Outcomes and Evaluation of Community Health Project It is important to evaluate any public health program to determine its contribution and health impact on the population it was designed to help, in addition to its sustainability. Processes should be established during the inception of the program to establish a baseline, and methods of gathering data, which would be used for this evaluation. The RE-AIM evaluation model was chosen to guide the process of evaluating the American Indian Diabetes Program (AIDP). This paper examines how the AIDP program’s methods and results will be measured and evaluated to ensure the best possible outcomes.
Elements of the Evaluation Model The RE-AIM model is specifically well suited for evaluating the population based-impact of large public health programs. It contends that some more effective, expensive, programs that conduct trials using a highly motivated population, are usually not generalizable to the real world. It is preferable for a program to have a more realistic efficacy goal, reach more people, and achieve a larger adoption by communities and policy makers, a program that is implemented as intended, and results in behavioral change that is maintained over the long term (Glasgow, Vogt, & Boles, 1999).
The name RE-AIM is an acronym that stands for reach, efficacy, adoption, implementation, and maintenance. The five RE-AIM dimensions are each given a 0 to 1 (or 0% to 100%) score during program evaluation (Glasgow et al. , 1999). It is suggested that the program’s implementation be evaluated over a period of at least 6 months to a year, and 2 years or longer for the maintenance portion of the program (Glasgow et al, 1999). This model is appropriate to use as a framework for evaluating the AIDP because it works well with programs that seek to reach large numbers of people.
In the AIDP we will be attempting to screen the entire adult Indian reservation population for diabetes or pre-diabetes. The model also works well with programs that require more than one intervention. This program offers both preventative and disease management interventions. We will be evaluating the marketing, screening, and the education process of the diabetes prevention side of the program by taking an initial census of the reservation adult population (age 18 and older), and comparing that number with those who participate in the screening and attend educational classes.
This will demonstrate the programs reach. “Screening for type 2 diabetes in high risk populations is widely recommended” because epidemiological studies have shown evidence to suggest that 30% to 50% of all diabetics are undiagnosed (Goyder, Wild, Fischbacher, Carlisle, & Peters, 2008, p. 370). This could be especially true for the American Indian. We will also be doing further tests on those who have been shown to be pre-diabetics and diabetics. Both groups plus family members will go through diabetes education courses.
Those with pre-diabetes would be rechecked every six months the first year and every six months in following years, with telephone follow-up on diet changes and exercise progress in between. All data would be recorded for future evaluation. The diabetics would be seen quarterly and all test results, patient compliance to diabetes management practices, along with physical improvement or complications would be utilized for evaluation via record review. It would be necessary to obtain patient consent prior to their participation in the program.
Measurable Objectives There are four main objectives this program would be seeking to achieve: behavioral changes, early diabetes detection, improved communication, and better monitoring in disease management. The expected early detection of pre-diabetes and new cases of diabetes would be high, perhaps 14. 2% or higher during the initial adult population screening, since diabetes among American Indians is more than twice that of white Americans which by comparison is 7. 1% (CDC, 2011).
Behavioral changes would be measured at all levels of the program. After a baseline behavior survey was taken, at six months and a year, population behavior changes would be measured by telephone surveys. Those with pre-diabetes would come in for weight checks every three months, after receiving the healthy diet and exercise education and weight loss counseling if necessary. Any weight improvements based on each individual’s ideal weight for height and gender, as well as their 6 month fasting blood glucose results, along with patient’s description of iet and exercise routine which would be scored from 1 to 5 with 5 being best, this should indicate behavioral change. These changes would be tracked and averaged to determine the overall result. Because the American Indian population is so far behind in healthy behaviors than the rest of the population, there needs to be a 20% improvement in lifestyle changes. Behavior changes are especially necessary in people who have been diagnosed with diabetes. After attending the diabetes disease management training, patients would be monitored for following the guidelines.
They would be expected to take their medication as directed, check their blood sugar twice a day a couple hours after meals and sometimes more is uncontrolled, follow the diabetic diet and exercise plan, and keep their quarterly appointments. Many diabetic patients do not follow doctor recommendations. We would do follow-up calls, home visits, and one on one teaching for patients and family members if behavior compliance is weak. Based on showing up for follow-up appointments, fasting blood glucose levels, HgA1c level, and weight change, all of which can be tracked and averaged, behavior change can be measured.
We also intend to institute better monitoring in the disease management portion of the program. Weight would be measured at every appointment. Family members would be encouraged to attend appointments with their diabetic relative to lend support. Fasting blood glucose would be drawn as well as HgA1c which more accurately depicts the level the diabetes is controlled. The HgA1c should be less than 7 and is even better if it is less than 6. An annual dilated eye exam would be done, and blood pressure along with foot examinations would be performed at every appointment.
We would actually be monitoring the consistency in which these tests would be performed by staff. The information would be found by reviewing the data in patient records. We expect 90% compliance, understanding that wheelchair status might make weights unobtainable. Finally, the last objective to be monitored is communication. Communication is vital to achieving success in every other aspect of the program. Communication incorporates educating the patient, family, community, tribal leaders, and politicians in Washington.
Except for the nurse/ patient relationship and new patient teaching which are ongoing, most of the community, family, and political communication should be completed during the first year. Communication with community, family and patient would be through marketing, local television, community education, school curriculum, flyers and diabetes fair, as well as one on one patient teaching. The communication could be measured by evaluating the level of understanding of the listeners, through phone surveys and an outcomes evaluation.
The majority (55% or greater) of the phone surveys should demonstrate an understanding of the information communicated in the media campaign and patient teaching sessions. Communication with tribal leaders would be measured by the leader’s cooperation with the program’s objectives and methods. It is important when communicating to listen as well as speak. The best results are derived when a discussion method is used instead of using a ‘telling’ approach. A patient satisfaction survey would be used to gauge the communication techniques in the nurse/patient relationship.
Reasons for Chosen Outcomes The first objective of early detection was chosen because Healthy People 2020 recommends this objective, since many people with diabetes go undiagnosed. There is very little we can do to help people until they are diagnosed. It is reasonable to expect an outcome of 14. 2% newly diagnosed diabetics during the first screening, as that is the current rate of diabetes in the American Indian population. The first year’s screening will detect many undiagnosed diabetics and will usher them into to treatment.
Behavioral change was listed because for any “therapeutic or preventive regimen to be effective, the patient must implement the self-care behaviors and adhere to the treatment regimen” (Evangelista & Shinnick, 2008, p. 250). It is vital that diabetics and pre-diabetics adhere to a healthy diet and exercise regimen in order to optimize glycemic control, reduce risk of complications, and loose weight (Eilat-Adar et al. , 2008). Unfortunately, according to Eilat-Adar (2008), most American Indians show a low adherence to dietary recommendations.
Much of the AIDP efforts would be put into teaching and motivating the American Indian to follow the recommended guidelines. We will be aiming for a 20% improvement in lifestyle change over the first year. The bar was set high, 90% when it came to adhering to the guidelines set out for monitoring patients in the clinic. These guidelines would be implemented at the onset of the program. Professional staff should understand the importance of performing these tests, so more is expected of them. Communication is an objective that is key to success in every other aspect of the program.
In order to achieve adherence to behavior changes, the patient must understand why it is important, and how to make those changes. Because communication is initiated by the health care group and people involved with the marketing of the health care information, the expectations are high. A realistic expectation that 55% of the general population would understand and remember the information presented. The number of diagnosed diabetics who receive a formal diabetic education would be set at 62. % because that is the target for the (Healthy People 2020, 2008) diabetic education. Overcoming Negative Outcomes A possible negative outcome could result if the American Indian fails to adhere to the behavior changes necessary to gain control over their blood sugar and thus prevent the serious complications associated with the disease. Nurses can help patients and families cope with diabetes and give them hope of a high quality of life if they follow the doctor’s recommendations with their diet and exercise.
They can talk to the patient and family about possible difficulties in changing their style of eating and increasing exercise and work with them to find solutions. They can help them discover attainable ways to live healthy. If people understand how important it is to change behaviors, they will at least try to do so. Sustainability There are three main elements necessary for this program to be able to be sustainable over time: funding, meeting the programs objectives and the ability to adapt as circumstances change.
We would initially apply for grants that would fund this study for three years. During those three years, it is important that we be able to show that the four objectives (early detection of diabetes, behavior changes, better monitoring, and communication) were met and could continue to help the American Indian manage their disease thus decreasing the complications associated with diabetes, and help lower the population’s risk of acquiring this disease.
Our strategy is unique in that we are harnessing the valuable effect of family and community support to help diabetics and pre-diabetics effect behavioral change in eating and exercise. No other program has attempted this method of behavior modification with the American Indian. It is believed that with success in meeting the objectives of this project continued funding would follow. It is understood that over time it may be necessary to change and adapt our methods to ensure continued effectiveness.
Summary This paper describes the evaluation model that would be used and why it was chosen. The RE-AIM model addresses the reach, efficacy, adoption, implementation and maintenance of the program. The programs objectives were restated along with their measurable desired or expected outcomes. The American Indian Diabetes Program (AIDP), has four stated objectives: early diabetes detection, behavior changes, better monitoring in disease management, and improved communication. The measurable outcomes were explained and supportive evidence given.
A possible negative outcome was given, listing lack of adhering to necessary behavior changes. Though this is a possibility and some patients will be noncompliant, it is believed with further education and follow-up we can help them achieve better self-management. Sustainability will be achieved by meeting the objectives previously laid out in this paper. This will show the value of the program and encourage future funding. If necessary to ensure continued effectiveness of the program, AIDP is capable of adapting its methods to new circumstances.