Patients' Perspectives on the Feasibility, Acceptability, and Impact of a Community Health Worker Program: A Qualitative Study

Purpose: To examine patients' perceptions of the feasibility, acceptability, and impact of a safety net-based community health worker (CHW) program. Methods: Semistructured interviews with patient participants diagnosed with type 2 diabetes (n=13) were analyzed using a traditional text analysis method based on grounded theory. Results: This study highlights that the CHW program can improve satisfaction in accessing health services and community resources, and overall health outcomes of patients in safety net practices. Conclusion: Patients' overall positive perception of the CHW program suggests that the intervention may be a viable solution to address the health and social needs of patients in safety net settings.


Introduction
Community health workers (CHWs) are trusted members of the community with extensive knowledge about community resources and work as an integral liaison between community members and local services. 1 Recent studies have found a wide range of positive outcomes associated with implementation of a CHW intervention program. Evidence from randomized clinical trials suggest CHW interventions led to improved health outcomes, better quality of care, and reduction in hospitalizations. [2][3][4] Moreover, systematic reviews of CHW interventions suggest that CHW interventions can significantly reduce health care utilizations and cost as well as provide cost-effective interventions for certain health conditions, especially among underserved populations. 5,6 However, despite a growing body of literature on how CHWs can improve health outcomes and decrease health care utilization, there is limited evaluations and knowledge around the effectiveness of CHW programs that is based on patients' perception. Thus, there is a need for research that examines the feasibility, acceptability, and impact of the pilot CHW program.
This study focuses on patients who have participated in the CHW pilot program to (1) explore patients' perspectives on the feasibility of the CHW program, including the timing and frequency, location, and attendance at sessions, (2) understand the acceptability of the CHW program, specifically with respect to the format and content of the intervention, and in comparison with other available supports, and (3) evaluate the impact of the CHW program, particularly in the areas of patients' knowledge of and access to medical and community resources, relationship with the health care team, as well as the program's impact on patients' social support, self-efficacy, and patient-stated goals.

Methods
Participants and procedure Community Health Center, Inc. (CHCI) has adopted the outpatient Individualized Management of Patient-Centered Targets approach, 7 which is a 6-month CHW intervention where patients work with a CHW to achieve their stated health goals. The intervention included 31 adults aged 18 years or older diagnosed with type 2 diabetes (with an glycosylated hemoglobin ‡ 8) and indicated English or Spanish as their primary language. All patients (N = 31) who participated in the CHW pilot intervention were invited to participate in a study. Patients who called the research line to opt out were excluded. This study was approved by the CHCI Institutional Review Board. A subset of eligible participants (n = 13) who previously enrolled in the CHW program provided consent to participate in the study. Semistructured interviews (Appendix A1) were conducted with consented patients to understand their experiences with the CHW program.

Data analysis
Interview transcripts were analyzed using a traditional text analysis method based on classic grounded theory. 8 The construction of traditional text analysis involves identifying themes from the interview transcripts, marking up the texts that relate to the themes of the research, eliminating the texts that are not related to the subject of the research, and sorting them into thematic categories. [8][9][10] Two researchers first coded independently, followed by mutual discussions with the principal investigator to ensure the accuracy of coding. Table 1 includes a summary of demographics of the sample (n = 13). In the present sample, the average age of participants was 56 years (standard deviation = 9.2). The majority of participants identified as female (69.2%) and Hispanic or Latino (69.2%).  Outcomes related to the CHW program Patients' perspectives on the feasibility of the CHW program. Participants talked about the feasibility of the CHW program, including timing of the sessions, frequency of interaction with CHW, location of meetings, and reasons behind missed session(s) ( Table 2). The results suggest an overall satisfaction with the length of the program, flexible location arrangements, and flexibility in scheduling. All participants (n = 13) reported that the timing and frequency of sessions were adequate. With regard to the location of the engagements, the majority (n = 10) mentioned the clinic as a convenient location for them to meet. However, three partic-ipants preferred their home as the primary location for meetup given their health conditions. In addition, 11 out of 13 participants had missed meetings due to forgetfulness (n = 1), work schedule (n = 3), transportation issues, mobility issues, and health conditions (n = 7).

Patient demographics
Patients' perspectives on the acceptability of the CHW program. Participants shared perspectives on the acceptability of the CHW program, specifically on the content, perception of the CHW, in comparison with other available nonmedical supports, and key recommendations for improving the program ( Table 3). All participants (n = 13) reported being satisfied with the  Impact on health-related social needs and resources Impact on access to health-related social needs ''Food stamps, sometimes CHW gives him the bus tickets, sent them by mail. Before joining the CHW program, appointment (substance use clinic) on Wednesdays in Rushford and cannot get back (daughter or sister would drop him off). Now CHW has gotten a bus pass for him and he has a ride back.'' 01 Impact on knowledge of community resources ''Resources-there aren't many, which I've always known since I worked for shelters. Leonora tried to find new resources, but it's hard. She tried to find programs to help me, but there weren't none.'' 06 ''She's informed me about resources in the community, she's asked me if I need anything in the community, and I've said I don't need them and it's better off for someone who needs them more to have them, but it's still nice of her to ask. She's informed me about resources to help pay for utilities, for example, but I don't really need it. I think someone who is in more need should use these services, but I'm still grateful.'' 11 ''I haven't really needed help with this since I already am enrolled in multiple benefits including Medicare/Medicaid and SNAP.'' 13 Impact on social support ''I've always had my mom and my kids. I haven't had many friends because they are always negative. Leonora helped me get comfortable opening up. I talk to my daughter better now and not just argue. I used to worry, worry, worry. Now I give something everything I have and then let it go.'' 06 ''I live alone so sometimes I feel isolated. However, now that I'm in this program, I feel more connected, especially since I'm able to connect my care team on a more regular basis for my diabetes.'' 08 ''I haven't really had any challenges with my social support system, so I can't say she's really helped me in this capacity.'' 10 Impact on self-efficacy and patient goals Impact on self-efficacy ''She had very low self-esteem before. CHW said every woman has something beautiful inside them, stuck in her mind.'' 02 ''She helped me get the confidence to work two jobs to do what I needed to do. She gave me the confidence to help me sell myself and get a job. One thing she always told me is 'you got this, don't give up.' If I feel like everyone is against me, I remember those words and keep going.'' 06 ''I know I have someone who is willing to help me so I'm not on my own in getting what I need, I know I have someone who is advocating for me in whatever situation I find myself in and I can have faith and confidence that the situation will work in my favor. '' 13 (continued) program, including the usefulness and appropriateness of topics covered, as well as the structure and flow of the program. Moreover, all respondents (n = 13) were satisfied with the CHW's professionalism, resourcefulness, knowledge, and engagement. When comparing the CHW program with other nonmedical supports, nine out of 13 participants mentioned they could not compare since they have not received any other supports (n = 6) or the focus areas of other programs and interventions were different (n = 3). In terms of recommendations for improving the program, five participants suggested the expansion of the program, which reflects the need to reach more people who could benefit from the CHW program by gaining access to the required medical and social support.
Patients' perspectives on the impact of the CHW program. When describing their perception regarding the impact of the CHW program, participants focused on three major themes: health care access and engagement, health-related social needs and resources, and self-efficacy and patient goals (Table 4). Specifically, patients noted the positive impact of the CHW program on improving medical knowledge, access to medical services, and self-efficacy. Participants stated their understanding of the importance of diabetes management and self-care (n = 10), medication adherence (n = 3), and keeping medical appointments (n = 2) have improved as a result of participating in the program, and contributed to the adoption of healthy behaviors. Moreover, participants shared that issues around access to medical services such as appointment scheduling (n = 7), medication retrieval (n = 2), and transportation (n = 6) have shown improvement with the integration of the CHW program to usual care. Furthermore, related to self-efficacy, participants demonstrated the support of CHW helped reduce anxiety (n = 3), boost self-esteem (n = 8), and improve the overall patient experience and health outcome (n = 8).

Patient engagement in the CHW program
Participation in the CHW program indicated the evidence of the effectiveness on health outcome (  '' 04 ''We worked on housing and self-esteem and getting work. She also helped me with my faith and patience and knowing that where I was at that point in my life was okay and that I needed to keep going and keep fighting. I was homeless and sick when we met. My son had just gone to jail. I didn't think things would get better, but she didn't let me give up. We worked on me getting a job. I'm working almost full time now.'' 06 ''My goal in the beginning was to lose weight, this was the first thing I shared with her. My weight is still fluctuating, sometimes I lose weight, then I gain it back because it's hard for me to get to the YMCA.'' 09 showed unchanged (15.4%), and increased (15.4%) A 1c level. Furthermore, the attendance of the program has a positive impact on patient engagement, allowing patients to meet their stated health goals. The results displayed that the best-performing participants (61.5%) were the ones who were present during almost all meetings with CHW. Patients who were contacted over the phone due to their medical conditions or other personal issues reported no significant improvement in their A 1c level regardless of their good attendance.

Discussion
This study offers qualitative insights into patients' perspectives on the feasibility, acceptability, and impact of a CHW program. A CHW program is one-of-akind intervention to improve patient's self-efficacy or medication adherence, 11 and to increase access to the hard-to-reach population. 12 This study suggests the effectiveness of the CHW program in the areas of increasing health knowledge and improving access to needed health services and health outcomes, which aligns with previous research. [13][14][15][16] In addition, the results of this study demonstrate the positive effect of professionalism of the CHW in enhancing patient self-efficacy and trust. With the help of the CHW, patients acknowledged that they built up skills and confidence to achieve their target goals by modifying their lifestyle behaviors, which is consistent with earlier research that documented the benevolent relationship between CHW and community. [17][18][19] By understanding patients' experiences with the CHW program, the findings advocate for improvements and expansion of the CHW program at CHCI. This study has several limitations. First, social desirability bias might be an issue since one of the data collectors has exposure to patients. This may have reported a higher patients' perception of and satisfaction with the CHW program. Comparing patients' stated goals in the semistructured interview with their baseline goals might mitigate this bias. Second, a small sample size where the majority of the participants identified as female, unreported race, and Hispanic or Latino might affect the generalizability of this study. Nonetheless, 6-12 interviews were sufficient enough to achieve thematic saturation. 20

Conclusion
With these limitations in mind, the findings from this study have several implications on policy, practice, and research. First, the study highlights how integra-tion of CHWs into clinical care teams could encourage patient self-advocacy by providing culturally appropriate health education, interpreting services, and health care system navigation. Establishing appropriate funding mechanisms such as grants, incentives, and reimbursement would allow for the sustainability and scalability of CHW programs within safety net settings. Similarly, health care practices working to address disparities and promote patient-centered care should invest in CHWs as extensions of the care team and the role of CHW needs to be recognized more for their contribution to increase health access and improve health outcomes. Further research regarding the solution to common pitfalls of the CHW program can help improve patient self-advocacy by addressing their medical and social needs, and health outcomes by strengthening the capacity of the CHW.
Perceptions of the CHW Please describe your overall experience with the CHW.
Probe about patient's overall satisfaction with the CHW, including professionalism, resourcefulness, knowledge, and engagement.
Contrast with other nonmedical supports offered How would you compare your experience in the CHW program with other types of supports offered?
Probe about how patient's participation in CHW program compared with other similar programs, including what worked well in CHW program compared with other programs and vice versa. Probe about what changes the patient would recommend implementing (e.g., length, structure, and content of program).

Impact on knowledge (medical)
To what extent, if at all, has your understanding of your medical care improved as a result of participating in this program?
Probe about changes in patient's understanding of health needs, medical care plan, medications taken/side effects (medication adherence), test results, referrals to specialists, discharge instructions if recently hospitalized.

Impact on knowledge (community resources)
To what extent, if at all, has your understanding of resources available in the community available to you improved as a result of participating in this program?
Probe about changes in patient's understanding of community resources (e.g., transportation, childcare, insurance, debt collection, drug and alcohol counseling, food assistance, and utilities).

Impact on access to medical services
To what extent, if at all, has your access to medical services improved as a result of participating in this program?
Probe about changes in patient's ability to access needed medical services. Probe about barriers that may have existed before engagement with CHW (e.g., transportation challenges, not understanding care plan), and to what extent these challenges have been addressed through this program.

Impact on engagement with health care team
To what extent, if at all, has your engagement with the health care team improved as a result of participating in this program?
Probe about changes in patient's engagement with the health care team, including the patient's perception of the Community Health Worker being part of the health care team.

Impact on access to health-related social needs
To what extent, if at all, has your access to healthrelated social needs improved as a result of participating in this program?
Probe about changes in patient's capacity to access resources that support well-being (see examples of community resources listed earlier).

Impact on social support
To what extent, if at all, has your social support improved as a result of participating in this program?
Probe about changes in patient's perception of support from others. Probe about particular types of support systems (e.g., family, friends, community, care team, and CHW).
Impact on self-efficacy How has participating in this program impacted your belief in your ability to succeed in specific situations/ accomplish a task?
Probe about changes in confidence in ability to set goals and achieve them.
Impact on short-term goals Please describe the progress you have made toward the short-term goals you identified at the beginning of the program.
Probe about specific short-term goals developed at baseline and steps taken to achieve goals. Probe about what supported progress toward short-term goals. Probe about challenges encountered in achieving short-term goals, and what would have been helpful to have in place to overcome identified challenges. Impact on long-term goals Please describe the progress you have made toward the long-term goals you identified at the beginning of the program.
Probe about specific long-term goals developed at baseline and steps taken to achieve goals. Probe about what supported progress toward long-term goals. Probe about challenges encountered in achieving long-term goals, and what would have been helpful to have in place to overcome identified challenges.

Closing
Is there anything else you would like to share that I have not already asked?
Thank participant for his/her time.