Rural Barriers: Healthy Lifestyles Program, Using Diabetes as a

Model

Diane SpokusDoctoral Candidate

The Pennsylvania State UniversityWorkforce Education/Training & Development

Background

– PEPPI– ACTIVE– AHEC

– Continuing Professional Development Programs/Health Education

– Adult Aging & Development/Biobehavioral Health

– Hartford Foundation (www.hhdev.psu.edu) – Retaining, Managing & Retraining Older

Workers

Americans’ use of information technologies has grown in many locations including the workplace, the schools, the home but not

as rapidly in lower-income housing and retirement residences or church organizations where older adults

congregate.

Healthy Lifestyles Program Sponsored By

• The Division of Endocrinology of• The Department of Internal Medicine and the• Department of Family and Community Medicine• Pennsylvania State University College of Medicine

and• Pennsylvania Area Health Education Centers (AHEC)

• Sponsored by:• Diabetes Control Program• Pennsylvania Department of Health

AHEC MISSION

The mission of the Pennsylvania AHEC Program is to help communities meet their primary health care needs

by creating a statewide infrastructure bridging community

and

academic resources to:

Recruit and retain primary care providers in underserved communities.

NEEDS LOCAL SOLUTIONS

Each underserved community & individual has a different set of

needs that

must be

identified and addressed.

AHEC Housed in 45 States

Southcentral PA AHEC Region

Goal Today

• To discuss the opportunities for improvement in the delivery of community-based health education programs for older adults living in rural areas.

Objectives Today

• To discuss the Healthy Lifestyles Program• To examine rural barriers to success in

implementing community-based programs for older adults

• To identify the physiological differences

that occur in the aging process that require adaptive technology

Objectives of the Healthy Lifestyle Program

Increase the awareness of the population in the area that everyone is at risk for a chronic diseaseDevelop and implement a community training program to empower the target audience with tools to improve their lifestylesEvaluate the training program through a pre- and post-trainee assessment

Target Audience

Older adults in low-income hi-rises, retirement communities, long-term care, assisted care facilities, church groups, and Pennsylvania Department of Aging Area Agencies on Aging.

Increased need in communities to obtain free community-based health education programs.

Risk Factors

OverweightOlder population is at greater risk for obesity-related health conditions such as hypertension, diabetes mellitus and hyperlipidemia.

Two major factors behind obesity include Inactivity Poor dietary habits

45 years of age or olderInactive lifestyleWoman having had a child weighing 9 pounds or moreFamily history of diabetes

Physical Activity

• Regular physical activity – for older adults can have an enormous effect

on their independence level and quality of life.

• Older adults at a greater risk for developing chronic diseases– such as diabetes, heart disease, or

hypertension

• Motivation – is the key to maintaining an active lifestyle

Number of People with Diabetes

• United States 13 million

• Pennsylvania 660,000

People with diabetes that do not know it:

• United States 5.2 Million

Facts

• In 1992 – 30 million persons over 65• In 2000 – 34 million persons over 65• About 5%, or over 1 million will be residents of an

institution• Most older men are married; most older women are

widowed• 86% suffer from one or more chronic health

conditions • > age 65, 23% limited in their activities of daily livingSource: National Center for Health Statistics. (1992). Facts about older Americans. Washington, DC: Author

Facts

• People > age 65 – hospitalized twice as often as people under 65

• People > age 65 – hospital visits average 50% longer

• People > age 65 – use twice as many prescriptions.

• Fastest U. S. growing population– > age 85

Source: National Center for Health Statistics. (1992). Facts about older Americans. Washington, DC: Author

Healthy Lifestyles Program, Using Diabetes as a Model

Train-the-Trainer Program Volunteers from the community who attend two-hour interactive training programs on how to facilitate the Healthy Lifestyles Program

Recruited from organizations, parish ministries and health professions students wishing to do community work.

Area Agencies on Aging

Implement various programs for older Pennsylvanians. 52 such Pennsylvania offices Serving all 67 counties Staffed with caseworkers skilled in such areas as

geriatrics, social work and community resources Assist older adults with questions

regarding nursing facilities community services in nursing facility placement, and a wide range of other community services tailored to your

specific needs.

Pennsylvania’s 67 Counties

Program Timeline

• Summary reports to Department of Health every 12 months– Under Pennsylvania Department of Health contract to

implement 16 programs per year.

• First Month:– Coordinator identified sites for courses

• Second Month:– The first trainee program for Facilitators held at

College of Medicine.

MARKETING

• The Third Month:– Advertisement began for course participants

and continued throughout the remaining months.

– Notices in church bulletins, newspapers, Area Agencies on Aging, Retiree residences, low-income housing.

– First courses implemented– Provided exercise and nutrition books as

incentives

Intervention

– Provide a one-time only follow-up session between one to two months to provide support to the individuals.

– Also, link individuals to community resources

Results From June, 2002 to July, 2004

Number of Train-the-Trainer Programs 6June 4, 2002 – 4

June 11, 2002 – 10

July 2, 2002 – 8

July 9, 2002 – 2

September 26, 2002 - 14

July 23, 2003 - 5

Number of Trainees 43who have participated in trainer program

Participants

• From June, 2002 to July 1, 200466 Healthy Lifestyle Programs conducted

887 individuals participated• particularly lower socio-economic groups,

including minorities participated

Attrition

Note:

Due to facilitator attrition, we could only depend on 5 new facilitators and 2 seasoned facilitators, including myself for community-based programs.– Reasons: Volunteer facilitators had good

intentions; however, when programs are held during the day, there are work conflicts

– In-Kind Contributions – approximately $17,000

EVALUATION

• Pre-post tests and follow-up questionnaires/surveys were used to determine how many people were able to change at least one unhealthy behavior and how much physical activity changed as a result of the educational program

Pre/Post Test Questions

Likert Scale (1 Disagree to 5 Agree)• This program gave me information that I did not know

before.• I learned how to live a healthy lifestyle.• I am more aware of the risk factors of diabetes.• I can name one healthy eating guideline that I can follow.• I can name one way I can increase my activity level.• I can understand the importance of using the wallet card.• I would recommend this program to my friends, family

and people I meet.• I was able to understand the material presented.

Facilitator’s Evaluation Questions

• Is the program written at an appropriate reading level for the general public?

• Is the content appropriate for the general public?• Does the content provided achieve the stated

objectives?• What suggestion do you have to change the content of

the program?• What suggestions do you have in presenting the

material?• Is the Trainer’s Manual complete enough to give the

trainer enough information to address the audiences concerns?

Facilitator Evaluations (cont’d.)

• If the audience has questions, that the trainer cannot answer, should they:– Contact the people that trained them?– Refer them to an educator in the area?– Refer them to their provider?– Leave it up to the discretion of the trainer?– Other (specify)_____________________– Do you have any other suggestions or

comments about the program?

Barriers

– Lack of funding for successful delivery of rural health education program

– Educational level (reading level, verbal abililty)

– Race and ethnicity (language barriers); need for more Spanish-speaking facilitators

– Income (inability to afford hearing aids, glasses)

– Health (age-related declines)

Observations in the Field• Cognitive difficulties in completing some simple pre/post test

questions• Need for material for various educational levels which may be

accomplished through adaptive technology• Increased lay person training in use of medical devices such as

infusion pumps, blood pressure monitors, etc.• Medications not taken properly (instructions too quick to grasp)• Hearing losses provided a challenged in giving directions; battery-

operated hearing aid transistors would have helped participants more actively participate

• Visual problems – although we had packets in large print, there was a need for technology in the field to present the material in different modalities, such as PowerPoint, microphone, virtual presentations, etc.

Recommendations

• Stimulate an increase in funding to provide computer and internet capabilities to community-based organizations that service older adults.

• Related to the above, increase the use of technology particularly to Area Agencies on Aging, retirement communities and low-income hi-rises that service older adults.

• Facilitate health care delivery communication in different formats that attracts different educational levels and compensates for age-related changes. This would include keeping an audience motivated through animation, video, and experiential tasks. Older adults may need to learn something new through several modalities: seeing it, hearing it and doing it.

• Build partnerships to avoid duplication of services• Provide technology training to facilitators as well as to participants

Age-Related Changes

• Vision • Lens yellows and thickens• Muscles controlling pupil size weaken• Result – need for additional light

» >65 years old →2x as much light as younger Lens person

• Lens grows unevenly → glare• Color perception → pastels look alike; darker colors

indistinguishable• Cataracts → cataract glasses thick to compensate for the

lack of a natural lens • Macular Degeneration → central vision loss

Richman, N., & Glantz, C. (1992a). Sensory deficits and ways to help. Unpublished

Manuscript. Riverwoods, IL: Rehabilitation Associates.

Ways to Help

• Use non-verbal feedback through touch to compensate for visual deficits—can’t see those warm smiles

• Adjust shade, tablecloths, curtains to avoid glare• Sunglasses, hats• Provide adequate lighting • Color coding doesn’t help in taking meds; contrast colors• Gradual lighting helps; e.g., night lights• Reassure them of their appearance• Finger foods

Richman, N., & Glantz, C. (1992a). Sensory deficits and ways to help. Unpublished Manuscript. Riverwoods, IL: Rehabilitation Associates.

Normal Aging

Hearing– Presbycusis → for men– Hearing worse at high frequency; sounds

distorted– Loss for consonants than vowels. S,Z,T,F,

and G sounds difficult to discriminate– ↓ Well-being, paranoid reactions common– Important for communication & safetyRichman, N., & Glantz, C. (1992a). Sensory deficits and ways to help. Unpublished

Manuscript. Riverwoods, IL: Rehabilitation Associates.

Ways to Help

• Provide amplifiers to older adults when doing community-based program

• Overall program evaluations are not always credible when you have individuals filling out pre/post test forms who can’t hear directions, etc.

Normal Aging

• Neurological Changes

– Instructions and information on disease may be too complex– 7% ↓in brain size; nerve cells lost– Older adults earn ↓ scores compared to young – Age differences represent decline in ability tested or

cautiousness of individual ↓speed of processing• Exaggerates declines in memory and learning

– Less willing to “guess”– long term memory when instructed to organize material in brain

for processing & storage– Recall, recognition & mneumonics— “tricks of the trade”Richman, N., & Glantz, C. (1992a). Sensory deficits and ways to help. Unpublished

Manuscript. Riverwoods, IL: Rehabilitation Associates.

Healthy Lifestyles Participant Manual

What is Diabetes?It is a serious, chronic disease in which you

have a high blood sugar level due to a lack of insulin

Insulin is needed to take the glucose (sugar out of the bloodstream and move it into the body’s cells to use for energy

What is Diabetes?

• It is a serious, chronic disease in which you have a high blood sugar level due to a lack of insulin

• Insulin is needed to take the glucose(sugar) out of the bloodstream and move it into the body’s cells to use for energy

Risk Factors

• Type 1– Genetic– Self-allergy – Environmental

(virus)

• Type 2

– Family members with Type 2 diabetes

– Being overweight– Physically inactive– Dietary intake– Advancing Age– Ethnicity (Race)

Types of Diabetes

• Type 1 Type 2– No Insulin Not enough insulin produced

produced Body unable to use insulin

produced

Signs and Symptoms of Diabetes

• Type 1– Frequent urination– Very thirsty/hunger– Feeling very tired– Blurred vision– Unexplained weight

loss

• Type 2– Frequent urination– Very hungry/thirsty– Feeling very tired– Blurred vision– Slow healing cuts– Frequent infections– No symptoms at all

What Happens When You Eat

• Cells in your body need sugars and starches for energy to do their job

• Food you eat is turned into sugar and starches by the stomach

• Sugars and starches are carried in the bloodstream to the cells

• The pancreas makes more insulin – the key- that opens the doors of the cells so the sugar goes into the cell

What Happens When You Eat

= Sugar

= Insulin

Not Having Diabetes

If you have Insulin, you have the Key

= Sugar

= Insulin

Having Diabetes

Not having Insulin - you lack the Key to open the door to cell wall

Diabetes

• The liver is a store house for sugar. The cells, not getting enough sugar send a message to the brain. “We need sugar to do our jobs!”

• The brain tells the liver to release stored sugar-so the cells have their energy

• But this also increase the sugar in the bloodstream

Diabetes

• And, Muscles cells may not have as many doors to be opened by the insulin – the sugar is there, but still cannot be used by the muscles

• And again the sugar stays in the bloodstream

Type 2 Diabetes

• Pancreas– Not making enough insulin

• Liver– Releases stored sugar

• Muscle– Not enough doors to be

opened

• And Sugar cannot enter the cell

Healthy Lifestyles• And, if you have diabetes:

• Check blood sugar as directed by your health care provider

• If you take insulin, check blood sugar before, during, after exercise

• Be prepared for low blood sugar (shaky, sweaty)

• Always wear some form of identification

Diabetes Management Tools

• Meal Plan – balanced diet• Activity – increase exercise• Medication – Pills (Are not Insulin)

– There is not one pill for everyone– People and pills are all different

• Medication – Insulin injection provides the key– If pills are not enough, insulin may be subscribed

Treatment

• Type 1– Insulin shots

– Healthy diet– Physical activity

• Type 2– Healthy diet

– Physical activity

– Weight loss

– Diabetes pills, insulin, or both, if necessary

Complications of Diabetes

• Eye Damage– Blindness

• Increased risk for heart attack and strokes

• Kidney damage

• Nerve damage

• Foot ulcers/impaired wound healing– Amputations

Lifestyle Changes

• Healthy diet

• Physical Activity

• Stop Smoking

• Reduce Stress

What is Hypoglycemia?• Low blood sugar level

• Causes– Too little food to eat– Too much insulin or

medicines– Extra physical activity

• Symptoms– Shaking– Sweating– Weak/Tired– Hunger– Fast Heartbeat– Blurry Vision– Headache– Irritable– Dizzy

How To Treat Low Blood Sugar

• Follow your facility’s protocols

• Treat with 15 gm of carbohydrates if awake:– Regular soda- ½ cup– Fruit juice- ½ cup– Glucose tablets- 3 to4– Hard candy

• If symptoms remain:– Retreat with 15 gm of

carbohydrates

• Once symptoms go away give light snack or meal in the next 30 minutes.– Example:

• ½ peanut butter or meat sandwich

and

• ½ glass milk

Eat A Variety of Food

Deck of Cards =3 OZ. of Meat

Thumb = 1 OZ of Cheese

Fist =1 Cup ofVegetables

Activity Benefits Us All

• Lowers and controls weight

• Prevents heart disease

• Builds strong bones and muscles

• Controls blood pressure

Reduces Stress

And for those with diabetes,

Lowers blood Sugar

ReducesStress

Ways to Help

• Studies indicate mental activity helps—”Use it or Lose it”

• Exercise daily, eliminate caffeine, play soft music

How To Treat High Blood Sugar

• Follow your facility’s protocol• Follow directions provided by doctor• Give fluids without sugar if able to swallow

– Such as:• Diet drinks

• Broth

• Ice Chips

• Water

Activity

• When we are more active, our cells need more energy• So, as we increase our activity, our cells burn more

sugar – lowering the sugar in our bloodstream

– Park further away from the front of the door– Don’t “be dropped off” while the car is being parked– Take the steps– Push a lawn mower, don’t ride– Shovel snow – don’t snow throw– Rake leaves – don’t blow– Work in your flower bed

Ways to Help

• Weight-bearing exercise

• Walking

• Running

• medications

Ways to Help

• Calcium

• Medications

• Weight-bearing exercise

• Hip pads to reduce fractures

Getting Started

Bicycling Dancing

Walking Swimming

General Guidelines

• Start Slow and Increase Slowly

• Warm up and cool down for 5 – 10 minutes by stretching

• Drink plenty of water before and during your activity

• It’s best to wait 60 -90 minutes after a meal before exercising

Healthy Lifestyles

• Wear shoes that fit and socks – they prevent blisters

• (People with diabetes are more at risk for foot problems)

• Exercise regularly at the same time every day

It becomes a habit

Foot Care

• Do’s– Look at feet daily– Wash feet daily

• Use lukewarm water• Keep skin soft• Dry feet well

– Check shoes before putting on

– Always wear socks– Keep feet warm and dry

• Don’ts– Walk barefoot

– Use heating pads/hot water bottles

– Wear tight socks or knee highs

– Wear socks with holes

– Wear torn or tight shoes

Thank YouThank You