There is sufficient evidence that Community Health Workers (CHW) interventions increase the consumption of healthy foods, reduce caregiver stress, reduce food insecurity, and support successful linkage to food benefit programs when engaged in such campaigns.
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A Community Health Worker (CHW) is "a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the worker to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery[1]." "Community Health Worker" is an umbrella term that includes community health representatives, promotores de salud, and peers[2].
CHWs are typically found in community and clinical settings and make connections in the community they serve. CHW interventions can ensure that community and/or cultural linkages support the delivery of services. Over 85% of CHWs report delivering food and nutritional support[3]. This assessment reviewed studies where CHWs addressed food needs as part of the intervention. For many studies, food-related outcomes were not included.
The findings below synthesize the results of the studies in the table across three domains of measurement:
Food-related needs fall into three interrelated categories: food insecurity, nutrition insecurity, and dietary quality.
Food Insecurity
Food insecurity is defined as not having access to enough food. In 2021, 10.2% (13.5 million) of United States (U.S.) households reported being food insecure over the last year. Of families experiencing food insecurity, 6.4% (8.4 million) were identified as having low food security and 3.8% (5.1 million) were identified as having very low food security[4]. Food insecurity varies by race, ethnicity, household makeup, and income. Rates of food insecurity are higher than the national average (10.2%) for families that identify as Black (19.8%) or Hispanic/Latino (16.2%), for households with children (12.5%), and for households with income below 185% of the poverty line (26.5%)[5]. The majority of Medicaid enrollees fall in this low-income bracket. Additionally, food insecurity may be more common for those whose employment status, neighborhood of residence, and access to transportation further impact their food access[6],[7],[8].
Nutrition Insecurity
Nutrition security is the “consistent and equitable access to healthy, safe, affordable foods essential to optimal health and wellbeing[9].” While most food insecure households are also nutrition insecure, food secure households can also be nutrition insecure. As most screenings focus on food security rather than nutrition security, national data on the prevalence of nutrition insecurity is not yet available. The concept of nutrition insecurity has been adopted by the United States Department of Agriculture (USDA) and the Centers for Disease Control and Prevention (CDC) as a core goal for their food-related initiatives. Nutrition security, beyond just food insecurity, is necessary to reduce the chronic illnesses caused as a result of poor nutrition[10].
Dietary Quality
While food and nutrition insecurity are primary drivers of poor diet, other factors such as food availability (food deserts), personal preference, nutrition knowledge, and other psychosocial factors may contribute to dietary options and choices[11]. Analysis found that 45% of U.S. adults have a poor diet[12]. According to analysis of a representative sample of U.S. high school students, only “8.5% of high school students nationwide met [USDA] fruit recommendations and 2.1% met vegetable recommendations[13].” Research on adult dietary consumption has shown that income is a predictor for inadequate vegetable consumption (only 7% of adults below or close to the poverty level consume adequate vegetables) but even high income groups had inadequate vegetable consumption (only 11.4% of adults in the highest income categories consume adequate vegetables)[14]. Healthy People 2030 includes a number of specific nutrition objectives including increasing calcium, potassium, fruit, and vegetable (including dark green, red and orange, beans and peas) consumption in people over age two[15],[16],[17],[18],[19],[20],[21].
Health Impacts of Food and Nutrition Insecurity and Poor Diet
Having an unhealthy diet and poor nutrition is associated with a range of physical and behavioral health conditions that are disproportionately experienced by people of color. Poor diet is associated with both obesity and Type 2 diabetes, as well as other chronic health conditions such as cardiovascular disease and cancer. Individuals experiencing food and nutrition insecurity are uniquely at risk and have a much higher risk of long-term chronic health conditions, including obesity, diabetes, and hypertension. Consuming unhealthy food and beverages, such as sugar-sweetened beverages and highly processed foods, puts people at higher risk of at least 13 types of cancer, including endometrial (uterine) cancer, breast cancer in postmenopausal women, and colorectal cancer.
The length of time a person is food insecure impacts the severity of the health impacts. A study examining food insecurity in children over four years of age found that children who experienced food insecurity for longer periods of time had worse health outcomes[29].
According to the CDC, among those ages 2 to 19, the prevalence of obesity was 19.7% and affected about 14.7 million. Childhood obesity is also more prevalent among certain racial and ethnic groups (26.2% among Hispanic/Latino children, 24.8% among non-Hispanic Black children). Obesity-related conditions include high blood pressure, high cholesterol, Type 2 diabetes, breathing problems such as asthma and sleep apnea, and joint problems[30].
The rate of cardiovascular disease in the Black population is disproportionately high and is a primary cause of differences in life expectancy between Black and White individuals[31]. Black Americans are disproportionately affected by colorectal cancer, with Black people being 20% more likely to develop colorectal cancer and 40% more likely to die from it than White people[32].
The impacts of food insecurity extend beyond diet-related diseases. Children who experience food insecurity have been shown to have a higher risk of iron deficiency anemia, lower non-cognitive performance, asthma, depression, suicide ideation, and tooth decay[33]. Food insecurity has been shown to be a major stressor in early childhood with implications for cognitive, language, motor, and socio-emotional skills[34]. Individuals experiencing food insecurity are more likely to go to the ER, less likely to have a usual source of care, and have higher healthcare costs[35],[36],[37],[38].
A Community Health Worker (CHW) is a trusted member of the community who connects people to health and social services, and ensures these services are accessible and culturally appropriate. Known as promotores de salud in Spanish-speaking areas and as community health representatives in Indigenous communities, CHWs work in diverse settings, from community organizations to healthcare systems. By providing outreach, health education, and advocacy, CHWs help individuals and communities gain knowledge and confidence in managing their health. They play a vital role in underserved communities, addressing health inequities by linking people to resources—including food and nutrition services—and improving the quality of care[39].
Twenty-four states currently provide funding for CHWs through Medicaid, with several more states implementing policies to do so[40]. Among other eligibility criteria, many states allow Medicaid enrollees to use CHW services as a result of “a social drivers of health screening indicating unmet health-related social needs, such as housing or food insecurity[41].” Coverage models and authorized services vary, including health education, advocacy, and outreach, with funding mechanisms like fee-for-service, managed care, or hybrid approaches[42]. These policies reflect the growing recognition of CHWs’ role in addressing the social determinants of health and expanding access to culturally competent care across the United States.
While Medicare reimburses CHW services as part of a provider’s care plan, efforts are underway to expand direct CHW funding and eliminate patient cost-sharing. Proposed legislation, such as the Community Health Worker Access Act, aims to improve Medicare and Medicaid reimbursement, promoting CHW services for broader health equity and cost savings[43].
Caregivers of children with special healthcare needs.
The SKATE (Special Kids Achieving Their Everything) CHW program. Enrolled families participate in a three to six month intervention that includes home visits, needs assessments, and goal-setting sessions during which caregivers and/or patients have the opportunity to develop their own goals. CHWs attend interdisciplinary medical home meetings at the practices weekly and provide updates to providers, nurse care managers, nursing staff, and social workers. CHWs serve as points of contact for families and assist with the navigation of resources available both in the community and in the medical home.
Retrospective pre-post analysis.
Social: On completion of the program, there was a significant improvement in caregiver distress scores (P < .001) and in understanding of their children's diagnoses (P < .001). Furthermore, the number of caregivers reporting food or housing issues was significantly reduced (P < .01 and P < .01, respectively).
Residents of two subsidized housing buildings in New York City.
The Health + Housing Project, a CHW intervention aimed to address residents’ self-identified health-related needs, including social and economic risk factors. CHWs conducted an intake form, worked with the resident on goal setting and action plan development, and then met with residents as frequently as needed over the course of 15 months to do motivational interviewing and helped them achieve their goals.
Pre-post analysis of surveys three months before and after the intervention. Of the 819 estimated adult building residents, 390 (48%) completed a baseline survey. Of those, 226 (58% of survey takers) completed an intake with a CHW. Most intervention participants were female (61%) and Latinx (69%), 28% were 65 years or older, 63% had a household income of less than $20,000, and many reported having chronic diseases. Of the 226 participants, 172 (76%) completed both baseline and post-intervention surveys.
Healthcare Cost, Utilization & Value: No immediate change was seen in acute healthcare use. However, there were significant improvements in residents’ connection to primary care.
Health: No immediate change was seen in defined health outcomes.
Social: Compared with the baseline, the percentage of participants who reported food insecurity and the inability to pay rent on time after the intervention significantly decreased.
Significantly fewer participants reported needing and being unable to access food, a place to exercise, job training or employment placement programs, and education.
Latino community, nationwide (UnidosUS program). National, community-based program "Comprando Rico y Sano" (Buying Healthy and Flavorful Foods).
The use of promotores de salud (community health workers) to reduce hunger and food insecurity by educating Latinos on healthy shopping and eating habits and providing SNAP enrollment assistance. The program aimed to dispel misconceptions about SNAP and thoroughly review the application process with participants.
Issue brief, descriptive study with program impact data.
n = 73,602 participants
Social:
Low-income adults (incomes <250% of the federal poverty line) from three Washington State health systems with type 2 diabetes and a HbA1c ≥ 8%.
In-home community health worker-led intervention. CHWs develop and revise diabetes self-management plans, including setting behavioral goals, identifying actions to achieve those goals, evaluating progress, addressing challenges and concerns, and providing education and referrals to group activities and community resources.
Randomized controlled trial.
Enrollment: CHW intervention = 145 participants; usual care (control) = 142 participants
Social: Compared to controls, intervention participants engaged in more physical activity and reported better dietary behaviors for some measures (general diet, frequency of skipping meals, and frequency of eating out) at 12 months, but there was no evidence of mediation by self-efficacy or social support. Evidence of moderation was limited: improvements in the frequency of skipping meals were restricted to participants with baseline HbA1c < 10%.
Residents in permanent supportive housing (PSH) in Houston, Texas. Age was obtained for 81 residents, ranging from 25 to 73 years (mean age of 55.8 years). The majority of baseline respondents identified as male (n = 64; 77.1%), while 18 identified as female (21.7%), and 1 identified as a transgender female (1.2%). The majority also identified as Black/African American (n = 61; 73.5%), while 13 (15.7%) identified as Non-Hispanic White, 2 (2.4%) identified as Asian, 2 (2.4%) identified as Hispanic/Latinx, 1 (1.2%) identified as American Indian/Alaskan Native, and 1 (1.2%) identified as Arab/Middle Eastern American.
CHWs engaged food insecure PSH residents in meal planning, label reading, and delivery of healthy foods through (1) the distribution of 176 large boxes of food (fresh vegetables and nonperishable items from the bi-weekly distribution provided by the regional food bank); (2) linkage to food pantries (both through the distribution of flyers with directions and/or accompanying residents to pick up food); (3) assisting residents with SNAP benefits in signing up for Amazon Fresh deliveries since there was not a grocery store close-by. They also provided residents with necessary kitchen items so they could cook and eat healthy food in their Single Residency Occupancies (pots/pans, dishes, utensils/flatware, and small cooking appliances).
Descriptive data. 83 PSH residents completed the baseline USDA Food Security Survey, which included additional needs assessment items. 140 total residents completed 294 separate individual-level interventions by the end of the one-year pilot.
Social: 55% of residents improved food security scores between baseline and the 90-day follow-up however food insecurity remained a concern. Of the 294 interventions, the most common was pantry inspections for food insecurity/nutritional deficiency and the second most common was social services assistance including SNAP and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)applications and linkage to primary care.
Patients from three primary care facilities in Philadelphia, Pennsylvania and who resided in a high-poverty zip code, were insured or publicly insured, and had a diagnosis for two or more chronic diseases. Participants were recruited between January 28, 2015, and March 28, 2016.
Of the 592 participants, 370 (62.5%) were female, with a mean (SD) age of 52.6 (11.1) years.
CHWs used a semi-structured interview guide to assess their socioeconomic determinants of health (e.g., trauma, food insecurity, housing instability, drug and alcohol use, or family stress). CHWs provided six months of tailored support spanning the domains of coaching, social support, advocacy, and navigation to help patients achieve their action plans.
Two-armed, single-masked, multicenter randomized clinical trial. Follow-up assessments were conducted at six and nine months after enrollment. Data were analyzed using an intention-to-treat approach.
Study enrollment (n)= 592
Healthcare Cost, Utilization & Value: Patients in the intervention group were more likely to report the highest quality of care (odds ratio [OR], 1.8; 95% CI, 1.4-2.4; risk difference [RD], 0.12; P < .001) and spent fewer total days in the hospital at six months (155 days vs 345 days; absolute event rate reduction, 69%) and nine months (300 days vs 471 days; absolute event rate reduction, 65%). This reduction was driven by a shorter average length of stay (difference, −3.1 days; 95% CI, −6.33 to 0.22; P = .06) and a lower mean number of hospitalizations (difference, −0.3; 95% CI, −0.6 to 0.0; P = .07) among patients who were hospitalized. Patients in the intervention group had lower odds of repeat hospitalizations (OR, 0.4; 95% CI, 0.2-0.9; RD, −0.24; P = .02), including 30-day readmissions (OR, 0.3; 95% CI, 0.1-0.9; RD, −0.17; P = .04).
Health: Participants in both arms had similar improvements in self-rated physical health (mean [SD], 1.8 [11.2] vs 1.6 [9.9]; P = .89).
Patients from an academic medical center with type 2 diabetes and self-reported food insecurity. Participants were 84% female, 32% Black, and 58 years on average, with an average HbA1c of 8%.
The intervention used a community health worker to address food insecurity for individuals by linking them to resources for sustainable food access with the goal of improving diabetes outcomes. Control group participants received food alone while the intervention group received food in combination with community health work counseling and resource linkage.
Pilot randomized controlled study.
n=31
Health: For the intervention group, there was a statistically significant reduction in the average value of HbA1c by 0.85 points from baseline to three months (p=0.039) and by 1.65 points from baseline to six months (p=0.012). 81% of participants in the intervention group (13/16) had a reduction in HbA1c over the course of the intervention. There was no significant change in HbA1c for the control group at either time point. Diastolic blood pressure increased 6.5 mmHg (p= 0.02) between baseline and three months for the control group and remained stable for the intervention group. Systolic blood pressure and weight showed no significant changes for either group.
Participants in the Comprando Rico y Sano program, a national, community-based program.
The Comprando Rico y Sano program provided nutrition education and SNAP enrollment assistance through community health workers (promotores de salud).
A quasi-experimental study with pre-, post-, and follow-up surveys assessing changes in nutrition behavior and SNAP enrollment. 997 participants were recruited, of which 989 completed the pre-survey, and 132 completed the three-month follow-up survey.
Social: Increased nutrition knowledge and healthy food consumption were observed, and 10,502 households received SNAP enrollment/recertification assistance (6,356 new applications and 4,416 recertifications).
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