Diabetes Care in American Samoa (DCAS)

Overview

Purpose of Intervention:

Utilize a culturally-adapted nurse and community health worker team primary-care based approach to improve diabetes management among adult Samoans in American Samoa

Intervention Type:

Research-Tested — Interventions with strong methodological rigor that have demonstrated short-term or long-term positive effects on one or more targeted health outcomes to improve minority health and/or health disparities through quantitative measures; Studies have a control or comparison group and are published in a peer-review journal; No pilot, demonstration or feasibility studies.

Intervention Details

Intervention was Primarily Driven, Led, or Managed by:

Academic/Clinical Researchers Only

Citations:

DePue JD, Rosen RK, Seiden A, Bereolos N, Chima ML, Goldstein MG, Nu'usolia O, Tuitele J, McGarvey ST. Implementation of a culturally tailored diabetes intervention with community health workers in American Samoa. The Diabetes educator. 2013 Nov-Dec;39(6):761-71. Epub 2013 Sep 19. PubMed PubMed Central DOI
Relevance: Main Intervention
DePue JD, Dunsiger S, Seiden AD, Blume J, Rosen RK, Goldstein MG, Nu'usolia O, Tuitele J, McGarvey ST. Nurse-community health worker team improves diabetes care in American Samoa: results of a randomized controlled trial. Diabetes care. 2013 Jul;36(7):1947-53. Epub 2013 Feb 7. PubMed PubMed Central DOI
Relevance: Post-Intervention Outcomes
Hamid S, Dunsiger S, Seiden A, Nu'usolia O, Tuitele J, DePue JD, McGarvey ST. Impact of a diabetes control and management intervention on health care utilization in American Samoa. Chronic illness. 2014 Jun;10(2):122-34. Epub 2013 Oct 1. PubMed PubMed Central DOI
Relevance: Evaluations and Assessments

Adaptation of Another Research-based Intervention:

Yes

Name of Original Intervention:

Project Sugar (PS)

Name of Original Intervention Author:

Tiffany L. Gary tgary@pitt.edu

URL to original Intervention:

https://wiki.duke.edu/download/attachments/14125183/Project%20Sugar.pdf

Citations:

Gary TL, Batts-Turner M, Bone LR, Yeh HC, Wang NY, Hill-Briggs F, Levine DM, Powe NR, Hill MN, Saudek C, McGuire M, Brancati FL. A randomized controlled trial of the effects of nurse case manager and community health worker team interventions in urban African-Americans with type 2 diabetes. Controlled clinical trials. 2004 Feb;25(1):53-66. PubMed DOI

Intervention Primary Outcomes were comparable to the original:

Yes

Contact Information

Primary Contact Name:

Stephen T McGarvey

Primary Contact Affiliation:

Department of Epidemiology and International Health Institute, Brown University School of Public Health Preventive Medicine, the Miriam Hospital, Providence, Rhode Island, USA & Alpert Medical School at Brown University, Providence, Rhode Island, USA

Intervention URL:

Not available

Primary Contact Email:

stephen_mcgarvey@brown.edu

Primary Contact Phone Number:

401-863-1354

Results

Intention

Improve minority health or the health of other populations with health disparities (e.g. rural populations, populations with low SES, and sexual and gender minorities)

Intervention Primary Outcome:

HbA1c level

Intervention Secondary Outcome:

Health care utilization

Key Findings:

HbA1c was 0.53% lower among CHW participants at the end of treatment than among the usual care group, controlling for confounders (b = -0.53; SE = 0.21; P = 0.03). Those in the CHW group had twice the odds of making a clinically significant improvement in HbA1c of at least 0.5% compared to those in usual care (OR = 2.07; 95% CI, 1.00–4.34).

The adjusted incidence rate ratio (RR) for primary care visits was higher in the CHW group relative to the usual care group (RR=1.71; 95% CI, 1.25–2.33). The number of ED visits in the prior year modified the intervention effect on ED visits during the intervention (p=0.18). There were fewer ED visits among the CHW subgroup who had more ED visits in the prior year. Each additional ED visit in the prior year was associated with a 20% (95% CI: 12%, 26%) reduction in the relative risk of ED visits during the intervention year. Increased primary care physician utilization was associated with greater decreases in HbA1c (b= -0.10, SE=0.04, p=0.01).

Statistical Method Used:

Mixed effects longitudinal regression models, intent to treat analyses, and longitudinal regression model with generalized estimating equations accounting for clustering.

Was statistical method used to analyze data from original Intervention comparable to the original:

Yes

Evaluations and Assessments

Were Any of the Following Assessments Conducted (Economic Evaluation, Needs Assessment, Process Evaluation)?:

Yes

Economic Evaluation: We assessed cost-effectiveness of the CHW intervention against usual care by collecting clinical, utilization and cost data over two years, and modelling quality-adjusted life years (QALYs) gained based on HbA1c improvements in the CHW group. The CHW group mean increase was $594, but 0.05 QALYs. The incremental cost-effectiveness ratio (ICER) for CHW group compared to usual care control was $1,121 per percentage point HbA1c reduced and $13,191 per QALY gained; intervention was cost-effective.
Process Evaluation: While developing intervention materials and training of the CHWs, we held frequent informal discussions about approach and intervention language, goals and illustrations. We tested CHWs diabetes knowledge, measurements and techniques and trained project staff. Progress notes were approved by the Nurse for entry into participants’ chart. A focus group with CHWs and a nurse was done at end of intervention along with discussions with hospital and health center staff on what did or did not work.

Demographic and Implementation Description

Diseases, Disorders, or Conditions:

Type 2 Diabetes

Race/Ethnicity:

Native Hawaiian or other Pacific Islander

Populations with Health Disparities:

People with Lower Socioeconomic Status (SES), Racial and Ethnic Minority Populations, Underserved Rural Communities

Age:

Adults

Socio-demographics / Population Characteristics

Community Type:

Rural, Villages on the main island of Tutuila, American Samoa

Other Populations with Health Disparities:

People with Low Education

Gender Identity:

Female, Male

Sexual Orientation:

Unspecified

Geographic Location:

American Samoa

Socio-Economic Status:

Low SES

Minority Health and Health Disparities Research Framework

		Levels of Influence
		Individual	Interpersonal	Community	Societal
Determinant Types	Biological
	Behavioral	✔	✔
	Physical / Built Environment
	Sociocultural Environment
	Health Care System	✔	✔	✔

Community Involvement

The community's role in different areas of the Intervention (Choices are "No Role", "Participation", and "Leadership"):

Design:

Participation

Dissemination:

Participation

Evaluation:

Participation

Implementation:

Participation

Outreach:

Participation

Planning :

Participation

Recruitment:

Participation

Sustainability:

Participation

Characteristics and Implementation

Intervention Focus Area:

Behavior Change, Patient-Clinician Communication

Disease Continuum:

Tertiary Prevention

Delivery Setting:

Clinic / Health Care Facility, Home

Mode of Delivery:

In-person

Who delivered the Intervention?:

Community Health Worker/Promoters, Healthcare Professional (Physician, Nurse, Technician)

Conceptual Framework

Intervention Theory:

Precede-Proceed model

Intervention Framework:

PRECEDE-PROCEED

Implementation

Intervention Study Design:

Cluster Randomized Controlled Trial

Targeted Intervention Sample Size:

268

Actual Intervention Sample Size:

268

Start Year:

2009

End Year:

2011

Intervention Exposures

Duration of Intervention/How Long it Lasted:

10-12 months

Frequency of Intervention Delivery:

Frequency depended on risk profile of participants, ranging from every week to every three months (answer also applies to #13; number of sessions varies)

Number of Sessions/Meetings/Visits/Interactions:

More than 10 Sessions

Average Length of Each Session/Meeting/Visit/Interaction:

1-2 Hours

Format of Delivery:

Dyad/Group of two (e.g. participant & partner; mother & child), Group (e.g. Community leaders), Individual

Highest Reading Level of Intervention Materials Provided to Participants:

Grade 4-5

Adaptations and Modifications

Were modifications made?

Intervention Elements	Modified
Content	Yes
Context	Yes
Implementation	Yes
Funding	Yes
Organization	No
Providers	No
Sociopolitical	No
Stages of Occurrence	Yes

Modification Details

	Explanation
Content
Adding Elements	To facilitate CHWs’ teaching, the project team developed flip charts, modeled on the National Diabetes Education Program flipcharts for diabetes prevention and adapted for the 8 topics listed previously. The CHW flipchart pages included background information, talking points, and a small view of the corresponding participant’s page, while the participants’ flipcharts included parallel pages with bigger images and minimal text. Although project staff and many Samoans are bilingual, flipcharts included both languages, as many speakers shift from one language to the other. Cultural features identified during the formative research were incorporated, such as motivational quotes from focus groups, healthy local foods and exercise, examples of barriers to medication taking, sources of stress, and effective coping strategies. Group visits also utilized flipchart content, as well as other teaching aids in Samoan language.
Context
Format, Personnel, Setting	We adapted the Project Sugar intervention to the local Samoan social, cultural and economic context. This required broadening the range of people selected and trained to be CHWs, the reality of how Samoan physicians and nurses cared for people with diabetes, and the level of health literacy about type 2 diabetes among the participants.
Implementation
Delivery	More frequent visits were planned for those with higher HbA1c levels, due to the range of HbA1c levels we found among those with a diagnosis of type 2 diabetes. This was implemented with a clearly defined algorithm as explained in full detail in our publications.
Funding
Federal Government	We were able to receive an administrative supplement from NIH/NIDDK that allowed us to take longer to perform the formative work and then adapt the intervention to the Samoan context.
Stages of Occurrence
Planning/Pre-implementation/Pilot	We performed detailed and lengthy formative work using qualitative methods of focus groups with type 2 diabetes patients and families, in-depth individual interviews with some patients, and with health care providers, a certified Samoan diabetes educator, and nutritionists in American Samoa. This research led us to adapt and expand, and more thoroughly deepen the context of the intervention for the sociocultural and economic context of American Samoa.

Impact, Lessons, Components

Produced an impact or change beyond the primary or secondary outcome:

Yes

The American Samoa Dept of Health was able to hire two of our CHWs and the nurse to positions as outreach workers. They were able to influence others about diabetes care and educate patients in the community.

Essential Aspects for Success:

Individual CHW visits to patients' homes and detailed and flexible goal setting conversations during the intervention

Intervention Impact:

The American Samoa Dept of Health was able to hire two of our CHWs and the nurse to positions as outreach workers. They were able to influence others about diabetes care and educate patients in the community.

Lessons Learned

Key Lessons Learned and/or Things That Could be Changed or Done Differently:

1. Flexibility of scheduling individual visits was necessary especially for the high-risk participants.
2. Health literacy must be assessed more clearly to maximize the intervention.
3. Goal setting between CHWs and patients was crucial.

Insights Gained During Implementation

Insight Category	Insight Description
Cost of Implementing or Sustaining	The local Dept of Health was not able to sustain the intervention due to insufficient buy-in from leadership due to competing budget demands.
Equipment / Technologies	We were unprepared for the difficulty that participants had in purchasing portable glucometers and test strips.
Training / Technical Assistance	In the formative stage, we met with local diabetes care providers and offered updated training about the levels of blood glucose they should try to achieve with their patients. There is a need for regular continuing medical education for local diabetes care providers.
Staffing	We found that motivated individuals can be CHWs regardless of prior formal education and health training.

Intervention Components

Intervention Has Multiple Components:

Yes

Assessed Each Unique Contribution:

No

Products, Materials, and Funding

Expertise, Partnerships, and Funding Sources

	Used for Implementation	Needed for Sustainability
Expertise
Clinical Care	Yes	Unknown
Patient Navigation	Yes	Unknown
Health Education / Health Literacy	Yes	Unknown
Community mobilization, community organization/coalition building	Yes	Unknown
Key informants, Tribal leaders, Community gatekeepers	Yes	Unknown
Research/Data science	Yes	Unknown
Behavior Change Theory & Practice	Yes	Unknown
Qualitative Formative Research	Yes	Unknown
Epidemiology and Anthropology among Samoans	Yes	Unknown
Chronic Care Model & Patient-doctor communications	Yes	Unknown
Partnerships
Health care facilities (local clinics)	Yes	Unknown
Government agencies (city/state/county health department, law enforcement/criminal justice agencies)	Yes	Unknown
Community groups (e.g. faith-based organizations, barbershops, beauty-salons, laundromats, food markets, community centers, cultural associations, tribal groups)	Yes	Unknown
Political leaders	Yes	Unknown
Universities	Yes	Unknown
Funding Sources
Public funding (e.g., federal, state or local government)	Yes	Unknown
Private funding (e.g., foundations, corporations, institutions, facilities)	Yes	Unknown

Product/Material/Tools

	Tailored For Language	Language(s) if other than English	Material
Outreach/Recruitment Tools
Traditional Media (e.g. radio, television, newspaper)	No		Attachment available for request at the bottom of the page.
Recruitment & enrollment script	Yes	Samoan	Attachment available for request at the bottom of the page.
Informed Consent Form	Yes	Samoan	Attachment available for request at the bottom of the page.
Participant Educational Tools
Brochures/Factsheets/Pamphlets	Yes	Samoan	Attachment available for request at the bottom of the page.
Brochures/Factsheets/Pamphlets	Yes	Samoan	Attachment available for request at the bottom of the page.
Brochures/Factsheets/Pamphlets	Yes	Samoan	Attachment available for request at the bottom of the page.
Brochures/Factsheets/Pamphlets	Yes	Samoan	Attachment available for request at the bottom of the page.
Brochures/Factsheets/Pamphlets	Yes	Samoan	Attachment available for request at the bottom of the page.
Brochures/Factsheets/Pamphlets	Yes	Samoan	Attachment available for request at the bottom of the page.
Brochures/Factsheets/Pamphlets	Yes	Samoan	Attachment available for request at the bottom of the page.
Brochures/Factsheets/Pamphlets	Yes	Samoan	Attachment available for request at the bottom of the page.
Brochures/Factsheets/Pamphlets	Yes	Samoan	Attachment available for request at the bottom of the page.
Measurement Tools
Non-Standardized Instruments/Surveys/Questionnaires	Yes	Samoan	Attachment available for request at the bottom of the page.
Non-Standardized Instruments/Surveys/Questionnaires	Yes	Samoan	Attachment available for request at the bottom of the page.

Implementation Materials and Products

	Material
Implementation/Delivery Materials
CHW Manual topics 2 Healthy eating	Attachment available for request at the bottom of the page.
CHW Manual topic 3 being active	Attachment available for request at the bottom of the page.
CHW Manual topic 4 Monitoring	Attachment available for request at the bottom of the page.
CHW Manual topic 5 Taking medication	Attachment available for request at the bottom of the page.
CHW Manual topic 6 Reducing risks	Attachment available for request at the bottom of the page.
CHW Manual topic 7 Healthy coping	Attachment available for request at the bottom of the page.
CHW Manual topic 8 Problem solving	Attachment available for request at the bottom of the page.
Training/Operations manual	Attachment available for request at the bottom of the page.
Implementation/Output Materials
No Implementation/Output Materials provided.

Articles Related to Submitted Intervention

	Article
Reports/Monographs
Final Project Report to NIH for grant award period	Attachment available for request at the bottom of the page.
Additional Articles
social context	Attachment available for request at the bottom of the page.
Evaluation	https://diabetesjournals.org/care/article/36/7/1947/32971/Nurse-Community-Health-Worker-Team-Improves
Methodology	Attachment available for request at the bottom of the page.
Cost-related	Attachment available for request at the bottom of the page.
Qualitative findings	Attachment available for request at the bottom of the page.
Qualitative findings	Attachment available for request at the bottom of the page.
Qualitative findings	Attachment available for request at the bottom of the page.
Qualitative findings	Attachment available for request at the bottom of the page.
Evaluation	Attachment available for request at the bottom of the page.
Evaluation	Attachment available for request at the bottom of the page.

Materials Available for Request

Script for Radio Spot April 29 08.doc
Recruitment Script for Calling Subjects April 30 2008.doc
Brown & AS IRB apprvd Consent Main study transl 6-25-08.doc
NDEP-67 Four steps to control your diabetes for life in Samoan language.pdf
flip chart #1 intro pt pages.ppt
flip chart #2 healthy eating pt pages.ppt
flip chart #3 Being Active pt pages.ppt
flip chart #4 monitoring pt pages.ppt
flip chart #5 taking medication pt pages.ppt
flip chart #6 reducing risk pt pages.ppt
flip chart #7 healthy coping pt pages.ppt
flip chart #8 problem solving- patient.ppt
Baseline Interview 4-1-09 Final version.docx
12-Mo Follow-up Interview final.doc
DCAS Flip Chart CHW Topic 2 Healthy eating.ppt
DCAS Flip Chart CHW Topic 3 Being active.ppt
DCAS Flip Chart CHW Topic 4 Monitoring.ppt
DCAS Flip Chart CHW Topic 5 Taking medication.ppt
DCAS Flip Chart CHW Topic 6 Reducing risks.ppt
DCAS Flip Chart CHW Topic 7 Healthy coping.ppt
DCAS Flip Chart CHW Topic 8 Problem solving.ppt
DCAS Flip Chart CHW Topic 1 Intro.ppt
Final Progress Report Sept 2013 DCAS 9-20-13.doc
AJPH DePue et al DCAS Nov 2010 print.PDF
The Diabetes Educator-DCAS Implementation DePue et al print pub 12-20-13.pdf
CEA Samoan T2DM CHW intrvntn publshd 3-5-19.pdf
Stewart et al Medication taking beliefs print pub Mar 2013.pdf
Held et al depression & diabetes pub Nov 2010.pdf
Elstad et al 2008 living w ma'i suka Prev Chron Dis.pdf
Rosen Anthro Perspectives on Diabetes & Obesity from CHW intervention May 2013.pdf
DCAS Utilization print pub Chronic Illness 5-13-14.pdf
DCAS long-term diabetes control e pub Preventing Chronic Disease 10-26-15.pdf

Intervention IP-057: Diabetes Care in American Samoa (DCAS)

Summary

Overview

Intervention Details

Contact Information

Results

Evaluations and Assessments

Demographic and Implementation Description

Socio-demographics / Population Characteristics

Minority Health and Health Disparities Research Framework

Community Involvement

Characteristics and Implementation

Conceptual Framework

Implementation

Intervention Exposures

Adaptations and Modifications

Modification Details

Impact, Lessons, Components

Lessons Learned

Insights Gained During Implementation

Intervention Components

Products, Materials, and Funding

Product/Material/Tools

Implementation Materials and Products

Articles Related to Submitted Intervention

Materials Available for Request