Long-Term Impact of a Community Health Worker Intervention on Diabetes Control in American Samoa.

INTRODUCTION: Diabetes Care in American Samoa (DCAS) was a randomized controlled trial of a 12-month intervention facilitated by community health workers (CHWs) that demonstrated improved HbA1c levels compared with usual care at trial completion. We sought to evaluate the long-term impact of this intervention on diabetes control. METHODS: We retrospectively collected HbA1c measurements from medical records of DCAS participants (n = 268). The study group received the intervention during the trial, and the control group received the intervention after the trial. We used mixed-effects longitudinal regression models to assess change in HbA1c within each trial arm during 3 time periods: DCAS (12 months of the study group's intervention), the first year after DCAS (control group's intervention), and the second year after DCAS. Models were adjusted for baseline characteristics that differed significantly for participants with a low number of HbA1c measurements from those with a high number of HbA1c measurements. RESULTS: After adjustment for confounders, the experiment group experienced a decrease in HbA1c of 0.28 units per year (95% confidence interval [CI], -0.64 to 0.07) during DCAS (intervention). HbA1c decreased by 0.88 units per year (95% CI, -1.31 to -0.45) during the year after the intervention. No significant change was observed the following year. HbA1c of the control group did not significantly change during DCAS (usual care) but decreased by 1.31 units per year (95% CI, -1.72 to -0.91) during its intervention. During the year after the control group's intervention, HbA1c increased by 1.18 units per year (95% CI, 0.42 to 1.93). CONCLUSION: Both groups had initial improvements in glycemic control, but HbA1c later plateaued or increased. These results suggest that time-limited CHW programs improve diabetes control in the short term, but ongoing programs are needed for sustained impact.

Barriers to adequate prenatal care utilization in American Samoa.

The objective of this study is to describe the utilization of prenatal care in American Samoan women and to identify socio-demographic predictors of inadequate prenatal care utilization. Using data from prenatal clinic records, women (n = 692) were categorized according to the adequacy of prenatal care utilization index as having received adequate plus, adequate, intermediate or inadequate prenatal care during their pregnancy. Categorical socio-demographic predictors of the timing of initiation of prenatal care (week of gestation) and the adequacy of received services were identified using one way analysis of variance and independent samples t tests. Between 2001 and 2008 85.4 % of women received inadequate prenatal care. Parity (P = 0.02), maternal unemployment (P = 0.03), and both parents being unemployed (P = 0.03) were negatively associated with the timing of prenatal care initiation. Giving birth in 2007-2008, after a prenatal care incentive scheme had been introduced in the major hospital, was associated with earlier initiation of prenatal care (20.75 vs. 25.12 weeks; P < 0.01) and improved adequacy of received services (95.04 vs. 83.8 %; P = 0.02). The poor prenatal care utilization in American Samoa is a major concern. Improving healthcare accessibility will be key in encouraging women to attend prenatal care. The significant improvements in the adequacy of prenatal care seen in 2007-2008 suggest that the prenatal care incentive program implemented in 2006 may be a very positive step toward addressing issues of prenatal care utilization in this population.

Impact of a diabetes control and management intervention on health care utilization in American Samoa.

OBJECTIVES: To examine the impact of a successful 12-month behavioral intervention to improve diabetes control on health care utilization in American Samoa. METHODS: A cluster-randomized design was used to assign 268 diabetes patients to a nurse-community health worker intervention or usual care. Hospitalizations, emergency department, and primary care physician visits were collected retrospectively for 1 year prior to, and during, the intervention to assess changes in health care utilization. The association of utilization changes with change in HbA1c during the intervention was assessed. RESULTS: Adjusted incidence rate ratios (RR) for primary care physician visits were significantly higher in the community health worker relative to the usual care group (RR = 1.71; 95% CI, 1.25-2.33). There was no main intervention effect on emergency department utilization, but visits in the prior year modified the intervention effect on emergency department visits. Increased primary care physician utilization was associated with greater decreases in HbA1c (b = -0.10, SE = 0.04, p = 0.01). CONCLUSIONS: A culturally adapted community health worker diabetes intervention in American Samoa significantly increased primary care physician visits, and decreased emergency department visits among those with high emergency department usage in the prior year. These changes suggest important and beneficial impacts on health system utilization from the diabetes intervention in a low resource and high-risk population.

Implementation of a culturally tailored diabetes intervention with community health workers in American Samoa.

PURPOSE: The purpose of this article is to answer key implementation questions from our translation research with a primary care-based, nurse-community health worker (CHW) team intervention to support type 2 diabetes self-management. METHODS: Descriptive data are given on intervention delivery, CHW visit content, patient safety, and intervention costs, along with statistical analyses to examine participant characteristics of higher attendance at visits. RESULTS: In the intervention sample (n = 104), 74% (SD = 16%) of planned intervention visits occurred, guided by an algorithm-based protocol. Higher risk participants had a significantly lower dose of their weekly assigned visits (66%) than those at moderate (74%) and lower risk (90%). Twenty-eight percent of participants moved to a lower risk group over the year. Estimated intervention cost was $656 per person. Participants with less education were more likely to attend optimal percentage of visits. CONCLUSIONS: A nurse-CHW team can deliver a culturally adapted diabetes self-management support intervention with excellent fidelity to the algorithm-based protocols. The team accommodated participants' needs by meeting them whenever and wherever they could. This study provides an example of adaptation of an evidence-based model to the Samoan cultural context and its resource-poor setting.

Medication-taking beliefs and diabetes in American Samoa: a qualitative inquiry.

In American Samoa (AS), nearly 22% of adults have type 2 diabetes. Diabetes is best managed by diet and lifestyle modifications and strict medication adherence. Cultural aspects might affect medication-taking beliefs, and thereby influence medication adherence. This study aims to explore diabetes medication-taking experiences and knowledge and related cultural beliefs in AS adults with diabetes and healthcare providers. Six focus groups were conducted with 39 AS adults with diabetes and individual interviews were performed with 13 diabetes healthcare providers. Data were transcribed and analyzed using NVivo 8 software. Themes pertaining to medication taking and adherence were identified. Patients and providers reported that barriers such as confusion about medications and concern about medication costs negatively influence medication taking, while cultural values and obligations both positively and negatively impact medication adherence. These findings help elucidate the relationship between medication-taking beliefs and culture in AS adults with diabetes and highlight the importance of continued research within this population.

Nurse-community health worker team improves diabetes care in American Samoa: results of a randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness of a culturally adapted, primary care-based nurse-community health worker (CHW) team intervention to support diabetes self-management on diabetes control and other biologic measures. RESEARCH DESIGN AND METHODS: Two hundred sixty-eight Samoan participants with type 2 diabetes were recruited from a community health center in American Samoa and were randomly assigned by village clusters to the nurse-CHW team intervention or to a wait-list control group that received usual care. RESULTS: Participants had a mean age of 55 years, 62% were female, mean years of education were 12.5 years, 41% were employed, and mean HbA1c was 9.8% at baseline. At 12 months, mean HbA1c was significantly lower among CHW participants, compared with usual care, after adjusting for confounders (b = -0.53; SE = 0.21; P = 0.03). The odds of making a clinically significant improvement in HbA1c of at least 0.5% in the CHW group was twice the odds in the usual care group after controlling for confounders (P = 0.05). There were no significant differences in blood pressure, weight, or waist circumference at 12 months between groups. CONCLUSIONS: A culturally adapted nurse-CHW team intervention was able to significantly improve diabetes control in the U.S. Territory of American Samoa. This represents an important translation of an evidence-based model to a high-risk population and a resource-poor setting.

Patient and health care provider views of depressive symptoms and diabetes in American Samoa.

High Type 2 diabetes prevalence, associated with recent cultural changes in diet and physical activity, characterizes the U.S. territory of American Samoa. Comorbid diabetes and depression rates are high worldwide and contribute to negative diabetes outcomes; these rates have not been assessed in American Samoa. In this study, 6 focus groups were conducted with 39 American Samoan adults with diabetes; questions on perceptions of diabetes and depressive symptoms were included. Thirteen health care staff interviews were conducted to gain insight into diabetes care in American Samoa. Focus groups and health care staff interviews were translated, transcribed, and entered into NVivo 8 to facilitate analysis. Thematic analysis showed that diabetes patients saw depressive symptoms as directly contributing to high blood sugar. However, these symptoms were rarely mentioned spontaneously, and providers reported they seldom assess them in patients. Many patients and health care staff believed the best ways to respond to feelings of depression involved relaxing, leaving difficult situations, or eating. Staff also discussed cultural stigma associated with depression and the importance of establishing rapport before discussing it. Health care providers in American Samoa need training to increase their awareness of depressive symptoms' negative impact on diabetes management in patients who screen positive for depression. All providers must approach the subject in a supportive context after establishing rapport. This information will be used for cultural translation of a community health worker and primary care-coordinated intervention for adults with diabetes in American Samoa, with the goal of creating an effective and sustainable intervention.

Cultural translation of interventions: diabetes care in American Samoa.

Translation of research advances into clinical practice for at-risk communities is important to eliminate disease disparities. Adult type 2 diabetes prevalence in the US territory of American Samoa is 21.5%, but little intervention research has been carried out there. We discuss our experience with cultural translation, drawing on an emerging implementation science, which aims to build a knowledge base on adapting interventions to real-world settings. We offer examples from our behavioral intervention study, Diabetes Care in American Samoa, which was adapted from Project Sugar 2, a nurse and community health worker intervention to support diabetes self-management among urban African Americans. The challenges we experienced and solutions we used may inform adaptations of interventions in other settings.