Understanding Barriers to Engagement in the Diabetes Prevention Program among Low-Income Latino Patients: Design and Implementation of an Intervention in Community Health Centers

摘要： 我的长期职业目标是成为少数民族健康差异研究的独立调查员， 改善弱势和边缘化群体的成果。我的短期（五年）职业目标是 获得二级数据分析的定量技能，加强我在因果推理方面的专业知识，并学会 实施务实的社区临床试验，解决健康的结构性障碍。我们中间 在拉丁美洲人中，2型糖尿病（T2 D）的患病率高得惊人，大约有1/2的人有患糖尿病的风险。 在他们的一生中发展T2 D。糖尿病预防计划（DPP）研究表明， 结构化的生活方式改变计划，以实现5-7%的体重减轻和/或使用二甲双胍治疗超重和 患有前驱糖尿病的肥胖个体可以预防和/或延迟T2 D的发作。加州最近通过了一项法律 (SB 97）规定Medicaid（Medi-Cal）计划为有兴趣和符合条件的Medi-Cal提供DPP 糖尿病前期患者。然而，拉丁美洲人和低收入患者面临DPP的重大障碍 参与的我们需要新的、可持续的方法来招募、吸引和留住拉丁美洲人和低收入者， 包括社区伙伴关系办法，将参与者与 支持生活方式改变和减肥的低成本资源。我的具体目标如下： 1.在对来自两个大型加州卫生系统的数据进行的差异分析中， SB 97对12个月体重变化的影响，达到>5%的体重减轻（主要结局），收缩压 拉丁裔Medi-Cal糖尿病前期患者的血压和T2 D发生率（次要结局） 与健康保险交易所覆盖的类似SES的糖尿病前期拉丁美洲患者相比。 2.通过社区合作方法和社区咨询委员会，评估障碍， 在提供DPP项目的三家卫生诊所，促进招聘、参与和保留 服务LEP拉丁裔患者，并制定干预措施，提高招聘和保留， 通过解决结构层面的障碍，改善现有的西班牙语DPP计划。 3.进行一项社区知情干预的单臂可行性和可接受性试点试验（目标2） 招募，参与和保留有资格参加DPP课程的西班牙语患者， 在南洛杉矶的一家医院。流程成果包括成功招聘、提供 临床环境中的干预，以及测量研究结果的能力。临床结局包括体重 变化，身体活动和健康的社会决定因素。 这个奖项将使我能够与经验丰富的导师团队合作，获得职业发展技能， 以社区为基础的务实临床试验，让少数群体参与研究的最佳实践，以及 促进卫生公平的干预措施。收集的初步数据将支持未来的R 01赠款， 社区合作DPP干预西班牙语拉丁裔糖尿病前期患者的随机试验。

ABSTRACT: My long-term career goal is to be an independent investigator in minority health disparities research, working to improve outcomes for vulnerable and marginalized populations. My short-term (five-year) career goal is to gain quantitative skills in secondary data analysis, strengthen my expertise in causal inference, and learn to implement pragmatic community-based clinical trials that address structural barriers to health. Among US Latinos, the prevalence of type 2 diabetes (T2D) is alarmingly high, with approximately 1 in 2 at risk for developing T2D during their lifetime. The Diabetes Prevention Program (DPP) study demonstrated that a structured lifestyle change program to achieve 5-7% weight loss and/or use of metformin in overweight and obese individuals with prediabetes can prevent and/or delay the onset of T2D. California recently passed a law (SB 97) mandating that Medicaid (Medi-Cal) plans cover the DPP for interested and eligible Medi-Cal beneficiaries with prediabetes. However, Latinos and low-income patients face significant barriers to DPP participation. We need new, sustainable approaches to recruit, engage, and retain Latino and low- income populations in the DPP, including community-partnered approaches linking participants with low-cost resources that support lifestyle change and weight loss. My Specific Aims are as follows: 1. In a difference-in-difference analysis with data from two large California health systems, to determine the effect of SB 97 on 12-month weight change, achieving >5% weight loss (primary outcomes), systolic blood pressure, and T2D incidence (secondary outcomes) among Latino Medi-Cal patients with prediabetes compared with Latino patients of similar SES with prediabetes covered by the health insurance exchange. 2. Through a community-partnered approach and a community advisory board (CAB), to assess barriers and facilitators to recruitment, engagement, and retention at three health clinics that provide DPP programs serving LEP Latino patients, and develop an intervention that enhances recruitment and retention and improves existing Spanish-language DPP programs by addressing structural-level barriers. 3. To conduct a one-arm feasibility and acceptability pilot trial of a community-informed intervention (Aim 2) to recruit, engage, and retain Spanish-speaking patients who are eligible to participate in DPP classes at 3 FQHCs in South Los Angeles. Process outcomes include success with recruitment, ability to deliver the intervention in a clinical setting, and ability to measure study outcomes. Clinical outcomes include weight change, physical activity, and social determinants of health. This award will enable me to work with an experienced team of mentors to gain career development skills in community-based pragmatic clinical trials, best practices to engage minority populations in research, and interventions promoting health equity. The preliminary data collected will support a future R01 grant for a larger randomized trial of the community-partnered DPP intervention for Spanish-speaking Latinos with prediabetes.