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

Abstract

Introduction: Community health worker (CHW) programs have proven effective in improving diabetes control in many locations and settings, but data on feasibility and efficacy are lacking in the Middle East and settings of chronic violence. A Palestinian CHW program, Health for Palestine (H4P), addresses chronic diseases in West Bank refugee camps. Our study assesses the feasibility and effectiveness of the program's diabetes and hypertension interventions.

Methods: Data on home visits, patient retention, and blood pressure were extracted from the CHW records and analyzed. To assess diabetic patient progress, we conducted a retrospective matched cohort study using data obtained from a United Nations (UN) clinical database to analyze the trajectory of hemoglobin A1c (A1c) values. Thirty of the 47 diabetic patients in the H4P CHW program met study inclusion criteria and were each matched with 3 patients from the Bethlehem UN clinic (n=120). We tested for significance using multivariable linear regression with robust standard errors.

Results: The average number of home visits per patient per month was 7.3 (standard deviation=4.1), and the patient retention rate was 100% over an average of 11.2 months. For hypertension patients in the CHW program (n=33), mean systolic blood pressure decreased by 7.3 mmHg (95% confidence interval [CI]=1.93, 12.25; P=.009) and mean diastolic blood pressure by 4.3 mmHg (95% CI=0.80, 7.91; P=.018) from March 2018 to November 2019. On average, diabetic patients within the CHW group experienced a 1.4 point greater decline in A1c per year compared to those in the non-CHW group, after adjusting for potential confounders (95% CI=-0.66, -2.1; P<.001).

Discussion: The results suggest that CHW accompaniment may be an effective model for improving diabetes and hypertension control in refugee camps experiencing direct violence and extreme adversity. A low exclusion cut-off for A1c (≤6.4%) may underestimate the program's impact.

Community health workers in the West Bank discuss symptoms with a patient. © 2018 Nashat Jawabreh/Health for Palestine

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

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.

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.

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.

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.