Integrating community health representatives with health care systems: clinical outcomes among individuals with diabetes in Navajo Nation

Int J Equity Health. 2019 Nov 27;18(1):183. doi: 10.1186/s12939-019-1097-9.


Background: We studied the impact of Community Outreach and Patient Empowerment (COPE) intervention to support Community Health Representatives (CHR) on the clinical outcomes of patients living with diabetes in the Navajo Nation extending into the States of Arizona, Utah, and New Mexico. The COPE intervention integrated CHRs into healthcare teams by providing a structured approach to referrals and home visits.

Methods: We abstracted routine clinical data from the Indian Health Service's information system on individuals with diabetes mellitus seen at participating clinical sites from 2010 to 2014. We matched 173 COPE participants to 2880 patients with similar demographic and clinical characteristics who had not participated in COPE. We compared the changes in clinical outcomes between the two groups using linear mixed models.

Results: Over the four years of the study, COPE patients had greater improvements in glycosylated hemoglobin (- 0.56%) than non-COPE participants (+ 0.07%) for a difference in differences of 0.63% (95% confidence interval (CI): 0.50, 0.76). Low-density lipoprotein fell more steeply in the COPE group (- 10.58 mg/dl) compared to the non-COPE group (- 3.18 mg/dl) for a difference in differences of 7.40 mg/dl (95%CI: 2.00, 12.80). Systolic blood pressure increased slightly more among COPE (2.06 mmHg) than non-COPE patients (0.61 mmHg). We noted no significant change for body mass index in either group.

Conclusion: Structured outreach by Community Health Representatives as part of an integrated care team was associated with improved glycemic and lipid levels in the target Navajo population.

Trial registration: Trial registration: NCT03326206. Registered 31 October 2017 - Retrospectively registered,

Keywords: Chronic disease; Community health workers; Diabetes mellitus; Education and behavioral intervention; Navajo.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Arizona
  • Community Health Workers / organization & administration*
  • Delivery of Health Care, Integrated*
  • Diabetes Mellitus / ethnology*
  • Diabetes Mellitus / therapy*
  • Female
  • Humans
  • Indians, North American / statistics & numerical data*
  • Male
  • Middle Aged
  • New Mexico
  • Treatment Outcome
  • Utah

Associated data