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Cardiovascular Disease Prevention and Control: Interventions Engaging Community Health Workers

Task Force Finding

The Community Preventive Services Task Force recommends interventions that engage community health workers to prevent cardiovascular disease (CVD). There is strong evidence of effectiveness for interventions that engage community health workers in a team-based care model to improve blood pressure and cholesterol in patients at increased risk for CVD. There is 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 patients at increased risk for CVD.

Additionally, 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.

Read the full Task Force Finding and Rationale Statement for details including implementation issues, possible added benefits, potential harms, and evidence gaps.

Intervention Definition

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 communities and healthcare systems. They are from, or have an unusually close understanding of, the community served. Community health workers are trained to provide culturally appropriate health education and information, offer social support and informal counseling, connect people with the services they need, and in some cases deliver health services such as blood pressure screening. Because community health workers are considered informed and trusted community members, they are uniquely positioned to advocate on behalf of individuals and communities and help build capacity. Community health workers often receive on-the-job training and work without professional titles. Organizations may hire paid community health workers or recruit volunteers to act in this role.

Community health workers may address a broad range of health issues. Interventions that engage community health workers to focus on cardiovascular disease (CVD) prevention implement one or more of the following models of care:

  • Screening and Health Education. Community health workers 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, such as increasing physical activity and smoking cessation.
  • Outreach, Enrollment, and Information. Community health workers 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, such as appointment reminders and home visits.
  • Team-Based Care. In a team-based care arrangement, community health workers partner with patients and licensed providers, such as physicians and nurses, to improve coordination of care and support for patients.
  • Patient Navigation. Community health workers help individuals and families navigate complex medical service systems and processes to increase their access to care.
  • Community Organization. Community health workers facilitate self-directed change and community development by serving as liaisons between the community and healthcare systems.

About the Systematic Review

The Task Force finding is based on evidence from a systematic review of 31 studies with 35 study arms (search period: beginning of database – July 2013). The systematic review was conducted on behalf of the Task Force by a team of specialists in systematic review methods, and in research, practice, and policy related to cardiovascular disease prevention.

Results

  • Included studies were stratified based on suitability of study designs, as defined by the Task Force (Briss et al., 2000).
    • 18 studies used designs considered to be of greatest/moderate suitability: individual randomized controlled trial (7 studies), group randomized controlled trial (4 studies), non-randomized trial (3 studies), prospective cohort (1 study), case-control (1 study), and other designs that have a concurrent comparison group (2 studies).
    • 13 studies used a design considered to be least suitable: before-after without a comparison group.
  • Included studies evaluated interventions that engaged CHWs as screening and health education providers (31 study arms), outreach, enrollment, and information agents (20 study arms), members of care delivery teams (17 study arms), patient navigators (8 study arms), and community organizers (4 study arms).
  • 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 while 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 on interventions engaging CHWs as patient navigators or as community organizers.
  • 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
      • Greatest/moderate suitability studies: median increase of 17.6 percentage points (range: 3.8 to 22.5; 4 studies)
      • Least suitable studies: increase of 10.8 percentage points (95% confidence interval [CI]: 3.2, 18.3; 1 study) and increase of 14.5 percentage points (95% CI: 11.1, 18.0; 1 study)
    • Change in systolic blood pressure
      • Greatest/moderate suitability studies: median reduction of 6.0 mmHg (interquartile interval [IQI]: ‑6.4 to 2.4; 6 studies with 7 study arms)
      • Least suitable studies: median reduction of 11.2 mmHg (range: ‑17.9 to ‑2.0; 4 studies)
    • Change in diastolic blood pressure
      • Greatest/moderate suitability studies: median reduction of 1.1 mmHg (IQI: ‑4.0 to 0.21; 6 studies with 7 study arms)
      • Least suitable studies: median reduction of 4.2 mmHg (range: ‑11.4 to 5.0; 3 studies)
  • Cholesterol Outcomes
    • Proportion of clients with total cholesterol at goal
      • Greatest/moderate suitability studies: increase of 7.0 percentage points (95% CI: ‑5.5, 19.5; 1 study)
    • Change in total cholesterol
      • Greatest/moderate suitability studies: decreases of 19.7 mg/dL (p>0.05; 1 study) and 0.4 mg/dL (not significant; 1 study)
      • Least suitable studies: increase of 1.5 mg/dL (not significant; 1 study)
    • Proportion of clients with LDL cholesterol at goal
      • Greatest/moderate suitability studies: increase of 28.9 percentage points (1 study) and increase of 3.2 percentage points (95% CI: ‑6.1, 12.5; 1 study)
      • Least suitable studies: increase of 10.0 percentage points (95% CI: ‑1.0, 2.1; 1 study)
    • Change in LDL cholesterol
      • Greatest/moderate suitability studies: median decrease of 15.5 mg/dL (range: ‑15.9 to ‑2.7; 3 studies)
      • Least suitable studies: median decrease of 15.0 mg/dL (range: ‑22.0 to 3.2; 3 studies)
    • Change in HDL cholesterol
      • Greatest/moderate suitability studies: median of 0 mg/dL (range: ‑0.4 to 0.8; 3 studies)
      • Least suitable studies: increase of 1.0 mg/dL (not significant; 1 study) and decrease of 2.1 mg/dL (not significant; 1 study)
    • Change in triglycerides
      • Greatest/moderate suitability studies: median decrease of 8.0 mg/dL (range: ‑16.3 to 2.7; 3 studies)
      • Least suitable studies: decrease of 23.0 mg/dL (p<0.05; 1 study) and increase of 1.7 mg/dL (not significant; 1 study)
  • When team-based care was not implemented with interventions that engaged CHWs as health educators; as outreach, enrollment, and information agents; or as patient navigators; improvements in blood pressure and cholesterol outcomes were smaller.

Interventions that Engaged CHWs as Health Educators

  • Physical activity outcomes
    • Greatest/moderate suitability studies: one study reported a statistically significant improvement in physical activity and one study reported non-significant improvements
    • Least suitable studies: five studies with 6 study arms reported statistically significant improvements
  • Nutrition outcomes
    • Greatest/moderate suitability studies: two studies reported statistically significant improvements
    • Least suitable studies: five studies with 6 study arms reported statistically significant improvements
  • Smoking outcomes
    • Greatest/moderate suitability studies: median decrease of 0.5 percentage points in the proportion of current smokers (range: ‑1.9 to 1.0; 3 studies)
    • Least suitable studies: decrease in the proportion of current smokers of 3.7 percentage points (95% CI: ‑10.7, 3.3; 1 study) and 0.6 percentage points (95% CI: ‑4.4, 3.3; 1 study)

Interventions that Engaged CHWs as Outreach, Enrollment, and Information Agents

  • Physical activity outcomes
    • Greatest/moderate suitability studies: one study reported statistically significant improvements in physical activity and one study reported non-significant improvements
    • Least suitable studies: three studies with 4 study arms reported statistically significant improvements
  • Nutrition outcomes
    • Greatest/moderate suitability studies: two studies reported statistically significant improvements
    • Least suitable studies: three studies with 4 study arms reported statistically significant improvements
  • Smoking outcomes
    • Greatest/moderate suitability studies: decreases in the proportion of current smokers of 1.9 percentage points (95% CI: ‑5.1, 1.3; 1 study) and 0.5 percentage points (95% CI: ‑2.5, 1.5; 1 study)

Additional Findings Across all Models of Care

  • Improvements also were found for appropriate use of health care services (2 studies); screening for CVD risk factors (1 study); and CVD-related morbidity and mortality (2 studies).

Study Characteristics

  • Studies were conducted in the United States (28 studies), Canada (2 studies), and Western Europe (1 study).
  • Included studies evaluated interventions within the healthcare system (13 studies), community (11 studies), or both (7 studies).
  • Studies were set primarily in urban areas (22 studies).
  • Study populations mainly included adults ages 18-64 years old (23 studies) and older adults 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.
  • Included studies mainly covered underserved populations, that is, 75% or more of clients enrolled were African-American (9 studies), Hispanic (8 studies), or low-income (12 studies).
  • Community health workers were frequently matched to the population they served by location (16 study arms), race/ethnicity (17 study arms), or language (15 study arms).
  • Community health workers 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).

Applicability

Based on results for interventions in different settings and populations, findings are 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

Economic Evidence

Four studies were included in the review, all of which evaluated community health workers in team-based care arrangements. Monetary values are presented in 2013 U.S dollars.

  • Estimated intervention costs were $17 and $271 per person per year (2 studies).
  • Estimated healthcare cost decreased by a mean of $1377 per person per year (range $19 to $3616; 3 studies).
    • The incremental cost of adding a CHW to the care team could not be calculated from information reported.
    • The large healthcare cost savings reported in one study was from averted emergency room visits and in-patient stays for recently discharged Medicaid patients with diabetes.
    • The study that reported both the smallest intervention cost ($17 per person per year) and smallest healthcare cost saving ($19 per person per year), was a community-wide trial conducted among the elderly in multiple locations. Analysis was based on the entire eligible population and cost averted included all healthcare costs and not just those specific to cardiovascular disease.
  • None of the included studies provided cost-effectiveness information and there was not enough evidence to determine cost-benefit ratios.

Considerations for Implementation

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion. The Community Guide does not conduct systematic reviews of implementation.

  • 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 community health workers.
  • Included studies suggested the following approaches to address implementation barriers: achieve community buy-in during the planning phase; address issues related to gender and culture; and provide periodic quality assurance checks to assess intervention adaptation to different cultures or intervention fidelity.
  • The Community Health Worker Toolkit External Web Site Icon includes information state health departments can use to train and further build capacity for CHWs and resources CHWs can use in their communities. The site is maintained by CDC's Division for Heart Disease and Stroke Prevention.

Supporting Materials

Publication Status

Full peer-reviewed articles of this systematic review will be posted on the Community Guide website when published. Subscribe External Web Site Icon to be notified when we post these publications or other materials. See our library for previous Community Guide publications on this and other topics.

Promotional Materials

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One Pagers

More promotional materials for Community Guide reviews about Cardiovascular Disease Prevention and Control.

References

Briss PA, Zaza S, Pappaionau M et al. Developing an evidence-based Guide to Community Preventive Services-methods. Am J Prev Med 2000;18(1S):35-43.

CMS 2013: Centers for Medicare & Medicaid Services (CMS). 78 Fed Reg 42160 (July 15, 2013). "a. Diagnostic, Screening, Preventive, and Rehabilitative Services (Preventive Services) (§ 440.130)" (paragraph citation: 78 FR 42226) www.gpo.gov/fdsys/pkg/FR-2013-07-15/pdf/2013-16271.pdf Adobe PDF File [PDF - 1.0 MB] External Web Site Icon




Disclaimer

The findings and conclusions on this page are those of the Community Preventive Services Task Force and do not necessarily represent those of CDC. Task Force evidence-based recommendations are not mandates for compliance or spending. Instead, they provide information and options for decision makers and stakeholders to consider when determining which programs, services, and policies best meet the needs, preferences, available resources, and constraints of their constituents.

Sample Citation

The content of publications of the Guide to Community Preventive Services is in the public domain. Citation as to source, however, is appreciated. Sample citation: Guide to Community Preventive Services. Cardiovascular disease prevention and control: interventions engaging community health workers. www.thecommunityguide.org/cvd/CHW.html. Last updated: MM/DD/YYYY.

Review Completed: March 2015