Understanding critical factors associated with integration of community health workers into health and hospital systems.

Community health worker (CHW) models have been shown to improve health behaviors and health outcomes and reduce cost, particularly among low-income underserved populations. Consequently, health systems are increasingly employing CHWs to provide health services in clinical environments. A growing body of the literature suggests that effective integration of CHWs within the healthcare system is important to achieve the desired outcomes, but the question of how to achieve effective integration is less clear. This study seeks to explore the integration of CHWs within a large state university health system to identify factors critical to the effective integration of CHWs into the clinical care environment. We conducted a qualitative descriptive multiple embedded case study of the University of Illinois at Chicago's Hospital and Health Science System (UI Health). The embedded subunits of analysis were teams within the UI Health System that currently employ CHWs to assist with the provision of clinical care or services to patients. Data were collected via semi-structured interviews and document review. In total, six sub-units were enrolled, and 17 interviews were conducted with CHWs (n = 9), and administrators or healthcare providers (n = 8). Fourteen factors related to effective CHW integration were identified and organized in four categories: individual, team, organization, and community. Findings suggest that in addition to commonly recognized elements of effective CHW models including training, supervision, and the presence of a champion, programs must consider the organizational context in which the program is positioned as well as the ways in which both CHWs and the organization engage with communities served. This research can serve as a roadmap for health systems that seek to integrate CHWs within healthcare services and can be used to promote best practice in CHW integration.

Understanding the relationship between care team perceptions about CHWs and CHW integration within a US health system, a qualitative descriptive multiple embedded case study.

BACKGROUND: Community health workers (CHW) have grown in prominence within the healthcare sector, yet there is no clear consensus regarding a CHW's role, purpose, and value within health systems. This lack of consensus has the potential to affect how CHWs are perceived, utilized, and ultimately integrated within the healthcare sector. This research examines clinical care teams that currently employ CHWs to (1) understand how members of the care team perceive CHWs' purpose and value, and (2) consider how perceptions of CHWs are related to CHW integration within health care teams. METHODS: Researchers conducted a qualitative descriptive multiple embedded case study at the University of Illinois at Chicago's Hospital and Health Science System (UI Health). The embedded subunits of analysis were teams within UI Health that are currently employing CHWs to assist with the provision of clinical care or services to patients. Data were collected via semi-structured interviews and document review. RESULTS: In total, 6 sub-units were enrolled to participate, and 17 interviews were conducted with CHWs (n = 9), and administrators or health care providers (n = 8). Reported perceptions of CHWs were inconsistent across respondents. CHWs roles were not always understood, and the CHW's purpose and value was perceived differently by different members of the care team. Moreover, evaluation metrics did not always capture CHWs' value to the health care system. In some cases, care teams were more aligned around a shared understanding of the CHW's roles and purpose within the care team. When perceptions regarding CHWs were both positive and aligned, respondents reported higher levels of integration within the healthcare system. CONCLUSIONS: Alignment in a care team's perception of a CHW's role, purpose, and value within the health system could play an important role in the integration of CHWs within healthcare teams.

Framing the Integration of Community Health Workers Into Health Care Systems Along Health Care and Community Spectrums.

Research calls for community health worker (CHW) integration within health systems, yet there is no agreement regarding what CHW integration is or guidance for how it can be achieved. This study examines factors associated with CHW integration in community and health care settings using a qualitative descriptive multiple-embedded case study of CHW teams at the University of Illinois at Chicago. Data were collected via semistructured interviews/document review and analyzed using thematic coding and quantitative content analysis. Factors associated with higher clinical integration included culture, communication, protocols, and training while higher community integration was associated with accessibility, relationships, and empathy.

Impact of Natural Disasters on Health Outcomes and Cancer Among Older Adults.

There is growing evidence that older adults exposed to natural disasters are at disproportionate risk for adverse health events such as all-cause mortality, injury, hospital admissions, stroke, displacement, cardiopulmonary distress, stress-related mental health problems, and exacerbation of chronic illnesses. Typically, analyses of the health consequences of natural disasters focus only on the populations impacted for the duration and immediate aftermath of the disaster. With few exceptions, the long-term effects of natural disasters on older adult health have not been examined. This article describes the potential consequences of exposure to natural disasters that contribute to cancer and disruption of cancer care treatment systems for older adults. It is argued that exposures to floods and wildfires in particular present an underestimated threat to the onset and/or progression of cancer and cancer care management in older adults. We propose that these impacts should be examined not only from an emergency preparedness perspective during the event but also from a public health focus that prospectively assesses risks for cancer and other health disparities. Recommendations for comprehensive longitudinal risk assessment and emergency preparedness models that address the full impact of natural disasters on the health and well-being of vulnerable, at risk, older adults are offered.

Implementing visual cervical cancer screening in Senegal: a cross-sectional study of risk factors and prevalence highlighting service utilization barriers.

BACKGROUND: Senegal ranks 15th in the world in incidence of cervical cancer, the number one cause of cancer mortality among women in this country. The estimated participation rate for cervical cancer screening throughout Senegal is very low (6.9% of women 18-69 years old), especially in rural areas and among older age groups (only 1.9% of women above the age of 40 years). There are no reliable estimates of the prevalence of cervical dysplasia or risk factors for cervical dysplasia specific to rural Senegal. The goals of this study were to estimate the prevalence of cervical dysplasia in a rural region using visual inspection of the cervix with acetic acid (VIA) and to assess risk factors for cervical cancer control. PATIENTS AND METHODS: We conducted a cross-sectional study in which we randomly selected 38 villages across the Kédougou region using a three-stage clustering process. Between October 2013 and March 2014, we collected VIA screening results for women aged 30-50 years and cervical cancer risk factors linked to the screening result. RESULTS: We screened 509 women; 5.6% of the estimated target population (9,041) in the region. The point prevalence of cervical dysplasia (positive VIA test) was 2.10% (95% confidence interval [CI]: 0.99-3.21). Moreover, 287 women completed the cervical cancer risk factor survey (56.4% response rate) and only 38% stated awareness of cervical cancer; 75.9% of the screened women were less than 40 years of age. CONCLUSION: The overall prevalence of dysplasia in this sample was lower than anticipated. Despite both overall awareness and screening uptake being less than expected, our study highlights the need to address challenges in future prevalence estimates. Principally, we identified that the highest-risk women are the ones least likely to seek screening services, thus illustrating a need to fully understand demand-side barriers to accessing health services in this population. Targeted efforts to educate and motivate older women to seek screenings are needed to sustain an effective cervical cancer screening program.

Impact of telephone reinforcement and negotiated contracts on behavioral predictors of exercise maintenance in older adults with osteoarthritis.

OBJECTIVES: To examine the impact of telephone reinforcement (TR) on predictors of physical activity (PA) maintenance in older adults with osteoarthritis. METHODS: Mixed effects modeling was conducted of data from a randomized PA trial that used negotiated maintenance contracts, supplemented by TR, to test impact of TR on barriers, decisional balance, and stage of change at multiple points in time. RESULTS: Participants who were referred to a PA program and received TR improved the most in barriers and decisional balance. Participants who negotiated a tailored maintenance contract but did not receive TR improved the most in stage. CONCLUSIONS: TR appears to positively affect perceptions around engagement, whereas negotiation positively impacts PA behavior. Further research should examine the effectiveness of specific PA maintenance strategies.

The Preparedness and Emergency Response Learning Centers: advancing standardized evaluation of public health preparedness and response trainings.

INTRODUCTION: The Centers for Disease Control and Prevention funded Preparedness and Emergency Response Learning Centers (PERLCs) across the United States. The PERLCs provide training to state, local, and tribal public health organizations to meet workforce development needs in the areas of public health preparedness and response, specialized training, education, and consultation. METHODS/ACTIVITY: Using Donald Kirkpatrick's training evaluation model, the PERLC network established 4 evaluation working groups that developed evaluation criteria to address each level of the model. The purpose of the working groups was to inform and promote center-level and program-level evaluation across the PERLC network; identify common training evaluation methods and measures; and share materials, resources, and lessons learned with state, local, and tribal public health organizations for potential replication. RESULTS/OUTCOMES: The evaluation of education and training, irrespective of its modality (eg, in-person, online, webinars, seminars, symposia) can be accomplished using Kirkpatrick's 4-level taxonomy. DISCUSSION: The 4 levels aim to measure the following aspects of training programs: (1) trainees' reaction; (2) knowledge acquired, skills improved, or attitudes changed; (3) behavior changed; and (4) results or impact. To successfully evaluate emergency preparedness training, drills and exercises, it is necessary to understand the fundamental tenets of each level and how to apply each to measure training outcomes. LESSONS LEARNED/NEXT STEPS: The PERLC evaluators have adopted the basic schema of Kirkpatrick's 4-level model and applied its structure to a wide variety of preparedness and emergency response training and related activities. The PERLC evaluation working groups successfully developed and tested survey methods and instruments for each of the 4 levels of Kirkpatrick's training evaluation model. Each can be used for replication by state, local, and tribal public health professionals.

The instructional impact of the American Medical Association's Older Drivers Project online curriculum.

The Older Drivers Project (ODP) of the American Medical Association has provided evidence-based training for clinicians since 2003. More than 10,000 physicians and other professionals have been trained via an authoritative manual, the Physician's Guide to Assessing & Counseling Older Drivers, and an associated continuing medical education five-module curriculum offered formally by multidisciplinary teams from 12 U.S. States from 2003 to 2008. An hour-long, online version was piloted with medical residents and physicians (N = 259) from six academic and physician office sites from 2010 to 2011. Pre/postsurveys were completed. Most rated the curriculum of high quality and relevant to their practice. A majority (88%) reported learning a new technique or tool, and 89% stated an intention to incorporate new learning into their daily clinical practice. More than one half (62%) reported increased confidence in addressing driving. This transition from in-person to online instruction will allow the ODP to reach many more clinicians, at all levels of training, in the years to come.

Perceptions of cardiovascular health in underserved communities.

INTRODUCTION: Cardiovascular disease is the leading cause of deaths and illnesses in US adults, and the prevalence is disproportionately high in underserved populations. In this study, we assessed respondents' understanding of context-specific differences in knowledge and perceptions of disease, risk, and prevention in 6 underserved communities, with the longer-term goal of developing appropriate interventions. METHODS: Thirty-nine small-group sessions and 14 interviews yielded data from 318 adults. Each site's researchers coded, analyzed, and extracted key themes from local data. Investigators from all sites synthesized results and identified common themes and differences. RESULTS: Themes clustered in 3 areas (barriers to cardiovascular health, constraints related to multiple roles, and suggestions for effective communications and programs). Barriers spanned individual, social and cultural, and environmental levels; women in particular cited multiple roles (eg, competing demands, lack of self-care). Programmatic suggestions included the following: personal, interactive, social context; information in language that people use; activities built around cultural values and interests; and community orientation. In addition, respondents preferred health-related information from trusted groups (eg, AARP), health care providers (but with noticeable differences of opinion), family and friends, and printed materials. CONCLUSION: Interventions to decrease barriers to cardiovascular health are needed; these strategies should include family and community context, small groups, interactive methods, culturally sensitive materials, and trusted information sources. New-immigrant communities need culturally and linguistically tailored education before receiving more substantive interventions.

The effect of giving global coronary risk information to adults: a systematic review.

BACKGROUND: Global coronary heart disease (CHD) risk estimation (ie, a quantitative estimate of a patient's chances of CHD calculated by combining risk factors in an empirical equation) is recommended as a starting point for primary prevention efforts in all US adults. Whether it improves outcomes is currently unknown. METHODS: To assess the effect of providing global CHD risk information to adults, we performed a systematic evidence review. We searched MEDLINE for the years 1980 to 2008, Psych Info, CINAHL, and the Cochrane Database and included English-language articles that met prespecified inclusion criteria. Two reviewers independently reviewed titles, abstracts, and articles for inclusion and assessed study quality. RESULTS: We identified 20 articles, reporting on 18 unique fair or good quality studies (including 14 randomized controlled studies). These showed that global CHD risk information alone or with accompanying education increased the accuracy of perceived risk and probably increased intent to start therapy. Studies with repeated risk information or risk information and repeated doses of counseling showed small significant reductions in predicted CHD risk (absolute differences, -0.2% to -2% over 10 years in studies using risk estimates derived from Framingham equations). Studies providing global risk information at only 1 point in time seemed ineffective. CONCLUSIONS: Global CHD risk information seems to improve the accuracy of risk perception and may increase intent to initiate CHD prevention among individuals at moderate to high risk. The effect of global risk presentation on more distal outcomes is less clear and seems to be related to the intensity of accompanying interventions.

Implications of the aging process: opportunities for prevention in the farming community.

This paper provides an overview of the demographic trends in aging, and of the process of aging and its implications on physical and mental health, with special reference to farmers. Agriculture employs more workers age 55 and over than any other industry (22.9% in agriculture versus 13.6% for all industries). Aging is an intricate process with inevitable physiological and physical impacts on the various body systems. These changes in the older farmer community are highlighted, along with preventive measures that can be adopted by farmers to maximize life span and quality of life. The farmer community can acquire knowledge about maintenance of workplace safety, preservation of good health, and prevention of chronic diseases that compromise healthy aging.

Listening to rural Hispanic immigrants in the Midwest: a community-based participatory assessment of major barriers to health care access and use.

Hispanic immigrants are increasingly residing in rural communities, including in the midwestern United States. Limitations in the ability of rural Hispanics to access and utilize health care contribute to patterns of poor health and health disparity. A conceptual model of "vulnerability" guides this community-based participatory assessment project designed to explore rural Hispanics' perceived barriers to accessing and utilizing health care. Findings from a series of 19 focus groups with 181 participants from three communities in the upper Midwest identified perceived barriers at the individual and health care system levels. The most commonly perceived barriers were the lack of and limitations in health insurance coverage, high costs of health care services, communication issues involving patients and providers, legal status/discrimination, and transportation concerns. Findings imply that these barriers could be addressed using multiple educational and health service delivery policy-related strategies that consider the vulnerable nature of this growing population.

Physical activity and cognitive functioning: translating research to practice with a public health approach.

A growing body of research, from retrospective cross-sectional studies to randomized clinical trials, suggests that physical activity among the elderly has positive effects on a wide range of physiologic systems and tissues, including the cardiovascular, immune, and endocrine systems, and even cognitive functioning. The latter is particularly relevant to the management of Alzheimer's disease and other forms of dementia. There is increasing support that the positive effects of physical activity on cognitive functioning have been obtained at the primary (cognitively healthy older adults), secondary (persons with some loss of cognitive functioning to mild cognitive impairment), and tertiary (older adults with significant cognitive impairment) prevention levels. However, there are several specific components and potential roles for physical activity in the field of cognitive health and functioning that have not been addressed. Moreover, we argue that a population-based public health perspective is needed as efforts to investigate the physical activity/cognitive health relationship are developed and disseminated for large-scale implementation. This perspective discusses some of the problems that might be faced when translating basic research findings into public health practice for cognitive impairment and/or dementia in older adults and addresses how some of these problems might be overcome.

The views of dentists, nurses and nutritionists on the association between diabetes and periodontal disease: a qualitative study in a Latino community.

OBJECTIVE: To interview health professionals in a Latino community about the association between diabetes and periodontitis, and provide a basis to develop interventions for them to promote oral health and good glycemic control among patients with diabetes. METHODS: Five dentists, seven nurses and two nutritionists were interviewed about their practices relevant to oral health and diabetes, knowledge about the association, beliefs about Latinos, recommendations on reaching others in their fields, and barriers. The interviews were audiotaped, transcribed, and analyzed qualitatively. RESULTS: Professionals identified policy, community and practice barriers for promoting diabetic control and oral health. CONCLUSIONS: Producing a resource list, cross-educating professionals about diabetes and oral health, training professionals to better serve Latino patients, developing appropriate protocols for each profession regarding the association between diabetes and periodontitis, and educating the community about diabetic control, oral health and disease prevention were identified as potential strategies to improve oral health among Latino persons with diabetes.