Background:  Diabetes is the second leading cause of death in Mexico , accounting for 76,298 deaths in 2015 . Individuals living with diabetes face a number of challenges, both personal and cultural, when it comes to managing the disease. Effective diabetes self-management requires a knowledge of basic disease physiology; support to understand and maintain complex behavior and lifestyle changes; and access to health services and medication. In Mexico City, approximately one-third of deaths among adults (35-74 years) are the result of diabetes complications.  Failure to achieve metabolic control is largely due to a lack of knowledge and self-management skills among patients and a lack of time and training among health care providers (HCPs) to deliver effective diabetes education. There is an urgent need for interventions that enable early detection and effective diabetes education so patients can successfully manage their own care.  

Aims: The “5-Steps to Self-Care” intervention aims to improve health outcomes and quality of life of diabetes patients through strengthening both HCP’s capacity to deliver effective diabetes education and patients’ ability to effectively manage their own care. 

Method: In 2016, Project HOPE and Ser Bien utilized Train-the-Trainers (TOT) methodology to implement the “5 Steps to Self-Care” intervention in three districts in the Mexico City metropolitan area – Iztapalapa, Nezahuacoyotl and Ecatepec – home to nearly 4 million people, of which 80% are served by government clinics. The intervention is a low-cost, game-based, diabetes self-management curriculum that teaches people with diabetes to identify and modify risk factors, adopt healthier lifestyles, improve medication adherence and utilize available health services. Developed by Project HOPE in 2003, the curriculum is designed to build the knowledge, skills and proactive attitude required by patients to engage in daily self-care. It also addresses cultural misconceptions and the need for on-going social support.
The TOT model creates a sustainable cadre of “5 Steps” HCP facilitators. Patient graduates are encouraged to become peer educators, acting as powerful role models and enablers of positive self-care. The curriculum is  delivered in 12 two-hour sessions over 12 weeks focusing on five key components of effective diabetes management: 1) ”Life-long diabetes education” grounded in an understanding of physiology and disease progression; 2) “Knowing the Numbers” which uses a traffic light system to interpret test results (including glucose, A1c, body mass index (BMI), blood pressure and lipids); 3) “Healthy Eating” to manage food group portions and balance macronutrient intake; 4) “Exercise” reaching optimum cardiac rate while monitoring foot health; and 5) “Active Collaboration with HCPs” to emphasize the importance of a team approach to care,  as well as routine access to specialists and lab work.  Patient graduates are encouraged to support community screenings to identify undiagnosed cases of diabetes and pre-diabetes and provide clinic referrals to attend “5 Steps”.

Results: The intervention trained 40 HCPs in “5 Steps to Self-Care” serving in 15 government clinics, who then delivered the curriculum to 298 patients across the three districts. Pre- and post-test analysis showed an increase in self-management knowledge among 92% of participants, leading to improved clinical outcomes. After completing the 12 week course, 85% of patients had decreased A1C levels with the average level declining from 8.5 to 7.1. BMI decreased among 76% of participants with the average score declining from 30.37 to 28.7. Prior to the program, 51% of participants were obese compared to 38% at its conclusion. In addition, 90% of participants reported improved Quality of Life using the WHO 5 Well-Being Index.  Patient graduates then helped conduct 3,171 screenings through community outreach tables, detecting and referring 554 (17%) new cases of diabetes and 499 (16%) cases of pre-diabetes, suggesting national statistics may underestimate actual prevalence rates.

Discussion: Implementation of “5 Steps to Self-Care” successfully improved patient knowledge, health outcomes and quality of life over a 12-week period, demonstrating the impact of effective self-management. The program also demonstrates the importance of active screening in high-risk communities to capture people with undiagnosed disease and increase their access to care. With the growing global burden of diabetes, aggressive screening and effective patient self-management are critical to reduce costly complications and enhance quality of life. “5 Steps to Self-Care” is an effective strategy that can be replicated and sustained to strengthen the quality of health services in at-risk communities.

Improving health outcomes for diabetes patients in Mexico through self-management education and outreach