Dulce Mothers: Promotoras and Mothers with Gestational Diabetes
Clayton Velicer, MPH
For a long time, promotoras have helped improve access to healthcare and self-management of chronic diseases. See our previous coverage of the great work done by promotoras in mental health, improving mother’s dietary intake and improving hypertension outcomes.
In this week’s blog we highlight a recent article by Athena Philis-Tsimikas that examined the effectiveness of the Dulce Mothers program, a promotora intervention designed to lower diabetes and cardiovascular risk in Latinas following gestational diabetes.
All women with a history of gestational diabetes mellitus have a sevenfold higher likelihood of future type 2 diabetes and also have a higher risk for developing cardiovascular disease (CVD) compared to mothers that do not have gestational diabetes. Latinas, in particular, are at higher risk for both gestational diabetes and type 2 diabetes compared to non-Latino whites.
Training and Intervention
The Dulce Mothers intervention adopted the Diabetes Prevention Program (DPP) core curriculum, which includes a focus on developing health knowledge, behavioral skills such as goal setting and self-monitoring and learning via modeling (from peer educators and group members). The program also included topics specific to Latina mothers with a history of gestational diabetes, including breastfeeding, childhood obesity and modeling healthy behaviors to family members. The curriculum was further tailored for Latino culture and individuals with low socioeconomic status (SES) by incorporating discussions of culturally-driven beliefs about diabetes and income-related barriers to healthy lifestyles.
The program was delivered to groups of 5–12 in a community clinic setting and each session included a 15-20 minute physical activity component.
The promotoras received standardized training led by a health educator with at least 5 years of experience in delivering peer-led interventions with additional support from a multidisciplinary health care team. The training itself included 40 hours of material on disease content, group management dynamics and motivational interviewing skills.
Newly trained promotoras co-teach a class series with an experienced peer and then teach under the observation of a mentor. After all the training phases are completed, peers are eligible to independently lead the intervention. Promotoras were compensated for their time.
Results and Discussion
The cultural tailoring of the program was appropriate as the participants expressed changes in fatalistic and culturally-driven beliefs concerning diabetes that are important for maintaining long term changes in behavior.
The results for cardiovascular risk factors were small, with slight decreases in LDL-C and triglycerides and a <2 mmHg decrease in DBP (Diastolic Blood Pressure). However, the authors note that in aggregate, the observed changes may be clinically meaningful at the population level in the long-term prevention of cardiovascular disease.
These modest clinical findings can be significant because primary prevention trials have shown that heart disease risk is modestly reduced even with only small changes in lipids. The authors also highlight published findings that a 2-mm Hg reduction in DBP at the population level would result in a 17% lower prevalence of hypertension and a 6% lower risk of coronary heart disease.
The findings were not as clear for reductions in type 2 diabetes risk. The primary outcome of A1C showed a small but statistically significant increase (0.09%) over 6 months. The authors felt that given limited available comparative studies and the high-risk low SES, post-gestational diabetes population, it is difficult to determine whether Dulce Mothers helped maintain glycemic regulation.
We strongly encourage our readers to read the full article for additional information on this excellent intervention and further discussion of working with vulnerable populations. This article not only represents additional evidence for promotoras to have a positive impact on the health of populations, but also a strong example of how to adapt an intervention to meet the local cultural needs. We welcome readers to share your thoughts on this program and other adaptations of peer support programs for diabetes.