Results of the northern Manhattan diabetes community outreach project: a randomized trial studying a community health worker intervention to improve diabetes care in Hispanic adults.

OBJECTIVE The Northern Manhattan Diabetes Community Outreach Project evaluated whether a community health worker (CHW) intervention improved clinically relevant markers of diabetes care in adult Hispanics. RESEARCH DESIGN AND METHODS Participants were adult Hispanics, ages 35-70 years, with recent hemoglobin A1c (A1C) ≥8% (≥64 mmol/mol), from a university-affiliated network of primary care practices in northern Manhattan (New York City, NY). They were randomized to a 12-month CHW intervention (n = 181), or enhanced usual care (educational materials mailed at 4-month intervals, preceded by phone calls, n = 179). The primary outcome was A1C at 12 months; the secondary outcomes were systolic blood pressure (SBP), diastolic blood pressure, and LDL-cholesterol levels. RESULTS There was a nonsignificant trend toward improvement in A1C levels in the intervention group (from unadjusted mean A1C of 8.77 to 8.40%), as compared with usual care (from 8.58 to 8.53%) (P = 0.131). There was also a nonsignificant trend toward an increase in SBP and LDL cholesterol in the intervention arm. Intervention fidelity, measured as the number of contacts in the intervention arm (visits, phone contacts, group support, and nutritional education), showed a borderline association with greater A1C reduction (P = 0.054). When assessed separately, phone contacts were associated with greater A1C reduction (P = 0.04). CONCLUSIONS The trend toward A1C reduction with the CHW intervention failed to achieve statistical significance. Greater intervention fidelity may achieve better glycemic control, and more accessible treatment models, such as phone-based interventions, may be more efficacious in socioeconomically disadvantaged populations.

Protocol for the Northern Manhattan Diabetes Community Outreach Project. A randomised trial of a community health worker intervention to improve diabetes care in Hispanic adults.

OBJECTIVE: Hispanics in the USA are affected by the diabetes epidemic disproportionately, and they consistently have lower access to care, poorer control of the disease and higher risk of complications. This study evaluates whether a community health worker (CHW) intervention may improve clinically relevant markers of diabetes care in adult underserved Hispanics. METHODS AND ANALYSIS: The Northern Manhattan Diabetes Community Outreach Project (NOCHOP) is a two-armed randomised controlled trial to be performed as a community-based participatory research study performed in a Primary Care Setting in Northern Manhattan (New York City). 360 Hispanic adults with poorly controlled type 2 diabetes mellitus (haemoglobin A1c >8%), aged 35-70 years, will be randomised at a 1:1 ratio, within Primary Care Provider clusters. The two study arms are (1) a 12-month CHW intervention and (2) enhanced usual care (educational materials mailed at 4-month intervals, preceded by phone calls). The end points, assessed after 12 months, are primary = haemoglobin A1c and secondary = blood pressure and low-density lipoprotein-cholesterol levels. In addition, the study will describe the CHW intervention in terms of components and intensity and will assess its effects on (1) medication adherence, (2) medication intensification, (3) diet and (4) physical activity. ETHICS AND DISSEMINATION: All participants will provide informed consent; the study protocol has been approved by the Institutional Review Board of Columbia University Medical Center. CHW interventions hold great promise in improving the well-being of minority populations who suffer from diabetes mellitus. The NOCHOP study will provide valuable information about the efficacy of those interventions vis-à-vis clinically relevant end points and will inform policy makers through a detailed characterisation of the programme and its effects. CLINICAL TRIAL REGISTRATION NUMBER: NCT00787475 at clinicaltrials.gov.

Awareness of sickle cell among people of reproductive age: Dominicans and African Americans in northern Manhattan.

Sickle cell disease is a chronic condition that is characterized by severe anemia, painful crises, and organ dysfunction. In the U.S.A., sickle cell is a health burden typically associated with African Americans. Dominicans constitute the largest Latino group in New York City (N.Y.C.) and have the second overall highest prevalence of sickle trait-one in 20 births, compared to one in 12 African American births. We aimed to document the prevalence of sickle within the largely Dominican and African American community of Northern Manhattan (Washington Heights, Inwood, Harlem), assess and compare knowledge about sickle disease and carrier status in young adults of reproductive age between African Americans and Dominicans, and elicit preferred sources of health information. N.Y. State Newborn Screening data in Northern Manhattan were analyzed by zip code. A brief oral survey was administered to 208 parents of young children-150 Dominicans and 58 African Americans. Significant differences were seen in knowledge about sickle-27% of Dominican parents surveyed correctly defined sickle cell disease as an inherited blood disorder, compared to 76% of African Americans (p < 0.001). Only 7% of African Americans did not know their own trait status, compared to 43% of Dominicans (p < 0.001). Parents were better informed if they or family members were affected by sickle conditions. Participants from both groups prefer receiving information from doctors and online. A separate group of 168 predominantly Dominican youth, ages 14-24, demonstrated knowledge levels similar to that of Dominican parents. These results suggest that many of reproductive age in a N.Y.C. community affected by sickle conditions frequently lack basic relevant information, with larger information gaps among Dominicans. Expanded efforts are warranted to inform young adults of diverse affected communities.

Communities as teachers: learning to deliver culturally effective care in pediatrics.

A patient's culture has an effect on her or his view of illness, decision to seek care, and adherence to treatment plans and follow-up visits. In this article, we describe community-academic partnerships designed to teach improved delivery of culturally effective care conducted in pediatric residency training programs in New York, New York, and San Diego, California. Columbia University-Children's Hospital of New York-Presbyterian focuses most of residents' cultural-training experiences within 1 community program, a home-visitation program (Best Beginnings) with which residents work in various capacities throughout residency. The University of California, San Diego and Naval Medical Center San Diego use a series of cultural "immersion experiences" as a primary method. The creation of community-academic partnerships for the purpose of service and training can be a critical asset in the development of culturally effective care training: community partners become teachers and local communities serve as classrooms.

How a community-based organization and an academic health center are creating an effective partnership for training and service.

Community-academic partnerships in the training of doctors offer unique learning opportunities of great importance. Such partnerships can induce a paradigm shift such that physicians view community as a teaching resource and partner rather than as a passive recipient of services or solely as a placement site. The authors describe a model of a community-academic partnership in New York City, begun in 1995, in which, for training and service, pediatric residents are integrally involved in a community-based program. Principles adapted from the Community-Campus Partnerships for Health's principles of partnership provide a framework for portraying the essential elements of developing and maintaining the partnership. The authors explain the clashes that may arise between partners and show how the principles of partnership guide partnership members in working and learning within a setting that by its nature entails conflict and inequality. This report is based on the knowledge gained from the structured reflections of both members of this partnership: the residency program at a large academic health center and the community-based social service organization. Such partnerships provide the training ground for the development of physicians who understand the social and cultural determinants of health and constructively use community agencies' input in promoting child health and well-being. Within this framework, community-based organizations are not solely service providers but become educators of physicians-in-training who, with new knowledge gained through the partnership, more effectively contribute to the overall health of the communities they serve.