Secondary analysis of a randomized trial testing community health educator interventions for diabetes prevention among refugees with depression: effects on nutrition, physical activity and sleep

BACKGROUND

Refugees have high levels of psychological distress that hamper lifestyle change efforts. We previously reported that community health educator (CHE) diabetes prevention interventions decreased HbA1c and depressive symptoms among Cambodian-American refugees with depression; this paper reports health behavior outcomes of those interventions.

METHODS

Participants were aged 35-75, Khmer speaking, at risk for diabetes, and met study criteria for likely depression by either a) antidepressant medication and/or b) prolonged elevated depressive symptoms. Participants were randomized to one of three CHE interventions: 1) lifestyle intervention called Eat, Walk, Sleep (EWS), 2) EWS plus medication therapy management with a pharmacist/CHE team (EWS + MTM), or, 3) social services (SS; control). Physical activity and sleep were measured with 7 days of actigraphy. Nutrition was measured as carbohydrates as reported in a culturally tailored food frequency questionnaire. Assessments were at baseline, end point (12 months), and follow-up (15 months).

RESULTS

The n = 188 participants were 78% female, average age of 55 years, half had a household income < $20,000, and modal education was 7.0 years. Individuals in the two treatment groups that received the EWS intervention significantly increased their brown rice consumption (p < .001, Cohen's d = 0.76) and their moderate-to-vigorous activity (p = .039, d = 0.32). No intervention changed sleep duration, timing, efficiency or wake after sleep onset. Across groups, individuals who increased brown rice consumption, increased vigorous activity and decreased total sleep time variability showed decreased HbA1c, with small effect sizes.

CONCLUSIONS

CHEs may improve nutrition and physical activity in refugees with depression but more intensive interventions may be required to impact sleep. Improvements in all three behaviors appear to be associated with HbA1c lowering TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02502929.

Pharmacists and community health workers improve medication-related process outcomes among Cambodian Americans with depression and risk for diabetes

BACKGROUND

Cambodian Americans have high rates of cardiometabolic and psychiatric disorders and disadvantaged social determinants of health (SDOH). These factors can make it challenging to resolve drug therapy problems (DTPs) and improve medication-related outcomes. This manuscript reports planned analyses from a randomized controlled trial in which participants were randomized to one of 3 treatment arms: (1) community health worker (CHW)-delivered lifestyle intervention called Eat, Walk, sleep (EWS), (2) EWS plus pharmacist/CHW-delivered medication therapy management (EWS + MTM), or (3) social services (SS: control).

OBJECTIVES

We compared the 3 arms on changes in self-reported medication adherence, barriers, and beliefs. Within the EWS + MTM arm only, we assessed the impact of EWS + MTM on DTP resolution and examined predictors of DTP resolution.

METHODS

Cambodian Americans at the age of 35-75 years at high risk of developing diabetes and meeting the criteria for likely depression (N = 188) were randomized (EWS, n = 67; EWS + MTM, n = 63; SS, n = 50; control). For all participants, self-reported surveys were collected at baseline, 12 months, and 15 months. DTPs were assessed on the same schedule but only for participants in the EWS + MTM.

RESULTS

All 3 groups reported a significant decrease in barriers to taking medications. Compared with the other arms, the EWS + MTM arm reported a decrease in forgetting to take medications at 15 months. In the EWS + MTM arm, mean DTPs per patient was 6.57 and 84% of DTPs were resolved. SDOH predictors of DTP resolution included years of education (odds ratio [OR] 0.94, P = 0.016), ability to write English (OR 0.73, P = 0.015), difficulty communicating with provider (OR 1.39, P < 0.001), private insurance (OR 1.99, P = 0.030), disability (OR 0.51, P = 0.008), and years living under Pol Pot (OR 0.66, P = 0.045). Medication barriers at baseline predicted DTP resolution (OR 0.79, P = 0.019) such that each additional barrier was associated with a 21% reduction (1-0.79) in the odds of having a resolution.

CONCLUSION

CHWs can reduce medications barriers and help pharmacists reduce DTPs in disadvantaged populations.