Compared to whites, African Americans suffer much higher rates of non- insulin-dependent diabetes mellitus (NIDDM) and its complications. Prior research provides strong evidence that control of glycemia, blood pressure, serum lipids, and other risk factors can prevent these complications. Unfortunately, primary diabetes care for inner-city African Americans continues to be suboptimal due to economic, cultural, and psychosocial factors. Office-based strategies that emphasize nursing and educational interventions have been proven effective in the care of middle-class white populations, but are largely untested in urban blacks. Community-outreach strategies that emphasize peer counseling have been effective for Africans Americans with hypertension, but have not been adapted for diabetes. Thus, we propose a two-phase project to test strategies to control risk factors for micro-and macrovascular disease among inner-city African Americans with NIDDM. In Phase I, we will refine two behaviorally-oriented, culturally sensitive intervention strategies. The interventions will be based in adult general medical practices where the vast majority of persons with NIDDM receive primary diabetes care. An Enhanced Practice Intervention will utilize a certified diabetes nurse-educator as case manager to coordinate multidisciplinary patient care, to provide patient care, to maximize adherence to treatment recommendations, and to prompt primary-care clinicians to provide optimal preventive care. In contrast, a Community Outreach Intervention will utilize a trained, supervised African American community member as a peer counselor to monitor health behavior, to mobilize social support, to reinforce adherence to treatment recommendations, and to provide feedback to primary care providers. In Phase II, we will enroll 440 African Africans with NIDDM from primary-care practices in East Baltimore in a randomized, controlled, trial with a 2x2 factorial, parallel-arm design. Participants will be allocated to one of 4 groups for 36 months: 1) Usual medical care, 2) Usual medical care + Enhanced Practice, 3) Usual medical care + Community Outreach, or 4) Usual medical care + Enhanced Practice + Community Outreach. Thus, the trial will determine whether these two interventions, either alone or in combination, can produce and sustain long-term improvements in glycemia (primary end-point), blood pressure, lipids, weight, and in diabetes- related health behaviors. This study will build upon the investigators' extensive work on the epidemiology and prevention of diabetic complications, on randomized trials of behavioral interventions, and on community-outreach programs in the African American population of East Baltimore. Furthermore, this study will provide an empiric basis for multidisciplinary primary-care-based strategies to control the epidemic of diabetic complications among inner- city African Americans.
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