Effectiveness of community health workers in the care of persons with diabetes

Article (PDF Available)inDiabetic Medicine 23(5):544-56 · June 2006with1,225 Reads
DOI: 10.1111/j.1464-5491.2006.01845.x · Source: PubMed
Abstract
The purpose of this systematic review was to examine the effectiveness of community health workers in supporting the care of persons with diabetes. Computerized searches were conducted of multiple electronic bibliographic dababases until March 2004. We identified studies in any language and of any design that examined the effectiveness of diabetes-related interventions involving community health workers and reported outcomes in persons with diabetes. Results were synthesized narratively. Eighteen studies were identified, including eight randomized controlled trials. Most studies focused on minority populations in the USA. The roles and duties of community health workers in diabetes care were varied, ranging from substantial involvement in patient care to providing instrumental assistance in education sessions taught by other health professionals. Participants were generally satisfied with their contacts with community health workers and participant knowledge increased. Improvements in physiological measures were noted for some interventions and positive changes in lifestyle and self-care were noted in a number of studies. There were few data on economic outcomes, but several studies demonstrated a decrease in inappropriate health care utilization. Diabetes programmes include community health workers as team members in a variety of roles. There are some preliminary data demonstrating improvements in participant knowledge and behaviour. Much additional research, however, is needed to understand the incremental benefit of community health workers in multicomponent interventions and to identify appropriate settings and optimal roles for community health workers in the care of persons with diabetes.

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Introduction
Type 2 diabetes is complex in its causation and management.
Biological risk factors (e.g. overweight and inadequate physical
activity) and little-understood innate individual traits (e.g.
genetics and intrauterine environment) interact with social,
historical, economic and other environmental factors, also
poorly understood, to make whole communities susceptible to
Type 2 diabetes and its complications.
The findings and conclusions in this report are those of the authors and do not
necessarily represent the views of the Centers for Disease Control and
Prevention.
Correspondence to
: Dawn W. Satterfield RN, PhD, Division of Diabetes
Translation, Centers for Disease Control and Prevention, MS K-10, 4770
Buford Highway NE, Atlanta, GA 30341, USA.
E-mail: dxs9@cdc.gov
Abstract
Aims
The purpose of this systematic review was to examine the effectiveness
of community health workers in supporting the care of persons with diabetes.
Methods
Computerized searches were conducted of multiple electronic
bibliographic dababases until March 2004. We identified studies in any language
and of any design that examined the effectiveness of diabetes-related interventions
involving community health workers and reported outcomes in persons with
diabetes. Results were synthesized narratively.
Results
Eighteen studies were identified, including eight randomized controlled
trials. Most studies focused on minority populations in the USA. The roles and
duties of community health workers in diabetes care were varied, ranging from
substantial involvement in patient care to providing instrumental assistance in
education sessions taught by other health professionals. Participants were gener-
ally satisfied with their contacts with community health workers and participant
knowledge increased. Improvements in physiological measures were noted for
some interventions and positive changes in lifestyle and self-care were noted in
a number of studies. There were few data on economic outcomes, but several
studies demonstrated a decrease in inappropriate health care utilization.
Conclusions
Diabetes programmes include community health workers as team
members in a variety of roles. There are some preliminary data demonstrating
improvements in participant knowledge and behaviour. Much additional research,
however, is needed to understand the incremental benefit of community health
workers in multicomponent interventions and to identify appropriate settings and
optimal roles for community health workers in the care of persons with diabetes.
Diabet. Med. 23, 544–556 (2006)
Keywords
community health workers, diabetes education, lay health workers,
self-management
Abbreviations
CHW, community health worker; LHW, lay health worker;
RCT, randomized controlled trial; SD, standard deviation
Blackwell Publishing LtdOxford, UKDMEDiabetic Medicine0742-3071Blackwell Publishing, 200623
Original ArticleOriginal articleCommunity health workers in diabetes care
S. L. Norris et al.
Effectiveness of community health workers in
the care of persons with diabetes
S. L. Norris, F. M. Chowdhury
*, K. Van Le, T. Horsley*, J. N. Brownstein, X. Zhang*,
L. Jack Jr* and D. W. Satterfield*
Department of Medical Informatics and Clinical
Epidemiology, Oregon Health Sciences University,
Portland, OR, *Division of Diabetes Translation,
National Center for Chronic Disease Prevention and
Health Promotion, Centers for Disease Control and
Prevention, Atlanta, GA, †Cedars Sinai Medical
Center, Los Angeles, CA and ‡Division for the
Prevention of Heart Disease and Stroke, National
Center for Chronic Disease Prevention and Health
Promotion, Centers for Disease Control and
Prevention, Atlanta, GA, USA
Accepted 3 October 2005
Original article
545
© 2006 Diabetes UK.
Diabetic Medicine
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, 544–556
Care practices to optimize glucose control, to reduce cardi-
ovascular risk factors and to detect complications at an early
and treatable stage can help to prevent or delay morbidity
[1,2]. However, many persons with diabetes do not receive re-
commended preventive services [3] or achieve optimal glycaemic
control [4]. Diabetes self-management education is considered
to be an integral component of diabetes care [5]. Many people,
however, do not receive self-management instruction [6] or
they receive interventions that are not effective [7].
The failure to secure optimal preventive care and treatment
practices and to achieve optimal self-care is rooted in numer-
ous individual, environmental and healthcare system-based
variables. A major barrier to optimal care is the lack of access
to quality, culturally appropriate preventive healthcare, which
is exacerbated by the fact that many people with diabetes, or
who are at risk, do not have health insurance [8]. Even with
access to healthcare, there may be multiple individual and
community level barriers to adequate self-care. Communities
can become daunted by a seeming lack of power to improve
outcomes for their members [9]. Indeed, the health of individuals
cannot be separated from the health of the larger community [6].
There is increasing interest in the use of community health
workers (CHWs) as a strategy for improving the health of
individuals and communities that recognizes the influence of
a person’s and a community’s peer network in health actions
[10,11]. Various institutions have recently recognized the con-
tributions of CHWs and recommended their participation in
community-based interventions [12–15].
CHWs are defined as ‘community members who work almost
exclusively in community settings and who serve as connectors
between health care consumers and providers to promote health
among groups that have traditionally lacked access to adequate
health care’ [16]. They have been said to serve as ‘vital links’
[17], ‘bridges’ [11], and ‘in-between people’, brokering
between the world in which they and their neighbours live and
the healthcare system [18]. CHWs can provide the ‘context-
specific’ advocacy and the reciprocal exchange of information
that characterize both emotional and instrumental social
support [19]. A number of different terms are used for CHWs
including promotores de salud, patient navigators, lay health
workers, and natural helpers, among others.
The purpose of this review was to examine the effectiveness
of CHWs in the care of persons with diabetes. Several relevant
reviews have been conducted, but these are dated [20], or include
only a limited (American) perspective [20]. A complete picture
of the current knowledge base will facilitate the planning of
evidence-based programmes and will help target future research.
Methods
Data sources
We developed a systematic review protocol using methods
described by The Cochrane Collaboration [21]. Using Medical
Subject Headings and text words, including community health
aides, lay health workers, volunteers, promotora and multiple
other words, we searched the following electronic databases
for potentially relevant articles in any language from the dates
indicated until March 2004: MEDLINE® (1966), Educational
Resources Information Center (1980), Cumulative Index to
Nursing and Allied Health (1982), Sociological Abstracts (1963),
Chronic Disease Prevention Databases, PsychINFO (1967) and
Web of Science (1980). Review by two authors (S.L.N. and
T.A.) of the first 500 citations from a search of EMBASE
revealed no relevant citations; therefore, this database was not
further screened. Abstracts were excluded as, in general, there
were inadequate descriptions of interventions. Dissertations
were also excluded because the full text was rarely available.
Two reviewers independently identified potentially relevant
studies by reviewing titles and abstracts retrieved from the bib-
liographic databases. Studies identified as potentially relevant
were retrieved in full text and screened in duplicate for inclu-
sion. Consensus was achieved through discussion and, when
needed, consultation with a third reviewer.
Study selection
Studies included in this review reported the evaluation of an
intervention involving CHWs delivered to adults with diabetes
(the latter are referred to herein as participants). CHWs were
defined as any healthcare worker who: (i) carried out functions
related to healthcare delivery; (ii) was trained in some way in
the context of the interventions; (iii) had no formal professional
or paraprofessional training in healthcare [22]; and (iv) had a
relationship with the community being served [20]. CHWs
were either the sole focus of the intervention under study or one
component of a multicomponent intervention or team.
Studies reporting at least one outcome among the participants
were included in our review. Studies examining only outcomes
among the CHWs (e.g. reports of CHW training interventions)
were excluded. No restrictions were placed on participant out-
comes in order to assess the effect of CHW interventions on all
process, health, quality-of-life and economic outcomes.
Participants were
18 years old and had diabetes; there
were no other restrictions on the types of participants. Settings
for interventions were unrestricted; interventions could have
occurred in the clinic, home or community setting and were
delivered in either developed or undeveloped countries.
There were no restrictions on study design; we included
randomized controlled trials (RCTs), controlled before–after
trials, and studies with a before–after or postintervention only
design. The latter design was included to allow examination of
process outcomes (e.g. provider or patient satisfaction with
CHW services). The follow-up interval was of any duration.
Studies involving peer-led patient support groups were ex-
cluded because these interventions were believed to be different
from CHW interventions. Studies involving family members as
providers of care were also excluded.
Data extraction
Using a standardized template, data from eligible studies were
abstracted by one of the authors (F.M.C.) and checked by
another (S.L.N.). For each study we examined attrition, as well
© 2006 Diabetes UK.
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Community health workers in diabetes care •
S. L. Norris et al.
as how the participants were recruited (an indication of the rep-
resentativeness of study participants of target populations). We
also examined the completeness of descriptions of participant
and CHW demographic characteristics and CHW training and
duties. Quantitative estimates are reported as means (
SD
), unless
otherwise indicated.
Results
There were 18 appropriate studies [2339] in 25 publications
(including seven companion papers [4046]) (Fig. 1). The 18
primary studies were published between 1986 and 2003 and
included eight RCTs [24,26,28,30,32,35,37,38], six studies
with a before–after design [23,25,27,33,36,47], three studies
with non-randomized allocation of treatment and comparison
groups [31,34,39] and one study with postintervention meas-
ures only [29] (Table 1). Sample size varied widely. In one
study [34], six participants were assigned to peer mentors; in
another study [47], 4525 persons attended diabetes education
classes that the CHW assisted in organizing. The mean follow-up
interval for all studies was 13.7 months (range 2–36 months).
Most of the studies were conducted in the USA, one was
conducted in Britain [30] and one in the Australian Torres
Strait Islands [38]. All of the identified studies were published
in English. None of the studies was conducted in developing
countries. A number of additional articles describing com-
munity interventions involving CHWs were identified in both
developed and undeveloped countries, but none reported out-
comes data among participants. Intervention settings varied,
including urban and rural clinics, community centres and the
home.
Minority populations were the target of the CHW interven-
tion in all studies but two [32,34]. The majority of intervention
participants were female (range 53–100%) and middle-aged.
Most of the studies examined Type 2 diabetes exclusively; in
three studies participants with either Type 1 or Type 2 diabetes
were included [27,34,39]. Two of the studies examined popu-
lations with chronic diseases, including diabetes [27,37]. One
study examined pregnant women with either preexisting or
gestational diabetes [33]. A variety of strategies were used to
recruit participants: selection by the researchers; review of
research rosters, clinic charts, or billing databases; provider
selection; or advertising in community settings or in the media.
CHW characteristics were often poorly reported. The
CHWs were members of the local community and were of
the same race/ethnicity as the participants in all of the studies
in which this information was reported. The age and sex of
CHWs were reported in only one study [27]. Information on
the education or experience of the CHW was reported in only
six studies; in three studies, the CHW had some prior health-
care experience [26,33,36]. Brown
et al
. [24] and Moore and
Mengel [47] recruited CHWs who had Type 2 diabetes them-
selves; the intervention of Lorig and colleagues [36,37]
involved CHWs with a variety of chronic conditions.
Figure 1 Systematic review flow diagram. CDP, Chronic Disease Prevention Database; Cinahl
®
, Nursing and Allied Health database; ERIC™,
Educational Resources Information Center database; WOS, Web of Science.
Original article
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Table 1
Study characteristics
Study Study design N, Client N, CHW
Follow-up
(months)
Quality Participants CHWs
Attrition,
client (%)
Attrition,
CHW (%)
Participant
recruitment
Age (mean
[
SD
], years) Race/ethnicity
Sex (%
female)
Diabetes
type Setting Training Race/ethnicity
Education,
experience Supervision Duties
Anonymous
2003 [23]
Before–after 35 NR 6 NR NR NR NR Hispanic NR NR Urban, primary
care clinics
Diabetes,
communication
skills
Hispanic; local
resident
NR NR Liaison between
client and
healthcare system
Brown 1995
[25]
Before–after 7 1 5 29 0 Randomly
selected from
research roster
60 (3) Hispanic 60 2 Agricultural
extension office
Office
organization,
taking
measurements
Hispanic; local
resident
NR NR Led social support
class; assisted in
organizaing
educational
sessions by nurse
Brown 2002
[24]
RCT 256 8 12 10 (90% data
retention rate)
NR Randomly selected
from research
roster
54 (5.8)
(range
35–70)
Hispanic 64 2 Communities along
US-Mexico border
8-week training
programme on
diabetes self-
management
Hispanic; local
resident
High school; had
Type 2 diabetes
NR Assisted in
educational and
social support
sessions
Corkery
1997 [26]
RCT 64 1 7.7 (mean) 37 0 Newly referred,
consecutive clinic
patients
52.8 (11.7) Hispanic 74 NR Urban diabetes clinic NR Hispanic; local
resident
Previously
worked at
diabetes clinic
NR Interpreter,
reinforced self-
care instructions,
liaison between
patient and
healthcare system
Fedder 2003
[27]
Before–after 117 68 trained,
38 provided
services
12 NR NR Data from claims
database
57.4 (12.0) African-
American
78 1 or 2; 27%
with hyper-
tension and
not diabetes
State Medicaid
program
Diabetes, hyper-
tension, behaviour
change; 60 or more
hours over 6 m
NR; lived in target
areas
Most < 12 years
school
Close
supervision
with biweekly
meetings
Assisted in
appointment
making, care
coordination,
monitoring for
complications,
provide social
support
Gary 2003
[28]
RCT 186 1 24 16 0 Medical chart
review with follow-
up visit
59 (9) African-
American
77 2 Urban, primary care
clinics
NR NR, local resident High school
graduate
Met biweekly
with NCM
Home visits or
telephone contacts
for disease
monitoring,
treatment
adherence,
mobilize social
support, client
education
Griffin
1999, 2000
[29,41]
Post
measures
only
206 8 7 19 for group
classes
NR Targeted
population was
invited
59.2
(mean)
Native American NR 2 Pueblos 5 training sessions
on diabetes and
behaviour change
Local resident,
Native American
NR NR Taught
educational
sessions,
demonstrate
exercises, assist in
behaviour change
Hawthorne
1997 [30]
RCT 201 1 6 5 0 Patients from
diabetes centre and
neighbouring
practices; unclear
how selected
52.9 (15.2) British Pakistani 53 2 Clinic or home Informal training in
diabetes education
British Pakistani NR NR Helped develop
educational
flashcards;
delivered
standardized
interview
questionnaire and
individual
education
© 2006 Diabetes UK.
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Community health workers in diabetes care •
S. L. Norris et al.
Heath 1987
[31]
Cohort with
comparison
86
intervention
56
comparison
48 12 (mean) 33% engaged
in exercise
sessions for
< 3 months
NR Invitations, media;
comparison group
from a registry
43.3 (10) Zuni Indian 80 2 Indian reservations Exercise and group
leadership
Native American,
local resident
NR Coordinated
by health
educators
Aided in
coordinating
exercise
programme,
weigh participants
Holtrop
2002 [32]
RCT 132 NR 6 33 NR Computerized
billing lists of
primary care clinics
61.4
(mean)
Caucasian 100 2 Rural clinics Programme
facilitation
NR NR NR Led discussion on
behaviour
management
skills, social
support;
telephoned clients
to provide support
Humphrey
1997 [33]
Before–after 52 non-
pregnant 18
pregnancies
NR 34.8
(mean)
(range
0.4–4.2)
20 (non-
pregnant)
NR Selected patients
from health centre
with pattern of
repeated missed
appointments and
poor metabolic
control, or a
diagnosis of
diabetes in
pregnancy
Non-
pregnant:
9% < 20,
27% 21–
30, 12%
31–40,
35% 41–
60, 17%
> 60
61% Native/part
Hawaiian, 11%
Samoan, 11%
caucasian, 9%
Philipino, 4%
Japanese, 4%
Hispanic
Non-
pregnant
75
Pregnant:
66% Type
1 Non-
pregnant:
NR
Community health
centre, Hawaii
12-week college-
level curriculum; 4-
week clinical
preceptorship with
diabetes team, 4-
weeks with public
health nurse
NR Medical
assistants or
para-
professional;
some medical
background
Worked as
part of
healthcare
team
Principal
coordinator of
health services for
client; nutrition,
diabetes education
with advice from
healthcare team;
reviewed patients
weekly with
diabetes team to
develop treatment
plans; case
management;
helped establish
regular patient
contact with care
team
Joseph 2001
[34]
Matched
pairs
6521720Selected by
reseachers
NR Caucasian NR 1 and 2 Home 2-h session by
diabetes nurse
educator and social
worker: role of
coach with role
playing to develop
skills in listening
and asking
questions
Caucasian NR Nurse
educator
available by
phone
1 h with partner;
telephone call to
partner weekly for
10–15 min;
shared personal
stories to promote
behaviour change
Keyserling
2002 [35]
RCT 200 NR 12 15 NR Physician invited
patients to
participate
59.2
(mean)
African-
American
100 2 Primary care
practices
4-h sessions for 4
weeks: diet and
exercise; general
diabetes care;
resources; listening
skills; skills in stress
management, goal
setting, problem
solving; trained
how to make
telephone contacts
and use study
materials
African-American NR Clinic-based
health
counsellor
Social support and
feedback to
participants;
reinforced diet
and activity goals
during monthly
telephone calls;
assisted with
group sessions
Study Study design N, Client N, CHW
Follow-up
(months)
Quality Participants CHWs
Attrition,
client (%)
Attrition,
CHW (%)
Participant
recruitment
Age (mean
[
SD
], years) Race/ethnicity
Sex (%
female)
Diabetes
type Setting Training Race/ethnicity
Education,
experience Supervision Duties
Table 1
Continued
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Lorig 2000
[36]
Before–after 149 19 3 27 Community media 54.6 (12.3) Hispanic 66 2 Urban community
centres, clinics
28-h course
conducted in
Spanish; manual
with course content
and processes for
all the activities
Hispanic; local
resident
Some with prior
healthcare
experience;
many with
diabetes
NR Taught diabetes
education course
Lorig 2003
[37]
RCT and
before–after
551 2 4 (RCT);
12
(before–
after)
20
(4 months);
32
(12 months)
0 Community
outreach to
churches,
community centres,
clinics
57.0 (13.9) Hispanic 79 45% Type
2 diabetes
(52%
hyper-
tension,
19% lung
disease)
Urban community
centres, clinics
4 days training
from a standard-
ized protocol; two
practice teaching
sessions; evaluated
prior to teaching
Spanish speaking;
1 or more chronic
diseases
Most with 1 or
more chronic
conditions
NR Taught diabetes
education course
McDermott
2003 [38]
Cluster RCT 921 NR 12 and 36 7 at 1 year,
NR 3 years
NR Audit of disease
registries and
hospital
admissions,
referrals
53.3 (13.6) Melanesian or
aboriginal
descent
62 2 Community-based Basic diabetes care Members of local
indigenous
community
NR Supported by
a specialist
outreach
service
Managed
registries, recall
and reminder
systems; provided
basic regular
clinical checks
Moore 2002
[47]
Before–after 4525
(attended
classes)
30–35 36 NR NR Media and local
physicians
NR NR NR NR Clinic Educated on
privacy, telephone
answering
protocols,
programme
assistance tasks,
computer data
entry, other office
procedures
NR Had diabetes Met monthly
with nurse
Answered
telephone, host for
public
programmes and
classes, verified
class attendance,
downloaded data
from blood
glucose meters,
reminder phone
calls to registrants
for provider
follow-up,
maintained
mailing lists,
previewed
educational
materials,
prepared and sent
out quarterly
follow-up surveys
Philis-
Tsimikas
2001, 2004
[46,39]
Cohort with
comparison
153 NR 12 28 NR Referral from
providers or by
review of
laboratory values
51 (12.9) 72% Latino 68 82% Type
2
Clinic Extensive diabetes
training; had to
meet established
competencies
before teaching
classes
Latino NR NR Taught health
promotion and
self-management
N, Number of studies; NR, not reported; NCM, nurse case manager; NSD, no significant difference; RCT, randomized, controlled trial;
SD
, standard deviation; SMBG, self-monitoring blood glucose; TG, triglycerides; UC, usual care.
Study Study design N, Client N, CHW
Follow-up
(months)
Quality Participants CHWs
Attrition,
client (%)
Attrition,
CHW (%)
Participant
recruitment
Age (mean
[
SD
], years) Race/ethnicity
Sex (%
female)
Diabetes
type Setting Training Race/ethnicity
Education,
experience Supervision Duties
Table 1
Continued
© 2006 Diabetes UK.
Diabetic Medicine
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, 544–556
550
Community health workers in diabetes care •
S. L. Norris et al.
There was a great deal of variability in the roles and duties
of CHWs in diabetes care and these roles could be classified
into five types of services, although there could be overlap of
the CHW’s roles in a specific intervention. The first type of
service involved significant responsibilities for patient care
and support [27,28,38]. For example, Fedder and colleagues
[27] trained CHWs on general concepts, including chronic
illnesses, resource identification, case management, telephone
outreach, and documentation, as well as on diabetes-specific
topics, including medications, emergencies, self-monitoring
of blood glucose and diabetes complications. These CHWs,
working closely with the medical care team, had significant
responsibilities with weekly patient contacts by phone or in the
participant’s home. The CHW facilitated care coordination
and provided follow-up; assisted in the monitoring of
blood glucose, blood pressure and potential complications;
and provided social support to the patient as well as to their
family.
In the second role, the CHW was primarily a patient educator
[26,28,29,33,36,37,39] or provided assistance with self-care
skills [25]. In the third role, the CHW provided instrumental
support for care delivery or educational programmes provided
by other healthcare professionals [24,25,27,31,35,38,47].
In a fourth role, the CHW coordinated care or functioned as a
liaison with the healthcare system [23,26,33]. In the fifth role,
the CHW primarily provided social support [25,34,35].
Supervision of the CHWs varied among the studies where
it was reported, but in most, the CHW was an integral part
of the team and worked closely with a nurse. Training of the
CHWs varied in content and intensity and generally corre-
sponded to the responsibilities of the CHWs.
Outcomes are reported in Table 2. Quantitative synthesis
(meta-analysis) was not possible due to the heterogeneity of
populations, settings, interventions and outcomes. Data were
therefore presented and synthesized narratively.
Data on attendance in the CHW programmes were provided
in 12 studies and, in most studies, more than half of partici-
pants either completed the programme or obtained the
intended number of contacts with the CHWs. Data on partic-
ipant satisfaction with the CHWs were most often reported in
very general terms, without statistical comparisons.
Knowledge about diabetes and self-care was noted to
increase significantly among participants (
P <
0.05) in five
[24,25,30,35,39] of seven studies reporting this outcome. Posi-
tive behavioural changes were noted in a number of studies,
with improvements in diet [28,32,35,36], physical activity levels
[28,32,35–37], self-monitoring of blood glucose [30,37,38]
and in other self-care behaviours [30]. In two studies [38,39],
monitoring of glycaemic control by providers was improved,
as were rates of retinopathy screening.
Significant improvement in HbA
1c
levels was reported in
four of 11 studies reporting this outcome [25,26,28,39]; how-
ever, only one of these was an RCT with a significant between-
group difference [24]. Lipid levels were measured in a number
of studies [24,25,28,35,39] and improvements were noted in
two [28,39]. Blood pressure decreased significantly in two
[28,38] (
P <
0.05) of four studies [28,33,38,39] in which it
was measured.
Healthcare utilization outcomes were examined in four
studies [27,36–38], and both Fedder and colleagues [27] and
Lorig and colleagues [37] noted a decrease in emergency attend-
ances in the treatment groups. McDermott and colleagues
[38] found a significant decrease in hospital admissions
related to diabetes (
P <
0.05) and Fedder
et al
. [27] noted a de-
crease in hospital admissions occurring directly through the
emergency department.
Only one study reported health outcomes (neonatal out-
comes in a programme focused on pregnant women [33]); no
other study reported health outcomes such as morbidity or
mortality. Few data were reported on quality of life. Lorig and
Gonzales [36] noted an increase in self-efficacy among their
participants (
P <
0.0001) and Lorig and colleagues [37] noted
a decrease in fatigue (
P =
0.002) and an increase in both role
function (
P <
0.001) and self-reported health (
P <
0.001). A
study by Moore and Mengel [47] reported outcomes among
the CHWs and the participants, with improved knowledge,
glycaemic control and blood pressure, although statistical
analyses were not presented.
The quality of studies included in this review was variable.
Important characteristics of study participants were often
missing and the characteristics of the CHWs were often incom-
plete. Among the eight RCTs, only two reported blinding of
the assessor [28,37]. The methods of randomization were also
reported in only two studies [30,35] and allocation conceal-
ment was reported in three studies [28,30,35]. For studies
involving two or more groups, comparability of the compari-
son groups at baseline was documented in most [24,28,30–
32,35,39,45]. CHW attrition from the study was reported in
all studies but three [23,27,47], and ranged from 4% (at
6 months [30]) to 37% (at 7.7 months [26]). Attrition among
CHWs was not consistently reported.
Discussion
There is an emerging literature on the effectiveness of CHWs
in diabetes care, including eight RCTs. Preliminary data sug-
gested that the participants were satisfied with their contacts
with CHWs and that participant knowledge levels increased.
Effects on physiological measures and health behaviours were
mixed, however, and data on health-related quality of life,
healthcare utilization and economic efficiency were sparse.
A great deal of variability existed in the reported roles and
duties of CHWs in diabetes care, which ranged from sub-
stantial involvement in patient care to providing assistance
with implementing education sessions taught by other health
professionals. Studies examining any one role for the CHW
were not sufficient in number to draw conclusions as to the
optimal roles for CHWs in community interventions.
There was also much variability in the number and nature of
intervention components. This makes it difficult to determine
Original article
551
© 2006 Diabetes UK.
Diabetic Medicine
,
23
, 544–556
Table 2
Outcomes
Study Attendance Client satisfaction
Knowledge and behaviour
outcomes
Physiological measures and health
outcomes Economic outcomes
Anonymous
2003 [23]
Clients found sessions helpful
in improving health practices
HbA
1c
: 9.4% at baseline, 7.1% after
intervention (no statistics)
Brown 1995 [25] All 5 programme completers
attended all educational sessions;
support persons attended 6 of 9
meetings
Sessions helpful in improving
health practices; having
support person at sessions was
helpful
Knowledge self-management
principles:
(
P =
0.04)
GHb:
2.4% (1.8) (
P =
0. 4); FBS:
73.2 mg/dl (30.5) (
P =
0.04) Cholesterol:
NSD; TG: NSD; Weight: NSD
Brown 2002 [24] Diabetes knowledge:
(
P <
0.001)
HbA
1c
: Between-group difference: –0.8%
(95% CI
1.3,
0.2); FBS: Between-group
difference
21.5 mg/dl (
33.6,
9.6)
Cholesterol: NSD; TG: NSD; BMI: NSD
Estimated intervention cost
$384/person
Corkery 1997
[26]
Program completion: 80%
intervention group, 47% control
group (
P =
0.01); programme
completion correlated with use of
CHW (
P =
0.007)
For all completers of education
programme (with or without
CHW): knowledge:
(
P <
0.001);
following meal plan
(
P =
0.013);
carrying fast-acting sugar
(
P <
0.001); performing daily foot
care
(
P <
0.001)
For all completers of education programme
(with or without CHW): HbA
1c
:
2.2% at
last follow-up (
P <
0.001, within group)
Fedder 2003 [27] Mean number of CHW contacts
18.2 (range 5–68)
Health care utilization:
ER
visits 38% (
P
-value NR);
admissions through the ER
53% (
P =
0.02); no significant
relationship between age, sex,
number of CHW contacts, and
outcomes
Gary 2003 [28] 62% of CHW group received 3 or
more visits/year
Dietary risk factors: CHW:
HbA
1c
: within-group group:
(
P
> 0.05) Physical activity score:
CHW + NCM and CHW:
(
P <
0.05, within-group change)
HbA
1c
: within-group change: CHW
0.3%
(0.5); NCM
0.3% (0.5); CHW + NCM
0.8% (0.5) (
P <
0.05, within group); BMI:
NSD; SBP: NCM
(
P <
0.05); DBP:
between-group change: NCM + CHW
5.6 mmHg (
P =
0.042); TG: between-
group change: NCM + CHW
35 mg/dl
(
P =
0.04)
Griffin 1999,
2000 [29,41]
40% of target population
participated in 1 or more of 5
sessions. Retention rates: 81% for
group sessions, 91% for individual
Satisfaction: 97% had (+)
responses to satisfaction
questionnaire
Hawthorne
1997 [30]
Satisfaction: ‘Pictures (flashcards)
well received.’ ‘Preferred one-to-
one opportunistic health education
at clinics rather than organized
group sessions’
Knowledge:
intervention group
(
P <
0.05); SMBG: 92% of clients
doing regularly at 6 months; Self-
care behaviours:
(
P <
0.05)
HbA
1c
: Between-group difference
0.14%
© 2006 Diabetes UK.
Diabetic Medicine
,
23
, 544–556
552
Community health workers in diabetes care •
S. L. Norris et al.
Heath 1987 [31] Mean duration participant
attendance 37 weeks (16.3);
1.7 sessions/week
43% participants began home
exercise programme (18% of
non-participants)
Weight: participants
4.1 kg (4.9); non-
participants
0.9 kg (3.9) (between-group,
P
< 0.05); FBS (mg/dl): participants
43
(78), non-participants
2 (67) (between-
group difference,
P
< 0.05)
Holtrop 2002
[32]
‘High patient satisfaction’ Physical activity (15 min/
day
×
3 days/week)
(
P =
0.003);
limit high-fat foods to
1/day
(
P =
0.008); eat
5 servings of
fruits and vegetables/day
(
P =
0.0001); limit refined sugar
products to
1/day
(
P =
0.001);
eat 3 meals/day NSD
HbA
1c
: NSD; BMI: NSD
Humphrey 1997
[33]
Non-pregnant: 22 encounters per
person with CHW
Non-pregnant: 32%
completed satisfaction survey:
83% ‘always’ satisfied with
care by CHW, 9%
‘somewhat’, 1% ‘never’
Non-pregnant: weight: 2.5 kg; BS:
49.8 mg/dl; SBP (among those with
hypertension): 20.5 mmHg; DBP (among
those with hypertension): 6.1 mmHg;
Pregnant: preterm hospitalization: 18%;
Caesarean section: 56%; Premature
delivery: 12%; Macrosomia: 6%
Joseph 2001 [34] One pair (coach and participant)
broke up
All participants felt was
positive experience, learned
useful information
Programme helped to change
behaviour of participants to
improve their diabetes (no data
provided)
Keyserling 2002
[35]
CHW delivered 9.7 telephone calls
per participant
Clinic and CHW group: 85%
felt number of telephone calls
appropriate, 86% felt CHW
role important, and 84%
‘strongly agreed’ that talking
to someone else with diabetes
was very helpful; 100% of
participants who attended
group sessions enjoyed them
Diabetes knowledge: (overall
group effect, P = 0.037); Physical
activity: clinic group and clinic
and CHW groups vs. control
(P = 0.29 and 0.0055,
respectively); diet (% calories
from saturated fats, dietary
cholesterol intake, total energy
intake) NSD at 6 months
HbA
1c
: NSD; Weight: NSD; Cholesterol:
NSD; HDL: NSD
Lorig 2000 [36] Participant attended average 4.3 of
6 sessions
Aerobic exercise: +50 min/week
(121) (P 0.0001); Practice
relaxation: (P 0.0002);
Communicate with physician:
(P 0.001); Examine feet: NSD;
Vegetables eaten daily: (P
0.01); Self-efficacy: (P 0.0001);
Have glucometer: 11%
(P 0.02); Days monitoring/week:
mean 0.67 (2.34) (P < 0.05)
Out-patient visits: NSD; ER
visits: NSD; Hospitalizations:
NSD; Hospital days: NSD;
Economic: NR
Study Attendance Client satisfaction
Knowledge and behaviour
outcomes
Physiological measures and health
outcomes Economic outcomes
Table 2 Continued
Original article 553
© 2006 Diabetes UK. Diabetic Medicine, 23, 544–556
Lorig 2003 [37] 49% completed 1-year follow-up 4 month results: Self-reported
health: (P < 0.001); Fatigue:
(P = 0.002); Pain/discomfort:
(P = 0.016); Exercise (min/
week): (P = 0.001);
4-month results: No. physician
visits/4 months: NSD; ER
visits: (P < 0.005);
maintained at 1 year; Hospital
days: NSD;
1-year results: Self-reported
health: (P < 0.001); Role
function: (P < 0.001); Exercise
(min/week): (P = 0.001)
1-year results: Number
physician visits/4 months:
NSD; Hospital days: NSD
McDermott
2003 [38]
Self-monitoring blood glucose:
(P < 0.05); Annual influenza
vaccination: 24% (P < 0.05);
Retinopathy screening: 30%
(1999), 63% (2002) (P < 0.05);
HbA
1c
in last 6 months: 65%
(1999), 56% (2002) (P < 0.05);
Use of insulin: 7% (1999), 16%
(2002) (P < 0.05)
HbA
1c
: 9.2 (1999), 9.0 (2002) (NSD)
HbA
1c
7.0%: 18% (1999), 25% (2002);
Well-controlled hypertension (< 140/
90 mmHg): 40% (1999), 60% (2002)
(P < 0.05); Weight (kg): 87 (1999), 91
(2002) (P < 0.05)
Hospital admission related to
diabetes: 25% (1999) to 20%
(2002) (P < 0.05)
Moore 2002 [47] More than 2500 people attended
follow-up and diabetes education
classes. Approximately 800 people
met with nurse educators for one-
on-one appointments
CHW: Knowledge (no data) 7.0%: HbA
1c
> 8.0%: 26.6% (1998),
9.6% (2001); < 49.3% (1999), 78.7%
(2001) (no CHW: HbA
1c
: 6.7% initially,
6.3% at follow-up (P-value NR);
BP: (no data)
Philis-Tsimikas
2001, 2004
[46,39]
56% of participants attended peer-
led education Average 8 NCM
visits/year
Treatment satisfaction:
(P < 0.05)
Knowledge: (P < 0.05)
Inaccurate culture-bound beliefs:
(P < 0.05); Compliance with
testing: Intervention group: 100%
for foot exams, HbA
1c
Eye exams:
81% intervention group, 6%
control group
Treatment group changes: Cholesterol:
5.8–4.8 mmol/l (between-group,
P = 0.0001); HbA
1c
: 12.0–8.3% (between-
group, P < 0.001); LDL: 3.4–2.8 mmol/l
(between-group, P = 0.03); HDL: NSD;
BMI: NSD; SBP: 128–123 mmHg
(P = 0.06)
Values are mean or percent (standard deviation) or (95% confidence interval).
BMI, Body mass index (kg/m
2
); BP, blood pressure; CHW, community health worker; CI, confidence interval; DBP, diastolic blood pressure; ER, emergency room; FBS, fasting blood glucose; GHb, glycated
haemoglobin; HbA
1c
, haemoglobin A1c; NCM, nurse case manager; NR, not reported; NSD, no significant difference; SBP, systolic blood pressure; SMBG, self-monitoring blood glucose; TG, triglycerides.
Study Attendance Client satisfaction
Knowledge and behaviour
outcomes
Physiological measures and health
outcomes Economic outcomes
Table 2 Continued
© 2006 Diabetes UK. Diabetic Medicine, 23, 544–556
554 Community health workers in diabetes care • S. L. Norris et al.
what intervention characteristics led to positive outcomes
and the role of the CHW in producing the observed effect.
Improvements in physiological measures were noted for
interventions where the CHW was involved in patient care
[28], provided assistance for interventions delivered by other
health providers [24,31] and assumed a direct teaching role
[28,37,39]. Some of the successful interventions were multi-
component (with interventions involving personnel other than
CHWs) [31,38] and other successful interventions primarily
or exclusively involved the CHW [24,28,37,39].
There are important limitations of our review. The applica-
bility of these results to other settings and to broader popula-
tions is unclear. Although most participants were members of
underserved communities in the USA, participants were gener-
ally selected by either the researcher or the provider, or were
self-selected.
Our reporting and assessment of each intervention study
was limited to published data because no attempts were made
to contact authors for additional information. In many cases,
the reporting of study details was inadequate, particularly for
descriptions of the CHW education, training, experience and
supervision, as well as CHW attrition rates.
The potential for publication bias clearly exists in this review.
Many interventions involving CHWs are not implemented with
an evaluation component. In addition, it is likely that many
community programmes, local health departments or private
healthcare organizations that include CHWs in their teams
have conducted evaluations, but these data are not published.
Several systematic reviews have been published that in-
cluded studies examining the effectiveness of CHWs involved
in chronic disease care. Lewin and colleagues [22] published
a review of RCTs examining the effectiveness of lay health
workers (LHWs) in a broad range of prevention and treat-
ment interventions. They concluded that interventions in-
volving LHWs showed promising benefits for improving
immunization uptake and outcomes for acute respiratory
infections and malaria, but that evidence was insufficient to
recommend the implementation of LHWs in other programme
areas. Swider [48] reviewed the effectiveness of CHWs within
the USA and noted preliminary support for CHWs in increas-
ing access to care, particularly in underserved populations. She
found a small number of studies documenting an increase in
health knowledge, improved health status and positive behav-
ioural changes and she called for better-designed studies.
With the growing need to provide effective, culturally
appropriate healthcare and support, much more research is
warranted. Additional studies are needed to identify specific,
replicable characteristics of successful interventions. Roles for
CHWs in programmes will undoubtedly vary among settings.
Optimal CHW recruitment strategies, training, supervision
and evaluation as well as optimal participant selection, how-
ever, have yet to be determined for various CHW roles. The
contributions of CHWs to the success of multicomponent,
team interventions remain unclear because multifactorial
designs were not implemented. Evaluation studies are needed
in more diverse settings, including in developing countries,
where the literature is confined to descriptive information,
with no evaluation reported.
Further research is needed to determine the facilitators and
barriers to successful implementation of CHW interventions.
Participant expectation and satisfaction are clearly key issues
and, although most of the studies had some measure of partic-
ipant attendance, few examined participant satisfaction and of
those, few examined specific aspects of satisfaction [25,35]. It
is also important to examine physicians’ and nurses’ views and
expectations of CHWs, healthcare system barriers to imple-
mentation and strategies for integrating the CHW into the
healthcare team. Likewise, an examination of CHW satisfac-
tion and perceptions of barriers among CHWs is needed.
The underlying characteristics of settings that might lead
to effective CHW interventions have yet to be delineated.
Perhaps interventions involving CHWs are most effective in
settings where a certain infrastructure is already in place, par-
ticularly one involving well-developed community networks
and strong social ties among members. In particular, the most
successful CHW programmes may be based on a community-
based, participatory model, in which community members
and healthcare and other agencies have shared values, equity,
planning and participation. Some populations are much more
likely to turn initially to informal healthcare systems rather
than formal ones, and the CHW model seems to fit these
populations well. However, future research is needed to iden-
tify populations in which the model works best and on how to
tailor interventions to participants from diverse cultures.
Research is also needed to examine intermediate, health and
quality of life outcomes. The improvements in participant
knowledge noted among populations where traditional
healthcare interventions have often failed, may represent an
important step forward in raising diabetes health literacy
among members of target populations. These improvements,
however, must be demonstrated to lead to positive changes in
lifestyle, self-care behaviours, physiological outcomes and
quality of life. Future research also needs to incorporate meas-
ures of healthcare utilization and economic efficiency, includ-
ing cost-effectiveness.
Studies with strong designs are needed, thereby maximizing
internal validity. Although RCTs potentially provide the least
biased information on CHW effectiveness, they are resource
intensive and difficult to implement. In addition, they are often
less generalizable than studies where the participants or groups
are not randomized (or where there is no comparison group at
all) [49]. Researchers have successfully used non-randomized
designs with contemporaneous comparison groups, with care-
ful identification and adjustment for known potential con-
founders. In addition, researchers and programme evaluators
need to document the key characteristics of participant popu-
lations, settings and interventions so that readers can better
assess study quality and replicate successful interventions.
Community diabetes programmes are increasingly includ-
ing CHWs in a variety of roles. There are some data to support
Original article 555
© 2006 Diabetes UK. Diabetic Medicine, 23, 544–556
their effectiveness in improving participant knowledge levels
and satisfaction, but data on health, quality-of-life and eco-
nomic outcomes are sparse. Much additional research, how-
ever, is needed to understand the incremental benefit of CHWs
in multicomponent interventions, and to identify appropriate
settings and optimal roles for CHWs in the care of persons
with diabetes.
Competing interests
None declared.
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    • "Peer support interventions may provide assistance with accessing resources and developing skills for better diabetes management. CHW interventions were efficacious in improving outcomes, especially in remote or poor communities where individuals are severely affected by poverty and other psychosocial and physiological barriers [34,35,37]. For disadvantaged populations, interventions must be compatible with the realities of what is feasible and acceptable to these target populations in their home environments. "
    [Show abstract] [Hide abstract] ABSTRACT: Diabetes disproportionately affects disadvantaged populations. Eighty percent of deaths directly caused by diabetes occurred in low- and middle-income countries. In high-income countries, there are marked disparities in diabetes control among racial/ethnic minorities and those with low socio-economic status. Innovative, effective and cost-effective strategies are needed to improve diabetes outcomes in these populations. Technological advances, peer educators and community health workers have expanded methodologies to reach, educate and monitor individuals with diabetes. In the present manuscript we review the outcomes of these strategies, and describe the barriers to and facilitators of these approaches for improving diabetes outcomes.
    Full-text · Article · Jun 2016
    • "It is difficult to evaluate the effect of CHW-based interventions in diabetes care because the scope of CHW involvement can vary widely. However, some positive outcomes, including knowledge and behavioral changes, have been described in a review [13] but none of the studies included had been performed in low-resource settings. A study performed in Hawaii [14] among patients with GDM demonstrated that monitoring by CHW once or twice each month could improve patient compliance with GDM management [14]. "
    [Show abstract] [Hide abstract] ABSTRACT: Objective: To identify screening and management practices for gestational diabetes mellitus (GDM) in low-income and lower-middle-income countries. Methods: A cross-sectional survey was conducted between November 12, 2014 and May 11, 2015. Questionnaires were distributed to gynecologists, endocrinologists, and medical doctors who were representatives of national professional societies or were involved in providing care to patients with GDM in low-income or lower-middle-income countries in Africa, South Asia, and Latin America. The data were descriptively analyzed. Results: Questionnaires were sent to 182 individuals and 77 healthcare providers from 26 countries completed the survey. The results demonstrated high diversity in screening and management practices. Only 52 (68%) participants reported that any guidelines were available in their setting. Management of GDM was found to take place mainly at the tertiary level and reported practices, including the frequency of post-diagnosis follow-up, modalities of glucose surveillance, and treatment and practices surrounding delivery, varied and did not always reflect the most recent evidence. Conclusion: Attempts to ensure greater adherence to latest consensus guidelines are required, and should be accompanied by systemic changes to improve the detection and management of GDM at primary- and secondary-level healthcare facilities to facilitate patient access to GDM screening and treatment.
    Article · May 2016
    • "Community health workers (CHWs) often act as frontline health navigators in these programs by providing additional services to pregnant and postpartum women [1, 19, 29]. They also are embedded in more robust interventions to improve participant health by educating expectant and postpartum mothers on appropriate health-seeking behavior, and fostering improved social relationships and social support [14, 19]. CHWs are lay health workers recruited from the local community, who often share a common language, ethnicity , or race with their target populations [27]. "
    [Show abstract] [Hide abstract] ABSTRACT: The Scale to Assess the Therapeutic Relationship in Community Mental Health Care (STAR) is a frequently-administered tool for measuring therapeutic relationships between clinicians and patients. This manuscript tested the STAR's psychometric properties within a community health worker (CHW)-led intervention study involving pregnant and postpartum women. Women (n = 141) enrolled in the study completed the 12-item participant STAR survey (STAR-P) at two time points over the course of pregnancy and at two time points after delivery. The factor structure of the STAR-P proved to be unstable with this population. However, a revised 9-item STAR-P revealed a two-factor model of positive and negative interactions, and demonstrated strong internal consistency at postpartum time points. The revised STAR-P shows strong psychometric properties, and is suitable for use to evaluate the relationship developed between CHWs and pregnant and postpartum women in an intervention program.
    Full-text · Article · Apr 2016
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