Sonjia Kenya

Can community health workers improve adherence to highly active antiretroviral therapy in the USA? A review of the literature.

Highly active antiretroviral therapy (HAART) has transformed HIV infection into a manageable chronic illness, yet AIDS mortality among ethnic minorities persists in the USA. HAART nonadherence is associated with increased HIV viral load, low CD4 cell count and racial disparities in HIV outcomes. While there is no universal consensus on how to improve medical adherence in HIV‐positive populations, the community health worker (CHW) model is emerging as an effective strategy to overcome barriers to HAART adherence. Although utilized in international settings, there is little evidence regarding the effects of CHWs on HIV outcomes in the USA.

Rationale and design of the Miami Healthy Heart Initiative: a randomized controlled study of a community health worker intervention among Latino patients with poorly controlled diabetes.

Background Type 2 diabetes mellitus disproportionately affects the Latino community. Latinos with diabetes are also less likely to have adequate control of cardiovascular risk factors such as cholesterol and blood pressure. Community health workers (CHWs) are increasingly being used to address various health disparity conditions, including diabetes. However, evidence of their effectiveness from randomized controlled trials is limited. Methods The Miami Health Heart Initiative is a randomized controlled trial of 300 Latino patients with diabetes. Patients with hemoglobin A1c (HbA1c) ≥8.0% were recruited from Miami-Dade’s public hospital system. At baseline, all patients underwent phlebotomy, physical examination, and a structured 90-minute research interview. They were then randomized to either usual care or a CHW intervention called Cariño. For participants in the Cariño arm of the study, CHW services included assistance with nonmedical social services, health education, and patient navigation in which the CHWs serve as a bridge between patients and the health care system. These services were delivered through home visits, phone calls, and group visits. At 12 months, all subjects had a follow-up examination. The primary outcomes at 1 year are changes in systolic blood pressure, low-density lipoprotein, and HbA1c. Secondary outcomes include medication adherence, medication intensification, diabetes self-efficacy, physical activity, and self-reported fruit and vegetable intake. Discussion The Miami Healthy Heart Initiative is one of the first rigorously conducted randomized controlled trials to provide evidence on the impact of CHWs on diabetes intermediate outcomes among Latinos. If the data support our primary hypotheses, the study would lend added support to ongoing efforts to incorporate CHWs as part of our national efforts to reduce and ultimately eliminate health disparities.

Glucometer Use and Glycemic Control Among Hispanic Patients With Diabetes in Southern Florida

BACKGROUND Self-monitoring of blood glucose (SMBG) has been deemed a critical component of diabetes care in the United States. To be effective, patients must have some diabetes knowledge, glucometer proficiency, and an ability to take appropriate actions when certain readings are obtained. However, most patients take no action in response to out-of-range glucometer readings, and in many populations, SMBG practices are not associated with improved glycemic control. Thus, SMBG utilization is being reconsidered in other countries. Nonetheless, SMBG behaviors are increasingly recommended in the United States, where the Hispanic population represents the fastest-growing minority group and is disproportionately affected by suboptimal diabetes outcomes. Because a growing number of interventions aim to reduce diabetes disparities by improving glycemic control among minorities, it is essential to determine whether efforts should focus on SMBG practices. We present data on SMBG behaviors and glycemic control among participants from the Miami Healthy Heart Initiative (MHHI), a National Institutes of Health/National Heart, Lung, and Blood Institute-sponsored trial assessing a community health worker (CHW) intervention among Hispanic patients with poorly controlled diabetes. OBJECTIVE This study examined the effects of a CHW intervention on SMBG practices, glycosylated hemoglobin (HbA1c), and knowledge of appropriate responses to glucometer readings among Hispanic patients with diabetes. METHODS This study was an ancillary investigation within MHHI, a randomized, controlled trial in 300 Hispanic patients. Participants were intervention-group members who received 12 months of CHW support. Assessments were administered at baseline and poststudy to determine potential barriers to optimal health. Items from validated instruments were used to determine knowledge of appropriate responses to different glucose readings. These data were linked to HbA1c values. Means and frequencies were used to describe population characteristics and glucometer proficiency. Paired-sample t tests examined potential differences in HbA1c outcomes and SMBG practices. Qualitative data were collected from the CHWs who worked with study participants. RESULTS Our population was diverse, representing several countries. Mean HbA1c improved significantly, from 10% to 8.8% (P ≤ 0.001). SMBG practices did not change. At baseline, 96% of patients reported owning a glucometer and 94% reported knowing how to use it. However, quantitative assessments and qualitative data suggested that participants had suboptimal knowledge regarding actions that could cause an out-of-range reading or how to respond to certain readings. CONCLUSIONS SMBG behaviors were not associated with glycemic control in our sample. We conclude that a CHW intervention may improve glycemic control without improving SMBG practices. Future interventions may reconsider whether efforts should be directed toward improving SMBG behaviors.

Human Papilloma Virus and Cervical Cancer Education Needs among HIV-Positive Haitian Women in Miami

BACKGROUND Haitian immigrant women, the largest growing Black ethnic group in Miami, experience the highest rates of cervical cancer and account for one of the largest populations diagnosed with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) in South Florida. Using community-based participatory research methods, we conducted a pilot study to examine human papilloma virus (HPV)/cervical cancer knowledge and identify intervention preferences among HIV positive Haitian women. METHODS Community health workers conducted three focus groups with 21 HIV-positive Haitian women. All sessions were conducted in Haitian Kreyol, digitally recorded, and subsequently interpreted and transcribed into English. The first focus group assessed HPV/cervical cancer knowledge, the second session explored HPV/cervical cancer considerations specific to HIV-positive women, and the third focus group discussed HPV/cervical cancer screening and intervention preferences. Data analysis was guided by a grounded theory approach. FINDINGS Our sample had limited HPV/cervical cancer knowledge. Misconceptions about screening, transmission, and treatment were common. Participants felt that stigma by providers impacted negatively the care they received and that stigma by the community diminished social support. Strong support for culturally tailored interventions to improve HPV/cervical cancer knowledge was expressed. Although no participants had participated in research previously, all were willing to participate in future trials. CONCLUSIONS There is critical need for culturally relevant interventions to improve HPV/cervical cancer knowledge among HIV-positive Haitian women.

Is greater acculturation associated with an increased prevalence of cardiovascular risk factors among Latinos in South Florida

Objective:To examine the association of acculturation with various cardiovascular risk factors (CRFs) among Latinos with diabetes in South Florida. Methods:In a cross-sectional analysis of data collected from 300 Latinos with poorly controlled diabetes we measured acculturation using the Marin Short Acculturation Scale. We examined correlations between acculturation and the following 7 CRFs: hemoglobin A1C, low-density lipoprotein, systolic blood pressure, body mass index, smoking status, physical activity, and fruit and vegetable intake. Results:Cubans made up 38% of our population; no other Latino subgroup represented over 17% of the sample. Of the 8 outcomes examined, only smoking was associated with increased acculturation; 12% of Latinos in the 2 lowest acculturation groups were current smokers versus 25% in the highest acculturation group (P=0.02). Furthermore, Cuban Americans from our sample had over double the prevalence of smoking compared with non-Cubans in both the lowest and highest acculturation groups. Conclusions:With the exception of smoking, our data does not support a link between increased acculturation and higher prevalence of CRFs in Latinos with diabetes. Smoking prevention and cessation programs targeting Latinos and particularly among Cubans are needed.

Effect of a Community Health Worker Intervention Among Latinos With Poorly Controlled Type 2 Diabetes: The Miami Healthy Heart Initiative Randomized Clinical Trial.

Importance Community health worker (CHW) intervention is a promising approach to address type 2 diabetes among Latinos. However, evidence from randomized clinical studies is limited. Objective To compare a CHW intervention with enhanced usual care. Design, Setting, and Participants This 52-week, single-blind, randomized clinical trial included 300 Latino adults aged 18 to 65 years who were treated in 2 public hospital outpatient clinics in Miami-Dade County, Florida, from July 1, 2010, through October 31, 2013. Eligible participants had a hemoglobin A1c (HbA1c) level of 8.0 or greater. Follow-up was completed January 31, 2015, and data were analyzed from March 10, 2015, to June 6, 2016. Interventions A 1-year CHW intervention consisted of home visits, telephone calls, and group-level activities. Main Outcomes and Measures Primary outcomes included systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDLC) levels, and HbA1c levels. Secondary outcomes included body mass index, medication regimen intensification, and self-reported measures of diet, physical activity, and medication regimen adherence. Results Of the 300 participants randomized (135 men [45%] and 165 women [55%]; mean [SD] age, 55.2 [7.0] years), we obtained follow-up data on 215 (71.7%). Participants in the CHW group received a median of 4 home visits and 20 telephone calls. After adjusting for baseline values and covariates, participants in the CHW group had an HbA1c level that was 0.51% lower (95% CI, −0.94% to −0.08%) than that of participants in the enhanced usual care group. The reduction in SBP of 4.62 mm Hg (95% CI, −9.01 to −0.24 mm Hg) did not meet the preplanned target of 8 mm Hg and was not statistically significant in unadjusted models. No significant differences in LDLC levels (mean difference, −8.2 mg/dL; 95% CI, −18.8 to 2.3 mg/dL) or any of the preplanned secondary outcomes were observed. Post hoc analyses suggest that the intervention may be more beneficial among those with worse control of their type 2 diabetes at baseline. Conclusions and Relevance Among Latinos with poorly controlled type 2 diabetes, a 12-month CHW intervention lowered HbA1c levels by 0.51%. The intervention did not lead to improvements in LDLC levels, and the findings with respect to SBP were variable and half of what was targeted. Future studies should examine whether CHW interventions affect other measures, such as access to health care or social determinants of health. Trial Registration clinicaltrials.gov Identifier: NCT01152957

Strategies to Improve HIV Testing in African Americans

&NA; Only 17% of Miami‐Dade County residents are African American, yet this population accounts for 59% of the countys HIV‐related mortality. The Centers for Disease Control and Prevention recommend annual testing for persons at increased risk for HIV, but 40% of African Americans have never been tested. OraQuick® (OraSure Technologies, Inc., Bethlehem, PA), the first US Food and Drug Administration‐approved home‐based HIV rapid test (HBHRT), has the potential to increase testing rates; however, there are concerns about HBHRT in vulnerable populations. We conducted focus groups in an underserved Miami neighborhood to obtain community input regarding HBHRT as a potential mechanism to increase HIV testing in African Americans. We queried HIV knowledge, attitudes toward research, and preferred intervention methods. Several HIV misconceptions were identified, and participants expressed support for HIV research and introducing HBHRT into the community by culturally appropriate individuals trained to provide support. We concluded that community health workers paired with HBHRT were a promising strategy to increase HIV testing in this population.

Community Health Workers, Access to Care, and Service Utilization Among Florida Latinos: A Randomized Controlled Trial

Objectives To determine whether a 1-year community health worker intervention improves access to care and service utilization among Latinos with diabetes. Methods We conducted a single-blind randomized trial of 300 adults with poorly controlled diabetes treated in 2 public hospital clinics in Miami, Florida. We began enrollment in 2010 and completed follow-up in 2015. We examined access and utilization using self-reported measures and data from electronic medical records. Results Participants randomized to the community health worker intervention self-reported fewer problems accessing needed care and prescriptions than did those in the usual care group (30% vs 43% and 28% vs 41%, respectively; P < .05 for both). Adjusting for age, gender, education, depression, and comorbidities showed similar results (odds ratio [OR] = 0.52; 95% confidence interval [CI] = 0.29, 0.93 and OR = 0.45; CI = 0.24, 0.82, respectively). We found no significant utilization differences in primary care visits, emergency department utilization, or hospitalization between the 2 groups. Conclusions Among Latinos with poorly controlled diabetes, a 1-year community health worker intervention was associated with improvements in self-reported access to care but not service utilization.

Can Home-Based HIV Rapid Testing Reduce HIV Disparities Among African Americans in Miami?

Sixty percent of African Americans have had an HIV test, yet this population disproportionately contributes to AIDS mortality, suggesting that testing is not occurring early enough to achieve optimal outcomes. OraQuick, the first Food and Drug Administration–approved home-based HIV rapid test (HBHRT) could potentially increase testing rates. We assessed whether community health workers (CHWs) paired with HBRHT could improve HIV screening and health care access among African Americans in Miami, Florida. In October-November 2013, 60 African Americans were enrolled and randomized to the experimental condition, which received CHW assistance to complete HBHRT, or the control condition, which were instructed to complete HBHRT independently. Intervention participants were significantly (p ≤ .05) more likely than control participants to complete HBHRT and, if positive, get linked to HIV care (100% vs. 83%) χ2 (1, N = 60) = 5.46, p ≤ .02. We concluded that CHW-assisted HBHRT may be a promising strategy to improve HIV testing and care among African Americans.

Tales from the Miami Healthy Heart Initiative: The Experiences of Two Community Health Workers

Community health workers (CHWs) have been bridging the gap between under-served populations and health care systems for centuries; however, their experiences are rarely recounted. The Miami Healthy Heart Initiative is a randomized control trial designed to examine the effectiveness of CHWs on reducing the risk for cardiovascular disease among Hispanics with poorly controlled diabetes in South Florida. This manuscript, told from the perspective of CHWs, is a summary of cases that were successful and some that did not achieve optimal outcomes. These case summaries include anecdotal data and clinical variables that demonstrate each patient’s progress during the intervention.