An evaluation of a peer supervision pilot project among community health workers in rural Uganda

BackgroundLiving Goods operates a Community Health Worker (CHW) program in 19 districts of Uganda, where CHWs are supervised by full time Community Health Supervisors. This model is effective, but expensive. Evidence indicates that peer supervision can be a substitute and cheaper model for CHW supervision. We describe our experience and outcomes while implementing peer supervision among CHWs in Mayuge districtObjectives1. To compare health services delivery outcomes between the two supervision models. 2. To compare costs of the two supervision models..MethodsInternal organizational records from January to December 2019 were reviewed. Focus group discussions and in-depth interviews with participating CHWs were also conducted. Qualitative analysis was performed using thematic content analysis. Quantitative data was summarized to generate averages, percentages and graphs.FindingsCHWs under the peer supervision performed better than those under standard supervision against all key performance indicators. The total cost to maintain the peer supervision model for 1 year was USD $176 per CHW versus USD $273 among CHWs under the standard supervision model. Peer supervision thus resulted in overall cost savings of 36%. There was lower attrition among CHWs under peer supervision compared to standard supervision (10% versus 17%).ConclusionsPeer supervision is a feasible and more affordable model of supervising CHWs.     

Probing for depression and finding diabetes: a mixed-methods analysis of depression interviews with adults treated for type 2 diabetes

Background

Depression has increased prevalence and consistently predicts poor health outcomes among patients with diabetes. The impact of stressors related to diabetes and its treatment on depression assessment is infrequently considered.

Methods

We used mixed methods to evaluate depressive symptoms in adults with type 2 diabetes. We categorized responses related to diabetes and its treatment during interviews (n=70) using the Montgomery–Åsberg Depression Rating Scale (MADRS) and administered questionnaires to measure diabetes-related distress and depressive symptoms.

Results

Participants (M age=56, SD=7; 67% female; 64% Black; 21% Latino) had mild depression on average (MADRS M=10, SD=9). Half of those with symptoms spontaneously mentioned diabetes context; 61% said diabetes contributed to their symptoms when questioned directly. Qualitative themes included: overlapping symptoms of diabetes and depression; burden of diabetes treatment; emotional impact of diabetes; and the bidirectional influence of depression and diabetes. Diabetes was mentioned more often at higher levels of depression severity (r=.38, p=.001). Higher HbA1c was associated with mentioning diabetes as a context for depressive symptoms (r=.32, p=.007). Insulin-users mentioned diabetes more often than those on oral medications only (p=.005).

Limitations

MADRS is not a traditional qualitative interview so themes may not provide an exhaustive view of the role of diabetes context in depression assessment.

Conclusions and clinical implications

The burden of type 2 diabetes and its treatment often provide an explanatory context for depressive symptoms assessed by structured clinical interviews, the gold standard of depression assessment. Diabetes context may influence accuracy of assessment and should inform intervention planning for those needing treatment.     

Using path analysis to model the process of change in HbA1c among African Americans and Latinos in a community health worker diabetes intervention

ObjectiveTo examine which components of a culturally tailored community health worker (CHW) intervention improved glycemic control and intermediate outcomes among Latina/o and African American participants with diabetes.MethodsThe sample included 326 African American and Latina/o adults with type 2 diabetes in Detroit, MI. CHWs provided interactive group diabetes self-management classes and home visits, and accompanied clients to a clinic visit during the 6-month intervention period. We used path analysis to model the processes by which each intervention component affected change in diabetes self-efficacy, diabetes-related distress, knowledge of diabetes management, and HbA1c.ResultsThe group-based healthy lifestyle component was significantly associated with improved knowledge. The group-based self-management section was significantly associated with reduced diabetes-related distress. Intervention class attendance was positively associated with self-efficacy. Diabetes self-management mediated the reductions in HbA1c associated with reductions in diabetes distress.ConclusionsPath analysis allowed each potential pathway of change in the intervention to be simultaneously analyzed to identify which aspects of the CHW intervention contributed to changes in diabetes-related behaviors and outcomes among African Americans and Latinas/os.Practice Implications: Findings reinforce the importance of interactive group sessions in efforts to improve diabetes management and outcomes among Latina/o and African American adults with diabetes.     

Efficacy of a language-concordant health coaching intervention for latinx with diabetes

ObjectiveTo describe the effect of a language-concordant health coaching intervention for Spanish-speaking patients with limited English proficiency (LEP) and uncontrolled Type 2 Diabetes (T2D) on glycemic control, anxiety, depression, and diabetes self-efficacy.Methods64 patients with T2D were randomly assigned to a control or intervention group. Outcomes were assessed by blood work and surveys pre and post intervention.ResultsThe mean sample age was 47.8 years (SD=11.3) and 81% were female. HbA1c was not significantly different between groups at baseline. The intervention group’s HbA1c was significantly lower at times 2 and 3 than in the control arm (p < .01 and p < .001). There were significant reductions in the intervention group’s mean HbA1c levels from baseline 10.37 to midpoint 9.20, p < .001; and from baseline 10.42 to study end 8.14, p < .001. Depression and anxiety scores significantly decreased (p < .05 and p < .001), and diabetes self-efficacy significantly increased (p < .001).ConclusionHealth coaching led to statistically significant and clinically meaningful decreases in HbA1c, depression, and anxiety scores among LEP Latinx adults with uncontrolled T2D.Practice ImplicationsHeath coaching can be conducted in primary care clinics by nurses or advanced practice nurses. The short-term intervention tested here could be adapted to the clinical setting.     

Fostering informed decisions: A randomized controlled trial assessing the impact of a decision aid among men registered to undergo mass screening for prostate cancer

Objective

Screening asymptomatic men for prostate cancer is controversial and informed decision making is recommended. Within two prostate cancer screening programs, we evaluated the impact of a print-based decision aid (DA) on decision-making outcomes.

Methods

Men (N = 543) were 54.9 (SD = 8.1) years old and 61% were African-American. The 2(booklet type: DA vs. usual care (UC)) × 2(delivery mode: Home vs. Clinic) randomized controlled trial assessed decisional and screening outcomes at baseline, 2-months, and 13-months.

Results

Intention-to-treat linear regression analyses using generalized estimating equations revealed that DA participants reported improved knowledge relative to UC (B = .41, p < .05). For decisional conflict, per-protocol analyses revealed a group by time interaction (B = −.69, p < .05), indicating that DA participants were less likely to report decisional conflict at 2-months compared to UC participants (OR = .49, 95% CI: .26–.91, p < .05).

Conclusion

This is the first randomized trial to evaluate a DA in the context of free mass screening, a challenging setting in which to make an informed decision. The DA was highly utilized by participants, improved knowledge and reduced decisional conflict.

Practice implications

These results are valuable in understanding ways to improve the decisions of men who seek screening and can be easily implemented within many settings.     

Evidence-based training of frontline health workers for door-to-door health promotion: a pilot randomized controlled cluster trial with Lady Health Workers in Sindh Province, Pakistan

OBJECTIVE: Demonstrate the effective use of community-based evidence for health promotion by Lady Health Workers (LHWs) in Sindh, Pakistan. METHODS: A baseline study on mothers and children provided local evidence for risk communication tools designed and tested by LHWs. The communities were randomized to intervention and control. LHWs visited women before and after childbirth to discuss safe practices in pregnancy, in the intervention group LHW using the new tools and in the control group using their standard procedures. A household survey and focus groups permitted assessment of the impact of the intervention. RESULTS: Women in the intervention communities were more likely to attend prenatal checkups, to stop routine heavy work during pregnancy, to give colostrum to newborn babies, and to maintain exclusive breastfeeding for four months. Community focus groups confirmed a positive reaction to the tools. CONCLUSION: Discussion by lay health workers of local evidence underlying safe motherhood messages improved uptake of protective health practices. PRACTICE IMPLICATIONS: Door-to-door health promotion based on culturally appropriate interaction around relevant evidence can have a positive impact on health practices. Engaging health workers from the onset builds capacities, improves dialogue within the health system and performance of frontline health workers.     

A multi-site community randomized trial of community health workers to provide counseling and support for patients newly entering HIV care in rural Ethiopia: study design and baseline implementation

Background: Although HIV therapy is delivered to millions globally, treatment default (especially soon after entering care) remains a challenge. Community health workers (CHWs) can provide many services for people with HIV, including in rural and resource-limited settings.

Objectives: We designed and implemented a 32 site community randomized trial throughout southern Ethiopia to assess an intervention using CHWs to improve retention in HIV care.

Methods: Sixteen district hospital and 16 local health center HIV clinics were randomized 1:1 to be intervention or control sites. From each site, we enrolled adults newly entering HIV care. Participants at intervention sites were assigned a CHW who provided: HIV and health education; counseling and social support; and facilitated communication with HIV clinics. All participants are followed through three years with annual health surveys, plus HIV clinic record abstraction including clinic visit dates. CHWs record operational data about their client contacts.

Results: 1799 HIV patients meeting inclusion criteria were enrolled and randomized: 59% were female, median age = 32 years, median CD4 + count = 263 cells/mm³, and 41% were WHO Stage III or IV. A major enrollment challenge was fewer new HIV patients initiating care at participating sites due to shortage of HIV test kits. At intervention sites, 71 CHWs were hired, trained and assigned to clients. In meeting with clients, CHWs needed to accommodate to various challenges, including HIV stigma, distance, and clients lacking cell phones.

Conclusions: This randomized community HIV trial using CHWs in a resource-limited setting was successfully launched, but required flexibility to adapt to unforeseen challenges.     

Maternal health outcomes among HIV-infected breastfeeding women with high CD4 counts: results of a treatment strategy trial

Background: IMPAACT PROMISE 1077BF/FF was a randomized study of antiretroviral therapy (ART) strategies for pregnant and postpartum women with high CD4+ T-cell counts. We describe postpartum outcomes for women in the study who were randomized to continue or discontinue ART after delivery.

Methods: Women with pre-ART CD4+ cell counts ≥350 cells/mm³ who started ART during pregnancy were randomized postpartum to continue or discontinue treatment. Women were enrolled from India, Malawi, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe. The primary outcome was a composite of progression to AIDS-defining illness or death. Log-rank tests and Cox regression models assessed treatment effects. Incidence rates were calculated per 100 person-years. A post hoc analysis evaluated WHO Stage 2/3 events. All analyses were intent-to-treat.

Findings: 1611 women were enrolled (June 2011–October 2014) and 95% were breastfeeding. Median age at entry was 27 years, CD4+ count 728 cells/mm³ and the majority of women were Black African (97%). After a median follow-up of 1.6 years, progression to AIDS-defining illness or death was rare and there was no significant difference between arms (HR: 0·55; 95%CI 0·14, 2·08, p?=?0.37). WHO Stage 2/3 events were reduced with continued ART (HR: 0·60; 95%CI 0·39, 0·90, p?=?0.01). The arms did not differ with respect to the rate of grade 2, 3, or 4 safety events (p?=?0.61).

Interpretation: Serious clinical events were rare among predominately breastfeeding women with high CD4+ cell counts over 18 months after delivery. ART had significant benefit in reducing WHO 2/3 events in this population.     

A randomized controlled trial for the primary prevention of osteoporosis among preadolescent girl scouts: 1-year outcomes of a behavioral program

OBJECTIVE: To provide 1-year outcomes for a randomized controlled trial of a behavioral-educational intervention for the primary prevention of osteoporosis among 247 preadolescent girls. METHODS: Girl Scout troops were randomly assigned to one of two intervention groups-a group comprising girls only (n = 73) and girls with their mothers (n = 94)-and a healthy-lifestyles control group (n = 80). Multilevel (hierarchical) models were employed to account for clustering of girls within troops. RESULTS: Among girls who met the recommended levels of Ca at baseline, those in the intervention were significantly more likely to maintain or improve their intake at follow-up compared to controls. No significant group differences were found for changes in WBPA. CONCLUSIONS: A behavioral intervention for the primary prevention of osteoporosis holds promise for maintaining adequate Ca intake among preadolescent females.     

Family mediators and moderators of treatment outcomes among youths with poorly controlled type 1 diabetes: results from a randomized controlled trial

OBJECTIVE: To determine whether multisystemic therapy (MST) improved family relationships among youths with poorly controlled type 1 diabetes and whether these changes mediated MST effects on health outcomes. The moderating effect of family demographics on study outcomes was also assessed. METHODS: A randomized controlled trial was conducted with 127 youths. Changes in general family relationships and caregiver support for diabetes care from baseline to treatment completion were assessed. Structural equation modeling (SEM) was used to test whether changes in family relations mediated improvements in frequency of blood glucose testing (BGT) and metabolic control. RESULTS: MST increased support for diabetes care from both primary and secondary caregivers in two-parent but not in single-parent families. However, MST had the strongest effects on BGT and metabolic control in single-parent families. SEM did not support family relations as the mediator of improved BGT or metabolic control. Rather, MST had a direct effect on BGT for all participants. BGT mediated improvements in metabolic control among single-parent families. CONCLUSIONS: MST improved family relationships for youths with diabetes in two-parent but not in single-parent families. Objective outcomes related to diabetes were strongest for single-parent families. Other processes such as increased parental monitoring may have been responsible for improved health outcomes among these families.     

Effectiveness and acceptability of a text message intervention (DTEXT) on HbA1c and self-management for people with type 2 diabetes. A randomized controlled trial

ObjectiveDetermine the effectiveness and acceptability of a text message intervention (DTEXT) on HbA1c and self-management behaviors for Australian adults with type 2 diabetes.MethodsUsing intention to treat analysis and generalized estimating equations, this randomized controlled trial of 395 adults determined change in HbA1c at 3 and 6 months between the intervention and control group. Secondary outcomes included change in nutrition, physical activity, blood lipid profile, body mass index, quality of life, self-efficacy, medication taking and program acceptability.ResultsNo significant difference was observed between the intervention or control group for HbA1c at 3 months (P = 0.23) or 6 months (P = 0.22). Significant improvements were seen in consumption of vegetables at 3 months (P < 0.001) and 6 months (P = 0.04); fruit at 3 months (P = 0.046) and discretionary sweet foods at 3 months (P = 0.02). No other significant effects seen. The intervention demonstrated high rates of acceptability (94.0%) and minimal withdrawal (1.5%).ConclusionsDTEXT was an acceptable text message intervention that improved some nutritional behaviors in people with type 2 diabetes, but did not significantly improve HbA1c or other outcomes. Further research is required to optimize DTEXT.Practice implicationsDTEXT provides an acceptable, feasible form of self-management support that may complement existing diabetes care.     

Comparison of the efficacy of an education program for people with diabetes and insulin pump treatment (INPUT) in a randomized controlled trial setting and the effectiveness in a routine care setting: Results of a comparative effectiveness study

ObjectiveTo compare the efficacy of an education program for people with diabetes and insulin pump treatment (INPUT) in a randomized controlled trial (RCT) to the effectiveness in an implementation trial (IT).Methods135 people with diabetes on insulin pump treatment (CSII) underwent structured education with INPUT under RCT-conditions, 191 people with diabetes on CSII underwent structured education with INPUT under IT-conditions. Baseline characteristics and treatment outcomes at the 6-month follow-up were compared.ResultsAt baseline, RCT-participants were younger (42.7 ± 14.2 vs. 47.2 ± 14.1 years, p = 0.005), had higher HbA1c-values (8.3 ± 0.8% vs. 7.8 ± 1.2%, p = 0.001) and had more diabetes-related distress (27.8 ± 16.4 vs 22.4 ± 14.4, p = 0.002). At follow-up, INPUT results were comparable under the RCT and IT settings. After adjustment for baseline HbA1c, reduction of HbA1c in the IT was significantly greater than in the RCT (Δ0.17%; 95% CI 0.023–0.319%, p = 0.024). Participants with higher HbA1c-levels, more diabetes-related distress and more hypoglycemia problems were most likely to benefit from INPUT regardless of the trial setting.ConclusionsEfficacy of the INPUT program for people with CSII was demonstrated under RCT- and routine care conditions.Practice implicationsEducation with the INPUT program is effective not only under standardized RCT conditions but also under conditions of routine care.