Peers for Progress Blog
Welcome to the Peers for Progress Blog. Stay up-to-date on what we’re up to and check back frequently for our latest news.
Clayton Velicer, MPH
In our August Newsletter we highlighted the growth of community health workers (CHWs), particularly in Latino communities. We also highlighted an example of CHWs using mobile technology to boost impact in underserved Latino communities. In this blog, we’ll look at a related study that was recently covered by Medscape Medical News.
This article in Diabetes Care published results from the Diabetes Among Latinos Best Practices Trial (DIALBEST). In this study, 211 adult Latinos with diabetes were randomized to receive either 17 in-home educational sessions delivered by trained and supervised bilingual/bicultural CHWs or standard care. To help others replicate and scale up the model, the study thoroughly described the CHW training program and delivery of the intervention. In this blog, we took highlights from the article on Medscape Medical News, including commentaries from the research team.
Training and Supporting CHWs
Strong CHW training programs are essential to ensure program quality and improve its effectiveness. This trial recruited two CHWs from different backgrounds that were employed by a community-based nonprofit. One was a nurse from Puerto Rico and second was a medical assistant originally from El Salvador.
The CHWs received 65 hours of interdisciplinary training in which they received training specific to motivational interviewing and communication skills as part of a structured curriculum that covered self-management, lifestyle, adherence and mental health. The CHWs maintained ties to clinical care through weekly meetings with patients’ primary care medical team and a dietician. In a statement published on Medscape Medical News, Dr. Perez-Escamilla underscored the importance of these meetings:
“Those interactions were crucial for the success of DIALBEST, as on the one hand the CHWs learned what to recommend and the clinical basis of these recommendations….On the other hand, providers learned quite a bit about the life circumstances — ie, the social determinants of health — and mental-health challenges being faced by their patients that were preventing them from complying with medical appointments and their ability to self-manage their type 2 diabetes effectively,”
Improved Self-Management, but More Emotional Support Needed
This intervention significantly improved diabetes outcomes and helped patients maintain those improvements over time. The intervention group showed lower HbA1c scores (-0.42 at 3 months, -0.47 at 6 months, -0.57 at 12 months, and -0.55 at 18 months), which were statistically significant at 12 and 18 months.
However, despite including a nutrition education component that tried to account for food access issues and provided step counters, there was no decrease in several physical measures, including body weight.
Dr. Perez-Escamilla states in Medscape Medical News that the lack of weight loss may have been impacted by participants having little social support, mobility issues, and many showing signs of clinical depression.
Take Home Lessons
Shared lived experience and cultural understanding played a key role in the effectiveness of the CHWs. Specifically, the research team cited that an understanding of low economic resources, low health literacy, and low English fluency as areas in which the CHWs were able to address in helping patients improve self-management.
The participants reported a very high level of satisfaction of working with the CHWs. Dr. Perez-Escamilla took the impact of this study as an opportunity to underscore the recent opportunities for CHWs in the US Healthcare system, citing the Affordable Care Act and new funding for the development and implementation of CHW programs. For more, see this Brief on Opportunities for CHWs in the Affordable Care Act.
Looking ahead, the researchers of the DIALBEST study want to further investigate the effectiveness of CHWs in an integrated approach to improve mental health and diabetes self-management at the same time. Dr. Perez-Escamilla is co-leading a randomized controlled trial to investigate whether stress-management sessions delivered by a community health educator might improve blood glucose control among Latinos with type 2 diabetes.
At Peers for Progress we encourage our readers to check out the full article from Medscape Medical News and the findings published in Diabetes Care. We will continue to highlight the great work being done by CHWs and peer supporters and the many ways they can improve chronic-disease self management.
Huyen Vu, MSPH
Involving peer support workers in mental health services is an effective means to improve the recovery outcomes for people living with mental illness. Evidence from the U.K., Australia, New Zealand and the U.S. suggests that by sharing their own experience of mental illness and supporting other patients in their own recovery journeys, peer workers can significantly improve treatment and recovery outcomes of people with psychiatric disability, and contributes to a substantial reduction in re-admission rates and bed days of mentally ill patients.
In the U.S., peer worker programs should grow in importance as the Affordable Care Act comes into effect. With an additional 8 million people eligible for Medicaid, and with the requirement to include mental health service coverage in all health plans, peer worker programs may be an effective strategy to alleviate the shortage of mental health professionals.
However, inclusion of the peer worker interventions as part of a national strategy for mental health care has been hampered by a lack of systematic evidence and robust evaluation on the value of peer workers as measured by gold-standard trials. A group of Australian researchers conducted a systematic review of 11 randomized control trials and found inconclusive evidence of the benefit of peer workers as providers of mental health services, and concluded that the lack of a clear change model was the potential limitation for those trials. (A change model is “an understanding of how what peer workers do is associated with outcomes.”)
To this end, Steve Gillard and colleagues recently developed a model articulating the change mechanisms that highlight the impact of peer workers on mentally-ill patients (Figure 1). Theoretical and practical components included in the model were derived from a comparative, qualitative case study. Seventy-one peer workers from 10 mental health services in England were interviewed about their role as peer workers and the implementation issues they experienced, such as human resource issues, working on teams, and training and support.
Analysis of the qualitative data helped the researchers to construct a change model for peer worker interventions. It indicates that building trust relationships based on shared experience is the primary mechanism behind the success of peer worker interventions, and establishing a personal connection is the necessary first stage of relationship building. Specifically, peer workers might share their lived experience of mental illness, or of utilizing services, which patients may recognize as a similar or shared experience. The next stage in building a trust relationship is through talking and listening. In this stage, it is important that peer worker shows understanding of the patient’s experiences based on their own lived experience, and give the patient a sense of validation. Once the relationship is formed, the peer worker should allow the patient to initiate discussion and disclosure instead of requiring it from them. Patients may thus be more willing to share their experience with peer workers and listen to their advice.
As the relationship is established, two parallel mechanisms arise from the trust relationship:
- Role model for recovery and learning to live with mental health problems: Peer workers act as role models to the patients they support by showing their own recovery progress and ability to function well socially. Patients then observe that the peer worker has moved on from where they currently see themselves, and they start to develop a sense of hope for the future. Seeing peer workers in the care role also has a significant impact on the patient, as it demonstrates their usefulness and value, and acts as a powerful symbol of recovery. As role models, peer workers challenge the self-stigmatizing effects of mental illness by the fact of their working role, increased resilience, empowerment and self-efficacy, and this prompts patients to engage in better self-care and to improve their social functioning.
- Bridging the engagement with mental health services and the community: As the relationship between the patient and peer worker grows stronger, it helps ease the patient’s engagement and connection with mental health professionals, care services, and the wider community. Through this bridging function, the patient’s trust in peer workers can also be extended to other non-peer members of the team which may enable the patient to overcome their fear of being stigmatized and their reticence to disclose difficult personal issues with the mental health team. In this role, peer workers may facilitate patients’ engagement with the community by encouraging them to attend outside activities, helping them break their isolation and increase the range and quality of their social networks.
Gillard’s change model aligns closely with the four key functions of peer support, as articulated by Peers for Progress. Our experience with peer support programs have taught us that building rapport between the peer supporter and the patient is the first step in engaging that patient. We share the belief that fostering positive interpersonal relationships is the driving force in peer support interventions.
In summary, the change model can provide a theoretically grounded framework to develop, evaluate, and plan peer support interventions. The model can identify associations between process outcomes and clinical outcomes, thus providing a strategy for formal evaluation of peer support interventions. This approach would facilitate the inclusion of the peer worker role and intervention as a recognized element of a national strategy for mental health care.
Yudy Galvan and Lizette Martinez
Alivio Medical Center
Evoking the energy and warmth of the sun, the Fiesta del Sol festival in Chicago has grown from a block party into the largest Latino festival in the Midwest. Fiesta del Sol began in 1972 as a celebration to commemorate Pilsen Neighbors Community Council’s (PNCC) PNCC’s role in securing the city’s commitment to building Benito Juarez Leadership Academy. Today, Fiesta del Sol continues to reflect the organization’s desire for social transformation.
Recognizing the burden of chronic health diseases in Latino communities, Alivio Medical Center’s Mi Salud es Primero Diabetes Program organizes the Keeping Healthy Campaign with Fiesta del Sol every year. The Keeping Healthy Campaign encourages healthy lifestyles, good eating and exercise habits, stress reduction, healthy cooking, weight control, and high blood pressure and diabetes prevention and control. CHWs from Alivio Medical Center led the community outreach efforts over the three-day festival. The CHWs are the ideal ambassad ors for health, drawing in thousands of visitors with their enthusiasm and helpful nature.
This year, more than 2,689 people (2141 adults and 548 children) visited the Health Booth, receiving information on healthy eating and healthy weight, and prevention of overweight, obesity, sedentary lifestyle, hypertension, and diabetes. Visitors also received information about the programs and services that were available at neighborhood health clinics.
The CHWs conducted 812 screenings for weight, blood pressure, and diabetes for 356 participants. These screenings helped identify 28 people that were pre-diabetic and 19 people that did not have their diabetes under control. People that were identified to be at risk of overweight, obesity, hypertension and diabetes were offered the option to help get a medical appointment for a more thorough assessment and receive appropriate treatment if needed.
Alivio Medical Center’s outreach and education programming at Fiesta del Sol always offers a great opportunity to meet people in the community and engage them in open discussions about the health of themselves and their families. We look forward to seeing everyone at next year’s festival!