Participants' Assessments of the Effects of a Community Health Worker Intervention on Their Diabetes Self-Management and Interactions with Healthcare Providers


      The specific ways in which community health worker (CHW) programs affect participants' healthcare behaviors and interactions with their healthcare providers, as well as mechanisms by which CHW programs influence these outcomes, are poorly understood. A qualitative descriptive study of participants in a successful CHW diabetes self-management program was designed to examine: (1) what gaps in diabetes care, with a focus on patient–doctor interactions, participants identify; (2) how the program influences participants' diabetes care and interactions with healthcare providers, and what gaps, if any, it addresses.


      From November 2005 to December 2006, semi-structured interviews with 40 African- American and Latino adults were conducted and analyzed. Participants had diabetes and had completed or were active in a CHW-led diabetes self-management program developed and implemented using community-based participatory research principles in Detroit. Interviews were audiotaped, transcribed, and coded through a consensual and iterative process.


      Participants reported that prior to the intervention they had received inadequate information from healthcare providers for effective diabetes self-management, had had low expectations for help from their providers, and had not felt comfortable asking questions or making requests of their healthcare providers. Key ways participants reported that the program improved their ability to manage their diabetes were by providing (1) clear and detailed information on diabetes and diabetes care; (2) education and training on specific strategies to meet diabetes care goals; (3) sustained and nonjudgmental assistance to increase their motivation and confidence; and (4) social and peer support that enabled them to better manage their diabetes. The knowledge and confidence gained through the CHW intervention increased participants' assertiveness in asking questions to and requesting necessary tests and results from their providers.


      Study findings suggest ways that CHW programs that provide both one-on-one support and group self-management training sessions may be effective in promoting more effective diabetes care and patient–doctor relationships among Latino and African-American adults with diabetes. Through these mechanisms, such interventions may help to mitigate racial and ethnic disparities in diabetes care and outcomes.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Smedley B.D.
        • Stith A.Y.
        • Nelson A.R.
        • IOM
        Committee on Understanding and Eliminating Racial and Ethinic Disparities in Health Care: unequal treatment confronting racial and ethnic disparities in healthcare.
        National Academy Press, Washington DC2002
        • Harris M.I.
        • Eastman R.C.
        • Cowie C.C.
        • Flegal K.M.
        • Eberhardt M.S.
        Racial and ethnic differences in glycemic control of adults with type 2 diabetes.
        Diabetes Care. 1999; 22: 403-408
        • Karter A.J.
        • Ferrara A.
        • Liu J.Y.
        • Moffet H.H.
        • Ackerson L.M.
        • Selby J.V.
        Ethnic disparities in diabetic complications in an insured population.
        JAMA. 2002; 287: 2519-2527
        • Cowie C.C.
        • Port F.K.
        • Wolfe R.A.
        • Savage P.J.
        • Moll P.P.
        • Hawthorne V.M.
        Disparities in incidence of diabetic end-stage renal disease according to race and type of diabetes.
        N Engl J Med. 1989; 321: 1074-1079
        • Pugh J.A.
        • Stern M.P.
        • Haffner S.M.
        • Eifler C.W.
        • Zapata M.
        Excess incidence of treatment of end-stage renal disease in Mexican Americans.
        Amer J Epidemiol. 1988; 127: 135-144
        • Saaddine J.B.
        • Engelgau M.M.
        • Beckles G.L.
        • Gregg E.W.
        • Thompson T.J.
        • Narayan K.M.
        A diabetes report card for the United States: quality of care in the 1990s.
        Ann Intern Med. 2002; 136: 565-574
        • Cowie C.C.
        • Harris M.I.
        Ambulatory medical care for non-Hispanic whites, African-Americans, and Mexican-Americans with NIDDM in the U.S.
        Diabetes Care. 1997; 20: 142-147
        • Heisler M.
        • Faul J.D.
        • Hayward R.A.
        • Langa K.M.
        • Blaum C.
        • Weir D.
        Mechanisms for racial and ethnic disparities in glycemic control in middle-aged and older Americans in the health and retirement study.
        Arch Intern Med. 2007; 167: 1853-1860
        • Israel B.A.
        • Eng E.
        • Schulz A.J.
        Methods in community-based participatory research for health.
        John Wiley and Sons, San Francisco2005
        • Kieffer E.C.
        • Willis S.K.
        • Odoms-Young A.M.
        • et al.
        Reducing disparities in diabetes among African-American and Latino residents of Detroit: the essential role of community planning focus groups.
        Ethn Dis. 2004; 14: S27-S37
        • Two Feathers J.
        • Kieffer E.
        • Palmisano G.
        • et al.
        Development, implementation and evaluation of the REACH Detroit Diabetes Lifestyle Curriculum.
        Diabetes Educ. 2007; 33: 509-520
        • Lewin S.A.
        • Dick J.
        • Pond P.
        • et al.
        Lay health workers in primary and community health care.
        The Cochrane Database of Systematic Reviews. 2005; 1
        • Swider S.
        Outcome effectiveness of community health workers: an integrative literature review.
        Public Health Nurs. 2002; 19: 11-20
        • Navarro A.M.
        Por La Vida model intervention enhances use of cancer screening tests among Latinas.
        Am J Prev Med. 1998; 15: 32-41
        • Norris S.L.
        • Chowdhury F.M.
        • Van Let K.
        • et al.
        Effectiveness of community health workers in the care of persons with diabetes.
        Diabet Med. 2006; 23: 544-556
        • Reinschmidt K.
        • Hunter J.
        • Fernández M.
        • Lacy-Martínez C.
        • Guernsey de Zapien J.
        • Meister J.
        Understanding the success of promotoras in increasing chronic diseases screening.
        J Health Care Poor Underserved. 2006; 17: 256-264
        • Davis K.
        • O'Toole M.
        • Brownson C.
        • Llanos P.
        • Fisher E.
        Teaching how, not what: the contributions of community health workers to diabetes self-management.
        Diabetes Educ. 2007; 33: S208-S215
        • Stewart A.L.
        • Napoles-Springer A.
        • Perez-Stable E.J.
        Interpersonal processes of care in diverse populations.
        Milbank Q. 1999; 77 (274): 305-339
        • Collins K.S.
        Diverse communities, common concerns: assessing health care quality for minority Americans. Findings from the Commonwealth Fund 2001 Health Care Quality Survey.
        The Commonwealth Fund, New York2002
        • DiMatteo M.R.
        • Sherbourne C.D.
        • Hays R.D.
        • et al.
        Physicians' characteristics influence patients' adherence to medical treatment: results from the Medical Outcomes Study.
        Health Psychol. 1993; 12: 93-102
        • Cooper-Patrick L.
        • Gallo J.J.
        • Gonzales J.J.
        • et al.
        Race, gender, and partnership in the patient–physician relationship.
        JAMA. 1999; 282: 583-589
        • Kaplan S.H.
        • Gandek B.
        • Greenfield S.
        • Rogers W.
        • Ware J.E.
        Patient and visit characteristics related to physicians' participatory decision-making style.
        Med Care. 1995; 33: 1176-1187
        • Cooper L.A.
        • Roter D.L.
        • Johnson R.L.
        • Ford D.E.
        • Steinwachs D.M.
        • Powe N.R.
        Patient-centered communication, ratings of care, and concordance of patient and physician race.
        Ann Intern Med. 2003; 139: 907-915
        • Shavers V.L.
        • Lynch C.F.
        • Burmeister L.F.
        Racial differences in factors that influence the willingness to participate in medical research studies.
        Ann Epidemiol. 2002; 12: 248-256
        • Young M.
        • Klingle R.S.
        Silent partners in medical care: a cross-cultural study of patient participation.
        Health Commun. 1996; 8: 29-53
        • Kaplan S.H.
        • Greenfield S.
        • Ware Jr, J.E.
        Assessing the effects of physician–patient interactions on the outcomes of chronic disease.
        Med Care. 1989; 27: S110-S127
        • Ong L.M.
        • de Haes J.C.
        • Hoos A.M.
        • Lammes F.B.
        Doctor–patient communication: a review of the literature.
        Soc Sci Med. 1995; 40: 903-918
        • Stewart M.A.
        Effective physician–patient communication and health outcomes: a review.
        CMAJ. 1995; 152: 1423-1433
        • Heisler M.
        • Bouknight R.R.
        • Hayward R.A.
        • Smith D.M.
        • Kerr E.A.
        The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management.
        J Gen Intern Med. 2002; 17: 243-252
        • Piette J.D.
        • Schillinger D.
        • Potter M.B.
        • Heisler M.
        Dimensions of patient–provider communication and diabetes self-care in an ethnically diverse population.
        J Gen Intern Med. 2003; 18: 624-633
        • Heisler M.
        • Smith D.M.
        • Hayward R.A.
        • Krein S.L.
        • Kerr E.A.
        How well do patients' assessments of their diabetes self-management correlate with actual glycemic control and receipt of recommended diabetes services?.
        Diabetes Care. 2003; 26: 738-743
        • Bandura A.
        Self-efficacy: toward a unifying theory of behavioral change.
        Psychol Rev. 1977; 84: 191-215
        • Bandura A.
        Social foundations of thought and action.
        Prentice-Hall, Englewood Cliffs NJ1986
        • Heisler M.
        • Vijan S.
        • Anderson R.M.
        • Ubel P.A.
        • Bernstein S.J.
        • Hofer T.P.
        When do patients and their physicians agree on diabetes treatment goals and strategies, and what difference does it make?.
        J Gen Intern Med. 2003; 18: 893-902
        • Williams G.C.
        • Freedman Z.R.
        • Deci E.L.
        Supporting autonomy to motivate patients with diabetes for glucose control.
        Diabetes Care. 1998; 21: 1644-1651
        • Anderson R.M.
        • Funnell M.M.
        • Butler P.M.
        • Arnold M.S.
        • Fitzgerald J.T.
        • Feste C.C.
        Patient empowerment.
        Diabetes Care. 1995; 18: 943-949
        • Lorig K.R.
        • Sobel D.S.
        • Stewart A.L.
        • et al.
        Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial.
        Med Care. 1999; 37: 5-14
        • Bodenheimer T.
        • Lorig K.
        • Holman H.
        • Grumbach K.
        Patient self-management of chronic disease in primary care.
        JAMA. 2002; 288: 2469-2475
        • Gilliland S.S.
        • Azen S.P.
        • Perez G.E.
        • Carter J.S.
        Strong in body and spirit: lifestyle intervention for Native American adults with diabetes in New Mexico.
        Diabetes Care. 2002; 25: 78-83
        • Two Feathers J.
        • Kieffer E.C.
        • Palmisano G.
        • et al.
        Racial and Ethnic Approaches to Community Health (REACH) Detroit Partnership: improving diabetes-related outcomes among African American and Latino adults.
        Amer J Pub Health. 2005; 95: 1552-1560
        • Crabtree B.
        • Miller W.
        Doing qualitative research.
        Sage Publications, Thousand Oaks CA1999
        • Patton M.
        Qualitative research and evaluation methods.
        3rd ed. Sage Publications, Thousand Oaks CA2002
        • Educators AAoD
        Diabetes community health workers.
        Diabetes Educ. 2003; 29: 818-824