Outcomes and costs of community health worker interventions: a systematic review

Implementation of Community Health Worker Support for Tobacco Cessation: A Mixed-Methods Study

OBJECTIVE

Adults with serious mental illness have high rates of tobacco use disorder and underuse pharmacotherapy for tobacco cessation. In a previous randomized controlled trial, participants receiving community health worker (CHW) support and education for their primary care providers (PCPs) had higher tobacco abstinence rates at 2 years, partly because of increased initiation of tobacco-cessation pharmacotherapy. The authors aimed to determine the association between CHW-participant engagement and tobacco abstinence outcomes.

METHODS

The authors conducted a secondary, mixed-methods analysis of 196 participants in the trial's intervention arm. Effects of the number and duration of CHW visits, number of smoking-cessation group sessions attended, and number of CHW-attended PCP visits on initiation of tobacco-cessation pharmacotherapy and tobacco abstinence were modeled via logistic regression. Interviews with 12 CHWs, 17 patient participants, and 17 PCPs were analyzed thematically.

RESULTS

Year 2 tobacco abstinence was significantly associated with CHW visit number (OR=1.85, 95% CI=1.29-2.66), visit duration (OR=1.51, 95% CI=1.00-2.28), and number of group sessions attended (OR=1.85, 95% CI=1.33-2.58); effects on pharmacotherapy initiation were similar. One to three CHW visits per month across 2 years were optimal for achieving abstinence. Interviews identified CHW-patient engagement facilitators (i.e., trust, goal accountability, skills reinforcement, assistance in overcoming barriers to treatment access, and adherence). Training and supervision facilitated CHW effectiveness; barriers included PCPs' and care teams' limited understanding of the CHW role.

CONCLUSIONS

Greater CHW-participant engagement, within feasible dose ranges, was associated with tobacco abstinence among adults with serious mental illness. Implementation of CHW interventions may benefit from further CHW training and integration within clinical teams.

Roadmap for Health Equity: Understanding the Importance of Community-Engaged Research

Achieving health equity in stroke prevention, treatment, and recovery has continued to be a significant challenge. This article highlights the significance of health equity and the role of community-engaged research in addressing stroke disparities, including concepts around health equity as the fair and just opportunity for everyone to attain their highest level of health and well-being. Social determinants impact stroke incidence, prevalence, morbidity, and mortality, which emphasizes the importance of intersectionality and social risk-informed care. A comprehensive roadmap for achieving health equity in stroke through the integration of community-engaged research is presented, including the necessity of community involvement in all aspects of research. Community is defined beyond geographic boundaries, highlighting the importance of shared identities and values. The process of developing targeted goals with communities toward social justice reform is reviewed, including an evolved community engagement framework, emphasizing the need for training to inform about issues and collaborative leadership models. Several stroke disparities intervention studies are highlighted, demonstrating the successful incorporation of community engagement into intervention design and intervention platforms. For enhanced engagement, the use of community health workers and better integration of community health worker models are essential. There may be a critical need for community engagement to optimize inclusion in clinical trials. Finally, acknowledging the complexities of research around decreasing stroke disparities in prevention, treatment, and recovery, this article delves into a framework for understanding the mechanisms by which interventions affect inequities and the need for multifaceted solutions with the community as a partner. Highlighting the roadmap to health equity, this research argues that community engagement is an integral component at all steps along the road to achieving optimum brain health through equitable stroke treatment, prevention, and recovery.

"Veteran to Veteran, There's Automatically a Trust": A Qualitative Study of Veterans' Experiences in a Peer Health-Coaching Program for Hypertension

Introduction

Veteran peer Coaches Optimizing and Advancing Cardiac Health was an randomized controlled trial (RCT) to test the effectiveness of a peer support intervention to reduce blood pressure among veterans with hypertension and 1 or more cardiovascular risks. The authors studied participant perceptions of the intervention, including barriers and facilitators to participation, factors promoting behavior change, and disease self-management practices.

Methods

The authors enrolled participants at their exit visit for the Veteran peer Coaches Optimizing and Advancing Cardiac Health study. Participants received primary care at the Veterans Administration healthcare system and had multiple cardiovascular disease risks, including a diagnosis of hypertension. The authors conducted a qualitative content analysis of semistructured interviews about their experience with the Veteran peer Coaches Optimizing and Advancing Cardiac Health intervention.

Results

Interview participants (N=29) were aged 60 years on average (SD=8.6), were 71% male, and were 55% White. They had mean systolic blood pressure of 138 mmHg (SD=18) at baseline. Authors identified themes across 3 major categories, which follow the general progression of the intervention: participation, relationship building, and behavior change. Scheduling flexibility, shared identity and experiences with the coach, acquisition of new knowledge and skills, and goal setting were important determinants of participants' experiences in the program. In the participation category, the themes were scheduling, visit modality, life circumstances, and staffing. In the relationship category, the themes were the coach's professional role, shared identity and experiences, and social support. In the behavior change category, the themes were memory, attention, and decision processes; goal setting; skills and knowledge; and environmental context and resources. Authors report differences across patients varying by blood pressure reduction after the intervention and number of coaching visits.

Conclusions

Participants generally reported positive experiences in a peer support intervention for veterans with hypertension. Participant perceptions provide important insights into the intervention design and implementation. These findings may inform future implementation of peer support among veterans in hypertension and chronic disease self-management more generally.

Trial registration

This study was registered at Clinicaltrial.gov with the identifier NCT02697422.

Equitable Care for Hypertension: Blood Pressure and Patient-Reported Outcomes of the RICH LIFE Cluster Randomized Trial

BACKGROUND

Disparities in hypertension control are well documented but underaddressed.

METHODS

RICH LIFE (Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone) was a 2-arm, cluster randomized trial comparing the effect on blood pressure (BP) control (systolic BP ≤140 mm Hg, diastolic BP ≤90 mm Hg), patient activation, and disparities in BP control of 2 multilevel interventions, standard of care plus (SCP) and collaborative care/stepped care (CC/SC). SCP included BP measurement standardization, audit and feedback, and equity-leadership training. CC/SC added roles to address social or medical needs. Primary outcomes were BP control and patient activation at 12 months. Generalized estimating equations and mixed-effects regression models with fixed effects of time, intervention, and their interaction compared change in outcomes at 12 months from baseline.

RESULTS

A total of 1820 adults with uncontrolled BP and ≥1 other risk factors enrolled in the study. Their mean age was 60.3 years, and baseline BP was 152.3/85.5 mm Hg; 59.4% were women; 57.4% were Black, 33.2% were White, and 9.4% were Hispanic; 74% had hyperlipidemia; and 45.1% had type 2 diabetes. CC/SC did not improve BP control rates more than SCP. Both groups achieved statistically and clinically significant BP control rates at 12 months (CC/SC: 57.3% [95% CI, 52.7%-62.0%]; SCP: 56.7% [95% CI, 51.9%-61.5%]). Pairwise comparisons between racial and ethnic groups showed overall no significant differences in BP control at 12 months. Patients with coronary heart disease showed greater achievement of BP control in CC/SC than in SCP (64.0% [95% CI, 54.1%-73.9%] versus 50.8% [95% CI, 42.6%-59.0%]; P=0.04), as did patients in rural areas (67.3% [95% CI, 49.8%-84.8%] versus 47.8% [95% CI, 32.4%-63.2%]; P=0.01). Individuals in both arms experienced statistically and clinically significant reductions in mean systolic BP (CC/SC: -13.8 mm Hg [95% CI, -15.2 to -12.5]; SCP: -14.6 mm Hg [95% CI, -15.9 to -13.2]) and diastolic BP (CC/SC: -6.9 mm Hg [95% CI, -7.8 to -6.1]; SCP: -5.5 mm Hg [95% CI, -6.4 to -4.6]) over time. The difference in diastolic BP reduction between CC/SC and SCP over time was statistically significant (-1.4 mm Hg [95% CI, -2.6 to -0.2). Patient activation did not differ between arms. CC/SC showed greater improvements in patient ratings of chronic illness care (Patient Assessment of Chronic Illness Care score) over 12 months (0.12 [95% CI, 0.02-0.22]).

CONCLUSIONS

Adding a collaborative care team to enhanced standard of care did not improve BP control but did improve patient ratings of chronic illness care.

Creating a community advisory board for pediatric bladder health

Introduction

Pediatric lower urinary tract symptoms (LUTS) are highly prevalent in neurologically healthy school-aged children. However, no evidence-based programs exist to prevent or treat LUTS in the community setting. To address this, we established the first community advisory board (CAB) that aims to identify individual and societal structures impacting pediatric bladder health in Northern California's Bay Area and co-design culturally relevant bladder health interventions.

Methods

Probability and non-probability sampling methods were used to recruit community stakeholders to the CAB. Our final CAB comprised of two parents, two community health workers, one educator, one pediatric urology registered nurse, and one pediatrician. The CAB met quarterly during the 1-year study period.

Results

Bi-directional feedback identified community-level barriers to bladder health, particularly in the school environment, and the need for tailored resources to teach children and families about healthy bladder behaviors.

Discussion

The CAB co-designed school-based bladder health interventions, including bladder health posters, and provided feedback on three school-based research study proposals. The CAB will continue to guide and inform future community-engaged research efforts.

Engaging Community Health Workers in Primary Care Practices: Provider Understanding of Roles, Benefits, and Barriers

Community health workers (CHWs) are increasingly addressing health disparities in primary care settings; however, there is little information about how primary care practitioners (PCPs) interact with CHWs or perceive CHW roles. We examined PCP engagement with CHWs in adult primary care settings. Overall, 55% of 1504 PCPs reported working with CHWs; involvement with CHWs differed by some PCP demographic and practice-related factors. While PCPs perceived CHWs as engaging in most nationally endorsed CHW roles, they identified several barriers to integrating CHWs into care teams. Findings can inform ongoing efforts to advance health equity through integrating CHWs into primary care practices.

Evaluating Effects of Multilevel Interventions on Disparity in Health and Healthcare Decisions

In this paper, we introduce an analytic approach for assessing effects of multilevel interventions on disparity in health outcomes and health-related decision outcomes (i.e., a treatment decision made by a healthcare provider). We outline common challenges that are encountered in interventional health disparity research, including issues of effect scale and interpretation, choice of covariates for adjustment and its impact on effect magnitude, and the methodological challenges involved with studying decision-based outcomes. To address these challenges, we introduce total effects of interventions on disparity for the entire sample and the treated sample, and corresponding direct effects that are relevant for decision-based outcomes. We provide weighting and g-computation estimators in the presence of study attrition and sketch a simulation-based procedure for sample size determinations based on precision (e.g., confidence interval width). We validate our proposed methods through a brief simulation study and apply our approach to evaluate the RICH LIFE intervention, a multilevel healthcare intervention designed to reduce racial and ethnic disparities in hypertension control.

Implementation of Community Health Worker Support for Tobacco Cessation: A Mixed-Methods Study

Objective

Adults with serious mental illness have high tobacco use disorder rates and underutilization of first-line tobacco cessation pharmacotherapy. In a randomized trial, participants offered community health worker (CHW) support and primary care provider (PCP) education had higher tobacco abstinence rates at two years, partly through increased tobacco cessation pharmacotherapy initiation. This study determined the association between participant-CHW engagement and tobacco abstinence outcomes.

Methods

This was a secondary, mixed-methods analysis of 196 participants in the trial's intervention arm. Effects of CHW visit number and duration, CHW co-led smoking cessation group sessions attended, and CHW-attended PCP visit number on tobacco use disorder pharmacotherapy initiation and tobacco abstinence were modeled using logistic regression. Interviews with 12 CHWs, 16 participants, and 17 PCPs were analyzed thematically.

Results

Year-two tobacco abstinence was associated with CHW visit number (OR=1.85, 95% CI=[1.29, 2.66]) and duration (OR=1.85, 95% CI=[1.33, 2.58]) and number of groups attended (OR=1.51, 95% CI=[1.00, 2.28]); effects on pharmacotherapy initiation were similar. 1-3 CHW visits per month over two years was optimal for achieving abstinence. Interviews identified engagement facilitators, including CHWs establishing trust, providing goal accountability, skills reinforcement, and assistance overcoming barriers to treatment access and adherence related to social determinants of health and illness factors. Robust training and supervision facilitated CHW effectiveness. Barriers included PCPs' and care teams' limited understanding of the CHW role.

Conclusions

Feasible CHW engagement was associated with tobacco abstinence in adults with serious mental illness. CHW implementation may benefit from promoting CHW training and integration within clinical teams.

Knowledge, skills, and training of community health workers to contribute to interprofessional education: a scoping review

A scoping review of 32 publications was conducted with the aim of mapping literature to determine what is known about the knowledge, skills, and training of community health workers that could contribute to interprofessional education. Interprofessional education, as a pedagogical approach, prepares health professions students to serve patients in collaboration with other health professionals to improve patient outcomes. All over the world, the role of community health workers is vital for its support of community service and community health outcomes. However, no evidence could be found on the knowledge, skills, and training of community health workers that contribute to interprofessional education. The knowledge that community health workers need to contribute to interprofessional education, as reported by the literature, relates to case management, communication, health education, recordkeeping and referrals. Skills, such as critical thinking, interprofessional collaboration, and various clinical procedures, were noted. Training approaches reported included the use of technology such as mobile phones and web-based learning. The scoping review improved our understanding of the knowledge, skills, and training of community health workers that could contribute to interprofessional education. Applying a fit-for-purpose approach, and building on existing knowledge, skills, and training, could fast-track the contribution of community health workers to interprofessional education.

Impact of community health workers on quality of life in adolescents and young adults with sickle cell disease: The SHIP-HU study

Health-related quality of life (HRQoL) is an important outcome for patients with sickle cell disease (SCD). It is often poor compared with other chronic medical conditions or measured as a multidomain disease-specific construct. We previously reported outcomes in the Start Healing in Patients with Hydroxyurea (SHIP-HU) randomized controlled trial in adolescents and adults with SCD at six clinical sites. Besides the primary outcomes, we also measured HRQoL as a secondary outcome. Patients in the intervention arm were each assigned community health workers (CHWs) who provided case management services. CHW services were independent of medical management, and medical managers were blinded to the study arm. Patients in the control arm received only standard of care. We hypothesized that having a CHW would improve HRQoL in patients enrolled in SHIP-HU. We did not find significant differences between domains of HRQoL in the two study arms. Possible explanations include selection bias of enrolled versus unenrolled patients, selection bias of sites, medical providers and medical management, enforced blinding, and a lack of cooperation between medical managers and CHWs. The importance of CHWs and HRQoL is nonetheless recognized based on the literature. Future interventions on HRQoL in SCD should consider alternative study designs and multimodal interventions.

Community Health Worker Interventions for Men: A Scoping Review Using the RE-AIM Framework

INTRODUCTION

Community health workers (CHWs) are health promotion specialists who are trusted members of the community served and have a close understanding of the community's needs and values. CHWs are a cost-effective and scalable workforce to promote health among men through tailored approaches. The purpose of the present review was to use the RE-AIM Framework to assess design, implementation, and outcomes of CHW-implemented health promotion efforts tailored for men to provide recommendations for future efforts.

METHODS

The protocol was pre-registered with PROSPERO. The primary inclusion criteria were that the interventions were (a) implemented at least partially by CHWs, (b) conducted only among men, and (c) designed to improve a health-related outcome. PubMed, EMBASE, PsycINFO, CINAHL, Web of Science, and Global Index Medicus were searched using a librarian-generated search strategy. In all, 1,437 articles were uploaded to Rayyan and two reviewers blindly reviewed each article for inclusion. A total of 24 articles met the inclusion criteria.

RESULTS

Most interventions (a) targeted men under 50 years, (b) were conducted among a subset of underserved men, (c) improved health outcomes, (d) community-based and informed, (e) atheoretical, and (f) had satisfactory retention rates. The roles and responsibilities of CHWs were varied. Attention was given to training of CHWs, but limited attention was given to how/if the CHWs were supervised.

DISCUSSION

CHW-implemented interventions can improve health outcomes among men. Opportunities exist to build on past interventions, such as addressing mental health and incorporating prosocial aspects of masculinity. The results have implications for designing similar interventions.

Preventing diabetes in Latino families: A protocol for a randomized control trial

BACKGROUND

Latino families are disproportionately affected by type 2 diabetes (T2D) and lifestyle intervention is the first-line approach for preventing T2D. The purpose of this study is to test the efficacy of a culturally-grounded lifestyle intervention that prioritizes health promotion and diabetes prevention for Latino families. The intervention is guided by a novel Family Diabetes Prevention Model, leveraging the family processes of engagement, empowerment, resilience, and cohesion to orient the family system towards health.

METHOD

Latino families (N = 132) will be recruited and assessed for glucose tolerance as measured by an Oral Glucose Tolerance Test (OGTT) and General and Weight-Specific Quality of Life (QoL) at baseline, four months, and 12 months. All members of the household age 10 and over will be invited to participate. Families will be randomized to the intervention group or a control group (2:1). The 16-week intervention includes weekly nutrition and wellness classes delivered by bilingual, bicultural Registered Dietitians and community health educators at a local YMCA along with two days/week of supervised physical activity classes and a third day of unsupervised physical activity. Control families will meet with a physician and a Registered Dietitian to discuss the results of their metabolic testing and recommend lifestyle changes. We will test the efficacy of a family-focused diabetes prevention intervention for improving glucose tolerance and increasing QoL and test for mediators and moderators of long-term changes.

CONCLUSION

This study will provide much needed data on the efficacy of a family-focused Diabetes Prevention Program among high-risk Latino families.

NEW Soul in the neighborhood-reach and effectiveness of a dissemination and implementation feasibility study

Dissemination and implementation (D&I) studies of dietary interventions for African Americans are limited. Restaurants may be an innovative setting to deliver dietary interventions. Purpose: Assess weight loss, self-efficacy for healthy eating, diet quality, and quality of life in African Americans in two groups: virtual synchronous and virtual asynchronous. Guided by RE-AIM, the Nutritious Eating with Soul @ Rare Variety Café Feasibility study included nutrition education, accountability partners for support, and cooking demonstrations led by a community health worker and was delivered across two cohorts in a non-randomized design. The intervention was conducted over 12 consecutive weekly classes. Due to the COVID-19 pandemic, intervention delivery was online. African Americans between 18-65 years old with overweight/obesity, not currently following a plant-based diet or taking medications to control diabetes, and living in a southeastern city were recruited. Participants completed in-person weight assessments and online surveys at baseline and post-intervention. Linear mixed models analyzed changes in outcomes and differences in 3-month outcomes between groups. All models controlled for age and sex. Regarding Reach, 199 participants expressed interest, and 60 enrolled. Among the full sample, participants decreased body weight -2.6 ± 0.5 kg (p < .0001) and increased self-efficacy 1.6 ± 0.7 points (p = .03). No differences in 3-month outcomes between groups were observed. This D&I feasibility study successfully recruited participants during the COVID-19 pandemic and produced significant results. The successful online intervention delivery compared to in-person suggests the potential for greater D&I in vegan soul food restaurants. As restrictions are loosened, future studies will test in-person delivery.

Evaluating the impact of community health worker certification in Massachusetts: Design, methods, and anticipated results of the Massachusetts community health worker workforce survey

Background

Professional certification of community health workers (CHWs) is a debated topic. Although intended to promote CHWs, certification may have unintended impacts given the grassroots nature of the workforce. As such, both intended effects and unintended adverse effects should be carefully evaluated. However, there is a lack of published literature describing such effective evaluations with a robust methodology. In this methods paper, we describe a key component of evaluating CHW certification in Massachusetts-the Massachusetts CHW Workforce Survey.

Methods

Design of the surveys was informed by a program theory framework that delineated both positive and negative potential impacts of Massachusetts CHW certification on CHWs and CHW employers. Using this framework, we developed measures of interest and preliminary CHW and CHW employer surveys. To validate and refine the surveys, we conducted cognitive interviews with CHWs and CHW employers. We then finalized survey tools with input from state and national stakeholders, CHWs, and CHW employers. Our sample consisted of three frames based on where CHWs are most likely to be employed in Massachusetts: acute care hospitals, community-based organizations, and ambulatory care health centers, primarily community health centers and federally qualified health centers. We then undertook extensive outreach efforts to determine whether each organization employed CHWs and to obtain CHW and CHW employer contact information. Our statistical analysis of the data utilized inverse probability score weighting accounting for organizational, site, and individual response.

Anticipated results

Wave one of the survey was administered in 2016 prior to launch of Massachusetts CHW certification and wave two in 2021. We report descriptive statistics of the three sample frames and response rates of each survey for each wave. Further, we describe select anticipated results related to certification, including outcomes of the program theory framework.

Conclusions

The Massachusetts CHW Workforce Survey is the culmination of 5 years of effort to evaluate the impact of CHW certification in Massachusetts. Our comprehensive description of our methodology addresses an important gap in CHW research literature. The rigorous design, administration, and analysis of our surveys ensure our findings are robust, valid, and replicable, which can be leveraged by others evaluating the CHW workforce.

Design, implementation, and evaluation of community health worker training programs in Latinx communities: A scoping review

This review examines the current reporting trends of program design, implementation, and evaluation of training programs for Latinx community health workers. Five scholarly databases were searched using a scoping review methodology to identify articles describing training programs for Latinx community health workers. The timeframe was 2009 to 2021. We identified 273 articles, with 59 meeting inclusion criteria. Researchers thematically coded the articles to identify reporting strategies related to program design, implementation, and evaluation. Findings suggest a lack of consensus in reporting elements critical to program resources, instructor qualifications, frequency and length of training implementation, theoretical background, and pedagogical tools associated with the training program. We offer detailed reporting recommendations of community health worker training programs to support the consistent dissemination of promising practices and facilitate the initiation of new programs for Latinx community health workers.

Community Health Workers in Schools: A Systematic Review

BACKGROUND

Community health workers (CHWs) are trusted community members who provide health education and care. However, no consensus exists regarding whether community health worker-based interventions are effective within the school setting.

OBJECTIVE

To determine outcomes and best practices of school-based community health worker interventions.

DATA SOURCES

PubMed, CINAHL, and SCOPUS databases.

STUDY ELIGIBILITY CRITERIA

This systematic literature review examined articles that described an intervention led by community health workers, targeted children and/or parents, and took place primarily within a Kindergarten-12th grade school setting. Articles were excluded if they described an intervention outside the United States.

PARTICIPANTS

Community health workers, children, and/or their parents INTERVENTIONS: School-based community health worker programs RESULTS: Of 1875 articles identified, 13 met inclusion criteria and were included in the final analysis. Of these, 5 described a statistically significant primary outcome. Seven articles provided details regarding community health worker recruitment, training, and roles that would enable reproduction of the intervention.

LIMITATIONS

This review focused on interventions in the United States. Bias of individual studies had a wide range of scores (9-21). Heterogeneity of studies also precluded a meta-analysis of primary outcomes.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

The utilization of Community health workers in school-based interventions for children and/or parents is promising. This review identified a lack of detail and uniformity in program presentation, specifically with Community health worker recruitment, training, and roles. A standardized reporting mechanism for Community health worker interventions in schools would better allow for reproducibility and scalability of existing studies.

Barriers and Facilitators to Community Health Worker Outreach and Engagement in Detroit, Michigan: A Qualitative Study

An effective approach to engaging populations who face health care access barriers is support from community health workers (CHWs). There is little research, however, on specific barriers and facilitators related to two key areas of CHW practice: outreach, defined as the ability to make any initial contact with the priority population, and engagement, defined as the ability to continue to work with the priority population after initial contact is made. The current qualitative study is ancillary to a randomized evaluation of a CHW-led program for Medicaid Health Plan enrollees. Implementation experiences with outreach and engagement led the evaluators to develop the current study in which health plan and nonhealth plan CHWs (n = 12) serving low-income, predominantly Black populations in Detroit participated in qualitative semistructured interviews to elucidate barriers and facilitators to outreach and engagement. All audio recordings were transcribed verbatim. The study team used inductive qualitative data analysis techniques. Barriers to outreach included inaccurate contact information and mistrust. Barriers to engagement included lack of ability to provide needed resources, leading to hopelessness and diminished trust, and discontinuity of services due to eligibility changes and terminated programs. Facilitators included adapting outreach schedules and strategies to community needs, availability of resources, and relational strategies that leveraged CHW social proximity. Further research should systematically investigate the relative success of different CHW-led outreach and engagement strategies for specific populations so as to better design and implement CHW programs.

Needs assessment and planning for a clinic-community-based implementation program for hypertension control among blacks in New York City: a protocol paper

BACKGROUND

Hypertension (HTN) control among Blacks in the USA has become a major public health challenge. Barriers to HTN control exist at multiple levels including patient, physician, and the health system. Patients also encounter significant community-level barriers, such as poor linkage to social services that impact health (unstable housing, food access, transportation). We describe a multi-component needs assessment to inform the development, implementation, and evaluation of a program to improve HTN management within a large healthcare system in New York City (NYC).

METHODS

Guided by the Community-Based Participatory Research (CBPR) and Consolidated Framework for Implementation Research (CFIR) frameworks, data will be collected from four main sources: (1) quantitative surveys with health systems leadership, providers, and staff and with community-based organizations (CBOs) and faith-based organizations (FBOs); (2) qualitative interviews and focus groups with health systems leadership, providers, and staff and with CBOs and FBOs; (3) NYC Community Health Survey (CHS); and (4) New York University (NYU) Health system Epic Electronic Health Record (EHR) system. The data sources will allow for triangulation and synthesis of findings.

DISCUSSION

Findings from this comprehensive needs assessment will inform the development of a clinic-community-based practice facilitation program utilizing three multi-level evidence-based interventions (nurse case management, remote blood pressure (BP) monitoring, and social determinants of health (SDoH) support) integrated as a community-clinic linkage model for improved HTN control in Black patients. Integration of stakeholders' priorities, perspectives, and practices into the development of the program will improve adoption, sustainability, and the potential for scale-up.

TRIAL REGISTRATION

NCT05208450; registered on January 26, 2022.

Predictors and Effects of Participation in Peer Support: A Prospective Structural Equation Modeling Analysis

BACKGROUND

Peer support provides varied health benefits, but how it achieves these benefits is not well understood.

PURPOSE

Examine a) predictors of participation in peer support interventions for diabetes management, and b) relationship between participation and glycemic control.

METHODS

Seven peer support interventions funded through Peers for Progress provided pre/post data on 1,746 participants' glycemic control (hemoglobin A1c), contacts with peer supporters as an indicator of participation, health literacy, availability/satisfaction with support for diabetes management from family and clinical team, quality of life (EQ-Index), diabetes distress, depression (PHQ-8), BMI, gender, age, education, and years with diabetes.

RESULTS

Structural equation modeling indicated a) lower levels of available support for diabetes management, higher depression scores, and older age predicted more contacts with peer supporters, and b) more contacts predicted lower levels of final HbA1c as did lower baseline levels of BMI and diabetes distress and fewer years living with diabetes. Parallel effects of contacts on HbA1c, although not statistically significant, were observed among those with baseline HbA1c values > 7.5% or > 9%. Additionally, no, low, moderate, and high contacts showed a significant linear, dose-response relationship with final HbA1c. Baseline and covariate-adjusted, final HbA1c was 8.18% versus 7.86% for those with no versus high contacts.

CONCLUSIONS

Peer support reached/benefitted those at greater disadvantage. Less social support for dealing with diabetes and higher PHQ-8 scores predicted greater participation in peer support. Participation in turn predicted lower HbA1c across levels of baseline HbA1c, and in a dose-response relationship across levels of participation.

COVID-19 - an opportunity to improve access to primary care through organizational innovations? A qualitative multiple case study in Quebec and Nova Scotia (Canada)

BACKGROUND

COVID-19 catalyzed a rapid and substantial reorganization of primary care, accelerating the spread of existing strategies and fostering a proliferation of innovations. Access to primary care is an essential component of a healthcare system, particularly during a pandemic. We describe organizational innovations aiming to improve access to primary care and related contextual changes during the first 18 months of the COVID-19 pandemic in two Canadian provinces, Quebec and Nova Scotia.

METHODS

We conducted a multiple case study based on 63 semi-structured interviews (n = 33 in Quebec, n = 30 in Nova Scotia) conducted between October 2020 and May 2021 and 71 documents from both jurisdictions. We recruited a diverse range of provincial and regional stakeholders (e.g., policy-makers, decision-makers, family physicians, nurses) involved in reorganizing primary care during the COVID-19 pandemic using purposeful sampling (e.g., based on role, region). Interviews were transcribed verbatim and thematic analysis was conducted in NVivo12. Emerging results were discussed by team members to identify salient themes and organized into logic models.

RESULTS

We identified and analyzed six organizational innovations. Four of these - centralized public online booking systems, centralized access centers for unattached patients, interim primary care clinics for unattached patients, and a community connector to health and social services for older adults - pre-dated COVID-19 but were accelerated by the pandemic context. The remaining two innovations were created to specifically address pandemic-related needs: COVID-19 hotlines and COVID-dedicated primary healthcare clinics. Innovation spread and proliferation was influenced by several factors, such as a strengthened sense of community amongst providers, decreased patient demand at the beginning of the first wave, renewed policy and provider interest in population-wide access (versus attachment of patients only), suspended performance targets (e.g., continuity ≥80%) in Quebec, modality of care delivery, modified fee codes, and greater regional flexibility to implement tailored innovations.

CONCLUSION

COVID-19 accelerated the uptake and creation of organizational innovations to potentially improve access to primary healthcare, removing, at least temporarily, certain longstanding barriers. Many stakeholders believed this reorganization would have positive impacts on access to primary care after the pandemic. Further studies should analyze the effectiveness and sustainability of innovations adapted, developed, and implemented during the COVID-19 pandemic.

Impact on Health Care Utilization and Costs of a Medicaid Community Health Worker Program in Detroit, 2018-2020: A Randomized Program Evaluation

Objectives. To compare health care utilization and costs between beneficiaries randomly assigned to usual services versus a community health worker (CHW) program implemented by 3 Medicaid health plans. Methods. From February 2018 to June 2019, beneficiaries residing in Detroit, Michigan's Cody Rouge neighborhood with more than 3 emergency department (ED) visits or at least 1 ambulatory care‒sensitive hospitalization in the previous 12 months were randomized. CHWs reached out to eligible beneficiaries to assess their needs and link them to services. We compared ED and ambulatory care visits, hospitalizations, and related costs over 12 months. Results. In intention-to-treat analyses among 2457 beneficiaries, the 1389 randomized to the CHW program had lower adjusted ratios of ED visits (adjusted rate ratio [ARR] = 0.96; P < .01) and ED visit costs (ARR = 0.96; P < .01), but higher adjusted ratios of ambulatory care costs (ARR = 1.15; P < .01) and no differences in inpatient or total costs compared with the usual-care group. Conclusions. Initial increases in ambulatory care use from effective programs for underserved communities may mitigate savings from decreased acute care use. Longer-term outcomes should be followed to assess potential cost savings from improved health. Trial Registration: ClinicalTrials.gov identifier: NCT03924713. (Am J Public Health. 2022;112(5):766-775. https://doi.org/10.2105/AJPH.2021.306700).

“Many people have no idea”: a qualitative analysis of healthcare barriers among Yazidi refugees in the Midwestern United States

Background

The COVID-19 pandemic has shed new light on inequities in healthcare access faced by immigrant and refugee communities. To address ongoing disparities, there is an urgent need for ecological approaches to better understand the barriers that hinder and resources that facilitate access to healthcare. This study investigates barriers to healthcare system access faced by Yazidi refugees in the Midwestern United States.

Methods

Informed by the Interpretative Phenomenological Approach, three focus group meetings with a community advisory board were conducted between September 2019 and January 2020. The nine-member focus group included social workers, healthcare providers, and members of the Yazidi community. Meeting recordings were transcribed into English, coded for themes, and validated.

Results

We describe themes related to specific barriers to healthcare access; analyze the influence of relational dynamics in the focus group; explore experiential themes related to healthcare access in the Yazidi community, and finally interpret our findings through a social-ecological lens.

Conclusion

Community agencies, healthcare organizations, policymakers, and other stakeholders must work together to develop strategies to reduce systemic barriers to equitable care. Community representation in priority-setting and decision-making is essential to ensure relevance, acceptability, and utilization of developed strategies.

Digital Health-Enabled Community-Centered Care: Scalable Model to Empower Future Community Health Workers Using Human-in-the-Loop Artificial Intelligence

Digital health-enabled community-centered care (D-CCC) represents a pioneering vision for the future of community-centered care. D-CCC aims to support and amplify the digital footprint of community health workers through a novel artificial intelligence-enabled closed-loop digital health platform designed for, and with, community health workers. By focusing digitalization at the level of the community health worker, D-CCC enables more timely, supported, and individualized community health worker-delivered interventions. D-CCC has the potential to move community-centered care into an expanded, digitally interconnected, and collaborative community-centered health and social care ecosystem of the future, grounded within a robust and digitally empowered community health workforce.

Latino Health Access: Comparative Effectiveness of a Community-Initiated Promotor/a-Led Diabetes Self-management Education Program

Community-initiated health interventions fill important gaps in access to health services. This study examines the effectiveness of a community-initiated health intervention to improve diabetes management in an underserved community of color using a retrospective observational study, comparing a study intervention, the Latino Health Access Diabetes Self-Management Program (LHA-DSMP), with usual care. The LHA-DSMP is a 12-session community health worker (promotor/a) intervention developed and implemented by a community-based organization in a medically underserved area. Usual care was delivered at a federally qualified health center in the same geographic area. Participants were 688 predominantly Spanish-speaking Latinx adults with type 2 diabetes. The main outcome was change in glycemic control (glycosylated hemoglobin [HbA1c]) from baseline to follow-up. At 14-week follow-up, mean (95% CI) HbA1c decrease was -1.1 (-1.3 to -0.9; P < .001) in the LHA-DSMP cohort compared with -0.3 (-0.4 to -0.2; P < .001) in the comparison cohort. Controlling for baseline differences between cohorts, the adjusted difference-in-differences value in HbA1c was -0.6 (-0.8 to -0.3; P < .001) favoring the LHA-DSMP. A community-initiated promotor/a-led educational program for diabetes self-management is associated with clinically significant improvement in blood sugar control, superior to what was observed with usual medical care.

The Feasibility of a Primary Care Based Navigation Service to Support Access to Health and Social Resources: The Access to Resources in the Community (ARC) Model

INTRODUCTION

We established a patient centric navigation model embedded in primary care (PC) to support access to the broad range of health and social resources; the Access to Resources in the Community (ARC) model.

METHODS

We evaluated the feasibility of ARC using the rapid cycle evaluations of the intervention processes, patient and PC provider surveys, and navigator log data. PC providers enrolled were asked to refer patients in whom they identified a health and/or social need to the ARC navigator.

RESULTS

Participants: 26 family physicians in four practices, and 82 of the 131 patients they referred. ARC was easily integrated in PC practices and was especially valued in the non-interprofessional practices. Patient overall satisfaction was very high (89%). Sixty patients completed the post-intervention surveys, and 33 reported accessing one or more service(s).

CONCLUSION

The ARC Model is an innovative approach to reach and support a broad range of patients access needed resources. The Model is feasible and acceptable to PC providers and patients, and has demonstrated potential for improving patients' access to health and social resources. This study has informed a pragmatic randomized controlled trial to evaluate the ARC navigation to an existing web and telephone navigation service (Ontario 211).

Evaluating the association of state regulation of community health workers on adoption of standard roles, skills, and qualities by employers in select states: a mixed methods study

BACKGROUND

The occupation of community health worker (CHW) has evolved to support community member navigation of complex health and social systems. The U.S. Bureau of Labor Statistics formally recognized the occupation of community health worker (CHW) in 2009. Since then, various national and state efforts to professionalize the occupation have been undertaken. The Community Health Workers Core Consensus (C3) project released a set of CHW roles and competency recommendations meant to provide evidence-based standards for CHW roles across work settings. Some states have adopted the recommendations; however, there are a variety of approaches regarding the regulation of the occupation. As of 2020, 19 U.S. states have implemented voluntary statewide CHW certification programs. The purpose of this study was to explore the relationship between state regulation of CHWs and adoption of standard roles, skills, and qualities by employers in select states.

METHODS

This mixed methods study used purposive sampling of job ads for CHWs posted by employers from 2017 to 2020 in select states. Natural language processing was used to extract content from job ads and preprocess the data for statistical analysis. ANOVA, chi-square analysis, and MANOVA was used to test hypotheses related to the relationship between state regulation of CHWs and differences in skills, roles, and qualities employers seek based on seniority of state regulatory processes and employer types.

RESULTS

The mean job ads with nationally identified roles, skills, and qualities varies significantly by state policy type (F(2, 4801) = 26.21) and by employer type (F(4, 4799) = 69.08, p = 0.000).

CONCLUSIONS

Employment of CHWs is increasing to provide culturally competent care, address the social determinants of health, and improve access to health and social services for members of traditionally underserved communities. Employers in states with CHW certification programs were associated with greater adoption of occupational standards set by state and professional organizations. Wide adoption of such standards may improve recognition of the CHW workforce as a valuable resource in addressing the needs of high-need and marginalized groups.

Adding a Seat at the Table: A Case Study of the Provider's Perspective on Integrating Community Health Workers at Provider Practices in California

Blue Shield of California's Community Health Advocate Program was created to support whole person-health needs by helping individuals of all socio-economic statuses navigate and access community resources, social services, and medical systems. Blue Shield's Health Reimagined team is partnering with medical providers, community resources centers, and community partners to provide intensive person-centered and technology-enabled care to patients, ensuring social needs are met while promoting health equity. A key aspect of the Health Reimagined initiative embeds Community Health Advocates (CHAs) within physician practices serving patients using a payor-agnostic approach, by which Blue Shield aims to increase access to social services and community resources, improve health outcomes, reduce medical costs, and improve overall patient experience. The purpose of this case study is to understand the provider's perspective of embedding a CHA into the care team and the resulting impact on the practice and patients. Blue Shield also sought to identify best practices and barriers of a CHA program within primary and specialty care practices. As part of an ongoing two-year mixed-methods impact evaluation (2019–2021), 10 semi-structured interviews were conducted with a total of 18 providers and office staff at five primary care and specialty practices where CHAs have been embedded. We also conducted two focus groups with the same five CHAs at different points in time. Several themes emerged from the provider, office staff, and CHA interviews. Provider practices found great value in adding a CHA to their care team as the CHA brings flexibility and continuity to patient care. They also found that having access to a CHA with shared life experiences of the communities they served is a key component to the program's success. Providers and staff reported a new understanding of the social determinants of health that impacts a patient's wellbeing with the embedding of a CHA in the care team. Overall, practitioners expressed high satisfaction with the CHA program. During the COVID-19 pandemic, CHAs have been critically important in care, as social needs have increased, and resources have shifted. The CHA program is constantly adapting to address challenges faced by all stakeholders and applying new knowledge to ensure best practices are implemented within the CHA program.

A randomised controlled provider-blinded trial of community health workers in sickle cell anaemia: effects on haematologic variables and hydroxyurea adherence

Hydroxyurea (hydroxycarbamide) (HU) for sickle cell anaemia (SCA) is underutilised. Case management is an evidence-based health management strategy and in this regard patient navigators (PNs) may provide case management for SCA. We hypothesised that HU-eligible patients exposed to PNs would have improved indicators of starting HU and HU adherence. We randomised 224 HU-eligible SCA adults into the Start Healing in Patients with Hydroxyurea (SHIP-HU) Trial. All patients received care from trained physicians using standardised HU prescribing protocols. Patients in the Experimental arm received case management and education from PNs through multiple contacts. All other patients were regarded as the Control arm and received specialty care alone. Study physicians were blinded to the study arms and did not interact with PNs. At baseline, 6 and 12 months we assessed and compared laboratory parameters and HU adherence indicators. Experimental patients had higher 6-month mean fetal haemoglobin (HbF) levels than controls. But at 12 months, mean HbF was similar, as were white blood cell count, absolute neutrophil count, total haemoglobin, platelet count and mean corpuscular volume. At 12 months there were fewer experimental patients missing HU doses than controls (mean 1·8 vs. 4·5, P = 0·0098), and more recent HU prescriptions filled than for controls (mean 53·8 vs. 92 days, median 27·5 vs. 62 days, P = 0·0082). Mean HU doses were largely similar. We detected behavioural improvements in HU adherence but no haematological improvements by adding PNs to specialty care.

Resource Brokering: Efforts to Assist Patients With Housing, Transportation, and Economic Needs in Primary Care Settings

PURPOSE

Clinicians and policy makers are exploring the role of primary care in improving patients' social conditions, yet little research examines strategies used in clinical settings to assist patients with social needs.

METHODS

Study used semistructured interviews with leaders and frontline staff at 29 diverse health care organizations with active programs used to address patients' social needs. Interviews focused on how organizations develop and implement case management-style programs to assist patients with social needs including staffing, assistance intensity, and use of referrals to community-based organizations (CBOs).

RESULTS

Organizations used case management programs to assist patients with social needs through referrals to CBOs and regular follow-up with patients. About one-half incorporated care for social needs into established case management programs and the remaining described standalone programs developed specifically to address social needs independent of clinical needs. Referrals were the foundation for assistance and included preprinted resource lists, patient-tailored lists, and warm handoffs to the CBOs. While all organizations referred patients to CBOs, some also provided more intense services such as assistance completing patients' applications for services or conducting home visits. Organizations described 4 operational challenges in addressing patients' social needs: (1) effectively engaging CBOs; (2) obtaining buy-in from clinical staff; (3) considering patients' perspectives; and (4) ensuring program sustainability.

CONCLUSION

As the US health care sector faces pressure to improve quality while managing costs, many health care organizations will likely develop or rely on case management approaches to address patients' social conditions. Health care organizations may require support to address the key operational challenges.Visual abstract.

Expectations and needs of socially vulnerable patients for navigational support of primary health care services

BACKGROUND

Primary healthcare is the main entry to the health care system for most of the population. In 2008, it was estimated that about 26% of the population in Quebec (Canada) did not have a regular family physician. In early 2017, about 10 years after the introduction of a centralized waiting list for patients without a family physician, Québec had 25% of its population without a family physician and nearly 33% of these or 540,000, many of whom were socially vulnerable (SV), remained registered on the list. SV patients often have more health problems. They also face access inequities or may lack the skills needed to navigate a constantly evolving and complex healthcare system. Navigation interventions show promise for improving access to primary health care for SV patients. This study aimed to describe and understand the expectations and needs of SV patients.

METHODS

A descriptive qualitative study rooted in a participatory study on navigation interventions implemented in Montérégie (Quebec) addressed to SV patients. Semi-structured individual face-to-face and telephone interviews were conducted with patients recruited in three primary health care clinics, some of whom received the navigation intervention. A thematic analysis was performed using NVivo 11 software.

RESULTS

Sixteen patients living in socially deprived contexts agreed to participate in this qualitative study. Three main expectations and needs of patients for navigation interventions were identified: communication expectations (support to understand providers and to be understood by them, discuss about medical visit, and bridge the communication cap between patients and PHC providers); relational expectations regarding emotional or psychosocial support; and pragmatic expectations (information on available resources, information about the clinic, and physical support to navigate the health care system).

CONCLUSIONS

Our study contributes to the literature by identifying expectations and needs specified to SV patients accessing primary health care services, that relate to navigation interventions. This information can be used by decision makers for navigation interventions design and inform health care organizational policies.

Standardization and adaptability for dissemination of telephone peer support for high-risk groups: general evaluation and lessons learned

Beyond demonstrated effectiveness, research needs to identify how peer support can be implemented in real-world settings. Telephone peer support offers one approach to this. The purpose of this study is to evaluate telephone peer support provided by trained peer staff for high-risk groups, implemented according to key tasks or functions of the Reciprocal Peer Support model (RPS) providing both standardization and adaptability. The methods used in the study include the review of contact data for years 2015-2016 from telephone peer support services of Rutgers Health University Behavioral Health Care, serving veterans, police, mothers of children with special needs, and child protection workers; structured interviews with peer supporters and clients; and audit of case notes. Across 2015-2016, peer supporters made 64,786 contacts with a total of 5,616 callers. Adaptability was apparent in 22% of callers' relationships lasting ≤1 month and 43% ≥1 year, voicemails valued as communicating presence, 92% of callers receiving support with psychosocial issues, 65% with concrete problems, such as medical or other services, 88% receiving social support, and 88% either resolving an issue (e.g., finding employment) or making documented progress (e.g., getting professional treatment, insurance, or children's services). With the balance of standardization and adaptability provided by the RPS, telephone peer support can address diverse needs and provide diverse contact patterns, assistance, support, and benefits.

Community Health Representative Workforce: Meeting the Moment in American Indian Health Equity

In 2018, the Community Health Representative (CHR) workforce celebrated their 50th year and serve as the oldest and only federally funded Community Health Worker (CHW) workforce in the United States. CHRs are a highly trained, well-established standardized workforce serving the medical and social needs of American Indian communities. Nationally, the CHR workforce consists of ~1,700 CHRs, representing 264 Tribes. Of the 22 Tribes of Arizona, 19 Tribes operate a CHR Program and employ ~250 CHRs, equivalent to ~30% of the total CHW workforce in the state. Since 2015, Tribal CHR Programs of Arizona have come together for annual CHR Policy Summits to dialogue and plan for the unique issues and opportunities facing CHR workforce sustainability and advancement. Overtime, the Policy Summits have resulted in the Arizona CHR Workforce Movement, which advocates for inclusion of CHRs in state and national level dialogue regarding workforce standardization, certification, training, supervision, and financing. This community case study describes the impetus, collaborative process, and selected results of a 2019–2020 multi-phase CHR workforce assessment. Specifically, we highlight CHR core roles and competencies, contributions to the social determinant of health and well-being and the level to which CHRs are integrated within systems and teams. We offer recommendations for strengthening the workforce, increasing awareness of CHR roles and competencies, integrating CHRs within teams and systems, and mechanism for sustainability.

Community health worker interventions for older adults with complex health needs: A systematic review

BACKGROUND/OBJECTIVES

The number of older adults with complex health needs is growing, and this population experiences disproportionate morbidity and mortality. Interventions led by community health workers (CHWs) can improve clinical outcomes in the general adult population with multimorbidity, but few studies have investigated CHW-delivered interventions in older adults.

DESIGN

We systematically reviewed the impact of CHW interventions on health outcomes among older adults with complex health needs. We searched for English-language articles from database inception through April 2020 using seven databases. PROSPERO protocol registration CRD42019118761.

SETTING

Any U.S. or international setting, including clinical and community-based settings.

PARTICIPANTS

Adults aged 60 years or older with complex health needs, defined in this review as multimorbidity, frailty, disability, or high-utilization.

INTERVENTIONS

Interventions led by a CHW or similar role consistent with the American Public Health Association's definition of CHWs.

MEASUREMENTS

Pre-defined health outcomes (chronic disease measures, general health measures, treatment adherence, quality of life, or functional measures) as well as qualitative findings.

RESULTS

Of 5671 unique records, nine studies met eligibility criteria, including four randomized controlled trials, three quasi-experimental studies, and two qualitative studies. Target population and intervention characteristics were variable, and studies were generally of low-to-moderate methodological quality. Outcomes included mood, functional status and disability, social support, well-being and quality of life, medication knowledge, and certain health conditions (e.g., falls, cognition). Results were mixed with several studies demonstrating significant effects on mood and function, including one high-quality RCT, while others noted no significant intervention effects on outcomes.

CONCLUSION

CHW-led interventions may have benefit for older adults with complex health needs, but additional high-quality studies are needed to definitively determine the effectiveness of CHW interventions in this population. Integration of CHWs into geriatric clinical settings may be a strategy to deliver evidence-based interventions and improve clinical outcomes in complex older adults.

Evidence-Based Community Health Worker Program Addresses Unmet Social Needs And Generates Positive Return On Investment

Interventions that address socioeconomic determinants of health are receiving considerable attention from policy makers and health care executives. The interest is fueled in part by expected returns on investment. However, many current estimates of returns on investment are likely overestimated, because they are based on pre-post study designs that are susceptible to regression to the mean. We present a return-on-investment analysis that is based on a randomized controlled trial of Individualized Management for Patient-Centered Targets (IMPaCT), a standardized community health worker intervention that addresses unmet social needs for disadvantaged people. We found that every dollar invested in the intervention would return $2.47 to an average Medicaid payer within the fiscal year.

Migrant and Seasonal Farmworkers: Cancer Risks, Barriers to Care, and Ways to Overcome Them

Migrant and seasonal farmworkers (MSFWs) encounter numerous and overlapping barriers to healthcare access, including economic, cultural, linguistic, and logistic factors, all of which may contribute to disparities in cancer outcomes. For many MSFWs and their families, healthcare access and continuity are further eroded by their mobility. In addition, MSFWs experience occupational exposures that increase their risk of cancer.

The Lived Experiences of Community Health Workers Serving in a Large-Scale Water, Sanitation, and Hygiene Intervention Trial in Rural Bangladesh

Community health workers (CHWs) are key to implementing community-based health interventions and quality can be enhanced by better understanding their lived experiences. The WASH Benefits, Bangladesh trial engaged 540 female CHWs to promote varying health intervention packages. We report on factors influencing their lived experiences during the trial, to aid future recruitment, training and retention of CHWs. Nine focus groups and 18 in-depth interviews were conducted with CHWs. Focus groups and interviews were transcribed and thematic content analysis performed to summarize the results. All CHWs described experiencing positive working conditions and many benefits both socially and financially; these contributed to their retention and job satisfaction. Their honorarium was commonly applied towards their children's education and invested for income generation. CHWs gained self-confidence as women, to move unaccompanied in the community and speak in public. They earned respect from the community and their family members who helped them manage their family obligations during work and were viewed as a resource for advice on health and social issues. Many participated in family decision-making from which they were previously excluded. Health programs should foster a positive experience among their CHWs to aid the recruitment, retention and development of this important human resource.

Social Determinants of Health, Goals and Outcomes in High-Risk Children With Type 1 Diabetes

OBJECTIVES

Despite advances in technology and type 1 diabetes (T1D) care, children from low-income families continue to have suboptimal outcomes and increased health-care utilization. In this study, we describe social determinants of health (SDOH) in high-risk children with T1D, as well as their SDOH-related priority goals, and assess the correlation between SDOH, glycemic control and health-care utilization.

METHODS

Caregivers of children aged 4 to 18 years with a diagnosis of T1D of >1 year, poor glycemic control (glycated hemoglobin [A1C] ≥9.5%) or high health-care utilization (≥2 diabetes-related hospitalizations, emergency department attendances or missed outpatient appointments in the previous year) were included. Primary caregiver health-related quality of life (HRQOL), self-efficacy (Maternal Self-Efficacy in Diabetes [MSED] scale) and SDOH were assessed. Goals were identified after assessment by a community health worker.

RESULTS

Fifty-three families were included, most (n=48, 91%) of whom had government insurance. Children had a median age of 13.4 (interquartile range [IQR], 12 to 15.3) years and a median A1C of 11.1% (IQR, 10% to 13%). Almost half of the families (n=24, 45%) reported at least 1 adverse SDOH. One or more adverse SDOH was associated with significantly lower total HRQOL scores (56.6 [IQR, 38.5 to 70.7] vs 77.8 [IQR, 60.8 to 92.4], p=0.004), but not associated with A1C (p=0.3), emergency department visits (p=0.9) or MSED (p=0.5).

CONCLUSIONS

Screening for adverse SDOH and addressing these barriers to glycemic control is not part of routine T1D care. In children with poorly controlled T1D and high health-care utilization, we have demonstrated a high prevalence of adverse SDOH, which may represent a modifiable factor to improve outcomes in this patient population.

Opportunities for and Perceptions of Integrating Community Health Workers Via the Affordable Care Act: Medicaid Health Homes

CONTEXT

The Affordable Care Act created opportunities for innovative, cost-saving measures to improve health care access. Community health workers (CHWs) are frontline public health workers who have a close understanding of the communities they serve. States that expanded Medicaid coverage could also create Medicaid Health Homes (MHHs)-virtual health care networks-to coordinate care for people with chronic conditions. New York was the second state to implement MHHs and gave the option to include CHWs as part of the health care team.

OBJECTIVE

To understand the perceptions of MHH administrators regarding CHW engagement in MHHs, as well as the facilitators and barriers to adoption in MHHs that are unknown.

DESIGN, SETTING, AND PARTICIPANTS

Semistructured qualitative interviews (n = 18) were conducted with MHH administrators throughout New York State guided by the Diffusion of Innovations (DOI) framework. Qualitative thematic analysis was used to explore the domains and themes.

RESULTS

Most MHH administrators believed that CHWs fit within MHHs. The DOI constructs of compatibility and complexity and the Consolidated Framework for Implementation Research construct of external policies helped explain CHW integration. CHWs were compatible with MHHs by enrolling patients, helping coordinate patient care, and providing social support. The complexities of CHW integration into MHHs included barriers to CHW integration, no direct reimbursement for their services, lack of clarity for CHW roles and responsibilities, and no explicit external policy for their use in MHHs.

CONCLUSIONS

CHWs can, and have, been integrated into the relatively novel Health Home system. While some barriers have prevented their integration into all MHHs, lessons learned could provide guidance for CHW integration into other health care systems in the United States.

Peer-Assisted Lifestyle (PAL) intervention: a protocol of a cluster-randomised controlled trial of a health-coaching intervention delivered by veteran peers to improve obesity treatment in primary care

INTRODUCTION

Among US veterans, more than 78% have a body mass index (BMI) in the overweight (≥25 kg/m²) or obese range (≥30 kg/m²). Clinical guidelines recommend multicomponent lifestyle programmes to promote modest, clinically significant body mass (BM) loss. Primary care providers (PCPs) often lack time to counsel and refer patients to intensive programmes (≥6 sessions over 3 months). Using peer coaches to deliver obesity counselling in primary care may increase patient motivation, promote behavioural change and address the specific needs of veterans. We describe the rationale and design of a cluster-randomised controlled trial to test the efficacy of the Peer-Assisted Lifestyle (PAL) intervention compared with enhanced usual care (EUC) to improve BM loss, clinical and behavioural outcomes (aim 1); identify BM-loss predictors (aim 2); and increase PCP counselling (aim 3).

METHODS AND ANALYSIS

We are recruiting 461 veterans aged 18-69 years with obesity or overweight with an obesity-associated condition under the care of a PCP at the Brooklyn campus of the Veterans Affairs NY Harbor Healthcare System. To deliver counselling, PAL uses in-person and telephone-based peer support, a tablet-delivered goal-setting tool and PCP training. Patients in the EUC arm receive non-tailored healthy living handouts. In-person data collection occurs at baseline, month 6 and month 12 for patients in both arms. Repeated measures modelling based on mixed models will compare mean BM loss (primary outcome) between study arms.

ETHICS AND DISSEMINATION

The protocol has been approved by the Institutional Review Board and the Research and Development Committee at the VA NY Harbor Health Systems (#01607). We will disseminate the results via peer-reviewed publications, conference presentations and meetings with stakeholders.

TRIAL REGISTRATION NUMBER

NCT03163264; Pre-results.

Patients' Preferences for Artificial Intelligence Applications Versus Clinicians in Disease Diagnosis During the SARS-CoV-2 Pandemic in China: Discrete Choice Experiment

Background

Misdiagnosis, arbitrary charges, annoying queues, and clinic waiting times among others are long-standing phenomena in the medical industry across the world. These factors can contribute to patient anxiety about misdiagnosis by clinicians. However, with the increasing growth in use of big data in biomedical and health care communities, the performance of artificial intelligence (Al) techniques of diagnosis is improving and can help avoid medical practice errors, including under the current circumstance of COVID-19.

Objective

This study aims to visualize and measure patients’ heterogeneous preferences from various angles of AI diagnosis versus clinicians in the context of the COVID-19 epidemic in China. We also aim to illustrate the different decision-making factors of the latent class of a discrete choice experiment (DCE) and prospects for the application of AI techniques in judgment and management during the pandemic of SARS-CoV-2 and in the future.

Methods

A DCE approach was the main analysis method applied in this paper. Attributes from different dimensions were hypothesized: diagnostic method, outpatient waiting time, diagnosis time, accuracy, follow-up after diagnosis, and diagnostic expense. After that, a questionnaire is formed. With collected data from the DCE questionnaire, we apply Sawtooth software to construct a generalized multinomial logit (GMNL) model, mixed logit model, and latent class model with the data sets. Moreover, we calculate the variables’ coefficients, standard error, P value, and odds ratio (OR) and form a utility report to present the importance and weighted percentage of attributes.

Results

A total of 55.8% of the respondents (428 out of 767) opted for AI diagnosis regardless of the description of the clinicians. In the GMNL model, we found that people prefer the 100% accuracy level the most (OR 4.548, 95% CI 4.048-5.110, P<.001). For the latent class model, the most acceptable model consists of 3 latent classes of respondents. The attributes with the most substantial effects and highest percentage weights are the accuracy (39.29% in general) and expense of diagnosis (21.69% in general), especially the preferences for the diagnosis “accuracy” attribute, which is constant across classes. For class 1 and class 3, people prefer the AI + clinicians method (class 1: OR 1.247, 95% CI 1.036-1.463, P<.001; class 3: OR 1.958, 95% CI 1.769-2.167, P<.001). For class 2, people prefer the AI method (OR 1.546, 95% CI 0.883-2.707, P=.37). The OR of levels of attributes increases with the increase of accuracy across all classes.

Conclusions

Latent class analysis was prominent and useful in quantifying preferences for attributes of diagnosis choice. People’s preferences for the “accuracy” and “diagnostic expenses” attributes are palpable. AI will have a potential market. However, accuracy and diagnosis expenses need to be taken into consideration.

Details of developing and implementing an intensive interdisciplinary care program for high need, high cost patients

1. Developing and implementing an intensive interdisciplinary medical home within a large academic medical center was feasible. 2. Deploying a complex care management program that shared staff and resources with an intensive primary care program was not successful. 3. Barriers included traversing legal barriers to text messaging patients, making hospital consults feasible financially, managing challenging patients, team wellness, provider back up, managing homebound patients, and discharging patients. 4. Although expensive, this model may have hidden benefits including improved patient satisfaction, quality of care, and providing a solid care system for a health system's most challenging and vulnerable population.

Acceptability and appropriateness of a novel parent-staff co-leadership model for childhood obesity prevention in Head Start: a qualitative interview study

Background

Peer leadership can be an effective strategy for implementing health programs, benefiting both program participants and peer leaders. To realize such benefits, the peer leader role must be appropriate for the community context. Also, peer leaders must find their role acceptable (i.e., satisfactory) to ensure their successful recruitment and retention. To date, parent peer leaders have seldom been part of early childhood obesity prevention efforts. Moreover, parents at Head Start preschools have rarely been engaged as peer leaders. The aim of this study is to evaluate the appropriateness and acceptability of an innovative model for engaging parents as peer leaders for this novel content area (early childhood obesity prevention) and setting (Head Start).

Methods

Parents Connect for Healthy Living (PConnect) is a 10-session parent program being implemented in Head Start preschools as part of the Communities for Healthy Living early childhood obesity prevention trial. PConnect is co-led by a parent peer facilitator who is paired with a Head Start staff facilitator. In the spring of 2019, 10 PConnect facilitators participated in a semi-structured interview about their experience. Interview transcripts were analyzed by two coders using an inductive-deductive hybrid analysis. Themes were identified and member-checked with two interviewees.

Results

Themes identified applied equally to parent and staff facilitators. Acceptability was high because PConnect facilitators were able to learn and teach, establish meaningful relationships, and positively impact the parents participating in their groups, although facilitators did express frustration when low attendance limited their reach. Appropriateness was also high, as PConnect provided adequate structure and support without being overly rigid, and facilitators were able to overcome most challenges they encountered.

Conclusions

The PConnect co-facilitation model was highly acceptable and appropriate for both the parent facilitators (peer leaders) and the staff facilitators. Including parents as peer leaders aligns to Head Start’s emphasis on parent engagement, making it a strong candidate for sustained implementation in Head Start. The insights gained about the drivers of peer leadership appropriateness and acceptability in this particular context may be used to inform the design and implementation of peer-led health programs elsewhere.

Trial registration

clinicaltrials.gov, NCT03334669 (7–11-17).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10159-3.

Addressing unmet basic needs for children with sickle cell disease in the United States: clinic and staff perspectives

Background

The purpose of this study was to assess pediatric hematology clinic staff’s perspectives regarding barriers and facilitators in addressing unmet basic needs for children with sickle cell disease (SCD).

Methodology

Six focus groups were held at four urban pediatric hematology clinics in the Northeastern region of the United States from November to December 2019. Discussion questions were developed to align with the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) implementation science framework, focusing on the domains of context and recipient and how clinics address adverse social determinants of health (SDoH) in their patient populations. A summative content analytical approach was taken to identify major themes in the data.

Results

We discerned the following themes: (1) families of children with SCD experience numerous unmet basic needs; (2) clinic staff believed they had a role to play in addressing these unmet basic needs; (3) staff felt their ability to address families’ unmet basic needs depended upon caregivers’ capacity to act on staff’s recommendations; and (4) clinic staff’s ability to address these needs was limited by organizational and systemic factors beyond their control.

Conclusions

These findings have important implications for how best to address adverse SDoH for this vulnerable pediatric population so that urban-based pediatric hematology clinics can more equitably support families.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-06055-y.

Talk to PAPA: A Systematic Review of Patient/Participant (PAPA) Feedback on Interactions With Community Health Workers Using a Depth Analysis Approach

Because of their shared backgrounds, community health workers' (CHWs) care of patients/program participants (PAPAs) is assumed to be acceptable, and often not evaluated empirically. Using PRISMA guidelines, we reviewed 9560 articles from 5 databases, selected 37 articles for full-text review, and developed a 5-dimensional depth analysis (focus, context, meaning, range, and voices) to characterize quality/quantity of PAPA feedback. Depth analyses clarified a spectrum of PAPA responses from extremely positive to ambivalence to outright distrust and frustration with perceived CHW limitations. Designing evaluations with 5-dimensional depth analysis can enhance PAPA feedback quality and improve evidence-based, patient-centered, CHW care delivery.

Raising Well at Home: a pre-post feasibility study of a lifestyle intervention for caregivers and their child with obesity

Background

Few efficacious pediatric obesity interventions have been successfully translated and sustained in real-world practice, often due to inadequate fit with the priorities of under-resourced populations. Lifestyle interventions, which incorporate tailoring of essential weight loss ingredients and adaptation of mode and intensity to the living circumstances of children with obesity, are needed. The purpose of this pilot study was to test the feasibility and efficacy of a tailored lifestyle intervention for caregivers and their children with obesity, conducted in partnership with Envolve, Inc., a family of comprehensive health solutions and wholly owned subsidiary of Centene Corporation.

Methods

This 6-month pilot study employed a pretest-posttest design to assess the impact of a tailored lifestyle intervention delivered by peer coaches on (a) caregiver and child weight impacted by changes in dietary intake, walking, and screen time; (b) changes in the home environment; and (c) caregiver engagement and satisfaction. The intervention was delivered via 3 core home visits every 4-6 weeks, with additional support via text.

Results

The majority of caregivers were female (95.2%) and Black (73.7%). Children had median age of 11.1 years and majority were female (57.6%), with a median BMI near the 99th percentile (Mdn 98.8, IQR 3.5) or 118.3% (IQR 35.8) of the 95th percentile for their sex and age. Participants expressed high satisfaction with the program (mean range 96.7-100.0% agreement on satisfaction items). From baseline to post, caregivers' BMI decreased by 1.8% (p = 0.016, r = 0.22), while children's BMI percentile z-score decreased significantly (p = 0.023, r = 0.18) and BMI percent of the 95th percentile remained constant (p = 0.05, r = 0.15). Caregivers and children decreased sugar-sweetened beverage intake (p = 0.026, r = 0.22; p = 0.006, r = 0.23, respectively), reduced presence of soda in the home (p = 0.002, g = 0.43), and decreased screen time (p = 0.046, g = 0.22). Other eating and walking behaviors remained stable for caregivers and child.

Conclusion

The Raising Well at Home pilot demonstrated that tailored lifestyle interventions, delivered by peer coaches in the home and via text, are feasible and can improve weight, eating, and environmental measures of caregivers and children with obesity. Future work should determine the effectiveness, sustainability, and scalability of this intervention in sites located across the country.

Trial registration

ClinicalTrials.gov (NCT04224623). Registered 9 January 2020-retrospectively registered.

Online versus in-person training of community health workers to enhance hepatitis B virus screening among Korean Americans: Evaluating cost & outcomes

From 2014 to 2018, we developed and implemented culturally appropriate interventions delivered by community health workers (CHWs) in Pennsylvania and New Jersey. To determine the most cost-effective approach, we recruited 40 predominantly foreign-born Korean American CHWs and used cluster sampling to assign them into two training groups (online training vs. in-person training). We prospectively assessed the cost of training 40 Korean American CHWs and the cost of subsequent HBV educational workshops delivered by the CHWs. We also assessed these costs relative to the success of each training approach in recruiting participants for HBV screening and vaccination. We found that the training costs per participant were higher for in-person training ($1.71 versus $1.12), while workshop costs per participant were lower for in-person training ($2.19 versus $4.22). Workshop attendee costs were comparable. After accounting for site clustering, there were no significant differences in total costs per participant ($24.55 for the online-trained group and $26.05 for the in-person group). In-person trained CHWs were able to generate higher HBV screening and vaccination rates (49.3% versus 21.4% and 17.0% versus 5.9%, respectively) among their participants compared with online-trained CHWs. Given better outcomes and no differences in costs, in-person training dominated the online training option. Despite the potential for efficiency to be gained with online training, CHWs who attended live training outperformed their online-trained colleagues. Elements of the didactic approach or practice with peers in the live session may have contributed to the superior training effectiveness and, ultimately, improved cost-effectiveness of the in-person approach.

The RICH LIFE Project: A cluster randomized pragmatic trial comparing the effectiveness of health system only vs. health system Plus a collaborative/stepped care intervention to reduce hypertension disparities

Disparities in the control of hypertension and other cardiovascular disease risk factors are well-documented in the United States, even among patients seen regularly in the healthcare system. Few existing approaches explicitly address disparities in hypertension care and control. This paper describes the RICH LIFE Project (Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone) design.

METHODS

RICH LIFE is a two-arm, cluster-randomized trial, comparing the effectiveness of enhanced standard of care, "Standard of Care Plus" (SCP), to a multi-level intervention, "Collaborative Care/Stepped Care" (CC/SC), for improving blood pressure (BP) control and patient activation and reducing disparities in BP control among 1890 adults with uncontrolled hypertension and at least one other cardiovascular disease risk factor treated at 30 primary care practices in Maryland and Pennsylvania. Fifteen practices randomized to the SCP arm receive standardized BP measurement training; race/ethnicity-specific audit and feedback of BP control rates; and quarterly webinars in management practices, quality improvement and disparities reduction. Fifteen practices in the CC/SC arm receive the SCP interventions plus implementation of the collaborative care model with stepped-care components (community health worker referrals and virtual specialist-panel consults). The primary clinical outcome is BP control (<140/90 mm Hg) at 12 months. The primary patient-reported outcome is change from baseline in self-reported patient activation at 12 months.

DISCUSSION

This study will provide knowledge about the feasibility of leveraging existing resources in routine primary care and potential benefits of adding supportive community-facing roles to improve hypertension care and reduce disparities.

TRIAL REGISTRATION

Clinicaltrials.govNCT02674464.