Population Health and Epidemiology
Disease epidemiology is influenced by race among other factors. The African American population has a higher prevalence of certain medical conditions than other races. These conditions include but are not limited to hypertension, diabetes, stroke, sickle cell disease, and other cardiovascular conditions.
The development and quantitative risk of diabetes in this population are yet to be ascertained. Despite the increasing medical and technological advancements, the management of diabetes is still facing obstacles that require modifications of approaches at the population health and public health level.
The reason behind the Topic Selection
My research question stated ‘Among African American females aged between 21 and 65 with prediabetes, what is the effects of taking metformin compared to teaching on lifestyle modifications [diet and exercise] on HgbA1c levels within three months?
Among African American females aged 21 – 65 with prediabetes: what are the perceived barriers to the use of metformin compared to implementing diet and exercise to lower HgbA1c levels within three months?’ This PICOT question was driven by the existing epidemiological data of diabetes among African American females.
To reduce the incidence of diabetes among this population, preventive measures should be directed at the earlier and ‘prodromal’ stages of the disease development. The best-case scenario would involve prevention in the at-risk populations.
The population health approach requires an understanding of the patterns of the disease at the cellular, person, health organization, and public health levels. Primary and secondary preventions would be required in steering the interventions at the population health level.
Medical interventions in preventing the progression of prediabetes to diabetes have been used as well as non-pharmacological means. The effectiveness of using medications to prevent disease progression has been discussed through research but not extensively concerning the African American population.
Significance of the Problem of the Population
Prediabetes is characterized by persistently ‘high-normal blood sugar levels that do not qualify diagnosis of diabetes mellitus in a person. This description means that the plasma glucose levels are borderline high but not high enough to reach the levels for diagnosis of diabetes mellitus.
It is usually an asymptomatic condition but is associated with a high risk of development of diabetes mellitus and associated cardiovascular sequelae. The centers for Disease Prevention and Control, CDC, (2020) estimates that one person out of every three Americans suffer from diabetes and more than four-fifths of this population do not know that they have this disease condition. The risk factors are similar to those in diabetes mellitus but the symptoms may be absent in most cases.
This condition has been managed by risk reduction and medication control of blood glucose levels. The American Diabetes Association (ADA) recommends pharmacological and non-pharmacological means of maintaining blood glucose levels below the higher normal limits.
Lifestyle change and modifications have remained the mainstay of the management of prediabetes (Hostalek, 2019). The lifetime risk of development of type 2 diabetes in those with prediabetes is not fixed and varies among populations and races.
A journal review by Brown (2019) published by the American Association of Family Physicians (AAFP) reported that the management of prediabetes using metformin has been based on the previous randomized control trials but the significance of this intervention.
The American Diabetes Association set arbitrary cutoffs for the impression of prediabetes but making a diagnosis of prediabetes in otherwise healthy people unnecessary considering it is only a ‘risk’ and not a disease condition. Therefore, management of metformin may be considered an off-label use in ‘healthy’ people with prediabetes.
However, prediabetes is a billable condition with ICD 10 codes included. The cutoffs of prediabetes according to the ADA include random serum glucose between 5.6 and 6.9 mmol/L (100 and 125 mg/dL); 2-hour postprandial glucose of between 7.8 mmol/L and 11.0 mmol/L or (140–199 mg/dL); or an HbA1c levels between 5.7–6.4%.
The World Health Organization usually refers to prediabetes as intermediate hyperglycemia. Their diagnostic or screening cutoffs vary slightly from those of the ADA. The International Diabetes Federation (IDF) does not provide clear cutoffs for prediabetes but recognizes this serum physio-biochemical state as a disease condition under the term impaired glucose tolerance.
This study will include female African Americans aged between 21 and 65 years. The target population would include pregnant females, incarcerated, or inmates, and patients with immunocompromised states. The age selection eliminates the elderly who may be in the nursing homes or receiving family care.
This age group has fewer chronic medical comorbidities as compared to people above 65 years. Moreover, exclusion of people with already confirmed diabetes mellitus type 2 or type 2, hypertension, cardiovascular diseases, and other endocrinologic diseases, and mental illness would be required in this study.
The target population will be geographically limited to the State of Mississippi, Hinds County. The African Americans form 13.4% of the total US population (US Census Bureau, n.d.) and the majority of this number live in southern states including Mississippi (Noonan et al., 2016). Various health factors, determinants, and outcomes are peculiar to this population, especially Mississippi county as will be discussed.
Population Risk factors
Age is the first risk factor for prediabetes. Individuals above 18 years of age are at risk of developing prediabetes states that the younger population in the United States. Therefore, the selected population for this study are appropriate candidates (CDC, 2020).
The International Diabetes Federation (IDF) explained geographical disparities in the global privilege of prediabetes. The highest prevalence in the IDF eighth edition showed that the United States had the highest estimates (15.4%) of the people with prediabetes and projected estimates at 16.7% by 20145 (Hostalek, 2019). This justifies the selection of African Americans in this study.
The relationship between ethnicity or race and prediabetes has been studied over the past years. Research evidence has shown that prediabetes is more common among African Americans (Yip et al., 2017) than Asians and Caucasians. The prevalence among Indians was the lowest (3%) according to IDF’s eighth edition estimates (Hostalek, 2019). This supports the concept of race in prediabetes prevalence.
According to the Office of Minority Health (n.d.), the known risk factors among African Americans include genetic predisposition, high prevalence of obesity, and increased insulin resistance. African Americans are more likely to be diagnosed with diabetes mellites and prediabetes than non-Hispanic blacks and whites.
Complications arising from uncontrolled or undiagnosed diabetes mellitus are also common in African Americans. The National Institute of Health (2018) reported that the high prevalence of prediabetes and diabetes in African Americans is associated with biological factors. Obesity among African Americans in combination with other factors such as behavior, psychosocial and socioeconomic livelihood predispose the African Americans to develop prediabetes and diabetes.
Social Determinants of Health (SDH)
The African American population faces various social determinants of health. Discriminatory issues in socioeconomic and behavioral aspects of the health of African American males and females (Healthy-People, 2020) have been implicated in their health disparities. Segregations concerning residential conditions are important social determinants leading to disparity in the health of African Americans and whites.
The consequences are poor socioeconomic resource distributions among African Americans. Racial discrimination has led to unequal access to healthcare by African Americans and late diagnosis of medical conditions such as diabetes. This discrimination in combination with other social determinants of health such as poverty and incarceration have been associated with poor access and quality of health among this population.
Religion and culture are also major determinants of the health of African Americans. Their beliefs that their health is subject to fate, destiny, and a supernatural being (God) impact greatly on their health-seeking behavior and perception of health. Timely diagnosis and screening of chronic illness leading to earlier identification, therefore, relies on the capacity of this population to recognize the urgency and importance of preventive health measures (Kim et al., 2021). Poverty and unemployment have contributed greatly to the overall health of African Americans.
Priority Population Health Needs and Factors
African Americans have been disadvantaged in various health aspects as compared with other races. However, their better ability to endure mental health disparities has been commendable. Their health needs are mainly chronic disease management, homicide and interpersonal violence (Noonan et al., 2016), management of HIV/AIDS and STDs, behavioral health needs, and health literacy (Berkley-Patton et al., 2018).
The poor management of the chronic disease has been associated with reduced access to better care services due to racial discrimination, poverty, and unemployment. The rates of interpersonal violence and homicides are higher in African Americans. The level of health literacy among African Americans has been lower than other races.
Health literacy is defined by the population’s average abilities in obtaining, processing, understanding, and decision-making regarding basic health information. This concept determines the population’s ability to incorporate preventive health measures such as the prevention progression of prediabetes to diabetes.
The concept of health literacy influences the preventive population health interventions and the success rates of such interventions. As aforementioned, population health management of the chronic disease requires prediabetes risk factors modification. Fulfilling the health needs of African Americans should ensure modification of modifiable risk factors that necessitate improving health literacy concerning such risk factors.
Priority Population Health Data and Sources
According to Hoover et al., (2015), the health literacy regarding risk reduction such as smoking among other health indicators among African American adults was 19%. In their study, 1457 church-going African American adults were studied for knowledge and decision-making regarding health risk reduction, physical health, and mental health. Despite the low health literacy among this population, the study James & Harville (2016) rates highly their ability to use relevant sources to acquire health information and delineate useful from misleading health information.
According to the University of Wisconsin Population Health Institute (2020), adult smoking and obesity in Mississippi were weighed at 10% and 5% in 2017 and 2016 respectively. The specific ethnic data are not available. These are a health risk for prediabetes and diabetes for which knowledge and health literacy are important in population health surveillance and intervention.
Hinds County, Mississippi ranks among the top counties regarding the overall health factor ranking. The current proportion of the national population that are active smokers is at 17% while 29% are obese according to the University of Wisconsin Population Health Institute (2020) estimates.
The American Diabetes Association and the CDC recognized the burden of diabetes nationwide and in Mississippi. As a result, the Division of Diabetes Translation at the CDC and National Institute of Diabetes and Digestive and Kidney Diseases at the National Institutes of Health started an initiative in 2014 and 2015 that aimed at preventing diabetes, improving lives, and possibly find a cure. This initiative has since invested in research and education in Mississippi in attempts to alleviate the burden of diabetes in Mississippi.
Preventing diabetes and managing disease progression requires multilevel and multidisciplinary approaches. Community-based and patient-centered interventions must, therefore, be put in place. Various stakeholders are needed in the discussion table.
Health prevention and transformation through health policing would require the state representative, the local and community facilities, and care professionals for implementation. The input from the diabetic patients and the at-risk population themselves will be required in ensuring evidence-based practice through research studies and practice. Services of educators such as community nurses and social workers would be essential in promoting educational programs and behavioral change activities.
Barriers for this population
This target population’s anticipated barriers would include low socioeconomic status, culture & health-seeking behavior, poor access to healthcare, and low care insurance coverage. The uptake of the interventions by this population will be determined by their perception and understanding of health and disease.
Their culture and religion would play a crucial part in ensuring the success of the process. Their willingness to participate in the study and interventional research would be determined greatly by the perceived benefits. Therefore, major challenges and barriers would require deeper and proper understanding and avoidance of stereotyping of participants.
Proposed Healthcare Program
A proposed healthcare program or study will include a quality improvement program for this target population. This program will involve providing education to healthcare providers with the aims of improving their awareness and knowledge about prediabetes as a disease entity and its timely diagnosis.
Educating the health care providers about screening for prediabetes and providing patient education will be the core activities of this program. A screening tool to be used will measure the HbA1c level, random plasma glucose, fasting plasma glucose, and postprandial glucose.
The criteria for screening and diagnosis will be laid out to the care providers at the point of care and through systematic education sessions to nurses and primary care physicians. This education will involve teaching 30-minute sessions explaining the pre-survey and post-survey screening of prediabetes.
The risk education and prediabetes screening would be a targeted process. The selection of clients to be screened would be based on the presence of risk factors such as race, age, gender, and physical measurements. Screening and educating patients on preventive measures would be aimed at ensuring the reduction in the incidence of diabetes in prediabetic individuals over time.
Healthcare providers would be the best effectors and implementers of this proposed program because they are usually the first contact with patients in any healthcare organization. The population health policymakers may not have direct contact with the actual at-risk patients in most cases. The knowledge of such risk factors among the target population would require proper education and training to improve the specificity and sensitivity of the procedure and screening.
Methods and Statistics
The best epidemiological method to use would adopt a cohort design. The subjects will be selected based on a set of risk factors. The inclusion criteria of individuals to be screened and educated would include the aforementioned description of the target population.
This prospective cohort design would include registration of subjects based on their baseline glucose and anthropometric measurements and risk assessment. This cohort, sharing similar risks and related measurements, would be observed after patient education and implementation of various behavior changes strategies over the three months. Assessment of desired outcomes would then follow.
Statistical Analysis and Evaluation of Outcomes
Descriptive analysis of serum glucose measurements, HbA1c, and Body Mass Index would provide that the basis for statistical inference and drawing of conclusions. The measurement of A1c and analysis of changes (increase or decrease in A1c) levels from the baseline would provide the quantitative analysis of serum glucose control over the three months. It would provide the assessment of the outcome of the interventions. The descriptive analysis of changes in serum glucose levels from the baseline would also be used in statistical analysis.
Understanding population health and epidemiology enhance evidence-based practice. This proposed study’s population included adult African American females because they are at more risk of developing diabetes from prediabetic situations than other populations.
The concept of population health risk, epidemiology, social determinates of health, and population needs would direct the framework of this study. The study would adopt a cohort design because the subjects would share similar risks and results analyzed after the administration of intervention. Identification of appropriate and relevant stakeholders would be useful in implementors of the study.
American Diabetes Association. (2019). 3. Prevention or delay of type 2 diabetes: Standards of Medical Care in diabetes-2019. Diabetes Care, 42(Suppl 1), S29–S33. https://doi.org/10.2337/dc19-S003
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Brown, S. R. (2019). Should adults with prediabetes be prescribed metformin to prevent diabetes mellitus? No: Evidence does not show improvements in patient-oriented outcomes. American Family Physician, 100(3), 136–138. https://www.aafp.org/afp/2019/0801/p136.html
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Healthypeople. (2020). Discrimination. Healthypeople.Gov. https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health/interventions-resources/discrimination
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Yip, W. C. Y., Sequeira, I. R., Plank, L. D., & Poppitt, S. D. (2017). Prevalence of pre-diabetes across ethnicities: A review of impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) for classification of dysglycaemia. Nutrients, 9(11). https://doi.org/10.3390/nu9111273