Implementation of a Culturally Tailored Diabetes Intervention With Community Health Workers in American Samoa

Abstract

Purpose The examination of implementation process in translation research can inform other interventions’ modifications for different socio-cultural contexts. The purpose of this paper is to answer key implementation questions of a primary-care based, nurse-community health worker (CHW) team intervention to support type 2 diabetes self-management, as part of a randomized trial: 1) How was the evidence-based model adapted? 2) How were CHWs trained and supervised? 3) What was fidelity to protocols? 4) What were intervention costs? Lessons learned during implementation are also discussed. Methods Descriptive data are given on intervention delivery, CHW visit content, patient safety and intervention costs, along with statistical analyses to examine participant characteristics of higher attendance at visits. Results In the intervention sample (n=104), 74% (SD 16) of planned intervention visits occurred, guided by an algorithm-based protocol. Higher risk participants had a significantly lower dose of their weekly assigned visits (66%), than those at moderate (74%) and lower risk (90%). Twenty-eight percent of participants moved to a lower risk group over the year. Estimated intervention cost was $656 per person. Participants with less education were more likely to attend optimal percent of visits. Conclusions A nurse-CHW team can deliver a culturally adapted diabetes self-management support intervention with excellent fidelity to the algorithm-based protocols. The team accommodated participants’ needs by meeting them whenever and wherever they could. This study provides an example of adaptation of an evidence-based model to the Samoan cultural context and its resource-poor setting.

Community health workers for non-communicable diseases prevention and control in developing countries: Evidence and implications

“…[28, 32, 34, 37–41, 43, 45] The pooled effect showed a statistically significant reduction in systolic (MD: -4.80, 95% CI: -8.12, -1.49) as well as diastolic blood pressure (MD: -2.88, 95% CI: -5.65, -0.10) due to interventions. However the results needed careful interpretation due to statistically significant trial heterogeneity (SBP: I 2 = 93%, DBP: I 2 = 96%).…”

“…[28, 32, 33, 37, 38, 41, 45] There were no statistically significant differences in mean BMI between intervention and control groups (MD: -0.75, 95% CI: -1.63, 0.13). Significant heterogeneity was found in these trials.…”

“…[32, 39, 41, 42] The pooled results presented a statistically significant difference in percentage HbA1c levels between CHW and routine care group from baseline percentage of HbA1c (MD: -0.83%, 95% CI: -1.25,-0.41).…”

Prevalence of adiposity and associated cardiometabolic risk factors in the samoan genome‐wide association study

“…National and local resources must be mobilized to help individuals, communities and organizations address the high NCD levels with priorities to: (1) identify and treat high risk individuals; (2) promote healthful ways of life in diet and exercise and other known risk factors such as cigarette smoking; and (3) plan health interventions in adults and youth to reduce NCD risk levels. Our ongoing translational intervention research on type 2 diabetes in neighboring American Samoa may be a guide for such interventions and the necessary evaluation research (DePue et al, ; Hamid et al, 2013).…”

Impact of a diabetes control and management intervention on health care utilization in American Samoa

“…Intervention content included a menu of eight topics, including basic diabetes information and seven diabetes-related behaviors (healthy eating, physical activity, medication adherence, monitoring, risk reduction, healthy coping, and problem solving). 18,22,23 During their visits, CHWs used flipcharts modeled on the National Diabetes Education Program flipcharts for diabetes prevention to facilitate their teaching of basic diabetes education. 21 These flipcharts included eight sections corresponding to the aforementioned diabetes-related behaviors and were adapted to the local context by incorporating cultural features that had been identified through formative focus groups with diabetes patients and in-depth interviews with health care providers.…”