Alberta Health Services-Calgary finds “Better Ways” to provide Diabetes Care for Vulnerable and Hard-to-Reach Populations – Two Success Stories (2002-2004; 2008-2009)

Although Canada’s population has become rapidly more diverse, one characteristic is shared by specific populations – the increased risk for developing type 2 diabetes. Certain ethnic minorities that make up increasing proportions of the Canadian mosaic (people of Indo-Asian, Asian, Latin American and African descent), Aboriginal people and those experiencing extreme poverty bear a disproportionate burden of chronic disease, particularly type 2 diabetes. Despite this trend, vulnerable segments of these populations face multiple and complex barriers, including language difficulties, low literacy skills and lack of social support, to access diabetes care. In the context of a diverse society, the unique cultural and social needs of vulnerable populations should be recognized and adequately addressed by health care planning and provision.

In 2001, Alberta Health Services-Calgary partnered with Indo-Asian communities of Calgary to confront this challenge by initiating a two-phase culturally-sensitive and community-based diabetes intervention project. The results of Phase 1 (2001-2002), a community-wide Diabetes Risk Factor Screening Pilot Project, indicated the high prevalence of risk factors for diabetes among Indo-Asian populations and identified an urgent need for the development of targeted diabetes intervention strategies.

In response to this need, in 2002, Alberta Health Services-Calgary, in collaboration with local Indo-Asian communities and with funding support from The Lawson Foundation, developed a community-based and culturally-appropriate diabetes prevention and management initiative (2002-2004). The goal of this innovative project was to improve health outcomes for Indo-Asian populations with and at risk for diabetes by tackling the complex socio-cultural factors that prevented them from accessing and benefiting from mainstream diabetes services in Calgary. The interventions, offered in Punjabi, Gujarati, Hindi and Urdu languages, were delivered by trained health professionals from the community in accessible community-based settings such as temples and mosques.

Over 1,200 Indo-Asians participated in diabetes screening programs and 2,000 participated in educational presentations and demonstrations. The project evaluation showed statistically significant and sustained improvements in clinical outcomes such as fasting blood glucose, hemoglobin A1c, lipid profiles, weight status, and in diabetes management and prevention knowledge and health behaviour indicators. The project’s approach – population-oriented (culturally-sensitive) health promotion strategies that could be implemented by communities and the health care system – was shown to be effective in building integration and coordination among health care providers and high risk communities. Enhanced access to care and increased patient satisfaction suggested the feasibility of providing effective interventions in ethnic communities. Capacity at both the individual and community levels was improved, increasing the number of trained staff by 25%, the number of family physicians supporting the project by 100%, and the number of culturally competent educational tools by 400%.

In 2004, the successful Indo-Asian Diabetes Initiative became an operational program in Calgary to ensure continued progress and ongoing effective diabetes service delivery to Indo-Asian populations. Since then, the program has reached out to other high risk ethnic communities (Chinese and Filipino, Spanish) in Calgary to fill service gaps.

  

 “I wish my mother, two sisters and my uncle who died of diabetes, knew what I know.”

A quote from an Indo-Asian patient – 2003

However, the journey didn’t end there....

In 2008, recognizing that the poorest Canadians are almost three times as likely to have multiple chronic health conditions, particularly diabetes, Alberta Health Services-Calgary began to address the health needs of yet another extremely marginalized population – people experiencing homelessness. Homelessness increases the risk for serious health problems, magnifies existing illness and complicates treatment. In particular, the need for life-long management of diabetes, with demands related to blood glucose self-monitoring, medical therapy, diet, lifestyle and ongoing education, compounds the challenges for the homeless. Within a system of universal health care and despite high levels of need, homeless people frequently encounter many barriers to appropriate health care. Health care providers also face challenges to care for patients. A limited number of strategies are in place worldwide to improve the health of homeless individuals. Innovative, effective and appropriate strategies are needed to address the complex health needs of this vulnerable population. 

With a second grant from The Lawson Foundation, the Calgary Zone of Alberta Health Services and the Calgary Drop-In & Rehab Centre, the largest homeless shelter in the city, created a community-based diabetes prevention and management program for people experiencing homelessness and poverty (2008-2010). The objectives of the project were to develop strong partnerships with the homeless population and key community groups, identify barriers experienced by the homeless and create appropriate strategies for the delivery of diabetes programming to this underserved population. More importantly, the project aimed to improve the external factors affecting homeless people’s access to effective diabetes care. The project’s objectives have been achieved and continue to help those in need.

With the active engagement of homeless people and community groups as true “partners in care”, the project provided innovative and accessible diabetes screening prevention and management programs. Components of the standard diabetes care model were modified to reflect the unique needs of the homeless and were delivered by a non-judgmental, compassionate multidisciplinary team in the shelter where homeless people congregate.

    

Case management in the Homeless Diabetes Initiative had no ‘smooth edges and refinement’, it did anything that was needed and anywhere, to reach the patients where they were in their illness trajectory”

The Homeless Diabetes project identified and responded to challenges experienced by this population, including lack of access to primary health care professionals, diabetes services, healthy food, foot care, medication, information about health in general and diabetes in particular, equipment for self-monitoring of blood sugars, and social/family support.

• The project successfully facilitated access to diabetes medication and blood monitoring supplies (through donations from pharmaceutical companies), referral to foot care programs, access to the services of primary care physicians, nurses, dieticians and social workers, and access to healthier foods.
• The project team screened over 500 people for diabetes and risk factors. Among participants with higher than normal blood glucose levels, 25% were identified as new diabetics. This is critical, since early detection of diabetes promotes the prevention of secondary complications.
• The project created strong connections built on trust with the homeless community, resulting in improved health outcomes and care. Increased diabetes and health awareness among the homeless participants led to a general improvement in lifestyle, including self-care and self-worth behaviours. Participants made better decisions about physical activity and food, including requests for healthier food choices in the shelter’s kitchen and vending machines and the creation of Community Gardens.

Overall, this innovative service delivery model resulted in enhanced awareness, access and patient outcomes. Stakeholders became more responsive to the unique needs of this often ignored population. The active engagement of homeless people and organizations serving the homeless, and working with the “whole person” in his/her world were critical in identifying barriers and best strategies. Since April 2010, based on the initiative’s success and as a result of the partnerships among Alberta Health Services-Calgary, Calgary Drop-In & Rehab Centre and Mosaic Primary Care Networks, the project has become a sustained and ongoing Chronic Disease Management Program for the homeless in Calgary.

The Lawson Foundation’s vision and commitment to the application of diabetes research in communities helped make these outcomes possible. Both initiatives have had a profound impact on the health of populations that are regularly overlooked. Together, we have created successful and sustainable diabetes care models which could address the needs of vulnerable populations across Alberta, Canada and beyond.

For more information, contact:

Shahnaz Davachi, PhD, RD Director, Diverse Populations

Community & Rural, Primary Care & Chronic Disease Management

Alberta Health Services

Shahnaz.davachi@albertahealthservices.ca

Last Updated ( Thursday, 02 June 2011 )