Integration of Community Health Workers into Hypertension Management and Medication Adherence Open Access
Allen, Caitlin Gloeckner (2015)
Published
Abstract
Background: Rates of hypertension control remain particularly low among underserved populations; consequently the disparities in cardiovascular disease mortality in underrepresented groups are increasing. While evidence exists to support community health workers (CHWs) as effective interventionists for hypertension self-management among underserved groups, the level of integration and coordination with health teams is unknown. This study aims to understand the roles CHWs have in hypertension self-management, ways that CHWs promote and support medication adherence, and factors that support CHWs in their roles.
Methods: CHWs were recruited through an American Public Health Association sponsored listserv of 30 CHW networks and associations from 19 states. The first phase of the study included an online survey open for eight weeks. The survey included items about CHWs work in hypertension self-management and integration into health are teams. We also conducted 23 semi-structured interviews with CHWs from 17 states and the District of Columbia. Quantitative data were imported from Survey Monkey into SPSS Statistics version 22 and analysis included descriptive statistics and bivariate statistics. Interviews were compiled into MAXQDA version 11 and analyzed by two coders using inductive thematic analysis.
Results: Findings revealed that CHWs' roles in hypertension self-management include: education (84%), removing knowledge barriers about medicines (74%), increasing access to providers (73%), and improving patient-provider relationships (70%). Over half of CHWs considered themselves an important part of the care team for patients with hypertension and 75% reported feeling well supported in their work. CHWs feel most supported when they have strong relationships with their team, are well trained, and make connections with CHWs outside of their organization.
Conclusions: By understanding CHWs' roles in hypertension self-management, healthcare professionals can better prepare to integrate CHWs into healthcare teams. This research is unique because of its focus on gaining CHWs' perspective about their work. Results from this study will help healthcare professionals, policy makers, and academics better understand CHWs and how they can best be integrated into care teams to address barriers for patients prevent and manage hypertension.
Table of Contents
Chapter 1. Introduction and Theoretical Framework 1
Problem Definition 1 Study Purpose and Justification 2
Theoretical Framework 2
The Medication Adherence Model 2
Consolidated Framework for Implementation Research 3
Research Questions 3
Chapter 2. Literature Review 5
The Burden of Hypertension in the United States 5
Hypertension Self-Management and the Chronic Care Model 6
Hypertension Medication Management 8
Hypertension Management Strategies and Research 10
Community Health Workers 11
Hypertension Self-Management and Community Health Workers 13
Community Health Workers and Hypertension Medication Management 17
The Multidimensional Adherence Model and Community Health Workers Roles 19
Community Health Workers as Part of the Care Team for Patients with Hypertension 22
Combined Multidimensional Adherence Model and Consolidated Framework for Implementation Research 24
Chapter 3. Methods 26
Participants 26
Measures 27
Procedures 28
Institutional Review Board Approval 30
Study Consenting 31
Data Collection and Management 31
Analysis 32
Quantitative Data Analysis 32
Qualitative Data Analysis 32
Chapter 4. Results 34
Descriptive Statistics 34
Research Question 1: What are CHWs' roles in hypertension self-management? 40
Who CHWs Work With 41
Service Delivery 42
CHW Roles in Hypertension Self-Management 45
CHWs as Partners in Hypertension Self-Management 60
Getting to the Root of the Problem: CHWs Addressing More than Hypertension 60
Research Question 2: What are ways CHWs promote and support hypertension medication adherence according to the five dimensions of adherence? 63
Patient-Related Barriers and Roles 64
Condition-Related Barriers and Roles 68
Therapy-Related Barriers and Roles 71
Health System Barriers and Roles 77
Social and Economic Barriers and Roles 81
Success Stories 85
Research Question 3: How are CHWs integrated into their healthcare organization? 87
Organizational Support 87
Organizational Support Scale 98
Characteristics of Successful CHW Organizations 99
Research Question 4: What organizational factors support CHWs in their roles in hypertension self-management and hypertension medication adherence? 105
Attending Staff Meetings 105
Being Part of a Multidisciplinary Care Team 108
Other Staff 110
Support from Leadership or Program Champion 110
Lack of Support 111
Electronic Health Record Access 112
Support and Validation from Patients 114
Training as Support for CHWs 116
Non-organizational Factors that Support Work as CHWs 122
Summary of Inner Setting and Outer Setting CFIR Constructs 130
Other Findings 133
CHWs and the Chronic Care Model 135
Chapter 5. Discussion 138
Key Findings 138
Descriptive Information about Sample 138
What are CHWs' roles in hypertension self-management? 138
What are ways CHWs promote and support hypertension medication adherence according to the five dimensions of adherence? 139
How are CHWs integrated into their healthcare organization? 141
What organizational factors support CHWs in their roles in hypertension self-management and hypertension medication adherence? 141
CHWs and the Chronic Care Model 144
Strengths and Limitations 144
Strengths 144
Limitations 145
Implications and Recommendations for Further Study 146
Descriptive Information about Sample 153
What are CHWs' roles in hypertension self-management? 155
What are ways CHWs promote and support hypertension medication adherence according to the five dimensions of adherence? 158
How are CHWs integrated into their healthcare organization? 163
What other organizational factors support CHWs in their roles in hypertension self-management and hypertension medication adherence? 165
Other Findings and New Models 170
Beyond Models: Monitoring and Evaluation 177
Conclusion 179
References 181
Appendix A. CFIR Construct with Short Definitions 194
Appendix B. Quantitative Survey Guide 196
Appendix C. Interview Guide 209
Appendix D. Qualitative Codebook 213
Appendix E. Medication Adherence Model Quotes 217
Appendix F. Organizational Support Quotes 236
Appendix G. Outer Setting Support Quotes 254
Appendix H. Training Quotes 274
Appendix I. Additional Quotes 287
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