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Effect of Community Health Worker Support on Clinical Outcomes of Low-Income Patients Across Primary Care Facilities: A Randomized Clinical Trial.

ABSTRACT: Importance:Addressing the social determinants of health has been difficult for health systems to operationalize. Objective:To assess a standardized intervention, Individualized Management for Patient-Centered Targets (IMPaCT), delivered by community health workers (CHWs) across 3 health systems. Design, Setting, and Participants:This 2-armed, single-blind, multicenter randomized clinical trial recruited patients from 3 primary care facilities in Philadelphia, Pennsylvania, between January 28, 2015, and March 28, 2016. Patients who resided in a high-poverty zip code, were uninsured or publicly insured, and who had a diagnosis for 2 or more chronic diseases were recruited, and patients were randomized to either the CHW intervention or the control arm (goal setting only). Follow-up assessments were conducted at 6 and 9 months after enrollment. Data were analyzed using an intention-to-treat approach from June 2017 to March 2018. Intervention:Participants set a chronic disease management goal with their primary care physician; those randomized to the CHW intervention received 6 months of tailored support. Main Outcomes and Measures:The primary outcome was change in self-rated physical health. The secondary outcomes were self-rated mental health, chronic disease control, patient activation, patient-reported quality of primary care, and all-cause hospitalization. Results:Of the 592 participants, 370 (62.5%) were female, with a mean (SD) age of 52.6 (11.1) years. Participants in both arms had similar improvements in self-rated physical health (mean [SD], 1.8 [11.2] vs 1.6 [9.9]; P?=?.89). Patients in the intervention group were more likely to report the highest quality of care (odds ratio [OR], 1.8; 95% CI, 1.4-2.4; risk difference [RD], 0.12; P?

SUBMITTER: Kangovi S

PROVIDER: S-EPMC6469661 | biostudies-literature | 2018 Dec

REPOSITORIES: biostudies-literature

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Effect of Community Health Worker Support on Clinical Outcomes of Low-Income Patients Across Primary Care Facilities: A Randomized Clinical Trial.

Kangovi Shreya S Mitra Nandita N Norton Lindsey L Harte Rory R Zhao Xinyi X Carter Tamala T Grande David D Long Judith A JA

JAMA internal medicine 20181201 12

<h4>Importance</h4>Addressing the social determinants of health has been difficult for health systems to operationalize.<h4>Objective</h4>To assess a standardized intervention, Individualized Management for Patient-Centered Targets (IMPaCT), delivered by community health workers (CHWs) across 3 health systems.<h4>Design, setting, and participants</h4>This 2-armed, single-blind, multicenter randomized clinical trial recruited patients from 3 primary care facilities in Philadelphia, Pennsylvania, ...[more]

PMID: 30422224

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Project description:ObjectiveTo identify which primary healthcare (PHC) principles are reflected in the implementation of national community health worker (CHW) programmes and how they may contribute to the outcomes of these programmes in the context of low-income and middle-income countries (LMICs).DesignScoping review.Data sourcesA systematic search was conducted through PubMed, CINAHL, EMBASE and Scopus databases.Eligibility criteriaThe review considered published primary studies on national programmes, projects or initiatives using the services of CHWs in LMICs focused on maternal and child health. We included only English language studies. Excluded were programmes operated by non-government organisations, study protocols, reviews, commentaries, opinion papers, editorials and conference proceedings.Data extraction and synthesisWe reviewed the application of four PHC principles (universal health coverage, community participation, intersectoral coordination and appropriateness) in the CHW programme's objectives, implementation and stated outcomes. Data extraction was undertaken systematically in an excel spreadsheet while the findings were synthesised in a narrative manner. The quality appraisal of the selected studies was not performed in this scoping review.ResultsFrom 1280 papers published between 1983 and 2019, 26 met the inclusion criteria. These 26 papers included 14 CHW programmes from 13 LMICs. Universal health coverage and community participation were the two commonly reported PHC principles, while intersectoral coordination was generally missing. Similarly, the cultural acceptability aspect of the principle of appropriateness was present in all programmes as these programmes select CHWs from within the communities. Other aspects, particularly effectiveness, were not evident.ConclusionThe implementation of PHC principles across national CHW programmes in LMICs is patchy. For comprehensiveness and improved health outcomes, programmes need to incorporate all attributes of PHC principles. Future research may focus on how to incorporate more attributes of PHC principles while implementing national CHW programmes in LMICs. Better documentation and publications of CHW programme implementation are also needed.

Project description:BackgroundAlthough patients who work and have related health issues are usually first seen in primary care, providers in these settings do not routinely ask questions about work. Guidelines to help manage such patients are rarely used in primary care. Electronic health record (EHR) systems with worker health clinical decision support (CDS) tools have potential for assisting these practices.ObjectiveThis study aimed to identify the need for, and barriers and facilitators related to, implementation of CDS tools for the clinical management of working patients in a variety of primary care settings.MethodsWe used a qualitative design that included analysis of interview transcripts and observational field notes from 10 clinics in five organizations.ResultsWe interviewed 83 providers, staff members, managers, informatics and information technology experts, and leaders and spent 35 hours observing. We identified eight themes in four categories related to CDS for worker health (operational issues, usefulness of proposed CDS, effort and time-related issues, and topic-specific issues). These categories were classified as facilitators or barriers to the use of the CDS tools. Facilitators related to operational issues include current technical feasibility and new work patterns associated with the coordinated care model. Facilitators concerning usefulness include users' need for awareness and evidence-based tools, appropriateness of the proposed CDS for their patients, and the benefits of population health data. Barriers that are effort-related include additional time this proposed CDS might take, and other pressing organizational priorities. Barriers that are topic-specific include sensitive issues related to health and work and the complexities of information about work.ConclusionWe discovered several themes not previously described that can guide future CDS development: technical feasibility of the proposed CDS within commercial EHRs, the sensitive nature of some CDS content, and the need to assist the entire health care team in managing worker health.

Project description:IntroductionPrimary Health Care (PHC) gained considerable momentum in the past four decades and led to improved health outcomes across a wide variety of settings. In low-and middle-income countries (LMICs), national or large-scale Community Health Worker Programs (CHWPs) are considered as vehicles to incorporate PHC principles into healthcare provision and are an essential aspect of the PHC approach to achieve health for all and sustainable development goals. The success of CHWPs is rooted in the application of PHC principles. However, there is evidence that shows patchy implementation of PHC principles across national CHWPs in LMICs. This may reflect the lack of information on what activities would illustrate the application of these principles in CHWPs. This study aimed to identify a set of core/indicator-activities that reflect the application of PHC principles by CHWPs in LMICs.MethodsA two-round modified Delphi study was undertaken with participants who have extensive experience in planning, implementation and evaluation of CHWPs. Survey design and analysis was guided by the four PHC principles namely Universal Health Coverage, Community Participation, Intersectoral Coordination and Appropriateness. Responses were collected using a secure online survey program (survey monkey). In round one, participants were asked to list 'core activities' that would reflect the application of each PHC principle and its sub-attributes and challenges to apply these principles in CHWPs. In round two, participants were asked to select whether they agree or disagree with each of the activities and challenges. Consensus was set a priori at 70% agreement of participants for each question.ResultsSeventeen participants from 15 countries participated in the study. Consensus was reached on 59 activities reflecting the application of PHC principles by CHWPs. Based on participants' responses, a set of 29 indicator-activities for the four PHC principles was developed with examples for each indicator-activity.ConclusionThese indicator-activities may provide guidance on how PHC principles can be implemented in CHWPs. They can be used in the development and evaluation of CHWPs, particularly in their application of PHC principles. Future research may focus on testing the utility of indicator-activities on CHWPs in LMICs.

Project description:OBJECTIVE:Community-based peer and community health worker-led diabetes self-management programs (COMP-DSMP) can benefit diabetes care, but the supporting evidence has been inadequately assessed. This systematic review explores the nature of COMP-DSMP in low- and middle-income countries' (LMIC) primary care settings and evaluates implementation strategies and diabetes-related health outcomes. METHODS:We searched the Cochrane Library, PubMed-MEDLINE, SCOPUS, CINAHL PsycINFO Database, International Clinical Trials Registry Platform, Clinicaltrials.gov, Pan African Clinical Trials Registry (PACTR), and HINARI (Health InterNetwork Access to Research Initiative) for studies that evaluated a COMP-DSMP in adults with either type 1 or type 2 diabetes in World Bank-defined LMIC from January 2000 to December 2019. Randomised and non-randomised controlled trials with at least 3 months follow-up and reporting on a behavioural, a primary psychological, and/or a clinical outcome were included. Implementation strategies were analysed using the standardised implementation framework by Proctor et al. Heterogeneity in study designs, outcomes, the scale of measurements, and measurement times precluded meta-analysis; thus, a narrative description of studies is provided. RESULTS:Of the 702 records identified, eleven studies with 6090 participants were included. COMP-DSMPs were inconsistently associated with improvements in clinical, behavioural, and psychological outcomes. Many of the included studies were evaluated as being of low quality, most had a substantial risk of bias, and there was a significant heterogeneity of the intervention characteristics (for example, peer definition, selection, recruitment, training and type, dose, and duration of delivered intervention), such that generalisation was not possible. CONCLUSIONS:The level of evidence of this systematic review was considered low according to the GRADE criteria. The existing evidence however does show some improvements in outcomes. We recommend ongoing, but well-designed studies using a framework such as the MRC framework for the development and evaluation of complex interventions to inform the evidence base on the contribution of COMP-DSMP in LMIC.

Project description:BackgroundRecording and reporting health data in facilities is the backbone of routine health information systems which provide data collected by health facility workers during service provision. Data is firstly collected in a register, to record patient health data and care process, and tallied into nationally designed reporting forms. While there is anecdotal evidence of large numbers of registers and reporting forms for primary health care (PHC) facilities, there are few systematic studies to document this potential burden on health workers. This multi-country study aimed to document the numbers of registers and reporting forms use at the PHC level and to estimate the time it requires for health workers to meet data demands.MethodsIn Cambodia, Ghana, Mozambique, Nigeria and Tanzania, a desk review was conducted to document registers and reporting forms mandated at the PHC level. In each country, visits to 16 randomly selected public PHC facilities followed to assess the time spent on paper-based recording and reporting. Information was collected through self-reports of estimated time use by health workers, and observation of 1360 provider-patient interactions. Data was primarily collected in outpatient care (OPD), antenatal care (ANC), immunization (EPI), family planning (FP), HIV and Tuberculosis (TB) services.ResultCross-countries, the average number of registers was 34 (ranging between 16 and 48). Of those, 77% were verified in use and each register line had at least 20 cells to be completed per patient. The mean time spent on recording was about one-third the total consultation time for OPD, FP, ANC and EPI services combined. Cross-countries, the average number of monthly reporting forms was 35 (ranging between 19 and 52) of which 78% were verified in use. The estimated time to complete monthly reporting forms was 9 h (ranging between 4 to 15 h) per month per health worker.ConclusionsPHC facilities are mandated to use many registers and reporting forms pausing a considerable burden to health workers. Service delivery systems are expected to vary, however an imperative need remains to invest in international standards of facility-based registers and reporting forms, to ensure regular, comparable, quality-driven facility data collection and use.

Project description:INTRODUCTION:Community health workers (CHWs) are increasingly being tasked to prevent and manage cardiovascular disease (CVD) and its risk factors in underserved populations in low-income and middle-income countries (LMICs); however, little is known about the required training necessary for them to accomplish their role. This review aimed to evaluate the training of CHWs for the prevention and management of CVD and its risk factors in LMICs. METHODS:A search strategy was developed in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and five electronic databases (Medline, Global Health, ERIC, EMBASE and CINAHL) were searched to identify peer-reviewed studies published until December 2016 on the training of CHWs for prevention or control of CVD and its risk factors in LMICs. Study characteristics were extracted using a Microsoft Excel spreadsheet and quality assessed using Effective Public Health Practice Project's Quality Assessment Tool. The search, data extraction and quality assessment were performed independently by two researchers. RESULTS:The search generated 928 articles of which 8 were included in the review. One study was a randomised controlled trial, while the remaining were before-after intervention studies. The training methods included classroom lectures, interactive lessons, e-learning and online support and group discussions or a mix of two or more. All the studies showed improved knowledge level post-training, and two studies demonstrated knowledge retention 6?months after the intervention. CONCLUSION:The results of the eight included studies suggest that CHWs can be trained effectively for CVD prevention and management. However, the effectiveness of CHW trainings would likely vary depending on context given the differences between studies (eg, CHW demographics, settings and training programmes) and the weak quality of six of the eight studies. Well-conducted mixed-methods studies are needed to provide reliable evidence about the effectiveness and cost-effectiveness of training programmes for CHWs.

Dataset Information

Effect of Community Health Worker Support on Clinical Outcomes of Low-Income Patients Across Primary Care Facilities: A Randomized Clinical Trial.

Publications

Effect of Community Health Worker Support on Clinical Outcomes of Low-Income Patients Across Primary Care Facilities: A Randomized Clinical Trial.

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