The Effect of Integrating Primary Care and Mental Health Services on Diabetes and Depression: A Multi-site Impact Evaluation on the US-Mexico Border

BACKGROUND

Health care delivery systems are increasingly integrating physical and mental health services to address patients' complex needs, contain costs, and improve satisfaction. Therefore, it is critical to understand whether adoption of integrated care models is effective in diverse settings.

OBJECTIVE

This study examined the effect of integrated care on physical and mental health outcomes among low-income Latino participants on the US-Mexico border.

RESEARCH DESIGN

In this quasi-experimental multisite study, individual-level data were pooled from 8 studies of locally adapted integrated care models.

SUBJECTS

Participants were 18 years or older and had 1 or more chronic conditions: diabetes, depression, hypertension, or obesity. The study enrolled 4226 participants with 2254 participants in the intervention group and 1972 in the comparison group.

MEASURES

Primary outcomes were depressive symptoms as measured by the Patient Health Questionnaire-9 score and blood glucose measured by hemoglobin A1c (HbA1c). Blood pressure, body mass index, and quality of life were secondary outcomes.

RESULTS

Multivariable linear regression analyses indicated intervention participants had significantly lower Patient Health Questionnaire-9 scores (β=-0.39, P=0.03) and HbA1c (β=-0.14, P=0.02) at 12 months compared with comparison group participants. Stratified analyses showed improvements in HbA1c were even greater among intervention participants who had diabetes, depression, severe and persistent mental illness, were older or female compared with their counterparts in the comparison group.

CONCLUSIONS

Health care is constantly transforming, making it critical to study these changes across populations and settings. Findings from this study indicate that integrated care can significantly improve mental and physical health in an underserved Latino population.

Incorporating an Increase in Plant-Based Food Choices into a Model of Culturally Responsive Care for Hispanic/Latino Children and Adults Who Are Overweight/Obese

Introduction: The national rate of obesity in US Hispanic/Latinos exceeds all other major ethnic subgroups and represents an important health disparity. Plant-based diet interventions that emphasize whole plant foods with minimal processing and less refined grains and sugar have shown great promise in control of obesity, but there is a paucity of data translating this treatment effect to disparate populations. The objective of our study was to evaluate the efficacy of the Healthy Eating Lifestyle Program (HELP) for accomplishing weight management in a hospital-based, family centered, culturally tailored, plant-based diet intervention for Hispanic/Latino children who were overweight or obese. Methods: Our mixed methods evaluation included: (1) A one arm study to measure changes in body mass index (BMI) from pre- to post-intervention, and (2) A stakeholder analysis of the program staff. Results: For children ages 5–12 years who were overweight/obese, we found no evidence of excess weight gain evidenced by BMI Z scores (Z_post-pre = −0.02, p = 0.11). Among the parent/guardians who were overweight or obese, we found a decrease in BMI that was stronger in men (BMI _post-pre = −0.75 kg/m², p = 0.01) than in women (BMI _post-pre = −0.12 kg/m², p = 0.30). A program strength was the cultural tailoring of the plant-based diet choices. Conclusions: The evaluation raises the possibility that incorporating intervention components of HELP (plant-based food choices, family-based, cultural tailoring) into pediatric weight management can improve the standard of care.

Diabetes Self-Management Behaviors, Health Care Access, and Health Perception in Mexico-US Border States

Purpose

The purpose of this study was to describe diabetes self-management behaviors, diabetes health care access, and health perception for Mexican adults and Hispanics residing in the Mexico-US border region.

Methods

This study used data from the Behavior Risk Factor Surveillance System (BRFSS) survey diabetes items (n = 26) to assess characteristics of Hispanics in 4 Arizona border counties (n = 216) and cross-sectional data from a modified BRFSS in a convenience sample of adults residing in Monterrey, Mexico (n = 351). Data were analyzed for descriptive statistics with SPSS.

Results

The Mexico cohort was younger than the Arizona cohort (59.36 [11.5] vs 65.54 [11.1], respectively) and the mean length of time with type 2 diabetes was similar. Less than 10% (9.7%) of the Arizona cohort reported never monitoring blood glucose compared to 22.5% of the Mexico cohort. The mean (SD) number of times in the past 12 months the Mexico cohort saw their health care provider was 9.09 (6.8) vs 4.49 (8.3) for the Arizona cohort. Despite provider access, there were differences in self-management behaviors between the cohorts.

Conclusions

Due to environmental and policy factors in the Mexico-US border region, there continues to be a gap in evidence-based practice and uptake of self-management behaviors for adults with diabetes. Resources such as the BRFSS and shared practice guidelines would bridge this gap.

A Systematic Review of Barriers to Access-to-Care in Hispanics With Type 2 Diabetes

INTRODUCTION

A systematic review was conducted to highlight current barriers to access-to-care for Hispanics with type 2 diabetes (T2D).

METHOD

PubMed and CINAHL databases (2010-2015) using PRISMA guidelines. 84 studies were identified, 12 quantitative studies were selected for review remained based on inclusion/exclusion criteria. There were five research questions: (1) What samples/settings were included? (2) What theories guided each study? (3) What were the study aims and (4) designs? (5) What barriers of access-to-care were identified? Barriers were placed into three categories set a priori.

RESULTS

The word "barrier" was in one study aim. Barriers of self (92%), provider (50%), and environment (25%) were identified. Self-care behaviors (diet and exercise), individual resources (cost factors), lack of providers specializing in T2D, and environmental factors affect Hispanics with T2D access-to-care.

DISCUSSION

These barriers to access underscore current importance to Hispanics with T2D. A follow-up review should be conducted as new barriers are expected to emerge.

A Modified Behavior Risk Factor Surveillance System to Assess Diabetes Self-management Behaviors and Diabetes Care in Monterrey Mexico: A Cross-sectional Study

Type 2 diabetes mellitus (T2DM) is one of the leading causes of death from worldwide non-communicable diseases. The prevalence of diabetes in the Mexico (MX)–United States border states exceeds the national rate in both countries. The economic burden of diabetes, due to decreased productivity, disability, and medical costs, is staggering and increases significantly when T2DM-related complications occur. The purpose of this study was to use a modified behavioral risk factor surveillance system (BRFSS) to describe the T2DM self-management behaviors, diabetes care, and health perception of a convenience sample of adults with T2DM in Monterrey, MX. This cross-sectional study design, with convenience sampling, was conducted with a convenience sample (n = 351) of adults in the metropolitan area of Monterrey, MX who self-reported a diagnosis of T2DM. Potential participants were recruited from local supermarkets. Twenty-six diabetes and health-related items were selected from the BRFSS and administered in face-to-face interviews by trained data collectors. Data analysis was conducted using descriptive statistics. The mean age was 47 years, and the mean length of time with T2DM was 12 years. The majority was taking oral medication and 34% required insulin. Daily self-monitoring of feet was performed by 56% of the participants; however, only 8.8% engaged in blood glucose self-monitoring. The mean number of health-care provider visits was 9.09 per year, and glycated hemoglobin level (HbA1c) was assessed 2.6 times per year. Finally, only 40.5% of the participants recalled having a dilated eye exam. We conclude the modified BRFSS survey administered in a face-to-face interview format is an appropriate tool for assessing engagement in T2DM self-management behaviors, diabetes care, and health perception. Extension of the use of this survey in a more rigorous design with a larger scale survey is encouraged.

Evaluating an Outpatient Diabetes Program Telephone Follow-Up Process on Glycosylated Hemoglobin Levels

Purpose: The purpose of this study was to determine if increased frequency of telephone contact immediately following diabetes self-management education (DSME) impacts improvements in A1C levels versus routine telephone follow-up. Methods: This study used a quasi-experimental design consisting of a control group (n = 30) who received routine follow-up (1 telephone call 4-6 weeks after DSME class completion) and an intervention group (n = 26) who received an average of 5 telephone calls over a 3-month period following DSME. Participants were obtained from an outpatient diabetes education program assoctiated with a large urban health care system. Results: Most participants were female, White, with the average age of 57.2 years (SD = 14.1). Preintervention A1C levels ranged from 6.5% to 14.3%, whereas postintervention A1C levels ranged from 5.2% to 13.6%. There was significant improvement in A1C levels for both the intervention and the control groups. However, no statistically significant difference in A1C change scores was found between the groups. Sixty percent of the control group participants had post-A1C levels below 7% compared to 54% of the intervention group. Increased telephone contact was associated with A1C reductions, although this relationship was not statistically significant. Conclusions: This study demonstrated that A1C reductions can occur with either frequency of telephone follow-up. The diabetes educator should evaluate the telephone follow-up needs of each DSME participant to support his or her diabetes self-management success.

Imbedding Interdisciplinary Diabetes Group Visits Into a Community-Based Medical Setting

PURPOSE

The purpose of this study was to evaluate an interdisciplinary approach and test the efficacy of diabetes group visits tailored to low-income patients in a community-based medical practice.

METHODS

A randomized repeated measures design was used with 40 patients in the experimental group and 40 patients in the control group. The diabetes group visit consisted of individualized sessions with a physician or nurse practitioner to review medications and conduct a medical examination and group sessions to deliver diabetes self-management education. Data collected included clinical data and questionnaires. A control group shared comparable demographic characteristics, medication regimens, and baseline A1C levels.

RESULTS

The patients in the experimental group decreased their A1C, triglycerides, and heart rate from time 1 to time 5 and maintained their high-density lipoprotein significantly more than the control group. In exit interviews, the patients said that the group diabetes visits helped them be more accountable about their diabetes self-management goals.

CONCLUSIONS

Diabetes group visits that combined diabetes self-management education and a medical visit with a health care provider improved A1C and were well received by the patients. The study provided patients with a quality program in an environment in which they felt safe to learn and that met them where they were in their diabetes self-management behaviors. This approach could be widely disseminated into other clinic settings that serve patients with type 2 diabetes.

Self-Care Behaviors and Glycemic Control in Low-Income Adults in México With Type 2 Diabetes Mellitus May Have Implications for Patients of Mexican Heritage Living in the United States

This study examined self-care behaviors and their relationship to glycemic control in low-income Mexican adults with type 2 diabetes in Southeastern Tamaulipas, México. A total of 135 patients were enrolled from 17 community health centers. The most frequent self-care behavior was medication management (80%), and the least frequent self-care behavior was self blood glucose monitoring (7%). All the patients demonstrated poor glycemic control, with glycated hemoglobin > 7%. Self-care behaviors were associated with fasting blood glucose (rs = .223, p = .005). Medication management was influenced by cognitive performance, F(1, 130) = 4.49, p = .036, and depression, F(1, 130) = 8.22, p = .005. Dietary behaviors were influenced by previous diabetes education, F(1, 130) = 6.73, p = .011. These findings indicate that education and cognitive behavioral interventions in Spanish for Mexican adults with type 2 diabetes are urgently needed.