• Questions? E-mail library@dshs.texas.gov

Community Health Worker Research Materials

This page provides a selected list of current articles from the research literature of interest to stakeholders in the Promotor(a) or Community Health Worker Training and Certification Program.  A promotora/community health worker is defined here as a person who, with or without compensation:

  • provides cultural mediation between their communities and health and human service systems; 
  • provides informal counseling and social support; 
  • provides culturally and linguistically appropriate health education; 
  • advocates for individual and community needs; 
  • assures people get the services they need; 
  • builds individual and community capacity; 
  • or provides referral and follow-up services.

For further information on the following articles contact the Medical and Research Library at library@dshs.texas.gov or call 512-776-7559. For further information on promotoras/es and community health workers in Texas, contact chw@dshs.texas.gov, (512) 776-2570 or (512) 776-2624, or visit the Promotor(a) or Community Health Worker Training and Certification Program website, part of the Office of Title V and Family Health, at http://www.dshs.texas.gov/mch/chw.shtm.

External links to other sites are intended to be informational and do not have the endorsement of the Texas Department of State Health Services. These sites may also not be accessible to people with disabilities. The links were working at the time they were created.


mrl-diamond Selected Current Journal Articles and Reports

[See a more comprehensive bibliography of articles on community health workers.]

Cardiovascular Disease Prevention: Interventions Engaging Community Health Workers - Task Force Finding and Rationale Statement   http://www.thecommunityguide.org/cvd/RRCHW.html

Community Health Workers: Recommendations for Bridging Healthcare Gaps in Rural America, a National Rural Health Association Policy Brief, February 2017. This policy paper reviews select research findings on Community Health Worker (CHW) integration relevant to policymakers, considers challenges, and presents recommendations to incorporate the CHW model in rural communities to improve health outcomes, reduce health disparities and enhance quality of life for rural Americans. Read it at  https://www.cdc.gov/dhdsp/pubs/toolkits/chw-toolkit.htm

Community Health Worker (CHW) Resources

    - Community Health Workers (CHWs) Training/Certification Standards Current Status http://www.astho.org/Public-Policy/Public-Health-Law/Scope-of-Practice/CHW-Certification-Standards/
   - Strategies for Supporting Expanded Roles for Non-Clinicians on Primary Care Teams, National Academy for State Health Policy http://www.nashp.org/sites/default/files/NOSOLO-new3.pdf

Community Health Worker Toolkit
The Division for Heart Disease and Stroke Prevention has compiled evidence-based research that supports the effectiveness of CHWs in a Community Health Worker (CHW) Toolkit. The toolkit also includes information that state health departments can use to train and further build capacity for CHWs in their communities as well as helpful resources that CHWs can use within their communities (https://www.cdc.gov/dhdsp/pubs/toolkits/chw-toolkit.htm).    

Diffusion of Community Health Workers within Medicaid Managed Care: A Strategy to Address Social Determinants of Health. Carolina Nkouaga, Arthur Kaufman, Charlie Alfero, and Claudia Medina, Health Affairs Blog. Read it at http://healthaffairs.org/blog/2017/07/25/diffusion-of-community-health-workers-within-medicaid-managed-care-a-strategy-to-address-social-determinants-of-health/

Map on Community Health Worker Models
This new NASHP map and chart makes it easy for you to find information about various activities related to CHWs in the states. http://www.nashp.org/state-community-health-worker-models/

States Implementing Community Health Worker Strategies
This new technical assistance guide summarizes the successful work of organizations as it relates to Domains 3 and 4 (Health Systems Interventions and Community-Clinical Linkages, respectively) of CDC’s State Public Health Actions program (CDC-RFA-DP13-1305).  It also offers insights for states that are implementing CHW strategies.  Recommendations were developed by compiling interviews with 9 organizations experienced in integrating CHWs into healthcare teams and engaging CHWs in promoting linkages between the health care system and community resources.  Additional findings from a review of evidence-based literature are also included. http://www.cdc.gov/dhdsp/programs/spha/docs/1305_ta_guide_chws.pdf

Understanding Scope and Competencies: A Contemporary Look at the United States Community Health Worker Field. Progress Report of the Community Health Worker (CHW) Core Consensus (C3) Project: Building National Consensus on CHW Core Roles, Skills, and Qualities. Rosenthal EL, Rush, CH, Allen CG. April 2016 http://files.ctctcdn.com/a907c850501/1c1289f0-88cc-49c3-a238-66def942c147.pdf?ver=1462294723000

Allen CG, Brownstein JN, Satsangi A, Escoffery C. Community health workers as allies in hypertension self-management and medication adherence in the United States, 2014. Prev Chronic Dis. 2016 Dec 29;13:E179. doi: 10.5888/pcd13.160236.
Introduction: Rates of hypertension control remain low among underserved populations in the United States; moreover, disparities in hypertension-related cardiovascular disease death are increasing. Community health workers (CHWs) can address barriers to hypertension control among underrepresented and diverse populations. We identify unique roles CHWs play in hypertension self-management and medication adherence. Methods: In 2014, we conducted a mixed methods study with an online survey of 265 CHWs and 23 telephone interviews. The survey and interview guide contained questions about CHWs' roles in hypertension self-management and hypertension medication adherence. We used descriptive statistics to analyze survey data and used inductive thematic analysis for the qualitative data. Results:  CHWs described working in partnership with patients and various health care providers to assist people in hypertension self-management. Roles were flexible and multifaceted but patient-driven. CHWs used various delivery methods to assist patients in overcoming barriers to medication adherence. CHWs interacted with patients primarily through individual clinical sessions or home visits. On average, they visit about 8 times per month, about 40 minutes per visit, over 7 months. CHWs often addressed barriers related to medicine-taking and refills and support patient-provider communications. Conclusion: Results from this study will help health care professionals, policy makers, and academics better understand the work of CHWs. CHWs are important provider allies for improving hypertension prevention and self-management, especially among underserved and diverse populations in the United States.

Anugu M, Braksmajer A, Huang J, et al. Enriched medical home intervention using community health worker home visitation and ED use. Pediatrics. 2017 May;139(5). pii: e20161849. doi: 10.1542/peds.2016-1849. 
Background and Objectives: Community health workers (CHWs) have great potential to extend medical home services and reduce emergent health care use, but evidence in pediatrics is scarce. We evaluated the impact of an existing enriched medical home intervention (EMHI) that directly integrates CHWs into emergency department (ED) visits and hospitalizations for pediatric ambulatory care-sensitive conditions (ACSCs). Methods: The EMHI group in this prospective cohort study received home visits from trained CHWs to support adherence to recommended care; the comparison group received usual care (UC). Sociodemographic characteristics were compiled from the EMHI database, and ED and hospitalization information was extracted for study participants from a statewide database. The Wilcoxon signed rank test was used to compare ED data and the Wald test was used to compare hospitalization use for ACSCs between the intervention and UC groups after adjusting for different characteristics between groups by using propensity score matching method. Results: The study sample included 922 children (225 intervention, 697 UC). After propensity score matching, the analytic sample included 450 children (225 intervention, 225 UC). After propensity score matching, the intervention group was significantly less likely than the UC group to visit the ED for an ACSC (18.2% vs 35.1%; P = .004). We found no differences in ACSC hospitalizations between the 2 groups. Conclusions: Our findings suggest that EMHIs using trained CHWs may be a cost-effective model to reduce preventable ED utilization, especially among vulnerable children.

Bailey JE, Surbhi S, Bell PC, et al. SafeMed: Using pharmacy technicians in a novel role as community health workers to improve transitions of care. J Am Pharm Assoc (2003). 2016 Jan;56(1):73-81.
Objectives: To describe the design, implementation, and early experience of the SafeMed program, which uses certified pharmacy technicians in a novel expanded role as community health workers (CPhT-CHWs) to improve transitions of care. Setting: A large nonprofit health care system serving the major medically underserved areas and geographic hotspots for readmissions in Memphis, TN. Practice Innovation: The SafeMed program is a care transitions program with an emphasis on medication management designed to use low-cost health workers to improve transitions of care from hospital to home for superutilizing patients with multiple chronic conditions and polypharmacy. Evaluation: CPhT-CHWs were given primary responsibility for patient outreach after hospital discharge with the use of home visits and telephone follow-up. SafeMed program CPhT-CHWs served as pharmacist extenders, obtaining medication histories, assisting in medication reconciliation and identification of potential drug therapy problems (DTPs), and reinforcing medication education previously provided by the pharmacist per protocol. Results: CPhT-CHW training included patient communication skills, motivational interviewing, medication history taking, teach-back techniques, drug disposal practices, and basic disease management. Some CPhT-CHWs experienced difficulties adjusting to an expanded scope of practice. Nonetheless, once the Tennessee Board of Pharmacy affirmed that envisioned SafeMed CPhT-CHW roles were consistent with Board rules, additional responsibilities were added for CPhT-CHWs to enhance their effectiveness. Patient outreach teams including CPhT-CHWs achieved increases in home visit and telephone follow-up rates and were successful in helping identify potential DTPs. Conclusion: The early experience of the SafeMed program demonstrates that CPhT-CHWs are well suited for novel expanded roles to improve care transitions for superutilizing populations. CPhT-CHWs can identify and report potential DTPs to the pharmacist to help target medication therapy management. Critical success factors include strong CPhT-CHW patient-centered communication skills and strong pharmacist champions. In collaboration with state pharmacy boards and pharmacist associations, the SafeMed CPhT-CHW model can be successfully scaled to serve superutilizing patients throughout the country.

Basu S, Jack HE, Arabadjis SD, Phillips RS. Benchmarks for reducing emergency department visits and hospitalizations through community health workers integrated into primary care: a cost-benefit analysis. Med Care. 2017 Feb;55(2):140-147.
Background: Uncertainty about the financial costs and benefits of community health worker (CHW) programs remains a barrier to their adoption. Objectives: To determine how much CHWs would need to reduce emergency department (ED) visits and associated hospitalizations among their assigned patients to be cost-neutral from a payer's perspective. Research Design: Using a microsimulation of patient health care utilization, costs, and revenues, we estimated what portion of ED visits and hospitalizations for different conditions would need to be prevented by a CHW program to fully pay for the program's expenses. The model simulated CHW programs enrolling patients with a history of at least 1 ED visit for a chronic condition in the prior year, utilizing data on utilization and cost from national sources. Results: CHWs assigned to patients with uncontrolled hypertension and congestive heart failure, as compared with other common conditions, achieve cost-neutrality with the lowest number of averted visits to the ED. To achieve cost-neutrality, 4-5 visits to the ED would need to be averted per year by a CHW assigned a panel of 70 patients with uncontrolled hypertension or congestive heart failure-approximately 3%-4% of typical ED visits among such patients, respectively. Most other chronic conditions would require between 7% and 12% of ED visits to be averted to achieve cost-savings. Conclusion: Offsetting costs of a CHW program is theoretically feasible for many common conditions. Yet the benchmark for reducing ED visits and associated hospitalizations varies substantially by a patient's primary diagnosis.

Bryant-Stephens T, Reed-Wells S, Canales M, et al. Home visits are needed to address asthma health disparities in adults. J Allergy Clin Immunol. 2016 Dec;138(6):1526-1530. doi: 10.1016/j.jaci.2016.10.006.
Research on asthma frequently recruits patients from clinics because the ready pool of patients leads to easy access to patients in office waiting areas, emergency departments, or hospital wards. Patients with other chronic conditions, and with mobility problems, face exposures at home that are not easily identified at the clinic. In this article, we describe the perspective of the community health workers and the challenges they encountered when making home visits while implementing a research intervention in a cohort of low-income, minority patients. From their observations, poor housing, often the result of poverty and lack of social resources, is the real elephant in the chronic asthma room. To achieve a goal of reduced asthma morbidity and mortality will require a first-hand understanding of the real-world social and economic barriers to optimal asthma management and the solutions to those barriers.

Carrasquillo O, Lebron C, Alonzo Y, et al. Effect of a community health worker intervention among Latinos with poorly controlled type 2 diabetes: the Miami healthy heart initiative randomized clinical trial. JAMA Intern Med. 2017 Jul 1;177(7):948-954.
Importance: Community health worker (CHW) intervention is a promising approach to address type 2 diabetes among Latinos. However, evidence from randomized clinical studies is limited. Objective: To compare a CHW intervention with enhanced usual care. Design, Setting, and Participants: This 52-week, single-blind, randomized clinical trial included 300 Latino adults aged 18 to 65 years who were treated in 2 public hospital outpatient clinics in Miami-Dade County, Florida, from July 1, 2010, through October 31, 2013. Eligible participants had a hemoglobin A1c (HbA1c) level of 8.0 or greater. Follow-up was completed January 31, 2015, and data were analyzed from March 10, 2015, to June 6, 2016. Interventions: A 1-year CHW intervention consisted of home visits, telephone calls, and group-level activities. Main Outcomes and Measures: Primary outcomes included systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDLC) levels, and HbA1c levels. Secondary outcomes included body mass index, medication regimen intensification, and self-reported measures of diet, physical activity, and medication regimen adherence. Results: Of the 300 participants randomized (135 men [45%] and 165 women [55%]; mean [SD] age, 55.2 [7.0] years), we obtained follow-up data on 215 (71.7%). Participants in the CHW group received a median of 4 home visits and 20 telephone calls. After adjusting for baseline values and covariates, participants in the CHW group had an HbA1c level that was 0.51% lower (95% CI, -0.94% to -0.08%) than that of participants in the enhanced usual care group. The reduction in SBP of 4.62 mm Hg (95% CI, -9.01 to -0.24 mm Hg) did not meet the preplanned target of 8 mm Hg and was not statistically significant in unadjusted models. No significant differences in LDLC levels (mean difference, -8.2 mg/dL; 95% CI, -18.8 to 2.3 mg/dL) or any of the preplanned secondary outcomes were observed. Post hoc analyses suggest that the intervention may be more beneficial among those with worse control of their type 2 diabetes at baseline. Conclusions and Relevance: Among Latinos with poorly controlled type 2 diabetes, a 12-month CHW intervention lowered HbA1c levels by 0.51%. The intervention did not lead to improvements in LDLC levels, and the findings with respect to SBP were variable and half of what was targeted. Future studies should examine whether CHW interventions affect other measures, such as access to health care or social determinants of health.

Castaneda SF, Giacinto RE, Medeiros EA, Brongiel I, Cardona O, Perez P, Talavera GA. Academic-community partnership to develop a patient-centered breast cancer risk reduction program for Latina primary care patients. J Racial Ethn Health Disparities. 2016 Jun;3(2):189-99.
This collaborative study sought to address Latina breast cancer (BC) disparities by increasing health literacy (HL) in a community health center situated on the US-Mexico border region of San Diego County. An academic-community partnership conducted formative research to develop a culturally tailored promotora-based intervention with 109 individuals. The Spanish language program, entitled Nuestra Cocina: Mesa Buena, Vida Sana (Our Kitchen: Good Table, Healthy Life), included six sessions targeting HL, women's health, BC risk reduction, and patient-provider communication; sessions include cooking demonstrations of recipes with cancer-risk-reducing ingredients. A pilot study with 47 community health center Latina patients was conducted to examine the program's acceptability, feasibility, and ability to impact knowledge and skills. Pre- and post-analyses demonstrated that participants improved their self-reported cancer screening, BC knowledge, daily fruit and vegetable intake, and ability to read a nutrition label (p < 0.05). Results of the pilot study demonstrate the importance of utilizing patient-centered culturally appropriate noninvasive means to educate and empower Latina patients.

D'Alonzo KT, Smith BA, Dicker LH. Outcomes of a culturally tailored partially randomized patient preference controlled trial to increase physical activity among low-income immigrant Latinas. J Transcult Nurs. 2017 Jul 1:1043659617723073. doi: 10.1177/1043659617723073. [Epub ahead of print]
Introduction: Almost half (47.8%) of adult Latinas report they never engage in any leisure time physical activity (PA) which is an independent risk factor for the development of cardiovascular disease and other chronic illnesses. There is a pressing need to develop and test PA interventions among Latinas. Therefore, the purpose of this study was to evaluate the effects of a PA Intervention for Latinas, a culturally tailored, promotora-facilitated 12-week PA intervention. It was hypothesized that at the completion of the intervention, participants would have (a) higher daily PA levels; (b) improved aerobic fitness, muscle strength, and flexibility; and (c) lower body mass index and percentage of body fat. Methodology: A partially randomized patient preference trial design with lag group was used to test the intervention. Participants ( N = 76) attended twice weekly, low-impact aerobic/Latin dance PA classes taught by laywomen trained as promotoras. Results: Significant improvements were measured in aerobic fitness, muscle strength and flexibility, and daily PA levels ( p < .001). Sixty percent of the participants attended at least 60% of the PA sessions. Discussion: Findings suggest laywomen trained as promotoras can successfully facilitate the delivery of an intervention to increase PA among immigrant Latinas.

Daniels AS, Bergeson S, Myrick KJ. Defining peer roles and status among community health workers and peer support specialists in integrated systems of care. Psychiatr Serv. 2017 Jul 17:appips201600378. doi: 10.1176/appi.ps.201600378. [Epub ahead of print]
Current strategies for integrating general medical and behavioral health services focus primarily on improving the coordination of care and expanding team-based services. Absent from most discussion has been a focus on the workforces that provide the bulk of community-based outreach, engagement, activation, motivational support, and self-management: community health workers (CHWs) and peer support specialists (PSSs). CHWs have primarily been deployed in general medical care and PSSs in behavioral health care. Understanding the unique contributions that CHWs and PSS provide for health promotion and wellness and improved population health outcomes is an important challenge. This Open Forum reviews the key elements of peer status as a way to help illustrate the differences between these workforces and the best deployment strategies for each workforce. A framework is proposed that outlines key support roles provided by the CHW and PSS workforces.

Falbe J, Friedman LE, Sokal-Gutierrez K, et al. "She gave me the confidence to open up": bridging communication by promotoras in a childhood obesity intervention for Latino families. Health Educ Behav. 2017 Aug 1:1090198117727323. doi: 10.1177/1090198117727323. [Epub ahead of print]
Childhood obesity is a public health threat that disproportionally affects Latino youth in the United States. Active and Healthy Families (AHF) is a culturally tailored, family-based program for addressing obesity disparities in a predominantly immigrant Latino population. AHF was the first primary care, culturally tailored intervention for Latino children to significantly reduce BMI in a randomized controlled trial. The 10-week AHF intervention reduced BMI (kg/m2) among overweight or obese children by 0.5, compared with an increase of 0.3 in the control group, yielding a -0.8 difference ( p < .01). A unique aspect of the program is its provider team: a physician, dietitian, and promotora. Because early feedback from families highlighted the importance of promotoras specifically, we sought to understand the unique mechanisms of promotora effectiveness in AHF. We conducted in-depth, semistructured interviews with the AHF providers ( n = 5) and parent participants ( n = 23) by phone between November 2012 and May 2013. In a grounded theory analysis, three main categories encompassing five themes emerged: (a) bridging communication by promotoras; (b) promotoras' personal qualities, including themes of kindness and caring and shared experiences with patients; and (c) impactful task performance, including themes of motivation, positive environment, and self-efficacy. Together, the themes serve as the basis of a conceptual model illustrating the process through which promotoras may enhance the impact of team-based obesity programs for the Latino community. Because this study identifies the specific ways through which promotoras can bridge cultural, linguistic, and other divides, it may inform development and dissemination of evidence-based approaches for obesity prevention in the Latino community.

Flores AL, Isenburg J, Hillard CL, et al. Folic acid education for Hispanic women: the Promotora de Salud model. J Womens Health (Larchmt). 2017 Jan 9. doi: 10.1089/jwh.2016.6116. [Epub ahead of print]
Background: Although rates of neural tube defects (NTDs) have declined in the United States since fortification, disparities still exist with Hispanic women having the highest risk of giving birth to a baby with a NTD. The Promotora de Salud model using community lay health workers has been shown to be an effective tool for reaching Hispanics for a variety of health topics; however, literature on its effectiveness in folic acid interventions is limited. Materials and Methods: An intervention using the Promotora de Salud model was implemented in four U.S. counties with large populations of Hispanic women. The study comprised the following: (1) a written pretest survey to establish baseline levels of folic acid awareness, knowledge, and consumption; (2) a small group education intervention along with a 90-day supply of multivitamins; and (3) a postintervention (posttest) assessment conducted 4 months following the intervention. Results: Statistically significant differences in pre- and posttests were observed for general awareness about folic acid and vitamins and specific knowledge about the benefits of folic acid. Statistically significant changes were also seen in vitamin consumption and multivitamin consumption. Folic acid supplement consumption increased dramatically by the end of the study. Conclusions: The Promotora de Salud model relies on interpersonal connections forged between promotoras and the communities they serve to help drive positive health behaviors. The findings underscore the positive impact that these interpersonal connections can have on increasing awareness, knowledge, and consumption of folic acid. Utilizing the Promotora de Salud model to reach targeted populations might help organizations successfully implement their programs in a culturally appropriate manner.

Hilfinger Messias DK, Sharpe PA, Del Castillo-Gonzalez L, Trevino L, Parra-Medina D. Living in limbo: Latinas' assessment of lower Rio Grande Valley colonias communities. Public Health Nurs. 2016 Dec 5. doi: 10.1111/phn.12307. [Epub ahead of print]

Community asset mapping (CAM) is the collective process of identifying local assets and strategizing processes to address public health issues and concerns and improve quality of life. Prior to implementing a community-based physical activity intervention with Latinas in the Texas Lower Rio Grande Valley, promotoras [community health workers] conducted 16 interactive sessions in 8 colonias. The analysis of the transcribed CAM recordings and on-site observational data resulted in the construction of Living in Limbo as the thematic representation of these Latinas' social isolation and marginalization associated with pervasive poverty, undocumented immigration status or lack of citizenship, their fears emanating from threats to physical and emotional safety, and the barriers created by lack of availability and access to resources.

Kangovi S, Mitra N, Grande D, et al. Community health worker support for disadvantaged patients with multiple chronic diseases: a randomized clinical trial. Am J Public Health. 2017 Aug 17:e1-e8. doi: 10.2105/AJPH.2017.303985. [Epub ahead of print]
Objectives: To determine whether a community health worker (CHW) intervention improved outcomes in a low-income population with multiple chronic conditions. Methods: We conducted a single-blind, randomized clinical trial in Philadelphia, Pennsylvania (2013-2014). Participants (n = 302) were high-poverty neighborhood residents, uninsured or publicly insured, and diagnosed with 2 or more chronic diseases (diabetes, obesity, tobacco dependence, hypertension). All patients set a disease-management goal. Patients randomly assigned to CHWs also received 6 months of support tailored to their goals and preferences. Results: Support from CHWs (vs goal-setting alone) led to improvements in several chronic diseases (changes in glycosylated hemoglobin: -0.4 vs 0.0; body mass index: -0.3 vs -0.1; cigarettes per day: -5.5 vs -1.3; systolic blood pressure: -1.8 vs -11.2; overall P = .08), self-rated mental health (12-item Short Form survey; 2.3 vs -0.2; P = .008), and quality of care (Consumer Assessment of Healthcare Providers and Systems; 62.9% vs 38%; P < .001), while reducing hospitalization at 1 year by 29.7% (P = .11). There were no differences in patient activation or self-rated physical health. Conclusions: A standardized CHW intervention improved chronic disease control, mental health, quality of care, and hospitalizations and could be a useful population health management tool for health care systems.

Kim KB, Kim MT, Lee HB, et al. Community health workers versus nurses as counselors or case managers in a self-help diabetes management program. Am J Public Health. 2016 Jun;106(6):1052-8. doi: 10.2105/AJPH.2016.303054.
Objectives: To confirm the effectiveness of community health workers' involvement as counselors or case managers in a self-help diabetes management program in 2009 to 2014. Methods: Our open-label, randomized controlled trial determined the effectiveness of a self-help intervention among Korean Americans aged 35 to 80 years in the Baltimore-Washington metropolitan area with uncontrolled type 2 diabetes. We measured and analyzed physiological and psychobehavioral health outcomes of the community health worker-counseled (n = 54) and registered nurse (RN)-counseled (n = 51) intervention groups in comparison with the control group (n = 104). Results: The community health workers' performance was comparable to that of the RNs for both psychobehavioral outcomes (e.g., self-efficacy, quality of life) and physiological outcomes. The community health worker-counseled group showed hemoglobin A1C reductions from baseline (-1.2%, -1.5%, -1.3%, and -1.6%, at months 3, 6, 9, and 12, respectively), all of which were greater than reductions in the RN-counseled (-0.7%, -0.9%, -0.9%, and -1.0%) or the control (-0.5%, -0.5%, -0.6%, and -0.7%) groups. Conclusions: Community health workers performed as well as or better than nurses as counselors or case managers in a self-help diabetes management program in a Korean American community.

Kollannoor-Samuel G, Shebl FM, Segura-Pérez S, et al. Effects of food label use on diet quality and glycemic control among Latinos with type 2 diabetes in a community health worker-supported intervention. Am J Public Health. 2016 Jun;106(6):1059-66. doi: 10.2105/AJPH.2016.303091.
Objectives: To determine the impact of an intervention led by community health workers (CHWs) on food label use and to assess whether food label use and diet quality mediate the intervention's impact on glycemic control. Methods: From 2006 to 2010, 203 Latinos (intervention group, n = 100; control group, n = 103) in Hartford County, Connecticut, with type 2 diabetes were randomized to an intervention that included 17 CHW-led home-based sessions over a 12-month period in addition to the standard of care available in both study arms. Data on food label use, diet quality, covariates, and glycated hemoglobin (HbA1c) were collected at baseline and at 3, 6, 12, and 18 months. Data were analyzed via mixed effects and multilevel structural equation modeling. Results: Food label use in the intervention (vs control) group was significantly higher at 3, 12, and 18 months (odds ratio = 2.99; 95% confidence interval = 1.69, 5.29). Food label use and diet quality were positive mediators of improved HbA1c levels. Conclusions: Culturally tailored interventions led by CHWs could increase food label use. Also, CHW-delivered food label education may lead to better diet quality and improve glycemic control among Latinos with type 2 diabetes.

Litzelman DK, Inui TS, Griffin WJ, et al. Impact of community health workers on elderly patients' advance care planning and health care utilization: moving the dial. Med Care. 2017 Apr;55(4):319-326.
Background: Advance care planning (ACP) is recommended for all persons to ensure that the care they receive aligns with their values and preferences. Objective: To evaluate an ACP intervention developed to better meet the needs and priorities of persons with chronic diseases, including mild cognitive impairment. Research Design: A year-long, pre-post intervention using lay community health workers [care coordinator assistants (CCAs)] trained to conduct and document ACP conversations with patients during home health visits with pre-post evaluation. Subjects: The 818 patients were 74.2 years old (mean); 78% women; 51% African American; 43% white. Measures: Documentation of ACP conversation in electronic health record fields and health care utilization outcomes. Results:  In this target population ACP documentation rose from 3.4% (pre-CCA training) to 47.9% (post) of patients who had at least 1 discussion about ACP in the electronic health record. In the 1-year preintervention period, there were no differences in admissions, emergency department (ED) visits, and outpatient visits between patients who did and did not have ACP discussion. After adjusting for prior hospitalization and ED use histories, ACP discussions were associated with a 34% less probability of hospitalization (hazard ratios, 0.66; 95% confidence interval, 0.45-0.97), and similar effects are apparent on ED use independent of age and prior ED use effects. Conclusions:  Patients with chronic diseases including mild cognitive impairment can engage in ACP conversations with trusted home health care providers. Having ACP conversation is associated with significant reduction in seeking urgent health care and in hospitalizations.

Malcarney MB, Pittman P, Quigley L, Horton K, Seiler N. The changing roles of community health workers. Health Serv Res. 2017 Feb;52 Suppl 1:360-382.
Objective: To examine what different types of employers value in hiring community health workers (CHWs) and determine what new competencies CHWs might need to meet workforce demands in the context of an evolving payment landscape and substantial literature suggesting that CHWs are uniquely qualified to address health disparities. Study Design: We used a multimethod approach, including a literature review, development of a database of 76 programs, interviews with 24 key informants, and a qualitative comparison of major CHW competency lists. Principal Findings: We find a shift in CHW employment settings from community-based organizations to hospitals/health systems. Providers that hire CHWs directly, as opposed to partnering with community organizations, report that they value education and training more highly than traditional characteristics, such as peer status. We find substantial similarities across competency lists, but a gap in competencies that relate to CHWs' ability to integrate into health systems while maintaining their unique identity. Conclusions: As CHW integration into health care organizations advances, and as states move forward with CHW certification efforts, it is important to develop new competencies that relate to CHW-health system integration. Chief among them is the ability to explain and defend the CHW's unique occupational identity.

Massengale KE, Morrison SD, Sudha S. Community health advocate-identified enablers of HIV testing for Latina immigrant women. AIDS Educ Prev. 2016 Aug;28(4):325-40. doi: 10.1521/aeap.2016.28.4.325.
This study aims to identify enablers or facilitators of HIV testing among Latina immigrant women through qualitative interviews with five community health advocates (CHAs). CHAs act as cultural bridges between Latinos and service providers. We employed a single case-study design using the PEN-3 model as a conceptual framework for situating HIV testing behaviors within cultural and structural contexts of Latina immigrant women's lives. A cross-case analysis of themes revealed that intrinsic enablers of HIV testing included individual trust, confidentiality, intergenerational family participation, and peers. The extrinsic enablers were local community outreach, bicultural/bilingual testing staff, service location and mass media outlets. These results have implications for the cultural competency of health and social service providers, instituting and revising HIV testing outreach interventions, and the earlier identification of women who may have been infected. They offer important insights for promoting other health behaviors among the Latino communities. 

Molokwu J, Penaranda E, Flores S, Shokar NK. Evaluation of the effect of a promotora-led educational intervention on cervical cancer and human papillomavirus knowledge among predominantly Hispanic primary care patients on the US-Mexico Border. J Cancer Educ. 2016 Dec;31(4):742-748.
Despite declining cervical cancer rates, ethnic minorities continue to bear an unequal burden in morbidity and mortality. While access to screening is a major barrier, low levels of knowledge and cultural influences have been found to play a part in underutilization of preventive services. The aim of our study was to evaluate the effect of a promotora-led educational intervention on cervical cancer and human papillomavirus knowledge in mainly Hispanic females attending a primary care clinic. One hundred ten females were recruited from the waiting room of a busy primary care clinic and invited to attend individual or small group educational sessions. Participants completed knowledge surveys pre- and post-intervention. An overall evaluation of the educational session was also completed. Following the educational intervention, participants showed an improvement in knowledge scores from a mean score of 10.8 (SD 3.43) out of a possible score of 18 to a mean score of 16.0 (SD1.51) (p < 0.001). 94.5 % of participants rated as excellent, the presentation of information in a way that was easy to understand, most reported that it was a good use of their time and that it lowered their anxiety about testing for early detection of cervical cancer. An educational intervention delivered by well-trained Promotora/Lay health care worker significantly improves patient's cervical cancer and HPV knowledge and can be a useful tool in patient education in the clinical setting especially with high risk populations.

Morgan AU, Grande DT, Carter T, Long JA, Kangovi S. Penn Center for Community Health Workers: step-by-step approach to sustain an evidence-based community health worker intervention at an academic medical center. Am J Public Health. 2016 Sep 15:e1-e3. [Epub ahead of print]
Community-engaged researchers who work with low-income communities can be reliant on grant funding. We use the illustrative case of the Penn Center for Community Health Workers (PCCHW) to describe a step-by-step framework for achieving financial sustainability for community-engaged research interventions. PCCHW began as a small grant-funded research project but followed an 8-step framework to engage both low-income patients and funders, determine outcomes, and calculate return on investment. PCCHW is now fully funded by Penn Medicine and delivers the Individualized Management for Patient-Centered Targets (IMPaCT) community health worker intervention to 2000 patients annually.

Roman LA, Zambrana RE, Ford S, Meghea C, Williams KP. Casting a wider net: engaging community health worker clients and their families in cancer prevention. Prev Chronic Dis. 2016 Sep 15;13:E130. doi: 10.5888/pcd13.160114.
Engaging family members in an intervention to prevent breast and cervical cancer can be a way to reach underserved women; however, little is known about whether family member recruitment reaches at-risk women. This study reports the kin relationship and risk characteristics of family members who chose to participate in the Kin Keeper(SM) cancer prevention intervention, delivered by community health workers (CHWs) via existing community programs. African American, Latina, and Arab family members reported risk factors for inadequate screening, including comorbid health conditions and inadequate breast or cervical cancer literacy. CHW programs can be leveraged to reach underserved families with cancer preventive interventions.

Schwingel A, Wiley AR, Teran-Garcia M, et al. Promotoras and the semantic gap between Latino community health researchers and Latino communities. Health Promot Pract. 2016 Oct 18. pii: 1524839916670576. [Epub ahead of print]
Promotoras are identified as a unique group of community health workers adept at reducing health disparities. This qualitative study was conducted to better understand perceptions of the term promotora, broadly used in research but not well documented in everyday Latina vocabulary. Six focus groups to better understand perceptions of the term promotora were conducted with 36 Latina women living in three nonmetropolitan areas in Illinois. Results suggest that Latina participants in the study do not understand the meaning of "promotora" in the same way as it is used in the literature. Latina participants understood "promotoras" as referring to people who sell or deliver information, or organize events in the community that are not necessarily related to health events or community health work. Furthermore, they usually understood the term to refer to paid work rather than volunteering. Results underscore the importance of being sensitive to Latinas' perceptions of community health terminology by assessing their context, needs, and expectations. These findings call researchers' attention to the need to educate certain Latino communities about the concept of promotoras, with implications for the implementation and dissemination of promotora-led community health programs, as the semantic discrepancy could affect the recruitment of promotoras as well as community participation in the programs they deliver.

Shokar NK, Byrd T, Salaiz R, et al. Against colorectal cancer in our neighborhoods (ACCION): A comprehensive community-wide colorectal cancer screening intervention for the uninsured in a predominantly Hispanic community. Prev Med. 2016 Aug 26. pii: S0091-7435(16)30251-1. doi: 10.1016/j.ypmed.2016.08.039. [Epub ahead of print]
Colorectal cancer (CRC) is the second leading cause of cancer deaths in the USA. Screening is widely recommended but underutilized, particularly among the low income, the uninsured, recent immigrants and Hispanics. The study objective was to determine the effectiveness of a comprehensive community-wide, bilingual, CRC screening intervention among uninsured predominantly Hispanic individuals. This prospective study was embedded in a CRC screening program and utilized a quasi-experimental design. Recruitment occurred from Community and clinic sites. Inclusion criteria were aged 50-75years, uninsured, due for CRC screening, Texas address and exclusions were a history of CRC, or recent rectal bleeding. Eligible subjects were randomized to either promotora (P), video (V), or combined promotora and video (PV) education, and also received no-cost screening with fecal immunochemical testing or colonoscopy and navigation. The non-randomly allocated controls recruited from a similar county, received no intervention. The main outcome was 6month self-reported CRC screening. Per protocol and worst case scenario analyses, and logistic regression with covariate adjustment were performed.784 subjects (467 in intervention group, 317 controls) were recruited; mean age was 56.8years; 78.4% were female, 98.7% were Hispanic and 90.0% were born in Mexico. In the worst case scenario analysis (n=784) screening uptake was 80.5% in the intervention group and 17.0% in the control group [relative risk 4.73, 95% CI: 3.69-6.05, P<0.001]. No educational group differences were observed. Covariate adjustment did not significantly alter the effect. A multicomponent community-wide, bilingual, CRC screening intervention significantly increased CRC screening in an uninsured predominantly Hispanic population.

Spence Cagle C, Wells JN. Culturally sensitive care: enlisting community partners to meet Mexican American caregiver needs. Clin J Oncol Nurs. 2017 Feb 1;21(1):E1-E8.
Background: Culturally sensitive interventions are needed to assist Mexican American (MA) patients with cancer and their family members in managing their care, navigating the healthcare system, and decreasing disparities in healthcare outcomes for Hispanics with cancer. Objectives: The objectives of this study were to understand the meaning of culturally sensitive care for oncology clinic healthcare providers and to assess the usefulness and feasibility of the role of a promotora de salud to meet caregiver needs. Methods: This study involved focus groups of 18 diverse providers who provided data for qualitative analyses. Findings: The findings (themes) defined the facilitators of and barriers to culturally sensitive care and the perceived role of a promotora de salud to support the healthcare team and improve cancer care provided by MA caregivers. In addition, promotoras de salud can help reduce health costs by decreasing patient clinic visits.

Thompson B, Carosso EA, Jhingan E, et al. Results of a randomized controlled trial to increase cervical cancer screening among rural Latinas. Cancer. 2016 Oct 27. doi: 10.1002/cncr.30399. [Epub ahead of print]
Background: Latinas have the highest rates of cervical cancer in the United States and the second highest rate of cervical cancer mortality. One factor in the disparity is the relatively low rate of screening for cervical cancer in this population. Methods:  Eligible women who were out of adherence with cervical cancer screening (>3 years since their last Papanicolaou [Pap] test) were identified via medical record review by a federally qualified local health center. The effects of a low-intensity intervention (video delivered to participants' homes; n = 150) and a high-intensity intervention (video plus a home-based educational session; n = 146) on cervical cancer screening uptake in comparison with a control arm (usual care; n = 147) were investigated. A cost-effectiveness analysis of the interventions was conducted: all intervention costs were calculated, and the incremental cost-effectiveness ratio was computed. Finally, women with positive Pap tests were provided navigation by a community health educator to ensure that they received follow-up care. Results: A total of 443 Latinas participated. Seven months after randomization, significantly more women in the high-intensity arm received a Pap test (53.4%) in comparison with the low-intensity arm (38.7%; P < .001) and the usual-care arm (34.0%; P < .01). The incremental cost-effectiveness ratio for high-intensity women versus the control group amounted to $4.24. Twelve women had positive Pap tests, which encompassed diagnoses ranging from atypical squamous cells of unknown significance to invasive cancer; these women received navigation for follow-up care. Conclusions:  A culturally appropriate, in-home, promotora-led educational intervention was successful in increasing cervical cancer screening among Latinas.

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Last updated November 20, 2017