Scaling Community-Clinical Linkage Models to Address Diabetes and Hypertension Disparities in the Southeast United States

Not Applicable

Completed

Brief Summary: The purpose of this study is to work with primary care physicians and their staff, and with community health workers (CHWs) to improve diabetes and hypertension management, health behaviors and improve blood pressure for South Asian patients with uncontrolled diabetes and hypertension in primary care clinics in Atlanta, Georgia. The CHWs are community members who are trained to work with patients to address health needs holistically by providing information on wellness, nutrition, stress relief, and blood pressure management in a culturally-appropriate and language-appropriate manner.

Detailed Description: The study will provide research training, technical assistance, and capacity-building to community and clinical sites in Georgia for implementation of culturally tailored, evidenced-based CHW programs to improve HTN and diabetes management for South Asians. In addition, the use a multi-theoretical framework to test the effectiveness of a CHW-led intervention compared to usual care among South Asian individuals with diabetes and uncontrolled HTN in Atlanta. The primary outcome is blood pressure control, defined as 130/80 mmHg. It is hypothesized that, compared to usual care, individuals receiving the CHW intervention will be 20% more likely to achieve blood pressure control at 6 months.

And to apply RE-AIM and CFIR frameworks to delineate factors influencing appropriateness, fidelity, adoption, and maintenance of the intervention within clinical and community settings to optimize intervention replication.

In addition, this study will serve as a national information and dissemination resource in the adaptation of evidence-based strategies to reduce geographic disparities in HTN and diabetes across Asian American groups.

Recruitment & Eligibility

Inclusion Criteria

identified as of South Asian ethnicity
are at least 21 years of age and younger than age 80
had an appointment with a physician or mid-level clinician for routine non-emergent primary care in the last 12 months
a diagnosis of diabetes
a diagnosis of hypertension
an uncontrolled BP reading (>130/80mmHg) in the last 6 months

Provider Surveys Inclusion criteria

Key Informant Interviews Inclusion criteria

CHW intervention

Exclusion Criteria

Provider Surveys Inclusion criteria

Key Informant Interviews Inclusion criteria

who are unable to participate in the interview conducted in the English language.

Arm && Interventions

Group	Intervention	Description
Community Health Workers (CHW) treatment group	CHW	Once recruited and consented, surveys will be administered and collected at baseline and 6 months in person or by a study coordinator within two weeks of completion of the CHW coaching component of the intervention. Participants enrolled in the intervention will receive monthly text and phone call reminders. in addition, multiple sessions will be hosted at varying times/days of the week to accommodate schedules of both working individuals and at-home caretakers. Finally, small incentives will be provided at each session to encourage ongoing attendance, and a cash raffle prize will be distributed at program completion for individuals who attend all five sessions.

Primary Outcome Measures

Name	Time	Method
Percentage of Patients Who Achieve Blood Pressure (BP) Control.	Month 6	The primary outcome will be the percentage of eligible patients at a practice site to achieve BP control (130/80 mmHg) six months following the index office visit. The primary outcome will be measured by the treatment participants and providers surveys.

Secondary Outcome Measures

Name	Time	Method
Change in Haemoglobin A1c (HbA1c)	6 months	Change in HbA1c will be measured in participants of CHW intervention versus the control participants. Clinical data will be retrieved from EHR.
Systolic Blood Pressure (SBP)	Month 6	SBP will be measured in participants of CHW intervention versus the control participants. Clinical data will be retrieved from EHR.
Diastolic Blood Pressure (DBP)	Month 6	DBP will be measured in participants of CHW intervention versus the control participants. Clinical data will be retrieved from EHR.
Body Mass Index (BMI)	Month 6	BMI will be measured in participants of CHW intervention versus the control participants. Clinical data will be retrieved from EHR.