Community health workers as an integral strategy in the REACH U.S. program to eliminate health inequities

Harlem Health Advocacy Partners: A Local Health Department's Place-Based Community Health Worker Program

In January 2015, the New York City Department of Health and Mental Hygiene launched Harlem Health Advocacy Partners (HHAP), a place-based initiative to demonstrate the capacity of a CHW workforce to improve the health of residents of public housing. The long-term goal of HHAP is to improve the population health of residents of public housing in East and Central Harlem and to close racial gaps in health and social outcomes. A variety of evaluation approaches have been used to assess the initiative. This paper describes the HHAP model and methods for evaluating the program.

Pandemic preparedness and response: a new mechanism for expanding access to essential countermeasures

As the world comes together through the WHO design and consultation process on a new medical counter-measures platform, we propose an enhanced APT-A (Access to Pandemic Tools Accelerator) that builds on the previous architecture but includes two new pillars - one for economic assistance and another to combat structural inequalities for future pandemic preparedness and response. As part of the APT-A, and in light of the Independent Panel on Pandemic Preparation & Response's call for an enhanced end-to-end platform for access to essential health technologies, we propose a new mechanism that we call the Pandemic Open Technology Access Accelerator (POTAX) that can be implemented through the medical countermeasures platform and the pandemic accord currently under negotiation through the World Health Assembly and supported by the High-Level Meeting review on Pandemic Prevention, Preparedness, and Response at the United Nations. This mechanism will provide (1) conditional financing for new vaccines and other essential health technologies requiring companies to vest licenses in POTAX and pool intellectual property and other data necessary to allow equitable access to the resulting technologies. It will also (2) support collective procurement as well as measures to ensure equitable distribution and uptake of these technologies.

Supporting the Development of Grassroots Maternal and Childhood Health Leaders through a Public-Health-Informed Training Program

The purpose of this research was to assess leadership growth (i.e., changes in personal capacity and social capital) among women living in high-risk infant mortality zip codes who completed a grassroots maternal and childhood health leadership (GMCHL) training program. We used semi-structured qualitative interviews and thematic analysis. Three major themes associated with the training program experience were identified: (1) building personal capacity and becoming community brokers; (2) linking and leveraging through formal organizations; and (3) how individual change becomes community change. Although many of the grassroots leaders were already brokers (i.e., connecting individuals to information/services), they were able to become community brokers by gaining new skills and knowledge about strategies to reduce adverse birth outcomes in their community. In particular, joining and participation in formal organizations aimed at improving community health led to the development of linking or vertical ties (e.g., "people in high places"). The grassroots leaders gained access to people in power, such as policymakers, which enabled leaders to access more resources and opportunities for themselves and their social networks. We outline the building blocks for supporting potential grassroots leaders by enhancing personal capacity and social capital, thus leading to increases in collective efficacy and collective action.

Individual and Systemic Barriers Blocking Community Health Workers from Helping the Seriously Ill

Background: Palliative care is a valuable component of health care that improves a patient's quality of life, yet its availability to patients with serious chronic illness remains relatively low. Due to their knowledge of community preferences and ability to improve patient education and access to care, community health workers (CHWs) can increase palliative care usage by patients. Notably, barriers to CHWs helping patients with serious chronic illness remain poorly understood. Objective: Explore the perception of barriers CHWs feel they face when attempting to support the health care of patients with serious chronic illness. Design: Qualitative semistructured individual interviews of CHWs and qualitative descriptive analysis. Setting/Subjects: Twelve CHWs who have worked with patients with serious chronic illness were recruited from the Johns Hopkins Healthcare LLC and the Baltimore Alliance for Careers in Healthcare organizations to virtually participate. Results: CHWs perceived both active and passive barriers that obstructed their efforts to work with seriously ill patients. CHWs shared that these barriers were dependent on themselves, their peers, and their work environments. Prevalent themes included interprofessional conflict, poor health care worker understanding of the CHW's role, and lack of access to quality resource organizations. CHWs noted job-specific training, better means to identify needed resources for patients, and inclusive health care teams as solutions to support their professional goals, while helping patients with serious illness. Conclusions: There are multiple perceived barriers to CHWs helping seriously ill patients. CHWs aiding patients with serious illness can be supported through better job training, better resource management tools, and improved communication between health care team members.

Community Partnership to Co-Develop an Intervention to Promote Equitable Uptake of the COVID-19 Vaccine Among Pediatric Populations

Objective

To describe the process of engaging community, caregiver, and youth partners in codeveloping an intervention to promote equitable uptake of the COVID-19 vaccine in non-Hispanic Black (Black) and Hispanic youth who experience higher rates of COVID-19 transmission, morbidity, and mortality but were less likely to receive the COVID-19 vaccine.

Methods

A team of 11 Black and Hispanic community partners was assembled to codevelop intervention strategies with our interdisciplinary research team. We used a mixed-methods crowdsourcing approach with Black and Hispanic youth (n=15) and caregivers of Black and Hispanic youth (n=20) who had not yet been vaccinated against COVID-19, recruited from primary care clinics, to elicit perspectives on the acceptability of these intervention strategies.

Results

We codeveloped five strategies: (1) community-tailored handouts and posters, (2) videos featuring local youth, (3) family-centered language to offer vaccines in the primary care clinic, (4) communication-skills training for primary care providers, and (5) use of community health workers to counsel families about the vaccine. The majority (56-96.9%) of youth and caregivers rated each of these strategies as acceptable, especially because they addressed common concerns and facilitated shared decision-making.

Conclusions

Engaging community and family partners led to the co-development of culturally- and locally-tailored strategies to promote dialogue and shared decision-making about the COVID-19 vaccine. This process can be used to codevelop interventions to address other forms of public health disparities.

Policy Implications

Intervention strategies that promote dialogues with trusted healthcare providers and support shared decision-making are acceptable strategies to promote COVID-19 vaccine uptake among youth from historically underserved communities. Stakeholder-engaged methods may also help in the development of interventions to address other forms of health disparities.

Feasibility, acceptability and effectiveness of a culturally informed intervention to decrease stress and promote well-being in reservation-based Native American Head Start teachers

BACKGROUND

While benefiting from strong cultural ties to family, land and culture Native Americans residing on reservations experience psychological distress at rates 2.5 times that of the general population. Treatment utilization for psychological health in reservation-based communities is low with access to culturally appropriate care lacking. Evidence suggests that for mental health treatment, Native Americans prefer culturally informed care that respects Native perspectives on health and well-being.

METHODS

To decrease stress and promote well-being in tribal Head Start teachers we adapted and implemented a culturally focused intervention within a community-based participatory research framework using mixed methods. Feasibility and acceptability of the adapted 5-session curriculum was tested in a single arm intervention study with a sample of 18 teachers on the Fort Peck Reservation. Participants completed surveys at baseline and upon completion of the intervention. Within session observations and two post-intervention focus groups (n = 8, n = 10) were conducted to elaborate and explain the quantitative results eliciting participant experience of intervention effectiveness and feasibility, acceptably and appropriateness. Implementation outcomes were assessed quantitatively using the Acceptability of Intervention, Intervention Appropriateness, and Feasibility of Intervention measures.

RESULTS

Quantitively, attendance rate overall was 93% with no dropouts. Pretest/posttest surveys were analyzed using t-tests and Hedges g to measure effect size. Contrary to our hypothesis, self-perceived stress showed a small positive effect size, indicating that participants were more stressed post intervention. However, depression decreased, with tribal identity and resilience showing positive effect sizes. Content analysis for the qualitative data collected within session observations and post intervention focus groups revealed how lifetime traumas were affecting participants, providing some explanation for the increase in stress. Teachers reported that the sessions helped their psychological health and well-being, supporting feasibility of future interventions. Acceptability scored highest with a mean (SD) of 4.25 (.84) out of 5, appropriateness 4.18 (.86) and feasibility 4.06 (.96) supporting intervention to be acceptable, appropriate, and feasible.

CONCLUSION

Utilizing a culturally based intervention to buffer stress and support the well-being of reservation-based teachers showed promise in helping them recognize their cultural strengths, stress, and need for ongoing support. Implementation outcomes show that intervention scale-out is feasible.

Evaluation of an online research best practices training for community health workers and promotoras

Introduction

Community health workers and promotoras (CHW/Ps) have a fundamental role in facilitating research with communities. However, no national standard training exists as part of the CHW/P job role. We developed and evaluated a culturally- and linguistically tailored online research best practices course for CHW/Ps to meet this gap.

Methods

After the research best practices course was developed, we advertised the opportunity to CHW/Ps nationwide to complete the training online in English or Spanish. Following course completion, CHW/Ps received an online survey to rate their skills in community-engaged research and their perceptions of the course using Likert scales of agreement. A qualitative content analysis was conducted on open-ended response data.

Results

104 CHW/Ps completed the English or Spanish course (n = 52 for each language; mean age 42 years SD ± 12); 88% of individuals identified as female and 56% identified as Hispanic, Latino, or Spaniard. 96%-100% of respondents reported improvement in various skills. Nearly all CHW/Ps (97%) agreed the course was relevant to their work, and 96% felt the training was useful. Qualitative themes related to working more effectively as a result of training included enhanced skills, increased resources, and building bridges between communities and researchers.

Discussion

The CHW/P research best practices course was rated as useful and relevant by CHW/Ps, particularly for communicating about research with community members. This course can be a professional development resource for CHW/Ps and could serve as the foundation for a national standardized training on their role related to research best practices.

Community Health Workers During COVID-19: Supporting Their Role in Current and Future Public Health Responses

Community health workers advance health equity and foster community-clinical linkages. By promoting culturally relevant care, sharing their own stories, and bridging gaps, they can reach populations burdened with higher rates of chronic diseases due to adverse social determinants of health and structural racism. Given the disproportionate impacts of COVID-19, lessons learned from a forum, an expert group, and a survey showed a need by community health workers for (1) training, (2) health and safety practices, (3) workplace guidance, and (4) mental health resources. Community health workers are integral to expanding access to services and require a robust infrastructure for their growth.

Insurance-Based Discrimination Reports and Access to Care Among Nonelderly US Adults, 2011-2019

Objectives. To report insurance-based discrimination rates for nonelderly adults with private, public, or no insurance between 2011 and 2019, a period marked by passage and implementation of the Affordable Care Act (ACA) and threats to it. Methods. We used 2011-2019 data from the biennial Minnesota Health Access Survey. Each year, about 4000 adults aged 18 to 64 years report experiences with insurance-based discrimination. Using logistic regressions, we examined associations between insurance-based discrimination and (1) sociodemographic factors and (2) indicators of access. Results. Insurance-based discrimination was stable over time and consistently related to insurance type: approximately 4% for adults with private insurance compared with adults with public insurance (21%) and no insurance (27%). Insurance-based discrimination persistently interfered with confidence in getting needed care and forgoing care. Conclusions. Policy changes from 2011 to 2019 affected access to health insurance, but high rates of insurance-based discrimination among adults with public insurance or no insurance were impervious to such changes. Public Health Implications. Stable rates of insurance-based discrimination during a time of increased access to health insurance via the ACA suggest deeper structural roots of health care inequities. We recommend several policy and system solutions. (Am J Public Health. 2023;113(2):213-223. https://doi.org/10.2105/AJPH.2022.307126).

Mi Plan: Using a Pediatric-Based Community Health Worker Model to Facilitate Obtainment of Contraceptives Among Latino Immigrant Parents with Contraceptive Needs

BACKGROUND

Bilingual community health workers (CHWs) play an important role in helping Latino immigrants with limited English proficiency (LEP) access health care services and information. Contraceptive health care services and Spanish-language contraceptive information are particularly challenging to access for uninsured LEP immigrants. Contraceptive and reproductive care are longitudinal health needs, and pediatric settings pose a unique opportunity to address these needs among parents whose children access pediatric care. The purpose of this study was to pilot the feasibility of a CHW to support parental contraceptives needs within a pediatric setting serving a high number of Latino immigrant families. This article describes Mi Plan/My Plan, a CHW contraceptive counseling and resource navigation pilot program.

METHODS

The research team conducted a retrospective analysis of demographic and contraceptive use data from a 15-month CHW pilot within an urban, primary care pediatrics clinic. The CHW provided contraceptive counseling, referral, and appointment coordination. The outcome was desired contraceptive method obtainment within three months of counseling.

RESULTS

All 311 individuals counseled were Latina mothers with median child age of 3 months. At baseline, 64.3% were using contraception and 76.5% desired to start or change their current method. Among those who desired a change, 47.9% (114/238) obtained their desired method within three months of initial counselor contact.

CONCLUSION

Bilingual CHW contraceptive counseling and care coordination is feasible and acceptable in a pediatric setting serving a high number of Latino immigrant families. CHWs in pediatric settings support health care access equity and are relevant to optimal maternal and child health.

Using Health Navigators to Connect At-Risk Clients to Community Resources

CONTEXT

The coupling of health care services with complementary resources that address unmet social needs is a progressively popular approach for improving health outcomes among low-income populations. Community health workers are increasingly recognized as a helpful intermediary for clients navigating community and clinical services.

PROGRAM

The Wellness Center at the Historic General Hospital in East Los Angeles employs a team of community health workers, referred to as Health Navigators, who are trained to link low-income clients to resources such as chronic disease management programs, food pantries, free or low-cost legal aid, health insurance enrollment, group fitness classes, and counseling and peer support services.

IMPLEMENTATION

The Center's model of practice has evolved over time, continuously increasing the breadth and depth of services provided by the Health Navigator team. Its goal has been to address clients' unmet social needs while optimizing their health outcomes through the building of stronger community-clinical linkages.

EVALUATION

A program review showed that Health Navigators serve as a critical bridge for clients navigating a complex network of health and social services. They actively engage, recruit, and deliver services to clients. Since 2014, the Health Navigator team has connected more than 28 000 unique clients to resources for health and well-being.

DISCUSSION

By using Health Navigators to assist clients with community resource engagement, the Center has prototyped and promoted an approach that complements clinical care, strengthening the community-clinical linkages that are needed to meaningfully manage chronic disease outside of the hospital or clinic setting.

Mi Familia Entera: Contraceptive Use Among Spanish-Speaking Mothers of Young Children

OBJECTIVES

To characterize contraceptive method use and satisfaction among Spanish-speaking Latina immigrants who attend their child's well care visit.

METHODS

Spanish-speaking women whose youngest child was ≤ 4 years old completed an orally-administered Spanish-language survey in a pediatric clinic (N = 194). Survey items were based on previously published contraceptive use assessments among diverse populations. We used chi-square and Fisher exact test to describe maternal characteristics by contraceptive method effectiveness categories: Tier 1, most effective methods (hormonal implant, intrauterine device, tubal ligation, and vasectomy); Tier 2, very effective methods (hormonal injection, oral contraceptive pill, hormonal patch, and hormonal ring); Tier 3, effective methods (condoms), and no method.

RESULTS

34% of women were using a Tier 1 method, 40% were using a Tier 2 method, and 17% had unmet contraceptive need (no pregnancy intention, no birth control); 84% were satisfied with their current method and 82% of women were uninsured. Tier 2 method or no method users were more likely than women using a Tier 1 method to have children < 9 months old (X² (6, N = 190) = 20.4, p = .002).

CONCLUSIONS

Latina immigrants with young children who attend their child's pediatric visit are mostly using effective contraceptives and are satisfied with their method. A culturally supportive medical home and access to no-cost long-acting reversible contraceptives through a temporary private grant likely contributed to high contraceptive use and satisfaction in our study. Describing maternal contraceptive use among Latina immigrant mothers can inform future equitable, culturally tailored, approaches to pediatric maternal contraceptive need screening.

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 Community Health Worker Approach for Ending the HIV Epidemic

INTRODUCTION

In the second half of 2019, East Baton Rouge Parish, Louisiana was selected as 1 of the 3 jump-start pilot jurisdictions for the Centers for Disease Control and Prevention-funded Ending the HIV Epidemic in the U.S. Initiative. An innovative community health worker program was among the strategies developed to reduce the number of new HIV infections. In addition to testing for HIV/sexually transmitted infections in nontraditional settings, community health workers provided integrated services, including linkage for people with HIV, pre-exposure prophylaxis navigation, sterile injection supplies and referrals to syringe services programs, and other social services.

METHODS

The 5-member community health worker team was representative of the populations they intended to reach. They conducted outreach, from October 2019 to December 2020, within areas known to have a high incidence of new HIV infections.

RESULTS

The community health worker team documented 977 encounters with individuals in their communities. The vast majority of encounters were among Black clients; 9% were among White clients. In total, 48% were among cisgender women, 50% were among cisgender men, and 2% were among transgender women. People who inject drugs represented 7% of the sample. Community health workers conducted rapid testing for HIV (n=320), hepatitis C (n=274), and syphilis (n=280). In addition, they successfully linked 10 people with HIV to HIV medical care and 20 people who inject drugs to a syringe services program and assisted 19 people at risk of HIV infection with pre-exposure prophylaxis initiation.

CONCLUSIONS

The community health worker team successfully facilitated access to HIV prevention and treatment for priority populations in East Baton Rouge Parish.

Awareness and Use of Community Services among Primary Care Physicians

Primary care physicians play an important role in care coordination, including initiating referrals to community resources. Yet, it is unclear how awareness and use of community resources vary between physicians practising with and without an extended healthcare team. We conducted a cross-sectional survey of primary care physicians practising in Toronto, Canada, to compare awareness and use of community services between physicians practising in team- and non-team-based practice models. Team-based models included Community Health Centres and Family Health Teams - settings in which the government provides funding for the practice to hire non-physician health professionals, such as social workers, pharmacists, nurse practitioners, registered nurses and others. The survey was mailed to physicians, and reminders were done by phone, fax and e-mail. We used logistic regression to compare awareness between physicians in team-based (N = 89) and non-team-based (N = 138) models after controlling for confounders. We found that fewer than half of the physicians were aware of five of eight centralized intake services (e.g., ConnexOntario, Telehomecare). For most services, team-based physicians had at least twice the odds of being aware of the service compared to non-team-based physicians. Our findings suggest that patients in team-based practices may be doubly advantaged, with access to non-physician health professionals within the practice as well as to physicians who are more aware of community resources.

Potential for community based surveillance of febrile diseases: Feasibility of self-administered rapid diagnostic tests in Iquitos, Peru and Phnom Penh, Cambodia

Rapid diagnostic tests (RDTs) have the potential to identify infectious diseases quickly, minimize disease transmission, and could complement and improve surveillance and control of infectious and vector-borne diseases during outbreaks. The U.S. Defense Threat Reduction Agency's Joint Science and Technology Office (DTRA-JSTO) program set out to develop novel point-of-need RDTs for infectious diseases and deploy them for home use with no training. The aim of this formative study was to address two questions: 1) could community members in Iquitos, Peru and Phnom Penh, Cambodia competently use RDTs of different levels of complexity at home with visually based instructions provided, and 2) if an RDT were provided at no cost, would it be used at home if family members displayed febrile symptoms? Test kits with written and video (Peru only) instructions were provided to community members (Peru [n = 202]; Cambodia [n = 50]) or community health workers (Cambodia [n = 45]), and trained observers evaluated the competency level for each of the several steps required to successfully operate one of two multiplex RDTs on themselves or other consenting participant (i.e., family member). In Iquitos, >80% of residents were able to perform 11/12 steps and 7/15 steps for the two- and five-pathogen test, respectively. Competency in Phnom Penh never reached 80% for any of the 12 or 15 steps for either test; the percentage of participants able to perform a step ranged from 26-76% and 23-72%, for the two- and five-pathogen tests, respectively. Commercially available NS1 dengue rapid tests were distributed, at no cost, to households with confirmed exposure to dengue or Zika virus; of 14 febrile cases reported, six used the provided RDT. Our findings support the need for further implementation research on the appropriate level of instructions or training needed for diverse devices in different settings, as well as how to best integrate RDTs into existing local public health and disease surveillance programs at a large scale.

Improving Breastfeeding in Rural Tanzania Using Eight-Step Policy Analysis Methodology

Appropriate breastfeeding has the potential to have the broadest impact on childhood survival in children under 5 years compared with all other preventive interventions. The World Health Organization and United Nations International Children's Emergency Fund recommend that all facilities providing maternal services and newborn care have a written policy addressing breastfeeding that is routinely disseminated to staff. A Mara region hospital in rural Tanzania does not have a breastfeeding policy. Collins adapted Bardach's eightfold path for policy analysis specifically for health policies. This eight-step process was used to evaluate three promising policies to improve breastfeeding in populations in and around this hospital. These policies include exclusive breastfeeding education, complementary food education, and community health worker home visits. Analysis identified exclusive breastfeeding with adjunct complementary food education as the most feasible policies to increase breastfeeding in and around the target hospital. With improved feeding practices, chronic malnutrition rates are expected to decline in the villages that the hospital serves. This methodology can be used by nurses to develop health polices addressing a wide range of health issues in a wide variety of settings.

Community-based participatory design of a community health worker breast cancer training intervention for South Florida Latinx farmworkers

OBJECTIVE

Community health worker (CHW)-led education is an important strategy to increase awareness and access to breast cancer screening in medically-underserved communities. This study aimed to develop a context-specific, culturally-appropriate training intervention for South Florida CHWs to educate Latinx immigrant farmworkers on breast cancer and early detection.

METHODS

A community-based participatory research (CBPR) study, conducted 2017-2019, informed the design of a training curriculum for CHWs and educational dissemination materials. Twenty-two CHWs were trained and knowledge gains were measuring using a one-group pre-and post-test design. Triangulated evaluation consisted of field observations of CHW-client interactions, CHW self-reports, and rapid assessment surveys of community members.

RESULTS

A community stakeholder-informed breast cancer training curriculum resulted in significant, sustained breast cancer knowledge gains among CHWs when comparing pre-, post-, and 4-6 month post-training follow-up test scores. Field observations of educational material dissemination, CHW self-reported evaluations, and community rapid assessment surveys at three health fairs demonstrated this was an effective strategy to engage female Latinx farmworkers in breast cancer education.

CONCLUSIONS

Community and key stakeholder participation in the development of a breast cancer educational intervention allowed for tailored design priorities around knowledge-based content, comprehensiveness, relevance, appropriateness, and ease of dissemination to community members. This model of participatory CHW training intervention design can enable future train-the-trainer approaches to disseminate and scale-up evidence-based health education interventions.

Community health workers: improving population health through integration into healthcare systems

PURPOSE OF REVIEW

The purpose of this review is to describe the role, responsibilities, hiring, training, and retention of community health workers (CHWs) on clinical care teams in the United States.

RECENT FINDINGS

CHWs are unique members of clinical care teams because of their ability to foster a deep trust and understanding with patients by sharing similar life experiences, participating in home visits, and providing constant support and advocacy. By partnering with CHWs, other clinical care members also gain a better understanding of their patients allowing them to deliver more culturally competent, patient/family-centered care. CHWs when incorporated into interdisciplinary teams have shown to lower healthcare costs, reduce hospital stays and admissions, and improve health outcomes and quality of life for children and families. However, the lack of standardization among CHW programs makes it difficult to quantify the overall effect and impact of integrating CHWs into clinical care teams.

SUMMARY

CHWs are able to improve health outcomes and address social determinants of health when properly integrated into clinical care teams. However, without adequate support, integration, funding, and training, CHWs are not able to reach their full potential. The standardization of CHWs' responsibilities and training, like other clinical care team members, is lacking within the United States, making it a challenge to evaluate programs and maintain sustainable funding for these vital members of the clinical care team.

Community Health Workers as an Extension of Care Coordination in Primary Care: A Community-Based Cosupervisory Model

Community health workers (CHWs) bring their unique capacity as liaisons for patients, communities, and health care systems to health care teams. We describe the collaborative development of a community-based CHW program to address the social determinants of health that affect patients. This cosupervisory, generalist CHW model provides an innovative template for cocreation of patient-centered infrastructure and resourcing within an evolving and replicable holistic care continuum across patient ages, diagnoses, health care payers, and communities to promote health equity. The program has been effective in decreasing health care utilization and cost.

Opportunities for Community Health Worker Training to Improve Access to Health Care for Medicaid Enrollees

Limited access to care can negatively affect population health, which is particularly concerning for individuals of lower socioeconomic status. Shortages of US health care providers in areas that predominantly serve Medicaid enrollees contribute to a lack of access. The Ohio Medicaid Technical Assistance and Policy Program Healthcare Access Initiative was designed as a workforce development initiative to train and deploy community health workers (CHWs). The authors conducted 55 key informant interviews with preceptors, CHWs, and administrators across 5 sites with the specific aim of improving understanding of common barriers to and benefits of CHW program implementation across different CHW programs in Ohio. CHW programs reportedly act as a bridge between the patient and providers, and program benefits were reported for participants, organizations, and patients. This study found that CHW programs enabled training of health professionals that can empower participants while allowing them to also give back to their communities. Organizations employing CHWs reported being able to extend clinic services, increase utilization of community resources, and improve patient compliance through the efforts of CHWs; program impacts also led to increased patient support, patient education, and overall better care. To better integrate CHWs into health care organizations, organizations should focus on clearly defining the CHW role and ensuring adequate infrastructure to support CHW efforts.

Patient-level Predictors of Extent of Exposure to a Community Health Worker Intervention in a Randomized Controlled Trial

Objective

Community health worker (CHW) interventions have been cited as a best practice for reducing health disparities, but patient-level attributes may contribute to differential uptake. We examined patient characteristics associated with the extent of exposure to a CHW coaching intervention among a predominantly low-income, African American population participating in a randomized controlled trial of hypertension interventions.

Design

We conducted a within-group longitudinal analysis of those receiving a CHW intervention from a study conducted between September 2003 and August 2005. We employed mixed effects models to ascertain relationships between patients' characteristics, length of time spent with the CHW, and the number of topics discussed during the intervention.

Setting

Baltimore, MD.

Participants

140 patients with a diagnosis of hypertension in the CHW intervention arm.

Results

Marital status, stress, depression symptomology, and having multiple comorbid conditions were each independently and positively related to the length of time patients spent with CHWs. An indirect relationship between higher perceived physical health and time spent with the CHW was observed. Patients with multiple comorbid conditions discussed more intervention-related topics, while patients who perceived themselves as being healthier discussed fewer topics. Marital status and extreme poverty were the strongest predictors of the length of time spent with the CHW, while having multiple comorbid conditions was the strongest predictor of the number of coaching topics discussed.

Conclusions

Differential exposure to a CHW intervention is influenced by patients' physical, psychosocial, and sociodemographic characteristics.

Evaluating a Community-Placed and Clinically Integrated Community Health Worker Program: A Realist Approach

Community health worker (CHW) programs can act as bridges between patients and health care teams, but the complexity and variability of program components and outcomes make them difficult to evaluate. This evaluation used a realist approach to identify underlying mechanisms and contextual factors associated with successful implementation of a community-placed CHW program affiliated with a primary care practice in the Midwest United States. The analysis identified mechanisms by which stakeholders built trust, self-efficacy, and empowerment to improve patient-centered outcomes and experiences. It also identified conditions that support activation of these mechanisms, including the ability of CHWs to make home visits, effective communication between members of the care team across settings, and clarity about the role of the CHW relative to other support services for patients. This type of context-mechanism-outcome evaluation facilitated development of recommendations responsive to local context.

Do community health workers affect non-urgent, ambulatory healthcare utilization among low-income, minority patients with diabetes?

Community health workers (CHWs) can reduce emergent care among low-income, ethnic minority patients with type 2 diabetes. A secondary analysis of a randomized controlled trial evaluated the effect of CHWs on non-urgent, ambulatory healthcare utilization. Within this trial, no effect on ambulatory care was found.

Fidelity of HIV programme implementation by community health workers in rural Mopani district, South Africa: a community survey

BACKGROUND

South Africa has implemented a community health programme delivered by community health workers (CHWs) to strengthen primary healthcare services. Provision of community Human Immunodeficiency Virus (HIV) services constitutes an important component of this programme. To support effectiveness, we assessed fidelity of HIV programme implementation by CHWs from the community's perspective in a rural South African setting.

METHODS

A cross-sectional study was conducted targeting 900 randomly selected households in twelve wards of two sub-districts (Greater Giyani and Greater Letaba) of Mopani District (Limpopo Province, South Africa). Questionnaires were administered to the traditionally most appropriate adult member of the household. Included were questions related to the four standard components to measure implementation fidelity against local guidelines: coverage, frequency, duration and content of HIV programme implementation.

RESULTS

Participants were enrolled at 534 households; in most other cases there was nobody or no adult member at home (n = 291). Reported coverage of 55% (141/253) and a frequency of 47% (66/140) were higher in Greater Giyani as compared to Greater Letaba (44%; 122/278 and 29%; 33/112, respectively, p = 0.007 for both comparisons). Coverage was not associated with the distance from the participant's household to the facility (p = 0.93). Duration of programme delivery was reported to be high, where all CHW visits (253/253; 100%) were conducted within the last 6 months and the content delivered was adequate (242/253; 96%). Individuals reporting a CHW visit were more likely to know their HIV status than those not visited (OR = 2.0; 95% CI 1.06-3.8; p = 0.032). Among those visited by the CHW discussion of HIV was associated with knowing the HIV status (OR = 2.2; 95% CI 1.02-4.6; p = 0.044); in particular for women (OR = 2.9; 95% CI 1.5-5.4; p = 0.001).

CONCLUSIONS

This study demonstrates promising HIV programme implementation fidelity by CHWs in rural South Africa. Programme coverage and frequency should be improved whilst maintaining the good levels of duration and content. Resource investment, strengthening of operational structure, and research to identify other facilitators of programme implementation are warranted to improve programme effectiveness and impact.

The Brazilian Family Health Strategy and the management of intestinal parasitic infections

AimThis study analyzed the management of intestinal parasitic infections in the Family Health Strategy covering Brazilian urban slums.

BACKGROUND

The Family Health Strategy is the preferred strategy for providing public, community-based primary health care in the Brazilian Unified Health System (SUS). Through this strategy, Family Health teams are responsible for the health of residents of a defined territory, including health promotion, health education and control of neglected tropical diseases such as intestinal parasitic infections.

METHODS

Knowledge, attitudes and practices surveys were applied with Family Health team members (n=58) and patients (n=571) of an agglomeration of Brazilian urban slums in Rio de Janeiro.FindingsThe management of intestinal parasitic infections and health promotion were limited. Health education was not considered an essential aspect of team members' work and did not include environmental or social determinants of health. Community health workers and urban slum residents presented similar knowledge, attitudes and practices regarding intestinal parasitic infections.

CONCLUSIONS

Multiple, competing demands promote prioritization of the aspects of care where curative, biomedical activities predominate over prevention and an integral approach to health. However, the complex processes involving the cycle of poverty and disease go beyond the biomedical, limiting the potential for health in urban slums. Implications include a need to better prepare health professionals for primary health care services through reflection on local concerns and the social determinants of health, highlighting the importance of territorialized care and permanent education.

Documenting Community Health Worker Roles in Primary Care: Contributions to Evidence-Based Integration Into Health Care Teams, 2015

The Patient Protection and Affordable Care Act provided community health workers (CHWs) with new opportunities, and current efforts develop evidence-based guidelines for CHW integration into clinical teams. This qualitative study documents CHW roles and activities in 3 federally qualified health care centers in southern Arizona. Community health worker clinical roles, activities, and integration varied by health center and were in flux. Integration included complementary roles, scheduled and everyday communications with team members, and documentation in the electronic health records. These findings contribute to evidence-based guidelines for CHW integration into clinical teams that are critical to maximizing CHW contributions to patient health improvements.

Diabetes Mellitus Management Among Patients with Limited English Proficiency: A Systematic Review and Meta-Analysis

BACKGROUND

Patients with limited English proficiency (LEP) and type 2 diabetes mellitus (T2DM) have several health disparities, including suboptimal patient-provider interactions, poorer glycemic control, and T2DM complications. Understanding existing interventions for improving T2DM outcomes in this population is critical for reducing disparities.

METHODS

We performed a systematic review of randomized controlled trials (RCTs) and observational studies examining the effectiveness of interventions in improving T2DM outcomes among patients with LEP in North America. Quality was assessed using the Cochrane risk of bias tool for RCTs and the Newcastle-Ottawa Scale for non-RCT studies. Meta-analysis was conducted using the random-effects model.

RESULTS

Fifty-four studies, 39 of which reported sufficient data for meta-analysis of glycemic control, were included. The interventions were associated with a statistically significant reduction in hemoglobin A_1c (HbA_1c) (weighted difference in means, -0.84% [95% CI, -0.97 to -0.71]) that was, however, very heterogeneous across studies (I² = 95.9%). Heterogeneity was explained by study design (lower efficacy in RCTs than non-RCTs) and by intervention length and delivery mode (greater reduction in interventions lasting <6 months or delivered face-to-face); P < 0.05 for all three covariates. The interventions were also associated in most studies with improvement in knowledge, self-efficacy in diabetes management, quality of life, blood pressure, and low-density lipoprotein cholesterol.

DISCUSSION

Multiple types of interventions are available for T2DM management in patients with LEP. Multicomponent interventions delivered face-to-face seem most effective for glycemic control. More research is needed to better understand other aspects of multicomponent interventions that are critical for improving important outcomes among patients with T2DM and LEP.

Community Health Workers and Use of mHealth: Improving Identification of Pregnancy Complications and Access to Care in the Dominican Republic

This article presents the feasibility and acceptability of using mobile health technology by community health workers (CHWs) in San Juan Province, Dominican Republic, to improve identification of pregnancy complications and access to care for pregnant women. Although most women in the Dominican Republic receive four antenatal care visits, poor women and adolescents in remote areas are more likely to have only one initial prenatal visit to verify the pregnancy. This community-based research began when community leaders raised concern about the numbers of their mothers who died in childbirth annually; San Juan's maternal mortality rate is 144/100,000 compared to the Caribbean rate of 85/100,000. Eight CHWs in three communities were taught to provide third-trimester antenatal assessment, upload the data on a mobile phone application, send the data to the local physician who monitored data for "red flags," and call directly if a mother had an urgent problem. Fifty-two pregnant women enrolled, 38 were followed to delivery, 95 antenatal care postintake were provided, 2 urgent complications required CHW home management of mothers, and there were 0 deaths. Stakeholders endorsed acceptability of intervention. Preliminary data suggest CHWs using mobile health technology is feasible, linking underserved and formal health care systems with provision of primary care in mothers' homes.

Changing medical relationships after the ACA: Transforming perspectives for population health

American health care has undergone significant organizational change in recent decades. But what is the state of core medical relationships in the wake of these changes? Throughout ACA-era health care reform, the doctor-patient relationship was targeted as a particularly important focus for improving communication and health outcomes. Recent developments however have shifted the focus from individual-level outcomes to the wellbeing of populations. This, we argue, requires a fundamental rethinking of health care reform as an opportunity to renegotiate relationships. For example, the move to population medicine requires that the very concept of a patient be resituated and the scope of relevant relationships expanded. Medical relationships in this era of health care are likely to include partnerships between various types of clinicians and the communities in which patients reside, as well as a host of new actors, from social workers and navigators to scribes and community health workers. To address the upstream determinants of population health, providers must be increasingly willing and trained to collaborate with community stakeholders to address both medical and non-medical issues. These community-based partnerships are critical to providing health care that is both relevant and appropriate for addressing problems, and sustainable. Approaching health care reform, and the focus on population health, as a fundamental reworking of relationships provides scholars with a sharper theoretical lens for understanding 21st century American health care.

Evangelical Protestants and the ACA: An Opening for Community-Based Primary Care?

Evangelical Protestants make up the largest religious subgroup in the United States, and previous research has shown that Evangelical churches are disproportionately active in community engagement and efforts toward social change. Although Evangelical Protestant perspectives have been considered with regard to persistent socioeconomic stratification and racial discrimination, less focus has been given to how churches interpret poor health outcomes within the United States. In particular, this research addresses how enduring health disparities are understood within the larger discussion of healthcare reform. Due to the similarity of approaches favored by participants in this study and community-based philosophy, a suggestion is made for future health policy dialogue. Although Evangelical Protestants have been most likely to reject all aspects of the Affordable Care Act, in many ways the findings of this study suggest the potential for successful future health policy collaboration. In particular, community-based primary care might appeal to Evangelicals and health professionals in the ongoing effort to improve population health and the quality of healthcare in the United States.

Reduced Prevalence of Obesity in 14 Disadvantaged Black Communities in the United States: A Successful 4-Year Place-Based Participatory Intervention

OBJECTIVES

To assess the impact of a large-scale place-based intervention on obesity prevalence in Black communities.

METHODS

The Racial and Ethnic Approaches to Community Health across the United States (REACH US) project was conducted in 14 predominantly Black communities in California, Illinois, Massachusetts, New York, Ohio, Pennsylvania, South Carolina, Virginia, Washington, and West Virginia. We measured trends from 2009 to 2012 in the prevalence of obesity. We used Behavioral Risk Factor Surveillance System data to compare these trends with trends among non-Hispanic Whites and non-Hispanic Blacks in the United States and in the 10 states where REACH communities were located, and with a propensity score-matched national sample of non-Hispanic Blacks.

RESULTS

The age-standardized prevalence of obesity decreased in REACH US communities (P = .045), but not in the comparison populations (P = .435 to P = .996). The relative change was -5.3% in REACH US communities versus +2.4% in propensity score-matched controls (P value for the difference = .031). The net effect on the reduction of obesity prevalence was about 1 percentage point per year for REACH.

CONCLUSIONS

Obesity prevalence was reduced in 14 disadvantaged Black communities that participated in the REACH project.

Improving actions to control high blood pressure in Hispanic communities - Racial and Ethnic Approaches to Community Health Across the U.S. Project, 2009-2012

BACKGROUND

Compared with the general population in the United States (U.S.), Hispanics with hypertension are less likely to be aware of their condition, to take antihypertensive medication, and to adopt healthy lifestyles to control high blood pressure. We examined whether a multi-community intervention successfully increased the prevalence of actions to control hypertension among Hispanics.

METHODS

Annual survey from 2009-2012 was conducted in six Hispanic communities in the Racial and Ethnic Approaches to Community Health (REACH) Across the U.S.

PROJECT

The survey used address based sampling design that matched the geographies of intervention program.

RESULTS

Age- and sex-standardized prevalences of taking hypertensive medication, changing eating habits, cutting down on salt, and reducing alcohol use significantly increased among Hispanics with self-reported hypertension in REACH communities. The 3-year relative percent increases were 5.8, 6.8, 7.9, and 35.2% for the four indicators, respectively. These favorable (healthier) trends occurred in both foreign-born and U.S.-born Hispanics.

CONCLUSION

This large community-based participatory intervention resulted in more Hispanic residents in the communities taking actions to control high blood pressure.

Activating Patients for Sustained Chronic Disease Self-Management: Thinking Beyond Clinical Outcomes

This article describes the impact of an 8-week community program implemented by trained volunteers on the hypertension self-management of 185 patients who were batch randomized to intervention or wait-list control groups. Compared with control group participants, a higher proportion of treatment group participants moved from the cognitive to behavioral stages of motivational readiness for being physically active (P < .001), practicing healthy eating habits (P = .001), handling stress well (P = .001), and living an overall healthy lifestyle (P = .003). They also demonstrated a greater average increase in perceived competence for self-management, F(1.134) = 4.957, P = .028, η2 = .036, and a greater increase in mean hypertension-related knowledge, F(1.160) = 16.571, P < .0005, η(2) = .094. Enduring lifestyle changes necessary for chronic disease self-management require that psychosocial determinants of health behavior are instilled, which is typically beyond standard medical practice. We recommend peer-led, community-based programs as a complement to clinical care and support the increasing health system interest in promoting population health beyond clinical walls.