Nurse–Community Health Worker Team Improves Diabetes Care in American Samoa

Abstract

OBJECTIVETo 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 METHODSTwo 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.RESULTSParticipants 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.CONCLUSIONSA 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.

Community Health Worker Interventions to Improve Glycemic Control in People with Diabetes: A Systematic Review and Meta-Analysis

“…Participant attrition rates were high in some studies, reaching 50 % in the usual care (control) group of the trial performed by Babamoto et al 14 Only nine trials had a clinically meaningful follow-up of at least 12 months. [10][11][12][13][20][21][22][23][24] Of note, those nine studies also exhibited higher quality, and substantially lower risk of bias, than shorter-term studies. For example, all of them described the standardized method applied to measure A1c, and they all followed the intention to treat principle to analyze A1c changes.…”

“…We identified 13 completed randomized clinical trials. [8][9][10][11][12][13][14][19][20][21][22][23][24] Table 1 describes the basic characteristics of those thirteen trials, including the setting for participant recruitment, duration of the study, and ethnicity of the study populations. Most of them studied minority populations, either AfricanAmerican, 13 Hispanics, 9,10,12,14,19,21,23,24 or both.…”

“…11 DePue et al recruited American Samoans. 20 The components of the control arm varied substantially across studies. In two of the studies, participants in the control arm were placed on a waiting list, and received no additional care during the study.…”

“…In eight of the studies, the CHWs worked on their own, whereas in the remaining cases, the CHW worked with either a certified diabetes educator, 19 a nurse and a dietician, 10 a nurse practitioner, 11 or a nurse case manager. 13,20 As described in Table 2, in all the studies, CHWs worked for a local non-profit organization. In most cases, they had received formal training in preparation for the study, and followed a well-defined intervention protocol.…”

“…In addition, those longer-term studies tended to have larger samples that enhanced their statistical power, and either achieved a balanced distribution of baseline characteristics across the randomized groups, or adjusted appropriately for them in the analysis. [10][11][12][13][20][21][22][23][24] …”