Transition to Virtual Diabetes Self-Management Education Delivery in the Setting of Health Care Disruption for Adults With Diabetes and Their Support Persons

Patient and family engagement in culturally-tailored diabetes self-management education in a Hispanic community.

Introduction: In the United States, disparities in cancer screening, morbidity, and mortality are well documented, and often are related to race/ethnicity and socioeconomic indicators including income, education, and healthcare access. Public health approaches that address social determinants of health have the greatest potential public health benefit, and can positively impact health disparities. As public health interventions, community health workers (CHWs), and patient navigators (PNs) work to address disparities and improve cancer outcomes through education, connecting patients to and navigating them through the healthcare system, supporting patient adherence to screening and diagnostic services, and providing social support and linkages to financial and community resources. Clinical settings, such as federally qualified health centers (FQHCs) are mandated to provide care to medically underserved communities, and thus are also valuable in the effort to address health disparities. We conducted a systematic literature review to identify studies of cancer-related CHW/PN interventions in FQHCs, and to describe the components and characteristics of those interventions in order to guide future intervention development and evaluation.Method: We searched five databases for peer-reviewed CHW/PN intervention studies conducted in partnership with FQHCs with a focus on cancer, carried out in the United States, and published in English between January 1990 and December 2013.Results: We identified 24 articles, all reporting positive outcomes of CHW/PNs interventions in FQHCs. CHW/PN interventions most commonly promoted breast, cervical, or colorectal cancer screening and/or referral for diagnostic resolution. Studies were supported largely through federal funding. Partnerships with academic institutions and community-based organizations provided support and helped develop capacity among FQHC clinic leadership and community members.Discussion: Both the FQHC system and CHW/PNs were borne from the need to address persistent, complex health disparities among medically underserved communities. Our findings support the effectiveness of CHW/PN programs to improve completion and timeliness of breast, cervical, and colorectal cancer screening in FQHCs, and highlight intervention components useful to design and sustainability.

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The purpose of the study was to assess a culturally tailored, family-focused diabetes self-management education and support intervention with community health worker (CHW) support among Black families with prediabetes and diabetes. The study enrolled 70 Black family members and assigned them CHWs for a 20-week diabetes prevention and self-management education and support intervention. Family members and CHWs were interviewed, and thematic analysis identified 4 themes associated with family-CHW dynamics that affected program outcomes: (1) family and CHW communication, (2) health literacy support, (3) technology support, and (4) program adherence support. The communication dynamics were bidirectional, and the health literacy, program adherence, and technology support flowed from CHWs to families. Participants appreciated that their CHWs were empathetic, relatable, adaptable, and good communicators, and both families and CHWs spoke of strong emotional and task-based bonds. CHWs' positive impact on adherence was confirmed. Data on health literacy and technology support activities identify families' additional needs to be successful in these programs. The study results on family-CHW dynamics add to the literature on family-based diabetes prevention and self-management education and support programs and the limited literature on how participants and CHWs interact, communicate, and share information during lengthy chronic disease programs. Expanding the public health impact of diabetes programs for Black adults may come from innovations in family-based programs supported by positive CHW interactions.

Research suggests that community health worker (CHW) integration within clinical care teams can improve chronic disease outcomes and address health-related social needs. However, the processes by which CHWs are integrated in Federally Qualified Health Centers (FQHCs) and organizational factors enabling their success remain incompletely understood. Within the context of a national initiative sponsored by the Centers for Disease Control and Prevention, this study assessed CHW integration across three North Carolina FQHCs with distinct patient populations, management systems, and levels of prior CHW experience to identify facilitators, barriers, and CHW impact. We conducted a qualitative evaluation using inductive thematic analysis of semistructured key informant interviews with CHWs, their managers, and clinicians at each FQHC. Transcripts were analyzed using reflexive thematic analysis to identify themes and extract representative quotes. Facilitators included collaboration, targeted training, management systems, prior CHW and clinician experience, and organizational support. Barriers included unclear CHW role definition, CHW capacity and community resource constraints, and inconsistent communication about integration strategies. CHWs supported care coordination, health-related social needs referrals, and chronic disease management, improving patient engagement and outcomes. Findings confirmed known enablers and barriers to CHW integration, including role definition, capacity constraints, resource availability, and supportive leadership. We additionally identified novel factors impacting CHW integration, including the influence of prior experience of CHWs and clinical staff, CHW leadership in workflow development, the role of peer-learning collaboratives, and the importance of inclusive communication and data practices. Integration was most successful when CHWs shaped workflows, clinicians and managers had foundational CHW understanding, and collaborative learning spaces enabled peer exchange. These findings highlight the importance of CHW-centered program design and implementation, and may enhance existing frameworks for clinical integration of CHWs in FQHCs and similar settings.

Introduction: Over 30 million low-income and underinsured individuals in the U.S. receive primary care services, including colorectal cancer (CRC) screening, at Federally Qualified Health Centers (FQHCs). Given known differences in healthcare access in rural settings, we aimed to quantify CRC screening rates and factors associated with a decline in screening between 2019 and 2020 at FQHCs based on urban-rural status. Methods: We abstracted data from the Uniform Data System (UDS)—which compiles preventive health utilization data, including CRC screening rates among patients ages 50-74—for each FQHC. Our primary outcome was screening rate change (SRC), calculated as 2020 CRC screening rate minus 2019 CRC screening rate. We separated FQHCs based on urban-rural status and then created quartiles based on SRC. We used Wilcoxon Rank-Sum and x2 testing to compare rural and urban FQHCs and performed backward stepwise multivariable logistic regression to determine FQHC-level characteristics (2020 data) associated the largest decline in screening participation between 2019 and 2020 (SRC Q1 status). Results: In 2020, 734 urban and 527 rural FQHCs served 6,438,433 patients who were age-eligible for CRC screening. FQHC characteristics were significantly different between urban and rural FQHCs (Table). CRC screening rates were lower in rural FQHCs than urban FQHCs in 2019 (p=0.04) and 2020 (p< 0.0001), and SRC was lower in urban (-3.6%) than rural (-1.2%) FQHCs (p< 0.0001) (Table). Urban FQHCs were more likely to see a decline in CRC screening in 2020 if they served a majority non-Hispanic Black patients (aOR 2.05, 95%CI=1.19-3.52) or if they served a high proportion of uninsured patients (data not shown). Rural FQHCs were more likely to see a decline in CRC screening in 2020 if they served a majority Hispanic/Latinx patients (aOR 2.78, 95% CI=1.50-5.15) or if they were in a non-Medicaid expansion state (aOR 1.81, 95% CI 1.09-2.99) (data not shown). SRC was calculated by state for rural FQHCs and mapped in the Figure. Conclusion: Urban FQHCs had a greater decline in CRC screening rates from 2019 to 2020 than rural FQHCs and experienced larger declines if the patient population was predominantly Black or uninsured. Rural FQHCs saw a steep decline if they served a majority Hispanic/Latinx population or were in a non-Medicaid expansion state. These findings suggest that efforts to increase CRC screening at US FQHCs may need to be tailored to their location, demographics, and insurance and Medicaid eligibility status.Figure 1.: Map of screening rate change (2020 CRC screening rate – 2019 CRC screening rate) by state for rural FQHCs and indication of Medicaid expansion status as of 2020 Table 1. - FQHC characteristics (2020 data), colorectal cancer (CRC) screening rates (2019 and 2020), and screening rate changes (SRC) for urban and rural FQHCs in the US overall and by SRC comparison groups All FQHCs (n=1261) Urban FQHCs (n=734) Rural FQHCs (n=527) p-value* Frequency or percent SRC Q1 (n=218) SRC Q2+Q3+Q4 (n=516) Total (n=734) SRC Q1 (n=98) SRC Q2+Q3+Q4 (n=429) Total (n=527) Total patients eligible for CRC screening (age 50-74) 6,438,433 1,328,330 2,811,734 4,140,064 483,110 1,815,259 2,298,369 n/a CRC screening rate in 2019 (median %) 42.9 48.0 38.3 41.6 48.5 43.7 44.7 0.04 CRC screening rate in 2020 (median %) 38.8 32.4 38.8 36.9 32.7 43.9 42.4 < 0.0001 Median 2019-2020 SRC -2.7 -13.7 -1.2 -3.6 -12.6 0.1 -1.2 < 0.0001 Male patients (median %) 42.9 42.1 42.3 42.2 43.4 43.9 43.8 < 0.0001 Majority Race/Ethnicity served at FQHC (median %) Non-Hispanic White 36.4 16.0 25.2 21.7 66.9 70.4 70.1 < 0.0001 Non-Hispanic Black 8.2 12.7 19.1 17.3 2.6 1.6 1.6 < 0.0001 Hispanic/Latinx 15.8 33.4 24.7 26.8 7.7 5.5 6.1 < 0.0001 Other Non-Hispanic 4.6 5.2 5.9 5.7 2.5 3.4 3.3 < 0.0001 Patients with a preference for non-English Language (median %) 11.7 27.1 17.9 19.2 6.7 3.5 3.8 < 0.0001 Patients experiencing homelessness (median %) 1.8 3.2 2.6 2.7 1.1 1.0 1.0 < 0.0001 Patients with income Level >200% FPL (median %) 4.6 2.9 3.8 3.5 6.5 8.1 7.8 < 0.0001 Uninsured patients (median %) 19.6 23.9 21.5 22.3 19.7 16.2 16.7 < 0.0001 Medicaid Expansion (%) 71.6 76.6 73.6 74.5 59.2 69.5 67.6 0.007 *p-values represent Wilcoxon rank-sum or chisq tests comparing overall characteristics between urban and rural FQHCs.

To explore how Federally Qualified Health Centers (FQHCs) are addressing food insecurity by understanding their existing and needed services, policies, and community partnerships using a social determinants of health perspective to promote health equity. A mixed-methods, exploratory case study research design consisting of two phases was conducted in 2023. Phase I involved a survey of FQHC leaders in Ohio. From these data, eight FQHC cases were identified for Phase II qualitative interviews of staff and patients. Ohio Federally Qualified Health Centers. Executives, Frontline Staff and Patient Board Members of Federally Qualified Health Centers. Policies, services, and community partnerships used by FQHCs to address food insecurity; FQHC screening staff and tools; resources to support food security; facilitators and barriers; FQHC methods to address health equity. The majority of survey respondents (54%) stated that nutrition counseling was the most popular FQHC service provided, followed by the National Diabetes Prevention Program, and National Hypertension Control Initiative each at 24%. Policies related to federal food programs were listed by most respondents (N = 18) for addressing food insecurity, followed by food assistance programs including food pantries and food banks (N = 14). Farmers markets (40.54%) and local health departments (21.62%) were listed most frequently as community partners for FQHCs. Equity-related responses included screening all patients for food insecurity and having the screening tool available in multiple languages. FQHCs provide services to underserved and at-risk patients. The top three diet-related chronic diseases addressed by FQHCs were diabetes, hypertension, and obesity. The most common social determinants of health concerns were food insecurity and transportation. Federally Qualified Health Centers staff and patient board members indicated that there should be an increased focus on equity.

As trusted members of their communities, community health workers (CHWs) have the potential to link hard-to-reach underserved populations with appropriate health care. As part of a National Cancer Institute (NCI)-funded initiative, we are examining the effectiveness of CHWs at increasing cervical cancer screening among minority women. CHWs are placed at one of three federally qualified health centers (FQHCs)/FHQC-look alike and obtain additional input from project specific Community Advisory Boards (CABs) in each community. Using a mixed methods approach consisting of quantitative recruitment data as well as key informant interviews we have identified several barriers and enablers for outreach, recruitment and retention of participants in our project. CHW characteristics facilitating study participant recruitment and retention include: personality, prior field experience, language, cultural congruence, degree of familiarity with community, ability to connect with their CAB members and degree of interaction with existing resources at their respective FQHCs (programmatic, structural, environmental and personnel). Ongoing CWH training and quality control were also important enablers of achieving our recruitment targets. Study participant characteristics such as cultural norms/beliefs, immigration status, health insurance, and economic factors (ability to meet clinic co-payments) were frequently cited as barriers. Structural/organizational characteristics of each FQHCs such as how health services are delivered, paperwork requirements, accessibility of location and tight linkages with local health departments also served as enablers and/or barriers. Lessons learned from our CHW led cervical cancer screening study can be applied to many distinct community based programs aimed at improving health care in underserved communities. Note: This abstract was withdrawn after the Proceedings was printed and was not presented at the conference. Citation Format: Brendaly Rodriguez, Shelia McCann, Olveen Carrasquillo, Erin Kobetz, Anthony Amofah, Tulay Koru-Sengul. Barriers faced and enablers used by community health workers in 3 underserved communities on cervical cancer screening among Haitian, Hispanic, and African American women. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr A35. doi:10.1158/1538-7755.DISP13-A35

Background: There are well-documented disparities in diabetes care outcomes and technology usage, stemming from differences in healthcare access, distrust in healthcare providers, and other factors. This study evaluated patient-level outcomes of a diabetes support coach (DSC) intervention aimed at improving underserved adults' diabetes technology use, diabetes distress, and HbA1c levels. Methods: As part of a Project Extension for Community Healthcare Outcomes (ECHO) Diabetes program, a social support intervention involving 28 DSCs was piloted at 33 Federally Qualified Health Centers (FQHCs) in Florida and California from May 2021 to May 2022. DSCs, who were adults with diabetes, served in a capacity similar to peer mentors and community health workers and received uniform training/oversight by a clinical team. Intervention participants (n = 74 adults with insulin-requiring diabetes at FQHCs) self-enrolled and engaged with DSCs via text messages, phone calls, and events. Participants' outcomes were evaluated cross-sectionally via the Diabetes Distress Scale (DDS-17) and a diabetes technology usage survey and longitudinally via HbA1c tests upon enrollment and at 6-month follow-up. A group of adults with insulin-requiring diabetes from the same FQHCs who did not receive the DSC intervention (n = 363) was used for comparison. Descriptive statistics were computed for all outcomes (n, percentage; mean, SD/95% CI). Between-group comparisons were evaluated via chi-squared and t-tests. Results: DSC intervention participants reported significantly lower diabetes distress than the comparison group (DDS-17 score mean = 1.6 vs. 2.1, p < 0.001), and significantly more participants in the DSC intervention regularly used continuous glucose monitors (CGMs) than the comparison group (69.9% vs. 38.8%, p < 0.0001). There were no significant differences in insulin pump usage or HbA1c. Conclusions: Lower diabetes distress and greater CGM usage among intervention participants suggest that the DSCs' shared lived experiences and healthcare navigation support positively influenced underserved adults' outcomes. These findings show DSCs' potential for improving diabetes care and technology equity.

ObjectivePopulation-based studies of reasons for not participating in diabetes self-management education (DSME) are scarce. Therefore, we investigated what sociodemographic and disease-related factors are associated with participation in DSME, the reasons for not participating in DSME and how participants evaluate DSME.Research design and methodsWe used data from the nationwide survey “Disease knowledge and information needs–Diabetes mellitus 2017”, which included a total of 1396 participants diagnosed with diabetes mellitus (diabetes; n = 394 DSME-participants, n = 1002 DSME-never-participants). Analyses used weighted logistic or multinominal regression analyses with bivariate and multivariable approaches.ResultsParticipants were more likely to attend DSME if they had a medium (OR 1.82 [95%CI 1.21–2.73]),or high (OR 2.04 [95%CI 1.30–3.21]) level of education, had type 1 diabetes (OR 2.46 [1.24–4.90]) and insulin treatment (OR 1.96 [95%CI 1.33–2.90]). Participants were less likely to attend DSME if they lived in East Germany (OR 0.57 [95%CI 0.39–0.83]), had diabetes for >2 to 5 years (OR 0.52 [95%CI 0.31–0.88] compared to >5 years), did not agree that diabetes is a lifelong disease (OR 0.30 [95%CI 0.15–0.62], had never been encouraged by their physician to attend DSME (OR 0.19 [95%CI 0.13–0.27]) and were not familiar with disease management programs (OR 0.67 [95%CI 0.47–0.96]). The main reasons for non-participation were participant’s personal perception that DSME was not necessary (26.6%), followed by lack of recommendation from treating physician (25.7%) and lack of information on DSME (20.7%). DSME-participants found DSME more helpful if they had a medium educational level (OR 2.06 [95%CI 1.10–3.89] ref: low level of education) and less helpful if they were never encouraged by their treatment team (OR 0.46 [95%CI 0.26–0.82]).DiscussionProfessionals treating persons with diabetes should encourage their patients to attend DSME and underline that diabetes is a lifelong disease. Overall, the majority of DSME participants rated DSME as helpful.

Background: Underserved adults are disproportionately not up-to-date with cancer screening. This systematic review examined effectiveness of multicomponent interventions (MCIs) to increase breast, cervical, and colorectal cancer (CRC) screening. Special attention was paid to underserved populations and interventions that engage community health workers (CHWs) and patient navigators (PNs). Methods: This systematic review consists of studies in high-income countries with eligible screening outcomes (recent or repeat mammography, Pap test, or CRC screening). Summary effects were calculated and stratified by income, insurance, involvement of Federally Qualified Health Centers (FQHCs) or community health centers (CHCs), and involvement of CHWs and PNs. Results: Eighty-eight studies were included. Among majority low-income populations, MCIs increased breast (median increase 10.5 percentage points (pp), interquartile interval (IQI) 6.5-25.7; 10 arms), cervical (median 7.0 pp, IQI 5.3-58.9; 7 arms), and CRC screening (median 15.5 pp, IQI 6.9-23.6; 13 arms). Screening use increased among majority uninsured populations across all three cancers (median 31.8 pp, range 23.2-40; 3 arms). MCIs involving FQHCs or CHCs increased breast and cervical (median 7.0 pp, IQI 2.3-11.0; 5 arms) and CRC screening (median 16.3 pp, IQI 13.9-23.8; 8 arms). Interventions engaging CHWs and PNs among low-income, majority-uninsured populations, or those utilizing FQHCs or CHCs also increased screening use across all three cancer types combined (CHWs: median 15.5 pp, IQI 5.8-60.1; 10 arms; PNs: median 11.9 pp, IQI 7.0-15.5; 11 arms). Conclusions: MCIs targeting underserved populations are effective in increasing breast, cervical, and CRC screening. MCIs engaging CHWs and PNs are effective among these populations. Citation Format: Devon Okasako-Schmucker, Yinan Peng, Susan Sabatino, Ismaila Ramon, Kristin Tansil Roberts, Shawna L. Mercer, Randy Elder. A community guide systematic review of multicomponent interventions to increase breast, cervical, and colorectal cancer screening: Findings in underserved populations [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr C70.

Diabetes self-management education (DSME) programs are evidence-based interventions that improve glycemic control and self-care behaviors, yet their effectiveness may be limited by unaddressed health-related social needs (HRSN) (e.g., food insecurity, housing or utility instability, transportation barriers). This qualitative multiple case study examined the feasibility of integrating HRSN assessments into DSME delivery within three community-based organizations (CBOs) across urban and rural U.S. settings. Guided by the Consolidated Framework for Implementation Research, semi-structured interviews were conducted with 15 DSME facilitators and program leadership to identify contextual factors influencing implementation. Findings revealed that while DSME's structured, manualized design promotes fidelity and client autonomy, it constrains responsiveness to the client's HRSN. Facilitators expressed openness to integrating HRSN screening, particularly during intake, yet cited limited infrastructure, role clarity, and training as key barriers. CBOs were recognized as trusted, accessible spaces for holistic care, but growing expectations to address HRSN without adequate resources for referral created sustainability concerns. Participants recommended a parallel support model involving navigators or community health workers to manage HRSN screening and referrals alongside DSME sessions. Integrating HRSN assessment processes into DSME may enhance engagement, reduce attrition, and extend the reach of diabetes education to populations most affected by HRSN. However, successful implementation requires dedicated funding, workforce development, and cross-sector coordination. Findings underscore the importance of supporting CBOs as critical partners in bridging diabetes education and social care to advance whole-person, chronic disease management.

BackgroundDiabetes self-management education and support (DSMES) programs have struggled to deliver sustainable, effective support for adults with diabetes (AWDs) to improve self-management behaviors, achieve glycemic goals, and reduce risk for complications. One largely untapped resource for this support is AWDs’ social networks. Fifty to 75% of AWDs have an unpaid family member or friend (“support person”) who provides ongoing help with diabetes management. However, DSMES interventions to date lack structured and effective approaches to directly engage support persons in AWDs’ diabetes management.MethodsThis parallel arm randomized trial is designed to determine the effectiveness of Family Support for Health Action (FAM-ACT), a novel community health worker (CHW)-delivered program focused on educating and supporting patients with type 2 diabetes (T2D) and their support persons (SPs), relative to an established, CHW-delivered, individual patient-focused DSMES and care management (I-DSMES) intervention. Both interventions were developed using a community-based participatory research (CBPR) approach.The study will be conducted in partnership with an urban Federally Qualified Health Center (FQHC) serving a low-income, Latino/a community, with target enrollment of 268 dyads consisting of an FQHC patient with T2D with high HbA1c and an SP. Patient-SP dyads will be randomized to receive FAM-ACT or I-DSMES over 6 months.The primary outcome is change in patient HbA1c from baseline to 6 months. Secondary patient outcomes include 12-month change in HbA1c, changes in patient blood pressure, diabetes self-management behaviors, diabetes distress, patient activation, diabetes self-efficacy, and perceptions of and satisfaction with SP support for diabetes. Secondary SP outcomes include self-efficacy for helping the patient with diabetes management and SP distress about the patient’s diabetes. We also will assess the effect of the COVID-19 pandemic on patient’s ability to manage diabetes.DiscussionThis study will inform scalable, evidence-based approaches that leverage family support to help AWDs improve and sustain self-management strategies that underpin optimal management of multiple diabetes complication risk factors. The protocol is designed for and evaluated with a low-income and predominantly Latino/a community, which may increase applicability to other similar communities. The COVID-19 pandemic presented several challenges to study protocol and intervention delivery; modifications made to address these challenges are described.Trial registrationClinicalTrials.gov NCT03812614. Registered on 18 January 2019.

This was a randomized controlled study to test a scalable intervention model addressing the need for ongoing diabetes support. The study included individuals receiving care in a Federally Qualified Health Center (FQHC) with HbA1c >8. The aim of this project was to determine whether augmenting diabetes self-management education (DSME) with support for an economically vulnerable population might better meet patient needs and reduce morbidity and premature mortality. The intervention utilized pre and post comparisons and was designed to test the efficacy of a telephonic diabetes support intervention to increase patient engagement in self-care and with the health care system as a means to improve clinical outcomes. There were significant improvements in HbA1c, body mass index, low-density lipoprotein cholesterol, triglycerides, and depression screening scores in the year following DSME. However, there was no statistically significant difference between the 2 groups. This randomized controlled study demonstrated that comprehensive face-to-face care with consistent assessment and documentation over time in FQHCs produce clinically significant and predictable improvement for people with diabetes. The addition of structured provision of telephonic support overlapping in time with the comprehensive face-to-face process of care in this environment did not produce statistically significant clinical or behavioral care improvement.