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

Excerpt

Background: Depression has negative effects on patient self-care and social stress management. The negative effects of depression disproportionately affect low-income Latino patients with chronic medical illness.

Objectives: To evaluate the effectiveness of A Helping Hand (AHH; Programa Mano Amiga in Primary Care) for patients with depressive symptoms and comorbid medical illness.

Methods: Patients with significant depressive symptoms (9-item Patient Health Questionnaire score ≥10) and coexisting diabetes or heart disease were randomized to AHH or usual care (UC) in 3 Los Angeles County Department of Health Services (LAC-DHS) safety-net clinics that were implementing patient-centered medical home (PCMH) models. The AHH intervention supported patients, families, and care providers by facilitating self-care management skills and activating patient communication with clinic medical providers. Community based, bilingual promotoras delivered the intervention in 6 weekly in-person or telephone sessions, followed by 3 monthly booster sessions. From April 2014 to May 2015, we screened 1957 and enrolled 348 depressed patients, of whom 296 (85%) had diabetes, 14 (4%) had heart disease, and 38 (11%) had both diseases. All participants received care management materials and community resource information. An interviewer blind to intervention assignment assessed outcomes at 6 and 12 months. Baseline and outcome data include depression, mental health assessments, treatment receipt, comorbid illness self-care, social relationships, and environmental stressor assessments.

Results: Study participants were predominantly female (85%), Latino (99%), and born outside of the United States (91%). Overall study retention rate was 70% (121 AHH and 121 UC). Baseline characteristics did not vary significantly between retained and attrition groups. Half of AHH patients received 4 or more promotora sessions. Promotoras made 12 referrals to LAC-DHS providers and 154 referrals to community resources (most frequently requested community services: community/senior/wellness center, 88 occurrences; transportation, 33; food bank, 25). During the trial period, LAC-DHS activated health care improvements, including adding community health workers into UC clinics. Depression outcomes did not vary significantly between intervention and usual care groups (UC as the reference group; at 6 months: mean difference = 0.01; 95% CI, −1.3 to 1.3; at 12 months: mean difference = −1.1; 95% CI, −2.5 to 0.2); however, we found significant improvements in most assessed physical and mental health outcomes for each study group.

Conclusions: No significant differences existed in primary depression outcomes between the AHH intervention and the PCMH usual care study groups.

Limitations and Subpopulation Considerations: The challenges were to maximize intervention attendance and minimize study attrition given the high representation of immigrant, Spanish-speaking, safety-net population in the sample. The effects of the intervention were confounded by major quality improvement initiatives in the participating clinics. Future work is needed to provide a more definitive test of the AHH promotora model, while addressing these potential confounders.