MHP Salud White Paper

MHP Salud implements Community Health Worker programs to empower underserved Latino communities and promotes the CHW model nationally as a culturally appropriate strategy to improve health.

Community Health Workers & Diabetes Interventions:

A Resource for Program Managers and Administrators

mhpsalud.org© MHP Salud 2020

What is Diabetes and How Prevalent is it in the US?

Over 30 million people in the United States (or 9.1% of the population) have Diabetes. About 7 million of those with diabetes have not been formally diag-nosed. Diabetes is widespread across a wide variety of subgroups of the US population:

◊ Diabetes is more prevalent among peopleof Hispanic ethnicity (12.1%), non-Hispanicblacks (12.7%), and American Indians/Alaska Natives (15.1%) than non-Hispanicwhites (7.4%) or Asians (8.0%).

◊ In 2015, individuals 45 – 64 had the highestincidence rate of diabetes at 10.9%. Individ-uals 65 and older had an incidence rate ofdiabetes of 9.4%.

◊ 12.6% of adults with less than a high schooleducation in 2015 had diagnosed diabetes,vs 7.2% of those with greater than a highschool education (National Diabetes Statis-tics Report, 2017).

◊ A diagnosis of diabetes can bring significantcosts to both individuals and communities.For communities, it is a public health con-cern: in 2015, diabetes was the seventhleading cause of death in the nation, withover 250,000 deaths attributed to the dis-ease. Not only is diabetes deadly, it is alsocostly to the individuals experiencing it. Theaverage medical expenditures for people di-agnosed with diabetes was about $13,700annually. About $7,900 of this amount wasattributed directly to diabetes, which is 2.3x higher than expenditures for people with-out diabetes. (National Diabetes StatisticsReport, 2017).

There are many potential complications related with diabetes. Examples of complications include: heart disease, eye disease,nerve damage, kidney disease, gum disease, blood circulation problems, foot sores, delayed digestion, sexual dysfunction, and depression. Fortunately, byadequately treating and managing diabetes on the individual level, many of these complications related to the disease can be avoided. By implementing an intervention that focuses on individual behavior change, health centers and community organizations can effectively address the needs of patients with diabetes and help them to successfully manage their condition. Community Health Workers (CHWs) are an excellent resource for assisting individuals on their path to behavior change and management of their condition. CHWs are “frontline public health worker(s) who [are] a trusted member of and/or [have] an unusually close understanding of the community served.” (APHA, n.d.). CHWs’ combination of understanding of the community and trusting relationships with individuals play a key role in educating and addressing health issues like diabetes, as well as connecting individuals to vital health and social services.

The efficacy of CHW-led interventions targeting diabetes prevention and management has been well documented in scientific literature. The positive health outcomes related to CHW-led diabetes interventions include individual and community level benefits.

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Community Health Workers & Diabetes Interventions:A Resource for Program Managers and Administrators

vMHP Salud promotes the Community Health Worker (CHW) profession nationally as a culturally appropriate strategy to improve health and implements CHW programs to empower underserved Latino communities.

Evidence of Success: How Have CHWs addressed Diabetes in the Past?

© MHP Salud 2020

MHP Salud promotes the Community Health Worker (CHW) profession nationally as a culturally appropriate strategy to improve health and implements CHW programs to empower underserved Latino communities.

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Community Health Workers & Diabetes Interventions:A Resource for Program Managers and Administrators

How do CHW-led diabetes interventions positively impact individual patients?◊ Improvements in A1C levels: One of the most commonly reported positive health outcomes in CHW-

led diabetes interventions is the improvement/stabilization of A1C levels reported in patients. Thehemoglobin A1C test is a marker widely used to diagnose pre-diabetes and diabetes and to monitordiabetes control in patients. Collinsworth, Madhulika, Schmidt, & Snead, 2013; Ingram, et al., 2007;Palmas et al., 2015; Spencer et al., 2011)

◊ Increased physical activity: Studies have reported that CHW-led interventions have resulted in in-creased physical activity of participants, a key factor in preventing and managing diabetes. (Rothschildet al., 2014)

◊ Improved mental health and decreased diabetes distress: A 2015 study showed that CHW-led stressmanagement exercises were successful when incorporated into diabetes education and managementclasses. Mental stress has been shown to worsen glycemic control among persons with type 2 diabetes(Wagner et al, 2015), so addressing mental state is a key element in addressing diabetes holistically.

◊ Greater patient understanding of their disease: Frequently reported is the increase in participants’knowledge regarding how to prevent and manage diabetes. Results have been significantly betterwhen participating in CHW-led interventions as compared to control groups. (Spencer et al., 2011;Wagner et al, 2015).

How do CHW-led diabetes interventions positively impact organizations and communities?The benefits of CHW-led interventions targeting diabetes do not end with individual health outcomes. Several studies have also shown positive community-level benefits of CHW-led interventions:

◊ Reducing disparities: Disparities in prevalence of type 2 diabetes and complications in underservedpopulations have been linked to poor quality of care including lack of access to diabetes managementprograms (Walton et al., 2012). By providing access to cost-effective care, CHWs have been able to suc-cessfully address and mitigate these health disparities.

◊ Reducing ER utilization and medical costs: CHW interventions have resulted in decreased rates of un-necessary ER usage and decreased medical costs. In a CHW Outreach Program implemented in WestBaltimore City in the early 1990s targeting Medicaid Patients with diabetes, total ER visits declined by40% and Medicaid expenditures declined by 27%. The CHW program resulted in an average savings of$2,245 per patient per year, and a total savings of $262,080 for 117 patients, with improved quality oflife indicating cost effectiveness (Fedder, D. O. et al., 2013).

◊ Improving patient/provider satisfaction and coordination: In a survey assessing patient and providersatisfaction of a CHW-led diabetes intervention, 97% percent of patients were satisfied with the CHWs’support, and providers reported a very high comfort level in referring patients to CHWs. Patients andphysicians also reported higher satisfaction with overall care. By acting as a liaison between patientsand providers, CHWs positively impact the relationship of both parties, and ultimately the care the pa-tient receives. (Otero-Sabogal et al., 2010)

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Curricula and Resources for addressing Diabetes through CHWs

As CHWs have proven effective in addressing diabetes pre-vention and management by targeting behavior change in individuals, a variety of resources and curricula have been developed to assist organizations interested in implement-ing CHW diabetes programs within their own communities. Several are listed here, but this list should not be consid-ered all-inclusive.

Center for Disease Control’s Road to Health ToolkitTogether with the National Diabetes Education Program, the Center for Disease Control has developed The Road to Health Toolkit, a free, informational resource for Commu-nity Health Workers, nurses, dietitians and health educators alike. The overall goal of this toolkit is to share the mes-sage that type 2 diabetes is preventable and can be delayed in high risk groups. This toolkit consists of a user’s guide, flipchart, activities guide, quiz, educational posters, training videos, booklets, music and podcasts. Also included in the toolkit is an evaluation guide. The guide assists in measur-ing outreach and target audience, changes made by partici-pants, and key demographic data (CDC, 2016).

The flipchart is the primary instrument in this toolkit. The flipchart serves a dual purpose: it is a visual aid for the par-ticipant, and has notes for the instructor on the opposite side. The flipchart is divided into three topic areas: preven-tion and weight loss, healthy food choices, and increasing physical activity. Using findings from the Diabetes Preven-tion Program’s study, the toolkit aims to motivate individu-als at high risk to:

◊ lose 5 to 7 percent of their body weight, if they are con-sidered overweight;

◊ achieve and maintain weight loss through healthy foodchoices, eating low-fat foods, and reducing the totalnumber of daily calories consumed;

◊ and engage in moderate-intensity physical activity forat least 30 minutes a day, 5 days a week (The Road toHealth Toolkit, 2008).

The Road to Health Toolkit has been designed to be a viable option for both English and Spanish language audiences. The Toolkit is also available in Spanish as Kit El Camino Hacia la Buena Salud. (CDC, 2017). In both of these languages, the Toolkit has been tailored for different populations that experi-ence high rates of diabetes: the English version of the kit is designed to be culturally appropriate to the African American community, while the Spanish version is catered to cultural aspects of Hispanic and Latino populations. Although the ex-amples and themes in the toolkit are designed to be appropri-ate to these specific cultural groups, the curriculum and data used are identical and can be used within any cultural group.

Other Curricula and ResourcesBeyond The Road to Health Toolkit, the CDC provides a wide selection of resources and curricula relating to diabetes pre-vention and management. The PreventT2 Curriculum is a 12-month program that promotes lifestyle change throughself-efficacy, physical activity and diet. This curriculum consistsof 31 sessions, all available in both English and Spanish. Mostof the sessions also include handouts for program participants,which are available in both languages (CDC, 2017).

Other available models and resources focus on management rather than prevention. The Diabetes Initiative, funded by the Robert Wood Johnson Foundation offers tools and resources for developing and implementing programs that focus on im-proving diabetes self-management (The Diabetes Initiative, n.d.a). Included in their list of resources is a six-session diabe-tes self-management curriculum. The curriculum focuses onsuch topics as monitoring the disease, understanding bloodsugar levels, nutrition, medication and complications, healthtips, and navigating the supermarket/grocery store (Six-Ses-sion Diabetes, n.d.b).

Finally, the American Diabetes Association provides a large array of resources focused both on prevention and manage-ment of diabetes. Several helpful tools include an “Am I At Risk?” calculator for individuals, a resource locator for local communities, materials for researchers and policy makers, and several helpful tools for those currently living with Type 2 Diabetes (meal planning, explanations of treatment and care, complications, and information regarding diabetes and health insurance.) The entire ADA site is available in both English and Spanish.

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Community Health Workers & Diabetes Interventions:A Resource for Program Managers and Administrators

MHP Salud promotes the Community Health Worker (CHW) profession nationally as a culturally appropriate strategy to improve health and implements CHW programs to empower underserved Latino communities. © MHP Salud 2020

MHP Salud has been implementing a CHW-led diabe-tes intervention since 2015. The program, known as Salud y Vida, targets patients with uncontrolled type 2 Diabetic participants and includes a six session Diabet-ic Self-Management Program led by MHP Salud CHWs.

Since the inception of the program 767 participants (72.1% female) have entered the program. To date, program participants demonstrate a statistically signif-icant decrease in hemoglobin A1c (HgbA1c) between baseline (Mean HgbA1c= 10.01, SD= 1.59) and 3 months (Mean HgbA1c=9.20, SD= 1.89), t(504)=10.32, p<.001.

Further, there is a correlation between Hemoglobin A1C and class attendance. The correlation suggests that increased class attendance relates to lower Hg-bA1c. However, other factors affecting this relation-ship cannot be ruled out.

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MHP Salud promotes the Community Health Worker (CHW) profession nationally as a culturally appropriate strategy to improve health and implements CHW programs to empower underserved Latino communities.

Community Health Workers & Diabetes Interventions:A Resource for Program Managers and Administrators

Baseline 3 month A1C:

10.01 a 9.20*

*This represents a statistically significant decrease inHemoglobin A1C (p<.001).

Class Attendance

Hgba1c*x

*This was a bivariate regression and so other factors affectingthis relationship cannot be ruled out.

How Has MHP Salud Addressed Diabetes through CHW Programs?

© MHP Salud 2020

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Community Health Workers & Diabetes Interventions:A Resource for Program Managers and Administrators

How MHP Salud Can Help

MHP Salud has thirty years of experience implementing Community Health Worker programs and training organizations looking to start and strengthen their own CHW programs in their own communities. If your organization is interested in implementing a CHW program targeting diabetes prevetion and management, our Training and Tech-nical Assistance team is here to help.

Core Competencies and Skills Building for CHWs

Supervision for CHW Program Managers

Road to Health Toolkit Training for CHWs and

Program Managers

For more information about MHP Salud, our services, and how we can help you, p lease email us at info@mhpsalud.org

MHP Salud promotes the Community Health Worker (CHW) profession nationally as a culturally appropriate strategy to improve health and implements CHW programs to empower underserved Latino communities.

mhpsalud.org

Call us today!(956)-968-3600

© MHP Salud 2020

ReferencesAmerican Public Health Association [APHA] (n.d.) Community Health Workers. Retrieved from: https://www.apha.org/apha-communi-

ties/member-sections/community-health-workers Centers for Disease Control and Prevention [CDC]. (2017, March 10). Retrieved from https://www.cdc.gov/diabetes/prevention/lifestyle-program/curriculum.html

Centers for Disease Control and Prevention [CDC] (2017) National Diabetes Statistics Report, 2017. Retrieved from: https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf

Centers for Disease Control and Prevention [CDC]. (2016, February 19). Road to Health Toolkit. Retrieved from https://www.cdc.gov/diabetes/ndep/toolkits/road-to-health.html

Centers for Disease Control and Prevention [CDC]. (2017, June 16) Kit El camino hacia la buena salud. (2017, June 16). Retrieved from https://www.cdc.gov/diabetes/ndep/toolkits/camino-hacia-buena-salud.html

Collinsworth, A. W., Madhulika, V., Schmidt, K. L., & Snead, C. A. (2013). Effectiveness of a Community Health Worker–led Diabetes Self-Management Education Program and Implications for CHW Involvement in Care Coordination Strategies. The Diabetes Educa-tor, 39(6), 792-799.

“Diabetes,” Glossary of Terms. (2014, October 29). Retrieved from: https://www.cdc.gov/diabetes/library/glossary.html#d

Diabetes Initiative [Robert Wood Johnson Foundation] (n.d.a) Diabetes Initiative Retrieved from: http://www.diabetesinitiative.org/.

Diabetes Initiative [Robert Wood Johnson Foundation] (n.d.b) Six-Session Diabetes Self-Management Curriculum. Retrieved from: http://www.diabetesinitiative.org/resources/tools/documents/9-CHC-Session1-OverviewandMonitoring-RWJ047915_web.pdf.

Fedder, D. O., Chang, R. J., Curry, S., & Nichols, G. (2003). The effectiveness of a community health worker outreach program on health-care utilization of west baltimore city medicaid patients with diabetes with or without hypertension. Ethnicity and Disease, 13(1), 22-27.

Ingram, M., Torres, E., Redondo, F., Bradford, G., Wang, C., & O'Toole, M. (2007). The Impact of Promotoras on Social Support and Gly-cemic Control Among Members of a Farmworker Community on the US-Mexico Border. The Diabetes Educator, 33(S6), 172S-178S.

Otero-Sabogal, R., Arretz, D., Siebold, S., Hallen, E., Lee, R., Ketchel, A., ... & Newman, J. (2010). Physician--community health worker partnering to support diabetes self-management in primary care. Quality in Primary Care, 18(6).

Palmas, W., March, D., Darakjy, S., Findley, S. E., Teresi, J., Carrasquillo, O., & Luchsinger, J. A. (2015). Community health worker inter-ventions to improve glycemic control in people with diabetes: a systematic review and meta-analysis. Journal of general internal medicine, 30(7), 1004-1012.

Rothschild, S. K., Martin, M. A., Swider, S. M., Tumialán Lynas, C. M., Janssen, I., Avery, E. F., & Powell, L. H. (2014). Mexican American trial of community health workers: a randomized controlled trial of a community health worker intervention for Mexican Ameri-cans with type 2 diabetes mellitus. American journal of public health, 104(8), 1540-1548.

Spencer, M. S., Rosland, A., Kieffer, E. C., Sinco, B. R., Valerio, M., Palmisano, G., Anderson, M., Guzman, J. R., Heisler, M. (2011). Effec-tiveness of a Community Health Worker Intervention Among African American and Latino Adults with Type 2 Diabetes: A Random-ized Controlled Trial. American journal of public health, 101(12), 2253-2260.

Wagner, J., Bermudez-Millan, A., Damio, G., Segura-Perez, S., Chhabra, J., Vergara, C., & Perez-Escamilla, R. (2015). Community health workers assisting Latinos manage stress and diabetes (CALMS-D): rationale, intervention design, implementation, and process outcomes. Translational Behavioral Medicine, 5(4), 415–424.

Walton, J. W., Snead, C. A., Collinsworth, A. W., & Schmidt, K. L. (2012). Reducing diabetes disparities through the implementation of a community health worker-led diabetes self-management education program. Family & community health, 35(2), 161-171.care.pdf

Community Health Workers & Diabetes Interventions:A Resource for Program Managers and Administrators

This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under coopera-tive agreement number U30CS09744, Technical Assistance to Community and Migrant Health Centers and Homeless for $617,235.00 with 0% of the total NCA project financed with non-federal sources. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

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© MHP Salud 2020