Straight to the people: Community health worker advances in training, practice, and policy

Minority and disadvantaged children have consistently been found to suffer disproportionately from asthma.  Approximately 25% of children living in disadvantaged Chicago communities have asthma, a rate twice the national prevalence (12%).  Based on evidence suggesting that Community Health Workers (CHW) are an effective means of improving the management of chronic diseases, the Sinai Urban Health Institute (SUHI) and Sinai Children’s Hospital (SCH) developed an innovative CHW approach to improve asthma outcomes among children living in some of Chicago’s poorest neighborhoods.  Between November 2004 and July 2006, with funding from the Illinois Department of Public Health (IDPH), the model was pilot tested with 70 African American children between the ages of 2-16 years with severe asthma living in poor, inner-city Chicago neighborhoods surrounding SCH.  Ninety-six percent of enrolled children were Medicaid-insured and 54% lived with a smoker. The average child had visited an Emergency Department (ED), been hospitalized or visited a physician for worsening asthma 6.5 times in the year prior to participation.  CHWs were recruited from the communities being targeted by the intervention and were trained to deliver case-specific asthma education in the home environment.  CHWs met with enrolled families 3-4 times over a six month period.  The CHW also served as a liaison between the family and the medical system, helping to bridge the gap between parents and the healthcare system.  Fifty-eight (82.9%) completed the entire 6-month intervention phase.

Pilot findings were suggestive of improved asthma control.  Specifically, a significant improvement in four symptom-related variables was noted, with approximately two-fold reductions in frequency over the 12-month follow-up period. Urgent health resource utilization also decreased significantly. For example, ED visits decreased from 3.4 times in the year prior to the study to 0.9 in the year following (p < 0.05).  Parental Quality of Life significantly increased from 5.2 at baseline to 6.0 (p < 0.05) at 12 months post-baseline. Other important outcomes included improved asthma-related knowledge, decreased exposure to asthma triggers, and improved use of medications.  Furthermore, the approach is cost-effective, being associated with approximately $2500 saved/patient/year over costs incurred during the baseline year. Given the limited scope of the pilot, it was recognized that further study would be needed to affirm the results and assess the model’s generalizability.

The findings of the pilot project led to a larger IDPH initiative entitled Controlling Pediatric Asthma Through Collaboration and Education (CPATCE).  Initiated in the spring of 2006, CPATCE seeks to improve asthma management among high risk children in Illinois thereby reducing asthma-related healthcare expenditure, morbidity and mortality.  The initiative targets eleven counties throughout Illinois that are particularly affected by asthma.  The areas selected to participate are diverse in terms of urbanicity, race/ethnicity, and socioeconomic status.  Five asthma consortia representing the counties have been funded to hire and supervise CHWs.  SCH was funded to expand its own program to include any child with severe asthma between the ages of 2-16 years residing in the targeted disadvantaged Chicago communities.

SUHI serves as the coordinating, training and evaluation entity for the project.  In this capacity, SUHI works with each target consortium to identify and train CHWs, to standardize the intervention approach, and to evaluate the process and outcomes.  CHWs participated in an 18-hour asthma training workshop lead by SUHI.  CHWs were further trained by their respective site and participate in continuation training events sponsored by SUHI. As of May 31, 2008, 380 participants have been enrolled into the CPATCE program, 177 have completed the entire 6 month intervention phase, while 134 remain active.  Sixty-nine (18.2%) have been lost to the study.  Participants are largely minority and Medicaid-insured.  While CPATCE aims to recruit children with severe asthma, the sample enrolled to date have very poorly controlled asthma.  For example, the average child had been to the ED 2.5 times in the year prior to enrolling in the project and had utilized urgent health care an average of 5.8 times (sum of ED visits, hospitalizations and urgent clinic visits).   

Preliminary data through six months of follow-up has been analyzed for three of the six participating sites where at least 30 participants had completed a six month follow-up as of 5/31/08.  The total sample analyzed consisted of 366 children. Data analyzed to date has focused on the two primary goals of reducing asthma-related morbidity and improving quality of life.  Data cleaning and analysis is ongoing. Participants at all sites experienced significant improvements in all four symptom-related variables analyzed and marked improvement in urgent health resource utilization between the year prior to and following the program.  Clinically and statistically significant improvements were also noted in Parental Quality of Life, with overall scores at SCH improving from 5.7 to 6.5 (p=0.0015).  Preliminary data therefore suggest that individualized, one-on-one asthma education provided by a trained, culturally competent CHW in the home environment may be an effective means of improving asthma management among Illinois children with poorly controlled asthma.

Several important lessons were learned through the process of the pilot and CPATCE projects.  For one, having a CHW from the target community who shares a cultural connection with participants is vital in ensuring the acceptability of the intervention and its success.  Effective CHWs need to possess a true passion for giving back to their community, be willing to take initiative, and be able to think critically and problem solve.  Considerable resources should be devoted initially to training CHWs, and on-going continuing education should be provided.  CHWs often need to develop skills beyond asthma and the teaching of asthma (e.g., computer and organizational skills) and attention must be paid to these needs as well.  Also, sufficient time and resources need to be allocated to establishing relationships within the community, publicizing the program, securing buy-in, and identifying viable recruitment sources.  Finally, CPATCE lends power to critically look at the effectiveness of the model in unique populations and to study how both implementation and outcomes may differ, offering insight into culturally appropriate disease management programs.  Preliminary data comparing African American and Latino participants in Chicago show that while African American participants have more severe asthma at baseline, Latinos are more receptive to participating.  Nonetheless, both groups benefit from the program.   

The project also experienced certain challenges.  For one, it proved difficult to implement the CHW model in rural Illinois communities.  Interestingly, CHW models have been effectively implemented in other medically underserved rural areas in both the U.S. and internationally.  However, rural Illinois communities seem to embrace the traditional medical model and it will take considerable time and resources to change the mindset of both providers and community members to accept an alternative modality.  Another challenge involved the transient nature of the target population and the fact that participants often have little control over their home environment.  Third, many families were seeing multiple physicians (i.e., seeing whichever physician was convenient at the time) and as a result many children did not have an established relationship with one doctor who was managing their asthma.