Community Health Worker Program Outcomes for Diabetes and Hypertension Control in West Bank Refugee Camps: A Retrospective Matched Cohort Study

Asmaa Rimawi, Adarsh Shah, Henry Louis, David Scales, Jawad Abu Kheiran, Nashat Jawabreh, Sofia Yunez, Masako Horino, Akihiro Seita, Bram Wispelwey, Asmaa Rimawi, Adarsh Shah, Henry Louis, David Scales, Jawad Abu Kheiran, Nashat Jawabreh, Sofia Yunez, Masako Horino, Akihiro Seita, Bram Wispelwey

Abstract

Introduction: Community health worker (CHW) programs have proven effective in improving diabetes control in many locations and settings, but data on feasibility and efficacy are lacking in the Middle East and settings of chronic violence. A Palestinian CHW program, Health for Palestine (H4P), addresses chronic diseases in West Bank refugee camps. Our study assesses the feasibility and effectiveness of the program's diabetes and hypertension interventions.

Methods: Data on home visits, patient retention, and blood pressure were extracted from the CHW records and analyzed. To assess diabetic patient progress, we conducted a retrospective matched cohort study using data obtained from a United Nations (UN) clinical database to analyze the trajectory of hemoglobin A1c (A1c) values. Thirty of the 47 diabetic patients in the H4P CHW program met study inclusion criteria and were each matched with 3 patients from the Bethlehem UN clinic (n=120). We tested for significance using multivariable linear regression with robust standard errors.

Results: The average number of home visits per patient per month was 7.3 (standard deviation=4.1), and the patient retention rate was 100% over an average of 11.2 months. For hypertension patients in the CHW program (n=33), mean systolic blood pressure decreased by 7.3 mmHg (95% confidence interval [CI]=1.93, 12.25; P=.009) and mean diastolic blood pressure by 4.3 mmHg (95% CI=0.80, 7.91; P=.018) from March 2018 to November 2019. On average, diabetic patients within the CHW group experienced a 1.4 point greater decline in A1c per year compared to those in the non-CHW group, after adjusting for potential confounders (95% CI=-0.66, -2.1; P<.001).

Discussion: The results suggest that CHW accompaniment may be an effective model for improving diabetes and hypertension control in refugee camps experiencing direct violence and extreme adversity. A low exclusion cut-off for A1c (≤6.4%) may underestimate the program's impact.

© Rimawi et al.

Figures

https://www.ncbi.nlm.nih.gov/pmc/articles/instance/9622278/bin/GH-GHSP220115F005.jpg
Community health workers in the West Bank discuss symptoms with a patient. © 2018 Nashat Jawabreh/Health for Palestine
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/9622278/bin/GH-GHSP220115F006.jpg
Community health workers in the West Bank check a patient’s blood glucose during one of their first home visits. © 2018 Nashat Jawabreh/Health for Palestine
FIGURE 1
FIGURE 1
Selection of Intervention Patient Group, Bethlehem Governorate, West Banka Abbreviations: A1c, hemoglobin A1c; CHW, community health worker; H4P, Health for Palestine; T2DM, type 2 diabetes mellitus; UNRWA, United Nations Relief and Works Agency for Palestine Refugees in the Near East. a Of the 101 patients enrolled in H4P, 47 of the patients had a diagnosis of T2DM upon enrollment into the program. Of these 47 patients, 11 patients were excluded from the study for having a baseline hemoglobin A1c of less than or equal to 6.4. An additional 5 patients were excluded for receiving any diabetic care and A1c testing from a facility other than the UNRWA Bethlehem clinic. One patient was excluded for being in the program for less than 6 months. The remaining 30 patients met the eligibility criteria and were included in the study as the intervention group, or “with CHW care” group.
FIGURE 2
FIGURE 2
Selection of Control Patient Group, Bethlehem Governorate, West Banka Abbreviations: A1c, hemoglobin A1c; CHW, community health worker; UNRWA, United Nations Relief and Works Agency for Palestine Refugees in the Near East. a Data on potential matches included 2,374 potential controls. 1,187 patients without a second A1c value in the UNRWA records were removed from the database. Matches were selected from the remaining 1,157 potential controls and served as the “without CHW care” group. Three matches were selected for every patient within the intervention group.
FIGURE 3
FIGURE 3
Status of Type 2 Diabetes Patients at Baseline, Bethlehem Governorate, West Bank in CHW Group (A) and Non-CHW Group (B) Abbreviation: CHW, community health worker.
FIGURE 4
FIGURE 4
Status of Type 2 Diabetes Patients at Follow-up, Bethlehem Governorate, West Bank in CHW Group (A) and Non-CHW Group (B) Abbreviation: CHW, community health worker.

References

    1. United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA). UNRWA Health Department Annual Report 2017. UNRWA; 2018. Accessed June 6, 2021.
    1. Standl E. Global statistics on diabetes. European Society of Cardiology. April 1, 2019. Accessed June 6, 2021.
    1. United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA). UNRWA Health Department Annual Report 2018. UNRWA; 2019. Accessed June 6, 2021.
    1. Palestine National Diabetes Program, WDF15-1304. World Diabetes Foundation. Accessed June 6, 2021.
    1. Diabetes. World Health Organization. Accessed June 6, 2021.
    1. Abu Kishk N, Shahin Y, Mitri J, Turki Y, Zeidan W, Seita A. Model to improve cardiometabolic risk factors in Palestine refugees with diabetes mellitus attending UNRWA health centers. BMJ Open Diabetes Res Care. 2019;7(1):e000624. 10.1136/bmjdrc-2018-000624.
    1. UNRWA faces greatest financial crisis in its history following 2018 funding cuts, Commissioner-General tells Fourth Committee. Press release. United Nations; November 9, 2018. Accessed September 22, 2022.
    1. Farmer P, Léandre F, Mukherjee JS, et al. . Community-based approaches to HIV treatment in resource-poor settings. Lancet. 2001;358(9279):404–409. 10.1016/S0140-6736(01)05550-7.
    1. Farmer P, Kim JY. Community based approaches to the control of multidrug resistant tuberculosis: introducing “DOTS-plus”. BMJ. 1998;317(7159):671–674. 10.1136/bmj.317.7159.671.
    1. He J, Irazola V, Mills KT, et al. ; HCPIA Investigators. Effect of a community health worker–led multicomponent intervention on blood pressure control in low-income patients in Argentina. JAMA. 2017;318(11):1016–1025. 10.1001/jama.2017.11358.
    1. Carrasquillo O, Lebron C, Alonzo Y, Li H, Chang A, Kenya S. Effect of a community health worker intervention among Latinos with poorly controlled type 2 diabetes. JAMA Intern Med. 2017;177(7):948–954. 10.1001/jamainternmed.2017.0926.
    1. Hughes MM, Yang E, Ramanathan D, Benjamins MR. Community-based diabetes community health worker intervention in an underserved Chicago population. J Community Health. 2016;41(6):1249–1256. 10.1007/s10900-016-0212-8.
    1. Spencer MS, Kieffer EC, Sinco B, et al. . Outcomes at 18 months from a community health worker and peer leader diabetes self-management program for Latino adults. Diabetes Care. 2018;41(7):1414–1422. 10.2337/dc17-0978.
    1. Leite RGOF, Banzato LR, Galendi JSC, et al. . Effectiveness of non-pharmacological strategies in the management of type 2 diabetes in primary care: a protocol for a systematic review and network meta-analysis. BMJ Open. 2020;10(1):e034481. 10.1136/bmjopen-2019-034481.
    1. Xie B, Ye X, Sun Z, et al. . Peer support for patients with type 2 diabetes in rural communities of China: protocol for a cluster randomized controlled trial. BMC Public Health. 2014;14(1):747. 10.1186/1471-2458-14-747.
    1. Newman PM, Franke MF, Arrieta J, et al. . Community health workers improve disease control and medication adherence among patients with diabetes and/or hypertension in Chiapas, Mexico: an observational stepped-wedge study. BMJ Glob Health. 2018;3(1):e000566. 10.1136/bmjgh-2017-000566.
    1. Jeet G, Thakur JS, Prinja S, Singh M. Community health workers for non-communicable diseases prevention and control in developing countries: evidence and implications. PLoS One. 2017;12(7):e0180640. 10.1371/journal.pone.0180640.
    1. Flood D, Hawkins J, Rohloff P. A home-based type 2 diabetes self-management intervention in rural Guatemala. Prev Chronic Dis. 2017;14:170052. 10.5888/pcd14.170052.
    1. Saya A, Aung S, Gast P, Lewis C. The Refugee Community Health Worker Initiative (RCHWI) in Rhode Island: a pilot program. R I Med J (2013). 2016;99(8):28–30.
    1. Torres S, Spitzer DL, Labonté R, Amaratunga C, Andrew C. Community health workers in Canada: innovative approaches to health promotion outreach and community development among immigrant and refugee populations. J Ambul Care Manage. 2013;36(4):305–318. 10.1097/JAC.0b013e3182a5480f.
    1. Raines Milenkov A, Felini M, Baker E, et al. . Uptake of cancer screenings among a multiethnic refugee population in North Texas, 2014-2018. PLoS One. 2020;15(3):e0230675. 10.1371/journal.pone.0230675.
    1. Cheng IH, Wahidi S, Vasi S, Samuel S. Importance of community engagement in primary health care: the case of Afghan refugees. Aust J Prim Health. 2015;21(3):262–267. 10.1071/PY13137.
    1. Torres S, Labonté R, Spitzer D, Andrew C, Amaratunga C. Improving health equity: the promising role of community health workers in Canada. Healthc Policy. 2014;10(1):73–85. 10.12927/hcpol.2014.23983.
    1. Uribe Guajardo MG, Slewa-Younan S, Kitchener BA, Mannan H, Mohammad Y, Jorm AF. Improving the capacity of community-based workers in Australia to provide initial assistance to Iraqi refugees with mental health problems: an uncontrolled evaluation of a mental health literacy course. Int J Ment Health Syst. 2018;12(1):2. 10.1186/s13033-018-0180-8.
    1. Sami S, Kerber K, Tomczyk B, et al. . “You have to take action”: changing knowledge and attitudes towards newborn care practices during crisis in South Sudan. Reprod Health Matters. 2017;25(51):124–139. 10.1080/09688080.2017.1405677.
    1. Plummer M. Community health for Rwandan refugees. Can Nurse. 1995;91(11):45–46.
    1. Lee CI, Smith LS, Shwe Oo EK, et al. . Internally displaced human resources for health: villager health worker partnerships to scale up a malaria control programme in active conflict areas of eastern Burma. Glob Public Health. 2009;4(3):229–241. 10.1080/17441690802676360.
    1. Ghosh HA, Shaar A, Mashal J, et al. . Diabetes control in 3 villages in Palestine: a community-based quality improvement intervention. J Ambul Care Manage. 2007;30(1):74–78. 10.1097/00004479-200701000-00010.
    1. Aida Camp. United Nations Relief and Works Agency for Palestine Refugees in the Near East. Accessed June 6, 2021.
    1. Wispelwey BP, Jawabreh N, Alazzeh S, Scales D. Barriers to care in a West Bank refugee camp: a qualitative study. Lancet. 2019;393:S54–S54. 10.1016/S0140-6736(19)30640-3
    1. Palestinian Central Bureau of Statistics (PCBS). The International Day of Refugees 2019. PCBS; 2019. Accessed June 6, 2021.
    1. Nepal P, Schwarz R, Citrin D, et al. . Costing analysis of a pilot community health worker program in rural Nepal. Glob Health Sci Pract. 2020;8(2):239–255. 10.9745/GHSP-D-19-00393.
    1. United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA). Health and Education Efficiency in UNRWA. UNRWA; 2013. Accessed August 17, 2022.
    1. Giacaman R, Khatib R, Shabaneh L, et al. . Health status and health services in the occupied Palestinian territory. Lancet. 2009;373(9666):837–849. 10.1016/S0140-6736(09)60107-0
    1. Baker A, Shalhoub-Kevorkian N. Effects of political and military traumas on children: the Palestinian case. Clin Psychol Rev. 1999;19(8):935–950. 10.1016/S0272-7358(99)00004-5.
    1. Weizman E. Hollow Land: Israel's Architecture of Occupation. Verso; 2007.
    1. Palazuelos D, Farmer PE, Mukherjee J. Community health and equity of outcomes: the Partners In Health experience. Lancet Glob Health. 2018;6(5):e491–e493. 10.1016/S2214-109X(18)30073-1.
    1. Tsigos C Kyrou I Kassi E Chrousos GP. Stress: endocrine physiology and pathophysiology. In: Feingold KR, Anawalt B, Boyce A, et al.., eds. Endotext. , Inc.; 2000. –. Updated October 17, 2020. Accessed September 22, 2022.
    1. Giacaman R. Reframing public health in wartime: from the biomedical model to the “wounds inside”. J Palest Stud. 2018;47(2):9–27. 10.1525/jps.2018.47.2.9
    1. Wispelwey B, Jamei YA. The great march of return: lessons from Gaza on mass resistance and mental health. Health Hum Rights. 2020;22(1):179–185.
    1. Mendenhall E, Kohrt BA, Norris SA, Ndetei D, Prabhakaran D. Non-communicable disease syndemics: poverty, depression, and diabetes among low-income populations. Lancet. 2017;389(10072):951–963. 10.1016/S0140-6736(17)30402-6.
    1. Haar R, Ghannam J. No Safe Space: Health Consequences of Tear Gas Exposure Among Palestine Refugees. UC Berkeley School of Law Human Rights Center; 2018. Accessed June 6, 2021.
    1. Burns ME, Galbraith AA, Ross-Degnan D, Balaban RB. Feasibility and evaluation of a pilot community health worker intervention to reduce hospital readmissions. Int J Qual Health Care. 2014;26(4):358–365. 10.1093/intqhc/mzu046.
    1. Qato DM. Introduction: Public health and the promise of Palestine. J Palest Stud. 2020;49(4):8–26. 10.1525/jps.2020.49.4.8
    1. Qaseem A, Wilt TJ, Kansagara D, Horwitch C, Barry MJ, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Hemoglobin A 1c targets for glycemic control with pharmacologic therapy for nonpregnant adults with type 2 diabetes mellitus: a guidance statement update from the American College of Physicians. Ann Intern Med. 2018;168(8):569–576. 10.7326/M17-0939.
    1. Giacaman R, Husseini A, Gordon NH, Awartani F. Imprints on the consciousness: the impact on Palestinian civilians of the Israeli Army invasion of West Bank towns. Eur J Public Health. 2004;14(3):286–290. 10.1093/eurpub/14.3.286.
    1. Singer M, Bulled N, Ostrach B, Mendenhall E. Syndemics and the biosocial conception of health. Lancet. 2017;389(10072):941–950. 10.1016/S0140-6736(17)30003-X.
    1. Atallah DG. A community-based qualitative study of intergenerational resilience with Palestinian refugee families facing structural violence and historical trauma. Transcult Psychiatry. 2017;54(3):357–383. 10.1177/1363461517706287.
    1. Lage MJ, Boye KS. The relationship between HbA1c reduction and healthcare costs among patients with type 2 diabetes: evidence from a U.S. claims database. Curr Med Res Opin. 2020;36(9):1441–1447. 10.1080/03007995.2020.1787971.
    1. Grabner M, Abbott S, Nguyen M, Chen Y, Quimbo R. Estimated cost savings associated with A1c reductions in a large US commercial health plan. Value Health. 2013;16(3):A160. 10.1016/j.jval.2013.03.801
    1. Stratton IM, Adler AI, Neil HA, et al. . Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ. 2000;321(7258):405–412. 10.1136/bmj.321.7258.405.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe