Transforming care for patients living with diabetes in rural Mexico: a qualitative study of patient and provider experiences and perceptions of shared medical appointments

ABSTRACT

Background

Global prevalence of diabetes is increasing, causing widespread morbidity, mortality and increased healthcare costs. Providing quality care in a timely fashion to people with diabetes in low-resource settings can be challenging. In the underserved state of Chiapas, Mexico, which has some of the lowest diabetes detection and control rates in the country, there is a need to implement strategies that improve care for patients with diabetes. One such strategy is shared medical appointments (SMAs), a patient-centred approach that has proven effective in fostering patient engagement and comprehensive care delivery among underserved populations.

Objective

This study aimed to understand the perceptions, experiences and insights of both patients living with diabetes and healthcare providers, who took part in a pilot SMA strategy implemented in five outpatient clinics in rural Chiapas.

Methods

Following an exploratory qualitative approach, we conducted 50 in-depth interviews with patients and providers involved in diabetes SMAs and five focus group discussions with community health workers providing patient support and education.

Results

The implementation of an SMA model changed how diabetes care is perceived, structured and delivered. Patients felt sheltered by group interactions based on trust, which allowed for the exchange of experiences, learning and increased engagement in treatment and lifestyle changes. Providers gained insights into their patients’ context and lived experiences, which resulted in improved rapport and quality of care. SMAs also restructured some operational aspects in the clinics and fostered the sharing of power and responsibilities amongst the staff.

Conclusions

The SMAs model transformed care by providing a patient-centred, collaborative approach to diabetes care, education and support. Additionally, it reshaped the health-care team resulting in power-shifting and role-sharing among members of the interdisciplinary team. We therefore encourage decision-makers to expand the use of SMAs to improve care for patients with diabetes in low-resource settings.

KEYWORDS:

• Chronic diseases
• vulnerable populations
• low- and middle-income countries
• primary health care
• community health
• patient-centred care

Responsible editor

Maria Emmelin

Responsible editor

Maria Emmelin

Acknowledgments

To the MMSc-GHD Program Team at HMS, to all the team at CES, and to the clinical staff and patients that shared their insights and time with us. We would also like to especially thank Harvey Aspelling for his thoughtful proofreading of the manuscript.

Author contribution

MLAC is the first author of the manuscript. MLAC participated in all stages of the research, including conceptualisation of the study, literature review, design of interview guide, data collection through interviews and focus group discussions, and all stages of writing the manuscript. JM participated in the conceptualisation of the study and was involved in all stages of writing. HG participated in the conceptualisation of the study, advised on the development of the interview guide and data analysis, and participated in all stages of writing. HF participated in the conceptualisation of the research and participated in all stages of writing. MM assisted in the interviews and focus group discussions, participated in the transcription, revision, and analysis of the data, and participated in drafting the first version of the manuscript. ZA and SD participated in the literature review and in writing the final version of the manuscript. CN oversaw the entire study, participated in the conceptualisation of the study and the implementation of the SMA model, participated in the design of the interview guide, advised on the data analysis and presentation of the results, and participated in all stages of writing.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Ethics and consent

The SMA intervention described in the manuscript received approval from the authorities of the Health Jurisdictions IV and X of Chiapas. Verbal informed consent was obtained for patient participation in SMAs, patient and healthcare provider participation in interviews, and CHW participation in focus groups. The research received ethical approval from the Harvard Institutional Review Board and the Ethics Committee of the Chiapas Ministry of Health. The research was conducted in a manner that ensured confidentiality of participant information and no harm to participating providers and beneficiaries.

Paper context

Multiple studies have demonstrated the positive effects of shared medical appointments for vulnerable patients with chronic disease in the United States. However, implementation of this care delivery model in low- and middle-income countries has yet to be reported. Our study is the first to describe the experiences and perceptions of patients with diabetes and healthcare workers participating in shared medical appointments in low- and middle-income countries, specifically in rural Chiapas, Mexico, reporting many benefits.

Additional information

Funding

This study was made possible with funding from the Master’s in Global Health Delivery Program at Harvard Medical School and with funding from the Rockefeller Foundation’s DRCLASS Research Grant.