Diabetes Survival Skills Welcomed by Those Leaving Prison

Becky McCall

June 21, 2019

SAN FRANCISCO — A diabetes survival skills intervention specifically designed for men leaving prison and transitioning to life in their US communities was feasible and well received, according to a novel study conducted specifically in this underserved population.

Louise Reagan, PhD, ANP, assistant clinical professor at the University of Connecticut in Storrs, presented her findings at this year's American Diabetes Association (ADA) 2019 Scientific Sessions.

"Overall, the intervention was feasible and acceptable, with some increase in diabetes knowledge and reduction in diabetes-related distress," reported Reagan during a session titled Innovative Diabetes Education Across Diverse Populations.

The incarcerated population in the US is ethnically diverse and often cognitively impaired, so providing diabetes survival skills to these people before leaving jail has the potential to enhance health equity and improve outcomes, Reagan explained. She highlighted the fact that there has been a lack of research that includes this population.

"We know there are higher rates of hospitalization for short-term diabetes complications 7 days' post prison release," noted Reagan, explaining the unmet need of this population, in which the prevalence of diabetes ranges from 4.6%–9% and which has doubled since 2004.

"Around 95% re-enter the community with little knowledge and few skills for diabetes self-management, for example insulin administration or how to manage hypoglycemia," Reagan said. The problem is compounded by cognitive dysfunction and lower literacy among these individuals, she explained.

Moderator Donna Ryan, RN, RD, former president of the American Association of Diabetes Educators (AADE) and regional director of Community Health and Outreach at Sacred Heart Health System in Pensacola, Florida, reflected on the importance of including this population in diabetes management research.

"The incarcerated population with diabetes, in the US, is highly undertreated and insufficiently focused on. Often, we see these people discharged into the community without resources or education to care for their diabetes," she emphasized.

"It's a stigmatized population, but for health equity and disparity reasons, they are just as important [as the non-incarcerated] and have the right to diabetes care and education."

Improving Diabetes-Related Distress, Knowledge, and Self-Efficacy

Reagan's study aimed to evaluate the feasibility, acceptability, and preliminary efficacy of a diabetes self-management intervention on diabetes knowledge, diabetes distress, and self-efficacy.

Reagan and colleagues recruited a sample of 92 English-speaking men (46 treatment and 46 control; age ≥18 years, mean age 47 years; 40% black, 20% white, 30% Latino) with either type 1 or type 2 diabetes, all within 6 to 9 months of their release from prison.

The diabetes survival skills intervention was informed by the ADA and AADE standards for diabetes self-management and education. It comprised six 1-hour sessions discussing survival skills topics and involved completion of a workbook (tailored to low-literacy participants) in the prisoners' cells.

The study was carried out in two state prisons in the northeast US, one representing the intervention group and the other the control group, in which men received only usual discharge advice.

Measurements were taken at baseline, 6 weeks, and 12 weeks. A focus group evaluated the acceptability of the intervention.

Of the 92 participants, 84% had type 2 diabetes; 40% used insulin; 66% had a high school education or less; 84% had been incarcerated for 4 years or less; and the duration of diabetes was 7 to 12 years.

Recruitment rate, attrition, program completion rates, and intervention fidelity provided a measure of feasibility. Acceptability was assessed by content analysis of the focus group discussion.

Regarding feasibility, 76% completed the baseline assessment, 63% completed the 6-week assessment, and 53% made it to 12 weeks. In terms of attendance, 41% attended all sessions, and 65% attended half of the sessions. Overall, 41 men (44.5%) completed the study (19 in the intervention group, 22 in the control group).

In the intervention group, the rate of workbook completion was poor, and the 6-week intervention took 7 weeks to complete.

"The intervention went to plan with 50% bringing in glucose logs [to assess skills] for interpretation. Skills were also assessed by ability to set up the glucose meter and use the insulin pen, for example," explained Reagan.

"Turning to acceptability, assessed via focus groups, 16 out of 18 viewed the intervention favorably with a request for skill-based videos in future programs covering, for example, healthy eating and insulin administration," reported Reagan.

"Some felt a session that was longer than the 1 hour allocated would be good, and that those with prediabetes should participate, although insulin users felt it should be restricted to prisoners with diabetes only," she added.  

Preliminary efficacy looked at a variety of scores, including the problem areas in diabetes (PAID) 20-item test that measures emotional distress, and the 11-item Self-Care of Diabetes Inventory (SCODI) Confidence subscale (self-efficacy).

Both groups showed improvement in diabetes-related distress and outcome expectancy, with the treatment group experiencing greater and sustained improvement at the 12-week interval.

"Our results highlight the complexity of working with incarcerated populations," said Reagan. And she noted that, due to high attrition, the power to detect effects was "limited."  

And yet, the results suggest that the intervention is feasible and acceptable with an increased sample size and refined recruitment procedure.

"We…need larger sample sizes and to include levels of self-care. We'd also like to look at outcomes such as hospitalizations, HbA1c levels, and address issues around unscheduled releases to the community," she noted, looking ahead to expanding the program.

And "in the future, we'd like to continue the program on the outside, in the community, and establish links with healthcare workers who work with people who have a history of incarceration and diabetes," Reagan concluded.

Adding further comment, session moderator Ryan said: "I'm intrigued by…the education process that improved the distress symptoms. The psychosocial effects of the attention given by the educators and their peers should be reproduced, and I believe is important and sustainable."

American Diabetes Association (ADA) 2019 Scientific Sessions: Abstract 342-OR. Presented June 10, 2019.

Reagan and Ryan have disclosed no relevant financial relationships.

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