South Asian Americans have higher diabetes prevalence compared with non-Hispanic whites, other Asian groups, and racial/ethnic minority groups. However, there are few culturally and linguistically adapted interventions for diabetes management for this population. Community health worker (CHW) approaches have demonstrated efficacy for diabetes control in African American and Latino populations, but have not been systematically adapted and tested in South Asian communities. Recent efforts to expand electronic health record (EHR) systems across health care delivery organizations and harness that data infrastructure for patient-centered care have underscored the potential of strengthening care coordination teams through CHW integration for underserved populations. However, the upstream determinants of diabetes management are often viewed as outside of the clinical setting and not addressed in the context of care. By bridging community and health care systems, CHWs can help address these determinants. Mechanisms to effectively link primary care systems, CHWs, and community resources can be accelerated through health information technology (HIT) tools. Led by Dr. Nadia Islam, the proposed project leverages a well-established multi-sector and community- engaged collaboration to improve diabetes management among New York City South Asians with diabetes. This project will evaluate the effectiveness and implementation process of a multi-level intervention to support diabetes management for South Asian patients with uncontrolled diabetes. The integrated intervention tackles multiple levels and domains of influence as described in the NIMHD Framework on Minority Health & Health Disparities: 1) EHR-based registry system to identify patients with uncontrolled diabetes; 2) Culturally and linguistically adapted CHW-led intervention designed to improve self-management of diabetes among patients using individual and family-based approaches; 3) Linkage to culturally relevant community-level resources using HIT tools; and 4) CHW-integration into primary care teams.
The specific aims of the project are to: 1) Test the effectiveness of a multi-level diabetes management intervention compared to usual care; and 2) Use a mixed-methods approach to systematically assess the implementation process and delineate factors influencing adoption, fidelity, and maintenance of the intervention within clinical and community settings. Using a stepped wedge design, we will enroll 3,994 South Asian patients with uncontrolled diabetes in 25 primary care practice settings. This study will inform efforts to manage diabetes in a high-risk population. We will also generate a reproducible and sustainable model for use in healthcare and community settings engaging vulnerable populations that can potentially be replicated for the prevention and management of other chronic diseases, including cardiovascular disease and cancer.

National Institute of Health (NIH)
National Institute on Minority Health and Health Disparities (NIMHD)
Specialized Center--Cooperative Agreements (U54)
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Special Emphasis Panel (ZMD1)
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New York University
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