Transforming care for patients living with diabetes in rural Mexico: a qualitative study of patient and provider experiences and perceptions of shared medical appointments.

BACKGROUND: Global prevalence of diabetes is increasing, causing widespread morbidity, mortality and increased healthcare costs. Providing quality care in a timely fashion to people with diabetes in low-resource settings can be challenging. In the underserved state of Chiapas, Mexico, which has some of the lowest diabetes detection and control rates in the country, there is a need to implement strategies that improve care for patients with diabetes. One such strategy is shared medical appointments (SMAs), a patient-centred approach that has proven effective in fostering patient engagement and comprehensive care delivery among underserved populations. OBJECTIVE: This study aimed to understand the perceptions, experiences and insights of both patients living with diabetes and healthcare providers, who took part in a pilot SMA strategy implemented in five outpatient clinics in rural Chiapas. METHODS: Following an exploratory qualitative approach, we conducted 50 in-depth interviews with patients and providers involved in diabetes SMAs and five focus group discussions with community health workers providing patient support and education. RESULTS: The implementation of an SMA model changed how diabetes care is perceived, structured and delivered. Patients felt sheltered by group interactions based on trust, which allowed for the exchange of experiences, learning and increased engagement in treatment and lifestyle changes. Providers gained insights into their patients' context and lived experiences, which resulted in improved rapport and quality of care. SMAs also restructured some operational aspects in the clinics and fostered the sharing of power and responsibilities amongst the staff. CONCLUSIONS: The SMAs model transformed care by providing a patient-centred, collaborative approach to diabetes care, education and support. Additionally, it reshaped the health-care team resulting in power-shifting and role-sharing among members of the interdisciplinary team. We therefore encourage decision-makers to expand the use of SMAs to improve care for patients with diabetes in low-resource settings.

Genetic diversity in Oryza glumaepatula wild rice populations in Costa Rica and possible gene flow from O. sativa.

Wild crop relatives are an important source of genetic diversity for crop improvement. Diversity estimates are generally lacking for many wild crop relatives. The objective of the present study was to analyze how genetic diversity is distributed within and among populations of the wild rice species Oryza glumaepatula in Costa Rica. We also evaluated the likelihood of gene flow between wild and commercial rice species because the latter is commonly sympatric with wild rice populations. Introgression may change wild species by incorporating alleles from domesticated species, increasing the risk of losing original variation. Specimens from all known O. glumaepatula populations in Costa Rica were analyzed with 444 AFLP markers to characterize genetic diversity and structure. We also compared genetic diversity estimates between O. glumaepatula specimens and O. sativa commercial rice. Our results showed that O. glumaepatula populations in Costa Rica have moderately high levels of genetic diversity, comparable to those found in South American populations. Despite the restricted distribution of this species in Costa Rica, populations are fairly large, reducing the effects of drift on genetic diversity. We found a dismissible but significant structure (θ = 0.02 ± 0.001) among populations. A Bayesian structure analysis suggested that some individuals share a significant proportion of their genomes with O. sativa. These results suggest that gene flow from cultivated O. sativa populations may have occurred in the recent past. These results expose an important biohazard: recurrent hybridization may reduce the genetic diversity of this wild rice species. Introgression may transfer commercial traits into O. glumaepatula, which in turn could alter genetic diversity and increase the likelihood of local extinction. These results have important implications for in situ conservation strategies of the only wild populations of O. glumaepatula in Costa Rica.