11. Project Dulce
Background: Diabetes management programs have been found to improve health outcomes, and thus there is a need to translate and adapt them to meet the needs of minority, underserved, and underinsured populations. In 1997, a broad coalition of San Diego County health care and community-based organizations developed Project Dulce (Spanish for “sweet”) to test the effectiveness of a community-based, culturally sensitive approach involving case management by nurses and peer education to improve diabetes care and elevate health status among a primarily Latino underserved community in Southern California. Partners included the San Diego Medically Indigent Adult program and San Diego County Medical Services.
Methods: The goals of the project are to meet the American Diabetes Association’s standards of care and to achieve improvements in HbA1c (glycosylated hemoglobin), blood pressure, and lipid parameters. A bilingual team, consisting of a registered nurse/certified diabetes educator, a medical assistant, and a dietitian, travels to community clinics to see patients up to eight times per year, then enters patient-specific data into a computer registry that generates quarterly reports to guide future care. In addition to having one-on-one clinic visits with the Dulce team, patients are encouraged to participate in weekly peer education sessions.
At each clinic, “natural leaders” are identified out of the patient population with diabetes and trained to be peer educators or promotores. The training consists of a four-month competency-based and mentoring program that culminates with the promotor providing instruction in concert with an experienced educator.
The instructors use a detailed curriculum in teaching the weekly sessions in the patients’ native language. The classes are collaborative, including interactive sessions in which the patients discuss their personal experiences and beliefs. Emphasis is placed on overcoming cultural factors, such as fear of using insulin, that are not congruent with self-management.
Results: Project Dulce’s first group showed significant improvement in HbA1c, total cholesterol, and LDL (low-density lipoprotein) cholesterol compared with chart reviews of patients having similar demographics from the same clinics over the same time period. Participants’ belief that personal control over their health was possible and that contact with medical service providers was important in maintaining health increased. The success of the initial program has led to the creation of modified offshoots to address the diabetes-related needs of African American, Filipino, and Vietnamese communities. In 2008, Project Dulce added the care management program of IMPACT (Improving Mood-Promoting Access to Collaborative Treatment) to address the problem of depression among patients at three community clinics serving a low-income, predominantly Spanish-speaking Latino population. Up to 33% of patients tested positive for symptoms of major depression upon entering the program, and intervention resulted in a significant decline in the depression identification scores.
Comments: The ability to adapt Project Dulce to new communities and new components attests to its potential as a vehicle to administer care to underserved populations.
Applications of Principles of Community Engagement: Project Dulce has been shown to help patients overcome many cultural barriers to care that can result in poor adherence to medical advice. A key to the program is the identification and training of individuals within the community to lead the intervention’s interactive educational component. By facilitating the transformation of patients into peer educators, Project Dulce mobilizes the community’s existing assets and incorporates Principle 7, which stresses capacity building for achieving community health goals. Creating a peer education group coupled with a bilingual/bicultural nursing team illustrates the true partnership prescribed by Principle 5, and it is a model for community engagement that can be modified appropriately to reflect cultural diversity, as stressed in Principle 6. After initial success within the Latino community, Project Dulce has been able to adapt its curriculum and group education approach to address the needs of other communities. At the time of publication, it had programs in eight languages. These adaptations respond to the diversity of San Diego County and are congruent with Principle 9, which emphasizes that a long-term commitment is required to improve community health outcomes.
Gilmer TP, Philis-Tsimikas A, Walker C. Outcomes of Project Dulce: a culturally specific diabetes management program. Annals of Pharmacotherapy 2005;39(5):817-822.
Gilmer TP, Roze S, Valentine WJ, Emy-Albrecht K, Ray JA, Cobden D, et al. Cost-effectiveness of diabetes case management for low-income populations. Health Services Research 2007;42(5):1943-1959.
Philis-Tsimikas A, Walker C, Rivard L, Talavera G, Reimann JO, Salmon M, et al. Improvement in diabetes care of underinsured patients enrolled in Project Dulce: a community-based, culturally appropriate, nurse case management and peer education diabetes care model. Diabetes Care 2004;27(1):110-115.