Practicing Preventive Health: The Underlying Culture Among Low-Income Rural Populations

Context: Health disparities on the basis of geographic location, social economic factors and education levels are well documented. However, even when health care services are available, there is no guarantee that all persons will take preventive health measures. Understanding the cultural beliefs, practices, and lifestyle choices that determine utilization of health services is an important factor in combating chronic diseases. Purpose: The purpose of this study was to investigate personal, cultural, and external barriers that interfered with participating in a community-based preventive outreach program that included health screening for obesity, diabetes, heart diseases, and hypertension when cost and transportation factors were addressed. Methods: Six focus groups were conducted in a rural community of Louisiana. Focus groups were divided into 2 categories: participants and nonparticipants. Three focus groups were completed with Dubach Health Outreach Project (DUHOP) participants and 3 were completed with nonparticipants. The focus group interviews were moderated by a researcher experienced in focus group interviews; a graduate student assisted with recording and note-taking during the sessions. Findings: Four main themes associated with barriers to participation in preventive services emerged from the discussions: (1) time, (2) low priority, (3) fear of the unknown, and (4) lack of companionship or support. Health concerns, free services, enjoyment, and free food were identified as motivators for participation. Conclusions: The findings of this study indicated that the resulting synergy between low-income status and a lack of motivation regarding health care prevention created a complicated practice of health care procrastination, which resulted in unnecessary emergency care and disease progression. To change this practice to proactive disease prevention and self care, a concerted effort will need to be implemented by policy makers, funding agents, health care providers, and community leaders and members.     

健康教育对社区糖尿病管理效果的影响

目的观察健康教育对社区糖尿病管理效果的影响。方法选取我院下属社区管理的糖尿病病人126例,随机分为观察组63例,对照组63例,对观察组进行健康教育系统管理,对照组未进行系统的健康教育管理,6个月后对比分析两组患者血糖控制率和糖尿病知识知晓率。结果观察组的血糖控制率和糖尿病知识知晓率明显高于对照组,两组比较差异均有统计学意义(P<0.05)。结论健康教育能明显提高社区糖尿病管理效果,值得重视。     

Diabetes Prevention Education Program for Community Health Care Workers in Thailand

To evaluate the effects of a 4-month training program on the knowledge of CHCWs. CHCWs from 69 communities in Chiang Mai province in Thailand were assigned to the intervention group (IG, n = 35) or control group (CG, n = 34). All CHCWs were assessed for knowledge at baseline and at 4-months. The intervention group received a training program of 16 sessions of 2.5 h each within a 4-month period. A mix of classroom and E-learning approaches was used. All CHCWs were assessed for knowledge at baseline, 4-month, and follow-up at 8-month. Assessment was based on a pretested examination addressing understanding of nutritional terms and recommendations, knowledge of food sources related to diabetes prevention and diet-disease associations. Overall, the knowledge at baseline of both groups was not significantly different and all CHCWs scored lower than the 70% (mean (SD), 56.5% (6.26) for IG and 54.9% (6.98) for CG). After 4-month, CHCWs in the IG demonstrated improvement in total scores from baseline to 75.5% (6.01), P < .001 and relative to the CG 57.4% (5.59), P < .001. The follow up phase at 8-month, IG were higher in total scores than CG (71.3% (7.36) and 62.4% (6.81), P < .001). The diabetes prevention education program was effective in improving CHCWs’ health knowledge relevant to diabetes prevention. The innovative learning model has potential to expand chronic disease prevention training of CHCWs to other parts of Thailand.     

上海市社区糖尿病患者对不同健康传播模式需求的定量及定性研究

目的研究上海市社区面向糖尿病患者的健康传播模式和患者需求，为今后有效开展社区糖尿病健康教育工作提供科学的依据。方法采用定量和定性相结合的方法，对社区糖尿病患者进行问卷调查和小组访谈。结果社区面向糖尿病患者的各种健康传播方式效果参差不齐，健康传播针对性不强。结论目前的社区糖尿病健康传播模式尚不能满足患者的需求，必须提高社区卫生服务提供者的综合能力，积极开发社区潜能，规范大众媒体的健康传播。     

基层医疗机构糖尿病社区管理的相关问题及发展对策的定性研究

采用专题组讨论法,对我国东、中、西部41个基层卫生系统相关机构从事慢性病管理工作的关键知情人员93人进行访谈,以期了解基层医疗卫生服务机构开展糖尿病社区管理工作现状,找出影响糖尿病防治工作开展的深层次问题及原因,为促进我国慢性病防治工作可持续发展提供政策建议.     

Community Health Workers and Community Advocacy: Addressing Health Disparities

The Community Health Worker model is recognized nationally as a means to address glaring inequities in the burden of adverse health conditions that exist among specific population groups in the United States. This study explored Arizona CHW involvement in advocacy beyond the individual patient level into the realm of advocating for community level change as a mechanism to reduce the structural underpinnings of health disparities. A survey of CHWs in Arizona found that CHWs advocate at local, state and federal political levels as well as within health and social service agencies and business. Characteristics significantly associated with advocacy include employment in a not for profit organization, previous leadership training, and a work environment that allows flexible work hours and the autonomy to start new projects at work. Intrinsic characteristics of CHWs associated with advocacy include their belief that they can influence community decisions, self perception that they are leaders in the community, and knowledge of who to talk to in their community to make change. Community-level advocacy has been identified as a core CHW function and has the potential to address structural issues such as poverty, employment, housing, and discrimination. Agencies utilizing the CHW model could encourage community advocacy by providing a flexible working environment, ongoing leadership training, and opportunities to collaborate with both veteran CHWs and local community leaders. Further research is needed to understand the nature and impact of CHW community advocacy activities on both systems change and health outcomes.     

The Limits of Collaboration: A Qualitative Study of Community Ethical Review of Environmental Health Research

Objectives. We assessed the effectiveness of various systems of community participation in ethical review of environmental health research.Methods. We used situation analysis methods and a global workspace theoretical framework to conduct comparative case studies of 3 research organizations at 1 medical center.Results. We found a general institutional commitment to community review as well as personal commitment from some participants in the process. However, difficulty in communicating across divides of knowledge and privilege created serious gaps in implementation, leaving research vulnerable to validity threats (such as misinterpretation of findings) and communities vulnerable to harm. The methods used in each collaboration solved some, but not all, of the problems that hindered communication.Conclusions. Researchers, community spokespersons, and institutional review boards constitute organizational groups with strong internal ties and highly developed cultures. Few cross-linkages and little knowledge of each other cause significant distortion of information and other forms of miscommunication between groups. Our data suggest that organizations designed to protect human volunteers are in the best position to take the lead in implementing community review.It is well established that research can pose risks to participants. In recent years it has been recognized that research can also pose a threat to communities, because what individuals say when surveyed may be inappropriately generalized to their entire community. To protect communities from these and other potential harms, a new ethical principle, respect for communities, was established.¹ Community review of research is intended to protect against the collective harms that are a particular risk of environmental health research² and that are especially important in historically marginalized communities that have borne disproportionate burdens of both environmental degradation and ill-considered research.³Despite the ethical and scientific benefits of such a review, its implementation is piecemeal, with researchers, citizens, and community-based organizations struggling to achieve this oversight. Wallace et al. suggest that this problem can be understood from the perspective of global workspace theory, which posits that organizations are composed of cognitive work groups, systems designed to generate information and use it in making choices, decisions, appropriations, sanctions, and evaluations, among other tasks.^4–6 These work groups are internally organized teams that are externally linked to one another to create a larger system of distributed cognition. To be efficient, these interdependent teams must function both collectively and individually and must exchange information as rapidly and with as little distortion as possible. In the institution we studied, university researchers, community representatives, and ethical review boards were work groups whose separate but interrelated efforts formed a diffuse system that addressed the ethics of environmental health research.Wallace et al.''s model notes 3 obstacles to work group functioning: inattentional blindness, rate distortion, and policy or ideology.^4–6 Inattentional blindness is inherent in all observations, because it is impossible to take in all the information available in a situation. Rate distortion is a fundamental property of all information exchange: information travels through specific established channels, a process that is efficient but that inevitably causes some content to be lost or distorted, thus limiting the potential for innovation to emerge from the collaboration. Policy and ideology inform the starting assumptions that affect what people are able to see, hear, and use when confronted with new information; resource allocation and cultural constraints strongly influence this obstacle.We used Wallace et al.''s model as a tool to examine community ethical review for a variety of research projects involving environmental health. Although all of the projects shared an interest in human health outcomes, their methods ranged from molecular analysis of biological samples to in-depth qualitative research in specific neighborhoods. Studies were longitudinal and cross-sectional and conducted in various locations and populations. We defined the process of review as a collective inquiry in which researchers, clinicians, and community representatives constitute work groups that must create a functioning, shared workspace in which the review of environmental health research is conducted. Although intragroup dynamics such as leadership and facilitation are commonly understood to influence collaborative efforts, our global workspace approach was directed more broadly at systemic, intergroup issues. Here we present examples of the obstacles to efficient distributed cognition seen in an environmental health research workspace.We used situation analysis to assess the interactions among 3 work groups at 1 medical center in a major US city. We examined these interactions at each of the 6 steps of the research process: posing a question, designing a study to answer the question, obtaining institutional review board (IRB) approval, collecting data, analyzing data, and disseminating findings. Because research that is developed without local input,⁷ or whose findings are inadequately communicated to participants, can harm volunteers and their communities, the conduct of each stage has ethical ramifications. In line with Wallace et al.''s theory that contexts shape cognition, we also examined the context of the work groups.     

Impact of Community Health Workers on Access to Care for Rural Populations in the United States: A Systematic Review

Community Health Worker (CHW) interventions have shown potential to reduce inequities for underserved populations. However, there is a lack of support for CHW integration in the delivery of health care. This may be of particular importance in rural areas in the Unites States where access to care remains problematic. This review aims to describe CHW interventions and their outcomes in rural populations in the US. Peer reviewed literature was searched in PubMed and PsycINFO for articles published in English from 2015 to February 2021. Title and abstract screening was performed followed by full text screening. Quality of the included studies was assessed using the Downs and Black score. A total of 26 studies met inclusion criteria. The largest proportion were pre-post program evaluation or cohort studies (46.2%). Many described CHW training (69%). Almost a third (30%) indicated the CHW was integrated within the health care team. Interventions aimed to provide health education (46%), links to community resources (27%), or both (27%). Chronic conditions were the concern for most interventions (38.5%) followed by women’s health (34.6%). Nearly all studies reported positive improvement in measured outcomes. In addition, studies examining cost reported positive return on investment. This review offers a broad overview of CHW interventions in rural settings in the United States. It provides evidence that CHW can improve access to care in rural settings and may represent a cost-effective investment for the healthcare system.

     

农村社区糖尿病患者健康管理效果评价

目的评价农村社区卫生服务全科团队对糖尿病患者进行健康管理的效果。方法对径山镇社区卫生服务中心2012年和2013年两年间糖尿病患者健康管理情况进行统计分析。结果部分糖尿病患者的血糖水平得到了缓解与控制。对2012年和2013年干预前后指标比较分析发现,糖尿病患者血糖水平在4.40~6.10 mmol/L之间,分别增加了9.97%和21.34%,差异均具有统计学意义。结论社区健康管理对于缓解糖尿病患病现状具有较大的现实意义。应探索个性化健康管理,提升干预效果;建立社区健康小屋,引导患者自我管理;创新健康教育方式,提高患者的知晓率。     

社区人群糖尿病健康知识知晓情况调查

目的探讨哈尔滨市社区居民糖尿病(DM)相关知识的知晓情况和需求状况。方法采用多级随机抽样方法,抽取20～74岁本地常住居民2300人为调查对象,应用单因素分析及多因素非条件Logistic逻辑回归方法,分析社区居民的DM健康知识知晓情况,探讨各因素与知晓情况的关系。结果单因素分析显示调查人群两性DM健康知识知晓率差异无显著性(χ2=4.8181,P=0.1856);而年龄越长,DM健康知识全部回答正确率越低(χCMH2=18.7593,P0.0001);答对问题数越多,DM患病率和有DM家族史率也越高(分别为χCMH2=41.0114,P0.0001和χCMH2=24.2751,P0.0001)。多因素非条件Logistic回归分析结果,DM健康知识知晓情况与DM史、DM家族史、高脂血症、家庭人均收入和文化程度均成正相关,而与年龄成负相关关系。结论在该社区要大力加强DM知识的宣传教育工作,根据人群不同年龄、不同生活状况及文化程度和不同健康状况的需求,采取相应对策,确保健康教育效果。     

The Culture of Health Survey: A Qualitative Assessment of a Diabetes Prevention Coalition

In the past two decades, the fields of public health and social services have increasingly turned toward collaborative and community-based approaches to address complex health and social issues. One aspect of these approaches has been the development and implementation of community coalitions. Coalitions have been used to successfully address a wide range of issues, including cancer prevention, tobacco use, HIV/AIDS, youth violence, heart disease, diabetes, and sexual exploitation of youth runaways. In south Tucson, Arizona the SEAH coalition was developed to address diabetes and substance abuse prevention. Using a qualitative interview guide, the Culture of Health Survey, this study was aimed at identifying community perceptions of the coalition and its effectiveness in the areas of community leadership, partnerships, trust, and movement towards positive change. We also sought to document the dissemination, throughout a community, of information on the activities and functioning of a community based coalition and whether or not it was seen as one that held fast to the community values and not to individual agendas. Results highlight the importance of outreach, education, trust, and partnerships in promoting diabetes prevention through a community coalition.     

Mexican American Trial of Community Health Workers: A Randomized Controlled Trial of a Community Health Worker Intervention for Mexican Americans With Type 2 Diabetes Mellitus

Objectives. We assessed whether community health workers (CHWs) could improve glycemic control among Mexican Americans with diabetes.Methods. We recruited 144 Mexican Americans with type 2 diabetes between January 2006 and September 2008 into the single-blinded, randomized controlled Mexican American Trial of Community Health Workers (MATCH) and followed them for 2 years. Participants were assigned to either a CHW intervention, delivering self-management training through 36 home visits over 2 years, or a bilingual control newsletter delivering the same information on the same schedule.Results. Intervention participants showed significantly lower hemoglobin A1c levels than control participants at both year 1 Δ = −0.55; P = .021) and year 2 (Δ = −0.69; P = .005). We observed no effect on blood pressure control, glucose self-monitoring, or adherence to medications or diet. Intervention participants increased physical activity from a mean of 1.63 days per week at baseline to 2.64 days per week after 2 years.Conclusions. A self-management intervention delivered by CHWs resulted in sustained improvements in glycemic control over 2 years among Mexican Americans with diabetes. MATCH adds to the growing body of evidence supporting the use of CHWs to reduce diabetes-related health disparities.The growing prevalence of diabetes mellitus among adults in the United States is well documented, with adverse impact strongest among ethnic minorities and low-income populations. The age-adjusted prevalence of diabetes is 12.6% among non-Hispanic Blacks, 11.8% among Hispanics, and only 7.1% among non-Hispanic Whites.1 Mexican Americans, who make up almost two thirds of US Hispanics,2 have an even higher diabetes prevalence of 13.3%.3 Disparities also persist in both processes of care and clinical outcomes. Mexican Americans with diabetes are significantly less likely than non-Hispanic Whites with the disease to be aware of and treated for comorbid hypertension or dyslipidemia.4 Mexican Americans are less likely to receive recommended clinical services, such as regular ophthalmologic and foot exams,5 and are less likely than non-Hispanic Whites to have well-controlled hemoglobin A1c (HbA1c) and cholesterol levels. In this context, it is not surprising that they are more than twice as likely as non-Hispanic Whites to be hospitalized for uncontrolled diabetes or long-term complications of diabetes5 and that they experience higher diabetes mortality rates.6–8 Although non-Hispanic Whites have experienced reductions in diabetes-related mortality in the past decades, Hispanics have not.8 Thus, unless effective public health strategies are identified and implemented, gaps in health outcomes are likely to grow.Community health workers (CHWs) are frontline public health workers who serve as liaisons between providers and community members, facilitate access to services, and improve both quality and cultural competence of service delivery.9,10 Several characteristics suggest that they may be well suited to addressing diabetes disparities. Because CHWs share culture, language, and knowledge of the community, they engage minority populations more effectively than the formal health care system can.11,12 Living and working in the same community as the people they serve, CHWs are able to provide individualized attention, focus on behavior-related tasks, and deliver regular feedback on the completion of those tasks.13 These qualities should lead to improved diabetes self-management and clinical outcomes. Although much has been written about CHWs in the past decade, few rigorous randomized controlled trials have tested this hypothesis,14–18 and the efficacy of CHWs in improving clinical outcomes in diabetes is not established. Of 6 published randomized controlled trials,19–25 only 2 demonstrated improvements in HbA1c levels among intervention participants, and both of these studies followed participants for only 6 months.19,24 Methodological limitations led the authors of a 2009 Agency for Health Care Research and Quality review to rate the published evidence as fair at best.15The Mexican American Trial of Community Health Workers (MATCH) sought to address these limitations of the literature through a rigorously designed behavioral randomized controlled trial with outcomes measured at 1 and 2 years. The primary study hypothesis was that the CHW intervention, compared with an attention control, would result in improvement in short-term physiological outcomes (mean HbA1c levels and percentage with controlled blood pressure). A secondary hypothesis was that the CHW intervention would improve adherence to self-management behaviors, such as daily self-monitoring of blood glucose, medication taking, and adherence to diet and physical activity recommendations.     

Performance Evaluation of Community Health Workers: Case Study in the Amazon of Peru

A shortage in human resources for health is a growing crisis that has led to an inability to provide adequate health services to impoverished populations. By “task-shifting”, health systems can delegate certain activities, such as health promotion and referral, to trained community members to help fill the human resource gap. An effective community health agent program can improve maternal and child health and overall effectiveness of rural health systems. Such a program is most effective when the community health agents receive supervision and evaluation of their performance. There is a shortage of literature that provides instruction and example on how to conduct a performance evaluation in the developing world to improve maternal and child health outcomes. The current study provides a case study of a performance evaluation in the Amazon region of Peru and how the findings can be used to make program adjustments. A set of instruments to measure the performance of CHWs was adapted from the literature and then implemented in the field. The instruments were used to measure the quality of home visits by the CHWs, their knowledge of the health topics, and structural activities. Three communities with an active CHW program in Loreto, Peru were chosen to receive the evaluation. All CHWs in the communities were evaluated. The scores from the evaluation were compared internally to identify strengths and weaknesses of the program and within the population of CHWs. The evaluation was completed on 52 home visits and 27 CHWs in three communities. The CHWs were found to be most effective at creating good relationships with caregivers and delivering health messages, and least effective at interacting with the child during the home visit and using material to deliver health messages. The evaluation instruments were well suited for the CHW program that utilizes home visits to teach about child health and development.     

The Use of Video in Delivering Maternal Health Education in Mountainous Areas: A Qualitative Exploration of the Experience of Health Workers

Maternal and Child Health Journal - Health education via DVD/video has been demonstrated as a novel method to encourage a positive change and improvement in patients’ health behaviors. A...     

北京市朝阳区社区卫生服务机构医院感染管理现状的定性研究

目的 了解不同人群对社区卫生服务机构医院感染管理现状的认识,为提升社区卫生机构医疗质量提供依据.方法 对医院感染管理领域专家、卫生管理部门相关负责人、社区卫生服务机构医院感染管理兼职人员和部分医务人员进行个人深入访谈.结果 医院感染管理工作在社区卫生服务机构医疗质量管理中所占比重为30%～60%,多数医务人员认为社区工作和医院感染管理有关,存在的主要问题为组织体系不健全、培训不足、基础知识缺乏、灭菌设备监测不规范、部分现行医院感染管理政策法规对社区卫生服务机构不适宜.结论 社区卫生服务机构医院感染管理工作尚未达到保障医疗质量和患者安全的要求,培训质量亟待提高.     

Community Health Workers as Drivers of a Successful Community-Based Disease Management Initiative

In 2005, local leaders in New York City developed the Washington Heights/Inwood Network for Asthma Program to address the burden of asthma in their community. Bilingual community health workers based in community organizations and the local hospital provided culturally appropriate education and support to families who needed help managing asthma. Families participating in the yearlong care coordination program received comprehensive asthma education, home environmental assessments, trigger reduction strategies, and clinical and social referrals. Since 2006, 472 families have enrolled in the yearlong program. After 12 months, hospitalizations and emergency department visits decreased by more than 50%, and caregiver confidence in controlling the child''s asthma increased to nearly 100%. Key to the program''s success was the commitment and involvement of community partners from program inception to date.

KEY FINDINGS

• ▪Community health workers who are based in local community-based organizations and have strong ties to the community that they serve are uniquely positioned to initiate and nurture trusting partnerships with program participants.
• ▪Community health workers can move fluidly between the community and the health care settings, bridging gaps in care, providing culturally appropriate education and services, and connecting families to the clinical and social resources they desperately need.
• ▪The strength and success of the Washington Heights/Inwood Network (WIN) for Asthma Program is based in large part on the commitment and active involvement of community partners from program inception to date as well as the frequent exchange of program information and ideas among all partners and staff.
• ▪This hospital–community care coordination model is applicable to other populations and disease areas because of its customizable, culturally sensitive, and holistic approach to education and support.

     

社区健康教育对人群知、信、行影响的调查研究

社区健康教育的关键在于普及卫生知识 ,改变卫生观念和改善社区人群的卫生行为。为此 ,河南省洛阳市卫生学校于 2 0 0 2年对洛阳市西工区邙岭办事处居民不同人群进行健康教育 ,取得了一定效果 ,现将实验结果总结如下。对象与方法1 对象　洛阳市西工区邙岭办事处居民。抽样调查 80 0人 ,成年 3 0 0人 ,其中男 13 0人 ,女 170人 ;卫校学生 3 0 0人 ,其中男 10 0人 ,女 2 0 0人 ;中小学生 2 0 0人 ,其中男 10 0人 ,女 10 0人。2 方法　将辖区居民分为成年、中小学生、卫校在校生 3个人群 ,再进行系统抽样 ;调查对象自己填写调查表 ,于 2 0 0 2…