Among incarcerated persons, the rate of diabetes is almost 50% higher (9%) than the
general population (6.5%) when matched for sex, age, race, and Hispanic origin. The
burden of diabetes is carried forward post-incarceration, with 95% of incarcerated
persons reentering the community with minimal health-related skills stemming from
high-security environments with constrained self-care. These individuals lack critical
knowledge and skills for diabetes self-management (DSM) regarding what foods to eat, how
to control the formerly incarcerated person's blood sugar, and how and when to take
insulin. Furthermore, the Principal Investigator's research in correctional institutions
has demonstrated significant diabetes knowledge deficits related to treating potentially
life-threatening hypo/hyperglycemia. A1C, a measure of metabolic control and predictive
for diabetes complications, was suboptimal for the majority of participants. Furthermore,
these returning citizens have cognitive impairment and lower literacy than those living
in community households across age, sex, and educational attainment. The formerly
incarcerated have higher hospitalization rates for short-term diabetes complications
seven days' post-prison release compared to matched controls. Prevention is possible with
Diabetes Self-Management Education and Support (DSMES) and diabetes survival skills
(DSS). DSS refers to hypoglycemia and sick day management, insulin administration, and
consistent nutrition habits, among other behaviors to prevent acute diabetes issues
(hypo/hyperglycemia), and hospitalizations. At a minimum, incarcerated persons
transitioning to the community have a critical need for DSS and support.
There have been efforts to examine the effect of engaging incarcerated persons in blood
glucose monitoring on glycemic control. Still, those released from incarceration have not
benefitted from the decades of research that have resulted in improved outcomes. As a
first step to filling this gap, the research team developed a literacy-tailored 6-week
theory-based DSS intervention. The research team tested the feasibility and acceptability
of the DSS intervention in incarcerated men between 6 to 9 months of transitioning from
state prisons to supervised community housing or parole. The Principal Investigator found
improvements in diabetes knowledge and diabetes-related distress in both groups and
outcome expectancy with the treatment group. Analysis of focus group data revealed
acceptance of the literacy-tailored DSS education, a need for skill-based videos, and
ongoing support upon release. After an analysis of the research team's retention rate and
feasibility data, the research team identified the haphazard process of releasing
individuals to supervised community housing as a significant contributor to retention for
the research team's in-person pre-release DSS intervention.
Consequently, the primary investigator recognized a critical need to make the
literacy-tailored DSS and ongoing DSMES widely accessible to returning citizens with
diabetes after release to supervised housing via synchronous and asynchronous remote
options. Based on the evidence that virtual environments (VE) may lead to superior
learning and experience for the participants and can promote social and educational
interaction via repetition, practice, feedback, and application,24,25 the research team
aims to leverage the research team's collective experience with diabetes Learning in
Virtual Environments (LIVE) a diabetes educator-led, DSMES in a VE26-28 to develop the
Diabetes LIVE JustICE (Just In time for Community reentry) intervention using an
iterative participant engaged process. Because persons living in supervised community
housing do not have access to reliable private computers but do have access to mobile
devices, the research team will develop Diabetes LIVE JustICE as a mobile application.
The Principal Investigator's goal is to recruit a sample of vulnerable incarcerated
persons with multimorbidity, including diabetes on the transition to supervised community
living to develop and test the feasibility and acceptability of a multi-user virtual
diabetes community (Diabetes LIVE JustICE). This platform allows users to talk to each
other in real-time and participate in instructor-led education sessions and facilitated
support sessions accessed through IOS/Android mobile devices. The specific aims of this
study are to:
Examine feasibility and acceptability of the Diabetes LIVE JustICE application by
tracking the following outcomes: recruitment rate, participation rates (number of
log-ins, time spent in mobile application, retention) engagement (materials
accessed), and the user experience (usability, usefulness, satisfaction, and
attitudes toward use of Diabetes LIVE JustICE).
Examine the preliminary short-term effects of Diabetes LIVE JustICE compared to
usual pre-release diabetes care supplemented with low literacy diabetes education
materials on the following outcomes: A1C, diabetes knowledge, diabetes self-care,
diabetes-related emotional distress, social support, and perceived competence.
