Opportunities for involving men and families in chronic disease management: a qualitative study from Chiapas, Mexico.

BACKGROUND: A healthy lifestyle intervention was implemented in primary care health centers in urban parts of Tuxtla Gutiérrez, Chiapas, Mexico with an aim of reducing cardiovascular disease risk for patients with type 2 diabetes and/or hypertension. During implementation, research questions emerged. Considerably fewer men participated in the intervention than women, and an opportunity was identified to increase the reach of activities aimed at improving disease self-management through strategies involving family members. A qualitative study was conducted to identify strategies to involve men and engage family members in disease management and risk reduction. METHODS: Nine men with hypertension and/or type 2 diabetes with limited to no participation in disease self-management and health promotion activities, six families in which at least one family member had a diagnosis of one or both conditions, and nine health care providers from four different government health centers were recruited for the study. Participants took part in semi-structured interviews. During interviews with families, genograms and eco-maps were used to diagram family composition and structure, and capture the nature of patients' relationships to the extended family and community resources. Transcripts were coded and a general inductive analytic approach was used to identify themes related to men's limited participation in health promotion activities, family support and barriers to disease management, and health care providers' recommendations. RESULTS: Participants reported barriers to men's participation in chronic disease management and healthy lifestyle education activities that can be grouped into two categories: internal and external factors. Internal factors are those for which they are able to make the decision on their own and external factors are those that are not related solely to their decision to take part or not. Four primary aspects were identified related to families' relationships with disease: different roles within the family, types of support provided to patients, the opportunity to prevent disease among family members without a diagnosis, and - in some cases - lack of family support or stress-induced by other family members. There was an overlap in recommended strategies for engaging men and family members in chronic disease management activities. CONCLUSIONS: There is an opportunity to increase the reach of interventions aimed at improving disease self-management by engaging men and family members. The proposed strategies presented by patients, family members, and providers have implications for health education and service provision at primary care health centers and for future research.

Impact evaluation of a healthy lifestyle intervention to reduce cardiovascular disease risk in health centers in San José, Costa Rica and Chiapas, Mexico.

BACKGROUND: Previous healthy lifestyle interventions based on the Salud para Su Corazón curriculum for Latinos in the United States, and a pilot study in Guatemala, demonstrated improvements in patient knowledge, behavior, and clinical outcomes for adults with hypertension. This article describes the implementation of a healthy lifestyle group education intervention at the primary care health center level in the capital cities of Costa Rica and Chiapas, Mexico for patients with hypertension and/or type 2 diabetes and presents impact evaluation results. METHODS: Six group education sessions were offered to participants at intervention health centers from November 2011 to December 2012 and participants were followed up for 8 months. The study used a prospective, longitudinal, nonequivalent pretest-posttest comparison group design, and was conducted in parallel in the two countries. Cognitive and behavioral outcome measures were knowledge, self-efficacy, stage-of-change, dietary behavior and physical activity. Clinical outcomes were: body mass index, systolic and diastolic blood pressure, and fasting blood glucose. Group by time differences were assessed using generalized estimating equation models, and a dose-response analysis was conducted for the intervention group. RESULTS: The average number of group education sessions attended in Chiapas was 4 (SD: 2.2) and in Costa Rica, 1.8 (SD: 2.0). In both settings, participation in the study declined by 8-month follow-up. In Costa Rica, intervention group participants showed significant improvements in systolic and diastolic blood pressure and borderline significant improvement for fasting glucose, and significant improvement in the stages-of-change measure vs. the comparison group. In Chiapas, the intervention group showed significant improvement in the stages-of-change measure in relation to the comparison group. Significant improvements were not observed for knowledge, self-efficacy, dietary behavior or physical activity. In Chiapas only, a significant dose-response relationship was observed for systolic and diastolic blood pressure. CONCLUSION: Group education interventions at health centers have the potential to improve stage-of-change activation, and may also improve clinical outcomes. In the future, it will be essential to dedicate resources to understand ways to reach a representative group of the patient population, tailor the intervention so that patients are engaged to participate, and consider the broader family and community context that influences patients' capacity to manage their condition.