title: A pilot study of a Community Health Agent-led type 2 diabetes self-management program using Motivational Interviewing-based approaches in a public primary care center in São Paulo, Brazil.
abstract: Rates of noncommunicable diseases (NCDs) such as type 2 diabetes are escalating in low and middle-income countries such as Brazil. Scalable primary care-based interventions are needed to improve self-management and clinical outcomes of adults with diabetes. This pilot study examines the feasibility, acceptability, and outcomes of training community health agents (CHAs) in Motivational Interviewing (MI)-based counseling for patients with poorly controlled diabetes in a primary care center in São Paulo, Brazil.
  
  
  
  Nineteen salaried CHAs participated in 32 h of training in MI and behavioral action planning. With support from booster training sessions, they used these skills in their regular monthly home visits over a 6 month period with 57 diabetes patients with baseline HbA1cs > 7.0%. The primary outcome was patients' reports of the quality of diabetes care as measured by the Portuguese version of the Patient Assessment of Chronic Illness Care (PACIC) scale. Secondary outcomes included changes in patients' reported diabetes self-management behaviors and in A1c, blood pressure, cholesterol and triglycerides. We also examined CHAs' fidelity to and experiences with the intervention.
  
  
  
  Patients reported improvements over the 6 month period in quality of diabetes care received (PACIC score improved 33 (+/-19) to 68 (+/-21) (p < .001)). They reported increases in physical activity (p = .001), consumption of fruits and vegetables (p < .001) and medication adherence (p = .002), but no decreases in consumption of high-fat foods (p = .402) or sweets (p = .436). Participants had mean 6-month A1c levels 0.34% points lower than at baseline (p = .08) and improved mean LDL (-16.1 mg/dL, p = .005) and triglyceride levels (-38.725 mg/dL, p = .002). Of the 16 CHAs observed in fidelity assessments, 13 were categorized as medium- or high-performing on MI skills, while 3 were low-performing. CHAs expressed enthusiasm about learning new skills, and many described a shift from advice-giving to encouraging patients to define their own goals.
  
  
  
  In resource-scarce settings, it is essential to fully utilize existing primary care resources to stem the epidemic of diabetes and other NCDs. Our pilot results support the potential of training CHAs to incorporate effective diabetes self-management support into their routine patient encounters.
  
  
  
  NCT02994095 12/14/2016 Registered retrospectively.
authors.affiliation: Division of Endocrinology, Department of Internal Medicine, Faculdade de Medicina da Universidade de São Paulo, FMSUP--Medical Faculty of the University of São Paulo, São Paulo, SP, Brazil.|Unidade Básica de Saúde (UBS-Basic Health Unit) Vila Piauí, Fundacão Faculdade de Medicina da FMUSP, Western Region of São Paulo, SP, Brazil.
authors.forename: Thais Moura Ribeiro
authors.initials: TM
authors.lastname: do Valle Nascimento
authors.affiliation: Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA.
authors.forename: Ken
authors.initials: K
authors.lastname: Resnicow
authors.affiliation: Division of Endocrinology, Department of Internal Medicine, Faculdade de Medicina da Universidade de São Paulo, FMSUP--Medical Faculty of the University of São Paulo, São Paulo, SP, Brazil.
authors.forename: Marcia
authors.initials: M
authors.lastname: Nery
authors.affiliation: Department of Pediatrics, University of São Paulo Medical School, São Paulo, Brazil.
authors.forename: Alexandra
authors.initials: A
authors.lastname: Brentani
authors.affiliation: University of Michigan Medical School, Ann Arbor, MI, USA.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Kaselitz
authors.affiliation: University of Michigan Medical School, Ann Arbor, MI, USA.
authors.forename: Pooja
authors.initials: P
authors.lastname: Agrawal
authors.affiliation: University of Michigan Medical School, Ann Arbor, MI, USA.
authors.forename: Simanjit
authors.initials: S
authors.lastname: Mand
authors.affiliation: University of Michigan Medical School, Ann Arbor, MI, USA. mheisler@umich.edu.|Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA. mheisler@umich.edu.|Center for Clinical Management Research, Ann Arbor Veterans' Affairs (VA) Healthcare System, 1600 Plymouth Drive, Building 16, Ann Arbor, MI, 48109, USA. mheisler@umich.edu.
authors.forename: Michele
authors.initials: M
authors.lastname: Heisler
mesh_terms: D000328:Adult; D001794:Blood Pressure; D001938:Brazil; D002908:Chronic Disease; D003153:Community Health Services / Q000379:methods; D003924:Diabetes Mellitus, Type 2 / Q000188:drug therapy*; D005260:Female; D006293:Health Promotion; D006801:Humans; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D062405:Motivational Interviewing / Q000379:methods*; D010865:Pilot Projects; D011320:Primary Health Care / Q000379:methods; D012648:Self Care / Q000379:methods
keywords: Brazil; Community health worker; Diabetes; Motivational Interviewing; Pilot study; Primary care; Self-management