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Original research
Observational stepped-wedge analysis of a community health worker-led intervention for diabetes and hypertension in rural Mexico
  1. Devin T Worster1,2,
  2. Molly F Franke3,
  3. Rodrigo Bazúa2,
  4. Hugo Flores1,2,
  5. Zulema García2,
  6. Joanna Krupp2,
  7. Jimena Maza2,
  8. Lindsay Palazuelos4,
  9. Katia Rodríguez2,
  10. Patrick M Newman2,5,
  11. Daniel Palazuelos1,2,3,4
  1. 1Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
  2. 2Compañeros en Salud, Ángel Albino Corzo, Mexico
  3. 3Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
  4. 4Partners In Health, Boston, Massachusetts, USA
  5. 5Division of Pediatric Hospital Medicine, Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, California, USA
  1. Correspondence to Dr Devin T Worster; dtw4001{at}


Objectives There is emerging interest and data supporting the effectiveness of community health workers (CHWs) in non-communicable diseases (NCDs) in low/middle-income countries (LMICs). This study aimed to determine whether a CHW-led intervention targeting diabetes and hypertension could improve markers of clinical disease control in rural Mexico.

Design and setting A prospective observational stepped-wedge study was conducted across seven communities in rural Chiapas, Mexico from March 2014 to April 2018.

Participants 149 adults with hypertension and/or diabetes.

Intervention This study was conducted in the context of the programmatic roll-out of an accompaniment-based CHW-led intervention designed to complement comprehensive primary care for adults with diabetes and/or hypertension. Implementation occurred sequentially at 3-month intervals with point-of-care data collected at baseline and every 3 months thereafter for 12 months following roll-out in all communities.

Outcome measures Primary outcomes were glycated haemoglobin (HbA1c) and systolic blood pressure (SBP), overall and stratified by baseline disease control. We conducted an individual-level analysis using mixed effects regression, adjusting for time, cohort and clustering at the individual and community levels.

Results Among patients with diabetes, the CHW-led intervention was associated with a decrease in HbA1c of 0.35%; however, CIs were wide (95% CI −0.90% to 0.20%). In patients with hypertension, there was a 4.7 mm Hg decrease in SBP (95% CI −8.9 to −0.6). In diabetic patients with HbA1c ≥9%, HbA1c decreased by 0.96% (95% CI −1.69% to −0.23%), and in patients with uncontrolled hypertension, SBP decreased by 10.2 mm Hg (95% CI −17.7 to −2.8).

Conclusions We found that a CHW-led intervention resulted in clinically meaningful improvement in disease markers for patients with diabetes and hypertension, most apparent among patients with hypertension and patients with uncontrolled disease at baseline. These findings suggest that CHWs can play a valuable role in supporting NCD management in LMICs.

Trial registration number NCT02549495.

  • community health worker
  • CHW
  • non-communicable disease
  • NCD
  • diabetes
  • cardiovascular disease
  • hypertension
  • stepped-wedge
  • LMIC

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  • PMN and DP are joint senior authors.

  • Contributors DTW oversaw data collection, carried out the analysis, produced figures and tables, led the literature search and drafted the manuscript. MFF, HF, LP, PMN and DP contributed to study design. JK and KR led data collection teams. DTW, RB, ZG, JM and PMN oversaw the data collection process and ensured data quality. MFF was the lead methodologist, designed the analysis and critically reviewed the manuscript. JK contributed to the literature search and manuscript preparation. PMN and DP were responsible for the original conceptualisation, study oversight and critical review of the manuscript as principal investigators. All authors contributed to interpretation of the work, editing of the manuscript, final approval of this version and agree to be accountable for all aspects of the work.

  • Funding This study was partially funded by a grant from the Harvard Global Health Institute. DTW’s travel costs were supported by the Doris and Howard Hiatt Residency in Global Health Equity and Internal Medicine at the Brigham and Women’s Hospital. JK’s travel and living costs were partially supported by a Wesleyan Summer Grant from Wesleyan University.

  • Disclaimer The funders did not have any role in study design; in the collection, analysis and interpretation of the data; in the writing of the report or in the decision to submit the paper for publication.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This study was reviewed and approved by institutional review boards of the Brigham and Women’s Hospital (Partners Human Research Committee, Boston, USA) and the Instituto Tecnológico de Monterrey (Monterrey, México).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement De-identified primary data and a technical appendix are available on reasonable request from the authors.

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