Diabetes in the United States;Socio-economic determinant,add one paragraph for this part including the reference used.

Public Health Problem and Population
Type 2 diabetes is a chronic disease related to an increase in blood glucose level (American Diabetes Association, 2014). This abnormality is associated with a dysfunction of the pancreatic β-cells which role is to produce insulin, a hormone essential in the regulation of blood glucose (American Diabetes Association, 2014). Factors such as genetics, unhealthy lifestyle, obesity, and inactivity are incriminated in the occurrence of type 2 diabetes (DeFronzo et al., 2015). At an individual level, this disease is known to be life-threatening and disabling because of complications such as blindness, nerves failure, renal failure, and cardiovascular disease (American Diabetes Association, 2014). At the federal level, diabetes is responsible for a tremendous economic burden in the US. Statistics from 2007 has shown that about $153 billion are spent in medical care and $ 65 billion in reduced productivity (Dall, Zhang, Chen, Quick 
Yang, & Fogli, (2010).).
The issue of type 2 diabetes is a worldwide concern. According to the world health organization (2003), the number of individuals with type 2 Diabetes is increasing globally, and it will reach at least 350 million people in 2030. Diabetes is one of the most challenging health issues in the world, and the United States doesn’t make an exception. In the U.S. the 2015 incidence of type 2 diabetes was estimated to 6.7 per 1,000 people, and the prevalence of diagnosed and undiagnosed diabetes was 9.4 % (CDC, 2017). Diabetes is a leading cause of death in the United States. Around 79,535 deaths were attributed to this disease, and the crude mortality rate was estimated to 24.7 per 100,000 persons (CDC, 2017). 
Regarding Diabetes disparity, studies have shown that African-American presented a higher prevalence, higher mortality and also a higher risk of developing diabetes complications such as Retinopathy, Neuropathy, renal failure when compared to Non-Hispanic-white (Rosenstock et al., 2014). According to Rosenstock et al., (2014), African-American are four times more likely to develop a complication and two times more chances of dying from the disease. The primary cause of this health disparity among African-American is explained by a socio-economic inequality followed by segregation. This study has shown that poverty explained 58.5% of the disparity (Rosenstock et al., 2014)
Health Determinants
Multiple factors cause type 2 diabetes. While genetic factors play a role in the occurrence of the disease, there are other factors such as health behavior, environment, and socio-economic status that contribute to the development of Diabetes. (Kommoju & Reddy, 2011).
Genetic Factor
Genetics is a significant risk factor in the occurrence of type 2 diabetes. However, its mechanism remains unclear, there are many pieces of evidence about the increased risk among people who have relatives affected by diabetes. Studies have found an association between family history and a higher incidence of type 2 diabetes (Scott et al. 2013). Kommoju &Reddy (2011) argued that offspring have a 40% risk of developing diabetes if one parent has the disease and this risk increases when both parents present the condition.
Health Behavior
Individual’s degree of knowledge about diabetes and the environment in which they are living may have an impact on the occurrence of the disease. For example, a low perceived susceptibility combined to a low perceived risk may influence negative behavior that may lead to an increased risk of developing the disease. In general, knowledge regarding the different risk factors of type 2 diabetes is low in the United States (Paige, Bonnar, Black, & Coster 2018). Lifestyle also differs among people, and it is also an important determinant of type 2 diabetes. For some reasons, people may be more interested in sweet and fatty foods. Studies have found that red meat consumption (particularly the processed meats), sugar-sweetened beverage, and also a sedentary lifestyle are associated with higher risk of developing type 2 diabetes (Ley et al. 2016). The authors stated that most of type 2 Diabetes cases could be avoided if people adopted a healthier lifestyle that includes physical activities and healthy diet.
Environmental Determinant
The environment features may significantly impact people’s risk of developing type 2 Diabetes. There is evidence that an unsafe environment where a lot of violence occur is related to higher prevalence of the disease. In a cross-sectional study, Gebreab et al. (2017) found a strong relationship between Neighborhood problems and Higher prevalence of type 2 Diabetes among the African-American population. 
Furthermore, Lack of healthy food may be an issue in some environment. According to Gebreab et al., (2017) a higher number of unhealthy food store in a neighborhood was related to a 34% increase in the incidence of type 2 Dabetes.
Another Diabetes environmental determinant is the exposure to pollutants. Specific environmental pollutants are found to be related to the incidence burden of type 2 Diabetes. For instance, the Agricultural Health Study conducted in the U.S. has found a relationship between exposure to organophosphate insecticides and increased risk of developing type 2 Diabetes even after controlling for Body Mass Index (BMI), State of Residence and age (Montgomery, Kamel, Saldana, Alavanja, & Sandler, 2008).
Socio-economic determinant
I also need one paragraph for this part including the reference used.

Effective Strategies
Health Screening
Diabetes screening is performed routinely or for people who are at risk of developing the disease such as obese individuals or those with hypertension (Selph et al., 2015). However, there is no evidence that screening can lead to a decrease in blood glucose level, an early diagnosis of diabetes followed by an early treatment is essential to a better health outcome (Selph et al., 2015). In the United States, the 2008 recommendation from the U.S. Preventive Services Task Force (USPSTF) suggested systematic diabetes screening for all adults with elevated blood pressure (above 135/80 mmHg). The reason for this intervention is that hypertensive persons who also are screened positive for diabetes need a more intensive blood pressure treatment. This intensive treatment is associated with a decrease in cardiovascular issues including mortality (Selph et al., 2015). 
Furthermore, a Canadian study that assessed the effectiveness of diabetes screening in the workplace has found that screening is beneficial for Diabetics and prediabetics. The authors of this study found a significant decrease in glycated hemoglobin (average of three-month plasma glucose) among this population group during the follow-up period (Tarrid et al., 2018).
Educational Program 
In the United States, factors such as lifestyle may have a significant impact on the increasing incidence of type 2 Diabetes (Albright & Gregg, 2013). A body of evidence from various randomized clinical trials about a lifestyle change program was conducted in different countries (the U.S., China, Finland, Japan, and India) leading to exciting findings. The result from these studies found a 30% – 60% decrease in the incidence of diabetes among people at high risk who received the intervention (lifestyle change program) (Albright & Gregg, 2013).
In order to promote a behavioral change across the country, CDC established a program named the “Diabetes Training and Technical Support (DTTAC)” that train coaches all over the country. Those coaches in their turn deliver a lifestyle change program through in-person training, but they also provide continuous training for the communities (Albright & Gregg, 2013). Those intervention strategies may be the key to disseminate awareness regarding the effectiveness of behavioral change, especially a healthy lifestyle in the prevention or delay of type 2 diabetes in the U.S.
Social Support Intervention
Social support in Diabetes care management encompasses a variety of support forms that include emotional and financial support. There is evidence that people’s satisfaction from that support is beneficial to the improvement in the behavior of people with type 2 diabetes (Tang, Brown, Funnell, & Anderson, 2008). According to Tang et al., (2008), there is growing evidence that receiving a high level of support is associated with better diabetes-related health outcome and better self-management behavior. In a cross-sectional study conducted among African-American adults with type 2 diabetes, Tang et al., (2008) examined the relationship between social support and diabetes-specific quality of life and self-care behaviors. The authors found that participants who benefited from greater positive support are more likely to eat healthy, to respect the recommended carbohydrate consumption across the day and also to be involved more frequently in a 30 minutes exercise plan.
Policy Development and Implementation
To address the issue of type 2 Diabetes, both governmental and private sector need to develop and implement policies regarding healthy nutrition, a healthy environment that is suitable to practice exercise and promotion of affordable diabetes prevention for all U.S citizens who are at high risk of developing the disease (Bergman et al., 2012). The Affordable Care Act (ACA) is an example of a U.S. policy that may influence diabetes prevention at multiple levels (Konchak et al., 2016). ACA policy implementation includes insurance coverage, educational campaign regarding the benefit of prevention and the requirement for owners of chain restaurants to present information about the nutrients contained in the food and the daily calorie recommendation. (Konchak et al., 2016).
Program Proposition
Type 2 diabetes is a real public health concern in the United States, and there is a need for developing a program that may help to address this pandemic. Even though the risk of developing diabetes-related complications has decreased from 1995 to 2008, there is still a lot to do regarding complication prevention because of the rising prevalence of diabetes in the U.S. population overall (Albright & Gregg, 2013). The program that I will propose would not only consider diabetes and its complications, but it will also focus on primary prevention of type 2 Diabetes.
Educational Program for Healthy Lifestyle Promotion in Schools 
I propose to include in elementary schools an educational session that will be used as a primary prevention tool to reduce childhood obesity through the promotion of a healthy lifestyle such as the practice of physical education and the development of healthy eating behavior. This program may help decrease the incidence of diabetes in the future as studies have shown that there is evidence of a relationship between obesity and risk of developing diabetes (Mokdad, Bowman, Ford, Vinicor, Mark, & Koplan, 2001). This program will consist of training elementary school teachers that will administer a 30 minutes education session once a month. 
TV Educational Program 
This program will primarily target both the U.S. general population for whom the disease does not occur and also those who already have the condition. It will consist of a weekly 15-minute campaign that will spread awareness at a national level. This campaign will address the different risk factors, the potential disabling complications that result from type 2 Diabetes, the cost related to the disease management and the different ways of prevention such as a change in lifestyle.
In order to reach the maximum number of people, an educational TV program will be available on national TV channels. In a prospective controlled trial that examined the effectiveness of anti-smoking TV campaigns, the authors found a decrease in smoking prevalence in the region that received the anti-smoking TV campaign (McVey & Stapleton 2000). Based on this evidence, we assume that an educational TV program may be a great strategy to decrease the prevalence of type 2 diabetes as a result of adequate behavioral change.
Free Diabetes Screening and Free Transportation
Diabetes screening and transportation will be cost-free as some people may not access to health care for financial reasons. According to Rabi et al., (2006), the risk of developing diabetes is 13% higher among people with lower-income compare to those with higher income. We assume that if these people develop diabetes, their chance of lacking good health care by missing follow-up appointment, because of limited income may be high. This program will advertise a free annual diabetes screening by sending a notification through the mail for people free of Diabetes that are 40 years old and above. Regarding people with diabetes, they will be informed by their health care provider that the follow-up screening will be free of charge.
Another issue that needs to be considered is the problem of transportation. We will sign a contract with UBER to provide a free ticket to people with Diabetes who cannot afford transportation cost for their follow-up. One ticket will be available for each follow-up appointment and cannot be utilized for another purpose. 
Construction of Recreational facilities
Funding from state level will be needed to build a safe recreational facility in communities in need of it. Those facilities will include walking pathways allowing families to exercise at any time of the day. To increase the numbers of people who use the facilities, there will not be any cost related to its use. This program may be a way to motivate people who do not exercise for reasons such as lack of facilities in the neighborhood or safety reasons. The use of these facilities will help non-diabetics reduce their risk of developing diabetes, and it will also help people with diabetes to lower their blood sugar level. Studies have shown that exercise is related to the decrease of glucose level (Albright, & Gregg 2013).
Budget for Diabetes Program
A. Salary Total: 1,400,000 
Nursed will in one-time train teacher on how to deliver the educational program to their students. They will spend two hours on the training, and the cost will be $200 per nurse. 1000 nurses will be needed to cover all the U.S. Country The total cost for all nurses that will train teachers across the U.S. will be $200 x 1000 nurses = $ 200,000
The teacher will deliver a 30 minutes educational program that promote a healthy lifestyle to their student once a month, and this will be extra time to their regular teaching hours. The cost will be $ 50 for the 30 minutes with an individual annual cost of $ 600. The total cost for all trained teachers will be $600 X 2000 teachers = 1,200,000
B. TV advertising Total: $ 52,000 
There will be a 15 minutes weekly session of diabetes prevention campaign that will be delivered nationally. The TV channel company that will be used will receive a payment of $ 1000 per session. The annual cost will be $ 1000 x 52 weeks = $52,000
C. Recreational facilities Total: $ 2,000,000
Land appropriation: To build 300 recreational facilities across the country, we need to buy 300 pieces of land. The cost per plot is $20,000 and for the 300 plot it will be $20,000 X 300 = $6,000,000
Contract with construction companies: To build the recreational facilities we will give a contract to the construction’s companies. The cost to build one facility is $5000, and for the 300 facilities it will be $5000 x 300 = 1,500,000
D. Laboratory Cost: Total: $ 10,050,000
To perform the Diabetes screening, a blood sample is needed to be tested by laboratory personnel. The annual individual cost for the test is $50 for non-diabetics, and we estimate the number of people who will do the screening to 1000. The total cost is $50 x 1000 = $ 50,000. For Diabetics, their estimated number is 100.000, and they will do the follow-up screening twice a year. The cost is $ 100 x 100,000 = 10,000,000.
E. Transportation Total: $300,000
People with diabetes who cannot afford transportation will receive a free UBER ticket to go to their follow-up. Their number is estimated to 30.000. The Uber cost will be $ 10 x 30.000 = $ 300,000.
F. indirect Cost = N/A Total: $0.00
Total: $ 13,842,000








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