Empowering Community Health Workers With Mobile Technology to Treat Diabetes

Sean Duffy; Jim Svenson; Alejandro Chavez; Mark Kelly; Paul Wise

doi:10.1370/afm.2361

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Author Response to Drs. Agarwal and Kaysin
Sean M Duffy

Published on: 06 May 2019
A health systems perspective for developing mobile decision support tools
Smisha Agarwal

Published on: 01 April 2019

Published on: (6 May 2019)
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Author Response to Drs. Agarwal and Kaysin
Sean M Duffy, Primary Care Research Fellow
Thank you Drs. Agarwal and Kaysin for your thoughtful and insightful comments and for your leadership in mHealth and chronic disease management in low-resource settings. Your point about the variability of scope of practice for CHWs in different jurisdictions and the effect of this on adaptability to other locations is well-taken. In areas in which CHWs are not allowed to adjust medications, perhaps other non-physician he...
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Thank you Drs. Agarwal and Kaysin for your thoughtful and insightful comments and for your leadership in mHealth and chronic disease management in low-resource settings. Your point about the variability of scope of practice for CHWs in different jurisdictions and the effect of this on adaptability to other locations is well-taken. In areas in which CHWs are not allowed to adjust medications, perhaps other non-physician health workers who do have this authority (for example, nurses or clinical officers) could utilize clinical decision support applications for medication titration. Appropriate supervision of frontline health workers is paramount and in our case, remote physician supervision of CHWs enabled by the smartphone application and frequent communication between supervising physicians and the CHWs were essential to the success of the program.
You are right to point out that a full accounting of projects such as ours should include detailed reporting on CHW training, the implementation process and required resources, intermediate and process outcomes, and intervention safety. The format of the Innovations in Primary Care feature limited us to reporting only a basic description of our intervention and preliminary data on primary outcomes. We plan to publish a more comprehensive manuscript in the near future, including more long-term outcome data and utilizing the Mobile Health Evidence Reporting and Assessment (mERA) framework (developed by Dr. Agarwal and colleagues) as a guideline.
Regarding the promotion of lifestyle changes, we agree that such interventions should be a key element of any diabetes program (particularly in areas with structural barriers to long-term medication therapy) and should reflect careful attention to local culture and social context. We adapted material developed by Wuqu' Kawoq and Hospitalito Atitlan, two Guatemalan NGOs working with the same Mayan ethnic group served by our local partner, to train our CHWs in lifestyle counseling. In addition, the CHWs carrying out this program are all bilingual in Kaqchikel, the predominant local Mayan language, and Spanish and live in the same communities as the patients they are serving.
Just as there are structural barriers to long-term diabetes medication use in many LMIC, we have found that our patients face many obstacles to implementing lifestyle changes. For example, while small stores selling ultra-processed and calorically-dense foods are ubiquitous in Guatemala, patients in many rural villages have poor access to vegetables, fruits, and whole grains. In addition to behavioral and lifestyle counseling, program planners and health systems in LMIC need to consider structural interventions, such as community gardens and mobile markets, to reduce barriers to lifestyle changes. Finally, as you state, connection to existing primary and specialty care systems is essential for interventions attempting to close gaps in care. In our program, care delivered by CHWs is integrated with primary care and limited specialty care services provided by our local partner (the Friends of San Lucas).
Competing interests: None declared
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Competing Interests: None declared.
Published on: (1 April 2019)
Page navigation anchor for A health systems perspective for developing mobile decision support tools
A health systems perspective for developing mobile decision support tools
Smisha Agarwal, Assistant Professor
Other Contributors:
The use of mobile decision support tools by community health workers (CHWs) has great potential in addressing the epidemic of chronic and noncommunicable diseases. Mobile health tools have been shown, through local projects, to be a viable strategy in augmenting healthcare delivery systems in low and middle-income countries. While much of the extant literature and studies are focused on diagnosis and counselling for beh...
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The use of mobile decision support tools by community health workers (CHWs) has great potential in addressing the epidemic of chronic and noncommunicable diseases. Mobile health tools have been shown, through local projects, to be a viable strategy in augmenting healthcare delivery systems in low and middle-income countries. While much of the extant literature and studies are focused on diagnosis and counselling for behavioral modifications and management of diabetes, the proposed innovation is unique in empowering CHWs to engage more comprehensively in the treatment of patients with diabetes through titration of glucose lowering medication.
In attempting to implement similar interventions in Guatemala as well as other LMIC settings, investigators must first assess whether national and regional health departments allow CHWs to prescribe and/or adjust the medication regimen of patients, given their potential risks. For this reason, as the innovation is strengthened and scaled, the authors should monitor and report on aspects of safety and unintended consequences while working with local health officials and academic partners as well as local IRBs.
In addition to evaluating the impact of mobile decision aids on patients' control of diabetes, it would be helpful to assess intermediate outcomes such as CHWs' adherence to treatment protocols as well as the quality and accuracy of the counselling providing by CHWs regarding medication management and behavioral changes. While encouraging, improvement in diabetes control depends on a host of factors at varying levels of the health system. Access (i.e. physical and financial) to essential medication, culturally and linguistically-appropriate education and counseling, access to the formal health sector including primary care and specialists when needed, are important factors that deserve recognition and attention when working on interventions designed to fill gaps. Furthermore, in addition to the nature of the intervention delivered by the CHW, improvement in diabetes also depends on patients' health behaviors. The emphasis on measuring only short-term disease-specific outcomes, while important, might preclude the authors from identifying and reporting on the capacity of the CHWs to effectively deliver such interventions.
In terms of designing point of care support for behavioral and lifestyle counseling, investigators and program planners need to demonstrate that attention to local culture and social context was provided. This is especially pertinent as many low-income populations are unable to afford medication and may not have good long-term adherence to such treatments. Sustained positive changes in health behaviors would thereby strengthen outcomes and lead to other health benefits. Finally, the process of training and equipping CHWs to manage medication for non- communicable diseases has not been adequately evaluated, and if efficacious and safe has tremendous applications for other settings. For this reason, we hope the authors will continue to provide documentation of their experience with this evolving process.
Competing interests: None declared
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Competing Interests: None declared.