APHA Boston CHPPD 5100.1

1. APHA BostonCHPPD 5100.1 Abstract 142329 Roundtable 8

2. Cardiovascular Disease • One-fourth of Hispanic deaths result from heart disease. • There is a disproportionate distribution of CVD risk factors among Hispanics. • There is a slower decline in heart disease mortality in Hispanics. • The CVD mortality rate of Mexican Americans is equal to or greater than the rate of non-Hispanic whites.

3. Diabetes • 20.8 million Americans have diabetes — 7.0 percent of the U.S. population. Of these, 6.2 million do not know they have the disease. • Each year, about 1.5 million people ages 20 or older are diagnosed with diabetes. • The number of people diagnosed with diabetes has risen from 1.5 million in 1958 to 14.6 million in 2005, an increase of epidemic proportions. National Institute of Diabetes and Digestive and Kidney Diseases. National Diabetes Statistics fact sheet: general information and national estimates on diabetes in the United States, 2005. Bethesda, MD: U.S. Department of Health and Human Services, National Institute of Health, 2005.

4. North Texas Salud Para Su Corazόn (NTSPSC) (2001-2004) • Goals • Aims to reduce the burden of morbidity and mortality rates associated with cardiovascular disease among Latinos • Provide Bilingual culturally competent healthy lifestyle behavior education

5. NTSPSC (2001-2004) • Objectives • Utilize community health workers, (called Promotores de Salud) in a Latino community based heart health education intervention study • Examine the participants self reported heart health behaviors

6. Promotora Qualifications • Be of Hispanic/Latino descent. • Live in the barrio. • Speak the Spanish language. • Desire to help educate and empower the Hispanic community on health issues. • Receive training as a promotor de salud.

7. Targeted Community • Low socioeconomic status • Spanish and/or English language • Underserved Hispanic families residing in the Fort Worth, Dallas Metroplex areas of Texas

8. NTSPSC POPULALTION • A total of 213 male and female Hispanic individuals in a two-group, pre- and post-test design study utilizing promotores de salud.  • The mean age was 45 years old (range 23-68), 75% were married, 74% were born in Mexico, and resided in the U.S. for an average of 26 years.  • Among Classroom Group (intervention), 152 individuals agreed to participate, and 67 (44%) completed at least four promotora classes and a 6-month posttest assessment. • Among Home Group (standard), 61 individuals agreed to participate (no promotora class attendance), and 46 (75.4%) completed the same 6-month posttest assessment.  • From the 213 participants recruited to complete pre-intervention questions , 113 (53%) completed the program. 

9. Comprehensive Group’s Health Improvements

10. Relationship Between Type of Group and Health Improvements

11. DREAMS Project1 (2004-2006) • Goals • The purpose of this study is to decrease the risk factors for T2DM and CVD related to lifestyle such as low level of physical activity and diet in Hispanic families with overweight or obese children, previously identified as "at risk" for Type 2 diabetes mellitus (T2DM), using trained Hispanic community health workers. • The aim of the study is two fold: 1. to assess risk factors for T2DM and CVD in Hispanic families with overweight or obese children previously identified as "at risk" for Type 2 diabetes mellitus (T2DM); 2. to improve lifestyle practices, i.e., improve level of physical activity and diet in order to decrease the number of risk factors in family members.

12. DREAMS Project1 (2004-2006) • Objectives • Utilize community health workers, (called Promotores de Salud) in a Latino community based heart health education intervention study • Evaluate quantitative and qualitative aspects of the study participants.

13. DREAMS Project1 POPULATION • 258 families were enrolled in Project1 and randomly assigned to one of two groups. • There were a total of 857 DREAMS Project1 individuals; 474 (55%) were children. Overall one half (54.9%) were females. Females constituted 65.2% of the adults and 46.6 % of children. • The majority of adults were foreign born (88.8%) and most children (72.3%) were US born. The language of preference was Spanish for about one half (52.9%) of the participants. • Six-month health education Intervention Hispanic families (n=129) conducted by promotores de salud trained in Diabetes prevention and Salud para su Corazón CVD prevention curricula received bilingual and culturally-competent print materials during family sessions. • Control families (n=129) received bilingual culturally competent print material at home only without promotores de salud intervention.

14. DREAMS Proj1 Preliminary Results

16. Social Action Research Community Alliance Network of Partners Culturally-Enriched Process Dimensions—Planning, Development, Implementation & Evaluation Hispanic Family Cardiovascular Health Promotion Participatory Research Ecological Perspective Behavioral Change Theories Promotores de Salud Hispanic Family Health Education Train-the-Trainer Model Community Promotora Community Outreach Model

17. The Public Health Model Using Promotoras de Salud Model Elements Sustainability Connecting & Energizing Communities • Community-Based • Process Dimentionality • Outcome-Oriented

18. Enhanced Dissemination and Utilization • Sustainable Effects Translation Effective Dissemination Salud para su Corazón Utilization Personal Contact Lifestyle Changes

19. Salud para su Corazón Theoretical Model of Translation using Enhanced Dissemination and Utilization • Research  Knowledge  Translation • ▪ Network of alliances ▪ Technology and media • ▪Training ▪ Community-wide activities • Promotores de salud PRACTICE

20. Promotora Implementation Model DREAMS 2005 Post T2 Month 6 Home Visit Post T1 Month 2 Call at Month 4 Pre ←6 Sessions with the promotora de salud→ Intervention Family Group Pre Graduation Post T2 Month 6 ←No promotor/a de salud sessions→ Control Family Group • Educational materials distributed by MPH student every month • MPH student phone call every month • Post card reminder note mailed by MPH student every 3 months

21. Support for Program Delivery

22. Community Network Alliance • Family Session Location • Nurses for Health Screens • Culturally Competent Programs • Technical Support • Strength as an Alliance

23. Institutions • Print Materials • Name Badges • Business Cards • Technical Support • Materials Support • Certificates • Training & Development Promotores de Salud

24. MPH Students • Mentor • Maintain networks • Track data, process, train, evaluate Promotores de Salud

25. Promotores • People can relate to them. • Promotores energize others. • People see in promotores that changing to healthier lifestyles is possible. • Promotores build friendships and trust with people. • Promotores appear to enjoy being healthy. • Utilize cultural popular education techniques. • Build community capacity. Promotores de Salud

26. Roles Promotoras Play in Research Promotores... • Recruit families into research studies. • Collect information from families for research studies. • Contact families to explain study protocols. • Stay connected with participants in a study. • Provide health education and activities for families in studies. • Record education activities for study purposes. • Sustain health programs in the community after the study is over.

27. El Presente (Today) Estructura Promotoria Uno por Uno Organizaciones Comunitarias UNTHSC Alianza de Promotores de Salud

28. Community Capacity Building—Sustainability • Promotores participated voluntarily in community outreach activity as part of the promotora outreach model promoting sustainability of the initiative in the community. • A network of partner organizations have supported and continue to support promotores as part of the public health workforce. • The promotores initiated the development of an alliance of promotores de salud in the Dallas/Fort Worth Metroplex. • Promotional items regarding this model for health professionals include a promotora outreach model CD and a PowerPoint slide show of promotores de salud in research. • Promotores also became certified community health workers (CHW) by the Texas Department of Health in 2006. • The mutual goal to help Hispanic families always helped to bring resolution wherever there was conflict. Having a promotora alliance helped to unite the promotores with a common cause that alleviated some of the differences in personalities. Faculty and student mentoring and support was extremely vital in resolving this challenge.

29. Community Capacity Building—Sustainability • The network of partners consortium worked towards making more promotor positions available; this has been a significant incentive for the promotores. Eight of eleven (73%) active consortium partners promoting the utilization of CHWs in the public health workforce have initiated paid part-time and/or temporary positions, that were not previously available (UNTHSC (2), City of Fort Worth Public Health Department, Healthy Tarrant County Collaborative, Inc., North Side Inter-Church Agency, Inc., FWISD Family Resource Center, St. Paul Methodist Church in Cleburne, Texas Health Resources). • Every aspect of the promotora model had a process e.g. how to pickup educational materials, pay period procedure, mileage reimbursement, family reports, how to educate families, steps to follow the study protocols, etc. • Network partner organizations communications were also ongoing to confirm arrangements, thanking them for their support, or discussions regarding referral programs • Communications occurred during the day, in the evening, and on weekends. This was part of the cultural dimensions of process in planning, development, implementation, and evaluation.

30. Community Capacity Building—Sustainability • The community showed capacity-building efforts as evidence by the promotora alliance growth, family involvement, and organizations support of promotores. • Six American Public Health Association conference presentations are scheduled in Boston in November 2006 where a promotor de salud will be presenting with the project co-principal investigator. • Research Appreciation Day at UNTHSC presented several DREAMS Project1 presentations in 2005 and 2006. • Promotor Alliance received the Dallas Business Journal Health Care Heroes Award 2006 for best community outreach program. • Network partner organizations are establishing paid promotores de salud positions in their organizations. • Promotores de salud have volunteered their services in the community since 2001. They respond to requests from health fairs, church groups, missions, clinics, schools, and non-profit organizations to speak to groups of children and families on healthy lifestyle behaviors..

31. Community Capacity Building—Sustainability • Promotores currently participate in the Nutrition and Physical Activity Network, the Bishop Street Police Department Coalition in Dallas, the Hispanic Wellness Fair Committee, and others. • The alliance has appeared in the 2005 and the 2006 United Way of Metropolitan Tarrant FitFuture Nutrition and Physical Activity Resource Guide. • The American Dietetic Association magazine, ADA Times will feature a partner in a story entitled Chating with the champions: How these RDs make community programs work for kids in the November/December 2006 issue.

32. Community Capacity Building—Sustainability • The promotores have journeyed from infancy as the North Texas Salud para su Corazon Project to the DREAMS Promotores de Salud to today’s Community Health Worker/Promotor Alliance as depicted below. • The City of Fort Worth Public Health Department Outreach Division, a partner in the informal consortium, became a training center for the Texas Department of Pubic Health for community health workers in 2005.

33. Concluding Critical Remarks To maximize the effectiveness of promotoria in communities there has to be a continuous modest support by philanthropic organizations or the like to maintain incentives both monetary and in-kind to support the efforts of promotores de salud in communities. Without this support impact is unlikely to continue.

34. Promotoria • Promotoras have been granted the role, as health educators because they share the same cultural identity of the participants and can relate to the needs of the Hispanic population. • Similar level of acculturation in terms of shared language and years of residence by the promotora and the participant can play a vital role in improving participant trust by addressing concerns for the participant’s need to change their health behaviors.

36. References Balcázar H, Luna Hollen M, Medina M, Pedregn V, Alvarado M, and Fulwood R. The north Texas salud para su corazn promotor/a outreach program: an enhanced dissemination initiative. The Health Education Monograph Series Special Issue on Minority Health. 2005;22:19-27. Centers for Disease Control and Prevention, National Center for Health Statistics. (2003). Community-wide coronary heart disease mortality in Mexican Americans equals or exceeds that in non-Hispanic whites: The Corpus Christi Heart Project. (2001) The American Journal of Medicine, 110, 81-87. Deaths: Leading Causes for 2001. National Vital Statistics Report, 52(9). Luna Hollen, M., Balcázar, H., Medina, A., & Ahmed, N. (2002). The North Texas Salud para su Corazón (Health for your Heart) outreach initiative: Serving Hispanics in Fort Worth and Dallas. Texas Public Health Association Journal, 54, 5-12. National Institute of Diabetes and Digestive and Kidney Diseases. National Diabetes Statistics fact sheet: general information and national estimates on diabetes in the United States, 2005. Bethesda, MD: U.S. Department of Health and Human Services, National Institute of Health, 2005. Promotores De Salud Community Health Outreach Model Cdrom Stern, M.P., & Wei, M. (1999). Do Mexican Americans really have low rates of cardiovascular disease? Preventive Medicine, 29 (6 Pt.2), S90-S95.