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.