Community Health Workers: Improving Home Visiting Engagement of High-Risk Birthing People in Segregated Neighborhoods

Abstract

Context: Racial and ethnic disparities in perinatal health remain a public health crisis. Despite improved outcomes from home visiting (HV) participation during pregnancy, most eligible individuals of color do not engage. Neighborhood segregation, a manifestation of structural racism, may impose constraints on engaging eligible individuals in HV. Objective: To examine whether race, ethnicity, and/or language-concordant community health workers (CHWs) increased HV engagement for birthing people in segregated neighborhoods. Design: Program evaluation using administrative linked data from birth records, Medicaid claims, and HV program participation. Strong Beginnings (SB), a program with HV provided by CHWs working with nurses and social workers, was compared with the Maternal Infant Health Program (MIHP), a state Medicaid-sponsored HV program without CHW involvement. Data were analyzed using χ2 tests and Poisson regressions. Participants: A total of 4560 individuals with a Medicaid-eligible birth between 2016 and 2019, including 1172 from SB and 3388 from the MIHP. Main Outcome Measures: Penetration (percentage of participants in HV among all Medicaid-eligible individuals across quintiles of neighborhood segregation) and dosage (the total number of home visits from both CHWs and nurses/social workers, and then restricted to those from nurses/social workers). Results: SB penetrated more segregated neighborhoods than the MIHP (58.4% vs 48.3%; P < .001). SB participants received a higher dosage of home visits (mean [SD]: 11.9 [6.1]) than MIHP participants (mean [SD]: 4.4 [2.8], P < .001). Importantly, CHWs did not replace but moderately increased home visits from nurses and social workers (51.1% vs 35.2% with ≥5 intervention visits, P < .001), especially in more segregated neighborhoods. Policy Implication: Community-informed HV models intentionally designed for people facing disparities may help facilitate program outreach to segregated neighborhoods with concentrated deprivation and reduce racial and ethnic disparities. Conclusions: An HV program provided by CHWs working with nurses and social workers was associated with an increase in penetration and dosage in segregated neighborhoods, compared with HV without CHW involvement. This underscores the value of CHWs partnering with licensed professional workers in improving HV engagement in disadvantaged communities.