Design of an e-Learning Program for Type 2 Diabetes Latino Patients in a Rural Area of Indiana, US
Autor: Sarmiento Hernández, Carlos Andrés
Asesor: Vargas Rosero, Elizabeth (Thesis advisor)
Fecha: 2015-12
Programa: Bogotá - Medicina - Especialidad en Anestesiología y Reanimación
Facultad: Facultad de Medicina

Resumen: Abstract  Background: It is important to address diabetes in order to decrease the negative impact  on quality of life and prevent economic and health consequences; additionally, there is an  increasing interest and activities on eHealth to provide education about diabetes. Latino  population has one of the higher diabetes diagnosis rates in the country and in many  cases this population has a poor literacy level. The main question is: is it possible to  create new eHealth resources for low literacy type 2 diabetes Latino patients who obtain  health care in a Family Health Clinic of Indiana?  Objective: To design an e-learning program for type 2 diabetes Latino patients with low  literacy level in one family health clinic of Indiana.  Methodology: The design is an evaluation of a public health program based on the CDC  framework for programs evaluation. Three activities were done: Creation of the e-learning  tool, translation of a web portal from one rural clinic and validation with a group of  patients.  Results: The results are explained through six steps according with the CDC framework:  1) Engage stakeholders 2) Describe the program 3) Focus the Evaluation 4) Gather  credible evidence 5) Justify conclusion and 6) Sharing lessons learned. Three were the  main results: construction of an e-learning curriculum, analysis of existing resources and  results from a pilot study of the e-learning.

Design of an e-Learning Program for
Type 2 Diabetes Latino Patients in a
Rural Area of Indiana, US
Carlos Andrés Sarmiento Hernández
Universidad Nacional de Colombia
Facultad de Enfermería
Bogotá, Colombia
2015Design of an e-Learning Program for
Type 2 Diabetes Latino Patients in a
Rural Area of Indiana, US
Carlos Andrés Sarmiento Hernández
Tesis presentada como requisito parcial para optar al título de:
Enfermero
Tutoras:
Dra Rosibel Prieto Silva
Mg. Elizabeth Vargas Rosero
Intercambio Académico Internacional Universidad Nacional de Colombia-Purdue
University
Universidad Nacional de Colombia
Facultad de Enfermería
Bogotá, Colombia
2015“How very little can be done under the spirit of fear.”
Florence Nightingale, As quoted in The Book of Positive Quotations (2007) by John Cook, p. 479
“Let the future tell the truth and evaluate each one according to his work and
accomplishments. The present is theirs; the future, for which I really worked, is mine.”
Nikola Tesla, as quoted in Tesla, Master of Lightning (1999) by Margaret Cheney, Robert Uth, and Jim Glenn, p. 73Abstract VII
Acknowledgements
To Elizabeth O´Neil, who has been observing and guiding this project during six months,
and taking care at the same time of people who need the hands and the brilliant mind of a
Nurse Practitioner,
To Elizabeth Vargas, who is an excellent communicator and Colombian advisor of this
work. The clarity of her ideas and her interest in establishing new horizons for nursing has
been a source of strength for my activities,
To Vicki Simpson, who is a great leader and also a clear-minded person. Her advices
about how to perform nursing research were a milestone for the methodology of this
research,
To Rosibel Prieto, who dedicated the time and provided new suggestions to the project,
even when she had a short time to do it,
To Denise Schroeder, who teach me about diabetes counseling and nutrition. Her recipes
were part of the success for the accomplishment of our objectives.VIII Título de la tesis o trabajo de investigación
Abstract
Background: It is important to address diabetes in order to decrease the negative impact
on quality of life and prevent economic and health consequences; additionally, there is an
increasing interest and activities on eHealth to provide education about diabetes. Latino
population has one of the higher diabetes diagnosis rates in the country and in many
cases this population has a poor literacy level. The main question is: is it possible to
create new eHealth resources for low literacy type 2 diabetes Latino patients who obtain
health care in a Family Health Clinic of Indiana?
Objective: To design an e-learning program for type 2 diabetes Latino patients with low
literacy level in one family health clinic of Indiana.
Methodology: The design is an evaluation of a public health program based on the CDC
framework for programs evaluation. Three activities were done: Creation of the e-learning
tool, translation of a web portal from one rural clinic and validation with a group of
patients.
Results: The results are explained through six steps according with the CDC framework:
1) Engage stakeholders 2) Describe the program 3) Focus the Evaluation 4) Gather
credible evidence 5) Justify conclusion and 6) Sharing lessons learned. Three were the
main results: construction of an e-learning curriculum, analysis of existing resources and
results from a pilot study of the e-learning.
Keywords: Community Health, Public Health, Nursing, Health promotion and prevention,
vulnerable population.Contents IX
Contents
1. Background ............................................................................................................ 14
1.1 Characteristics of Latino Population ................................................................. 14
1.2 Diabetes ........................................................................................................... 14
1.3 E-learning ......................................................................................................... 15
2. Problem Statement ................................................................................................. 17
2.1 Purpose ............................................................................................................ 17
2.2 Objective .......................................................................................................... 17
2.3 Assumptions and Limitations ............................................................................ 17
3. Conceptual Framework .......................................................................................... 19
3.1 Diabetes: .......................................................................................................... 19
3.2 Diabetes self-management: .............................................................................. 19
3.3 E-learning: ........................................................................................................ 20
3.4 Health Literacy: ................................................................................................ 20
3.5 Latino Population:............................................................................................. 20
4. Literature Review ................................................................................................... 21
4.1 CDC Framework for Program Evaluation ......................................................... 21
4.1.1 Engage Stakeholders:.................................................................................... 21
4.1.2 Describe the program: ................................................................................... 22
4.1.3 Focus the evaluation ...................................................................................... 23
4.1.4 Gather Credible Evidence: ............................................................................. 23
4.1.5 Justify Conclusions: ....................................................................................... 24
4.1.6 Ensure Use of Evaluation Finding and Share Lessons Learned ..................... 24
5. Methodology ........................................................................................................... 25
5.1 Engage Stakeholders ....................................................................................... 25
5.2 Describe the Program ...................................................................................... 26
5.3 Focus the Evaluation ........................................................................................ 28
5.4 Gather Incredible Evidence .............................................................................. 28
5.5 Justify Conclusions ........................................................................................... 29
5.6 Ensure use of Evaluation Findings and Share Lessons Learned ...................... 29
5.7 Ethical aspects of Research ............................................................................. 29
6. Results and Conclusion ......................................................................................... 30
6.1 Engage Stakeholders ....................................................................................... 30
6.2 Describe the Program ...................................................................................... 30
6.3 Focus the Evaluation ........................................................................................ 31
6.4 Gather Incredible Evidence .............................................................................. 32X Design of an e-Learning Program for Type 2 Diabetes Latino Patients in a Rural
Area of Indiana, US
6.4.1 Translation of web portal for patients ..............................................................32
6.4.2 Analysis of existing resources ........................................................................32
6.4.3 Pilot Study with a Group of Patients ...............................................................33
6.5 Justify Conclusions ........................................................................................... 41
6.6 Ensure use of Evaluation Findings and Share Lessons Learned ....................... 42
Appendices .......................................................................................................................43
A. Appendix: Videos & Transcriptions ....................................................................... 43
B. Informed Consent ................................................................................................. 55
C. Appendix: Questionnaires for Patients Evaluation ................................................ 56
D. Appendix: Webpages found with diabetes prevention materials ............................ 62
References .....................................................................................................................65Contents XI
List of Figures
Figure 5-1 Logic Model proposed for the program .......................................................... 27
Figure 6-1 Audiovisual and written resources found (n=41) ............................................ 32
Figure 6-2 Web Sites Topics According with Self-management Areas (n=41) ................ 33XII Design of an e-Learning Program for Type 2 Diabetes Latino Patients in a Rural
Area of Indiana, US
List of Tables
Table 5-1 Components of the E-learning program ........................................................... 26
Table 5-2 Focused evaluation components ..................................................................... 28
Table 5-3 Indicators of Evidence ..................................................................................... 28
Table 6-1 DSME chosen areas ....................................................................................... 31
Table 6-2 Number of answers for each questionnaire ..................................................... 34
Table 6-3 Descriptive Analysis for Questionnaire 1 ......................................................... 35
Table 6-4 Kolmogorov-Smirnov Normality Test for Questionnaire 1 ................................ 35
Table 6-5 Paired Samples t-test for Questionnaire 1 ....................................................... 35
Table 6-6 Descriptive Analysis for Questionnaire 2 ......................................................... 36
Table 6-7 Kolmogorov-Smirnov Normality Test for Questionnaire 2 ................................ 36
Table 6-8 Descriptive Analysis for Questionnaire 3 ......................................................... 37
Table 6-9 Kolmogorov-Smirnov Normality Test for Questionnaire 3 ................................ 37
Table 6-10 Paired Samples t-test for Questionnaire 3 ..................................................... 37
Table 6-11 Descriptive Analysis for Questionnaire 4 ....................................................... 38
Table 6-12 Kolmogorov-Smirnov Normality Test for Questionnaire 4 .............................. 38
Table 6-13 Paired Samples t-test for Questionnaire 4 ..................................................... 38
Table 6-14 Descriptive Analysis for Questionnaire 5 ....................................................... 39
Table 6-15 Kolmogorov-Smirnov Normality Test for Questionnaire 5 .............................. 39
Table 6-16 Descriptive Analysis for Questionnaire 6 ....................................................... 40
Table 6-17 Kolmogorov-Smirnov Normality Test for Questionnaire 6 .............................. 40
Table 6-18 Paired Samples t-test for Questionnaire 6 ..................................................... 40
Table 6-19 t-test Results for each Questionnaire ............................................................ 41Introduction
The present research project has been done in the framework of an Undergraduate
Research Experience between Universidad Nacional de Colombia and Purdue University.
It has been coordinated by these both public organizations with the main objective of
growing the research spirit in the Colombian Students and increasing the opportunities for
them (for us) to get a post-graduate degree abroad. Nevertheless, in my own basis, this
has been also the opportunity to rediscover myself, to test my skills, my abilities, my
knowledge, and most that all, my own values as a Colombian citizen.
The project has been designed as a Public Health program evaluation, which means that
at the same time that the project was being developed, the researcher (me) was
performing an evaluation of each component of the program. Apparently, externally, this
project may look as just one small step for research, but it has been the biggest leap for
the author.
Finally, but not less important, is the socio-political calling that makes part of this project:
It is time for this world, for the science, for the technology, for the arts and for the
healthcare to turn the eyes to those who have suffered the indifference of the system, any
system, during many years.
Carlos Andrés Sarmiento Hernández
West Lafayette, Indiana-USA
December 1st of 201514 Design of a Health Education Program for Type 2 Diabetes Latino Patients in a rural
area of Indiana, US
1. Background
1.1 Characteristics of Latino Population
There are three important topics to be addressed. The first one are the characteristics of
Latino population in United States of America and in the state of Indiana. Currently,
Latino-Hispanic group represents 17.4 % of the total United States population (U.S.
Census Bureau, 2014; Colby & Ortman, 2014). It is estimated that in 2060, this group will
represent 28.6 % of the total country population (Colby & Ortman, 2014). With regard to
the state of Indiana, those of Latino ethnicity represent 6.2 % of this population, which
equates to 6,514,861 people (U.S. Census Bureau, 2014). It should be noted that in this
state, 72.4 % of the population live in urban areas, while 27.55 % of people live in rural
zones. Regarding the age, the mean age of Latino population is 23.5 years, with 57% of
people being between 18-64 years old and 3.3 % being over 65 years (U.S. Census
Bureaub, 2014).
1.2 Diabetes
The second important topic is Diabetes. This is a chronic disease that is affecting the life
quality and health around the United States and the world (WHO, 2014). According to the
National Health Interview Survey (2014), 8.6 % (21,319.000 of people) of adults aged 18
and over in the United States had ever been told by a health professional that they had
diabetes. In terms of ethnicity, 12.2% of the Latino population were told they haveBackground 15
diabetes, compared with 7.3% of those who report as white and single and 13.2% of black
or African American and single population. During their lifetime, half of the Hispanic/Latino
population are predicted to develop diabetes type 2 at some point of their lives (CDC,
2014).
Physical activity and exercise has been pointed as one of the most important
interventions to prevent Diabetes and complications of the disease. Regarding physical
activity levels, it has been found that latino adults (16%) are less likely to met the
guidelines for aerobic and muscle-strengthening activity than non-hispanic white adults
(Blackwell & Clarke, 2014).
1.3 E-learning
In relation to e-health and e-learning, Hardiker & Grant conducted a literature review in
2011 about factors that may influence engagement by the public with e-Health services.
They found that non-white population is less likely to use internet and that higher level of
education and literacy are associated with higher levels of Internet use (Hardiker & Grant,
2011). Based on these results, one of the recommendations of the study is to target
efforts to improve computer and internet access towards those who are underserved due
to age, ethinicity, education, etc. (Hardiker & Grant, 2011).
According to the Pew Research Center survey about Latinos and Technology Adoption,
three key demographic characteristics are correlated with technology adoption among
Latino population: age, educational attainment and annual family income (Lopez,
Gonzalez & Patten, 2013). Regarding smartphone or computer ownership, rates are
lowest among Hispanics ages 65 and older; the highest smartphone or computer
ownership rates are among Hispanics from families with annual incomes of $50,000 or
more. The educational attainment of those who are more likely to own a smartphone or
computer is High School and College (Lopez et al, 2013). These trends show that Latino
population who is older, have low incomes and low educational levels are not adopting
technology as fast as the rest of Latinos.16 Design of a Health Education Program for Type 2 Diabetes Latino Patients in a rural
area of Indiana, US
The adoption of technology allows people who live with Diabetes to find information about
their disease and actions that can be made to prevent complications. Also, Internet
resources help to take decisions about behavior changes for those who live with Diabetes
and need to improve their levels of exercise or change the type of diet they have
(Haddad, 2013).2. Problem Statement
As has been noted, it is important to address diabetes in order to decrease the negative
impact on quality of life and prevent economic and health consequences; Aditionally,
there is an increasing interest and activities on eHealth to provide education about
diabetes (U.S. Department of Health and Human Services [HHS], 2015; HHSb ,2015).
The Latino population has one of the higher diabetes diagnosis rates in the country and in
many cases this population has a poor literacy level (Kutner, Greenberg & Paulsen,
2006). The main question is: is it possible to create new eHealth resources for low literacy
type 2 diabetes Latino patients who obtain health care in a Family Health Clinic of
Indiana?
2.1 Purpose
To make more efficient and acceptable the health care provided to low literacy type 2
Diabetes Latino patients who obtain health care in the Family Health Clinic of Monon.
2.2 Objective
To design an e-learning kit for type 2 diabetes Latino patients with low literacy level in one
family health clinic of Indiana.
2.3 Assumptions and Limitations
- It is possible to design an e-learning kit for diabetic patients with low literacy level.18 Design of a Health Education Program for Type 2 Diabetes Latino Patients in a rural
area of Indiana, US
- E-learning access will improve diabetes self-management of low literacy Diabetes type 2
Latino patients.
- Time period: Six months is a short period of time to design and implement the e-learning
kit.3. Conceptual Framework
The following concepts are important definitions for the research:
3.1 Diabetes:
Diabetes is a metabolic disorder with multiple causes, characterized by chronic
hyperglicemia (elevated blood-glucose in the organism) with effects in the metabolism of
carbohydrates, fats and protein, as a result of inadequate insulin production or action
(WHO, 2013)
3.2 Diabetes self-management:
According with the National Standars for Diabetes Self-management education (Funnell,
Bronw et al, 2011), “Diabetes self-management education (DSME) is the ongoing process
of facilitating the knowledge, skill, and ability necessary for diabetes self-care. This
process incorporates the needs, goals, and life experiences of the person with diabetes
and is guided by evidence-based standards.” The purpose of diabetes self-management
is to support:
Informed decision-making,
Self-care behaviors,
Problem-solving
Active collaboration with the health care team
All the activities that are addressed to improve diabetes self-management are expected to
improve clinical outcomes, health status, and quality of life for the people (Funnell et al,
2011).20 Design of a Health Education Program for Type 2 Diabetes Latino Patients in a rural
area of Indiana, US
3.3 E-learning:
The CDC e-learning group provides the following definition of e-health: “instruction
accessed through computerized electronic technologies, such as the Internet, intranet,
compact disc, mobile devices, or other digital media” (CDC, 2014). In the context of this
study, e-learning is a method used to facilitate self-management education with Diabetes
type 2 Latino patients.
3.4 Health Literacy:
As defined by the American Medical Association, Health literacy is “a constellation of
skills, including the ability to perform basic reading and numerical tasks required to
function in the healthcare environment. Patients with adequate health literacy can read,
understand, and act on health care information” (Ad Hoc Committee on Health Literacy for
the Council on Scientific Affairs, American Medical Association, 1999).
Health literacy is a barrier and also a problem to deal with in this project. That is because
the potential users of the e-learning kit are people who ha low literacy level. This means
that they experience difficulty to understand medical and health terminology, and at the
end, acting on the information that they nurses provide about diabetes.
3.5 Latino Population:
The term Latino refers to the people who come from countries located in Central/South
America. For the design of the e-learning kit, the language used is Spanish.4. Literature Review
4.1 CDC Framework for Program Evaluation
The CDC framework for program evaluation in public health is a model which was
developed in 1999, with the objective of summarizing and organizing the elements of
program evaluation (CDC, 2011). According to the CDC framework, a program evaluation
is a systematic collection of information about the activities, characteristics, and outcomes
of programs to make judgments about the program, improve program effectiveness,
and/or inform decisions about future program development (CDC, 2011). The CDC
Framework is composed by six steps, which are:
1. Engage stakeholders
2. Describe the Program
3. Focus the Evaluation
4. Gather credible Evidence
5. Justify conclusions
6. Ensure use of evaluation findings and share lessons learned
It is also based on the following four standards: utility, feasibility, propriety and accuracy.
4.1.1 Engage Stakeholders:
This stage is used to identify, involve and ensure participation of stakeholders who are
interested in the program and the results. Stakeholders can be of three types: Those
involved in program operations, those who are directly affected and those who are users
of the evaluation results. Stakeholders are important because they can increase22 Design of a Health Education Program for Type 2 Diabetes Latino Patients
in a rural area of Indiana, US
credibility, implement interventions, authorize or fund the continuation or expansion of the
program.
4.1.2 Describe the program:
The objective in this step is creating a complete description of the program and how it
functions. In this stage, the CDC Guidelines recommends the use of a logic modeling tool
(CDC, 2011) to depict the complete program. The components of the logic modeling tool
are:
Need: Definition of the public health problem that the program aims to address.
Targets: Determine which population groups or organizations have the need.
Outcomes: The change expected to occur in the population. These can be defined in
terms of time: short-term, middle-term or long-term outcomes.
Activities: The specific actions that the program and its staff do in order to achieve the
outcomes/objectives.
Outputs: Refers to tangible products or capacities, not necessarily related to changes
(outcomes). An example of this is the total amount of hours given in a teaching
intervention.
Resources/Inputs: Resources that comes from the larger environment and are needed
for the program function.
Relationship of Activities and Outcomes: The possible effect of the activities on the
achievement of outcomes.
Stage of Development: Refers to where the program stage is: planning, implementation
or it has already developed for a long time.Methodology 23
Context: Consideration of factors from the environment that influence the program
performance.
4.1.3 Focus the evaluation
This stage includes determining the appropriate design for the evaluation. According to
the CDC framework, evaluation is considered as “an ongoing activity over the life of a
program that asks, Is the program working?” (CDC, 2011) This stage includes:
Define purpose and users of the evaluation
Determine components of the logic model that should be part of the focus
Review the design options (Experimental, quasi-experimental and observational)
4.1.4 Gather Credible Evidence:
Gathering evidence refers to the obtainment of data, like a research or data-oriented
project. This Step includes the following components
Indicator: In this component, the CDC recommends to develop own or draw on existing
indicators developed by others.
Sources of evidence/methods of data collection: In data collection it is possible to find
primary and secondary sources of data. Mixed-methods approach to data collection
should be considered. The most common primary data collection methods are:
- Surveys, including personal interviews, telephone interviews, and instruments
completed by respondent, received through the mail or e-mail
- Group discussions/focus groups
- Observation
- Document review, such as medical records, but also diaries, logs, minutes of
meetings, etc.24 Design of a Health Education Program for Type 2 Diabetes Latino Patients
in a rural area of Indiana, US
Quality and Quantity of data
Logistic: Here, the CDC recommends developing a detailed protocol for data collection.
4.1.5 Justify Conclusions:
This step encompasses analyzing the evidence, making claims about the program based
on the analysis, and justifying the claims by comparing the evidence against stakeholder
values.
Data analysis is the process of organizing and classifying the collected information,
tabulating it, summarizing it, comparing the results with other appropriate information, and
presenting the results in an easily understandable manner.
4.1.6 Ensure Use of Evaluation Finding and Share Lessons
Learned
The purpose in this final stage is using the information to improve programs. The
evaluation results can be used to demonstrate the effectiveness of a program, identify
ways to improve it, modify program planning, demonstrate accountability, and justify
funding. Finally, an evaluation program must considers the limitations of the evaluation:
Possible biases, validity and reliability of resultsMethodology 25
5. Methodology
The design is an evaluation of a public health program based on the CDC framework for
programs evaluation. The following are the proposed actions for every stage of the
program:
5.1 Engage Stakeholders
For this stage, several meetings were planned with people/organizations involved in the
attention of Latino population. The organizations involved the following:
Family Health Clinic of Monon
Staff: Advance Practitioner Nurses from the Clinic.
Purdue University Human and Health Sciences Extension
Staff: Diabetes educators from Purdue extension in White County.26 Design of a Health Education Program for Type 2 Diabetes Latino Patients
in a rural area of Indiana, US
5.2 Describe the Program
The following are the components of the program
Table 5-1 Components of the E-learning program
 Addressing Diabetes self-management in Latino patients with low
literacy level.
Need
 Provide a tool for Health Care providers and extension educators
who work with Latino people living with Diabetes.
 Latino patients with diagnosed diabetes type 2 and their families
Target Groups  Providers
 Extension educators
Short term:
 Providers receiving e-learning tool completed.
Medium term:
 Providers using e-learning tool.
Outcomes  Patients and families using e-learning
 Improvement in self-management outcomes: knowledge, skills
and abilities.
Long term:
 Decrease in diabetes complications for the selected population
 Creation of the e-learning tool
 Translation of a web portal from one rural clinic in Indiana in
Activities
order to make the e-learning available through internet.
 Validation with a group of patients.
 Web page translated in a Spanish version
Outputs
 E-learning tool based in evidence
Official diabetes educational resources from:
 The Center for Disease Control and Prevention (CDC),
Resources
 the National Diabetes Education Program (NDEP)
/Inputs  The American Diabetes Association (ADA)
 The National Diabetes Prevention Program (NDPP)
 The International working group for the diabetic foot (IWGDF).
Stage of
Planning
Development
Aditionally, a logic model (also called conceptual map or program hypothesis) has been
designed for the program (Figure 5-1).Figure 5-1 Logic Model proposed for the program5.3 Focus the Evaluation
In this evaluation, the design is observational and descriptive. The purpose of the
evaluation is collect information about the process of designing the e-learning program.
The final users of the evaluation results are the stakeholders interested in using the e-
learning tool with Latino patients (providers or diabetes educators).
The components of the logic model (Figure 5-1) part of the focused evaluation are shown
in Table 5-2:
Table 5-2 Focused evaluation components
Stage Logic Model Components
 Elaboration of e-learning tool
 Translation of web portal for patients
Activities
 Validation with potential users
 Analysis of existing resources
 Curriculum of e-learning program.
Outcomes
 Providers receive e-learning program.
5.4 Gather Incredible Evidence
The indicators proposed for the program are shown in Table 5-3
Table 5-3 Indicators of Evidence
Indicators Data collection Method/Sources
Web portal will be translated in a
 Document of translation
Spanish version.
Analysis of existing resources for  Matrix of web resources analyzed
diabetic patients will be performed  Analysis of data
 Videos
E-learning videos for patients will
 Transcripts with references
be completed
 Curriculum of the programMethodology 29
 Number of people participating
 Surveys (See Appendix C)
A pilot inquiry with patients will be
 Improvement in knowledge and skills level
realized
(self-management) through Statistical
Analysis.
 Number of providers who receive the e-
Providers will receive the e-
learning tool
learning tool
 Report delivered to the clinic
5.5 Justify Conclusions
In this part of the program evaluation process, the obtained results of the program
between the months of June-November 2015 were compared with results of previous
projects that have been found through journal publications.
5.6 Ensure use of Evaluation Findings and Share
Lessons Learned
For this stage, it is expected to present the results of the program evaluation in a
symposium with participants from Purdue University and Universidad Nacional de
Colombia on December 8th 2015. A complete report will be delivered to the Family Health
Clinic of Monon and Purdue School of Nursing.
5.7 Ethical aspects of Research
The main ethical aspects of the research are driven by the Health Insurance Portability
and Accountability act (HIPAA). According with this normative, human subjects research
disclosures require approval by the IRB and signed informed consent (authorization from
individuals). Researcher must obtain an HIPAA/IRB authorization prior to receiving any
protected health information. In order to accomplish with ethical issues, an informed
consent was delivered to the participants of session groups for6. Results and Conclusion
6.1 Engage Stakeholders
Several meetings were held with Advance Practitioner Nurses from the Family Health
Clinic of Monon, IN and Diabetes extension educators from White county, IN. During
these encounters the stakeholders specify several issues related to Health education with
diabetes population:
- Existence of many patients who come from Latin America or are Spanish-
speakers and live in rural areas of Indiana.
- A high prevalence of diabetes among this population.
- Poor Latino community involvement with health prevention programs, due to
language and cultural barriers.
- Difficulty from part of Latino population to mobilize from their homes/workplaces to
places to receive education about self-management.
These issues provided a starting point to formulate a program directed to Latino
population about diabetes self-management.
6.2 Describe the Program
For a detailed description of objectives, needs, activities and outcomes, please go over
Table 5-1. In this chapter, the curriculum of the program will be described.Results and Conclusion 31
The curriculum was developed according with the National Standards for Diabetes Self-
management education (Funnell et al, 2011). The areas that were considered for the
project are presented in Table 6-1.
Table 6-1 DSME chosen areas
E-learning video (See appendix B for
DSME areas (Pubmed 3)
transcriptions)
1. Describing the diabetes disease Animated video 1
process and treatment options (See appendix B.1)
Animated video 5
2. Incorporating nutritional management
Animated video 7
into lifestyle.
(See appendix B.5 and B.7)
3. Incorporating physical activity into Animated video 6
lifestyle. (See appendix B.6)
4. Monitoring blood glucose and other
Animated video 2
parameters and interpreting and using
Animated video 4
the results for self-management
(See appendix B.2 and B.4)
decision making.
5. Preventing detecting, and treating Animated video 3
chronic complications (See appendix B.3)
6.3 Focus the Evaluation
As shown in Table 5-2, the evaluation is focused in the following components:
- Translation of web portal for patients
- Analysis of existing resources
- Curriculum of e-learning program.
- Validation with potential users
- Providers receive e-learning program.32 Design of a Health Education Program for Type 2 Diabetes Latino Patients
in a rural area of Indiana, US
6.4 Gather Incredible Evidence
6.4.1 Translation of web portal for patients
As a possible resource to enhance the communication between the patients and the
providers at the Family Health Clinic (FHC), having the web portal of the clinic in a
Spanish version was considered as useful. In order to have this done, the original web
portal in English was translated and the translation was delivered to the Nurse in charge
of the web design and maintenance. The Spanish translation is available in Appendix A.
6.4.2 Analysis of existing resources
An analysis of online resources available for diabetes education was performed. 41 (forty
one) different webpages from organizations related with diabetes prevention were found
on the internet (See Appendix D). From the total web pages, 12 % (n=5) were found to
have audiovisual materials (Figure 6-1). An analysis of the self-management areas
showed that the main topics addressed through the webpages resources are behavior
change (n=42) followed by nutrition (n=43) and exercise (n=29). In Spanish language, the
main resources available were about nutrition (n=14), followed by behavior change (n=14)
and exercise (n=17).
Figure 6-1 Audiovisual and written resources found (n=41)
Audiovisual
Written
Audiovisual (English)
materials
32%
56% 44%
Audiovisual
(Spanish)
12%Results and Conclusion 33
Figure 6-2 Web Sites Topics According with Self-management Areas (n=41)
50
45
40
35 17 14
30
25
10
20
9
15 4
28
26 7 Spanish
10 6 19
4 English
13 13
5 9
7 6
0
Area of Self-management learning
6.4.3 Pilot Study with a Group of Patients
In order to establish the effectiveness and the feasibility of using the e-learning tool as an
educational resource for Latino people living with diabetes, a pilot inquiry was made
between October-November 2015. With the help of the Diabetes Extension Educator from
White County, four group sessions were organized.
 Participants
People living with diabetes and their families were invited to participate in group sessions
in on Family Health Clinic of Purdue University School of Nursing.
 Method and data analysis
In each session, the videos of the e-learning tool were showed to the participants and the
knowledge acquired for the patients was assessed using a pre-test and post-test34 Design of a Health Education Program for Type 2 Diabetes Latino Patients
in a rural area of Indiana, US
questionnaire for each video (See appendix C). Each questionnaire was composed by
four questions related to the video thematic. The responses for each questionnaire were
rated from 0 to 4 according with the right answers. The data was analyzed after using
SPSS 23 licensed for use by iTap services in Purdue University.
The data obtained was analyzed for normality distribution using the Kolmogorov-Smirnov
test. For the normal distributions, a dependent t-test was performed to establish if there
was any statistically significant improvement in self-management knowledge after of using
the e-learning tool. The hypothesis, in this case, was the following:
H = µ (Post-test value) ≤ µ (Pre-test value)
0 2 1
H = µ (Post-test value) > µ (Pre-test value)
1 2 1
 Results
15 participants participated in the sessions; nevertheless, different people participated in
each session (see table 6-2). 46.7% of the participants were man and 53.3% were
women. The mean age of the participants was 38.73 (SD= 15.04; range 13-55 years).
Table 6-2 Number of answers for each questionnaire
Number of
Questionnaire
participants
Questionnaire 1 6
Questionnaire 2 5
Questionnaire 3 5
Questionnaire 4 7
Questionnaire 5 7
Questionnaire 6 8
Questionnaire 1: Diabetes Concept
For the first questionnaire, the mean average of the scores obtained was 1.67 (SD=
1.966) in the pretest (PRE01) and 3 (SD= 1.673) for the posttest (POS01) (See Table 6-Results and Conclusion 35
3). The Kolmogorov-Smirnov significance value was 0.94, which means that this data was
normally distributed (See Table 6-4).
Table 6-3 Descriptive Analysis for Questionnaire 1
N Minimum Maximum Mean Std. Deviation
PRE01 6 0 4 1.67 1.966
POS01 6 0 4 3.00 1.673
N 6
Data analyzed with SPSS Statistics V.23.0.0
Table 6-4 Kolmogorov-Smirnov Normality Test for Questionnaire 1
Statistic df Sig.
PRE01a
.302 6 .094
a. Lilliefors Significance Correction. Data analyzed with SPSS Statistics V.23.0.0
Given the normality of the distribution, the t test for paired samples was applied (see
Table 6-5). The t value obtained was t=2.000 (p value=0.102). With this result, H is
0
retained (H = µ ≤ µ ).
0 2 1
Table 6-5 Paired Samples t-test for Questionnaire 1
Paired Differences
Sig.
95% Confidence Interval
t df
PRE01 - Std. Std. Error of the Difference
Mean (2-tailed)
POS01 Deviation Mean
Lower Upper
-1.333 1.633 .667 -3.047 .380 -2.000 5 .102
Data analyzed with SPSS Statistics V.23.0.036 Design of a Health Education Program for Type 2 Diabetes Latino Patients
in a rural area of Indiana, US
Questionnaire 2: Important measurements
For the second questionnaire, the mean average of the scores obtained was 0.20 (SD=
0.447) in the pretest (PRE02) and 2.6 (SD= 0.548) for the posttest (POS02) (See Table 6-
6). The Kolmogorov-Smirnov significance value was 0.001, which means that this data is
not normally distributed (See Table 6-7).
Table 6-6 Descriptive Analysis for Questionnaire 2
N Minimum Maximum Mean Std. Deviation
PRE02 5 0 1 .20 .447
POS02 5 2 3 2.60 .548
N 5
Data analyzed with SPSS Statistics V.23.0.0
Table 6-7 Kolmogorov-Smirnov Normality Test for Questionnaire 2
Statistic df Sig.
PRE02a
.473 5 .001
a. Lilliefors Significance Correction. Data analyzed with SPSS Statistics V.23.0.0
In this case, the data did not show a normal distribution; therefore, any statistical test was
applied.
Questionnaire 3: Plate Method
For the third questionnaire, the mean average of the scores obtained was 3 (SD= 0.447)
for the pretest (PRE03) and 4 (SD= 0.00) for the posttest (POS03) (See Table 6-8). The
Kolmogorov-Smirnov significance value was 0.161, which means that this data is normally
distributed (See Table 6-9).Results and Conclusion 37
Table 6-8 Descriptive Analysis for Questionnaire 3
N Minimum Maximum Mean Std. Deviation
PRE03 5 2 4 3.00 .707
POS03 5 4 4 4.00 .000
N 5
Data analyzed with SPSS Statistics V.23.0.0
Table 6-9 Kolmogorov-Smirnov Normality Test for Questionnaire 3
Statistic df Sig.
PRE03a
.300 5 .161
a. Lilliefors Significance Correction. Data analyzed with SPSS Statistics V.23.0.0
Given the normality of the distribution, the t test for paired samples was applied. The t
value obtained was t=3.162 (p value=0.034). With this result, H is rejected (H = µ ≤ µ ).
0 0 2 1
See Table 6-11 for more information.
Table 6-10 Paired Samples t-test for Questionnaire 3
Paired Differences
Sig.
95% Confidence Interval
t df
PRE03 - of the Difference
(2-tailed)
POS03 Std. Std. Error
Mean Deviation Mean Lower Upper
-1.000 .707 .316 -1.878 -.122 -3.162 4 .034
Data analyzed with SPSS Statistics V.23.0.0
Questionnaire Four: Foot Care
For the fourth questionnaire, the mean average of the scores obtained was 3 (SD= 0.447)
for the pretest (PRE04) and 4 (SD= 0.00) for the posttest (POS04) (See Table 6-11). The38 Design of a Health Education Program for Type 2 Diabetes Latino Patients
in a rural area of Indiana, US
Kolmogorov-Smirnov significance value was 0.161, which means that this data is normally
distributed (See Table 6-12).
Table 6-11 Descriptive Analysis for Questionnaire 4
N Minimum Maximum Mean Std. Deviation
PRE04 7 2 4 2.86 .900
POS04 7 4 4 4.00 .000
N 7
Data analyzed with SPSS Statistics V.23.0.0
Table 6-12 Kolmogorov-Smirnov Normality Test for Questionnaire 4
Statistic df Sig.
PRE04a
.258 7 .818
a. Lilliefors Significance Correction. Data analyzed with SPSS Statistics V.23.0.0
Given the normality of the distribution, the t test for paired samples was applied. The t
value obtained was t=3.162 (p value=0.034). With this result, H is rejected (H = µ ≤ µ ).
0 0 2 1
See Table 6-13 for more information
Table 6-13 Paired Samples t-test for Questionnaire 4
Paired Differences
Sig.
95% Confidence Interval
t df
of the Difference
(2-tailed)
Std. Std. Error
Mean Deviation Mean Lower Upper
PRE04 -
-1.143 .900 .340 -1.975 -.311 -3.361 6 .015
POS04
Data analyzed with SPSS Statistics V.23.0.0Results and Conclusion 39
Questionnaire Five: Exercise recommendations
For the fifth questionnaire, the mean average of the scores obtained was 3.43 (SD=
0.787) for the pretest (PRE05) and 4 (SD= 0.00) for the posttest (POS05) (See Table 6-
14). The Kolmogorov-Smirnov significance value was 0.015, which means that the
variable is not-normally distributed (See Table 6-15).
Table 6-14 Descriptive Analysis for Questionnaire 5
N Minimum Maximum Mean Std. Deviation
PRE05 7 2 4 3.43 .787
POS05 7 4 4 4.00 .000
N 7
Data analyzed with SPSS Statistics V.23.0.0
Table 6-15 Kolmogorov-Smirnov Normality Test for Questionnaire 5
Statistic df Sig.
PRE05a
.338 7 .015
a. Lilliefors Significance Correction. Data analyzed with SPSS Statistics V.23.0.0
Given the non-parametric distribution of the variable, any statistical test was applied.
Questionnaire Six: Nutritional Facts
For the sixth questionnaire, the mean average of the scores obtained was 3.43 (SD=
0.787) for the pretest (PRE06) and 4 (SD= 0.00) for the posttest (POS06) (See Table 6-
15). The Kolmogorov-Smirnov significance value was 0.246, which means that the
variable is normally distributed (See Table 6-17).40 Design of a Health Education Program for Type 2 Diabetes Latino Patients
in a rural area of Indiana, US
Table 6-16 Descriptive Analysis for Questionnaire 6
N Minimum Maximum Mean Std. Deviation
PRE06 8 0 4 2.25 1.165
POS06 8 3 4 3.75 .463
N 8
Data analyzed with SPSS Statistics V.23.0.0
Table 6-17 Kolmogorov-Smirnov Normality Test for Questionnaire 6
Statistic df Sig.
PRE06a
.290 8 .246
a. Lilliefors Significance Correction. Data analyzed with SPSS Statistics V.23.0.0
Given the normality of the distribution, the t test for paired samples was applied. The t
value was t=3.24 (p value=0.014). With this result, H was rejected. See Table 6-18 for
0
more information.
Table 6-18 Paired Samples t-test for Questionnaire 6
Paired Differences
Sig.
95% Confidence Interval
t df
of the Difference
(2-tailed)
Std. Std. Error
Mean Deviation Mean Lower Upper
PRE06 -
-1.500 1.309 .463 -2.595 -.405 -3.240 7 .014
POS06
Data analyzed with SPSS Statistics V.23.0.0
The results suggest that the mean of the questionnaires response was significantly higher
after of the intervention with the participants using the videos about plate method, foot
care and nutritional facts. For the questionnaires 1, 2 and 5 (diabetes concept, important
measurements and exercise recommendations) no significant difference was found afterResults and Conclusion 41
of using the intervention. It is possible that the small size of the sample resulted in an
inadequate statistical taste.
Table 6-19 t-test Results for each Questionnaire
Pretest Posttest
Questionnaire t p
Mean SD Mean SD
Diabetes concept 1.67 1.97 3 1.67 2 .102
Important measurements (Daily
glucose, HA1C, arterial 0.2 0.45 2.6 0.548 - -
pressure and lipid-cholesterol)
Plate method 3 0.7 4 0.00 3.16* .034
Foot care 2.86 0.9 4 0.00 3.36* 0.015
Exercise Recommendations 3.43 0.79 4 0.00 - -
Nutritional Facts 2.25 1.16 3.75 0.46 3.24* 0.14
*p<0.05
6.5 Justify Conclusions
The educational resources available on the web are written in the English language most
of the time, and even if a person has an adequate literacy level, it can be very tough to
understand some of the indications and advices provided (e.g. calorie/carbs counting,
portions and serving sizes). Even when these webpages have developed videos and
interactive resources, they are available mostly in English, and as a consequence this can
create an access barrier for Latino people with diabetes.
Regarding the e-learning program, through the pilot study statistically significant changes
were found in the knowledge level before and after of participating in the program.
Nevertheless, given the sample size and the methodology applied (which can lead to II
type error) the results are not conclusive and further evaluation is required in order to
establish a more evident effectiveness of the program.42 Design of a Health Education Program for Type 2 Diabetes Latino Patients
in a rural area of Indiana, US
6.6 Ensure use of Evaluation Findings and Share
Lessons Learned
The results of the project have been shared in academic events in both Universities. As a
possible guidance for future evaluations involving the use of the program, the indicators
proposed in Table 6-20 are examples of what can be done in the future. Of course, future
evaluations of the program depend mainly on how much the program is being used by the
providers and educators.
Table 6-20 Future Indicators for Program Evaluation
Component Indicator
-Development of tool: Translation of ongoing portal and
construction-adaptation of teaching material
Structure:
-Collection of data: Sociodemographic data and interests of patients
involved.
-Get patients involved with the portal
-Hours of use, Assessments of patient learning (Quantitative),
Process: feedbacks (quantitative).
-Collection of qualitative data, feelings about the process of being
diagnosed and deal with DM
- Socio demographic data of users
- Levels of use (At moment of being registered and 2-3 months
after)
- Levels of knowledge (At moment of being registered and 2-3
Outcomes: months after)
- Measures of: Ha1C, weight, BMI, Cholesterol (At moment of being
registered and 2-3 months after)
- Physical Activity (At moment of being registered and 2-3 months
after)Appendices
A. Appendix: Videos & Transcriptions
1. Diabetes concept
¿Qué es la diabetes tipo 2?
La diabetes tipo 2 (a veces llamada “diabetes mellitus” tipo 2) es una enfermedad que
afecta la forma en que tu organismo usa el azúcar.
El cuerpo necesita azúcar para funcionar normalmente. Los niveles de azúcar se
disminuyen con ayuda de una sustancia llamada insulina. Si hay poca insulina o si el
cuerpo no responde a la insulina, el azúcar se acumula en la sangre. Esto es lo que
llamamos diabetes.
Hay dos tipos de diabetes. En la diabetes tipo 2, el problema es que el organismo no
responde a la insulina o no produce suficiente.
¿Cuáles son los síntomas?
Por lo general, la diabetes tipo dos no produce síntomas. Cuando hay síntomas, se
pueden presentar las siguientes cosas:
Necesidad de orinar más seguido de lo normal
Sed intensa
Visión borrosa
Mayores deseos de comer
¿Cuáles son los problemas de la diabetes?
La diabetes puede provocar problemas graves con el paso del tiempo como infartos,
derrames cerebrales, falla renal, problemas de visión como ceguera, amputación de
dedos o extremidades.
¿Cómo sé que tengo diabetes?44 Design of an e-Learning Program for Type 2 Diabetes Latino Patients in a
Rural Area of Indiana, US
Generalmente, el médico o enfermero realiza una prueba de sangre para medir su azúcar
y así saber si tiene diabetes tipo 2.
¿Cómo se trata la diabetes?
La primera recomendación es que tengas un estilo de vida saludable, esto incluye
permanecer activo todos los días realizar mediante el ejercicio y mantener un consumo
de alimentos sanos.
Se pueden recetar algunos medicamentos para controlar la azúcar en la sangre. Algunas
veces son píldoras o pastillas para que el cuerpo genere más insulina o pueda funcionar
la insulina que ya existe. En otras ocasiones se deben aplicar inyecciones de insulina. Es
importante que consumas tus medicamentos todos los 44ías en las horas adecuadas.
Recuerda que la mejor alternativa, incluso si ya tienes diabetes y estas usando
medicamentos, es realizar ejercicio, bajar de peso y alimentarte en forma correcta, ya
que estas actividades mejoran los niveles de salud y ayudan al cuerpo a prevenir
enfermedades y controlar los niveles de azúcar en sangre.
References:
About diabetes. World Health Organization. Retrieved 10 October 2015 from:
www.who.int/diabetes/action_online/basics/en/index1.html
World Health Organization. (2006). Definition and Diagnosis of Diabetes Mellitus and
Intermediate Hyperglycemia. Who. doi:ISBN 92 4 159493 4
Video available through:
https://www.youtube.com/watch?v=DkPlGfNpuDI
2. Important Measures (Daily glucose, Lipids, Glycated Hemoglobin, Blood
Pressure)
Cosas que debes vigilarAppendices 45
Una vez que se ha diagnosticado diabetes, es importante que lleves un registro sobre
algunos factores importantes que nos ayudan a saber cómo está la azúcar en sangre y tu
nivel de salud. Te hablaremos de los siguientes factores:
Glucosa diaria
A1C
Presión arterial
Colesterol
1. Medir la glucosa en sangre: Para ello existen 2 pruebas importantes: la glucosa diaria
y la prueba de Hemoglobina glicosilada (A1C).
En la glucosa diaria, registramos los valores con ayuda de un pequeño dispositivo
llamado glucómetro. La glucosa diaria nos sirve para saber si hay algún alimento que
eleve mucho el azúcar, o si existen horas en el día en que los niveles sean demasiado
altos. También podemos saber si la azúcar se ha bajado demasiado.
Para la A1C es necesario asistir a una cita en la clínica, en donde tomaran una muestra
de sangre. La A1C nos muestra los niveles de azúcar en sangre durante los últimos tres
meses.
2. Control de la presión arterial: Esto permite saber cómo está el flujo de sangre en el
organismo. Las personas con Diabetes deben cuidar su presión arterial, ya que
corren mayor riesgo de sufrir enfermedades cardiovasculares e infartos.
3. Colesterol y trigliceridos: Con esta medida, básicamente podemos saber cómo están
los niveles de grasas en tu cuerpo. Tener niveles de colesterol altos también aumenta
el riesgo de sufrir infartos, derrames y otros problemas graves. Hay dos tipos de
colesterol: HDL y LDL. OjO! El colesterol LDL es el colesterol malo, y es el que
queremos mantener siempre abajo. Al contrario, el HDL se considera como colesterol
bueno, y está bien tener niveles elevados de HDL.46 Design of an e-Learning Program for Type 2 Diabetes Latino Patients in a
Rural Area of Indiana, US
Aquí te mostramos una tabla que resume los niveles que debes tener para la glucosa,
presión arterial y grasas.
Factor Valores adecuados
Antes de comer:
Glucosa diaria (Con Entre 70 y 130 mg/dL
glucómetro) 1 o dos horas luego de comer: menor a
180 mg/dL
A1C Menor a 7 %
Presión arterial Menor a 140/90
Total: menor a 200 mg/dL
LDL: menor a 100 mg/dL
Colesterol
HDL: mayor o igual a 40 mg/dL
Triglicéridos: menor a 150 mg/dL
References:
American Diabetes Association. Glycemic targets. Sec. 6. In Standards of Medical Care in
Diabetesd2015. Diabetes Care 2015;38(Suppl. 1):S33–S40
National Diabetes Education Program. 4 Steps to Manage Your Diabetes for Life.
Retrieved 09/08/2015 from:
http://ndep.nih.gov/publications/PublicationDetail.aspx?PubId=4 Last reviewed:
04/01/2014
Video available through:
https://www.youtube.com/watch?v=Ccn9xriuuUI
3. Foot Care
Cuidando la marchaAppendices 47
La diabetes provoca pérdida de sensibilidad en los pies con el paso del tiempo. Esto
significa que puedes tener heridas, cortes o infecciones en el pie y no darte cuenta.
¡Atención! Con el tiempo, se corre el gran riesgo de perder uno de los dedos, el pie o
incluso la pierna. Acá te contamos algunos cuidados para mantener sanos tus pies:
1. Revisa tus pies todos los días: asegúrate de no tener ampollas, heridas,
hinchazones. Contacta con tu proveedor de cuidado si detectas algo raro.
2. Lava los pies con agua tibia: Mantén los pies limpios a diario. ¡Advertencia! No
remojes los pies nunca ni utilices agua caliente. Sécate con una toalla suave.
3. Humecta tus pies: Aplica una loción hidratante por encima y debajo de tus pies,
pero no entre los dedos, ya que esto puede producir infección.
4. Corta tus uñas: Para ello utiliza un cortaúñas de pies y córtalas en forma recta y
sin redondear las esquinas de la uña.
5. Mantén siempre los pies secos y abrigados
6. Ponte siempre zapatos o chancletas, revísalos por dentro antes de colocárselos y
nunca andes descalzo, incluso si estas en casa
References:
Bus, S. A., van Netten, J. J., L.A., L., Monteiro, M., Rasmussen, A., Jubiz, Y., & Price, P.
E. (2015). Guidance on the prevention of foot ulcers in at-risk patients with diabetes.
IWGDF Working Group on Prevention of Foot Ulcers, 21. doi:10.1002/dmrr.2696
Video available through:
https://www.youtube.com/watch?v=lV8BWlYrv9U
4. Daily Glucose
Usando el glucómetro
Este aparato viene acompañado de unas tiras reactivas y unas lancetas (agujas). Existen
diferentes modelos, sin embargo el uso es muy similar:
1) Lava tus manos antes de usarlo.
2) Prepara el glucómetro insertando la tira reactiva.
3) Con tus manos limpias, pincha un lado de alguno de los dedos de la mano.
4) Depositar la gota de sangre en la tira reactiva.
5) El glucómetro indicara el nivel de azúcar que tienes en ese momento.48 Design of an e-Learning Program for Type 2 Diabetes Latino Patients in a
Rural Area of Indiana, US
6) Registra el valor que te da el glucómetro.
7) Desecha la tira reactiva y la lanceta.
5. Plate Method
Es tiempo de preparar un plato saludable
Primer paso
Usa un plato habitual de almuerzo o cena. No debe pasar 9 pulgadas (inch) de tamaño
Segundo paso
Traza una línea imaginaria por la mitad del plato. ¡Las combinaciones son infinitas!
Ahora vuelve a dividir la mitad que te queda libre en dos. Una de las partes la debes
llenar con granos y alimentos con almidón como:
Pan de grano integral, cereal de grano integral y fibra, cereal cocido como avena, maíz
machacado o sémola, arroz, fideos, tortillas, frijoles pintos o de carita, papas, arvejas o
chícharos, pallares, batata, boniato o camote, zapallo o calabaza, galletas, papitas, o
chips con bajo contenido de grasa, pretzels o palomitas de maíz sin grasa.
Recuerda, es un cuarto de tu plato.
Tercer paso
Llena la parte del plato faltante con alguna proteína como:
Pollo o pavo sin piel, pescado como atún, salmón bacalao, barbo o bagre; mariscos como
camarones, almejas, ostras, cangrejo o mejillones; cortes magros de carne o cerdo como
solomillo o lomo tofu huevos o queso con bajo contenido de grasa.
Tu plato está casi completo.
Puedes agregar una porción de fruta, del tamaño de tu puño cerrado. Agrega una bebida
baja en calorías, como agua, té sin azúcar o café.Appendices 49
Algunas recomendaciones
Disminuye al máximo posible el consumo de bebidas con endulzantes
Procura consumir pescado dos veces por semana.
Puedes agregar aguacate a tus ensaladas. Es una fuente natural de grasa
Consume fibra. La puedes encontrar en frutas, vegetales y granos como la avena,
nueces y almendras.
Consume poca sal.
Más información en:
www.diabetes.org
www.choosemyplate.gov
References:
Camelon, K. M., Hådell, K., Jämsén, P. T., Ketonen, K. J., Kohtamäki, H. M., Mäkimatilla,
S., … Valve, R. H. (1998). The Plate Model: a visual method of teaching meal planning.
DAIS Project Group. Diabetes Atherosclerosis Intervention Study. Journal of the
American Dietetic Association.
Cunningham, E. (2009). What Impact Does Plate Size Have on Food and Nutrition?
Journal of the American Dietetic Association, 109(10), 1816.
doi:10.1016/j.jada.2009.08.028
Cunningham, E. (2011). Where Can I Find Resources on the Local Food Movement?
Journal of the American Dietetic Association, 111(7), 1094.
doi:10.1016/j.jada.2011.05.022
Video available through:
https://www.youtube.com/watch?v=_qEFlpoDoxg
6. Exercise Recommendations
¡Es hora de hacer Ejercicio!50 Design of an e-Learning Program for Type 2 Diabetes Latino Patients in a
Rural Area of Indiana, US
¡El ejercicio es una parte importante de tu vida y es fundamental para combatir la
diabetes! ¡La edad no importa! El objetivo es que te ejercites durante media hora cinco
días a la semana.
¿Qué hacer antes de empezar?
Primero debes hablar con tu doctor para saber cuál es la mejor rutina de actividad física.
Si estas recibiendo medicamentos para la Diabetes, revisa tus niveles de azúcar antes de
salir a hacer ejercicio. Si tu azúcar (glucosa) está por debajo de 100 mg/dL, consume
algo como una fruta o snack antes de ejercitarte.
¿Cómo empezar?
Si no tienes la costumbre de realizar ejercicio, empieza por caminar 10 minutos durante
el día y ve aumentado poco a poco. Usa un reloj para saber cuánto tiempo estas
ejercitándote a diario. ¡No dejes pasar más de dos días sin salir a caminar!
¿Qué debo tener en cuenta?
- Utiliza zapatos adecuados. Recuerda que debes cuidar tus pies de cualquier
lesión.
- Lleva siempre un pequeño refrigerio para elevar tu azúcar: pueden ser dulces
pequeños, media taza de jugo o una cucharada de azúcar disuelta en agua.
- Detente si te sientes mareado, tienes visión borrosa, sientes falta de aliento o
sientes que puedes desmayarte. Cuando esto ocurra consume un refrigerio.
¿Qué hacer después de terminar?
- Revisa tus pies para estar seguros de que no hay ninguna lesión
- Revisa tus niveles de azúcar
Contacta con tu médico:
- Si tienes problemas de visión
- Si tienes algún problema en tus pies
- Si tienes episodios de dolor de pecho
- Si quieres iniciar una rutina de ejercicios de mayor intensidad.
Para mayor información visita:Appendices 51
www.diabetes.org
References:
American Diabetes Association. Standards of medical care in diabetes -- 2014. Diabetes
Care. 2014;37:S14-S80
Marwick TH, Hordern MD, Miller T, et al., on behalf of the American Heart Association
Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical
Cardiology; Council on Cardiovascular Disease in the Young; Council on Cardiovascular
Nursing; Council on Nutrition, Physical Activity, and Metabolism; and the Interdisciplinary
Council on Quality of Care and Outcomes Research. Exercise training for type 2 diabetes
mellitus: impact on cardiovascular risk: a scientific statement from the American Heart
Association. Circulation. 2009;119:3244-3262
Diabetes and exercise. Medline Plus. Retrieved October 10 2015 from:
https://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000083.htm
Mayo Clinic. Diabetes and exercise: When to monitor your blood sugar. Retrieved
October 10 2015 from: http://www.mayoclinic.org/diseases-conditions/diabetes/in-
depth/diabetes-and-exercise/art-20045697?pg=1
American Diabetes Association. Walking – A Great Place to Start! Retrieved October 10
2015 from: http://www.diabetes.org/food-and-fitness/fitness/types-of-activity/walking-a-
great-place-to-start.html
Video available through:
https://www.youtube.com/watch?v=tn8yJD_F5s452 Design of an e-Learning Program for Type 2 Diabetes Latino Patients in a
Rural Area of Indiana, US
7. Reading Nutritional Labels
¿Alguna vez le has dado la vuelta a los alimentos que compras? ¡Anímate a hacerlo!
Esto es lo que encontrarás [Nutritional Label]:
Nutrition Facts
Serving Size: 1 bar (40 g)
Servings Per container: 1
Amount Per Serving
Calories: 170 Calories from Fat 60
% Daily Value*
Total Fat 7 g 11 %
Saturated Fat 3 g 15 %
Trans Fat 0 g
Cholesterol 0 mg 0 %
Sodium 160 mg 7 %
Total
24g 8 %
Carbohydrate
Dietary Fiber 3g 12 %
Sugars 10g
Protein 5g
Vitamin A 2%
Vitamin C 2%
Calcium 20%
Iron 8%
Ahora miremos cada parte de la etiqueta:
El serving size es el tamaño de una porción del alimento que viene en la etiqueta.
Servings per container indica cuantas porciones vienen en un solo empaque del alimento.
¡Las Calorías!Appendices 53
Calories te anuncia la cantidad de calorías que contiene una porción de tu alimento.
Puedes comparar entre varios productos para saber cuál te ofrece menos calorías. Un
alimento se considera alto en calorías cuanto tiene más de 400.
¿Cómo se cuántas calorías debo consumir en un día?
Esto depende de varios factores como el peso, la edad, el género y la cantidad de
actividad física que realices. La recomendación para personas con Diabetes es mantener
un consumo de calorías de 1500 por día si hay sobrepeso.
Ahora regresemos a la etiqueta nutricional. Debajo de las calorías encontrarás
información sobre el contenido de grasas, colesterol, sodio, carbohidratos y proteínas.
¡Vamos a mirar las grasas!
Lo mejor para tu diabetes es mantener un bajo consumo de grasas (fats en inglés), y
consumir aquellas que son más saludables. Si te fijas en la etiqueta debajo de Total fat,
aparecen Saturated fat (Grasas saturadas) y Trans fat (Grasas trans). Ambas son grasas
perjudiciales. En algunas ocasiones aparecen en la etiqueta Monounsaturated y
Polyunsaturated (monoinsaturadas y poliinsaturadas); estas son grasas mucho más
saludables para tu organismo.
El colesterol es también un tipo de grasa, y por tanto es mejor consumirlo al mínimo
posible.
La sal, llamada “sodium en inglés” también debes consumirla al mínimo posible. En
realidad necesitas una cucharadita de sal al día distribuida en todas tus comidas para
mantenerte saludable.
¡Los carbohidratos básicamente son azúcar! Por ello hay que buscar aquellos alimentos
que los contengan en menor cantidad.
La fibra es un alimento sano para consumir, ayuda a tener una buena digestión y en
algunos casos, permite tener un mejor control de la glucosa. Un consumo de 14 de
gramos de fibra por cada 1000 calorías es recomendado.
Por último, las vitaminas A y C, el calcio y el hierro son alimentos muy necesarios para tu
nutrición. ¡Trata de consumirlos cada vez que puedas! ¡Mucho mejor si vienen de
alimentos naturales!54 Design of an e-Learning Program for Type 2 Diabetes Latino Patients in a
Rural Area of Indiana, US
¿Esta información ha sido demasiado para ti? ¡Calma! Solo intenta ir poco a poco,
empieza por analizar los alimentos más habituales que consumes y compara los
ingredientes que contienen. Recuerda también comentar todas las inquietudes que
tengas a tu equipo de salud.
Para más información te recomendamos las siguientes páginas web:
www.diabetes.org
www.fda.gov
www.usda.gov
References
U.S. Department of Agriculture, & U.S. Department of Health and Human Services.
(2010). Dietary Guidelines for Americans 2010. Government Printing Office, 7, 95.
U.S. Food and Drug Administration. (2015). How to Understand and Use the Nutrition
Facts Label. Retrieved from
http://www.fda.gov/Food/IngredientsPackagingLabeling/LabelingNutrition/ucm274593.htm
Asociacion latinoamericana de diabetes. (2013). Guías ALAD de diagnóstico, control y
tratamiento de la diabetes mellitus tipo 2, 14(3), 188. Retrieved from http://www.alad-
latinoamerica.org/phocadownload/guias alad.pdf
Video available through:
https://www.youtube.com/watch?v=KDDryUOGoP4Appendices 55
B. Informed Consent56 Design of an e-Learning Program for Type 2 Diabetes Latino Patients in a
Rural Area of Indiana, US
C. Appendix: Questionnaires for Patients
Evaluation
C.1. Instrument for Video 1: ¿Qué es la diabetes? (Diabetes Concept)
Nombre:________________________________
Lado 1
1. ¿Qué es la diabetes? 3. ¿Cuáles son los problemas de la Diabetes?
Una enfermedad relacionada con el aumento de
Se eleva el azúcar en sangre
azúcar en el organismo.
Puede provocar problemas graves como
Una enfermedad relacionada con la disminución infartos, derrames cerebrales, falla renal,
de azúcar en el organismo. problemas de visión como ceguera,
amputación de dedos o extremidades.
Una enfermedad pasajera Se baja el azúcar en sangre
No sabe/No responde No sabe/No responde.
2. ¿Cuáles son los síntomas de la diabetes? 4. ¿Cómo se trata la Diabetes?
Usando medicamentos y asistiendo a las
En la Diabetes nunca hay síntomas
citas
Con un estilo de vida saludable,
permaneciendo activo(a) todos los días
mediante el ejercicio, manteniendo un
Mareo y nausea
consumo de alimentos sanos y con
medicamentos para controlar la azúcar en la
sangre.
Necesidad de orinar más seguido de lo normal,
Dejando de comer durante un tiempo, ya que
sed intensa, visión borrosa, mayores deseos de
es una enfermedad pasajera
comer.
No sabe/No responde. No sabe/No responde
5. ¿Qué tanto le gustó el video? 6. ¿Volvería a ver este video?
Me gustó Sí
No me gustó No
Otra respuesta:_______________________________ Otra respuesta:__________________________________Appendices 57
C.2. Instrument for Video 2: Cosas que Vigilar (Important measurements)
Lado 2
1. ¿Cuáles son los factores importantes que nos ayudan a
3. ¿Por qué es importante la presión arterial?
saber cómo está la azúcar en sangre y tu nivel de salud?
Porque permite saber si estoy triste o
Glucosa diaria, A1C, Presión arterial, Colesterol.
ansiosa (o).
Porque permite saber mi nivel de energía
Glucosa.
durante el día.
Porque permite saber cómo está el flujo de
La insulina y el ejercicio
sangre en el organismo.
No sabe/No responde No sabe/No responde.
2. ¿Cómo puedo medir mi glucosa en sangre? 4. ¿Cuáles son las grasas que hay en el cuerpo?
Colesterol, triglicéridos, HDL y LDL
Con el glucómetro.
Con la A1C (Hemoglobina glucosilada) y el
Colesterol y triglicéridos
glucómetro.
Asistiendo a una cita. Almidón
No sabe/No responde. No sabe/No responde
5. ¿Qué tanto le gustó el video? 6. ¿Volvería a ver este video?
Me gustó Sí
No me gustó No
Otra respuesta:_______________________________ Otra respuesta:__________________________________58 Design of an e-Learning Program for Type 2 Diabetes Latino Patients in a
Rural Area of Indiana, US
C.3. Instrument for Video 3: Es Hora de un Plato Saludable (Plate Method)
Nombre:________________________________
3. ¿Qué tantos alimentos con almidón debo consumir en
1. ¿Qué es el método del plato?
una comida?
Una estrategia para disminuir el costo de
Aproximadamente la mitad de plato
comprar alimentos
Una estrategia para consumir alimentos en forma
Un cuarto (1/4) de plato
más saludable
Una forma de consumir menos alimentos Más de la mitad del plato
No sabe/No responde No sabe/No responde.
2. ¿Qué tantos vegetales debo consumir en una comida? 4. ¿Qué tanta proteína debo consumir en una comida?
Aproximadamente la mitad de plato Aproximadamente la mitad de plato
Menos de un cuarto (1/4) de plato Un cuarto (1/4) de plato
No es necesario consumir vegetales siempre Más de la mitad del plato
No sabe/No responde. No sabe/No responde
5. ¿Qué tanto le gustó el video? 6. ¿Volvería a ver este video?
Me gustó Sí
No me gustó No
Otra respuesta:_______________________________ Otra respuesta:__________________________________Appendices 59
C.4. Instrument for Video 4: Cuidando la Marcha (Foot Care)
Nombre:________________________________
Lado 1
1. ¿Cada cuanto debo revisar mis pies? 3. ¿Cuándo puedo andar descalzo?
Una vez a la semana Es mejor tratar de no andar descalzo
Cada vez que sienta algo extraño En la casa
Todos los días Cuando sienta la necesidad
No sabe/No responde No sabe/No responde.
2. ¿Cómo debo limpiar mis pies? 4. ¿Cómo debo cortar mis uñas?
Sumergiéndolos ó remojándolos en agua Redondeándolas con el cortauñas
Con agua tibia En forma recta
No hay que limpiarlos a diario Dando un ángulo en cada esquina de la uña
No sabe/No responde. No sabe/No responde
5. ¿Qué tanto le gustó el video? 6. ¿Volvería a ver este video?
Me gustó Sí
No me gustó No
Otra respuesta:_______________________________ Otra respuesta:__________________________________60 Design of an e-Learning Program for Type 2 Diabetes Latino Patients in a
Rural Area of Indiana, US
C.5. Instrument for Video 5: ¡Es hora de Hacer Ejercicio! (Exercise recomendations)
Lado 2
3. ¿Si antes de hacer ejercicio mi glucosa esta en 70 mg/dL,
1. ¿Cuál es la rutina recomendada para el ejercicio?
que debo hacer?
Más de una hora todos los días No hacer ningún ejercicio
No hay ningún problema, puedo salir a hacer
Treinta minutos diarios cinco días a la semana
ejercicio normalmente
Consumir un refrigerio, como una fruta o
Dos horas los fines de semana
snack antes de hacer ejericicio
No sabe/No responde No sabe/No responde.
2. ¿Qué debo hacer antes de empezar una rutina de
4. ¿Qué es importante hacer luego de realizar ejercicio?
ejercicios?
Revisar mis pies y los niveles de azúcar en
Aplicarme insulina
sangre
Comer en grandes cantidades ya que estoy
Descansar para poder recuperar energía
haciendo ejercicio
Si tengo medicamentos para la Diabetes, revisar
Comer inmediatamente
como esta mi glucosa en sangre.
No sabe/No responde. No sabe/No responde
5. ¿Qué tanto le gustó el video? 6. ¿Volvería a ver este video?
Me gustó Sí
No me gustó No
Otra respuesta:_______________________________ Otra respuesta:__________________________________Appendices 61
C.6. Instrument for Video 6: La etiqueta Nutricional (Nutritional Facts)
Lado 2
3. ¿Si antes de hacer ejercicio mi glucosa esta en 70 mg/dL,
1. ¿Cuál es la rutina recomendada para el ejercicio?
que debo hacer?
Más de una hora todos los días No hacer ningún ejercicio
No hay ningún problema, puedo salir a hacer
Treinta minutos diarios cinco días a la semana
ejercicio normalmente
Consumir un refrigerio, como una fruta o
Dos horas los fines de semana
snack antes de hacer ejericicio
No sabe/No responde No sabe/No responde.
2. ¿Qué debo hacer antes de empezar una rutina de
4. ¿Qué es importante hacer luego de realizar ejercicio?
ejercicios?
Revisar mis pies y los niveles de azúcar en
Aplicarme insulina
sangre
Comer en grandes cantidades ya que estoy
Descansar para poder recuperar energía
haciendo ejercicio
Si tengo medicamentos para la Diabetes, revisar
Comer inmediatamente
como esta mi glucosa en sangre.
No sabe/No responde. No sabe/No responde
5. ¿Qué tanto le gustó el video? 6. ¿Volvería a ver este video?
Me gustó Sí
No me gustó No
Otra respuesta:_______________________________ Otra respuesta:__________________________________D. Appendix: Webpages found with diabetes
prevention materials
s e e,r
URL e g a u g n a L la u s iv o id u As e c r u o s e R g n ib ir c s e De s a e s id la n o itir tu Ns t c e p s a t c e p s a e s ic r e e s o c u lGg n ir o tin o M e t u c As n o it a c ilp m o c in o r h Cs n o it a c ilp m o la ic o s o h c y s Ps e u s s i g n a h c r o iv a h a id e M la ic o S ,k o o b e c a F be utt Tiw u oT ,s r e h tO
x c C e
E B Y
http://ndep.nih.gov/resourc
es/index.aspx?SearchText
1 English Video No Yes Yes No No No No Yes Yes
=&ToolType=17&PageSize
=10&CurrentPage=0
http://ndep.nih.gov/resourc
2 es/ResourceDetail.aspx?R English Video No Yes Yes No No No Yes Yes Yes
esId=346
http://ndep.nih.gov/resourc
3 es/ResourceDetail.aspx?R English Video No No Yes No No No Yes Yes Yes
esId=341
https://www.youtube.com/
4 English Video No No Yes No No No No Yes Yes
watch?v=4_YOhBMZG3Q
http://ndep.nih.gov/media/d
5 Spanish Audio No No No No No No No Yes Yes
r-huerta-psa.mp3
http://ndep.nih.gov/resourc
6 es/ResourceDetail.aspx?R English Video No No No No No No No Yes Yes
esId=342
http://ndep.nih.gov/resourc
es/recursos.aspx?SearchT Text
7 ext=&ToolType=&Languag Bilingual and No Yes Yes Yes No Yes Yes Yes No
e=es&PageSize=10&Curre Image
ntPage=2
http://ndep.nih.gov/resourc
8 es/ResourceDetail.aspx?R English Video No No No No No No No Yes Yes
esId=343
https://www.youtube.com/
9 English Video No Yes Yes No No No No Yes Yes
watch?v=j0hekp7-fOs
http://ndep.nih.gov/resourc
10 es/ResourceDetail.aspx?R English Video No No No No No No Yes No Yes
esId=379
https://www.youtube.com/
11 English Video No Yes No No No No Yes Yes Yes
watch?v=LYGNf3SSWVE
http://ndep.nih.gov/resourc
12 es/ResourceDetail.aspx?R English Video No Yes No No No No Yes Yes Yes
esId=375Appendices 63
https://www.youtube.com/
13 English Video No No No No No No Yes Yes Yes
watch?v=G7iIQEzIHy8
http://ndep.nih.gov/resourc
14 es/ResourceDetail.aspx?R English Video No No No No No No Yes Yes Yes
esId=376
Text
http://www.choosemyplate.
15 Bilingual and No Yes No No No No No No Yes
gov/
Image
http://www.cdc.gov/diabete
16 Bilingual No No No No No No No No No No
s/ndep/road-to-health.htm
Text
http://therealbears.org/sod
17 English and No Yes No No No Yes No No Yes
afacts101.pdf
image
https://www.youtube.com/
18 Bilingual Video No Yes No No No Yes No No Yes
watch?v=rzm0i7iLu2s
http://kidshealth.org/kid/en
19 _espanol/enfermadades/ty Bilingual Video Yes No No No No No No No No
pe1_esp.html
http://www.diabetes.org/es/
vivir-con-
Text
diabetes/tratamiento-y-
20 Bilingual and No Yes No Yes No Yes No No No
cuidado/el-control-de-la-
image
glucosa-en-la-sangre/cmo-
medir-la-glucosa-en-la.html
https://www.youtube.com/
21 watch?t=58&v=0lHyQuW_ Bilingual Video No Yes No No No No No Yes Yes
QUs
https://donations.diabetes.
org/site/SPageServer/?pag
Text
ename=LWT2D_Spanish&l
22 Bilingual and Yes Yes Yes Yes Yes Yes Yes Yes No
oc=avocado-
image
dorg&s_src=d.org&s_subsr
c=avocado
http://ndep.nih.gov/media/ Text
23 NDEP48_Cuide_sus_pies_ Bilingual and No No No No No Yes No No No
2c_508.pdf image
Text
http://www.foothealthfacts.
24 English and No No No No No Yes No No No
org/Content.aspx?id=1246
image
Text
http://www.cdc.gov/diabete
25 Bilingual and Yes Yes Yes Yes Yes Yes Yes Yes Yes
s/spanish/pdfs/controle.pdf
image
http://ndep.nih.gov/publicat Text
26 ions/PublicationDetail.aspx Bilingual and Yes Yes Yes Yes No Yes No Yes No
?PubId=42 image
https://www.diabeteseduca
Text
tor.org/patient-
27 English and Yes Yes Yes Yes Yes Yes Yes Yes No
resources/diabetes-goal-
image
tracker-app
http://www.eatright.org/res
28 English Video No Yes Yes No No No No No No
ources/for-men64 Design of an e-Learning Program for Type 2 Diabetes Latino Patients in a
Rural Area of Indiana, US
http://public.health.oregon.
Text
gov/DiseasesConditions/C
29 Bilingual and No Yes No No No No No Yes No
hronicDisease/Diabetes/Pa
image
ges/Mealsmadeeasy.aspx
Text
http://tracker.diabetes.org/
30 Bilingual and No Yes No No No No No No No
es/recipe/browse/3/
image
http://www.ndep.nih.gov/pu
Text
blications/PublicationDetail
31 Bilingual and No Yes Yes No No No No Yes No
.aspx?PubId=73&lang=Sp
image
anish
http://professional.diabetes Text
32 .org/ResourcesForProfessi Bilingual and Yes Yes Yes Yes Yes Yes Yes Yes No
onals.aspx?cid=77080 image
http://www.cdc.gov/healthy Text
33 weight/spanish/healthyeati Bilingual and No Yes No No No No No No No
ng/rethinkyourdrink.html image
Text
http://www.healthystudy.or
34 English and No Yes Yes No No Yes Yes Yes No
g/materialsmatrix.htm
image
http://ndep.nih.gov/publicat
Text
ions/PublicationDetail.aspx
35 Bilingual and No Yes Yes No No No No Yes No
?PubId=158&lang=Spanis
image
h
Text
https://catalog.niddk.nih.go
36 Bilingual and No Yes No No No No No Yes No
v/detail.cfm?ID=411
image
http://healthfinder.gov/espa Text
37 nol/prevention/ViewTopicF Bilingual and Yes Yes Yes No No Yes No Yes No
ull.aspx?topicId=55&catId= image
http://www.diabetes.org/es/
alimentos-y-actividad-
38 Bilingual Audio No No Yes No No No No Yes No
fisica/condicion-fisica/tipos-
de-ejercicio/caminar.html
http://www.mayoclinic.org/
diseases-
Text
conditions/diabetes/in-
39 English and No No Yes Yes Yes No No Yes No
depth/diabetes-and-
image
exercise/art-
20045697?pg=1
https://www.nlm.nih.gov/m Text
40 edlineplus/ency/patientinstr Bilingual and No No Yes Yes Yes No No Yes No
uctions/000083.htm image
Text
http://ndep.nih.gov/media/l
41 Bilingual and No Yes No No No No No No No
earn-food-labels-508.pdf
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