标题：Effectiveness of a Community Health Worker Intervention Among African American and Latino Adults With Type 2 Diabetes: A Randomized Controlled Trial
摘要：Objectives. We tested the effectiveness of a culturally tailored, behavioral theory–based community health worker intervention for improving glycemic control. Methods. We used a randomized, 6-month delayed control group design among 164 African American and Latino adult participants recruited from 2 health systems in Detroit, Michigan. Our study was guided by the principles of community-based participatory research. Hemoglobin A1c (HbA1c) level was the primary outcome measure. Using an empowerment-based approach, community health workers provided participants with diabetes self-management education and regular home visits, and accompanied them to a clinic visit during the 6-month intervention period. Results. Participants in the intervention group had a mean HbA1c value of 8.6% at baseline, which improved to a value of 7.8% at 6 months, for an adjusted change of -0.8 percentage points ( P < .01). There was no change in mean HbA1c among the control group (8.5%). Intervention participants also had significantly greater improvements in self-reported diabetes understanding compared with the control group. Conclusions. This study contributes to the growing evidence for the effectiveness of community health workers and their role in multidisciplinary teams engaged in culturally appropriate health care delivery. African American and Latino adults experience a 50% to 100% higher burden of illness and mortality as a result of type 2 diabetes than do White Americans. 1 – 5 Both African American and Latino adults with diabetes have worse glycemic control and report experiencing more barriers to diabetes self-management than do non-Latino White adults. 6 – 9 Community health worker (CHW) interventions have demonstrated promise in improving health behaviors and outcomes, particularly for racial and ethnic minority communities and those who have traditionally lacked access to adequate health care. 10 – 17 CHW interventions enlist and train community members who work as bridges between their ethnic, cultural, or geographic communities and health care providers to promote health. 18 – 20 In chronic disease care, CHWs often educate patients, identify resources, provide case management, coordinate care in partnership with the health care system, and become part of the individual's support network. 16 Although initial results from CHW programs are encouraging, 11 , 12 , 16 many have had methodological limitations, including lack of grounding in behavioral theory and inadequately rigorous evaluation. 11 , 16 , 20 In particular, as noted in a recent Cochrane review of evaluations of CHW programs, 21 most have not used a randomized controlled trial design and thus have not adequately addressed potential threats to their external validity, such as selection bias and unmeasured differences between intervention and control groups. Moreover, in most prior evaluations of diabetes self-management interventions targeting underserved populations, the participating communities were not actively involved in identifying needs or in developing, implementing, and evaluating the interventions, which may have limited their effectiveness and potential sustainability. The intervention that we describe sought to address these deficiencies. The current intervention is among several diabetes interventions conducted since 2000 by the REACH Detroit Partnership, as part of the Centers for Disease Control and Prevention (CDC)-funded Racial and Ethnic Approaches to Community Health (REACH) Initiative. Using community-based participatory research (CBPR) principles, 22 – 26 community, health system, and academic partners completed a 1-year planning process to develop interventions to improve diabetes prevention and treatment in the participating communities. 27 Using a socioecological model, family, health system, and community-level interventions were developed to address sources of diabetes disparities at each level. 12 , 27 , 28 CHWs were central to each intervention. Interventions were grounded in empowerment theory, which emphasizes a collaborative approach to facilitating the self-directed behavior change of patients. 29 – 36 The empowerment philosophy includes self-determination and autonomy motivation theory, which postulates that an individual will be more successful in a disease-management plan if that individual's goals, objectives, and resources guide the development of that plan. 37 – 39 Empowerment-based approaches have been found to be effective in improving chronic disease self-management among racial and ethnic minority patients. 29 – 36 To date, we have completed 2 cohorts of the study intervention. Our first cohort included 180 African American and Latino participants who received CHW services and were compared with a historical control. Participants in that study had improved hemoglobin A1c (HbA1c) values compared with the control group at 6 months follow-up. 12 These encouraging findings led to the approval by our community partners of the 6-month randomized controlled trial design used in the current study. We report the results of a randomized controlled trial that tested whether a culturally tailored CHW intervention for diabetes self-management improved HbA1c levels, blood pressure, lipid levels, diabetes knowledge, diabetes self-management behavior, and diabetes-related distress more than usual care among low-income, inner-city African Americans and Latinos with diabetes.
