Heart Disease and Stroke Prevention: Interventions Engaging Community Health Workers

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Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) recommends interventions that engage community health workers to prevent cardiovascular disease (CVD) among clients at increased risk.

  • The CPSTF finds strong evidence of effectiveness for interventions that engage community health workers in a team-based care model to improve blood pressure and cholesterol.
  • The CPSTF finds sufficient evidence of effectiveness for interventions that engage community health workers for health education, and as outreach, enrollment, and information agents to increase self-reported health behaviors (physical activity, healthful eating habits, and smoking cessation) in clients at increased risk for CVD.

A small number of studies suggest that engaging community health workers improves appropriate use of healthcare services and reduces morbidity and mortality related to CVD.

When interventions engaging community health workers are implemented in minority or underserved communities, they can improve health, reduce health disparities, and enhance health equity.

Economic evidence indicates these interventions are cost-effective.

The full CPSTF Finding and Rationale Statement and supporting documents for Heart Disease and Stroke Prevention: Interventions Engaging Community Health Workers are available in The Community Guide Collection on CDC Stacks.

Intervention

Interventions that engage community health workers to prevent cardiovascular disease aim to reduce risk factors among those at higher risk by providing culturally appropriate education, offering social support and informal counseling, connecting people with services, and in some cases delivering health services such as blood pressure screening.

Community health workers (including promotores de salud, community health representatives, community health advisors, and others) are frontline public health workers who serve as a bridge between underserved communities and healthcare systems. They typically are from, or have a unique understanding of, the community served. Community health workers often receive on-the-job training and work without professional titles. Organizations may hire paid community health workers or recruit volunteers.

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review of 31 studies with 35 study arms (search period: beginning of database through July 2013).

Study Characteristics

  • Studies were conducted in the United States (28 studies), Canada (2 studies), and Western Europe (1 study).
  • Included studies evaluated interventions in healthcare systems (13 studies), communities (11 studies), or both (7 studies).
  • Studies were set primarily in urban areas (22 studies).
  • Study populations mainly included adults who were ages 18-64 years old (23 studies) and older adults who were 65 years and older (5 studies) who had one or more of the following risk factors: high blood pressure, high cholesterol, obesity, diabetes, or tobacco use.
  • In the included studies, 75% or more of the clients enrolled were African-American (9 studies), Hispanic (8 studies), or low-income (12 studies).
  • CHWs were frequently matched to the population they served by location (16 study arms), race/ethnicity (17 study arms), or language (15 study arms).
  • CHWs provided clients with culturally appropriate information and education on cardiovascular disease risk factors (21 study arms), lifestyle counseling (20 study arms), informal counseling and social support (22 study arms), and information on community resources (16 study arms).

Summary of Results

Interventions that engage community health workers (CHW) for cardiovascular disease prevention use one or more of the following models of care (HRSA 2007).

  • Screening and health education. CHWs screen for high blood pressure, cholesterol, and behavioral risk factors recommended by the United States Preventive Services Task Force (USPSTF); deliver individual or group education on CVD risk factors; provide adherence support for medications; and offer self-management support for health behavior changes (31 study arms).
  • Outreach, enrollment, and information. CHWs reach out to individuals and families who are eligible for medical services, help them apply for these services, and provide proactive client follow-up and monitoring (20 study arms).
  • Team-based care. As care team members, CHWs partner with clients and licensed providers, such as physicians and nurses, to improve coordination of care and support for clients (17 study arms).
  • Patient navigation. CHWs help individuals and families navigate complex medical service systems and processes to increase their access to care (8 study arms).
  • Community organizers. CHWs facilitate self-directed change and community development by serving as liaisons between the community and healthcare systems (4 study arms).

Overall, included studies showed the following:

  • Among populations at increased risk for CVD, interventions that engaged CHWs in a team-based care model led to large improvements in blood pressure and cholesterol outcomes. Interventions that engaged CHWs as health educators or as outreach, enrollment, and information agents led to modest improvements in health behavior outcomes.
  • There was not enough evidence to draw conclusions about interventions that engaged CHWs as patient navigators or community organizers.
  • Studies reported improvements for appropriate use of health care services (2 studies); screening for CVD risk factors (1 study); and CVD-related morbidity and mortality (2 studies).
  • Most included studies engaged CHWs to work with underserved groups, suggesting these interventions can be effective in improving minority health and reducing health disparities related to cardiovascular disease (22 studies).

Interventions that Engaged CHWs in a Team-Based Care Model

  • Blood pressure outcomes
    • Proportion of clients with blood pressure at goal: median increase of 17.6 percentage points in greatest/moderate suitability studies (4 studies)
    • Change in systolic blood pressure: median reduction of 6.0 mmHg in greatest/moderate suitability studies (6 studies with 7 study arms)
    • Change in diastolic blood pressure: median reduction of 1.1 mmHg in greatest/moderate suitability studies (6 studies with 7 study arms)
  • Cholesterol outcomes
    • Proportion of clients with LDL cholesterol at goal: increases of 28.9 and 3.2 percentage points in greatest/moderate suitability studies (2 studies)
    • Change in LDL cholesterol: median decrease of 15.5 mg/dL in greatest/moderate suitability studies (3 studies)

Summary of Economic Evidence

Economic evidence indicates that interventions engaging community health workers for the prevention of cardiovascular disease are cost-effective. All monetary values are reported in 2015 U.S. dollars.

The economic review included nine studies (6 from the United States, 2 from the United Kingdom, and 1 from Canada). Most patients in the studies came from minority or low-income populations.

  • The median intervention cost per person per year was $329 (8 studies)
  • The median change in healthcare cost per person per year was $82 (7 studies)
  • The median estimated cost per quality adjusted life year (QALY) gained was $17,670 (4 studies)
  • All estimates were below $50,000 a frequently used benchmark for cost-effectiveness.

Applicability

Based on results for interventions in different settings and populations, the CPSTF finding should be applicable to the following:

  • Adults and older adults who have high blood pressure or high cholesterol
  • Women and men
  • African-American, Hispanic, and low-income populations
  • Urban environments
  • Healthcare systems and community settings

Evidence Gaps

  • Most studies evaluated outcomes at 12 months, a relatively short follow-up time for some CVD risk factors. How effective are longer interventions and what are the sustained, ongoing effects of these programs on different CVD risk factors (e.g., blood pressure, cholesterol, morbidity)?
  • How effective are programs implemented among diverse populations that vary by comorbidity, sexual orientation, disability, race and ethnicity (e.g., American Indian, Alaskan native, Asian), and socioeconomic status (e.g., educational attainment, health coverage)?
  • How does intervention effectiveness vary by the frequency of CHW-patient interactions, visit length, mode of delivery (e.g., face-to-face, telephone), and context (e.g., individual or group session)?
  • How can financing, communication, and organization better facilitate the integration of CHWs into health promotion and health care efforts that bridge clients, community resources, and healthcare systems?
  • Do CHWs who work in both community and healthcare settings build and enhance community-clinical linkages that support effective patient navigation?
  • How can clients at high risk for cardiovascular disease be identified, particularly when they do not have a usual source of care?
  • How effectively do CHWs connect clients who lack sufficient health coverage with appropriate care and services?
  • Most of the included studies were funded by public grants. How can CHW programs be sustained and funded? How could reimbursement arrangements be used to pay for CHW services? Does the funding mechanism have an impact on intervention effectiveness?
  • How effective are interventions that use a community-based participatory approach?
  • What are best practices for recruiting, selecting, training, supervising, and evaluating CHWs?
  • What are optimal ways to match CHWs with patient populations (e.g., SES, personal experience)?
  • How effective are interventions that engage CHWs using the five identified models of care (i.e., screening and health education; outreach, enrollment and information; team-based care; patient navigation; community organization)?
  • What is the incremental effectiveness and cost of adding CHWs to team-based care programs?
  • In most studies, interventions delivered services in either community or healthcare settings and on a smaller-scale (i.e., = 500 clients). How effective are interventions that engage CHWs in rural and worksite settings, or on a larger-scale (i.e., >500 clients)?
  • What are the complete and detailed costs and economic benefits of CHW interventions? What cost should be assigned for CHW services, whether they are volunteer or salaried?

Implementation Considerations and Resources

  • The 2013 ruling by the Centers for Medicaid Services (CMS) allows states to provide Medicaid reimbursement for USPSTF recommended preventive services when “recommended by a physician or other licensed practitioner” and delivered by a broad array of health professionals, including CHWs. Implementers of CHW interventions should consider state-specific regulations in accordance with this ruling when making decisions about CHW engagement in their organizations.
  • The type of education and training provided to CHWs is important and should address collaboration with other healthcare providers.
  • Supervision, performance feedback, and coaching should be provided for CHWs.

Crosswalks

Healthy People 2030 icon Healthy People 2030 includes the following objectives related to this CPSTF recommendation.