Health Disparity in Diabetes Care—Impact of Community Health Representative–Led Patient Activation and Engagement

Objective: To compare the impact of home-based care and education delivered by community health representatives (CHRs) as part of a clinical care team vs. usual clinic-based care on measures of patient activation and risk factors for diabetes in adult Zuni Indians.

Methods: We conducted a pilot randomized controlled trial of a home-based intervention vs. usual clinic care provided by the local Zuni Indian Health Service (IHS). The study’s primary outcome was patient activation, assessed by the Patient Activation Measure (PAM). We screened 315 Zuni adults and enrolled and randomized 125 Zuni adults into the study. We used linear and logistic regression with generalized estimating equations to compare changes in the outcomes of interest over time between the two study groups.

Results: Compared to those receiving usual care at IHS, Zuni adults in the intervention group experienced significantly greater improvement in the patient activation measure, quality of life, and in several clinical measures of risk factors for diabetes at 12 months. Participants in the intervention increased their PAM total scores, on average, by 8.6 points more than participants randomized to usual care (p=0.023). BMI in the intervention group decreased by 1.kg/m² more than was observed in the control group (p=0.007). Hemoglobin A1C levels in the intervention group decreased by 8% more than in the control group (p=0.022). The hs-CRP levels in the intervention group decreased by 62% more than in the control group (p<0.001).

Discussion: Delivering culturally appropriate home-based care and education by CHRs is a promising approach for improving disease-specific knowledge, confidence, and self-management skills among rural minority populations at high risk for diabetes who experience barriers to accessing health care.