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Home » Systematic Review

Diabetes Prevention: Interventions Engaging Community Health Workers

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What the CPSTF Found

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.

Summary of Results

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

Interventions that engage community health workers for diabetes prevention use one or more of the following models of care (HRSA 2007).

  • Screening and health education. Community health workers deliver education about diabetes prevention and lifestyle changes as primary health education providers or lifestyle coaches. Community health workers, for example, might teach clients about healthy meal planning or show them how to use a physical activity diary (22 studies).
  • Outreach, enrollment, and information. Community health workers reach out to individuals and families who are eligible for medical services and help them obtain these services. They might deliver social support at home, or monitor and follow-up on clients’ physical activity by phone (6 studies).
  • Member of care delivery team. Community health workers partner with patients and licensed providers, such as physicians and nurses, to improve coordinated care and support for patients. Community health workers could coordinate client weight management session with nurses. (4 studies).
  • Patient navigation. Community health workers help individuals and families navigate complex medical service systems and processes to increase their access to care. Community health workers could improve client access to insurance, or prepare clients for healthcare visits (3 studies).
  • Community organizers. Although not reported in the included studies from this review, Community health workers may facilitate self-directed change and community development by serving as liaisons between communities and healthcare systems (0 studies).

Overall, included studies showed the following:

  • Interventions engaging community health workers improved participants’ glycemic or blood sugar control (HbA1c, fasting blood glucose) and weight-related outcomes, and reduced rates of progression to type 2 diabetes.
  • Improvements were seen for self-reported lifestyle changes (i.e. physical activity, nutrition) and mixed for CVD risk factors.

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 (3 studies): 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 HDL: median increase of 0.3 mg/dL (4 least suitable design studies; median: 5.5 months)
  • Mean triglycerides: median decrease of 13.8 mg/dL and an increase of 3.8 mg/dL (2 least suitable design studies; 6 and 12 months respectively)
  • 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)

Health Behavior Outcomes

  • Physical activity (19 studies): 5 studies reported significant improvements (median duration: 7 months), 8 reported non-significant improvements (median duration: 6 months), 5 showed no change, and 1 reported decreases in physical activity (median duration: 12 months),
  • Nutrition (15 studies): 4 studies reported significant improvements (median duration: 4.5 months), 6 reported non-significant improvements (median duration: 6 months), and 5 showed no change (median duration: 12 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).

Additional Findings

One study evaluated access to service (i.e., insurance coverage) and reported a favorable increase in the number of insured participants after community health worker engagement.

Summary of Economic Evidence

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

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). Most patients in the studies came from minority or low-income populations.
    • The median intervention cost per person per year was $600 (7 studies).
    • One study reported an increase in per person per year healthcare cost of $1,242, and another study reported no change.
    • Estimated costs per quality adjusted life year (QALY) gained were $4,720 and $41,154 (2 studies). Both estimates were below were below $50,000—a conservative benchmark for cost effectiveness.

Applicability

Based on results, the CPSTF finding should be applicable to interventions that engage community health workers in a range of settings and populations:

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

The CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are 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?

Study Characteristics

  • Studies included greatest suitability of design (group randomized controlled trials [7 studies], before-after with a comparison group [3 studies]) and least suitable design (before-after without a comparison group [12 studies])
  • 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). Within communities, studies were conducted in church-based settings and culturally tailored to target smaller groups in underserved areas (5 studies).
  • 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, including a few studies with 100% female clients enrolled (3 studies).
  • Included studies mainly focused on underserved populations.
    • Studies targeted Latinos (10 studies), African-Americans (3 studies), and Asians (3 studies).
    • Studies targeted low-income populations (4 studies), or those with less than high school education (7 studies).
  • Included studies limited their population to clients at risk for diabetes (10 studies) or allowed clients with diabetes to participate (12 studies).

Publications

Jacob V, Chattopadhyay SK, Hopkins DP, et al. Economics of community health workers for chronic disease: findings from Community Guide systematic reviews. American Journal of Preventive Medicine. 2019;56(3):e95-e106.

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