Interview: Community Empowerment through Peer-Education

Courtney Guthreau is a diabetes educator. She is currently Program the Regional Director for the Americas for Project HOPE, based in Mexico.

Abraham Castañeda Chávez is a physician. He is also a diabetes educator and Medical Director for Project HOPE in Mexico.

What is the health environment like for someone with diabetes in Mexico?

Abraham: Right now there is little understanding or promotion for the patient empowerment model in Mexico. The majority of patients with diabetes see a primary care physician, who may not understand the disease well enough to treat them appropriately – or worse, use insulin as a threat to control their symptoms. There are also occasional myths, such as, insulin causes blindness. Of course this isn’t the case and the opposite is true for a patient who needs insulin. This ends up causing a lot of issues with patient trust and compliance. Many doctors don’t feel comfortable using insulin.

A paradigm shift is required for a behavior change focused patient-physician relationship. There is a clear need to enroll physicians in the process both through training and exposure to our Project HOPE programs in Mexico. Project HOPE and SerBiem’s “traffic lights” have done a lot to provide basic standards of “healthy” levels to providers (and patients). A number of physicians have come a long way since we started working with them seven years ago, but there are many more that would need to be engaged for a larger or national program.

How did you decide to develop a community-based approach?

Courtney: Abraham and I started our work in rural Mexico doing TB and HIV/AIDs work.

Both of these programs have long accepted peer education models as a way to increase awareness and reduce prevalence in a community setting. When we started working with diabetes, we saw a huge opportunity for patient empowerment as a way to mobilize communities to focus on prevention and self-care.

Although diabetes is still viewed as a very clinic disease, it takes more than an army of physicians (or educators) to treat a community. “Diabetes is more than a disease, it’s a lifestyle” and requires peer support to overcome many of the emotional challenges that individuals face without role models and encouragement around them. The Art of Empowerment (Anderson & Funnell) has been an influential perspective as we worked to develop and refine our programs with diabetes over the years.

Do you view this as an extension of primary care for diabetes in Mexico?

Abraham: Physicians still must treat patients and monitor then on a routine basis. The only challenge is that they see a patient every 15 minutes on average. They will prescribe medication but do not have the time to do the educational component that is so important for changing a patient’s lifestyle. 5 Steps to Self Care, the "Educator de Pares" or Peer Educators, and elementary school programs have allowed us to reach dramatically more people in a powerful way.

Nurses have also said that they need 5 Steps to Self Care education to complement their knowledge, in addition to other trainings they receive, to understand all aspects of the disease (mental, physical, emotional). This is a real testament to the quality of education both from technical understanding to delivery.

What coordination do you have with public health programs at the municipal and federal levels?

Courtney: Our partnership with the local government secures the time required to train the healthcare workers through 5 Steps to Self Care. Since the program is 12 weeks long, this is a serious commitment for any professional or patient. They have seen our results in the community and are looking for more ways for us to work together to implement programs with a national focus.

Abraham: We hope to work with them more in the future to use 5 Steps to Self Care successful model and an example for a federal program. If we worked to certify health professionals, for example, we would want to show demonstrated results with patients after a certain period of time. What impact have they had on their patient populations? How many are in control? To what % have their A1c levels been reduced?

Right now Project HOPE is largely the “go to” organization in the community for physicians interested in diabetes education. If they need something new in their facility, they come to us first to see how we can help.

What results have you seen over the past 7 years?

Courtney: The impact on the communities has been profound. In order to effectively treat diabetes you have to also treat the families and communities. We have made a conscious effort to track the success of our programs with “real” outcomes. Although it is wonderful that all participants enjoy the 5 Steps to Self Care program, and patients return back to the Peer Educators – we want to know that we are having an impact on their personal and long-term health. “If you’re not impacting a patient’s A1c, then what are you doing?”

Abraham: We’ve also seen that patients often train others after the formal program is over, setting up a self-sustaining educational process. This is exactly what we would want to happen in the communities. Diabetes can be viewed as a normal progression in one’s life with age and weight gain. You may hear people say, "oh well, it's just diabetes." In addition, many people as they age see weight gain as a sign of “healthy reserves.” It takes a parent, brother, or daughter to intervene to support a community of healthy living.

Courtney: We’ve seen that A1c levels can drop quite a bit during the 5 Steps to Self Care program. 12 weeks is a standard interval for a check-up and around 40% of our patients with A1c 8% and above (many of which are much higher >12%) are able to move it down to 7% or below. In addition we use the WHO-5 as an indicator for emotional wellbeing and have seen significant reductions in depression, from 29% to only 6% of patients, in addition to a large increase in optimum scores (1% to 14%). We track A1c in the Peer Educators program and children’s eating and exercise habits with the elementary school programs. It’s important for us to provide education in the community, but we want to see tangible outcomes!

Thinking about outcomes for Project HOPE’s programs in Mexico reminds me of an excerpt from Nudge. Statistics have shown that you can have an impact on outcomes, often, just by measuring it in the first place. If each child is asked monthly about their eating, drinking, and exercise habits – would they not (1) think themselves about how they’re doing and (2) consciously or subconsciously try to give a better response each month? In some ways it’s similar to grades in school – if you have a test that is pass/fail, you are likely to get a different level of effort from the class than if it is graded on an A-F curve (or no curve at all!). This is why health metrics are so important to track in any system (whether by patient, facility, doctor, region, or country)!

Seeing is believing:

Berta and Consuelo are examples of patient-leaders who provide hope to others through their own personal strength to control their diabetes. Both of these women have their diabetes 100% in control through nutrition and exercise – what an inspiration! Their determination to reach out to members in the community who are undiagnosed and/or struggling to control their diabetes is astounding. Consuelo holds outdoor exercise classes in the park for people interested in increasing their physical activity in their daily life. Berta is a loyal “educator de pares” and motivated each day by the ability to reach out to patients in the community and lower glucose levels for both pre-diabetic and diabetic cases.

They have diabetes. They are patients. They are peer-educators. They are empowered.

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