Community health workers as partners in the management of non-communicable diseases

Community health worker intervention improves early childhood vaccination rates: results from a propensity-score matching evaluation

BACKGROUND

Arizona's Health Start Program is a statewide community health worker (CHW) maternal and child health home visiting intervention. The objective of this study was to test if participation in Health Start during 2006-2016 improved early childhood vaccination completion rates.

METHODS

This retrospective study used 11 years of administrative, birth certificate, and immunization records. Propensity score matching was used to identify control groups, based on demographic, socioeconomic, and geographic characteristics. Results are reported by historically disadvantaged subgroups and/or with a history of low vaccine uptake, including Hispanic/Latinx and American Indian children, and children of low socioeconomic status and from rural areas, children with teen mothers and first-born children. The average treatment-on-the-treated (ATT) effect estimated the impact of Health Start on timely completion of seven early childhood vaccine series: diphtheria/tetanus toxoids and acellular/whole-cell pertussis (DTaP/DTP), Haemophilus influenzae type b (Hib), hepatitis B (Hep. B), measles-mumps-rubella (MMR), pneumococcal conjugate vaccine (PCV13), poliovirus, and varicella.

RESULTS

Vaccination completion rates (by age five) were 5.0% points higher for Health Start children as a group, and on average 5.0% points higher for several subgroups of mothers: women from rural border counties (ATT 5.8), Hispanic/Latinx women (ATT 4.8), American Indian women (ATT 4.8), women with less than high school education (ATT 5.0), teen mothers (ATT 6.1), and primipara women (ATT 4.5), compared to matched control groups (p-value ≤ 0.05). Time-to-event analyses show Health Start children complete vaccination sooner, with a hazard rate for full vaccination 13% higher than their matches.

CONCLUSION

A state-operated home visiting intervention with CHWs as the primary interventionist can effectively promote early childhood vaccine completion, which may reduce the incidence of preventable diseases and subsequently improve children's health. Effects of CHW interventions on vaccination uptake is particularly relevant given the rise in vaccine-preventable diseases in the US and globally.

TRIAL REGISTRATION

Approved by the University of Arizona Research Institutional Review Board (Protocol 1701128802), 25 January 2017.

The role of community health workers in the surgical cascade: a scoping review

BACKGROUND

Community health workers (CHWs) can increase access to various primary healthcare services; however, their potential for improving surgical care is under-explored. We sought to assess the role of CHWs in the surgical cascade, defined as disease screening, linkage to operative care, and post-operative care. Given the well-described literature on CHWs and screening, we focused on the latter two steps of the surgical cascade.

METHODS

We conducted a scoping review of the peer-reviewed literature. We searched for studies published in any language from January 1, 2000 to May 1, 2020 using electronic literature databases including Pubmed/MEDLINE, Web of Science, SCOPUS, and Google Scholar. We included articles on CHW involvement in linkage to operative care and/or post-operative surgical care. Narrative and descriptive methods were used to analyze the data.

RESULTS

The initial search identified 145 articles relevant to steps in the surgical cascade. Ten studies met our inclusion criteria and were included for review. In linkage to care, CHWs helped increase surgical enrollment, provide resources for vulnerable patients, and build trust in healthcare services. Post-operatively, CHWs acted as effective monitors for surgical-site infections and provided socially isolated patients with support and linkage to additional services. The complex and wide-ranging needs of surgical patients illustrated the need to view surgical care as a continuum rather than a singular operative event.

CONCLUSION

While the current literature is limited, CHWs were able to maneuver complex medical, cultural, and social barriers to surgical care by linking patients to counseling, education, and community resources, as well as post-operative infection prevention services. Future studies would benefit from more rigorous study designs and larger sample sizes to further elucidate the role CHWs can serve in the surgical cascade.

Effectiveness of a multicomponent strategy for implementing guidelines for treating tobacco use in Vietnam Commune Health Centers

INTRODUCTION

Strategies are needed to increase implementation of evidence-based tobacco dependence treatment (TDT) in health care systems in low-and middle-income countries (LMICs).

METHODS

We conducted a two-arm cluster randomized controlled trial to compare the effectiveness of two strategies for implementing TDT guidelines in community health centers (n=26) in Vietnam. Arm 1 included training and a tool kit (e.g., reminder system) to promote and support delivery of the 4As (Ask about tobacco use, Advise to quit, Assess readiness, Assist with brief counseling) (Arm 1). Arm 2 included Arm 1 components plus a system to refer smokers to a community health worker (CHW) for more intensive counseling (4As+R). Provider surveys were conducted at baseline, six- and 12-months to assess the hypothesized effect of the strategies on provider and organizational-level factors. The primary outcome was provider adoption of the 4As.

RESULTS

Adoption of the 4As increased significantly across both study arms (all p<.001). Perceived organizational priority for TDT, compatibility with current workflow, and provider attitudes, norms and self-efficacy related to TDT also improved significantly across both arms. In Arm 2 sites, 41% of smokers were referred to a CHW for additional counseling.

CONCLUSION

The study demonstrated the effectiveness of a multicomponent and multilevel strategy (i.e., provider and system) for implementing evidence-based TDT in the Vietnam public health system. Combining provider-delivered brief counseling with opportunities for more in-depth counseling offered by a trained CHW may optimize outcomes and offers a potentially scalable model for increasing access to TDT in health care systems like Vietnam.

IMPLICATIONS

Improving implementation of evidence-based tobacco dependence treatment (TDT) guidelines is a necessary step towards reducing the growing burden of non-communicable disease (NCDs) and premature death in LMICs. The findings provide new evidence on the effectiveness of multilevel strategies for adapting and implementing TDT into routine care in Vietnam, and offers a potentially scalable model for meeting FCTC Article 14 goals in other LMICs with comparable public health systems. The study also demonstrates that combining provider-delivered brief counseling with referral to a community health worker for more in-depth counseling and support can optimize access to evidence-based treatment for tobacco use.

Critical appraisal of a mHealth-assisted community-based cardiovascular disease risk screening program in rural Kenya: an operational research study

Community health workers (CHWs) can participate in the cascade of hypertension and diabetes management in low and middle-income countries (LMICs). Their services may be enhanced with mobile health (mHealth) tools. In this operational research study, we describe the AFYACHAT mHealth-assisted cardiovascular health screening program in rural Kenya. In this study, A CHW screened a convenience sample of adults ≥ 40 years old in rural Kenya for cardiovascular disease (CVD) risk using the two-way AFYACHAT mHealth instrument. AFYACHAT analyzes a patient's age, sex, smoking, diabetes and systolic blood pressure and provides a four-tiered 10-year CVD risk score. User acceptability was assessed by an end-of-study interview with the CWH. Automated error logs were analyzed. Patient satisfaction was measured with a six-question satisfaction questionnaire. Screened participants with high CVD risk were followed-up via telephone to explore any actions taken following screening. In 24 months, one CHW screened 1650 participants using AFYACHAT. The 10-year risk of CVD was <10% for 1611 (98%) patients, 10 to <20% for 26 (1.6%), 20 to <30% in 12 (0.7%), and ≥30% for 1 (0.1%). The point prevalence of hypertension and diabetes was 27% and 1.9%, respectively. Seventy-five percent of participants with elevated CVD risk sought further medical care. There was high acceptability, a 15% miscode error rate, and high participant satisfaction with the screening program. Our operational research outlines how AFYACHAT mHealth tool can assist CHW perform rapid CVD screening; this provides a model framework for non-communicable disease screening in LMICs.

A protocol paper: community engagement interventions for cardiovascular disease prevention in socially disadvantaged populations in the UK: an implementation research study

Background

Cardiovascular disorders (CVD) are the single greatest cause of mortality worldwide. In the UK, the National Health Service (NHS) has launched an initiative of health checks over and above current care to tackle CVD. However, the uptake of Health Checks is poor in disadvantaged communities. This protocol paper sets out a UK-based study (Sussex and Nottingham) aiming to co-produce a community delivered CVD risk assessment and coaching intervention to support community members to reduce their risk of CVD.

The overall aim of the project is to implement a tailored-to-context community engagement (CE) intervention on awareness of CVD risks in vulnerable populations in high, middle and low-income countries. The specific objectives of the study are to enhance stakeholder’ engagement; to implement lifestyle interventions for cardiovascular primary prevention, in disadvantaged populations and motivate uptake of NHS health checks.

Methods

This study uses both qualitative and quantitative methods in three phases of evaluation, including pre-, per- and post-implementation. To ensure contextual appropriateness the ‘Scaling-up Packages of Interventions for Cardiovascular disease prevention in selected sites in Europe and Sub-Saharan Africa: An implementation research’ (SPICES) project will organize a multi-component community-engagement intervention. For the qualitative component, the pre-implementation phase will involve a contextual assessment and stakeholder mapping, exploring potentials for CVD risk profiling strategies and led by trained Community Health Volunteers (CHV) to identify accessibility and acceptability. The per-implementation phase will involve healthy lifestyle counselling provided by CHVs and evaluation of the outcome to identify fidelity and scalability. The post-implementation phase will involve developing sustainable community-based strategies for CVD risk reduction. All three components will include a process evaluation. A stepped wedge cluster randomised trial of the roll out will focus on implementation outcomes including uptake and engagement and changes in risk profiles. The quantitative component includes pre and post-intervention surveys. The theory of the socio-ecological framework will be applied to analyse the community engagement approach.

Discussion

Based on the results ultimately a sustainable community engagement-based strategy for the primary prevention of CVD risk will be developed to enhance the performance of NHS health care in the UK. The Trial Registration number is ISRCTN68334579.

Effectiveness of Village Health Worker-Delivered Smoking Cessation Counseling in Vietnam

INTRODUCTION

Smoking prevalence is high in Vietnam, yet tobacco dependence treatment (TDT) is not widely available.

METHODS

We conducted a quasiexperimental study that compared the effectiveness of health care provider advice and assistance (ARM 1) versus ARM 1 plus village health worker (VHW) counseling (ARM 2) on abstinence at 6-month follow-up. This study was embedded in a larger two-arm cluster randomized controlled trial conducted in 26 community health centers (CHCs) in Vietnam. Subjects (N = 1318) were adult patients who visited any participating CHC during the parent randomized controlled trial intervention period and were self-identified as current tobacco users (cigarettes and/or water pipe).

RESULTS

At 6-month follow-up, abstinences rates in ARM 2 were significantly higher than those in ARM 1 (25.7% vs. 10.5%; p < .001). In multivariate analyses, smokers in ARM 2 were almost three times more likely to quit compared with those in ARM 1 (adjusted odds ratio [AOR] = 2.96, 95% confidence interval [CI] = 1.78% to 4.92%). Compared to cigarette-only smokers, water pipe-only smokers (AOR = 0.4, 95% CI = 0.26% to 0.62%) and dual users (AOR = 0.62, 95% CI = 0.45% to 0.86%) were less likely to achieve abstinence; however, the addition of VHW counseling (ARM 2) was associated with higher quit rates compared with ARM 1 alone for all smoker types.

CONCLUSION

A team approach in TDT programs that offer a referral system for health care providers to refer smokers to VHW-led cessation counseling is a promising and potentially scalable model for increasing access to evidence-based TDT and increasing quit rates in low middle-income countries (LMICs). TDT programs may need to adapt interventions to improve outcomes for water pipe users.

IMPLICATIONS

The study fills literature gaps on effective models for TDT in LMICs. The addition of VHW-led cessation counseling, available through a referral from primary care providers in CHCs in Vietnam, to health care provider's brief cessation advice, increased 6-month biochemically validated abstinence rates compared to provider advice alone. The study also demonstrated the potential effectiveness of VHW counseling on reducing water pipe use. For LMICs, TDT programs in primary care settings with a referral system to VHW-led cessation counseling might be a promising and potentially scalable model for increasing access to evidence-based treatment.

Effectiveness of community health worker training programmes for cardiovascular disease management in low-income and middle-income countries: a systematic review

INTRODUCTION

Community health workers (CHWs) are increasingly being tasked to prevent and manage cardiovascular disease (CVD) and its risk factors in underserved populations in low-income and middle-income countries (LMICs); however, little is known about the required training necessary for them to accomplish their role. This review aimed to evaluate the training of CHWs for the prevention and management of CVD and its risk factors in LMICs.

METHODS

A search strategy was developed in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and five electronic databases (Medline, Global Health, ERIC, EMBASE and CINAHL) were searched to identify peer-reviewed studies published until December 2016 on the training of CHWs for prevention or control of CVD and its risk factors in LMICs. Study characteristics were extracted using a Microsoft Excel spreadsheet and quality assessed using Effective Public Health Practice Project's Quality Assessment Tool. The search, data extraction and quality assessment were performed independently by two researchers.

RESULTS

The search generated 928 articles of which 8 were included in the review. One study was a randomised controlled trial, while the remaining were before-after intervention studies. The training methods included classroom lectures, interactive lessons, e-learning and online support and group discussions or a mix of two or more. All the studies showed improved knowledge level post-training, and two studies demonstrated knowledge retention 6 months after the intervention.

CONCLUSION

The results of the eight included studies suggest that CHWs can be trained effectively for CVD prevention and management. However, the effectiveness of CHW trainings would likely vary depending on context given the differences between studies (eg, CHW demographics, settings and training programmes) and the weak quality of six of the eight studies. Well-conducted mixed-methods studies are needed to provide reliable evidence about the effectiveness and cost-effectiveness of training programmes for CHWs.

Behavioral lifestyle interventions for the primary prevention of type 2 diabetes and translation to Hispanic/Latino communities in the United States and Mexico

Lifestyle behaviors in overweight and obese individuals are closely linked to the development, course, and outcomes of type 2 diabetes and multiple comorbid health conditions. Behavior change theory and many randomized controlled studies offer strong support for screening and identifying adults at increased cardiometabolic risk and for providing early intervention to mitigate risk factors to prevent or delay the onset of disease. The current article reviews key lifestyle intervention efficacy and dissemination trials conducted with individuals deemed to be at increased risk for diabetes and describes the rationale for training teams of professionals and community health workers (e.g., promotores [in Spanish]) to implement comprehensive programs, with fidelity, in a variety of medical care and community settings. This evidence-based road map may be used to facilitate the design and implementation of strategies for structured behavioral diabetes risk reduction programs in the public and private healthcare sectors and other relevant community-based platforms serving individuals of Hispanic/Latino origin in the United States and Mexico.