title: Effects of Community-Based Health Worker Interventions to Improve Chronic Disease Management and Care Among Vulnerable Populations: A Systematic Review.
abstract: BACKGROUND
  Community-based health workers (CBHWs) are frontline public health workers who are trusted members of the community they serve. Recently, considerable attention has been drawn to CBHWs in promoting healthy behaviors and health outcomes among vulnerable populations who often face health inequities.
  
  
  OBJECTIVE
  We performed a systematic review to synthesize evidence concerning the types of CBHW interventions, the qualification and characteristics of CBHWs, and patient outcomes and cost-effectiveness of such interventions in vulnerable populations with chronic, noncommunicable conditions.
  
  
  METHODS
  We undertook 4 electronic database searches-PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane-and hand searched reference collections to identify randomized controlled trials published in English before August 2014.
  
  
  METHODS
  We screened a total of 934 unique citations initially for titles and abstracts. Two reviewers then independently evaluated 166 full-text articles that were passed onto review processes. Sixty-one studies and 6 companion articles (e.g., cost-effectiveness analysis) met eligibility criteria for inclusion.
  
  
  METHODS
  Four trained research assistants extracted data by using a standardized data extraction form developed by the authors. Subsequently, an independent research assistant reviewed extracted data to check accuracy. Discrepancies were resolved through discussions among the study team members. Each study was evaluated for its quality by 2 research assistants who extracted relevant study information. Interrater agreement rates ranged from 61% to 91% (average 86%). Any discrepancies in terms of quality rating were resolved through team discussions.
  
  
  RESULTS
  All but 4 studies were conducted in the United States. The 2 most common areas for CBHW interventions were cancer prevention (n = 30) and cardiovascular disease risk reduction (n = 26). The roles assumed by CBHWs included health education (n = 48), counseling (n = 36), navigation assistance (n = 21), case management (n = 4), social services (n = 7), and social support (n = 18). Fifty-three studies provided information regarding CBHW training, yet CBHW competency evaluation (n = 9) and supervision procedures (n = 24) were largely underreported. The length and duration of CBHW training ranged from 4 hours to 240 hours with an average of 41.3 hours (median: 16.5 hours) in 24 studies that reported length of training. Eight studies reported the frequency of supervision, which ranged from weekly to monthly. There was a trend toward improvements in cancer prevention (n = 21) and cardiovascular risk reduction (n = 16). Eight articles documented cost analyses and found that integrating CBHWs into the health care delivery system was associated with cost-effective and sustainable care.
  
  
  CONCLUSIONS
  Interventions by CBHWs appear to be effective when compared with alternatives and also cost-effective for certain health conditions, particularly when partnering with low-income, underserved, and racial and ethnic minority communities. Future research is warranted to fully incorporate CBHWs into the health care system to promote noncommunicable health outcomes among vulnerable populations.
authors.affiliation: Kyounghae Kim and Hae-Ra Han are with The Johns Hopkins University School of Nursing, Baltimore, MD. Janet S. Choi, Carrie L. Nieman, and Frank R. Lin are with Center on Aging and Health, The Johns Hopkins University. Eunsuk Choi is with College of Nursing and Research Institute of Nursing Science, Kyungpook National University, Daegu, South Korea. Carrie L. Nieman and Jin Hui Joo are with Johns Hopkins University School of Medicine. Laura N. Gitlin is with Center for Innovative Care in Aging, Johns Hopkins University School of Nursing and Medicine. Hae-Ra Han is also with Center for Cardiovascular and Chronic Care, Johns Hopkins University School of Nursing.
authors.forename: Kyounghae
authors.initials: K
authors.lastname: Kim
authors.affiliation: Kyounghae Kim and Hae-Ra Han are with The Johns Hopkins University School of Nursing, Baltimore, MD. Janet S. Choi, Carrie L. Nieman, and Frank R. Lin are with Center on Aging and Health, The Johns Hopkins University. Eunsuk Choi is with College of Nursing and Research Institute of Nursing Science, Kyungpook National University, Daegu, South Korea. Carrie L. Nieman and Jin Hui Joo are with Johns Hopkins University School of Medicine. Laura N. Gitlin is with Center for Innovative Care in Aging, Johns Hopkins University School of Nursing and Medicine. Hae-Ra Han is also with Center for Cardiovascular and Chronic Care, Johns Hopkins University School of Nursing.
authors.forename: Janet S
authors.initials: JS
authors.lastname: Choi
authors.affiliation: Kyounghae Kim and Hae-Ra Han are with The Johns Hopkins University School of Nursing, Baltimore, MD. Janet S. Choi, Carrie L. Nieman, and Frank R. Lin are with Center on Aging and Health, The Johns Hopkins University. Eunsuk Choi is with College of Nursing and Research Institute of Nursing Science, Kyungpook National University, Daegu, South Korea. Carrie L. Nieman and Jin Hui Joo are with Johns Hopkins University School of Medicine. Laura N. Gitlin is with Center for Innovative Care in Aging, Johns Hopkins University School of Nursing and Medicine. Hae-Ra Han is also with Center for Cardiovascular and Chronic Care, Johns Hopkins University School of Nursing.
authors.forename: Eunsuk
authors.initials: E
authors.lastname: Choi
authors.affiliation: Kyounghae Kim and Hae-Ra Han are with The Johns Hopkins University School of Nursing, Baltimore, MD. Janet S. Choi, Carrie L. Nieman, and Frank R. Lin are with Center on Aging and Health, The Johns Hopkins University. Eunsuk Choi is with College of Nursing and Research Institute of Nursing Science, Kyungpook National University, Daegu, South Korea. Carrie L. Nieman and Jin Hui Joo are with Johns Hopkins University School of Medicine. Laura N. Gitlin is with Center for Innovative Care in Aging, Johns Hopkins University School of Nursing and Medicine. Hae-Ra Han is also with Center for Cardiovascular and Chronic Care, Johns Hopkins University School of Nursing.
authors.forename: Carrie L
authors.initials: CL
authors.lastname: Nieman
authors.affiliation: Kyounghae Kim and Hae-Ra Han are with The Johns Hopkins University School of Nursing, Baltimore, MD. Janet S. Choi, Carrie L. Nieman, and Frank R. Lin are with Center on Aging and Health, The Johns Hopkins University. Eunsuk Choi is with College of Nursing and Research Institute of Nursing Science, Kyungpook National University, Daegu, South Korea. Carrie L. Nieman and Jin Hui Joo are with Johns Hopkins University School of Medicine. Laura N. Gitlin is with Center for Innovative Care in Aging, Johns Hopkins University School of Nursing and Medicine. Hae-Ra Han is also with Center for Cardiovascular and Chronic Care, Johns Hopkins University School of Nursing.
authors.forename: Jin Hui
authors.initials: JH
authors.lastname: Joo
authors.affiliation: Kyounghae Kim and Hae-Ra Han are with The Johns Hopkins University School of Nursing, Baltimore, MD. Janet S. Choi, Carrie L. Nieman, and Frank R. Lin are with Center on Aging and Health, The Johns Hopkins University. Eunsuk Choi is with College of Nursing and Research Institute of Nursing Science, Kyungpook National University, Daegu, South Korea. Carrie L. Nieman and Jin Hui Joo are with Johns Hopkins University School of Medicine. Laura N. Gitlin is with Center for Innovative Care in Aging, Johns Hopkins University School of Nursing and Medicine. Hae-Ra Han is also with Center for Cardiovascular and Chronic Care, Johns Hopkins University School of Nursing.
authors.forename: Frank R
authors.initials: FR
authors.lastname: Lin
authors.affiliation: Kyounghae Kim and Hae-Ra Han are with The Johns Hopkins University School of Nursing, Baltimore, MD. Janet S. Choi, Carrie L. Nieman, and Frank R. Lin are with Center on Aging and Health, The Johns Hopkins University. Eunsuk Choi is with College of Nursing and Research Institute of Nursing Science, Kyungpook National University, Daegu, South Korea. Carrie L. Nieman and Jin Hui Joo are with Johns Hopkins University School of Medicine. Laura N. Gitlin is with Center for Innovative Care in Aging, Johns Hopkins University School of Nursing and Medicine. Hae-Ra Han is also with Center for Cardiovascular and Chronic Care, Johns Hopkins University School of Nursing.
authors.forename: Laura N
authors.initials: LN
authors.lastname: Gitlin
authors.affiliation: Kyounghae Kim and Hae-Ra Han are with The Johns Hopkins University School of Nursing, Baltimore, MD. Janet S. Choi, Carrie L. Nieman, and Frank R. Lin are with Center on Aging and Health, The Johns Hopkins University. Eunsuk Choi is with College of Nursing and Research Institute of Nursing Science, Kyungpook National University, Daegu, South Korea. Carrie L. Nieman and Jin Hui Joo are with Johns Hopkins University School of Medicine. Laura N. Gitlin is with Center for Innovative Care in Aging, Johns Hopkins University School of Nursing and Medicine. Hae-Ra Han is also with Center for Cardiovascular and Chronic Care, Johns Hopkins University School of Nursing.
authors.forename: Hae-Ra
authors.initials: HR
authors.lastname: Han
mesh_terms: D002318:Cardiovascular Diseases / Q000517:prevention & control; D002908:Chronic Disease / Q000208:ethnology / Q000628:therapy*; D003150:Community Health Workers / Q000193:education*; D003362:Cost-Benefit Analysis; D003695:Delivery of Health Care; D019468:Disease Management; D006801:Humans; D008913:Minority Groups; D009369:Neoplasms / Q000517:prevention & control; D012307:Risk Factors; D014481:United States; D035862:Vulnerable Populations; D055815:Young Adult