Diabetes Prevention and Care Capacity at Urban Indian Health Organizations.

American Indian and Alaska Native (AI/AN) people suffer a disproportionate burden of diabetes and cardiovascular disease. Urban Indian Health Organizations (UIHOs) are an important source of diabetes services for urban AI/AN people. Two evidence-based interventions-diabetes prevention (DP) and healthy heart (HH)-have been implemented and evaluated primarily in rural, reservation settings. This work examines the capacity, challenges and strengths of UIHOs in implementing diabetes programs. Methods: We applied an original survey, supplemented with publicly-available data, to assess eight organizational capacity domains, strengths and challenges of UIHOs with respect to diabetes prevention and care. We summarized and compared (Fisher's and Kruskal-Wallis exact tests) items in each organizational capacity domain for DP and HH implementers vs. non-implementers and conducted a thematic analysis of strengths and challenges. Results: Of the 33 UIHOs providing services in 2017, individuals from 30 sites (91% of UIHOs) replied to the survey. Eight UIHOs (27%) had participated in either DP (n = 6) or HH (n = 2). Implementers reported having more staff than non-implementers (117.0 vs. 53.5; p = 0.02). Implementers had larger budgets, ~$10 million of total revenue compared to $2.5 million for non-implementers (p = 0.01). UIHO strengths included: physical infrastructure, dedicated leadership and staff, and community relationships. Areas to strengthen included: staff training and retention, ensuring sufficient and consistent funding, and data infrastructure. Conclusions: Strengthening UIHOs across organizational capacity domains will be important for implementing evidence-based diabetes interventions, increasing their uptake, and sustaining these interventions for AI/AN people living in urban areas of the U.S.

Implementation of a Diabetes Self-Management Education and Support Intervention in Rural Guatemala: A Mixed-Methods Evaluation Using the RE-AIM Framework.

INTRODUCTION: To address the global diabetes epidemic, lifestyle counseling on diet, physical activity, and weight loss is essential. This study assessed the implementation of a diabetes self-management education and support (DSMES) intervention using a mixed-methods evaluation framework. METHODS: We implemented a culturally adapted, home-based DSMES intervention in rural Indigenous Maya towns in Guatemala from 2018 through 2020. We used a pretest-posttest design and a mixed-methods evaluation approach guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Quantitative data included baseline characteristics, implementation metrics, effectiveness outcomes, and costs. Qualitative data consisted of semistructured interviews with 3 groups of stakeholders. RESULTS: Of 738 participants screened, 627 participants were enrolled, and 478 participants completed the study. Adjusted mean change in glycated hemoglobin A1c was -0.4% (95% CI, -0.6% to -0.3%; P < .001), change in systolic blood pressure was -5.0 mm Hg (95% CI, -6.4 to -3.7 mm Hg; P < .001), change in diastolic blood pressure was -2.6 mm Hg (95% CI, -3.4 to -1.9 mm Hg; P < .001), and change in body mass index was 0.5 (95% CI, 0.3 to 0.6; P < .001). We observed improvements in diabetes knowledge, distress, and most self-care activities. Key implementation factors included 1) recruitment barriers for men, 2) importance of patient-centered care, 3) role of research staff in catalyzing health worker involvement, 4) tradeoffs between home and telephone visits, and 5) sustainability challenges. CONCLUSION: A community health worker-led DSMES intervention was successfully implemented in the public health system in rural Guatemala and resulted in significant improvements in most clinical and psychometric outcomes. Scaling up sustainable DSMES in health systems in rural settings requires careful consideration of local barriers and facilitators.

Monitoring Study Participants and Implementation with Phone Calls to Support Hypertension Control During the COVID-19 Pandemic: The Case of a Multicomponent Intervention Trial in Guatemala.

Background: The COVID-19 pandemic presents a challenge to health care for patients with chronic diseases, especially hypertension, because of the important association and increased risk of these patients with a severe presentation of COVID-19 disease. The Guatemalan Ministry of Health has been implementing a multi-component program aimed at improving hypertension control in rural communities since 2019 as a part of an intervention research cluster randomized trial. When the first cases of COVID-19 were reported (March 13, 2020) in Guatemala, our study paused all study field activities, and began monitoring participants through phone calls. The objective of this paper is to describe the approach used to monitor study participants during the COVID-19 pandemic and compare data obtained during phone calls for intervention and control group participants. Methods: We developed a cross-sectional study within the HyTREC (Hypertension Outcomes for T4 Research within Lower Middle-Income Countries) project 'Multicomponent Intervention to Improve Hypertension Control in Central America: Guatemala' in which phone calls were made to participants from both intervention and control groups to monitor measures important to the study: delivery of antihypertensive medications in both groups, receipt of coaching sessions and use of a home blood pressure monitor by intervention group participants, as well as reasons that they were not implemented. Results: Regarding the delivery of antihypertensive drugs by the MoH to participants, those in the intervention group had a higher level of medication delivery (73%) than the control group (51%), p<0.001. Of the total participants in the intervention group, 62% had received at least one health coaching session in the previous three months and 81% used a digital home blood pressure monitor at least twice a week. Intervention activities were lower than expected due to restricted public transportation on top of decreased availability of health providers. Conclusion: In Guatemala, specifically in rural settings, access to antihypertensive medications and health services during pandemic times was impaired and less than expected, even after accounting for the program's implementation activities and actions.