A wealth of research has been conducted on the successful management of Type 2 diabetes. Yet for many patients and their families, this disease remains a considerable challenge and current care practices are insufficient. Previous research has highlighted how problematic this gap is with respect to patient- and community-health. Recently, scholarship and clinical practice have shifted attention to exploring alternative approaches to care. The use of community health workers (CHW) to bridge the gap between patients and the medical system has gained attention and support from preliminary research and practice. The present research aims to extend what is known about the association between CHW interventions and patients’ biopsychosocial health outcomes via a two-pronged approach. First, I conducted a systematic review of randomized controlled trials of CHW-delivered interventions to orient researchers and clinicians to the current state of this work and to present a call to action for where future research needs to go. This study identified the lack of consistency in the theoretical conceptualization, design, and delivery of CHW interventions. Specifically, there was great variation across studies’ intervention dosages, attrition rates, and methods of CHW training. The main foci across studies’ findings demonstrated a relationship between a CHW-delivered intervention and improvements in patients’ physical and emotional health, diabetes knowledge, and self-care behaviors. Second, I conducted a pilot study following a mixed-method design testing a one-year CHW-delivered intervention. A sequential, explanatory mixed-method approach was used to gain breadth and depth of understanding, and to corroborate findings. More specifically, quantitative data collection and analyses preceded the qualitative interviews and thematic analysis, which included a sample of the intervention group. Quantitative data were gathered at baseline, 6-months, and 12-months to assess patients’ physical health, emotional well-being, and perceived social support. Health outcomes data were compared with a matched control group. Phenomenological qualitative data were gathered via key informant interviews and analyzed using Crabtree and Miller’s (1999) thematic analysis method. Findings from statistical analyses based on standardized measures revealed a significant improvement in perceived social support from baseline to 6-months, and a significant improvement in dietary adherence from baseline to 12-months. Findings from phenomenological interviews showed a significant improvement in perceived social support from a special person and in dietary adherence. Thematic analysis revealed a major theme regarding CHW roles (i.e., coach, advocate, teacher, and confidant). A second major theme outlined ecological impacts (i.e., support that participants received from family members was primarily tangible in-nature, and diabetes management – for participants – represents only a part of a considerably larger and more complex picture of health and well-being). Implications of these two studies point to the need for comprehensive care that includes the CHW as a member of care teams. With the growing need to provide more comprehensive health care, future research is warranted to continue to tease out the primary mechanisms of change within CHW interventions. This information is important to further refine the hiring process of CHWs best equipped for the role, CHW training, and the foci of CHW attention in their work with patients. These efforts will also further-equip providers to support patients’ Type 2 diabetes management, advancing the Triple Aim of healthcare.
University of Minnesota Ph.D. dissertation.May 2017. Major: Family Social Science. Advisor: Tai Mendenhall. 1 computer file (PDF); x, 136 pages.
An Alternative Approach to Type 2 Diabetes Care: The Inclusion of Community Health Worker Interventions in Patient Care.
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