Can lay health workers promote better medical self-management by persons living with HIV? An evaluation of the Positive Choices program

Roth, Alexis M.; Holmes, Ann M.; Stump, Timothy E.; Aalsma, Matthew C.; Ackermann, Ronald T.; Carney, Theodore S.; Katz, Barry P.; Kesterson, Joe; Erdman, Sharon M.; Balt, Christine A.; Inui, Thomas S.

doi:10.1016/j.pec.2012.06.010

Cited by 18 publications

(15 citation statements)

References 23 publications

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“…Yet, without a formal role in the health system, the sustainability of peer activities has been questioned. Our findings affirm those of Moyer's study of the role of peers in the Kenyan health system, in which she concludes that while ART adherence is framed by administrators as the individual responsibility of patients, this framing “conceals the sociality of adherence and undervalues the work of peer mentors in treatment programmes.” While experiments to expand the role of peers in health systems are sometimes hampered by managerial challenges and continued questions regarding sustainability , efforts to involve PLHIV in delivering community‐based HIV care show promise for improving adherence and expanding models of care delivery in resource‐poor settings . Yet, there has been little research conducted, to date, to understand and make transparent both the unique effects of peers in public health practice, as well as their unique motivations, attitudes and beliefs about effective HIV care.…”

Section: Discussionmentioning

confidence: 99%

Redemption of the “spoiled identity:” the role of HIV‐positive individuals in HIV care cascade interventions

et al. 2017

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IntroductionThe concept of “therapeutic citizenship” has drawn attention to ways in which public testimony, the “story‐telling in the public sphere” undertaken by people living with HIV (PLHIV), has shaped the global response to the epidemic. This paper presents qualitative findings from two large studies in eastern Africa that reveal how the advent of population‐based HIV testing campaigns and efforts to accelerate antiretroviral “treatment for all” has precipitated a rapidly expanding therapeutic citizenship “project,” or social movement. The title of this paper refers to Goffman's original conceptualization of stigma as a social process through which a person's identity is rendered “spoiled.”MethodsData were derived from qualitative studies embedded within two clinical trials, Sustainable East African Research in Community Health (SEARCH) (NCT# 01864603) in Kenya and Uganda, and START‐ART (NCT# 01810289) in Uganda, which aimed to offer insights into the pathways through which outcomes across the HIV care continuum can be achieved by interventions deployed in the studies, any unanticipated consequences, and factors that influenced implementation. Qualitative in‐depth semi‐structured interviews were conducted among cohorts of adults in 2014 through 2015; across both studies and time periods, 217 interviews were conducted with 166 individuals. Theoretically informed, team‐based analytic approaches were used for the analyses.ResultsNarratives from PLHIV, who have not always been conceptualized as actors but rather usually as targets of HIV interventions, revealed strongly emergent themes related to these individuals' use of HIV biomedical resources and discourses to fashion a new, empowered subjecthood. Experiencing the benefits of antiretroviral therapy (ART) emboldens many individuals to transform their “spoiled” identities to attain new, valorized identities as “advocates for ART” in their communities. We propose that the personal revelation of what some refer to as the “gospel of ARVs,” the telling of personal stories about HIV in the public sphere and actions to accompany other PLHIV on their journey into care, is driven by its power to redeem the “spoiled identity:” it permits PLHIV to overcome self‐stigma and regain full personhood within their communities.Conclusions PLHIV are playing an unanticipated but vital role in the successful implementation of HIV care cascade interventions.

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Section: Discussionmentioning

confidence: 99%

Redemption of the “spoiled identity:” the role of HIV‐positive individuals in HIV care cascade interventions

et al. 2017

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“…1 Flowchart of inclusion and exclusion of studies baseline, 43,44,47 and one cohort study noted increased adherence relative to an observation cohort. 58 Of the four RCTs measuring preventable use, three found a statistically significant decrease relative to a control. 40,54,59 Three pre-post studies found a decrease in preventable use relative to baseline.…”

Section: Medication Usementioning

confidence: 99%

“…Eight studies found the CHW interventions decreased costs, while three suggested that the CHW interventions yielded no savings. 5,40,58 Two studies, both of which focused on care for adults with type II diabetes in Texas, assessed the cost-effectiveness of a CHW intervention. One found that each additional qualityadjusted life year (QALY) gained as a result of the CHW intervention cost $10,995 to $33,319.…”

Section: Cost Reportingmentioning

confidence: 99%

Impact of Community Health Workers on Use of Healthcare Services in the United States: A Systematic Review

et al. 2016

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BACKGROUND: As the US transitions to value-based healthcare, physicians and payers are incentivized to change healthcare delivery to improve quality of care while controlling costs. By assisting with the management of common chronic conditions, community health workers (CHWs) may improve healthcare quality, but physicians and payers who are making choices about care delivery also need to understand their effects on healthcare spending. METHODS: We searched PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PsycINFO, Embase, and Web of Science from the inception of each database to 22 June 2015. We included US-based studies that evaluated a CHW intervention for patients with at least one chronic health condition and reported cost or healthcare utilization outcomes. We evaluated studies using tools specific to study design. RESULTS: Our search yielded 2,941 studies after removing duplicates. Thirty-four met inclusion and methodological criteria. Sixteen studies (47%) were randomized controlled trials (RCTs). RCTs typically had less positive outcomes than other study designs. Of the 16 RCTs, 12 reported utilization outcomes, of which 5 showed a significant reduction in one or more of ED visits, hospitalizations and/or urgent care visits. Significant reductions reported in ED visits ranged from 23%-51% and in hospitalizations ranged from 21%-50%, and the one significant reduction in urgent care visits was recorded at 60% (p < 0.05 for all). DISCUSSION: Our results suggest that CHW interventions have variable effects, but some may reduce costs and preventable utilization. These findings suggest that it is possible to achieve reductions in care utilization and cost savings by integrating CHWs into chronic care management. However, variations in cost and utilization outcomes suggest that CHWs alone do not make an intervention successful. The paucity of rigorous studies and heterogeneity of study designs limited conclusions about factors associated with reduced utilization.

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“…Safety-net hospitals typically have limited resources for new initiatives and professional staff. Less costly community health workers (CHWs) 19 , 20 have increased medical follow-up with primary care and specialists, [21][22][23] improved adherence to medical regimens, 24,25 and provided meaningful social support. 22 These competencies may NIH Trial Registration ClinicalTrials.gov identifier: NCT01619098…”

Section: Introductionmentioning

confidence: 99%

A Patient Navigator Intervention to Reduce Hospital Readmissions among High-Risk Safety-Net Patients: A Randomized Controlled Trial

et al. 2015

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BACKGROUND: Evidence-based interventions to reduce hospital readmissions may not generalize to resourceconstrained safety-net hospitals. OBJECTIVE: To determine if an intervention by patient navigators (PNs), hospital-based Community Health Workers, reduces readmissions among high risk, low socioeconomic status patients. DESIGN: Randomized controlled trial. PARTICIPANTS: General medicine inpatients having at least one of the following readmission risk factors: (1) age≥60 years, (2) any in-network inpatient admission within the past 6 months, (3) length of stay≥3 days, (4) admission diagnosis of heart failure, or (5) chronic obstructive pulmonary disease. The analytic sample included 585 intervention patients and 925 controls. INTERVENTIONS: PNs provided coaching and assistance in navigating the transition from hospital to home through hospital visits and weekly telephone outreach, supporting patients for 30 days post-discharge with discharge preparation, medication management, scheduling of follow-up appointments, communication with primary care, and symptom management. MAIN MEASURES: The primary outcome was in-network 30-day hospital readmissions. Secondary outcomes included rates of outpatient follow-up. We evaluated outcomes for the entire cohort and stratified by patient age >60 years (425 intervention/584 controls) and ≤60 years (160 intervention/341 controls). KEY RESULTS: Overall, 30-day readmission rates did not differ between intervention and control patients. However, the two age groups demonstrated marked differences. Intervention patients >60 years showed a statistically significant adjusted absolute 4.1 % decrease [95 % CI: −8.0 %, -0.2 %] in readmission with an increase in 30-day outpatient follow-up. Intervention patients ≤60 years showed a statistically significant adjusted absolute 11.8 % increase [95 % CI: 4.4 %, 19.0 %] in readmission with no change in 30-day outpatient follow-up. CONCLUSIONS: A patient navigator intervention among high risk, safety-net patients decreased readmission among older patients while increasing readmissions among younger patients. Care transition strategies should be evaluated among diverse populations, and younger high risk patients may require novel strategies.KEY WORDS: care transitions; continuity of care; health care delivery; patient safety; underserved populations. J Gen Intern Med 30(7):907-15

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Can lay health workers promote better medical self-management by persons living with HIV? An evaluation of the Positive Choices program

Cited by 18 publications

References 23 publications

Redemption of the “spoiled identity:” the role of HIV‐positive individuals in HIV care cascade interventions

Redemption of the “spoiled identity:” the role of HIV‐positive individuals in HIV care cascade interventions

Impact of Community Health Workers on Use of Healthcare Services in the United States: A Systematic Review

A Patient Navigator Intervention to Reduce Hospital Readmissions among High-Risk Safety-Net Patients: A Randomized Controlled Trial

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