Community Health Workers as

an Intervention

Implementation Strategy in

Health Promotion Research

Lisa Quintiliani, PhD

Assistant Professor of Medicine

November 29, 2016

AHRQ, Outcomes of Community Health

Worker Interventions, No. 09-E014

What is a Community Health Worker?

Individuals who share a relationship with their

community who are not professionally

trained/licensed who serve as a bridge to

health care services and/or health promotion

services

Community Health Workers

Those who share one or more attributes with

target population called peers

Age

Language

Race/ethnicity

Medical condition

Peers can provide effective support due to their

‘insider knowledge’

https://www.youtube.com/watch?v=xcLpcwMR8rU

Peers for Progress, peersforprogress.org

Roles of Peers

1) Assistance in management of health behavior

How to test blood glucose

2) Provide social/emotional support

Overcome/cope with barriers

3) Linkage to health services

Referral to community programs; schedule appointments

4) On-going support

Maintain relationship over time

5) Behavioral counseling,

Systematic, evidenced-based

=Peer Counselors

Efficacy of community health worker

interventions Clinical outcomes

Blood pressure control (Browstein), hemoglobin A1c

(Long)

Health behaviors: diet (Keyserling)

Review involving 53 studies with community health

workers by AHRQ (Viswanathan)

Overall support for use of community health workers,

although results were mixed for behavior change and health

outcomes

Interventions targeting weight management were limitied

My program of research with peer

counselors Diet and physical activity behaviors

Trial with non-traditional college students peer

counseling (Quintiliani, 2016)

On-going trial among residents of Boston’s public

housing developments

Nontraditional college students

Large and growing population of college

students

Attend part-time, work full-time, have

dependents, are usually older

Tend to face different social and physical

environments compared to traditional college

students

Study design

2 group randomized trial with 2:1

randomization

Setting: Large, urban university

7 college students began training, 4

completed and served as peer counselors

current or recent undergraduates

3 MI telephone calls focused on 4 behavioral

topics using paper-based guide

Primary outcome

Diet and physical activity (self-reported)

Participant characteristics

Variable Intervention

(n=40)

Comparison

(n=20)

Total

(n=60)

Age, mean (SD) 32 (10) 32.3 (10) 32.2 (10)

Gender, % female 62 50 58

Hispanic/Latino, % 10 15 12

Race, % White

% Black

% 2 or more races

% other

37

22

25

17

60

5

5

30

45

17

17

22

Single, % 65 55 62

Employed, % 70 70 70

Children to support, % 17 20 18

Medicaid, % 27 20 25

Food stamps, % 23 16 21

Behaviors at Baseline

Variable Intervention

(n=40)

Comparison

(n=20)

Total

(n=60)

Fruits & vegetables,

mean (SD) servings/day 3.5 (1.7) 4.6 (1.7)* 3.9 (1.8)

Sugary drinks,

mean (SD) fl ounces/day 24.9 (29.3) 15.1 (17.5) 21.6 (26.3)

Fast food,

mean (SD) visits/week 2.8 (3.2) 2.6 (3.8) 2.7 (3.4)

Mod-vigorous physical activity,

mean (SD) min/week 221 (238) 192 (135) 212 (210)

*=significant difference b/t intervention and comparison groups

Intervention Dose

Most (78%) intervention group participants completed at least 2 peer counseling calls 42% received all 3 calls

Change in behavior

Variable Change from

baseline

Intervention

(n=37)

Change from

baseline

Comparison

(n=17)

Effect size

Fruits & vegetables,

mean (SD) servings/day

0.8 (1.6) 0.09 (1.3) 0.2

Favors intervention

Sugary drinks,

mean (SD) fl ounces/day

-6.8 (29.4) -0.5 (17.1) 0.01

Favors intervention

Fast food,

mean (SD) visits/week -1.5 (2.7) -1.3 (2.8)

0.1

Favors intervention

Mod-vigorous physical

activity,

mean (SD) min/week

% meeting rx at follow-up

-7.2 (200)

71

100 (187)

69

-0.6

Favors comparison

Next stepsHow can we creatively combine computer-based

technologies with community health workers to

improve prevention of chronic disease (and

implementation in the process)?

Fidelity in intervention design &

delivery Technology could assist in increasing fidelity

related to training and delivery for CHWs Consistency of delivery between interventionists &

participants

Motivational interviewing as a case study Preserving the ‘spirit of MI’ without sacrificing

consistency of delivery of core components

Community health workers supported by an eHealth program to enable standardized, evidenced-based behavioral counseling using motivational interviewing

Resnick et al., 2005; Hecht et al., 2005

Weight management intervention using

community health workers

Setting: Public housing developments

Study objective

Determine if peer counseling using eHealth

program demonstrates preliminary efficacy

and feasibility

Two-group trial, 74 per group

Comparison group = brief tailored feedback report

Intervention group = brief tailored feedback report

+ 12 weeks of MI-based phone counseling from a

peer counselor using eHealth program

Community health worker-based

intervention Peer counselor training

2 counselors living in housing developments and

surrounding communities

Behavioral counseling using small changes

approach

12 sessions (in-person & phone)

Text messaging

Use eHealth program called CuesWeight

Bennett et al., 2009; 2012 & Lutes et al., 2013

CuesWeight

Structured guided content

Wording suggestions

Sentence stems for reflections

Flexible enough for adding your ‘own spin’

Additional suggestions & questions

Useful for training, delivery of sessions &

quality assurance activities

Usability sessions

User informants (n=3)

1-3 sessions

Think aloud protocol

Perceived usefulness and perceived ease of

use

Range of 1 (best) to 7 (worst)

1.7 for both scales

Layout of session content

Feedback

Educational topic

Social contextImportance/Confidence

Motivation assessment & goal setting

Like the idea of

goal

setting/letting

them pick their 3

behaviors Asterisks for

exact language

sections are

good

radio button for

reflection is a

good reminder

for the

counselor

Summary of Measured Trial

OutcomesMeasure Source Baseline 3 mo.F/UP

Acceptability among participants &

counselors

Qualitative

interview X

Fidelity of implementation

# sessions reaching MI proficiency

# completed sessions

session review

database

X

X

Efficacy

BMI (weight/height)

Diet (F&V, fast food, sugary drinks)

Physical activity

Obj. measured

Survey

Accelerometer

X

X

X

X

X

X

Mediation

Self-efficacy, motivation, social

support

Survey X X

Socio-demographics Survey X

Efficacy of community health worker

interventions Clinical outcomes

Blood pressure control (Browstein), hemoglobin A1c

(Long)

Health behaviors: diet (Keyserling)

Review involving 53 studies with community health

workers by AHRQ (Viswanathan)

For behavior change and health outcomes, results were

mixed

“CHW interventions have the potential to address two

fundamental imperatives in improving health care in the

United States: the need to address substantial and

persistent health care disparities and the need to

translate more research into practice. CHWs, by virtue of

their role as a bridge to the health care system, can help

to disseminate widely efficacious interventions to

populations that rarely benefit from health care

advances.” (Viswanathan)

Need for the study of the

implementation and dissemination of

peer counseling programs

Translating from research to practice = less

control & resources; but potential for wide

impact

Research Tested Intervention Programs

https://rtips.cancer.gov/rtips/index.do

Implementation science

Implementation science can help us better

understand issues surrounding roll out,

adoption, and upkeep of these interventions

in community based settings

Case study: Body & Soul

Case study: Body & Soul

RTIPs website

Community-based program,

setting/population is African American church

members

Diet (fruit and vegetables) outcome

Positive results from earlier efficacy studies

led to support from NCI and ACS to

spearhead for further implementation

Body & Soul intervention

Intervention:

Pastoral involvement

Incorporation of health into sermons

Educational activities

Opportunities to sample & prepare fruit & vegetables

Church-wide environmental changes

establishing guidelines for the types of foods served at

church functions or changing snacks served at youth

camps

Peer counseling

Peer counselors are trained and conduct at least two

motivational counseling calls

Resnicow, 2004

Efficacy/effectiveness of Body & Soul

Training and technical support provided to

staff, but limited researcher involvement

Baseline to 6 month follow-up

Approximately 1 serving increase in

intervention churches vs control churches

(Resnicow)

Body & Soul: Dissemination study

Positive results led to the dissemination study

Disseminated directly to the target audience

Without researcher or agency support in training

or (planned/structured) technical assistance

15 churches, with a predominately African

American membership

Church coordinator identified in each

8 randomized to intervention and 7 to control

RE-AIM used as evaluation framework

Intervention churches

Church coordinator selected planning team

and together implemented intervention

activities

Including identifying & training peer counselors

Peer counselor training video:

https://rtips.cancer.gov/rtips/viewProduct.do?viewMode=pre

view&productId=1081867

Peer counselor handbook

Peer counseling coordinating guide

RE-AIM results

Implementation of peer counseling

Took 1-2 months post-baseline to complete training

Peer counselors found video to be culturally

appropriate & appropriate religious images

Allicock, 2013, 2010

Implementation of peer counseling

2 of 11 churches completed full training

Most only completed about half of the training

7 conducted a follow up training

Only a few coordinators reviewed training materials prior

to training

Barriers were logistical: recruiting, scheduling,

preparation work

Lower than expected exposure to intervention

likely had impact on lack of intervention

effectiveness

1/3 of participants recalled speaking to a peer counselor

Facilitators to use of peer

counselors/community health workers

in dissemination efforts Support for intervention fidelity

Technology-based approaches

Technical assistance

Supporting those implementing the intervention

Maintain motivation to participate by removing

barriers

Master trainers or organizations that could

share lessons learned with new settings

Organizational readiness to adopt programsAllicock 2010, 2013; Weiner 2009

Conclusions

Community health workers offer significant

opportunities to reach health disparity

populations & provide standardized,

evidenced-based behavioral counseling for

health promotion

Dissemination and implementation potential

could be enhanced with computer-based

technologies

Future implementation science efforts should

focus on studying adoption and spread of

interventions

References

Brownstein J, Chowdhury F, Norris S, Horsley T, Jack L, Zhang X, Satterfield D. Effectiveness of community

health workers in the care of people with hypertension. American Journal of Preventive Medicine. 2007;32(5):435–

447.

Long JA, Jahnle EC, Richardson DM, Loewenstein G, Volpp KG. Peer mentoring and financial incentives to

improve glucose control in African American veterans a randomized trial. Annals of Internal Medicine.

2012;156(6):416–424.

Keyserling T, Hodge C, Jilcott S, Johnston L, Garcia B, Gizlice Z, Gross M, Savinon C, Bangdiwala S, Will J,

Farris R, Trost S, Ammerman A. Randomized trial of a clinic-based, community-supported, lifestyle intervention to

improve physical activity and diet: The North Carolina enhanced WISEWOMAN project. Preventive Medicine.

2008;46(6):499–510.

Viswanathan M, Kraschnewski J, Nishikawa B, Morgan L, Thieda P, Honeycutt A, Lohr K, Jonas D. Outcomes of

Community Health Worker Interventions. Evidence Report/Technology Assessment No. 181. AHRQ Publication

No. 09-E014. Rockville MD; 2009.

Resnicow K, Kramish Campbell M, Carr C, McCarty F, Wang T, Periasamy S, Rahotep S, Doyle C, Williams A,

Stables G. (2004). Body and Soul. A Dietary Intervention Conducted Through African-American Churches.

American Journal of Preventive Medicine, 27(2), 97-105.

J Nutr Educ Behav. 2012 Nov-Dec;44(6):530-8. doi: 10.1016/j.jneb.2011.09.002. Epub 2012 Mar 9. Evaluating

the dissemination of Body & Soul, an evidence-based fruit and vegetable intake intervention: challenges

for dissemination and implementation research. Allicock M1, Campbell MK, Valle CG, Carr C, Resnicow

K, Gizlice Z.

Allicock M, Campbell MK, Valle CG, Barlow JN, Carr C, Meier A, Gizlice Z. Patient Educ Couns. 2010

Oct;81(1):37-42.Evaluating the implementation of peer counseling in a church-based dietary intervention for

African Americans.

Weiner BJ. A theory of organizational readiness for change. Implementation Science 2009 4:67