[Show abstract][Hide abstract] ABSTRACT: Community health workers (CHWs) have demonstrated effectiveness in improving health outcomes and addressing health inequities. Statewide CHW coalitions are supporting expansion of the CHW workforce and influencing health policy. Evaluations can play a key role in sustaining coalitions. This article discusses how evaluation has informed the development, processes, and initiatives of the Michigan Community Health Worker Alliance. We highlight the Michigan Community Health Worker Alliance's internal process evaluation, a statewide survey of CHW programs, and other evaluation activities to illustrate how CHW coalitions can use participatory evaluation to develop and reinforce coalition strengths and accomplish mutual goals.
Full-text · Article · Sep 2015 · The Journal of ambulatory care management
[Show abstract][Hide abstract] ABSTRACT: Examine influences of diabetes-specific social support (D-SS) and depressive symptoms on glycemic control over time, among adults randomized to a diabetes self-management education and support (DSME/S) intervention or usual care.
Data were from 108 African-American and Latino participants in a 6-month intervention trial. Multivariable linear regression models assessed associations between baseline D-SS from family and friends and depressive symptoms with changes in HbA1c. We then examined whether baseline D-SS or depression moderated intervention-associated effects on HbA1c.
Higher baseline D-SS was associated with larger improvements in HbA1c (adjusted ΔHbA1c -0.39% for each +1-point D-SS, p=0.02), independent of intervention-associated HbA1c decreases. Baseline depressive symptoms had no significant association with subsequent HbA1c change. Neither D-SS nor depression moderated intervention-associated effects on HbA1c.
Diabetes self-management education and support programs have potential to improve glycemic control for participants starting with varying levels of social support and depressive symptoms. Participants starting with more support for diabetes management from family and friends improved HbA1c significantly more over 6 months than those with less support, independent of additional significant DSME/S intervention-associated HbA1c improvements. Social support from family and friends may improve glycemic control in ways additive to DSME/S.
Published by Elsevier Ireland Ltd.
Full-text · Article · Jun 2015 · Patient Education and Counseling
[Show abstract][Hide abstract] ABSTRACT: Purpose: There is growing evidence of the benefits of community health workers (CHWs) in primary care for low resource settings. The Affordable Care Act encourages the utilization of CHWs in health teams. Little is known about how traditional health team members understand the role of CHWs in safety net systems. Accordingly, this study explores the perceptions of traditional health team members and CHWs about the roles and potential contributions of CHWs in care teams, within a federally qualified health center in Detroit, MI.
Methods: Using community-based participatory research (CBPR) principles, a committee from Community Health and Social Services (CHASS) Center, Inc., local community-based organizations and health systems, and academic partners developed collective specific aims and interview guides.
Qualitative, one-on-one, semi-structured interviews with 14 current providers, nurses, medical assistants, social workers, and community health workers were conducted at CHASS Center. Interviews were audio-recorded and transcribed. The committee used an iterative analysis process to identify common themes.
Results: Key barriers to integrating CHWs into care teams include low knowledge, lack of clarity on roles, clinical staff did not identify CHWS as members of the patient care team, and limited direct interaction among clinical staff. Facilitators include receptiveness to learn more, interest in working together on a team, and value of potential collaboration.
Conclusions: Creating more opportunities for face to face interaction among clinical staff members and CHWs and providing orientation and education about CHWs may aide in integrating CHWs into health care teams for safety net settings.
[Show abstract][Hide abstract] ABSTRACT: Background: Health care centers serving low-income, urban populations often lack resources to support medication decision-making among patients with poorly controlled diabetes. The extent to which outcomes are better when community health workers (CHWs) use tailored e-health tools rather than print materials with patients is not known. This study compares the effectiveness of CHWs in supporting diabetes medication decision making when using a tailored, interactive web-based tool (iDecide) versus using print educational materials.
Methods: Academic and community partners used community-based participatory research and user-centered design to create a tailored, interactive diabetes decision aid delivered via iPad by CHWs. An RCT tested iDecide versus printed educational materials with 188 patients who had an A1c ≥7.5%, or who reported questions/concerns/difficulty taking diabetes medications. Participants received a 1-2 hour session with a CHW using either iDecide or printed materials and two follow-up calls.
Results: CHW recommendations in developing iDecide contributed to the tool being linguistically and culturally appropriate, and tailored to the needs of target community. Of the 188 participants, 176 completed follow-up. Both groups significantly improved across most measures. iDecide participants reported greater improvements in diabetes distress compared to print materials group (p=0.002). Only iDecide participants had improvements in A1c from baseline (-0.4%, p=0.002) and were more likely to maintain or achieve an A1c<=7% (p<0.05), a high level of self-efficacy (p<0.01), and a low level of diabetes distress (p<0.01).
Conclusion: Interactive, tailored web-based tools developed in collaboration with CHWs and delivered by CHWs may improve the effectiveness of CHW diabetes decision support and coaching.
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE
To compare a peer leader (PL) versus a community health worker (CHW) telephone outreach intervention in sustaining improvements in HbA1c over 12 months after a 6-month diabetes self-management education (DSME) program.RESEARCH DESIGN AND METHODS
One hundred and sixteen Latino adults with type 2 diabetes were recruited from a federally qualified health center and randomized to 1) a 6-month DSME program followed by 12 months of weekly group sessions delivered by PLs with telephone outreach to those unable to attend or 2) a 6-month DSME program followed by 12 months of monthly telephone outreach delivered by CHWs. The primary outcome was HbA1c. Secondary outcomes were cardiovascular disease risk factors, diabetes distress, and diabetes social support. Assessments were conducted at baseline, 6, 12, and 18 months.RESULTSAfter DSME, the PL group achieved a reduction in mean HbA1c (8.2-7.5% or 66-58 mmol/mol, P < 0.0001) that was maintained at 18 months (-0.6% or -6.6 mmol/mol from baseline [P = 0.009]). The CHW group also showed a reduction in HbA1c (7.8 vs. 7.3% or 62 vs. 56 mmol/mol, P = 0.0004) post-6 month DSME; however, it was attenuated at 18 months (-0.3% or -3.3 mmol/mol from baseline, within-group P = 0.234). Only the PL group maintained improvements achieved in blood pressure at 18 months. At the 18-month follow-up, both groups maintained improvements in waist circumference, diabetes support, and diabetes distress, with no significant differences between groups.CONCLUSIONS
Both low-cost maintenance programs led by either a PL or a CHW maintained improvements in key patient-reported diabetes outcomes, but the PL intervention may have additional benefit in sustaining clinical improvements beyond 12 months.
[Show abstract][Hide abstract] ABSTRACT: Community health workers (CHWs) are an evidence-based key to delivering socially just health and human services. CHW models, which value community knowledge and skills, link systems and underserved populations by engaging community members through someone they trust. Public health social workers have the opportunity to promote and support CHW activities through the field's emphasis on policy change, community organization, and evaluation. As natural allies, CHWs and social workers can work together in coalitions to improve health and reduce health disparities. The University of Michigan School of Social Work (SSW) houses the Michigan Community Health Worker Alliance (MiCHWA), a multi-faceted, statewide coalition working to promote CHW sustainability and integration into health and human service programs. MiCHWA formed in 2011 following a statewide meeting of health system, academic, community organization, and CHW partners, supported by SSW's dean, faculty, staff, and students. Being hosted by an academic institution has provided infrastructure support and mutual capacity-building opportunities among MiCHWA partner organizations, faculty, and social work and public health students who maintain MiCHWA's steering committee, policy, education, communications, and CHW working groups. This relationship has also facilitated collaboration among academic researchers and community partners working with CHWs. Drawing from public health and social work research, MiCHWA employs community-based participatory research methods to unite stakeholders and support alliance activity. An evaluation unit housed at SSW provides ongoing evaluation planning and services vital to MiCHWA's sustainability. MiCHWA offers evidence of how social workers can be influential partners in sustaining CHWs and community alliances at a state level.
[Show abstract][Hide abstract] ABSTRACT: Solid evaluation protocols and practices are essential to community health worker (CHW) sustainability. Ongoing evaluation can support development and maintenance of infrastructure, strengthen partnerships, identify outcomes achievement, and assist in acquiring and maintaining funding. Since identifying evaluation as essential to the Michigan Community Health Worker Alliance (MiCHWA)'s sustainability, MiCHWA's Steering Committee incorporated evaluation as one of its goals and established the MiCHWA Program Evaluation Advisory Board. The board, made of MiCHWA staff, CHWs, and representatives from community and academic organizations, worked with the Curtis Center Program Evaluation Group at the University of Michigan School of Social Work to develop and implement a process, context, and outcome evaluation plan. MiCHWA's evaluation plan includes a logic model, evaluation questions, an outcomes matrix, and goals and objectives. Tools used to measure evaluation questions include Steering Committee and working group member surveys and key informant interviews, document review, and event surveys. MiCHWA's Program Evaluation Advisory Board facilitates MiCHWA's ongoing evaluation in collaboration with the Steering Committee and working groups, identifying focus areas and reviewing results. Results from our first year have identified MiCHWA focus areas that are successful, areas that need further attention and directions to improve our goals and objectives. The board also collaborates on recommending common evaluation indicators for the efficacy and return on investment of CHW programs and research in Michigan necessary for sustainable funding and integration of CHWs into health and human service systems. This presentation will discuss key evaluation elements, results, challenges, and lessons learned for evaluating CHW partnerships.
[Show abstract][Hide abstract] ABSTRACT: This study investigated the influence of a community health worker (CHW) diabetes lifestyle intervention on mental health outcomes. Our study was guided by the principles of community-based participatory research. Data were collected from 164 African American (N = 94) and Hispanic adults (N = 70) participating in a randomized, 6-month delayed intervention group design for improving glycemic control. The intervention time periods were baseline to 6 months for the treatment group and 6–12 months for the delayed group. Linear mixed models were used to conduct longitudinal analyses of the Problem Areas in Diabetes (PAID) and Patient Health Questionnaire (PHQ) scales. In the model adjusted for demographics, the PAID dropped significantly from pre-intervention to post-intervention within both the treatment and delayed groups (p < 0.05) with an average intervention effect of −6.4 (p < 0.01). The PAID dropped even further within the immediate group from 6 to 12 months. Although the PHQ did not change significantly, the PHQ-2 had an average intervention effect of −0.3 (p < 0.05) in the model adjusted for demographics. This study contributes to an understanding of how a CHW-led diabetes intervention can result in positive mental health outcomes for Latinos and African Americans with Type 2 diabetes. It also highlights the importance of further exploring what factors may contribute to racial/ethnic variation in mental health outcomes for African Americans and Latinos with diabetes and the role CHWs can play.
Full-text · Article · Jun 2013 · Race and Social Problems
[Show abstract][Hide abstract] ABSTRACT: It is not known how discrimination might affect diabetes-related distress (DRD), an important correlate of diabetes outcomes. We examined correlates of discrimination and the influence of discrimination on DRD and depressive symptoms (DS) for African Americans and Latinos with type 2 diabetes. We analyzed survey data (n = 157) collected at enrollment into a diabetes management intervention. Using multiple linear regression, we examined correlates of discrimination and the association between discrimination and DRD and DS. Discrimination was significantly associated with higher DRD for Latinos (b 1.58, 95 % CI 1.08, 2.31, p < 0.05), but not significant for African Americans (b 0.96, 95 % CI 0.59, 1.57). Discrimination was marginally significantly associated with more DS for Latinos (b 1.43, 95 % CI 0.97, 2.12, p < 0.10), but not significant for African Americans (b 1.21, 95 % CI 0.87, 1.70). These findings suggest the need to address stressors unique to racial/ethnic minorities to improve diabetes-related outcomes.
No preview · Article · May 2013 · Journal of Immigrant and Minority Health
[Show abstract][Hide abstract] ABSTRACT: Background. Community health worker (CHW) are community residents who are trained as social justice and health advocates who are vital to linking underserved and disenfranchised populations to health and social service systems. Although CHW interventions have demonstrated promise in improving health behaviors and outcomes, particularly for racial and ethnic minority communities, very little is known as to how these interventions produce positive outcomes. Thus, the purpose of this paper is to test a conceptual model for a CHW intervention for improving type 2 diabetes outcomes for African Americans and Latinos in Detroit, Michigan.
Research Questions. In our community-based participatory research (CBPR) intervention, CHWs use an empowerment-based, culturally tailored approach to provide diabetes education (individual and group formats) and support to patients in health clinics, conduct home visits, and accompany patients to clinic visits. This study asks whether components of our intervention had a differential impact on improving self-efficacy, diabetes-related distress, and self-management behaviors. Furthermore, we ask whether these changes lead to a reduction in our primary outcome, hemoglobin A1c (HbA1c), which is a measure of blood glucose.
Methods. African American and Latino participants with type 2 diabetes (N=326) were recruited from medical records at three healthcare sites in Detroit. We use Structural Equation Modeling (SEM) to test a conceptual model that CHW education and support serves a means for improving self-efficacy, distress, self-management behaviors and ultimately HbA1c from baseline to 6 months. SEM was chosen because it enables us to test the order in which measurable variables affect each other. The model was estimated by Full Information Maximum Likelihood (FIML). Goodness of fit was evaluated with Joreskorg-Sorbom GFI (Goodness of Fit Index) for absolute fit, Bentler’s CFI (Comparative Fit Index) for comparative fit, RMSEA (Root Mean Square Error of Approximation ) for parsimony, and SRMR for prediction. Power was calculated by the method of MacCullum, Browne, and Sugawara (1996).
Results. All post-intervention measures were highly correlated with pre-intervention values. Post-intervention HbA1c dropped by 0.55 per unit increase in self-management behavior. Improvement in self-management behavior was significantly associated with lower diabetes distress. Program attendance in group, versus individual format, was associated with a 6 point decrease in diabetes distress and significant increase in knowledge of diabetes management. Greater self-efficacy was associated with higher attendance. Based on GFI=.9928 and CFI=.935, the model explained 99.25% of the generalized covariance and was a 93.5% improvement over the null model. RMSEA was 0.067, indicating a reasonable fit, and the SRMR was 0.0464, which indicates that the model has good predictive ability.
Conclusion. Structural Equation Modeling is an effective method to understand the process of change in key outcome variables and to measure the effects of a CHW intervention. This study has implications for social work by informing researchers and practitioners of the differential effect of various components of a CHW intervention that has the potential for reducing complications related to diabetes. The study also informs social work about the value of CHWs and their role in eliminating health disparities.
[Show abstract][Hide abstract] ABSTRACT: Community health worker (CHW) interventions frequently lead to improved health outcomes but face financial and occupational barriers to sustainability. With funding from the Nokomis Foundation, an informal coalition of Michigan CHWs, health care, community and academic partners, and national consultants conducted a statewide planning meeting in August 2011. Experts, both CHWs and others, shared national and local CHW program and policy successes. Participants broke into workgroups that created objectives for CHW sustainability in Michigan. Following the meeting, the Michigan Community Health Worker Alliance (MiCHWA) was formed. MiCHWA's mission is to promote and sustain the integration of CHWs into Michigan's health and human service systems through coordinated changes in policy and workforce development. The meeting planning committee, supplemented by new partners, is developing MiCHWA governance processes and supporting four work groups, each co-led by a CHW: Education and Workforce, Policy and Finance, Communications, and a CHW Network. The Network is a CHW-led group focused on supporting the profession and promoting CHW leadership. MiCHWA activities include development of a policy brief, an awareness campaign, a website including a CHW database, a statewide employer survey, and recommendations for core competencies, certification, and training curriculum. Organizations like MiCHWA, working integrally with CHWs, are uniting stakeholders in a collaborative way to create and maintain the momentum necessary to achieve sustainable policy and systems level change in Michigan. This presentation will share several valuable lessons that MiCHWA members have learned in organizing CHW allies statewide with other groups seeking to do the same.
[Show abstract][Hide abstract] ABSTRACT: Objective. To use path analysis to test a hypothesis about the theory of change in Hemoglobin A1c among clients in a culturally tailored diabetes intervention. The hypothesis was that changes in self-efficacy, diabetes-related distress, and knowledge would lead to change in self-management behavior, which would lead to reduction in HbA1c. Methods. Two cohorts were combined for a sample size of 326. Path analysis was chosen because it enables the analyst to test the order in which measurable variables affect each other. Mardia's multivariate kurtosis, along with univariate skewness and kurtosis, were used to check for multivariate normality. MAR (Missing at Random) was evaluated by testing if pre-intervention means differed significantly by whether post-intervention values were present. The structural equation model was estimated by FIML (Full Information Maximum Likelihood). Goodness of fit was evaluated with Joreskorg-Sorbom GFI for absolute fit, Bentler's CFI for comparative fit, RMSEA for parsimony, and SRMR for prediction. Results. All post-intervention measures were strongly correlated with pre-intervention values. Post-intervention HbA1c dropped by 0.5 per unit increase in self-management behavior. Program attendance in group, versus individual format, was associated with a 6 point drop in diabetes distress and significant increase in knowledge of diabetes management. Greater self-efficacy was associated with higher attendance. Based on GFI=.9928 and CFI=.935, the model explained 99.25% of the generalized covariance and was a 93.5% improvement over the null model. Conclusion. Path Analysis is an effective method to model the process of change in key outcome variables and to measure quantitative intervention effects.
[Show abstract][Hide abstract] ABSTRACT: There have been increasing calls for the development of collaborative academic-community partnerships to examine and address health disparities, and which actively involve community partners in all aspects of the research process. Community entities and academic institutions need enhanced capacity to conduct such research, and sustainable infrastructures are necessary to fundamentally transform collaboration between communities and academic institutions. The Detroit Community-Academic Urban Research Center (URC), a CBPR partnership established in 1995, has successfully created an infrastructure that has fostered CBPR basic research, intervention and translation to policy change projects. Given the resources and health issues that exist in Detroit, there is need for expansion of such partnerships. The URC is expanding and reconfiguring its infrastructure to facilitate new, equitable community-academic partnerships and enhance their capacity to conduct health disparities research. We will describe and analyze the URC's approach to facilitate linkages between community and academic entities to increase the number of collaborative research partnerships in Detroit. Strategies include: creating a Steering Committee comprised of community and academic partners to guide the process; establishing a Community-Academic Research Network to foster linkages between academic researchers and communities; developing and maintaining an interactive communication system using social networking; hiring three community partners to facilitate communication and relationship building; implementing a planning grant program; and conducting capacity building efforts, e.g., community-academic mentoring, workshops, and research practicum. We will examine the role of community partners, and discuss challenges, facilitating factors, and lessons learned in creating and supporting community-academic partnerships to address community-based public health issues.
[Show abstract][Hide abstract] ABSTRACT: We tested the effectiveness of a culturally tailored, behavioral theory-based community health worker intervention for improving glycemic control.
We used a randomized, 6-month delayed control group design among 164 African American and Latino adult participants recruited from 2 health systems in Detroit, Michigan. Our study was guided by the principles of community-based participatory research. Hemoglobin A1c (HbA1c) level was the primary outcome measure. Using an empowerment-based approach, community health workers provided participants with diabetes self-management education and regular home visits, and accompanied them to a clinic visit during the 6-month intervention period.
Participants in the intervention group had a mean HbA1c value of 8.6% at baseline, which improved to a value of 7.8% at 6 months, for an adjusted change of -0.8 percentage points (P < .01). There was no change in mean HbA1c among the control group (8.5%). Intervention participants also had significantly greater improvements in self-reported diabetes understanding compared with the control group.
This study contributes to the growing evidence for the effectiveness of community health workers and their role in multidisciplinary teams engaged in culturally appropriate health care delivery.
Full-text · Article · Jun 2011 · American Journal of Public Health
[Show abstract][Hide abstract] ABSTRACT: African American and Latino youth are at high risk for type 2 diabetes. Preventive behaviors have been proven to delay/prevent onset of diabetes, however, many do not adopt these behaviors due to psychosocial factors and their level of functional health literacy. Inadequate functional health literacy reduces the ability of adolescents to understand their risk for diabetes. The Youth Health Promotion Challenge (YHPC) was developed and conducted to increase health literacy and promote diabetes prevention in this population. Using a CBPR approach, the project's steering committee members were directly involved in the development, recruitment, retention, delivery and assessment of the YHPC. We used a pre/post randomized pilot study design to test the YHPC program. Forty-six African Americans and Latinos aged 14-17 years with a family history of diabetes were enrolled. The 6-session YHPC addressed: family history and risk for diabetes, health disparities, prevention of diabetes (e.g. physical activity and nutrition), diabetes etiology, and communication with family/health providers. Surveys assessed pre/post changes between the intervention and comparison groups at baseline and post program. The study retention rate was 84% at post-interview. Thirty-eight percent (38%, (n=16) of participants had a blood glucose reading >100 mg/dl and 61% of adolescents had a BMI-for-age and sex percentile of 85% or greater. At post-test, participants had higher mean scores in diabetes knowledge (4.52 vs. 4.00); self-efficacy (69.00 vs. 65.31); and health literacy (REALM Teen) (59.16 vs. 57.05). We believe the CBPR approach we used was a significant contribution to these successful results.
[Show abstract][Hide abstract] ABSTRACT: Community health workers (CHWs) play a vital and unique role in linking diverse and underserved populations to health and social service systems. Despite their effectiveness, as documented by empirical studies across various disciplines including public health, nursing, and biomedicine, the value and potential role of CHWs in the social work practice and research literature has been largely absent. Thus, this article introduces social workers to CHWs, their role in promoting culturally appropriate practice, and their utility in collaboration with social workers in community settings. This integrative review also discusses current challenges identified by the CHW literature, including potential barriers to the expansion of CHW programs, as well as issues of training, certification, and sustainability. The review also discusses the close alignment of CHWs with social work values and principles of social justice, suggesting opportunities for enhanced social work practice and research.
[Show abstract][Hide abstract] ABSTRACT: The specific ways in which community health worker (CHW) programs affect participants' healthcare behaviors and interactions with their healthcare providers, as well as mechanisms by which CHW programs influence these outcomes, are poorly understood. A qualitative descriptive study of participants in a successful CHW diabetes self-management program was designed to examine: (1) what gaps in diabetes care, with a focus on patient-doctor interactions, participants identify; (2) how the program influences participants' diabetes care and interactions with healthcare providers, and what gaps, if any, it addresses.
From November 2005 to December 2006, semi-structured interviews with 40 African- American and Latino adults were conducted and analyzed. Participants had diabetes and had completed or were active in a CHW-led diabetes self-management program developed and implemented using community-based participatory research principles in Detroit. Interviews were audiotaped, transcribed, and coded through a consensual and iterative process.
Participants reported that prior to the intervention they had received inadequate information from healthcare providers for effective diabetes self-management, had had low expectations for help from their providers, and had not felt comfortable asking questions or making requests of their healthcare providers. Key ways participants reported that the program improved their ability to manage their diabetes were by providing (1) clear and detailed information on diabetes and diabetes care; (2) education and training on specific strategies to meet diabetes care goals; (3) sustained and nonjudgmental assistance to increase their motivation and confidence; and (4) social and peer support that enabled them to better manage their diabetes. The knowledge and confidence gained through the CHW intervention increased participants' assertiveness in asking questions to and requesting necessary tests and results from their providers.
Study findings suggest ways that CHW programs that provide both one-on-one support and group self-management training sessions may be effective in promoting more effective diabetes care and patient-doctor relationships among Latino and African-American adults with diabetes. Through these mechanisms, such interventions may help to mitigate racial and ethnic disparities in diabetes care and outcomes.
Full-text · Article · Dec 2009 · American journal of preventive medicine
[Show abstract][Hide abstract] ABSTRACT: Family support is important in diabetes self-management. However, children as providers of support have received little attention. This study examines the role of children in their parents' diabetes self-management, diet, and exercise.
This research used community-based participatory research principles. Researchers conducted semi-structured parallel interviews of 24 Latino and African-American adults with diabetes and with a child (aged 10-17 years) in their home (2004-2006). Interviews were transcribed, coded, and analyzed for themes (2004-2007).
Adults and children perceived that children play many roles related to adults' diabetes self-management. Parents described children as monitoring parents' dietary intake and reminding them what they should not be eating. Some children helped with shopping and meal preparation. Families described children reminding parents to exercise and exercising with their parents. Children reminded parents about medications and assisted with tasks such as checking blood sugar. Parents and children perceived that children played a role in tempting parents to stray from their diabetes diet, because children's diets included food that parents desired but tried to avoid.
Children and parents perceived that children have many roles in both supporting and undermining adults' diabetes self-management. There is more to learn about the bi-directional relationships between adults and children in this setting, and the most beneficial roles children can play. Healthcare providers should encourage family lifestyle changes, strengthen social support for families, and direct children toward roles that are beneficial for both parent and child without placing an unreasonable level of responsibility on the child.
Full-text · Article · Dec 2009 · American journal of preventive medicine