One-third of 986 patients achieved long-term self-care of their type 2 diabetes after building trusting relationships with community health workers (promotores in Spanish) over 12 weeks, according to a newly published study by faculty of The University of Texas Health Science Center at San Antonio (UT Health San Antonio).
Participants' health was monitored over a four-year period. Patients were recruited to the study prior to the COVID-19 pandemic from a primary care practice at University Health's Robert B. Green Campus in San Antonio and through physician referrals.
"Patients have many reasons to distrust the health care system," said Carolina Gonzalez Schlenker, MD, MPH, second author of the peer-reviewed study published Sept. 26 in Annals of Family Medicine. "So, you plug in a trust builder, a promotor or promotora, who becomes a bridge between what makes sense in primary care and what makes sense to the patient." Schlenker, who coordinated the promotores' time and efforts, is an assistant professor in the Department of Family and Community Medicine at UT Health San Antonio's Joe R. and Teresa Lozano Long School of Medicine.
"The intervention was only 12 weeks long and yet the effect was apparent four years later," said study senior author Carlos Roberto Jaén, MD, PhD, professor and chairman of family and community medicine in the Long School of Medicine and with University Health. Jaén is a member of the U.S. Preventive Services Task Force.
Results
Among the participants, 320 (32.4%) achieved a behavioral marker or definition of success that the researchers called "self-care generativity." "The patient in this classification plans self-care and progresses through milestones such as lowering the hemoglobin A1C, a blood test that measures average blood sugar levels over the past three months," said study first author Robert L. Ferrer, MD, MPH, professor of family and community medicine at UT Health San Antonio. Ferrer is an expert on social determinants of health status in Hispanic populations.
Meanwhile, 399 participants (40.5%) progressed to a stage called "stabilization" in which the patient and community health worker address obstacles to self-care together. "However, the patient in this group has stopped short of making the transition to self-care and continues to need help with problem-solving," Jaén said.
Finally, 267 participants (27.1%) remained in "outreach." They agreed to meet face-to-face with a community health worker but did not advance toward creating an alliance of care. "They make a plan with the promotores, but it falls through," Schlenker said. "We never really do the intervention, and then they come back years later, and maybe they need an amputation."
Those who advanced to "self-care generativity" had sustained A1C reductions and fewer hospitalizations and emergency room visits than the other two groups. "This is an important finding," Jaén said.
Knocking on doors
Physicians in busy practices require more information about patients than they can obtain in a 15-minute appointment, Schlenker said. This includes understanding life circumstances that hinder the patients from following what they are supposed to do for their type 2 diabetes.
"It's just a difficult situation where the doctor is, like, I need more information and more time, and I don't have it. And I care about this human being," Schlenker said.
"So, they send me a patient, I assign a promotor or a promotora, and they go and knock at the patient's door, and they say, 'I'm coming here because the doctor cares about you. We want to understand you.' And they do this authentically, and the patient feels the authenticity of the caring but also, the visit is not under the tick-tock of an accountant. Trust building can't be billed by the hour," Schlenker said.
During the study period (2013-2017), the team employed an average of 10 promotores to provide the intervention, Schlenker said.
The trust-building exercise is called Nosotros, which is Spanish for "we." Promotores and patients answer four questions together:
- What do we want?
- Why do we want it?
- What do we do?
- What do we get?
As patients let their walls come down, the goal is shared. A team is formed. "We build a nosotros, a we, that didn't exist before," Schlenker said.
The study findings are intriguing because few if any interventions utilizing promotores in primary care practices' outreach have been studied over four years, Jaén said. Most studies leveraging community health workers in chronic disease management have followed participants' status for six to 12 months, he said.
With funding, the Nosotros model could be replicated across settings. "During the drive to vaccinate the public against COVID-19, trust forged with promotores could have dispelled disinformation and distrust among groups such as the Hispanic population of San Antonio who historically have not been taken into account," Ferrer noted.
A key concern was the stabilization group that, despite repeated one-on-one interactions with community health workers, did not advance to self-care. "We see these participants really trying, and our hearts sink, witnessing how they deteriorate with their diabetes," Schlenker said. "That is the alarming thing."
Community Health Workers as Trust Builders and Healers: A Cohort Study in Primary Care
Robert L. Ferrer, MD, MPH; Carolina Gonzalez Schlenker, MD, MPH; Inez Cruz, PhD; Polly Hitchcock Noël, PhD; Raymond F. Palmer, PhD; Ramin Poursani, MD; Carlos Roberto Jaén MD, PhD
First published: Sept. 26, 2022, Annals of Family Medicine
https://doi.org/10.1370/afm.2848
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