Latino Health Initiative (LHI)Latino Health Initiative (LHI)Department of Health and Human ServicesDepartment of Health and Human Services

Montgomery County, MarylandMontgomery County, Maryland “ “Vías de la Salud”Vías de la Salud” Health Promoters Program Health Promoters Program

““Moving toward Barrios Saludables: Moving toward Barrios Saludables:

Lessons Learned from Promotores Lessons Learned from Promotores Interventions in Latino Neighborhoods” Interventions in Latino Neighborhoods”

STATE WORKSHOP ON LATINO HEALTHSTATE WORKSHOP ON LATINO HEALTH

March 11, 2009 March 11, 2009

Gianina Hasbun, MAGianina Hasbun, MA

Mercedes Moore, RNMercedes Moore, RN

Nancy Newton, MPHNancy Newton, MPH

““VIAS DE LA SALUD” VIAS DE LA SALUD” HEALTH PROMOTERS PROGRAMHEALTH PROMOTERS PROGRAM

Established in 1997. Became part of the LHI in 2000.Established in 1997. Became part of the LHI in 2000.

A comprehensive community program to promote A comprehensive community program to promote healthy behaviors and increase access to health care healthy behaviors and increase access to health care among low-income Latinos. among low-income Latinos.

Five year strategic plan guides its action. Five year strategic plan guides its action.

Mission:Mission:““Improve the health and well being of the low-income Latino Improve the health and well being of the low-income Latino community in Montgomery County through training and community in Montgomery County through training and empowerment of Latino health promoters to promote healthy empowerment of Latino health promoters to promote healthy behaviors, facilitate access to health services, and advocate of behaviors, facilitate access to health services, and advocate of health policies that benefit the community”.health policies that benefit the community”.

Priority APriority AImproving Improving the the collection, collection, analysis and analysis and reporting of reporting of health data health data on Latinos.on Latinos.

Priority BPriority BEnsuring Ensuring Access to Access to and Quality and Quality of health of health care.care.

Priority CPriority CEnsuring the Ensuring the availability availability of culturally of culturally and and linguistically linguistically competent competent health health services.services.

Priority DPriority DEnhancing Enhancing organizationorganizational capacity al capacity of Latino of Latino community-community-based based organizationorganizations to provide s to provide health health servicesservices..

Priority EPriority EIncreasing Increasing community community participation participation in decisions in decisions that affect that affect the health the health of the of the Latino Latino Community.Community.

Priority FPriority FExpanding Expanding health health promotion promotion and disease and disease prevention prevention efforts efforts targeting the targeting the Latino Latino Community.Community.

Priority GPriority GIncreasing Increasing the number the number of Latino of Latino Health care Health care Professionals Professionals working in working in the County.the County.

XX XX XX

VIAS AND THE BLUEPRINTVIAS AND THE BLUEPRINT

Activities are guided by priority areas outlined in the Activities are guided by priority areas outlined in the Blueprint for Latino Health in Montgomery County.Blueprint for Latino Health in Montgomery County.

LATINO HEALTH SNAPSHOTLATINO HEALTH SNAPSHOT

MORTALITYMORTALITY

1.1. Heart DiseaseHeart Disease

2.2. CancerCancer

3.3. Unintentional InjuriesUnintentional Injuries

(accidents)(accidents)

1.1. StrokeStroke

2.2. DiabetesDiabetes

HIGH PREVALENCE DISEASEHIGH PREVALENCE DISEASE

1.1. AsthmaAsthma

2.2. Chronic obstructive Chronic obstructive pulmonary diseasepulmonary disease

3.3. HIV/AIDSHIV/AIDS

4.4. ObesityObesity

5.5. SuicideSuicide

Source: Hispanic or Latino Populations, Office of Minority Health and Health Disparities, Centers forSource: Hispanic or Latino Populations, Office of Minority Health and Health Disparities, Centers for

Disease Control and Prevention, 2004Disease Control and Prevention, 2004

At a national level:At a national level:

LATINO HEALTH SNAPSHOTLATINO HEALTH SNAPSHOT

In Maryland, diabetic end-stage renal disease among In Maryland, diabetic end-stage renal disease among Latinos was 10% to 20% higher than for non Latino whites Latinos was 10% to 20% higher than for non Latino whites ages 55 and older and hypertensive end-stage renal ages 55 and older and hypertensive end-stage renal disease were 1.5 to 5 times higher than for whites. disease were 1.5 to 5 times higher than for whites. (Maryland Department of Health and Mental Hygiene)(Maryland Department of Health and Mental Hygiene)

In the U.S., the rate of obesity for Latinos increased from In the U.S., the rate of obesity for Latinos increased from 14.5% in 1987 to 24.9% in 2001 14.5% in 1987 to 24.9% in 2001 (Rhoades, Altman, Cornelius, 2002)(Rhoades, Altman, Cornelius, 2002)

In a Study conducted by LHI in 2005, three of four Latinos In a Study conducted by LHI in 2005, three of four Latinos ages 40 and over reported being overweight (46%) of obese ages 40 and over reported being overweight (46%) of obese (30%).(30%).

LATINO ACCESS TO HEALTH CARELATINO ACCESS TO HEALTH CARE

Lack of health insuranceLack of health insurance

Lack of culturally and linguistically competent Lack of culturally and linguistically competent servicesservices

Eligibility issues (lack of understanding of eligibility Eligibility issues (lack of understanding of eligibility requirements)requirements)

Unavailability of adequate transportation, limited Unavailability of adequate transportation, limited hours of operation, continuity of care. hours of operation, continuity of care.

Source: Blueprint for Latino Health in Montgomery County, 2008-20012.Source: Blueprint for Latino Health in Montgomery County, 2008-20012.

COMPONENTS OF THE PROGRAMCOMPONENTS OF THE PROGRAM

1. 1. Training and empowerment of health promoters.Training and empowerment of health promoters.

2. Promotion of healthy behaviors:2. Promotion of healthy behaviors: - Physical Activity- Physical Activity

- Healthy eating- Healthy eating- Tobacco- Tobacco- Oral health- Oral health

3. Facilitate access to care3. Facilitate access to care

4. Advocacy4. Advocacy

OTHER PROJECTSOTHER PROJECTS

Emergency PreparednessEmergency Preparedness

Smoking CessationSmoking Cessation

Pedestrian safetyPedestrian safety

National Kidney FoundationNational Kidney Foundation

THE THE PROMOTORESPROMOTORES

38 trained volunteer lay health promoters with same 38 trained volunteer lay health promoters with same cultural, linguistic and demographic characteristics of cultural, linguistic and demographic characteristics of the community they serve. the community they serve. 34 females34 females 4 males4 males 17 new health promoters in FY0917 new health promoters in FY09 21 of them have an average of 6 years in the program21 of them have an average of 6 years in the program

All immigrants: vast majority are from Central America. All immigrants: vast majority are from Central America.

Work: babysitting, housecleaning, elder care.Work: babysitting, housecleaning, elder care.

THE THE PROMOTORESPROMOTORES

Formal education: Formal education: elementary school to elementary school to college.college.

25% do not have health 25% do not have health insurance either for them insurance either for them or their families; 38% or their families; 38% have just for their have just for their children. children.

Average age: 50 yearsAverage age: 50 years

THE THE PROMOTORESPROMOTORES

Main roles of health promoters:Main roles of health promoters:

Help families with Maryland Child Health Insurance Program Help families with Maryland Child Health Insurance Program applications.applications.

Inform about programs and resources available in the CountyInform about programs and resources available in the County

Attend health fairs to educate Latinos on tobacco use prevention,Attend health fairs to educate Latinos on tobacco use prevention, healthy eating and the importance of physical activity.healthy eating and the importance of physical activity.

Conduct educational sessions in community centers and clinics.Conduct educational sessions in community centers and clinics.

Perform physical activity sessions (Perform physical activity sessions (caminatascaminatas). ).

Advocate for health issues relevant to the Latino Community. Advocate for health issues relevant to the Latino Community.

VIAS AS A CULTURALLY AND VIAS AS A CULTURALLY AND LINGUISTICALLY COMPETENT PROGRAMLINGUISTICALLY COMPETENT PROGRAM

Comprehensive experiential Comprehensive experiential training curriculum designed and training curriculum designed and tailored to respond to the needs tailored to respond to the needs of the health promoters. of the health promoters.

Popular Education and Popular Education and Participatory Methodology. Participatory Methodology. No lecture-type activitiesNo lecture-type activities Hands-on activities – Practice Hands-on activities – Practice

before community before community interventionsinterventions

Action – Reflection – ActionAction – Reflection – Action

VIAS AS A CULTURALLY AND VIAS AS A CULTURALLY AND LINGUISTICALLY COMPETENT PROGRAMLINGUISTICALLY COMPETENT PROGRAM

Promoters participates in the planning, design and Promoters participates in the planning, design and evaluation of the program.evaluation of the program.

Program is based on needs of the community. Program is based on needs of the community.

Understanding the concept of grass-roots health Understanding the concept of grass-roots health promoter.promoter.

All sessions are conducted in Spanish. All sessions are conducted in Spanish.

VIAS AS A CULTURALLY AND VIAS AS A CULTURALLY AND LINGUISTICALLY COMPETENT PROGRAMLINGUISTICALLY COMPETENT PROGRAM

Program conducted by bi-cultural staff.Program conducted by bi-cultural staff.

Speaking Spanish is insufficientSpeaking Spanish is insufficient Ability to connect, understand and respect cultural Ability to connect, understand and respect cultural

values, beliefs, practices and needs of the values, beliefs, practices and needs of the populationpopulation

Shared immigration experiences.Shared immigration experiences.

Trust: trusted community agencies, community trust in Trust: trusted community agencies, community trust in promoters. promoters.

VIAS AS A CULTURALLY AND VIAS AS A CULTURALLY AND LINGUISTICALLY COMPETENT LINGUISTICALLY COMPETENT

PROGRAMPROGRAM

Promotional items for Promotional items for community with key community with key messages.messages.

Interventions are conducted Interventions are conducted in pairs, in their in pairs, in their neighborhoods.neighborhoods.

Limited number of key Limited number of key messages. messages.

Simple language and Simple language and appropriate literacy level.appropriate literacy level.

VIAS AS A CULTURALLY AND VIAS AS A CULTURALLY AND LINGUISTICALLY COMPETENT PROGRAMLINGUISTICALLY COMPETENT PROGRAM

Health promoters’ and participants’ needs considered: Health promoters’ and participants’ needs considered: child care, healthy snacks and meals during trainings child care, healthy snacks and meals during trainings and educational interventions. and educational interventions.

Incentives: grocery store certificates, small gifts, Incentives: grocery store certificates, small gifts, professional learning opportunities, program professional learning opportunities, program recognitions, annual retreat. recognitions, annual retreat.

A time for socializing and networking. A time for socializing and networking.

WHERE DOES WHERE DOES THE PROGRAM THE PROGRAM TAKES PLACETAKES PLACE

ChurchesChurches SchoolsSchools ClinicsClinics NeighborhoodsNeighborhoods HomesHomes Community CentersCommunity Centers

TYPE OF TYPE OF INTERVENTIONSINTERVENTIONS

One on oneOne on one Small groupsSmall groups Brief contacts / healthBrief contacts / health

fairsfairs

PARTNERSHIPSPARTNERSHIPS

Linkages to LearningLinkages to Learning Community Ministries of RockvilleCommunity Ministries of Rockville Proyecto SaludProyecto Salud TESS CenterTESS Center Suburban HospitalSuburban Hospital American Cancer SocietyAmerican Cancer Society Advance Practice Center of MCAdvance Practice Center of MC National Kidney FoundationNational Kidney Foundation Primary Care CoalitionPrimary Care Coalition

STEPS FOR AN INTERVENTIONSTEPS FOR AN INTERVENTION

1.1. Coordinate with partner (school, clinic, church, Coordinate with partner (school, clinic, church, CBO, etc.)CBO, etc.)

2.2. Identify promoters to conduct interventions.Identify promoters to conduct interventions.3.3. Promoters plan interventionPromoters plan intervention4.4. Prepare educational and promotional material Prepare educational and promotional material

according to topic presentedaccording to topic presented5.5. Promoters pick-up material at officePromoters pick-up material at office6.6. Promoters implement interventionPromoters implement intervention7.7. Promoters/coordinators evaluate interventionPromoters/coordinators evaluate intervention8.8. Promoters report numbers to coordinators and on Promoters report numbers to coordinators and on

monthly reportmonthly report9.9. Coordinators enter data in database Coordinators enter data in database

PROGRAM EVALUATIONPROGRAM EVALUATION

Pre and post tests for promoters’ trainingsPre and post tests for promoters’ trainings Pre and post tests for caminatas Pre and post tests for caminatas Caminata reportCaminata report Monthly reportMonthly report Continuous improvement instrument (for Continuous improvement instrument (for

supervision and self evaluation)supervision and self evaluation) CFK reportsCFK reports

RESULTSRESULTS

26 26 caminatascaminatas during during 2006 – 2008: elementary 2006 – 2008: elementary schools, ESOL classes, schools, ESOL classes, low-income housing low-income housing services, and community services, and community organizations. organizations.

Over 400 participants Over 400 participants (adults and children).(adults and children).

RESULTSRESULTS

In FY08: In FY08:

Post-intervention surveys of parents indicated: Post-intervention surveys of parents indicated: 54% increased physical activity54% increased physical activity 64% increased consumption of fruits and vegetables64% increased consumption of fruits and vegetables 72% reported an increase in drinking water (vs soda).72% reported an increase in drinking water (vs soda).

Pre and Post test evaluation in adult participants showed: Pre and Post test evaluation in adult participants showed: 43.3% increase in healthy behaviors such as practicing 43.3% increase in healthy behaviors such as practicing physical activity more than 3 time a week. physical activity more than 3 time a week.

RESULTSRESULTS

IN FY08:IN FY08: 517 families were referred to MCHP, CFK, and other 517 families were referred to MCHP, CFK, and other

County ProgramsCounty Programs 2,261 individuals reached in 64 education interventions2,261 individuals reached in 64 education interventions 2,878 individuals reached in 27 health fairs2,878 individuals reached in 27 health fairs 423 individuals reached at 6 sites423 individuals reached at 6 sites 6,075 volunteers by 23 health promoters6,075 volunteers by 23 health promoters 56 training hours for health promoters56 training hours for health promoters 83% of HP were very satisfied and 17% satisfied with 83% of HP were very satisfied and 17% satisfied with

ProgramProgram 13% increase healthy eating and physical activity 13% increase healthy eating and physical activity

knowledge in health promoters.knowledge in health promoters. 92% retention rate92% retention rate

CHALLENGESCHALLENGES

Evaluation is a key element of the program however Evaluation is a key element of the program however too much paperwork can be overwhelming for HP too much paperwork can be overwhelming for HP and distract their attention from the core activities. and distract their attention from the core activities.

Promoters have difficulty using the monthly report – Promoters have difficulty using the monthly report – key instrument for data collection.key instrument for data collection.

Limited resources to manage expansion of program, Limited resources to manage expansion of program, mentoring system, professional development. mentoring system, professional development.

CHALLENGESCHALLENGES

Environment: weather (too hot or too cold), security Environment: weather (too hot or too cold), security (afraid to walk after dark).(afraid to walk after dark).

Fear of participating due to anti-immigration climate.Fear of participating due to anti-immigration climate.

Lack of concurrent educational efforts targeting the Lack of concurrent educational efforts targeting the Latino community. Parallel outreach efforts are Latino community. Parallel outreach efforts are crucial in helping people transition through the stages crucial in helping people transition through the stages of change. of change.

LESSONS LEARNEDLESSONS LEARNED Establishment of partnerships contributed to:Establishment of partnerships contributed to:

Increase opportunities for educational interventions Increase opportunities for educational interventions and and caminatas.caminatas.

Enhancement of networking skills of HPEnhancement of networking skills of HP

A limited number of key messages increased A limited number of key messages increased efficiency of promoters, their confidence and credibility efficiency of promoters, their confidence and credibility in the community.in the community.

Careful attention to building and nurturing Careful attention to building and nurturing relationships with HP contributed to a high retention relationships with HP contributed to a high retention rate. rate.

HP represent community: increased trust. HP represent community: increased trust.

LESSONS LEARNEDLESSONS LEARNED

Using wisely the HP’s skills, talents and experience Using wisely the HP’s skills, talents and experience of HP increased efficiency and self-efficacy. of HP increased efficiency and self-efficacy.

The caminatas more than a physical activity The caminatas more than a physical activity program, venue to socialize, share and feel sense of program, venue to socialize, share and feel sense of community (highly needed in the Latino Community).community (highly needed in the Latino Community).

Flexibility in promoters’ schedules to accommodate Flexibility in promoters’ schedules to accommodate demands of participants increased community demands of participants increased community participation. participation.

Incentives for promoters and participants are Incentives for promoters and participants are essential for maintaining high motivation. essential for maintaining high motivation.

CONTACT INFORMATIONCONTACT INFORMATION

MERCEDES MOORE, RNMERCEDES MOORE, RN(240) 777-3470(240) 777-3470

mercedes.moore@montgomerycountymd.govmercedes.moore@montgomerycountymd.gov

GIANINA HASBUN, MAGIANINA HASBUN, MA(240) 777-4519(240) 777-4519

gianina.hasbun@montgomerycountymd.govgianina.hasbun@montgomerycountymd.gov

NANCY NEWTON, MPHNANCY NEWTON, MPH301-585-3452301-585-3452

n.newton@verizon.netn.newton@verizon.net

WEBSITEWEBSITEwww.lhiinfo.orgwww.lhiinfo.org