TO achieve the goal of eliminating health disparities among racial and ethnic minorities attention must shift to the social determinants of health that contribute to disease. Included in the list of social determinants of health are social support, social cohesion, and universal access to medical care.1,2 Social support refers to support on the individual level when resources are provided by others, and social cohesion refers to support on a community level when the trust and respect between different sections of society result in cherishing people and their health.3 Community health workers (CHWs) impact these social determinants of health as they build supportive relationships with community members and community groups to promote access to resources and to health care. In New Mexico's community-based diabetes intervention, Lifestyle and Values Impacting Diabetes Awareness (LA VIDA), CHWs, or promotores, act as educators and advocates for individuals who have or are at risk for diabetes. The promotores utilize their cultural knowledge, sensitivity, and social networks to reach the medically underserved and to connect them with health care professionals and social services in the community.
Interventions designed to reduce diabetes health disparities require community-based interventions that focus on social conditions, environmental issues, and access to health care, rather than solely on individual lifestyle changes.4-8 The Centers for Disease Control and Prevention's REACH 2010 and REACH US initiatives endorse an expanded vision of intervention research for chronic disease that incorporates the social determinants of health.9 In findings from the first randomized controlled trial comparing 3 diabetes case management approaches-standard health care provider care, case management with registered nurses, and case management with CHWs-the patients in the CHW group alone significantly improved their health status. These patients benefited from their relationships with CHWs, who became trusted and accessible advocates.10
Promotores' effectiveness in providing social support, contributing to social cohesion, and facilitating access to health care relies on their culturally competent and culturally sensitive approaches. Cultural competency suggests that health care providers and health care organizations understand and respond effectively to the cultural needs and values brought to the health care experience.11 As members of the same culture and community, promotores integrate culturally sensitive approaches when interacting with clients. Cultural sensitivity implies that health care personnel are knowledgeable about racial and ethnic traditions and beliefs, including health traditions and beliefs.11Promotores help negotiate barriers to the health care system when health care professionals' ethnic or racial background and class are different from that of their patients.12,13 A review of culturally competent interventions for Hispanic adults with type 2 diabetes found that strategies with potential to improve health outcomes employed bilingual staff of the same cultural identity, provided sessions and educational materials in Spanish, and incorporated cultural traditions and beliefs in the intervention (food, family, and socialization).14 Culturally appropriate interventions for Hispanic women who have type 2 diabetes must involve support at the individual, familial, and community levels.15 For Hispanics and other ethnic and minority groups, programs that promote cultural competence consistently include CHWs whose cultural identity and community ties prove beneficial to health outcomes for the people they serve.15-17
In New Mexico, the Health Extension Rural Offices (HERO) program, represents a partnership with the University of New Mexico's Office of the Vice President for Community Health and the state's Agricultural Cooperative Extension Service to address social determinants of health. In turn, this partnership collaborated with safety net health care providers, such as Hidalgo Medical Services (HMS) in Grant and Hidalgo counties, to create the Health Commons model to improve access to health care among New Mexico's minority populations who have high numbers of uninsured individuals.18,19 Health Commons sites promote training and recruitment of diverse health professionals and expand local opportunities for employment. HMS is 1 of 6 New Mexico Health Commons sites that provide a seamless system of social, behavioral, and medical services for the uninsured using advanced case management methods, information systems, and links to community resources through CHWs or promotores.
With financial assistance from the Centers for Disease Control and Prevention's REACH cooperative agreement, the LA VIDA community-based program also emerged from the HERO program. This is an intervention program that targets individuals who have or are at risk for diabetes and employ promotores to give culturally sensitive and culturally competent support, education, and help in navigating the health care system. Promotores enable their clients to overcome longstanding barriers to the health care delivery system. LA VIDA partners with local and state institutions to promote the community integration of program activities (see Table 1).
|Table 1. LA VIDA Community Partners|
This article examines the LA VIDA diabetes intervention program as a model of a community integration approach that addresses racial and ethnic disparities in diabetes among Hispanics in New Mexico's Hidalgo and Grant counties. As the cornerstone of the LA VIDA program's community-based diabetes intervention, promotores use culturally sensitive approaches to affect the social determinants of health by providing social support, contributing to social cohesion, and improving access to health care and social and economic resources.
POPULATION SERVED BY THE LA VIDA PROGRAM
The LA VIDA program serves Hidalgo County, which has a 57% Hispanic population, and Grant County, with a 48.1% Hispanic community. Poverty rates, 21.2% in Hidalgo County and 17.9% in Grant County are high when compared with the US poverty rate of 12.7%.20 Rates of uninsured individuals, 28.4% in Hidalgo County and 23.5% in Grant County, are higher than the US uninsured rate of 17.8%21 (see Table 2).
|Table 2. Population Characteristics of Grant and Hidalgo Counties, U. S. Census 2000 Total Population (2006 estimate), Race and Ethnicity (2006 estimates), Poverty Rates (2006 estimates), and Rates of Uninsured|
In contrast to the US Census categories, residents in these 2 New Mexico counties most often identify as either Hispanic or Mexican categories, which often refer to their length of residency in New Mexico. Mexicans are more recent immigrants to New Mexico. Hispanics are those who were born in New Mexico and whose families may have lived in New Mexico for hundreds of years.
THE USE OF PROMOTORES IN THE LA VIDA DIABETES INTERVENTION PROGRAM
Beginning in 2002 and continuing to the present, LA VIDA program activities have expanded services for southwestern New Mexico Hispanics with or at risk for diabetes in Grant and Hidalgo counties. LA VIDA adapted the Latin American model that uses promotores to provide health care for the rural poor.22-24Promotores are CHWs who share a cultural identity similar to that of their clients and who provide a wide array of services to improve health outcomes.17,25-31
The holistic approach of promotores provides social support while addressing the health needs, socioeconomic issues, and lifestyle patterns of their clients. In the course of their interactions, promotores contribute to social cohesion by speaking Spanish with their clients, demonstrating respect, and emphasizing the importance of family and community relationships. Under the umbrella of the HMS Family Support Services, promotores access resources for financial aid and health care, and make referrals to agencies that focus on family issues. The promotores must prioritize needs and barriers and develop a strategy to overcome socioeconomic issues before addressing a client's diabetes.32
Hispanics participating in the LA VIDA program identified cultural barriers that affected their ability to prevent and control diabetes.33 Hispanics prefer a traditional diet, consisting of foods such as enchiladas, tacos, tortillas, beans, and rice. Consuming traditional foods is an integral component of their cultural identity. Therefore, recommendations to eliminate these foods from the regular diet are not realistic. Instead, the LA VIDA program promotores emphasized the consumption of smaller food portions and the use of alternative methods of food preparation, such as cooking with nonhydrogenated cooking oil instead of lard.
The centrality of the family and the social support that family members provide can either strengthen or undermine efforts to control diabetes. For example, enlisting the support of a wife who cooks the meals is essential to the well-being of her diabetic husband. The tendency to react to a diagnosis of diabetes with denial requires understanding and empathy on the part of promotores. The promotores play an important role in promoting culturally appropriate ways to negotiate barriers to diabetes prevention and control.
In addition, 2 Hispanic community members with diabetes and the local president of the League of United Latin American Citizens are members of the LA VIDA program Advisory Council. In addition to these Advisory Council members, Hispanic promotores and LA VIDA program administrators advocate for culturally tailored programs, events, and educational materials.
TRAINING AND RESPONSIBILITIES OF PROMOTORES
When promotores are recruited from the local community, desirable qualifications include having prior experience working with community resources and being nonjudgmental and compassionate. Promotores receive on-the-job training by shadowing and learning first hand from experienced promotores, thereby building and sustaining community capacity for diabetes prevention and control. Ongoing training workshops educate them about diabetes, as well as many other topics such as enrolling clients and family members in Medicare and Medicaid and how to use motivational interviewing during their client interactions. Principles of motivational interviewing guide the promotores' questions that they ask clients about increasing support in their family and friendship networks, accessing community resources for physical activity, and making referrals to community health professionals.
As conceptualized in the Health Commons model, the promotores assist clients with LA VIDA activities as well as activities encompassed by the HMS Family Support Program.
LA VIDA program activities led and facilitated by promotores:
* Grocery store tours that teach program participants how to read food labels.
* Diabetes support groups.
* Diabetes education in one-on-one sess-ions.
* Promotion of diabetes friendly menu choices in local restaurants.
* Active and Alive, a program providing physical activities and exercise instruction.
* Outreach to local agencies and churches about the activities and services provided by the LA VIDA program.
HMS Family Support Program activities offered by promotores:
* Teaching smoking cessation classes.
* Referrals to the Medication Assistance Program, which obtains free medications from pharmaceutical companies.
* Identifying emergency funding sources from community-based organizations that provide food, clothing, and financial support for the payment of rent or utilities.
* Enrolling clients and their family members in the HMS sliding fee scale as well as Medicare, Medicaid, and the New Mexico state coverage initiative.
* Referrals for health and social services to numerous local agencies and offices.
In outreach and educational activities, promotores emphasize the comprehensive services offered by HMS, including clinical and family support services and LA VIDA activities that benefit the total health of the client as well as contribute to diabetes control and prevention.
A mixed-methods approach was used to evaluate the effectiveness of the LA VIDA diabetes intervention program during 2004-2008. Qualitative methods were used to assess community involvement and program effectiveness. Quantitative methods were used to survey local health care providers and to measure their knowledge of the LA VIDA program, to survey behavior change among LA VIDA participants, and to analyze the HMS Promotora Monthly Reports and clinical data on glycated hemoglobin (HbA1C) levels. The study design was a quasi-experimental pre- to postdesign using cross-sectional data at various points to track changes in time.
As part of the LA VIDA program evaluation, 41 interviews were conducted with promotores, partners, and providers. The 17 promotores (16 women and 1 man) currently working with the LA VIDA program were interviewed. The 6 LA VIDA partners interviewed were identified by program administrators because of their significant contribution to the program. Eighteen local health care providers were selected from 20 providers who agreed to be contacted for a follow-up interview in the provider survey and from other key local providers. All respondents signed a consent form assuring them of confidentiality.
A structured interview guide was designed for each group. The guides featured open-ended questions addressing each respondent's role in the community, issues relevant to their role, as well as their relationship with the LA VIDA program. All interviews were tape recorded and transcribed in preparation for coding and analysis. Code sheets were used to track and organize responses. Using the guidelines from classical content analysis,34 each discrete group of interviews was coded and analyzed separately to identify prominent themes, patterns, and trends that emerged during the interviews. LA VIDA program staff and partners reviewed the results for accuracy and relevance.
Data from several sources were used to analyze the quantitative measures. These measures included both process measures (number of services offered by the promotores and knowledge about LA VIDA among community health providers) and outcome measures (diabetes knowledge, diabetes-related health behaviors, and clinical HbA1C levels).
The data sources for the process measures included: (1) HMS Promotora Monthly Reports and (2) a health care provider survey. The Promotora Monthly Reports documented the services, referrals and activities of promotores during 2004-2007. Information from each promotora was summarized each month and collated into an annual report.
A survey of primary health care providers in Grant and Hidalgo Counties was completed in January and February 2006. Health care providers (N = 46), including certified nurse practitioners, physician assistants, and certified nurse midwives, received a short questionnaire in the mail. Nonrespondents received a second follow-up letter 1 month after the initial first letter was mailed. Two weeks after the second letter, a reminder phone call was made to the health care provider's office. A total of 30 health care providers completed the questionnaire. The questionnaire topics included whether the health care provider diagnosed and cared for patients with type 2 diabetes, whether they had heard about the LA VIDA program and referred patients to the program for education classes and other activities, and how well they thought the program had done to improve a patient's ability to manage and control their diabetes.
Information for the outcome measures was collected from 2 sources: (1) LA VIDA participant enrollment and follow-up questionnaires and (2) clinical data on tracking changes in participants' HbA1C levels. Information on diabetes-related knowledge and health behaviors was self-reported by La VIDA program participants in enrollment and follow-up questionnaires during 2005-2007. LA VIDA program participants were consented to participate in these data collection activities when they enrolled in LA VIDA; the enrollment questionnaire was completed at the same time. The follow-up questionnaires were administered over the telephone to a random sample of LA VIDA program participants who completed the enrollment questionnaires on an annual basis. Questionnaire topics on the enrollment and follow-up questionnaires were similar and included diabetes status, knowledge about diabetes, diabetes self-monitoring behaviors, nutritional knowledge, and participation in recommended LA VIDA program activities. Additional questions on physical activity were addressed in the follow-up questionnaire. Descriptive analyses of the questionnaire data included comparison of enrollment and follow-up prevalences for categorical knowledge and behavior questions using [chi]2 tests. Continuous variables, such as the number of days a behavior occurred, were compared using 2-sample t tests.
Clinical data on HbA1C levels were obtained from participants' medical records at HMS and laboratory reports using the Patient Electronic Care System software. This information was linked with a LA VIDA program participant database maintained by the program, which included information on demographic characteristics and activities. The date of enrollment was calculated as the first date of any contact with the LA VIDA program, including a promotora visit or attendance at a diabetes education class.
A total of 246 (N = 246) participants had more than 1 HbA1C levels recorded for the time period of 1 year prior to program enrollment to 2 years after enrollment. The mean HbA1C levels were compared more than 3 time periods: 1 year prior to 14 days after enrollment, 14 days to 1 year after enrollment, and 1 year to 2 years after enrollment. The first time period (prior to enrollment) was extended to 14 days after enrollment to include those participants who had their HbA1C levels tested shortly after enrolling in the program. SAS/STAT statistical software (Version 8 of the SAS System, SAS Institute Inc., Cary, NC, USA) was used to compare mean HbA1C levels during the 3 time periods using generalized estimating equations.
A key finding of the qualitative analyses was the community-wide recognition of the important role the promotores played in supporting individuals diagnosed with diabetes. At the community level, partners collaborated with LA VIDA personnel to expand community services promoting health, and health care providers recognized that LA VIDA program activities were valuable resources for their patients.
The contributions of the promotores
Representative comments made by promo-tores document their culturally sensitive and culturally competent approach and their impact on the social determinants of health:
* Cultural competency
"I've found the resources that are available to me now, so I can help work with them because I know the community and I know this is my biggest strength right now. I'm able to understand where people are coming from being out here and what some of their needs are."
* Cultural sensitivity
"So LA VIDA has helped us. It's educated us in terms of really explaining and clarifying that we don't have to change our lives completely. We can still have our enchiladas, our tacos, everything that we enjoy, but we've learned how to prepare it in a healthier manner and everything in moderation."
* Accessing health care
"We have people who have diabetes. They come to the office but still don't have health care. And with the Family Support components of the program, we can help them to get the health care."
* Providing support by advocating for clients
"I can say I can talk to anybody in any agency, and I'm not a bit intimidated. I feel like what I have got to say is important, and they are going to listen to me. So I think motivational interviewing and customer service training really, really helped me to be able to put into practice the other things that I've learned."
* Contributing to social cohesion
One promotora enumerated her responsibilities: "The first is compassion, empathy, understanding my community, understanding where I live, understanding cultural diversities, and understanding illnesses, whether they be mental, physical, or emotional."
Promotores share their cultural identity with their clients and understand the importance of strong family and community ties. Participants' identity and relationships are validated rather than ignored or dismissed as a first step toward trust and empowerment. In these ways, promotores help their clients overcome cultural barriers to diabetes control.
Collaboration with partners
LA VIDA program partners share the common goal of controlling and preventing diabetes. In addition, their mutual respect for each other makes it possible for them to work together as they plan and organize diabetes prevention activities. Moreover, collaboration with health care providers and organizations enhances awareness and participation in the LA VIDA program.
LA VIDA partners organize innovative community events and media productions, such as the television program, "Cooking in the Gila." The Grant County Community Health Council's (GCCHC) reliance on the LA VIDA program allows them to concentrate on underlying issues of physical activity and maintaining a healthy weight, which are important for the prevention of diabetes.35 A LA VIDA promotora serves on the Grant County Community Health Council's Fitness and Nutrition in the Community committee, which focuses on these fundamental health issues. In some instances HMS has integrated diabetes and prevention programs into their services. For example, because of decreased funding from New Mexico's Diabetes Prevention and Control Program, the "Active and Alive" physical fitness program in Hidalgo County has been incorporated into HMS.
Collaboration with health care providers
The health care providers who were interviewed included 8 physicians, 2 physician assistants, a nurse practitioner, a public health nurse, a psychologist, a social worker, a nutritionist, the director of a dialysis, and 2 diabetes educators. Health care providers welcomed LA VIDA program activities and the support of the promotores as a way to reinforce their recommendations to patients. Providers benefited from the unique role played by the promotores when they helped their patients access resources, guided them through the LA VIDA program, and advocated for them when necessary.
As 1 provider stated, "Because on the diabetic's side you have diabetic episodes and so on, and on the family support side of health you have financial concerns and other social concerns that people have, and those things are linked together so closely that they can't be separated."
Another provider emphasized, "What you have is somebody bridging the gap and what happens is like using a peer to educate. And language is a big deal for your elderly because they're more likely to respond if you can speak to them-something they are more comfortable with. And if Spanish is their primary language, that is very, very, important. And addressing their differences."
Providers recognized the various ways in which the promotores had helped their patients by improving their level of knowledge about diabetes and by empowering them to make changes to control their diabetes. They identified specific support services such as the Medication Assistance Program and activities such as the grocery store tours and smoking cessation classes.
Summing up the role that the promotores played, a provider stated, "The promotores are essential to care of the diabetic patients because they are a part of the community, and the education and the support that people need to have healthy lives is greatly enhanced by these people."
Promotora monthly report
Promotores engaged in activities that ranged from making referrals, to conducting outreach events, to providing services, including educational classes on diabetes and its management. Table 3 compares the referrals and core services per 100 individuals served and the number of participants in the different educational classes for 2 different time periods, 2004 and 2007. As the LA VIDA program matured, promotores continued to provide referrals and core and educational services. However, the number of educational services dropped between the 2 years. This was due to the new emphasis of a new grant, REACH US, which replaced the previous funding from REACH 2010 in 2007. The REACH US grant emphasized disseminating the LA VIDA model to other communities. Thus, the promotores' activities shifted from referrals and core services to dissemination activities.
|Table 3. Activities of LA VIDA Program |
DIABETES KNOWLEDGE AND BEHAVIOR OF LA VIDA PROGRAM PARTICIPANTS
Data on diabetes knowledge and behaviors gathered from LA VIDA participants in enrollment and follow-up questionnaires were compared for respondents who had diabetes (Table 4). The mean number of days (5.5 days) in the preceding 7 days that respondents participating in LA VIDA activities checked their feet was significantly higher compared with those at enrollment (4.4 days) (P < .01).
|Table 4. Results From Self-reported Enrollment and Follow-up Questionnaire Data on Diabetes Knowledge and Behavior for LA VIDA Participants with Diabetes, 2005-2007|
The mean number of days (6.4 days) in the preceding 7 days that respondents took their diabetes medication as recommended by their health care provider was also significantly higher compared with those at enrollment (5.6 days) (P = .01). A higher percentage of respondents at follow-up compared to enrollment reported that they had their HbA1C checked at their last health care provider visit. However, no significant differences were observed between enrollment and follow-up in the percentages of respondents reporting that they had had a dilated eye examination or a foot examination in the past year.
CLINICAL HbA1C LEVELS
Mean HbA1C levels for the time period 1 year prior to enrollment to 14 days after enrollment ranged from 8.1 for non-Hispanic participants to 8.2 for all and Hispanic participants (Table 5). Mean HbA1C levels decreased significantly for all participants during the 2 time periods after enrollment (14 days after to 1 year after enrollment and 1 year after to 2 years after enrollment). When examined by ethnicity, mean HbA1C levels in Hispanics also decreased significantly over the 2 time periods. Although mean HbA1C levels decreased in non-Hispanic participants, the trend was not significant.
|Table 5. HbA|
Addressing the social determinants of health
The community-based participatory model implemented in Hidalgo and Grant counties employs an approach to eliminating health disparities that reaches beyond diabetes education and activities promoting lifestyle change to address the underlying social and economic factors affecting health. Through their participation in the LA VIDA program, promotores contribute to social cohesion by recognizing clients' concerns related to cultural identity and ethnic marginalization, as well as to their access to health care. Promotores develop personal, supportive relationships with clients making it possible for them to negotiate the health care system and to become empowered community members. Partners work closely with the promotores to impact a wider circle of community members. Health care providers and diabetes health educators rely on promotores as a valuable link to their patients.
IMPROVED ACCESS TO SERVICES WITH THE HEALTH COMMONS MODEL
The HMS Health Commons in Grant and Hidalgo counties improves access to numerous social, economic, and health services, including medical care, dental care, behavioral health, medication assistance, public health, and the family support program.19,20 Through the efforts of the promotores, more community members now have access to health care, have participated in LA VIDA activities, and have benefited from other social services. As the promotores participate in community health promotion and prevention activities, they become integral members of the health care workforce29 and act as community partners.27 LA VIDA program partnerships extend beyond the Advisory Council to include an expanding network of community members, organizations, churches, and businesses. Community integration of LA VIDA promotes capacity building for culturally relevant approaches and creates a foundation for sustainable diabetes prevention and control.
Cultural competence of the promotores
The LA VIDA promotores developed relationships with their clients that were based on mutual respect and trust. The promotores demonstrated cultural sensitivity and cultural competence by speaking Spanish with clients and identifying cultural barriers to effective control of diabetes. They understood the desire to continue eating traditional Hispanic foods and the hesitation to make appointments with unknown health care providers. They empathized with those who responded to a diagnosis of diabetes with denial and those who felt stigmatized and worked with them to move past the denial to take control of their diabetes. As members of the community, promotores recognized the social and economic needs of their clients and made referrals to social service agencies and other community resources that could meet these needs.
Central roles for communities
Empowerment and capacity building among community members enable communities to play a central role in decision making and implementing program activities. Inherent in community empowerment is a community-building approach that identifies the capacities, skills, and assets of people who lack resources.36 Empowered communities build on local and cultural strengths to move toward improved health.37-40
Community groups that collaborate with the LA VIDA program share in decision making as it relates to identifying community needs and program content. The promotores' ongoing training and expanding knowledge of community resources enable them to experience individual growth and to help build community capacity. The health care providers welcome promotores' support for the challenges they face in treating and educating the growing number of people who have diabetes. When given the opportunity to participate in LA VIDA program activities, community members often respond eagerly and positively due to their recognition of a disease that increasingly affects friends, family, customers, and clients, and sometimes themselves.
Improved health behaviors and outcomes
The HMS Health Commons model incorporates a strong diabetes control program and has been able to improve selected diabetes behaviors and outcomes in patients. Diabetic patients who participated in the LA VIDA program significantly increased the number of days they checked their feet and took their diabetes medication, as recommended by their health care provider. They also significantly lowered their HbA1C levels after enrolling in the program. This suggests that the Health Commons approach, combined with a targeted intervention program, can be an effective means to address the rising burden of chronic conditions in underserved populations, such as diabetes. Furthermore, these results demonstrate the progress made in reducing health disparities in diabetes control for residents of Hidalgo and Grant counties. The inclusion of promotores, with their similar cultural background to their clients and specific training, knowledge and skills, is an important component of the Health Commons model.