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Latinos who live in poverty are at high risk for type 2 diabetes (diabetes). Health guidelines recommend strategies for self-management, but many people find lifestyle change to be challenging. Systematic reviews show that culturally competent self-management programs that take values, customs, beliefs, and language from Latino culture into account can significantly improve diabetes outcomes.


We compared the effectiveness of two distinct evidence-based models of culturally competent diabetes health promotion: 1) The Diabetes Self-Management Support Empowerment Model (DSMS), an approach using a classroom-based educational sessions taught by trained diabetes educators, and 2) The Chronic Care Model (CCM), a holistic community-based program for treating chronic disease that includes wrap-around services and incorporation of patients’ needs. Although they are both described as “culturally competent,” they differ strongly in the extent to which they embody characteristics of cultural and contextual situatedness. Aim #1. Measure and compare improvement in patient capacity for diabetes self-management. Aim #2. Measure and compare patient success at diabetes self-management. Aim #3. Characterize the ways that two distinct culturally competent diabetes self-management programs interface with patient culture and socioeconomic context.


Our non-randomized, pragmatic, quasi-experimental, comparative effectiveness study compared patient outcomes at two existing sites that have each been using one of the two different models of culturally competent diabetes self-management described above in Albuquerque, New Mexico. The University of New Mexico Hospital Center for Diabetes Education uses the DSMS. One Hope Centro de Vida Health Center uses the CCM. Both serve a large population of Latino diabetes patients from low-income households.

Participants were enrolled as dyads—a patient participant and a social support participant who was an individual the patient participant identified as providing social support. We enrolled 226 patient participant-social support participant pairs.

Outcomes were assessed based on patient participant data. Social support participant data were used as covariates to help us better understand patient participant results.

PRIMARY OUTCOME: Improved capacity for diabetes self-management.

SECONDARY OUTCOME: Successful diabetes self-management.

We used validated surveys, measures of glycated hemoglobin A1c (A1c), depression, and BMI, and interviews, focus groups, and program assessments.

For Aim #1, we measured improvement in scores on the Diabetes Knowledge Questionnaire (DKQ) and the Patient Activation Measure (PAM). For Aim #2, we measured scores on Patient Health Questionnaire (PHQ-9) depression scale, and body mass index (BMI). For Aim #3, we characterized scores on the Consumer Assessment of Healthcare Providers and Systems Cultural Competence Set (CAHPS-CC), together with results of program assessments. Interview and focus group data were used to assess all three Aims.

Data were gathered by paid patient stakeholder data collectors (PSDCs) recruited from the patient population. Data collection was conducted in English or Spanish at baseline (BL), and 3, 6, and 12 months.

Outcomes for Aims #1 and #2 over time and by program were analyzed using longitudinal linear mixed modeling, adjusted for patient participant demographic characteristics and other potential confounding covariates. Secondary outcomes were also adjusted for potential confounders. Interactions with both time and program helped to assess outcomes.


We enrolled 452 participants (226 patient participants and 226 social support participants). The majority were female, married, and reported speaking Spanish as the only language at home. Compared to patient participants in the DSMS, those in the CCM were younger, more likely to be male and to be partnered or married, less likely to have graduated from high school, more likely to only speak Spanish at home, less likely to prefer to speak English, and less likely to speak English well. CCM PPs had much lower income-to-Federal Poverty Level (FPL) ratios (0.54 vs 0.94) and were more likely to live no higher than FPL (85.8% vs 55.0%).

We did not find statistically significant differences between program results for the primary outcomes (diabetes knowledge, patient activation) at 6 months. The main difference between programs was that depression decreased more for CCM than for DSMS.

Diabetes knowledge (DKQ-23) and patient activation (PAM-10) increased for patient participants in both programs (DKQ-23 DSMS 0.75, CCM 1.5), and PAM-10, 5 points for each program.

A1c had an initial slight decrease in both programs. An exploratory, subgroup analysis revealed that at CCM, patient participants with a very high A1c (>10) demonstrated a clinically meaningful decrease.

Depression showed an initial decrease from BL to 3 mos in both programs, but only sustained at CCM. CCM patient participants were lower at baseline, decreasing dramatically at 3 months and continuing downward throughout the study. In contrast, DSMS decreased only slightly to 6 months, then increased by 12 months, nearly rebounding to baseline levels.

BMI values were consistent over time in both programs.

Although overall quality of care, communication, equitable treatment, and trust were rated very high on the CAHPS-CC in both programs, quality of care (A), Patient participant-Provider Communication (B), and Trust (G) were scored higher at CCM. Qualitative analysis revealed the importance of social support participant in the lives of Latino diabetes patient participants and as a design feature of diabetes self-management programs.


This study did not find a difference between the two sites with respect to the primary outcome measures and only one of the three secondary outcomes showed differential results. Moreover, the design of this study was observational, and given major differences in site context and patients enrolled, residual confounding is likely. However, given the higher cultural competence rating for the CCM, statistically significant improvement in depression, and the importance of social support to the patients, results suggest that a culturally and contextually situated diabetes self-management and education program design may deliver benefit for patients, especially for some subgroups of patients.


Data collection was curtailed 2 weeks early because of the pandemic. The DSMS program made changes to the way they implement the program which we were not able to capture. Although patient participants at both sites were similar, this was a pragmatic study and there were some differences between the sites in relation to age, educational background, language, income, and insurance status.


Should a researcher be interested in accessing the data prior to the expiration of the embargo period, he or she would then request access by emailing the PI, Janet Page-Reeves, and/or other members of the research team. When a request to access the project data is received, we will implement the following data sharing protocol, which conforms to the data sharing standards established by the NIH. We will provide the opportunity for data sharing through the following avenues: 1.) We will share all research data as requested in accordance with federal regulations and the Freedom of Information Act (FOIA). 2.) We will share research tools and data with other researchers for analysis and/or replicating the research. The Research Team will review requests from researchers and, after approval from our patient partners, we will work with the requesting researchers to create a data-sharing agreement per NIH protocol, policies and procedures. 3.) We will make the data and associated documentation available to users only under a Data-Sharing Agreement that: a.) defines a commitment to using the data only for research purposes and not to identify any individual participant; b.) defines a commitment to securing the data using appropriate computer technology; c.) demonstrates a high-quality research proposal (significance, innovativeness, approach, and community benefit); d.) proposes a comprehensive dissemination plan (to community and scientific audiences); e.) covers administrative costs to prepare data and related documentation requested; f.) demonstrates appropriate approvals of research protocols by the institutional Human Research Review Committee; g.) demonstrates certification in research ethics, including the HIPAA Research Training Course and the Collaborative Institutional Training Initiative (CITI) Human Subjects Protection Training; and h.) demonstrates a commitment to destroying or returning the data after analyses are completed. The requesting researchers will be required to acknowledge our project, project team, our patient partners, and PCORI as a funder in any presentations, abstracts, or publications developed from use of the shared data.

Available for download on Thursday, August 31, 2023