Abstract
The global prevalence of diabetes has nearly doubled since 1980. Seventy-five percent of patients with diabetes live in low- and middle-income countries, such as Guatemala, where health care systems are often poorly equipped for chronic disease management. Community health workers (CHWs) and mobile health technology have increasingly been applied to the diabetes epidemic in these settings, although mostly in supportive rather than primary roles in diabetes management. We sought to improve diabetes care in rural Guatemala through the development of a CHW-led diabetes program and a smartphone application to provide CHWs with clinical decision support. We worked with our local partners to develop a program model and the smartphone application (using the CommCare platform) and to train CHWs. We recruited patients with type 2 diabetes living in rural communities. Program evaluation used a single-group, pre-post design. Primary outcomes were hemoglobin A1c and the percentage of patients meeting A1c goals compared with baseline. We also followed a variety of process metrics, including application reliability. Eighty-nine patients enrolled during the study period. The hemoglobin A1c percentage decreased significantly at 3 months (-1.0; 95% CI=-1.7, -0.6), 6 months (-1.5; 95% CI=-2.2, -0.8), 9 months (-1.3; 95% CI=-2.0, -0.6), and 12 months (-1.0; 95% CI=-1.7, -0.4). The percentage of patients with A1c ≤ 8% increased significantly at 3 months (23.6% to 44.4%, P=.007), 6 months (22.0% to 44.0%, P=.015), and 9 months (23.9% to 45.7%, P=.03). CHWs and supervising physicians agreed with application medication recommendations >90% of the time. Our results suggest that CHWs can safely and effectively manage diabetes with the assistance of a smartphone application and remote physician supervision. This model should be evaluated versus other standards of care and could be adapted to other low-resource settings and chronic diseases.
Highlights
The global prevalence of diabetes has increased dramatically over the past several decades, nearly doubling since 1980, from 4.7% to 8.5% of adults.[1]
Community health workers (CHWs, called health promoters)—lay people who are trained to carry out a variety of tasks and are often from or have a close connection to the communities they serve—are a common type of nonphysician health worker and are being increasingly utilized in health systems around the world, in Low- and middle-income countries (LMICs).[16,17]
We evaluated the efficacy of trained CHWs enabled by a clinical decision support tool in directly providing elements of diabetes care with remote physician supervision, a novel approach for which little evidence exists at this time
Summary
The global prevalence of diabetes has increased dramatically over the past several decades, nearly doubling since 1980, from 4.7% to 8.5% of adults.[1]. Seventy-five percent of patients with diabetes live in low- and middle-income countries, such as Guatemala, where health care systems are often poorly equipped for chronic disease management. We sought to improve diabetes care in rural Guatemala through the development of a CHW-led diabetes program and a smartphone application to provide CHWs with clinical decision support. Conclusion: Our results suggest that CHWs can safely and effectively manage diabetes with the assistance of a smartphone application and remote physician supervision. This model should be evaluated versus other standards of care and could be adapted to other low-resource settings and chronic diseases
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