A Home-Based Type 2 Diabetes Self-Management Intervention in Rural Guatemala

Abstract

IntroductionDiabetes self-management education (DSME) is a fundamental element of type 2 diabetes care. Although 75% of adults with diabetes worldwide live in low-income and middle-income countries (LMICs), limited DSME research has been conducted in LMICs. The objective of this study was to evaluate a home-based DSME intervention in rural Guatemala.MethodsWe conducted a prospective study of a DSME intervention using a quasi-experimental, single-group pretest–posttest design. We enrolled 90 participants in the intervention, which consisted of 6 home visits (May 2014–July 2016) conducted by a diabetes educator using a curriculum culturally and linguistically tailored to rural Mayan populations. Primary outcomes were changes in mean hemoglobin A1c (HbA1c) and mean systolic and diastolic blood pressure at baseline and at 12 months. Secondary outcomes were diabetes knowledge and self-care activities at baseline and intervention completion.ResultsHbA1c decreased significantly from baseline to 12 months (absolute mean change, −1.5%; 95% confidence interval [CI], −1.9% to −1.0%; P < .001). Systolic blood pressure also improved significantly at 12 months (−6.2 mm Hg; 95% CI, −10.1 to −2.2 mm Hg; P = .002); changes in diastolic blood pressure were not significant (−1.6 mm Hg; 95% CI, −3.9 to −0.7 mm Hg; P = .17). We also found significant improvements in diabetes knowledge and self-care activities from baseline to intervention completion.ConclusionDSME interventions can be successfully delivered in a setting with an underresourced health system, high poverty rate, and unique cultural characteristics like Mayan Guatemala. Our findings point to the need for more DSME research in resource-limited settings globally.

Current State of Diabetes Mellitus Prevalence, Awareness, Treatment, and Control in Latin America: Challenges and Innovative Solutions to Improve Health Outcomes Across the Continent

“…Kaselitz et al published a scoping review of policies and interventions for diabetes in LatAm [147], telehealth, mobile clinics, and other non-traditional health care delivery models. In addition, a non-exhaustive list of examples of past or current interventions, policies, and initiatives is provided in Table 4 [184,186,234,[236][237][238][239][240][241][242][243][244][245][246][247][248][249][250][251][252]. Interventions in the list include tele-ophthalmology [249,250,253,254], teambased foot self-care education [236], diabetic retinopathy education and screening at a community pharmacy [255], rapid assessment/diagnostic tools to screen for or detect retinopathy, nephropathy, and risk of developing foot ulcers [201,[256][257][258][259][260][261][262] and are examples of clinical research and/or implementation activities designed to strengthen the prevention and early detection of diabetes-associated complications and improve health outcomes throughout LatAm.…”

“…Some of the diabetes prevalence studies included in our review focused on or mentioned participants from indigenous groups [35,48,50,74,83] and other underrepresented groups (e.g., Garifuna, Afro-Panamanian, Afro-Peruvian, Afro-Ecuadorian) [55,76,90,91,166]. However, a few studies have evaluated diabetes care, prevalence, and/or prevention of macro-or microvascular complications, diabetes management interventions, other health care needs and access to health care among indigenous populations [241,244,246,[294][295][296][297][298][299][300][301][302], and none on the other groups (that we could identify through our search). Understanding the protective mechanisms (e.g., biochemical, immune, epigenetic) against diabetes experienced by some indigenous populations would be relevant to millions at high risk of developing diabetes.…”

“…It was associated with improved medication adherence, self-reported health status, and satisfaction. Prestes, 2017 [ 243 ] 2016–2017 Argentina DIAPREM – integrated diabetes care program including systemic changes education, registry and disease management Flood, 2016 [ 244 ] 2010 Guatemala Implementation and outcomes of a comprehensive type 2 diabetes program in rural Guatemala through a non-government organization and involving nurse-directed care Flood, 2017 [ 245 ] 2012 Rural Guatemala Implementation of a multi-level quality improvement program for ambulatory diabetes care based on input from patients and other stakeholders Flood, 2017 [ 246 ] 2014–2016 Rural Guatemala Home-based type 2 diabetes self-management – intervention delivered by diabetes educator at home and synchronized with clinic follow-up. Mayan communities Tapia-Conyer, 2016 [ 247 ] Gallardo-Rincón, 2017 [ 234 ] 2012 to present Mexico CASALUD Model –is a comprehensive primary health care model implemented in Mexico that enables proactive prevention and disease management using innovative technologies and a patient-centered approach.…”

Using Community Health Workers and a Smartphone Application to Improve Diabetes Control in Rural Guatemala

“…Other studies of diabetes management in LMICs have shown marked improvements in A1c resulting from reconstitution of medication therapy, particularly when baseline A1c is high. 56,57 However, 2 factors support the importance of the titration algorithm in our program. First, most patients (82%) reported that they were taking medications at the time of enrollment.…”

Needs and Resources of People With Type 2 Diabetes in Peri-urban Cochabamba, Bolivia: a People-centred Perspective

“…The few studies on T2D performed in LMICs are mainly based on isolated interventions related to training of formal or informal healthcare providers [10,11,12,13], pharmacological follow-up [14] and patient education and counselling [12,[15][16][17][18][19][20]. Despite their seemingly positive short-term effects, managing chronic conditions requires a long-term strategy which involves more than performing a series of disconnected interventions [21].…”