To prevent diabetes and increase equitable access to health care screenings, Touro University California has created and implemented a community outreach program called the Mobile Diabetes Education Center (MOBEC). This program is a joint effort that also involves Sutter Health, the California Department of Public Health, Kaiser Permanente, the Solano County Department of Public Health, and community-based organizations, focusing on advancing health equity in Solano County’s at-risk populations. This article reports on the services and initial successes of MOBEC. With its strong community collaboration, MOBEC has helped to raise awareness of diabetes and ensure access to much-needed health screenings and education. This model can potentially be used as a blueprint for similar efforts nationwide to address the health care needs of medically underserved communities.
Prediabetes and type 2 diabetes have become a noncommunicable pandemic. More than one in three Americans have prediabetes, and almost half of Americans >60 years of age have prediabetes (1). Despite abundant knowledge and evidence-based screening programs, >80% of these people are unaware of their diabetes status (1). Without any intervention, many will progress to type 2 diabetes. More than one in 10 American adults have diabetes, with 20% undiagnosed (1).
Type 2 diabetes is like many chronic diseases in the United States; it is closely tied to lifestyle behaviors, often asymptomatic, and requires risk-based screening. Almost 60% of U.S. adults have at least one chronic disease, and 40% have multiple chronic conditions (2). Chronic conditions such as diabetes impose significant morbidity and mortality, substantiating high health care system costs. It has been estimated that reducing unhealthy behaviors such as smoking, sedentary lifestyle, and excessive caloric intake could save 1.1 million lives and reduce the current $4.1 trillion annual cost of health care (3).
Diabetes is a progressive condition that requires timely diagnosis and intervention. Early detection and administration of preventive measures (in the case of prediabetes) or treatment (in those newly diagnosed) lowers the risks of complications. Strong evidence supports the use of asymptomatic screening programs for U.S. adults (4). The U.S. Preventive Services Task Force recommends screening all adults aged 35–70 years with overweight or obesity (4). For individuals at high risk of diabetes or who have prediabetes, enrolling in a lifestyle change program such as the Centers for Disease Control and Prevention’s (CDC’s) National Diabetes Prevention Program (National DPP) using CDC-provided Prevent T2 curriculum is recommended. The National DPP is a 1-year evidence-based lifestyle change program that focuses on achieving weight loss of 5–7% and increasing physical activity and has been shown to reduce progression to type 2 diabetes by >50%. When applied systematically, early detection and intervention with such proven strategies benefit patients, health care systems, and government expenditures (5).
Despite these recommendations, the disease burden of undiagnosed type 2 diabetes in the United States has remained largely unchanged throughout the past 20 years (6). In California, 10.5% of adults have diabetes, and another ∼2.9% have diabetes that has not yet been diagnosed (7). In Solano County, CA, the age-adjusted prevalence of diagnosed diabetes among adults in 2013 was 9.1% (8). Solano County has a lower rate of individuals getting annual A1C screenings than the rest of the state and has higher diabetes-related hospitalization rates, more diabetes-related emergency department visits, and higher rates of death from diabetes-related complications (8).
The relationship between the reduced prevention efforts and higher rates of suboptimal outcomes necessitates a push for targeting and providing a more aggressive approach to earlier awareness of diagnosis and treatment intervention to the undiagnosed population with diabetes. With screening and early intervention, the disease burden in the United States can be reduced. Early detection is most important. However, several clinical barriers make detecting diabetes early challenging (9), including delayed and infrequent assessments. The reasons for inadequate assessments are complex and include limited access to care, distrust of the medical complex, and health care disparities. Although these barriers are by no means new, they have been amplified by the coronavirus disease 2019 (COVID-19) pandemic; nationally, A1C screenings decreased by 59% since the start of the pandemic (10).
In addition, social determinants of health (SDOH) and health inequity are barriers to preventive care and are associated with worse outcomes for many Americans (11). Diabetes is seen more often in at-risk racial/ethnic minority populations. The prevalence of type 2 diabetes is greater in Native American, non-Hispanic Black, and Hispanic populations than among non-Hispanic Whites (1). Some of these populations face structural barriers that make receiving the care they need and deserve more challenging. Such barriers include reduced access to care, economic disparities, limited access to healthy food, and limited opportunities for exercise because of an unsafe living environment. Furthermore, unfamiliarity with the U.S. health care system, language differences, varying education levels, a paucity of financial resources, inadequate or absent health insurance coverage, and undocumented immigration status can all pose severe barriers to receiving needed medical care (12).
Given these challenges with regard to chronic metabolic conditions, novel strategies are needed to improve public health approaches to prevent disease and identify and treat them early when they develop. This article describes a community-based screening program that has had a positive impact in raising awareness of prediabetes and diabetes and improving access to health screenings and education in Solano County, CA. It includes discussion of the program’s development and implementation, which can serve as a template for similar efforts across the country, and summarizes its activities during the COVID-19 pandemic.
Research Design and Methods
The Mobile Diabetes Education Center (MOBEC) was developed in response to the challenges faced in Solano County, CA. These challenges include high rates of diabetes risk factors (e.g., obesity and hypertension), diabetes-related complications, and suboptimal access to health care services. In 2017, the Touro University California DREAM (Diabetes Research Education and Management) Team secured a 65-foot trailer at a reduced cost and received seed funding from Sutter Health to establish the MOBEC.
The MOBEC launch started with a seven-city tour in Solano County to introduce our services to residents. During the tour, the team conducted a needs assessment relating to diabetes education and health care access to inform the prioritization of strategies for screening and education. We asked about community demographics, resident living situations, rates of tobacco use, current levels of physical activity, what services the community members recommend we offer, and what dates and times were preferred for visits. We also asked how they best learn and what learning resources would be most helpful to them. This community needs assessment was crucial in determining what services we would provide initially through the platform. We could modify our offerings based on the needs of the specific community. We also worked with the county health department to form a community advisory board of local residents who were selected to represent the community and would provide input into our activities and advise us about other needed services. For example, the advisory board assisted with new community partnerships and advised changing the appearance of our mobile unit to be “less medical” and more community- and family-focused (Figure 1).
Over the past 5 years, the MOBEC has received funding from Sutter Health, the California Department of Public Health, Solano County Public Health, Kaiser Permanente Community Benefits, and the Janssen Foundation. The funding has been offered on a year-to-year basis.
The MOBEC was initially staffed by two full-time employees: an event coordinator who also drove and managed the MOBEC and a diabetes program manager who was a registered dietitian and a certified diabetes care and education specialist (CDCES). These staff members played a crucial role in successfully introducing the MOBEC to Solano County residents. The team also felt that it would be important to have a CDCES on site to provide timely educational interventions for people with abnormal screening results. Touro University California health professional students also assisted with services on the MOBEC as part of their service-learning opportunities. These students assisted with patient intake, language translation, blood glucose monitoring (BGM), blood pressure monitoring, depression and tobacco screening, and patient education.
As our activities grew, we hired additional staff. First, we hired a part-time, bilingual diabetes programs coordinator assistant who developed materials in Spanish, served Spanish-speaking participants, and served as our main point of contact for social media content development and management. We subsequently hired an outreach coordinator, who oversaw the community advisory group and was a key point of contact linking MOBEC visitors to our additional programmatic offerings, such as a National DPP class and Success with Diabetes (a diabetes education program).
Over the 5-year period, the MOBEC modified its community outreach approach. Initially, the team went to the main seven metropolitan areas in the county to be available as needed for the convenience of the community. A suggestion was made to partner with local organizations to amplify publicity and promotional opportunities for screening events. The team quickly learned that this refined community outreach approach helped to ensure local community buy-in because the local grassroots organizations with which we partnered were already trusted community organizations and could encourage residents unfamiliar with the MOBEC to try our services.
Through this approach, the team has received many invitations to visit local organizations’ sites. Gradually, the MOBEC accumulated a network of partners, including community centers, local food banks, the Salvation Army, county libraries, senior housing facilities, public schools, and churches. These partners could request that the MOBEC be present at their events or provide specific services. Our numerous community partners increased the likelihood that Solano County residents would gain access to and develop trust in the MOBEC.
The screening services offered on MOBEC include the American Diabetes Association’s Diabetes Risk Test questionnaire (13), the two-item Patient Health Questionnaire (PHQ-2) for depression screening (14), SDOH questions (15), blood pressure screening, and fingerstick BGM. Point-of-care (POC) A1C testing (Abbott Affinion 2 ) is offered to visitors with abnormal BGM values.
Based on our resource levels and time factors, we order the diabetes screening so that people complete the risk questionnaire first and then can choose to have a fingerstick BGM check. We only offer a POC A1C test to people who score high on the risk test or who have an elevated BGM reading. We further restrict POC A1C testing to people who do not have a previous diabetes diagnosis because we do not want to disrupt the routine primary diabetes care they are already receiving.
MOBEC visitors can decide which screenings they want. All visitors complete the intake questionnaire, are asked to provide basic demographic information, and are screened for tobacco use, readiness for change, and depression screening (with the PHQ-2). Information is collected on digital tablets and stored in a Qualtrics database. Data are analyzed every 6 months. Separately, we also review the intake questionnaires to determine the continued relevance of the questions. These data are used to assess our services’ efficacy and impact, supporting program evaluation and the reporting process.
Visitors with abnormal results are offered resources specific to their screening outcomes. We provide handouts relevant to the screenings completed (Figures 2 and 3). Additionally, we provide visitors with resources to find free food, a list of safety-net clinics in the area, and information on where to find mental health resources. We also offer both written and verbal education related to our health screenings, which is provided by our staff CDCES in addition to the education shared by our health professional students.
Between June 2017 and December 2022, the MOBEC conducted 456 visits in the community, and 12,261 individuals (adults and children) visited the MOBEC’s community outreach events. A total of 3,862 people completed fingerstick BGM checks, and 2,001 completed blood pressure screenings. The racial and ethnic diversity among the people we served was consistent with the diversity in Solano County. For example, 55% of our participants were either of Black, indigenous, or another minority racial/ethnic group. This finding is consistent with the demographic distributions in the region (59.6% White [with 27.3% Hispanic/Latino], 16.2% Asian, 14.8% Black, 1.3% American Indian/Native Alaskan, 1% Native Hawaiian/Pacific Islander, and 7.1% of two or more races) (17).
Of the screened population, nearly one in six was found to have a BGM reading in the prediabetes range (n = 343 [8.9%]), and more than one in three (n = 804 [40.2%]) had elevated blood pressure readings, with systolic blood pressure >140 mmHg.
Between June 2017 and December 2022, 380 POC A1C tests were performed. Of the visitors receiving a POC A1C test, 168 (44.2%) were found to have an A1C ≥5.7% within either the prediabetes range (n = 82 [48.8%]) or the diabetes range (n = 86 [51.2%]). Of these individuals, 147 (83.3%) said they had been unaware of their elevated glucose levels. These findings are consistent with national prevalence rates (1).
One of the key extensions of the initial MOBEC efforts was the creation of community-based education classes focusing on the prevention and management of type 2 diabetes. People identified through screening to have abnormal glucose levels are referred directly to a free local class. Touro University California is a CDC-recognized trainer of lifestyle coaches for the National DPP and a provider of a National DPP lifestyle change program using the Prevent T2 curriculum (18). We are able to refer people to a local National DPP directly because our education coordinator also oversees our education program.
More than 350 people have enrolled in our National DPP classes. In addition, we offer a community-based diabetes education class—Success with Diabetes—organized by our CDCES and run by health professional students. More than 300 people have completed this education series, which was previously called the Diabetes Empowerment and Education Program).
The MOBED program was affected by the COVID-19 pandemic. Our screening activities were reduced, and we had to transition all education programs to a distance-learning format. We also offered new programs, such as Connect with MOBEC, a public service that provides general education information for the community; Cooking Light with Chef Ray, a cooking demonstration that received >650 views; and Zoom into Wellness, a series of health-based interviews with >270 participants in attendance.
A public-health approach is necessary to better address the burden of prediabetes and diabetes. This need has become even more evident in the face of the COVID-19 pandemic. The MOBEC has been leading efforts to raise awareness of diabetes, prediabetes, hypertension, and depression in Solano County, CA. This program has become a nidus for community-university partnerships. The MOBEC has been able to bring other community groups together in a shared population-health effort.
A similar community program has been shown to be effective. An analysis of ∼4,000 women in underserved populations who received screenings from a mobile mammography unit supported this community outreach concept (19). Through that project, 31 breast cancer cases were identified. This concept can be applied to screenings for prediabetes and diabetes in underserved communities and, in the case of our MOBEC, has been proven to be effective. For this reason, models such as MOBEC can be viewed as a blueprint from which to create similar programs nationwide.
In our program, POC A1C testing was both novel and desired by our participants. In this sample, the community-based POC A1C testing was a powerful tool to find people who were unaware of their prediabetes or diabetes status. This success was especially important to the goal of reaching underserved and at-risk communities of people who may not regularly use traditional health care services. POC A1C testing has been used for screening in other at-risk communities, including in aboriginal Africa, thus demonstrating that it can be used where access to other services is limited (20). Another study in the United States found that, when POC A1C testing was used for diabetes screening, the screenings were completed more often, and more people with prediabetes were identified than with traditional venipuncture laboratory testing (21). Thus, POC A1C testing is both well received by patients and effective as a screening tool for prediabetes and diabetes.
Our mobile program has extended the reach of POC A1C testing into the community. Many Solano County residents have returned to the MOBEC for additional screenings and/or education. To date, we have provided opportunities for these individuals to supplement their previous education, but we have not tracked the number of such visits. Our community advisor group advised that individuals would be less likely to engage if we tracked their information because trust in health care and the government in this population was quite low at the start of the MOBEC program.
We have now begun tracking our referrals to other organizations and will report these findings in the future. Many community partners and faith-based organizations have asked for the MOBEC to attend community health events. Although the MOBEC program is still relatively young, the data collected to date have shown its effectiveness.
To best meet the needs of the diverse patient population in Solano County, the MOBEC team and our health professional students have offered services and classes in English, Spanish, Tagalog, Chinese, and Punjabi. These multilingual services are much needed because a sizable number of people in our population do not speak English as their primary language. We have also made cultural adaptations to educational materials such as changes to food examples and information related to eating norms to make the education sessions more relevant for participants of various cultures.
Based on our experience to date, our future development plans include expanding community outreach efforts from Solano County to surrounding areas with additional at-risk communities. We also hope to add mental health screening services (e.g., the nine-item PHQ and screening for diabetes distress), hire a health psychologist to join the team, and explore ways to safely provide cooking demonstrations while meeting the standards of Touro University California and Solano County Environmental Health.
Through its partnerships with community organizations, the MOBEC team has established a grassroots effort to identify and bridge the gaps in health disparities relating to prediabetes and diabetes within Solano County, CA. Use of POC A1C testing, depression screening, and assessment of the negative effects of SDOH all enhance the impact of this program. Future efforts will focus on expanding to unreached subpopulations and forming a more extensive community network to more comprehensively tackle diabetes and its related medical conditions.
The MOBEC program was made possible by generous foundational support from Sutter Health Community Benefits, Kaiser Permanente Community Health, the California Department of Public Health, and the Solano County Health Department. The authors acknowledge the MOBEC staff members who do this important work in the community, including Deanna Dickey (event coordinator, Touro University California), Anne Lee, MEd, RD, CDECS (diabetes programs manager, Touro University California), Maryelli Ray (diabetes program assistant, Touro University California), and Maya Ramsey, MPH (diabetes outreach coordinator, Touro University California). We also want to thank the community members who serve on SODAF—the Solano County Diabetes Advisory Forum—and graciously support our activities.
Duality of Interest
J.H.S. has been a consultant to Abbott Diabetes Care and is an associate editor of Clinical Diabetes. No other potential conflicts of interest relevant to this article were reported.
All of the authors researched data and wrote and edited the manuscript. J.H.S. is the guarantor of this work and, as such, had full access to the data in the program and takes responsibility for the integrity of the data and the accuracy of the data analysis.