Community Diabetes Education (CoDE) for uninsured Mexican Americans: A randomized controlled trial of a culturally tailored diabetes education and management program led by a community health worker

Abstract

Aims

The purpose of this randomized controlled trial was to determine the impact of a culturally tailored diabetes education program led by a community health worker (CHW) on the HbA1c, blood pressure, body mass index (BMI) and lipid status of uninsured Mexican Americans with diabetes.

Methods

Adult patients were recruited from a community clinic and randomized into intervention (n = 90) and control (n = 90) groups. Both groups received usual medical care from clinic physicians. The intervention group participated in the Community Diabetes Education (CoDE) program over 12 months. The primary outcome of interest was HbA1c. Secondary outcomes included blood pressure, BMI and lipid status. Variations in outcomes over time were assessed within groups and between groups using linear mixed-models and an intention-to-treat approach. Assessment of changes in HbA1c, blood pressure and lipid status over 12 months included variables to control for modifications made to antidiabetic, antihypertensive and lipid lowering medications.

Results

There was no difference in baseline characteristics between the intervention and control groups. Mean changes of HbA1c over 12 months showed a significant intervention effect (−.7%, p = .02) in the CoDE group compared with controls. HbA1c decreased significantly from baseline to 12 months within the intervention (−1.6%, p < .001) and control (−.9%, p < .001) groups. No differences between groups for secondary outcomes were found.

Conclusions

This study supports the effectiveness of CHWs as diabetes educators/case managers functioning as integral members of the health care team in community clinic settings serving uninsured Mexican Americans.

Introduction

The prevalence and incidence of diabetes mellitus in the United States (US) continue to rise, and diabetes now affects 25.8 million children and adults [1]. In 2010, there were 1.9 million new cases of diabetes in people over the age of 20 [1]. Diabetes affects 11.8% of Hispanics compared with 7.1% of non-Hispanic whites, and among Hispanics, diabetes affects 13.3% of Mexican Americans [1]. While the Hispanic population accounts for 16% of the US populace, 19% of US Hispanics live in Texas, constituting 38% of the state residents [2]. Furthermore, Mexican Americans, the largest Hispanic/Latino subgroup, are 1.9 times more likely to have diabetes and 1.6 times more likely to develop the diabetes complication of end stage renal disease than non-Hispanic whites of similar age [3], [4].

Adequate glycemic control reduces the likelihood of developing long-term complications from diabetes including retinopathy, nephropathy and neuropathy [5], [6]. Diabetes self-management education (DSME) is essential to increase the knowledge and skills of patients with diabetes in order to achieve this goal [7]. The importance of culturally tailored DSME was established in 2002 by a landmark intervention designed for Mexican Americans in Starr County, Texas [8]. Since that time multiple culturally tailored diabetes education interventions have been developed and implemented in Hispanic/Latino populations with documented improvements in knowledge, behaviors and clinical outcomes [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19]. A meta-analysis examining the effect of culturally tailored diabetes education in ethnic minorities showed that these interventions were effective for improving glycemic control, though the magnitude of effect was greater in hospital- or clinic- based settings than in community settings [20]. In addition, greater improvements were observed in patients with baseline hemoglobin A1c (HbA1c) levels ≤8.5%, and maximum improvement in HbA1c occurred at 6 months followed by a decline in glycemic control [20].

In response to the ever increasing demand for diabetes care services in socially disadvantaged populations, community health workers (CHWs) have emerged as an available resource to reduce disparities in health outcomes [21]. CHWs are typically bilingual and bicultural members of the local community who serve as bridges between patients and health care providers in underserved areas [22]. Systematic reviews of the effectiveness of CHWs in the care of patients with diabetes have documented improvements in health outcomes for vulnerable populations, including Mexican Americans [9], [21], [22], [23], [24], [25]. A role for CHWs in diabetes care is supported by the American Association of Diabetes Educators and the American Public Health Association, but the work of CHWs has not found relevance within the Chronic Care Model of evidence based practices [26], [27], [28]. Specific roles for CHWs in diabetes management have not been firmly established because few studies employing rigorous methodology have utilized CHWs in positions bearing full responsibility for delivery of DSME interventions to patients [10], [16], [19]. In addition, published studies have often failed to include detailed information about program development and implementation along with outcomes and measures of association between interventions and outcomes [29]. A systematic review of community-based diabetes education interventions targeting disadvantaged populations concluded that successful interventions were culturally tailored, individualized, led by community educators, of sufficient intensity (>10 contact times) and delivered over a long duration (≥6 months) [23].

Of patients with diabetes who have some form of health insurance, 56% report ever attending DSME, while only 42% of patients who are uninsured ever attend DSME [30], [31]. As the numbers of Certified Diabetes Educators (CDEs), diabetes nurse educators, and DSME programs are limited, the growing number of uninsured individuals in the US has forced communities and health care agencies to address the limited availability of quality DSME programs by engaging alternative lower cost personnel such as CHWs to provide diabetes education services. Furthermore, the number of culturally tailored diabetes education interventions involving large numbers of uninsured patients is limited, and to our knowledge no randomized controlled trials of culturally tailored diabetes interventions have been published involving exclusively uninsured patient populations [8], [32].

To date, few randomized controlled trials have been completed which evaluate the effectiveness of CHWs as integral members of clinical care teams with defined roles and responsibilities as patient educators in community settings [8], [10], [15], [16], [17], [18], [19], [33]. Even fewer studies have utilized CHWs as the sole provider of educational services without any direct involvement with more qualified personnel such as CDEs and nurse case managers [10], [13], [16], [19]. The Community Diabetes Education (CoDE) program was developed to provide access to DSME for uninsured patients with diabetes in Dallas, Texas where high diabetes prevalence (11.7%) is coupled with a high percentage of residents without health insurance (36.9%) [1], [13], [34], [35]. We report the results of a randomized controlled trial that tested whether a culturally tailored diabetes education and management program (CoDE) led solely by a CHW improved HbA1c levels, blood pressure, lipid levels and BMI more than usual care alone among uninsured Mexican Americans.