An innovative community health worker training program: Addressing the diabetes pandemic through expansion of the diabetes health care team

Abstract

Background and aims: Diabetes is rapidly becoming a pandemic. Health care systems are ill-equipped to meet the demands of the impending global diabetes crisis. Rapid expansion of the diabetes work force and mobilization of diabetes care teams will be essential to prevent devastating morbidity, mortality and financial disaster. Lay health workers serve as health care extenders and patient advocates across the world. They are effective in their mission due to their dedication, low cost, cultural, linguistic, and community understanding of the patients they advocate for. We hypothesize that community health workers (CHWs) can be trained using a distance learning model to become diabetes health extenders to increase the diabetes work force and expand the diabetes care team in a culturally appropriate, low cost, and effective manner. Materials and methods: We devised a mulit-modality diabetes training program for CHWs that included a three day hands on intensive didactic, clinical skills and communications training, along with asynchronous video modules. Subjects then participated in a 6-month weekly distance case based and didactic learning program, using internet and video conferencing. Subjects completed evaluations at baseline and following the 6-month program. Surveys used included the Michigan Diabetes Attitude Survey (DAS-3), a modified version of the Michigan Diabetes Knowledge Test (mDKT), and a Diabetes Confidence Survey (DCS) for both clinical and nonclinical slills for diabetes. Subjects also completed 1:1 pre and post participation evaluations to assess mastery of specific diabetes related clinical and knowledge skills. Finally supervisors were asked to evaluate the effect the training had on their organisations and diabetes programs. Data were analysed using paired students t tests. Significance (p) and effect size were determined (d). Results: Fifty CHWs completed the program including 4 men and 46 women; 30 Native Americans, 12 Hispanics, and 7 Whites. Subjects improved in all five domains of the DAS-3, but statistical significant improvements were only seen in the Seriousness and Patient Autonomy scales (p<0.01 and <0.05, d= 0.41 and 0.38 respectively). Participation in the program resulted in a significant improvement in the mDKT mean percent correct (pre 58.2% to post 68.4 % (p < 0.0001, d = 0.76). Significant improvements in confidence in clinical and non clinical skills were seen from pre to post testing (p <0.0001, d>0.9). All domains of clinical skills testing improved significantly including blood pressure, blood sugar, and BMI measurement and interpretation, depression screening, diabetic foot exam, and medication counseling. Finally, supervisors reported significant improvements in CHW's skills (composite score of 18 parameters) and integration into the diabetes care team as a result of participation in the program (p<0.001, d=1.7, and p<0.001 d=1.78, respectively). Conclusion: We have demonstrated that our innovative training program led to significant improvement in CHW attitudes, knowledge, clinical skills and confidence in their abilities in these areas. Additionally, their supervisors recognized the value of the training and increased CHW responsibility and integration in diabetes care teams. Specialized training of CHWs in diabetes is a potential mechanism to help address the global diabetes epidemic.