CoDE: Community Diabetes Education for uninsured Mexican Americans

Foot care intervention delivered by community health worker (CHWs): A scoping review

Variations of Community Health Workers (CHWs) interventions in diabetes self-management education (DSME) have been reviewed by many studies. In contrast, specific interventions regarding foot care intervention (FCI) are scarce and need to be explored further as one preventive measure to reduce diabetic foot problems in the community. This scoping review aimed to identify, and report nature of FCIs and the core components of FCIs delivered by CHWs. The scoping review was undertaken using PRISMA Extension for Scoping Reviews (PRISMA-ScR). The following electronic databases were searched for articles from data first indicated date through December 2022: CINAHL, EMBASE, Cochrane, Scopus, Web of Science, Theses ProQuest, PubMed, google scholar and other sources by using search terms related to foot care, community health workers, and diabetes mellitus. Descriptive synthesis was used to summarise the data. Nine studies from 1644 were included. All studies found that CHWs provided DSME in general, and foot care education was included. There was no detailed description of the core components of the intervention on foot care. Although, all studies might not provide detailed data on how CHW provided FCIs; the CHW intervention is an undoubtedly vital strategy to promote and prevent foot problems in medically underserved communities.

Challenges and Lessons Learned From a Telehealth Community Paramedicine Program for the Prevention of Hypoglycemia: Pre-Post Pilot Feasibility Study

Background

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.

Objective

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.

Methods

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.

Results

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 (P=.03).

Conclusions

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.

Trial Registration

ClinicalTrials.gov NCT03665870; https://clinicaltrials.gov/ct2/show/NCT03665870

Lifestyle interventions for type 2 diabetes management among migrants and ethnic minorities living in industrialized countries: a systematic review and meta-analyses

The objective of this systematic review was to determine the effectiveness of lifestyle interventions to improve the management of type 2 diabetes mellitus (T2DM) among migrants and ethnic minorities. Major searched databases included MEDLINE (via PubMed), EMBASE (via Ovid) and CINAHL. The selection of studies and data extraction followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. In the meta-analysis, significant heterogeneity was detected among the studies (I2 >50%), and hence a random effects model was used. Subgroup analyses were performed to compare the effect of lifestyle interventions according to intervention approaches (peer-led vs community health workers (CHWs)-led). A total of 17 studies were included in this review which used interventions delivered by CHWs or peer supporters or combination of both. The majority of the studies assessed effectiveness of key primary (hemoglobin (HbA1c), lipids, fasting plasma glucose) and secondary outcomes (weight, body mass index, blood pressure, physical activity, alcohol consumption, tobacco smoking, food habits and healthcare utilization). Meta-analyses showed lifestyle interventions were associated with a small but statistically significant reduction in HbA1c level (-0.18%; 95% CI -0.32% to -0.04%, p=0.031). In subgroup analyses, the peer-led interventions showed relatively better HbA1c improvement than CHW-led interventions, but the difference was not statistically significant (p=0.379). Seven studies presented intervention costs, which ranged from US$131 to US$461 per participant per year. We conclude that lifestyle interventions using either CHWs or peer supporters or a combination of both have shown modest effectiveness for T2DM management among migrants of different background and origin and ethnic minorities. The evidence base is promising in terms of developing culturally appropriate, clinically sound and cost-effective intervention approaches to respond to the growing and diverse migrants and ethnic minorities affected by diabetes worldwide.

A Systematic Review of Community Health Center Based Interventions for People with Diabetes

Community health centers (CHCs) focus on serving socioeconomically disadvantaged populations with heightened chronic disease burden, making CHCs an ideal setting for implementing diabetes care programs that target vulnerable populations. We aimed to synthesize evidence concerning the effects of CHC interventions in people with diabetes. To do this, four electronic databases were searched, including PubMed, EMBASE, CINAHL, and Scopus, and hand searches of reference collections were undertaken to identify intervention trials published in English. We screened 892 unique titles and abstracts. Two reviewers then independently evaluated 221 full-text articles. We discovered 29 articles met our eligibility criteria for inclusion. We found 27 unique studies with two companion articles. Seventeen studies were randomized controlled trials and the majority had a higher proportion of female and racial/ethnic minorities in the study sample. CHC interventions often involved either one-on-one or group education sessions supplemented by a phone follow-up that were delivered by health providers, nutritionists, or community health workers. CHC interventions using education sessions combined with follow up via phone generally resulted in significant improvements in hemoglobin A1C, while sole telephone-based education studies showed no significant improvements. CHC interventions had no significant effects on physical activity in all six studies that examined the outcome. Overall, we found that CHC interventions were in general effective in improving glucose control when using face-to-face interactions in low-income, underserved, and racial and ethnic minority patients with diabetes. Evidence was limited, however, in regards to other outcomes which suggests the need for continued evaluations of CHC intervention models.

Economics of Community Health Workers for Chronic Disease: Findings From Community Guide Systematic Reviews

CONTEXT

Cardiovascular disease in the U.S. accounted for healthcare cost and productivity losses of $330 billion in 2013-2014 and diabetes accounted for $327 billion in 2017. The impact is disproportionate on minority and low-SES populations. This paper examines the available evidence on cost, economic benefit, and cost effectiveness of interventions that engage community health workers to prevent cardiovascular disease, prevent type 2 diabetes, and manage type 2 diabetes.

EVIDENCE ACQUISITION

Literature from the inception of databases through July 2016 was searched for studies with economic information, yielding nine studies in cardiovascular disease prevention, seven studies in type 2 diabetes prevention, and 13 studies in type 2 diabetes management. Analyses were done in 2017. Monetary values are reported in 2016 U.S. dollars.

EVIDENCE SYNTHESIS

The median intervention cost per patient per year was $329 for cardiovascular disease prevention, $600 for type 2 diabetes prevention, and $571 for type 2 diabetes management. The median change in healthcare cost per patient per year was -$82 for cardiovascular disease prevention and -$72 for type 2 diabetes management. For type 2 diabetes prevention, one study saw no change and another reported -$1,242 for healthcare cost. One study reported a favorable 1.8 return on investment from engaging community health workers for cardiovascular disease prevention. Median cost per quality-adjusted life year gained was $17,670 for cardiovascular disease prevention, $17,138 (mean) for type 2 diabetes prevention, and $35,837 for type 2 diabetes management.

CONCLUSIONS

Interventions engaging community health workers are cost effective for cardiovascular disease prevention and type 2 diabetes management, based on a conservative $50,000 benchmark for cost per quality-adjusted life year gained. Two cost per quality-adjusted life year estimates for type 2 diabetes prevention were far below the $50,000 benchmark.

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.

Integrating Undergraduate Patient Partners into Diabetes self-management education: Evaluating a free clinic pilot program for the Underserved

BACKGROUND

Diabetes self-management education (DSME) improves glycemic control and health outcomes in patients with diabetes.

OBJECTIVE

A process evaluation of a two-year pilot intervention examined the feasibility and acceptability of undergraduate volunteers as Patient Partners to foster DSME participation among the underserved.Design setting, and participants. In the setting of a student-run free clinic, 22 patients enrolled in DSME were paired with 16 undergraduate volunteers. During the DSME courses, Patient Partners assisted patients during classes, called patients weekly, and accompanied patients to clinic appointments.Key process evaluation results. Average attendance at DSME classes was 79.4% and 94.7% for patients and Patient Partners, respectively. Sixty-three percent of phone calls were successful and Patient Partners attended 50% of appointments with their patients. Focus groups demonstrated resounding acceptability of the Patient Partner role.

CONCLUSIONS

Volunteer undergraduate Patient Partners are a beneficial adjunct to DSME delivery in the resource-constrained environment of a student-run free clinic.

Improving diabetes care and outcomes with community health workers

BACKGROUND

Type II diabetes continues to be a major health problem in USA, particularly in minority populations. The Diabetes Equity Project (DEP), a clinic-based diabetes self-management and education program led by community health workers (CHWs), was designed to reduce observed disparities in diabetes care and outcomes in medically underserved, predominantly Hispanic communities.

OBJECTIVE

The purpose of this study was to evaluate the impact of the DEP on patients' clinical outcomes, diabetes knowledge, self-management skills, and quality of life.

METHODS

The DEP was implemented in five community clinics from 2009 to 2013 and 885 patients completed at least two visits with the CHW. Student's paired t-tests were used to compare baseline clinical indicators with indicators obtained from patients' last recorded visit with the CHW and to assess differences in diabetes knowledge, perceived competence in managing diabetes, and quality of life. A mixed-effects model for repeated measures was used to examine the effect of DEP visits on blood glucose (HbA1c), controlling for patient demographics, clinic and enrolment date.

RESULTS

DEP patients experienced significant (P < 0.0001) improvements in HbA1c control, blood pressure, diabetes knowledge, perceived competence in managing diabetes, and quality of life. Mean HbA1c for all DEP patients decreased from 8.3% to 7.4%.

CONCLUSION

Given the increasing prevalence of diabetes in USA and documented disparities in diabetes care and outcomes for minorities, particularly Hispanic patients, new models of care such as the DEP are needed to expand access to and improve the delivery of diabetes care and help patients achieve improved outcomes.

The Community Diabetes Education (CoDE) program: cost-effectiveness and health outcomes

BACKGROUND

Limited evidence exists regarding the long-term effects of community health worker-led diabetes management programs on health outcomes and cost-effectiveness, particularly in low-income, ethnic minority populations.

PURPOSE

To examine the long-term cost-effectiveness and improvements in diabetes-related complications of a diabetes education and management intervention led by community health workers among uninsured Mexican Americans.

METHODS

Clinical data, changes in hemoglobin A1c over 12 months, and costs from an RCT of 180 uninsured Mexican Americans with type 2 diabetes conducted in 2006 were utilized for secondary analyses in 2012. Simulation modeling was used to estimate long-term cost and health outcomes using the validated Archimedes Model. The absolute differences for the incremental cost-effectiveness ratios and cumulative incidence of diabetes-related complications were derived by comparing intervention and control groups.

RESULTS

During a 20-year time horizon, participants who received the intervention would be expected to have significantly lower hemoglobin A1c levels (p<0.001), fewer foot ulcers (p<0.001), and a reduced number of foot amputations (p=0.005) in comparison with a control group receiving usual medical care. An incremental cost-effectiveness ratio of $355 per quality-adjusted life year gained was estimated for intervention participants during the same time period.

CONCLUSIONS

A simulated clinical trial suggests that a community health worker-led diabetes intervention is a cost-effective way to reduce diabetes-related complications for uninsured Mexican Americans during a 20-year horizon in comparison to usual medical care.

Impact of social determinants of health on outcomes for type 2 diabetes: a systematic review

Social determinants of health include the social and economic conditions that influence health status. Research into the impact of social determinants on individuals with type 2 diabetes has largely focused on the prevention of or risk of developing diabetes. No review exists summarizing the impact of social determinants of health outcomes in patients with type 2 diabetes. This systematic review examined whether social determinants of health have an impact on health outcomes in type 2 diabetes. Medline was searched for articles that (a) were published in English (b) targeted adults, ages 18 + years, (c) had a study population which was diagnosed with type 2 diabetes, (d) the study was done in the United States, and (e) the study measured at least one of the outcome measures-glycemic control, cholesterol (LDL), blood pressure, quality of life or cost. Using a reproducible strategy, 2,110 articles were identified, and 61 were reviewed based on inclusion criteria. Twelve were categorized as Economic Stability and Education, 17 were categorized as Social and Community Context, 28 were categorized as Health and Health Care, and three were categorized as Neighborhood and Built Environment. Based on the studies reviewed, social determinants have an impact on glycemic control, LDL, and blood pressure to varying degrees. The impact on cost and quality of life was not often measured, but when quality of life was investigated, it did show significance. More research is needed to better characterize the direct impact of social determinants of health on health outcomes in diabetes.

Characteristics and effectiveness of diabetes self-management educational programs targeted to racial/ethnic minority groups: a systematic review, meta-analysis and meta-regression

BACKGROUND

It is not clear to what extent educational programs aimed at promoting diabetes self-management in ethnic minority groups are effective. The aim of this work was to systematically review the effectiveness of educational programs to promote the self-management of racial/ethnic minority groups with type 2 diabetes, and to identify programs' characteristics associated with greater success.

METHODS

We undertook a systematic literature review. Specific searches were designed and implemented for Medline, EMBASE, CINAHL, ISI Web of Knowledge, Scirus, Current Contents and nine additional sources (from inception to October 2012). We included experimental and quasi-experimental studies assessing the impact of educational programs targeted to racial/ethnic minority groups with type 2 diabetes. We only included interventions conducted in countries members of the OECD. Two reviewers independently screened citations. Structured forms were used to extract information on intervention characteristics, effectiveness, and cost-effectiveness. When possible, we conducted random-effects meta-analyses using standardized mean differences to obtain aggregate estimates of effect size with 95% confidence intervals. Two reviewers independently extracted all the information and critically appraised the studies.

RESULTS

We identified thirty-seven studies reporting on thirty-nine educational programs. Most of them were conducted in the US, with African American or Latino participants. Most programs obtained some benefits over standard care in improving diabetes knowledge, self-management behaviors and clinical outcomes. A meta-analysis of 20 randomized controlled trials (3,094 patients) indicated that the programs produced a reduction in glycated hemoglobin of -0.31% (95% CI -0.48% to -0.14%). Diabetes knowledge and self-management measures were too heterogeneous to pool. Meta-regressions showed larger reduction in glycated hemoglobin in individual and face to face delivered interventions, as well as in those involving peer educators, including cognitive reframing techniques, and a lower number of teaching methods. The long-term effects remain unknown and cost-effectiveness was rarely estimated.

CONCLUSIONS

Diabetes self-management educational programs targeted to racial/ethnic minority groups can produce a positive effect on diabetes knowledge and on self-management behavior, ultimately improving glycemic control. Future programs should take into account the key characteristics identified in this review.

Cost-effectiveness of Community Health Workers in controlling diabetes epidemic on the U.S.-Mexico border

OBJECTIVES

This study attempted to evaluate clinical outcomes and long-term cost-effectiveness of an intervention involving Community Health Workers (CHW's, a.k.a. promotoras de salud in Spanish) in assisting Mexican-American diabetes type-2 patients with controlling their condition. The intervention has been carried out in Hidalgo County, TX which is situated on the U.S.-Mexico border.

STUDY DESIGN

The design of the study is experimental. The sample (n = 30) was recruited from Mexican-American diabetes patients aged 30 or above. The intervention group received monthly visits from CHW's, while the control group did not.

METHODS

Incremental lifetime health outcomes and related expenditures were calculated using the CDC Diabetes Cost-Effectiveness Model (DCEM) which is a probabilistic computer simulation model of disease progression and cost-effectiveness for type 2 diabetes patients. The DCEM allows projection of lifetime healthcare costs and Quality-Adjusted Life-Years (QALYs).

RESULTS

The intervention group showed a significant improvement in glycemic control and cholesterol management after two years of intervention. The intervention is expected to reduce long-term complications, resulting in an increase in residual life-years and quality-adjusted life-years. The incremental cost-effectiveness ratio has been estimated to be $13,810, which is below the level of comparable studies.

CONCLUSIONS

Intervention has a substantial impact on the medical costs of type 2 diabetes treatment. The estimates presented in this model may be used to analyse the cost-effectiveness of interventions involving CHW's for type 2 diabetes.

Effectiveness of a community health worker-led diabetes self-management education program and implications for CHW involvement in care coordination strategies

PURPOSE

The purpose of this study was to evaluate the effectiveness of a Community Health Worker (CHW)-led diabetes self-management education (DSME) program and to understand how CHWs and primary care providers (PCPs) work together to provide comprehensive diabetes care.

METHODS

A quantitative pre- and postassessment of change in patients' blood glucose levels (A1C), blood pressure, and body mass index was performed to determine the clinical effectiveness of the program. Qualitative, semi-structured interviews with 5 CHWs and 7 PCPs were conducted to assess how CHWs were incorporated into clinical teams and their impact on care delivery and diabetes-related outcomes.

RESULTS

Patients who participated in the program experienced a statistically significant decrease in mean A1C levels and systolic blood pressure readings 1 year post baseline. CHWs provided high-quality care and bridged the gap between patients and care providers through diabetes management support and education, medication assistance, access to community resources, and social support.

CONCLUSIONS

CHWs play a variety of roles in helping patients overcome barriers to diabetes control and can be successfully integrated into a health care system's care coordination strategy.

Community Diabetes Education (CoDE) for uninsured Mexican Americans: a randomized controlled trial of a culturally tailored diabetes education and management program led by a community health worker

AIMS

The purpose of this randomized controlled trial was to determine the impact of a culturally tailored diabetes education program led by a community health worker (CHW) on the HbA1c, blood pressure, body mass index (BMI) and lipid status of uninsured Mexican Americans with diabetes.

METHODS

Adult patients were recruited from a community clinic and randomized into intervention (n=90) and control (n=90) groups. Both groups received usual medical care from clinic physicians. The intervention group participated in the Community Diabetes Education (CoDE) program over 12 months. The primary outcome of interest was HbA1c. Secondary outcomes included blood pressure, BMI and lipid status. Variations in outcomes over time were assessed within groups and between groups using linear mixed-models and an intention-to-treat approach. Assessment of changes in HbA1c, blood pressure and lipid status over 12 months included variables to control for modifications made to antidiabetic, antihypertensive and lipid lowering medications.

RESULTS

There was no difference in baseline characteristics between the intervention and control groups. Mean changes of HbA1c over 12 months showed a significant intervention effect (-.7%, p=.02) in the CoDE group compared with controls. HbA1c decreased significantly from baseline to 12 months within the intervention (-1.6%, p<.001) and control (-.9%, p<.001) groups. No differences between groups for secondary outcomes were found.

CONCLUSIONS

This study supports the effectiveness of CHWs as diabetes educators/case managers functioning as integral members of the health care team in community clinic settings serving uninsured Mexican Americans.

En Balance: the effects of Spanish diabetes education on physical activity changes and diabetes control

PURPOSE

This study was designed to assess the feasibility of culturally and language-sensitive diabetes education as a way to increase physical activity and to improve health/diabetes management in a group of Spanish-speaking Hispanics in the Inland Empire region of Southern California.

METHODS

En Balance is a culturally sensitive diabetes education program designed for Spanish-speaking Hispanic adults. The 3-month educational intervention assessed 16 males and 23 females living in Riverside and San Bernardino counties of Southern California. Baseline and 3-month evaluations of physical activity were assessed using the validated Arizona Activity Frequency Questionnaire.

RESULTS

After 3 months on the En Balance program, there was a significant increase in moderate intensity physical activity energy expenditure (M = 368 ± 894 kcal/day, P < 0.01) and high intensity physical activity energy expenditure (M = 405 ± 2569 kcal/day, P = 0.05) compared to baseline and significant reductions in A1C (-0.90%, P = 0.01), total cholesterol (-13.44 mg/dl, P = 0.01), LDL cholesterol (-10.28 mg/dl, P = 0.03), and waist circumference (-1.52 cm, P = 0.04).

CONCLUSION

En Balance program resulted in significant mean increases in both moderate and high intensity physical activity energy expenditure among this group of Hispanic diabetic participants, indicating that despite a general pattern of low physical activity in this group, an intervention that stresses both nutrition and exercise in culturally sensitive ways can positively impact participant's physical activity levels as well as impact nutritional changes.

No-shows to primary care appointments: subsequent acute care utilization among diabetic patients

BACKGROUND

Patients who no-show to primary care appointments interrupt clinicians' efforts to provide continuity of care. Prior literature reveals no-shows among diabetic patients are common. The purpose of this study is to assess whether no-shows to primary care appointments are associated with increased risk of future emergency department (ED) visits or hospital admissions among diabetics.

METHODS

A prospective cohort study was conducted using data from 8,787 adult diabetic patients attending outpatient clinics associated with a medical center in Indiana. The outcomes examined were hospital admissions or ED visits in the 6 months (182 days) following the patient's last scheduled primary care appointment. The Andersen-Gill extension of the Cox proportional hazard model was used to assess risk separately for hospital admissions and ED visits. Adjustment was made for variables associated with no-show status and acute care utilization such as gender, age, race, insurance and co-morbid status. The interaction between utilization of the acute care service in the six months prior to the appointment and no-show was computed for each model.

RESULTS

The six-month rate of hospital admissions following the last scheduled primary care appointment was 0.22 (s.d. = 0.83) for no-shows and 0.14 (s.d. = 0.63) for those who attended (p < 0.0001). No-show was associated with greater risk for hospitalization only among diabetics with a hospital admission in the prior six months. Among diabetic patients with a prior hospital admission, those who no-showed were at 60% greater risk for subsequent hospital admission (HR = 1.60, CI = 1.17-2.18) than those who attended their appointment. The six-month rate of ED visits following the last scheduled primary care appointment was 0.56 (s.d. = 1.48) for no-shows and 0.38 (s.d. = 1.05) for those who attended (p < 0.0001); after adjustment for covariates, no-show status was not significantly related to subsequent ED utilization.

CONCLUSIONS

No-show to a primary care appointment is associated with increased risk for hospital admission among diabetics recently hospitalized.

Reducing diabetes disparities through the implementation of a community health worker-led diabetes self-management education program

Disparities in prevalence of type 2 diabetes and complications in underserved populations have been linked to poor quality of care including lack of access to diabetes management programs. Interventions utilizing community health workers (CHWs) to assist with diabetes management have demonstrated improvements in patient outcomes. Use of CHWs may be an effective model for providing care coordination and reducing disparities, but there is limited knowledge on how to implement this model on a large scale. This article describes how an integrated health care system implemented a CHW-led diabetes self-management education program targeting Hispanic patients and reports lessons learned from the first 18 months of operation.

The Impact of Community Health Workers on Behavioral Outcomes and Glycemic Control of Diabetes Patients on the U.S.-Mexico Border

This study attempts to determine the impact of Community Health Workers ( promotoras de salud) on the self-management practices of people with diabetes on the U.S.-Mexico Border. The region has higher incidence rates of type 2 diabetes than the nation as a whole due to its Mexican-American population, an ethnic group genetically vulnerable to the disease. Unlike prior research that investigated the overall effectiveness of the CHWs, this study monitored a wide range of biologic (HbA1c, BMI) and behavioral (diabetes knowledge, self-efficacy, self-management activities scores) outcomes among the diabetes patients. The experimental research design tested whether or not the monthly visits by CHWs to the diabetic patients helped them in controlling their disease. The sample ( N = 30) was recruited from Mexican-American diabetes patients aged 30 or above. The intervention group received monthly visits from CHWs, while the control group did not. The intervention group showed a significant improvement after 2 years of intervention in all outcomes, except Body Mass Index (BMI).

En Balance participants decrease dietary fat and cholesterol intake as part of a culturally sensitive Hispanic diabetes education program

PURPOSE

The purpose of this study was to assess dietary intake habits of Mexican American Hispanic adults participating in the En Balance diabetes education program.

METHODS

En Balance is a 3-month culturally sensitive diabetes education intervention for Spanish-speaking Hispanics. Of the 46 participants enrolled, 39 mainly Mexican American Hispanic adults with type 2 diabetes completed the En Balance program. Participants lived in the Riverside and San Bernardino counties of California, and all participants completed the program by June 2008. Dietary intake was assessed at baseline and at 3 months using the validated Southwest Food Frequency Questionnaire.

RESULTS

Clinically important decreases in glycemic control and serum lipid levels were observed at the end of the 3-month program. The baseline diet was characterized by a high intake of energy (2478 ± 1140 kcal), total fat (87 ± 44 g/day), saturated fat (28 ± 15 g/day), dietary cholesterol (338 ± 217 mg/day), and sodium (4236 ± 2055 mg/day). At 3 months, the En Balance group mean intake of dietary fat (P = .045) and dietary cholesterol (P = .033) decreased significantly. Low dietary intakes of docosahexaenoic acid, eicosapentaenoic acid, and vitamin E were also observed in these adults with type 2 diabetes.

CONCLUSIONS

The En Balance program improved glycemic control and lipid profiles in a group of Hispanic diabetic participants. En Balance also promoted decreases in dietary fat and dietary cholesterol intake.

Outcome effectiveness of the lay health advisor model among Latinos in the United States: an examination by role

The objective of this study was to examine lay health advisor (LHA) programs designed to promote health among US Latinos and the extent to which educator-only versus educator-plus-bridge programs differed in designs and outcomes achieved. Two independent coders reviewed 128 published articles on LHAs yielding information at two levels: (i) study design and participant and LHA characteristics from 61 studies that broadly compared educator-only versus educator-plus-bridge programs and (ii) implementation features and outcomes from 17 randomized controlled trials or quasi-experimental studies with outcome data. LHA programs have been widely used with Latinos in certain US regions; our findings indicate that LHAs are effective intervention agents. We identified differences between educator-only and educator-plus-bridge LHA programs, although the small number of educator-plus-bridge programs with outcome data limited comparisons. Major gaps remain in research targeting Latino subgroups other than Mexican immigrants/Mexican Americans. Sufficient research has evaluated LHA programs among Latinos on their ability to achieve health behavior and/or health status changes. In the future, more of a focus on organizational and policy changes is warranted. Questions remain about diversity in LHAs' characteristics and roles, which influence not only outcomes but also program sustainability and dissemination.

Training community health promoters to implement diabetes self-management support programs for urban minority adults

OBJECTIVE

To develop, implement, and evaluate a peer-led diabetes self-management support program in English and Spanish for a diverse, urban, low-income population. The program goals and objectives were to improve diabetes self-management behaviors, especially becoming more physically active, healthier eating, medication adherence, problem solving, and goal setting.

METHODS

After a new training program for peers led by a certified diabetes educator (CDE) was implemented with 5 individuals, this pilot evaluation study was conducted in 2 community settings in the East and South Bronx. Seventeen adults with diabetes participated in the new peer-led 5-session program. Survey data were collected pre- and postintervention on diabetes self-care activities, quality of well-being, and number of steps using a pedometer.

RESULTS

This pilot study established the acceptance and feasibility of both the peer training program and the community-based, peer-led program for underserved, minority adults with diabetes. Significant improvements were found in several physical activity and nutrition activities, with a modest improvement in well-being. Feedback from both peer facilitators and participants indicated that a longer program, but with the same educational materials, was desirable.

CONCLUSIONS

To reduce health disparities in urban communities, it is essential to continue program evaluation of the critical elements of peer-led programs for multiethnic adults with diabetes to promote self-management support in a cost-effective and culturally appropriate manner. Practice Implications A diabetes self-management support program can be successfully implemented in the community by peers, within a model including remote supervision by a CDE.

Role development of community health workers: an examination of selection and training processes in the intervention literature

BACKGROUND

Research evaluating community health worker (CHW) programs inherently involves these natural community leaders in the research process, and often represents community-based participatory research (CBPR). Interpreting the results of CHW intervention studies and replicating their findings requires knowledge of how CHWs are selected and trained.

METHODS

A summative content analysis was performed to evaluate the description of CHW selection and training in the existing literature. First-level coding focused on contextual information about CHW programs. Second-level coding identified themes related to the selection and training of CHWs.

RESULTS

There was inconsistent reporting of selection and training processes for CHWs in the existing literature. Common selection criteria included personal qualities desired of CHWs. Training processes for CHWs were more frequently reported. Wide variation in the length and content of CHW training exists in the reviewed studies. A conceptual model is presented for the role development of CHWs based on the results of this review, which is intended to guide future reporting of CHW programs in the intervention literature.

CONCLUSIONS

Consistent reporting of CHW selection and training will allow consumers of intervention research to better interpret study findings. A standard approach to reporting selection and training processes will also more effectively guide the design and implementation of future CHW programs. All community-based researchers must find a balance between describing the research process and reporting more traditional scientific content. The current conceptual model provides a guide for standard reporting in the CHW literature.

Impact of peer nutrition education on dietary behaviors and health outcomes among Latinos: a systematic literature review

OBJECTIVE

This systematic review assesses the impact of peer education/counseling on nutrition and health outcomes among Latinos and identifies future research needs.

DESIGN

A systematic literature search was conducted by: (1) searching Internet databases; (2) conducting backward searches from reference lists of articles of interest; (3) manually reviewing the archives of the Center for Eliminating Health Disparities among Latinos; (4) searching the Journal of Nutrition Education and Behavior; and (5) directly contacting researchers in the field. The authors reviewed 22 articles derived from experimental or quasi-experimental studies.

OUTCOME MEASURES

Type 2 diabetes behavioral and metabolic outcomes, breastfeeding, nutrition knowledge, attitudes and behaviors.

RESULTS

Peer nutrition education has a positive influence on diabetes self-management and breastfeeding outcomes, as well as on general nutrition knowledge and dietary intake behaviors among Latinos.

CONCLUSIONS AND IMPLICATIONS

There is a need for longitudinal randomized trials testing the impact of peer nutrition education interventions grounded on goal setting and culturally appropriate behavioral change theories. Inclusion of reliable scales and the construct of acculturation are needed to further advance knowledge in this promising field. Operational research is also needed to identify the optimal peer educator characteristics, the type of training that they should receive, the client loads and dosage (ie, frequency and amount of contact needed between peer educator and client), and the best educational approaches and delivery settings.