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

Kyounghae Kim; Janet S Choi; Eunsuk Choi; Carrie L Nieman; Jin Hui Joo; Frank R Lin; Laura N Gitlin; Hae-Ra Han

doi:10.2105/AJPH.2015.302987

. 2016 Apr;106(4):e3–e28. doi: 10.2105/AJPH.2015.302987

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

Kyounghae Kim ¹, Janet S Choi ¹, Eunsuk Choi ¹, Carrie L Nieman ¹, Jin Hui Joo ¹, Frank R Lin ¹, Laura N Gitlin ¹, Hae-Ra Han ^1,^✉

PMCID: PMC4785041 NIHMSID: NIHMS757772 PMID: 26890177

Abstract

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 promoting healthy behaviors and health outcomes among vulnerable populations 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, noncommunicable 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 eligibility 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% (average 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 prevention (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 evaluation (n = 9) and supervision procedures (n = 24) were largely underreported. 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, underserved, and racial and ethnic minority communities. Future research is warranted to fully incorporate CBHWs into the health care system to promote noncommunicable health outcomes among vulnerable populations.

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 support. 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 intervention or other alternatives, partnering with CBHWs tended to result in increasing screening tests for breast, cervical, and colorectal 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.

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 disadvantaged, 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 inadequate 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 delivery arrangements do not always address the complexity and breadth of needs. 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 counterparts, 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 disabilities 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” between the community and health care services, CBHWs play a role that could address health inequities: culturally appropriate health education, individual and community capacity building, advocacy, and informal counseling and social support in diverse settings (e.g., community-based organizations, community clinics, or primary and emergency care centers).¹⁴

A number of systematic reviews were published with regard to CBHW interventions.^15–21 Previous systematic reviews found that CBHW interventions are effective in promoting a wide range of healthy behaviors, such as breast cancer screening¹⁵; self-management of diabetes,^16–18 hypertension,¹⁹ and asthma²⁰; and medication adherence 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 comprehensive systematic review on CBHW interventions 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 characteristics of CBHWs, and the patient outcomes and cost-effectiveness of such interventions in vulnerable populations with noncommunicable 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 review systematically extends the previous efforts by providing an understanding of (1) how CBHWs are trained before the delivery of an intervention, (2) how CBHWs implement 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,” “community health worker,” and “randomized controlled 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 English before August 2014 (for studies focused on individuals with diabetes since 2011). The hand searches involved review of reference lists from articles obtained from the 4 electronic 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 independently 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.) independently 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 interventions, (3) studies focused on adults, and (4) studies focused on chronic conditions. We excluded 89 articles for the following reasons:

full texts were unavailable (i.e., conference abstracts; n = 16);
they were nonrandomized controlled trials (n = 55);
studies did not include a CBHW-led intervention (n = 6);
they were studies focused on diabetes that were published before 2011, given their inclusion in a recent systematic review on CBHWs for individuals with diabetes (n = 8);
they were studies that tested the effectiveness of an intervention to change behaviors among CBHWs (n = 1); and
articles reported preliminary or intermittent 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. Discrepancies regarding the extracted data (see data extraction selection in the next paragraph) between 2 reviewers were reconciled based on a series of team discussions. A total of 67 articles met criteria for inclusion. Figure 1 provides a detailed outline of the article selection process.

Data Extraction

Four trained research assistants (RAs) extracted relevant data by using a standardized 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 criteria, type of training, training frequency, training intensity, duration of training, participant satisfaction, delivery approach, control group, types of CBHW intervention, measurability of the CBHWs’ effect, intervention dose, intervention intensity, 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 discussions 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 additional evaluation items addressing intervention 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.

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

Open in a new tab

RESULTS

There were 67 publications including 61 studies^26–86 with 6 companion articles.^87–92 Table 2 summarizes the key characteristics of studies included in this review. The companion 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 predominantly 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.

TABLE 2—

Summary of Included Studies 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

Author (Year): Quality	Study Site	Sample	Intervention (Comparison)	Main Outcome(s): CHW Effects
Cancer screening: cervical cancer
Byrd et al.²⁸ (2013)^a; cost analysis: Lairson et al.⁹² (2014): High	Participants’ homes or preferred places in TX and WA	613 nonadherent Mexican-origin women, aged ≥ 21 y; mean age, y: 40	AMIGAS intervention using video plus flip chart, video only, or flip chart only (vs wait-list control)	Greater follow-up at 6 mo for full AMIGAs.ICER (video-only vs Cont): payer perspective, $980 (95% CI = $650, $1794), societal perspective: $1309 (95% CI = $869, $2396)
Engelstad et al.³² (2005)^a; cost analysis: Wagner et al.⁹⁰ (2007): High	Women’s homes or locations chosen by the woman in CA	348 women with an abnormal Pap test results; aged 18–39 y: Int = 69%; Cont = 75%	Computerized tracking with counseling and navigation assistance over ≥ 6 mo (vs usual care)	Higher rates of follow-up within 6 mo for Int ICER per follow-up: payer perspective, $926 (95% CI = $754, $1333), societal perspective, $959 (95% CI = $787, $1367)
Lam et al.³⁵ (2003)^a: Med	2 nonprofit health and social service agencies in CA	400 Vietnamese women, aged ≥ 18 y; mean age = 43 y (SD = 14)	Two 1.5- to 2-h group sessions, navigation assistance, and ethnic media campaign over 2 mo (vs media campaign only)	Int group showed greater increased lifetime Pap test use and intention, as well as awareness of cervical cancer causes vs Cont
Mock et al.³⁸ (2007)^a: Med	CHWs’ homes or a CBO office in CA	968 Vietnamese women, aged ≥ 18 y; mean age = 46 y (SD = 15)	1.5- to 2-h group sessions plus follow-up calls over 3-4 mo followed by separate Q&A plus ethnic media campaign (vs media campaign only)	Int group showed greater increased lifetime and < 12-mo Pap test use and awareness of cervical cancer causes vs controls
O’Brien et al.⁴² (2010)^a: High	CBOs, women’s homes, and the Mexican Consulate in PA	120 Hispanic women, aged 18–65 y; mean age, y: Int = 32 (SD = 11); Cont = 31 (SD = 12)	Two 3-h educational workshops over 4 mo (vs wait-list control)	Int group showed greater increased < 6-mo Pap test use as well as cervical cancer knowledge and self-efficacy vs controls
Paskett et al.⁴⁴ (2011)^a: High	Women’s homes in OH	280 nonadherent Appalachia women, aged 31–50 y: Int = 40.5%; Cont = 46.0%; White: 95.4%	2 individualized home visits plus 2 phone calls and 4 postcards over 10 mo (vs usual care)	No difference in rates of follow-up within 12 mo per chart review between 2 arms
Studts et al.⁴⁹ (2012)^a: High	Women’s homes in KY	345 nonadherent women, aged 40–64 y; range: 40–49 y: 40%; 50–59 y: 46.7%; White: 95.1%	One 2-h home visit using a tailored newsletter (vs wait-list control)	Int group showed greater increased Pap test use postintervention vs controls
Taylor et al.⁵¹ (2002)^a: High	Seattle in WA, and Vancouver in BC	234 nonadherent Chinese women, aged 20–69 y; range: 20–44 y: 42%; 45–69 y: 58%	1 home visit with navigation assistance + additional visit for those who did not have tests, or mailed an education packet (vs usual care)	Int groups (home visit, direct mail) showed greater increased < 6-mo Pap test use and intention vs Cont
Taylor et al.⁵² (2010)^a: High; cost analysis: Scoggins et al.⁸⁹ (2010)	Women’s homes in WA	234 nonadherent Vietnamese women, aged 20–79 y; range: < 50 y: Int = 47%; Cont = 43%; 50+ y: Int = 53%; Cont = 57%	1 home visit using DVD and pamphlet followed by phone call 1 mo after the home visit (vs mailing of physical activity materials)	No difference in < 6-mo Pap test use; Pap test ICER: $2071 per QALY ICER: $30 015 (an Int cost of $96.81 and an incremental effect on Pap test of 8.36%).
Cancer screening: breast cancer
Ahmed et al.²⁶ (2010)^a: High	Places chosen by women in TN	2357 nonadherent women, aged ≥ 40 y; mean age: 53 y (SD = 10); Black: 43%; Hispanic: 12%	Stepwise intervention: reminder letters from the MCO director and a PCP followed by CHW counseling, or simple intervention: reminder letters from the MCO director (vs usual care)	Greater follow-up at 1-y per chart review for stepwise Int followed by simple Int, and Cont, respectively; Stepwise group showed greater increased < 1-y mammogram vs simple Int group.
Bastani et al.²⁷ (2010)^a: High	Intervention delivered through telephone in LA	1708 low-income, minority women; range, 40–49 y: 32%; 50+ y: 42%; Hispanics: 76%	One 30- to 40-min phone call by a professional health worker plus CHW counseling over 6 mo (vs mailed postcard to schedule an appointment)	No difference in rates of diagnostic resolution of abnormal breast findings by 6 mo per chart review between 2 arms
Crump et al.³¹ (2008) half of the study period (27 wk): Med	Telephone contact in GA	83 African American women, aged ≥ 25 y; 50+ y: Int = 48%; Cont = 54%	Telephone contact plus emotional support and navigation assistance until 3 appointments (vs usual care)	Int group showed greater rates of first and all 3 follow-up appointments per chart review vs Cont
Nguyen et al.⁴⁰ (2009)^a: High	CBOs, a CHW’s or women’s home in CA	1100 Vietnamese women, aged ≥ 40 y; mean age, y: Int = 57 (SD = 10); Cont = 58 (SD = 11)	Two 1.5-h group sessions plus follow up calls plus ethnic media campaign (vs media campaign only)	Int group showed greater increased lifetime and < 2-y mammogram and CBE, and breast cancer knowledge vs Cont
Russell et al.⁴⁶ (2010)^a: High	An FQHC in IN	181 African American participants; mean age, y: 51 (SD = 7)	Tailored message with counseling and 3 phone calls over 6 mo (vs breast cancer pamphlet and mailed general nutrition information)	Int group showed greater increased < 6-mo mammogram per chart review vs Cont
Slater et al.⁴⁸ (1998)^b: High	Public housing high-rise buildings in MN	427 low-income women, aged 50–79 y, mean age, y: Int = 69 (SD = 8); Cont = 67 (SD = 8); White: Int = 84%; Cont = 78%	1 group session followed by CHW-led small group discussions and prompting women’s provider to offer a mammogram (vs wait-list control)	Int group showed greater increased< 15-mo mammogram vs Cont; No difference in breast cancer knowledge, attitudes, and beliefs between 2 arms
West et al.⁵³ (2004)^a: High	FQHC in AL	237 nonadherent women, mean age: 65 y; Black: 91%	1 tailored phone counseling (vs tailored letter)	Int group did not show greater increased < 6-mo mammogram vs Cont
Wilson et al.⁵⁴ (2008)^c: Med	Hair salons in NY	1185 African and Afro-Caribbean women; mean age, y: Int = 39 (SD = 15); Cont = 38 (SD = 13)	Tailored and culturally sensitive counseling over 3 mo (vs no intervention)	No difference in rates of < 3-mo mammogram and CBE and mammogram intention < 1-yInt group showed greater rates of BSE and CBE intention at 3 mo vs Cont
Zhu et al.⁵⁵ (2002)^b: Med	Women’s homes (public housing complexes) in TN	325 African American women, aged ≥ 65 y; range, y:65–74: Int = 61%; Cont = 43%; 75–84: Int = 28%; Cont = 40%	One individual education session with counseling (vs usual care)	No difference in mammogram, CBE, and BSE at 2 y between 2 groups; No changes in knowledge, attitudes, and beliefs in breast health
Cancer screening: cervical and breast cancer
Fernandez et al.³³ (2009)^d: High	Women’s homes in CA	497 nonadherent Hispanic female farmworkers, aged ≥ 50 y; range, % (mammogram/Pap test cohort); 50–59: 49/45; 60–69: 27/26	One 1- to 2-h home visit using the Cultivando la Salud materials and community resources plus 1 follow-up contact 2 wk after the initial session (vs no activities in control sites)	No difference in mammogram and Pap test at 6 mo between Int and Cont; Among women completed follow-up, Int group showed greater increased < 6-mo mammogram and Pap tests vs Cont
Margolis et al.³⁷ (1998)^a: High	Telephone contact in MN	Ethnically diverse women: mammogram (n = 1658); White: Int = 61%; Cont = 64%; mean age, y: Int = 56 (SD = 12); Cont = 55 (SD = 11)Pap test (n = 1102); White: Int = 63%; Cont = 65%; mean age, y: Int = 55 (SD = 13); Cont = 54 (SD = 12)	One individual reminder plus an offer to visit at the Women’s cancer screening clinic (vs usual care)	Int group showed greater increased < 12-mo mammogram and Pap test per chart review vs Cont; Higher rates of follow-up within 12-mo for Int vs Cont among nonadherent women at baseline; No difference in follow-up between 2 groups among women who were up to date
Navarro et al.³⁹ (1998)^e: Med	Southeast area of San Diego County in CA	512 Hispanic women recruited by each consejera’s social network; range, y: < 40: Int = 72%; Cont = 66%; 40–49: Int = 18%; Cont = 25%	12 weekly group education sessions (vs “Community Living Skills” group)	Int group showed greater increased BSE vs Cont but no < 12-mo mammogram and Pap test; Participants as a unit of analysis: difference in rates of < 12-mo mammogram and monthly BSE between 2 arms
Nuño et al.⁴¹ (2011)^a: High	Women’s homes in AZ	381 Hispanic women, aged ≥ 50 y; mean age, y: Int = 59 (SD = 8); Cont = 61 (SD = 9)	One 2-h interactive group session followed by refresher sessions 1-y after the initial session (vs usual care)	Int group showed greater increased < 1-y mammogram but no increased < 1-y Pap test use vs Cont
Paskett et al.⁴³ (2006)^a: High	Women’s homes in NC	851 nonadherent ethnically diverse women, aged ≥ 40 y receiving health care from an FQHC; range, y: 40–49: 43%; 50–59: 28%; Black: 33%; Native American: 42%	Three 30- to 60-min home visits including counseling and navigation assistance and follow-up calls plus mailings after visits over 9–12 mo (vs NCI brochure regarding cervical cancer followed by breast cancer brochure after survey)	Int group showed greater increased < 12-mo mammogram and belief scores and greater decreased barrier scores vs Cont; Cost of each additional mammogram in the Int group: $4986 (cost of delivering the Int over 12 mo: $329 054 /difference between 2 groups: 15.2%
Sung et al.⁵⁰ (1997)^a: Med	Women’s homes in GA	321 inner-city African American women, aged ≥ 18 y; range, y: 35–44: Int = 46%; Cont = 44%; 45–59: Int = 22%; Cont = 25%	2 home visits with 1 booster session using culturally tailored videotape, and print education materials over about 11 mo (vs wait-list control)	Int group showed greater increased < 11-mo mammogram vs Cont, whereas no difference in yearly Pap tests, BSE, and CBE
Cancer screening: colorectal cancer
Campbell et al.²⁹ (2004)^f: High	participants’ homes in NC; churches	587 active church members, aged ≥ 18 y; mean age: 52 y; female: 74%	Tailored print and video (TPV) plus CHW sessions, CHW sessions only, or TPV only (vs HIV/AIDS and prostate cancer education; materials given post-survey)	No difference in diet, physical activity, and colorectal cancer screening at 9 mo for TPV plus CHW vs Cont; TPV showed greater increased fruit/vegetable intake and physical activity vs Cont
Castañeda et al.³⁰ (2012)^a: Med	Before their clinic visit at an FQHC in CA	130 Hispanic patients, aged 50–80 y; mean age, y: 64 (SD = 8); female: 73%	CHW session including individualized messages and proactive discussions using a self-help brochure, or self-help brochure on colorectal cancer (vs a 5-a-day nutrition brochure)	No difference in colorectal cancer screening knowledge at post-Int for CHW vs Cont, whereas self-help brochure group showed greater increased knowledge vs Cont
Holt et al.³⁴ (2013)^f	16 African American churches in AL	285 nonadherent African Americans, aged 50–74 y; mean age, y: 60 (SD = 7); female: 70%	Two 1- to 2-h group educational sessions (e.g., starting with pray and ending with a Q&A) over 1 mo (vs nonspiritual comparison intervention)	Nonspiritual group showed greater increased < 12-mo FOBT vs controls; No difference in sigmoidoscopy, colonoscopy, and barium enema, and benefits and barriers
Percac-Lima et al.⁴⁵ (2008)^a: High	Telephone contact or community health center in MA	1223 nonadherent patients, mean age, y: 63 (SD = 8); female: Int = 58; Cont = 61; Hispanic: 40%	Individual counseling with navigation assistance plus social support over 9 mo (vs wait-list Cont)	Int group showed greater increased < 9-mo any colorectal cancer screening vs Cont
Larkey et al.³⁶ (2012)^g: Med	Women’s homes or recruitment sites in AZ	1006 Latina women, aged ≥ 18 y; mean age y: Int = 38 (SD = 13); Cont = 39 (SD = 14)	Six 80-min social support group sessions (SSG) with graduation at 7^th wk (vs 6 weekly individual sessions and Q&A at 7^th wk)	No difference in Pap test, mammogram, FOBT, and endoscopy at post-Int; Total cost per participant: $103.44 for SSG vs $392.38 for IND; Total cost per screening: conservative: $516.53 vs $1716.22
Cancer screening: oral cancer
Sankaranararayanan et al.⁴⁷ (2005)^d: High	Participants’ homes in Kerala, India	167 915 Indian participants, mean age, y: 49 (SD = 1); female: Int = 59%; Cont = 61%	Three home visits for oral visual inspection by trained CHWs (1996–2004) at 3-y intervals (vs usual care)	Int group had greater increased early detection of oral cancer and 5-y survival rate vs Cont; No difference in cancer deaths
Cardiovascular disease prevention
Allen et al.⁵⁶ (2011)^a: High; cost analysis: Allen et al.⁸⁷ (2013)	2 FQHCs and participants’ homes (if necessary) in MD	525 African American or White patients with 1+ CVD risk factors; mean age, y: Int = 54 (SD = 12); Cont = 55 (SD = 12); female: Int = 72%; Cont = 71%; Black: Int = 79%; Cont = 80%	Needs-based NP education sessions plus CHW counseling over 12 mo (vs enhanced usual care)	Int group showed greater decreased total cholesterol, LDL cholesterol, triglycerides, SBP, and DBP at 12 mo vs Cont; No between group differences in BMI, physical activity, saturated fat, or sodium at 12 mo; Mean incremental total cost/patient (NP/CHW and physician): $627 (95% CI = $248, $1015)ICER (health services perspectives):$157 /↓1% in SBP and $190 /↓1% in DBP, $149/↓1% in HbA1c, and $40/↓1% in LDL
Balcázar et al.⁵⁷ (2009)^a: High	A CBO in TX	98 Hispanic patients with hypertension; mean age, y: Int = 55; Cont = 50; female: Int = 88%; Cont = 65%	Nine 2-h educational sessions over 9 mo (vs educational materials related to overall health issues)	Int group showed greater increased sodium healthy habits, cholesterol, and fat healthy habits but no BP, BMI, and waist circumference at 12 mo but vs Cont
Balcázar et al.⁵⁸ (2010)^d: Med	A community clinic (Centro San Vicente clinic) in TX	328 Hispanic patients, aged 30–75 y with 1+ self-reported CVD risk factors; mean age, y: 54 (SD = 13); female: 70%	Eight 2-h health education classes followed by 3 phone calls and a small group session over 2 mo (vs basic educational materials)	Int group showed greater decreased DBP but not SBP, lipid profile, FBS, HbA1C at 4 mo vs Cont
Becker et al.⁵⁹ (2005)^a: High	A CBO for the intervention and a hospital for control group in MD	364 Black siblings of a proband with CHD; mean age, y: Int = 48 (SD = 7); Cont = 48 (SD = 6); female: 61%	Individually tailored 30-min counseling session over 12 mo (vs enhanced primary care)	Int group showed greater decreased LDL, SBP, DBP, and glucose at 12 mo vs Cont; No difference in triglyceride, HDL, and BMI
Daniels et al.⁶² (2012)^f: Med	4 churches serving for 50%+ African American	25 English-speaking African American individuals, aged ≥ 18 y with self-reported 1+ CVD risk factors; female: 68%	Six weekly group sessions including demonstration and role playing (vs six weekly sessions in a lecture format by a physician)	Int group showed greater decreased HbA1C and increased CVD risk knowledge at 6 wk vs Cont; No difference in SBP, DBP, HDL, LDL, total cholesterol, and weight
Hayashi et al.⁶⁴ (2010)^a: Med	Four community health centers in CA	869 Hispanic women in the California NBCCEDP at risk for developing CVD; mean age y: 52 (SD = 6)	Three 30- to 45-min individual sessions including assessment and counseling for nutritional and physical activity over 12 ±2.5 mo (vs usual care)	Int group showed greater decreased SBP and improved eating habits and physical activity at 12 mo vs Cont; No difference in DBP, TC, HDL, BMI, and 10-y CHD risk
Islam et al.⁶⁷ (2013)^a: Med	Convenient community setting in NY	48 Korean Americans at risk for developing diabetes; mean age, y: 60 (SD = 8); female: 64%	Six 3-h group sessions plus 10 follow-up phone calls from the CHW over 6 mo (vs first education session)	No difference in SBP, DBP, BMI, waist circumference, glucose, physical activity, nutrition, and mental health at 6 mo
Lynch et al.⁷³ (2014)^a: High	Classes were held in a local city park building near the recruitment FQHC in IL	61 African Americans with prescribed medication for T2DM, hypertension, and BMI from 25 to 45; mean age, y: 54; female: 67%	Eighteen 2-h group sessions led by a dietitian and weekly calls from a peer supporter over 6 mo (vs two 3-h CHW led group sessions of diabetes self-management)	No difference in weight loss, HbA1C, SBP, DBP between 2 groups; Int group showed greater improved physical activity, DM self-care activities, as well as nutrition knowledge vs Cont
Staten et al.⁸⁰ (2004)^a: Med	Either at the clinic in AZ or over the telephone	217 uninsured Hispanic women in the NBCCEDP; mean age, y: 57 (SD = 5); race: 74% Hispanic, 25% White	Provider counseling with education plus CHW social support over 12 mo, or provider counseling and education (vs provider counseling only)	No difference in BMI, SBP, DBP, cholesterol, glucose, triglyceride, physical activity, fruit and vegetable intake, and waist circumference among groups
Cardiovascular disease prevention: diabetes as a risk factor
DePue et al.⁶³ (2013)^d: High	Patient’s home, workplace, or at the study clinic, in American Samoa	268 Samoan Americans; mean age, y: 54 (SD = 12.9); female: 65%	Higher risk group: weekly nurse case manager led group meeting with CHW assistance over 12 mo; Moderate risk group: monthly meeting with CHWs; Lower risk group: seen every 3 mo (vs wait-list Cont)	High-risk group showed greater decreased HbA1C at 12 mo vs Cont; No difference in BP, weight, or waist circumference among groups
Katula et al.⁶⁹ (2013)^a: High; cost analysis: Lawlor et al.⁸⁸ (2013)	Community-based sites such as parks and recreation centers	301 obese or overweight (BMI 25–39) participants with fasting blood glucose (95–125 mg/dL); mean age, y: 58 (SD = 10); White: 74%; female: 58%	Weekly CHW led weight-loss group sessions and 3 individual counseling with a dietitian for 6 mo plus 2 contracts each mo from 7^th mo to 24^th mo (vs enhanced usual care)	Int group showed greater decreased FBS, insulin resistance, weight, and BMI at 2 y vs Cont; Direct medical costs per patient: Int: $850 vs Cont: $142 for 2 y, compared with $2631 of the DPP
Kenya et al.⁷⁰ (2014)^a: Med	Participants’ homes in FL	117 Hispanic patients with 1+ HbA1C ≥ 8 during the past 1 y; mean age, y: 56; female: 45%	Initial home visit followed by CHW support over 12 mo (vs no information given)	Greater decrease in HbA1C at 12 mo for Int vs Cont
Palmas et al.⁷⁶ (2014)^a: High	Participants’ homes, offices in NY	360 Hispanic patients with poorly controlled T2DM; age range, y: Int ≤ 65: 85.6%; Cont ≤ 65: 81%; female: Int = 61%; Cont = 63%	Multifaceted CHW-led Int including about 24 one-on-one visits and group sessions on nutrition and exercise activities plus phone calls over 12 mo (vs usual care)	Int group did not show greater decrease in HbA1C at 12 mo vs Cont; No changes in SBP, DBP, and LDL in the Int group
Prezio et al.⁷⁷ (2013)^a: High	Private dedicated office spots in TX	180 Hispanics aged 18–75 y with T2DM; mean age, y: Int = 47.9(SD = 10.99; Cont = 45.7(SD = 10.69; female: Int = 67%; Cont = 54%	Culturally tailored diabetes education and management program including 7 hours of contact with the CHW during their appointments over 12 mo (vs usual medical care)	Int group showed greater decrease in HbA1c at 12 mo vs Cont; No difference in BP, BMI, HDL, and triglyceride between 2 groups
Rothschild et al.⁷⁸ (2014)^a: High	Participants’ homes in IL	144 Mexican Americans with T2DM; mean age, y: 54 (SD = 13); female: 50%	36 home visits on self-managements over 24 mo (vs 36 mailed bilingual newsletters)	Int group showed greater decrease in HbA1C at 2 y vs Cont; No difference in BP, glucose self-monitoring, medication adherence
Spencer et al.⁷⁹ (2011)^a: High	Participants’ homes, an FQHC in MI	183 African American or Hispanic patients with T2DM; mean age, y: Int = 50; Cont = 55; female: Int = 75%; Cont = 67%	Eleven 2-h group sessions, twelve 1-h home visits, and 1 clinic visit with the participants and their PCP plus phone calls once every 2 wk over 6 mo (vs monthly phone calls)	Int group showed lower HbA1C at 6 mo vs Cont; Difference in DM knowledge, diabetes self-management but no difference in LDL, SBP, DBP, and BMI between 2 arms
Tang et al.⁸¹ (2014)^a: High	Participants’ homes in MI; telephone contact was also used	116 Latino patients, aged > 21 y with T2DM receiving medical care at CHASS; mean age, y: 49 (SD = 11); female: 59%	Peers DSMS: a 6-mo weekly session including two 1-h home visits/mo and 1 clinic visit plus patient-initiated discussion followed by peer support over 12 mo (vs CHW DSMS)	Int group did not show improvement in HbA1C, LDL, SBP, DBP, waist circumference, BMI, DM stress, and diabetes support at 18 mo vs Cont
Cardiovascular disease prevention: hypertension as a risk factor
Cooper et al.⁶¹ (2011)^a: Med	14 urban community health clinics serving for mainly African Americans in MD	41 physicians (MD) + 279 hypertensive patients (pt); mean age, y: MD = 43; pt = 61;female: MD = 52%; pt = 66%; African American: MD = 29%; pt = 62%	MD+pt intensive group, MD minimal+pt intensive group, MD intensive+pt minimal group, MD+pt minimal: MD minimal (vs JNC-VII treatment guidelines plus a monthly newsletter)	Int groups did not show improvement in SBP, DBP, and medication adherence at 12 mo vs Cont
Hill et al.⁶⁵ (2003)^a: High	An urban hospital; participants’ homes in MD	309 hypertensive African American men; mean age, y: 41 (SD = 6)	NP-led drug treatment and 3+ CHW home visits (vs referrals for sources of HTN care)	Int group showed lower SBP, DBP, left ventricular mass at 3 y vs Cont; No difference in serum creatinine
Jafar et al.⁶⁸ (2009)^d: High; cost analysis: Jafar et al.⁹¹ (2011)	Participants’ homes for HHE; GPs in Pakistan	1341 patients with high BP; mean age, y: GP+HHE: 54 (SD = 12); HHE: 53 (SD = 11); GP: 55 (SD = 12); control: 53 (SD = 12); men: GP+HHE: 34%; HHE: 38%; GP: 41%; control: 36%	HHE plus GP, HHE only, or GP only (vs Cont)	HHE plus GP group showed greater decrease in SBP and achieved controlled BP at 12 mo vs other 3 groups; No difference in DBP and BMI among groups
Krieger et al.⁷¹ (1999)^a: High	Participant homes, WA	421 low-income patients with hypertension, range, y: 18–39: Int = 24%; Cont = 26%; 40–64: Int = 58%; Cont = 56%; female: 28%; African American: 79%	Enhanced referral to medical care and navigation assistance plus assistance in eliminating barriers to care over 3 mo (vs usual care)	Int group showed greater increased completion of a medical follow-up and follow-up within 90 d of referral vs Cont
Levine et al.⁷² (2003)^a: High	Participants’ homes in MD	789 African American adults with hypertension; mean age, y: 54; female: 62%	Five 30-min individual sessions, CHW home visits, social support, community HBP education plus education materials over 40 mo (vs usual care and HBP education plus materials)	No difference in SBP, DBP, BP control at 40 mo between 2 arms
Margolius et al.⁷⁴ (2012)^a: High	A public hospital in CA	237 hypertensive patients, mean age, y: 60 (SD = 12); female: 63%; 46% Hispanic, 35% Asian, 11% African American	Home-titration without a physician appointment plus weekly phone calls by health coaches over 6 mo (vs weekly phone calls by health coaches)	No difference in SBP, DBP, no. of office visits at 6 mo between 2 arms
Morisky et al.⁷⁵ (2002)^a: Med	patients’ homes; clinic sites in a large West Coast city	1319 hypertensive outpatients; mean age, y: 54 (SD = 12); female: 59%; 76% African American, 21% Hispanic	Group 1: CHW weekly counseling, and appointment-keeping over 12 mo; Group 2: appointment tracking; Group 3: CHW home visit with discussion groups (vs usual care)	Greater increase in BP control for group 3 followed by group 2; No improvement in BP control in group 1 and group 4
Cardiovascular disease prevention: physical activity
Coleman et al.⁶⁰ (2012)^a: Med	4 community health clinics in the California NBCCEDP	868 low-income, underinsured Hispanic females, aged 40–64 y have 1+ CVD risk factors; mean age, y: 52 (SD = 6)	Three 50-min individually tailored, one-on-one counseling sessions plus social support over 6 mo (vs usual care)	Int group reported increases in moderate and vigorous physical activity at 12 mo compared with baseline
Cardiovascular disease prevention: chronic disease screening
Hunter et al.⁶⁶ (2004)^a: High	Community health clinics in AZ	101 Hispanic females, aged > 40 y; mean age, y: 50 (SD = 8); Hispanic: 96%	Two home visits to discuss barriers and facilitate appointment scheduling over 6 wk (vs post card reminder)	No difference in routine prevention chronic disease screening between 2 groups
Cognitive functions and mental disorders
Beck et al.⁸² (2013)^d: Med	16 senior centers in AR	228 obese senior adults, aged > 60 y; mean age, y: 71 (SD = 7); female: 84%; White: 92% for both groups	Twelve 1-h interactive group sessions regarding cognitive functions over 3–4 mo (vs a regular weight-loss Int)	Improvement in delayed memory for Int vs Cont; No difference in reliable improvement in immediate memory or in attention
Chatterjee et al.⁸³ (2014)^a: High	Participants’ homes in India	282 patients with schizophrenia; mean age, y: 36 (SD = 10); female: Int = 46%; Cont = 49%	Individualized, needs-based intervention delivered by a CHW over 12 mo (vs usual care)	Int group showed lower disability scores at 12 mo vs Cont
Waitzkin et al.⁸⁴ (2011)^a: Med	Two community health centers in NM	120 patients with depression (n = 464 randomly recruited); female: 31%	Collaborative PCP–CHW team approach over 12 mo (vs enhanced care)	No difference in depression, difficulty paying for housing, and unemployed at 12 mo between 2 groups
Asthma control
Martin et al.⁸⁵ (2009)^a: High	Clinics in IL; participants’ homes	42 patients with asthma; mean age, y: Int = 33 (SD = 9); Cont = 37 (SD = 8); female: Int = 60%; Cont = 77%	Four 2-h group sessions by social worker with CHWs plus 6 CHW home visits over 3 mo (vs mailed asthma education materials)	Int group showed greater increase in asthma quality of life at 6 mo vs Cont; No difference in having a spacer nor receiving action plan at 6 mo between groups
Medication safety
Wang et al.⁸⁶ (2013)^a: Med	A rural primary health clinic in Taiwan	62 community-dwelling elders, aged > 65 y with 2+ chronic illnesses; mean age, y: 71 (SD = 8); female: 55%	Volunteer coaching on medication safety including 3 home visits and 5 phone call reminders plus usual care over 2 mo (vs usual care)	Int group showed greater increased medication safety knowledge vs Cont; No difference in medication safety attitude, some safety behaviors between 2 groups

Open in a new tab

Note. AMIGAS = Ayudando a las Mujeres con Informacion, Guia, y Amor para su Salud; BMI = body mass index (weight in kilograms divided by the square of height in meters); BP = blood pressure; BSE = breast self-examination; CBE = clinical breast examination; CBO = community-based organization; CHASS = Community Health and Social Services; CHD = coronary heart disease; CHW = community health worker; CI = confidence interval; Cont = control; CVD = cardiovascular disease; DBP = diastolic blood pressure; DM = diabetes mellitus; DPP = Diabetes Prevention Project; DSMS = Diabetes self-management support; FBS = fasting blood sugar; FOBT = fecal occult blood test; FQHC = federally qualified health center; GP = general practitioner; HbA1C = hemoglobin A1c; HBP = high blood pressure; HHE = home health education; HPV = human papillomavirus; HTN = hypertension; ICER = incremental cost–effectiveness ratio; Int = intervention; LDL = low-density lipoprotein; MCO = managed care organization; NBCCEDP = National Breast and Cervical Cancer Early Detection Program; NCI = National Cancer Institute; NP = nurse practitioner; Pap = Papanicolaou; PC = provider counseling; PCP = primary care physician; Q&A = questions and answers; SBP = systolic blood pressure; T2DM = type 2 diabetes mellitus. A fuller version of this table is available as a supplement to the online version of this article at http://www.ajph.org.

^{^a}

Individually randomized.

^{^b}

Randomization by housing.

^{^c}

Randomization by hair salon.

^{^d}

Geographically randomized.

^{^e}

Randomization by community health worker.

^{^f}

Randomization by church.

^{^g}

Randomized by community site (church, school, community center, and apartment).

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} colorectal,^{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 hypertension.^{61,65,68,71,72,74,75} Two studies tested an intervention on other CVD-related topics including promotion of physical activity 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 (depression⁸⁴ and schizophrenia⁸³). Finally, 2 studies involved CBHWs for asthma⁸⁵ control and medication safety among rural elders with chronic diseases.⁸⁶

Forty-six (75%) studies employed individual randomization and 14 (23%) studies used cluster randomization.^{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 comparison 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 methodological 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 screening behavior through self-report only^{29,34–36,38–41,48–50,53–55} 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 intervention 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, counseling, navigation assistance, case management, social services, and social support. These interventions were often delivered in addition to traditional outreach responsibilities of CBHWs, which included participant recruitment and data collection. The CBHW interventions were performed in collaboration 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 providers,^{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 education via individual sessions or group education sessions^{34–36,38–42,48,52,57,58,62,67,69,73,77,79,81} of varying sizes, from 3^38,41 to 20⁵⁷participants (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 Education sessions took place at participating clinics, community locations, or participant’s home or work. Varying educational materials 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 individual’s risk profile after baseline assessment. In a study delivering a nurse–CBHW team intervention to support diabetes self-management in American Samoa, participants 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 reported 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 bicultural 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 counseling 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 telephone calls, home visits, or regular meetings to assess and problem-solve personal and environmental barriers throughout the intervention. In 1 study,³⁶ CBHWs provided theory-based scripted messages for each barrier, including personal belief, fear, health care provider, personal need, and management 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

In 21 articles, CBHWs provided navigation assistance for their study participants in obtaining preventive care services and managing chronic diseases.^{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 addition 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 transportation assistance through taxicabs or bus 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 delivering a diabetes education and management 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 participants 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 employment 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 behavior 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 component 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 publications including 6 companion articles also demonstrated that the use of trained, culturally 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 behaviors.^{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 screening^21,27 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 proportion 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 significant 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 significantly greater improvements in lipid profile (total cholesterol, low-density lipoprotein, high-density lipoprotein, or triglycerides),^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 studies^{63,69,70,76–79,81} that exclusively focused on HbA1C or fasting glucose as a primary outcome, all but 2^76,81 found significant improvements in diabetes control. Tang et al.⁸¹ compared the effect of peer leaders (bilingual residents in the target community with diabetes and aged ≥ 21 years) versus CBHWs on diabetes management. 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 interventions 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 results,^57,61,74,75 2 lacked statistical power.^57,61

Mental disorders, asthma control, and medication safety.

Three studies involved CBHWs to address issues related to cognitive functioning and mental disorders, such as depression and schizophrenia^82–84; 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) who were 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 interval = 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 findings 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 promoting 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 underpowered to detect self-management in asthma control and clinical outcomes. In a study⁸⁶ that tested the effect of a volunteer coaching on medication safety in community-dwelling elders with 2 or more chronic illnesses, the volunteer coaching program was effective in promoting medication 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 diabetes control,⁸⁸ high blood pressure control,⁹¹ and cardiovascular risk reduction.⁸⁷ Lawlor et al.⁸⁸ found that a lifestyle intervention 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 to lower blood pressure in 12 randomly selected communities 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 compared 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 reported 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 obtained an ICER of $959 per follow-up for the intervention compared with usual care. Although Larkey et al.³⁶ found no difference in cancer screening outcomes between intervention and comparison groups, the cost per participant screened was approximately 3 times greater in the individually delivered group than in the social support group ($1716.22 vs $516.53, respectively). Paskett et al.⁴³ estimated a cost associated with CBHW intervention to promote mammography screening among low-income, ethnically diverse 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. Approaches included identification by community leaders,^29,34,86 use of existing CBHWs in the community,^30,45 use of participating churches⁴⁹ or a community self-help organization,⁵⁰ or community members who demonstrated the positive behavior targeted within the study population.²⁶

TABLE 3—

Characteristics, Training, and Roles of Community-Based Health Workers in 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

Author (Year)	Recruitment or Selection Criteria: Sample Characteristics	Trainer: Training	Supervision	Reimbursement; Funding Source: Sustainability
Cancer screening: cervical cancer
Byrd et al.²⁸ (2013)	Not reported:Bilingual and bicultural promotoras of Hispanic origin and of similar socioeconomic status to participants	Not reported: 2 half-day initial testing and validation of the educational material with promotoras: Competency evaluation = 3 pilot sessions observed by study team	Direct observation during pilot sessions	Not reported; CDC: Program planned to be distributed by the CDC
Engelstad et al.³² (2005)	Not reported: 2 African American women and 1 bilingual Latina; had previous community outreach experience	Research coordinator: Trained on Pap testing, stress management, interviewing skills, patient tracking, personal safety; monthly skill-building and a peer support group	Weekly supervision by a health educator	$22/h; NCI: Not reported
Lam et al.³⁵ (2003)	Selected by partner agencies; Vietnamese women in the study county: Compassionate, dedicated; mostly married, homemakers	Vietnamese American staff: Two 3-h sessions on cancer information, recruitment, organizing and leading small group sessions, and giving oral presentations: Competency evaluation = not reported	Not reported	$1500 per each CHW; CDC and NCI: Not reported
Mock et al.³⁸ (2007)	Recruited by 5 coordinators from each CBO; Vietnamese American: No additional information	Research staff: Two 3-h training; received Vietnamese-language flip charts and booklets to use in the CHW outreach	Not reported	Paid $1500; CDC and NCI: Not reported
O’Brien et al.⁴² (2010)	Not reported: 4 female promotoras	Not reported: Not reported	Not reported	Not reported; NCRR: Not reported
Paskett et al.⁴⁴ (2011)	Indigenous women aged 40–50 y; no postsecondary education: No additional information	Not reported: Not reported	Observed by study coordinators	Not reported; NCI: Not reported
Studts et al.⁴⁹ (2012)	Women at participating churches: Mostly married, middle-aged, and middle-to-low socioeconomic status	Study team: 3 sessions on human participants, home visits, and tailored content regarding participants’ barriers	Project team; retrained as necessary	Not reported; NCI: Not reported
Taylor et al.⁵¹ (2002)	4 bicultural, trilingual (Cantonese, Mandarin, English) Chinese women: No additional information	Not reported: Not reported	Not reported	Not reported; NCI, NIH, DHHS: Not reported
Taylor et al.⁵² (2009)	Bilingual Vietnamese women: 2 CHWs, married with children	Not reported: Training sessions to act as role models, give social support, and provide tailored feedback	Not reported	Not reported; NCI and CDC: Not reported
Cancer screening: breast cancer
Ahmed et al.²⁶ (2010)	Hired from within the study population: Prir study participants compliant with cancer screening	Tennessee Coordinated Care Network: Trained on breast cancer and mammogram, skills to engage and empower clients	Not reported	Employed by MCO; US Army Medical Research: Not reported
Bastani et al.²⁷ (2010)	Female, matched with participants on ethnicity, age, time availability: 20 Latina, 8 White, 2 Black, 1 Asian	The Center for Healthy Aging: 7-wk trainings on basic counseling skills, breast cancer, and hospital-specific information regarding the county health system, using a specially prepared manual	Monthly meetings (supervisor not reported)	$5 for every completed phone call; NCI: Not reported
Crump et al.³¹ (2008)	African American women selected based on experience in health education and community activities: 3 African American women; college+	Not reported: A 2-d, 16-h training session on breast cancer, breast cancer screening, barriers to screening, roles and activities of CHW, research ethics, hospital policies	Not reported	$12.11/h; 40 h/mo during the study period; NCI: Not reported
Nguyen et al.⁴⁰ (2009)	Vietnamese women aged 40+ y; residing in the study county: 50 CHWs aged 22–67 y	Researchers: Two 4.5-h sessions to provide education about breast and cervical cancer causes and screening	Researchers and outreach coordinator	$1500 per CHW; CDC and NCI: Not reported
Russell et al.⁴⁶ (2010)	Word of mouth and community advisory board: 8 African American women residing in the targeted community	Not reported: Two 8-h sessions to deliver scripted messages addressing barriers, assisting navigation, and making referrals: Competency evaluation = skills performance evaluated by nurses	Not reported	“A small stipend”; NCI and University: Not reported
Slater et al.⁴⁸ (1998)	Not reported: High-rise resident volunteers	Not reported: Not reported	Not reported	Not reported; NCI: ACS exported the program into other settings in Minneapolis
West et al.⁵³ (2004)	Indigenous women: Female African American indigenous CHWs	Survey Research Unit, health psychologist: Trained in conducting semistructured interview (motivational interviewing)	Direct observation	Not reported; NCI, University, CDC: Not reported
Wilson et al.⁵⁴ (2008)	Same community; hair stylists: Either African American or Afro-Caribbean (92%)	Staff at the Arthur Ashe Institute for Urban Health: Two 2-h workshops and ongoing support and technical assistance: Competency evaluation = staff-administered assessment	Program staff visits to salons	Professional development classes (valued at $800); $30 for travel to the training site; NCI, Foundation, Hospital Fund: Not reported
Zhu et al.⁵⁵ (2002)	African American woman: Lay health educators from the same housing complex	Not reported: Four 3-h sessions on breast cancer, screening, benefits and barriers, the ways to implement education: Competency evaluation = a short test at each session	Evaluation completed by Interviewer	Not reported; US Army Medical Research Acquisition Activity: Not reported
Cancer screening: cervical and breast cancer
Fernandez et al.³³ (2009)	Not reported: Not reported	Clinic coordinators: 12 training sessions: Competency evaluation = clinical staff at study sites	Clinic coordinators	Employees; CDC and NCI: A program manual developed
Margolis et al.³⁷ (1998)^a	Low-income elderly lay women aged 55+ y: No additional information	Study coordinator: 1-mo training on basic professional skills, communication skills, cultural diversity, and principles of research design	Study coordinator	$ not reported (20 h/wk); NCI: Sustainable resources to County Medical Center given; 3 workers recruited and trained (> 3360 h of staff time added)
Navarro et al.³⁹ (1998)	Latina recommended by community site personnel: 36 Latinas; characteristics as natural helpers (e.g., humor, networks)	Not reported: Consejera manual specifically designed to guide the weekly sessions in the topic focus of the intervention	Not reported	Not reported; NCI: Not reported
Nuno et al.⁴¹ (2011)	Spanish-speaking: No additional information	Western AZ Area Health Education Center study coordinator: Five 2-h sessions on educational content, the CHW role of content delivery, staff development about self-esteem and dealing with problem participants, community resources, and human subjects and informed consent	Experienced field staff to ensure the fidelity	Not reported; CMS: Not reported
Paskett et al.⁴³ (2006)	Women with good social skills; organized, professional, and courteous; flexible work hours: 2 Native American women and 1 African American woman	Project manager and other study personnel: 1-wk training on general project information, knowledge regarding cancer screening; role-playing: Competency evaluation = exam, practice intervention sessions, breast self-exam demo on breast models	Weekly meetings with CHW supervisor; Observation	Not reported; NCI: Not reported
Sung et al.⁵⁰ (1997)	Recruited from a self-help group; residing in the target area: Self-help group leaders who worked with women in the study community	Not reported: 10-wk training on women’s health issues and interviewing, teaching, and human relations skills	Biweekly meeting (supervisor not reported)	Not reported; NCI and NIH: Not reported
Cancer screening: colorectal cancer
Campbell et al.²⁹ (2004)	Individuals identified by church members: 47 women and 15 men	Project staff: 16-h group sessions at respective churches: Competency evaluation = pre and post knowledge test	Not reported	No monetary compensation; ACS, Department of Agriculture, and NIH: Not reported
Castañeda et al.³⁰ (2012)	Existing promotoras: No additional information	Not reported: Not reported	Not reported	Not reported; NCI and NIMHD: Not reported
Holt et al.³⁴ (2013)	Individuals identified by pastors and key church staff: No additional information	Not reported: 2 half-day trainings; completed a mock educational session after training sessions	Not reported	Churches received $500; CDC: Not reported
Percac-Lima et al.⁴⁵ (2008)	Existing health outreach worker: 5 bilingual health center outreach college educated workers	Study PI and community health director: One 6-h session on navigation and colorectal cancer screening	Study PI and community health director	Not reported; Hospital, Trust, NCI: Not reported
Larkey et al.³⁶ (2012)	Bilingual Latina: 5 full-time, bilingual; prior experiences with community members	Juntos en la Salud program coordinators: Trained on the study, general cancer information and health, developing relationships with community organizations, scheduling and leadership skills	Not reported	$15.49/h; ACS: Not reported
Cancer screening: oral cancer
Sankaranararaynan et al.⁴⁷ (2005)	Residing in the same counties: 2 college graduates (1 male and 1 female) in biology or social sciences	Community Oncology Division: 3-mo training to get information about study eligibility, informed consent, and interviewing participants, and how to give health messages	Not reported	Not reported; Research fund; Research fellowship: Not reported
Cardiovascular disease prevention
Allen et al.⁵⁶ (2011)	Not reported: Trained CHWs with experiences working with minorities	Not reported: Training sessions on CHD and DM and lifestyle management; motivational interviewing	Not reported	Median = $18.32/h; NHLBI: Not reported
Balcázar et al.⁵⁷ (2009)	Not reported: 20 new promotoras trained by existing promotoras	Experienced promotoras: One 4-d session using the Salud Para Su Corazon (SPSC) promotora curriculum “Your Heart, Your Life”	Not reported	Not reported; CDC and professional association: Private funds secured
Balcázar et al.⁵⁸ (2010)	Recruited from promotores from the network of partner organizations: 3 promotores hired	A lead promotora from Centro San Vicente clinic: 1-wk training (16–18 h) using the SPSC curriculum	Not reported	Not reported; NIH: Expanding its reach through community partners
Becker et al.⁵⁹ (2005)	Not reported: No additional information	Not reported: Trained by YMCA standard training program for volunteers; also completed basic life support training	Not reported	Not reported; NHLBI, University, NCRR, NCI, companies: Not reported
Daniels et al.⁶² (2012)	Candidates suggested by pastors; African American, aged 18+ y; diagnosis of 1+ ABCD risk factors that were controlled: 12 CHWs	Study’s PI and project manager: 16-h training on recruiting; educating ABCD risk factors and depression; basic health literacy skills; teaching skills; online course on human participants	Not reported	Stipend; Pharmaceuticals: Not reported
Hayashi et al.⁶⁴ (2010)	Bilingual, bicultural women residing in the same communities: Relatively well educated	Professionals; State Cancer Detection Section staff: 2.5-d training on research activities, cardiovascular health, human protection, and research protocol	RN at each clinic site	Not reported; CDC: Not reported
Islam et al.⁶⁷ (2013)	Bilingual Korean American: Trained 6 CHWs from CBO	2 trainers: 8-day, 60-h training on comprehensive skills plus additional 30 h on mental health, motivational interviewing, and other related topics	Not reported	Not reported; CDC and NIH: Not reported
Lynch et al.⁷³ (2014)	CHW: not reported; Peer supporters: selected from the target community; 1 African American CHW; 2 African American peer supporters	Psychologist, dietitian, health educator: CHW: two 3-h training on self-management and nutrition; peer supporters: eight 2-h weekly training on nutrition, goal setting, problem-solving skills to address barriers to goal achievement	Weekly team meetings led by the study psychologist	Not reported; NIH: Not reported
Staten et al.⁸⁰ (2004)	Residing in the same county: 6 bilingual Hispanic women (5 aged 50 y); 4 previous CHWs	Not reported: Training sessions on outreach, translation, and transportation	Not reported	Not reported; CDC: Not reported
Cardiovascular disease prevention: diabetes as a risk factor
DePue et al.⁶³ (2013)	Not reported: Minimum of high-school education	Not reported: Training involved brief teaching sessions, role plays, and observing other staff during intervention visits	Field director; nurse case manager	Not reported; NIDDK: Not reported
Katula et al.⁶⁹ (2013)	Patients with well-controlled T2DM and leadership: 10 CHWs trained; mean age: 57 y; 7 Blacks, 8 women; 7 employed; 8 high school+ education	Registered dietitians: 36-h program on diabetes self-management and observation over 6–9 wk	Registered dietitians	First 6 mo = $100/wk; months 7–24 = $200/mo; NIDDK: Not reported
Kenya et al.⁷⁰ (2014)	Hispanic; considered to be respected peers: No additional information	Diabetes Research Institute: Trained in disease management skills, navigation, and making referrals	Not reported	Not reported; NHLBI: Not reported
Palmas et al.⁷⁶ (2014)	Not reported: 2 full-time CHWs based at Alianza Dominicana Inc.	Not reported: Competency evaluation = not reported	Not reported	Not reported; NIMHD: Not reported
Prezio et al.⁷⁷ (2013)	Bilingual, female, member of the local Mexican American community; high-school education and certified CHW in the state of TX: No additional information	Registered dietitians and an endocrinologist: 27-h instruction in the local community: Competency evaluation = written examination and observation	Not reported	Not reported; University and research institute: Intervention sustained with support from philanthropic and local agency funding; program expanded to 5 other sites
Rothschild et al.⁷⁸ (2014)	Bilingual Mexican Americans residing in the target community and working for a local nonprofit agency; 3 CHWs with knowledge and skills: No history of diabetes, no postsecondary education	A community-based organization: 90-h of initial training on promotora practice, formal training on diabetes knowledge, and project-specific training on self-management and home visiting: Competency assessment after the initial training and again at 6 and 12 mo into the intervention	Bimonthly consultation/ supervision by psychologist	$85 per participant per mo; NIDDK: Not reported
Spencer et al.⁷⁹ (2011)	Recruited from participating communities; matched for ethnicity: No additional information	Not reported: 80+ h training on empowerment-based approaches including diabetes education and motivational interviewing: Competency evaluation = not reported	Not reported	Not reported; NIDDK, CDC, and Foundation: Not reported
Tang et al.⁸¹ (2014)	Peer leader: bilingual, aged 21+ y with diabetes, residing in the community; CHW: Spanish-speaking, high-school+, hired by health clinics, in the same community; Peer leader: volunteers CHWs: an average 6 y of experience in leading DSME at CHASS	2 nurse certified as diabetes educators, 1 dietitian, and 1 clinical psychologist: Peer leader = 46-h training over 12 wk on diabetes communication, facilitation, and behavior modification, and skills in experiential learning CHW = 160-h of community outreach training and 80-h of DM education, home visits, human participants; behavior modification strategies, motivational interviewing, community-based participatory research; had basic computer/Internet skills	Not reported	Peer leader: “only a modest stipend”; CHW: a salary; Foundation, NIH, and CDC Peer leader = not reported: CHWs = employees of the health clinic
Cardiovascular disease prevention: hypertension as a risk factor
Cooper et al.⁶¹ (2011)	Not reported: No additional information	Not reported: Not reported	Not reported	NHLBI: Not reported
Hill et al.⁶⁵ (2003)	Not reported: Not reported	Not reported: Not reported	Not reported	Not reported: Not reported
Jafar et al.⁶⁸ (2009)	Not reported: 6 CHWs with education status consistent with the requirement of the government-sponsored Lady Health Workers Program of Pakistan (8 or preferably 10 y of schooling)	Not reported: 6-week sessions in methods for using behavior-changing communication strategies to convey standardized health education messages to study participants	Not reported	Salary scales and assigned workload consistent with requirements of the Lady Health Workers Program of Pakistan; Wellcome Trust: Not reported
Krieger et al.⁷¹ (1999)	Not reported: Predominantly African American (12/14), and from low-income neighborhood similar to where the project was conducted	Not reported: 100-h training on hypertension, cardiovascular system, risk factors for CVD, community resources, principles of research, stress management, and alcohol and other drugs; certified as BP measurement specialists	Not reported	Not reported; NHLBI: Not reported
Levine et al.⁷² (2003)	Not reported: No additional information	Not reported: 3-mo training on BP management, education, counseling, social support, outreach and follow-up	RN; advisory board supervised	Not reported; NHLBI: Not reported
Margolius et al.⁷⁴ (2012)	Not reported: 10 university employees and volunteers with bachelor’s degrees	Not reported: 16- to 20-h training on hypertension and its medications, and on lifestyle behavior change	Not reported	Not reported; Foundation: Not reported
Morisky et al.⁷⁵ (2002)	Not reported: Not reported	Not reported: 1-month training emphasizing eliciting issues during interviews that interfere with or enhance treatment adherence, and developing interview skills	Not reported	Not reported; NHLBI: Planned to be integrated into patient care delivery systems of the participating clinics
Cardiovascular disease prevention: physical activity
Coleman et al.⁶⁰ (2012)	Bilingual women in the same counties, prior experience with Latino communities, computer skills: 8 CHWs hired (7 younger than 30 y, 6 had 2 y+ college education)	Program staff and other state program partners: 2.5-d training on intervention delivery and data collection; CHWs and study staff participated in monthly 1-h teleconference meetings	Study staff	All CHWs remained employed and were paid salaries; CDC: Not reported
Cardiovascular disease prevention: chronic disease screenings
Hunter et al.⁶⁶ (2004)	Bilingual women in the same counties: Experience with cancer programs, adolescent and maternal and child health programs	Community health center staff: Trained in intervention delivery, participant consent, data collection, documenting activities, and coordinating efforts with community health center staff	Not reported	Not reported; CDC: Not reported
Cognitive and mental disorders
Beck et al.⁸² (2013)	Not reported: No additional information	Center staff: 32-h of in-person interactive seminars as well as weekly phone calls following each intervention session	Weekly phone sessions	Not reported; CDC and NCRR: Not reported
Chatteriee et al.⁸³ (2014)	Not reported: 10+ years of schooling and good interpersonal skills	Not reported: Trained over 6 wk and assessed for competence with the manual by intervention coordinators (social workers)	Social workers; psychiatrists	Not reported; Trust fund: Not reported
Waitzkin et al.⁸⁴ (2011)	Bilingual trusted member with high-school education+; 2 CHWs: receptionist, security guard	Staff (not specified): 5 sessions with additional educational session on depression for CHWs	Not reported	Not reported; Foundation: Not reported
Asthma control
Martin et al.⁸⁵ (2009)	Not reported: 3 CHWs	Not reported: 113-h training on asthma, specific training by investigators and hands-on experience to establish relationships with participants, home visits, and self-management techniques: Competency evaluation = standardized role-play scenario to examine each CHW’s achievement of the objectives and readiness for the field	Social worker and investigators	Not reported; NHLBI: Not reported
Medication safety
Wang et al.⁸⁶ (2013)	Community members suggested by the leader of the health center: 11 volunteers; high-school education+; 1+ y of experience at the health center	Not reported: Six 4-h classes with one 2-h evaluation; 12-h of formal training and 24-h of service experience at the health center; received a health care volunteer training certificate	Not reported	Volunteers; National Science Council of Taiwan: Not reported

Open in a new tab

Note. ABCD = A1C, blood pressure, cholesterol, and depression; ACS = American Cancer Society; BP = blood pressure; CDC = Centers for Disease Control and Prevention; CHASS = Community Health and Social Services; CHD = coronary heart disease; CHW = community health worker; CMS = Centers for Medicare and Medicaid Services; CVD = cardiovascular disease; DHHS = US Department of Health and Human Services; DM = diabetes mellitus; DSME = diabetes self-management education; FQHC = federally qualified health center; ICRETT = International Cancer Technology Transfer; JTH = Journey to Health; NCI = National Cancer Institute; NCRR = National Center for Research Resources; NHLBI = National Heart, Lung, and Blood Institute; NIDDK = National Institute of Diabetes and Digestive and Kidney Diseases; NIH = National Institutes of Health; NIMHD = National Institute on Minority Health and Health Disparities; NHLBI = National Heart, Lung, and Blood Institute; PI = principal investigator; REACH = Racial and Ethnic Approaches to Community Health; RN = registered nurse; SPSC = Salud Para Su Corazón; T2DM = type 2 diabetes mellitus; WISEWOMAn = Well-Integrated Screening and Evaluation for Women Across the Nation. A fuller version of this table is available as a supplement to the online version of this article at http://www.ajph.org.

^{^a}

Tyrrell et al.⁹⁵ (1996). Older women helping older women: employing senior workers in community research.

Studies also used different selection criteria. Twenty-five studies used living in the same residential area with the study participants as a CBHW selection criterion.^{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 level^31,45,47,60 or having previous experiences working with the 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.

All but 8 studies^{30,42,44,48,51,61,65,76} 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 reported length of training. The CBHWs with shorter training tended to serve relatively simple roles such as recruitment and education,^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 encompassing relevant health information as well as interviewing and teaching skills.

Competency evaluation was only reported in 9 studies. Studies reported that the competency of CBHWs was evaluated after training by using mock educational sessions,^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 managers),^{33,45,63,64,72,83,85} CBHW coordinators (n = 2),^40,43 and study psychologists (n = 2).^73,78 Supervision was imparted by weekly or monthly meetings with the study team members,^{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 maintained 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 understanding 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 interventions into other settings such as outpatient clinics,⁷⁵ community sites,⁷⁷ and rural or other urban communities.⁴⁸

DISCUSSION

To our knowledge, this is the first systematic 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 controlling 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 cardiovascular risk reduction were significantly improved. 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; respectively). Staten et al.⁸⁰ argued that questionable 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 systematic reviews^17,19 underscored the importance of required training and competency 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 populations. There is a strong need for studies to clearly elaborate the contents and processes of CBHW training such as competency evaluation and supervision to optimize the use of this approach.

Our findings offer implications for the successful delivery of CBHW interventions as part of patient-centered and community-oriented care teams. As “natural helpers,” CBHWs play an essential role in bridging between the health care services and the communities they serve.⁹⁸ In particular, their natural helper roles^98,99 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., culturally tailored health education) and nonmedical services (e.g., social support, social services) in the studies included in this review. 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 reimbursable, alternative model of care for vulnerable populations. For example, 2 states in the United States, Minnesota and Massachusetts, initiated policies to cultivate CBHWs. In response to a lack of a health care workforce and an increase in diverse populations, Massachusetts recognized CBHWs as an essential 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 reimbursable 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 integration of CBHWs into the health care delivery system for prevention and management 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 include 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 research into evidence-based guidelines and recommendations for clinical practice in vulnerable populations.

There are methodological issues to be taken into consideration when one is interpreting 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 in this review. A theoretically grounded CBHW intervention can strengthen the theoretical underpinnings of CBHW practice.¹⁰⁵ In some studies CBHWs took on both traditional outreach and recruitment responsibilities, 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, conducting intent-to-treat analyses, and concealing 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 literature 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 developed 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 findings concerning studies published in non-English languages. Fourth, some studies included CBHWs as 1 part of a multifaceted intervention and did not test the effectiveness 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 randomized) may contribute to its quality rating more so than others.

Conclusions

Working with CBHWs to deliver important health-related interventions is a growing trend. As CBHWs are typically trusted members of their communities with whom they share the same cultural and linguistic 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 community 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 primary 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 intervention model that is also cost-effective for certain health conditions (e.g., high blood pressure, diabetes) or behaviors (e.g., mammogram 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.

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 research assistants, Betsega Awelachew and Judy Liu, for their 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. Institutional review board approval was not needed.

REFERENCES

1. Merriam-Webster Dictionary. Vulnerable. Available at: h ttp://www.merriam-webster.com/dictionary/vulnerable?show=0&t=1377802131. Accessed November 25, 2014.
2.Centers for Disease Control and Prevention. Minority health: other at risk populations. 2014. Available at: http://www.cdc.gov/minorityhealth/populations/atrisk.html. Accessed November 25, 2014.
3.Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press; 2002. [PubMed] [Google Scholar]
4. Gallup. In US, uninsured rate holds at 13.4%. 2014. Available at: http://www.gallup.com/poll/178100/uninsured-rate-holds.aspx. Accessed January 10, 2015.
5. Gallup. Cost still a barrier between Americans and medical care. Available at: http://www.gallup.com/poll/179774/cost-barrier-americans-medical-care.aspx. 2014. Accessed January 10, 2015.
6.Kaiser Family Foundation. The uninsured: a primer. Key facts about health insurance and the uninsured in America. 2014. Available at: http://files.kff.org/attachment/the-uninsured-a-primer-key-facts-about-health-insurance-and-the-uninsured-in-america-primer. Accessed December 7, 2014.
7.Reed M. An update on Americans’ access to prescription drugs. Issue Brief Cent Stud Health Syst Change. 2005;(95):1–4. [PubMed] [Google Scholar]
8. The State of Aging and Health in America 2013. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2013.
9.Lee JC, Hasnain-Wynia R, Lau DT. Delay in seeing a doctor due to cost: disparity between older adults with and without disabilities in the United States. Health Serv Res. 2012;47(2):698–720. doi: 10.1111/j.1475-6773.2011.01346.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
10.Love MB, Gardner K, Legion V. Community health workers: who they are and what they do. Health Educ Behav. 1997;24(4):510–522. doi: 10.1177/109019819702400409. [DOI] [PubMed] [Google Scholar]
11.Witmer A, Seifer SD, Finocchio L, Leslie J, O’Neil EH. Community health workers: integral members of the health care work force. Am J Public Health. 1995;85(8 pt 1):1055–1058. doi: 10.2105/ajph.85.8_pt_1.1055. [DOI] [PMC free article] [PubMed] [Google Scholar]
12.American Public Health Association. Community health workers. Available at: https://www.apha.org/apha-communities/member-sections/community-health-workers. Accessed September, 27, 2015. [DOI] [PubMed]
13.Giblin PT. Effective utilization and evaluation of indigenous health care workers. Public Health Rep. 1989;104(4):361–368. [PMC free article] [PubMed] [Google Scholar]
14.A policy research project of The University of Arizona. Summary of the National Community Health Advisor Study. 1998. Available at: http://crh.arizona.edu/sites/default/files/pdf/publications/CAHsummaryALL.pdf. Accessed September 20, 2015.
15.Wells KJ, Luque JS, Miladinovic B et al. Do community health worker interventions improve rates of screening mammography in the United States? A systematic review. Cancer Epidemiol Biomarkers Prev. 2011;20(8):1580–1598. doi: 10.1158/1055-9965.EPI-11-0276. [DOI] [PMC free article] [PubMed] [Google Scholar]
16.Hunt CW, Grant JS, Appel SJ. An integrative review of community health advisors in type 2 diabetes. J Community Health. 2011;36(5):883–893. doi: 10.1007/s10900-011-9381-7. [DOI] [PubMed] [Google Scholar]
17.Norris SL, Chowdhury FM, Van Le K et al. Effectiveness of community health workers in the care of persons with diabetes. Diabet Med. 2006;23(5):544–556. doi: 10.1111/j.1464-5491.2006.01845.x. [DOI] [PubMed] [Google Scholar]
18.Shah M, Kaselitz E, Heisler M. The role of community health workers in diabetes: update on current literature. Curr Diab Rep. 2013;13(2):163–171. doi: 10.1007/s11892-012-0359-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
19.Brownstein JN, Chowdhury FM, Norris SL et al. Effectiveness of community health workers in the care of people with hypertension. Am J Prev Med. 2007;32(5):435–447. doi: 10.1016/j.amepre.2007.01.011. [DOI] [PubMed] [Google Scholar]
20.Chang AB, Taylor B, Masters IB, Laifoo Y, Brown AD. Indigenous healthcare worker involvement for indigenous adults and children with asthma. Cochrane Database Syst Rev. 2010;(5) doi: 10.1002/14651858.CD006344.pub2. CD006344. [DOI] [PubMed] [Google Scholar]
21.Kenya S, Chida N, Symes S, Shor-Posner G. Can community health workers improve adherence to highly active antiretroviral therapy in the USA? A review of the literature. HIV Med. 2011;12(9):525–534. doi: 10.1111/j.1468-1293.2011.00921.x. [DOI] [PubMed] [Google Scholar]
22.Jadad AR, Moore RA, Carroll D et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials. 1996;17(1):1–12. doi: 10.1016/0197-2456(95)00134-4. [DOI] [PubMed] [Google Scholar]
23.Han HR, Kim J, Lee JE et al. Interventions that increase use of Pap tests among ethnic minority women: a meta-analysis. Psychooncology. 2011;20(4):341–351. doi: 10.1002/pon.1754. [DOI] [PMC free article] [PubMed] [Google Scholar]
24.Price EG, Beach MC, Gary TL et al. A systematic review of the methodological rigor of studies evaluating cultural competence training of health professionals. Acad Med. 2005;80(6):578–586. doi: 10.1097/00001888-200506000-00013. [DOI] [PubMed] [Google Scholar]
25.Haynes RB, Sackett DL. Compliance With Therapeutic Regimens. Baltimore, MD: Johns Hopkins University Press; 1976. p. 293. [Google Scholar]
26.Ahmed NU, Haber G, Semenya KA, Hargreaves MK. Randomized controlled trial of mammography intervention in insured very low-income women. Cancer Epidemiol Biomarkers Prev. 2010;19(7):1790–1798. doi: 10.1158/1055-9965.EPI-10-0141. [DOI] [PubMed] [Google Scholar]
27.Bastani R, Mojica CM, Berman BA, Ganz PA. Low-income women with abnormal breast findings: results of a randomized trial to increase rates of diagnostic resolution. Cancer Epidemiol Biomarkers Prev. 2010;19(8):1927–1936. doi: 10.1158/1055-9965.EPI-09-0481. [DOI] [PubMed] [Google Scholar]
28.Byrd TL, Wilson KM, Smith JL et al. AMIGAS: a multicity, multicomponent cervical cancer prevention trial among Mexican American women. Cancer. 2013;119(7):1365–1372. doi: 10.1002/cncr.27926. [DOI] [PMC free article] [PubMed] [Google Scholar]
29.Campbell MK, James A, Hudson MA et al. Improving multiple behaviors for colorectal cancer prevention among African American church members. Health Psychol. 2004;23(5):492–502. doi: 10.1037/0278-6133.23.5.492. [DOI] [PubMed] [Google Scholar]
30.Castañeda SF, Xiong Y, Gallo LC et al. Colorectal cancer educational intervention targeting Latino patients attending a community health center. J Prim Care Community Health. 2012;3(3):164–169. doi: 10.1177/2150131911427731. [DOI] [PMC free article] [PubMed] [Google Scholar]
31.Crump SR, Shipp MP, McCray GG et al. Abnormal mammogram follow-up: do community lay health advocates make a difference? Health Promot Pract. 2008;9(2):140–148. doi: 10.1177/1524839907312806. [DOI] [PubMed] [Google Scholar]
32.Engelstad LP, Stewart S, Otero-Sabogal R, Leung MS, Davis PI, Pasick RJ. The effectiveness of a community outreach intervention to improve follow-up among underserved women at highest risk for cervical cancer. Prev Med. 2005;41(3-4):741–748. doi: 10.1016/j.ypmed.2005.06.003. [DOI] [PubMed] [Google Scholar]
33.Fernández ME, Gonzales A, Tortolero-Luna G et al. Effectiveness of Cultivando la Salud: a breast and cervical cancer screening promotion program for low-income Hispanic women. Am J Public Health. 2009;99(5):936–943. doi: 10.2105/AJPH.2008.136713. [DOI] [PMC free article] [PubMed] [Google Scholar]
34.Holt CL, Litaker MS, Scarinci IC et al. Spiritually based intervention to increase colorectal cancer screening among African Americans: screening and theory-based outcomes from a randomized trial. Health Educ Behav. 2013;40(4):458–468. doi: 10.1177/1090198112459651. [DOI] [PMC free article] [PubMed] [Google Scholar]
35.Lam TK, McPhee SJ, Mock J et al. Encouraging Vietnamese-American women to obtain Pap tests through lay health worker outreach and media education. J Gen Intern Med. 2003;18(7):516–524. doi: 10.1046/j.1525-1497.2003.21043.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
36.Larkey LK, Herman PM, Roe DJ et al. A cancer screening intervention for underserved Latina women by lay educators. J Womens Health (Larchmt) 2012;21(5):557–566. doi: 10.1089/jwh.2011.3087. [DOI] [PubMed] [Google Scholar]
37.Margolis KL, Lurie N, McGovern PG, Tyrrell M, Slater JS. Increasing breast and cervical cancer screening in low-income women. J Gen Intern Med. 1998;13(8):515–521. doi: 10.1046/j.1525-1497.1998.00161.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
38.Mock J, McPhee SJ, Nguyen T et al. Effective lay health worker outreach and media-based education for promoting cervical cancer screening among Vietnamese American women. Am J Public Health. 2007;97(9):1693–1700. doi: 10.2105/AJPH.2006.086470. [DOI] [PMC free article] [PubMed] [Google Scholar]
39.Navarro AM, Senn KL, McNicholas LJ, Kaplan RM, Roppe B, Campo MC. Por la Vida model intervention enhances use of cancer screening tests among Latinas. Am J Prev Med. 1998;15(1):32–41. doi: 10.1016/s0749-3797(98)00023-3. [DOI] [PubMed] [Google Scholar]
40.Nguyen TT, Le G, Nguyen T et al. Breast cancer screening among Vietnamese Americans: a randomized controlled trial of lay health worker outreach. Am J Prev Med. 2009;37(4):306–313. doi: 10.1016/j.amepre.2009.06.009. [DOI] [PMC free article] [PubMed] [Google Scholar]
41.Nuño T, Martinez ME, Harris R, Garcia F. A promotora-administered group education intervention to promote breast and cervical cancer screening in a rural community along the US–Mexico border: a randomized controlled trial. Cancer Causes Control. 2011;22(3):367–374. doi: 10.1007/s10552-010-9705-4. [DOI] [PubMed] [Google Scholar]
42.O’Brien MJ, Halbert CH, Bixby R, Pimentel S, Shea JA. Community health worker intervention to decrease cervical cancer disparities in Hispanic women. J Gen Intern Med. 2010;25(11):1186–1192. doi: 10.1007/s11606-010-1434-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
43.Paskett E, Tatum C, Rushing J et al. Randomized trial of an intervention to improve mammography utilization among a triracial rural population of women. J Natl Cancer Inst. 2006;98(17):1226–1237. doi: 10.1093/jnci/djj333. [DOI] [PMC free article] [PubMed] [Google Scholar]
44.Paskett ED, McLaughlin JM, Lehman AM, Katz ML, Tatum CM, Oliveri JM. Evaluating the efficacy of lay health advisors for increasing risk-appropriate Pap test screening: a randomized controlled trial among Ohio Appalachian women. Cancer Epidemiol Biomarkers Prev. 2011;20(5):835–843. doi: 10.1158/1055-9965.EPI-10-0880. [DOI] [PMC free article] [PubMed] [Google Scholar]
45.Percac-Lima S, Grant RW, Green AR et al. A culturally tailored navigator program for colorectal cancer screening in a community health center: a randomized, controlled trial. J Gen Intern Med. 2009;24(2):211–217. doi: 10.1007/s11606-008-0864-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
46.Russell KM, Champion VL, Monahan PO et al. Randomized trial of a lay health advisor and computer intervention to increase mammography screening in African American women. Cancer Epidemiol Biomarkers Prev. 2010;19(1):201–210. doi: 10.1158/1055-9965.EPI-09-0569. [DOI] [PMC free article] [PubMed] [Google Scholar]
47.Sankaranarayanan R, Ramadas K, Thomas G et al. Effect of screening on oral cancer mortality in Kerala, India: a cluster-randomised controlled trial. Lancet. 2005;365(9475):1927–1933. doi: 10.1016/S0140-6736(05)66658-5. [DOI] [PubMed] [Google Scholar]
48.Slater JS, Ha CN, Malone ME et al. A randomized community trial to increase mammography utilization among low-income women living in public housing. Prev Med. 1998;27(6):862–870. doi: 10.1006/pmed.1998.0370. [DOI] [PubMed] [Google Scholar]
49.Studts CR, Tarasenko YN, Schoenberg NE, Shelton BJ, Hatcher-Keller J, Dignan MB. A community-based randomized trial of a faith-placed intervention to reduce cervical cancer burden in Appalachia. Prev Med. 2012;54(6):408–414. doi: 10.1016/j.ypmed.2012.03.019. [DOI] [PMC free article] [PubMed] [Google Scholar]
50.Sung JF, Blumenthal DS, Coates RJ, Williams JE, Alema-Mensah E, Liff JM. Effect of a cancer screening intervention conducted by lay health workers among inner-city women. Am J Prev Med. 1997;13(1):51–57. [PubMed] [Google Scholar]
51.Taylor VM, Hislop TG, Jackson JC et al. A randomized controlled trial of interventions to promote cervical cancer screening among Chinese women in North America. J Natl Cancer Inst. 2002;94(9):670–677. doi: 10.1093/jnci/94.9.670. [DOI] [PMC free article] [PubMed] [Google Scholar]
52.Taylor VM, Jackson JC, Yasui Y et al. Evaluation of a cervical cancer control intervention using lay health workers for Vietnamese American women. Am J Public Health. 2010;100(10):1924–1929. doi: 10.2105/AJPH.2009.190348. [DOI] [PMC free article] [PubMed] [Google Scholar]
53.West DS, Greene P, Pulley L et al. Stepped-care, community clinic interventions to promote mammography use among low-income rural African American women. Health Educ Behav. 2004;31(4 suppl):29S–44S. doi: 10.1177/1090198104266033. [DOI] [PubMed] [Google Scholar]
54.Wilson TE, Fraser-White M, Feldman J et al. Hair salon stylists as breast cancer prevention lay health advisors for African American and Afro-Caribbean women. J Health Care Poor Underserved. 2008;19(1):216–226. doi: 10.1353/hpu.2008.0017. [DOI] [PubMed] [Google Scholar]
55.Zhu K, Hunter S, Bernard LJ et al. An intervention study on screening for breast cancer among single African-American women aged 65 and older. Prev Med. 2002;34(5):536–545. doi: 10.1006/pmed.2002.1016. [DOI] [PubMed] [Google Scholar]
56.Allen JK, Himmelfarb CR, Szanton SL, Bone L, Hill MN, Levine DM. COACH trial: a randomized controlled trial of nurse practitioner/community health worker cardiovascular disease risk reduction in urban community health centers: rationale and design. Contemp Clin Trials. 2011;32(3):403–411. doi: 10.1016/j.cct.2011.01.001. [DOI] [PMC free article] [PubMed] [Google Scholar]
57.Balcázar HG, Byrd TL, Ortiz M, Tondapu SR, Chavez M. A randomized community intervention to improve hypertension control among Mexican Americans: using the promotoras de salud community outreach model. J Health Care Poor Underserved. 2009;20(4):1079–1094. doi: 10.1353/hpu.0.0209. [DOI] [PubMed] [Google Scholar]
58.Balcázar HG, de Heer H, Rosenthal L et al. A promotores de salud intervention to reduce cardiovascular disease risk in a high-risk Hispanic border population, 2005–2008. Prev Chronic Dis. 2010;7(2):A28. [PMC free article] [PubMed] [Google Scholar]
59.Becker DM, Yanek LR, Johnson WR, II et al. Impact of a community-based multiple risk factor intervention on cardiovascular risk in Black families with a history of premature coronary disease. Circulation. 2005;111(10):1298–1304. doi: 10.1161/01.CIR.0000157734.97351.B2. [DOI] [PubMed] [Google Scholar]
60.Coleman KJ, Farrell MA, Rocha DA et al. Readiness to be physically active and self-reported physical activity in low-income Latinas, California WISEWOMAN, 2006–2007. Prev Chronic Dis. 2012;9 E87. [PMC free article] [PubMed] [Google Scholar]
61.Cooper LA, Roter DL, Carson KA et al. A randomized trial to improve patient-centered care and hypertension control in underserved primary care patients. J Gen Intern Med. 2011;26(11):1297–1304. doi: 10.1007/s11606-011-1794-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
62.Daniels EC, Powe BD, Metoyer T, McCray G, Baltrus P, Rust GS. Increasing knowledge of cardiovascular risk factors among African Americans by use of community health workers: the ABCD community intervention pilot project. J Natl Med Assoc. 2012;104(3-4):179–185. doi: 10.1016/s0027-9684(15)30139-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
63.DePue JD, Dunsiger S, Seiden AD et al. Nurse–community health worker team improves diabetes care in American Samoa: results of a randomized controlled trial. Diabetes Care. 2013;36(7):1947–1953. doi: 10.2337/dc12-1969. [DOI] [PMC free article] [PubMed] [Google Scholar]
64.Hayashi T, Farrell MA, Chaput LA, Rocha DA, Hernandez M. Lifestyle intervention, behavioral changes, and improvement in cardiovascular risk profiles in the California WISEWOMAN project. J Womens Health (Larchmt) 2010;19(6):1129–1138. doi: 10.1089/jwh.2009.1631. [DOI] [PubMed] [Google Scholar]
65.Hill MN, Han HR, Dennison CR et al. Hypertension care and control in underserved urban African American men: behavioral and physiologic outcomes at 36 months. Am J Hypertens. 2003;16(11 pt 1):906–913. doi: 10.1016/s0895-7061(03)01034-3. [DOI] [PubMed] [Google Scholar]
66.Hunter JB, de Zapien JG, Papenfuss M, Fernandez ML, Meister J, Giuliano AR. The impact of a promotora on increasing routine chronic disease prevention among women aged 40 and older at the US–Mexico border. Health Educ Behav. 2004;31(4, suppl):18S–28S. doi: 10.1177/1090198104266004. [DOI] [PubMed] [Google Scholar]
67.Islam NS, Zanowiak JM, Wyatt LC et al. A randomized-controlled, pilot intervention on diabetes prevention and healthy lifestyles in the New York City Korean community. J Community Health. 2013;38(6):1030–1041. doi: 10.1007/s10900-013-9711-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
68.Jafar TH, Hatcher J, Poulter N et al. Community-based interventions to promote blood pressure control in a developing country: a cluster randomized trial. Ann Intern Med. 2009;151(9):593–601. doi: 10.7326/0003-4819-151-9-200911030-00004. [DOI] [PubMed] [Google Scholar]
69.Katula JA, Vitolins MZ, Morgan TM et al. The healthy living partnerships to prevent diabetes study: 2-year outcomes of a randomized controlled trial. Am J Prev Med. 2013;44(4, suppl 4):S324–S332. doi: 10.1016/j.amepre.2012.12.015. [DOI] [PMC free article] [PubMed] [Google Scholar]
70.Kenya S, Lebron C, Reyes Arrechea E, Li H. Glucometer use and glycemic control among Hispanic patients with diabetes in Southern Florida. Clin Ther. 2014;36(4):485–493. doi: 10.1016/j.clinthera.2013.12.009. [DOI] [PubMed] [Google Scholar]
71.Krieger J, Collier C, Song L, Martin D. Linking community-based blood pressure measurement to clinical care: a randomized controlled trial of outreach and tracking by community health workers. Am J Public Health. 1999;89(6):856–861. doi: 10.2105/ajph.89.6.856. [DOI] [PMC free article] [PubMed] [Google Scholar]
72.Levine DM, Bone LR, Hill MN et al. The effectiveness of a community/academic health center partnership in decreasing the level of blood pressure in an urban African-American population. Ethn Dis. 2003;13(3):354–361. [PubMed] [Google Scholar]
73.Lynch EB, Liebman R, Ventrelle J, Avery EF, Richardson D. A self-management intervention for African Americans with comorbid diabetes and hypertension: a pilot randomized controlled trial. Prev Chronic Dis. 2014;11 doi: 10.5888/pcd11.130349. E90. [DOI] [PMC free article] [PubMed] [Google Scholar]
74.Margolius D, Bodenheimer T, Bennett H et al. Health coaching to improve hypertension treatment in a low-income, minority population. Ann Fam Med. 2012;10(3):199–205. doi: 10.1370/afm.1369. [DOI] [PMC free article] [PubMed] [Google Scholar]
75.Morisky DE, Lees NB, Sharif BA, Liu KY, Ward HJ. Reducing disparities in hypertension control: a community-based hypertension control project (CHIP) for an ethnically diverse population. Health Promot Pract. 2002;3(2):264–275. [Google Scholar]
76.Palmas W, Findley SE, Mejia M et al. Results of the Northern Manhattan diabetes community outreach project: a randomized trial studying a community health worker intervention to improve diabetes care in Hispanic adults. Diabetes Care. 2014;37(4):963–969. doi: 10.2337/dc13-2142. [DOI] [PMC free article] [PubMed] [Google Scholar]
77.Prezio EA, Cheng D, Balasubramanian BA, Shuval K, Kendzor DE, Culica D. Community diabetes education (CoDE) for uninsured Mexican Americans: a randomized controlled trial of a culturally tailored diabetes education and management program led by a community health worker. Diabetes Res Clin Pract. 2013;100(1):19–28. doi: 10.1016/j.diabres.2013.01.027. [DOI] [PubMed] [Google Scholar]
78.Rothschild SK, Martin MA, Swider SM et al. Mexican American trial of community health workers: a randomized controlled trial of a community health worker intervention for Mexican Americans with type 2 diabetes mellitus. Am J Public Health. 2014;104(8):1540–1548. doi: 10.2105/AJPH.2013.301439. [DOI] [PMC free article] [PubMed] [Google Scholar]
79.Spencer MS, Rosland AM, Kieffer EC et al. Effectiveness of a community health worker intervention among African American and Latino adults with type 2 diabetes: a randomized controlled trial. Am J Public Health. 2011;101(12):2253–2260. doi: 10.2105/AJPH.2010.300106. [DOI] [PMC free article] [PubMed] [Google Scholar]
80.Staten LK, Gregory-Mercado KY, Ranger-Moore J et al. Provider counseling, health education, and community health workers: the Arizona WISEWOMAN project. J Womens Health (Larchmt) 2004;13(5):547–556. doi: 10.1089/1540999041281133. [DOI] [PubMed] [Google Scholar]
81.Tang TS, Funnell M, Sinco B et al. Comparative effectiveness of peer leaders and community health workers in diabetes self-management support: results of a randomized controlled trial. Diabetes Care. 2014;37(6):1525–1534. doi: 10.2337/dc13-2161. [DOI] [PMC free article] [PubMed] [Google Scholar]
82.Beck C, Fausett JK, Krukowski RA et al. A randomized trial of a community-based cognitive intervention for obese senior adults. J Aging Health. 2013;25(1):97–118. doi: 10.1177/0898264312467374. [DOI] [PMC free article] [PubMed] [Google Scholar]
83.Chatterjee S, Naik S, John S et al. Effectiveness of a community-based intervention for people with schizophrenia and their caregivers in India (COPSI): a randomised controlled trial. Lancet. 2014;383(9926):1385–1394. doi: 10.1016/S0140-6736(13)62629-X. [DOI] [PMC free article] [PubMed] [Google Scholar]
84.Waitzkin H, Getrich C, Heying S et al. Promotoras as mental health practitioners in primary care: a multi-method study of an intervention to address contextual sources of depression. J Community Health. 2011;36(2):316–331. doi: 10.1007/s10900-010-9313-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
85.Martin MA, Catrambone CD, Kee RA et al. Improving asthma self-efficacy: developing and testing a pilot community-based asthma intervention for African American adults. J Allergy Clin Immunol. 2009;123(1):153–159. doi: 10.1016/j.jaci.2008.10.057. e3. [DOI] [PMC free article] [PubMed] [Google Scholar]
86.Wang CJ, Fetzer SJ, Yang YC, Wang JJ. The impacts of using community health volunteers to coach medication safety behaviors among rural elders with chronic illnesses. Geriatr Nurs. 2013;34(2):138–145. doi: 10.1016/j.gerinurse.2012.12.013. [DOI] [PubMed] [Google Scholar]
87.Allen JK, Dennison Himmelfarb CR, Szanton SL, Frick KD. Cost-effectiveness of nurse practitioner/community health worker care to reduce cardiovascular health disparities. J Cardiovasc Nurs. 2014;29(4):308–314. doi: 10.1097/JCN.0b013e3182945243. [DOI] [PMC free article] [PubMed] [Google Scholar]
88.Lawlor MS, Blackwell CS, Isom SP et al. Cost of a group translation of the diabetes prevention program: healthy living partnerships to prevent diabetes. Am J Prev Med. 2013;44(4, suppl 4):S381–S389. doi: 10.1016/j.amepre.2012.12.016. [DOI] [PMC free article] [PubMed] [Google Scholar]
89.Scoggins JF, Ramsey SD, Jackson JC, Taylor VM. Cost effectiveness of a program to promote screening for cervical cancer in the Vietnamese-American population. Asian Pac J Cancer Prev. 2010;11(3):717–722. [PMC free article] [PubMed] [Google Scholar]
90.Wagner TH, Engelstad LP, McPhee SJ, Pasick RJ. The costs of an outreach intervention for low-income women with abnormal Pap smears. Prev Chronic Dis. 2007;4(1):A11. [PMC free article] [PubMed] [Google Scholar]
91.Jafar TH, Islam M, Bux R et al. Cost-effectiveness of community-based strategies for blood pressure control in a low-income developing country: findings from a cluster-randomized, factorial-controlled trial. Circulation. 2011;124(15):1615–1625. doi: 10.1161/CIRCULATIONAHA.111.039990. [DOI] [PMC free article] [PubMed] [Google Scholar]
92.Lairson DR, Chang YC, Byrd TL, Lee Smith J, Fernandez ME, Wilson KM. Cervical cancer screening with AMIGAS: a cost-effectiveness analysis. Am J Prev Med. 2014;46(6):617–623. doi: 10.1016/j.amepre.2014.01.020. [DOI] [PMC free article] [PubMed] [Google Scholar]
93.Cooper LA, Roter DL, Bone LR et al. A randomized controlled trial of interventions to enhance patient–physician partnership, patient adherence and high blood pressure control among ethnic minorities and poor persons: study protocol NCT00123045. Implement Sci. 2009;4:7. doi: 10.1186/1748-5908-4-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
94.West DS, Bursac Z, Cornell CE et al. Lay health educators translate a weight-loss intervention in senior centers: a randomized controlled trial. Am J Prev Med. 2011;41(4):385–391. doi: 10.1016/j.amepre.2011.06.041. [DOI] [PMC free article] [PubMed] [Google Scholar]
95.Tyrrell M, Margolis K, Sandberg L, Slater J, Lurie N. Older women helping older women: employing senior workers in community research. Am J Public Health. 1996;86(4):588–589. [PubMed] [Google Scholar]
96.Rothschild SK, Martin MA, Swider SM et al. The Mexican-American Trial of Community Health Workers (MATCH): design and baseline characteristics of a randomized controlled trial testing a culturally tailored community diabetes self-management intervention. Contemp Clin Trials. 2012;33(2):369–377. doi: 10.1016/j.cct.2011.10.013. [DOI] [PMC free article] [PubMed] [Google Scholar]
97.The Community Guide. Cardiovascular disease prevention and control: interventions engaging community health workers. Available at: http://www.thecommunityguide.org/cvd/CHW.html. 2015. Accessed October 1, 2015.
98.Herman AA. Community health workers and integrated primary health care teams in the 21st century. J Ambul Care Manage. 2011;34(4):354–361. doi: 10.1097/JAC.0b013e31822cbcd0. [DOI] [PubMed] [Google Scholar]
99.Volkmann K, Castanares T. Clinical community health workers: linchpin of the medical home. J Ambul Care Manage. 2011;34(3):221–233. doi: 10.1097/JAC.0b013e31821cb559. [DOI] [PubMed] [Google Scholar]
100.Lemay CA, Ferguson WJ, Hargraves JL. Community health worker encounter forms: a tool to guide and document patient visits and worker performance. Am J Public Health. 2012;102(7):e70–e75. doi: 10.2105/AJPH.2011.300416. [DOI] [PMC free article] [PubMed] [Google Scholar]
101.Cherrington A, Ayala GX, Elder JP, Arredondo EM, Fouad M, Scarinci I. Recognizing the diverse roles of community health workers in the elimination of health disparities: from paid staff to volunteers. Ethn Dis. 2010;20(2):189–194. [PMC free article] [PubMed] [Google Scholar]
102.The Executive Office of Health and Human Services. Office of community health workers. Available at: http://www.mass.gov/eohhs/gov/departments/dph/programs/community-health/prevention-and-wellness/comm-health-wkrs. Accessed September 28, 2015.
103.Rosenthal EL, Brownstein JN, Rush CH et al. Community health workers: part of the solution. Health Aff (Millwood) 2010;29(7):1338–1342. doi: 10.1377/hlthaff.2010.0081. [DOI] [PubMed] [Google Scholar]
104.Martinez J, Ro M, Villa NW, Powell W, Knickman JR. Transforming the delivery of care in the post-health reform era: what role will community health workers play? Am J Public Health. 2011;101(12):e1–e5. doi: 10.2105/AJPH.2011.300335. [DOI] [PMC free article] [PubMed] [Google Scholar]
105.Katigbak C, Van Devanter N, Islam N, Trinh-Shevrin C. Partners in health: a conceptual framework for the role of community health workers in facilitating patients’ adoption of healthy behaviors. Am J Public Health. 2015;105(5):872–880. doi: 10.2105/AJPH.2014.302411. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib1] 1. Merriam-Webster Dictionary. Vulnerable. Available at: h ttp://www.merriam-webster.com/dictionary/vulnerable?show=0&t=1377802131. Accessed November 25, 2014.

[bib2] 2.Centers for Disease Control and Prevention. Minority health: other at risk populations. 2014. Available at: http://www.cdc.gov/minorityhealth/populations/atrisk.html. Accessed November 25, 2014.

[bib3] 3.Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press; 2002. [PubMed] [Google Scholar]

[bib4] 4. Gallup. In US, uninsured rate holds at 13.4%. 2014. Available at: http://www.gallup.com/poll/178100/uninsured-rate-holds.aspx. Accessed January 10, 2015.

[bib5] 5. Gallup. Cost still a barrier between Americans and medical care. Available at: http://www.gallup.com/poll/179774/cost-barrier-americans-medical-care.aspx. 2014. Accessed January 10, 2015.

[bib6] 6.Kaiser Family Foundation. The uninsured: a primer. Key facts about health insurance and the uninsured in America. 2014. Available at: http://files.kff.org/attachment/the-uninsured-a-primer-key-facts-about-health-insurance-and-the-uninsured-in-america-primer. Accessed December 7, 2014.

[bib7] 7.Reed M. An update on Americans’ access to prescription drugs. Issue Brief Cent Stud Health Syst Change. 2005;(95):1–4. [PubMed] [Google Scholar]

[bib8] 8. The State of Aging and Health in America 2013. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2013.

[bib9] 9.Lee JC, Hasnain-Wynia R, Lau DT. Delay in seeing a doctor due to cost: disparity between older adults with and without disabilities in the United States. Health Serv Res. 2012;47(2):698–720. doi: 10.1111/j.1475-6773.2011.01346.x. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib10] 10.Love MB, Gardner K, Legion V. Community health workers: who they are and what they do. Health Educ Behav. 1997;24(4):510–522. doi: 10.1177/109019819702400409. [DOI] [PubMed] [Google Scholar]

[bib11] 11.Witmer A, Seifer SD, Finocchio L, Leslie J, O’Neil EH. Community health workers: integral members of the health care work force. Am J Public Health. 1995;85(8 pt 1):1055–1058. doi: 10.2105/ajph.85.8_pt_1.1055. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib12] 12.American Public Health Association. Community health workers. Available at: https://www.apha.org/apha-communities/member-sections/community-health-workers. Accessed September, 27, 2015. [DOI] [PubMed]

[bib13] 13.Giblin PT. Effective utilization and evaluation of indigenous health care workers. Public Health Rep. 1989;104(4):361–368. [PMC free article] [PubMed] [Google Scholar]

[bib14] 14.A policy research project of The University of Arizona. Summary of the National Community Health Advisor Study. 1998. Available at: http://crh.arizona.edu/sites/default/files/pdf/publications/CAHsummaryALL.pdf. Accessed September 20, 2015.

[bib15] 15.Wells KJ, Luque JS, Miladinovic B et al. Do community health worker interventions improve rates of screening mammography in the United States? A systematic review. Cancer Epidemiol Biomarkers Prev. 2011;20(8):1580–1598. doi: 10.1158/1055-9965.EPI-11-0276. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib16] 16.Hunt CW, Grant JS, Appel SJ. An integrative review of community health advisors in type 2 diabetes. J Community Health. 2011;36(5):883–893. doi: 10.1007/s10900-011-9381-7. [DOI] [PubMed] [Google Scholar]

[bib17] 17.Norris SL, Chowdhury FM, Van Le K et al. Effectiveness of community health workers in the care of persons with diabetes. Diabet Med. 2006;23(5):544–556. doi: 10.1111/j.1464-5491.2006.01845.x. [DOI] [PubMed] [Google Scholar]

[bib18] 18.Shah M, Kaselitz E, Heisler M. The role of community health workers in diabetes: update on current literature. Curr Diab Rep. 2013;13(2):163–171. doi: 10.1007/s11892-012-0359-3. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib19] 19.Brownstein JN, Chowdhury FM, Norris SL et al. Effectiveness of community health workers in the care of people with hypertension. Am J Prev Med. 2007;32(5):435–447. doi: 10.1016/j.amepre.2007.01.011. [DOI] [PubMed] [Google Scholar]

[bib20] 20.Chang AB, Taylor B, Masters IB, Laifoo Y, Brown AD. Indigenous healthcare worker involvement for indigenous adults and children with asthma. Cochrane Database Syst Rev. 2010;(5) doi: 10.1002/14651858.CD006344.pub2. CD006344. [DOI] [PubMed] [Google Scholar]

[bib21] 21.Kenya S, Chida N, Symes S, Shor-Posner G. Can community health workers improve adherence to highly active antiretroviral therapy in the USA? A review of the literature. HIV Med. 2011;12(9):525–534. doi: 10.1111/j.1468-1293.2011.00921.x. [DOI] [PubMed] [Google Scholar]

[bib22] 22.Jadad AR, Moore RA, Carroll D et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials. 1996;17(1):1–12. doi: 10.1016/0197-2456(95)00134-4. [DOI] [PubMed] [Google Scholar]

[bib23] 23.Han HR, Kim J, Lee JE et al. Interventions that increase use of Pap tests among ethnic minority women: a meta-analysis. Psychooncology. 2011;20(4):341–351. doi: 10.1002/pon.1754. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib24] 24.Price EG, Beach MC, Gary TL et al. A systematic review of the methodological rigor of studies evaluating cultural competence training of health professionals. Acad Med. 2005;80(6):578–586. doi: 10.1097/00001888-200506000-00013. [DOI] [PubMed] [Google Scholar]

[bib25] 25.Haynes RB, Sackett DL. Compliance With Therapeutic Regimens. Baltimore, MD: Johns Hopkins University Press; 1976. p. 293. [Google Scholar]

[bib26] 26.Ahmed NU, Haber G, Semenya KA, Hargreaves MK. Randomized controlled trial of mammography intervention in insured very low-income women. Cancer Epidemiol Biomarkers Prev. 2010;19(7):1790–1798. doi: 10.1158/1055-9965.EPI-10-0141. [DOI] [PubMed] [Google Scholar]

[bib27] 27.Bastani R, Mojica CM, Berman BA, Ganz PA. Low-income women with abnormal breast findings: results of a randomized trial to increase rates of diagnostic resolution. Cancer Epidemiol Biomarkers Prev. 2010;19(8):1927–1936. doi: 10.1158/1055-9965.EPI-09-0481. [DOI] [PubMed] [Google Scholar]

[bib28] 28.Byrd TL, Wilson KM, Smith JL et al. AMIGAS: a multicity, multicomponent cervical cancer prevention trial among Mexican American women. Cancer. 2013;119(7):1365–1372. doi: 10.1002/cncr.27926. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib29] 29.Campbell MK, James A, Hudson MA et al. Improving multiple behaviors for colorectal cancer prevention among African American church members. Health Psychol. 2004;23(5):492–502. doi: 10.1037/0278-6133.23.5.492. [DOI] [PubMed] [Google Scholar]

[bib30] 30.Castañeda SF, Xiong Y, Gallo LC et al. Colorectal cancer educational intervention targeting Latino patients attending a community health center. J Prim Care Community Health. 2012;3(3):164–169. doi: 10.1177/2150131911427731. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib31] 31.Crump SR, Shipp MP, McCray GG et al. Abnormal mammogram follow-up: do community lay health advocates make a difference? Health Promot Pract. 2008;9(2):140–148. doi: 10.1177/1524839907312806. [DOI] [PubMed] [Google Scholar]

[bib32] 32.Engelstad LP, Stewart S, Otero-Sabogal R, Leung MS, Davis PI, Pasick RJ. The effectiveness of a community outreach intervention to improve follow-up among underserved women at highest risk for cervical cancer. Prev Med. 2005;41(3-4):741–748. doi: 10.1016/j.ypmed.2005.06.003. [DOI] [PubMed] [Google Scholar]

[bib33] 33.Fernández ME, Gonzales A, Tortolero-Luna G et al. Effectiveness of Cultivando la Salud: a breast and cervical cancer screening promotion program for low-income Hispanic women. Am J Public Health. 2009;99(5):936–943. doi: 10.2105/AJPH.2008.136713. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib34] 34.Holt CL, Litaker MS, Scarinci IC et al. Spiritually based intervention to increase colorectal cancer screening among African Americans: screening and theory-based outcomes from a randomized trial. Health Educ Behav. 2013;40(4):458–468. doi: 10.1177/1090198112459651. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib35] 35.Lam TK, McPhee SJ, Mock J et al. Encouraging Vietnamese-American women to obtain Pap tests through lay health worker outreach and media education. J Gen Intern Med. 2003;18(7):516–524. doi: 10.1046/j.1525-1497.2003.21043.x. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib36] 36.Larkey LK, Herman PM, Roe DJ et al. A cancer screening intervention for underserved Latina women by lay educators. J Womens Health (Larchmt) 2012;21(5):557–566. doi: 10.1089/jwh.2011.3087. [DOI] [PubMed] [Google Scholar]

[bib37] 37.Margolis KL, Lurie N, McGovern PG, Tyrrell M, Slater JS. Increasing breast and cervical cancer screening in low-income women. J Gen Intern Med. 1998;13(8):515–521. doi: 10.1046/j.1525-1497.1998.00161.x. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib38] 38.Mock J, McPhee SJ, Nguyen T et al. Effective lay health worker outreach and media-based education for promoting cervical cancer screening among Vietnamese American women. Am J Public Health. 2007;97(9):1693–1700. doi: 10.2105/AJPH.2006.086470. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib39] 39.Navarro AM, Senn KL, McNicholas LJ, Kaplan RM, Roppe B, Campo MC. Por la Vida model intervention enhances use of cancer screening tests among Latinas. Am J Prev Med. 1998;15(1):32–41. doi: 10.1016/s0749-3797(98)00023-3. [DOI] [PubMed] [Google Scholar]

[bib40] 40.Nguyen TT, Le G, Nguyen T et al. Breast cancer screening among Vietnamese Americans: a randomized controlled trial of lay health worker outreach. Am J Prev Med. 2009;37(4):306–313. doi: 10.1016/j.amepre.2009.06.009. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib41] 41.Nuño T, Martinez ME, Harris R, Garcia F. A promotora-administered group education intervention to promote breast and cervical cancer screening in a rural community along the US–Mexico border: a randomized controlled trial. Cancer Causes Control. 2011;22(3):367–374. doi: 10.1007/s10552-010-9705-4. [DOI] [PubMed] [Google Scholar]

[bib42] 42.O’Brien MJ, Halbert CH, Bixby R, Pimentel S, Shea JA. Community health worker intervention to decrease cervical cancer disparities in Hispanic women. J Gen Intern Med. 2010;25(11):1186–1192. doi: 10.1007/s11606-010-1434-6. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib43] 43.Paskett E, Tatum C, Rushing J et al. Randomized trial of an intervention to improve mammography utilization among a triracial rural population of women. J Natl Cancer Inst. 2006;98(17):1226–1237. doi: 10.1093/jnci/djj333. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib44] 44.Paskett ED, McLaughlin JM, Lehman AM, Katz ML, Tatum CM, Oliveri JM. Evaluating the efficacy of lay health advisors for increasing risk-appropriate Pap test screening: a randomized controlled trial among Ohio Appalachian women. Cancer Epidemiol Biomarkers Prev. 2011;20(5):835–843. doi: 10.1158/1055-9965.EPI-10-0880. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib45] 45.Percac-Lima S, Grant RW, Green AR et al. A culturally tailored navigator program for colorectal cancer screening in a community health center: a randomized, controlled trial. J Gen Intern Med. 2009;24(2):211–217. doi: 10.1007/s11606-008-0864-x. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib46] 46.Russell KM, Champion VL, Monahan PO et al. Randomized trial of a lay health advisor and computer intervention to increase mammography screening in African American women. Cancer Epidemiol Biomarkers Prev. 2010;19(1):201–210. doi: 10.1158/1055-9965.EPI-09-0569. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib47] 47.Sankaranarayanan R, Ramadas K, Thomas G et al. Effect of screening on oral cancer mortality in Kerala, India: a cluster-randomised controlled trial. Lancet. 2005;365(9475):1927–1933. doi: 10.1016/S0140-6736(05)66658-5. [DOI] [PubMed] [Google Scholar]

[bib48] 48.Slater JS, Ha CN, Malone ME et al. A randomized community trial to increase mammography utilization among low-income women living in public housing. Prev Med. 1998;27(6):862–870. doi: 10.1006/pmed.1998.0370. [DOI] [PubMed] [Google Scholar]

[bib49] 49.Studts CR, Tarasenko YN, Schoenberg NE, Shelton BJ, Hatcher-Keller J, Dignan MB. A community-based randomized trial of a faith-placed intervention to reduce cervical cancer burden in Appalachia. Prev Med. 2012;54(6):408–414. doi: 10.1016/j.ypmed.2012.03.019. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib50] 50.Sung JF, Blumenthal DS, Coates RJ, Williams JE, Alema-Mensah E, Liff JM. Effect of a cancer screening intervention conducted by lay health workers among inner-city women. Am J Prev Med. 1997;13(1):51–57. [PubMed] [Google Scholar]

[bib51] 51.Taylor VM, Hislop TG, Jackson JC et al. A randomized controlled trial of interventions to promote cervical cancer screening among Chinese women in North America. J Natl Cancer Inst. 2002;94(9):670–677. doi: 10.1093/jnci/94.9.670. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib52] 52.Taylor VM, Jackson JC, Yasui Y et al. Evaluation of a cervical cancer control intervention using lay health workers for Vietnamese American women. Am J Public Health. 2010;100(10):1924–1929. doi: 10.2105/AJPH.2009.190348. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib53] 53.West DS, Greene P, Pulley L et al. Stepped-care, community clinic interventions to promote mammography use among low-income rural African American women. Health Educ Behav. 2004;31(4 suppl):29S–44S. doi: 10.1177/1090198104266033. [DOI] [PubMed] [Google Scholar]

[bib54] 54.Wilson TE, Fraser-White M, Feldman J et al. Hair salon stylists as breast cancer prevention lay health advisors for African American and Afro-Caribbean women. J Health Care Poor Underserved. 2008;19(1):216–226. doi: 10.1353/hpu.2008.0017. [DOI] [PubMed] [Google Scholar]

[bib55] 55.Zhu K, Hunter S, Bernard LJ et al. An intervention study on screening for breast cancer among single African-American women aged 65 and older. Prev Med. 2002;34(5):536–545. doi: 10.1006/pmed.2002.1016. [DOI] [PubMed] [Google Scholar]

[bib56] 56.Allen JK, Himmelfarb CR, Szanton SL, Bone L, Hill MN, Levine DM. COACH trial: a randomized controlled trial of nurse practitioner/community health worker cardiovascular disease risk reduction in urban community health centers: rationale and design. Contemp Clin Trials. 2011;32(3):403–411. doi: 10.1016/j.cct.2011.01.001. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib57] 57.Balcázar HG, Byrd TL, Ortiz M, Tondapu SR, Chavez M. A randomized community intervention to improve hypertension control among Mexican Americans: using the promotoras de salud community outreach model. J Health Care Poor Underserved. 2009;20(4):1079–1094. doi: 10.1353/hpu.0.0209. [DOI] [PubMed] [Google Scholar]

[bib58] 58.Balcázar HG, de Heer H, Rosenthal L et al. A promotores de salud intervention to reduce cardiovascular disease risk in a high-risk Hispanic border population, 2005–2008. Prev Chronic Dis. 2010;7(2):A28. [PMC free article] [PubMed] [Google Scholar]

[bib59] 59.Becker DM, Yanek LR, Johnson WR, II et al. Impact of a community-based multiple risk factor intervention on cardiovascular risk in Black families with a history of premature coronary disease. Circulation. 2005;111(10):1298–1304. doi: 10.1161/01.CIR.0000157734.97351.B2. [DOI] [PubMed] [Google Scholar]

[bib60] 60.Coleman KJ, Farrell MA, Rocha DA et al. Readiness to be physically active and self-reported physical activity in low-income Latinas, California WISEWOMAN, 2006–2007. Prev Chronic Dis. 2012;9 E87. [PMC free article] [PubMed] [Google Scholar]

[bib61] 61.Cooper LA, Roter DL, Carson KA et al. A randomized trial to improve patient-centered care and hypertension control in underserved primary care patients. J Gen Intern Med. 2011;26(11):1297–1304. doi: 10.1007/s11606-011-1794-6. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib62] 62.Daniels EC, Powe BD, Metoyer T, McCray G, Baltrus P, Rust GS. Increasing knowledge of cardiovascular risk factors among African Americans by use of community health workers: the ABCD community intervention pilot project. J Natl Med Assoc. 2012;104(3-4):179–185. doi: 10.1016/s0027-9684(15)30139-5. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib63] 63.DePue JD, Dunsiger S, Seiden AD et al. Nurse–community health worker team improves diabetes care in American Samoa: results of a randomized controlled trial. Diabetes Care. 2013;36(7):1947–1953. doi: 10.2337/dc12-1969. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib64] 64.Hayashi T, Farrell MA, Chaput LA, Rocha DA, Hernandez M. Lifestyle intervention, behavioral changes, and improvement in cardiovascular risk profiles in the California WISEWOMAN project. J Womens Health (Larchmt) 2010;19(6):1129–1138. doi: 10.1089/jwh.2009.1631. [DOI] [PubMed] [Google Scholar]

[bib65] 65.Hill MN, Han HR, Dennison CR et al. Hypertension care and control in underserved urban African American men: behavioral and physiologic outcomes at 36 months. Am J Hypertens. 2003;16(11 pt 1):906–913. doi: 10.1016/s0895-7061(03)01034-3. [DOI] [PubMed] [Google Scholar]

[bib66] 66.Hunter JB, de Zapien JG, Papenfuss M, Fernandez ML, Meister J, Giuliano AR. The impact of a promotora on increasing routine chronic disease prevention among women aged 40 and older at the US–Mexico border. Health Educ Behav. 2004;31(4, suppl):18S–28S. doi: 10.1177/1090198104266004. [DOI] [PubMed] [Google Scholar]

[bib67] 67.Islam NS, Zanowiak JM, Wyatt LC et al. A randomized-controlled, pilot intervention on diabetes prevention and healthy lifestyles in the New York City Korean community. J Community Health. 2013;38(6):1030–1041. doi: 10.1007/s10900-013-9711-z. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib68] 68.Jafar TH, Hatcher J, Poulter N et al. Community-based interventions to promote blood pressure control in a developing country: a cluster randomized trial. Ann Intern Med. 2009;151(9):593–601. doi: 10.7326/0003-4819-151-9-200911030-00004. [DOI] [PubMed] [Google Scholar]

[bib69] 69.Katula JA, Vitolins MZ, Morgan TM et al. The healthy living partnerships to prevent diabetes study: 2-year outcomes of a randomized controlled trial. Am J Prev Med. 2013;44(4, suppl 4):S324–S332. doi: 10.1016/j.amepre.2012.12.015. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib70] 70.Kenya S, Lebron C, Reyes Arrechea E, Li H. Glucometer use and glycemic control among Hispanic patients with diabetes in Southern Florida. Clin Ther. 2014;36(4):485–493. doi: 10.1016/j.clinthera.2013.12.009. [DOI] [PubMed] [Google Scholar]

[bib71] 71.Krieger J, Collier C, Song L, Martin D. Linking community-based blood pressure measurement to clinical care: a randomized controlled trial of outreach and tracking by community health workers. Am J Public Health. 1999;89(6):856–861. doi: 10.2105/ajph.89.6.856. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib72] 72.Levine DM, Bone LR, Hill MN et al. The effectiveness of a community/academic health center partnership in decreasing the level of blood pressure in an urban African-American population. Ethn Dis. 2003;13(3):354–361. [PubMed] [Google Scholar]

[bib73] 73.Lynch EB, Liebman R, Ventrelle J, Avery EF, Richardson D. A self-management intervention for African Americans with comorbid diabetes and hypertension: a pilot randomized controlled trial. Prev Chronic Dis. 2014;11 doi: 10.5888/pcd11.130349. E90. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib74] 74.Margolius D, Bodenheimer T, Bennett H et al. Health coaching to improve hypertension treatment in a low-income, minority population. Ann Fam Med. 2012;10(3):199–205. doi: 10.1370/afm.1369. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib75] 75.Morisky DE, Lees NB, Sharif BA, Liu KY, Ward HJ. Reducing disparities in hypertension control: a community-based hypertension control project (CHIP) for an ethnically diverse population. Health Promot Pract. 2002;3(2):264–275. [Google Scholar]

[bib76] 76.Palmas W, Findley SE, Mejia M et al. Results of the Northern Manhattan diabetes community outreach project: a randomized trial studying a community health worker intervention to improve diabetes care in Hispanic adults. Diabetes Care. 2014;37(4):963–969. doi: 10.2337/dc13-2142. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib77] 77.Prezio EA, Cheng D, Balasubramanian BA, Shuval K, Kendzor DE, Culica D. Community diabetes education (CoDE) for uninsured Mexican Americans: a randomized controlled trial of a culturally tailored diabetes education and management program led by a community health worker. Diabetes Res Clin Pract. 2013;100(1):19–28. doi: 10.1016/j.diabres.2013.01.027. [DOI] [PubMed] [Google Scholar]

[bib78] 78.Rothschild SK, Martin MA, Swider SM et al. Mexican American trial of community health workers: a randomized controlled trial of a community health worker intervention for Mexican Americans with type 2 diabetes mellitus. Am J Public Health. 2014;104(8):1540–1548. doi: 10.2105/AJPH.2013.301439. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib79] 79.Spencer MS, Rosland AM, Kieffer EC et al. Effectiveness of a community health worker intervention among African American and Latino adults with type 2 diabetes: a randomized controlled trial. Am J Public Health. 2011;101(12):2253–2260. doi: 10.2105/AJPH.2010.300106. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib80] 80.Staten LK, Gregory-Mercado KY, Ranger-Moore J et al. Provider counseling, health education, and community health workers: the Arizona WISEWOMAN project. J Womens Health (Larchmt) 2004;13(5):547–556. doi: 10.1089/1540999041281133. [DOI] [PubMed] [Google Scholar]

[bib81] 81.Tang TS, Funnell M, Sinco B et al. Comparative effectiveness of peer leaders and community health workers in diabetes self-management support: results of a randomized controlled trial. Diabetes Care. 2014;37(6):1525–1534. doi: 10.2337/dc13-2161. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib82] 82.Beck C, Fausett JK, Krukowski RA et al. A randomized trial of a community-based cognitive intervention for obese senior adults. J Aging Health. 2013;25(1):97–118. doi: 10.1177/0898264312467374. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib83] 83.Chatterjee S, Naik S, John S et al. Effectiveness of a community-based intervention for people with schizophrenia and their caregivers in India (COPSI): a randomised controlled trial. Lancet. 2014;383(9926):1385–1394. doi: 10.1016/S0140-6736(13)62629-X. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib84] 84.Waitzkin H, Getrich C, Heying S et al. Promotoras as mental health practitioners in primary care: a multi-method study of an intervention to address contextual sources of depression. J Community Health. 2011;36(2):316–331. doi: 10.1007/s10900-010-9313-y. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib85] 85.Martin MA, Catrambone CD, Kee RA et al. Improving asthma self-efficacy: developing and testing a pilot community-based asthma intervention for African American adults. J Allergy Clin Immunol. 2009;123(1):153–159. doi: 10.1016/j.jaci.2008.10.057. e3. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib86] 86.Wang CJ, Fetzer SJ, Yang YC, Wang JJ. The impacts of using community health volunteers to coach medication safety behaviors among rural elders with chronic illnesses. Geriatr Nurs. 2013;34(2):138–145. doi: 10.1016/j.gerinurse.2012.12.013. [DOI] [PubMed] [Google Scholar]

[bib87] 87.Allen JK, Dennison Himmelfarb CR, Szanton SL, Frick KD. Cost-effectiveness of nurse practitioner/community health worker care to reduce cardiovascular health disparities. J Cardiovasc Nurs. 2014;29(4):308–314. doi: 10.1097/JCN.0b013e3182945243. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib88] 88.Lawlor MS, Blackwell CS, Isom SP et al. Cost of a group translation of the diabetes prevention program: healthy living partnerships to prevent diabetes. Am J Prev Med. 2013;44(4, suppl 4):S381–S389. doi: 10.1016/j.amepre.2012.12.016. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib89] 89.Scoggins JF, Ramsey SD, Jackson JC, Taylor VM. Cost effectiveness of a program to promote screening for cervical cancer in the Vietnamese-American population. Asian Pac J Cancer Prev. 2010;11(3):717–722. [PMC free article] [PubMed] [Google Scholar]

[bib90] 90.Wagner TH, Engelstad LP, McPhee SJ, Pasick RJ. The costs of an outreach intervention for low-income women with abnormal Pap smears. Prev Chronic Dis. 2007;4(1):A11. [PMC free article] [PubMed] [Google Scholar]

[bib91] 91.Jafar TH, Islam M, Bux R et al. Cost-effectiveness of community-based strategies for blood pressure control in a low-income developing country: findings from a cluster-randomized, factorial-controlled trial. Circulation. 2011;124(15):1615–1625. doi: 10.1161/CIRCULATIONAHA.111.039990. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib92] 92.Lairson DR, Chang YC, Byrd TL, Lee Smith J, Fernandez ME, Wilson KM. Cervical cancer screening with AMIGAS: a cost-effectiveness analysis. Am J Prev Med. 2014;46(6):617–623. doi: 10.1016/j.amepre.2014.01.020. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib93] 93.Cooper LA, Roter DL, Bone LR et al. A randomized controlled trial of interventions to enhance patient–physician partnership, patient adherence and high blood pressure control among ethnic minorities and poor persons: study protocol NCT00123045. Implement Sci. 2009;4:7. doi: 10.1186/1748-5908-4-7. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib94] 94.West DS, Bursac Z, Cornell CE et al. Lay health educators translate a weight-loss intervention in senior centers: a randomized controlled trial. Am J Prev Med. 2011;41(4):385–391. doi: 10.1016/j.amepre.2011.06.041. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib95] 95.Tyrrell M, Margolis K, Sandberg L, Slater J, Lurie N. Older women helping older women: employing senior workers in community research. Am J Public Health. 1996;86(4):588–589. [PubMed] [Google Scholar]

[bib96] 96.Rothschild SK, Martin MA, Swider SM et al. The Mexican-American Trial of Community Health Workers (MATCH): design and baseline characteristics of a randomized controlled trial testing a culturally tailored community diabetes self-management intervention. Contemp Clin Trials. 2012;33(2):369–377. doi: 10.1016/j.cct.2011.10.013. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib97] 97.The Community Guide. Cardiovascular disease prevention and control: interventions engaging community health workers. Available at: http://www.thecommunityguide.org/cvd/CHW.html. 2015. Accessed October 1, 2015.

[bib98] 98.Herman AA. Community health workers and integrated primary health care teams in the 21st century. J Ambul Care Manage. 2011;34(4):354–361. doi: 10.1097/JAC.0b013e31822cbcd0. [DOI] [PubMed] [Google Scholar]

[bib99] 99.Volkmann K, Castanares T. Clinical community health workers: linchpin of the medical home. J Ambul Care Manage. 2011;34(3):221–233. doi: 10.1097/JAC.0b013e31821cb559. [DOI] [PubMed] [Google Scholar]

[bib100] 100.Lemay CA, Ferguson WJ, Hargraves JL. Community health worker encounter forms: a tool to guide and document patient visits and worker performance. Am J Public Health. 2012;102(7):e70–e75. doi: 10.2105/AJPH.2011.300416. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib101] 101.Cherrington A, Ayala GX, Elder JP, Arredondo EM, Fouad M, Scarinci I. Recognizing the diverse roles of community health workers in the elimination of health disparities: from paid staff to volunteers. Ethn Dis. 2010;20(2):189–194. [PMC free article] [PubMed] [Google Scholar]

[bib102] 102.The Executive Office of Health and Human Services. Office of community health workers. Available at: http://www.mass.gov/eohhs/gov/departments/dph/programs/community-health/prevention-and-wellness/comm-health-wkrs. Accessed September 28, 2015.

[bib103] 103.Rosenthal EL, Brownstein JN, Rush CH et al. Community health workers: part of the solution. Health Aff (Millwood) 2010;29(7):1338–1342. doi: 10.1377/hlthaff.2010.0081. [DOI] [PubMed] [Google Scholar]

[bib104] 104.Martinez J, Ro M, Villa NW, Powell W, Knickman JR. Transforming the delivery of care in the post-health reform era: what role will community health workers play? Am J Public Health. 2011;101(12):e1–e5. doi: 10.2105/AJPH.2011.300335. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib105] 105.Katigbak C, Van Devanter N, Islam N, Trinh-Shevrin C. Partners in health: a conceptual framework for the role of community health workers in facilitating patients’ adoption of healthy behaviors. Am J Public Health. 2015;105(5):872–880. doi: 10.2105/AJPH.2014.302411. [DOI] [PMC free article] [PubMed] [Google Scholar]

PERMALINK

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

Hae-Ra Han, RN, PhD

Abstract

PLAIN-LANGUAGE SUMMARY

METHODS

Study Selection Process

FIGURE 1—

Data Extraction

TABLE 1—

RESULTS

TABLE 2—

Quality Ratings

Roles and Tasks of CBHWs in Intervention Studies

Effects of CBHW Interventions

Cancer prevention.

Cardiovascular disease risk reduction.

Mental disorders, asthma control, and medication safety.

Cost outcomes.

Qualifications and Characteristics of CBHWs

Identification and selection of community-based health workers.

TABLE 3—

Training and supervision of community-based health workers.

Reimbursement and sustainability of community-based health workers.

DISCUSSION

Limitations

Conclusions

ACKNOWLEDGMENTS

HUMAN PARTICIPANT PROTECTION

REFERENCES

ACTIONS

PERMALINK

RESOURCES

Similar articles

Cited by other articles

Links to NCBI Databases