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Protocol for the CHORD project (community health outreach to reduce diabetes): a cluster-randomized community health worker trial to prevent diabetes.

ABSTRACT: BACKGROUND:Type 2 diabetes mellitus (DM) affects 9.4% of US adults and children, while another 33.9% of Americans are at risk of DM. Health care institutions face many barriers to systematically delivering the preventive care needed to decrease DM incidence. Community health workers (CHWs) may, as frontline public health workers bridging clinic and community, help overcome these challenges. This paper presents the protocol for a pragmatic, cluster-randomized trial integrating CHWs into two primary care clinics to support DM prevention for at-risk patients. METHODS:The trial will randomize 15 care teams, stratified by practice site (Bellevue Hospital and Manhattan VA), totaling 56 primary care physicians. The study cohort will consist of ~?2000 patients who are 18-75 years of age, actively enrolled in a primary care team, able to speak English or Spanish, and have at least one glycosylated hemoglobin (HbA1c) result in the prediabetic range (5.7-6.4%) since 2012. Those with a current DM diagnosis or DM medication prescription (other than metformin) are ineligible. The intervention consists of four core activities - setting health goals, health education, activation for doctor's appointments, and referrals to DM prevention programs - adjustable according to the patient's needs and readiness. The primary outcome is DM incidence. Secondary outcomes include weight loss, HbA1C, and self-reported health behaviors. Clinical variables and health behaviors will be obtained through electronic medical records and surveys, respectively. Implementation outcomes, namely implementation fidelity and physicians' perspectives about CHW integration into the clinic, will be assessed using interviews and CHW activity logs and analyzed for the influence of moderating organizational factors. DISCUSSION:This is the first rigorous, pragmatic trial to test the effectiveness of integrating CHWs into primary care for DM prevention reaching a population-based sample. Our study's limitations include language-based eligibility and the use of HbA1c as a measure of DM risk. It will measure both clinical and implementation outcomes and potentially broaden the evidence base for CHWs and patient-centered medical home implementation. Further, the intervention's unique features, notably patient-level personalization and referral to existing programs, may offer a scalable model to benefit patients at-risk of DM. TRIAL REGISTRATION:Clinicaltrials.gov NCT03006666 (Received 12/27/2016).

SUBMITTER: Islam N

PROVIDER: S-EPMC5909211 | biostudies-literature | 2018 Apr

REPOSITORIES: biostudies-literature

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Protocol for the CHORD project (community health outreach to reduce diabetes): a cluster-randomized community health worker trial to prevent diabetes.

Islam Nadia N Gepts Thomas T Lief Isaac I Gore Radhika R Levy Natalie N Tanner Michael M Fang Yixin Y Sherman Scott E SE Schwartz Mark D MD

BMC public health 20180419 1

<h4>Background</h4>Type 2 diabetes mellitus (DM) affects 9.4% of US adults and children, while another 33.9% of Americans are at risk of DM. Health care institutions face many barriers to systematically delivering the preventive care needed to decrease DM incidence. Community health workers (CHWs) may, as frontline public health workers bridging clinic and community, help overcome these challenges. This paper presents the protocol for a pragmatic, cluster-randomized trial integrating CHWs into t ...[more]

PMID: 29673333

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Project description:Background:Community Health Workers (CHWs) are considered to be a cost-effective and inclusive solution to address the persistent health workforce shortage in many low and middle-income countries. In recent years, microfinance institutions (MFIs) got increasingly engaged in providing health services delivered by CHWs. Despite their growing importance, little is known about the impacts and implementation barriers of these mostly small-scale initiatives. This paper evaluates an MFI-led CHW program in the Philippines and studies the role of microfinance group networks in influencing program outreach and impact. The intervention aims at disseminating information in poor communities, improving health monitoring through increased check-ups and raising social support. Methods:Clustered randomized controlled trial in 70 communities in the greater area of Metro Manila, the Philippines. The main data was collected in a baseline and follow-up survey and is complemented with extensive sociometric network and geographical data. The main outcome variable is a composite health index based on 10 indicators. The role of the health worker's embeddedness and connectedness in the community for program success is tested using tools of social network analysis. Results:The intervention led to a 3.8% (95% confidence interval (CI)?=?1.3, 6.4) improvement in the composite health outcome. Effects across indicators are mixed and mainly driven by changes in immediate health monitoring behavior: The probability for routine examinations increased in the treatment group by 10.6% (95% CI?=?3.2, 18.1), for regular blood pressure checks by 9.6% (95% CI?=?3.3, 15.9), and for having access to a health care provider by 7.2% (95% CI?=?0.93, 13.5). No statistical effects on general knowledge and social support are observable. Social networks are a key driver of program outreach and impact. Close friends and acquaintances of health workers used and benefited substantially more from the program than more distant ties. Conclusions:Despite the promising immediate behavioral impacts, it remains questionable to what extent such small-scale MFI initiatives can bring transformative and sustainable changes without external support. Microfinance group networks played an important role for the success of the health intervention and further research is needed to better understand how these affect the health care utilization decisions of the clients.

Project description:BackgroundDelays in preventative service uptake are increasing in the UK. Universal, comprehensive monthly outreach by Community Health and Wellbeing Workers (CHW), who are integrated at the GP practice and local authority, offer a promising alternative to general public health campaigns as it personalises health promotion and prevention of disease holistically at the household level. We sought to test the ability of this model, which is based on the Brazilian Family Health Strategy, to increase prevention uptake in the UK.MethodsAnalysis of primary care patient records for 662 households that were allocated to five CHWWs from July 2021. Primary outcome was the Composite Referral Completion Indicator (CRCI), a measure of how many health promotion activities were received by members of a household relative to the ones that they were eligible for during the period July 2021-April 2022. The CRCI was compared between the intervention group (those who had received at least one visit) and the control group (allocated households that were yet to receive a visit). A secondary outcome was the number of GP visits in the intervention and control groups during the study period and compared to a year prior.ResultsIntervention and control groups were largely comparable in terms of household occupancy and service eligibilities. A total of 2251 patients in 662 corresponding households were allocated to 5 CHWs and 160 households had received at least one visit during the intervention period. The remaining households were included in the control group. Overall service uptake was 40% higher in the intervention group compared to control group (CRCI: 0.21 ± 0.15 and 0.15 ± 0.19 respectively). Likelihood of immunisation uptake specifically was 47% higher and cancer screening and NHS Health Checks was 82% higher. The average number of GP consultations per household decreased by 7.4% in the intervention group over the first 10 months of the pilot compared to the 10 months preceding its start, compared with a 0.6% decrease in the control group.ConclusionsDespite the short study period these are promising findings in this deprived, traditionally hard to reach community and demonstrates potential for the Brazilian community health worker model to be impactful in the UK. Further analysis is needed to examine if this approach can reduce health inequalities and increase cost effectiveness of health promotion approaches.

Project description:BackgroundEffective implementation strategies are needed to increase engagement in HIV services in hyperendemic settings. We conducted a pragmatic cluster-randomized trial in a high-risk, highly mobile fishing community (HIV prevalence: approximately 38%) in Rakai, Uganda, to assess the impact of a community health worker-delivered, theory-based (situated Information, Motivation, and Behavior Skills), motivational interviewing-informed, and mobile phone application-supported counseling strategy called "Health Scouts" to promote engagement in HIV treatment and prevention services.Methods and findingsThe study community was divided into 40 contiguous, randomly allocated clusters (20 intervention clusters, n = 1,054 participants at baseline; 20 control clusters, n = 1,094 participants at baseline). From September 2015 to December 2018, the Health Scouts were deployed in intervention clusters. Community-wide, cross-sectional surveys of consenting 15 to 49-year-old residents were conducted at approximately 15 months (mid-study) and at approximately 39 months (end-study) assessing the primary programmatic outcomes of self-reported linkage to HIV care, antiretroviral therapy (ART) use, and male circumcision, and the primary biologic outcome of HIV viral suppression (<400 copies/mL). Secondary outcomes included HIV testing coverage, HIV incidence, and consistent condom use. The primary intent-to-treat analysis used log-linear binomial regression with generalized estimating equation to estimate prevalence risk ratios (PRR) in the intervention versus control arm. A total of 2,533 (45% female, mean age: 31 years) and 1,903 (46% female; mean age 32 years) residents completed the mid-study and end-study surveys, respectively. At mid-study, there were no differences in outcomes between arms. At end-study, self-reported receipt of the Health Scouts intervention was 38% in the intervention arm and 23% in the control arm, suggesting moderate intervention uptake in the intervention arm and substantial contamination in the control arm. At end-study, intention-to-treat analysis found higher HIV care coverage (PRR: 1.06, 95% CI: 1.01 to 1.10, p = 0.011) and ART coverage (PRR: 1.05, 95% CI: 1.01 to 1.10, p = 0.028) among HIV-positive participants in the intervention compared with the control arm. Male circumcision coverage among all men (PRR: 1.05, 95% CI: 0.96 to 1.14, p = 0.31) and HIV viral suppression among HIV-positive participants (PRR: 1.04, 95% CI: 0.98 to 1.12, p = 0.20) were higher in the intervention arm, but differences were not statistically significant. No differences were seen in secondary outcomes. Study limitations include reliance on self-report for programmatic outcomes and substantial contamination which may have diluted estimates of effect.ConclusionsA novel community health worker intervention improved HIV care and ART coverage in an HIV hyperendemic setting but did not clearly improve male circumcision coverage or HIV viral suppression. This community-based, implementation strategy may be a useful component in some settings for HIV epidemic control.Trial registrationClinicalTrials.gov NCT02556957.

Dataset Information

Protocol for the CHORD project (community health outreach to reduce diabetes): a cluster-randomized community health worker trial to prevent diabetes.

Publications

Protocol for the CHORD project (community health outreach to reduce diabetes): a cluster-randomized community health worker trial to prevent diabetes.

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