Allies community health workers: Bridging the gap

Understanding How Community Health Workers Build Trust with Low-Income Women of Color At-Risk for Maternal Child Health Disparities: A Grounded Theory Study

This article examines how Community Health Workers (CHWs) build trust with low-income women of color who have a historical distrust of the healthcare system, and are at risk for maternal-child health disparities. This qualitative study used a grounded theory methodology guided by Charmaz's inductive social constructivist approach. Data were collected using open-ended semi-structured interviews and focus groups with CHWs who worked in community-based and hospital-based programs in California, Oregon, Illinois, Texas, South Carolina, New York, and Maine. Thirty-two CHWs participated, with 95% of participants being of Latinx and African American ethnicity. They served women from Latinx, African American, and Migrant communities. The CHW communication strategies represent aspects of respect and client-centered care and are applied in the development of a theoretical framework. CHWs were able to build and sustain trust at the initial encounter through these specific strategies: 1) addressing immediate needs related to social determinants of health; 2) embodying mannerisms and dress; 3) speaking appropriately to the client's age, culture, and knowledge; 4) easing client's fears through locus of control, and 5) allowing for time flexibility. These findings have implications for practice through interventions to train healthcare providers to build trust with low-income women of color who have a historical distrust of the healthcare system and who are at risk for maternal-child health disparities. Future research is recommended to explore how the communication trust-building constructs also benefit all other groups at similar risk, including those with mental health disorders and infectious diseases. The findings indicate specific communication strategies through which trust can be built, beginning at the initial encounter with low-income women at risk for maternal-child health disparities and who have a historical distrust of the healthcare system.

Understanding the Impacts of the COVID-19 Pandemic on Small Businesses and Workers Using Quantitative and Qualitative Methods

The COVID-19 pandemic has simultaneously exacerbated and elucidated inequities in resource distribution for small businesses across the United States in terms of worker health and the financial stability of both owners and employees. This disparity was further intensified by the constantly changing and sometimes opposing health and safety guidelines and recommendations to businesses from the local, state, and federal government agencies. To better understand how the pandemic has impacted small businesses, a cross-sectional survey was administered to owners, managers, and workers (n = 45) in the beauty and auto shop sectors from Southern Arizona. The survey identified barriers to safe operation that these businesses faced during the pandemic, illuminated worker concerns about COVID-19, and elicited perceptions of how workplaces have changed since the novel coronavirus outbreak of 2019. A combination of open-ended and close-ended questions explored how businesses adapted to the moving target of pandemic safety recommendations, as well as how the pandemic affected businesses and workers more generally. Almost all the beauty salons surveyed had to close their doors (22/25), either temporarily or permanently, due to COVID-19, while most of the auto repair shops were able to stay open (13/20). Beauty salons were more likely to implement exposure controls meant to limit transmission with customers and coworkers, such as wearing face masks and disallowing walk-ins, and were also more likely to be affected by pandemic-related issues, such as reduced client load and sourcing difficulties. Auto shops, designated by the state of Arizona to be 'essential' businesses, were less likely to have experienced financial precarity due to the pandemic. Content analysis of open-ended questions using the social-ecological model documented current and future worker concerns, namely financial hardships from lockdowns and the long-term viability of their business, unwillingness of employees to return to work, uncertainty regarding the progression of the pandemic, conflict over suitable health and safety protocols, and personal or family health and well-being (including anxiety and/or stress). Findings from the survey indicate that small businesses did not have clear guidance from policymakers during the pandemic and that the enacted regulations and guidelines focused on either health and safety or finances, but rarely both. Businesses often improvised and made potentially life-changing decisions with little to no support. This analysis can be used to inform future pandemic preparedness plans for small businesses that are cost-efficient, effective at reducing environmental exposures, and ultimately more likely to be implemented by the workers.

Ethical practice in my work: community health workers' perspectives using photovoice in Wakiso district, Uganda

Background

Health service delivery should ensure ethical principles are observed at all levels of healthcare. Working towards this goal requires understanding the ethics-related priorities and concerns in the day-to-day activities among different health practitioners. These practitioners include community health workers (CHWs) who are involved in healthcare delivery in communities in many low-and middle-income countries such as Uganda. In this study, we used photovoice, an innovative community based participatory research method that uses photography, to examine CHWs' perspectives on ethical concerns in their work.

Methods

We explored perspectives of 10 CHWs (5 females and 5 males) on ethical dimensions of their work for 5 months using photovoice in a rural community in Wakiso district, Uganda. As part of the study, we: 1. Oriented CHWs on photovoice research and ethics; 2. Asked CHWs to take photographs of key ethical dimensions of their work; 3. Held monthly meetings to discuss and reflect on the photos; and 4. Disseminated the findings. The discussions from the monthly meetings were audio recorded, transcribed, and emerging data analysed using conventional content analysis with the help of Atlas ti version 6.0.15.

Results

CHWs were aware of and highly concerned about the need to observe ethical principles while carrying out their roles. The ethical principles CHWs were aware of and endeavoured to observe during their work were: maintaining professional integrity and abiding by ethical principles of practice; ethical responsibility in patient care; maintaining confidentiality while handling clients; respect for persons and communities; and enhancing their knowledge and skills for better practice. However, CHWs also identified challenges concerning their observance of ethical principles including: low commitment to their work due to other obligations; availability of some reference materials and guidelines in English yet majority could only read in the local language; and minimal avenues for knowledge enhancement such as trainings.

Conclusions

CHWs were aware of and keen to discuss ethical issues in their work. However, there is need to address the challenges they face so as to facilitate observing ethical principles during the course of their work in communities.

Who are community health workers and what do they do? Development of an empirically derived reporting taxonomy

Objectives

To develop an empirically-informed reporting taxonomy for Community Health Worker (CHW) services to address concerns about the transparency and consistency of descriptions of these interventions in the existing literature.

Methods

We undertook in-depth interviews (n = 43) with CHWs and service staff working in four case studies selected using maximum variation sampling. Interviewees were encouraged to talk about the service, how they had become involved with the service, the CHW role and relationship with clients.

Results

Thematic analysis identified recurrent cross-case observations which we classed as 'who CHW are' and 'what CHW do'. CHW's personal characteristics comprised the sub-groups knowledge and skills, personal qualities, similarity to client and voluntary/paid status; role characteristics comprised time and continuity, settings, limited responsibility, core task and enacted philosophies.

Conclusions

We have developed a conceptual framework for reporting CHW interventions based on the existing literature and our own empirical work. Compared with existing work in the field, the taxonomy uses nomenclature that minimizes current overlap and confusion, and provides a more complete description of CHW characteristics.

Hispanic Community-Engaged Research: Community Partners as Our Teachers to Improve Diabetes Self-Management

INTRODUCTION

Community-based participatory research (CBPR) is a strategy often employed to address public health priorities. We explored how to build effective, trusting relationships with key community stakeholders and a group of Hispanic/Latinos with type 2 diabetes (T2D) to develop culturally appropriate projects.

METHOD

In the process of implementing a Patient-Centered Outcome Research Initiative (PCORI) award, our Community Advisory Board (CAB) met monthly to develop a set of comparative effectiveness research questions along with the interventions to develop specific strategies to improve Hispanic/Latino individuals' self-management of T2D. An agenda was prepared for each meeting targeting the PCORI grant timeline. Notes were taken during these meetings and analyzed to determine effective strategies.

RESULTS

Ten strategies were identified that led to the success of this CBPR project and to the current sustainability phase. Instrumental to our success was our partnership with a community health worker (CHW) who co-lead this research project. The CHW and CAB individualized general CBPR strategies to make this project successful in their community.

CONCLUSION

Our community partners became influential knowledge holders throughout this research process. They improved researchers' understanding of how to address the needs of Hispanic/Latino individuals with T2D and how community members could become leaders within their community.

An Exploration of Patient Navigation and Community Health Worker Activities Across National Comprehensive Cancer Control Programs

Purpose: Health disparities persist across the cancer care continuum. Patient navigator (PN) and community health worker (CHW) interventions are designed to increase health equity. National Comprehensive Cancer Control Program (NCCCP) awardees develop and implement plans to coordinate cancer prevention and control activities, including supporting PN and CHW interventions. This content analysis examined NCCCP action plans to assess the extent to which jurisdictions report engaging in PN and/or CHW activities.

Methods: We abstracted PN and CHW content from NCCCP action plans and coded content according to specific areas of PN and/or CHW intervention (e.g., screening, survivorship, and cancer type), used descriptive statistics to characterize overall results, and calculated chi-squares to determine whether programs engaged PNs and CHWs differently.

Results: Eighty-two percent (n=53) of 65 NCCCP action plans had content related to PN and/or CHW activities, with more PN language (83%) than CHW (58%). These action plans described engaging PNs and CHWs in activities across the cancer continuum, but particularly for screening (60%) and survivorship (55%). Eighty-one percent of these plans described activities related to workforce development, such as training and standardizing roles and competencies. Programs engaged CHWs more often than PNs for outreach and in community settings.

Conclusion: The majority of NCCCP awardees reported engaging in PN and/or CHW activities. Understanding how NCCCP awardees engage PNs and CHWs, including awardees' needs for workforce development in this area, can help Centers for Disease Control and Prevention provide more focused technical assistance as programs increase engagement of PNs and CHWs to improve health equity.

Policy and system change and community coalitions: outcomes from allies against asthma

Objectives. We assessed policy and system changes and health outcomes produced by the Allies Against Asthma program, a 5-year collaborative effort by 7 community coalitions to address childhood asthma. We also explored associations between community engagement and outcomes. Methods. We interviewed a sample of 1,477 parents of children with asthma in coalition target areas and comparison areas at baseline and 1 year to assess quality-of-life and symptom changes. An extensive tracking and documentation procedure and a survey of 284 participating individuals and organizations were used to ascertain policy and system changes and community engagement levels. Results. A total of 89 policy and system changes were achieved, ranging from changes in interinstitutional and intrainstitutional practices to statewide legislation. Allies children experienced fewer daytime (P = .008) and nighttime (P = .004) asthma symptoms than comparison children. In addition, Allies parents felt less helpless, frightened, and angry (P = .01) about their child's asthma. Type of community engagement was associated with number of policy and system changes. Conclusions. Community coalitions can successfully achieve asthma policy and system changes and improve health outcomes. Increased core and ongoing community stakeholder participation rather than a higher overall number of participants was associated with more change.

Building social networks for maternal and newborn health in poor urban settlements: a cross-sectional study in Bangladesh

BACKGROUND

The beneficial influence of social networks on health and wellbeing is well-established. In poor urban settlements in Bangladesh, BRAC's Manoshi programme trains community health workers (CHWs) to support women through pregnancy, delivery and postpartum periods. This paper test the hypothesis that the introduction of CHWs as weak ties into the social networks of Manoshi members mediates improvements in maternal and neonatal health (MNH) best practices by providing support, facilitating ideational change, connecting mother to resources, and strengthening or countering the influence of strong ties.

METHODS

1000 women who had given birth in the last three months were identified and interviewed as part of ongoing monitoring of 5 poor urban settlements in Dhaka, Bangladesh. A social networks questionnaire was administered which elicited women's perceived networks around pregnancy, delivery and post-partum periods. Mediation analysis was performed to test the hypothesis that penetration of Manoshi CHWs into women's perceived networks has a beneficial effect on MNH best practises.

RESULTS

The presence and influence of Manoshi CHWs in women's networks significantly mediated the effect of Manoshi membership on MNH best practices. Respondents who were Manoshi members and who listed Manoshi CHWs as part of their support networks were significantly more likely to deliver with a trained birth attendant (OR 3.61; 95%CI 2.36-5.51), to use postnatal care (OR 3.09; 95%CI 1.83-5.22), and to give colostrum to their newborn (OR 7.51; 95%CI 3.51-16.05).

CONCLUSION

Manoshi has succeeded in penetrating the perceived pregnancy, delivery and post-partum networks of poor urban women through the introduction of trained CHWs. Study findings demonstrate the benefits of moving beyond urban health care delivery models that concentrate on the provision of clinical services by medical providers, to an approach that nurtures the power of social networks as a means to support the poorest and most marginalized in changing behaviour and effectively accessing appropriate maternal services.

Hope and despair: community health assistants' experiences of working in a rural district in Zambia

BACKGROUND

In order to address the challenges facing the community-based health workforce in Zambia, the Ministry of Health implemented the national community health assistant strategy in 2010. The strategy aims to address the challenges by creating a new group of workers called community health assistants (CHAs) and integrating them into the health system. The first group started working in August 2012. The objective of this paper is to document their motivation to become a CHA, their experiences of working in a rural district, and how these experiences affected their motivation to work.

METHODS

A phenomenological approach was used to examine CHAs' experiences. Data collected through in-depth interviews with 12 CHAs in Kapiri Mposhi district and observations were analysed using a thematic analysis approach.

RESULTS

Personal characteristics such as previous experience and knowledge, passion to serve the community and a desire to improve skills motivated people to become CHAs. Health systems characteristics such as an inclusive work culture in some health posts motivated CHAs to work. Conversely, a non-inclusive work culture created a social structure which constrained CHAs' ability to learn, to be innovative and to effectively conduct their duties. Further, limited supervision, misconceptions about CHA roles, poor prioritisation of CHA tasks by some supervisors, as well as non- and irregular payment of incentives also adversely affected CHAs' ability to work effectively. In addition, negative feedback from some colleagues at the health posts affected CHA's self-confidence and professional outlook. In the community, respect and support provided to CHAs by community members instilled a sense of recognition, appreciation and belonging in CHAs which inspired them to work. On the other hand, limited drug supplies and support from other community-based health workers due to their exclusion from the government payroll inhibited CHAs' ability to deliver services.

CONCLUSIONS

Programmes aimed at integrating community-based health workers into health systems should adequately consider multiple incentives, effective management, supervision and support from the district. These should be tailored towards enhancing the individual, health system and community characteristics that positively impact work motivation at the local level if such programmes are to effectively contribute towards improved primary healthcare.

'It's the sense of responsibility that keeps you going': stories and experiences of participation from rural community health workers in Guatemala

BACKGROUND

In 1978, the Alma-Ata declaration on primary health care (PHC) recognized that the world's health issues required more than just hospital-based and physician-centered policies. The declaration called for a paradigm change that would allow governments to provide essential care to their population in a universally acceptable manner. The figure of the community health worker (CHW) remains a central feature of participation within the PHC approach, and being a CHW is still considered to be an important way of participation within the health system.

METHODS

This study explores how the values and personal motivation of community health workers influences their experience with this primary health care strategy in in the municipality of Palencia, Guatemala. To do this, we used an ethnographic approach and collected data in January-March of 2009 and 2010 by using participant observation and in-depth interviews.

RESULTS

We found that the CHWs in the municipality had a close working relationship with the mobile health team and with the community, and that their positions allowed them to develop leadership and teamwork skills that may prove useful in other community participation processes. The CHWs are motivated in their work and volunteerism is a key value in Palencia, but there is a lack of infrastructure and growth opportunities.

CONCLUSION

Attention should be paid to keeping the high levels of commitment and integration within the health team as well as keeping up supervision and economic funds for the program.

Factors associated with attaining coaching goals during an intervention to improve child asthma care

PURPOSE

To examine parent and child characteristics associated with engagement in a coaching intervention to improve pediatric asthma care and factors associated with readiness to adopt and maintain targeted asthma management behaviors.

METHODS

Using methods based on the Transtheoretical Model, trained lay coaches worked with 120 parents of children with asthma promoting adoption and maintenance of asthma management strategies (behaviors). Coaches assigned stage-of-change (on continuum: pre-contemplation, contemplation, preparation, action, maintenance) for each behavior every time it was discussed. Improvement in stage-of-change was analyzed for association with characteristics of the participants (parents and children) and coaching processes.

RESULTS

Having more coach contacts was associated with earlier first contact (p<0.001), fewer attempts per successful contact (p<0.001), prior asthma hospitalization (p=0.021), more intruding events (p<0.001), and less social support (p=0.048). In univariable models, three factors were associated with forward movement at least one stage for all three behaviors: more coach contacts overall, fewer attempts per successful contact, and more discussion/staging episodes for the particular behavior. In multivariable models adjusting for characteristics of participants and coaching process, the strongest predictor of any forward stage movement for each behavior was having more contacts (p<0.05).

CONCLUSIONS

Improvement in readiness to adopt and maintain asthma management behaviors was mostly associated with factors reflecting more engagement of participants in the program. Similar coaching interventions should focus on early and frequent contacts to achieve intervention goals, recognizing that parents of children with less severe disease and who have more social support may be more difficult to engage.

Community-based care coordination: practical applications for childhood asthma

Care coordination programs have been used to address chronic illnesses, including childhood asthma, but primarily via practice-based models. An alternative approach employs community-based care coordinators who bridge gaps between families, health care providers, and support services. Merck Childhood Asthma Network, Inc. (MCAN) sites developed community-based care coordination approaches for childhood asthma. Using a community-based care coordination logic model, programs at each site are described along with program operational statistics. Four sites used three to four community health workers (CHWs) to provide care coordination, whereas one site used five school-based asthma nurses. This school-based site had the highest caseload (82.5 per year), but program duration was 3 months with 4 calls or visits. Other sites averaged fewer cases (35 to 61 per CHW per year), but families received more (7 to 17) calls or visits over a year. Retention was 43% to 93% at 6 months and 24% to 75% at 12 months. Pre-post cross-site data document changes in asthma management behaviors and outcomes. After program participation, 93% to 100% of caregivers had confidence in controlling their child's asthma, 85% to 92% had taken steps to reduce triggers, 69% to 100% had obtained an asthma action plan, and 46% to 100% of those with moderate to severe asthma reported appropriate use of controller medication. Emergency department visits for asthma decreased by 36% to 63%, and asthma-related hospitalizations declined by 26% to 78%. More than three fourths had fewer school absences. In conclusion, MCAN community-based care coordination programs improved management behaviors and decreased morbidity across all sites.

Home-based educational interventions for children with asthma

BACKGROUND

While guidelines recommend that children with asthma should receive asthma education, it is not known if education delivered in the home is superior to usual care or the same education delivered elsewhere. The home setting allows educators to reach populations (such as the economically disadvantaged) that may experience barriers to care (such as lack of transportation) within a familiar environment.

OBJECTIVES

To perform a systematic review on educational interventions for asthma delivered in the home to children, caregivers or both, and to determine the effects of such interventions on asthma-related health outcomes. We also planned to make the education interventions accessible to readers by summarising the content and components.

SEARCH STRATEGY

We searched the Cochrane Airways Group Specialised Register of trials, which includes the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED and PsycINFO, and handsearched respiratory journals and meeting abstracts. We also searched the Education Resources Information Center database (ERIC), reference lists of trials and review articles (last search January 2011).

SELECTION CRITERIA

We included randomised controlled trials of asthma education delivered in the home to children, their caregivers or both. In the first comparison, eligible control groups were provided usual care or the same education delivered outside of the home. For the second comparison, control groups received a less intensive educational intervention delivered in the home.

DATA COLLECTION AND ANALYSIS

Two authors independently selected the trials, assessed trial quality and extracted the data. We contacted study authors for additional information. We pooled dichotomous data with fixed-effect odds ratio and continuous data with mean difference (MD) using a fixed-effect where possible.

MAIN RESULTS

A total of 12 studies involving 2342 children were included. Eleven out of 12 trials were conducted in North America, within urban or suburban settings involving vulnerable populations. The studies were overall of good methodological quality. They differed markedly in terms of age, severity of asthma, context and content of the educational intervention leading to substantial clinical heterogeneity. Due to this clinical heterogeneity, we did not pool results for our primary outcome, the number of patients with exacerbations requiring emergency department (ED) visit. The mean number of exacerbations requiring ED visits per person at six months was not significantly different between the home-based intervention and control groups (N = 2 studies; MD 0.04; 95% confidence interval (CI) -0.20 to 0.27). Only one trial contributed to our other primary outcome, exacerbations requiring a course of oral corticosteroids. Hospital admissions also demonstrated wide variation between trials with significant changes in some trials in both directions. Quality of life improved in both education and control groups over time.A table summarising some of the key components of the education programmes is included in the review.

AUTHORS' CONCLUSIONS

We found inconsistent evidence for home-based asthma educational interventions compared to standard care, education delivered outside of the home or a less intensive educational intervention delivered at home. Although education remains a key component of managing asthma in children, advocated in numerous guidelines, this review does not contribute further information on the fundamental content and optimum setting for such educational interventions.

Home is Where the Triggers Are: Increasing Asthma Control by Improving the Home Environment

Asthma remains the most common chronic condition of childhood. Strong evidence has linked exposure to allergens and other triggers commonly found in homes to allergen sensitization and asthma incidence and morbidity. A growing body of evidence has demonstrated that a home visit strategy that includes an environmental component that addresses multiple triggers through multiple interventions is effective. Such home visits reduce exposure to triggers, decrease symptoms and urgent health-care use, and increase quality of life. To make home visits widely available will require health-care payor reimbursement, government and health plan funding, training and certification of home visitors, and active referrals from health-care providers. However, a strategy based solely on education and behavior change is limited, because it cannot adequately reduce exposures due to adverse housing conditions. Therefore, approaches that address substandard housing are needed. These include remediation of existing housing and construction of new asthma-friendly homes. Most studies of remediation have made relatively narrow and focused improvements, such as insulation, heating, or ventilation. Outcomes have been mixed. Studies of new asthma-friendly homes are in their infancy, with promising pilot data. Further investigation is needed to establish the effectiveness of improving housing. A final strategy is improving housing quality through policy change, such as implementation of healthy housing guidelines for new construction, enhancement and increased enforcement of housing codes, and assuring smoke-free multi-unit homes. The combination of home visits, improved housing construction, and policy change has great potential for reducing the global burden of asthma.

Policy and system change and community coalitions: outcomes from allies against asthma

OBJECTIVES

We assessed policy and system changes and health outcomes produced by the Allies Against Asthma program, a 5-year collaborative effort by 7 community coalitions to address childhood asthma. We also explored associations between community engagement and outcomes.

METHODS

We interviewed a sample of 1477 parents of children with asthma in coalition target areas and comparison areas at baseline and 1 year to assess quality-of-life and symptom changes. An extensive tracking and documentation procedure and a survey of 284 participating individuals and organizations were used to ascertain policy and system changes and community engagement levels.

RESULTS

A total of 89 policy and system changes were achieved, ranging from changes in interinstitutional and intrainstitutional practices to statewide legislation. Allies children experienced fewer daytime (P = .008) and nighttime (P = .004) asthma symptoms than comparison children. In addition, Allies parents felt less helpless, frightened, and angry (P = .01) about their child's asthma. Type of community engagement was associated with number of policy and system changes.

CONCLUSIONS

Community coalitions can successfully achieve asthma policy and system changes and improve health outcomes. Increased core and ongoing community stakeholder participation rather than a higher overall number of participants was associated with more change.

Problem-solving skills training for vulnerable families of children with persistent asthma: report of a randomized trial on health-related quality of life outcomes

OBJECTIVES

To test the efficacy of problem-solving skill training (PST) in improving health-related quality of life (HRQOL) of children with persistent asthma from predominantly lower socioeconomic status (SES) Spanish-speaking Hispanic families.

METHODS

Randomized controlled trial comparing standard care waitlist (SC) control, home-visiting asthma education/care coordination (CC), and combined intervention (CC + PST) at baseline, after intervention, and 6-month follow-up. The primary outcome was parent proxy-report child HRQOL (PedsQL).

RESULTS

Participants (n = 252) were 83.3% Hispanic and 56.3% monolingual Spanish speakers, and 72.6% of mothers had not graduated high school. We found a significant (P = 0.05) intervention effect for parent proxy-reported child generic (but not asthma-specific) HRQOL, with CC + PST superior to SC [83.8 vs 79.8; adjusted mean difference of 4.05 points (95% confidence interval 0.63-7.4], but no difference between the CC and SC groups.

CONCLUSIONS

In this sample of vulnerable families of children with persistent asthma, a CC + PST intervention was efficacious in improving children's generic HRQOL.

Community health workers and environmental interventions for children with asthma: a systematic review

Community health worker (CHW)-delivered, home-based environmental interventions for pediatric asthma were systematically reviewed. Seven PubMed/MEDLINE listed randomized controlled trials that encompassed the following intervention criteria were identified: (1) home-based; (2) delivered by a CHW; (3) delivered to families with children with asthma; and (4) addressed multiple environmental triggers for asthma. Details of research design, intervention type, and setting, interventionist, population served, and the evaluated outcomes were abstracted. Outcome assessment was broad and non-uniform. Categories included direct mediators of improved health outcomes, such as trigger-related knowledge, trigger reduction behaviors and allergen or exposure levels, and asthma-related health outcomes: change in lung function, medication use, asthma symptoms, activity limitations, and health care utilization. Indirect mediators of health outcomes, or psychosocial influences on health, were measured in few studies. Overall, the studies consistently identified positive outcomes associated with CHW-delivered interventions, including decreased asthma symptoms, daytime activity limitations, and emergency and urgent care use. However, improvements in trigger reduction behaviors and allergen levels, hypothesized mediators of these outcomes, were inconsistent. Trigger reduction behaviors appeared to be tied to study-based resource provision. To better understand the mechanism through which CHW-led environmental interventions cause a change in asthma-related health outcomes, information on the theoretical concepts that mediate behavior change in trigger control (self-efficacy, social support) is needed. In addition, evaluating the influence of CHWs as clinic liaisons that enhance access to health professionals, complement clinic-based teaching, and improve appropriate use of asthma medications should be considered, alongside their effect on environmental management. A conceptual model identifying pathways for future investigation is presented.

A randomized controlled trial of asthma self-management support comparing clinic-based nurses and in-home community health workers: the Seattle-King County Healthy Homes II Project

OBJECTIVE

To compare the marginal benefit of in-home asthma self-management support provided by community health workers (CHWs) with standard asthma education from clinic-based nurses.

DESIGN

Randomized controlled trial.

SETTING

Community and public health clinics and homes.

PARTICIPANTS

Three hundred nine children aged 3 to 13 years with asthma living in low-income households.

INTERVENTIONS

All participants received nurse-provided asthma education and referrals to community resources. Some participants also received CHW-provided home environmental assessments, asthma education, social support, and asthma-control resources.

OUTCOME MEASURES

Asthma symptom-free days, Pediatric Asthma Caretaker Quality of Life Scale score, and use of urgent health services.

RESULTS

Both groups showed significant increases in caretaker quality of life (nurse-only group: 0.4 points; 95% confidence interval [CI], 0.3-0.6; nurse + CHW group: 0.6 points; 95% CI, 0.4-0.8) and number of symptom-free days (nurse only: 1.3 days; 95% CI, 0.5-2.1; nurse + CHW: 1.9 days; 95% CI, 1.1-2.8), and absolute decreases in the proportion of children who used urgent health services in the prior 3 months (nurse only: 17.6%; 95% CI, 8.1%-27.2%; nurse + CHW: 23.1%; 95% CI, 13.6%-32.6%). Quality of life improved by 0.22 more points in the nurse + CHW group (95% CI, 0.00-0.44; P = .049). The number of symptom-free days increased by 0.94 days per 2 weeks (95% CI, 0.02-1.86; P = .046), or 24.4 days per year, in the nurse + CHW group. While use of urgent health services decreased more in the nurse + CHW group, the difference between groups was not significant.

CONCLUSION

The addition of CHW home visits to clinic-based asthma education yielded a clinically important increase in symptom-free days and a modest improvement in caretaker quality of life.