Linking community-based blood pressure measurement to clinical care: a randomized controlled trial of outreach and tracking by community health workers

Evaluating Intensity, Complexity, and Potential for Causal Inference in Social Needs Interventions: A Review of a Scoping Review

Importance

Interventions that address needs such as low income, housing instability, and safety are increasingly appearing in the health care sector as part of multifaceted efforts to improve health and health equity, but evidence relevant to scaling these social needs interventions is limited.

Objective

To summarize the intensity and complexity of social needs interventions included in randomized clinical trials (RCTs) and assess whether these RCTs were designed to measure the causal effects of intervention components on behavioral, health, or health care utilization outcomes.

Evidence Review

This review of a scoping review was based on a Patient-Centered Outcomes Research Institute-funded evidence map of English-language US-based RCTs of social needs interventions published between January 1, 1995, and April 6, 2023. Studies were assessed for features related to intensity (defined using modal values as providing as-needed interaction, 8 participant contacts or more, contacts occurring every 2 weeks or more often, encounters of 30 minutes or longer, contacts over 6 months or longer, or home visits), complexity (defined as addressing multiple social needs, having dedicated staff, involving multiple intervention components or practitioners, aiming to change multiple participant behaviors [knowledge, action, or practice], requiring or providing resources or active assistance with resources, and permitting tailoring), and the ability to assess causal inferences of components (assessing interventions, comparators, and context).

Findings

This review of a scoping review of social needs interventions identified 77 RCTs in 93 publications with a total of 135 690 participants. Most articles (68 RCTs [88%]) reported 1 or more features of high intensity. All studies reported 1 or more features indicative of high complexity. Because most studies compared usual care with multicomponent interventions that were moderately or highly dependent on context and individual factors, their designs permitted causal inferences about overall effectiveness but not about individual components.

Conclusions and Relevance

Social needs interventions are complex, intense, and include multiple components. Our findings suggest that RCTs of these interventions address overall intervention effectiveness but are rarely designed to distinguish the causal effects of specific components despite being resource intensive. Future studies with hybrid effectiveness-implementation and sequential designs, and more standardized reporting of intervention intensity and complexity could help stakeholders assess the return on investment of these interventions.

Lay advisor interventions for hypertension outcomes: A Systematic Review, Meta-analysis and a RE-AIM evaluation

Introduction

Lay advisor interventions improve hypertension outcomes; however, the added benefits and relevant factors for their widespread implementation into health systems are unknown. We performed a systematic review to: (1) summarize the benefits of adding lay advisors to interventions on hypertension outcomes, and (2) summarize factors associated with successful implementation in health systems using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework.

Methods

We systematically searched several databases, including Ovid MEDLINE, CINAHL, PsycINFO from January 1981 to May 2023. All study designs of interventions delivered solely by lay advisors for adults with hypertension were eligible. If both arms received the lay advisor intervention, the study arm with lower intensity was assigned as the low-intensity intervention.

Results

We included 41 articles, of which 22 were RCTs, from 7,267 screened citations. Studies predominantly included socially disadvantaged populations. Meta-analysis (9 RCTs; n = 4,220) of eligible lay advisor interventions reporting outcomes showed improved systolic blood pressure (BP) [-3.72 mm Hg (CI -6.1 to -1.3; I2 88%)], and diastolic BP [-1.7 mm Hg (CI -1 to -0.9; I2 7%)] compared to control group. Pooled effect from six RCTs (n = 3,277) comparing high-intensity with low-intensity lay advisor interventions showed improved systolic BP of -3.6 mm Hg (CI -6.7 to -0.5; I2 82.7%) and improved diastolic BP of -2.1 mm Hg (CI -3.7 to -0.4; I2 70.9%) with high-intensity interventions. No significant difference in pooled odds of hypertension control was noted between lay advisor intervention and control groups, or between high-intensity and low-intensity intervention groups. Most studies used multicomponent interventions with no stepped care elements or reporting of efficacious components. Indicators of external validity (adoption, implementation, maintenance) were infrequently reported.

Discussion

Lay advisor interventions improve hypertension outcomes, with high intensity interventions having a greater impact. Further studies need to identify successful intervention and implementation factors of multicomponent interventions for stepped upscaling within healthcare system settings as well as factors used to help sustain interventions.

Advancing health equity through social care interventions

OBJECTIVE

To use evidence on addressing racism in social care intervention research to create a framework for advancing health equity for all populations with marginalized social identities (e.g., race, gender, and sexual orientation). Such groups have disproportionate social needs (e.g., food insecurity) and negative social determinants of health (SDOH; e.g., poverty). We recommend how the Agency for Healthcare Research and Quality (AHRQ) could advance health equity for marginalized populations through social care research and care delivery.

DATA SOURCES AND STUDY SETTING

This commentary is informed by a literature review of social care interventions that were affiliated with healthcare systems; input from health equity researchers, policymakers, and community leaders attending the AHRQ Health Equity Summit; and consensus of the authors.

PRINCIPAL FINDINGS

We recommend that AHRQ: (1) create an ecosystem that values research on SDOH and the effectiveness and implementation of social care interventions in the healthcare sector; (2) work with other federal agencies to (a) develop position statements with actionable recommendations about racism and other systems that perpetuate marginalization based on social identity and (b) develop aligned, complementary approaches to research and care delivery that address social marginalization; (3) advance both inclusive care delivery and inclusive research teams; (4) advance understanding of racism as a social determinant of health and effective strategies to mitigate its adverse impact on health; (5) advance the creation and scaling of effective strategies for addressing SDOH in healthcare systems, particularly in co-creation with community partners; and (6) require social care intervention researchers to use methods that advance our understanding of social health equity.

CONCLUSIONS

AHRQ, as a federal agency, could help advance health equity using a range of strategies, including using the agency's levers to ensure AHRQ stakeholders examine and address the unique experiences of socially marginalized populations in SDOH and social care intervention research.

Family physician services and blood pressure control in China: A population-based retrospective cohort study

OBJECTIVE

Given the importance of continuous family physician (FP) care in the management of hypertension, we explored the effects of such care among hypertensive patients in China, a country where such care is generally underutilized. We examined the longitudinal association between the use and continuity of FP services and health outcomes including blood pressure (BP) control rate, systolic blood pressure (SBP), and diastolic blood pressure (DBP).

METHODS

We conducted a population-based cohort study using data from the retrospective regional electronic health record database in Xiamen City, China. The study considered 18,119 hypertensive patients aged over 18 years who had at least two visits to a health center in the preceding 12 months. The generalized estimating equation model was adopted to estimate the longitudinal association between FP service utilization and health outcomes.

RESULTS

Hypertensive patients treated by their own FPs had a higher BP control rate (OR = 1.14, 95% CI: 1.02-1.28) and lower DBP (-0.36 mmHg, 95% CI: -0.52 to -0.20) than those without a FP or those with a FP but treated by a general community physician (GCP). Compared with hypertensive patients treated exclusively by GCPs, patients treated continuously and exclusively by a FP were 45% more likely to have their BP under control (OR = 1.45, 95% CI: 1.32-1.60), and their SBP and DBP were lower by 0.6 mmHg (95% CI: -0.78 to -0.39) and 0.6 mmHg (95% CI: -0.79 to -0.47), respectively.

CONCLUSIONS

Hypertensive patients continuously treated by their own FPs performed better in terms of BP control rate, SBP and DBP values. In addition, the number and continuity of FP visits were associated with better BP control.

Racial Health Equity and Social Needs Interventions: A Review of a Scoping Review

IMPORTANCE

Social needs interventions aim to improve health outcomes and mitigate inequities by addressing health-related social needs, such as lack of transportation or food insecurity. However, it is not clear whether these studies are reducing racial or ethnic inequities.

OBJECTIVE

To understand how studies of interventions addressing social needs among multiracial or multiethnic populations conceptualize and analyze differential intervention outcomes by race or ethnicity.

EVIDENCE REVIEW

Sources included a scoping review of systematic searches of PubMed and the Cochrane Library from January 1, 1995, through November 29, 2021, expert suggestions, and hand searches of key citations. Eligible studies evaluated interventions addressing social needs; reported behavioral, health, or utilization outcomes or harms; and were conducted in multiracial or multiethnic populations. Two reviewers independently assessed titles, abstracts, and full text for inclusion. The team developed a framework to assess whether the study was "conceptually thoughtful" for understanding root causes of racial health inequities (ie, noted that race or ethnicity are markers of exposure to racism) and whether analyses were "analytically informative" for advancing racial health equity research (ie, examined differential intervention impacts by race or ethnicity).

FINDINGS

Of 152 studies conducted in multiracial or multiethnic populations, 44 studies included race or ethnicity in their analyses; of these, only 4 (9%) were conceptually thoughtful. Twenty-one studies (14%) were analytically informative. Seven of 21 analytically informative studies reported differences in outcomes by race or ethnicity, whereas 14 found no differences. Among the 7 that found differential outcomes, 4 found the interventions were associated with improved outcomes for minoritized racial or ethnic populations or reduced inequities between minoritized and White populations. No studies were powered to detect differences.

CONCLUSIONS AND RELEVANCE

In this review of a scoping review, studies of social needs interventions in multiracial or multiethnic populations were rarely conceptually thoughtful for understanding root causes of racial health inequities and infrequently conducted informative analyses on intervention effectiveness by race or ethnicity. Future work should use a theoretically sound conceptualization of how race (as a proxy for racism) affects social drivers of health and use this understanding to ensure social needs interventions benefit minoritized racial and ethnic groups facing social and structural barriers to health.

Effect of health extension workers led home-based intervention on hypertension management in Northwest Ethiopia, 2021: study protocol for a cluster randomised controlled trial

INTRODUCTION

Although hypertension is highly prevalent in Ethiopia, it is poorly diagnosed, treated and controlled. Poor access to care and a shortage of healthcare providers are major barriers. This study aims to evaluate the effects of health extension workers' led home-based intervention on hypertension management in patients with hypertension in rural districts of northwest Ethiopia.

METHODS AND ANALYSIS

A two-arm cluster randomised controlled trial will be conducted among 456 hypertensive patients. Adults aged ≥25 years who have a diagnosis of hypertension both in the home-based hypertension screening study and at another measurement prior to recruitment will be eligible for the study. Randomisation will be done at the kebele level. In the intervention clusters, trained health extension workers will provide home-based intervention for hypertensive patients every 2 months for 9 months. The primary outcomes of the trial will be clinical linkage and blood pressure changes, whereas the secondary outcomes will be lifestyle modification, medication adherence and blood pressure control. Intention-to-treat analysis will be used for all primary analyses. A linear mixed-effect regression model will be used to model the change in blood pressure, while a mixed effect logistic regression model will be used to evaluate the intervention's effect on the binary outcomes. Effect sizes such as mean difference for the continuous outcomes and relative risk, attributable risk and population attributable risk for binary outcomes will be used. All statistical analyses are two sided and a p<0.05 will be used.

ETHICS AND DISSEMINATION

This study has been approved by institutional review board of the University of Gondar (Ref. No: V/P/RCS/05/2293/2020). The district's health office will grant permission for cluster randomisation, and each participant will provide written informed consent for participation. The findings will be presented at scientific conferences and published in peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

PACTR202102729454417.

Cluster-randomized controlled trial for the early promotion of clinic visits for untreated hypertension

Despite clear evidence of the benefits of lowering blood pressure among patients with hypertension, the treatment rate remains <40% worldwide. In the present trial, we aimed to investigate the effects of the early promotion of clinic visits among patients with untreated hypertension detected during annual health checkups. This was a worksite-based, parallel group, cluster-randomized trial with blinded outcome assessment. Employees of 152 Japanese supermarket stores found to have untreated hypertension (blood pressure levels ≥ 160/100 mmHg) during health checkups were assigned to an early promotion group (encouraged to visit a clinic in face-to-face interviews and provided with a referral letter to a physician as well as a leaflet) or a control group (received usual care), according to random assignment. The primary outcome was the completion of a clinic visit within 6 months. Odds ratios with 95% confidence intervals for the early promotion group versus the control group were estimated using multilevel logistic regression with random effects of clusters. A total of 273 participants (mean age 50.3 years, 55% women) from 107 stores were assigned to the early promotion group (138 from 55 stores) or control group (135 from 52 stores). During the 6-month follow-up, 47 (34.1%) participants in the early promotion group visited a clinic, as did 26 (19.3%) in the control group (odds ratio 2.33, 95% confidence interval 1.12-4.84, P = 0.024). Early promotion using a referral letter during health checkups significantly increased the number of clinic visits within 6 months completed by participants with untreated hypertension (UMIN000025411).

Development and Validation of a Tool to Assess Perceptions and Practices Regarding Hypertension and Associated Comorbidities among Primary Health Care Providers of a Rural Community in India

BACKGROUND

Primary health-care providers can play a crucial role in the prevention and early detection of non-communicable diseases. Knowledge, attitude, and practice (KAP) survey of primary health-care providers is needed to assess their gaps in knowledge, and identify barriers for effective implementation of the national program. However, such KAP instruments are lacking.

OBJECTIVE

The aim of this study is to develop, validate and assess the reliability of a questionnaire to determine the KAPs of primary health-care providers about hypertension and associated comorbidities.

MATERIALS AND METHODS

This study was conducted in the following steps: item construction and psychometric testing, by validity and reliability analysis.

RESULTS

The final KAP questionnaire comprised 25 knowledge items, 12 attitude items, and 8 practice items. Exploratory factor analysis using principal axis factoring with varimax rotation revealed four dimensions in the attitude section explaining 35.93% and two dimensions in practice sections explaining 65.96% of the total variance. Cronbach's alpha coefficient for attitude and practice session measured 0.65 and 0.85, respectively. A Kuder Richardson value of 0.70 was obtained for the knowledge section. ICC coefficients were 0.56 (P < 0.00) for knowledge, 0.77 (P < 0.00) for attitude and 0.88 (P < 0.00) for practice sections indicating moderate-to-good correlations. Overall, the instrument developed had acceptable validity and reliability.

CONCLUSION

Overall, the instrument developed had acceptable validity and reliability to assess the perceptions and practices of primary healthcare providers about prevention and control of hypertension and associated comorbidities in the community.

A Systematic Review of Interventions to Minimize Transportation Barriers Among People with Chronic Diseases

Transportation is an important social determinant of health. Transportation barriers disproportionately affect the most vulnerable groups of society who carry the highest burden of chronic diseases; therefore, it is critical to identify interventions that improve access to transportation. We synthesized evidence concerning the types and impact of interventions that address transportation to chronic care management. A systematic literature search of peer-reviewed studies that include an intervention with a transportation component was performed using three electronic databases-PubMed, EMBASE, and CINAHL-along with a hand-search. We screened 478 unique titles and abstracts. Two reviewers independently evaluated 41 full-text articles and 10 studies met eligibility criteria for inclusion. The transportation interventions included one or more of the following: providing bus passes (n = 5), taxi/transport vouchers or reimbursement (n = 3), arranging or connecting participants to transportation (n = 2), and a free shuttle service (n = 1). Transportation support was offered within multi-component interventions including counseling, care coordination, education, financial incentives, motivational interviewing, and navigation assistance. Community health/outreach workers (n = 3), nurses (n = 3), and research or clinic staff (n = 3) were the most common interventionists. Studies reported improvements in cancer screening rates, chronic disease management, hospital utilization, linkage and follow up to care, and maternal empathy. Overall, transportation is a well-documented barrier to engaging in chronic care among vulnerable populations. We found evidence suggesting transportation services offered in combination with other tailored services improves patient health outcomes; however, future research is warranted to examine the separate impact of transportation interventions that are tested within multi-component studies.

Evaluating the Feasibility and Acceptability of a Mobile Health-Based Female Community Health Volunteer Program for Hypertension Control in Rural Nepal: Cross-Sectional Study

BACKGROUND

Hypertension is a major modifiable risk factor for cardiovascular disease, the world's leading cause of death. The prevalence of hypertension is disproportionately higher in South Asian countries than in other regions of the world. Screening for hypertension in primary care settings remains a challenge in many South Asian countries, including Nepal. Nepal is located in the Himalayan Mountains region, posing significant geographical challenges for its rural citizens to access primary health care and service delivery. This barrier increases the costs and inconvenience for rural Nepalis to access hypertension screening and treatment. As a result, the prevalence of hypertension in Nepal tripled in the last 25 years to 22.4%-38.6%. Nepal's Ministry of Health and Population relies on female community health volunteers to link health centers and communities to provide basic health services. Over 50,000 of these volunteers in Nepal have received basic health care training and are assigned to take care of maternal and child health. Due to limited health care resources, adopting new methods to control hypertension is an urgent need in Nepal. Several recent studies in Nepal have recommended extending the role of female community health volunteers to include hypertension management through blood pressure monitoring and home-based education.

OBJECTIVE

The goal of this study was to assess if a mobile health-based female community health volunteer approach of combining the traditional community health volunteer program with digital technologies would be feasible and acceptable in rural Nepal.

METHODS

In this study, we recruited 17 female community health volunteers and extended their role from maternal and child health to hypertension management through screening blood pressures.

RESULTS

All 17 female community health volunteers successfully measured 1113 rural Nepalis' blood pressures, identified 169 hypertensive patients, and collected health behaviors data of the 169 hypertensive patients. Among the 169 patients, 70% of them had a mobile phone, and 92% were interested in receiving health-related information via a mobile phone. Among those who were interested in receiving information via a mobile phone, 84% preferred voice calls, and 7% and 1% preferred texting and apps, respectively.

CONCLUSIONS

Results from this study indicate that a digital health intervention that leverages feature-phones combined with female community health volunteers may be an acceptable and pragmatic way to implement an evidence-based program to reduce hypertension in rural Nepal.

Linkage to primary care after home-based blood pressure screening in rural KwaZulu-Natal, South Africa: a population-based cohort study

OBJECTIVES

The expanding burden of non-communicable diseases (NCDs) globally will require novel public health strategies. Community-based screening has been promoted to augment efficiency of diagnostic services, but few data are available on the downstream impact of such programmes. We sought to assess the impact of a home-based blood pressure screening programme on linkage to hypertension care in rural South Africa.

SETTING

We conducted home-based blood pressure screening withinin a population cohort in rural KwaZulu-Natal, using the WHO Stepwise Approach to Surveillance (STEPS) protocol.

PARTICIPANTS

Individuals meeting criteria for raised blood pressure (≥140 systolic or ≥90 diastolic averaged over two readings) were referred to local health clinics and included in this analysis. We defined linkage to care based on self-report of presentation to clinic for hypertension during the next 2 years of cohort observation. We estimated the population proportion of successful linkage to care with inverse probability sampling weights, and fit multivariable logistic regression models to identify predictors of linkage following a positive hypertension screen.

RESULTS

Of 11 694 individuals screened, 14.6% (n=1706) were newly diagnosed with elevated pressure. 26.9% (95% CI 24.5% to 29.4%) of those sought hypertension care in the following 2 years, and 38.1% (95% CI 35.6% to 40.7%) did so within 5 years. Women (adjusted OR (aOR) 2.41, 95% CI 1.68 to 3.45), those of older age (aOR 11.49, 95% CI 5.87 to 22.46, for 45-59 years vs <30) and those unemployed (aOR 1.71, 95% CI 1.10 to 2.65) were more likely to have linked to care.

CONCLUSIONS

Linkage to care after home-based identification of elevated blood pressure was rare in rural South Africa, particularly among younger individuals, men and the employed. Improved understanding of barriers and facilitators to NCD care is needed to enhance the effectiveness of blood pressure screening in the region.

Mental Health Outcomes of Psychosocial Intervention Among Traditional Health Practitioner Depressed Patients in Kenya

Task-shifting in mental health such as engaging Traditional Health Practitioners (THPs) in appropriate management of mental disorders is crucial in reducing global mental health challenges. This study aims to determine the outcomes of using evidence-based mental health Global Action Programme Intervention guide (mhGAP-IG) to provide psychosocial interventions among depressed patients seeking care from THPs. THPs were trained to deliver psychosocial interventions to their patients screening positive for mild to severe depression on Beck's Depression Inventory (BDI). Assessments were conducted at 0, 6 and 12 weeks and Analysis of Variance (ANOVA) performed to determine the change in depression scores over the three time period. BDI mean score was 26.52 before intervention and reduced significantly at 6 (13%) and 12 (35%) weeks after intervention. 58 and 78% of patients showed reduction in symptoms of depression at 6 and 12 weeks. It is therefore crucial to engage THPs in the care of patients with depression and the need for inclusion of training packages; and other mental disorders in order to establish and maintain collaboration between THPs and conventional health workers and promote evidence-based care among marginalized populations. Moreover, further research on randomized control trials of mhGAP-IG intervention versus usual care is required.

A community pharmacy-based cardiovascular risk screening service implemented in Iran

BACKGROUND

Cardiovascular disease is a major health concern around the world.

OBJECTIVE

To assess the outcomes and feasibility of a pharmacy-based cardiovascular screening in an urban referral community pharmacy in Iran.

METHODS

A cross sectional study was conducted in a referral community pharmacy. Subjects aged between 30-75 years without previous diagnose of cardiovascular disease or diabetes were screened. Measurement of all major cardiovascular risk factors, exercise habits, medical conditions, medications, and family history were investigated. Framingham risk score was calculated and high risk individuals were given a clinical summary sheet signed by a clinical pharmacist and were encouraged to follow up with their physician. Subjects were contacted one month after the recruitment period and their adherence to the follow up recommendation was recorded.

RESULTS

Data from 287 participants were analyzed and 146 were referred due to at least one abnormal laboratory test. The results showed 26 patients with cardiovascular disease risk greater than 20%, 32 high systolic blood pressure, 22 high diastolic blood pressures, 50 high total cholesterol levels, 108 low HDL-C levels, and 22 abnormal blood glucose levels. Approximately half of the individuals who received a follow up recommendation had made an appointment with their physician. Overall, 15.9% of the individuals received medications and 15.9% received appropriate advice for risk factor modification. Moreover, 7.5% were under evaluation by a physician.

CONCLUSION

A screening program in a community pharmacy has the potential to identify patients with elevated cardiovascular risk factor. A plan for increased patient adherence to follow up recommendations is required.

Impact of Community Health Workers on Use of Healthcare Services in the United States: A Systematic Review

BACKGROUND

As the US transitions to value-based healthcare, physicians and payers are incentivized to change healthcare delivery to improve quality of care while controlling costs. By assisting with the management of common chronic conditions, community health workers (CHWs) may improve healthcare quality, but physicians and payers who are making choices about care delivery also need to understand their effects on healthcare spending.

METHODS

We searched PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PsycINFO, Embase, and Web of Science from the inception of each database to 22 June 2015. We included US-based studies that evaluated a CHW intervention for patients with at least one chronic health condition and reported cost or healthcare utilization outcomes. We evaluated studies using tools specific to study design.

RESULTS

Our search yielded 2,941 studies after removing duplicates. Thirty-four met inclusion and methodological criteria. Sixteen studies (47%) were randomized controlled trials (RCTs). RCTs typically had less positive outcomes than other study designs. Of the 16 RCTs, 12 reported utilization outcomes, of which 5 showed a significant reduction in one or more of ED visits, hospitalizations and/or urgent care visits. Significant reductions reported in ED visits ranged from 23%-51% and in hospitalizations ranged from 21%-50%, and the one significant reduction in urgent care visits was recorded at 60% (p < 0.05 for all).

DISCUSSION

Our results suggest that CHW interventions have variable effects, but some may reduce costs and preventable utilization. These findings suggest that it is possible to achieve reductions in care utilization and cost savings by integrating CHWs into chronic care management. However, variations in cost and utilization outcomes suggest that CHWs alone do not make an intervention successful. The paucity of rigorous studies and heterogeneity of study designs limited conclusions about factors associated with reduced utilization.

Do State Community Health Worker Laws Align with Best Available Evidence?

Community health workers (CHWs) are expected to improve patient care and population health while reducing health care costs. Law is a tool states are using to build a supportive infrastructure for the CHW workforce. This study assessed the extent existing state law pertaining to the CHW workforce aligned with best available evidence. We used the previously developed Quality and Impact of Component (QuIC) Evidence Assessment method to identify and prioritize those components that could comprise an evidence-informed CHW policy at the state level. We next assessed the extent codified statutes and regulations in effect as of December 31, 2014 for the 50 states and D.C. included the components identified in the evidence assessment. Fourteen components of an evidence-informed CHW policy were identified; eight had best, three had promising, and three had emerging evidence bases. Codified law in 18 states (35.3 % of 51) pertained to the CHW workforce. Fifteen of these 18 states authorized at least one of the 14 components from the evidence assessment (maximum: nine components, median: 2.5). The most frequently authorized component was a defined scope of practice for CHWs (authorized by eight states) followed by a standard core competency curriculum and inclusion of CHWs in multidisciplinary health care teams (each authorized by six states). States could consider the components presented in this article when developing new or strengthening existing law.

Promotora Diabetes Intervention for Mexican Americans

PURPOSE

The purpose of this randomized controlled trial is to determine the effectiveness of an intervention led by promotoras (community lay workers) on the glycemic control, diabetes knowledge, and diabetes health beliefs of Mexican Americans with type 2 diabetes living in a major city on the Texas-Mexico border.

METHODS

One hundred fifty Mexican American participants were recruited at a Catholic faith-based clinic and randomized into 2 groups. Personal characteristics, acculturation, baseline A1C level, diabetes knowledge, and diabetes health beliefs were measured. The intervention was culturally specific and consisted of participative group education, telephone contact, and follow-up using inspirational faith-based health behavior change postcards. The A1C levels, diabetes knowledge, and diabetes health beliefs were measured 3 and 6 months postbaseline, and the mean change between the groups was analyzed.

RESULTS

The 80% female sample, with a mean age of 58 years, demonstrated low acculturation, income, education, health insurance coverage, and strong Catholicism. No significant changes were noted at the 3-month assessment, but the mean change of the A1C levels, F(1, 148) = 10.28, P < .001, and the diabetes knowledge scores, F(1, 148) = 9.0, P < .002, of the intervention group improved significantly at 6 months, adjusting for health insurance coverage. The health belief scores decreased in both groups.

CONCLUSIONS

The intervention resulted in decreased A1C levels and increased diabetes knowledge, suggesting that using promotoras as part of an interdisciplinary team can result in positive outcomes for Mexican Americans who have type 2 diabetes. Clinical implications and recommendations for future research are suggested.

Lay Health Worker Intervention Improved Compliance with Hepatitis B Vaccination in Asian Americans: Randomized Controlled Trial

Background

This study aimed to evaluate the effect of a lay health worker (LHW) telephone intervention on completing a series of hepatitis B virus (HBV) vaccinations among foreign-born Asian Americans in the Baltimore-Washington Metropolitan area.

Methods

During the period of April 2013 and March 2014, we recruited Asian Americans who were 18 years of age and older in the community-based organizations. Of the 645 eligible participants, 600 (201 Chinese, 198 Korean, 201 Vietnamese) completed a pretest survey and received hepatitis B screening. Based on the screening results, we conducted a randomized controlled trial among those unprotected (HBsAg-/HBsAB-) by assigning them either to an intervention group (n = 124) or control group (n = 108). The intervention group received a list of resources by mails for where to get free vaccinations as well as reminder calls for vaccinations from trained LHWs, while the control group received only list of resources by mail. Seven months after mailing the HBV screening results, trained LHWs followed up with all participants by phone to ask how many of the recommended series of 3 vaccinations they had received: none, 1 or 2, or all 3 (complete). Their self-reported vaccinations were verified with the medical records. Multinomial logistic regressions were used to examine the effect of the LHW intervention. Process evaluation was conducted by asking study participants in the intervention group to evaluate the performance of the LHWs.

Results

After seven months, those in the intervention group were more likely to have 1 or more vaccines than the control group, compared to the no vaccination group (OR = 3.04, 95% CI, 1.16, 8.00). Also, those in the intervention group were more likely to complete a series of vaccinations than the control group, compared to the no vaccination group (OR = 7.29, 95% CI 3.39, 15.67). The most important barrier preventing them from seeking hepatitis B vaccinations was lack of time to get the vaccination. The most important promoters to getting vaccinations, among those who had vaccinations (n = 89), were our intervention program (70.8%) and self-motivation (49.4%). The majority of participants in the intervention group received the phone calls from LHWs (93%) and almost all of them got the reminder to receive vaccines (98%).

Conclusion

The LHW intervention was successful at increasing HBV vaccinations rates among foreign-born Asian Americans. This study suggests that this culturally integrated intervention program may be useful for reducing liver cancer disparities from chronic HBV infection in high risk Asian Americans.

Trial Registration

ClinicalTrials.gov NCT02760537

Effects of Community-Based Health Worker Interventions to Improve Chronic Disease Management and Care Among Vulnerable Populations: A Systematic Review

BACKGROUND

Community-based health workers (CBHWs) are frontline public health workers who are trusted members of the community they serve. Recently, considerable attention has been drawn to CBHWs in promoting healthy behaviors and health outcomes among vulnerable populations who often face health inequities.

OBJECTIVES

We performed a systematic review to synthesize evidence concerning the types of CBHW interventions, the qualification and characteristics of CBHWs, and patient outcomes and cost-effectiveness of such interventions in vulnerable populations with chronic, noncommunicable conditions.

SEARCH METHODS

We undertook 4 electronic database searches-PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane-and hand searched reference collections to identify randomized controlled trials published in English before August 2014.

SELECTION

We screened a total of 934 unique citations initially for titles and abstracts. Two reviewers then independently evaluated 166 full-text articles that were passed onto review processes. Sixty-one studies and 6 companion articles (e.g., cost-effectiveness analysis) met eligibility criteria for inclusion.

DATA COLLECTION AND ANALYSIS

Four trained research assistants extracted data by using a standardized data extraction form developed by the authors. Subsequently, an independent research assistant reviewed extracted data to check accuracy. Discrepancies were resolved through discussions among the study team members. Each study was evaluated for its quality by 2 research assistants who extracted relevant study information. Interrater agreement rates ranged from 61% to 91% (average 86%). Any discrepancies in terms of quality rating were resolved through team discussions.

MAIN RESULTS

All but 4 studies were conducted in the United States. The 2 most common areas for CBHW interventions were cancer prevention (n = 30) and cardiovascular disease risk reduction (n = 26). The roles assumed by CBHWs included health education (n = 48), counseling (n = 36), navigation assistance (n = 21), case management (n = 4), social services (n = 7), and social support (n = 18). Fifty-three studies provided information regarding CBHW training, yet CBHW competency evaluation (n = 9) and supervision procedures (n = 24) were largely underreported. The length and duration of CBHW training ranged from 4 hours to 240 hours with an average of 41.3 hours (median: 16.5 hours) in 24 studies that reported length of training. Eight studies reported the frequency of supervision, which ranged from weekly to monthly. There was a trend toward improvements in cancer prevention (n = 21) and cardiovascular risk reduction (n = 16). Eight articles documented cost analyses and found that integrating CBHWs into the health care delivery system was associated with cost-effective and sustainable care.

CONCLUSIONS

Interventions by CBHWs appear to be effective when compared with alternatives and also cost-effective for certain health conditions, particularly when partnering with low-income, underserved, and racial and ethnic minority communities. Future research is warranted to fully incorporate CBHWs into the health care system to promote noncommunicable health outcomes among vulnerable populations.

Effect Sizes and Primary Outcomes in Large-Budget, Cardiovascular-Related Behavioral Randomized Controlled Trials Funded by NIH Since 1980

PURPOSE

We reviewed large-budget, National Institutes of Health (NIH)-supported randomized controlled trials (RCTs) with behavioral interventions to assess (1) publication rates, (2) trial registration, (3) use of objective measures, (4) significant behavior and physiological change, and (5) effect sizes.

METHODS

We identified large-budget grants (>$500,000/year) funded by NIH (National Heart Lung and Blood Institute (NHLBI) or National Institute of Diabetes & Digestive and Kidney Diseases (NIDDK)) for cardiovascular disease (dates January 1, 1980 to December 31, 2012). Among 106 grants that potentially met inclusion criteria, 20 studies were not published and 48 publications were excluded, leaving 38 publications for analysis. ClinicalTrials.gov abstracts were used to determine whether outcome measures had been pre-specified.

RESULTS

Three fourths of trials were registered in ClinicalTrials.gov and all published pre-specified outcomes. Twenty-six trials reported a behavioral outcome with 81 % reporting significant improvements for the target behavior. Thirty-two trials reported a physiological outcome. All were objectively measured, and 81 % reported significant benefit. Seventeen trials reported morbidity outcomes, and seven reported a significant benefit. Nine trials assessed mortality, and all were null for this outcome.

CONCLUSIONS

Behavioral trials complied with trial registration standards. Most reported a physiological benefit, but few documented morbidity or mortality benefits.

Exploring the role of community engagement in improving the health of disadvantaged populations: a systematic review

BACKGROUND

Although community engagement (CE) is widely used in health promotion, components of CE models associated with improved health are poorly understood. This study aimed to examine the magnitude of the impact of CE on health and health inequalities among disadvantaged populations, which methodological approaches maximise the effectiveness of CE, and components of CE that are acceptable, feasible, and effective when used among disadvantaged populations.

DESIGN

The systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We carried out methodological assessments of the included studies using rating scales. The analysis focussed on model synthesis to identify the key CE components linked to positive study outcomes and comparative analysis between positive study outcomes, processes, and quality indicators of CE.

RESULTS

Out of 24 studies that met our inclusion criteria, 21 (87.5%) had positively impacted health behaviours, public health planning, health service access, health literacy, and a range of health outcomes. More than half of the studies (58%) were of good quality, whereas 71% and 42% of studies showed good community involvement in research and achieved high levels of CE, respectively. Key CE components that affected health outcomes included real power-sharing, collaborative partnerships, bidirectional learning, incorporating the voice and agency of beneficiary communities in research protocol, and using bicultural health workers for intervention delivery.

CONCLUSIONS

The findings suggest that CE models can lead to improved health and health behaviours among disadvantaged populations if designed properly and implemented through effective community consultation and participation. We also found several gaps in the current measurement of CE in health intervention studies, which suggests the importance of developing innovative approaches to measure CE impact on health outcomes in a more rigorous way.

Community health workers recruitment from within: an inner-city neighborhood-driven framework

Background

Community health workers (CHWs) are frontline public health workers who are trusted members of and/or have an unusually close understanding of the community served (APHA 2009). Among other roles, they are effective in closing critical communication gap between healthcare providers and patients as they possess key abilities to overcome cultural barriers, minimize disparities, and maximize adherence to clinical directions. In previous descriptions of the selection of CHWs, the role of community is clearly emphasized, but residence in the community is not indicated.

Objective

We present an effective model of CHW selection by the community of members that reside in the community to be served.

Methods

We outlined and implemented necessary steps for recruiting CHWs from within their target neighborhood between years 2011 and 2013. The identified community was an “isolated” part of Newark, New Jersey comprised of approximately 3000 people residing in three publicly-funded housing developments. We utilized a community empowerment model and established a structure of self-governance in the community of interest. In all phases of identification and selection of CHWs, the Community Advisory Board (CAB) played a leading role.

Results

The process for the successful development of a CHW initiative in an urban setting begins with community/resident engagement and ends with employment of trained CHWs. The steps needed are: (1) community site identification; (2) resident engagement; (3) health needs assessment; (4) CHW identification and recruitment; and (5) training and employment of CHWs. Using an empowered community model, we successfully initiated CHW selection, training, and recruitment. Thirteen CHW candidates were selected and approved by the community. They entered a 10-week training program and ten CHWs completed the training. We employed these ten CHWs.

Conclusions

These five steps emerged from a retrospective review of our CHW initiative. Residing in the community served has significant advantages and disadvantages. Community empowerment is critical in changing the health indices of marginalized communities.

Strategies to Improve the Integration of Community Health Workers Into Health Care Teams: "A Little Fish in a Big Pond"

Introduction

The Patient Protection and Affordable Care Act acknowledges the value of community health workers (CHWs) as frontline public health workers. Consequently, growing attention has been placed on promoting CHWs as legitimate partners to provide support to health care teams and patients in the prevention, management, and control of chronic disease, particularly among diverse populations and high-need individuals.

Methods

Using a mixed-methods research approach, we investigated the integration of CHWs into health care teams from the CHW perspective. We conducted a survey of 265 CHWs and interviews with 23 CHWs to better understand and describe their experience and their perceived opportunities and challenges regarding their integration within the context of health care reform.

Results

Feelings of organizational support were positively correlated with the number of CHWs in the organization. CHWs reported the following facilitators to integration: having team meetings (73.7%), training inside (70.4%) and outside of the organization (81.6%), access to electronic health records, and ability for CHWs to stay connected to the community.

Conclusion

The perspectives of CHWs on their positive and negative experiences offer useful and innovative insight into ways of maximizing their impact on the health care team, patients, and their role as key emissaries between clinical services and community resources.

A Patient Navigator Intervention to Reduce Hospital Readmissions among High-Risk Safety-Net Patients: A Randomized Controlled Trial

BACKGROUND

Evidence-based interventions to reduce hospital readmissions may not generalize to resource-constrained safety-net hospitals.

OBJECTIVE

To determine if an intervention by patient navigators (PNs), hospital-based Community Health Workers, reduces readmissions among high risk, low socioeconomic status patients.

DESIGN

Randomized controlled trial.

PARTICIPANTS

General medicine inpatients having at least one of the following readmission risk factors: (1) age ≥60 years, (2) any in-network inpatient admission within the past 6 months, (3) length of stay ≥3 days, (4) admission diagnosis of heart failure, or (5) chronic obstructive pulmonary disease. The analytic sample included 585 intervention patients and 925 controls.

INTERVENTIONS

PNs provided coaching and assistance in navigating the transition from hospital to home through hospital visits and weekly telephone outreach, supporting patients for 30 days post-discharge with discharge preparation, medication management, scheduling of follow-up appointments, communication with primary care, and symptom management.

MAIN MEASURES

The primary outcome was in-network 30-day hospital readmissions. Secondary outcomes included rates of outpatient follow-up. We evaluated outcomes for the entire cohort and stratified by patient age >60 years (425 intervention/584 controls) and ≤60 years (160 intervention/341 controls).

KEY RESULTS

Overall, 30-day readmission rates did not differ between intervention and control patients. However, the two age groups demonstrated marked differences. Intervention patients >60 years showed a statistically significant adjusted absolute 4.1% decrease [95% CI: -8.0%, -0.2%] in readmission with an increase in 30-day outpatient follow-up. Intervention patients ≤60 years showed a statistically significant adjusted absolute 11.8% increase [95% CI: 4.4%, 19.0%] in readmission with no change in 30-day outpatient follow-up.

CONCLUSIONS

A patient navigator intervention among high risk, safety-net patients decreased readmission among older patients while increasing readmissions among younger patients. Care transition strategies should be evaluated among diverse populations, and younger high risk patients may require novel strategies.

Referral outcomes of individuals identified at high risk of cardiovascular disease by community health workers in Bangladesh, Guatemala, Mexico, and South Africa

Background

We have found that community health workers (CHWs) with appropriate training are able to accurately identify people at high cardiovascular disease (CVD) risk in the community who would benefit from the introduction of preventative management, in Bangladesh, Guatemala, Mexico, and South Africa. This paper examines the attendance pattern for those individuals who were so identified and referred to a health care facility for further assessment and management.

Design

Patient records from the health centres in each site were reviewed for data on diagnoses made and treatment commenced. Reasons for non-attendance were sought from participants who had not attended after being referred. Qualitative data were collected from study coordinators regarding their experiences in obtaining the records and conducting the record reviews. The perspectives of CHWs and community members, who were screened, were also obtained.

Results

Thirty-seven percent (96/263) of those referred attended follow-up: 36 of 52 (69%) were urgent and 60 of 211 (28.4%) were non-urgent referrals. A diagnosis of hypertension (HTN) was made in 69% of urgent referrals and 37% of non-urgent referrals with treatment instituted in all cases. Reasons for non-attendance included limited self-perception of risk, associated costs, health system obstacles, and lack of trust in CHWs to conduct CVD risk assessments and to refer community members into the health system.

Conclusions

The existing barriers to referral in the health care systems negatively impact the gains to be had through screening by training CHWs in the use of a simple risk assessment tool. The new diagnoses of HTN and commencement on treatment in those that attended referrals underscores the value of having persons at the highest risk identified in the community setting and referred to a clinic for further evaluation and treatment.

Rationale and design of a randomized controlled trial evaluating community health worker-based interventions for the secondary prevention of acute coronary syndromes in India (SPREAD)

BACKGROUND

There is a need to evaluate and implement cost-effective strategies to improve adherence to treatments in coronary heart disease. There are no studies from low- to middle income countries (LMICs) evaluating trained community health worker (CHW)-based interventions for the secondary prevention of coronary heart disease.

METHODS

We designed a hospital-based, open randomized trial of CHW-based interventions versus standard care. Patients after an acute coronary syndrome (ACS) were randomized to an intervention group (a CHW-based intervention package, comprising education tools to enhance self-care and adherence, and regular follow-up by the CHW) or to standard care for 12 months during which study outcomes were recorded. The CHWs were trained over a period of 6 months. The primary outcome measure was medication adherence. The secondary outcomes were differences in adherence to lifestyle modification, physiological parameters (blood pressure [BP], body weight, body mass index [BMI], heart rate, lipids), and major adverse cardiovascular events.

RESULTS

We recruited 806 patients stabilized after an ACS from 14 hospitals in 13 Indian cities. The mean age was 56.4 (± 11.32) years, and 17.2% were females. A high prevalence of risk factors such as hypertension (43.4%), diabetes (31.9%), tobacco consumption (35.4%), and inadequate physical activity (70.5%) was documented. A little over half had ST-elevation myocardial infarction (53.7%), and 46.3% had non-ST-elevation myocardial infarction or unstable angina.

CONCLUSION

The CHW interventions and training for SPREAD have been developed and adapted for local use. The results and experience of this study will be important to counter the burden of cardiovascular diseases in low- to middle income countries.

Check it, change it: a community-based, multifaceted intervention to improve blood pressure control

BACKGROUND

Although home blood pressure (BP) monitoring interventions have shown potential in selected populations, it is unclear whether such strategies can be generalized. We sought to determine whether a multifaceted BP control program that uses a web-based health portal (Heart360), community health coaches, and physician assistant guidance could improve hypertension control in a diverse community setting.

METHODS AND RESULTS

Between September 12, 2010, and November 11, 2011 Check It, Change It, a community-based hypertension quality improvement program, enrolled 1756 patients with hypertension from 8 clinics in Durham County, NC. The Check It, Change It community intervention was evaluated using a prepost study design without a concurrent control. Participants were stratified into 3 tiers according to their initial BP: tier 0 (BP <140/90 mm Hg)=51% of population, tier 1 (BP=140/90-159/99 mm Hg)=30% of total, and tier 2 (BP ≥159/99 mm Hg)=19% of total. Overall, median age was 59 years (interquartile range, 49-69), 67% were female, and 76% black. After 6 months, the mean overall systolic BP declined 4.7 mm Hg. Rates of achieving target BP control (<140/90) increased overall from 51% at baseline to 63% by 6 months, and 69% had either reached their BP target or had reduced their baseline systolic BP by 10 mm Hg or more.

CONCLUSIONS

A multicomponent-tiered hypertension program was associated with improved BP control in a diverse community-based population.

Peer Support for Achieving Independence in Diabetes (Peer-AID): design, methods and baseline characteristics of a randomized controlled trial of community health worker assisted diabetes self-management support

BACKGROUND & OBJECTIVES

Community health workers (CHWs) may be an important mechanism to provide diabetes self-management to disadvantaged populations. We describe the design and baseline results of a trial evaluating a home-based CHW intervention.

METHODS & RESEARCH DESIGN

Peer Support for Achieving Independence in Diabetes (Peer-AID) is a randomized, controlled trial evaluating a home-based CHW-delivered diabetes self-management intervention versus usual care. The study recruited participants from 3 health systems. Change in A1c measured at 12 months is the primary outcome. Changes in blood pressure, lipids, health care utilization, health-related quality of life, self-efficacy and diabetes self-management behaviors at 12 months are secondary outcomes.

RESULTS

A total of 1438 patients were identified by a medical record review as potentially eligible, 445 patients were screened by telephone for eligibility and 287 were randomized. Groups were comparable at baseline on socio-demographic and clinical characteristics. All participants were low-income and were from diverse racial and ethnic backgrounds. The mean A1c was 8.9%, mean BMI was above the obese range, and non-adherence to diabetes medications was high. The cohort had high rates of co-morbid disease and low self-reported health status. Although one-third reported no health insurance, the mean number of visits to a physician in the past year was 5.7. Trial results are pending.

CONCLUSIONS

Peer-AID recruited and enrolled a diverse group of low income participants with poorly controlled type 2 diabetes and delivered a home-based diabetes self-management program. If effective, replication of the Peer-AID intervention in community based settings could contribute to improved control of diabetes in vulnerable populations.

Adherence and retention in clinical trials: a community-based approach

BACKGROUND

The Community Health Advisor (CHA) model has been widely used to recruit rural and low-income, mostly African American women into clinical and behavioral research studies. However, little is known about its effectiveness in promoting retention and adherence of such women in clinical trials.

METHODS

The Community-Based Retention Intervention Study evaluated the effectiveness of a community-based intervention strategy using the CHA model and the empowerment theory to improve the retention and adherence of minority and low-income women in clinical trials. The research strategy included the training and use of the volunteer CHAs as research partners. The target population included women participating in the University of Alabama at Birmingham clinical site of the Atypical Squamous Cells of Undetermined Significance-Low-Grade Squamous Intraepithelial Lesion (ASCUS-LSIL) Triage Study (ALTS), a multicenter, randomized clinical trial. Two communities in Jefferson County, Alabama, that were matched according to population demographics were identified and randomly assigned to either an intervention group or a control group. Thirty community volunteers were recruited to be CHAs and to implement the intervention with the ALTS trial participants. In total, 632 ALTS participants agreed to participate in the project, including 359 in the intervention group, which received CHA care, and 273 in the control group, which received standard care.

RESULTS

Adherence rates for scheduled clinic visits were significantly higher in the intervention group (80%) compared with the control group (65%; P < .0001).

CONCLUSIONS

The results indicate that volunteer CHAs can be trained to serve as research partners and can be effective in improving the retention and adherence of minority and low-income women in clinical trials.

Check it, change it: a community-based intervention to improve blood pressure control

BACKGROUND

Despite the widespread availability of effective and affordable therapies, hypertension remains this country's most significant modifiable cardiovascular risk factor. Approximately 30% to 50% of individuals with hypertension currently fail to reach guideline-recommended target blood pressure (BP) goals. Although multiple interventions have been proposed to affect better hypertension control, the integration of multiple elements in a community-based program has not been evaluated to date.

METHODS AND RESULTS

We created a broadly inclusive community-based initiative to control hypertension called Check It, Change It: The Durham Blood Pressure Challenge (CICI). We enrolled ≈2000 participants with hypertension in 8 ambulatory clinics across Durham County, NC. The CICI program engaged individuals by providing them with tools for self-monitoring and tied this information to their caregivers via a web-based portal (the American Heart Association's Heart360, a remote BP monitoring system). Additionally, the CICI facilitated clinical intervention of high-risk individuals using physician assistants and community health coaches. The primary outcome will be a change in BP during the 6 months postenrollment in the program, which will be compared with concurrent and historical control populations of nonparticipants.

CONCLUSIONS

We think that this integrated and tiered approach will lead to improved BP control within 6 months. If successful, the CICI program has the potential to enhance community-level BP control.

Community engagement to reduce inequalities in health: a systematic review, meta-analysis and economic analysis

Background

Community engagement has been advanced as a promising way of improving health and reducing health inequalities; however, the approach is not yet supported by a strong evidence base.

Objectives

To undertake a multimethod systematic review which builds on the evidence that underpins the current UK guidance on community engagement; to identify theoretical models underpinning community engagement; to explore mechanisms and contexts through which communities are engaged; to identify community engagement approaches that are effective in reducing health inequalities, under what circumstances and for whom; and to determine the processes and costs associated with their implementation.

Data sources

Databases including the Cochrane Database of Systematic Reviews (CDSR), The Campbell Library, the Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment (HTA) database, the NHS Economic Evaluation Database (NHS EED) and EPPI-Centre’s Trials Register of Promoting Health Interventions (TRoPHI) and Database of Promoting Health Effectiveness Reviews (DoPHER) were searched from 1990 to August 2011 for systematic reviews and primary studies. Trials evaluating community engagement interventions reporting health outcomes were included.

Review methods

Study eligibility criteria: published after 1990; outcome, economic, or process evaluation; intervention relevant to community engagement; written in English; measured and reported health or community outcomes, or presents cost, resource, or implementation data characterises study populations or reports differential impacts in terms of social determinants of health; conducted in an Organisation for Economic Co-operation and Development (OECD) country. Study appraisal: risk of bias for outcome evaluations; assessment of validity and relevance for process evaluations; comparison against an economic evaluation checklist for economic evaluations. Synthesis methods: four synthesis approaches were adopted for the different evidence types: theoretical, quantitative, process, and economic evidence.

Results

The theoretical synthesis identified key models of community engagement that are underpinned by different theories of changes. Results from 131 studies included in a meta-analysis indicate that there is solid evidence that community engagement interventions have a positive impact on health behaviours, health consequences, self-efficacy and perceived social support outcomes, across various conditions. There is insufficient evidence – particularly for long-term outcomes and indirect beneficiaries – to determine whether one particular model of community engagement is likely to be more effective than any other. There are also insufficient data to test the effects on health inequalities, although there is some evidence to suggest that interventions that improve social inequalities (as measured by social support) also improve health behaviours. There is weak evidence from the effectiveness and process evaluations that certain implementation factors may affect intervention success. From the economic analysis, there is weak but inconsistent evidence that community engagement interventions are cost-effective. By combining findings across the syntheses, we produced a new conceptual framework.

Limitations

Differences in the populations, intervention approaches and health outcomes made it difficult to pinpoint specific strategies for intervention effectiveness. The syntheses of process and economic evidence were limited by the small (generally not rigorous) evidence base.

Conclusions

Community engagement interventions are effective across a wide range of contexts and using a variety of mechanisms. Public health initiatives should incorporate community engagement into intervention design. Evaluations should place greater emphasis on long-term outcomes, outcomes for indirect beneficiaries, process evaluation, and reporting costs and resources data. The theories of change identified and the newly developed conceptual framework are useful tools for researchers and practitioners. We identified trends in the evidence that could provide useful directions for future intervention design and evaluation.

Funding

The National Institute for Health Research Public Health Research programme.

Effectiveness of a community health worker cardiovascular risk reduction program in public health and health care settings

OBJECTIVES

We evaluated whether a program to prevent coronary heart disease (CHD) with community health workers (CHWs) would improve CHD risk in public health and health care settings.

METHODS

The CHWs provided point-of-service screening, education, and care coordination to residents in 34 primarily rural Colorado counties. The CHWs utilized motivational interviewing and navigated those at risk for CHD into medical care and lifestyle resources. A software application generated a real-time 10-year Framingham Risk Score (FRS) and guideline-based health recommendations while supporting longitudinal caseload tracking. We used multiple linear regression analysis to determine factors associated with changes in FRS.

RESULTS

From 2010 to 2011, among 4743 participants at risk for CHD, 53.5% received medical or lifestyle referrals and 698 were retested 3 or more months after screening. We observed statistically significant improvements in diet, weight, blood pressure, lipids, and FRS with the greatest effects among those with uncontrolled risk factors. Successful phone interaction by the CHW led to lower FRS at retests (P = .04).

CONCLUSIONS

A CHW-based program within public health and health care settings improved CHD risk. Further exploration of factors related to improved outcomes is needed.

Community health workers and medicaid managed care in New Mexico

We describe the impact of community health workers (CHWs) providing community-based support services to enrollees who are high consumers of health resources in a Medicaid managed care system. We conducted a retrospective study on a sample of 448 enrollees who were assigned to field-based CHWs in 11 of New Mexico's 33 counties. The CHWs provided patients education, advocacy and social support for a period up to 6 months. Data was collected on services provided, and community resources accessed. Utilization and payments in the emergency department, inpatient service, non-narcotic and narcotic prescriptions as well as outpatient primary care and specialty care were collected on each patient for a 6 month period before, for 6 months during and for 6 months after the intervention. For comparison, data was collected on another group of 448 enrollees who were also high consumers of health resources but who did not receive CHW intervention. For all measures, there was a significant reduction in both numbers of claims and payments after the community health worker intervention. Costs also declined in the non-CHW group on all measures, but to a more modest degree, with a greater reduction than in the CHW group in use of ambulatory services. The incorporation of field-based, community health workers as part of Medicaid managed care to provide supportive services to high resource-consuming enrollees can improve access to preventive and social services and may reduce resource utilization and cost.

Social support among African Americans with heart failure: is there a role for community health advisors?

OBJECTIVE

The study had 2 objectives: (1) to gather the observations of community health advisors (CHAs) on the role of social support in the lives of African Americans; and (2) to develop a lay support intervention framework, on the basis of the existing literature and observations of CHAs, depicting how social support may address the needs of African American patients with heart failure.

METHODS

Qualitative data were collected in semistructured interviews among 15 CHAs working in African American communities in Birmingham, Alabama.

RESULTS

Prominent themes included the challenge of meeting clients' overlapping health care and general life needs, the variation in social support received from family and friends, and the opportunities for CHAs to provide multiple types of social support to clients. CHAs also believed that their support activities could be implemented among populations with heart failure.

CONCLUSION

The experience of CHAs with social support can inform a potential framework of a lay support intervention among African Americans with heart failure.

The effectiveness of culturally appropriate interventions to manage or prevent chronic disease in culturally and linguistically diverse communities: a systematic literature review

Culturally and linguistically diverse (CALD) communities in Australia experience both significant health disparities and a lack of access to services. Consequently, there have been calls for culturally appropriate services for people with chronic disease in CALD populations. This paper presents a systematic review of the literature on the effectiveness of culturally appropriate interventions to manage or prevent chronic disease in CALD communities. Evidence was sought from randomized controlled trials and controlled studies that examined strategies for promoting cultural competence in health service delivery to CALD communities. The outcomes examined included changes in consumer health behaviours, utilisation/satisfaction with the service, and the cultural competence of health-care providers. Of the 202 studies that were identified only 24 met the inclusion criteria. The five categories of intervention that were identified included: (1) the use of community-based bi-lingual health workers; (2) providing cultural competency training for health workers; (3) using interpreter service for CALD people; (4) using multimedia and culturally sensitive videos to promote health for CALD people and (5) establishing community point-of-care services for CALD people with chronic disease. The review supported the use of trained bi-lingual health workers, who are culturally competent, as a major consideration in the development of an appropriate health service model for CALD communities.

Reaching individuals at risk for cardiovascular disease through community outreach in Colorado

OBJECTIVE

The aim of this program was to (1) increase awareness of individual cardiovascular disease (CVD) risk in underserved communities, (2) educate participants about lifestyle modifications to reduce CVD risk, and (3) link individuals at moderate to high risk with healthcare. Community health workers (CHWs) delivered the program in 14 urban, rural and frontier Colorado communities.

METHOD

We analyzed data from CVD screenings of 17,995 individuals throughout Colorado between 2006 and 2009 in order to understand the reach and impact of the program on reaching target populations, identifying at-risk individuals and improving awareness of CVD risk.

RESULTS

In 3 years, 15 CHWs screened 17,995 clients for CVD risk, of which, almost 60% were racial and ethnic minorities and 42% were uninsured. Twenty-nine percent of participants had medium or high Framingham Risk Scores. Over three-quarters were overweight or obese, over one-fifth had mildly to severely high blood pressure, and 42% had borderline high or high cholesterol. Significantly, 82% had no knowledge of their CVD risk prior to screening.

CONCLUSION

This program is a replicable model for reaching minority and medically underserved populations who are at risk for CVD in urban, rural and frontier communities.

Self-monitoring and other non-pharmacological interventions to improve the management of hypertension in primary care: a systematic review

BACKGROUND

Patients with high blood pressure (hypertension) in the community frequently fail to meet treatment goals: a condition labelled as 'uncontrolled' hypertension. The optimal way to organise and deliver care to hypertensive patients has not been clearly identified.

AIM

To determine the effectiveness of interventions to improve control of blood pressure in patients with hypertension.

DESIGN OF STUDY

Systematic review of randomised controlled trials.

SETTING

Primary and ambulatory care.

METHOD

Interventions were categorised as following: self-monitoring; educational interventions directed to the patient; educational interventions directed to the health professional; health professional- (nurse or pharmacist) led care; organisational interventions that aimed to improve the delivery of care; and appointment reminder systems. Outcomes assessed were mean systolic and diastolic blood pressure, control of blood pressure and proportion of patients followed up at clinic.

RESULTS

Seventy-two RCTs met the inclusion criteria. The trials showed a wide variety of methodological quality. Self-monitoring was associated with net reductions in systolic blood pressure (weighted mean difference [WMD] -2.5 mmHg, 95%CI = -3.7 to -1.3 mmHg) and diastolic blood pressure (WMD -1.8 mmHg, 95%CI = -2.4 to -1.2 mmHg). An organised system of regular review allied to vigorous antihypertensive drug therapy was shown to reduce blood pressure and all-cause mortality in a single large randomised controlled trial.

CONCLUSION

Antihypertensive drug therapy should be implemented by means of a vigorous stepped care approach when patients do not reach target blood pressure levels. Self-monitoring is a useful adjunct to care while reminder systems and nurse/pharmacist -led care require further evaluation.

Community health worker intervention to decrease cervical cancer disparities in Hispanic women

INTRODUCTION

U.S. Hispanic women suffer a disproportionate burden of cervical cancer, with incidence and mortality rates almost twice that of whites. Community health workers, or promotoras, are considered a potential strategy for eliminating such racial and ethnic health disparities. The current study is a randomized trial of a promotora-led educational intervention focused on cervical cancer in a local Hispanic community.

METHODS

Four promotoras led a series of two workshops with community members covering content related to cervical cancer. Sociodemographic characteristics, cervical cancer risk, previous screening history, cervical cancer knowledge, and self-efficacy were measured by a pre-intervention questionnaire. The post-intervention questionnaire measured the following outcomes: cervical cancer knowledge (on a 0-6 scale), self-efficacy (on a 0-5 scale), and receipt of Pap smear screening during the previous 6 months (dichotomous). Univariate analyses were performed using chi square, t-test, and the Mann-Whitney test. Multivariate logistic regression was used to model the association between explanatory variables and receipt of Pap smear screening.

RESULTS

There were no statistically significant differences between the two experimental groups at baseline. Follow-up data revealed significant improvements in all outcome measures: Pap smear screening (65% vs. 36%, p-value 0.02), cervical cancer knowledge (5.4 vs. 3.5, p-value<0.001), and self-efficacy (4.7 vs. 4.0, p-value 0.002). In multivariate analysis, cervical cancer knowledge (OR 1.68, 95% CI 1.10-2.81) and intervention group assignment (OR 6.74, 95% CI 1.77-25.66) were associated with receiving a Pap smear during the follow-up period.

DISCUSSION

Our randomized trial of a promotora-led educational intervention demonstrated improved Pap screening rates, in addition to increased knowledge about cervical cancer and self-efficacy. The observed association between cervical cancer knowledge and Pap smear receipt underscores the importance of educating vulnerable populations about the diseases that disproportionately affect them. Future research should evaluate such programs on a larger scale, and identify novel targets for intervention.

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

OBJECTIVES

We conducted a systematic review on outcomes and costs of community health worker (CHW) interventions. CHWs are increasingly expected to improve health outcomes cost-effectively for the underserved.

RESEARCH DESIGN

We searched Medline, Cochrane Collaboration resources, and the Cumulative Index to Nursing and Allied Health Literature for studies conducted in the United States and published in English from 1980 through November 2008. We dually reviewed abstracts, full-text articles, data abstractions, quality ratings, and strength of evidence grades and resolved disagreements by consensus.

RESULTS

We included 53 studies on outcomes of CHW interventions and 6 on cost or cost-effectiveness. For outcomes, limited evidence (5 studies) suggests that CHW interventions can improve participant knowledge compared with alternative approaches or no intervention. We found mixed evidence for participant behavior change (22 studies) and health outcomes (27 studies). Some studies suggested that CHW interventions can result in greater improvements in participant behavior and health outcomes compared with various alternatives, but other studies suggested that CHW interventions provide no statistically different benefits than alternatives. We found low or moderate strength of evidence suggesting that CHWs can increase appropriate health care utilization for some interventions (30 studies). Six studies with economic information yielded insufficient data to evaluate the cost-effectiveness of CHW interventions relative to other interventions.

CONCLUSIONS

CHWs can improve outcomes for underserved populations for some health conditions. The effectiveness of CHWs in many health care areas requires further research that addresses the methodologic limitations of prior studies and that contributes to translating research into practice.

Interventions used to improve control of blood pressure in patients with hypertension

BACKGROUND

Patients with high blood pressure (hypertension) in the community frequently fail to meet treatment goals - a condition labelled as "uncontrolled" hypertension. The optimal way to organize and deliver care to hypertensive patients has not been clearly identified.

OBJECTIVES

To determine the effectiveness of interventions to improve control of blood pressure in patients with hypertension. To evaluate the effectiveness of reminders on improving the follow-up of patients with hypertension.

SEARCH STRATEGY

All-language search of all articles (any year) in the Cochrane Controlled Trials Register (CCTR) and Medline; and Embase from January 1980.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of patients with hypertension that evaluated the following interventions: (1) self-monitoring (2) educational interventions directed to the patient (3) educational interventions directed to the health professional (4) health professional (nurse or pharmacist) led care (5) organisational interventions that aimed to improve the delivery of care (6) appointment reminder systemsOutcomes assessed were: (1) mean systolic and diastolic blood pressure (2) control of blood pressure (3) proportion of patients followed up at clinic

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently and in duplicate and assessed each study according to the criteria outlined by the Cochrane Handbook.

MAIN RESULTS

72 RCTs met our inclusion criteria. The methodological quality of included studies varied. An organized system of regular review allied to vigorous antihypertensive drug therapy was shown to reduce systolic blood pressure (weighted mean difference (WMD) -8.0 mmHg, 95% CI: -8.8 to -7.2 mmHg) and diastolic blood pressure (WMD -4.3 mmHg, 95% CI: -4.7 to -3.9 mmHg) for three strata of entry blood pressure, and all-cause mortality at five years follow-up (6.4% versus 7.8%, difference 1.4%) in a single large RCT- the Hypertension Detection and Follow-Up study. Other interventions had variable effects. Self-monitoring was associated with moderate net reduction in systolic blood pressure (WMD -2.5 mmHg, 95% CI: -3.7 to -1.3 mmHg) and diastolic blood pressure (WMD -1.8 mmHg, 95% CI: -2.4 to -1.2 mmHg). RCTs of educational interventions directed at patients or health professionals were heterogeneous but appeared unlikely to be associated with large net reductions in blood pressure by themselves. Nurse or pharmacist led care may be a promising way forward, with the majority of RCTs being associated with improved blood pressure control and mean SBP and DBP but these interventions require further evaluation. Appointment reminder systems also require further evaluation due to heterogeneity and small trial numbers, but the majority of trials increased the proportion of individuals who attended for follow-up (odds ratio 0.41, 95% CI 0.32 to 0.51) and in two small trials also led to improved blood pressure control, odds ratio favouring intervention 0.54 (95% CI 0.41 to 0.73).

AUTHORS' CONCLUSIONS

Family practices and community-based clinics need to have an organized system of regular follow-up and review of their hypertensive patients. Antihypertensive drug therapy should be implemented by means of a vigorous stepped care approach when patients do not reach target blood pressure levels. Self-monitoring and appointment reminders may be useful adjuncts to the above strategies to improve blood pressure control but require further evaluation.

A promotora de salud model for addressing cardiovascular disease risk factors in the US-Mexico border region

INTRODUCTION

In 2002, the National Heart, Lung, and Blood Institute partnered with the Health Resources and Services Administration's (HRSA's) Bureau of Primary Health Care and Office of Rural Health Policy to address cardiovascular health in the US-Mexico border region. From 2003 through 2005, the 2 agencies agreed to conduct an intervention program using Salud para su Corazón with promotores de salud (community health workers) in high-risk Hispanic communities served by community health centers (CHCs) in the border region to reduce risk factors and improve health behaviors.

METHODS

Promotores de salud from each CHC delivered lessons from the curriculum Your Heart, Your Life. Four centers implemented a 1-group pretest-posttest study design. Educational sessions were delivered for 2 to 3 months. To test Salud para su Corazón-HRSA health objectives, the CHCs conducted the program and assessed behavioral and clinical outcomes at baseline, 3 months, 6 months, and 12 months after the intervention. A 2-sample paired t test and analyses of variance were used to evaluate differences from baseline to postintervention.

RESULTS

Changes in heart-healthy behaviors were observed, as they have been in previous Salud para su Corazón studies, lending credibility to the effectiveness of a promotores de salud program in a clinical setting. Positive changes were also observed in low-density lipoprotein cholesterol level, triglyceride level, waist circumference, diastolic blood pressure, weight, and glycated hemoglobin (HbA1c).

CONCLUSION

Results suggest that integrating promotores de salud into clinical practices is a promising strategy for culturally competent and effective service delivery. Promotores de salud build coalitions and partnerships in the community. The Salud para su Corazón-HRSA initiative was successful in helping to develop an infrastructure to support a promotores de salud workforce in the US-Mexico border region.

Abnormal mammogram follow-up: do community lay health advocates make a difference?

This pilot study evaluates a community lay health advocate (CLHA) intervention in promoting follow-up for abnormal mammograms among African American women. A controlled trial was implemented at an urban hospital in Atlanta, with 48 women in a CLHA intervention group and 35 in a usual care group. Participants were 25 or older and had an abnormal mammogram between March 25, 2002, and May 2, 2003. Intervention group women received CLHA support including encouragement of timely abnormal mammogram follow-up, reminders of follow-up appointments, identification and removal of barriers to follow-up, and accompaniment to follow-up appointments. Women in the intervention group were significantly more likely to keep their first abnormal mammogram follow-up appointment, all of their scheduled follow-up appointments, and their biopsy or fine needle aspiration appointment. CLHAs are effective in promoting abnormal mammogram followup among African American women and may be an important resource in reducing racial disparities in breast cancer mortality.

Improving health behaviors in an African American community: the Charlotte Racial and Ethnic Approaches to Community Health project

OBJECTIVES

We examined the effect on 3 behavioral risk factors for heart disease and diabetes (low fruit and vegetable consumption, low physical activity, and cigarette smoking) of an intervention in an African American community in North Carolina.

METHODS

A community coalition, a lay health advisor program, and policy and community environment change strategies were implemented in a community of 20,000 African Americans in 2001 to 2005. Health behavior questions from the Behavioral Risk Factor Surveillance System survey were administered to a cross-section of the community annually. The results were compared with African Americans' responses from a statewide survey.

RESULTS

All 3 health behaviors improved in the study population. Improvements were statistically significant for physical activity (P=.02) and smoking (P=.03) among women and for physical activity among middle-aged adults (P=.01). Lower baseline physical activity rates improved to levels comparable to those of African Americans statewide (2001, P<.001; 2005, P=.38), and comparable fruit and vegetable consumption rates became significantly higher (2001, P=.68; 2005, P<.001).

CONCLUSIONS

Our findings support the emerging role of policy and community environment change strategies and community participation as promising practices to improve health behaviors in African American communities and to reduce health disparities.

How family, community, and work structured high blood pressure accounts: from African Americans in Washington State

High blood pressure is one of the most often researched, yet least understood health disparities among African Americans. This descriptive, critical discourse analysis examined how family and community demographics and paid and unpaid work structured participants' accounts of high blood pressure experiences in Washington State. Thirty-seven urban-dwelling African American women (n = 17) and men (n = 20) in Washington State enrolled in the study from 2000-2001. Reports about stress, concerns, worry, loneliness, and paid and unpaid work were given in semi-structured interviews. Analysis results are embedded within three major themes: (a) Aware, But Not Informed, (b) Negotiating Self, Kin and Community Health, and (c) Distant Lives, Distant Love. Knowledge of life factors influencing African Americans' high blood pressure appraisals will help develop context-specific health programs focused on their concerns.

A Lay Health Advisor Program to Promote Community Capacity and Change Among Change Agents

The Charlotte REACH 2010 project focuses on cardiovascular disease and diabetes among African Americans in a geographically defined community. The goal of the project is to create changes in individual behaviors, community capacity, change agents, and systemic policies and actions that will result in the reduction of health disparities related to cardiovascular disease and diabetes. The project consists of three main components: lay health advisors as change agents, targeted interventions (exercise, nutrition, smoking cessation, primary care), and environmental and systemic interventions. The purpose of this article is to describe the lay health advisor intervention using qualitative methodologies that were developed to document changes in community capacity and change among change agents. Lay health advisors report that they have internalized their role as a community advocate and have made positive changes in their own personal health behavior. Their understanding of the underlying causes of poor health has expanded to include social and institutional factors and they have begun to shift their emphasis toward advocacy for social and institutional change.

Strategies for Implementing a Promotores-Led Diabetes Self-management Program Into a Clinic Structure

Purpose The purpose of this article is to describe a process for integrating promotores who teach diabetes self-management into a community clinic structure.

Methods The Donbedian structure, process, and outcome method- ology was used to integrate promotores into a community clinic.

Results The model described here resulted in (1) employment of promotores (community health workers) to teach diabetes self-management courses, (2) integration of provider and nurse oversight of course design and implementation, (3) management of promotora training and the development of teaching competencies and skills, (4) coordination of care through communication and documentation policies and procedures, (5) use of quality control mechanisms to maintain patient safety, and (6) promotion of a culturally competent approach to the educational process.

Conclusions The model presented here provides a systematic approach to safely address the educational needs of large numbers of patients with type 2 diabetes who live in communities that suffer from a lack of health care professionals.