Student Name

Capella University

NURS FPX 6011

Professor Name

Submission Date

Implementing Evidence-Based Practice

Type 2 diabetes is an increasing chronic disease in the U.S., as it encroaches on various communities within the country. One population that has an increased incidence of Type 2 diabetes is South Asian immigrants (Ali et al., 2021). While there are a significant number of evidence-based methods to treat patients with Type 2 diabetes, many from this community do not have access to these treatments as a result of barriers (cultural, linguistic, systemic) to receiving treatment. Much of the role of the nurse who is prepared at the master level is to bridge evidence-based practice and clinical practice. This poster contains an implementation plan that is built on evidence-based practice towards enhancing outcomes in South Asian adults with Type 2 diabetes using a structured action plan, which involves a PICOT question, stakeholder engagement, and measurable outcomes aligned with the Quadruple Aim.

Background information on the clinical problem

Type 2 diabetes is more prevalent among South Asian adults in the United States compared to other ethnic groups (Misra et al., 2025). South Asian adults are more likely to be affected by the disease at earlier ages and lower body weight compared to other ethnicities due to many aspects of their lives, such as their diet consisting of large quantities of refined carbohydrates, less physical activity, linguistic barriers, and distrust in the healthcare system. Moreover, South Asians are frequently unable to afford preventive services or even lack access to health insurance, which introduces an even bigger gap between what evidence there is that applies to diabetes treatment and the clinical treatment of South Asian adults with diabetes. The implementation plan will close this gap by availing evidence-based and culturally competent tools to manage diabetes among the South Asian communities.

PICOT Question

Among South Asian adult immigrants aged 30-60 years who have type 2 diabetes in the United States, does a culturally sensitive, community-based health worker-led diabetes self-management education intervention, including mHealth technology, versus the standard treatment with diabetes care, lower HbA1c levels by at least 0.5 percent and improve the attendance rates in diabetes education by 60 percent at a six-month follow-up?

·         P (Population): South Asian adult immigrants in the United States aged between 30 and 60 years and who have been diagnosed with type 2 diabetes.

•         I (Intervention): A culturally-based educational program on self-management of diabetes using the native languages and administered by community health workers, and the MySugr mHealth application for daily blood glucose monitoring.
•         C (Comparison): Routine diabetes care offered, which lacks culturally oriented education or community health worker interventions.
•         (Outcome): Decreased average HbA1c by at least 0.5% and 60% more attendance at diabetes education sessions.
•         T (Time): in six months

Action plan for implementation

The new practice change to substitute the current diabetes education that is generic in nature is a culturally-based Diabetes Self-management education program. The program will take the form of a program by Community Health Workers (CHWs) who have been trained on how to conduct the program in the local mosques and community centers using Urdu, Hindi, and Punjabi. The content will be based on educating people on how to handle their traditional foods that South Asian communities consume by controlling their portions, engaging in more activity, and recording their daily blood sugar levels using MySugr. Subhan et al. (2022) observed that culturally adapted diabetes education leads to many more improvements in medication adherence as well as food behaviors than traditional care in South Asian populations.

This project has a 6-month timeline. During the initial month of the project, the recruitment and training of CHWs, translation of the materials into each of the 3 languages, creating partnerships with local organizations, and establishing FQHCs will be completed. During months 2-4, CHWs will hold group educational sessions at various community locations each month. The CHWs will also onboard patients to MySugr during these same months and support patients in between sessions. The monthly 5-6 telehealth check-ins and HbA1c tests at the local FQHCs will be conducted to assess patient progress.

Tools and Resources

These materials will include educational materials in Spanish-speaking and English-speaking communities and some of the Urdu/Hindi/Punjab-language visual aids. A diabetes management App, such as MySugr, and telehealth to provide distance consultation; home near point-of-care (POC) devices to measure HbA1c; collaborations between FQHCs to provide clinical support in delivering medical care (such as laboratory tests) (Rural Health Information Hub, 2025). Moreover, reminder services through SMS messages in their native language over the telephone to patients who lack access to a smart device (Dawson et al., 2025).

Stakeholders Identification

The most important stakeholders will be the patients since they will enjoy improved diabetes education and a lot more choices for managing their diabetes. An important role in delivering the intervention and building trust in the community will be the Community Health Workers (CHWs). The nurse and physician in the primary care system will primarily be responsible for clinical improvement tracking and reviewing laboratory tests (Smith et al., 2022). The South Asian Health Network (SAHN) will help in participant outreach and recruitment. Mosques and cultural centers will help in promoting the program to their members through religious and community leaders. Community staff will offer HbA1c tests, telehealth, and medication management throughout the project.

Opportunities for Innovation

Another important aspect of the project is that it is aimed at offering new and innovative means of providing community-based health services to underserved communities. One way that the use of Community Health Workers (CHWs) provides opportunities to overcome some of the most severe barriers to effective engagement is through their ability to provide culturally congruent care and establish trust with their patients by being able to communicate in the same language and share similar cultural experiences (Lapidos et al., 2021). Numerous studies reveal that culturally competent care will raise the utilization of services among immigrant groups.

The study area will help patients monitor their blood sugar levels and their diet, including the foods commonly consumed by South Asian communities, by utilizing the MySugr mHealth app. Unfortunately, traditional diabetes self-management tools do not have those foods available (Tuobenyiere et al., 2023). Patients who do not have smartphones have an opportunity to get messages in their language as a more affordable method of getting reminded. Healthcare can be provided to patients in the form of telehealth services, and thus patients do not need to visit the office and see doctors. It helps long-time workers or patients who may have difficulty getting transportation, and a study has revealed that patients under telehealth services have better blood sugar regulation and are more satisfied when compared to patients who meet their doctors face to face.

Possible obstacles and Response

Our current initiative has many barriers to effective implementation. Nevertheless, we can take some real-life actions to deal with each of them. One way to work with cultural barriers to implementing this program is to have members of the targeted community serving as community health workers (CHWs) deliver the program, as well as having religious leaders introduce the program at large community functions (Idriss-Wheeler et al., 2024). We will also make all program materials available in Urdu, Hindi, and Punjabi and will also have CHWs on hand to offer face-to-face assistance to participants during each session. In the case of patients with low digital literacy, CHWs will also guide them through the process of MySugr app setup, and SMS-based messages will be used as an alternative reminder method for patients who lack access to a smartphone. There will be no costs related to any aspects of the program, as it will eliminate financial barriers, and privacy issues will be ensured through the HIPAA-compliant communication process. There will be an informed consent process prior to the data collection.

Outcomes Criteria

Three outcomes that can be measured will be used to evaluate the project. The first outcome will be a 0.5% decrease in the average HbA1c level by the end of 6 months from baseline. It can be defined as the mean of three point-of-care HbA1c tests that the Federally Qualified Healthcare Center (FQHC) location facilitated by the study location collected at the initial data collection and collected at the end of 6 months. HbA1c lacks a clinically significant variation, but a 0.5% reduction in HbA1c has been widely reported as a valid measure of improved glycemic control. The second quantifiable change will be the 60 percentage of the attendance rate in the diabetes education classes in the first 3 months following the program implementation, which will be monitored every month. The rate of attendance at diabetes education classes can show whether or not the program is efficient in responding and reaching the target community (Deverts et al., 2025). The third outcome that can be measured is that at least half of the participants will consistently utilize the MySugr app or SMS self-management tools for at least 90 days. The data on the usage of the app and the records of SMS responses will be used to gauge the use of the MySugr app or SMS reminders by the participants, and regular use of self-management technology correlates with higher quality of health outcomes in the long-term.

Congruence with Quadruple Aim

The project is in alignment with all four aspects of the Quadruple Aim. To achieve a patient experience, education provided in the first language of the patient across the different known places in the community enhances the level of comfort, trust, as well as satisfaction. To enhance population health, the reduction of HbA1c in a high-risk population will enhance the overall health outcome of the South Asian community (Farhat, 2023). To reduce costs, self-management will be enhanced, leading to fewer emergency room visits and hospitalizations, as well as reduced overall cost of diabetes care. To ensure provider and workforce wellness, the clearly defined duties and structure of Community Health Workers and nurses will decrease care coordination-related burdens and aid in eliminating provider burnout.

Evidence-Based Practice Impact

The interventions in this project are backed by evidence from peer-reviewed studies. South Asian populations had higher rates of Type 2 Diabetes as compared to all the other ethnicities in the United States. Widiastuti et al. (2026) also reported that culturally-based diabetes education resulted in better self-management and medication adherence, and Liu and Xia (2025) discovered that the use of m-health apps to monitor blood glucose resulted in better glycemic control. Also, Zábó et al. (2025) found that interventions using SMS led to a higher number of people attending appointments and adherence to medication among underserved populations. Ethical concerns, including the need to have informed consent of the participants before any data is collected, security of the data collected by the community health workers under HIPAA guidelines, and training of community health workers to honor confidentiality and cultural sensitivity, in both their training process and the overall period of this initiative, have been addressed.

Value and Relevance

The authors conducted a systematic search of research articles written in English concerning type 2 diabetes among South Asian immigrants who receive culturally sensitive education, mHealth, community health workers, and diabetes self-management through online databases such as PubMed, CINAHL, and Google Scholar. The search strategy included peer-reviewed articles that were published in the last 5 years. The quality, relevance, and methodological strength of the articles were evaluated.

Taken altogether, the evidence is overwhelming in support of a practice change, with Gong et al. (2025) showing that adults of South Asian descent have a higher rate of diabetes compared to other ethnicities, which means that there is a dire need to provide culturally targeted intervention. Rahim et al. (2024) found that culturally-specific education for South-Asian patients can help in managing diabetes. Belete et al. (2023) revealed that text message apps as mobile health (mHealth) tools were effective in the management of blood glucose levels, enhanced treatment adherence, and augmentation of quality of life in patients who often have minimal or no access to health care treatment resources. The three references above were included in this implementation plan due to either their relevance to the target clinical problem that is being tackled by this implementation plan or their relevance to the target patient population. All three sources are reputable and reliable scholarly peer-reviewed journals, and thus they have the credibility that is appropriate to be used as references in this implementation plan. 

Conclusion

Most of the South Asian people are at a higher risk of Type 2 diabetes (T2D) mainly because of their genetic predisposition, poor eating habits, and lack of health resources in their culture. With the help of mobile health (mHealth) technologies to create a diabetes self-management educational program (DSME), South Asian populations will be equipped with more means of managing their diabetes by using community health workers (CHWs) and telemedicine. Finally, provide culturally competent education and support to South Asians at risk of T2D and narrow the research-to-practice gap in diabetes self-management for this group.