the current times, the interactive technology has evolved into powerful platform to motivate people to take up control programs. The major advantage is that it encourages people of all age and gender to take up health related programs on the basis of self-efficacy. The interactive programs enable regular feedback through emails or phone to supervise the progress. The self-management program is also helpful for chronic as well as general patients as it helps the patients to recover and become self-reliant at a shorter time than those who are constantly under medication. Social cognitive theory influences lifestyle changes to boost positive outcome and improve the quality of their life. Critique few institutional and social change system that support HPP Health promotional programs are greatly supported by institutional and change system. The government health policies and healthcare strategies help develop framework that guides and regulates people’s actions. The ban on public smoking is strong facilitator that augments better habits. Healthy People 2010 is important institutional program that promotes equity in health status and creates facilitating environment for equal participation in health programs. National Diabetes Education Program is sponsored by U. S Department of Health and Human services that promotes public-private collaboration in integrated way which is more streamlined and focused (ndep, 2012). It is based on community hub model that relies on partnership and uses government resources to create extensive awareness regarding myriad aspects of the diseases. DPAC or Diabetes Partners in Action is partnership of around 100 individuals and group who work towards reducing the impact of diabetes in Michigan. It promotes healthy lifestyle changes to prevent and control diabetes and its impact on health. The leadership initiative of DPAC is recommendable as it has launched highly effective and innovative promotional campaigns to create state wide awareness of diabetes. Make a Move is one such campaign that disseminates pertinent information on the various aspects of diabetes and how it can be easily managed or prevented and controlled through self-efficacy techniques. Health promoting lifestyle is key element in the self-management of the diabetes. It broadly caters to the defined activities and changes that help improve the overall health of the individuals. Heath promotion behaviour is focused on the belief that one is competent in carrying out certain actions that would have positive health outcome (Johnson, 2005). Knowledge about diabetes, medication, diet, physical activity, and glucose monitoring are important elements in self-management of diabetes outcomes. African Americans with type 2 diabetes lack diabetes knowledge (von Goeler et al., 2003). Knowledge deficit about diabetes is one of the crucial barriers to self-management of the disease that significantly increases the risk factors. Ohio Diabetes Alliance is important advisory group that addresses the various issues of diabetes in the state and creates effective environment of collaboration for diabetes prevention and control (odh, 2012). The leadership initiatives of the alliance have identified African Americans as major target that is greatly at risk from the diabetes and its complications. It therefore promotes community efforts to empower people with knowledge so that they can be motivated to change their lifestyle and manage their diabetes. Description of new HPP based on informed choices Health promotion project on the diabetes management, prevention and control program for African Americans in Ohio would focus on the creation of cross cultural understanding and providing advocacy to the family. The main objective of the project is to disseminate information about the diabetes and how it adversely impacts family life. The project would be community based with volunteers taken from the local colleges. This would not only create diabetes awareness amongst the Afro-American youth but it would also motivate the young people to adopt lifestyle changes that would enhance quality of their life. The change process is important facilitator that would significantly contribute towards healthier family life. The project goals would ensure greater affinity with the cultural competencies of the target population so that health workers and people can build constructive relationship based on mutual respect and cross-cultural understanding. The project would use intervention mapping process as developed by Bartholomew et al., (2011). It is conceptual framework of planning effective strategic actions for developing behaviour change intervention. The process broadly includes six steps that define the procedure of intervention. The need assessment identifies the problem and looks for the causes and the risk groups. The second step develops objectives for the project and rationalizes the same for effective interventions. The third stage evolves strategies for determining the change perspectives and change of behaviour that would accomplish the desired goals. The next step develops the program constituents that would bring about changes in the behaviour. The fifth step is highlights the implementation process that incorporates sustainability of the project. The last step seeks feedback for improving the processes for higher outcome of the project. The intervention mapping is intrinsic part of the project as it facilitates the project planners to streamline the processes and rationalize each step for making empowered decisions. The various steps of the intervention mapping encourage comprehensive understanding of the problem as well its wider ramifications on the target group. Most importantly, it also incorporates the interests of the target population and develops goals that align with the welfare of the people at large. It emphasises focused approach where core problem is key issue in each step. The expected outcome is major motivation for the planners or project advocates. The participatory approach is important priority and mechanism to achieve project goals and objectives. The process is very relevant for diabetes management as it highlights the quality of life as core issue and how effective management of the diabetes can develop better lifestyle habits that would sustain higher quality of life. The various theories as discussed earlier greatly support the intervention mapping and help develop strategies to influence health behaviour. It is evidence based framework that helps to make empowered decisions for effective diabetes management, prevention and control. The African American community in Ohio is a high risk target group that urgently needs intervention to prevent and control diabetes and its complications. The mapping is important mechanism for developing relevant components that would complement project goals and objectives. The various perspectives of program implementation like developing appropriate structure and framework, identifying delivery vehicles that would optimize outcome and creating themes that would attract target group. The project would use local media to create awareness and develop action groups of community based leaders and volunteers to influence lifestyle changes. The advocacy would be important ingredient of the project as it would help people to clarify their doubts and seek information to manage the disease. It would equip the patients and those who are at risk to take preventive steps to delay the onset of the disease. The various imperatives of the mapping processes are designed to evolve creative solution to the problem that would be easy to adopt and sustain for life.  Schaalma and Kok, (2009) affirm that mapping helps to develop new mechanisms of intervention that meet the changing needs of the society and seeks innovative solution to the identified problem. The need assessment lays strong foundation for the project success as it looks at the core of the problem and critically applies knowledge to various alternatives and evaluates the best option that would help achieve the wider goals of the project. It also highlights the integrated approach where group of people brainstorm ideas for optimal solution. The rationalization of each step ensures that focus is maintained on the key issue and expected outcome. The demographic characteristics provide important linkages in developing effective intervention strategies. The health related responsibilities and diabetes knowledge are examined for their efficacy in self-management of the disease. The mapping also helps to understand the constraints of the target group and encourages new mechanisms that can overcome the barriers of socio-economic status, cultural biases, education, gender and race. These factors adversely impact the overall quality of life and need to be incorporated within the wider framework of the intervention model which maps the decision making processes for developing effective intervention mechanisms for diabetes management of African Americans in Ohio. The model is culturally sensitive and promotes interventions that include cultural beliefs and traditions. It exploits community health advocates’ knowledge and linguistic skills to identify cultural differences and language barriers so that better understanding of diabetes related knowledge can be effectively communicated amongst the target group whose first language is not English. The health promotion project in diabetes management encompasses wide range of issues that impact African American community in Ohio. The diabetes is major public concern that hugely impacts the health of the target community. The rational approach of decision making that is used in the intervention mapping process evaluates the pros and con of the myriad aspects of the disease and the alternative solutions that can be adopted to improve the health of the target group. The assessment of the problem and the feedback system ensure that sustainability of the solution is maintained and taken on a priority basis. Creating knowledge base is vital part of the project because people cannot change behaviour without understanding the adverse consequences of the same (Brady & Nies, 1999). The knowledge helps them to adopt new ways that would help to improve their lives. Conclusions In the current times, it is crucial for the government to forge alliances and foster partnership with private and public organizations within the healthcare setting so that changing demands of the pluralistic society can be met with efficiency. Diabetes has emerged as major social problem with fatal consequences if not diagnosed early. The diabetes management, prevention and control depend on successful intervention strategies. The environmental factors greatly influence behaviour which increases the risk of diabetes. The new approach not only addresses the traditional model of healthcare but also promotes sustainable health promotion based on understanding and awareness. Intervention mapping also corroborates the theory of self-actualization as proposed by Plummer (1989). He asserts that people are self-centered and their actions and behavior is designed towards self-development and improved lifestyle. The project leadership initiatives are essential imperatives that use communication to disseminate vital information amongst the target community so that they are better equipped to accept change behavior and make lifestyle changes. (words: 4639) Reference Ashkanasy, N. Hartel, C. and Daus, C. (2000). Diversity and emotion: The new frontiers in organizational behavior research. Journal of management, 28(3), 307-338. Bandura, Albert. (2004). Health Promotion by Social Cognitive Means. Health education and Behavior, 31(2), 143-164. Bolden R, et al. (2003). A Review of Leadership Theory and Competency Frameworks. Centre for Leadership Studies, University of Exeter. Retrieved from: http://centres.exeter.ac.uk/cls/research/abstract.php?id=29 Brady, B. & Nies, M. (1999). Health-Promoting Lifestyles and Exercise A Comparison of Older African American Women above and below Poverty Level. J Holist Nurs,(17) 2 , 197-207 Burns, J.M. (1978). Leadership. New York: Harper Row. CDC, (2013 ). Healh Disparities of Minorities: African Americans. Retrieved from http://www.cdc.gov/minorityhealth/brochures/BAA.pdf Donaher, K., Russell, G., Scoble, K., & Chen, J. (2007). The human capital competencies inventory for developing nurse managers. The Journal of Continuing Education in Nursing, 38(6), 277. Fiscella, K., Franks, P,, Doescher, M. P,, & Saver, B. G. (2002). Disparities in health care by race, ethnicity, and language among the insured: Findings from a national sample. Medical Care, 40(1), 52-59. Grossman, Sheila C. and Valiga, Theresa M. (2012). The New Leadership Challenge: Creating the Future of Nursing. 4th ed. NY: FA Davis Co. Health Care Criteria for Performance Excellence. (1998). Baldrige National Quality Program. Gaithersburg: National Institute of Standards and Technology Johnson, R. L. (2005). Gender differences in health-promoting lifestyles of African Americans. Public Health Nursing, 22(2), 130-137. Kouzes, James M and Posner, Barry Z. (2007) The Leadership Challenge. 4th ed. NY: Jossey Bass publishers. National Diabetes Education Program. (2012). Make a Move: Small Steps can prevent Diabetes. Retrieved from: ndep.nih.gov/partners-community-organization/PartnerSpotlight.aspx Ohio Department of Health (2012). Healthy Ohio Program: Ohio Diabetes Prevalence. Retrieved from http://www.healthyohioprogram.org/diabetes/alliance/oda.aspx Osland, J., Kolb, D., Rubin, I., Turner, M. (2007). Organizational Behavior: An Experiential Approach (8th ed) pp. 468-488. Upper Saddle River, NJ: Pearson Education Inc. Pearson A, Laschinger H, Porritt K et al. (2007). Comprehensive systematic review of evidence on developing and sustaining nursing leadership that fosters a healthy work environment in healthcare. International Journal of Evidence-based Healthcare, 5(2), 208-253. Shaw S. (2007). Nursing Leadership. Oxford: Blackwell Publishing. Schaalma, Herman and Kok, Gerjo. (2009). Decoding health education interventions: The times are changing. Psychology and Health, 24(1), 5-9. Snow, L. F. (1983, December). Traditional health beliefs and practices among lower class black Americans. The Western Journal of Medicine. 139(6), 820-828. Trout, J. (1999). The Power of Simplicity. New York: McGraw Hill, Inc. von Goeler, D. S., Rosal, M. C., et al. (2003). Self-management of type 2 diabetes: A survey of low-income urban Puerto Ricans. The Diabetes Educator, 29(4), 663-672. US Department of Health and Human Services, Office of Minority Health. Diabetes and African-Americans. Retrieved from: http://minorityhealth.hhs.gov/templates/content.aspx?lvl=2&lvlID=51&ID=3017. Read More