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Prevention through Intervention is a community paramedicine program developed by Birmingham Fire and Rescue Services in Alabama. This program aims to reduce dependency on emergency medical services (EMS) for nonemergency-related events through education and to lower the frequency of emergency calls in underserved populations. A telehealth intervention with an emphasis on hypoglycemia was implemented to (1) tailor the intervention to meet the educational needs of participants and (2) facilitate follow-ups. A pre-post pilot feasibility evaluation of the telehealth intervention was conducted.
This paper describes the results of the feasibility evaluation, implementation challenges, and the lessons learned about the deployment of a hypoglycemia prevention program in an underserved area and its evaluation.
This single-arm pretest-posttest intervention included (1) an initial in-person visit (week 1), (2) 3 weekly telecoaching calls (weeks 2-4), (3) 1 biweekly call (week 6), and (4) a final in-person visit (week 8) for collecting posttest data from individuals who called EMS due to hypoglycemic events. In-person visits included educational sessions conducted by EMS personnel. Participants’ education included tailored content related to hypoglycemia. Weekly telecoaching calls focused on hypoglycemia symptom monitoring and education reinforcement via a telehealth dashboard. The primary measures focused on feasibility measures, and exploratory measures focused on the fear of hypoglycemia, self-efficacy, and a knowledge of diabetes.
A total of 40 participants participated in the intervention. However, the study was marred with high attrition. The various factors behind the low retention rate were discussed. There was a decreasing trend in all three subdomains of the fear of hypoglycemia from pretest to posttest. There was also a significant increase in participants’ self-efficacy in hypoglycemia self-management (
This study shows preliminary and promising results for a community-based intervention specifically for hypoglycemia. However, the socioeconomic setting in which the intervention was delivered may have resulted in high dropout rates and low attendance during the intervention, which are considerations for future telehealth studies.
ClinicalTrials.gov NCT03665870; https://clinicaltrials.gov/ct2/show/NCT03665870
Hypoglycemia is a common but potentially avoidable health problem that can be a barrier to achieving good glycemic control. Hypoglycemia is indicated by abnormally low blood glucose concentrations (usually <70 mg/dl) and can result from physical exercise, certain diets, the misuse of drugs, endocrine disorders, and renal insufficiency [
Inadequate health literacy is common among vulnerable populations. It is independently associated with poor glycemic control and an increased incidence of hypoglycemia (59%) in patients with diabetes [
As a model of mobile integrated health care programs, community paramedicine is an evolving community-based health care design that ultimately aims to increase access to basic paramedic services by integrating the services of multiple disciplines [
A community paramedicine program, Prevention through Intervention, was initiated by the Birmingham Fire and Rescue Department in Alabama. This community paramedicine program attempts to expand access to health services for underserved rural populations who lack consistent primary care or preventive services and therefore frequently seek nonurgent care. The program involves educational home visits that are conducted by 1 paramedic who is assigned full-time to the program and provides services such as wellness and medication checks, safety assessments, and services for connecting people to primary care when such care is needed. This study was conducted as part of the Prevention through Intervention program. This study aimed to use telehealth to facilitate the tailoring of a telehealth intervention to meet the precise educational needs of participants, enable follow-ups, and perform a preliminary pilot feasibility and acceptability evaluation of the program.
A single-arm pretest
The home of the community paramedicine program, which was where this study was conducted, receives about 1000 hypoglycemia-related EMS calls on an annual basis. All patients who called 911 due to hypoglycemia-related events were screened based on the following inclusion criteria: (1) residents in the service area of the fire district, (2) individuals aged ≥18 years, (3) individuals receiving intravenous 50% dextrose (intravenous treatment for hypoglycemia provided by EMS personnel), and (4) individuals who are not enrolled in any diabetes-related educational programs. All successfully screened participants were provided with an informed consent form. Participants were only enrolled in this study after they provided consent. Any resident who met the first 3 inclusion criteria based on EMS records (prescreening) was contacted via telephone by EMS personnel to assess their interest in participating in this study. If they were interested and were successfully screened for the last inclusion criterion, the resident was scheduled for an in-person consenting and baseline data collection session. This was done sequentially until 40 participants were enrolled in this study.
Unlike paramedics, emergency medical technicians in fire departments are not allowed to administer glucagon in prehospital settings [
The intervention included an initial in-person visit (week 1), which was followed by 3 weekly telecoaching calls (weeks 2-4), 1 biweekly call (week 6), and a final in-person visit in week 8 to perform posttest data collection (
During weeks 1 and 6 of this study, EMS personnel visited the homes of the recruited participants. During the week 1 visit, the EMS personnel used tablet computers to educate the participants. Their education involved the retrieval of tailored multimedia content, which was shown as a part of the verbal education provided on topics related to hypoglycemia. Based on an assessment of participants’ diabetes literacy, numeracy [
Student volunteers and EMS personnel used a telehealth dashboard, which was designed for this study, to coach and monitor participants over the phone during weeks 2, 3, 4, and 6. These calls focused on the active monitoring of hypoglycemia-related symptoms and the reinforcement of any education that participants received during week 1.
Study intervention design. EMS: emergency medical services.
The telehealth platform was built by repurposing, refining, and customizing a proven technical infrastructure that is currently being used by multiple projects (
The telehealth dashboard automatically scheduled all of the recurring coaching calls for times that were convenient to the participants and in line with the intervention protocol. The community paramedicine personnel received alerts when it was time to call a participant and were able to mark the success or failure of completing the calls. When the calls were not successful, the calls could be rescheduled. It was also possible to perform weekly data collection and take notes during calls.
Telehealth dashboard.
The primary focus of this study was evaluating the feasibility of recruitment, intervention delivery, retention, and data collection.
One of the most important impacts of hypoglycemia is noncompliance with diabetes treatment due to the FH. This was measured by using the Hypoglycemia Scale: FH-15 questionnaire, which includes 15 items (5-point Likert scale) [
Self-efficacy in hypoglycemia self-management was assessed with the Perceived Diabetes Self-Management Scale (PDSMS) [
The Spoken Knowledge in Low Literacy Diabetes (SKILLD) [
All data pertaining to the exploratory measures were collected during the in-person visits conducted in week 1 and week 8 of this study. The data were directly entered into the tablet computer that was carried by the EMS personnel.
Participant attrition, session attendance, and overall instrument completion were recorded and analyzed by using descriptive statistics. We tested the pre-post exploratory measures by using simple parametric tests (one-tailed Student
The findings from this study fell into 2 categories. First, we focused on the feasibility-related aspects of this study. Second, we focused on the exploratory outcomes. The lessons learned and challenges in implementing this study are presented in the
A total of 40 participants enrolled in this study. The mean age of participants was 67.13 years. The average age of males (n=18) was 69.33 years, and the average age of females (n=22) was 65.32 years.
For recruitment, we relied on EMS personnel to review EMS records and screen participants. Of the 92 people who were identified (prescreened) in a 6-month period, we were able to contact 52 (57%). Of the 52 people contacted, 40 (77%) fully qualified for and agreed to participate in this study (
Participant enrollment flowchart.
The first step of the intervention was an in-person visit, which was by the EMS personnel, to the participants’ homes. This session focused on obtaining consent, collecting baseline data, and educating participants. All 40 people who agreed to participate in this study made it through this session. However, as shown in
The number of participants who were reached via telephone.
Time point | Participants, n (%) |
Week 2 | 25 (62) |
Week 3 | 15 (37) |
Week 4 | 13 (32) |
Week 6 | 9 (22) |
The pretest and posttest data were collected with the tablet computers that were provided to the EMS personnel during the in-person visits. The outcome assessment measures were embedded in the telehealth dashboard. This resulted in no missing or incomplete data, and little to no cleanup was required during the data analysis phase.
The FH survey results revealed a decreasing trend in the overall average scores for all three subdomains—the average scores for fear (mean 13.78, SD 6.3 vs mean 9.38, SD 1.19), avoidance (mean 8.19, SD 4.42 vs mean 6.08, SD 4.37), and interference (mean 10.97, SD 5 vs mean 7.92, SD 1.55). The sum of the scores in the pretest scale was 32.95. This decreased to 23.38 after the intervention. However, no significant decrease in posttest scale scores was identified (
The one-tailed paired
The SKILLD survey results also showed improvements in participants’ knowledge of the complications of diabetes. The mean difference between the pre- and postsurvey scores was 0.5 (SD 0.65;
To our knowledge, this is the first study to conduct a community paramedicine and mobile integrated health care intervention [
Residents of the area that was served by this project belong to the lowest quartile of health literacy scores [
This study helped us learn about several other aspects about the involvement of EMS personnel in community paramedicine programs. During our intervention, we experienced some challenges with completing the in-person visits. Due to safety concerns, EMS personnel carried out the visits at their convenience. Relying on EMS personnel hindered the collection of the data and the completion of this study. Additionally, because of the nature of this pilot study, we were unable to have exclusive staff join the EMS personnel during the in-person visits. Moreover, the EMS staff in this study changed several times during the intervention due to organizational reasons. Future studies should consider including exclusive staff to ensure protocol fidelity. Another solution is employing the temporarily injured employees of fire departments. Employees who are unable to actively return to fieldwork are often available in fire stations and are best suited for telehealth calls. Future research should consider using protocols for including injured EMS personnel who could actively participate as health coaches in studies.
Another valuable insight we learned from this intervention was about the impact that EMS personnel’s attire had on the participants’ confidence and trust. We observed that wearing a professional uniform favorably influenced participants’ trust and confidence in the paramedics. Participants also expressed the most confidence when the same EMS personnel attended to their emergency medical needs. Future studies that try to evaluate community paramedicine or telehealth need to ensure that such factors of trust are considered in the intervention design.
We designed a telehealth dashboard that the EMS personnel in this study could use to coach and monitor participants with hypoglycemia over the phone. At the end of the 8-week intervention period, nonsignificant improvements were found across various knowledge domains and subdomains (fear:
Although hypoglycemia can usually be safely and cost-effectively treated by paramedics, EMS protocols have been developed independently. This has led to variations in protocol content and formats, which can result in varying standards of care. However, the clinical practices of paramedics and emergency care protocols should be evidence-based and reflect common standards of care, formats, and content [
Although we wanted to conduct a randomized feasibility study, the establishment of an untreated control group was not accepted by our community partner due to ethical concerns. Therefore, we chose a pre-post study design. Future studies should consider using designs that involve either simple randomization (by individuals) trials or cluster randomization (by fire districts) trials to understand our intervention’s broader impacts. Although this pilot study was limited to a sample size of 40, future studies should also consider having larger sample sizes. Given the high attrition and the challenging socioeconomic settings in which this study was conducted, the findings of this study cannot be generalized. Similar studies should be conducted across areas with different socioeconomic populations. Finally, we offered health kits that were comprised of blood glucose test kits, blood pressure cuffs, and dextrose gels. However, it should be noted that these kits could have had a confounding effect on the outcomes of this study, as there is evidence suggesting that the mere presence of self-monitoring equipment can influence diabetes-related outcomes [
Our study shows early promising results for a community-based hypoglycemia prevention intervention. However, our pilot study has several limitations. We comprehensively presented the challenges we faced and the lessons we learned throughout this study, and these should be considered when designing future studies.
Diabetes Literacy and Numeracy Education Toolkit
emergency medical services
fear of hypoglycemia
Perceived Diabetes Self-Management Scale
Spoken Knowledge in Low Literacy Diabetes
This project was funded by the University of Alabama at Birmingham Center for the Study of Community Health—a member of the Prevention Research Centers Network—and was supported by the Centers for Disease Control and Prevention Cooperative Agreement (award number: U48/DP006404) and the University of Alabama at Birmingham Diabetes Research Center (award number: P30DK079626) of the National Institute of Diabetes and Digestive and Kidney Diseases.
MT was the principal investigator and conducted all aspects of the research. AGZ and EE helped prepare the manuscript.
None declared.