Post a brief description of the disadvantaged or vulnerable population you selected. Then, explain three of the greatest challenges this population faces, as well as the influence that addressing each of the challenges might make in the lives’ of members

Effects of Community-Based Health Worker Interventions to Improve Chronic Disease Management and Care Among Vulnerable Populations: A Systematic Review

Kyounghae Kim, RN, MSN, Janet S. Choi, MPH, Eunsuk Choi, RN, PhD, MPH, Carrie L. Nieman, MD, MPH, Jin Hui Joo, MD, MA, Frank R. Lin, MD, PhD, Laura N. Gitlin, PhD, and Hae-Ra Han, RN, PhD

Background. Community-based health workers (CBHWs) are frontline

public health workers who are trusted members of the community they

serve. Recently, considerable attention has been drawn to CBHWs in pro-

moting healthy behaviors and health outcomes among vulnerable pop-

ulations who often face health inequities.

Objectives. We performed a systematic review to synthesize evidence

concerning the types of CBHW interventions, the qualification and

characteristics of CBHWs, and patient outcomes and cost-effectiveness

of such interventions in vulnerable populations with chronic, non-

communicable conditions.

Search methods. We undertook 4 electronic database searches—PubMed,

EMBASE, Cumulative Index to Nursing and Allied Health Literature, and

Cochrane—and hand searched reference collections to identify randomized

controlled trials published in English before August 2014.

Selection. We screened a total of 934 unique citations initially for titles

and abstracts. Two reviewers then independently evaluated 166 full-

text articles that were passed onto review processes. Sixty-one studies

and 6 companion articles (e.g., cost-effectiveness analysis) met eligi-

bility criteria for inclusion.

Data collection and analysis. Four trained research assistants extracted

data by using a standardized data extraction form developed by the

authors. Subsequently, an independent research assistant reviewed

extracted data to check accuracy. Discrepancies were resolved through

discussions among the study team members. Each study was evaluated

for its quality by 2 research assistants who extracted relevant study

information. Interrater agreement rates ranged from 61% to 91% (av-

erage 86%). Any discrepancies in terms of quality rating were resolved

through team discussions.

Main results. All but 4 studies were conducted in the United States.

The 2 most common areas for CBHW interventions were cancer pre-

vention (n = 30) and cardiovascular disease risk reduction (n = 26). The

roles assumed by CBHWs included health education (n = 48), counseling

(n = 36), navigation assistance (n = 21), case management (n = 4), social

services (n = 7), and social support (n = 18). Fifty-three studies provided

information regarding CBHW training, yet CBHW competency evalua-

tion (n = 9) and supervision procedures (n = 24) were largely under-

reported. The length and duration of CBHW training ranged from 4

hours to 240 hours with an average of 41.3 hours (median: 16.5 hours) in

24 studies that reported length of training. Eight studies reported the

frequency of supervision, which ranged from weekly to monthly. There

was a trend toward improvements in cancer prevention (n = 21) and

cardiovascular risk reduction (n = 16). Eight articles documented cost

analyses and found that integrating CBHWs into the health care delivery

system was associated with cost-effective and sustainable care.

Conclusions. Interventions by CBHWs appear to be effective when

compared with alternatives and also cost-effective for certain health

conditions, particularly when partnering with low-income, un-

derserved, and racial and ethnic minority communities. Future re-

search is warranted to fully incorporate CBHWs into the health care

system to promote noncommunicable health outcomes among vul-

nerable populations. (Am J Public Health. Published online ahead of

print February 18, 2016; e3–e28. doi:10.2105/AJPH.2015.302987)

PLAIN-LANGUAGE SUMMARY We conducted a review of the studies in

which the effect of community-based health workers (CBHWs)—public health workers who are trusted members of the community they serve—was tested for chronic disease management and care among people who are at risk for health disparities. We found 67 relevant studies. Most studies focused on preventing cancer and cardiovascular diseases.

In these studies, CBHWs carried out several tasks. The tasks included providing health education and counseling, helping patients navigate the health care system, managing care, and providing social services and sup- port. How CBHWs were trained or verified for their ability to carry out certain tasks, or who supervised their work was mostly underreported. Compared with no in- tervention or other alternatives, partnering

with CBHWs tended to result in increasing screening tests for breast, cervical, and co- lorectal cancers; decreasing blood pressure, blood glucose, and weight; and promotion of exercise in study samples. In several studies reporting costs, CBHWs tended to save costs as well. Our findings support the benefits of working with CBHWs in promoting health among people who are at risk for health disparities.

April 2016, Vol 106, No. 4 AJPH Kim et al. Peer Reviewed Systematic Review e3

AJPH RESEARCH

Vulnerable populations—defined as those“capable of being hurt” or “susceptible to injury or disease”1—refer to a wide range of groups including the economically disad- vantaged, the uninsured, racial and ethnic minorities, the elderly and children, or those who encounter barriers to accessing health care.2 Their health problems often intersect with social factors such as housing, poverty, absence of a usual source of care, and in- adequate education.3

The needs of vulnerable populations are multifold and require extensive medical and nonmedical outreach and services. However, current health care financing and service de- livery arrangements do not always address the complexityandbreadth ofneeds.For example, since the advent of the Patient Protection and Affordable Care Act (ACA; Pub L No. 111–148), the rate of the uninsured dropped initially (nearly 4%) in early 2014, but there has been no substantial change in this statistic from the second to the third quarter of 2014.4 In addition, the proportion of US adults who delay medical treatment of serious conditions in the past year has risen since 2013 (from 19% to 22%).5 In 2013, more than 41 million US individuals younger than 65 years did not have health insurance, because in large part of the fact that they could not afford coverage.6

Compared with their insured counter- parts, the uninsured were less likely to receive timely preventive care within the past year (33% vs 67% of the nonelderly with Medicaid and 74% of nonelderly individuals with employer-based insurance) or to have access to appropriate follow-up care after abnormal screening results.6 More than half (58%) of the uninsured with a chronic illness reported that they did not buy a prescription drug because of cost, compared with 39% of those with publicly funded insurance and 34% of those with private insurance.7 Other vulnerable populations such as the elderly or individuals with disabilities also have high levels of unmet health care needs. For example, the State of Aging and Health in America 2013 report revealed that only about 51% of male and 53% of female older adults (aged ‡ 65 years) were up to date on certain preventive care such as influenza vaccination or colorectal cancer screening.8 Similarly, individuals with dis- abilities had more than 1.5-times-higher odds of delaying care because of costs compared with those without.9

Novel approaches to address the risks and multiple needs of vulnerable populations is an important public health imperative.10,11

An emerging approach is to work with community-based health workers (CBHWs)—indigenous public health workers who not only share the same ethnicity, language, or geographic community of the patients they serve, but also share the life experiences with target populations and communities.12 Hence, they are uniquely aware of the ethnic, linguistic, socioeconomic, cultural, and experiential factors that may influence that community’s use of health care services.13

With their unique ability to provide “bridges” betweenthecommunityandhealthcareservices, CBHWs play a role that could address health inequities: culturally appropriate health educa- tion, individual and community capacity building, advocacy, and informal counseling and social support in diverse settings (e.g., community-based organizations, community clinics,orprimaryandemergencycarecenters).14

A number of systematic reviews were published with regard to CBHW in- terventions.15–21 Previous systematic reviews found that CBHW interventions are effective in promoting a wide range of healthy be- haviors, such as breast cancer screening15; self-management of diabetes,16–18 hyperten- sion,19 and asthma20; and medication ad- herence among patients with HIV/AIDS.21

Only a few reviews highlighted the additional emphasis on the roles and training of CBHWs, however.16–18 Furthermore, the field is rapidly evolving with greater attention to the synergistic effects of CBHWs as part of patient-centered care teams. A comprehen- sive systematic review on CBHW in- terventions to control noncommunicable diseases among vulnerable populations is needed, to develop a better understanding of integrating CBHWs into the delivery of care to vulnerable populations.

The purpose of this article is to provide a critical review of the evidence on CBHW interventions. Specifically, we examined the types of interventions in which CBHWs were employed, the qualifications and character- istics of CBHWs, and the patient outcomes and cost-effectiveness of such interventions in vulnerable populations with non- communicable chronic conditions. We also considered the integration of CBHWs into the mainstream health care workforce for both the prevention and management of noncommunicable chronic diseases that overburden vulnerable populations. Our re- view systematically extends the previous ef- forts by providing an understanding of (1) how CBHWs are trained before the delivery of an intervention, (2) how CBHWs im- plement an assigned intervention, (3) how CBHW interventions achieve desired effects, and (4) how CBHWs are integrated into the current health care system.

METHODS We searched 4 electronic databases—

PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane—and conducted hand searches of reference collections for potential studies. Following consultation with a health science librarian, we used a combination of keywords that contained Medical Subject Headings terms: “vulnerable populations,” “commu- nity health worker,” and “randomized con- trolled trials.” More detailed information about search terms is given in Appendix A (available as a supplement to the online version of this article at http://www.ajph. org). The searches were restricted to articles published in peer-reviewed journals in En- glish before August 2014 (for studies focused on individuals with diabetes since 2011). The

ABOUT THE AUTHORS Kyounghae Kim and Hae-Ra Han are with The Johns Hopkins University School of Nursing, Baltimore, MD. Janet S. Choi, Carrie L. Nieman, and Frank R. Lin are with Center on Aging and Health, The Johns Hopkins University. Eunsuk Choi is with College of Nursing and Research Institute of Nursing Science, Kyungpook National University, Daegu, South Korea. Carrie L. Nieman and Jin Hui Joo are with Johns Hopkins University School of Medicine. Laura N. Gitlin is with Center for Innovative Care in Aging, Johns Hopkins University School of Nursing and Medicine. Hae-Ra Han is also with Center for Cardiovascular and Chronic Care, Johns Hopkins University School of Nursing.

Correspondence should be sent to Hae-Ra Han, RN, PhD, Johns Hopkins University School of Nursing, 525 N Wolfe St, Baltimore, MD 21205-2110 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.

This article was accepted November 2, 2015. doi: 10.2105/AJPH.2015.302987

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e4 Systematic Review Peer Reviewed Kim et al. AJPH April 2016, Vol 106, No. 4

hand searches involved review of reference lists from articles obtained from the 4 elec- tronic databases.

Study Selection Process Figure 1 summarizes the results of the

literature search. Initially, we retrieved 922 studies from 4 electronic databases after we discarded 575 duplicates. We obtained 12 additional studies from hand searches of reference collections. Two reviewers in- dependently conducted an initial screening of titles and abstracts with relevance to

noncommunicable chronic diseases. After screening the initial titles and abstracts, they passed 397 abstracts onto a second review process to exclude (1) studies focused on children, (2) non–data-based articles (e.g., editorials, commentaries), and (3) studies focused on nonvulnerable populations. Of 397 abstracts, we included 166 abstracts in a full-text review.

Two reviewers (K. K. and B. A.) in- dependently evaluated full-text articles to determine whether studies met the following inclusion criteria: (1) randomized controlled trials published in English in peer-reviewed

journals, (2) studies testing CBHW-led in- terventions, (3) studies focused on adults, and (4) studies focused on chronic conditions. We excluded 89 articles for the following reasons:

1. full texts were unavailable (i.e., con- ference abstracts; n = 16);

2. they were nonrandomized controlled trials (n= 55);

3. studies did not include a CBHW-led intervention (n = 6);

4. they were studies focused on diabetes that were published before 2011, given their inclusion in a recent systematic

PubMed: 621

EMBASE: 532

CINAHL: 165

Cochrane: 179

934 titles with abstracts

reviewed

Excluded (n = 231) Articles focusing on children: 43 Nondatabased articles: 62 Nonintervention studies: 119 Nonvulnerable populations: 7

397 abstracts passed onto

second review process

Excluded (n = 89) Conference abstracts: 16 Non-RCTs: 55 No CHW involvement: 6 Focusing on diabetes before 2011: 8 RCT among CHWs: 1 Reporting preliminary findings: 3

166 full-text articles passed

onto review process

67 full text articles selected

and included in the review

(61 primary + 6 companion

articles)

12 of additional records

identified through reference

collection

575 duplicates removed

537 of records excluded because

nonrelevant to chronic disease

FIGURE 1—Review and Selection Process for Systematic Review of Randomized Controlled Trials on the Effect of Community-Based Health Workers on Chronic Disease Management and Care Among People at Risk for Health Disparities, up to August 2014

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April 2016, Vol 106, No. 4 AJPH Kim et al. Peer Reviewed Systematic Review e5

review on CBHWs for individuals with diabetes (n= 8);

5. they were studies that tested the effec- tiveness of an intervention to change behaviors among CBHWs (n= 1); and

6. articles reported preliminary or inter- mittent findings or reported the long- term findings of other articles (n = 3).

We merged articles that included a cost- effectiveness analysis only into the main outcome studies.Discrepanciesregardingtheextracteddata (see data extraction selection in the next para- graph) between 2 reviewers were reconciled based on a series of team discussions. A total of 67 articlesmetcriteriaforinclusion.Figure1provides a detailed outline of the article selection process.

Data Extraction Four trained research assistants (RAs)

extracted relevant data by using a standard- ized data extraction form developed by the authors. They extracted the following data from the selected studies: author, year, country, randomization, intervention unit, setting, sample (% non-White), the method of outcome ascertainment, time to outcome measure, theory use, CBHW selection cri- teria, type of training, training frequency, training intensity, duration of training, participant satisfaction, delivery approach, control group, types of CBHW in- tervention, measurability of the CBHWs’ effect, intervention dose, intervention in- tensity, intervention duration, number of participants in the study groups, mean age and gender proportion of the study sample, proportion of target condition or behavior for the treatment and control groups at baseline and follow-up, fidelity, and study quality. Subsequently, an independent RA reviewed extracted data to check accuracy. Discrepancies were resolved through dis- cussions among all RAs and authors.

We evaluated each study for its quality, based on published quality rating scales (Table 1).22–25 Specifically, we used the quality rating scales published by Jadad et al.22 and Haynes and Sackett.25 Our quality rating scale also incorporated addi- tional evaluation items addressing in- tervention setting and outcome assessment methods used in published systematic

reviews.23 The total quality rating scale score ranged from 0 to 12 with 0 being the lowest quality and 12 indicating the highest quality. Based on the possible range of scores, we categorized studies with quality ratings of 0 to 4, 5 to 8, and 9 or more as low-, medium-, and high-quality studies, respectively. Two RAs who extracted relevant study information rated each study for its quality independently. Interrater agreement statistics using percentage agreement ranged from 61% to 91% (average 86%). Any discrepancies in terms of quality rating were resolved through team discussions.

RESULTS There were 67 publications including 61

studies26–86 with 6 companion articles.87–92

Table 2 summarizes the key characteristics of studies included in this review. The com- panion articles presented cost analysis of the

main studies. All but 4 of the 67 studies were conducted in the United States; 2 studies were conducted in India,47,83 1 in Pakistan,68 and 1 in Taiwan.86 Ethnic minorities were the focus of all but 4 studies, which included pre- dominantly low-income non-Hispanic White participants (61% to 95%) at risk for experiencing inequality in health care access (e.g., Appalachians).37,44,48,49 Across the 67 articles, sample sizes varied widely from 2562

to 167 915.47 Participants generally ranged in age from 32 years42 to 71 years,82 and 28%71

to 100%26–28,31–33,35-44,46,48–55,60,64,66,80 of participants were women.

Of 67 articles, 30 studies involved CBHWs for cancer prevention for specific cancer types (cervical,28,32,33,35–39,41–44,49–52

breast,26,27,31,33,36,37,39–41,46,48,50,53–55 co- lorectal,29,30,34,36,45 and oral47). Twenty-six studies focused on cardiovascular disease (CVD),56–59,62,64,67,73,80 and key risk factors such as diabetes,63,69,70,76–79,81 and

TABLE 1—Study Quality Ratings for Systematic Review of Randomized Controlled Trials on the Effect of Community-Based Health Workers on Chronic Disease Management and Care Among People at Risk for Health Disparities, up to August 2014

Item Score

Research questions 1 = Clearly described

0 = Not clear

Type of facility where the study was conducted 1 = Described

0 = Not described

Participant inclusion or exclusion criteria 1 = Specified

0 = Not provided

Participants in sample 1 = Clearly described

0 = Unclear

Sample size justification 1 = Provided and justified before the study was conducted

0 = Not provided or unclear

Method of randomization 1 = Described

0 = Unclear

Outcome measure 1 = Claims data or chart review

0 = Self-reported data

Clarity of outcome 1 = Description of outcome was provided

0 = No definition of outcome provided

Clarity of time until outcome was measured 1 = Described

0 = Unclear

Information on withdrawal or dropout rate 1 = The number and the reasons for withdrawal were stated

0 = Only the number described or not discussed

Analysis performed by intervention allocation status 1 = Yes (i.e., intention to treat)

0 = No

Awareness of group assignments of outcome assessor 1 = Unaware

0 = Aware

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e6 Systematic Review Peer Reviewed Kim et al. AJPH April 2016, Vol 106, No. 4

T A B L E 2 —

S u m m a ry

o f In cl u d e d S tu d ie s fo r S ys te m a ti c R e vi e w

o f R a n d o m iz e d C o n tr o ll e d T ri a ls

o n th e E ff e ct

o f C o m m u n it y- B a se

d H e a lt h W o rk e rs

o n C h ro n ic

D is e a se

M a n ag

e m e n t a n d C a re

A m o n g P e o p le

a t R is k fo r H e a lt h D is p a ri ti e s,

u p to

A u g u st

2 0 1 4

Au th or

(Y ea r) : Q ua lit y

St ud y Si te

Sa m pl e

In te rv en ti on

(C om

pa ri so n)

M ai n O ut co m e( s) : CH

W Ef fe ct s

C a n ce

r sc re e n in g : ce

rv ic a l ca n ce

r

B yr d et

al .2 8 (2 01 3) a ; co st

an al ys is : La ir so n et

al .9 2

(2 01 4) : H ig h

Pa rt ic ip an ts ’ ho m es

or pr ef er re d

pl ac es

in TX

an d W A

61 3 no na dh er en t M ex ic an -o ri gi n w om

en ,

ag ed

‡ 21

y; m ea n ag e, y: 40

AM IG AS

in te rv en ti on

us in g vi de o pl us

fl ip ch ar t, vi de o on ly , or

fl ip ch ar t on ly

(v s w ai t- lis t co nt ro l)

G re at er

fo llo w -u p at

6 m o fo r fu ll AM

IG As .

IC ER

(v id eo -o nl y vs Co nt ): pa ye r pe rs pe ct iv e, $9 80

(9 5%

CI = $6 50 , $1 79 4) , so ci et al pe rs pe ct iv e:

$1 30 9 (9 5%

CI = $8 69 , $2 39 6)

En ge ls ta d et

al .3 2 (2 00 5) a ; co st

an al ys is : W ag ne r et

al .9 0

(2 00 7) : H ig h

W om

en ’s ho m es

or lo ca ti on s

ch os en

by th e w om

an in

CA

34 8 w om

en w it h an

ab no rm

al Pa p te st re su lt s;

ag ed

18 –3 9 y: In t=

69 % ; Co nt = 75 %

Co m pu te ri ze d tr ac ki ng

w it h co un se lin g

an d na vi ga ti on

as si st an ce

ov er

‡ 6 m o

(v s us ua l ca re )

H ig he r ra te s of fo llo w -u p w it hi n 6 m o fo r In t IC ER

pe r fo llo w -u p: pa ye r pe rs pe ct iv e, $9 26

(9 5%

CI = $7 54 , $1 33 3) , so ci et al pe rs pe ct iv e, $9 59

(9 5%

CI = $7 87 , $1 36 7)

La m et

al .3 5 (2 00 3) a : M ed

2 no np ro fi t he al th

an d so ci al

se rv ic e ag en ci es

in CA

40 0 Vi et na m es e w om

en , ag ed

‡ 18

y; m ea n

ag e = 43

y (S D = 14 )

Tw o 1. 5- to

2- h gr ou p se ss io ns , na vi ga ti on

as si st an ce , an d et hn ic m ed ia ca m pa ig n ov er

2 m o (v s m ed ia ca m pa ig n on ly )

In t gr ou p sh ow

ed gr ea te r in cr ea se d lif et im e Pa p

te st us e an d in te nt io n,

as w el l as

aw ar en es s

of ce rv ic al ca nc er

ca us es

vs Co nt

M oc k et

al .3 8 (2 00 7) a : M ed

CH W s’ ho m es

or a CB O

of fi ce

in CA

96 8 Vi et na m es e w om

en , ag ed

‡ 18

y; m ea n

ag e = 46

y (S D = 15 )

1. 5- to 2- h gr ou p se ss io ns pl us fo llo w -u p ca lls ov er

3- 4 m o fo llo w ed

by se pa ra te

Q & A pl us

et hn ic

m ed ia ca m pa ig n (v s m ed ia ca m pa ig n on ly )

In t gr ou p sh ow

ed gr ea te r in cr ea se d lif et im e an d

< 12 -m o Pa p te st us e an d aw ar en es s of

ce rv ic al

ca nc er

ca us es

vs co nt ro ls

O ’B ri en

et al .4 2 (2 01 0) a : H ig h

CB O s, w om

en ’s ho m es , an d th e

M ex ic an

Co ns ul at e in

PA

12 0 H is pa ni c w om

en ,a ge d 18 –6 5 y; m ea n ag e, y:

In t=

32 (S D = 11 ); Co nt = 31

(S D = 12 )

Tw o 3- h ed uc at io na l w or ks ho ps

ov er

4 m o

(v s w ai t- lis t co nt ro l)

In t gr ou p sh ow

ed gr ea te r in cr ea se d < 6- m o Pa p

te st us e as

w el l as

ce rv ic al ca nc er

kn ow

le dg e

an d se lf -e ffi ca cy

vs co nt ro ls

Pa sk et t et

al .4 4 (2 01 1) a : H ig h

W om

en ’s ho m es

in O H

28 0 no na dh er en t Ap pa la ch ia w om

en , ag ed

31 –5 0 y: In t=

40 .5 % ;C on t=

46 .0 % ;W

hi te :9 5. 4%

2 in di vi du al iz ed

ho m e vi si ts pl us 2 ph on e ca lls an d

4 po st ca rd s ov er

10 m o (v s us ua l ca re )

N o di ff er en ce

in ra te s of

fo llo w -u p w it hi n 12

m o

pe r ch ar t re vi ew

be tw ee n 2 ar m s

St ud ts et

al .4 9 (2 01 2) a : H ig h

W om

en ’s ho m es

in K Y

34 5 no na dh er en t w om

en , ag ed

40 –6 4 y; ra ng e:

40 –4 9 y: 40 % ; 50 –5 9 y: 46 .7 % ; W hi te : 95 .1 %

O ne

2- h ho m e vi si t us in g a ta ilo re d ne w sl et te r

(v s w ai t- lis t co nt ro l)

In t gr ou p sh ow

ed gr ea te r in cr ea se d Pa p

te st us e po st in te rv en ti on

vs co nt ro ls

Ta yl or

et al .5 1 (2 00 2) a : H ig h

Se at tl e in

W A,

an d

Va nc ou ve r in

B C

23 4 no na dh er en t Ch in es e w om

en , ag ed

20 –6 9 y;

ra ng e: 20 –4 4 y: 42 % ; 45 –6 9 y: 58 %

1 ho m e vi si t w it h na vi ga ti on

as si st an ce

+

ad di ti on al vi si tf or th os e w ho

di d no th av e te st s,

or m ai le d an

ed uc at io n pa ck et

(v s us ua l ca re )

In t gr ou ps

(h om

e vi si t, di re ct m ai l) sh ow

ed

gr ea te r in cr ea se d < 6- m o Pa p te st

us e an d in te nt io n vs

Co nt

Ta yl or et al .5 2 (2 01 0) a : H ig h; co st

an al ys is : Sc og gi ns

et al .8 9

(2 01 0)

W om

en ’s ho m es

in W A

23 4 no na dh er en t Vi et na m es e w om

en , ag ed

20 –7 9 y; ra ng e: < 50

y: In t=

47 % ; Co nt = 43 % ;

50 + y: In t=

53 % ; Co nt = 57 %

1 ho m e vi si tu si ng

D VD

an d pa m ph le tf ol lo w ed

by

ph on e ca ll 1 m o af te r th e ho m e vi si t (v s m ai lin g

of ph ys ic al ac ti vi ty

m at er ia ls )

N o di ff er en ce

in < 6- m o Pa p te st us e; Pa p te st

IC ER : $2 07 1 pe r Q AL Y IC ER : $3 0 01 5 (a n In t

co st of

$9 6. 81

an d an

in cr em

en ta l ef fe ct

on Pa p te st of

8. 36 % ).

C a n ce

r sc re e n in g : b re a st

ca n ce

r

Ah m ed

et al .2 6 (2 01 0) a : H ig h

Pl ac es

ch os en

by w om

en

in TN

23 57

no na dh er en t w om

en , ag ed

‡ 40

y; m ea n

ag e: 53

y (S D = 10 ); B la ck : 43 % ; H is pa ni c: 12 %

St ep w is e in te rv en ti on : re m in de r le tt er s fr om

th e M CO

di re ct or

an d a PC P fo llo w ed

by

CH W

co un se lin g, or

si m pl e in te rv en ti on :

re m in de r le tt er s fr om

th e M CO

di re ct or

(v s us ua l ca re )

G re at er

fo llo w -u p at

1- y pe r ch ar t re vi ew

fo r

st ep w is e In t fo llo w ed

by si m pl e In t, an d Co nt ,

re sp ec ti ve ly ; St ep w is e gr ou p sh ow

ed gr ea te r

in cr ea se d < 1- y m am

m og ra m vs

si m pl e In t

gr ou p.

Co nt in ue d

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April 2016, Vol 106, No. 4 AJPH Kim et al. Peer Reviewed Systematic Review e7

T A B L E 2 —

Co nt in ue d

B as ta ni

et al .2 7 (2 01 0) a : H ig h

In te rv en ti on

de liv er ed

th ro ug h

te le ph on e in

LA

17 08

lo w -in co m e, m in or it y w om

en ; ra ng e,

40 –4 9 y: 32 % ; 50 + y: 42 % ; H is pa ni cs : 76 %

O ne

30 - to

40 -m in

ph on e ca ll by

a pr of es si on al

he al th

w or ke r pl us

CH W

co un se lin g

ov er

6 m o (v s m ai le d po st ca rd

to sc he du le

an ap po in tm

en t)

N o di ff er en ce

in ra te s of

di ag no st ic re so lu ti on

of ab no rm

al br ea st fi nd in gs

by 6 m o

pe r ch ar t re vi ew

be tw ee n 2 ar m s

Cr um

p et

al .3 1 (2 00 8)

ha lf of

th e st ud y pe ri od

(2 7 w k) : M ed

Te le ph on e co nt ac t in

G A

83 Af ri ca n Am

er ic an

w om

en , ag ed

‡ 25

y;

50 + y: In t=

48 % ; Co nt = 54 %

Te le ph on e co nt ac t pl us

em ot io na l su pp or t an d

na vi ga ti on

as si st an ce

un ti l 3 ap po in tm

en ts

(v s us ua l ca re )

In t gr ou p sh ow

ed gr ea te r ra te s of

fi rs t an d

al l 3 fo llo w -u p ap po in tm

en ts pe r ch ar t

re vi ew

vs Co nt

N gu ye n et

al .4 0 (2 00 9) a : H ig h

CB O s, a CH

W ’s or

w om

en ’s

ho m e in

CA

11 00

Vi et na m es e w om

en , ag ed

‡ 40

y;

m ea n ag e, y: In t=

57 (S D = 10 ); Co nt = 58

(S D = 11 )

Tw o 1. 5- h gr ou p se ss io ns

pl us

fo llo w up

ca lls

pl us

et hn ic m ed ia ca m pa ig n (v s m ed ia

ca m pa ig n on ly )

In t gr ou p sh ow

ed gr ea te r in cr ea se d lif et im e

an d < 2- y m am

m og ra m

an d CB E, an d br ea st

ca nc er

kn ow

le dg e vs

Co nt

R us se ll et

al .4 6 (2 01 0) a : H ig h

An FQ

H C in

IN 18 1 Af ri ca n Am

er ic an

pa rt ic ip an ts ;

m ea n ag e, y: 51

(S D = 7)

Ta ilo re d m es sa ge

w it h co un se lin g an d 3 ph on e

ca lls

ov er

6 m o (v s br ea st ca nc er

pa m ph le t

an d m ai le d ge ne ra l nu tr it io n in fo rm

at io n)

In t gr ou p sh ow

ed gr ea te r in cr ea se d < 6- m o

m am

m og ra m

pe r ch ar t re vi ew

vs Co nt

Sl at er

et al .4 8 (1 99 8) b : H ig h

Pu bl ic ho us in g hi gh -r is e

bu ild in gs

in M N

42 7 lo w -in co m e w om

en , ag ed

50 –7 9 y, m ea n

ag e, y: In t=

69 (S D = 8) ; Co nt = 67

(S D = 8) ;

W hi te : In t=

84 % ; Co nt = 78 %

1 gr ou p se ss io n fo llo w ed

by CH

W -le d sm

al l

gr ou p di sc us si on s an d pr om

pt in g w om

en ’s

pr ov id er

to of fe r a m am

m og ra m (v s w ai t- lis t

co nt ro l)

In t gr ou p sh ow

ed gr ea te r in cr ea se d

< 15 -m o m am

m og ra m vs

Co nt ; N o di ff er en ce

in br ea st ca nc er

kn ow

le dg e, at ti tu de s, an d

be lie fs be tw ee n 2 ar m s

W es t et

al .5 3 (2 00 4) a : H ig h

FQ H C in

AL 23 7 no na dh er en t w om

en , m ea n ag e: 65

y;

B la ck : 91 %

1 ta ilo re d ph on e co un se lin g (v s ta ilo re d

le tt er )

In t gr ou p di d no t sh ow

gr ea te r in cr ea se d

< 6- m o m am

m og ra m vs

Co nt

W ils on

et al .5 4 (2 00 8) c : M ed

H ai r sa lo ns

in N Y

11 85

Af ri ca n an d Af ro -C ar ib be an

w om

en ;

m ea n ag e, y: In t=

39 (S D = 15 ); Co nt = 38

(S D = 13 )

Ta ilo re d an d cu lt ur al ly se ns it iv e co un se lin g

ov er

3 m o (v s no

in te rv en ti on )

N o di ff er en ce in ra te so f<

3- m o m am

m og ra m an d

CB E an d m am

m og ra m in te nt io n < 1- y

In t gr ou p sh ow

ed gr ea te r ra te s of

B SE

an d CB E

in te nt io n at

3 m o vs

Co nt

Zh u et

al .5 5 (2 00 2) b : M ed

W om

en ’s ho m es

(p ub lic

ho us in g

co m pl ex es ) in

TN

32 5 Af ri ca n Am

er ic an

w om

en , ag ed

‡ 65

y;

ra ng e, y:

65 –7 4: In t=

61 % ; Co nt = 43 % ; 75 –8 4: In t=

28 % ;

Co nt = 40 %

O ne

in di vi du al ed uc at io n se ss io n w it h

co un se lin g (v s us ua l ca re )

N o di ff er en ce in m am

m og ra m ,C B E, an d B SE at 2 y

be tw ee n 2 gr ou ps ; N o ch an ge s in

kn ow

le dg e,

at ti tu de s, an d be lie fs in

br ea st he al th

C a n ce

r sc re e n in g : ce

rv ic a l a n d b re a st

ca n ce

r

Fe rn an de z et

al .3 3 (2 00 9) d :H

ig h

W om

en ’s ho m es

in CA

49 7 no na dh er en t H is pa ni c fe m al e

fa rm

w or ke rs , ag ed

‡ 50

y; ra ng e,

% (m am

m og ra m /P ap

te st co ho rt );

50 –5 9: 49 /4 5; 60 –6 9: 27 /2 6

O ne

1- to

2- h ho m e vi si t us in g th e C u lt iv a n d o

la S a lu d m at er ia ls an d co m m un it y re so ur ce s

pl us

1 fo llo w -u p co nt ac t 2 w k af te r th e in it ia l

se ss io n (v s no

ac ti vi ti es

in co nt ro l si te s)

N o di ff er en ce in m am

m og ra m an d Pa p te st at 6 m o

be tw ee n In t an d Co nt ;A m on g w om

en co m pl et ed

fo llo w -u p, In t gr ou p sh ow

ed gr ea te r in cr ea se d

< 6- m o m am

m og ra m an d Pa p te st s vs

Co nt

M ar go lis

et al .3 7 (1 99 8) a : H ig h

Te le ph on e co nt ac t in

M N

Et hn ic al ly di ve rs e w om

en : m am

m og ra m

(n = 16 58 ); W hi te : In t=

61 % ; Co nt = 64 % ; m ea n

ag e, y: In t=

56 (S D = 12 ); Co nt = 55

(S D = 11 )

Pa p te st (n = 11 02 ); W hi te :I nt = 63 % ;C on t=

65 % ;

m ea n ag e, y: In t=

55 (S D = 13 ); Co nt = 54

(S D = 12 )

O ne

in di vi du al re m in de r pl us

an of fe r to

vi si t

at th e W om

en ’s ca nc er

sc re en in g cl in ic

(v s us ua l ca re )

In t gr ou p sh ow

ed gr ea te r in cr ea se d < 12 -m o

m am

m og ra m

an d Pa p te st pe r ch ar t re vi ew

vs

Co nt ;H ig he r ra te s of fo llo w -u p w it hi n 12 -m o fo r

In t vs

Co nt

am on g no na dh er en t w om

en at

ba se lin e; N o di ff er en ce

in fo llo w -u p be tw ee n

2 gr ou ps

am on g w om

en w ho

w er e up

to da te

Co nt in ue d

AJPH RESEARCH

e8 Systematic Review Peer Reviewed Kim et al. AJPH April 2016, Vol 106, No. 4

T A B L E 2 —

Co nt in ue d

N av ar ro

et al .3 9 (1 99 8) e : M ed

So ut he as t ar ea

of Sa n D ie go

Co un ty

in CA

51 2 H is pa ni c w om

en re cr ui te d by

ea ch

co n se je ra ’s so ci al ne tw or k; ra ng e, y: < 40 :

In t=

72 % ; Co nt = 66 % ; 40 –4 9: In t=

18 % ;

Co nt = 25 %

12 w ee kl y gr ou p ed uc at io n se ss io ns

(v s

“C om

m un it y Li vi ng

Sk ill s”

gr ou p)

In t gr ou p sh ow

ed gr ea te r in cr ea se d B SE

vs Co nt

bu t no

< 12 -m o m am

m og ra m

an d Pa p te st ;

Pa rt ic ip an ts as

a un it of

an al ys is : di ff er en ce

in ra te s of

< 12 -m o m am

m og ra m an d m on th ly

B SE

be tw ee n 2 ar m s

N uñ o et

al .4 1 (2 01 1) a : H ig h

W om

en ’s ho m es

in AZ

38 1 H is pa ni c w om

en , ag ed

‡ 50

y; m ea n

ag e, y: In t=

59 (S D = 8) ; Co nt = 61

(S D = 9)

O ne

2- h in te ra ct iv e gr ou p se ss io n fo llo w ed

by re fr es he r se ss io ns

1- y af te r th e in it ia l

se ss io n (v s us ua l ca re )

In t gr ou p sh ow

ed gr ea te r in cr ea se d < 1- y

m am

m og ra m

bu t no

in cr ea se d < 1- y Pa p

te st us e vs

Co nt

Pa sk et t et

al .4 3 (2 00 6) a : H ig h

W om

en ’s ho m es

in N C

85 1 no na dh er en t et hn ic al ly di ve rs e w om

en ,

ag ed

‡ 40

y re ce iv in g he al th

ca re

fr om

an

FQ H C; ra ng e, y: 40 –4 9: 43 % ; 50 –5 9: 28 % ;

B la ck : 33 % ; N at iv e Am

er ic an : 42 %

Th re e 30 - to

60 -m in

ho m e vi si ts in cl ud in g

co un se lin g an d na vi ga ti on

as si st an ce

an d

fo llo w -u p ca lls

pl us

m ai lin gs

af te r vi si ts ov er

9– 12

m o (v s N CI

br oc hu re

re ga rd in g ce rv ic al

ca nc er fo llo w ed

by br ea st ca nc er br oc hu re af te r

su rv ey )

In t gr ou p sh ow

ed gr ea te r in cr ea se d < 12 -m o

m am

m og ra m

an d be lie f sc or es

an d gr ea te r

de cr ea se d ba rr ie r sc or es

vs Co nt ; Co st of

ea ch

ad di ti on al m am

m og ra m in th e In t gr ou p: $4 98 6

(c os t of

de liv er in g th e In t ov er 12

m o: $3 29

05 4

/d if fe re nc e be tw ee n 2 gr ou ps : 15 .2 %

Su ng

et al .5 0 (1 99 7) a : M ed

W om

en ’s ho m es

in G A

32 1 in ne r- ci ty

Af ri ca n Am

er ic an

w om

en ,

ag ed

‡ 18

y; ra ng e, y: 35 –4 4: In t=

46 % ;

Co nt = 44 % ; 45 –5 9: In t=

22 % ; Co nt = 25 %

2 ho m e vi si ts w it h 1 bo os te r se ss io n us in g

cu lt ur al ly ta ilo re d vi de ot ap e, an d pr in t

ed uc at io n m at er ia ls ov er

ab ou t 11

m o

(v s w ai t- lis t co nt ro l)

In t gr ou p sh ow

ed gr ea te r in cr ea se d < 11 -m o

m am

m og ra m

vs Co nt , w he re as

no di ff er en ce

in ye ar ly Pa p te st s, B SE , an d CB E

C a n ce

r sc re e n in g : co

lo re ct a l ca n ce

r

Ca m pb el l et

al .2 9 (2 00 4) f : H ig h

pa rt ic ip an ts ’ ho m es

in N C;

ch ur ch es

58 7 ac ti ve

ch ur ch

m em

be rs , ag ed

‡ 18

y;

m ea n ag e: 52

y; fe m al e: 74 %

Ta ilo re d pr in t an d vi de o (T PV ) pl us

CH W

se ss io ns , CH

W se ss io ns

on ly , or

TP V on ly

(v s H IV /A ID S an d pr os ta te

ca nc er

ed uc at io n;

m at er ia ls gi ve n po st -s ur ve y)

N o di ff er en ce

in di et , ph ys ic al ac ti vi ty , an d

co lo re ct al ca nc er

sc re en in g at

9 m o fo r TP V

pl us

CH W

vs Co nt ; TP V sh ow

ed gr ea te r

in cr ea se d fr ui t/ ve ge ta bl e in ta ke

an d ph ys ic al

ac ti vi ty

vs Co nt

Ca st añ ed a et

al .3 0 (2 01 2) a : M ed

B ef or e th ei r cl in ic vi si t at

an

FQ H C in

CA

13 0 H is pa ni c pa ti en ts , ag ed

50 –8 0 y;

m ea n ag e, y: 64

(S D = 8) ; fe m al e: 73 %

CH W

se ss io n in cl ud in g in di vi du al iz ed

m es sa ge s

an d pr oa ct iv e di sc us si on s us in g a se lf -h el p

br oc hu re , or

se lf -h el p br oc hu re

on co lo re ct al

ca nc er

(v s a 5- a- da y nu tr it io n br oc hu re )

N o di ff er en ce

in co lo re ct al ca nc er

sc re en in g

kn ow

le dg e at po st -In t fo r CH

W vs Co nt ,w he re as

se lf -h el p br oc hu re

gr ou p sh ow

ed gr ea te r

in cr ea se d kn ow

le dg e vs

Co nt

H ol t et

al .3 4 (2 01 3) f

16 Af ri ca n Am

er ic an

ch ur ch es

in AL

28 5 no na dh er en t Af ri ca n Am

er ic an s,

ag ed

50 –7 4 y; m ea n ag e, y: 60

(S D = 7) ;

fe m al e: 70 %

Tw o 1- to

2- h gr ou p ed uc at io na l se ss io ns

(e .g .,

st ar ti ng

w it h pr ay

an d en di ng

w it h a Q & A)

ov er

1 m o (v s no ns pi ri tu al co m pa ri so n in te rv en ti on )

N on sp ir it ua l gr ou p sh ow

ed gr ea te r in cr ea se d

< 12 -m o FO

B T vs

co nt ro ls ; N o di ff er en ce

in

si gm

oi do sc op y, co lo no sc op y, an d ba ri um

en em

a, an d be ne fi ts an d ba rr ie rs

Pe rc ac -L im a et

al .4 5 (2 00 8) a :

H ig h

Te le ph on e co nt ac t or

co m m un it y

he al th

ce nt er

in M A

12 23

no na dh er en t pa ti en ts , m ea n ag e, y:

63 (S D = 8) ; fe m al e: In t=

58 ; Co nt = 61 ;

H is pa ni c: 40 %

In di vi du al co un se lin g w it h na vi ga ti on

as si st an ce

pl us

so ci al su pp or t ov er 9 m o (v s w ai t- lis t Co nt )

In t gr ou p sh ow

ed gr ea te r in cr ea se d < 9- m o

an y co lo re ct al ca nc er

sc re en in g vs

Co nt Co nt in ue d

AJPH RESEARCH

April 2016, Vol 106, No. 4 AJPH Kim et al. Peer Reviewed Systematic Review e9

T A B L E 2 —

Co nt in ue d

La rk ey

et al .3 6 (2 01 2) g : M ed

W om

en ’s ho m es

or re cr ui tm

en t

si te s in

AZ

10 06

La ti na

w om

en , ag ed

‡ 18

y; m ea n ag e y:

In t=

38 (S D = 13 ); Co nt = 39

(S D = 14 )

Si x 80 -m in

so ci al su pp or t gr ou p se ss io ns

(S SG )

w it h gr ad ua ti on

at 7t h w k (v s 6 w ee kl y

in di vi du al se ss io ns

an d Q & A at

7t h w k)

N o di ff er en ce

in Pa p te st , m am

m og ra m , FO

B T,

an d en do sc op y at

po st -In t; To ta l co st pe r

pa rt ic ip an t: $1 03 .4 4 fo r SS G vs

$3 92 .3 8 fo r

IN D ; To ta l co st pe r sc re en in g: co ns er va ti ve :

$5 16 .5 3 vs

$1 71 6. 22

C a n ce

r sc re e n in g : o ra l ca n ce

r

Sa nk ar an ar ar ay an an

et al .4 7

(2 00 5) d : H ig h

Pa rt ic ip an ts ’ ho m es

in K er al a, In di a

16 7 91 5 In di an

pa rt ic ip an ts , m ea n ag e, y:

49 (S D = 1) ; fe m al e: In t=

59 % ; Co nt = 61 %

Th re e ho m e vi si ts fo r or al vi su al in sp ec ti on

by tr ai ne d CH

W s (1 99 6– 20 04 ) at

3- y

in te rv al s (v s us ua l ca re )

In t gr ou p ha d gr ea te r in cr ea se d ea rl y de te ct io n

of or al ca nc er

an d 5- y su rv iv al ra te

vs Co nt ;

N o di ff er en ce

in ca nc er

de at hs

C a rd io va

sc u la r d is e a se

p re ve

n ti o n

Al le n et

al .5 6 (2 01 1) a : H ig h; co st

an al ys is : Al le n et

al .8 7 (2 01 3)

2 FQ

H Cs

an d pa rt ic ip an ts ’

ho m es

(i f ne ce ss ar y) in

M D

52 5 Af ri ca n Am

er ic an

or W hi te

pa ti en ts w it h

1+ CV D ri sk

fa ct or s; m ea n ag e, y: In t=

54

(S D = 12 ); Co nt = 55

(S D = 12 ); fe m al e:

In t=

72 % ; Co nt = 71 % ; B la ck : In t=

79 % ;

Co nt = 80 %

N ee ds -b as ed

N P ed uc at io n se ss io ns

pl us

CH W

co un se lin g ov er

12 m o

(v s en ha nc ed

us ua l ca re )

In t gr ou p sh ow

ed gr ea te r de cr ea se d to ta l

ch ol es te ro l, LD L ch ol es te ro l, tr ig ly ce ri de s, SB P,

an d D B P at

12 m o vs

Co nt ; N o be tw ee n gr ou p

di ff er en ce s in

B M I, ph ys ic al ac ti vi ty , sa tu ra te d

fa t, or so di um

at 12

m o; M ea n in cr em

en ta lt ot al

co st /p at ie nt (N P/ CH

W an d ph ys ic ia n) :$ 62 7 (9 5%

CI = $2 48 , $1 01 5)

IC ER

(h ea lt h se rv ic es

pe rs pe ct iv es ): $1 57

/↓ 1%

in

SB P an d $1 90

/↓ 1%

in D B P,

$1 49 /↓ 1%

in H bA 1c , an d $4 0/ ↓ 1%

in LD L

B al cá za r et

al .5 7 (2 00 9) a : H ig h

A CB O in

TX 98

H is pa ni c pa ti en ts w it h hy pe rt en si on ;

m ea n ag e, y: In t=

55 ; Co nt = 50 ; fe m al e:

In t=

88 % ; Co nt = 65 %

N in e 2- h ed uc at io na l se ss io ns

ov er

9 m o (v s ed uc at io na l m at er ia ls re la te d to

ov er al l he al th

is su es )

In t gr ou p sh ow

ed gr ea te r in cr ea se d so di um

he al th y ha bi ts , ch ol es te ro l, an d fa t he al th y

ha bi ts bu t no

B P, B M I, an d w ai st ci rc um

fe re nc e

at 12

m o bu t vs

Co nt

B al cá za r et

al .5 8 (2 01 0) d : M ed

A co m m un it y cl in ic (C en tr o Sa n

Vi ce nt e cl in ic ) in

TX

32 8 H is pa ni c pa ti en ts , ag ed

30 –7 5 y w it h

1+ se lf -r ep or te d CV D ri sk

fa ct or s; m ea n ag e,

y: 54

(S D = 13 ); fe m al e: 70 %

Ei gh t 2- h he al th

ed uc at io n cl as se s fo llo w ed

by 3 ph on e ca lls

an d a sm

al l gr ou p se ss io n

ov er

2 m o (v s ba si c ed uc at io na l m at er ia ls )

In t gr ou p sh ow

ed gr ea te r de cr ea se d D B P bu t no t

SB P,

lip id pr ofi le , FB S, H bA 1C

at 4 m o vs

Co nt

B ec ke r et

al .5 9 (2 00 5) a : H ig h

A CB O fo r th e in te rv en ti on

an d

a ho sp it al fo r co nt ro l

gr ou p in

M D

36 4 B la ck

si bl in gs

of a pr ob an d w it h CH

D ;

m ea n ag e, y: In t=

48 (S D = 7) ; Co nt = 48

(S D = 6) ; fe m al e: 61 %

In di vi du al ly ta ilo re d 30 -m in

co un se lin g se ss io n

ov er

12 m o (v s en ha nc ed

pr im ar y ca re )

In t gr ou p sh ow

ed gr ea te r de cr ea se d LD L, SB P,

D B P, an d gl uc os e at

12 m o vs

Co nt ; N o

di ff er en ce

in tr ig ly ce ri de , H D L, an d B M I

D an ie ls et

al .6 2 (2 01 2) f : M ed

4 ch ur ch es

se rv in g fo r 50 % + Af ri ca n

Am er ic an

25 En gl is h- sp ea ki ng

Af ri ca n Am

er ic an

in di vi du al s, ag ed

‡ 18

y w it h se lf -r ep or te d

1+ CV D ri sk

fa ct or s; fe m al e: 68 %

Si x w ee kl y gr ou p se ss io ns

in cl ud in g

de m on st ra ti on

an d ro le pl ay in g

(v s si x w ee kl y se ss io ns

in a le ct ur e fo rm

at

by a ph ys ic ia n)

In t gr ou p sh ow

ed gr ea te r de cr ea se d H bA 1C

an d

in cr ea se d CV D ri sk

kn ow

le dg e at

6 w k vs

Co nt ;

N o di ff er en ce

in SB P,

D B P,

H D L, LD L, to ta l

ch ol es te ro l, an d w ei gh t

H ay as hi

et al .6 4 (2 01 0) a : M ed

Fo ur

co m m un it y he al th

ce nt er s in

CA

86 9 H is pa ni c w om

en in

th e Ca lif or ni a

N B CC ED

P at

ri sk

fo r de ve lo pi ng

CV D ;

m ea n ag e y: 52

(S D = 6)

Th re e 30 -t o 45 -m in in di vi du al se ss io ns

in cl ud in g

as se ss m en t an d co un se lin g fo r nu tr it io na l

an d ph ys ic al ac ti vi ty

ov er

12 6 2. 5 m o

(v s us ua l ca re )

In t gr ou p sh ow

ed gr ea te r de cr ea se d SB P an d

im pr ov ed

ea ti ng

ha bi ts an d ph ys ic al ac ti vi ty at

12 m o vs

Co nt ; N o di ff er en ce

in D B P, TC , H D L,

B M I, an d 10 -y CH

D ri sk

Co nt in ue d

AJPH RESEARCH

e10 Systematic Review Peer Reviewed Kim et al. AJPH April 2016, Vol 106, No. 4

T A B L E 2 —

Co nt in ue d

Is la m et

al .6 7 (2 01 3) a : M ed

Co nv en ie nt

co m m un it y se tt in g in N Y

48 K or ea n Am

er ic an s at

ri sk

fo r de ve lo pi ng

di ab et es ; m ea n ag e, y: 60

(S D = 8) ;

fe m al e: 64 %

Si x 3- h gr ou p se ss io ns

pl us

10 fo llo w -u p ph on e

ca lls fr om

th e CH

W ov er 6 m o (v s fi rs t ed uc at io n

se ss io n)

N o di ff er en ce

in SB P,

D B P,

B M I, w ai st

ci rc um

fe re nc e, gl uc os e, ph ys ic al ac ti vi ty ,

nu tr it io n,

an d m en ta l he al th

at 6 m o

Ly nc h et

al .7 3 (2 01 4) a : H ig h

Cl as se s w er e he ld in

a lo ca l ci ty

pa rk

bu ild in g ne ar

th e re cr ui tm

en t

FQ H C in

IL

61 Af ri ca n Am

er ic an s w it h pr es cr ib ed

m ed ic at io n

fo r T2 D M , hy pe rt en si on , an d B M I fr om

25 to

45 ; m ea n ag e, y: 54 ; fe m al e: 67 %

Ei gh te en

2- h gr ou p se ss io ns le d by

a di et it ia n an d

w ee kl y ca lls

fr om

a pe er su pp or te r ov er 6 m o (v s

tw o 3- h CH

W le d gr ou p se ss io ns

of di ab et es se lf -

m an ag em

en t)

N o di ff er en ce

in w ei gh t lo ss , H bA 1C , SB P,

D B P

be tw ee n 2 gr ou ps ; In t gr ou p sh ow

ed gr ea te r

im pr ov ed

ph ys ic al ac ti vi ty , D M

se lf -c ar e

ac ti vi ti es ,a s w el la s nu tr it io n kn ow

le dg e vs Co nt

St at en

et al .8 0 (2 00 4) a : M ed

Ei th er

at th e cl in ic in AZ

or ov er

th e

te le ph on e

21 7 un in su re d H is pa ni c w om

en in th e N B CC ED

P;

m ea n ag e, y: 57

(S D = 5) ; ra ce : 74 %

H is pa ni c, 25 % W hi te

Pr ov id er

co un se lin g w it h ed uc at io n pl us

CH W

so ci al su pp or t ov er

12 m o, or

pr ov id er

co un se lin g an d ed uc at io n (v s pr ov id er

co un se lin g on ly )

N o di ff er en ce

in B M I, SB P,

D B P,

ch ol es te ro l,

gl uc os e, tr ig ly ce ri de ,p hy si ca la ct iv it y, fr ui t an d

ve ge ta bl e in ta ke , an d w ai st ci rc um

fe re nc e

am on g gr ou ps

C a rd io va

sc u la r d is e a se

p re ve

n ti o n : d ia b e te s a s a ri sk

fa ct o r

D eP ue

et al .6 3 (2 01 3) d : H ig h

Pa ti en t’ s ho m e, w or kp la ce , or

at th e st ud y cl in ic , in

Am er ic an

Sa m oa

26 8 Sa m oa n Am

er ic an s; m ea n ag e, y: 54

(S D = 12 .9 ); fe m al e: 65 %

H ig he rr is k gr ou p: w ee kl y nu rs e ca se m an ag er le d

gr ou p m ee ti ng

w it h CH

W as si st an ce ov er 12

m o;

M od er at e ri sk

gr ou p: m on th ly m ee ti ng

w it h

CH W s; Lo w er

ri sk

gr ou p: se en

ev er y 3 m o (v s

w ai t- lis t Co nt )

H ig h- ri sk gr ou p sh ow

ed gr ea te r de cr ea se d H bA 1C

at 12

m o vs Co nt ;N o di ff er en ce in B P, w ei gh t, or

w ai st ci rc um

fe re nc e am

on g gr ou ps

K at ul a et al .6 9 (2 01 3) a : H ig h; co st

an al ys is : La w lo r et

al .8 8 (2 01 3)

Co m m un it y- ba se d si te s su ch

as pa rk s an d re cr ea ti on

ce nt er s

30 1 ob es e or ov er w ei gh t (B M I2 5– 39 )p ar ti ci pa nt s

w it h fa st in g bl oo d gl uc os e (9 5– 12 5 m g/ dL );

m ea n ag e, y: 58

(S D = 10 ); W hi te : 74 % ;

fe m al e: 58 %

W ee kl y CH

W le d w ei gh t- lo ss gr ou p se ss io ns an d 3

in di vi du al co un se lin g w it h a di et it ia n fo r 6 m o

pl us

2 co nt ra ct s ea ch

m o fr om

7t h m o to 24

th m o

(v s en ha nc ed

us ua l ca re )

In t gr ou p sh ow

ed gr ea te r de cr ea se d FB S, in su lin

re si st an ce ,w ei gh t, an d B M Ia t2

y vs Co nt ;D ir ec t

m ed ic al co st sp er pa ti en t: In t: $8 50

vs Co nt :$ 14 2

fo r 2 y, co m pa re d w it h $2 63 1 of

th e D PP

K en ya

et al .7 0 (2 01 4) a : M ed

Pa rt ic ip an ts ’ ho m es

in FL

11 7 H is pa ni c pa ti en ts w it h 1+

H bA 1C

‡ 8 du ri ng

th e pa st 1 y; m ea n ag e, y: 56 ; fe m al e: 45 %

In it ia l ho m e vi si t fo llo w ed

by CH

W su pp or t ov er

12 m o (v s no

in fo rm

at io n gi ve n)

G re at er

de cr ea se

in H bA 1C

at 12

m o fo r

In t vs

Co nt

Pa lm as

et al .7 6 (2 01 4) a : H ig h

Pa rt ic ip an ts ’ ho m es , of fi ce s in

N Y

36 0 H is pa ni c pa ti en ts w it h po or ly co nt ro lle d

T2 D M ; ag e ra ng e, y: In t£

65 : 85 .6 % ;

Co nt £ 65 : 81 % ; fe m al e: In t=

61 % ; Co nt = 63 %

M ul ti fa ce te d CH

W -le d In ti nc lu di ng

ab ou t2 4 on e-

on -o ne

vi si ts an d gr ou p se ss io ns

on nu tr it io n

an d ex er ci se

ac ti vi ti es

pl us

ph on e ca lls

ov er

12

m o (v s us ua l ca re )

In tg ro up

di d no ts ho w gr ea te r de cr ea se in H bA 1C

at 12

m o vs Co nt ;N

o ch an ge s in SB P, D B P, an d

LD L in

th e In t gr ou p

Pr ez io et

al .7 7 (2 01 3) a : H ig h

Pr iv at e de di ca te d of fi ce

sp ot s in

TX

18 0 H is pa ni cs ag ed

18 –7 5 y w it h T2 D M ;m

ea n ag e,

y: In t=

47 .9 (S D = 10 .9 9; Co nt = 45 .7 (S D = 10 .6 9;

fe m al e: In t=

67 % ; Co nt = 54 %

Cu lt ur al ly ta ilo re d di ab et es

ed uc at io n an d

m an ag em

en t pr og ra m in cl ud in g 7 ho ur s of

co nt ac t w it h th e CH

W du ri ng

th ei r

ap po in tm

en ts ov er 12

m o (v su su al m ed ic al ca re )

In tg ro up

sh ow

ed gr ea te rd ec re as e in H bA 1c at 12

m o vs Co nt ;N

o di ff er en ce in B P, B M I, H D L, an d

tr ig ly ce ri de

be tw ee n 2 gr ou ps

R ot hs ch ild

et al .7 8 (2 01 4) a : H ig h

Pa rt ic ip an ts ’ ho m es

in IL

14 4 M ex ic an

Am er ic an s w it h T2 D M ;

m ea n ag e, y: 54

(S D = 13 ); fe m al e: 50 %

36 ho m e vi si ts on

se lf -m an ag em

en ts ov er

24 m o

(v s 36

m ai le d bi lin gu al ne w sl et te rs )

In tg ro up

sh ow

ed gr ea te rd ec re as e in H bA 1C

at 2 y

vs Co nt ; N o di ff er en ce

in B P,

gl uc os e se lf -

m on it or in g, m ed ic at io n ad he re nc e

Sp en ce r et

al .7 9 (2 01 1) a : H ig h

Pa rt ic ip an ts ’ ho m es , an

FQ H C in

M I

18 3 Af ri ca n Am

er ic an

or H is pa ni c pa ti en ts

w it h T2 D M ; m ea n ag e, y: In t=

50 ;

Co nt = 55 ; fe m al e: In t=

75 % ; Co nt = 67 %

El ev en

2- h gr ou p se ss io ns ,t w el ve

1- h ho m e vi si ts ,

an d 1 cl in ic vi si t w it h th e pa rt ic ip an ts an d th ei r

PC P pl us

ph on e ca lls

on ce ev er y 2 w k ov er 6 m o

(v s m on th ly ph on e ca lls )

In t gr ou p sh ow

ed lo w er

H bA 1C

at 6 m o vs

Co nt ;

D if fe re nc e in

D M

kn ow

le dg e, di ab et es

se lf -

m an ag em

en t bu t no

di ff er en ce

in LD L, SB P,

D B P, an d B M I be tw ee n 2 ar m s

Co nt in ue d

AJPH RESEARCH

April 2016, Vol 106, No. 4 AJPH Kim et al. Peer Reviewed Systematic Review e11

T A B LE

2 — Co nt in ue d

Ta ng

et al .8 1 (2 01 4) a : H ig h

Pa rt ic ip an ts ’ ho m es in M I; te le ph on e

co nt ac t w as

al so

us ed

11 6 La ti no

pa ti en ts , ag ed

> 21

y w it h T2 D M

re ce iv in g m ed ic al ca re at CH

AS S; m ea n ag e, y: 49

(S D = 11 ); fe m al e: 59 %

Pe er s D SM

S: a 6- m o w ee kl y se ss io n in cl ud in g tw o

1- h ho m e vi si ts /m o an d 1 cl in ic vi si tp lu sp at ie nt -

in it ia te d di sc us si on

fo llo w ed

by pe er

su pp or t

ov er

12 m o (v s CH

W D SM

S)

In t gr ou p di d no t sh ow

im pr ov em

en t in

H bA 1C ,

LD L, SB P,

D B P, w ai st ci rc um

fe re nc e, B M I, D M

st re ss , an d di ab et es

su pp or t at

18 m o vs

Co nt

C a rd io va

sc u la r d is e a se

p re ve

n ti o n : h yp

e rt e n si o n a s a ri sk

fa ct o r

Co op er

et al .6 1 (2 01 1) a : M ed

14 ur ba n co m m un it y he al th

cl in ic s

se rv in g fo r m ai nl y Af ri ca n

Am er ic an s in

M D

41 ph ys ic ia ns

(M D ) + 27 9 hy pe rt en si ve

pa ti en ts

(p t) ; m ea n ag e, y: M D = 43 ; pt = 61 ;f em

al e:

M D = 52 % ; pt = 66 % ; Af ri ca n Am

er ic an :

M D = 29 % ; pt = 62 %

M D +p ti nt en si ve gr ou p, M D m in im al +p ti nt en si ve

gr ou p, M D in te ns iv e+ pt

m in im al gr ou p, M D +p t

m in im al : M D m in im al (v s JN C- VI I tr ea tm

en t

gu id el in es

pl us

a m on th ly ne w sl et te r)

In t gr ou ps

di d no t sh ow

im pr ov em

en t in

SB P,

D B P,

an d m ed ic at io n ad he re nc e at

12 m o vs

Co nt

H ill

et al .6 5 (2 00 3) a : H ig h

An ur ba n ho sp it al ; pa rt ic ip an ts ’

ho m es

in M D

30 9 hy pe rt en si ve

Af ri ca n Am

er ic an

m en ; m ea n

ag e, y: 41

(S D = 6)

N P- le d dr ug

tr ea tm

en t an d 3+

CH W

ho m e vi si ts

(v s re fe rr al s fo r so ur ce s of

H TN

ca re )

In tg ro up

sh ow

ed lo w er SB P, D B P, le ft ve nt ri cu la r

m as s at

3 y vs

Co nt ; N o di ff er en ce

in se ru m

cr ea ti ni ne

Ja fa r et

al .6 8 (2 00 9) d :H

ig h; co st

an al ys is : Ja fa r et

al .9 1 (2 01 1)

Pa rt ic ip an ts ’ ho m es

fo r H H E; G Ps

in

Pa ki st an

13 41

pa ti en ts w it h hi gh

B P; m ea n ag e, y: G P+ H H E:

54 (S D = 12 ); H H E: 53

(S D = 11 ); G P: 55

(S D = 12 );

co nt ro l: 53

(S D = 12 ); m en : G P+ H H E: 34 % ; H H E:

38 % ; G P:

41 % ; co nt ro l: 36 %

H H E pl us

G P,

H H E on ly , or

G P on ly (v s Co nt )

H H E pl us

G P gr ou p sh ow

ed gr ea te r de cr ea se

in

SB P an d ac hi ev ed

co nt ro lle d B P at

12 m o vs

ot he r 3 gr ou ps ; N o di ff er en ce

in D B P an d B M I

am on g gr ou ps

K ri eg er

et al .7 1 (1 99 9) a : H ig h

Pa rt ic ip an t ho m es , W A

42 1 lo w -in co m e pa ti en ts w it h hy pe rt en si on ,

ra ng e, y: 18 –3 9: In t=

24 % ; Co nt = 26 % ; 40 –6 4:

In t=

58 % ; Co nt = 56 % ; fe m al e: 28 % ; Af ri ca n

Am er ic an : 79 %

En ha nc ed

re fe rr al to m ed ic al ca re an d na vi ga ti on

as si st an ce pl us as si st an ce in el im in at in g ba rr ie rs

to ca re

ov er

3 m o (v s us ua l ca re )

In tg ro up

sh ow

ed gr ea te ri nc re as ed

co m pl et io n of

a m ed ic al fo llo w -u p an d fo llo w -u p w it hi n 90

d of

re fe rr al vs

Co nt

Le vi ne

et al .7 2 (2 00 3) a : H ig h

Pa rt ic ip an ts ’ ho m es

in M D

78 9 Af ri ca n Am

er ic an

ad ul ts w it h hy pe rt en si on ;

m ea n ag e, y: 54 ; fe m al e: 62 %

Fi ve

30 -m in in di vi du al se ss io ns ,C H W ho m e vi si ts ,

so ci al su pp or t, co m m un it y H B P ed uc at io n pl us

ed uc at io n m at er ia ls ov er

40 m o (v s us ua l ca re

an d H B P ed uc at io n pl us

m at er ia ls )

N o di ff er en ce

in SB P, D B P, B P co nt ro l at

40 m o

be tw ee n 2 ar m s

M ar go liu s et

al .7 4 (2 01 2) a : H ig h

A pu bl ic ho sp it al in

CA 23 7 hy pe rt en si ve

pa ti en ts , m ea n ag e, y: 60

(S D = 12 ); fe m al e: 63 % ;4 6%

H is pa ni c, 35 % As ia n,

11 % Af ri ca n Am

er ic an

H om

e- ti tr at io n w it ho ut

a ph ys ic ia n ap po in tm

en t

pl us w ee kl y ph on e ca lls by

he al th co ac he s ov er 6

m o (v s w ee kl y ph on e ca lls

by he al th

co ac he s)

N o di ff er en ce in SB P, D B P, no .o fo ffi ce vi si ts at 6

m o be tw ee n 2 ar m s

M or is ky

et al .7 5 (2 00 2) a : M ed

pa ti en ts ’ ho m es ;c lin ic si te s in a la rg e

W es t Co as t ci ty

13 19

hy pe rt en si ve

ou tp at ie nt s; m ea n ag e, y: 54

(S D = 12 ); fe m al e: 59 % ; 76 % Af ri ca n Am

er ic an ,

21 % H is pa ni c

G ro up

1: CH

W w ee kl y co un se lin g, an d

ap po in tm

en t- ke ep in g ov er

12 m o; G ro up

2:

ap po in tm

en t tr ac ki ng ;G ro up

3: CH

W ho m e vi si t

w it h di sc us si on

gr ou ps

(v s us ua l ca re )

G re at er

in cr ea se

in B P co nt ro l fo r gr ou p 3

fo llo w ed

by gr ou p 2; N o im pr ov em

en t in

B P

co nt ro l in

gr ou p 1 an d gr ou p 4

C a rd io va

sc u la r d is e a se

p re ve

n ti o n : p h ys ic a l a ct iv it y

Co le m an

et al .6 0 (2 01 2) a : M ed

4 co m m un it y he al th

cl in ic s in

th e

Ca lif or ni a N B CC ED

P

86 8 lo w -in co m e, un de ri ns ur ed

H is pa ni c fe m al es ,

ag ed

40 –6 4 y ha ve 1+

CV D ri sk fa ct or s; m ea n ag e,

y: 52

(S D = 6)

Th re e 50 -m in

in di vi du al ly ta ilo re d, on e- on -o ne

co un se lin g se ss io ns

pl us

so ci al su pp or t ov er

6

m o (v s us ua l ca re )

In t gr ou p re po rt ed

in cr ea se s in

m od er at e an d

vi go ro us

ph ys ic al ac ti vi ty

at 12

m o co m pa re d

w it h ba se lin e

Co nt in ue d

AJPH RESEARCH

e12 Systematic Review Peer Reviewed Kim et al. AJPH April 2016, Vol 106, No. 4

T A B L E 2 —

Co nt in ue d

C a rd io va

sc u la r d is e a se

p re ve

n ti o n : ch

ro n ic

d is e a se

sc re e n in g

H un te r et

al .6 6 (2 00 4) a : H ig h

Co m m un it y he al th

cl in ic s in

AZ 10 1 H is pa ni cf em

al es ,a ge d > 40

y; m ea n ag e, y: 50

(S D = 8) ; H is pa ni c: 96 %

Tw o ho m e vi si ts to

di sc us s ba rr ie rs an d fa ci lit at e

ap po in tm

en t sc he du lin g ov er 6 w k (v s po st ca rd

re m in de r)

N o di ff er en ce

in ro ut in e pr ev en ti on

ch ro ni c

di se as e sc re en in g be tw ee n 2 gr ou ps

C o g n it iv e fu n ct io n s a n d m e n ta l d is o rd e rs

B ec k et

al .8 2 (2 01 3) d : M ed

16 se ni or

ce nt er s in

AR 22 8 ob es e se ni or ad ul ts ,a ge d > 60

y; m ea n ag e, y:

71 (S D = 7) ; fe m al e: 84 % ; W hi te : 92 % fo r bo th

gr ou ps

Tw el ve

1- h in te ra ct iv e gr ou p se ss io ns

re ga rd in g

co gn it iv e fu nc ti on s ov er

3– 4 m o (v s a re gu la r

w ei gh t- lo ss In t)

Im pr ov em

en t in de la ye d m em

or y fo r In t vs Co nt ;

N o di ff er en ce

in re lia bl e im pr ov em

en t in

im m ed ia te

m em

or y or

in at te nt io n

Ch at te rj ee

et al .8 3 (2 01 4) a : H ig h

Pa rt ic ip an ts ’ ho m es

in In di a

28 2 pa ti en ts w it h sc hi zo ph re ni a; m ea n ag e, y: 36

(S D = 10 ); fe m al e: In t=

46 % ; Co nt = 49 %

In di vi du al iz ed , ne ed s- ba se d in te rv en ti on

de liv er ed

by a CH

W ov er

12 m o (v s us ua l ca re )

In t gr ou p sh ow

ed lo w er di sa bi lit y sc or es at 12

m o

vs Co nt

W ai tz ki n et

al .8 4 (2 01 1) a : M ed

Tw o co m m un it y he al th ce nt er s in N M

12 0 pa ti en ts w it h de pr es si on

(n = 46 4 ra nd om

ly

re cr ui te d) ; fe m al e: 31 %

Co lla bo ra ti ve

PC P– CH

W te am

ap pr oa ch

ov er

12

m o (v s en ha nc ed

ca re )

N o di ff er en ce

in de pr es si on ,d if fi cu lt y pa yi ng

fo r

ho us in g, an d un em

pl oy ed

at 12

m o be tw ee n 2

gr ou ps

A st h m a co

n tr o l

M ar ti n et

al .8 5 (2 00 9) a : H ig h

Cl in ic s in

IL ; pa rt ic ip an ts ’ ho m es

42 pa ti en ts w it h as th m a; m ea n ag e, y: In t=

33

(S D = 9) ; Co nt = 37

(S D = 8) ; fe m al e: In t=

60 % ;

Co nt = 77 %

Fo ur

2- h gr ou p se ss io ns

by so ci al w or ke r w it h

CH W s pl us

6 CH

W ho m e vi si ts ov er

3 m o (v s

m ai le d as th m a ed uc at io n m at er ia ls )

In t gr ou p sh ow

ed gr ea te r in cr ea se

in as th m a

qu al it y of lif e at 6 m o vs Co nt ;N

o di ff er en ce

in

ha vi ng

a sp ac er no rr ec ei vi ng

ac ti on

pl an

at 6 m o

be tw ee n gr ou ps

M e d ic a ti o n sa fe ty

W an g et

al .8 6 (2 01 3) a : M ed

A ru ra l pr im ar y he al th

cl in ic in

Ta iw an

62 co m m un it y- dw

el lin g el de rs , ag ed

> 65

y w it h

2+ ch ro ni c ill ne ss es ; m ea n ag e, y: 71

(S D = 8) ;

fe m al e: 55 %

Vo lu nt ee r co ac hi ng

on m ed ic at io n sa fe ty

in cl ud in g 3 ho m e vi si ts an d 5 ph on e ca ll

re m in de rs pl us

us ua l ca re

ov er

2 m o (v s us ua l

ca re )

In t gr ou p sh ow

ed gr ea te r in cr ea se d m ed ic at io n

sa fe ty

kn ow

le dg e vs

Co nt ; N o di ff er en ce

in

m ed ic at io n sa fe ty

at ti tu de , so m e sa fe ty

be ha vi or s be tw ee n 2 gr ou ps

N o te .A

M IG A S = A yu d a n d o a la s M u je re s co n In fo rm

a ci o n ,G

u ia ,y

A m o r pa ra

su Sa lu d ;B

M I=

b o d y m as s in d e x (w

e ig h t in ki lo g ra m s d iv id e d b y th e sq u ar e o f h e ig h t in m e te rs ); B P = b lo o d p re ss u re ;B

SE = b re as t se lf -

e xa m in at io n ; C B E = cl in ic al

b re as t e xa m in at io n ; C B O = co m m u n it y- b as e d o rg an

iz at io n ; C H A SS

= C o m m u n it y H e al th

an d So

ci al

Se rv ic e s; C H D = co ro n ar y h e ar t d is e as e ; C H W

= co m m u n it y h e al th

w o rk e r;

C I=

co n fi d e n ce

in te rv al ;C

o n t = co n tr o l; C V D = ca rd io va sc u la r d is e as e ;D

B P = d ia st o lic

b lo o d p re ss u re ;D

M = d ia b e te s m e lli tu s; D P P = D ia b e te s P re ve n ti o n P ro je ct ;D

SM S = D ia b e te s se lf -m

an ag

e m e n t su p p o rt ;

FB S = fa st in g b lo o d su g ar ;F O B T = fe ca lo cc u lt b lo o d te st ;F Q H C = fe d e ra lly

q u al ifi e d h e al th

ce n te r; G P = g e n e ra lp ra ct it io n e r; H b A 1 C = h e m o g lo b in A 1 c; H B P = h ig h b lo o d p re ss u re ;H

H E = h o m e h e al th

e d u ca ti o n ;

H P V = h u m an

p ap

ill o m av ir u s; H T N = h yp

e rt e n si o n ;I C E R = in cr e m e n ta lc o st – e ff e ct iv e n e ss

ra ti o ;I n t = in te rv e n ti o n ;L D L = lo w -d e n si ty

lip o p ro te in ;M

C O = m an

ag e d ca re

o rg an

iz at io n ;N

B C C E D P = N at io n al B re as t

an d C e rv ic al C an

ce r E ar ly D e te ct io n P ro g ra m ;N

C I=

N at io n al C an

ce r In st it u te ;N

P = n u rs e p ra ct it io n e r; P ap

= P ap

an ic o la o u ;P C = p ro vi d e r co u n se lin g ;P C P = p ri m ar y ca re

p h ys ic ia n ;Q

& A = q u e st io n s an

d an

sw e rs ;

SB P = sy st o lic

b lo o d p re ss u re ; T 2 D M

= ty p e 2 d ia b e te s m e lli tu s. A fu lle r ve rs io n o f th is ta b le

is av ai la b le

as a su p p le m e n t to

th e o n lin e ve rs io n o f th is ar ti cl e at

h tt p :/ /w

w w .a jp h .o rg .

a In d iv id u al ly

ra n d o m iz e d .

b R an

d o m iz at io n b y h o u si n g .

c R an

d o m iz at io n b y h ai r sa lo n .

d G e o g ra p h ic al ly

ra n d o m iz e d .

e R an

d o m iz at io n b y co

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d ap

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e n t) .

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hypertension.61,65,68,71,72,74,75 Two studies tested an intervention on other CVD-related topics including promotion of physical ac- tivity in women who have 1 or more CVD risk factors60 and chronic disease screening (e.g., annual examination).66 Three studies tested CBHW interventions on cognitive functioning82 and mental disorders (de- pression84 and schizophrenia83). Finally, 2 studies involved CBHWs for asthma85 con- trol and medication safety among rural elders with chronic diseases.86

Forty-six (75%) studies employed individual randomization and 14 (23%) studies used cluster randomiza- tion.29,33,34,36,39,47,48,54,55,58,62,63,68,82 The 2 most common types of comparison groups were less-intensive intervention (n = 17; 28%),27,35,36,38,40,46,53,57,58,62,65–67,73,74,78,85

and usual care (n = 16; 26%)31,32,37,41,44,47, 51,55,60,64,71,72,76,77,83,86 or enhanced usual care (n = 4; 7%)56,59,69,84 followed by wait-list control (n = 7; 11%),42,45,48–50,63,77

and attention control (n = 3; 5%).39,52,82

Eight studies involved more than 1 com- parison group (e.g., usual care and minimal intervention).26,28–30,61,68,75,80 Study sites commonly involved participants’ homes (n = 31; 51%),28,29,32,33,36,38,40–44,52,55,56, 63,65,68,70,72,75,76,78,79,81,83,85,86 community health clinics (n = 15; 25%),30,31,45,46,56,58, 60,61,63,64,66,73,79,84,86 community-based organizations (n = 11; 18%),35,36,38,40,57,59, 67,69,73,77,82 and faith-based organizations (n = 4; 7%).34,36,42,62 Some studies relied solely on telephone contact for CBHW interventions.27,37,53,74

Quality Ratings Thirty-nine studies fell under the high-

quality category (i.e., quality scores of 9 or higher with a maximum possible score of 12; Table 1). Most studies clearly described the research questions, study design, sample characteristics, sample inclusion and exclusion criteria, study setting, study outcomes, and data collection timepoints. None of the studies were considered to be low quality. However, there were several notable meth- odological limitations. For example, only about half of the studies (n = 34) discussed using a theoretical framework to develop the intervention or from which to select study outcomes.26–29,31–35,39,41–44,46,49,53–55,62–

65,73–80,84,85 In addition, less than one third of the selected studies discussed conducting a power analysis a priori (n = 21),26,29,40,42– 47,49,56,63,68,71,73,77,78,81,83–85 and about half of the studies (n = 34)26,28,29,30,32,34,37,40– 44,46–48,51-54,56,57,59,63,65,68,69,71,74,76–

78,81,83,84 clearly described how they randomized study participants. Similarly, less than 1 in 4 studies discussed any type of blinding (i.e., the outcome assessor was aware of the status of the participant’s group assignment; n = 15).33,37,43,45,48,49,51,52,54,63,65,69,76,81,83

In the context of cancer screening, half of the studies measured primary cancer screen- ing behavior through self-report only29,34– 36,38–41,48–50,53–55 as opposed to objective chart review. Of the 7 cancer screening studies that verified self-reported screening behavior with chart review, discrepancies were noted in all studies (sensitivities from 59%52 to 83%33,42 and specificities from 81%33 to 100%28). Finally, less than one third of the studies (n = 21) described how they maintained and monitored CBHW in- tervention fidelity.28,32–34,37,42–44,46,47,49,51– 56,60,67,70,78

Roles and Tasks of CBHWs in Intervention Studies

The CBHWs delivered a wide range of interventions including education, counsel- ing, navigation assistance, case management, social services, and social support. These in- terventions were often delivered in addition to traditional outreach responsibilities of CBHWs, which included participant re- cruitment and data collection. The CBHW interventions were performed in collabora- tion with health care professionals. The CBHWs were supervised by research staff, clinic staff, and study psychologists (Table 2). Fifty out of 61 interventions involved CBHWs alone or the effect of the work of CBHWs was tested separately, whereas in 11 studies, CBHWs partnered with other professionals such as primary care pro- viders,26,27,48,56,84,93 nurse case managers,63

dietitians,69,73 and social workers85 to deliver the study intervention.

In 48 articles, CBHWs fulfilled the role of an educator. The CBHWs provided educa- tion via individual sessions or group education sessions34–36,38–42,48,52,57,58,62,67,69,73,77,79,81

of varying sizes, from 338,41 to 2057partici- pants (median = 3.5–11), with a duration of intervention up to 30 months72 and each session lasting from 5 to 10 minutes75 to 3 hours (average = 93 minutes).42,52,67 Edu- cation sessions took place at participating clinics, community locations, or participant’s home or work. Varying educational mate- rials were used, including standardized PowerPoint presentations,34 videos,28,50,52

print education materials,50,52 and monthly newsletters.61 In addition, role playing was also adopted for interactive education sessions.62

Some studies provided different types of CBHW-led education based on the in- dividual’s risk profile after baseline assessment. In a study delivering a nurse–CBHW team intervention to support diabetes self- management in American Samoa, partici- pants assigned to a higher-risk group attended weekly group sessions whereas participants assigned to moderate- or lower-risk group were seen individually by CBHWs monthly or at a lower frequency.63 Only 1 study re- ported initial testing and validation of the educational materials.28 In a study promoting cervical cancer screening among Mexican American women, Byrd et al.28 validated the educational materials and lesson plans at 2 half-day workshops with bilingual or bi- cultural CBHWs who had experiences working with Mexican American women. The CBHWs reported that the materials were easy to use and successfully demonstrated their ability to use lesson plans.28

In 36 articles, CBHWs delivered coun- seling sessions to address barriers in adopting target behaviors and to reinforce benefits of behavior change.26,27,30–32,37,43–46,49,51–55,57– 64,66,67,72,75–77,79,81,83,85,86 The CBHWs communicated with participants via tele- phone calls, home visits, or regular meetings to assess and problem-solve personal and environmental barriers throughout the in- tervention. In 1 study,36 CBHWs provided theory-based scripted messages for each barrier, including personal belief, fear, health care provider, personal need, and manage- ment barriers.46 In another study,65 CBHWs delivered weekly 5 to 10 minutes of counseling to reinforce patient lifestyle, medication-taking, and appointment- keeping behaviors.75

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In 21 articles, CBHWs provided navigation assistance for their study participants in obtaining preventive care services and managing chronic dis- eases.27,31,33,37,38,40,41,43,45,46,49,51,62,63,70– 72,77,79,81 As navigators, CBHWs provided information on how to access medical services and helped with scheduling appointments at health centers. Information on access to medical services included availability of low- cost or free medical services in the community, local providers, and health insurance. In addi- tion to appointment scheduling, CBHWs facilitated participants’ attendance at scheduled health services by arranging transportation and accompanying participants to appointments. In a study addressing cervical cancer screening among Chinese women, CBHWs provided transportationassistancethroughtaxicabsorbus passes and medical interpreter services during clinic visits for Papanicolaou (Pap) testing.51

In 4 studies, CBHWs were involved in case management by planning and coordinating appropriate health care services.74,77,79,83

Studies in which CBHWs provided case management services usually addressed chronic conditions often involving care from multiple health professionals. In a study de- livering a diabetes education and manage- ment program for uninsured Mexican Americans,77 CBHWs facilitated immediate physician contact to address acute problems, assisted with pharmacy refills, and arranged specialty visits, such as dental care and dilated retinal exam. These CBHWs were state- certified health workers and they delivered management services in the setting of an urban community health services clinic.

In 7 articles, CBHWs assisted participants in assessing social services in addition to medical services.56,65,71,72,76,83,84 In these studies, investigators attempted to address systematic barriers preventing study partici- pants from adopting target behaviors by connecting them to existing social services. The social services provided included referrals to community transportation,71 child care,71

housing,65,76,84 legal benefits,83 and em- ployment opportunities.65,83,84

Eighteen studies assigned CBHWs to provide social support to promote targeted health behaviors.27,29, 31,36,48,49,51,52,55,58,60,63,72,80,81,86 The CBHWs directly provided support for be- havior change by encouraging the study

participants through multiple conversations and offering emotional support. Social support was also offered indirectly by educating family and friends on how to be supportive. For example, in a study delivering an intervention to decrease blood pressure in an urban African American population,72 CBHWs taught family members or friends how to provide daily support to the patient, and also to assist with appointment keeping or with behaviors related to blood pressure control.

Effects of CBHW Interventions The effects of CBHW interventions

reviewed are summarized in Table 2. The findings presented in this section highlight the effects of CBHWs as an intervention com- ponent as long as the effect was measured separately. Because of the heterogeneity of settings, sample characteristics, and types of interventions, it was not possible to conduct a quantitative meta-analysis. Overall, most studies reviewed reported positive outcomes for the targeted health behavior. Eight pub- lications including 6 companion articles also demonstrated that the use of trained, cul- turally competent CBHWs resulted in cost savings.36,43,87–92

Cancer prevention. Of the 30 studies that tested the effect of a CBHW-led intervention on cancer control, 21 studies (70%) found improvements in cancer screening behav- iors.26,28,30–33,35,37,38,40–51 Positive changes in mammogram uptake (6% to 33% increase)26, 31,37,40,41,43,46,48,50 were noted in 9 of the 16 studies that focused on breast cancer. The trial with the largest increase in mammogram screening (33%) employed a multifaceted intervention designed for African American women that included 4 monthly CBHW-led, culturally tailored counseling sessions and mailing of a postcard message tailored to the participant’s barriers.46 Similarly, significant improvements in Pap tests, ranging from 7% to 29%,28,32,35,37,38,42,49,50,52 were reported in 9 of the 16 studies that targeted cervical cancer. Of the 3 studies focused on colorectal cancer, only 1 yielded a significant increase in colorectal cancer screening in the CBHW-led education group compared with usual care (27% vs 12%; P < .001).45

The studies without significant changes in mammogram,27,36,53,55 Pap test,27,30,32,34 or colorectal cancer screening21,27 tended to

compare one type of CBHW intervention to another (e.g., education vs social support group)27 or to a less-intensive intervention (as opposed to no intervention).27,53 In addition, some of these studies included a high pro- portion of participants who were up to date for screening41 or had significantly different demographic characteristics between the 2 groups at baseline.55 One study44 reported significant improvement in self-reported Pap test use among Appalachian women (n = 286; 71% vs 54%; P = .008); however, the result ceased to be significant when chart review was used to ascertain the outcome (51% vs 42%; P = .135). Holt et al.34 found a sig- nificant negative effect of spiritually based CBHW-led intervention on fecal occult blood testing among African Americans compared with the nonspiritual group (2% decrease vs 9% increase, respectively; P = .03).

Cardiovascular disease risk reduction. Sixteen studies (62%) included in the review found a significant effect of CBHW intervention on CVD risk reduction.56,58–60,62–65,68–72,77–79

Of the 9 studies that tested the effect of CBHW-led intervention on global CVD prevention, 5 (56%) studies found signifi- cantly greater improvements in lipid profile (total cholesterol, low-density lipopro- tein, high-density lipoprotein, or tri- glycerides),56,59,62 blood pressure,56,58,62,64

hemoglobin A1C (HbA1C),56 and global CVD risk59 for the CBHW intervention group compared with the comparison group. Mixed or nonsignificant results were noted in the 3 remaining studies, which might have been attributable to a small sample size (48–61),67,73 low statistical power,80 low follow-up rates (67% to 73%),67,80 or variability in fidelity of intervention implementation.80

Of the 2 studies that focused on other CVD-related topics,60,66 only 1 study60

found a significant improvement in self- reported moderate (71% to 84%; P < .001) and vigorous (13% to 33%; P < .001) physical activity from baseline to 6-month follow-up in the intervention group. No significant increase was noted in the comparison group.

Of the 8 studies63,69,70,76–79,81 that ex- clusively focused on HbA1C or fasting glu- cose as a primary outcome, all but 276,81 found significant improvements in diabetes control. Tang et al.81 compared the effect of peer

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leaders (bilingual residents in the target community with diabetes and aged ‡ 21 years) versus CBHWs on diabetes manage- ment. In the study,81 the peer leader group had a significant reduction in HbA1C at 18-month follow-up (–0.6% from baseline; P = .009). By contrast, the CBHW group failed to maintain an HbA1C reduction (–0.3% from baseline; P = .234).

Eight studies examined CBHW in- terventions for better blood pressure control. Significant improvements in blood pressure control were seen in 4 studies.65,68,71,72 Of the 4 studies that found nonsignificant re- sults,57,61,74,75 2 lacked statistical power.57,61

Mental disorders, asthma control, and med- ication safety. Three studies involved CBHWs to address issues related to cognitive func- tioning and mental disorders, such as de- pression and schizophrenia82–84; the study results were mixed. With data collected from a cluster randomized trial94 designed to test the effect of a weight-loss intervention for obese older adults (‡ 60 years) whowere using cognitive training as an attention control, Beck et al.82 compared a cognitive training intervention to a weight-loss intervention. Participants in the intervention group had about 3 times higher odds of achieving better cognitive functioning compared with those in the attention control (weight-loss) group (odds ratio = 2.7; 95% confidence inter- val = 1.3, 5.6; P = .011).82 Two studies that focused on mental disorders yielded partially significant83 or nonsignificant findings.84

Chatterjee et al.83 found a significant decrease in disability from schizophrenia (P = .01) but not in symptom severity. In the study84 that tested a CBHW intervention on depression, the authors argued that nonsignificant find- ings might have been associated with fidelity issues, instead of an ineffective intervention.

One study tested the effect of CBHW intervention on asthma control and found that the intervention was effective in pro- moting self-efficacy; however, there was no significant difference in clinical outcomes (e.g., symptomatic days and nights over the past 14 days) between groups.85 However, the authors reported that this study was un- derpowered to detect self-management in asthma control and clinical outcomes. In a study86 that tested the effect of a volun- teer coaching on medication safety in community-dwelling elders with 2 or more

chronic illnesses, the volunteer coaching program was effective in promoting medi- cation safety knowledge as well as 3 (out of 6) medication safety behaviors, compared with the usual care.

Cost outcomes. Eight out of 61 studies (13%) included cost analyses. Of the 8 articles with cost analyses, 3 studies focused on di- abetes control,88 high blood pressure con- trol,91 and cardiovascular risk reduction.87

Lawlor et al.88 found that a lifestyle in- tervention delivered by a registered dietitian– CBHW group could be cost-effective. In the study, estimated direct medical costs per capita were $850 and $142 for the registered dietitian–CBHW and the registered dietitian groups, respectively. When total costs were calculated, however, it was higher for the registered dietitian–only group than for the registered dietitian–CBHW group ($7596 vs $6027, respectively). In a study tolower blood pressure in 12 randomly selected communi- ties in Pakistan,91 Jafar et al. found that a “home health education by CBHWs plus trained general practitioner” intervention was the most cost-effective intervention com- pared with “home health education only,” “general practitioner only,” and “usual care” interventions. The combined intervention resulted in an incremental cost-effectiveness ratio (ICER) of $23 (95% confidence interval = 6%, 99%) per millimeter of mercury (mm Hg) systolic blood pressure reduction compared with the usual-care group.91 In a CVD risk reduction program delivered by nurse practitioner (NP)–CBHW teams in urban community health centers,87

Allen et al. also reported estimated savings of $157 and $190 per 1% reduction in systolic and diastolic blood pressure, respectively. They also reported an ICER of $149 for 1% reduction in HbA1C and $40 for 1% reduction in low-density lipoprotein cholesterol.

Five studies assessed cost-effectiveness of CBHW intervention in the context of cancer screening. A CBHW intervention designed to promote cervical cancer screening among Vietnamese American women resulted in an ICER of $30 015 per quality-adjusted life year.89 In a study that tested the effect of a CBHW-facilitated AMIGAS (Ayudando a Las Mujeres con Información, Guía y Amor para su Salud: Helping Women with Information, Guidance, and Love for Their Health, in

English) program (video, flipchart, or both) among nonadherent Mexican-origin women aged 21 years and older, Lairson et al.92 re- ported an ICER of $980 per additional women screened compared with a video-only intervention and wait-list control. Wagner et al.90 conducted a CBHW outreach program for low-income women with abnormal Pap test results in Alameda, California, and ob- tained an ICER of $959 per follow-up for the intervention compared with usual care. Al- though Larkey et al.36 found no difference in cancer screening outcomes between in- terventionandcomparison groups,thecostper participant screenedwas approximately3 times greaterintheindividuallydeliveredgroupthan in the social support group ($1716.22 vs $516.53, respectively). Paskett et al.43 esti- mated a cost associated with CBHW in- tervention to promote mammography screening among low-income, ethnically di- verse female patients aged 40 years or older, which equated to a cost savings of $4986 per each mammogram in the CBHW group.

Qualifications and Characteristics of CBHWs

Identification and selection of community- based health workers. The characteristics, training, and roles of CBHWs are summarized in Table 3. Studies widely varied in their approaches to identifying CBHWs. Ap- proaches included identification by com- munity leaders,29,34,86 use of existing CBHWs in the community,30,45 use of par- ticipating churches49 or a community self- help organization,50 or community members who demonstrated the positive behavior targeted within the study population.26

Studies also used different selection cri- teria. Twenty-five studies used living in the same residential area with the study participants as a CBHW selection crite- rion.27,31,35,40,44,47–50,53–55,60,62,64,66,69,70,77–81,84,86

All studies targeting racial/ethnic minorities included bilingual CBHWs.28, 36,45,52,60,64,66,67,77,78,81,84 Three studies selected CBHWs on the basis of their similar background to the study population in terms of marital status, age, socioeconomic status, occupation, or having children.35,49,52

Some studies selected CBHWs on the basis of their educational level31,45,47,60 or having previous experiences working with the

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T A B L E 3 —

C h ar a ct e ri st ic s,

T ra in in g , a n d R o le s o f C o m m u n it y- B a se

d H e a lt h W o rk e rs

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April 2016, Vol 106, No. 4 AJPH Kim et al. Peer Reviewed Systematic Review e17

T A B L E 3 —

Co nt in ue d

B as ta ni

et al .2 7 (2 01 0)

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R es ea rc he rs : Tw o 4. 5- h se ss io ns

to pr ov id e

ed uc at io n ab ou t br ea st an d ce rv ic al ca nc er

ca us es

an d sc re en in g

R es ea rc he rs an d ou tr ea ch

co or di na to r

$1 50 0 pe r CH

W ; CD

C an d N CI : N ot

re po rt ed

R us se ll et

al .4 6 (2 01 0)

W or d of

m ou th

an d co m m un it y ad vi so ry

bo ar d: 8 Af ri ca n Am

er ic an

w om

en re si di ng

in th e ta rg et ed

co m m un it y

N ot

re po rt ed :T w o 8- h se ss io ns

to de liv er sc ri pt ed

m es sa ge s ad dr es si ng

ba rr ie rs ,a ss is tin g na vi ga tio n,

an d m ak in g re fe rr al s: Co m pe te nc y ev al ua tio n =

sk ill s pe rf or m an ce

ev al ua te d by

nu rs es

N ot

re po rt ed

“A sm

al ls ti pe nd ”; N CI an d U ni ve rs it y:

N ot

re po rt ed

Sl at er

et al .4 8 (1 99 8)

N ot

re po rt ed : H ig h- ri se

re si de nt

vo lu nt ee rs

N ot

re po rt ed : N ot

re po rt ed

N ot

re po rt ed

N ot

re po rt ed ; N CI : AC S ex po rt ed

th e

pr og ra m in to

ot he r se tt in gs

in

M in ne ap ol is

W es t et

al .5 3 (2 00 4)

In di ge no us

w om

en :F em

al e Af ri ca n Am

er ic an

in di ge no us

CH W s

Su rv ey

R es ea rc h U ni t, he al th

ps yc ho lo gi st :

Tr ai ne d in co nd uc ti ng

se m is tr uc tu re d in te rv ie w

(m ot iv at io na l in te rv ie w in g)

D ir ec t ob se rv at io n

N ot

re po rt ed ; N CI , U ni ve rs it y, CD

C:

N ot

re po rt ed

W ils on

et al .5 4 (2 00 8)

Sa m e co m m un it y; ha ir st yl is ts :E it he r Af ri ca n

Am er ic an

or Af ro -C ar ib be an

(9 2%

)

St af f at

th e Ar th ur

As he

In st it ut e fo r U rb an

H ea lt h: Tw o 2- h w or ks ho ps an d on go in g su pp or t

an d te ch ni ca l as si st an ce : Co m pe te nc y

ev al ua ti on

= st af f- ad m in is te re d as se ss m en t

Pr og ra m st af f vi si ts to

sa lo ns

Pr of es si on al de ve lo pm

en t cl as se s

(v al ue d at

$8 00 ); $3 0 fo r tr av el to

th e tr ai ni ng

si te ; N CI , Fo un da ti on ,

H os pi ta l Fu nd : N ot

re po rt ed

Zh u et

al .5 5 (2 00 2)

Af ri ca n Am

er ic an

w om

an : La y he al th

ed uc at or s fr om

th e sa m e ho us in g co m pl ex

N ot

re po rt ed :F ou r 3- h se ss io ns

on br ea st ca nc er ,

sc re en in g, be ne fi ts an d ba rr ie rs , th e w ay s to

im pl em

en t ed uc at io n:

Co m pe te nc y

ev al ua ti on

= a sh or t te st at

ea ch

se ss io n

Ev al ua ti on

co m pl et ed

by

In te rv ie w er

N ot

re po rt ed ; U S Ar m y M ed ic al

R es ea rc h Ac qu is it io n Ac ti vi ty : N ot

re po rt ed

C a n ce

r sc re e n in g : ce

rv ic a l a n d b re a st

ca n ce

r

Fe rn an de z et

al .3 3 (2 00 9)

N ot

re po rt ed : N ot

re po rt ed

Cl in ic co or di na to rs :1 2 tr ai ni ng

se ss io ns :C om

pe te nc y

ev al ua ti on

= cl in ic al st af f at st ud y si te s

Cl in ic co or di na to rs

Em pl oy ee s; CD

C an d N CI : A pr og ra m

m an ua l de ve lo pe d

M ar go lis

et al .3 7 (1 99 8) a

Lo w -in co m e el de rl y la y w om

en ag ed

55 + y: N o

ad di ti on al in fo rm

at io n

St ud y co or di na to r: 1- m o tr ai ni ng

on ba si c

pr of es si on al sk ill s, co m m un ic at io n sk ill s,

cu lt ur al di ve rs it y, an d pr in ci pl es

of re se ar ch

de si gn

St ud y co or di na to r

$ no t re po rt ed

(2 0 h/ w k) ; N CI :

Su st ai na bl e re so ur ce s to

Co un ty

M ed ic al Ce nt er

gi ve n;

3 w or ke rs

re cr ui te d an d tr ai ne d (> 33 60

h of

st af f ti m e ad de d)

Co nt in ue d

AJPH RESEARCH

e18 Systematic Review Peer Reviewed Kim et al. AJPH April 2016, Vol 106, No. 4

T A B L E 3 —

Co nt in ue d

N av ar ro

et al .3 9 (1 99 8)

La ti na

re co m m en de d by

co m m un it y si te

pe rs on ne l: 36

La ti na s; ch ar ac te ri st ic s as

na tu ra l he lp er s (e .g ., hu m or , ne tw or ks )

N ot

re po rt ed : C o n se je ra

m an ua l sp ec ifi ca lly

de si gn ed

to gu id e th e w ee kl y se ss io ns

in th e

to pi c fo cu s of

th e in te rv en ti on

N ot

re po rt ed

N ot

re po rt ed ; N CI : N ot

re po rt ed

N un o et

al .4 1 (2 01 1)

Sp an is h- sp ea ki ng : N o ad di ti on al in fo rm

at io n

W es te rn

AZ Ar ea

H ea lt h Ed uc at io n Ce nt er

st ud y

co or di na to r: Fi ve

2- h se ss io ns

on ed uc at io na l

co nt en t, th e CH

W ro le of co nt en t de liv er y, st af f

de ve lo pm

en ta bo ut se lf -e st ee m an d de al in g w it h

pr ob le m pa rt ic ip an ts ,c om

m un it y re so ur ce s, an d

hu m an

su bj ec ts an d in fo rm

ed co ns en t

Ex pe ri en ce d fi el d st af f to

en su re

th e fi de lit y

N ot

re po rt ed ; CM

S: N ot

re po rt ed

Pa sk et t et

al .4 3 (2 00 6)

W om

en w it h go od

so ci al sk ill s; or ga ni ze d,

pr of es si on al , an d co ur te ou s; fl ex ib le w or k

ho ur s: 2 N at iv e Am

er ic an

w om

en an d

1 Af ri ca n Am

er ic an

w om

an

Pr oj ec t m an ag er an d ot he r st ud y pe rs on ne l: 1- w k

tr ai ni ng

on ge ne ra lp ro je ct in fo rm at io n, kn ow le dg e

re ga rd in g ca nc er sc re en in g; ro le -p la yi ng :

Co m pe te nc y ev al ua tio n = ex am

,p ra ct ic e in te rv en tio n

se ss io ns ,b re as t se lf- ex am

de m o on

br ea st m od el s

W ee kl y m ee ti ng s w it h CH

W

su pe rv is or ; O bs er va ti on

N ot

re po rt ed ; N CI : N ot

re po rt ed

Su ng

et al .5 0 (1 99 7)

R ec ru it ed

fr om

a se lf -h el p gr ou p; re si di ng

in

th e ta rg et ar ea :S el f- he lp gr ou p le ad er s w ho

w or ke d w it h w om

en in th e st ud y co m m un it y

N ot

re po rt ed : 10 -w k tr ai ni ng

on w om

en ’s he al th

is su es

an d in te rv ie w in g, te ac hi ng , an d hu m an

re la ti on s sk ill s

B iw ee kl y m ee ti ng

(s up er vi so r

no t re po rt ed )

N ot

re po rt ed ; N CI

an d N IH : N ot

re po rt ed

C a n ce

r sc re e n in g : co

lo re ct a l ca n ce

r

Ca m pb el l et

al .2 9 (2 00 4)

In di vi du al s id en ti fi ed

by ch ur ch

m em

be rs :

47 w om

en an d 15

m en

Pr oj ec t st af f: 16 -h

gr ou p se ss io ns

at re sp ec ti ve

ch ur ch es :C om

pe te nc y ev al ua ti on

= pr e an d po st

kn ow

le dg e te st

N ot

re po rt ed

N o m on et ar y co m pe ns at io n;

AC S,

D ep ar tm

en t of

Ag ri cu lt ur e, an d

N IH : N ot

re po rt ed

Ca st añ ed a et

al .3 0 (2 01 2)

Ex is ti ng

p ro m o to ra s: N o ad di ti on al

in fo rm

at io n

N ot

re po rt ed : N ot

re po rt ed

N ot

re po rt ed

N ot

re po rt ed ; N CI

an d N IM H D : N ot

re po rt ed

H ol t et

al .3 4 (2 01 3)

In di vi du al s id en ti fi ed

by pa st or s an d ke y

ch ur ch

st af f: N o ad di ti on al in fo rm

at io n

N ot

re po rt ed : 2 ha lf -d ay

tr ai ni ng s; co m pl et ed

a m oc k ed uc at io na ls es si on

af te rt ra in in g se ss io ns

N ot

re po rt ed

Ch ur ch es

re ce iv ed

$5 00 ; CD

C: N ot

re po rt ed

Pe rc ac -L im a et

al .4 5 (2 00 8)

Ex is ti ng

he al th

ou tr ea ch

w or ke r: 5 bi lin gu al

he al th

ce nt er

ou tr ea ch

co lle ge

ed uc at ed

w or ke rs

St ud y PI an d co m m un ity

he al th

di re ct or :O

ne 6- h

se ss io n on

na vi ga tio n an d co lo re ct al ca nc er sc re en in g

St ud y PI

an d co m m un it y

he al th

di re ct or

N ot

re po rt ed ; H os pi ta l, Tr us t, N CI :

N ot

re po rt ed

La rk ey

et al .3 6 (2 01 2)

B ili ng ua l La ti na : 5 fu ll- ti m e, bi lin gu al ; pr io r

ex pe ri en ce s w it h co m m un it y m em

be rs

Ju n to s e n la

S a lu d pr og ra m co or di na to rs :

Tr ai ne d on

th e st ud y, ge ne ra l ca nc er

in fo rm

at io n an d he al th , de ve lo pi ng

re la ti on sh ip s w it h co m m un it y or ga ni za ti on s,

sc he du lin g an d le ad er sh ip sk ill s

N ot

re po rt ed

$1 5. 49 /h ; AC S: N ot

re po rt ed

C a n ce

r sc re e n in g : o ra l ca n ce

r

Sa nk ar an ar ar ay na n et

al .4 7 (2 00 5)

R es id in g in

th e sa m e co un ti es : 2 co lle ge

gr ad ua te s (1 m al e an d 1 fe m al e) in bi ol og y

or so ci al sc ie nc es

Co m m un it y O nc ol og y D iv is io n:

3- m o tr ai ni ng

to

ge t in fo rm

at io n ab ou t st ud y el ig ib ili ty ,

in fo rm

ed co ns en t, an d in te rv ie w in g

pa rt ic ip an ts , an d ho w to

gi ve

he al th

m es sa ge s

N ot

re po rt ed

N ot

re po rt ed ; R es ea rc h fu nd ;

R es ea rc h fe llo w sh ip : N ot

re po rt ed

Co nt in ue d

AJPH RESEARCH

April 2016, Vol 106, No. 4 AJPH Kim et al. Peer Reviewed Systematic Review e19

T A B L E 3 —

Co nt in ue d

C a rd io va

sc u la r d is e a se

p re ve

n ti o n

Al le n et

al .5 6 (2 01 1)

N ot re po rt ed :T ra in ed

CH W s w it h ex pe ri en ce s

w or ki ng

w it h m in or it ie s

N ot

re po rt ed : Tr ai ni ng

se ss io ns

on CH

D an d D M

an d lif es ty le m an ag em

en t; m ot iv at io na l

in te rv ie w in g

N ot

re po rt ed

M ed ia n = $1 8. 32 /h ; N H LB I: N ot

re po rt ed

B al cá za r et

al .5 7 (2 00 9)

N ot

re po rt ed : 20

ne w p ro m o to ra s tr ai ne d

by ex is ti ng

p ro m o to ra s

Ex pe ri en ce d p ro m o to ra s: O ne

4- d se ss io n

us in g th e S a lu d P a ra

S u C o ra zo

n (S PS C)

p ro m o to ra

cu rr ic ul um

“ Yo ur

H ea rt , Yo ur

Li fe ”

N ot

re po rt ed

N ot

re po rt ed ; CD

C an d pr of es si on al

as so ci at io n:

Pr iv at e fu nd s se cu re d

B al cá za r et

al .5 8 (2 01 0)

R ec ru it ed

fr om

p ro m o to re s fr om

th e

ne tw or k of

pa rt ne r or ga ni za ti on s: 3

p ro m o to re s hi re d

A le ad

p ro m o to ra

fr om

Ce nt ro

Sa n Vi ce nt e

cl in ic : 1- w k tr ai ni ng

(1 6– 18

h) us in g th e SP SC

cu rr ic ul um

N ot

re po rt ed

N ot

re po rt ed ; N IH : Ex pa nd in g it s

re ac h th ro ug h co m m un it y pa rt ne rs

B ec ke r et

al .5 9 (2 00 5)

N ot

re po rt ed : N o ad di ti on al in fo rm

at io n

N ot re po rt ed :T ra in ed

by YM

CA st an da rd

tr ai ni ng

pr og ra m fo rv ol un te er s; al so co m pl et ed

ba si cl if e

su pp or t tr ai ni ng

N ot

re po rt ed

N ot

re po rt ed ; N H LB I, U ni ve rs it y,

N CR R , N CI , co m pa ni es : N ot

re po rt ed

D an ie ls et

al .6 2 (2 01 2)

Ca nd id at es

su gg es te d by

pa st or s; Af ri ca n

Am er ic an ,a ge d 18 + y; di ag no si s of 1+

AB CD

ri sk

fa ct or s th at

w er e co nt ro lle d: 12

CH W s

St ud y’ s PI an d pr oj ec t m an ag er :1 6- h tr ai ni ng

on

re cr u it in g;

ed uc at in g AB

CD ri sk

fa ct or s an d

de pr es si on ;b as ic he al th lit er ac y sk il ls ;t ea ch in g

sk il ls ; on lin e co ur se

on hu m an

pa rt ic ip an ts

N ot

re po rt ed

St ip en d; Ph ar m ac eu ti ca ls : N ot

re po rt ed

H ay as hi

et al .6 4 (2 01 0)

B ili ng ua l, bi cu lt ur al w om

en re si di ng

in th e

sa m e co m m un it ie s: R el at iv el y w el le du ca te d

Pr of es si on al s; St at e Ca nc er

D et ec ti on

Se ct io n

st af f: 2. 5- d tr ai ni ng

on re se ar ch

ac ti vi ti es ,

ca rd io va sc ul ar

he al th , hu m an

pr ot ec ti on , an d

re se ar ch

pr ot oc ol

R N at

ea ch

cl in ic si te

N ot

re po rt ed ; CD

C: N ot

re po rt ed

Is la m et

al .6 7 (2 01 3)

B ili ng ua l K or ea n Am

er ic an : Tr ai ne d 6 CH

W s

fr om

CB O

2 tr ai ne rs :8 -d ay ,6 0- h tr ai ni ng

on co m pr eh en si ve

sk ill s pl us

ad di ti on al 30

h on

m en ta l he al th ,

m ot iv at io na l in te rv ie w in g, an d ot he r re la te d

to pi cs

N ot

re po rt ed

N ot

re po rt ed ; CD

C an d N IH : N ot

re po rt ed

Ly nc h et

al .7 3 (2 01 4)

CH W : no t re po rt ed ;

Pe er

su pp or te rs : se le ct ed

fr om

th e ta rg et

co m m un it y; 1 Af ri ca n Am

er ic an

CH W ;

2 Af ri ca n Am

er ic an

pe er

su pp or te rs

Ps yc ho lo gi st , di et it ia n,

he al th

ed uc at or : CH

W :

tw o 3- h tr ai ni ng

on se lf -m an ag em

en t an d

nu tr it io n;

pe er

su pp or te rs : ei gh t 2- h w ee kl y

tr ai ni ng

on nu tr it io n,

go al se tt in g, pr ob le m -

so lv in g sk ill s to

ad dr es s ba rr ie rs to

go al

ac hi ev em

en t

W ee kl y te am

m ee ti ng s

le d by

th e st ud y ps yc ho lo gi st

N ot

re po rt ed ; N IH : N ot

re po rt ed

St at en

et al .8 0 (2 00 4)

R es id in g in

th e sa m e co un ty : 6 bi lin gu al

H is pa ni c w om

en (5

ag ed

50 y) ; 4 pr ev io us

CH W s

N ot

re po rt ed : Tr ai ni ng

se ss io ns

on ou tr ea ch ,

tr an sl at io n,

an d tr an sp or ta ti on

N ot

re po rt ed

N ot

re po rt ed ; CD

C: N ot

re po rt ed

Co nt in ue d

AJPH RESEARCH

e20 Systematic Review Peer Reviewed Kim et al. AJPH April 2016, Vol 106, No. 4

T A B L E 3 —

Co nt in ue d

C a rd io va

sc u la r d is e a se

p re ve

n ti o n : d ia b e te s a s a ri sk

fa ct o r

D eP ue

et al .6 3 (2 01 3)

N ot

re po rt ed : M in im um

of hi gh -s ch oo l

ed uc at io n

N ot

re po rt ed : Tr ai ni ng

in vo lv ed

br ie f te ac hi ng

se ss io ns , ro le pl ay s, an d ob se rv in g ot he r st af f

du ri ng

in te rv en ti on

vi si ts

Fi el d di re ct or ; nu rs e

ca se

m an ag er

N ot

re po rt ed ; N ID D K : N ot

re po rt ed

K at ul a et

al .6 9 (2 01 3)

Pa ti en ts w it h w el l-c on tr ol le d T2 D M

an d

le ad er sh ip :1 0 CH

W st ra in ed ;m

ea n ag e: 57

y;

7 B la ck s, 8 w om

en ; 7 em

pl oy ed ; 8 hi gh

sc ho ol + ed uc at io n

R eg is te re d di et it ia ns : 36 -h

pr og ra m on

di ab et es

se lf -m an ag em

en t an d ob se rv at io n ov er

6– 9 w k

R eg is te re d di et it ia ns

Fi rs t 6 m o = $1 00 /w k;

m on th s 7– 24

= $2 00 /m o; N ID D K : N ot

re po rt ed

K en ya

et al .7 0 (2 01 4)

H is pa ni c; co ns id er ed

to be

re sp ec te d pe er s:

N o ad di ti on al in fo rm

at io n

D ia be te s Re se ar ch

In st itu te :T ra in ed

in di se as e

m an ag em

en ts ki lls ,n av ig at io n, an d m ak in g re fe rr al s

N ot

re po rt ed

N ot

re po rt ed ; N H LB I: N ot

re po rt ed

Pa lm as

et al .7 6 (2 01 4)

N ot

re po rt ed : 2 fu ll- ti m e CH

W s ba se d at

Al ia nz a D om

in ic an a In c.

N ot

re po rt ed : Co m pe te nc y ev al ua ti on

= no t

re po rt ed

N ot

re po rt ed

N ot

re po rt ed ; N IM H D : N ot

re po rt ed

Pr ez io et

al .7 7 (2 01 3)

B ili ng ua l, fe m al e, m em

be r of

th e lo ca l

M ex ic an

Am er ic an

co m m un it y; hi gh -s ch oo l

ed uc at io n an d ce rt ifi ed

CH W in th e st at e of

TX : N o ad di ti on al in fo rm

at io n

Re gi st er ed

di et it ia ns

an d an

en do cr in ol og is t: 27 -h

in st ru ct io n in th e lo ca l co m m un it y: Co m pe te nc y

ev al ua ti on

= w ri tt en

ex am

in at io n an d ob se rv at io n

N ot

re po rt ed

N ot re po rt ed ;U ni ve rs it y an d re se ar ch

in st it ut e: In te rv en ti on

su st ai ne d

w it h su pp or t fr om

ph ila nt hr op ic

an d lo ca l ag en cy

fu nd in g; pr og ra m

ex pa nd ed

to 5 ot he r si te s

R ot hs ch ild

et al .7 8 (2 01 4)

B ili ng ua l M ex ic an

Am er ic an s re si di ng

in th e

ta rg et

co m m un it y an d w or ki ng

fo r a lo ca l

no np ro fi t ag en cy ; 3 CH

W s w it h kn ow

le dg e

an d sk ill s: N o hi st or y of

di ab et es , no

po st se co nd ar y ed uc at io n

A co m m un it y- ba se d or ga ni za ti on : 90 -h of

in it ia l

tr ai ni ng

on p ro m o to ra

pr ac ti ce ,f or m al tr ai ni ng

on di ab et es

kn ow

le dg e, an d pr oj ec t- sp ec ifi c

tr ai ni ng

on se lf -m an ag em

en t an d ho m e vi si ti ng :

Co m pe te nc y as se ss m en t af te r th e in it ia lt ra in in g

an d ag ai n at

6 an d 12

m o in to

th e in te rv en ti on

B im on th ly co ns ul ta ti on /

su pe rv is io n by

ps yc ho lo gi st

$8 5 pe r pa rt ic ip an t pe r m o; N ID D K :

N ot

re po rt ed

Sp en ce r et

al .7 9 (2 01 1)

R ec ru it ed

fr om

pa rt ic ip at in g co m m un it ie s;

m at ch ed

fo r et hn ic it y: N o ad di ti on al

in fo rm

at io n

N ot

re po rt ed : 80 + h tr ai ni ng

on em

po w er m en t-

ba se d ap pr oa ch es

in cl ud in g di ab et es

ed uc at io n

an d m ot iv at io na l in te rv ie w in g: Co m pe te nc y

ev al ua ti on

= no t re po rt ed

N ot

re po rt ed

N ot

re po rt ed ; N ID D K , CD

C, an d

Fo un da ti on : N ot

re po rt ed

Ta ng

et al .8 1 (2 01 4)

Pe er

le ad er : bi lin gu al , ag ed

21 + y w it h

di ab et es , re si di ng

in th e co m m un it y; CH

W :

Sp an is h- sp ea ki ng , hi gh -s ch oo l+ , hi re d by

he al th

cl in ic s, in th e sa m e co m m un it y; Pe er

le ad er : vo lu nt ee rs

CH W s: an

av er ag e 6 y of ex pe ri en ce in le ad in g

D SM

E at

CH AS S

2 nu rs e ce rt ifi ed

as di ab et es ed uc at or s, 1 di et it ia n,

an d 1 cl in ic al ps yc ho lo gi st : Pe er

le ad er = 46 -h

tr ai ni ng

ov er 12

w k on

di ab et es co m m un ic at io n,

fa ci lit at io n,

an d be ha vi or

m od ifi ca ti on , an d

sk ill s in

ex pe ri en ti al le ar ni ng

CH W = 16 0- h of co m m un it y ou tr ea ch

tr ai ni ng

an d

80 -h

of D M

ed uc at io n,

ho m e vi si ts , hu m an

pa rt ic ip an ts ; be ha vi or

m od ifi ca ti on

st ra te gi es ,

m ot iv at io na l in te rv ie w in g, co m m un it y- ba se d

pa rt ic ip at or y re se ar ch ; ha d ba si c co m pu te r/

In te rn et

sk ill s

N ot

re po rt ed

Pe er le ad er :“ on ly a m od es ts ti pe nd ”;

CH W :a sa la ry ;F ou nd at io n, N IH ,a nd

CD C

Pe er

le ad er = no t re po rt ed :

CH W s=

em pl oy ee s of

th e he al th

cl in ic

Co nt in ue d

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T A B L E 3 —

Co nt in ue d

C a rd io va

sc u la r d is e a se

p re ve

n ti o n : h yp

e rt e n si o n a s a ri sk

fa ct o r

Co op er

et al .6 1 (2 01 1)

N ot

re po rt ed : N o ad di ti on al in fo rm

at io n

N ot

re po rt ed : N ot

re po rt ed

N ot

re po rt ed

N H LB I: N ot

re po rt ed

H ill

et al .6 5 (2 00 3)

N ot

re po rt ed : N ot

re po rt ed

N ot

re po rt ed : N ot

re po rt ed

N ot

re po rt ed

N ot

re po rt ed : N ot

re po rt ed

Ja fa r et

al .6 8 (2 00 9)

N ot

re po rt ed : 6 CH

W s w it h ed uc at io n st at us

co ns is te nt

w it h th e re qu ir em

en t of

th e

go ve rn m en t- sp on so re d La dy

H ea lt h

W or ke rs Pr og ra m of

Pa ki st an

(8 or

pr ef er ab ly 10

y of

sc ho ol in g)

N ot

re po rt ed : 6- w ee k se ss io ns

in m et ho ds

fo r

us in g be ha vi or -c ha ng in g co m m un ic at io n

st ra te gi es

to co nv ey

st an da rd iz ed

he al th

ed uc at io n m es sa ge s to

st ud y pa rt ic ip an ts

N ot

re po rt ed

Sa la ry

sc al es

an d as si gn ed

w or kl oa d

co ns is te nt w it h re qu ir em

en ts of th e

La dy

H ea lt h W or ke rs Pr og ra m of

Pa ki st an ; W el lc om

e Tr us t: N ot

re po rt ed

K ri eg er

et al .7 1 (1 99 9)

N ot

re po rt ed : Pr ed om

in an tl y Af ri ca n

Am er ic an

(1 2/ 14 ), an d fr om

lo w -in co m e

ne ig hb or ho od

si m ila r to

w he re

th e pr oj ec t

w as

co nd uc te d

N ot

re po rt ed : 10 0- h tr ai ni ng

on hy pe rt en si on ,

ca rd io va sc ul ar

sy st em

, ri sk

fa ct or s fo r CV D ,

co m m un it y re so ur ce s, pr in ci pl es

of re se ar ch ,

st re ss m an ag em

en t, an d al co ho l an d ot he r

dr ug s; ce rt ifi ed

as B P m ea su re m en t sp ec ia lis ts

N ot

re po rt ed

N ot

re po rt ed ; N H LB I: N ot

re po rt ed

Le vi ne

et al .7 2 (2 00 3)

N ot

re po rt ed : N o ad di ti on al in fo rm

at io n

N ot

re po rt ed :3 -m o tr ai ni ng

on B P m an ag em

en t,

ed uc at io n,

co un se lin g, so ci al su pp or t, ou tr ea ch

an d fo llo w -u p

R N ; ad vi so ry

bo ar d su pe rv is ed

N ot

re po rt ed ; N H LB I: N ot

re po rt ed

M ar go liu s et

al .7 4 (2 01 2)

N ot

re po rt ed : 10

un iv er si ty

em pl oy ee s an d

vo lu nt ee rs w it h ba ch el or ’s de gr ee s

N ot re po rt ed :1 6- to 20 -h tr ai ni ng

on hy pe rt en si on

an d it s m ed ic at io ns , an d on

lif es ty le be ha vi or

ch an ge

N ot

re po rt ed

N ot

re po rt ed ; Fo un da ti on : N ot

re po rt ed

M or is ky

et al .7 5 (2 00 2)

N ot

re po rt ed : N ot

re po rt ed

N ot

re po rt ed : 1- m on th

tr ai ni ng

em ph as iz in g

el ic it in g is su es

du ri ng

in te rv ie w s th at

in te rf er e

w it h or

en ha nc e tr ea tm

en t ad he re nc e, an d

de ve lo pi ng

in te rv ie w sk ill s

N ot

re po rt ed

N ot

re po rt ed ; N H LB I: Pl an ne d to

be

in te gr at ed

in to

pa ti en t ca re

de liv er y sy st em

s of

th e

pa rt ic ip at in g cl in ic s

C a rd io va

sc u la r d is e a se

p re ve

n ti o n : p h ys ic al

a ct iv it y

Co le m an

et al .6 0 (2 01 2)

B ili ng ua l w om

en in th e sa m e co un ti es ,p ri or

ex pe ri en ce

w it h La ti no

co m m un it ie s,

co m pu te r sk ill s: 8 CH

W s hi re d (7

yo un ge r

th an

30 y, 6 ha d 2 y+

co lle ge

ed uc at io n)

Pr og ra m st af f an d ot he r st at e pr og ra m pa rt ne rs :

2. 5- d tr ai ni ng

on in te rv en ti on

de liv er y an d da ta

co lle ct io n; CH

W s an d st ud y st af f pa rt ic ip at ed

in

m on th ly 1- h te le co nf er en ce

m ee ti ng s

St ud y st af f

Al l CH

W s re m ai ne d em

pl oy ed

an d

w er e pa id sa la ri es ; CD

C: N ot

re po rt ed

C a rd io va

sc u la r d is e a se

p re ve

n ti o n : ch

ro n ic

d is e a se

sc re e n in g s

H un te r et

al .6 6 (2 00 4)

B ili ng ua l w om

en in

th e sa m e co un ti es :

Ex pe ri en ce

w it h ca nc er

pr og ra m s,

ad ol es ce nt

an d m at er na l an d ch ild

he al th

pr og ra m s

Co m m un it y he al th

ce nt er

st af f: Tr ai ne d in

in te rv en ti on

de liv er y, pa rt ic ip an t co ns en t, da ta

co lle ct io n,

do cu m en ti ng

ac ti vi ti es , an d

co or di na ti ng

ef fo rt s w it h co m m un it y he al th

ce nt er

st af f

N ot

re po rt ed

N ot

re po rt ed ; CD

C:

N ot

re po rt ed

Co nt in ue d

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T A B L E 3 —

Co nt in ue d

C o g n it iv e a n d m e n ta l d is o rd e rs

B ec k et

al .8 2 (2 01 3)

N ot

re po rt ed : N o ad di ti on al in fo rm

at io n

Ce nt er

st af f: 32 -h

of in -p er so n in te ra ct iv e

se m in ar s as w el la s w ee kl y ph on e ca lls

fo llo w in g

ea ch

in te rv en ti on

se ss io n

W ee kl y ph on e se ss io ns

N ot

re po rt ed ; CD

C an d N CR R : N ot

re po rt ed

Ch at te ri ee

et al .8 3 (2 01 4)

N ot re po rt ed :1 0+

ye ar so fs ch oo lin g an d go od

in te rp er so na l sk ill s

N ot

re po rt ed :T ra in ed

ov er 6 w k an d as se ss ed

fo r

co m pe te nc e w it h th e m an ua l by

in te rv en ti on

co or di na to rs (s oc ia l w or ke rs )

So ci al w or ke rs ; ps yc hi at ri st s

N ot

re po rt ed ; Tr us t fu nd : N ot

re po rt ed

W ai tz ki n et

al .8 4 (2 01 1)

B ili ng ua l tr us te d m em

be r w it h hi gh -s ch oo l

ed uc at io n+ ; 2 CH

W s: re ce pt io ni st , se cu ri ty

gu ar d

St af f (n ot

sp ec ifi ed ): 5 se ss io ns

w it h ad di ti on al

ed uc at io na l se ss io n on

de pr es si on

fo r CH

W s

N ot

re po rt ed

N ot

re po rt ed ; Fo un da ti on : N ot

re po rt ed

A st h m a co

n tr o l

M ar ti n et

al .8 5 (2 00 9)

N ot

re po rt ed : 3 CH

W s

N ot

re po rt ed :1 13 -h tr ai ni ng

on as th m a, sp ec ifi c

tr ai ni ng

by in ve st ig at or s an d ha nd s- on

ex pe ri en ce

to es ta bl is h re la ti on sh ip s w it h

pa rt ic ip an ts , ho m e vi si ts , an d se lf -

m an ag em

en t te ch ni qu es : Co m pe te nc y

ev al ua ti on

= st an da rd iz ed

ro le -p la y sc en ar io

to ex am

in e ea ch

CH W ’s ac hi ev em

en t of

th e ob je ct iv es

an d re ad in es s fo r

th e fi el d

So ci al w or ke ra nd

in ve st ig at or s

N ot

re po rt ed ; N H LB I: N ot

re po rt ed

M e d ic a ti o n sa fe ty

W an g et

al .8 6 (2 01 3)

Co m m un it y m em

be rs su gg es te d by

th e le ad er

of th e he al th

ce nt er : 11

vo lu nt ee rs ; hi gh -

sc ho ol ed uc at io n+ ;1 + y of ex pe ri en ce at th e

he al th

ce nt er

N ot

re po rt ed : Si x 4- h cl as se s w it h on e 2- h

ev al ua ti on ;1 2- h of

fo rm

al tr ai ni ng

an d 24 -h of

se rv ic e ex pe ri en ce

at th e he al th

ce nt er ;

re ce iv ed

a he al th

ca re

vo lu n te er

tr ai ni ng

ce rt ifi ca te

N ot

re po rt ed

Vo lu nt ee rs ; N at io na l Sc ie nc e Co un ci l

of Ta iw an : N ot

re po rt ed

N o te . A B C D = A 1 C , b lo o d p re ss u re , ch

o le st e ro l, a n d d e p re ss io n ; A C S = A m e ri ca n C a n ce

r S o ci e ty ; B P = b lo o d p re ss u re ; C D C = C e n te rs

fo r D is e a se

C o n tr o l a n d P re ve

n ti o n ; C H A S S = C o m m u n it y

H e a lt h a n d S o ci a l S e rv ic e s;

C H D = co

ro n a ry

h e a rt

d is e a se

; C H W

= co

m m u n it y h e a lt h w o rk e r; C M S = C e n te rs

fo r M e d ic a re

a n d M e d ic a id

S e rv ic e s;

C V D = ca rd io va

sc u la r d is e a se

; D H H S = U S

D e p a rt m e n t o f H e a lt h a n d H u m a n S e rv ic e s;

D M

= d ia b e te s m e ll it u s;

D S M E = d ia b e te s se

lf -m

a n a g e m e n t e d u ca ti o n ; F Q H C = fe d e ra ll y q u a li fi e d h e a lt h ce

n te r; IC R E T T = In te rn a ti o n a l C a n ce

r T e ch

n o lo g y T ra n sf e r; JT

H = Jo

u rn e y to

H e a lt h ; N C I=

N a ti o n a l C a n ce

r In st it u te ; N C R R = N a ti o n a l C e n te r fo r R e se

a rc h R e so

u rc e s;

N H L B I=

N a ti o n a l H e a rt , L u n g , a n d B lo o d In st it u te ;

N ID D K = N a ti o n a l In st it u te

o f D ia b e te s a n d D ig e st iv e a n d K id n e y D is e a se

s; N IH

= N a ti o n a l In st it u te s o f H e a lt h ; N IM

H D = N a ti o n a l In st it u te

o n M in o ri ty

H e a lt h a n d H e a lt h D is p a ri ti e s;

N H L B I=

N a ti o n a lH

e a rt ,L u n g ,a n d B lo o d In st it u te ;P

I= p ri n ci p a li n ve

st ig a to

r; R E A C H = R a ci a la

n d E th n ic A p p ro a ch

e s to

C o m m u n it y H e a lt h ;R

N = re g is te re d n u rs e ;S

P S C = S a lu d P a ra

S u C o ra zó n ;

T 2 D M

= ty p e 2 d ia b e te s m e ll it u s; W IS E W O M A n = W e ll -I n te g ra te d S cr e e n in g a n d E va

lu a ti o n fo r W o m e n A cr o ss

th e N a ti o n .A

fu ll e r ve

rs io n o f th is ta b le

is a v a il a b le

a s a su

p p le m e n t to

th e o n li n e

ve rs io n o f th is

a rt ic le

a t h tt p :/ /w

w w .a jp h .o rg .

a T yr re ll e t al .9 5 (1 9 9 6 ). O ld e r w o m e n h e lp in g o ld e r w o m e n : e m p lo yi n g se n io r w o rk e rs

in co

m m u n it y re se ar ch

.

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community.32,36,50,56,66,80,86 Studies addressing women’s health–related diseases or recruiting only female participants used gender as one of the selection criteria (n=16).27,28,31,32,35,37,39,40,42,44,49,52,53,60,64,66

Two studies addressing women’s cancer screening specified age selection criteria as 55 years or older37 and 40 years or older.40

Training and supervision of community-based health workers. Allbut8studies30,42,44,48,51,61,65,76

reported information regarding training of CBHWs, yet the extent and breadth of such information varied. Occupation of trainers varied from health center staff to study team members including study coordinators and investigators. One study used previously trained CBHWs from community-based organizations as trainers.57 The length and duration of training ranged from 454 to 240 hours81 with an average of 41.3 hours (median = 16.5 hours) in 24 studies that re- ported length of training. The CBHWs with shorter training tended to serve relatively simple roles such as recruitment and educa- tion,38,40,73 whereas CBHWs with longer training tended to take on additional roles including data collection, care management or coordination, and navigation assistance. Longer training also encompassed both knowledge-based and competency-based contents such as motivational interviewing techniques and computer or Internet skills.67,79,81,85,96 For example, in Tang et al.,81 CBHWs received 240 hours of training covering both intervention-specific (e.g., diabetes education and home visit) and general contents (e.g., human participants and computer skills). Training was delivered via didactics and interactive sessions encompass- ing relevant health information as well as interviewing and teaching skills.

Competency evaluation was only reported in 9 studies. Studies reported that the com- petency of CBHWs was evaluated after training by using mock educational ses- sions,28,34 role-playing scenarios,85 or written assessments.29,55 The CBHWs received continual training after initial training sessions through monthly skill-building sessions in 3 studies.32,53,78

Supervision of CBHWs was largely underreported. Twenty-nine (48%) studies reported details of CBHW supervision for quality control. In these studies, CBHWs were supervised by the study team

members including study coordinators (n = 13),27,28,32,37,41,43,49,53–55,60,69,82

clinic staff (n = 7; e.g., community health directors, nurse case man- agers),33,45,63,64,72,83,85 CBHW co- ordinators (n = 2),40,43 and study psychologists (n = 2).73,78 Supervision was imparted by weekly or monthly meetings with the study team mem- bers,27,32,37,43,50,73,82 direct observations by the supervisors, or both.28,44,53,63 In 1 study, the fidelity of the intervention was main- tained by having CBHWs document details of intervention implementation, including outcome of home visit attempts, types of study materials used, and follow-up phone calls.52 No studies reported the amount of time spent in supervision, limiting an un- derstanding of the resources (personnel and cost) needed to support CBHWs.

Reimbursement and sustainability of community-based health workers. Twenty- three of 61 studies (38%) reported details of payment to CBHWs. Hourly rates of CBHWs from those reported ranged from $12.11 per hour31 to $22.26 per hour.89 Two studies reported that the CBHWs were paid $1500 after recruiting 20 to 22 participants from their social networks and providing group sessions.35,40 Funding sources of CBHWs were mostly from study grants. The CBHWs were also employed by a managed care organization26 or compensated by a community-based organization.57 In some studies, CBHWs were entirely volunteer- based without pay.29,86 The inclusion of CBHWs into the health care system as a way to improve the care of vulnerable populations was rarely discussed. However, some studies pointed out that sustaining CBHWs beyond the funding period was made possible through establishment of long-term, nonfederal funds (philanthropic and local agency funding) for CBHWs.57,77 Other studies maintained and expanded CBHW interventions following the cessation of grants by exporting the in- terventions into other settings such as out- patient clinics,75 community sites,77 and rural or other urban communities.48

DISCUSSION To our knowledge, this is the first sys-

tematic review that provides a critical

appraisal of CBHW interventions targeting vulnerable populations with or at risk for noncommunicable chronic diseases. Overall, we found that CBHW interventions were effective in promoting CVD risk reduction, cancer screening, and cognitive functioning, although mixed results were also noted by studies. The 2015 Community Preventive Services Task Force report also revealed that CBHW interventions are effective in con- trolling blood pressure and cholesterol among patients who are at risk for CVD.97 There was insufficient evidence to support CBHWs in addressing mental disorders. In addition, there was insufficient evidence concerning the cost-effectiveness of CBHW interventions.

There was no consistency in terms of the duration and intensity of CBHW training in the included studies. In fact, more than half of the studies lacked full descriptions of CBHW training and fidelity monitoring; many failed to describe the characteristics of CBHW and criteria for their selection. When CBHWs received rigorous training, patient outcomes related to cancer prevention and cardiovas- cular risk reduction were significantly im- proved. For example, CBHWs in the Prezio et al. study77 were required to obtain a state-level certificate. In the study, the CBHW intervention group had a significant decrease in HbA1C compared with the usual care group (1.6% vs 0.9%; P < .05; re- spectively). Staten et al.80 argued that ques- tionable competency levels of CBHWs before studies and variability in fidelity of CBHW intervention implementation could be possible explanations for nonsignificant effects found in some studies. Previous sys- tematic reviews17,19 underscored the im- portance of required training andcompetency levels in relation to assigned responsibilities. Limited yet growing research has focused on the degree to which CBHWs can achieve their competency levels to serve successfully as an interventionist in vulnerable pop- ulations. There is a strong need for studies to clearly elaborate the contents and processes of CBHW training such as competency evalu- ation and supervision to optimize the use of this approach.

Our findings offer implications for the successful delivery of CBHW in- terventions as part of patient-centered and community-oriented care teams. As “nat- ural helpers,” CBHWs play an essential role

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in bridging between the health care services and the communities they serve.98 In par- ticular, their natural helper roles98,99

building on trust, rapport, and an ability to communicate with the community draw much attention to CBHWs as part of patient-centered care teams. Indeed, CBHWs delivered both medical (e.g., cul- turally tailored health education) and non- medical services (e.g., social support, social services) in the studies included in this re- view. Nevertheless, their natural helper roles were not easily quantifiable and created difficulty in evaluating the quality of the work of CBHWs. A recent diabetes management study100 developed and used a comprehensive CBHW encounter form that seems to offer a promising avenue for monitoring and evaluating CBHW work in a naturalistic setting. In the study, Lemay et al.100 argued that CBHWs’ daily activities with patients as captured and documented in a standardized encounter form need to be incorporated into a patient’s medical record. This information may help establish a foundation for proper payment for CBHWs’ services.

Cherrington et al.101 acknowledged that paid CBHWs tend to cover a wider scope of work, be more flexible in terms of scheduling, and produce the full impact of which they are capable. In countries such as the United States and some Asian countries such as Pakistan, where the included studies were conducted, failure to secure sustainable funding sources for CBHWs appears to be a major barrier to the full integration and maintenance of this model into health care delivery systems.

A few recent examples present promising avenues for working with CBHWs as a re- imbursable, alternative model of care for vul- nerablepopulations.Forexample,2statesinthe United States, Minnesota and Massachusetts, initiated policies to cultivate CBHWs. In re- sponse to a lack of a health care workforce and an increase in diverse populations, Massachusetts recognized CBHWs as an es- sential component of the state health care workforce; however, many CBHWs in Massachusetts still rely on federally funded or philanthropic programs, rather than a statewide funding program.102 Minnesota made diagnosis-related (e.g., patient education), not social service–related, CBHW services re- imbursable under Medicaid if the CBHWs

completed a 14-credit certificate program and worked under the supervision of Medicaid-approved health care professionals such as physicians, advanced practice nurses, dentists, public health nurses, and mental health providers. This was the first state in the United States to establish a potentially sustainable funding source to maintain CBHWs.103

Only 8 articles (13%) documented cost– benefit analyses associated with the in- tegration of CBHWs into the health care delivery system for prevention and manage- ment of chronic conditions that most often overburden vulnerable populations. The ACA—also called Obamacare or Affordable Care Act—aims to increase the quality and affordability of health insurance, lower the uninsured rate by expanding public and private insurance coverage, and reduce the costs of health care for individuals and the government. The ACA acknowledges the essential role of CBHWs in improving health behaviors and outcomes by indicating CBHWs as an important part of health care teams for the delivery of care, particularly among medically underserved populations and communities. The ACA emphasizes the need for CBHWs in communities with a high rate of uninsured but eligible individuals with a high percentage of chronic diseases or infant mortality; ACA calls for more attention to be focused on tailored interventions responsive to multifaceted, underlying challenges threatening communities.104 The ACA presents unprecedented opportunities to in- clude CBHWs as a core component of medical teams, promoting health behaviors and outcomes as a sustainable part of the health care system. Clearly, more systematic cost evaluations of collaborating with CBHWs as an alternate care model are warranted to expedite the translation of re- search into evidence-based guidelines and recommendations for clinical practice in vulnerable populations.

There are methodological issues to be taken into consideration when one is inter- preting the findings in this review. Although 39 of 67 studies (58%) were of high quality, many studies lacked methodological rigor, which might have led to false-negative results (no effects of CBHW interventions). For example, studies without a priori power analysis failed to find significant effects for CBHWs.62,66,73 In addition, approximately

1 in 4 studies did not report the number or reasons for participant drop-outs, and 31 studies used per-protocol analysis instead of intent-to-treat analysis. About half of the studies were conducted without the guidance of a theoretical framework, which might have resulted in mixed results in some selected studies inthisreview.A theoretically grounded CBHW intervention can strengthen the the- oretical underpinnings of CBHW practice.105

In some studies CBHWs took on both traditional outreach and recruitment re- sponsibilities, as well as the delivery of the intervention.42 This dual role is likely to have led to the disclosure of group allocation, hence threatening the internal validity of the results. Future studies should address these issues by calculating proper sample size a priori, con- ducting intent-to-treat analyses, and conceal- ing group assignments.

Limitations A few limitations of this review should be

noted. First, because many terms are used to describe CBHWs and front-line outreach public health workers, it is possible that we did not extract all relevant articles in the existing literature. However, to avoid this, in addition to hand searches of reference collections, we conducted a systematic electronic search using a comprehensive list of Medical Subject Headings terms as well as similar keywords, such as lay health advisor or lay health counselor, after a consultation with a trained health science librarian. Nonetheless, given the diversity in the CBHW literature—including gray litera- ture such as research findings outside of academia or reports from organizations— publication bias may exist. The inclusion of gray literature might have offered a more comprehensive understanding of CBHW characteristics and roles.

Second, the CBHW workforce was de- veloped to predominantly serve vulnerable populations, though it is possible that some skills can be used for other populations. Thus, our findings may not be applicable to other populations such as mid- or high- income populations. Third, we included only articles written in English; therefore, we limited the generalizability of the find- ings concerning studies published in non- English languages. Fourth, some studies

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included CBHWs as 1 part of a multifaceted intervention and did not test the effective- ness of CBHWs separately. Therefore, caution should be taken when one is interpreting the effects of CBHWs. Finally, we arbitrarily categorized studies with quality ratings of 0 to 4, 5 to 8, and 9 or more as low-, medium-, and high-quality studies, respectively. We considered that each item is an equally weighed factor that constitutes study quality. However, one might argue that certain factors (e.g., how a study is ran- domized) may contribute to its quality rating more so than others.

Conclusions Working with CBHWs to deliver im-

portant health-related interventions is a growing trend. As CBHWs are typically trusted members of their communities with whom they share the same cultural and lin- guistic backgrounds and life experiences, they are ideally positioned to provide tailored, culturally responsive interventions. Thus, CBHWs have a unique role in facilitating community health promotion and may be the mechanism by which to establish close ties between health care providers and commu- nity members. Also, CBHW models support the movement from a health care system that focuses only on “sickness care” to one that is also “prevention-focused.” As Rosenthal et al.103 pointed out, integration of CBHW models into the health care system appears to be an effective strategy for restructuring pri- mary care delivery, and focuses on accessible, continuous, comprehensive, compassionate, and culturally effective care.

In conclusion, our review of 67 articles shows that CBHWs can be an effective in- tervention model that is also cost-effective for certain health conditions (e.g., high blood pressure, diabetes) or behaviors (e.g., mam- mogram and Pap test use) for low-income, underserved, and racial and ethnic minority communities. Our findings support the use of CBHWs as an intervention model and suggest as well the need for more rigorous and continued evaluations of this approach for a wide range of conditions and populations.

CONTRIBUTORS K. Kim reviewed records and articles for eligibility, re- trieved and coded the relevant articles, and cowrote the

article. J. S. Choi retrieved and coded the relevant articles, and cowrote the article. E. Choi reviewed records and articles for eligibility and provided critical comments on the article. C. L. Nieman, J. H. Joo, F. R. Lin, and L. N. Gitlin provided substantive contributions, including ad- vice on the coding scheme and directions, and made substantive edits to the article. H.-R. Han originated the project, designed the coding scheme, led the writing, and, along with K. Kim, J. S. Choi, and E. Choi, reviewed studies.

ACKNOWLEDGMENTS This study was supported, in part, by a grant from the National Cancer Institute (R01CA129060). Additional resources were provided by Center for Cardiovascular and Chronic Care and Center for Innovative Care in Aging at the Johns Hopkins University School of Nursing.

We would like to express our appreciation to our re- searchassistants,BetsegaAwelachewandJudyLiu,fortheir work in article search and data extraction.

Note. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

HUMAN PARTICIPANT PROTECTION This is a systematic review of published articles. In- stitutional review board approval was not needed.

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