Objectives: There is emerging interest and data supporting the effectiveness of community health workers (CHWs) in non-communicable diseases (NCDs) in low/middle-income countries (LMICs). This study aimed to determine whether a CHW-led intervention targeting diabetes and hypertension could improve markers of clinical disease control in rural Mexico.
Design and setting: A prospective observational stepped-wedge study was conducted across seven communities in rural Chiapas, Mexico from March 2014 to April 2018.
Participants: 149 adults with hypertension and/or diabetes.
Intervention: This study was conducted in the context of the programmatic roll-out of an accompaniment-based CHW-led intervention designed to complement comprehensive primary care for adults with diabetes and/or hypertension. Implementation occurred sequentially at 3-month intervals with point-of-care data collected at baseline and every 3 months thereafter for 12 months following roll-out in all communities.
Outcome measures: Primary outcomes were glycated haemoglobin (HbA1c) and systolic blood pressure (SBP), overall and stratified by baseline disease control. We conducted an individual-level analysis using mixed effects regression, adjusting for time, cohort and clustering at the individual and community levels.
Results: Among patients with diabetes, the CHW-led intervention was associated with a decrease in HbA1c of 0.35%; however, CIs were wide (95% CI -0.90% to 0.20%). In patients with hypertension, there was a 4.7 mm Hg decrease in SBP (95% CI -8.9 to -0.6). In diabetic patients with HbA1c ≥9%, HbA1c decreased by 0.96% (95% CI -1.69% to -0.23%), and in patients with uncontrolled hypertension, SBP decreased by 10.2 mm Hg (95% CI -17.7 to -2.8).
Conclusions: We found that a CHW-led intervention resulted in clinically meaningful improvement in disease markers for patients with diabetes and hypertension, most apparent among patients with hypertension and patients with uncontrolled disease at baseline. These findings suggest that CHWs can play a valuable role in supporting NCD management in LMICs.
Trial registration number: NCT02549495.
Keywords: CHW; LMIC; NCD; cardiovascular disease; community health worker; diabetes; hypertension; non-communicable disease; stepped-wedge.
© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
Conflict of interest statement
Competing interests: None declared.
Community health workers improve disease control and medication adherence among patients with diabetes and/or hypertension in Chiapas, Mexico: an observational stepped-wedge study.BMJ Glob Health. 2018 Feb 15;3(1):e000566. doi: 10.1136/bmjgh-2017-000566. eCollection 2018. BMJ Glob Health. 2018. PMID: 29527344 Free PMC article.
Changes in blood pressure among users of lay health worker or volunteer operated community-based blood pressure programs over time: a systematic review protocol.JBI Database System Rev Implement Rep. 2015 Oct;13(10):30-40. doi: 10.11124/jbisrir-2015-1927. JBI Database System Rev Implement Rep. 2015. PMID: 26571280
Effect of a Community Health Worker Intervention Among Latinos With Poorly Controlled Type 2 Diabetes: The Miami Healthy Heart Initiative Randomized Clinical Trial.JAMA Intern Med. 2017 Jul 1;177(7):948-954. doi: 10.1001/jamainternmed.2017.0926. JAMA Intern Med. 2017. PMID: 28459925 Free PMC article. Clinical Trial.
Community health workers for non-communicable diseases prevention and control in developing countries: Evidence and implications.PLoS One. 2017 Jul 13;12(7):e0180640. doi: 10.1371/journal.pone.0180640. eCollection 2017. PLoS One. 2017. PMID: 28704405 Free PMC article. Review.
Behavioral Counseling to Promote a Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Known Cardiovascular Disease Risk Factors: Updated Systematic Review for the U.S. Preventive Services Task Force [Internet].Rockville (MD): Agency for Healthcare Research and Quality (US); 2017 Jul. Report No.: 15-05222-EF-1. Agency for Healthcare Research and Quality (US). 2017. PMID: 29364620 Free Books & Documents. Review.
- World Health Organization Noncommunicable diseases, 2018. Available: https://www.who.int/en/news-room/fact-sheets/detail/noncommunicable-diseases [Accessed 1 Jan 2020].