Form 2 Survey of State-based Diabetes Prevention and Control Pr

The National Public Health Initiative on

Diabetes and Women’s Health

Introduction

The National Public Health Initiative on Diabetes on Diabetes and Women’s Health (Initiative)—co-sponsored by the American Association of Diabetes Educators (AADE), the American Diabetes Association (ADA), the American Public Health Association (APHA), the Association of State and Territorial Health Officials (ASTHO), and the Centers for Disease Control and Prevention (CDC)—has released objectives which focus on the needs of women with and at risk for diabetes. The intent of these objectives is to develop measurable indicators that can be used to evaluate the impact of the Initiative.

These objectives were developed based on input from previous working meetings with co-sponsors and partners of the Initiative. Partners is defined as organizations which have expressed interest in diabetes and women’s health and has had some interaction with the National Public Health Initiative on Diabetes and Women’s Health through collaborations, working meetings, and communication.

The Co-Sponsors of the Initiative are interested in developing a report to highlight the work that co-Sponsors and partners are doing to address diabetes and women’s health issues.

Participation in the survey is voluntary. It will take only about 30 minutes of your time. You do not have to answer every question and can skip those that you do not feel comfortable answering. Your individual responses will not be linkable to any information that identifies you.

Instructions

In this electronic survey, there are 10 objectives listed within six categories: Community Health, State Programs, Education and Community Outreach, Quality Care, Research, and Surveillance.

Respondents to this survey should only respond to objectives that focus on work that your organization has completed or is in the process of completing. Respondents do not have to complete a response for all 10 objectives.

Help us understand who benefits from your organization and its mission. Please select the appropriate demographic information.

Organization

Name of organization ___________________________________

Please describe the type of Organization you represent:

Why type of organization to you represent?

___Non-Profit

___Corporate

___Government

___Other (Specify):_____________________

What size is your organization?

___Less than 100 members

___100-200 members

___201-301 members

___302+ members

How many members has your organization delegated to assist in completing the National Public Health Initiative on Diabetes and Women’s Health objectives?

___None

___Less than 5 members

___6-12 members

___13-19 members

___20+ members

Does your organization serve:

__Men

__Women

__Both

How is your organization funded?

Community

Please describe the type of community you serve:

The type(s) of community my team (those delegated to assist in the completing the objectives) serves:

___Rural

___Urban

___Both Rural and Urban

The communities we serve, in relations to the United States, are located in the (check all that apply)

__North

__North East

__North West

__Central

__Mid-West

__South

__South East

__South West

__ International

What age range does your organization serves: (Check all that apply)

__10-17

__18-44

__45-64

__65+

What ethnicity does your organization serves: (Check all that apply)

__African-American/African Ancestry

__Hispanic/Latino

__Caucasian

__Asian/Pacific Islander

__American Natives/Alaska Native

__Other

This survey will only generate questions specifically related to objectives that are achieved or in process. Please indicate below what objectives your organization has completed or is in the process of completing. By indicating the objectives your organization has completed or is working on, this will allow the survey to provide addition questions related to those objectives. Please mark “Achieved” if you have completed the specific objective. Mark “In Process” if the objective has not been achieved, but will be 2010. Mark “No” if your organization does not have intentions on fulfilling the specified objective.

Objective Description	Achieved	In Process	No
Community A1. By 2010, Partner Organizations and Co-sponsors of the Initiative (Partners) will develop talking points for at least one article in magazines and/or newsletters about diabetes prevention and control.
Community A2. By 2010, Partner Organizations and Co-sponsors will use the NDEP gestational diabetes (GDM) Tip Sheet in Community-based state-based activities to educate women about diabetes prevention and control.
Community A4. By 2010, Partner Organizations and Co-sponsors will conduct at least one training program on the use of NDEP products and tools which emphasize how to prevent and control diabetes for women.
Community A5. By 2010, Partner Organizations and Co-sponsors will collaborate with at least two faith-based initiatives for the prevention of diabetes in at risk women who live in rural areas.
Community and Education C3. By 2010, Partner Organizations will actively participate in at least one Community-based activity related to diabetes and women’s health.
Research E2. By 2010, Partner Organizations and Co-sponsors will disseminate research findings on diabetes and women’s health in at least one Web-based report, one peer-reviewed publication, or one conference.
Research E4. By 2010, Partner Organizations and Co-sponsors will collaborate with at least two population-based programs to establish ongoing research to identify the unique needs of women with and at risk for diabetes in different life stages.
Research E5. By 2012, Partner Federal Agencies and Co-sponsors will develop and advertise at least one FOA to encourage research to develop models of preventive health care to women with and at risk for diabetes in different life stages.1

Community Health

A1. By 2010, Partner Organizations (Partners) and Co-sponsors will develop at least one article in magazines and/or newsletters about diabetes prevention and control.

Please check all that apply.

Articles were developed for:

___Magazine(s)

___Newsletter(s)

___Both

Who was the article developed for?

(Insert Life stages)

__10-17

__18-44

__45-64

__65+

Please list the publication(s): ______________________________

___N/A

How many magazine articles were developed?

__0

__1-2

__3-4

__5+

How many newsletter articles were developed?

__0

__1-2

__3-4

__5+

• Describe one activity developed: (maximum 50 words.)

___N/A

• State the goal of this project.

• What agencies served as lead for this project?

__N/A

• Federal Government

• State Government

• Local Government

• Academic

• Voluntary

• Business

• Community-based/Faith-based

• Professional

• Other____________________________

• Who were the partners for this project? (Identify actual partners)

_N/A

• Describe the target audience: (if applicable, please use key demographic information such as age, race, location, etc.)

_N/A

• If known, what was the estimated cost of the project?

_

N/A

• Describe the resources used (time, funding, staff, other):

_N/A

• Describe the results of the activity for participants, organizations, and/or communities:

_N/A

A2. By 2010, Partner Organizations and Co-sponsors will use the National Diabetes Education Program gestational diabetes (GDM) Tip Sheet in Community-based/regional-based/state-based activities to educate women about diabetes prevention and control.

Please indicate if the tip sheet was used in a:

___Community-based activity

___State-based activity

___Regional-based

___Both

If known, how many regional-based activities? If none, check N/A

___1-3

___4-6

___ 6+

___N/A

If known, how many Community-based activities? If none, check N/A

___1-3

___4-6

___ 6+

___N/A

If known, how many state-based activities? If none, check N/A

___1-3

___4-6

___ 6+

• Describe one activity developed: (maximum 50 words.)

___N/A

• State the goal of this project.

• What agencies served as lead for this project?

__N/A

• Federal Government

• State Government

• Local Government

• Academic

• Voluntary

• Business

• Community-based/Faith-based

• Professional

• Other____________________________

• Who were the partners for this project? (Identify actual partners)

_N/A

• Describe the target audience: (if applicable, please use key demographic information such as age, race, location, etc.)

_N/A

• If known, what was the estimated cost of the project?

_N/A

• Describe the resources used (time, funding, staff, other):

_N/A

• Describe the results of the activity for participants, organizations, and/or communities:

_N/A

A4. By 2010, Partner Organizations and Co-sponsors will conduct at least one training program on the use of NDEP products and tools which emphasize how to prevent and control diabetes for women.

How many training programs were conducted?

__1

__2-3

__3-4

__5+

On average, how many were trained?

__Less than 5

__5-10

__11-15

__16-20

__21

• Describe one activity developed: (maximum 50 words.)

___N/A

• State the goal of this project.

What agencies served as lead for this project?

__N/A

• Federal Government

• State Government

• Local Government

• Academic

• Voluntary

• Business

• Community-based/Faith-based

• Professional

• Other____________________________

• Who were the partners for this project? (Identify actual partners)

_N/A

• Describe the target audience: (if applicable, please use key demographic information such as age, race, location, etc.)

_N/A

• If known, what was the estimated cost of the project?

_N/A

• Describe the resources used (time, funding, staff, other):

_N/A

• Describe the results of the activity for participants, organizations, and/or communities:

_N/A

A5. By 2010, Partner Organizations and Co-sponsors will collaborate with at least two faith-based initiatives for the prevention of diabetes in at risk women who live in rural areas.

How many faith-based initiatives have your organization collaborated with?

__1

__2

__3

__4+

• Describe one activity developed: (maximum 50 words.)

___N/A

• State the goal of this project.

• What agencies served as lead for this project?

__N/A

• Federal Government

• State Government

• Local Government

• Academic

• Voluntary

• Business

• Community-based/Faith-based

• Professional

• Other____________________________

• Who were the partners for this project? (Identify actual partners)

_N/A

• Describe the target audience: (if applicable, please use key demographic information such as age, race, location, etc.)

_

N/A

• If known, what was the estimated cost of the project?

_N/A

• Describe the resources used (time, funding, staff, other):

_N/A

• Describe the results of the activity for participants, organizations, and/or communities:

_N/A

C3. By 2010, Partner Organizations will actively participate in at least one Community-based/Faith-based activity related to diabetes and women’s health.

• Describe one activity developed: (maximum 50 words.)

___N/A

• State the goal of this project.

• What agencies served as lead for this project?

__N/A

• Federal Government

• State Government

• Local Government

• Academic

• Voluntary

• Business

• Community-based/Faith-based

• Professional

• Other____________________________

• Who were the partners for this project? (Identify actual partners)

_N/A

• Describe the target audience: (if applicable, please use key demographic information such as age, race, location, etc.)

_N/A

• If known, what was the estimated cost of the project?

_N/A

• Describe the resources used (time, funding, staff, other):

_N/A

• Describe the results of the activity for participants, organizations, and/or communities:

_N/A

Research

E2. By 2010, Partner Organizations and Co-sponsors will disseminate research findings on diabetes and women’s health in at least one Web-based report, one peer-reviewed publication, or one conference.

• Describe one activity developed: (maximum 50 words.)

___N/A

• State the goal of this project.

• What agencies served as lead for this project?

__N/A

• Federal Government

• State Government

• Local Government

• Academic

• Voluntary

• Business

• Community-based/Faith-based

• Professional

• Other____________________________

• Who were the partners for this project? (Identify actual partners)

_N/A

• Describe the target audience: (if applicable, please use key demographic information such as age, race, location, etc.)

_N/A

• If known, what was the estimated cost of the project?

_N/A

• Describe the resources used (time, funding, staff, other):

_N/A

• Describe the results of the activity for participants, organizations, and/or communities:

_N/A

E4. By 2010, Partner Organizations and Co-sponsors will collaborate with at least two population-based programs to establish ongoing research to identify the unique needs of women with and at risk for diabetes in different life stages.

• Describe one activity developed: (maximum 50 words.)

___N/A

• State the goal of this project.

• What agencies served as lead for this project?

__N/A

• Federal Government

• State Government

• Local Government

• Academic

• Voluntary

• Business

• Community-based/Faith-based

• Professional

• Other____________________________

• Who were the partners for this project? (Identify actual partners)

_N/A

• Describe the target audience: (if applicable, please use key demographic information such as age, race, location, etc.)

_N/A

• If known, what was the estimated cost of the project?

_N/A

• Describe the resources used (time, funding, staff, other):

_N/A

• Describe the results of the activity for participants, organizations, and/or communities:

_N/A

­­­­­­­­­­­­­­­­­­­­­­­­­­­­

E5. By 2012, Co-sponsors and Partner Federal Agencies will develop and advertise at least one FOA to encourage research to develop models of preventive health care to women with and at risk for diabetes in different life stages.²

• Describe one activity developed: (maximum 50 words.)

___N/A

• State the goal of this project.

• What agencies served as lead for this project?

__N/A

• Federal Government

• State Government

• Local Government

• Academic

• Voluntary

• Business

• Community-based/Faith-based

• Professional

• Other____________________________

• Who were the partners for this project? (Identify actual partners)

_N/A

• Describe the target audience: (if applicable, please use key demographic information such as age, race, location, etc.)

_N/A

• If known, what was the estimated cost of the project?

_N/A

• Describe the resources used (time, funding, staff, other):

_N/A

• Describe the results of the activity for participants, organizations, and/or communities:

_N/A

­­­­­­­

Surveillance

F2. By 2010, Partnering Federal Agencies and CDC will develop a system to assess and monitor the usage of evidence-based recommendations at the patient, provider, and health systems levels in DHHS programs for women with and at risk for diabetes.

• Describe one activity developed: (maximum 50 words.)

___N/A

• State the goal of this project.

• What agencies served as lead for this project?

__N/A

• Federal Government

• State Government

• Local Government

• Academic

• Voluntary

• Business

• Community-based/Faith-based

• Professional

• Other____________________________

• Who were the partners for this project? (Identify actual partners)

_N/A

• Describe the target audience: (if applicable, please use key demographic information such as age, race, location, etc.)

_N/A

• If known, what was the estimated cost of the project?

_N/A

• Describe the resources used (time, funding, staff, other):

_N/A

• Describe the results of the activity for participants, organizations, and/or communities:

_N/A

F6. By 2010, using current surveillance data, Partner Organizations will highlight 2 specific needs of women with and at risk for diabetes, including recent progress and challenges and report findings on Web site.

• Describe one activity developed: (maximum 50 words.)

___N/A

• State the goal of this project.

• What agencies served as lead for this project?

__N/A

• Federal Government

• State Government

• Local Government

• Academic

• Voluntary

• Business

• Community-based/Faith-based

• Professional

• Other____________________________

• Who were the partners for this project? (Identify actual partners)

_N/A

• Describe the target audience: (if applicable, please use key demographic information such as age, race, location, etc.)

_N/A

• If known, what was the estimated cost of the project?

_N/A

• Describe the resources used (time, funding, staff, other):

_N/A

• Describe the results of the activity for participants, organizations, and/or communities:

_N/A

1 Model is defined as: “A conceptual basis for how a program or evaluation is supposed to work, explaining key factors and variables.” Modeste NN. Dictionary of Public Health Promotion and Education: Terms and Concepts. Thousand Oaks: Sage Publications.

2 Model is defined as: “A conceptual basis for how a program or evaluation is supposed to work, explaining key factors and variables.” Modeste NN. Dictionary of Public Health Promotion and Education: Terms and Concepts. Thousand Oaks: Sage Publications.