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Service Delivery Innovation Profile

Community Partnership Uses Lay Health Advisers to Reduce Chronic Disease Risk Factors, Leading to Improvements in Lifestyle and Health in Low-Income African Americans


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Snapshot

Summary

In the 8-year Charlotte Racial and Ethnic Approaches to Community Health (REACH) 2010 project, a primary care center, the county health department, community organizations, and lay health advisers jointly developed and implemented a variety of activities designed to reduce risk factors for cardiovascular disease and diabetes in a low-income, largely African-American population. Activities included support groups, health and nutrition education classes, exercise programs, smoking cessation classes, and a farmers’ market. Recruited from local neighborhoods, the lay health advisers served as liaisons between the community and providers, encouraged positive changes in health-related behaviors, and made referrals to health professionals as necessary. The program, which involved two distinct project periods (1999-2000 for planning and 2000-2007 for implementation), improved health-related skills and behaviors (e.g., eating more healthfully, engaging in more physical activity), leading to anecdotal reports of better health. Most components of the program ended in 2007 after grant funding ran out, although some aspects continued past this time and others continue to operate today.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation feedback from participants given during focus groups, along with trends in the results of annual community-wide surveys related to diet and physical activity conducted before and after program implementation.
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Developing Organizations

Carolinas HealthCare System; Fighting Back Cluster One Neighborhood Association; Healthy Families/Healthy Communities; McCrorey Family YMCA; Mecklenberg County (NC) Health Department
Multiple community organizations, including a 14-neighborhood association, also participated in the development of this initiative.end do

Use By Other Organizations

A total of 40 communities adopted the REACH 2010 initiative. A list of REACH grantee partners can be found at: http://www.cdc.gov/reach/index.htm.

Date First Implemented

1999
The 8-year program ran from 1999 to 2007.begin pp

Patient Population

Race and Ethnicity > Black or african american; Vulnerable Populations > Impoverishedend pp

Problem Addressed

African Americans are more likely to get and die from heart disease and diabetes than whites.1,2 Many low-income, minority neighborhoods have limited access to resources (e.g., educational programs, fresh produce, safe places to exercise) that can prevent or mitigate risk factors associated with these conditions. As widely respected community residents, lay health advisers can help facilitate access to these resources, but such advisers remain underutilized in most areas.
  • Greater risk of getting, dying from diabetes and heart disease: African-American adults face nearly twice the risk of being diagnosed with (1.9 times) and dying from (2.2 times) diabetes than do whites.1 They also face greater risks related to heart disease, with African Americans being 1.4 times more likely to have high blood pressure (a risk factor for the disease) than the average white, and African-American men being 30 percent more likely to die from heart disease than white men.1,2 In Charlotte, NC, in 2000, those living in the northwest part of the city (a largely African-American area) faced a 40 percent greater risk of dying from cardiovascular disease, nearly double the risk of dying from stroke, and nearly triple the risk of being hospitalized due to diabetes.
  • Limited access to programs and resources to help: Residents of many urban minority communities have limited access to healthy foods, particularly fresh produce, and to safe places to engage in physical activities such as biking and walking (due to high crime rates, inadequate street lighting, and lack of sidewalks). In addition, formal community-based programs to promote wellness often do not exist. A survey of African-American households in the northwest area of Charlotte found that only 64 percent participated in some physical activity, compared with 75 percent of the general population; 13 percent reported eating at least five servings of fruits and vegetables daily, well below the national average (which ranges from 19 to 23 percent).3
  • Largely unrealized potential of lay health advisers: Lay health advisers—widely respected community residents seen as natural helpers by their neighbors—can promote better health by creating and encouraging use of community-based activities and programs, helping individuals adopt healthier lifestyles, and serving as a link between consumers and health professionals.4 In minority communities, these advisers can serve as a critical component of an environmental approach to community health, which recognizes that health-related behaviors represent part of a large social system of behaviors that can be influenced by the community.5 Yet many minority communities do not proactively identify and make full use of such lay health advisers.

What They Did

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Description of the Innovative Activity

Charlotte Racial and Ethnic Approaches to Community Health (REACH) 2010 used various activities and strategies to reduce risk factors for cardiovascular disease and diabetes in 14 contiguous, low-income, predominantly African-American neighborhoods. Clinical professionals and trained lay health advisers led programs to improve the health of neighborhood residents, with a focus on promoting healthy eating, exercise, smoking cessation, and access to primary care. The lay health advisers also served as liaisons between community residents and the primary care center and generally promoted disease prevention and management within the community. Key program elements included the following:
  • Counseling by clinical professionals to address health needs: Clinical professionals located in a local primary care center and at the county health department (including a diabetes nurse educator, nutritionist, and smoking cessation educator) regularly counseled community members about specific health needs.
  • Outreach and education by trained lay health advisers: Lay health advisers (long-time residents who were typically heavily involved in community activities), promoted exercise, healthy diet, and smoking cessation in interactions with community residents, distributed educational materials, provided peer education, made referrals to clinical professionals as needed, encouraged residents to join preventive health activities, and served as liaisons between community residents and the primary care center (e.g., by explaining how to make appointments at the primary care center).
  • Programs to promote healthier lifestyles and better health: Together, clinical professionals and lay health advisers developed and offered multiple programs focused on promoting healthy eating, physical activity, smoking cessation, and access to primary care. Through a collaborative, dynamic and flexible working relationship, these professionals and advisers came up with ideas and supported each other in implementing them. Community members could self-refer to these activities or be referred by the clinical professionals or advisers. Examples of specific programs include the following:
    • Door-to-door visits: Lay health advisers made door-to-door visits in their neighborhoods to distribute information about the REACH initiative, providing descriptions of the various available community activities, helping people determine which activities might be best for them, and assisting individuals in accessing these activities and in obtaining needed care from the primary care center.
    • Exercise classes and walking groups: A wellness specialist—a YMCA employee dedicated part-time to the REACH program—ran exercise programs and helped residents design personalized physical activity goals and programs. The local YMCA and other community recreational facilities also offered free aerobics classes (through 2009). In addition, lay health advisers organized, recruited, and led residents in walking programs held 3 days a week. The YMCA also assisted interested lay health workers in becoming certified aerobics instructors.
    • Diabetes education and support: A diabetes nurse from the CMC Biddle Point Family Practice provided diabetes education to patients referred by lay health advisers. This center also developed a diabetes registry to track patient health. (When the REACH grant was completed in 2007, Carolinas Healthcare System agreed to keep the full-time nurse position even after REACH ended.) Lay health advisers developed and ran a weekly diabetes support group in a neighborhood center where they discussed the impact of lifestyle choices and led participants in discussions of strategies to cope with the disease. The diabetes nurse attended these sessions to address participant questions.
    • Smoking cessation classes and support group: A smoking cessation educator held weekly smoking cessation classes and a support group. Lay health advisers supported this program by attending meetings and encouraging participation during their regular their interactions with residents.
    • House parties: Lay health advisers led house parties (hosted by a neighbor in the community) at which they presented information related to the prevention of cardiovascular disease and diabetes. Attendees received healthy snacks and door prizes.
    • Neighborhood farmers' market: In 2001, a neighborhood farmers’ market opened on the grounds of the county health department, with the goal of improving access to fresh produce. Open every Saturday from May through early October, the market attracted 350 to 500 customers weekly, and became a significant social event within the community, providing a forum for lay advisers to share updated information about REACH and other community activities with neighbors. (The market continued after the grant ended; however, customer participation numbers suffered when the location changed due to Health Department renovations. Subsequently, the market closed.)
    • Other programs and activities: The program also offered periodic hypertension classes, grocery store tours, health fairs, and demonstrations on healthy cooking.

Context of the Innovation

The Carolinas Healthcare System has 32 affiliated hospitals in North and South Carolina, including the Carolinas Medical Center, an 874-bed hospital in Charlotte, NC. In 1997, Carolinas Healthcare System opened a primary care center—called Carolinas Medical Center Biddle Point—to serve a 14-neighborhood area in northwest Charlotte. In this community of 20,000 residents (90 percent of whom are African American), one-fourth of the population lives below the Federal poverty level, well above the 11 percent poverty rate for all of Charlotte. Medical center administrators hoped that Biddle Point would improve access to high-quality primary care in the area, and also restore resident trust in the health system, which remained low. To that end, medical center leaders developed strong relationships with a coalition of community leaders, inviting them to provide input and guidance on the center’s design and service offerings. During this time, the medical center received grant funds from the U.S. Health Resources and Services Administration to conduct a needs assessment in Biddle Point and three other communities. This assessment documented significant health disparities between these areas and the rest of the county, particularly related to cardiovascular disease and diabetes. These findings, coupled with strong community engagement in the primary care center project, led the health system to apply for a health disparities grant under the REACH 2010 program, a federal initiative funded by the U.S. Centers for Disease Control and Prevention (CDC) to eliminate health disparities in racial and ethnic minority communities. Carolinas Health System served as the fiscal agent on the project, with the Mecklenberg County Health Department and the YMCA of Greater Charlotte being subcontractors.

Did It Work?

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Results

The program improved health-related skills and behaviors (e.g., eating more healthfully, engaging in more physical activity), leading to anecdotal reports of better health.
  • Improved health-related skills and behaviors: Focus groups suggest that the program allowed participants to learn new skills related to health, such as how to select more healthful foods.5 A community-wide survey found that 73 percent of area residents reported eating more fresh fruits and vegetables daily, 72 percent reported being more physically active, and 67 percent reported reducing fat consumption after implementation of the program. An annual community-wide telephone survey found that the percentage of physically inactive residents in the northwest part of Charlotte fell from 31.9 to 27.4 percent between 2001 and 2005; over the same time period, this percentage increased statewide, from 23.1 to 25.5 percent. In addition, by 2005, 25.3 percent of residents of northwest Charlotte reported eating at least five servings of fruits and vegetables daily, well above the 17.5 percent statewide average.6
  • Better health: Focus groups suggest that the program helped participants improve their overall health, lose weight, and/or exercise more regularly. Anecdotal reports confirm such improvements. For example, one participant reported that her doctor reduced the dosage by half for her blood pressure and diabetes medications, and reduced glucose monitoring from every day to twice a week. Other participants reported having more energy, being in better shape, and feeling less stressed as a result of the program.5
  • Greater sense of family and community: Focus group participants reported that the program made them more likely and willing to promote positive behavior changes in other members of their families. Participants also reported having a greater sense of community as a result of the program; for example, the farmers’ market became a way to socialize with neighbors and share healthy recipes.5

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation feedback from participants given during focus groups, along with trends in the results of annual community-wide surveys related to diet and physical activity conducted before and after program implementation.

How They Did It

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Planning and Development Process

Key elements of the planning and development process included the following:
  • Creating coalition: The health system created a coalition to guide the project; members included representatives from the primary care center, churches, community groups, the county health department, the McCrorey Family YMCA, Healthy Families/Healthy Communities, a local housing revitalization group, and the Fighting Back Cluster One Neighborhood Association, an association representing 14 neighborhoods focused on opportunities to improve community health.
  • Recruiting staff and lay health advisers: Program leaders hired staff, while coalition members recommended and selected lay health advisers.
  • Holding biweekly meetings: During the implementation phase, lay health advisers and staff met every other week to discuss and plan development of REACH program activities.
  • Learning from other programs: During the planning and implementation phases, the REACH program invited representatives with expertise in these types of programs to provide guidance and share lessons learned and best practices; these representatives included leaders of another community-provider partnership (Project Direct in Raleigh, NC) and an expert from the University of North Carolina School of Public Health with hands-on experience in developing lay health adviser–based programs.
  • Training advisers: Lay health advisers participated in a 40-hour training course taught by college professors, community activists, health promotion experts from the county health department, and local substance abuse experts. The course provided general information about the social determinants of health and on cardiovascular disease and diabetes, including risk factors and preventive strategies related to nutrition, exercise, and smoking cessation. The course also taught hands-on strategies and techniques related to communication, promotion of behavior change, and advocacy.
  • Visiting primary care center: The lay health workers toured the primary care center and met with its providers and administrators. They also learned how patients make an appointment at the center, and what patients should expect once they arrive. In turn, the lay health workers shared information they learned from Biddle Point administrators with the community. This education helped community residents understand policies and procedures of the Carolinas Medical Center Biddle Point Family Practice.
  • Holding ongoing meetings: During monthly meetings held throughout the program, lay health advisers and staff discussed program updates, highlighted continuing community needs, shared ideas, and developed new activities. Lay health advisers also shared challenges and concerns related to the community and those of being a lay health adviser.

Resources Used and Skills Needed

  • Staffing: Full-time staff included a lay health adviser program manager, a lay health adviser supervisor, a lay health adviser program administrative assistant, a nurse diabetes educator, a dietitian/nutritionist, a health educator (smoking cessation). The grant paid also funded a half-time wellness coordinator. The program trained 26 lay health advisers, with 15 to 18 of these advisers typically serving on a steady-state basis during the project. Advisers generally had an outgoing personality, existing trust-based relationships with people in the community, and a strong interest in the project.
  • Costs: Costs consisted primarily of salaries and benefits for staff, payments to the lay health advisers (who received $10 per hour for up to 10 hours a week), and expenses associated with activity-specific materials and programming.
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Funding Sources

Centers for Disease Control and Prevention
The CDC funded the program via a 1-year planning grant of approximately $250,000 and a 7-year implementation grant of roughly $1 million a year; these funds covered all staff and other program-related costs.end fs

Adoption Considerations

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Getting Started with This Innovation

  • As possible, take time during planning: The structure of the grant allowed for 1 year of formal planning, thus giving program developers adequate time to design program activities, hire staff, educate the community about program goals, and engage community members in the effort. This time allowed for a smoother implementation process.
  • Educate community and set expectations: Early in the process, lay health advisers described the project to their neighbors and set expectations for its timing. These conversations helped the community to understand the long-term nature of the project, including the fact that it would take time to get up and running.
  • Select advisers carefully: Lay health advisers drive the ultimate success of the program. They should be highly involved in and committed to their community and to the program, have an outgoing personality and excellent communication skills, and be trusted and respected by their neighbors.
  • Learn from other programs: The implementation strategies and challenges experienced by others who have developed similar programs can be enlightening. For example, community members interested in pursuing a certain type of community-based activity became dissuaded after hearing negative comments about its potential effectiveness from those working on a similar program in Raleigh, NC.

Sustaining This Innovation

  • Elicit and act on feedback from community and lay advisers: Continually evaluate community needs and elicit feedback from lay health advisers, and then develop new programs accordingly. This approach not only helps to improve program effectiveness, but also enhances the ability to retain advisers (who will see that their contributions are valued) and builds trust between providers and the community.
  • Build on positive experiences: Ensure that providers offer excellent, culturally competent service. Once community members begin to have positive experiences, historical mistrust will begin to dissipate. Eventually, the community will trust the system and hence be more likely to seek primary and preventive care.
  • Plan for sustainability: Develop a plan for sustainability and transition, including which organizations will fund the program and which individuals/positions will serve as program champions. This approach can help to ensure that program activities can be sustained once grant funding ends.

Use By Other Organizations

A total of 40 communities adopted the REACH 2010 initiative. A list of REACH grantee partners can be found at: http://www.cdc.gov/reach/index.htm.

More Information

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Contact the Innovator

LaTonya Chavis Keener, MS
SciMetrika, Contractor
Centers for Disease Control and Prevention
CDC/NCCDPHP/DCH
CHAM Bldg 107, MS-K56
Chamblee, GA 30341
Phone: (770) 488-6061
E-mail: LChavis@cdc.gov

Marcus Plescia MD, MPH
Director, Division of Cancer Prevention and Control
Centers for Disease Control and Prevention
CDC/NCCDPHP/DCPC
CHAM Bldg 107, MS-F76
Chamblee, GA 30341
Phone: (770) 488-3055
E-mail: Ifs1@cdc.gov

Innovator Disclosures

Ms. Chavis Keener reported having no financial interests or business/professional affiliations relevant to the work described in the profile other than the funders listed in the Funding Sources section. Dr. Plescia has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Information about REACH, an initiative of the Centers for Disease Control and Prevention, is available at: http://www.cdc.gov/reach/index.htm

Plescia M, Herrick H, Chavis L. Improving health behaviors in an African American community: The Charlotte Racial and Ethnic Approaches to Community Health project. Am J Public Health. 2008;98(9):1678-84. [PubMed]

Plescia M, Groblewski M, Chavis L. A lay health advisor program to promote community capacity and change among change agents. Health Promot Pract. 2008;9(4):434-9. [PubMed]

DeBate R, Plescia M, Joyner D, et al. A qualitative assessment of Charlotte REACH: an ecological perspective for decreasing CVD and diabetes among African Americans. Ethn Dis. 2004;14(3 suppl 1):S77-82. [PubMed]

Plescia M, Groblewski M. A community-oriented primary care demonstration project: refining interventions for cardiovascular disease and diabetes. Ann Fam Med. 2004;2:103-9. [PubMed]

Footnotes

1 U.S. Department of Health & Human Services, Office of Minority Health. African American Profile Web site. 2009. Available at: http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlid=51.
2 Centers for Disease Control and Prevention, Office of Minority Health and Health Disparities. Highlights in Minority Health and Health Disparities Web site. February 2009. Available at: http://www.cdc.gov/omhd/Highlights/2009/HFeb09.htm.
3 Plescia M, Groblewski M. A community-oriented primary care demonstration project: refining interventions for cardiovascular disease and diabetes. Ann Fam Med. 2004;2:103-9. [PubMed]
4 Plescia M, Groblewski M, Chavis L. A lay health advisor program to promote community capacity and change among change agents. Health Promot Pract. 2008;9(4):434-9. [PubMed]
5 DeBate R, Plescia M, Joyner D, et al. A qualitative assessment of Charlotte REACH: an ecological perspective for decreasing CVD and diabetes among African Americans. Ethn Dis. 2004;14(3 suppl 1):S77-82. [PubMed]
6 Plescia M, Herrick H, Chavis L. Improving health behaviors in an African American community: The Charlotte Racial and Ethnic Approaches to Community Health project. Am J Public Health. 2008;98(9):1678-84. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: September 15, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: September 25, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: September 17, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.