Community to clinic navigation to improve diabetes outcomes

Testing the 'Faith Moves Mountains model' to increase Alzheimer's disease awareness, detection, and diagnosis among rural, racially, and ethnically diverse older adults

OBJECTIVES

Racially and ethnically diverse populations have recently contributed to the majority of rural and small-town growth. Consequently, the disproportionately high risk and prevalence of Alzheimer's disease and related dementias (ADRD) among rural and minoritized older residents will likely increase. To address this threat, we tested the hypotheses that (1) a faith-based, resident-led approach would increase basic ADRD knowledge and diagnosis, and (2) older age, female gender, lower educational levels, and more years lived rural would predict number of referrals, new dementia diagnoses, and treatment.

METHODS

An adaptation of Schoenberg's Faith Moves Mountains model, previously successful in detection and management of other chronic illnesses in rural settings, guided this community-based participatory research. Local faith community members were trained as research assistants to recruit, administer surveys, conduct brief memory assessments, teach brain health strategies, and follow-up with residents. Outreaches were offered virtually during the pandemic, then in-person monthly at rotating church sites, and repeated ∼1 year later.

RESULTS

This rural sample was racially and ethnically diverse (74.5% non-White), with 28% reporting eight or less years of formal education. Findings included that referrals and years lived rural were significant and positive predictors of new ADRD treatments [(b = 3.74, χ2(1, n = 235) = 13.01, p < 0.001); (b = 0.02, χ2(1, n = 235 = 3.93, p = 0.048)], respectively, regardless of participant characteristics.

CONCLUSION

Resident-led action research in rural, diverse, faith communities is a successful approach to increasing ADRD disease knowledge, detection, diagnosis, and treatment.

Process Evaluations of Diabetes Self-Management Programs: A Systematic Review of the Literature

OBJECTIVE

To conduct a systematic review of process evaluations (PEs) of diabetes self-management programs (DSMPs).

DATA SOURCE

An electronic search using Medline (Ovid), Embase (Ovid), CINAHL (Ensco), Academic Search (Ebsco), and APA PsycInfo (Ebsco).

STUDY INCLUSION AND EXCLUSION CRITERIA

Peer-reviewed, empirical quantitative, qualitative, or mixed-method studies were included if they (1) were a traditional, group-based DSMP, (2) involved adults at least 18 years with T1DM or T2DM, (3) were a stand-alone or embedded PE, and (4) published in English.

DATA EXTRACTION

The following process evaluation outcomes were extracted: fidelity, dose delivered, dose received, reach, recruitment, retention, and context. Additional items were extracted, (eg, process evaluation type, data collection methods; theories; frameworks or conceptual models used to guide the process evaluation, and etc).

DATA SYNTHESIS

Due to heterogeneity across studies, studies were synthesized qualitatively (narratively).

RESULTS

Sixty-eight studies (k) in 78 articles (n) (k = 68; n = 78) were included. Most were mixed methods of low quality. Studies were typically integrated into outcome evaluations vs being stand-alone, lacked theoretical approaches to guide them, and incorporated limited outcomes such as dose received, reach, and retention.

CONCLUSION

Future research should 1) implement stand-alone theoretically grounded PE studies and 2) provide a shared understanding of standardized guidelines to conduct PEs. This will allow public health practitioners and researchers to assess and compare the quality of different programs to be implemented.

Foot care intervention delivered by community health worker (CHWs): A scoping review

Variations of Community Health Workers (CHWs) interventions in diabetes self-management education (DSME) have been reviewed by many studies. In contrast, specific interventions regarding foot care intervention (FCI) are scarce and need to be explored further as one preventive measure to reduce diabetic foot problems in the community. This scoping review aimed to identify, and report nature of FCIs and the core components of FCIs delivered by CHWs. The scoping review was undertaken using PRISMA Extension for Scoping Reviews (PRISMA-ScR). The following electronic databases were searched for articles from data first indicated date through December 2022: CINAHL, EMBASE, Cochrane, Scopus, Web of Science, Theses ProQuest, PubMed, google scholar and other sources by using search terms related to foot care, community health workers, and diabetes mellitus. Descriptive synthesis was used to summarise the data. Nine studies from 1644 were included. All studies found that CHWs provided DSME in general, and foot care education was included. There was no detailed description of the core components of the intervention on foot care. Although, all studies might not provide detailed data on how CHW provided FCIs; the CHW intervention is an undoubtedly vital strategy to promote and prevent foot problems in medically underserved communities.

Effectiveness of self-management interventions for long-term conditions in people experiencing socio-economic deprivation in high-income countries: a systematic review and meta-analysis

BACKGROUND

Long-term conditions (LTCs) are prevalent in socio-economically deprived populations. Self-management interventions can improve health outcomes, but socio-economically deprived groups have lower participation in them, with potentially lower effectiveness. This review explored whether self-management interventions delivered to people experiencing socio-economic deprivation improve outcomes.

METHODS

We searched databases up to November 2022 for randomized trials. We screened, extracted data and assessed the quality of these studies using Cochrane Risk of Bias 2 (RoB2). We narratively synthesized all studies and performed a meta-analysis on eligible articles. We assessed the certainty of evidence using GRADE for articles included in the meta-analysis.

RESULTS

The 51 studies included in this review had mixed findings. For the diabetes meta-analysis, there was a statistically significant pooled reduction in haemoglobin A1c (-0.29%). We had moderate certainty in the evidence. Thirty-eight of the study interventions had specific tailoring for socio-economically deprived populations, including adaptions for low literacy and financial incentives. Each intervention had an average of four self-management components.

CONCLUSIONS

Self-management interventions for socio-economically deprived populations show promise, though more evidence is needed. Our review suggests that the number of self-management components may not be important. With the increasing emphasis on self-management, to avoid exacerbating health inequalities, interventions should include tailoring for socio-economically deprived individuals.

Quality improvement strategies for diabetes care: Effects on outcomes for adults living with diabetes

BACKGROUND

There is a large body of evidence evaluating quality improvement (QI) programmes to improve care for adults living with diabetes. These programmes are often comprised of multiple QI strategies, which may be implemented in various combinations. Decision-makers planning to implement or evaluate a new QI programme, or both, need reliable evidence on the relative effectiveness of different QI strategies (individually and in combination) for different patient populations.

OBJECTIVES

To update existing systematic reviews of diabetes QI programmes and apply novel meta-analytical techniques to estimate the effectiveness of QI strategies (individually and in combination) on diabetes quality of care.

SEARCH METHODS

We searched databases (CENTRAL, MEDLINE, Embase and CINAHL) and trials registers (ClinicalTrials.gov and WHO ICTRP) to 4 June 2019. We conducted a top-up search to 23 September 2021; we screened these search results and 42 studies meeting our eligibility criteria are available in the awaiting classification section.

SELECTION CRITERIA

We included randomised trials that assessed a QI programme to improve care in outpatient settings for people living with diabetes. QI programmes needed to evaluate at least one system- or provider-targeted QI strategy alone or in combination with a patient-targeted strategy. - System-targeted: case management (CM); team changes (TC); electronic patient registry (EPR); facilitated relay of clinical information (FR); continuous quality improvement (CQI). - Provider-targeted: audit and feedback (AF); clinician education (CE); clinician reminders (CR); financial incentives (FI). - Patient-targeted: patient education (PE); promotion of self-management (PSM); patient reminders (PR). Patient-targeted QI strategies needed to occur with a minimum of one provider or system-targeted strategy.

DATA COLLECTION AND ANALYSIS

We dual-screened search results and abstracted data on study design, study population and QI strategies. We assessed the impact of the programmes on 13 measures of diabetes care, including: glycaemic control (e.g. mean glycated haemoglobin (HbA1c)); cardiovascular risk factor management (e.g. mean systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), proportion of people living with diabetes that quit smoking or receiving cardiovascular medications); and screening/prevention of microvascular complications (e.g. proportion of patients receiving retinopathy or foot screening); and harms (e.g. proportion of patients experiencing adverse hypoglycaemia or hyperglycaemia). We modelled the association of each QI strategy with outcomes using a series of hierarchical multivariable meta-regression models in a Bayesian framework. The previous version of this review identified that different strategies were more or less effective depending on baseline levels of outcomes. To explore this further, we extended the main additive model for continuous outcomes (HbA1c, SBP and LDL-C) to include an interaction term between each strategy and average baseline risk for each study (baseline thresholds were based on a data-driven approach; we used the median of all baseline values reported in the trials). Based on model diagnostics, the baseline interaction models for HbA1c, SBP and LDL-C performed better than the main model and are therefore presented as the primary analyses for these outcomes. Based on the model results, we qualitatively ordered each QI strategy within three tiers (Top, Middle, Bottom) based on its magnitude of effect relative to the other QI strategies, where 'Top' indicates that the QI strategy was likely one of the most effective strategies for that specific outcome. Secondary analyses explored the sensitivity of results to choices in model specification and priors.  Additional information about the methods and results of the review are available as Appendices in an online repository. This review will be maintained as a living systematic review; we will update our syntheses as more data become available.

MAIN RESULTS

We identified 553 trials (428 patient-randomised and 125 cluster-randomised trials), including a total of 412,161 participants. Of the included studies, 66% involved people living with type 2 diabetes only. Participants were 50% female and the median age of participants was 58.4 years. The mean duration of follow-up was 12.5 months. HbA1c was the commonest reported outcome; screening outcomes and outcomes related to cardiovascular medications, smoking and harms were reported infrequently. The most frequently evaluated QI strategies across all study arms were PE, PSM and CM, while the least frequently evaluated QI strategies included AF, FI and CQI. Our confidence in the evidence is limited due to a lack of information on how studies were conducted.  Four QI strategies (CM, TC, PE, PSM) were consistently identified as 'Top' across the majority of outcomes. All QI strategies were ranked as 'Top' for at least one key outcome. The majority of effects of individual QI strategies were modest, but when used in combination could result in meaningful population-level improvements across the majority of outcomes. The median number of QI strategies in multicomponent QI programmes was three.  Combinations of the three most effective QI strategies were estimated to lead to the below effects:  - PR + PSM + CE: decrease in HbA1c by 0.41% (credibility interval (CrI) -0.61 to -0.22) when baseline HbA1c < 8.3%; - CM + PE + EPR: decrease in HbA1c by 0.62% (CrI -0.84 to -0.39) when baseline HbA1c > 8.3%;  - PE + TC + PSM: reduction in SBP by 2.14 mmHg (CrI -3.80 to -0.52) when baseline SBP < 136 mmHg; - CM + TC + PSM: reduction in SBP by 4.39 mmHg (CrI -6.20 to -2.56) when baseline SBP > 136 mmHg;  - TC + PE + CM: LDL-C lowering of 5.73 mg/dL (CrI -7.93 to -3.61) when baseline LDL < 107 mg/dL; - TC + CM + CR: LDL-C lowering by 5.52 mg/dL (CrI -9.24 to -1.89) when baseline LDL > 107 mg/dL. Assuming a baseline screening rate of 50%, the three most effective QI strategies were estimated to lead to an absolute improvement of 33% in retinopathy screening (PE + PR + TC) and 38% absolute increase in foot screening (PE + TC + Other).

AUTHORS' CONCLUSIONS

There is a significant body of evidence about QI programmes to improve the management of diabetes. Multicomponent QI programmes for diabetes care (comprised of effective QI strategies) may achieve meaningful population-level improvements across the majority of outcomes. For health system decision-makers, the evidence summarised in this review can be used to identify strategies to include in QI programmes. For researchers, this synthesis identifies higher-priority QI strategies to examine in further research regarding how to optimise their evaluation and effects. We will maintain this as a living systematic review.

A New Look at Barriers to Clinical Care Among Appalachian Residents Living With Diabetes

In the United States, diabetes is the seventh leading cause of death and continues to rise in prevalence, with type 2 diabetes accounting for 90-95% of all cases. Rates of diabetes in Kentucky, and, in particular, the Appalachian region, are among the highest in the nation and are increasing faster than the national average. Despite this disproportionate burden, barriers to clinical appointment attendance have not been fully explored in this population. This article examines the association among perceived barriers to clinical attendance, glycemic control, and diabetes self-care as part of an ongoing study. We used a 25-item checklist developed using the Chronic Care Model to assess participants' barriers to clinic attendance. Glycemic control was assessed via A1C measurement. Diabetes self-care was assessed using the Summary of Diabetes Self-Care Activities measure. At the time of analysis, 123 of the 356 participants (34.6%) did not report any barriers to clinic attendance. For the remainder, the major reported barriers included forgetting appointments, inability to afford medicines or other treatment, and placing faith above medical care. The average A1C was 7.7%, and the average diabetes self-care summary score was 17.1 out of 35 points (with higher values indicating better self-care). Missing clinic appointments is associated with lower health outcomes, especially in vulnerable populations. This study can help educate clinic staff on perceived barriers to type 2 diabetes management among people with diabetes in Appalachia.

The relationship between psychosocial factors, self-care, and blood sugar in an Appalachian population

Introduction

Appalachian residents are more likely than other populations to have Type 2 Diabetes Mellitus (T2DM) and to experience more severe complications from the disease, including excess and premature mortality.

Methods

This study examines health alongside sociodemographic factors, psychosocial factors (including knowledge, empowerment, social support/function, religiosity, distress), and perceived problems in diabetes management that may influence self-care and HbA1c among vulnerable rural residents. A survey of a community-based sample of 356 adults with diagnosed diabetes or HbA1c > 6.5 was conducted in six counties in Appalachian Kentucky.

Results

Findings suggest that neither religiosity nor social support/function mediate/moderate the relationship between psychosocial factors and dependent variables (problem areas in diabetes, T2DM self-care or HbA1c). Results also suggest that distress is a predictor of problem areas in diabetes, and both distress and empowerment are predictors of T2DM self-care.

Implications

This study addresses the gap in the literature concerning the influence of psychosocial factors on problem areas in diabetes, T2DM self-care and HbA1c among vulnerable rural residents, as well as the potential mediating/modifying effects of religiosity and social function/support. Future research is needed to inform strategies for identifying and addressing distress among vulnerable populations burdened by T2DM, including Appalachian adults.

The "Ups and Downs" of Living With Type 2 Diabetes Among Working Adults in the Rural South

The purpose of this qualitative study was to gain a better understanding of the spheres of influence on engagement in recommended diabetes preventive health services among rural, working adults. Additionally, this study sought to understand the unique factors that influence diabetes self-management among rural, working adult populations. The sample included mostly African-American, low-income females with self-reported diabetes, who scored low on the Patient Activation Measure (PAM-10). Semi-structured interviews (N = 20) revealed that most participants struggled with the "ups and downs" of living with diabetes. Four major themes emerged from the data: "the struggle," "doing things together," "diabetes is not the priority," and "we're lucky to have what we have." Most participants were developing individual responsibility and motivation for a healthy future, but were overwhelmed by inconsistency in self-management, diabetes distress, lack of effective coping strategies, and lack of social and economic capital. The findings of this study indicate the need to further address psychological well-being among rural, working adults, yet rural populations often lack sufficient access to mental health care and formalized psychological support. Psychological support and resources are essential to facilitate engagement in diabetes self-management and preventive health services for rural, working adults.

The mediating/moderating role of cultural context factors on self-care practices among those living with diabetes in rural Appalachia

Background

The aim of this study was to examine whether cultural factors, such as religiosity and social support, mediate/moderate the relationship between personal/psychosocial factors and T2DM self-care in a rural Appalachian community.

Methods

Regression models were utilized to assess for mediation and moderation. Multilevel linear mixed effects models and GEE-type logistic regression models were fit for continuous (social support, self-care) and binary (religiosity) outcomes, respectively.

Results

The results indicated that cultural context factors (religiosity and social support) can mediate/moderate the relationship between psychosocial factors and T2DM self-care. Specifically, after adjusting for demographic variables, the findings suggested that social support may moderate the effect of depressive symptoms and stress on self-care. Religiosity may moderate the effect of distress on self-care, and empowerment was a predictor of self-care but was not mediated/moderated by the assessed cultural context factors. When considering health status, religiosity was a moderately significant predictor of self-care and may mediate the relationship between perceived health status and T2DM self-care.

Conclusions

This study represents the first known research to examine cultural assets and diabetes self-care practices among a community-based sample of Appalachian adults. We echo calls to increase the evidence on social support and religiosity and other contextual factors among this highly affected population.

Trial registration

US National Library of Science identifier NCT03474731. Registered March 23, 2018, www.clinicaltrials.gov.

Overcoming the COVID-19 Pandemic for Dementia Research: Engaging Rural, Older, Racially and Ethnically Diverse Church Attendees in Remote Recruitment, Intervention and Assessment

BACKGROUND

Access to cognitive screening in rural underserved communities is limited and was further diminished during the COVID-19 pandemic. We examined whether a telephone-based cognitive screening intervention would be effective in increasing ADRD knowledge, detecting the need for further cognitive evaluation, and making and tracking the results of referrals.

METHOD

Using a dependent t-test design, older, largely African American and Afro-Caribbean participants completed a brief educational intervention, pre/post AD knowledge measure, and cognitive screening.

RESULTS

Sixty of 85 eligible individuals consented. Seventy-percent of the sample self-reported as African American, Haitian Creole, or Hispanic, and 75% were female, with an average age of 70. AD knowledge pre-post scores improved significantly (t (49) = -3.4, p < .001). Of the 11 referred after positive cognitive screening, 72% completed follow-up with their provider. Five were newly diagnosed with dementia. Three reported no change in diagnosis or treatment. Ninety-percent consented to enrolling in a registry for future research.

CONCLUSION

Remote engagement is feasible for recruiting, educating, and conducting cognitive screening with rural older adults during a pandemic.

Is Theory Guiding Our Work? A Scoping Review on the Use of Implementation Theories, Frameworks, and Models to Bring Community Health Workers into Health Care Settings

Community health workers (CHWs) are becoming a well-recognized workforce to help reduce health disparities and improve health equity. Although evidence demonstrates the value of engaging CHWs in health care teams, there is a need to describe best practices for integrating CHWs into US health care settings. The use of existing health promotion and implementation theories could guide the research and implementation of health interventions conducted by CHWs. We conducted a standard 5-step scoping review plus stakeholder engagement to provide insight into this topic. Using PubMed, EMBASE, and Web of Science, we identified CHW intervention studies in health care settings published between 2000 and 2017. Studies were abstracted by 2 researchers for characteristics and reported use of theory. Our final review included 50 articles published between January 2000 and April 2017. Few studies used implementation theories to understand the facilitators and barriers to CHW integration. Those studies that incorporated implementation theories used RE-AIM, intervention mapping, cultural tailoring, PRECEDE-PROCEED, and the diffusion of innovation. Although most studies did not report using implementation theories, some constructs of implementation such as fidelity or perceived benefits were assessed. In addition, studies that reported intervention development often cited specific theories, such as the transtheoretical or health belief model, that helped facilitate the development of their program. Our results are consistent with other literature describing poor uptake and use of implementation theory. Further translation of implementation theories for CHW integration is recommended.

Impact of a community-based approach to patient engagement in rural, low-income adults with type 2 diabetes

OBJECTIVE

This secondary analysis examined the relationships between Patient Activation Measure (PAM) scores, use of health services, and HgA1C.

DESIGN

A feasibility study was conducted for a community-based intervention for high-risk adults with uncontrolled diabetes. Data were collected at baseline and monthly, including PAM and modified Diabetes Self-Management Assessment Report Tool.

INTERVENTION

Participants (n = 58) were randomized to a 3-month nurse (RN) telephone management or community health worker (CHW) in-home intervention, focusing on medication adherence, timely follow-up, diabetes self-management coaching, and linkage to resources.

RESULTS

Sample was mostly female (73%), African-American (90%), low income (75%), high school education or less (80%), and mean age of 59 years. A positive association between PAM score and self-reported diabetes care recommendations was found (r = .356, p = .014) and significant correlation between baseline PAM score and HgA1C levels (r = -.306, p = .029). A paired samples t test showed statistically significant increases in PAM scores in the CHW intervention group (mean increase +8.5, CI [+2.49 to +14.65]); baseline (M = 60.31, SD = 13.3) to end of study ([M = 68.89, SD = 16.39], t(22) = 2.924, p = .008 [two-tailed]).

CONCLUSION

A community-based approach to diabetes management demonstrated a positive effect on patient activation. Although disparities in health care access among rural, low-income populations exist, community-based interventions show potential for improving patient engagement in diabetes management and recommended health services.

Lay Advisor Interventions in Rural Populations: A Systematic Review and Meta-analysis

CONTEXT

Age-adjusted death rates for heart disease are higher in rural areas than in urban areas. Lay advisors could potentially facilitate improvement in cardiovascular health outcomes. The aim of this systematic review and meta-analysis is to estimate lay advisor intervention effects on cardiovascular health metrics in rural populations.

EVIDENCE ACQUISITION

Searches of databases including MEDLINE, CINAHL, and Scopus from 1975 through October 2017 retrieved 323 citations, of which 272 abstracts were reviewed. Two authors independently abstracted data from eligible studies. Analysis was conducted in March 2018.

EVIDENCE SYNTHESIS

Of 21 articles included in the systematic review, eight were RCTs and 13 were pre- and post-intervention studies. Of the RCTs, three took place in the U.S. Only two studies had low risk of bias. Using a random effects model, meta-analysis of six RCTs (1,641 participants) showed that lay advisor interventions in rural residents were associated with improvement in HbA1c of 0.4% (95% CI=0.13, 0.66, p=0.004, I²=60.65%). From four RCTs (873 participants), lay advisor interventions significantly improved BMI with pooled effect of 2.18 (95% CI=1.13, 3.24, p<0.001, I²=0.00%). Most studies had normal baseline blood pressure and cholesterol levels before intervention, and no significant effects were noted for these outcomes. Diverse types of measures used for diet, physical activity, and smoking precluded statistical synthesis.

CONCLUSIONS

Lay advisor interventions had significant positive effects on glycemic control and BMI for rural residents; however, further rigorous studies are needed in U.S. rural populations, and elements of effective lay advisor interventions require further investigation.

A qualitative process evaluation of a diabetes navigation program embedded in an endocrine specialty center in rural Appalachian Ohio

BACKGROUND

Diabetes in the United States has reached epidemic proportions and the people of Appalachia have been disproportionately affected by this disease. Strategies that complement standard diabetes care are critically important to mitigate the risk of complications, reduce health expenditures, and improve the quality of life of patients living in rural Appalachia. The purpose of this study was to conduct a qualitative process evaluation of a patient navigation program for diabetes after its first year of implementation.

METHODS

The process evaluation assessed how the Diabetes Navigation Program was delivered as well as how it was experienced by the navigators, providers, health administrators, and office staff at an endocrine specialty center in rural Appalachian Ohio. We employed total population sampling to conduct in-depth, face-to-face interviews with all providers, health administrators, staff, and navigators at a Diabetes Endocrine Center. Interviews were transcribed, coded, and analyzed via content and thematic analyses using NVivo 11 software.

RESULTS

Seventeen individuals (providers n = 5, health administrators n = 4, office staff members n = 3, and navigators n = 5) participated in in-depth, face-to-face interviews (age = 44.7 ± 11.6 years, 82.4% female, 94.1% white, 13.3 ± 9.6 years work experience). Fidelity of implementation: The navigation team carried out most of the activities denoted in the Work Plan, therefore the program was implemented somewhat successfully. Qualitative analysis revealed three themes: 1) The navigator addresses sources of health disparities: All participants described the role of the diabetes navigator as someone who is knowledgeable about diabetes and able to identify and address health disparities. 2) The navigators are the eyes in the community and the patients' homes: Navigators offered providers and clinic staff a rare glimpse into the personal lives of patients, which led to the identification of unrecognized barriers. 3) Difficulties with cross-system integration of services: Differences in the organizational culture and vision of the specialty center and navigation office contributed to systemic barriers.

CONCLUSIONS

Overall, this process evaluation highlights the importance of coordinating providers, health administrators, medical office staff, and navigators to address barriers to diabetes care. Forthcoming research is needed to document the clinical effectiveness and sustainability of the Diabetes Navigation Program in rural Appalachia.