Outcomes of Community Health Worker Interventions

[Pages:611]Evidence Report/Technology Assessment

Number 181

Outcomes of Community Health Worker Interventions

Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 540 Gaither Road Rockville, MD 20850 Contract No. 290 2007 10056 I Prepared by: RTI International?University of North Carolina Evidence-based Practice Center Research Triangle Park, North Carolina

Investigators Meera Viswanathan, Ph.D. Jennifer Kraschnewski, M.D. Brett Nishikawa, M.D. Laura C. Morgan, M.A. Patricia Thieda, M.A. Amanda Honeycutt, Ph.D. Kathleen N. Lohr, Ph.D. Dan Jonas, M.D., M.P.H.

AHRQ Publication No. 09-E014 June 2009

This report is based on research conducted by the RTI International ? University of North Carolina at Chapel Hill, North Carolina (RTI-UNC) Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290 2007 10056 I). The findings and conclusions in this document are those of the author(s) who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of the Agency for Healthcare Research and Quality or of the U.S. Department of Health and Human Services.

The information in this report is intended to help clinicians, employers, policymakers, and others make well-informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment.

This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

This document is in the public domain and may be used and reprinted without permission except those copyrighted materials noted for which further reproduction is prohibited without the specific permission of copyright holders.

Suggested Citation:

Viswanathan M, Kraschnewski J, Nishikawa B, Morgan LC, Thieda P, Honeycutt A, Lohr KN, Jonas D. Outcomes of Community Health Worker Interventions. Evidence Report/Technology Assessment No. 181 (Prepared by the RTI International?University of North Carolina Evidence-based Practice Center under Contract No. 290 2007 10056 I.) AHRQ Publication No. 09-E014. Rockville, MD: Agency for Healthcare Research and Quality. June 2009.

No investigators have any affiliations or financial involvement (e.g., employment, consultancies, honoraria, stock options, expert testimony, grants or patents received or pending, or royalties) that conflict with material presented in this report.

Preface

The Agency for Healthcare Research and Quality (AHRQ), through its Evidence-based Practice Centers (EPCs), sponsors the development of evidence reports and technology assessments to assist public- and private-sector organizations in their efforts to improve the quality of health care in the United States. The reports and assessments provide organizations with comprehensive, science-based information on common, costly medical conditions and new health care technologies. The EPCs systematically review the relevant scientific literature on topics assigned to them by AHRQ and conduct additional analyses when appropriate prior to developing their reports and assessments.

To bring the broadest range of experts into the development of evidence reports and health technology assessments, AHRQ encourages the EPCs to form partnerships and enter into collaborations with other medical and research organizations. The EPCs work with these partner organizations to ensure that the evidence reports and technology assessments they produce will become building blocks for health care quality improvement projects throughout the Nation. The reports undergo peer review prior to their release.

AHRQ expects that the EPC evidence reports and technology assessments will inform individual health plans, providers, and purchasers as well as the health care system as a whole by providing important information to help improve health care quality.

We welcome comments on this evidence report. They may be sent by mail to the Task Order Officer named below at: Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850, or by e-mail to epc@.

Carolyn M. Clancy, M.D. Director Agency for Healthcare Research and Quality

Jean Slutsky, P.A., M.S.P.H. Director, Center for Outcomes and Evidence Agency for Healthcare Research and Quality

Beth Collins Sharp, R.N., Ph.D. Director, EPC Program Agency for Healthcare Research and Quality

Margaret Coopey, R.N., M.G.A., M.P.S. EPC Program Task Order Officer Agency for Healthcare Research and Quality

Structured Abstract

Objectives. To conduct a systematic review of the evidence on characteristics of community health workers (CHWs) and CHW interventions, outcomes of such interventions, costs and costeffectiveness of CHW interventions, and characteristics of CHW training.

Data sources. We searched MEDLINE?, Cochrane Collaboration resources, and the Cumulative Index to Nursing and Allied Health Literature for studies published in English from 1980 through November 2008.

Review methods. We used standard Evidence-based Practice Center methods of dual review of abstracts, full-text articles, abstractions, quality ratings, and strength of evidence grades. We resolved disagreements by consensus.

Results. We included 53 studies on characteristics and outcomes of CHW interventions, 6 on cost-effectiveness, and 9 on training. CHWs interacted with participants in a broad array of locations, using a spectrum of materials at varying levels of intensity. We classified 8 studies as low intensity, 18 as moderate intensity, and 27 as high intensity, based on the type and duration of interaction.

Regarding outcomes, limited evidence (five studies) suggests that CHW interventions can improve participant knowledge when compared with alternative approaches such as no intervention, media, mail, or usual care plus pamphlets. We found mixed evidence for CHW effectiveness on participant behavior change (22 studies) and health outcomes (27 studies): some studies suggested that CHW interventions can result in greater improvements in participant behavior and health outcomes when compared with various alternatives, but other studies suggested that CHW interventions provide no statistically different benefits than alternatives. Low or moderate strength of evidence suggests that CHWs can increase appropriate health care utilization for some interventions (30 studies). The literature showed mixed results of effectiveness when analyzed by clinical context: CHW interventions had the greatest effectiveness relative to alternatives for some disease prevention, asthma management, cervical cancer screening, and mammography screening outcomes. CHW interventions were not significantly different from alternatives for clinical breast examination, breast self-examination, colorectal cancer screening, chronic disease management, or most maternal and child health interventions.

Six studies with economic and cost information yielded insufficient data to evaluate the costeffectiveness of CHW interventions relative to other community health interventions.

Limited evidence described characteristics of CHW training; no studies examined the impact of CHW training on health outcomes.

Conclusions. CHWs can serve as a means of improving outcomes for underserved populations for some health conditions. The effectiveness of CHWs in numerous areas requires further research that addresses the methodological limitations of prior studies and that contributes to translating research into practice.

Contents

Executive Summary ........................................................................................................................ 1

Evidence Report

Chapter 1. Introduction ..................................................................................................................11 Background ................................................................................................................................... 11

Health Disparities in the United States ..................................................................................11 Role of the Community Health Worker in Addressing Health Disparities ...........................11 History of Community Health Workers.................................................................................12 Key Questions and Analytic Framework...................................................................................... 14 Key Questions........................................................................................................................14 Analytic Framework for Outcomes of Community Health Worker Interventions ....................... 14 Production of This Evidence Report............................................................................................. 15 Organization...........................................................................................................................15 Technical Expert Panel (TEP) ...............................................................................................15 Uses of This Report ...................................................................................................................... 16

Chapter 2. Methods........................................................................................................................17 Literature Review Methods........................................................................................................... 17

Inclusion and Exclusion Criteria............................................................................................17 Literature Search and Retrieval Process ................................................................................18 Literature Synthesis ...................................................................................................................... 21 Development of Evidence Tables and Data Abstraction Process..........................................21 Quality Rating of Individual Studies .....................................................................................22 Strength of Available Evidence .............................................................................................22 Applicability of the Evidence ................................................................................................23 External Peer Review.................................................................................................................... 23

Chapter 3. Results ..........................................................................................................................25 KQ 1: Interaction of Community Health Workers and Participants............................................. 25

Overview of Interaction Between Community Health Workers and Participants.................26 Intensity of Interaction...........................................................................................................27 Community Health Worker-Participant Interaction by Clinical Context ..............................27 KQ 2: Outcomes of Community Health Worker Interventions .................................................... 37 Outcomes for Health Promotion and Disease Prevention......................................................38 Outcomes for Injury Prevention.............................................................................................46 Outcomes for Maternal and Child Health..............................................................................49 Outcomes for Cancer Screening ............................................................................................60 Outcomes for Chronic Disease Management ........................................................................84 KQ 3: Cost-Effectiveness of Community Health Worker Interventions ...................................... 99 Overview of Economic Analyses...........................................................................................99 KQ 4: Training of Community Health Workers ......................................................................... 106 Characteristics of Training for Community Health Workers ..............................................106 Patient Outcomes of Community Health Worker Training .................................................110

Chapter 4. Discussion ..................................................................................................................111

Interactions between Community Health Workers and Clients (KQ 1) ..................................... 111 Outcomes of Community Health Worker Interventions (KQ 2) ................................................ 112

Knowledge ...........................................................................................................................114 Behavior ...............................................................................................................................115 Satisfaction...........................................................................................................................118 Health Outcomes..................................................................................................................118 Health Care Utilization ........................................................................................................121 Applicability of Findings about Outcomes ..........................................................................124 Summary Findings by Clinical Context...............................................................................125 Cost-Effectiveness of Community Health Worker Interventions (KQ 3) .................................. 127 Training of Community Health Workers (KQ 4) ....................................................................... 129 Limitations of this Review.......................................................................................................... 130 Limitations of the Evidence Base ........................................................................................130 Limitations of the Review....................................................................................................131 Future Research Directions......................................................................................................... 132 Conclusion .................................................................................................................................. 134

References....................................................................................................................................137

Figures

Figure 1. Figure 2.

Outcomes of community health worker interventions: conceptual framework.....15 Results of literature search.....................................................................................21

Tables

Table 1. Table 2. Table 3. Table 4. Table 5. Table 6. Table 7. Table 8. Table 9. Table 10.

Table 11.

Table 12.

Table 13. Table 14. Table 15.

Table 16.

Inclusion/exclusion criteria....................................................................................18 MEDLINE search strategy and unduplicated results for April 2008.....................19 Overall unduplicated results and sources of all searches.......................................20 Strength of evidence grades and definitions ..........................................................23 CHW-participant interactions for health promotion and disease prevention.........28 CHW-participant interactions for injury prevention..............................................30 CHW-participant interactions for maternal and child well-being..........................31 CHW-participant interactions for cancer screening...............................................33 CHW-participant interactions for chronic disease management ...........................35 CHWs and health promotion and disease prevention: pediatric immunization interventions...........................................................................................................39 CHWs and health promotion and disease prevention: Latina health promotion interventions...........................................................................................................41 CHWs and health promotion and disease prevention: disease prevention interventions...........................................................................................................43 CHW injury prevention interventions and home safety ........................................47 CHW injury prevention interventions and workplace safety.................................48 CHW maternal and child interventions and prenatal care and perinatal outcomes ................................................................................................................50 CHW maternal and child interventions and child development ............................53

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