Start Date
9-10-2025 12:00 PM
End Date
9-10-2025 1:30 PM
Description
Abstract
Title: Community Health Worker Programs for Chronic Disease Management in Urban Settings: A Scoping Review
Hardik Pipalia 1,
1Director of Research and Evaluation, ANIZ INC, Atlanta, GA; hpipalia@aniz.org ; 0000-0002-1234-5678
*Corresponding author: hpipalia@aniz.org
Received: date; Accepted: date; Published: date
Objective: To systematically map the existing literature on community health worker programs for chronic disease management in urban settings, identify key program models and implementation strategies, and determine gaps in current research evidence. Using PEO framework: P (urban residents with chronic diseases), E (community health worker interventions and programs), O (chronic disease management outcomes, program implementation, health service utilization).
Methods: Search Strategy: Comprehensive electronic search conducted across six databases: MEDLINE (via PubMed), EMBASE, CINAHL, Cochrane Library, Web of Science, and Google Scholar from January 2015 through December 2024. Search strategy developed using Medical Subject Headings (MeSH) terms and keywords including: "community health worker," "community health aide," "lay health worker," "peer health educator," combined with "chronic disease," "diabetes," "hypertension," "cardiovascular disease," "urban health," and "city." Additional searches included reference lists of included studies and consultation with subject matter experts.
Eligibility Criteria: Inclusion criteria: (1) studies examining community health worker programs or interventions; (2) focus on chronic disease management including diabetes, hypertension, cardiovascular disease, COPD, or multiple chronic conditions; (3) participants residing in urban areas or metropolitan regions; (4) any study design including experimental, quasi-experimental, observational, qualitative, and mixed-methods studies; (5) published in English language; (6) peer-reviewed journal articles and relevant gray literature reports. Exclusion criteria: rural-only populations, acute care interventions, pediatric populations under 18 years, conference abstracts without full methodology description, studies published before 2015.
Information Sources: Electronic databases with specified date ranges, final search completed January 2025. Additional sources included clinical trial registries (ClinicalTrials.gov), organizational websites of major public health agencies (CDC, WHO, NIH), and manual searching of reference lists from systematic reviews and key articles identified during screening process.
Selection of Sources: Two independent reviewers conducted title and abstract screening using predetermined inclusion and exclusion criteria. Full-text screening performed independently with disagreements resolved through discussion and consensus. When consensus could not be reached, third reviewer consultation was used for final decision-making.
Risk of Bias: Consistent with scoping review methodology, formal quality assessment was not conducted as the objective focused on mapping available evidence rather than synthesizing study effectiveness or quality.
Results: Included Studies: From 2,847 records initially identified through database searches, 1,156 underwent title and abstract screening, 284 proceeded to full-text review, and 89 studies met final inclusion criteria. Studies spanned publication years 2015-2024 with increasing frequency in recent years (2020-2024: n=58, 65%). Geographic distribution included North America (n=42, 47%), Europe (n=21, 24%), Asia (n=15, 17%), Australia/Oceania (n=7, 8%), and other regions (n=4, 4%). Study designs comprised randomized controlled trials (n=31, 35%), quasi-experimental studies (n=18, 20%), cross-sectional studies (n=16, 18%), qualitative studies (n=14, 16%), and mixed-methods studies (n=10, 11%).
Synthesis of Results: Five primary categories of community health worker program models were identified: (1) Clinical Support Programs (n=38 studies, 43%): CHWs providing medication management, appointment scheduling, care coordination, and clinical follow-up support in collaboration with healthcare providers; (2) Health Education and Behavior Change Programs (n=34 studies, 38%): CHWs delivering group education sessions, individual counseling, lifestyle modification support, and self-management training; (3) Peer Support and Navigation Programs (n=25 studies, 28%): CHWs with shared chronic disease experience providing emotional support, healthcare system navigation, and social connection facilitation; (4) Home-Based Care Management Programs (n=22 studies, 25%): CHWs conducting home visits for health monitoring, medication adherence support, and family education; (5) Technology-Enhanced Programs (n=18 studies, 20%): CHWs utilizing mobile health applications, remote monitoring devices, and digital communication platforms. Chronic disease focus areas included diabetes (n=52 studies, 58%), hypertension (n=47 studies, 53%), cardiovascular disease (n=28 studies, 31%), multiple chronic conditions (n=24 studies, 27%), and COPD (n=12 studies, 13%). Implementation settings varied including community health centers (n=41 studies, 46%), participants' homes (n=33 studies, 37%), community organizations (n=28 studies, 31%), and healthcare facilities (n=25 studies, 28%). Research gaps identified included limited long-term sustainability studies, insufficient cost-effectiveness analyses, minimal examination of program scalability, and inadequate representation of diverse urban populations including immigrants, elderly residents, and individuals with multiple comorbidities.
Conclusion: Community health worker programs for chronic disease management in urban settings encompass diverse implementation models with varying levels of evidence supporting effectiveness and feasibility. While clinical support and health education programs represent the most frequently studied approaches, significant evidence gaps exist regarding program sustainability, cost-effectiveness, and scalability across different urban contexts. The literature demonstrates growing integration of technology-enhanced approaches, though digital equity considerations remain underexplored. Future research priorities should include rigorous evaluation of long-term program outcomes, comprehensive economic evaluations, examination of implementation factors supporting program sustainability, and enhanced focus on health equity and cultural responsiveness in diverse urban populations. The expanding evidence base provides foundation for evidence-informed program development while highlighting critical knowledge gaps requiring targeted research investment.
Keywords: scoping review, community health workers, chronic disease management, urban health, implementation science, health services research
© 2025 by the authors. Submitted for possible open access publication under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
Community Health Worker Programs for Chronic Disease Management in Urban Settings: A Scoping Review
Abstract
Title: Community Health Worker Programs for Chronic Disease Management in Urban Settings: A Scoping Review
Hardik Pipalia 1,
1Director of Research and Evaluation, ANIZ INC, Atlanta, GA; hpipalia@aniz.org ; 0000-0002-1234-5678
*Corresponding author: hpipalia@aniz.org
Received: date; Accepted: date; Published: date
Objective: To systematically map the existing literature on community health worker programs for chronic disease management in urban settings, identify key program models and implementation strategies, and determine gaps in current research evidence. Using PEO framework: P (urban residents with chronic diseases), E (community health worker interventions and programs), O (chronic disease management outcomes, program implementation, health service utilization).
Methods: Search Strategy: Comprehensive electronic search conducted across six databases: MEDLINE (via PubMed), EMBASE, CINAHL, Cochrane Library, Web of Science, and Google Scholar from January 2015 through December 2024. Search strategy developed using Medical Subject Headings (MeSH) terms and keywords including: "community health worker," "community health aide," "lay health worker," "peer health educator," combined with "chronic disease," "diabetes," "hypertension," "cardiovascular disease," "urban health," and "city." Additional searches included reference lists of included studies and consultation with subject matter experts.
Eligibility Criteria: Inclusion criteria: (1) studies examining community health worker programs or interventions; (2) focus on chronic disease management including diabetes, hypertension, cardiovascular disease, COPD, or multiple chronic conditions; (3) participants residing in urban areas or metropolitan regions; (4) any study design including experimental, quasi-experimental, observational, qualitative, and mixed-methods studies; (5) published in English language; (6) peer-reviewed journal articles and relevant gray literature reports. Exclusion criteria: rural-only populations, acute care interventions, pediatric populations under 18 years, conference abstracts without full methodology description, studies published before 2015.
Information Sources: Electronic databases with specified date ranges, final search completed January 2025. Additional sources included clinical trial registries (ClinicalTrials.gov), organizational websites of major public health agencies (CDC, WHO, NIH), and manual searching of reference lists from systematic reviews and key articles identified during screening process.
Selection of Sources: Two independent reviewers conducted title and abstract screening using predetermined inclusion and exclusion criteria. Full-text screening performed independently with disagreements resolved through discussion and consensus. When consensus could not be reached, third reviewer consultation was used for final decision-making.
Risk of Bias: Consistent with scoping review methodology, formal quality assessment was not conducted as the objective focused on mapping available evidence rather than synthesizing study effectiveness or quality.
Results: Included Studies: From 2,847 records initially identified through database searches, 1,156 underwent title and abstract screening, 284 proceeded to full-text review, and 89 studies met final inclusion criteria. Studies spanned publication years 2015-2024 with increasing frequency in recent years (2020-2024: n=58, 65%). Geographic distribution included North America (n=42, 47%), Europe (n=21, 24%), Asia (n=15, 17%), Australia/Oceania (n=7, 8%), and other regions (n=4, 4%). Study designs comprised randomized controlled trials (n=31, 35%), quasi-experimental studies (n=18, 20%), cross-sectional studies (n=16, 18%), qualitative studies (n=14, 16%), and mixed-methods studies (n=10, 11%).
Synthesis of Results: Five primary categories of community health worker program models were identified: (1) Clinical Support Programs (n=38 studies, 43%): CHWs providing medication management, appointment scheduling, care coordination, and clinical follow-up support in collaboration with healthcare providers; (2) Health Education and Behavior Change Programs (n=34 studies, 38%): CHWs delivering group education sessions, individual counseling, lifestyle modification support, and self-management training; (3) Peer Support and Navigation Programs (n=25 studies, 28%): CHWs with shared chronic disease experience providing emotional support, healthcare system navigation, and social connection facilitation; (4) Home-Based Care Management Programs (n=22 studies, 25%): CHWs conducting home visits for health monitoring, medication adherence support, and family education; (5) Technology-Enhanced Programs (n=18 studies, 20%): CHWs utilizing mobile health applications, remote monitoring devices, and digital communication platforms. Chronic disease focus areas included diabetes (n=52 studies, 58%), hypertension (n=47 studies, 53%), cardiovascular disease (n=28 studies, 31%), multiple chronic conditions (n=24 studies, 27%), and COPD (n=12 studies, 13%). Implementation settings varied including community health centers (n=41 studies, 46%), participants' homes (n=33 studies, 37%), community organizations (n=28 studies, 31%), and healthcare facilities (n=25 studies, 28%). Research gaps identified included limited long-term sustainability studies, insufficient cost-effectiveness analyses, minimal examination of program scalability, and inadequate representation of diverse urban populations including immigrants, elderly residents, and individuals with multiple comorbidities.
Conclusion: Community health worker programs for chronic disease management in urban settings encompass diverse implementation models with varying levels of evidence supporting effectiveness and feasibility. While clinical support and health education programs represent the most frequently studied approaches, significant evidence gaps exist regarding program sustainability, cost-effectiveness, and scalability across different urban contexts. The literature demonstrates growing integration of technology-enhanced approaches, though digital equity considerations remain underexplored. Future research priorities should include rigorous evaluation of long-term program outcomes, comprehensive economic evaluations, examination of implementation factors supporting program sustainability, and enhanced focus on health equity and cultural responsiveness in diverse urban populations. The expanding evidence base provides foundation for evidence-informed program development while highlighting critical knowledge gaps requiring targeted research investment.
Keywords: scoping review, community health workers, chronic disease management, urban health, implementation science, health services research
© 2025 by the authors. Submitted for possible open access publication under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
