Community Health Worker Program Outcomes for Diabetes and Hypertension Control in West Bank Refugee Camps: A Retrospective Matched Cohort Study

Asmaa Rimawi; Adarsh Shah; Henry Louis; David Scales; Jawad Abu Kheiran; Nashat Jawabreh; Sofia Yunez; Masako Horino; Akihiro Seita; Bram Wispelwey

doi:10.9745/GHSP-D-22-00168

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Community health workers in the West Bank discuss symptoms with a patient. © 2018 Nashat Jawabreh/Health for Palestine
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Community health workers in the West Bank check a patient’s blood glucose during one of their first home visits. © 2018 Nashat Jawabreh/Health for Palestine
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FIGURE 1
Selection of Intervention Patient Group, Bethlehem Governorate, West Bank^a
Abbreviations: A1c, hemoglobin A1c; CHW, community health worker; H4P, Health for Palestine; T2DM, type 2 diabetes mellitus; UNRWA, United Nations Relief and Works Agency for Palestine Refugees in the Near East.
^a Of the 101 patients enrolled in H4P, 47 of the patients had a diagnosis of T2DM upon enrollment into the program. Of these 47 patients, 11 patients were excluded from the study for having a baseline hemoglobin A1c of less than or equal to 6.4. An additional 5 patients were excluded for receiving any diabetic care and A1c testing from a facility other than the UNRWA Bethlehem clinic. One patient was excluded for being in the program for less than 6 months. The remaining 30 patients met the eligibility criteria and were included in the study as the intervention group, or “with CHW care” group.
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FIGURE 2
Selection of Control Patient Group, Bethlehem Governorate, West Bank^a
Abbreviations: A1c, hemoglobin A1c; CHW, community health worker; UNRWA, United Nations Relief and Works Agency for Palestine Refugees in the Near East.
^a Data on potential matches included 2,374 potential controls. 1,187 patients without a second A1c value in the UNRWA records were removed from the database. Matches were selected from the remaining 1,157 potential controls and served as the “without CHW care” group. Three matches were selected for every patient within the intervention group.
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FIGURE 3
Status of Type 2 Diabetes Patients at Baseline, Bethlehem Governorate, West Bank in CHW Group (A) and Non-CHW Group (B)
Abbreviation: CHW, community health worker.
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FIGURE 4
Status of Type 2 Diabetes Patients at Follow-up, Bethlehem Governorate, West Bank in CHW Group (A) and Non-CHW Group (B)
Abbreviation: CHW, community health worker.

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TABLE 1.

Characteristics of Patients with Type 2 Diabetes, Bethlehem Governorate, West Bank^a

Patient Characteristics	With CHW Care (n=30)	Without CHW Care (n=90)	P Value
Mean age, years (range)	62.3 (38–84)	61.8 (39–83)	.71
Women, No. (%)	19 (63.3)	57 (63.3)	.83
Mean baseline A1c (SD)	8.6 (1.7)	8.6 (1.7)	.89
Mean follow-up time, months	11.2	12.3	.06
Prescribed insulin, No. (%)	10 (33.3)	41 (45.6)	.29
Prescribed OHA, No. (%)	30 (100)	48 (53.3)	.19
Prescribed anti-HTN, No. (%)	26 (86.7)	79 (87.7)	1.0
Physical activity, No. (%)	8 (26.7)	9 (10)	.03
Smoker, No. (%)	8 (26.7)	3 (3.3)	.001
Myocardial infarction history, No. (%)	7 (23.3)	10 (11.1)	.13
Stroke history, No. (%)	2 (6.7)	1 (1.11)	.15

Abbreviations: A1c, hemoglobin A1c; anti-HTN, antihypertensive medications; CHW, community health worker; OHA, oral hypoglycemic agent; SD, standard deviation.
↵^a T-test for age and baseline A1c, Satterthwaite for follow-up time, Fisher’s exact for binary variables.

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TABLE 2.

Hypertension Patient Outcomes, Bethlehem Governorate, West Bank^a

	Hypertension Patients (n=33)
	Baseline	After 1 Year	P Value	Mean Difference (95% CI)
Average BP, mmHg, systolic/diastolic (SD)	138/85 (13/8)	131/80 (12/10)	.009/.018	7.3 (1.93, 12.25) / 4.3 (0.80, 7.91)
Controlled hypertension (BP<130/80), No. (%)	0 (0)	19 (58)	<.001	N/A
Stage II hypertension (BP≥ 140/90), No. (%)	21 (64)	6 (18)	<.001	N/A

Abbreviations: BP, blood pressure; CI, confidence interval; N/A, not applicable; SD, standard deviation.
↵^a Paired 2-sided t-test.

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TABLE 3.

Diabetes Patient Outcomes, Bethlehem Governorate, West Bank^a^,^b

Predictor	Coefficient for A1c Change	P Value	95% CI
Unadjusted key measures
Enrollment in CHW intervention	−1.2	<.001	−0.51, −1.88
No enrollment in CHW intervention	0.08	.56	−0.2, 0.36
Adjusted key measures from multivariable linear regression model
Enrollment in CHW intervention	−1.4	<.001	−0.66, −2.1

Abbreviations: A1c, hemoglobin A1c; CHW, community health worker; CI, confidence interval; UNRWA, United Nations Relief and Works Agency for Palestine Refugees in the Near East.
↵^a Shown are the mean values for the outcome in the CHW group and the non-CHW group. Calculation of the unadjusted mean A1c change was based on an indicator from an ordinary least-squares regression of the outcome, with no other covariates. Calculation of the adjusted A1c change was based on an indicator for the CHW group from an ordinary least-squares regression of the outcome with prespecified covariates. All CIs were calculated with the use of heteroskedasticity-robust standard errors. Prespecified covariates included history of myocardial infarction, history of stroke, physical activity status, smoking status, and hypertension status. All covariates were measured at time of baseline A1c and were extracted from the UNRWA Bethlehem clinic medical records.
↵^b See further coefficients in Supplement Table S2.