The effectiveness of a community health program in improving diabetes knowledge in the Hispanic population: Salud y Bienestar (Health and Wellness)

A systematic review and narrative synthesis of health literacy interventions among Spanish speaking populations in the United States

BACKGROUND

While many populations struggle with health literacy, those who speak Spanish preferentially or exclusively, including Hispanic, immigrant, or migrant populations, may face particular barriers, as they navigate a predominantly English-language healthcare system. This population also faces greater morbidity and mortality from treatable chronic diseases, such as hypertension and diabetes. The aim of this systematic review was to describe existing health literacy interventions for patients with a Spanish-language preference and present their effectiveness.

METHODS

We carried out a systematic review where Web of Science, EMBASE, and PubMed were queried using MeSH terms to identify relevant literature. Included articles described patients with a Spanish-language preference participating in interventions to improve health literacy levels in the United States. Screening and data abstraction were conducted independently and in pairs. Risk of bias assessments were conducted using validated appraisal tools.

RESULTS

A total of 2823 studies were identified, of which 62 met our eligibility criteria. The studies took place in a variety of community and clinical settings and used varied tools for measuring health literacy. Of the interventions, 28 consisted of in-person education and 27 implemented multimedia education, with 89% of studies in each category finding significant results. The remaining seven studies featured multimodal interventions, all of which achieved significant results.

CONCLUSION

Successful strategies included the addition of liaison roles, such as promotores (Hispanic community health workers), and the use of multimedia fotonovelas (photo comics) with linguistic and cultural adaptations. In some cases, the external validity of the results was limited. Improving low health literacy in patients with a Spanish-language preference, a population with existing barriers to high quality of care, may help them better navigate health infrastructure and make informed decisions regarding their health.

REGISTRATION

PROSPERO (available at https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021257655.t ).

Cardiovascular Disease and Stroke-Focused Competency Assessment Tools for Community Health Workers in the United States: A Scoping Review

Cardiovascular disease (CVD) and stroke are major contributors to chronic disease burden in the United States. Despite the high prevalence of stroke, 90% of all stroke events are preventable and can be attributed to seven key modifiable risk factors (MRFs)-high blood pressure (BP), high cholesterol, diabetes mellitus (DM), smoking, obesity, unhealthy diet, and physical inactivity. In the United States, stroke prevention interventions led by community health workers (CHWs) have been proven to be highly effective in preventing the onset of MRFs. We conducted a scoping review of the competency assessment methods used in CVD and stroke-focused CHW training programs. We searched six online databases: PubMed, Cochrane, CINAHL, Embase, Web of Science, and HaPI, from all available years until January 2021. Of the 1,774 initial articles found, we identified 30 eligible articles to be included in the review. Nine of these studies used previously validated instruments, whereas the remaining 21 studies used tools from the training curriculum or independently developed instruments. Only five of these validated tools reported psychometric properties; none of them were designed for the CHW population. Our scoping review of literature revealed that CHW-specific competency assessment methods were limited, with few or no domain-referenced tools on CVD or stroke risk factors that complied with established measurement standards. We conclude that there is an urgent need for the development of a comprehensive and valid assessment instrument in CVD and stroke prevention to evaluate CHW performance and optimize their credibility, representing important first steps toward integrating CHWs into health care systems.

A Community Health Volunteer Involvement Program for Glycated Hemoglobin Reduction Among Thai Patients With Uncontrolled Type 2 Diabetes: A Mixed-Method Study

Background:

Diabetes mellitus is increasing and a shortage exists of nurses to care for patients. Community health volunteers (CHVs) pose potential supportive networks in assisting patients to perform healthy behaviors.

Aim:

The study aimed to develop and investigate the effects of a CHV involvement program on reducing glycated hemoglobin (HbA_1c) levels among Thai patients with uncontrolled type 2 diabetes.

Methods:

This sequential mixed-method study was conducted from January to June 2019. Sixty patients with HbA_1c exceeding 7% were recruited from 2 communities assigned as the intervention and comparison groups. Using King’s General Systems Framework as a basis to develop the program, the study initially explored the perceptions of diabetes and its management among patients, family members, and CHVs. Then, a quasi-experimental study with 2 groups pretest-posttest design was conducted and compared with usual care. The intervention included educational sessions, home visits, and activities created by CHVs including a campaign, broadcasting, and health food shops. Quantitative data were collected at baseline and 20-week follow-up and analyzed by descriptive statistics, Independent t-test, and paired t-test.

Results:

The intervention group exhibited a lower mean HbA_1c (p < .001) and reported significant, improvement concerning diabetes knowledge, self-efficacy, perceived support, and behavior compared with the comparison group at the end of the study (Cohen’s d > 1.0, effect size large).

Conclusion:

Applying this framework to develop the program could benefit glycemic control among patients with uncontrolled diabetes residing in communities. Further studies should be conducted on a large sample to demonstrate the efficacy of the program.

Addressing Learner-Centred Barriers to Sexuality Education in Rural Areas of South Africa: Learners' Perspectives on Promoting Sexual Health Outcomes

Introduction

The school-based sexuality education programmes in South Africa aim to improve the sexual and reproductive health of school-going adolescents. However, the high rate of unplanned pregnancy and sexually transmitted infections among learners in some schools in rural areas of King Cetshwayo district suggests that the programmes in these schools might not be effective due to certain learner-centred factors.

Method

This qualitative study explored lived experiences of 84 learners from nine public schools in 2020 through focus group interviews. Data was analysed using Interpretative Phenomenological Analysis.

Results

Learner-centred barriers to effective school-based sexuality education identified in this study were attitudes, age disparity, psychological status, peer pressure, socio-economic status, the exploratory attitude of learners, media, lack of role models, previous experiences, socio-economic status, and lack of parental love. These factors could reduce good sexual health. Learner-targeted interventions such as campaigns, using guest professionals, condom distribution, videos, on-site family planning, formal demonstrations, and on-site counselling could address these barriers.

Conclusions

Addressing these barriers and implementing the proposed interventions will enhance school-based sexuality education and consequently improve adolescents' sexual health.

Policy Implications

The findings could guide programming, implementation, and delivery of school-based sexuality education leading to improved adolescents' sexual and reproductive health.

Community health workers involvement in preventative care in primary healthcare: a systematic scoping review

OBJECTIVES

To review effective models of community health worker (CHW) involvement in preventive care for disadvantaged culturally and linguistically diverse (CALD) patients in primary healthcare (PHC) that may be applicable to the Australian context.

DESIGN

Systematic scoping review.

DATA SOURCES

The studies were gathered through searching Medline, EMBASE, EMCARE, PsycINFO, CINAHL and online portals of relevant organisations.

ELIGIBILITY CRITERIA

All selected studies were original research studies which essentially evaluated preventive intervention undertake by CHWs in PHC. The intervened population were adults with or without diagnosed chronic health disease, culturally and linguistically diverse, or vulnerable due to geographic, economic and/or cultural characteristics that impede or compromise their access to healthcare.

DATA EXTRACTION AND SYNTHESIS

Data extraction was undertaken systematically in an excel spreadsheet while the findings were synthesised in a narrative manner. The quality appraisal of the selected studies was performed using effective public health practice project quality assessment tool.

RESULTS

A total of 1066 articles were identified during the initial search of six bibliographic databases. After screening the title, abstract and full text, 37 articles met the selection and methodological criteria and underwent data extraction. A high-quality evidence-base supporting the positive impact of CHWs supporting patients' access to healthcare and influencing positive behaviour change was found. Positive impacts of CHW interventions included improvements in clinical disease indicators, screening rates and behavioural change. Education-focused interventions were more effective in improving patient behaviour, whereas navigation interventions were most effective in improving access to services. Implementation was enhanced by cultural and linguistic congruence and specific training of CHWs in the intervention but reduced by short duration interventions, dropouts and poor adherence of patients.

CONCLUSION

The evidence generated from this systematic scoping review demonstrates the contribution of CHWs to improving access to preventive care for patients from CALD and disadvantaged backgrounds by providing both education and navigational interventions. More research is needed on CHW training and the incorporation of CHWs into primary health care (PHC) teams.

Evaluating Community-Based Health Improvement Programs

Increasingly, public and private resources are being dedicated to community-based health improvement programs. But evaluations of these programs typically rely on data about process and a pre-post study design without a comparison community. To better determine the association between the implementation of community-based health improvement programs and county-level health outcomes, we used publicly available data for the period 2002-06 to create a propensity-weighted set of controls for conducting multiple regression analyses. We found that the implementation of community-based health improvement programs was associated with a decrease of less than 0.15 percent in the rate of obesity, an even smaller decrease in the proportion of people reporting being in poor or fair health, and a smaller increase in the rate of smoking. None of these changes was significant. Additionally, program counties tended to have younger residents and higher rates of poverty and unemployment than nonprogram counties. These differences could be driving forces behind program implementation. To better evaluate health improvement programs, funders should provide guidance and expertise in measurement, data collection, and analytic strategies at the beginning of program implementation.

Role of community health workers in type 2 diabetes mellitus self-management: A scoping review

BACKGROUND

Globally the number of people with Type 2 diabetes mellitus (T2DM) has risen significantly over the last few decades. Aligned to this is a growing use of community health workers (CHWs) to deliver T2DM self-management support with good clinical outcomes especially in High Income Countries (HIC). Evidence and lessons from these interventions can be useful for Low- and Middle-Income countries (LMICs) such as South Africa that are experiencing a marked increase in T2DM prevalence.

OBJECTIVES

This study aimed to examine how CHW have been utilized to support T2DM self-management globally, their preparation for and supervision to perform their functions.

METHOD

The review was guided by a stepwise approach outlined in the framework for scoping reviews developed by Arksey and O'Malley. Peer reviewed scientific and grey literature was searched using a string of keywords, selecting English full-text articles published between 2000 and 2015. Articles were selected using inclusion criteria, charted and content analyzed.

RESULTS

1008 studies were identified of which 54 full text articles were selected. Most (53) of the selected studies were in HIC and targeted mostly minority populations in low resource settings. CHWs were mostly deployed to provide education, support, and advocacy. Structured curriculum based education was the most frequently reported service provided by CHWs to support T2DM self-management. Support services included informational, emotional, appraisal and instrumental support. Models of CHW care included facility linked nurse-led CHW coordination, facility-linked CHW led coordination and standalone CHW interventions without facility interaction.

CONCLUSION

CHWs play several roles in T2DM self-management, including structured education, ongoing support and health system advocacy. Preparing and coordinating CHWs for these roles is crucial and needs further research and strengthening.

Hypertension and Diabetes Mellitus: A Preliminary South African Health Promotion Activity Using Service-Learning Principles

A marked increase in the chronic non-communicable diseases such as hypertension and diabetes mellitus in the South African population is in concert with global trends. A health promotion activity carried out by pharmacy students for school learners during the Sasol National Festival of Science and Technology (SciFest) in South Africa was used as a service-learning opportunity. Pilot tested quizzes on hypertension and diabetes were used to determine the level of knowledge of attendees before and after taking the computer based quiz. Posters, information leaflets and interactive models on these two conditions were also used to reach out to the larger population. Of the 203 participants for the hypertension quiz, 169 completed both the pre- and post-intervention quizzes. Similarly, 86 of the 104 participants for the diabetes quiz, completed both the pre- and post-intervention quizzes. The results show that the post-intervention quiz resulted in a significant increase in the scores from 78.2 to 85.6 % in the case of Hypertension while a marginal increase from 94.2 to 95.5 % was obtained in the case of diabetes. The knowledge of the SciFest attendees with regard to both conditions is above average and improved further after the educational intervention. Health promotion activities which include interactive educational methods and culturally appropriate materials carried out by pharmacy students during service-learning courses are important for improving the awareness on the prevention of these chronic health conditions. Heath promotion service-learning courses can assist in addressing the health care gaps which arise because of a lack of co-ordinated efforts between NGO's and local Government to address the prevention and management of non-communicable diseases such as hypertension and diabetes mellitus.

Efficacy of sleep education in a Dominican Republic neighborhood through training of community health promoters

INTRODUCTION

The Children's Hospital of Philadelphia (CHOP) Global Health Allies program in the Dominican Republic trains nine health promoters (HPs) in various health subjects with the goal to educate the community. This time we evaluated our teaching session on sleep and sleep disorders.

METHODS

Questionnaires were randomly administered to HPs, and community members in the Dominican Republic before and after the HP educational intervention. Nine HPs already enrolled in the CHOP program, received a 4-hour training session in sleep and sleep disorders. HPs were then instructed to educate the community as they usually do during their supervised weekly home visits.

RESULTS

The nine HP demonstrated knowledge of sleep disorders in their post-training assessment. In the community, 93 adults responded to the initial questionnaire. Although 92 (99%) stated that sleep is important, very few knew about obstructive sleep apnea (n = 17; 18%) and narcolepsy (n = 11; 12%). The post-education questionnaire revealed no statistically significant change in the knowledge about sleep and sleep disorders in the community.

CONCLUSION

The HP knowledge about sleep disorders improved after a 4-hour training session. The community knowledge did not change after education by HPs. Barriers to community education must be explored and the need for other forms of community education about sleep and sleep disorders should be addressed.

The relationship between diabetes attitudes and treatment among free clinic patients and volunteers

Free clinics provide free primary care to the under or uninsured and have been playing an important role in serving the socio-economically disadvantaged. Free clinic patients represent a group of people who experience significant barriers to receiving diabetes prevention and intervention. This study examined diabetes attitudes among free clinic patients and volunteers. English or Spanish speaking patients and volunteers (N = 384), aged 18 years or older completed a self-administered survey. Diabetic patients and volunteers shared similar levels of diabetes attitudes compared to non-diabetic patients. Among patients, ethnicity, education level, diabetes education, and family history affected diabetes attitudes. Among volunteers, diabetes education was an important factor associated with positive diabetes attitudes. Whether the volunteer is a healthcare professional or student was related only to one aspect of diabetes attitudes, seriousness of type 2 diabetes. The results, indicating free clinic diabetic patients and volunteers shared similar levels of diabetes attitudes, were positive for maintaining and developing diabetes education programs at a free clinic. Unfortunately, the average length of volunteering at this free clinic was short and student volunteers likely leave the clinic upon graduation. Future research should examine issues of volunteer retention in free clinics. Diabetes education for patients may need to be diversified according to ethnicity, family history of diabetes, and educational level. Finally, non-healthcare professional volunteers could potentially be involved in diabetes education at a free clinic.

Vida Sana: a lifestyle intervention for uninsured, predominantly Spanish-speaking immigrants improves metabolic syndrome indicators

Metabolic syndrome is an increasingly common condition that can contribute to the development of type 2 diabetes and cardiovascular disease. 35 % of adults living in the United States meet the criteria for having metabolic syndrome, with that number being even higher in populations with health disparities. We describe a 'healthy lifestyles' program implemented at a free clinic serving a predominantly Hispanic cohort of low-income, uninsured individuals living in Providence, Rhode Island. The "Vida Sana/Healthy Life" (Vida Sana) program uses low literacy, language-appropriate materials and trained peers to educate participants about healthy lifestyles in a setting that also provided opportunities for social engagement. 192 of 126 (65.6 %) participants in Vida Sana completed 6 out of 8 sessions of the Vida Sana program over a 12-month period. At the completion of the program, nearly 90 % of Vida Sana participants showed an increase in their health literacy, and at least 60 % of participants decreased each of the risk factors (blood sugar, cholesterol, body mass index or waist circumference) associated with metabolic syndrome.

Linking community resources in diabetes care: a role for technology?

Designing and implementing effective lifestyle modification strategies remains one of the great challenges in diabetes care. Historically, programs have focused on individual behavior change with little or no attempt to integrate change within the broader social framework or community context. However, these contextual factors have been shown to be associated with poor diabetes outcomes, particularly in low-income minority populations. Recent evidence suggests that one way to address these disparities is to match patient needs to existing community resources. Not only does this position patients to more quickly adapt behavior in a practical way, but this also refers patients back to their local communities where a support mechanism is in place to sustain healthy behavior. Technology offers a new and promising platform for connecting patients to meaningful resources (also referred to as "assets"). This paper summarizes several noteworthy innovations that use technology as a practical bridge between healthcare and community-based resources that promote diabetes self-care.

Building skill in heart failure self-care among community dwelling older adults: results of a pilot study

OBJECTIVE

Most of the day-to-day care for heart failure (HF) is done by the patient at home and requires skill in self-care. In this randomized controlled trial (RCT) we tested the efficacy of a community-based skill-building intervention on HF self-care, knowledge and health-related quality of life (HRQL) at 1- and 3-months.

METHODS

An ethnically diverse sample (n=75) of patients with HF (53% female; 32% Hispanic, 27% Black; mean age 69.9±10 years) was randomized to the intervention group (IG) or a wait-list control group (CG). The protocol intervention focused on tactical and situational HF self-care skill development delivered by lay health educators in community senior centers. Data were analyzed using mixed (between-within subjects) ANOVA.

RESULTS

There was a significant improvement in self-care maintenance [F(2,47)=3.42, p=.04, (Cohen's f=.38)], self-care management [F(2,41)=4.10, p=.02, (Cohen's f=.45) and HF knowledge [F(2,53)=8.00, p=.001 (Cohen's f=.54)] in the IG compared to the CG.

CONCLUSIONS

The skill-building intervention improved self-care and knowledge but not HRQL in this community-dwelling sample.

PRACTICE IMPLICATIONS

Delivering an intervention in a community setting using lay health educators provides an alternative to clinic- or home-based teaching that may be useful across diverse populations and geographically varied settings.