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Community Health Workers as
an Intervention
Implementation Strategy in
Health Promotion Research
Lisa Quintiliani, PhD
Assistant Professor of Medicine
November 29, 2016
AHRQ, Outcomes of Community Health
Worker Interventions, No. 09-E014
What is a Community Health Worker?
Individuals who share a relationship with their
community who are not professionally
trained/licensed who serve as a bridge to
health care services and/or health promotion
services
Community Health Workers
Those who share one or more attributes with
target population called peers
Age
Language
Race/ethnicity
Medical condition
Peers can provide effective support due to their
‘insider knowledge’
https://www.youtube.com/watch?v=xcLpcwMR8rU
Peers for Progress, peersforprogress.org
Roles of Peers
1) Assistance in management of health behavior
How to test blood glucose
2) Provide social/emotional support
Overcome/cope with barriers
3) Linkage to health services
Referral to community programs; schedule appointments
4) On-going support
Maintain relationship over time
5) Behavioral counseling,
Systematic, evidenced-based
=Peer Counselors
Efficacy of community health worker
interventions Clinical outcomes
Blood pressure control (Browstein), hemoglobin A1c
(Long)
Health behaviors: diet (Keyserling)
Review involving 53 studies with community health
workers by AHRQ (Viswanathan)
Overall support for use of community health workers,
although results were mixed for behavior change and health
outcomes
Interventions targeting weight management were limitied
My program of research with peer
counselors Diet and physical activity behaviors
Trial with non-traditional college students peer
counseling (Quintiliani, 2016)
On-going trial among residents of Boston’s public
housing developments
Nontraditional college students
Large and growing population of college
students
Attend part-time, work full-time, have
dependents, are usually older
Tend to face different social and physical
environments compared to traditional college
students
Study design
2 group randomized trial with 2:1
randomization
Setting: Large, urban university
7 college students began training, 4
completed and served as peer counselors
current or recent undergraduates
3 MI telephone calls focused on 4 behavioral
topics using paper-based guide
Primary outcome
Diet and physical activity (self-reported)
Participant characteristics
Variable Intervention
(n=40)
Comparison
(n=20)
Total
(n=60)
Age, mean (SD) 32 (10) 32.3 (10) 32.2 (10)
Gender, % female 62 50 58
Hispanic/Latino, % 10 15 12
Race, % White
% Black
% 2 or more races
% other
37
22
25
17
60
5
5
30
45
17
17
22
Single, % 65 55 62
Employed, % 70 70 70
Children to support, % 17 20 18
Medicaid, % 27 20 25
Food stamps, % 23 16 21
Behaviors at Baseline
Variable Intervention
(n=40)
Comparison
(n=20)
Total
(n=60)
Fruits & vegetables,
mean (SD) servings/day 3.5 (1.7) 4.6 (1.7)* 3.9 (1.8)
Sugary drinks,
mean (SD) fl ounces/day 24.9 (29.3) 15.1 (17.5) 21.6 (26.3)
Fast food,
mean (SD) visits/week 2.8 (3.2) 2.6 (3.8) 2.7 (3.4)
Mod-vigorous physical activity,
mean (SD) min/week 221 (238) 192 (135) 212 (210)
*=significant difference b/t intervention and comparison groups
Intervention Dose
Most (78%) intervention group participants completed at least 2 peer counseling calls 42% received all 3 calls
Change in behavior
Variable Change from
baseline
Intervention
(n=37)
Change from
baseline
Comparison
(n=17)
Effect size
Fruits & vegetables,
mean (SD) servings/day
0.8 (1.6) 0.09 (1.3) 0.2
Favors intervention
Sugary drinks,
mean (SD) fl ounces/day
-6.8 (29.4) -0.5 (17.1) 0.01
Favors intervention
Fast food,
mean (SD) visits/week -1.5 (2.7) -1.3 (2.8)
0.1
Favors intervention
Mod-vigorous physical
activity,
mean (SD) min/week
% meeting rx at follow-up
-7.2 (200)
71
100 (187)
69
-0.6
Favors comparison
Next stepsHow can we creatively combine computer-based
technologies with community health workers to
improve prevention of chronic disease (and
implementation in the process)?
Fidelity in intervention design &
delivery Technology could assist in increasing fidelity
related to training and delivery for CHWs Consistency of delivery between interventionists &
participants
Motivational interviewing as a case study Preserving the ‘spirit of MI’ without sacrificing
consistency of delivery of core components
Community health workers supported by an eHealth program to enable standardized, evidenced-based behavioral counseling using motivational interviewing
Resnick et al., 2005; Hecht et al., 2005
Weight management intervention using
community health workers
Setting: Public housing developments
Study objective
Determine if peer counseling using eHealth
program demonstrates preliminary efficacy
and feasibility
Two-group trial, 74 per group
Comparison group = brief tailored feedback report
Intervention group = brief tailored feedback report
+ 12 weeks of MI-based phone counseling from a
peer counselor using eHealth program
Community health worker-based
intervention Peer counselor training
2 counselors living in housing developments and
surrounding communities
Behavioral counseling using small changes
approach
12 sessions (in-person & phone)
Text messaging
Use eHealth program called CuesWeight
Bennett et al., 2009; 2012 & Lutes et al., 2013
CuesWeight
Structured guided content
Wording suggestions
Sentence stems for reflections
Flexible enough for adding your ‘own spin’
Additional suggestions & questions
Useful for training, delivery of sessions &
quality assurance activities
Usability sessions
User informants (n=3)
1-3 sessions
Think aloud protocol
Perceived usefulness and perceived ease of
use
Range of 1 (best) to 7 (worst)
1.7 for both scales
Layout of session content
Feedback
Educational topic
Social contextImportance/Confidence
Motivation assessment & goal setting
Like the idea of
goal
setting/letting
them pick their 3
behaviors Asterisks for
exact language
sections are
good
radio button for
reflection is a
good reminder
for the
counselor
Summary of Measured Trial
OutcomesMeasure Source Baseline 3 mo.F/UP
Acceptability among participants &
counselors
Qualitative
interview X
Fidelity of implementation
# sessions reaching MI proficiency
# completed sessions
session review
database
X
X
Efficacy
BMI (weight/height)
Diet (F&V, fast food, sugary drinks)
Physical activity
Obj. measured
Survey
Accelerometer
X
X
X
X
X
X
Mediation
Self-efficacy, motivation, social
support
Survey X X
Socio-demographics Survey X
Efficacy of community health worker
interventions Clinical outcomes
Blood pressure control (Browstein), hemoglobin A1c
(Long)
Health behaviors: diet (Keyserling)
Review involving 53 studies with community health
workers by AHRQ (Viswanathan)
For behavior change and health outcomes, results were
mixed
“CHW interventions have the potential to address two
fundamental imperatives in improving health care in the
United States: the need to address substantial and
persistent health care disparities and the need to
translate more research into practice. CHWs, by virtue of
their role as a bridge to the health care system, can help
to disseminate widely efficacious interventions to
populations that rarely benefit from health care
advances.” (Viswanathan)
Need for the study of the
implementation and dissemination of
peer counseling programs
Translating from research to practice = less
control & resources; but potential for wide
impact
Research Tested Intervention Programs
https://rtips.cancer.gov/rtips/index.do
Implementation science
Implementation science can help us better
understand issues surrounding roll out,
adoption, and upkeep of these interventions
in community based settings
Case study: Body & Soul
Case study: Body & Soul
RTIPs website
Community-based program,
setting/population is African American church
members
Diet (fruit and vegetables) outcome
Positive results from earlier efficacy studies
led to support from NCI and ACS to
spearhead for further implementation
Body & Soul intervention
Intervention:
Pastoral involvement
Incorporation of health into sermons
Educational activities
Opportunities to sample & prepare fruit & vegetables
Church-wide environmental changes
establishing guidelines for the types of foods served at
church functions or changing snacks served at youth
camps
Peer counseling
Peer counselors are trained and conduct at least two
motivational counseling calls
Resnicow, 2004
Efficacy/effectiveness of Body & Soul
Training and technical support provided to
staff, but limited researcher involvement
Baseline to 6 month follow-up
Approximately 1 serving increase in
intervention churches vs control churches
(Resnicow)
Body & Soul: Dissemination study
Positive results led to the dissemination study
Disseminated directly to the target audience
Without researcher or agency support in training
or (planned/structured) technical assistance
15 churches, with a predominately African
American membership
Church coordinator identified in each
8 randomized to intervention and 7 to control
RE-AIM used as evaluation framework
Intervention churches
Church coordinator selected planning team
and together implemented intervention
activities
Including identifying & training peer counselors
Peer counselor training video:
https://rtips.cancer.gov/rtips/viewProduct.do?viewMode=pre
view&productId=1081867
Peer counselor handbook
Peer counseling coordinating guide
RE-AIM results
Implementation of peer counseling
Took 1-2 months post-baseline to complete training
Peer counselors found video to be culturally
appropriate & appropriate religious images
Allicock, 2013, 2010
Implementation of peer counseling
2 of 11 churches completed full training
Most only completed about half of the training
7 conducted a follow up training
Only a few coordinators reviewed training materials prior
to training
Barriers were logistical: recruiting, scheduling,
preparation work
Lower than expected exposure to intervention
likely had impact on lack of intervention
effectiveness
1/3 of participants recalled speaking to a peer counselor
Facilitators to use of peer
counselors/community health workers
in dissemination efforts Support for intervention fidelity
Technology-based approaches
Technical assistance
Supporting those implementing the intervention
Maintain motivation to participate by removing
barriers
Master trainers or organizations that could
share lessons learned with new settings
Organizational readiness to adopt programsAllicock 2010, 2013; Weiner 2009
Conclusions
Community health workers offer significant
opportunities to reach health disparity
populations & provide standardized,
evidenced-based behavioral counseling for
health promotion
Dissemination and implementation potential
could be enhanced with computer-based
technologies
Future implementation science efforts should
focus on studying adoption and spread of
interventions
References
Brownstein J, Chowdhury F, Norris S, Horsley T, Jack L, Zhang X, Satterfield D. Effectiveness of community
health workers in the care of people with hypertension. American Journal of Preventive Medicine. 2007;32(5):435–
447.
Long JA, Jahnle EC, Richardson DM, Loewenstein G, Volpp KG. Peer mentoring and financial incentives to
improve glucose control in African American veterans a randomized trial. Annals of Internal Medicine.
2012;156(6):416–424.
Keyserling T, Hodge C, Jilcott S, Johnston L, Garcia B, Gizlice Z, Gross M, Savinon C, Bangdiwala S, Will J,
Farris R, Trost S, Ammerman A. Randomized trial of a clinic-based, community-supported, lifestyle intervention to
improve physical activity and diet: The North Carolina enhanced WISEWOMAN project. Preventive Medicine.
2008;46(6):499–510.
Viswanathan M, Kraschnewski J, Nishikawa B, Morgan L, Thieda P, Honeycutt A, Lohr K, Jonas D. Outcomes of
Community Health Worker Interventions. Evidence Report/Technology Assessment No. 181. AHRQ Publication
No. 09-E014. Rockville MD; 2009.
Resnicow K, Kramish Campbell M, Carr C, McCarty F, Wang T, Periasamy S, Rahotep S, Doyle C, Williams A,
Stables G. (2004). Body and Soul. A Dietary Intervention Conducted Through African-American Churches.
American Journal of Preventive Medicine, 27(2), 97-105.
J Nutr Educ Behav. 2012 Nov-Dec;44(6):530-8. doi: 10.1016/j.jneb.2011.09.002. Epub 2012 Mar 9. Evaluating
the dissemination of Body & Soul, an evidence-based fruit and vegetable intake intervention: challenges
for dissemination and implementation research. Allicock M1, Campbell MK, Valle CG, Carr C, Resnicow
K, Gizlice Z.
Allicock M, Campbell MK, Valle CG, Barlow JN, Carr C, Meier A, Gizlice Z. Patient Educ Couns. 2010
Oct;81(1):37-42.Evaluating the implementation of peer counseling in a church-based dietary intervention for
African Americans.
Weiner BJ. A theory of organizational readiness for change. Implementation Science 2009 4:67