Using participant information to develop a tool for the evaluation of community health worker outreach services.

OBJECTIVE: Because there is no instrument that measures how clients judge community health worker (CHW) services, we sought to develop such a questionnaire. We report how we used client information to develop a brief questionnaire evaluating CHW services. DESIGN: We conducted and content-analyzed 18 in-depth semi-structured interviews of clients receiving CHW services to determine aspects of care salient to clients. Based on the results of these analyses, we developed and administered an in-person survey measuring the importance of 57 aspects of CHW services to 84 clients in 3 programs using CHWs to help control hypertension or diabetes. RESULTS: Clients perceived a broad array of aspects of CHW care including CHW attributes, services, benefits or outcomes of service and service arrangements. The 15 aspects ranking highest included: 1) CHW knows job; 2) CHW keeps client alive; 3) CHW gives information on high blood pressure; 4) CHW shows respect; 5) blood pressure is lowered; 6) CHW pays attention; 7) client gets better medical care; 8) CHW speaks understandably; and 9) client gets needed care. CONCLUSION: We used client information to generate and determine the relative importance of a pool of aspects that we and others can use to construct brief questionnaires to measure clients' judgments of CHW services. Such questionnaires are needed for ongoing evaluation as more providers and managed care organizations increase their use of CHWs for outreach programs.

The effectiveness of a community/academic health center partnership in decreasing the level of blood pressure in an urban African-American population.

This study investigated the effectiveness of a community-academic health center partnership, utilizing nurse-supervised indigenous community health workers, in decreasing the blood pressure in an urban African-American population. A four-year randomized clinical trial was conducted in the Sandtown-Winchester community, which has an excess prevalence of high blood pressure, in order to test the effectiveness of 2 different levels of intervention intensity on increasing the control of high blood pressure. Community health workers were trained and certified in blood pressure management, monitoring, education and counseling, social support mobilization, and community outreach and follow up. The primary results were a significant decrease in mean systolic and diastolic pressures after both levels of intervention, and a significant increase in the percentage of individuals with controlled high blood pressure. Surprisingly, no differences in results were observed between the 2 levels of intervention intensity. This study supports the use of community-based partnership efforts, and the utilization of indigenous health workers, to enhance the control of high blood pressure in a high-risk, African-American urban population.

Variation in quality of men's health care by race/ethnicity and social class.

BACKGROUND: Until recently, minority and poor men have been characterized as "an invisible population," overlooked by public and private efforts to improve the health status of women, children, and the elderly. OBJECTIVE: This study compares the health care experiences of racial and ethnic minority men with that of white men, and low socioeconomic status with those of higher status. MEASURES/SUBJECTS: Quality-of-care measures in multiple clinical domains are evaluated. The authors use data from several databases, including the National Health Interview Survey, Medical Expenditure Panel Survey, and Health Care Cost and Utilization Project State Inpatient Database. The relative difference between each racial/ethnic and socioeconomic group and a fixed reference group is used to assess differences in use of services. Statistical significance is assessed using z tests. RESULTS: Hispanic men were much less likely to receive colorectal cancer screening (relative risk [RR] range, 0.61-0.69), cardiovascular risk factor screening and management (RR, 0.84-0.88), and vaccinations (RR, 0.47-0.94). Black and Asian men were significantly less likely to have received selected preventive services (adult immunization and colorectal cancer screening). The differences in end-stage renal disease care that black and white men received were statistically significant (RR, 0.39-0.97), with black men consistently receiving worse care. For some measures of management of end-stage renal disease, Asian men received care that was similar to or better than that received by non-Hispanic whites. CONCLUSION: Minority men are at a markedly elevated risk for the receipt of poor health care quality. However, generalizations about "minority" men are likely to be misleading and incomplete. There is a considerable variation in the magnitude, direction, and significance of these risks.

African American church participation and health care practices.

BACKGROUND: While religious involvement is associated with improvements in health, little is known about the relationship between church participation and health care practices. OBJECTIVES: To determine 1) the prevalence of church participation; 2) whether church participation influences positive health care practices; and 3) whether gender, age, insurance status, and levels of comorbidity modified these relationships. DESIGN: A cross-sectional analysis using survey data from 2196 residents of a low-income, African-American neighborhood. MEASUREMENTS: Our independent variable measured the frequency of church attendance. Dependent variables were: 1) Pap smear; 2) mammogram; and 3) dental visit-all taking place within 2 years; 4) blood pressure measurement within 1 year, 5) having a regular source of care, and 6) no perceived delays in care in the previous year. We controlled for socioeconomic factors and the number of comorbid conditions and also tested for interactions. RESULTS: Thirty-seven percent of community members went to church at least monthly. Church attendance was associated with increased likelihood of positive health care practices by 20% to 80%. In multivariate analyses, church attendance was related to dental visits (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.3 to 1.9) and blood pressure measurements (OR, 1.6; 95% CI, 1.2 to 2.1). Insurance status and number of comorbid conditions modified the relationship between church attendance and Pap smear, with increased practices noted for the uninsured (OR, 2.3; 95% CI, 1.2 to 4.1) and for women with 2 or more comorbid conditions (OR, 1.9; 95% CI, 1.1 to 3.5). CONCLUSION: Church attendance is an important correlate of positive health care practices, especially for the most vulnerable subgroups, the uninsured and chronically ill. Community- and faith-based organizations present additional opportunities to improve the health of low-income and minority populations.