Using Community Health Workers and a Smartphone Application to Improve Diabetes Control in Rural Guatemala
A smartphone application providing algorithmic clinical decision support enabled community health workers to improve diabetes control for a group of patients in rural Guatemala. This approach enables task sharing with physicians and other advanced practitioners for chronic disease care, which is particularly important in low resource settings. Key Findings A smartphone application providing algorithmic clinical decision support enabled community health workers to improve diabetes control for a group of patients in rural Guatemala. Key Implications Program managers should consider equipping community health workers with clinical decision support applications to enable task sharing for chronic disease management. Researchers should examine the efficacy of this approach for chronic diseases other than diabetes and compared to traditional models of care. ABSTRACT Background: The global prevalence of diabetes has nearly doubled since 1980. Seventy five percent of patients with diabetes live in low and middle income countries, such as Guatemala, where health care systems are often poorly equipped for chronic disease management. Community health workers (CHWs) and mobile health technology have increasingly been applied to the diabetes epidemic in these settings, although mostly in supportive rather than primary roles in diabetes management. We sought to improve diabetes care in rural Guatemala through the development of a CHW led diabetes program and a smartphone application to provide CHWs with clinical decision support. Methods: We worked with our local partners to develop a program model and the smartphone application (using the CommCare platform) and to train CHWs. We recruited patients with type 2 diabetes living in rural communities. Program evaluation used a single group, pre post design. Primary outcomes were hemoglobin A1c and the percentage of patients meeting A1c goals compared with baseline. We also followed a variety of process metrics, including application reliability. Results: Eighty nine patients enrolled during the study period. The hemoglobin A1c percentage decreased significantly at 3 months 1.0; 95% CI= 1.7, 0.6) 6 months 1.5; 95% CI= 2.2, 0.8) 9 months 1.3; 95% CI= 2.0, 0.6) and 12 months 1.0; 95% CI= 1.7, 0.4) The percentage of patients with A1c 8% increased significantly at 3 months (23.6% to 44.4% P=.007) 6 months (22.0% to 44.0% P=.015) and 9 months (23.9% to 45.7% P=.03) CHWs and supervising physicians agreed with application medication recommendations >90% of the time. Conclusion: Our results suggest that CHWs can safely and effectively manage diabetes with the assistance of a smartphone application and remote physician supervision. This model should be evaluated versus other standards of care and could be adapted to other low resource settings and chronic diseases.
Global Health: Science and Practice