Welcome to The Community Guide! Let us know what you think of the website by completing this quick survey.

Cardiovascular Disease: Interventions Engaging Community Health Workers

Tabs

What the CPSTF Found

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 – July 2013).

The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to cardiovascular disease prevention.

Context

There is no content for this section.

Summary of Results

More details about study results are available in the CPSTF Finding and Rationale Statement.

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, such as increasing physical activity and smoking cessation (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, such as appointment reminders and home visits (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).

Included studies were stratified based on suitability of study designs, as defined by the CPSTF (Briss et al., 2000).

  • Eighteen 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)
    • Other designs with a concurrent comparison group (2 studies)
  • Thirteen studies used a design considered to be least suitable:
    • Before-after without a comparison group

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 (4 studies)
      • Least suitable studies: increase of 10.8 percentage points (1 study) and increase of 14.5 percentage points (1 study)
    • Change in systolic blood pressure
      • Greatest/moderate suitability studies: median reduction of 6.0 mmHg (6 studies with 7 study arms)
      • Least suitable studies: median reduction of 11.2 mmHg (4 studies)
    • Change in diastolic blood pressure
      • Greatest/moderate suitability studies: median reduction of 1.1 mmHg (6 studies with 7 study arms)
      • Least suitable studies: median reduction of 4.2 mmHg (3 studies)
  • Cholesterol outcomes
    • Proportion of clients with total cholesterol at goal
      • Greatest/moderate suitability studies: increase of 7.0 percentage points (1 study)
    • Change in total cholesterol
      • Greatest/moderate suitability studies: decreases of 19.7 mg/dL (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 low-density lipoprotein (LDL) cholesterol at goal
      • Greatest/moderate suitability studies: increases of 28.9 percentage points (1 study) and 3.2 percentage points (1 study)
      • Least suitable studies: increase of 10.0 percentage points (1 study)
    • Change in LDL cholesterol
      • Greatest/moderate suitability studies: median decrease of 15.5 mg/dL (3 studies)
      • Least suitable studies: median decrease of 15.0 mg/dL (3 studies)
    • Change in high-density lipoprotein (HDL) cholesterol
      • Greatest/moderate suitability studies: median change of 0 mg/dL (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 (3 studies)
      • Least suitable studies: decrease of 23.0 mg/dL (1 study) and increase of 1.7 mg/dL (not significant; 1 study)
  • Improvements in blood pressure and cholesterol outcomes were smaller when interventions engaged CHWs using other models of care other than team-based care.

Interventions that Engaged CHWs as Health Educators

  • Physical activity outcomes
    • Greatest/moderate suitability studies: significant (1 study) and nonsignificant (1 study) improvements in physical activity
    • Least suitable studies: significant improvements (5 studies with 6 study arms)
  • Nutrition outcomes
    • Greatest/moderate suitability studies: significant improvements (2 studies)
    • Least suitable studies: significant improvements (5 studies with 6 study arms)
  • Smoking outcomes
    • Greatest/moderate suitability studies: median decrease of 0.5 percentage points in the proportion of current smokers (3 studies)
    • Least suitable studies: decreases in the proportion of current smokers of 3.7 percentage points (1 study) and 0.6 percentage points (1 study)

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

  • Physical activity outcomes
    • Greatest/moderate suitability studies: significant (1 study) and nonsignificant (1 study) improvements in physical activity
    • Least suitable studies: significant improvements (3 studies with 4 study arms)
  • Nutrition outcomes
    • Greatest/moderate suitability studies: significant improvements (2 studies)
    • Least suitable studies: significant improvements (3 studies with 4 study arms)
  • Smoking outcomes
    • Greatest/moderate suitability studies: decreases in the proportion of current smokers of 1.9 percentage points (1 study) and 0.5 percentage points (1 study)

Summary of Economic Evidence

More details about study results are available in the CPSTF Finding and Rationale Statement.

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

Additional research and evaluation are needed in these areas, to fill existing gaps in the evidence base. (What are 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?

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).

Publications