Madeline Lasell

SPH 222
Final Project

Accessibility of Medical Nutrition Therapy Among Type II Diabetics Living in Rural South
Sacramento County

The Problem
Uncontrolled diabetes mellitus can result in serious or life-threatening complications. Diabetes
can lead to the development of comorbid conditions, increased healthcare costs, and an overall poor
quality of life. Globally, the prevalence of diabetes has nearly doubled since 1980.1 In 2012, diabetes
resulted in the deaths of 1.5 million individuals worldwide.1 Moreover, rural communities experience type
II diabetes deaths at a rate higher than those of urban, metropolitan communities.2 Rural areas can be
isolated from certain health care services, as well as specialized services like medical nutrition therapy.
Thus, as diabetes prevalence persists as a public health issue, rural communities are at increased risk of
having inadequate access to diabetes treatment, and, consequently, continued high rates of death.

Background
Brief Review of Literature
There are several barriers that make it difficult for rural communities to access health care
services. Prior studies utilized both rural inhabitant focus groups and telephone interviews with healthcare
providers to identify the barriers for receiving care, specific to this population.2-3 Among them include:
denial of illness severity (lack of knowledge), unsupportive social networks, lack of time, poor
motivation, minimal relevant skills, insufficient finances, and transportation issues.2 Rural communities
have high concentrations of individuals whose work resides on the farm, resulting in highly inflexible
schedules to work around. Studies show that many rural diabetics not only lack the time and motivation to
physically see a healthcare provider, but to effectively transform their lifestyle to support their diabetes
self-management.2-3
These barriers are further compounded by the unavailability of services that cater to the rural
population. In fact, Rural Healthy People 2020 guidelines emphasize prioritization of access to healthcare
among rural patients, due to their dire need for more services.4 While 17% of Americans live in rural
communities, only 9% of physicians and 16% of registered nurses practice in them.4 The research shows
that it is especially important for rural individuals (particularly those living with chronic disease) to
maintain regular contact with a healthcare provider so as to maximize their ability to improve health
behaviors.5 Otherwise, the large number of diabetic patients who lack the knowledge and skills necessary
to manage their disease will not be capable of engaging in self-management.2
Still, studies convey that there is an undersupply of specialty services available to rural
communities.2,4 Rural healthcare providers are pressed to provide information outside their scope of
practice to compensate for a lack of specialty services, such as medical nutrition therapy (MNT).2 MNT is
an in-depth service provided by registered dietitians or other certified nutrition professionals. Registered
dietitians apply the Nutrition Care Process using diagnostic, therapy, and counseling services to assist
with disease management in the clinical setting. 13 Some health professionals have reported providing
dietary advice despite not being credentialed as a registered dietitian.2 Several articles discuss the clinical
effectiveness of the dietitian conducting MNT within diabetes self-management services.6-10 The dietitian
is best equipped to maneuver the complexities that arise when constructing a nutrition intervention.7 MNT
was originally recommended by the Institute of Medicine to be covered as a Medicare Part B benefit in
diabetes self-management programs, due to its ability to improve clinical outcomes and potentially
decease the costs (both patient and Medicare costs) of managing diabetes.11 It should be noted, however,
that despite the need for specialized services, organized communication between specialty providers and
primary care providers can be challenging, as studies have shown that information is wrongfully
exchanged between primary and secondary sources of care.12 While this communication difficulty is not
limited to rural communities alone, it is important to consider in the development of future research or
interventions that incorporate referrals to dietitians outside of the immediate healthcare teams servicing
rural communities.
Madeline Lasell
SPH 222
Final Project

Proposed Research Framework

The following framework defines the social and behavioral determinants of whether diabetic
individuals in rural-agricultural communities have sufficient access to care for diabetes management.
Specifically, this framework addresses the two-tiered research question: do type II diabetics residing in
rural-agricultural communities have access to 1) general health care and 2) the specialty service of
medical nutrition therapy? This framework draws from two other theoretical models: the Anderson
Behavioral Model and the Socioecological Model. In much the same way as Davidson et al. adapted their
version of the Anderson Behavioral Model, this version expands from the original to incorporate
community-level influences.14 While the primary purpose of this framework is to include community-
level determinants, it also pulls from the Socioecological Model to incorporate more individualized
characteristics to note, such as genetics and biological risk factors, education level, and living
conditions.15 By incorporating these factors, the research will address a more comprehensive set of the
complex factors that influence access to healthcare services.
In the existing literature, there is little discussion about health insurance coverage seen in rural-ag
populations and how this affects the accessibility of certain health services. Similarly, there is little
discussion surrounding how policies might influence healthcare access among these communities.
Primarily, rural individuals identified proximity to services and personal barriers (time, money,
transportation, motivation) as what hindered their access to care.2-3 By including health insurance, income
levels, public transportation, education levels, and the supply of healthy, affordable foods as additional
variables to consider in the framework below, this research project can account for other community-level
determinants that have been omitted from other studies to date.

Figure 1. Conceptual framework to evaluate community-level influences on access to health care services for type II
diabetes among rural-ag communities.

Framework Components
Health care access and outcomes. In the original Anderson model, this section is titled Health
Behavior.16 For this model, this section was adapted to reflect Healthcare access and outcomes, which is
influenced by Community characteristics and Individual characteristics. Like the model seen in Davidson
et al., this section distinguishes between realized access (the managed care that the target population is
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SPH 222
Final Project

already aware of and/or already utilizes) and potential access (other services of which the target
population may not be aware or may not have access to).14 For the proposed research, it will be
imperative to source what avenues of care are already available to this target population, as well as to
discuss with the target population what services they know are available to them. Lastly, this section
names the outcomes that should result from adequate access. With regard to type II diabetes, there might
be prevention of further complications, sufficient self-management, and other health, social, or economic
outcomes.6 These health outcomes are important to note for the importance of accessing care, and could
be used in future interventions to determine the knowledge-base of participants and/or their motivations
for accessing care.
Community characteristics. It is important to look at the community characteristics when
determining the widespread accessibility of healthcare services. These characteristics constitute a large
portion of the environment for each of the individuals in this target population. While the characteristics
include social and demographic influences, they also include the number of physicians and services
available to the community, as well as whether these practitioners are in close proximity, have enough
time to see these patients (i.e. they are not overbooked or their services are not too competitive), and
whether they require insurance. It is important to note that with the levels of low socioeconomic (SES)
status seen in rural communities, the density of healthcare practitioners dwindles and poor health
outcomes are more likely to surface.17 This research project aims to survey available healthcare providers
to see what specialty services they provide, how well marketed they are, what insurance is needed for the
services, and whether services would be feasible via alternative avenues, such as telehealth.
Other community characteristics include this population’s main source of employment (farming)
and related factors, such as lower education levels, low-income brackets, inflexible schedules, and
isolation.2 Particularly with isolation and low funds, members of this population my not have adequate
transportation to drive to various services.2 Moreover, it is important to note that rural populations can be
subject to low-quality foods with little nutritive-density.17 This can be attributed to isolation from produce
and other foods that contribute to a healthy diet, which are necessary for diabetes management.8
Individual characteristics. The community characteristics of this population likely play a role in
each individual’s approach to receiving healthcare. If it is not routine for neighbors to make regular health
care visits or to forgo health insurance, this may determine whether or not individuals will pursue regular
check-ups, screenings, and/or treatment for disease.5,12 Moreover, obtaining care may be influenced by
personal beliefs and attitudes toward health care and how symptoms should be treated, managed, or
perceived.5,12 While genetics are not highly malleable, the perceptions of how those genetics have affected
former or current family members may even perpetuate health beliefs, so genetic and biological factors
have been included in this program’s framework. Social relationships are a form of the environment that
can greatly influence an individual’s thoughts towards something related to their health, and, further, can
make or break their health decisions based on whether or not those relationships are supportive or not.5,12
In addition, other individual determinants of health, such as personal income, sources of
transportation, health insurance coverage, current providers, living conditions, and education level are
important to address when determining disparities seen in healthcare access.5 Some of these individuals
may not have education in terms of knowing how to manage their health or even in terms of knowing the
services available to them.5 Without this knowledge, individuals in this target population likely cannot
alter their behaviors. In addition to health practices, income can also affect living conditions, which may
be subpar and negatively affect health outcomes.5 In this research project, it will be important to highlight
the relationship between both the community-level factors and the individual-level factors in determining
the accessibility of services to the members of this target population.

Conclusion & Identified Gaps

With the increasing prevalence of diabetes, the volume of rural Americans, and the consistent
challenge of providing sufficient rural access to health care services, there is an apparent need for more
research and new approaches that ensure rural diabetics can engage in diabetes self-management.
Madeline Lasell
SPH 222
Final Project

Currently, widespread knowledge is lacking with regard to the number of dietitians available to perform
MNT in rural areas. It is not clear what the protocol is for administering nutrition therapy when a dietitian
or other nutrition professional is not available in these locations. While specialized services like medical
nutrition therapy are in high demand in rural areas, it is important that they cater to the barriers identified
by rural inhabitants to maximize the efficacy of these services. More research is needed to determine the
extent to which health insurance coverage seen in rural-ag populations and affects the accessibility of
health care services.

Goal and Objectives

Our goal is to determine the barriers to accessing medical nutrition therapy among type II diabetics in
rural-ag communities within south Sacramento County. Within an 8-month time frame, we expect to
achieve the following objectives:

1. Determine target population’s self-perceived access and motivations for obtaining healthcare, and
by extension, medical nutrition therapy.

2. Determine the extent to which dietitians are available within the major medical groups of
Sacramento to provide medical nutrition therapy services to rural-ag communities.
Methods
Target Population/Setting
In Sacramento County alone, approximately 7.2% of the population is afflicted by type II diabetes
(T2DM), which accounts for a total of 76,000 individuals. 18 Our target population includes individuals
with type II diabetes residing in nine rural-ag communities of south Sacramento County (Clay, Courtland,
Galt, Herald, Hood, Isleton, Rancho Murieta, Walnut Grove, Wilton). This project will span a total of five
months, from January-May of 2018. Data will be collected remotely from the above-identified rural
communities and from the top six medical groups within Sacramento County (Kaiser Permanente Medical
Group Inc., UC Davis Medical Group, Hills Physicians Medical Group, Sutter Independent Physicians
IPA, Sutter Medical Group, Mercy Medical Group).19
Data Resources
While existing studies have examined accessibility of healthcare among rural populations, this
study will survey a specific locale to determine the accessibility of medical nutrition therapy (MNT).
Thus, our data will be collected from the activities defined in this project. Focus groups of 5-10
individuals will be held at a location central to each of the nine identified counties. We will contractually
hire a bilingual (English- and Spanish-speaking) focus group moderator who will work with two research
assistants to develop a survey instrument that will reflect the self-perceived access and motivations of our
target population. We plan to break our nine focus groups into either English or Spanish speaking groups,
as necessary, for a total of 18 groups maximum. All focus group interview sessions will be recorded for
purposes of data analysis.
Activities
Flyers, newspaper ads, and radio ads (in both English and Spanish language) will be disseminated
throughout the nine respective rural communities and at community health fairs to garner participation
from type II diabetics. The advertisements will contain a phone number and webpage address that
interested participants can use to confirm their interest in attending the focus group. Research assistants
will sort participants and call them back to confirm attendance prior to the dates of the focus groups. Each
of the 9-18 focus groups will be facilitated in-person at their pre-determined, centralized locations.
Questions will also address considerations not widely included in the literature, such as employer-
sponsored insurance coverage. Questions pertaining to ethnic and cultural backgrounds will also be
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Final Project

included. The contract moderator will facilitate our focus group(s). We expect focus group questions to
address barriers identified in the literature, such as: transportation, time, lack of knowledge, social
networks, motivation, skillsets, and finances.2-3 Our Program Director will initiate, schedule, and conduct
phone interviews with the top six medical groups in Sacramento to determine whether they utilize
dietitians on-staff, via contract, or via referrals for providing MNT services. This data will be used to
determine whether MNT is available within our target population’s locale, while also setting the stage for
future interventions that allow these services to reach our population, if they are not already.
Analysis/Evaluation
Data will be collected via phone and in-person interviews and entered into a designated project
laptop, either in real time (i.e. directly into computerized electronic fields during phone interviews) or
immediately following a focus group. Data will remain on this computer for statistical analysis, and will
be solely accessible by the Project Director and two research assistants via private login credentials. In
alignment with our project objectives, our outcome measures are as follows: 1) individuals from each of
the nine rural communities were represented, 2) the focus groups addressed groups of questions that
determine which set of barriers are specific to this target population, and 3) the phone interviews
determined whether dietitians are available for individualized MNT services, whether they are only
available in-person, and whether they are available often enough for rural patients to access them.
Timeline

Task Time to be Timeframe Personnel Responsible

completed

Research and assemble contact 1 week 2nd week of January Project Director
information of Medical Groups in 2018
Sacramento County

Hire and discuss needs with contract focus 6-7 weeks 2nd week of January Project Director
group moderator through February 2018

Schedule and conduct phone interviews 4 weeks Mid-January through Project Director
with six Sac County Medical Groups, Mid-February 2018
collect and compile responses

Determine location of focus group that will 2-3 weeks 2nd week of January to Research Assistants 1 & 2
be central to the nine identified rural February 2018
communities, prepare information for
distribution to target community (i.e.
flyers, ads), attend health fairs (e.g.
Ventanilla de Salud Health Fair)

Distribute information regarding focus 6 weeks February to Mid- Research Assistants 1 & 2
group within each of the nine target March 2018
communities (i.e. newspapers, radio,
storefronts), attend health fairs (e.g.
Ventanilla de Salud Health Fair), collect
and attendance confirmations
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SPH 222
Final Project

Select/sort focus group(s) participants, 1-2 weeks Mid-End of March Contract Focus Group
prepare for focus group and contact 2018 Moderator, Research
participants to confirm attendance Assistants 1 & 2

Facilitate focus group(s) at pre-determined 8 weeks April-May 2018 Contract Focus Group
locations, compile and organize responses Moderator, Research
(data) Assistants 1 & 2

Review responses from Medical Groups 12 weeks June-August 2018 Program Director, Research
and focus groups for thorough statistical Assistants 1 & 2
analysis

Budget Considerations
Direct costs will include the part-time wages of our Program Director and Research Assistants, as
well as the contract fees for our Focus Group Moderator. Materials for information dissemination (i.e.
flyers, advertisement space) will also be considered within this total, along with the fee for a designated
program laptop. Indirect costs might include transportation, phone fees, facility use/utilities for the focus
group meeting location, and hospitality services (e.g. coffee, water).

Expected Results
We expect that the self-perceived access and motivations for rural South Sacramento residents
obtaining healthcare and specialty services like medical nutrition therapy (MNT) will be low. Second, we
similarly expect a sparse number of available dietitians to provide medical nutrition therapy services in
these communities. Because T2DM affects a significant number of people within our greater target
population, we expect that there will be several individuals within each of the nine communities selected
for this project.18 Thus, we expect that there will be adequate representation from each community, in
alignment with our project’s first outcome measure. By contracting with a professional focus group
moderator, we expect our project’s focus group questions to be effective at determining whether the
barriers we believe will influence our population do actually hinder them from accessing healthcare and,
ultimately, medical nutrition therapy. We hypothesize that these barriers will hold true for this population,
in addition to other barriers that are specific to this locale. Jones et al. mention that rural communities
themselves are not homogenous, which suggests that there a variety of unique factors that might
distinguish rural community from rural community.2 Therefore, we expect to see variance in the social,
behavioral, and environmental factors that affect each of our target communities. However, because we
are targeting rural-agricultural communities, we anticipate members of our population to maintain frigid
schedules relative to their farm work, a low SES status, and transportation limitations.
The second segment of the project will consist of detailed phone interviews with various medical
groups in Sacramento County. These phone interviews will inquire about the on-site and off-site
availability of dietitians, as well as insurance coverage considerations for their services. We hypothesize
that most dietitians will be on-site staff, whether they are contracted part-time or are part of the medical
groups full-time. Given that Medicare covers MNT services for prediabetes, type I, and type II diabetes,
we expect to that individuals with insurance are able to receive covered MNT. 20 At this time, MNT
services are not covered under Medicaid. However, we hypothesize that individuals who are uninsured
will not have the out-of-pocket means to receive MNT.

Anticipated Challenges and Proposed Strategies

While we have identified several ways in which we plan to reach the target population, it is
possible that some of the population will not be reached by way of our strategies. Jones et al. describe that
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Final Project

recruitment of rural participants is a challenging process, given their geographical isolation, inflexible
schedules, and other factors pertaining to each respective rural community.2 Jones et al. purport that
because rural communities are not homogenous, these other factors for nonparticipation can vary greatly.2
This project aims to make MNT services more available to all rural type II diabetics, but we anticipate
that those who voluntarily choose to participate in our focus groups will be more likely to volunteer their
concerns and the barriers they experience, and will be more motivated to seek out MNT services. 2 If we
are unable to garner enough participation that is representative of our population, we may consider
speaking with diabetics in the community one-on-one to get adequate feedback. We may hold focus
groups in one or two centralized locations and offer up transportation services, in order to still collect data
for the purposes of this project. It is also possible that individuals who we reach will not want to
participate in a focus group for reasons of anonymity or a desire to be spoken with individually.
Nagelkerk et al. found that, when learning about self-management, diabetics may prefer one-on-one
interaction, rather than group education sessions.3 This preference may similarly carry over to groups
discussions about healthcare access, where diabetics may prefer to be spoken to one-on-one for all issues
pertaining to their individual health. Some of our target population may also not have the scheduling
flexibility to attend a focus group session, given that their agricultural occupations keep them from
attending certain scheduled appointments.2 Thus, we may ask our focus group moderator to develop a
survey based on focus group responses that we can utilize in future projects, or in one-on-one meetings
with diabetics who prefer to remain anonymous or require an individualized meeting due to scheduling
conflicts. Moreover, we do not have data indicating the exact prevalence of diabetes within each of the
nine communities we are targeting. So, it is possible that we will not have enough diabetic participants to
have a sampling that is representative of each community. Lastly, we anticipate that some of our
identified medical groups will not have the time or desire to participate in phone interviews. In this
instance, we will consider reaching out to clinics or other individual healthcare facilities where we would
expect to see dietitians servicing rural communities.
Madeline Lasell
SPH 222
Final Project

References
1. Global Report on Diabetes. World Health Organization 2016.
2. Jones L, Crabb S, Turnbull D, Oxlad M. Barriers and facilitators to effective type 2 diabetes
management in a rural context: a qualitative study with diabetic patients and health professionals.
J Health Psychol. 2014;19(3):441-453.
3. Nagelkerk J, Reick K, Meengs L. Perceived barriers and effective strategies to diabetes self-
management. J Adv Nurs. 2006;54(2):151-158.
4. Bolin JN, Bellamy GR, Ferdinand AO, et al. Rural Healthy People 2020: New Decade, Same
Challenges. J Rural Health. 2015;31(3):326-333.
5. Kurpas D, Mroczek B, Bielska D. Rural and urban disparities in quality of life and health-related
behaviors among chronically ill patients. Rural and Remote Health. 2014;14(2485).
6. Marincic PZ, Salazar MV, Scott S, Fan SX, Gaillard PR. Diabetes Self-Management Education
and Medical Nutrition Therapy Improve Patient Outcomes: A Pilot Study Documenting the
Efficacy of Registered Dietitian Nutritionist Interventions through Retrospective Chart Review.
Journal of the Academy of Nutrition and Dietetics. 2017;117(8):1254-1264.
7. Franz MJ, Powers MA; Lahkkamnweg CL. The Evidence for Medical Nutrition Therapy for
Type 1 and Type 2 Diabetes in Adults. Journal of the American Dietetic Association
2010;110:1852.
8. Daly A, Michael P, Johnson EQ, Harrington CC, Patrick S, Bender T. Diabetes White Paper:
Defining the Delivery of Nutrition Services in Medicare Medical Nutrition Therapy vs Medicare
Diabetes Self-Management Training Programs. American Dietetic Association. 2009;109(3):528-
539.
9. Pastors JG; Franz MJ; Warshaw H, Daly A, Arnold MS. How effective is medical nutrition
therapy in diabetes care? Journal of the American Dietetic Association. 2003;103(7):827-831.
10. Soria-Contreras DC, Bell RC, McCargar LJ, Chan CB. Feasibility and efficacy of menu planning
combined with individual counselling to improve health outcomes and dietary adherence in
people with type 2 diabetes: a pilot study. Can J Diabetes. 2014;38(5):320-325.
11. Pastors JG, Warshaw H, Daly A, Franz M, Kulkarni K. The evidence for the effectiveness of
medical nutrition therapy in diabetes management. Diabetes Care. 2002;25(3):608-613.
12. Smith SM, O'Leary M, Bury G, et al. A qualitative investigation of the views and health beliefs of
patients with Type 2 diabetes following the introduction of a diabetes shared care service. Diabet
Med. 2003;20(10):853-857.
13. MNT Versus Nutrition Education. The Academy of Nutrition and Dietetics.
http://www.eatrightpro.org/resources/payment/coding-and-billing/mnt-vs-nutrition-education.
Accessed September 13, 2017.
14. Davidson PL, Anderson RM, Wyn R, Brown ER. A Framework for Evaluating Safety-Net and
Other Community-Level Factors on Access for Low-Income Populations. Inquiry. 2004;41:21-
38.
15. Kaplan GA, Everson SA, Lynch JW. The contribution of social and behavioral research to an
understanding of the distribution of disease: a multilevel approach. In Smedley BD, Syme SL
(eds), Promoting health: intervention strategies from social and behavioral research. Washington,
DC: National Academies Press; 2000.
16. Anderson, RM. The Anderson Healthcare Utilization Model. 1968.
17. Myers C, Slack, T, Martin C, Broyles S, Heymsfield S. Change in Obesity Prevalence across the
United States Is Influenced by Recreational and Healthcare Contexts, Food Environments, and
Hispanic Populations. PLoS One. 2016;11(2): e0148394.
18. Burden of Diabetes in California. California Department of Public Health, Chronic Disease
Control Branch. 2014.
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19. Top of the List: Medical Groups. Sacramento Business Journal 2013.
https://www.bizjournals.com/sacramento/news/2013/07/19/top-of-the-list-medical-groups.html.
Accessed August 30, 2017.
20. Nutrition therapy services (medical). U.S. Centers for Medicare & Medicaid Services.
https://www.medicare.gov/coverage/nutrition-therapy-services.html. Accessed September 7,
2017.