Implementation and clinical effectiveness of a community-based non-communicable disease treatment programme in rural Mexico: a difference-in-differences analysis

Abstract

Non-communicable diseases (NCDs) account for the five largest contributors to burden of disease in Mexico, with diabetes representing the greatest contributor. However, evidence supporting chronic disease programmes in Mexico is limited, especially in rural communities. Compañeros En Salud (CES) partnered with the Secretariat of Health of Chiapas, Mexico to implement a novel community-based NCD treatment programme. We describe the implementation of this programme and conducted a population-based, retrospective analysis, using a difference-in-differences regression approach to estimate the impact of the programme. Specifically, we examined changes in diabetes and hypertension control rates between 2014 and 2016, comparing CES intervention clinics (n = 9) to care-as-usual at non-CES clinics (n = 806), adjusting for differences in facility-level characteristics. In 2014, the percent of diabetes patients with this condition under control was 36.9% at non-CES facilities, compared with 41.3% at CES facilities (P > 0.05). For hypertension patients, these figures were 45.2% at non-CES facilities compared with 56.2% at CES facilities (P = 0.02). From 2014 to 2016, the percent of patients with diabetes under control declined by 9.2% at non-CES facilities, while improving by 11.3% at non-CES facilities where the Compañeros En Salud Programa de Enfermedades Crónicas intervention was implemented (P < 0.001). Among hypertension patients, those with the condition under control increased by 21.5% at non-CES facilities between 2014 and 2016, compared with 16.2% at CES facilities (P > 0.05). Introduction of the CES model of NCD care was associated with significantly greater improvements in diabetes management between 2014 and 2016, compared with care-as-usual. Hypertension control measures were already greater at CES facilities in 2014, a difference that was maintained through 2016. These findings highlight the successful implementation of a framework for providing NCD care in rural Mexico, where a rapidly increasing NCD disease burden exists.

Early Lessons From Launching an Innovative Community Health Household Model Across 3 Country Contexts

“…Working with the local health authorities in rural communities in the Sierra Madre mountains, CES revitalized nearly a dozen rural clinics and connected them to 4 cadres of CHWs (locally known as Acompañantes) that were initially focused on providing treatment support for: (1) NCDs, (2) maternal and newborn health, (3) mental health, and (4) child development and nutrition (including early childhood stimulation). Although a stepped-wedge analysis showed that the NCD-focused CHW program had helped achieve some of the best rates of clinical control for NCDs in the region, 11 , 12 the team saw the potential for the NCD and maternal/newborn health cadres to be collapsed into a single cadre through the HHM. In 2019, after regular consultation with the teams in Malawi and Liberia, the Mexico team piloted a new CHW program that moved away from a physician-directed vertical care model, toward a model where CHWs could have more autonomy to use algorithms for screening, follow-up, and referral to the health center.…”

The Long and Winding Road: A Systematic Literature Review Conceptualising Pathways for Hypertension Care and Control in Low- and Middle-Income Countries

“…A complex primary care intervention in Mexico involving a new cadre of community health workers, supply chain improvements, active casefinding, and education support for rural doctors did not lead to any significant improvement in blood pressure control among the population of Chiapas State. 43 Medication-specific issues: In addition to problems associated with purchasing medication (see above), 4 studies reported on availability (or lack thereof) of medicine. 30,34,42,45 Unsurprisingly, all reported lack of access, at health facilities, 42 in pharmacies, 34 and more generally 45 as a barrier to adherence.…”

Prospects and Challenges of Precision Medicine in Lower- and Middle-Income Countries: A Brief Overview

“…Mexico achieves a lot to decrease morbidity and mortality associated with undernourishment, transmittable infectious diseases such as diarrheal diseases and sanitation, especially among the pediatric population [53][54][55] . Nevertheless, the fifth principal burden of chronic NCDs became the major basis of public health apprehension [54][55][56] . Additionally, diabetes mellitus appears as the sole principal cause of disability-adjusted life years and expected to deteriorate in the upcoming day 57,58 .…”