Running head: Internship Proposal 1

Internship Proposal to Conduct an Evaluation of a Diabetes Prevention Program Among African

American College Students

Parrish. M. Webster
Center of Excellence for the Elimination of Health Disparities
Winston-Salem, North Carolina
Preceptor: Dr. Melicia Whitt-Glover
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Table of Contents

Description of the Health Problem………………………………………………………3

Description of the Non-Health Problem…………………………………………………5

Relevancy to Agency…………………………………………………………………….6

SWOT Analysis………………………………………………………………………….6

 Table 1. SWOT Analysis

Ethical Analysis………………………………………………………………………….8

Problem Analysis………………………………………………………………………..9

 Figure 1. Conceptual Model

 Figure 2. Logic Model

Data Collection Plan …………………………………………………………………..14

Internship Timeline…………………………………………………………………….15

 Table 2. Gantt Chart

Reference List…………………………………………………………………………..17
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Description of the Health Problem

Diabetes is a public health concern that has the potential to become an epidemic requiring

global attention and urgent action. As of 2017, more than 30.3 million people in the United

States have been diagnosed with diabetes, which considers the 7.3 million who have diabetes yet

remain undiagnosed (CDC, 2017). There are various forms of diabetes including Gestational,

Pre-Diabetes, Type 1 and Type 2 that are all characterized by elevated levels of blood glucose.

With the exception of pre-diabetes, the variations of the disease are distinguished by the body’s

response to insulin, its production, lack thereof, or a combination. With over 90% of diagnosed

cases being classified as type 2 (non-insulin dependent) it is the most common form of diabetes

(CDC, 2017). The onset of type 2 diabetes is due to various contributing factors such as poor

diet, lack of physical activity, and genetics however, diabetes is a preventable disease. Though

preventable, if left untreated it can lead to serious health complications such as nerve damage,

organ failure, blindness, cardiovascular accidents, limb amputations, or death (CDC, 2017).

As a persisting public health problem that can affect anyone regardless of their gender,

race, or ethnicity, diabetes gives rise to the racial and ethnic disparities that are associated with

the disease. African Americans and other minorities are disproportionately affected and

experience higher prevalence rates of diabetes in comparison to their White counterparts

(Rodriguez et. al, 2017). The prevalence of diagnosed type 2 diabetes based upon race and ethnic

backgrounds is as follows: Native American (15.5), African Americans (13.2%), Hispanics

(12.8%), and Asian Americans (9.0%), in comparison to White Americans (7.6%) (Rodriguez et

al., 2017). Aside from experiencing higher prevalence rates of diabetes, African Americans and

other minorities are further immobilized by other aspects of the disease. Decades of literature
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have found racial and ethnic disparities in the prevalence of access to diabetes care, quality of

care, diabetes-related complications, and mortality rates (Hu et. al, 2016).

Diabetes is a leading cause of morbidity and mortality as it remains the seventh leading

cause of death in the United States. In addition to disproportionately impacting racial and ethnic

minorities, diabetes poses as a financial burden with direct and indirect costs totaling an

estimated $245 billion annually (ADA, 2013). Even though adjustments were made for

differences in age and sex at the population level, at the individual level, average medical costs

for those diagnosed with diabetes were 2.3 times higher than among people those without

diabetes (ADA, 2013).

In addition to disproportionately affecting racial and ethnic minorities diabetes gives rise

to another relevant health disparity. As the burden of diabetes persists its prevalence varies

among those who reside in rural, semi-urban and urban areas in comparison to residents of

suburban areas. Those who reside in high-risk areas such as Forsyth County are more likely to be

diagnosed with diabetes. Residents can be subjected to high rates of poverty, have low education

attainment, or reside in environments that limit their access to healthy food options, space for

exercise, and healthcare. Furthermore, if residents are either medically uninsured or underinsured

this poses as another barrier in terms of seeking quality preventative diabetes care and education.

These barriers are present within Forsyth County with an 11.2% prevalence of diabetes which

mirrors that of the North Carolina average. However, 18% of residents are living in poverty,

which is higher than the North Carolina average of 15.4% (U.S Census Bureau, 2017). The

above statistics give rise to the progressing problem of diabetes in urban areas such as Forsyth

County and the need for immediate action to aide in its prevention.
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The State of the County Health Report for Forsyth County delineated diabetes as a

priority health issue and reported plans to implement several diabetes prevention programs. In

conjunction, Winston Salem State University received a $385,000 grant to carry out a model

diabetes program for high-risk, low income communities like Forsyth County. This is because

many historically Black colleges and universities (HBCUs) like Winston Salem State University

(WSSU) are located within communities that are at high risk for chronic disease as Dr. Whitt-

Glover mentioned. Since the model diabetes prevention program (DPP) has been piloted at

WSSU, I want to conduct an evaluation that will assess the students’ overall experience with the

program as well as measure the feasibility of the DPP. If proven effective at WSSU, this program

could serve as a guide for future implementation of subsequent programs, especially at other

historically Black institutions.

Description of the Non-Health Problem*

Many historically Black colleges and universities are located within communities that are

at high risk for chronic diseases such as diabetes. The population is largely in part made up of

African American students who mirror those disproportionately impacted by the disease. The

DPP being piloted at WSSU was a part of a more profound initiative to prevent the onset of

chronic disease among African American college students. These efforts stand to impact the lives

of students, the surrounding communities which they serve, and possibly other institutions as

well. I am hopeful that the research and efforts of the Center of Excellence for the Elimination of

Health Disparities (CEEHD) will prove the program to be feasible and sustainable enough to

create access to reach and engage those most at risk. Also, in doing so, the program can

demonstrate not only its capacity to address the prevalence of diabetes, but the prevention of the

disease among African American college students.

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Relevance of Problem for the Agency

As one of the many HBCU’s located within a community deemed high-risk for the

development of chronic disease, it was ideal for WSSUs School of Health Sciences to pilot the

model prevention program. The two-year grant titled “Implementing Evidence-Based

Interventions to Prevent Chronic Disease through HBCU’s” has been carried out by CEEHD, led

in part by Dr. Melicia Whitt-Glover. The center of excellence stands to promote health equity in

health care delivery and treatment through quality community engaged research, dissemination

of findings, and student education. The vision of CEEHD directly correlates with the diabetes

prevention program framework for delaying or preventing the onset of type 2 diabetes.

SWOT Analysis

After discussing the relevancy of the health and non-health problem in relation to the agency, it

is critical to also assess factors that will affect the direction of the internship itself. The SWOT

analysis within table 1.1 below details and helps to identify factors and variables such as internal

strengths and weaknesses alongside possible opportunities and threats related to the feasibility of

the diabetes prevention program.

Table 1. SWOT Analysis

Factors/Variables Internal External

Strengths Opportunities

Positive -Interest and commitment to -Build upon what has been

the cause done previously

-Existing data and information -Establish partnerships to

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on diabetes prevention implement program within

programs other HBCU institutions

-Support from some -To prevent or delay the onset

stakeholders of Type 2 Diabetes

-Resources and capacity for -Improve overall health of

the program and evaluation those deemed prediabetic, thus

-Program has been previously increasing their knowledge,

implemented in other settings and self-efficacy

-Relevant knowledge around -Diverse interest in group

diabetes, prediabetes, in -Community readiness

relation to African American -Creating more visibility

population specifically

Weaknesses Threats

Negative -Time constraints -At the conclusion of the 2-

-If the program does need to year grant, funding could

revamp or make changes, decrease and or not continued

there may be a delay in seeing -Despite efforts, those still at

those changes greatest risk unaware of

-A lack of engagement from prevention initiatives or

other stakeholders maintain negative feelings or

-Lack of access for those most disbeliefs about the program

at risk being beneficial

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-Difficulty showing immediate

results

Ethical Analysis

Theoretically, identifying methods of prevention would reduce the burden of diabetes in high-

risk, low-income communities. As the prevalence of diabetes continues to increase there has

been an influx in the implementation of diabetes prevention programs; with one recently being

modeled at WSSU with approximately thirty students. In addition to using the SWOT analysis

for this program to prevent the onset of diabetes it is important to consider the ethics of this

initiative, but more so of the evaluation itself. As it was being piloted, the program should have

been free of any ethical dilemmas when addressing the health concern. Now that an evaluation

will be underway, it too should be free of ethical dilemmas and it is imperative to consider any

that can arise. To ensure that the evaluation of the program is ethical, it is essential for the

evaluator to maintain confidentiality as well as ensure honesty and integrity throughout its

entirety. Furthermore, the evaluator should prove to be competent to provide a clear, useful, and

accurate evaluation to the stakeholders. There should not be an instance where the evaluator is

stepping outside of their boundaries or behaving in a manner that could affect the quality of the

evaluation.
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Problem Analysis

Prior to creating an initiative to combat the onset of type 2 diabetes would require

understanding factors that contribute to the health problem. Employing the use of the

PRECEDE-PROCEED planning model can aide in identifying and mapping several of those

factors to then devise an intervention to better address the problem. The PRECEDE-PROCEED

planning model was introduced in 1970 to describe factors influencing health outcomes and

provides a comprehensive structure for health needs assessment, program design,

implementation and evaluation of health promotion programs (Green & Kreuter, 2005). The

PRECEDE model is devised into phases that include social, epidemiological, behavioral and

environmental, educational and ecological, administrative and policy assessment. The model

posits that predisposing, reinforcing and enabling factors influence behavior and the

environment; therefore, through behavior and environment, predisposing, reinforcing and

enabling factors have an impact on quality of life (Green & Kreuter, 2005).

For now, I will be primarily focusing on the PRECEDE portion of the model in which the

first phases examine the quality of life for those most at risk based upon a social assessment. The

subsequent phases focus on how environmental, behavioral, and organizational contributors

influence the health problem. Identifying these contributors as well as acknowledging the

predisposing, enabling, and reinforcing factors will help to better understand the health problem

and its prevalence. Research indicates that development of type 2 diabetes is promoted by a

genetic predisposition, however, it is also noted that genetics alone only account for a small

proportion for risk (Arner et al., 2011). Though genetics is basis for the risk of developing type 2

diabetes evidence shows that risk is greater when combined with other detrimental risk factors.
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In fact, research has presented evidence that changeable risk factors such as obesity and

lack of physical activity are among the main nongenetic determinants of diabetes mellitus

(Moskhi et al., 2016). Risk factors include old age, obesity, family history of type 2 diabetes,

previous history of gestational diabetes, and living a sedentary lifestyle (Moskhi et al., 2016).

Below is a conceptual model I constructed to illuminate how these factors work together to

influence increased rates of diabetes.

Figure 1. Conceptual Model

-Sedentariness
-Poor diet
-Tobacco use
-Alcohol use
Predisposing
-High stress levels
Contributors Poverty Level
Detrimental Older Age
Education
Lifestyle Race/Ethnicity
Behaviors
-Lack of Health
Insurance
-Lack of access Lack of
Enabling to preventative Access Type 2
Contributors care Poor Physical Diabetes
-Lack of access & Built
to prevention Environment
services

Reinforcing -Poor density

Contributors -Lack of sidewalks
Genetics,
-Lack of grocery
stores
-Proximal to fast
food
-Food insecurity
-Lack of recreational
space
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As depicted in the conceptual map above, there are many factors present at the

community level that influence increased rates of diabetes such as the environmental

contributors. At this level, barriers can arise because of the community’s physical and/or poorly

built environment. As a result, limitations are imposed and prevent access to quality preventative

care which greatly contributes to the prevalence of diabetes. Many of these poorly built

environments are “food deserts,” a termed used to refer to areas with limited access to affordable

nutritious foods (Hill, 2013). They lack quality grocery stores, farmers markets, and community

gardens and are instead overrun and in proximity to an overwhelming amount of fast food

restaurants. These obesogenic environments lack healthy food options and in turn contribute to

the poor diet for those in high-risk communities. In addition to limited access to care and healthy

food options, many of the communities also lack recreational space that supports an active

lifestyle. The decreased access to gyms, parks and trails prevents those most at risk from

incorporating much needed physical activity in their daily routines; this results in them not

meeting the recommended physical activity goal of 150 minutes as outlined by Healthy People

2020 (Healthy People 2020).

The physical and built environment of a community heavily influences access to care,

recreational space, and consumption of healthy foods. If poorly built, this can reinforce health

disparities like diabetes, that disproportionately affect high-risk, lower-income neighborhoods in

which impacted minorities reside (Hill, 2013). The above factors at the community level and

their effect on the health of those most at risk highlight the need for prevention and interventions

to address the health problem. In addition to factors at the community level there is an outline of

behavioral factors that contribute to the health problem as well. As previously mentioned,

increased risk of diabetes is the result of the interaction between genetic predisposition,
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behavioral and other risk factors. Lifestyle behaviors including an overall poor diet, excessive

alcohol consumption, smoking, sedentariness, and stress profoundly increase the risk of

developing diabetes (Spruijt et al., 2014).

When using the PRECEDE-PROCEED planning model as a guide to plan an initiative

such as diabetes prevention program for implementation it is pivotal to understand the influence

of genetics, the environment, and lifestyle behaviors. However, it is equally important to

understand how the predisposing, enabling and reinforcing factors influence the health problem

as well. This helps to ensure that the prevention is being designed to properly address the health

problem especially at the individual level. Predisposing contributors such as a lack of

knowledge, negative attitudes, and beliefs give rise to the pessimism that can shape a person’s

perception of the prevention program. The enabling contributors facilitate an individual’s

readiness to change or address their lifestyle behaviors. Contributors include the availability or

accessibility of resources in place to help the individual reach a desired health outcome. Though

resources that aide in the prevention of diabetes may exist, they may not be as visible or

accessible to those who could benefit from them. This can negatively impact the reinforcing

factors a person has; reinforcing contributors are the factors which reward or reinforce a certain

behavior and the likelihood of the behavior persisting or not. A person at high-risk for diabetes

with limited or no access to preventative care can lack essential support, have a low self-efficacy,

and lack motivation to try and generate changes with their health.

The PRECEDE-PROCEED planning model can assist with identifying important factors

as well as how to properly address them when designing the intervention for the health problem.

Since the model diabetes program has been implemented among students at WSSU I want to
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assess whether the program is sustainable and feasible enough to address the health problem

among other African American students.

Figure 2. Logic Model

Logic Model

The logic model is a useful tool to help link the agencies available resources to address

the health problem to the activities and outputs that will aide in the desired health outcome.

Using a logic model can prove to be beneficial in carefully planning a prevention initiative and

useful for conducting an evaluation of the prevention program. The logic model above and listed

in the appendix illustrates a generalized list of activities necessary to address the health problem.

A detailed list of the activities that will be performed will be generated upon further discussions

with my preceptor, co-investigator of the program and other agency personnel. Then the logic
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model of the program will help to plan and conduct the evaluation prior to disseminating the

results to the key stakeholders.

Data Collection Plan

To conduct an evaluation that will assess whether the prevention program piloted at

WSSU is feasible and sustainable, it is essential to employ a variety of instruments for data

collection. A variety of data collection instruments will aide in a better understanding of the

contributing factors of the health program, the program, and its impact amongst the targeted

population. For this evaluation I would like to take a mixed method approach utilizing both

qualitative and quantitative data. This approach helps to collect data from various sources

directly involved with the program resulting in a thorough and accurate evaluation. However, a

concrete data collection plan will be generated based upon further discussions with my preceptor,

co-investigator of the program and other agency personnel.

When evaluating a program, it is helpful to review existing documentation as a method of

gathering information. Documents such as sign in sheets, surveillance data, literature, and an

outline of the curriculum provide information about the activities of the program and its reach.

This can help with the design of the evaluation because the data has already been presented and

can provide historical or comparison data. A survey, is a commonly used data collection

instrument that I hope to employ when designing my evaluation. Utilizing a survey would allow

data to be collected from a wide range of people directly involved with the program and its

rollout with the option of remaining anonymous. Administering a survey about the program,

their involvement, and its impact if any would be rather convenient for the respondents and for
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me as the evaluator. The survey can generate data quickly and efficiently allow me to collect

pertinent qualitative and quantitative data. Another data collection instrument that I have

previously discussed with my preceptor is conducting focus groups. Focus groups can assist me

in collecting in-depth information from those involved with the program or its rollout. I can gain

a better understanding of their perceptions of the health concern and their experiences with the

intervention to combat it. An in-depth discussion with the input from multiple people can be very

beneficial for my evaluation because of the group interaction and insight that can be produced.

Timeline for Internship Activities

As with any evaluation, time management is essential and prior to the completion of my

internship I would need to have finished all the activities pertinent to the evaluation. The Gantt

chart below provides a visual depiction of my timeline for the completion of the activities for my

evaluation of the program.

Table 2. Gantt Chart

January February March April

Recruit/Engage X
Stakeholders of the
program
Determine X
measures to be
used for data
collection
Conduct X X X
documentation
review
Conduct surveys X X
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and focus groups

Enter, analyze, and X
interpret data
Write final report X X
Justify and present X
results

If completed within this timeframe, results could show that this model program featured

at Winston Salem State University was a success. With such success at this HBCU, this program

could be deemed sustainable enough to be fully implemented and amongst more participants.

Also, the program could be found to be feasible enough for subsequent programs to be

implemented at other institutions.

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Works Cited

American Diabetes Association. (2013). Economic costs of diabetes in the U.S. in 2012.
Diabetes Care, 36(4), 1033104. doi: 10.2337/dc122625

Arner, P., Arner, E., Hammarstedt, A., & Smith, U. (2011). Genetic Predisposition for Type 2
Diabetes, but Not for Overweight/Obesity, Is Associated with a Restricted Adipogenesis. PLoS
ONE, 6(4). doi:10.1371/journal.pone.0018284

Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and
Health Promotion. (2017). National diabetes Statistics report, 2017. Retrieved from:
https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf
Hill, J. O., Galloway, J. M., Goley, A., Marrero, D. G., Minners, R., Montgomery, B., Peterson,
G. E., Ratner, R. E., Sanchez, E., … Aroda, V. R. (2013). Scientific statement: Socioecological
determinants of prediabetes and type 2 diabetes. Diabetes care, 36(8), 2430-9.

Hu, R., Shi, L., Liang, H., Haile, G. P., & Lee, D. (2016). Racial/Ethnic Disparities in Primary Care
Quality Among Type 2 Diabetes Patients, Medical Expenditure Panel Survey, 2012. Preventing
Chronic Disease, 13. doi:10.5888/pcd13.160113

Green, L. W., & Kreuter, M. W. (2005). Health program planning: An educational and ecological
approach. Boston: McGraw Hill.

Moshki, M., Dehnoalian, A. and Alami, A. (2016). Effect of Precede–Proceed Model on Preventive
Behaviors for Type 2 Diabetes Mellitus in High-Risk Individuals. Clinical Nursing Research,
26(2), pp.241-253.

Physical Activity. (n.d.). Retrieved from https://www.healthypeople.gov/2020/topics-

objectives/topic/physical-activity

Rodríguez, J. E., & Campbell, K. M. (2017). Racial and Ethnic Disparities in Prevalence and Care
of Patients with Type 2 Diabetes. Clinical Diabetes, 35(1), 66-70. doi: 10.2337/cd15-0048

Spruijt-Metz, D., O’Reilly, G. A., Cook, L., Page, K. A., & Quinn, C. (2014). Behavioral
Contributions to the Pathogenesis of Type 2 Diabetes. Current Diabetes Reports,14(4). doi:
10.1007/s11892-014-0475-3