A Randomized-Controlled, Pilot Intervention on Diabetes Prevention and Healthy Lifestyles in the New York City Korean Community
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- Islam, N.S., Zanowiak, J.M., Wyatt, L.C. et al. J Community Health (2013) 38: 1030. doi:10.1007/s10900-013-9711-z
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Asian Americans experience diabetes at a higher rate than non-Hispanic whites. Diabetes prevention programs using lifestyle interventions have been shown to produce beneficial results, yet there have been no culturally-tailored programs for diabetes prevention in the Korean community. We explore the impact and feasibility of a pilot Community Health Worker (CHW) intervention to improve health behaviors and promote diabetes prevention among Korean Americans using a randomized controlled trial. Between 2011 and 2012, a total of 48 Korean Americans at risk for diabetes living in New York City (NYC) participated in the intervention. Participants were allocated to treatment or control groups. A community-based participatory research approach guided development of the intervention, which consisted of 6 workshops held by CHWs on diabetes prevention, nutrition, physical activity, diabetes complications, stress and family support, and access to health care. Changes over 6 months were examined for clinical measurements (weight, BMI, waist circumference, blood pressure, glucose, and cholesterol); health behaviors (physical activity, nutrition, food behaviors, diabetes knowledge, self-efficacy, and mental health); and health access (insurance and self-reported health). In this small pilot study, changes were seen in weight, waist circumference, diastolic blood pressure, physical activity nutrition, diabetes knowledge, and mental health. Qualitative findings provide additional contextual information that inform ways in which CHWs may influence health outcomes. These findings demonstrate that a diabetes prevention program can be successful among a Korean American population in NYC, and important insight is provided for ways that programs can be tailored to meet the needs of vulnerable populations.
KeywordsAsian AmericansKorean AmericansCommunity health workersCommunity-based participatory researchDiabetes prevention
Diabetes, a group of diseases marked by high levels of blood glucose, can lead to serious complications and morbidity. Type 2 diabetes accounts for about 90–95 % of diagnosed diabetes cases. In the United States (US), diabetes affects nearly 26 million people, over 8 % of the population, and 7 million of these cases are undiagnosed . However, diabetes has been shown to be preventable through dietary changes and weight loss, lifestyle changes, and increased physical activity .
Asian Americans experience diabetes at a higher rate than non-Hispanic whites; the Centers for Disease Control and Prevention (CDC) estimates that the risk of diagnosed diabetes from the 2007–2009 National Health and Nutrition Examination Survey (NHANES) was 18 % higher among Asian Americans compared to non-Hispanic white adults; 8.4 % of Asian Americans had diagnosed diabetes compared to 7.1 % of non-Hispanic whites . Prevalence has also been shown to differ by subgroup, with the highest rates among Asian Indians and Filipinos [3–5]. The Agency for Healthcare Research and Quality (AHRQ) reports that the prevalence of diabetes among Korean Americans is higher than the prevalence among whites, although in national research, diabetes rates among Korean Americans often are low or unreported. Recent New York City (NYC) data finds the age-adjusted rate of diagnosed diabetes among Korean Americans to be 10 % . In Korea, the prevalence of diabetes and impaired fasting glucose (IFG) is rising; in the past 30 years, diabetes has increased five-fold to 9–11 % .
Diabetes prevention programs enabling lifestyle changes have been shown to be the most effective method of preventing type 2 diabetes; in addition to lowering the risk of diabetes, these interventions promote additional health benefits and are less costly than drug treatment . The Diabetes Prevention Program (DPP), the largest diabetes prevention program to date, was conducted in a multiethinic US sample; the program found that diet and exercise reduced the incidence of diabetes among individuals with elevated fasting glucose by 58 % over a follow-up period of 2.8 years . Positive results have also been shown in Japan, India, Finland, and China .
While diabetes prevention programs using a lifestyle intervention have reported beneficial results, there have been no culturally-tailored programs to prevent diabetes or promote healthful behavioral changes in the Korean community. However, findings from a randomized-controlled study promoting diabetes management among Korean Americans living in the Baltimore-Washington area support the clinical efficacy of a culturally-tailored diabetes program among Korean Americans with type 2 diabetes .
The purpose of this study is to explore the impact and feasibility of a pilot community health worker (CHW) intervention designed to improve health behaviors and clinical measures related to diabetes prevention among Korean Americans identified as at-risk for diabetes living in NYC. This paper presents the findings from the pilot phase of the Project RICE (Reaching Immigrants through Community Empowerment), an intervention designed to test the efficacy of a CHW program to promote diabetes prevention and healthy lifestyle changes in the Korean population.
Recruitment and Study Design
Individuals were eligible to participate in the intervention if they: (1) self-identified as Korean; (2) were identified as at-risk by an interviewer-administered diabetes risk assessment adapted from the American Diabetes Association diabetes risk test which calculates “at-risk” scores based on family history of diabetes, BMI, and other factors; and were between 18 and 75 years of age . Participants were ineligible if they had confirmed diabetes from a health professional, had serious health problems (e.g. terminal illness), or had participated in a previous cardiovascular disease study. CHWs recruited subjects in-person at various community-based venues, including health fairs and cultural fairs at churches and community settings between May and July 2011. The protocol was approved by the New York University School of Medicine Institutional Review Board.
Project RICE was guided by the the principles of community based participatory research (CBPR), in which stakeholders with various knowledge and expertise partner to understand community concerns and develop action-oriented solutions to address them. A coalition of community partners, researchers, health providers, and CHWs was developed, and coalition members engaged as active and equal partners in the research process. The CHW and staff at the Korean American-serving community-based organization (CBO) were active members of the coalition and a unique source of community knowledge, providing critical input and guidance during all phases of the study.
The intervention was led by a trained, bilingual Korean American CHW and several programmatic staff at the CBO. Six CHW-facilitated 2-hour group sessions were held for the treatment group participants, which included the following topics: diabetes prevention overview, nutrition, physical activity, diabetes complications and other cardiovascular diseases, stress and family support, and access to health care. Sessions were held every 3 weeks in a convenient community setting. Treatment group participants also received follow-up phone calls from the CHW (2 calls after sessions one through five for a total of 10 calls over the 6 month intervention period), during which challenges and strategies for improving diet and physical activity and reducing stress were discussed. All participants received the first educational session, and participants were randomized into treatment and control groups after attending the first session.
Tailored cultural components
Diabetes/diabetes prevention overview
Prevention of diabetes
Myths and Facts about diabetes
Discussion of diabetes prevalence and increased risk of diabetes in Asians
Explanation of BMI and at-risk BMI in Asian communities
Dispelling common cultural misconceptions regarding diabetes
Incorporation of culturally appropriate images and language
Nutrition and Food
Eating a balanced diet
Overcoming barriers- Eating out and in social situations
Reading a Nutrition Label
Goal-setting for healthy eating
Photos of typical Korean foods
Healthy elements in traditional Korean cooking such as whole grain options for rice, noodles, and bread and limiting portions of rice
Identifying and limiting Korean foods high in salt
Fish eaten by Koreans that are high in Omega-3 s
Discussion of traditional Korean practice to eat fruits as an alternative to high fat desserts
Discussion of small plates typical of Korean dining in relation to the Plate Method
Managing cultural expectations for eating in other homes when invited as a guest
Reading food labels in Korean and English
Culturally appropriate images and language
Energy balance between foods and physical activity
Benefits and types of exercise
Incorporating physical activities, such as Yoga and Tai-Chi
Home-based exercise/activities for seniors
List of free community exercise classes
Incorporation of culturally appropriate images and language
Cardiovascular disease and diabetes complications
Heart disease and stroke
Staying motivated and goal-setting
Discussion of blood pressure and salt in diet
Review of Korean foods high in salt and fat and limiting these foods
Incorporation of culturally appropriate images/language
Social support and stress management
Effects of stress on health, diet, smoking, and physical activity
Stress and anger management
Depression effects and management strategies
Progressive muscle relaxation for stress relief
Discussion around guilt related to family members and perceived shortcomings
List of community resources/providers
Incorporation of culturally appropriate images and language
Access to healthcare
Communicating with the doctor
Preparing for a doctor’s visit
Accessing health services
Health access for undocumented immigrants
Patient bill of rights and language access laws
Review of NYC Health and Hospitals Corporation Options Program
Health access resources in Korean
Incorporation of culturally appropriate images and language
The project CHW and support staff participated in a 60-hour core-competency-based training, given over 8 days in a 3-week period in January 2011 . The training focused on comprehensive skills training for CHWs, and was facilitated by two trainers associated with an independent CHW professional association. The project CHW and staff also attended approximately 30 hours of additional trainings on mental health, motivational interviewing, and other related topics.
Data Collection and Measures
Quantitative Data Collection
Study participants completed a baseline survey after consenting to be in the study and follow-up assessments were conducted at 3- and 6-months. Surveys were administered in Korean by a trained interviewer.
Primary outcomes were measured at baseline, 3-months, and 6-months, and included weight, BMI, and hip-to-waist ratio reduction, access to and utilization of care, and knowledge and practice of physical activity and healthful eating.
Demographic questions were adapted from the Census American Community Survey  and the Behavioral Risk Factor Surveillance Survey (BRFSS) . Self-efficacy questions related to exercise, nutrition, and health-related decisions were adapted from the Bandura Self-Efficacy Scale . Questions on diabetes knowledge were adapated from the Diabetes Knowledge Test and risk assessment questions from the American Diabetes Association [20, 21]. Questions on food behaviors such as portion control, preparation/buying, and planning as well as intent to engage in and motivators of physical activity, were adapted from measurement of the behavioral objectives of a weight management intervention . Mental health questions were adapted from the Personal Health Questionnaire (PHQ-2)  and the Generalized Anxiety Disorder Scale (GAD-2) . Measures used on the participant satisfaction survey were based on a review of peer-reviewed literature and were adapted from other studies. All survey questions were developed in English and translated into Korean by bi-lingual study staff. Questions were reviewed by project coalition members for accuracy and cultural appropriateness and culturally relevant examples were integrated.
Qualitative Data Collection
CHWs completed detailed logs during follow-up phone calls with the participants, documenting challenges to healthcare access and engaging in healthy behaviors, as well as a proposed follow-up plan by the CHW. Qualitative interviews were also conducted with the CHWs by an independent evaluator after intervention completion to assess experiences in implementing the program, including barriers and facilitators to recruitment, retention, and diabetes prevention promotion. The lead investigator and the evaluator developed interview questions using a review of relevant literature. In addition, a focus group was facilitated by an independent Korean-speaking evaluator for both active and non-active participants to assess participant satisfaction after the 6-month intervention period.
Quantitative Data Analysis and Sample
Descriptive statistics summarize and compare baseline characteristics of the treatment and control groups for all individuals randomized into the intervention. Group differences were assessed using t-tests for continuous variables and Chi square tests for categorical variables. Changes in outcome variables were reported across baseline and 6-months for all individuals with complete data. For continuous variables, mean change and standard deviation (SD) was reported, and for categorical variables, total n and percent were reported. P-values report within-group significance using paired-sample t-tests of each variable and between-group significance using paired-sample t-tests of the total change across timepoints.
A total of 25 participants were randomized to the treatment group, and 23 were randomized to the control group. Among treatment group participants, 60 % (n = 15) completed at least 4 of the 6 group educational sessions (considered completion of intervention), while 36 % (n = 9) completed all 6 sessions. Results include 21 treatment and 14 control group participants who had complete baseline and follow-up data and completed any part of the intervention. Analyses were conducted using SPSS 19.0.
Qualitative Data Analysis
Notes from the CHW interviews, focus group transcripts, and CHW call logs were reviewed and coded by two authors for themes related to feasibility, acceptability, and changes in outcomes among pilot participants. Narrative analysis techniques were utilized whereby segments of text that relate to themes were identified and core codes and secondary codes were assigned. Relationships between codes within themes were also explored. Discrepancies in coding were resolved by discussion and consensus between the two coders.
Baseline characteristics of participants, mean (SD) or %
Total (N = 48)
Treatment (N = 25)
Control (N = 23)
Born in Korea
Years lived in US
Annual household income
Waist circumference, inches
Blood pressure, mmHg
≥140 mg/dL—at risk
Changes in clinical variables at 6 months, mean (SD)
Treatment (T) group n = 21
Control (C) group n = 14
T v. C
Mean 6 M
Change BL—6 M
Mean 6 M
Change BL—6 M
Waist Circumference, inches
Changes in Self-efficacy and knowledge between baseline and 6 months, mean (SD)
Treatment (T) group n = 21
Control (C) Group n = 14
T vs. C
Change BL—6 M
Change BL—6 M
Changes in health behaviors between baseline and 6 months, n (%)
Treatment n = 21
Control n = 14
Do you do any sustained physical activity for 10 min or more?
Recommended level of physical activity per week
<150 min per week
≥150 min per week
Over the past week, how often do you drink soda or sweet drinks?
<once a week
1–6 Times a week
Once a day or more
Over the past week, how often did you east brown rice?
How often did you eat fruits, instead of desserts or snacks that contain high amounts of sugar?
I do not like how healthier foods taste
Health and access
Individuals in the treatment arm completed questions evaluating the CHW and the program. Overall, responses about the CHW were positive. Participants thought it was most important to have the following in common with their CHWs: language (81 %), culture (74 %), and country of birth (67 %). All believed that the CHW understood their culture and that they could be honest with their CHW. Additionally, 90 % believed that the CHW helped them change their behaviors. The majority of individuals felt that the length and number of the sessions was just right, and the biggest factor preventing individuals from coming to the sessions was work schedule (48 %) followed by family obligations (29 %).
The project CHW shared participants’ cultural backgrounds and language, and leveraged her knowledge of community resources and networks, such as churches and English language programs to increase outreach efforts and study relevance and acceptability. The CHW expressed that “being from the same culture helps overcome resistance,” but more importantly, “being a native Korean speaker is key” to help overcome language barriers for this largely limited English proficient community. Prior to project implementation, some key community informants expressed concern that participants may question a CHW’s role and qualifications to provide health information and lead the intervention compared to a clinician. The CHW, however, did not find this to be true; rather, she believed that “People trusted [her] as the person in charge.” In addition, the CHW’s connection to and training at an academic medical school facilitated trust with participants. Both the CHW and participants spoke about their relationship in warm, familial terms. For example, the CHW expressed “respect” for program participants, many of whom were older adults, and that she tried “to treat them as [her] grandparents.” She referred to participants as “sun seng nim,” a formal term of respect which translates to “teacher” in Korean language. Participants expressed that they felt cared for: “Not even my kids check up on me like that so I was very appreciative of her calling and taking care of me.” In addition, the program was described as “valuable” and “helpful” to the community, creating a sense of duty: “I decided to participate in order to help the Korean community.” Participants were also impressed and grateful that the CDC-funded program demonstrated an interest by the government in promoting the health of Korean communities: “It’s very important. We think that we need to participate more so that the Korean community will receive a lot of interest.”
Qualitative results provided insight into recruitment and retention issues and the organization and implementation of the pilot. Retention was facilitated by trust in the CHW, and assistance provided in accessing resources, such as translation or external linkages to health services and public insurance, both for participants and their friends.
Several challenges to recruitment and retention emerged, including low-turn out at screening events and difficulty scheduling screening events at community churches with busy programmatic schedules; extended travel by participants to Korea during the intervention period; and difficulty scheduling education sessions and data collection meetings. In addition, community members often believed that if they did not have symptoms of diabetes, they did not need to take steps to prevent the disease, particularly if they had insurance and a primary care physician. For example, the CHW provided: “Prevention is not important in the culture… unless they really want to be healthy or unless they have a family member with the disease.” One focus group participant shared: “I haven’t referred back to the hand-outs [given out at each education session] because currently I’m not sick and not diagnosed with anything.” The CHW also acknowledged that some participants may not be intrinsically motivated to attend sessions, but may attend “because they don’t want to let [her] down.” Participants would say: “you work so hard” and “I know it helps you,” demonstrating that motivators to participation may involve unique cultural components of a sense of obligation or guilt. It was also challenging to schedule meetings to collect survey questionnaires and clinical measurements in addition to the six group sessions. Participants with busy schedules and family obligations reported irritation with the length of surveys and sessions, as well as with the number of follow-up phone calls and goal-setting exercises. The CHW also agreed that goal-setting exercises were challenging for participants, who often asked her to assign them goals rather than develop their own personal goals.
In regards to intervention organization and implementation, facilitators included hosting sessions in community locations convenient for participants, during weekends, and offering one-on-one session makeups for participants who were unable to attend group sessions. In addition, participants reported that the sessions were “very detailed and practical” and “useful because [they] could apply to [their] real lives.”
Follow-up phone calls helped to reinforce key health behavior messages from educational sessions, and goal-setting exercises allowed the CHW to provide tailored advice on how to make changes to diet and physical activity. Using information gained from the CHW, participants were empowered to ask more questions of their physicians, request information about test results, and obtain referrals for appointments. Participants also reported that the Korean-language hand-outs on the content of each session were easy to understand and helpful to refer to after the sessions: “I kept forgetting what I have learned but the print-outs was helpful because I could look at them later… I made a note on the print-outs and I could bring them when I needed to ask questions.” Others reported feeling healthier or losing weight. Many reported eating smaller portions of rice and more vegetables during the follow-up calls, and were incorporating more walking into their day-to-day routines.
Overall, Project RICE demonstrated high acceptability and suggested efficacy of a intervention aimed at improving health behaviors to promote diabetes prevention among individuals completing the pilot program. Participants reported positive feedback about the program and about the CHW, particularly regarding the linguistically- and culturally-tailored nature of the program. Moreover, the qualitative findings demonstrate some of the mechanisms through which CHWs can facilitate support by serving as a bridge to the health care system and providing culturally- and linguistically-tailored health education information. Additionally, many participants felt connected to and appreciative of the CHW’s efforts, suggesting that CHWs serve a unique role in health promotion efforts. Both quantitative and qualitative findings demonstrated high appropriateness and acceptability to the target community, indicating that the pilot can be successfully translated into a full intervention.
Positive changes were seen among treatment group participants between baseline and 6 months. Individuals demonstrated a greater knowledge of diabetes, had improved self-efficacy of behaviors to improve their health (e.g. diet and exercise), and showed positive behavior change in terms of diet and exercise. Individuals in the treatment arm also showed lower self-reported health at the 6 month follow-up. This could be related to knowledge gained in the workshops and could be beneficial to changing health behaviors.
These results are consistent with other diabetes prevention and diabetes management pilot studies in Asian and minority communities that have shown improvements in diabetes knowledge, diet and physical activity behaviors, and self-efficacy through education workshops and follow-up support [9, 25, 26]. While between group clinical changes were not significant in the small study sample compared to other studies with much larger samples [9, 25], the changes in clinical measures that approached significance were encouraging.
Challenges and recommendations
Difficulty accessing Korean immigrants due to busy work schedules
Stronger partnerships and outreach to physicians to encourage at risk patient referrals
Misperception that having a regular doctor means do not need program
Better messaging on complementary roles doctors and community health prevention programs play for provision of comprehensive optimal health care
Misperception that if not diabetic or no symptoms, do not need program
Word-of-mouth referrals—ask screening and intervention participants to refer their friends and family members
Lack of understanding regarding who CHWs are and their role in the program
Build in a break after the pilot round to build awareness in the community about the program and need for diabetes prevention—get the word out
Difficulty retaining participants due to work schedules, travel to home country
Hold more community education events on diabetes and diabetes prevention in the Korean community
Work with Korean language media (e.g. newspapers and TV stations) about program and who CHWs are
Develop a promotional video about the program, the role of CHWs and testimonials from participants
Build in more incentives/prizes for retention
Several limitations should also be mentioned. Due to a high attrition rate and loss to follow-up, there was incomplete data from participants who did not complete the pilot, thus quantitative findings are based on a small sample size. However, the sample reported in this paper is similar to or larger than several other diabetes pilot studies [27, 28], and a randomized controlled design is used. The clinical measures indicate modest improvements, suggesting that with a larger sample size there may be more substantial clinical impacts of the program.
Conclusion and Implications
This study is the first to report on the results of a pilot CHW intervention to promote diabetes prevention in the Korean American community of NYC. As such, it fills an important gap in the literature on developing culturally-tailored interventions for underserved minority communities. Study findings indicate that the CHW model is acceptable in this community and helps to promote behavior changes in nutrition and physical activity, important components of diabetes prevention. Another major strength of this study is the use of both qualitative and quantitative methods to assess the feasibility, acceptability, and outcomes of the pilot. Furthermore, few CHW program evaluations have examined the impact of the CHW on participant outcomes. Qualitative findings provide contextual information that may inform efforts to understand the mechanisms by which CHWs potentially influence health outcomes. Finally, in highlighting some of the unique challenges faced by immigrant community members in participating in health promotion projects, the study findings provide important insight into and recommendations for ways that programs can be tailored to meet the needs of minority populations.
The population size of Koreans in the US will continue to increase in coming years. Given the rising rates of diabetes among Koreans living in the US and in Korea, as well as the linguistic and access to care barriers faced by this community, effective and culturally-tailored health care interventions are needed to overcome barriers and provide support for diabetes prevention. The development, implementation, and evaluation of innovative programs that address local ethnic and cultural norms, build upon community assets, and are conducted in community-academic partnerships will provide important information to improve diabetes prevention programs and the health of communities.
This study was supported by Grant 1U48DP001904-01 from the Centers for Disease Control and Prevention, Grants P60MD000538 and MD001786 from the National Institutes of Health, Grant R24MD001786 from the National Insitutes of Health National Institute on Minority Health and Health Disparities, and Grant UL1 TR000038 from the National Center for Advancing Translational Sciences, National Institutes of Health. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the funding organizations. The authors would also like to thank the following individuals for their guidance and support on the project: Mariano J. Rey at the New York University School of Medicine, Sunhi Shin at the New York University Langone Medical Center, Miyong Kim and Hae-Ra Han at Johns Hopkins University School of Nursing, Kim B. Kim at Korean Resource Center, Ashwini Rao at Columbia University Medical Center, Darius Tandon at Johns Hopkins University School of Medicine, Tazuko Shibusawa at the New York University Silver School of Social Work, the Project RICE community health workers Christina Choi and Hyunjae Yim, and the staff at Korean Community Services for their service and dedication in implementing this project.