Introduction
The Latino Education Project (LEP) is conducting a multilevel Racial and Ethnic Approaches
to Community Health (REACH) 2010 diabetes prevention project in Nueces County, one
of 12 counties located in the Coastal Bend area of south Texas. Nueces County is characterized
by high levels of poverty and diabetes-related complications and disability. The LEP
chose a community capacity-building approach to diabetes prevention and health promotion
to help midlife and elderly Latinos increase their ability to prevent, control, and
manage diabetes and associated disabilities.
In each intervention conducted through the LEP, project workers emphasize the importance
of building community health-promotion capacity and recognize the important role that
local leaders play in this process. Community-wide health forums, coalitions, and
partnership development are key elements in promoting organizational development.
These activities increase the social participation necessary for effective community
building and problem solving. The use of study circles, or Ollas del Buen Comer, are
one of the key approaches used to reinforce health-related culture, language-specific
needs, and the lifestyle of participants in relation to the environment.
Participation of community lay health educators, promotores de salud, is crucial to
achieve project goals because of the leadership they provide in their communities.
Promotores are helpful in one-on-one interactions, and they are crucial in creating
environmental changes necessary to reduce the prevalence of risk factors associated
with diabetes and other chronic diseases. Some of the tasks required for promotores
to be effective in this REACH 2010 project are the focus of this discussion.
Background
In Nueces County, Texas, approximately 33% of Hispanic females and 31.5% of Hispanic
males aged 62 years and above have diabetes (1). The prevalence of diabetes in Texas
Mexican Americans is as high as 33% in some counties (2). The authors believe that
the incidence rate of diabetes among the Hispanic community is greater than reported.
Diabetes among many Hispanic residents remains undiagnosed because of their barriers
to health care access, including lack of available health care services, lack of knowledge
regarding services, lack of familiarity with policies and procedures to obtain health
care services, lack of insurance coverage, high cost of health care, lack of transportation
to health care facilities, misunderstandings arising from difference in cultural expectations
and communication styles, and values and language differences regarding health care
(3,4,5).
Project site
In 2000, the Centers for Disease Control and Prevention (CDC) awarded the LEP a REACH
2010 demonstration grant to focus on health promotion and disease prevention and to
address the inordinately high rates of diabetes and its complications in the Coastal
Bend area of south Texas. The project is being conducted in Nueces County, which includes
the city of Corpus Christi and surrounding smaller rural communities. These rural
areas depend on seasonal agriculture-related jobs and have limited resources to sustain
a growth economy and needed health and social services.
According to the 2002 U.S. Census (6), 2.6% of the total Texas population resides
in the Coastal Bend area. Sixteen percent of residents are aged 60 years and older,
and 42% are Hispanic. The population of older Hispanic adults in the Coastal Bend
area is fast-growing and diverse and, like other population groups throughout the
nation, is living longer (7).
In Nueces County, 55.8% of the population is Hispanic, and 38.3% is Anglo. In most
of the rural communities in the county, the size of the Hispanic population fluctuates,
and Hispanic people may at times account for 80% to more than 90% of the total population.
Overall, 17.7% of those aged 65 years and older in this area and 28.3% of the Hispanic
population aged 65 years and older live below the national poverty level. In the Coastal
Bend region, 47.2% of residents did not graduate from high school compared to 24.4%
of the population generally in the state of Texas, and 26.9% are high school graduates
compared to 24.6% of the population in the state as a whole. In the Coastal Bend region,
18.1% have 12 years of school but no diploma compared to 12.9% of the population in
the state, and 34.7% have less than a ninth-grade education compared to 11.5% of the
population of the state as a whole (6). The relatively high overall unemployment rate
in the area (6.2% in 2002) prompts young Hispanic people to leave the area to seek
employment elsewhere.
More than 50% of all deaths in Nueces County can be attributed to chronic diseases,
including diabetes and its complications as well as cardiovascular diseases (8,9).
Although the county has some health and social service systems with bilingual providers
and support staff, public financing for needed services is inadequate. This inadequacy
negatively impacts the quality of health care services. The Nueces County area has
been medically underserved for a number of years (10).
Sociodemographic and behavioral factors have been associated with increased risk for
certain health problems (11). For example, level of education has been correlated
with prevalence of health risks such as obesity, lack of physical activity, and cigarette
smoking (12). Health-compromising behaviors, such as physical inactivity and poor
nutrition, have been clearly linked to increased risk for many chronic diseases (13).
Nutrition-related risk factors often work synergistically to adversely affect the
health status of older people, and these risk factors may lead to an increased rate
of medical complications and result in loss of independence, institutionalization,
and higher health care costs for people affected.
Older Hispanic adults in the Nueces County area share socioeconomic characteristics
associated with poor health status and experience a high incidence of diabetes-related
health problems (e.g., amputations, kidney failure, loss of vision, obesity). Discrimination
based on ethnicity, language, culture, and socioeconomic status often isolates and
limits older Hispanic adults, and their contact with the Anglo community is generally limited
and superficial. Relationships with representatives from outside agencies, particularly
those from governmental and health and human service providers, are often characterized
by a lack of trust.
Older Hispanic residents share characteristics that enhance a sense of commonality
and cohesiveness, and these characteristics result in a strong sense of community.
Shared characteristics include ethnicity, language, culture, strong Hispanic (Mexican
American) identification, and value for family. Easy access to Spanish-language radio,
television, and newspapers is supplemented by easy and frequent travel across the
border to Mexico. These ties repeatedly reinforce culture, language, and identity.
Most residents, including those who are older, are bilingual in English and Spanish,
but the language of preference is Spanish. Through language, residents share a common
communication system, formal and informal networks, and personal histories.
Community
For the past two decades, public health researchers and practitioners have shown increasing
interest in community-based approaches to health promotion and disease prevention
(14). Evidence suggests that the most effective prevention strategies actively engage
the communities they are intended to serve (15). Communities can be mobilized to identify,
plan, channel resources, and undertake effective action for health promotion and health-enhancing
social change (16). A number of researchers have urged an ecological approach to public
health interventions (17) to build on the concept that community is the solution to
its problems. There is considerable support for designing community-based interventions
to improve the health behaviors and overall health status of community members (18).
These community-based interventions are important because health disparities and the
high rate of chronic diseases in minority populations, particularly among those who
are poor and lack access to community resources, are not likely to be prevented without
them.
Community has been defined as a place where identities and meanings are shaped
and where values, beliefs, and norms that guide different dimensions of social relationships
are rooted (19). Individuals matter to a community, and social ties are valued for
their reciprocity and strength. Communities are places where opportunities for behaviors
may be offered or limited, and communities may restrict as well as support the growth
and health of its members (18). Hispanic people in general, and Mexican American people
in particular, value and often define themselves by their strong sense of community.
The LEP chose a community-based strategy to guide its diabetes prevention efforts
because of the community-related characteristics of the target population. This strategy
supports the idea that communities can create problems, but communities can also provide
solutions and a context for health promotion activities focused on prevention and
control of diabetes.
Building community capacity
Building community health promotion capacity is the basic theoretical concept that
guides the LEP's community-based interventions to improve health status through the
multidimensional REACH 2010 project. Control and management of diabetes are the primary
issues addressed by project activities, and project efforts are focused within the
context of daily lifestyle activities of the target population group.
The importance of controlling and managing life circumstances, including diabetes-related
needs, is integrated into every LEP program activity. Programs are designed to improve
the health, economic status, and housing of older Hispanic adults and to address community
factors that can affect their ability and that of their families to address systemic
problems. The LEP activities focus on the interdependence of people, the importance
of mobilizing organizational resources for those most in need, and ways to build social
capital (e.g., skills, knowledge, resources) within the Hispanic community for a more
equitable distribution of resources.
The LEP REACH 2010 project
This LEP REACH 2010 project focuses on the development of interventions designed to
strengthen the capacity of individuals, social networks, and organizations to create
social change and ultimately individual behavior change. To strengthen the capacity
of these various systems separately and as a whole, LEP's REACH 2010 project interventions
focus on the following themes and messages: 1) building trust among consumers and
health care providers; 2) acknowledging the value of cultural, ethnic, and linguistic
identities as a strength and catalyst for change; 3) recognizing the importance of
social connectedness; 4) improving the quality of ties among community sectors; 5)
promoting the importance of individual control over health-related decisions; and
6) seeking to establish organizational relationships and partnerships to mobilize
community resources.
The project focuses on three capacity-building strategies: increasing community awareness
about the diabetes crisis facing Hispanic communities; solving problems through organizational
collaborations and partnerships; and developing community leadership. These strategies
work by 1) ensuring participation of community educators or promotores de salud in
every aspect of project activities; 2) sponsoring community-wide health forums and
building coalitions and partnerships; and 3) using study circles, Ollas del Buen Comer,
to provide health-related knowledge, skill building, and group support.
The first phase of the project emphasized the importance of organizational development
as a necessary antecedent to community participation, and action focused on two sets
of activities: strengthening the LEP as a community-based, nonprofit, advocate organization
that convenes, influences, and mobilizes other organizations; and promoting organizational
collaboration and problem solving through coalition and partnership building to promote
community ownership of the diabetes-related crisis.
The present phase of the project emphasizes the importance of skill development in
building community capacity to promote social and individual change and in building
knowledge and skill development of promotores. The development of a data system to
track indicators of the effectiveness of promotores is part of this process.
Program Planning
Coalition and partnership building
As part of building community capacity, the LEP REACH 2010 project began with the
premise that health promotion programs must demonstrate a capacity and willingness
to allow community priorities to guide program development and services. This premise
required the inclusion of other community organizational stakeholders at the beginning
rather than as an afterthought in the design and implementation of this prevention
project. The LEP began by forming an action-oriented partnership that included elected
officials, older adults, and representatives of community groups and agencies (e.g.,
hospitals, educational institutions, nutrition centers). The initial purpose of the
coalition was to establish a network of organizations to examine local resources and
eventually to develop a community plan to reduce community-level barriers to health
care services.
Coalition members involve their professional networks to expand the scope of the coalition,
identify project gaps, suggest new programs and approaches, and locate funding sources.
The coalition meets regularly, reviews REACH 2010 interventions, and makes suggestions
to ensure that LEP activities represent the interests and well-being of the community.
To increase the involvement of coalition members, the LEP offers a number of opportunities
to participate in its various diabetes interventions.
Focus groups
The Center on Aging and Health (CoAH) at the University of Texas-Pan American conducted
a series of focus groups in 2001, a year before the REACH 2010 project began, to gain
insights from the analysis of focus group data to help LEP staff design effective
health prevention programs and to develop efficient strategies for reaching out to
midlife and older Latino populations (20).
A total of 96 Mexican American adults aged 65 years and older participated in eight
focus groups that took place in settings that ensured diversity of group composition.
All groups were conducted in Spanish and were videotaped. Three staff members independently
watched each videotape and met later to discuss their notes and identify the major
points raised by the focus groups. The principal investigator watched all videotapes
a second time and prepared the findings for analysis. All three staff members met
again to review the prepared findings and arrived at a consensus on the major points
that were independently observed regarding overall diabetes-related knowledge and
the needs of focus group participants.
Key findings were that focus group participants 1) had limited knowledge about diabetes
and cardiovascular disease and were unable to identify symptoms early and at the most
appropriate time for effective treatment and control; 2) were aware that proper diet
and exercise contributed to the management and control of diabetes and cardiovascular
disease; 3) were aware that proper diet and exercise were powerful preventive mechanisms
that would dramatically lower their risk of ever having the diseases and that this
awareness among most group participants who indicated they had one or both conditions
came late in life and only after they were diagnosed with the disease; and 4) expressed
a desire to increase their knowledge and understanding of their diseases as a means
of preventing serious complications.
All participants expressed problems adhering to a healthy diet and a moderate exercise
schedule and had trouble associating any form of exercise with pleasure. Participants
who had been or were avid dancers did not see dancing as a form of exercise. Most
admitted that they should walk more than they actually did, but few gave any concrete
indication as to what kind of strategy would allow them to do so on a regular basis.
Most participants found foods high in carbohydrates and calories to be pleasurable,
particularly the typical Mex-Tex cuisine, and expressed little motivation to change
to healthier foods.
Most participants did not see access to health care as problematic or difficult. All
reported that they had Medicare, and most had seen a doctor during the past 6 months.
Most were satisfied with their doctors despite the brevity of their visits. Participants
acknowledged this brevity prevented any opportunity for meaningful patient–doctor
dialogue that might help them better understand their health conditions. No participants
expressed a problem paying for medical bills, but many expressed their belief that
they were overmedicated and had no opportunity to discuss this issue with their doctor
or other health care provider. Most participants noted that transportation was a problem
since they depended on either a child or a senior-center van to take them to medical
appointments.
The findings of the focus groups highlighted a number of themes that were incorporated
in the different REACH 2010 interventions, including
increasing older Hispanic adults' knowledge of diabetes and cardiovascular diseases;
changing participants' attitudes and behaviors to diminish risk for diabetes and cardiovascular
diseases;
identifying prevention strategies that work and strategies that do not work with this
population group;
examining barriers associated with the present health care system that limit interactions
between patient and health care provider; and
developing outreach programs for local neighborhoods.
Interventions
Building human capital and leadership: promotores de salud
Involvement of promotores de salud (e.g., health promoters, health facilitators, health
supporters, lay health educators, community health workers) is a fundamental dimension
of the community-building framework because these workers share a deep understanding
of beliefs, perceptions, and salient concerns with the populations and communities
with which they work. They help fill gaps in health care and human services for medically
underserved and resource-poor communities and have been particularly effective in
reaching rural, minority, and other socioeconomically disadvantaged populations (21).
Most programs that use lay health educators emphasize educators' ability to help people
access health and human services. The community-building approach the LEP uses has
promotores de salud as essential human capital to perform leadership roles that result
in social change as well as individual behavior change. Primary targets for interventions
include organizational systems, communication channels, and small groups in which
promotores can play active roles in initiating changes that are crucial to health
promotion and disease prevention for both communities and individuals (22).
The 2001 National Community Health Advisor Study conducted by the American Public
Health Association identified seven core roles performed by community health workers:
1) providing cultural mediation between communities and health and social service
systems; 2) providing culturally appropriate health education and information; 3)
ensuring that people get the services they need; 4) providing informal counseling
and social support; 5) advocating for individual and community needs; 6) administering
health screening tests; and 7) building individual and community health care capacity
(23, 24).
In the LEP's REACH 2010 project, promotores are expected to help change environmental
factors to reduce individual risk for certain diseases. Rather than using promotores
in their usual roles (e.g., case managers, coordinators of services), the LEP begins
with the desired outcomes of each intervention, determines the knowledge and skills
required to accomplish the intervention, and then seeks promotores who have the necessary
knowledge and skills. Promotores are expected to be leaders in creating social and
economic conditions that help individuals control and manage their diseases. Effective
leadership requires communication, analytical skills, and teaching skills as well
as abilities in coaching, creating a vision, building trust, teamwork, reflection,
learning, and partnering (23). Promotores can mobilize resources and are valuable
tools in building a community's capacity to help those in need.
Establishing community health forums
The LEP sponsors four community-wide health forums each year. These forums are designed
to raise awareness of the many risk factors for type 2 diabetes mellitus among older
Hispanic adults and their families and to demonstrate methods of managing and controlling
these risk factors. Goals of these forums are to improve community capacity to identify
and treat residents with diabetes, increase community participation in health-related
activities, and provide opportunities for local leaders to address diabetes-related
issues at the community level. Information about causes and control of diabetes provided
at the forums is appropriate to the culture, language, age, and education level of
the audience.
Community forums are cosponsored by local agencies that partner with the LEP's REACH
2010 project and are conducted by volunteers. Student nurses from a local community
college provide basic screening tests, the local HMO (Humana) demonstrates an age-appropriate
exercise program, and local physicians participate in presentations on diabetes and
its complications. Forum participants are offered screening tests for hypertension,
high cholesterol, and diabetes as well as foot and eye examinations. Local agencies,
such as home health care agencies, nursing homes, and senior centers, advertise their
services, distribute informational materials, and give participating seniors an opportunity
to learn about services available in the community and how to access them.
Community forums bring together representatives of community organizations, health
care and social service professionals, advocates for seniors, elected officials, representatives
of public and private health care and human service agencies, and seniors. Presentations
are bilingual, interactive to encourage maximum audience participation, and use cultural
symbols, communication styles, and visual materials appropriate for older citizens
who may be illiterate in English, Spanish, or both.
Assessments about the effectiveness of these community forums are based on the number
of participants at each event, who the partners or cosponsors were, and which organizations
or individuals contributed concrete resources. Examples of contributions include 1)
providing the site for the event (usually contributed by a church, city, or community
center); 2) providing basic screening tests; 3) providing free media announcements
about the event; and 4) providing meals and gifts for participants. Assessments are
also based on participant feedback about the value of presentations in meeting individual
needs.
Conversations with participating seniors indicate an increase in knowledge about diabetes
and its risk factors as a result of health forum attendance. Because a number of seniors
attend these community events repeatedly, LEP staff, in collaboration with the CoAH
at the University of Texas-Pan American (a project partner), have begun to develop
evaluation tools to assess diabetes-related knowledge gained by participants over
time and to determine which topic, style of presentation, and individual presenters
are most effective in promoting healthy lifestyle and behavior changes.
Promotores de salud assume primary responsibility for outreach to various community
sectors represented at community forums. Promotores design a community-wide media
campaign and participate in selecting messages and a communication style that are
appealing to older Hispanic adults. Comentarios (exchange of ideas), a program sponsored
by a local Spanish-language radio station, interviews people at event sites and encourages
exchanges between seniors, agency representatives, local leaders, health professionals,
and promotores. A quarterly newsletter, Nuestra Salud, is published to inform the
community about these events and to provide information about diabetes and its management
to more than 1500 organizations and individuals.
The success of these community events reflects the importance of involving community
leaders who understand the community and its needs. Forums are bilingual and reflect community
culture. Participants are shown how to mobilize community resources so that residents
can access resources easily. These events are influential, visible, and credible,
and they bring together participants from many organizations and community sectors.
Establishing study circles: Ollas del Buen Comer
In addition to sponsoring community events designed to reach a broad segment of the
community, the LEP also sponsors a series of small group sessions called Ollas del
Buen Comer (Skillets for Healthful Eating) to focus attention on individual participants
within their own cultural context. These time-limited sessions have a dual function:
to teach participants diabetes-related self-care practices (e.g., nutrition, physical
activity) and to provide them with group support by using cultural identification
as a tool for behavior change.
In these study circles, participants are encouraged to think critically about cultural
assumptions underlying their health-related ideas and actions. They have opportunities
to examine their lifestyle behaviors and beliefs and how these affect their health
and nutrition. In small interactive sessions, participants consider alternative ways
of thinking and behaving and look for lessons from past actions. They are encouraged
to develop self-awareness and to view errors and failures as resources for learning
instead of excuses for not acting or as reasons to blame themselves.
Ollas del Buen Comer have been particularly effective in helping participants
examine barriers to making diet and exercise behavior changes. Participants examine
their financial limitations, family customs and habits, and attitudes (e.g., fatalism
about diabetes, skepticism about the benefits of prevention). They discuss other barriers
such as a lack of transportation to reach stores where there are lower food prices
and dental problems that prevent them from consuming certain foods. Presenters and
participants identify what nutrition education is needed and how nutrition information
can best be presented. Promotores are particularly suited to interact with their peers
in a study-circle format because of their culturally appropriate manner and knowledge
of language, culture, and common historical roots.
Ollas del Buen Comer sessions include food-preparation demonstrations with culturally
appropriate, inexpensive, and accessible foods, such as nopalitos or springtime fresh
cactus pods. Sessions include demonstrations of age-appropriate physical activities
(e.g., stretch exercises, walking, dancing), Heart Smart sessions on cardiovascular
disease adapted from American Heart Association literature, and presentations on diabetes-related
issues adapted from American Diabetes Association materials about proper foot and
eye care and explanations about the differences between type 1 and type 2 diabetes
mellitus.
Promotores are facilitators and mediators. They help participants navigate health
care and human service systems, clarify and interpret community resources, and encourage
those who need them to use appropriate services. Promotores help participants reflect
and think through their problems and connect with health care and social service providers
as they seek solutions. They lead participants through necessary steps for lifestyle
changes and raise individual awareness about potential barriers to such changes.
The LEP has developed a computerized data management system to help promotores track
activities and outcomes and identify indicators of effectiveness. With assistance
from its university partner, the LEP is developing the necessary tools to determine
outcomes.
The Importance of the REACH 2010 Program
The high rates of diabetes and diabetes-related complications among elderly Hispanic
populations such as those in Nueces County, Texas, need to be understood in terms
of the environment in which they exist. This understanding cannot be attained quickly
nor can the problems associated with this health disparity be solved soon. Problems
take years, and sometimes generations, to develop, and solutions require ongoing analyses
and application of resources over time.
Community-based nonprofit organizations can play an important role in resolving the
diabetes crisis faced by Hispanic communities through effective interventions. Long-term
financial support provided by the REACH 2010 project has significantly diminished
the traditional funding instability that has often undermined the ability of these
organizations to fully achieve their goals. The REACH 2010 project plays an equally
important role by focusing on community-wide, comprehensive, multilayered strategies
with which to identify, develop, and test knowledge and skills critical for effective
community building in minority communities.
The next step for the LEP is to focus on finding resources to document the contributions
that promotores make to promote healthy communities. The LEP will continue its involvement
in a statewide effort to develop effective training curricula with defined core roles
and competencies for promotores. More work is needed to determine how the roles of
promotores are different from those of other service providers in building community
capacity and leadership. Challenges that the LEP REACH 2010 project needs to address
include selecting a process for standardized baseline data collection and developing
research methods that capture the subtleties of promotores' strategies, such as their
approach to differing consumer cultures and communities. Observations thus far indicate
that promotores contribute to improved health status in Hispanic communities by encouraging
use of appropriate health services and by implementing prevention and health promotion
services.