Diabetes Prevention: Interventions Engaging Community Health Workers
Findings and Recommendations
The Community Preventive Services Task Force (CPSTF) recommends interventions that engage community health workers for diabetes prevention to improve glycemic (blood sugar) control and weight-related outcomes among people at increased risk for type 2 diabetes.
Economic evidence indicates these interventions are cost-effective. Some evidence suggests interventions may reduce rates of progression to type 2 diabetes, though more research is needed. Interventions implemented in underserved communities may improve health, reduce health disparities, and enhance health equity.
The full CPSTF Finding and Rationale Statement and supporting documents for Diabetes Prevention: Interventions Engaging Community Health Workers are available in The Community Guide Collection on CDC Stacks.
Intervention
Community health workers (including promotores de salud, community health representatives, community health advisors, and others) are frontline public health workers who serve as a bridge between underserved communities and healthcare systems. They typically are from or have a unique understanding of the community served. Community health workers often receive on-the-job training, and work without professional titles. Organizations may hire paid community health workers or recruit volunteers.
Community health workers may address a broad range of health issues. Interventions that focus on diabetes prevention aim to reduce one or more risk factors for type 2 diabetes among members of the community by improving their diet, physical activity, and weight management. Community health workers may work alone or as part of an intervention team comprising counselors, clinicians, or other health professionals.
About The Systematic Review
This CPSTF finding is based on evidence from a Community Guide systematic review of 22 studies (search period through May 2015). This review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to diabetes prevention and control.
Study Characteristics
- Studies were conducted in the United States (21 studies) and New Zealand (1 study)
- Included studies evaluated interventions in communities (16 studies), homes (1 study), both communities and homes (4 studies), or worksites (1 study)
- Studies were set primarily in urban areas (7 studies)
- Study populations mainly included adults ages 18-64 years old (19 studies) and youth (2 studies) who were at risk for type 2 diabetes
- Across all studies (22 studies), more than 70% of participants were female
- Included studies mainly focused on underserved populations and targeted Latinos (10 studies), African-Americans (3 studies), and Asians (3 studies)
Summary of Results
Overall, included studies showed interventions engaging community health workers improved participants’ glycemic or blood sugar control and weight-related outcomes, and reduced rates of progression to type 2 diabetes.
Glycemic (Blood Sugar) Control and Progression to Type 2 Diabetes
- Mean HbA1c: median decrease of 0.09% (6 studies; median intervention duration: 9 months)
- Mean fasting blood glucose: median decrease of 2.4 mg/dL (7 studies; median duration: 12 months)
- Proportion of participants who progressed to type 2 diabetes: 1 study (24 months) reported a non-significant decrease of 5.1 percentage points, 1 study (12 months) reported a decrease of 2.2 percentage points (significance not reported), and 1 study (12 months) showed no effect
Weight-related Outcomes
- Mean weight: median decrease of 3.0 lbs (14 studies; median duration: 9.5 months)
- Mean body mass index (BMI): median decrease of 0.5 kg/m² (13 studies; median duration: 9.5 months)
- Mean waist circumference: median decrease of 1.4 inches (10 studies; median duration: 6.5 months)
CVD Risk Factors Outcomes
- Mean total cholesterol: median decrease of 5.7 mg/dL (6 studies; median duration: 6 months)
- Mean LDL: median decrease of 5.0 mg/dL (6 studies; median duration: 6 months)
- Mean SBP: median decrease of 2.6 mg/dL (8 studies; median duration: 6 months)
- Mean DBP: median decrease of 2.4 mg/dL (8 studies; median duration: 6 months)
Most included studies engaged community health workers to work with underserved groups suggesting these interventions can be effective in improving minority health and reducing health disparities related to populations at risk for diabetes (19 studies).
Summary of Economic Evidence
Economic evidence indicates that interventions engaging community health workers for diabetes prevention are cost-effective. All monetary values are reported in 2015 U.S. dollars. The economic review included 7 studies (6 from the United States, 1 from the United Kingdom).
- The median intervention cost per person per year was $600 (7 studies).
- Estimated costs per quality adjusted life year (QALY) gained were $4,720 and $41,154 (2 studies). Both estimates were below $50,000 a conservative benchmark for cost effectiveness.
Applicability
Based on results, findings are applicable to the following:
- Adults and youth who are at risk for type 2 diabetes
- Women and men
- Hispanics, African-Americans, and Asians
- Low-income and low-education populations
- Urban environments
- Community and home settings
Evidence Gaps
- How effective are large-scale programs (i.e., >500 participants), programs conducted in rural settings, and programs evaluated over a longer time period?
- What are the roles and impacts of community health workers in a team-based care environment?
- What are the challenges or barriers that impact the recruitment and retention of male clients in lifestyle modification interventions?
- How can community health workers be more engaged as outreach/enrollment/information agents, members of care delivery teams patient navigators, and community organizers?
- How will implementation and funding of community health worker services by the Centers for Medicaid Services (CMS), through clinical or community-based providers, impact reimbursement arrangements?
Implementation Considerations and Resources
- The National Diabetes Prevention Program (National DPP) provides communities an opportunity to implement sustainable programs which engage community health workers for diabetes prevention, especially in diverse and underserved communities. Trained community health workers may be potentially important providers of CDC-recognized lifestyle change programs which meet standards and use curriculum approved by the Diabetes Prevention Recognition Program (DPRP).
- The 2013 ruling by the Centers for Medicaid and Medicaid Services (CMS) allows states to provide Medicaid reimbursement for preventive services recommended by the U.S. Preventive Services Task Force. Services must be “recommended by a physician or other licensed practitioner” and delivered by a health professionals, which may include community health workers.
- Community health workers may work with clients alone or as part of a team. Services may be limited to health education, informal counseling, and extended support, or they may include a broader range of services in community and clinical settings.
- Community health workers are typically matched to the populations they serve (i.e. location, race or ethnicity, or language) and the specific services they deliver (e.g. culturally appropriate lifestyle programs).
- Community health workers typically provide clients with culturally appropriate information and education on diabetes prevention, lifestyle counseling to build individual capacity and social support.
Crosswalks
Healthy People 2030 includes the following objectives related to this CPSTF recommendation.