Ongoing challenges in access to diabetes care among the indigenous population: perspectives of individuals living in rural Guatemala.

BACKGROUND: Indigenous persons living in Latin America suffer from a higher prevalence of type 2 diabetes compared to their non-indigenous counterparts. This difference has been attributed to a wide range of factors. Future interventions could be influenced by a deeper understanding of the challenges that impact care in rural regions and in other low-income settings. METHODS: This study was conducted using a modified grounded theory approach. Extended observations and fifteen interviews were performed with adult male and female residents of three rural Mayan towns in Sololá Department, Guatemala using purposive sampling. Questions focused on the perceptions of individuals living with type 2 diabetes and their caregivers regarding disease and treatment. RESULTS: Across interviews the most common themes that emerged included mistreatment by healthcare providers, mental health comorbidity, and medication affordability. These perceptions were in part influenced by indigeneity, poverty, and/or gender. CONCLUSIONS: Both structural and cultural barriers continue to impact diabetes care for indigenous communities in rural Guatemala. The interviews in this study suggest that indigenous people experience mistrust in the health care system, unreliable access to care, and mental health comorbidity in the context of type 2 diabetes care. These experiences are shaped by the complex relationship among poverty, gender, and indigeneity in this region. Targeted interventions that are conscious of these factors may increase their chances of success when attempting to address similar health disparities in comparable populations.

Medical Student Exposure to Integrated Behavioral Health.

OBJECTIVE: Integrated behavioral health (IBH) allows for effective care delivery for patients with mental health and behavioral health disorders in primary care settings. This study assesses the state of exposure current medical students have to the IBH model in family medicine clerkships, in order to augment the readiness of students to participate in IBH as developing professionals. METHODS: Clerkship directors at US and Canadian medical schools with a required family medicine run course (n = 141) were asked to estimate the percentage of students exposed to IBH in their clerkships, as part of the Council of Academic Family Medicine Educational Research Alliance (CERA) 2016 survey. RESULTS: The response rate was 86% (n = 118). Forty-four percent of clerkship directors reported that 0-20% of students are exposed to the IBH model in their clerkships. A comparison of schools with low and high exposure showed no significant differences among clerkship characteristics. CONCLUSIONS: A majority of medical students in the USA and Canada are not exposed to IBH models during their primary care clerkship. Larger systematic studies are needed to elucidate the steps necessary to prepare graduating medical students to collaborate in IBH models.

Impact of store-and-forward (SAF) teledermatology on outpatient dermatologic care: A prospective study in an underserved urban primary care setting.

BACKGROUND: The clinical value of teledermatology in the primary care setting remains relatively unknown. OBJECTIVE: We sought to determine the impact of teledermatology on outpatient diagnosis, management, and access to dermatologic care in a resource-poor primary care setting. METHODS: We performed a prospective study of store-and-forward teledermatology consults submitted between January and November 2013 from 11 underserved clinics in Philadelphia to the University of Pennsylvania using mobile devices and the Internet. We assessed diagnostic and management concordance between primary care providers and dermatologists, time to consult completion, anticipated level of dermatology input in the absence of teledermatology, and number of consults managed with teledermatology alone. RESULTS: The study included 196 consults encompassing 206 dermatologic conditions. Diagnoses and management plans of primary care providers and dermatologists were fully concordant for 22% and 23% of conditions, respectively. The median time to consult completion was 14 (interquartile range 3-28) hours. At least 61% of consults would not otherwise have received dermatology input, and 77% of consults were managed with teledermatology alone. LIMITATIONS: Lack of a diagnostic gold standard, limited patient follow-up, and uncertain generalizability are limitations. CONCLUSION: Teledermatology is an innovative and impactful modality for delivering dermatologic care to outpatients in resource-poor primary care settings.

Primary care providers' perceptions of mobile store-and-forward teledermatology.

INTRODUCTION: Although teledermatology offers promise as a tool to increase access to care, adoption has been limited. Understanding the perspectives and experiences of key stakeholders, such as primary care providers (PCPs) and patients, is important to identify opportunities to reduce barriers to adoption and to improve teledermatology programs. Although many studies have examined patients' experiences and satisfaction with teledermatology, few have examined referring PCPs' perspectives. OBJECTIVE: To identify PCPs' perceptions on the strengths and limitations of teledermatology in order to identify opportunities to improve teledermatology programs. METHODS: We distributed an anonymous, web-based survey to 30 PCPs involved in a two-year study evaluating a mobile app-based teledermatology platform. RESULTS: 100% (18/18) agreed or strongly agreed that teledermatology increases access to dermatologic care, improves patient care, and is acceptable to patients. 100% (18/18) agreed or strongly agreed that teledermatology provides educational benefit to the PCP. Only 6% (1/18) agreed that teledermatology increases medical liability and 11% (2/18) agreed that it increases risk of a breach in privacy or confidentiality. CONCLUSIONS: Our findings highlight that PCPs are highly satisfied with mobile app-based, store-and-forward teledermatology and that they believe teledermatology offers synergistic educational benefit. We hope these results will help guide the development of teledermatology programs to increase access to timely, cost-effective care.

A random spatial sampling method in a rural developing nation.

BACKGROUND: Nonrandom sampling of populations in developing nations has limitations and can inaccurately estimate health phenomena, especially among hard-to-reach populations such as rural residents. However, random sampling of rural populations in developing nations can be challenged by incomplete enumeration of the base population. METHODS: We describe a stratified random sampling method using geographical information system (GIS) software and global positioning system (GPS) technology for application in a health survey in a rural region of Guatemala, as well as a qualitative study of the enumeration process. RESULTS: This method offers an alternative sampling technique that could reduce opportunities for bias in household selection compared to cluster methods. However, its use is subject to issues surrounding survey preparation, technological limitations and in-the-field household selection. Application of this method in remote areas will raise challenges surrounding the boundary delineation process, use and translation of satellite imagery between GIS and GPS, and household selection at each survey point in varying field conditions. This method favors household selection in denser urban areas and in new residential developments. CONCLUSIONS: Random spatial sampling methodology can be used to survey a random sample of population in a remote region of a developing nation. Although this method should be further validated and compared with more established methods to determine its utility in social survey applications, it shows promise for use in developing nations with resource-challenged environments where detailed geographic and human census data are less available.

Criticisms of chlorination: social determinants of drinking water beliefs and practices among the Tz'utujil Maya.

OBJECTIVE: To explore social determinants of drinking water beliefs and practices among the Tz'utujil Maya of Santiago Atitlán, Guatemala, through analysis of demographics, socioeconomic status, memory of historical events, sensory experience, and water attitudes. METHODS: Parallel mixed (qualitative and quantitative) methods, including participant observation, in-depth interviews based on a purposive sample, and 201 semi-structured interviews based on a regional quota sample, were used to collect data from March 2007 to August 2008. Data analysis included the use of grounded theory methodology and Pearson's chi-square test for independence. RESULTS: Qualitative results based on grounded theory highlighted how memory of the Guatemalan Civil War and Hurricane Stan, attitudes about Lake Atitlán water, and the taste and smell of chlorine influenced Tz'utujil Maya drinking water beliefs. Quantitative survey results revealed that differences in ethnicity, literacy, years of schooling, distrust of the water supply during the Civil War and Hurricane Stan, and current beliefs about Lake Atitlán and tap water quality were associated with significantly different water self-treatment practices. CONCLUSIONS: In accordance with social determinants of health paradigms, demographic, socioeconomic, social, cultural, political, and historical factors continue to be significant determinants of water-related health. Public health water interventions must address inequalities related to these underlying factors in order to achieve maximum effectiveness.

Coca-colonization and hybridization of diets among the Tz'utujil Maya.

Biomedical health professionals express increasing concern that rising consumption of soft drinks and processed foods in Mayan and Latin American eating patterns may lead to detrimental nutritional and health consequences. Scholars debate whether the pervading presence of Coca-Cola and Pepsi in developing countries represents "Coca-Colonization," synonymous with cultural imperialism, or cultural hybridization. Using mixed qualitative and quantitative research methods, including participant observation and semi-structured interviews, this study explores the development of Coca-Colonization and cultural hybridization among the Tz'utujil Maya of Santiago Atitlán, Guatemala. By specifically examining biomedical perspectives, cycles of conquest, the political economy, religion, celebrations, and the physical environment through the lens of soft drinks, this study finds that Coca-Colonization and cultural hybridization are complementary rather than mutually exclusive processes that contribute to dietary transitions, economic development, and differential health beliefs related to soft drink consumption.

Who, What, and Where: Transforming Primary Care Education to Advance Health Equity.

To transform primary care with the goal of achieving health equity, changes in the way the health care workforce is selected, trained, and ultimately delivers care should be expedited. Research has repeatedly shown the immense impact of the social determinants of health and the gaps related to health equity in the United States. Despite this knowledge, health care education and delivery systems have been slow to evolve. The Health Resources and Services Administration established the Academic Units for Primary Care Training and Enhancement to work towards strengthening the primary care workforce. Through their research, the six individual Academic Units (AU) have identified gaps related to health equity in their areas of focus. This article provides recommendations from the AUs on ways primary care health professions education can be transformed to advance health equity and serves as background for the articles to follow in the remainder of the supplement.

Identifying Prevalence and Characteristics of Behavioral Health Education in Family Medicine Clerkships: A CERA Study.

BACKGROUND AND OBJECTIVES: Many patients with behavioral health disorders do not seek or receive adequate care for their conditions. Among those that do, most will receive care in a primary care setting. To best meet this need, clinicians will need to demonstrate proficiency of behavioral health skills and evidence-based practices. We sought to explore the degree to which these skills are being taught in family medicine clerkships. METHODS: The Council of Academic Family Medicine's (CAFM) Educational Research Alliance (CERA) 2016 survey of clerkship directors (CDs) was sent to 141 CDs at US and Canadian medical schools with a required family medicine run course. CDs were asked about the inclusion of behavioral health topics, tools, and techniques in the clerkship, as well as rating the importance of these items. RESULTS: Eighty-six percent of CDs completed the survey. Mood disorders (81.4%) were most frequently taught, followed by anxiety disorders (77.8%), substance use disorders (74.4%), and impulse control disorders (39.1%). Screening tools and behavioral health counseling skills were less commonly taught. CONCLUSIONS: Many behavioral health topics are not taught universally to all family medicine clerkship students. Gaps exist between what is included in current curriculum and what is recommended by the National Clerkship Curriculum for family medicine. These gaps may represent challenges for improving the care for patients with behavioral health disorders.

Diabetes prevalence in rural Indigenous Guatemala: A geographic-randomized cross-sectional analysis of risk.

BACKGROUND: Developing countries and Indigenous populations are disproportionately affected by global trends in diabetes (T2DM), but inconsistent data are available to corroborate this pattern in Guatemala and indigenous communities in Central America. Historic estimates of T2DM, using a variety of sampling techniques and diagnostic methods, in Guatemala include a T2DM prevalence of: 4·2% (1970) and 8·4% (2003). Objectives of this geographically randomized, cross-sectional analysis of risk include: (1) use HbA1c to determine prevalence of T2DM and prediabetes in rural Indigenous community of Atitlán (2) identify risk factors for T2DM including age, BMI and gender. METHODS: A spatially random sampling method was used to identify 400 subjects. Prevalence was compared using the confidence interval method, and logistic regression and linear regression were used to assess association between diabetes and risk factors. FINDINGS: The overall prevalence of T2DM using HbA1c was 13·81% and prediabetes was also 13·81% in Atitlán, representing a tripling in diabetes from historic estimates and a large population with pre-diabetes. The probability of diabetes increased dramatically with increasing age, however no significant overall relationship existed with gender or BMI. CONCLUSIONS: Diabetes is a larger epidemic than previously expected and appears to be related to ageing rather than BMI. Our proposed explanations for these findings include: possible Indigenous unique genetic susceptibility to T2DM, shortcomings in BMI as a metric for adiposity in assessing risk, changes in lifestyle and diet, and an overall aging population. The conclusion of this study suggest that (1) T2DM in rural regions of Guatemala may be of epidemic proportion. With pre-diabetes, more than 25% of the population will be diabetic in the very near future; (2) Age is a significant risk factor in the Indigenous population but BMI is not. This suggests that in some populations diabetes may be a disease of ageing.