poster - Global Health at Emory University

Collaborative Design and Implementation of Caminemos Juntos, a Community Health
Worker Intervention for Diabetes Self-management among the Tz’utujil Maya of
San Pablo and San Juan La Laguna, Guatemala
Mary Micikas, Alyse Lopez-Salm, Danielle Lungelow, Allison Weis
Nell Hodgson Woodruff School of Nursing, Rollins School of Public Health, and Emory School of Medicine
Background and Significance
Goal and Specific Aims
Progress to Date
This project is part of a trend in global health that focuses on community-based primary
health care grounded in empowerment theory. (1; 2) In Guatemala, between 2001-2003,
type II Diabetes Mellitus rose to the 8th leading cause of mortality with a rate of 19.9 per
100,000 people and was the 5th leading cause of mortality among women (3).
Goal
To discover if a structured community-led diabetes self-management intervention can be
implemented successfully, and if it will improve selected health outcomes for diabetic
patients in two rural indigenous communities in Guatemala.
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In a health needs assessment conducted by ODIM in the villages of San Juan and San Pablo
La Laguna, Sololá between 2009-2010, a significant proportion of individuals surveyed (38%)
identified diabetes as their top health concern. The needs assessment also highlighted
residents’ strong desire for health services conducted in their native language (Tz’utujil) by
individuals from their own community. This project focuses on providing local community
members with the knowledge and skills to promote diabetes self-management in their
communities and to function as an extension of the health services provided at the ODIM
clinics.
First Aim
Evaluate community health workers’ knowledge and application of diabetes selfmanagement, health promotion, and teaching techniques after structured training with a
culturally-relevant diabetes self-management curriculum.
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Second Aim
Evaluate changes in biometric indicators and health beliefs and practices surrounding
diabetes in participating diabetic patients receiving treatment at the ODIM clinic.
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Lake Atitlan
Caminemos Juntos
Clinica Sanjuanerita, San Juan L.L.
Guatemala
Administered 140 baseline surveys, Hemoglobin A1c and other biometric screenings of
diabetic patients receiving care at the clinic.
Conducted 2 focus group interviews with patients with diabetes in the two targeted Tz’utujil
communities, San Juan and San Pablo La Laguna.
Conducted 6 key-informant interviews.
Developed a culturally-relevant diabetes ―train-the-trainer‖ curriculum informed by focus
group interviews with patients.
Facilitated training of 21 community health promoters using the ―train-the-trainer‖ diabetes
self-management curriculum.
Developing and implementing, with collaboration of selected community health promoters
the Caminemos Juntos (Let’s Walk Together) program including educational ―diabetes club,‖
clinical check-ups, and patient advocacy.
Continued development of curriculum for Diabetes Educators to implement via ―diabetes
club‖
Quotations from Focus Groups and Interviews with Key Informants
“Lo llaman sagrado (el maíz) porque si no… porque una persona
indígena sin su maíz no puede hacer su trabajo, aunque solo
tengan tortillas con sal… ellos viven… o nosotros vivimos…no
importa si no tenemos comida.”
They call it sacred (maize) because if no…because an indigenous person without their maize cannot do their
work, although all they have is tortillas with salt..they live…or we live…it doesn’t matter if they have no food.
“Salió el resultado que ya tengo diabetes, tuve miedo y me puse
muy triste, hasta lloré.”
Figure 1. Map showing location of San Juan and San Pablo, La Laguna
The result came back that now I have diabetes, I was afraid, I became sad, I even cried.
Timeline
Feb-April, 2012
• Develop goals, specific aims, literature review and revise proposal. Seek IRB approval.
• Read qualitative interviews and preliminary data analysis from a health needs
assessment from host organization conducted 2009-2010.
May 2012
• In-country field work: Conduct baseline surveys and biometric indicator screenings,
conduct focus groups and key informant interviews.
June 2012
• Develop ―train-the-trainers‖ curriculum, implement 2 weeks of training for community
health workers (CHWs), select 8 CHWs to serve as Diabetes Educators.
July 2013
• Program implementation: Launch meeting with diabetic patients, commence diabetes
club, diabetes health promoter home visits, and clinical pre-consults.
August 2013
• Curriculum module development, data entry.
"La diabetes no nos mata…pero tenemos que estar de acuerdo
con la diabetes…”
Diabetes doesn’t kill us, but we have to be in agreement with diabetes.
Figure 3. The Caminemos Juntos (Let’s Walk Together) team (L-R, F-B-):
Micaela, Lesbia, Antonia, Josefa, Melyna, Olinda, Alyse, Allison, Mary, Pedro, Álvaro, Danielle
Population and Sample
The Clínica Sanjuanerita serves primarily two villages (San Juan La Laguna and San Pablo La
Laguna, Sololá) with a combined population of about 16,000 of which is nearly 100% Tz’utujil
Maya
• Inclusion criteria for study purposes is as follows: Diabetes Mellitus Type II diagnosis,
completion of entrance questionnaire, participation in ―diabetes club‖ meetings, and
receipt of treatment at the Sanjuanerita Clinic within the 8 months prior to program
commencement.
Next Steps
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Analyze baseline data from interviews, surveys and biometric indicators
Continue to develop ―diabetes club‖ curriculum informed by feedback from community
health promoters.
Administer follow-up interviews and biometric indicator screenings for participants in
November/December 2012.
Continue collaboration with Diabetes Program Coordinator and Community Health
Promoters to further develop program.
Seek outside funding to sustain program: ―Sponsor a Person with Diabetes‖ program,
including a joint HOLA and EISNA fundraiser and grant writing activities.
Project Partners
Figure 2. Timoteo (Nurse) and Elena (Health Promoter) engage in activity that demonstrates the way in
which insulin works to process glucose in the blood.
Figure 4. Patients go on a ―caminata,‖ or walk, in order to
regulate blood glucose levels and practice exercise.
Figure 5. Pedro (Program Coordinator) and Lesbia (Health
Promoter) practice testing blood sugar levels.
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Emory Global Health Institute—Multidisciplinary Team Field Scholars Award
Organización para el Desarollo de la Indígena Maya (ODIM)—host organization
(Clínica Sanjuanerita)
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Jennifer Foster RN, MPH, CNM, PhD – Mentor (Nell Hodgson Woodruff
Pedro Méndez Coche -- Diabetes Program Coordinator
Clínica Sanjuanerita, Community Health Workers
Emory School of Nursing)
(1) Laverack, G. (2006). Improving health outcomes through community empowerment: a review of the literature. [Journal Article Review]. Journal of health, population, and nutrition, 24(1), 113-120.
(2) Fawcett, S. B., Paine-Andrews, A., Francisco, V. T., Schultz, J. A., Richter, K. P., Lewis, R. K., . . . et al. (1995). Using empowerment theory in collaborative partnerships for community health and development.
[Journal Article]. American Journal of Community Psychology, 23(5), 677-697.
(3) Guatemala. (2007) Health In the Americas: Volume II--Countries (pp. 374-393). Washington D.C.: Pan American Health Organization
(4) Pontaza, P. O., Ramirez-Zea, M., Barcelo, A., Gil, E., Gregg, E., Mejners, M., . . . Cafiero, E. (2007). Central America Diabetes Initiative(CAMDI): Survey of Diabetes, Hypertension, and Chronic Disease Risk Factors,
Villa Nueva, Guatemala, 2006. Washington DC: Pan American Health Organization, Centers for Disease Control.