Increasing Reach of the Diabetes Prevention Program in African American Churches: Project FIT Lessons Learned in Using an Interprofessional Student Service-Learning Approach

Abstract

The Diabetes Prevention Program (DPP) is an evidence-based lifestyle intervention proven to reduce/delay diabetes onset with diet change, physical activity, and modest weight loss. However, access to the program is limited in low-resource communities. Having health profession students facilitate DPP groups as a service learning course-credit opportunity may benefit their interprofessional training while also expanding DPP access in underserved communities. We sought to use student reflections to identify themes to assist with program evaluation and to inform program refinements. Students (N=95) from the University of Missouri–Kansas City (UMKC) medical, physician assistant, and pharmacy programs led DPP groups in urban Kansas City African American churches alongside church health liaisons as part of an interprofessional service-learning course. Students reported creating satisfying, ongoing relationships with participants; developing a deeper understanding of obstacles to weight loss; and learning the role of other health professionals in the care of patients. They also identified obstacles to successful program implementation, such as needing less time in training and having equal participation from students across their interprofessional teams. Students learned important lessons by leading the DPP, but interprofessional service-learning courses have multiple obstacles to successful delivery. Still, this approach has great potential to increase access to the DPP in African American communities and promote skill development in health profession students.

Introduction

One out of three adults in the United States has prediabetes.¹ Type 2 diabetes affects nearly 10% of the general population. African Americans are disproportionately burdened by diabetes compared to Whites (13% versus 7.5%).^1–3 Intensive lifestyle interventions have been shown to prevent progression to type 2 diabetes.^4–5 Studies demonstrate that the Diabetes Prevention Program (DPP), which focuses on modest weight loss (7% of initial body weight) and 150 minutes of physical activity weekly, is more effective than standard treatments at preventing the development of type 2 diabetes in adults.^4–6 The National DPP is a Centers for Prevention and Disease Control (CDC)-led collaborative between public and private organizations to prevent or delay type 2 diabetes.^7–8 It makes the DPP curriculum (and the updated T2 curriculum) freely available to enhance widespread dissemination. However, access to the DPP remains limited, especially in African American communities.^7,9

The Black Church has tremendous reach and influence in African American communities. Studies indicate that most African Americans attend church weekly (Pew Religious Landscape, 2009) and highly value religiosity.^10–11 Therefore, partnering with African American churches may serve as an effective strategy for achieving meaningful behavioral change for chronic medical conditions.^12–13

An untapped strategy to increase the accessibility of the DPP in African American community may be to train health professional students to lead the sessions in collaboration with church members. Service-learning is increasingly used as a strategy to promote effective communication skills, civic engagement, cultural competency, and professional skills.^14–17 Interprofessional service-learning allows students from different disciplines to work together on teams – an essential skill for healthcare professionals, especially those with a desire to address community health.^18–19 Interprofessional service-learning programs may be a resource that can assist in making the DPP more accessible and ensure health professional students are trained to care for this often underserved population.

We report student perspectives on their role as members of interprofessional teams leading the DPP in African American churches.

Methods

Background

The Community Health Research Group (CHRG) at the University of Missouri–Kansas City (UMKC) School of Medicine SOM has expertise in working with African American churches to improve health outcomes. A needs assessment performed by the CHRG identified diabetes and cardiovascular disease (CVD) as essential health priorities for the African American faith community.²⁰ Based on the needs assessment findings and input from a community action board, a diabetes and CVD prevention intervention (Project Faith Influencing Transformation [FIT]) was developed. Project FIT was religiously-tailored and designed to improve healthy food intake, increase physical activity, and promote weight loss.²¹ Church members who participated in the DPP as part of Project FIT were significantly more likely to lose five pounds compared to controls.²¹ To increase the reach of Project FIT, CHRG collaborated with faculty from the SOM to train students to serve as DPP coaches.

UMKC has several health science professional schools, including a SOM (with both medical [MD] and physician assistant [PA] programs) and a School of Pharmacy (PharmD). Faculty from the MD and PA programs, joined later by PharmD faculty, collaborated to develop a curriculum to train students to facilitate the DPP as health coaches in African American churches.

Church Recruitment

The DPP was conducted in 23 churches in urban low-resource Kansas City, Missouri, (KCMO) and Kansas City, Kansas, (KCKS) areas. Information about Project FIT was distributed in several ways: a) meetings of faith-based organizations discussing the health of KC’s African American communities; b) CHRG staff contacting churches with whom past relationships had been built; and c) word-of-mouth between churches. Participating churches agreed to host 11 sessions and to recruit at least 15 participants.

Each church appointed one to two church health liaisons (CHLs). CHLs received about four hours of training on the background of DPP and Project FIT, strategies to work with the student coaches, and recommendations to promote the class. CHLs were informed that students were there for their education, not worship or to be evangelized. CHL’s were responsible for a) opening the church, b) storing class materials; c) opening and closing each session in prayer; d) reading scripture reflections relevant to class topics; d) passing out Project FIT educational materials; and e) contacting participants throughout the week to encourage them to engage in healthy behaviors and to attend class.

Course Design

A total of 95 students have led DPP classes over three academic years. The first two years included MD and PA students; the third year added PharmD students. PharmD students were first- and second-year students completing a directed individual study program in addition to their usual required didactic curriculum. UMKC SOM is a six-year combined bachelor and MD program. MD health coach students were in Year 2 and in an alternate program for those who require additional time before promotion to Year 3 of the program. PA health coach students were in their third and fourth semester of a seven-semester program. Both groups of these students were required to participate as a part of their class/program requirements.

In the first cohort, students met weekly for two hours in the fall semester to learn how to facilitate the DPP. Based on feedback from this cohort, training was shortened to one-half day for subsequent years. For the first two cohorts, the DPP classes were delivered in the spring; for the final cohort, the DPP classes were delivered in the fall. Training included an introduction to the data supporting the DPP, African American church culture, cultural competence, leading small groups, and course expectations, as shown in Table 1.

Table 1.

Project FIT Student Course Description

Course Topics	Course Objectives
The Diabetes Prevention Program	Understand the diagnosis of prediabetes List the consequences of type 2 diabetes, especially cardiovascular disease Recommend evidence-based lifestyle interventions for patients with type 2 diabetes
African American church culture and Project FIT	Describe the importance of the Black Church in African American communities Explain to the impact of church culture on the social networks, individual behaviors, and eating habits of African Americans. Identify the impact of a pastor’s words on a congregation’s behavior Discuss strategies health professionals and community researchers may use to improve the health of the African American population by forming relationships with the church Work within an African American church to promote healthy behaviors, including weight loss, regular exercise, and healthy food choices.
Health disparities and the social determinants of health	Express how a person’s zip code can impact their health and life expectancy, especially in the greater Kansas City metropolitan area Identify elements of a community that can negatively impact a population’s health, such as lack of safe sidewalks and access to fresh produce Recall the known disparities in the prevalence of type 2 diabetes between African Americans and other races in the United States Debate the impact of a healthcare professional’s own implicit biases on their ability to provide equitable care to all patients Use culturally sensitive language and demonstrate culturally sensitive behaviors in a community setting
Patient education and motivational interviewing	Counsel patients on elements of a healthy diet Use patient-centered communication techniques to encourage adoption of healthy lifestyle behaviors Design and lead a low-intensity exercise program for individuals at various fitness levels
Interprofessional teamwork and communication skills	State the differences in training and skillset amongst various health professionals Participate as an engaged team member leading a DPP group Demonstrate effective communication skills with individuals from a variety of health professional schools

Grading consisted of evaluations completed by program faculty, the CHLs, and the students’ peers. Students were required to attend a course orientation, the training sessions, a minimum of 10 of the 11 DPP sessions, two debriefing sessions (one at the mid-point of the program and one after the program), and weekly reflections on their experiences in serving as a DPP coach. They were also required to complete an anonymous course evaluation. Students in cohort 3 were required to complete similar activities.

Program Implementation

Sessions occurred on weeknight, beginning at 6:00p, with group discussion for 45 minutes and 30 minutes of low-intensity physical activity (e.g., walking throughout the church, walking outside, exercise videos). The initial session included intake with documentation of each participant’s baseline weight, height, BMI, and blood pressure; subsequent weeks only included documenting participants’ weight by the students. Data were collected and managed using REDCap electronic data capture tools hosted at UMKC.

The initial cohort had interprofessional teams of five to seven students; subsequent cohorts had three to six students per team. Students took turns leading the DPP discussion and exercise sessions. DPP sessions were consolidated into 11 sessions by faculty, as the limitations of semester scheduling did not allow for the 16 core sessions recommended in the T2 curriculum. For cohorts 2 and 3, maintenance sessions were condensed to two sessions covering four modules; cohort 1 did not include maintenance sessions. Students were provided a plan for emergencies, including contacting emergency services and faculty. The CHLs were the students’ primary contact in the churches.

Program Evaluation

Program evaluation included analysis of written course evaluations. For cohort 3, analysis of weekly reflections was also used. Faculty participated in iterative discussions of key themes noted across students’ comments from their reflections and the class evaluations throughout program implementation. Two course faculty (Authors 1 and 3) then summarized the key reoccurring themes and conducted “member checking” with the course faculty to resolve any disagreements, and ensure the key themes were salient and properly interpreted.

Descriptive statistics were calculated using Microsoft Excel for Mac version 16.23. A determination of non-human subjects research was provided by the UMKC Institutional Review Board.

Results

Churches and Student Characteristics

Across the three cohorts, 23 churches participated, as shown in Table 2. Among these, three hosted the DPP more than once. The Baptist denomination was most frequently represented, followed by Methodist churches. Church membership sizes ranged from 50 to 2,900 members. Most of the churches were close to the UMKC Health Science District campus (within five miles on average).

Table 2.

Characteristics of Participating Churches

	Cohort 1	Cohort 2	Cohort 3
Denomination (n, %)
Baptist	2 (67%)	5 (56%)	4 (27%)
Church of God in Christ	1 (33%)	-	1 (7%)
Pentecostal	-	1 (11%)	-
Methodist	-	2 (22%)	5 (33%)
Non-denominational	-	1 (11%)	3 (20%)
Other	-	-	2 (3%)
Total	3	9	15
Membership size (mean, range)	433 (250–750)	680 (60–2,900)	481 (20–2,900)
Distance from university (mean, range)	3 (2–4)	5 (1–10)	5 (2–13)
Number of enrolled DPP participants per class (mean, range)	24 (18–29)	17 (4–36)	19 (5–57)
Total DPP participants per cohort	72	151	281

Student demographics are summarized in Table 3. In general, most of the students were white and female. Across all cohorts, PA students have made up the largest group of DPP student health coaches.

Table 3.

Student Demographics

			2016–2017	2017–2018	2018–2019
MD	White	Female	1	4	4
		Male	1	1	3
	Minority race	Female	3	7	6
		Male	-	-	3
	Decline to answer	Female	-	1	1
		Male	-	-	-
PA	White	Female	11	9	11
		Male	6	8	2
	Minority race	Female	-	1	3
		Male	1	2	-
	Decline to answer	Female	-	-	1
		Male	-	-	1
PharmD	White	Female	-	-	1
		Male	-	-	1
	Minority race	Female	-	-	3
		Male	-	-	3
	Decline to answer	Female	-	-	-
		Male	-	-	-
Total			23	33	39

Themes from Student Reflections

Key themes identified in reviewing students’ reflections focused on their positive interactions with participants, their experiences on interprofessional teams, impact on their future as a health professional, and challenges in facilitating the project and suggestions for course refinement. Comments below are representative of students’ comments from the course evaluation for all cohorts and weekly reflections for cohort 3.

First, students reported that it was rewarding to develop longitudinal relationships and to help individuals adopt a healthier lifestyle.

• “I think the most valuable part of the course is spending time with the participants and helping them achieve their goals.”

• “As a physician, I might not have time to follow deeply a patient’s progress toward a health goal, but this course allowed me to track participants’ progress and give them motivation along the way.”

• “Participants were very grateful for this program and how it has helped them so far - they are not eager to see us go in a few weeks.”

Students commented on having a better understanding of the struggles of participants, which could aid them in being more empathetic to future patients.

• “Hearing first-hand from individuals struggling with weight, high blood pressure, etc., who want to change but are having a difficult time doing so.”

• “I have a better understanding of struggles experienced by my patients because of this.”

Students enjoyed the opportunity to form meaningful relationships with participants, especially participants from a different background.

• “Before the program, I was extremely nervous about driving through the area of town my church was in but after driving there every week and hearing the women in the church talk about walking around the neighborhood and knowing that they live there, I realized my fears were rooted in stereotypes and “unintentional” racism. Also, I had never been exposed to an African American church setting before and the feeling of community and positivity was amazing. I would love to work with this population in the future…. This experience taught me the positive impact that working in a community setting can have on me personally and on patients.”

Students also expressed a greater understanding and appreciation for other health professionals, although this varied dramatically as some groups were more effective in working together as an interprofessional team than others.

• “… It was also nice to get to know the students from the other program. It gave me some insight into their field, and I value their profession a lot more now.

• “I was in a group with 2…students [from another school] who barely spoke at most of our classes. Myself and the other 2 people in my group encouraged them to get involved and speak up, and they refused to contribute to the lesson or to participate in exercise.”

• Students commented about how they enjoyed hearing that participants wanted to take preventative actions to be healthier. They also commented on factors they need to take into consideration when talking to patients, especially as future health professionals.

• “… a lot of participants said they joined the program because they have already been diagnosed with [type 2 diabetes] and don’t want the disease to progress further or they want to get off of their medications. As a future healthcare provider, it is awesome to see patients wanting to take control of the aspects of their health that they have control over.”

• “… one of the participants exclaimed that the driving factor for them coming to the session was wanting to be able to breathe and walk normally. That comment really made me realize how important good health is for the life quality of each individual.”

As anticipated, not all students were enthusiastic about the service-learning experience, especially in the first cohort and when sessions competed with their other coursework.

• “This is not more valuable than clinic work…. I learned more in one day shadowing…I feel like I am just being used as a warm body to run sessions for research.”

• “Sometimes we had very few people come to class, and some weeks it really conflicted with schoolwork and made it difficult to stay committed when few participants started to come.”

Students expressed concern that the material in the DPP was unnecessarily simplistic and repetitive for their group participants.

• “The DPP curriculum was very basic compared to the knowledge the participants in my church had. I didn’t learn anything that I didn’t already know, and it was review for many of the participants as well.”

The appropriate duration and depth of the initial training was also a concern, with the first cohort expressing the training was too long and subsequent cohorts expressing that it was too short.

• “The whole first semester of training was the least valuable. We spent so much time on activities that we could have done in just a weekend or a couple of days. Because of this, we lost valuable patient care experience in that first semester.”

• “The training did not seem adequate to prepare us for the class experience, which led to a lot of learning as we went.”

Additionally, a few students expressed concern about serving in a faith-based setting where certain religious practices took place that made them feel uncomfortable.

• “It made me feel uncomfortable that this took place in a church and it was advertised to the participants as a church faith-based activity. It felt uncomfortable having the prayer and having the class at a faith-based center.”

Discussion

To our knowledge, this is the first study to report on students facilitating the DPP as a community service-learning experience for course credit. The DPP is an effective and cost-conscious intervention to delay the development of type 2 diabetes in at-risk patient populations (Herman et al. 2005; Faridi et al. 2010; Davis-Smith et al.).^6,22–24 African Americans are disproportionately affected by type 2 diabetes (Davis-Smith et al.),² and church-based interventions have been found to be acceptable and effective at improving the health of this underserved population (Berkley-Patton et al. 2013; Boltri et al.).^12,25 Service-learning using interprofessional teams encourages the development of key skills for health professionals, including cultural competency and teamwork skills.^18,26–27 Thus far, we have trained 95 students to serve as DPP coaches and have demonstrated the feasibility of this model to both increase access to the DPP and improve the skills of these students.

This program had many successes. Several churches have participated in more than one cohort and have members who keep returning to extend or maintain their weight loss. Participants were highly satisfied with the program and have lost significant amounts of weight, comparable to weight loss in other DPP studies in community and church settings.^21,24,25,28 Anecdotally, church member participants commented to faculty that they appreciated the students taking the time to lead the class, had great camaraderie with students, and wanted to see the program continue. Several students have returned to serve as volunteers in subsequent cohorts, providing leadership for other students and using their experience to design their own research projects. Additionally, there have been waitlists for churches to host the DPP, indicating a demand in Kansas City’s urban low-resource area. Churches on the waitlist heard about the program from other participating churches that had previously participated, suggesting past churches in the program believed their members benefited from the program.

Limitations

The current study has several limitations. Our study was designed to show the feasibility and acceptability of having teams of interprofessional students lead the DPP in African American churches. Subsequent studies will be needed to assess effectiveness of the model. Studies will also need to be completed to determine if this shortened program is as effective as the longer program. Further assessment of outcome studies could help confirm our report of student comments. Finally, the student feedback was obtained immediately after the completion of the program. Therefore, it is difficult to assess if the program had any meaningful long-term impact on the students.

Next Steps and Lessons Learned

Scheduling and getting buy-in from all involved parties were two key obstacles. Course faculty had existing relationships with African American churches. However, even with existing relationships, arranging session times and engaging leadership was difficult in some churches. As the number of interested churches continues to grow, we are continually refining our approach to reduce cost and maintain high fidelity. The primary obstacles at this time are ensuring consistent, effective communication with students from different schools and supporting and retaining church participants. It is anticipated that other schools in the UMKC system will be FIT program partners. Addtionally, the program has had initial success with student volunteers and has expectations to expand this opportunity as well.

Conclusion

Use of an interprofessional service-learning course may provide opportunities to enhance students’ interpersonal skills while also increasing access to lifestyle programs, especially in low-resource African American communities.

Practice Points

1. The Diabetes Prevention Program (DPP) is an evidence-based, intensive lifestyle intervention to prevent type 2 diabetes in high-risk patients, including African American individuals.

2. Health profession students can lead the DPP with minimal additional training in a way that is acceptable to both students and participants.

3. Students leading the DPP develop enhanced understanding of barriers to healthy habits and how interprofessional teams can address them.

4. Partnering with the African American church may be one strategy to increase the accessibility of the DPP and train interprofessional teams of students to help patients achieve a healthier lifestyle.