Working with Bilingual Community Health Worker Promotoras to Improve Depression and Self-Care among Latino Patients with Long-Term Health Problems

This project has results

Abstracts

Public Abstract

Download this abstract: English (pdf) | Español (pdf) | Audio Recording (mp3)

What was the research about?

Depression is a health problem that makes people feel sad, hopeless, or empty most days. Depression makes it hard for people to take care of themselves. It is common among people who have other health problems, such as diabetes or heart disease. Many people with low income have depression.

This study about depression treatment took place at three community health clinics. The research team wanted to learn if adding help from a community health worker, or a promotora in Spanish, to regular care could improve depression and overall health. Promotoras spoke English and Spanish. They had training in helping patients learn how to manage their diseases, work with their doctors, and know what community resources were available.

What were the results?

This study found no differences between patients who had help from promotoras and patients who received regular care alone. After 12 months, patients in both groups managed their illnesses better, felt less depressed, had less pain, and had less stress.

Who was in the study?

The study included 348 patients, almost all of whom were Latino, at three health clinics in Los Angeles, California. About 85 percent were women and 91 percent were born outside the United States. Patients were adults with low income and an average age of 57. Each patient had depression along with diabetes, heart disease, or both.

What did the research team do?

The research team assigned patients to one of two groups by chance. Patients in the first group met with trained promotoras once a week for six weeks in person or by phone. Then, for three more months, patients talked with the promotoras once a month by phone or in person. Promotoras talked with patients about their mood and health problems, ways to communicate with their doctors or nurses, and ways to take care of themselves. Promotoras also helped patients meet needs such as getting food or rides to the health clinic.

Patients in the second group received regular care at the health clinic. Patients in both groups received care from doctors and nurses for depression and other illnesses.

The research team gathered information from the patients using surveys before the study started, 6 months after the study started, and 12 months after the study started. The team compared information from patients in both groups.

What were the limits of the study?

After the study started, the Los Angeles health clinics made changes to improve regular care, including hiring community health workers. These changes made the two study groups more alike than the study team had planned, which made it hard to measure the effect of the promotoras. The study team also didn’t get survey results from 30 percent of patients 12 months after the study started. Results may have been different if the team had feedback from all patients.

Future research could look at ways promotoras and other community health workers help patients manage their health and health care.

How can people use the results?

Both care from promotoras and regular care that included community health workers helped patients manage their diseases, feel less depressed, have less pain, and have less stress. Clinics can consider using these methods to help Latino patients with depression and other long-term health problems.

Professional Abstract

Objective

To compare the effectiveness of community-based disease self-management support from promotoras, English–Spanish bilingual community health workers, versus the effectiveness of usual care, in improving patient depression and overall health at safety net health systems serving Latino patients with depression and co-occurring diabetes or heart disease

Study Design

Design Element	Description
Design	Randomized controlled trial
Population	348 English- and Spanish-speaking adults with depression and co-occurring diabetes, heart disease, or both
Interventions/ Comparators	A Helping Hand (AHH) intervention involving English–Spanish bilingual community health worker promotoras plus usual care at a safety net patient-centered medical home (PCMH) PCMH services alone (usual care)
Outcomes	Primary: depression symptoms, disease self-management Secondary: health services utilization, physical function, disability, pain, stress, social support
Timeframe	12-month follow-up for primary outcomes

This randomized controlled trial compared an intervention called A Helping Hand (AHH), which involves self-management support from promotoras, versus the standard Los Angeles County Department of Health Services (DHS) patient-centered medical home (PCMH) model of care for Latino patients with depression and concurrent diabetes or heart disease. The research team wanted to see if the addition of promotoras to usual care affected patients’ depression symptoms or disease self-management.

The research team recruited promotoras from Visión y Compromiso, an organization that provides training and employment opportunities for promotoras to work in community agencies. Promotoras received intensive training in health-literacy skill development and in working with marginalized groups.

The research team designed the AHH program to teach disease self-management skills and help patients communicate with clinic medical providers. The intervention consisted of six weekly sessions, in person or by phone, with one of three trained promotoras. During these sessions, promotoras built rapport with patients, assessed patients’ self-care needs, taught self-care strategies, helped patients navigate community resources, planned next steps, and collected patient feedback. Three shorter monthly sessions followed the six weekly sessions.

Usual care for both groups of patients included customary depression care from a team of medical providers.

After recruitment and baseline assessment, the research team randomly assigned patients to receive either AHH or usual care. Researchers surveyed patients at baseline, 6 months, and 12 months to assess depression symptoms, disease self-management, use of health services, physical function, disability, pain, stress, and social support.

This study included three safety net clinics with similar demographics. Of the 348 patients who took part in baseline assessments (178 in the AHH group, 170 in usual care), 122 patients remained in each group at the end of 12 months. Patients were predominantly Latino (99%), female (85%), and born outside the United States (91%). The average patient age was 57. Patients had low household income, and a significant number lived below the poverty line. Eighty-five percent of patients had diabetes, 4% had heart disease, and 11% had both.

Results

There were no differences between patients in the AHH and usual-care groups from baseline to 12 months in the primary outcomes of depression symptoms and disease self-management. However, patients in both groups showed significant improvements in these outcomes over time (p<.001).

There were also no significant differences between patients in the AHH and usual-care groups in secondary outcomes. However, patients in both groups showed significant improvements in disability, pain, and social support over time (p<.001).

Limitations

Due to attrition, 30% of patients did not complete the follow-up interview at 12 months. During the study period, DHS expanded its PCMH model of care, providing services that were originally unique to the intervention. These services included depression screening, self-care management, and access to community health workers serving in a similar role to the promotoras. These changes to the usual-care group likely confounded study results.

Conclusions and Relevance

Researchers found no differences in outcomes between the AHH program and the PCMH care. Both programs improved health outcomes over time for Latino patients with low incomes who had depression and concurrent long-term health problems.

Future Research Needs

Future research could focus on determining which parts of AHH and PCMH care improve outcomes over time by comparing these models with standard care.

Peer-Review Summary

Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.

The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.

Reviewers’ comments and the investigator’s changes in response included the following: To address its adherence to PCORI’s Methodology Standards, the awardee clarified the ways patient and stakeholder engagement and contributions led to changes in study design. The awardee described how it used patient input in formulating the research question.
The awardee revised the data analysis section of the methods section to more completely describe the statistical approaches it used to calculate power to detect clinically meaningful differences, conduct the main analyses, account for missing data, and do sensitivity analyses to evaluate the effects of the high attrition of participants during the follow-up period.
The awardee revised its conclusions to clarify that the active promotora intervention did not significantly improve primary or secondary outcomes, and to acknowledge that the study did not prove that either of the interventions were responsible for improvements in the study outcomes over time.

Final Research Report

View this project's final research report.

Conflict of Interest Disclosures

View the COI disclosure form.

Journal Articles

Contemporary Clinical Trials

Promotora assisted depression and self-care management among predominantly Latinos with concurrent chronic illness: Safety net care system clinical trial results

Diabetes Care

Associations Between Changes in Depressive Symptoms and Social Support and Diabetes Management Among Low-Income, Predominantly Hispanic Patients in Patient-Centered Care

Contemporary Clinical Trials

Promotora assisted depression care among predominately Hispanic patients with concurrent chronic illness: Public care system clinical trial design

Research On Social Work Practice

Integrating biopsychosocial intervention research in a changing health care landscape

Project Details

Principal Investigator

Kathleen Ell, DPH

Project Status

Completed; PCORI Public and Professional Abstracts, and Final Research Report Posted

Project Title

A Helping Hand to Activate Patient-Centered Depression Care among Low-Income Patients (AHH)

Board Approval Date

September 2013

Project End Date

December 2017

Organization

University of Southern California

Year Awarded

2013

State

California

Year Completed

2017

Project Type

Research Project

Health Conditions

Mental/Behavioral Health

Depression

Multiple/Comorbid Chronic Conditions

Cardiovascular Diseases

Congestive Heart Failure

Funding Announcement

Addressing Disparities

Project Budget

$1,377,585

DOI - Digital Object Identifier

10.25302/3.2018.AD.13047364

Study Registration Information

HSRP20143390

NCT02147522

Page Last Updated:

April 18, 2019