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
|Randomized controlled trial
|348 English- and Spanish-speaking adults with depression and co-occurring diabetes, heart disease, or both
- 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)
Primary: depression symptoms, disease self-management
Secondary: health services utilization, physical function, disability, pain, stress, social support
|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.
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).
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.