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Health Promotion Practice

http://hpp.sagepub.com/content/7/1/68The online version of this article can be found at:

 DOI: 10.1177/1524839904266799

2006 7: 68Health Promot PractKristine Lykens

Hector Balcazar, Matilde Alvarado, Mary Luna Hollen, Yanira Gonzalez-Cruz, Odelinda Hughes, Esperanza Vazquez andBehaviors Among Hispanics

Salud Para Su Corazón-NCLR: A Comprehensive Promotora Outreach Program to Promote Heart-Healthy  

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HEALTH PROMOTION PRACTICE / January 200671January

Salud Para Su Corazón-NCLR: A ComprehensivePromotora Outreach Program to PromoteHeart-Healthy Behaviors Among Hispanics

Hector Balcazar, PhDMatilde Alvarado, RN, MSNMary Luna Hollen, PhD, RDYanira Gonzalez-Cruz, MPH

Odelinda HughesEsperanza Vazquez

Kristine Lykens, PhD

This article describes results of year-1 implementationof the Salud Para Su Corazón (Health For Your Heart)—National Council of la Raza (NCLR) promotora (layhealth worker) program for promoting heart-healthybehaviors among Latinos. Findings of this communityoutreach initiative include data from promotorapledges and self-skill behaviors, cardiovascular diseaserisk factors of Latino families, family heart-health edu-cation delivery, and program costs associated withpromotora time. Participation included 29 trainedpromotoras serving 188 families from three NCLR affili-ates in Escondido, California; Chicago, Illinois; and OjoCaliente, New Mexico. Using several evaluation tools,the results showed that the promotora approach workedbased on evidence obtained from the following indica-tors: changes in promotora’s pre-post knowledge andperformance skills, progress toward their pledge goalsfollowing training, recruiting and teaching families,providing follow-up, and organizing or participating incommunity events. Strengths and limitations of the pro-motora model approach are also discussed.

Keywords: participatory research; community out-reach; lay health workers; Latino families;cardiovascular health

Reducing health disparities for cardiovascular dis-ease (CVD) and associated risk factors continuesto be an important public health problem for the

nation. Mortality statistics for heart disease show thatCVD is the leading cause of death for Hispanics (in this

article, the terms Hispanics and Latinos are usedinterchangeably; nationally, these terms are used exten-sively). Of great concern is the fact that recent epidemi-ological data show that Mexican Americans (who com-prise the largest percentage of the U.S. Hispanicpopulation) are not protected from CVD (Rainwater etal., 2000). The CVD mortality rate of Mexican Ameri-cans is equal or higher than the rate for non-HispanicWhites (Pandey, Labarthe, Goff, Chan, & Nichaman,2001; Stern & Wei, 1999). There are many modifiablerisk factors among Hispanics that are more prevalent inthis population than among other groups including non-Hispanic Whites. Epidemiological data have shown anincrease and disproportionate burden of being over-weight, a lack of physical activity, high cholesterol, andhigh-fat diets among Hispanics, particularly MexicanAmericans (Perez-Stable, Juarbe, & Moreno-John, 2001).

Culturally appropriate heart-health prevention strat-egies for Hispanics are needed given the fact that thereare many barriers that contribute to the deficient state ofcardiovascular health among different Hispanic sub-groups (Moreno et el., 1997): (a) Compared with otherAmericans, Hispanics do not have health insurance and

68

Authors’ Note: Acknowledgements and recognition of leadpromotoras are as follows: Teresa Andrews, Escondido Commu-nity Health Center; Janet Lucero, Hands Across Cultures Corpora-tion; Rosario Sanchez and Irma Pacheco, Centro San Bonifacio.Acknowledgements and recognition of community-based organi-zations and their representatives are as follows: Lori Ramos, exec-utive director, Centro San Bonifacio, Chicago, IL; Tracey Ream,executive director, Escondido Community Health Center, CA;Ruth Manzano, director of health promotion, Escondido Commu-nity Health Center, CA; Henry Montoya, chief executive officer,Hands Across Cultures Corporation, Española, NM; CristinaRodriguez, chief financial officer, Hands Across Cultures Corpora-tion, Española, NM; John Romero, executive director, Centro SanVicente, El Paso, TX; Claudia Garcia, director of the Health Educa-tion Department, Centro San Vicente, El Paso, TX. Funding wasprovided by the Metropolitan Life Foundation.

Health Promotion PracticeJanuary 2006 Vol. 7, No. 1, 68-77DOI: 10.1177/1524839904266799©2006 Society for Public Health Education

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lack access to routine primary and preventive healthcare; (b) more Hispanics live below the poverty level; (c)public health messages are in English and many His-panic individuals are monolingual Spanish speakers oronly read in the Spanish language; and (d) many His-panic individuals are unaware of preventive measuresto reduce the risk of heart attacks and stroke and there-fore suffer disproportionately from the risk factors asso-ciated with CVD.

In 1994, the National Heart, Lung, and Blood Insti-tute’s (NHLBI) Salud Para Su Corazón (SPSC) initiativebegan development of a heart-health, community-basedoutreach and prevention model program aimed atincreasing knowledge about CVD risk factors and heart-healthy behaviors among Latinos (Alcalay, Alvarado,Balcazar, Newman, & Huerta, 1999; Alcalay, Alvarado,Balcazar, Newman, & Ortiz, 2000; Balcazar, Alvarado,Alcalay, Huerta, & Ortiz, 1999; Balcazar et al., 2001;NHLBI, 1996).

SPSC has utilized the lay health worker (promotora)model to help reduce health disparities in the area ofCVD in Latinos. SPSC has developed a unique partner-ship with the National Council of la Raza (NCLR), andNCLR has adopted the NHLBI’s SPSC initiative as partof their community outreach efforts.

The purpose of this article is to report on severalaspects of the SPSC-NCLR promotora model that guided1st-year implementation of this initiative in three par-ticipating Latino communities from different regions ofthe United States. Specifically, we report on how theproject was structured and its conceptual framework,the promotora training, the program curriculum as aculturally appropriate health education tool, and theapplication of the promotora model to the delivery ofthe CVD prevention curriculum in these three Latinocommunities.

�METHOD/STRATEGIES/INTERVENTION APPLICATIONS

The SPSC-NCLR PromotoraModel: Theoretical Perspective

Many public health interventions that combine com-munity outreach processes and participatory researchare using community health workers to address healthdisparities among racial and ethnic minority groups(Corkery et al., 1997; Eng, Parker, & Harlan, 1997; Keg-ler, Stern, Whitecrow-Ollis, & Halinka, 2003).

Promotora programs have used a variety of concep-tual and theoretical frameworks of health education andhealth promotion (Witmer, Seifer, Finnochio, Leslie, &O’Neil, 1995). To date, these conceptual frameworks areguiding the different methods of health educationdelivery used by promotoras (Castro et al., 1995; Enget al., 1997; Meister, Warrick, de Zapien, & Word, 1992;NHLBI, 2002; Navarro et al., 1998). For example, the Porla Vida Model Intervention in San Diego was developedusing the theoretical framework of natural networksamong Hispanics and the concept of the natural helpersdefined by Eng and colleagues (Eng et al., 1997; Navarroet al., 1998).

Figure 1 describes the SPSC-NCLR promotora out-reach model components. This model incorporates sev-eral key components: (a) theory-driven elements thatguided the original SPSC project including participa-tory and social action research (Flores, Castro, &Fernandez-Esquer, 1995; Minkler & Wallerstein, 2003);(b) the community-based organizations (CBOs); (c) cul-turally enriched process dimensions incorporated inthe planning, development, implementation, and eval-uation of the promotora approach; (d) the train-the-trainer model of promotoras; (e) the dynamic relation-

Balcazar et al. / SALUD PARA SU CORAZÓN 69

Social Action Research

Ecological Perspective

Behavioral Change Theories

Community-Based Organizations

Culturally-Enriched Process Dimensions—Planning, Development, Implementation & Evaluation

Hispanic Family Cardiovascular

Health Promotion

Promotores de Salud

Hispanic Family Health Education

Community

Train-the-Trainer Model

Participatory Research

FIGURE 1 Salud Para Su Corazón—National Council of la Raza Promotora Model

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70 HEALTH PROMOTION PRACTICE / January 2006

ships between promotoras, program participant fami-lies, and the community agency; and finally (f) cardio-vascular health promotion outcomes for Hispanicprogram participants.

Table 1 presents a timeline of the SPSC-NCLR projectcomponents. It provides a picture of the sequence ofactivities of the promotora outreach model. We describenext the methods used for the different components ofthe project.

Needs Assessment Survey of CBOs

The SPSC-NCLR initiative conducted a needsassessment survey of NCLR-affiliated agencies toassess their health education needs and communityoutreach services including promotora programs pro-vided to Latinos. The survey was conducted by NCLRstaff between March 30 and July 7, 1998. NCLR is thelargest constituency-based Latino organization in theUnited States serving more than two million Latinosand is affiliated with more than 200 community-basedagencies throughout the country. These agencies pro-vide a wide range of services to Latinos in the commu-

nity that include health, community, and eco-nomic development; employment and train-ing; and outreach activities such as forumsand national meetings.

The findings of the needs assessment sur-vey (not shown) from 136 community agencyparticipants revealed that almost all of theCBOs had a health focus (97%). A total of 88agencies (67%) used lay health educators(promotoras de salud) in their efforts. About90% of the CBOs reported that theirpromotoras provided health promotion andhealth education activities.

Request for Proposals (RFP)and Selection of CBOs

The 88 agencies that had promotora pro-grams were invited to submit an RFP devel-oped by the SPSC-NCLR team. Three CBOswere selected from the pool of applicants.Each CBO received a grant for $11,000 tocover the cost of the planning and implemen-tation phases of the program (see Table 1). Afourth CBO was selected to help in the train-ing of promotoras. These promotora trainersworked at Centro San Vicente in El Paso,Texas. A brief description of the three com-munities selected follows.

Escondido Community Health Center,Escondido, California. Escondido is a citywith a population of 108,000 located inNorthern San Diego County. The Hispanic

population in Escondido increased by 171% between1980 and 1990 and represents approximately 25% ofthe total population. Almost 27% of Escondido His-panic families live below the poverty line, and 73%indicate that Spanish is the language spoken at home.

Centro San Bonifacio, Chicago, Illinois. The ChicagoWest Town area is an underserved urban communitywith 65,000 residents, approximately 60% of which areLatinos. West Town area has traditionally been knownas a port of entry for new, very low income, culturallyisolated, monolingual immigrants.

Hands Across Cultures, Clincas del Norte, Ojo Caliente,New Mexico. Ojo Caliente is a rural, mountainous areain Northern New Mexico. Latinos make up 72.6% of thepopulation in Rio Arriba and 49% of Santa Fe counties.About 64% of Latinos in this area lack health insurance,and 34.7% live in poverty. The city of Española, NewMexico, was the site that supported the program. One ofthe clinics was located in Ojo Caliente. We will refer toEspañola in subsequent descriptions for thiscommunity site.

TABLE 1Salud Para Su Corazón—National Council of la Raza

Promotora Outreach Model: Project Components and Timeline

Planning/Development Phase 1998-2000• Needs assessment survey of community-based organizations (CBOs)• Request for propoals and selection of CBOs• Development of goals and program activities for the Latino

communities• Development of participatory approaches and community capacity

efforts• Selection of promotora/mentor community site• Development of evaluation plan and testing of instruments

Implementation Phase 2000-2001• Delivery of promotora training activities• Delivery of program curriculum “Your Heart, Your Life” educational

sessions• Reporting of risk factors for heart disease among Latino family

members• Delivery of community activities including referral activities and

follow-up

Evaluation Phase 2001-2003• Process evaluation of promotora activities including knowledge and

skills• Process evaluation of CBOs’ experiences with promotora outreach

program• Process evaluation of cost estimation of program implementation by

promotoras• Outcome evaluation of self-reported heart-healthy behavioral

changes among Latino families

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Goals, Objectives, and Program Activities

The goals and objectives of the SPSC-NCLR commu-nity outreach projects were developed based on a par-ticipatory process using the RFP guidelines and inputfrom lead promotoras, agency administrators/managers,and other SPSC-NCLR team members.

The goals and objectives of the SPSC-NCLR commu-nity outreach projects included the following compo-nents: (a) monitor changes in heart health knowledge,attitudes, and skills of promotores; (b) track the deliveryof the program curriculum and educational sessionsdelivered by promotoras to Latino families; (c) deliver aseries of community educational activities; (d) assessperceptions of community-based agencies associatedwith the promotora model to build community capac-ity; and (e) evaluate changes in heart-healthy behaviorsreported by Latino family participants. In this report,we describe results for objectives a through d.

Community Participatory Processand Capacity Building

Several capacity-building elements supported theSPSC-NCLR promotora model for all community out-reach projects. These included (a) a team-building ap-proach consisting of member staff from NHLBI, NCLR,and the University of North Texas Health ScienceCenter—School of Public Health (UNT-SPH) providingconsultation with promotoras for training structureneeds, training lead promotoras and CBO facilitators,providing technical assistance to promotoras throughmonthly conference calls, and providing site visits toreview progress, engage in group problem solving, sup-port goals, and provide SPSC resource materials to eachof the communities; (b) supervision by the three CBOsin the planning, implementation, and evaluation of theSPSC-NCLR promotora model; and (c) participation ofpromotoras from mentor sites to provide guidance andbring field experience to the project.

The “Your Heart, Your Life” Curriculum

The “Your Heart, Your Life” curriculum was used todeliver the educational sessions of the promotora modelprogram. Promotoras were responsible for providingeducation using seven 2-hour sessions. Each promotoramaintained a log of the sessions delivered to participat-ing family members. Follow-up was performed by tele-phone calls or visits to support families in their commit-ment to lifestyle heart-health promotion. Each promo-tora was responsible for delivering at least 50% of sevensessions. Promotoras delivered the educational sessionsand provided follow-up activities within a 6-monthintervention period. The “Your Heart, Your Life“ cur-riculum is a user-friendly, bilingual program for promo-toras developed by NHLBI specifically for Latino com-munities. It offers a variety of cultural and language-appropriate instructional methods including lectures,

handouts, recipes, hands-on demonstrations, videos,informal individual and group discussions, role-playing,peer teaching, actor scripts, problem solving, games,values and symbolism, and group activities. A copyof the curriculum can be downloaded from theNHLBI’s web site at www.nhlbi.nih.gov/health/prof/heart/latino/lat_mnl.htm.

Development of the Evaluation Plan

An evaluation tool (called Cuéntamelo) was design-ed to monitor and measure the quality of the projectsby looking at the activities and benefits at three levels:the promotoras, the individuals and families, and theCBOs.

Cuéntamelo: Data Collection

The Cuéntamelo evaluation tool employed a varietyof culturally specific qualitative and quantitative meth-ods to track, guide, and assess the performance of theproject at the level of the promotoras, families, andCBOs. Cuéntamelo was designed to capture the progressof the programs and generate ideas for improvement.We describe next the Cuéntamelo assessment tools:

1. Pretest and posttest heart-health knowledge ofpromotoras. A curriculum-based, 8-item pretest andposttest questionnaire was administered to evaluatechanges in promotoras’ knowledge of cardiovascu-lar health as a result of the training.

2. Promotoras’self-skill behaviors. This self-skill toolwas a self-administered pre-post test consisting of a22-item Likert-type scale to assess promotora per-sonal characteristics and performance skills. Thepretest was administered during the training andthe posttest at the end of year 1.

3. CVD risk factors of families. Assessment of CVD riskfactors was recorded for the participant represent-ing the family in the program using a family healthcard tool. Participants were prompted to answereach of the questions pertaining to the presence ofrisk factors (i.e., smoking, high cholesterol, highblood pressure, heart disease runs in family, etc.).

4. Family heart-health education. This included anassessment of the number of sessions delivered bypromotoras using the “Your Heart, Your Life”curriculum.

5. Testimonials/diary. Promotoras were responsiblefor collecting testimonials and writing journalentries of their experience in delivering heart-healtheducation activities to Latino families.

6. Pledges (compromisos). At the initial kickoff meet-ing at NCLR headquarters, lead promotoras in coor-dination with their agency administrators and theSPSC-NCLR team developed the pledges for each ofthe three community outreach projects.

7. Assessment form for CBOs. The participating CBOswere asked to complete an assessment form togather information about their opinions, ideas, sat-isfaction, disappointments, suggestions, and hopesrelated to the project.

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Pretesting of data collection instruments was com-pleted before project implementation. Promotora men-tors and SPSC-NCLR team members helped in the pre-testing of all instruments. Data from some of the siteswere analyzed using frequency distributions and per-centages of responses and recorded activities. Whenappropriate, statistically significant differences weretested using chi-square tests. The results are based on 29trained promotoras serving a total of 188 families at thethree sites. To keep data collection to a minimum,sociodemographic and personal information from thepromotoras was not compiled. Some results aredescribed for all three sites separately to give more spec-ificity to the findings. Our interest however, was onevaluating the overall performance of all three sites. Acost analysis was developed to estimate the total num-ber of hours of promotora activity in each community.

�RESULTS

The results shown below describe the delivery ofpromotora training activities, promotora pledges,promotora self-skill behaviors assessment, family CVDrisk factors assessment, family heart-health educationdelivery, program participant testimonial, and CBO per-ceptions of the promotora model.

SPSC-NCLR Promotora Training

Each of the CBOs selected a lead promotora for theproject. An administrator or manager representing each

of the CBOs joined the team to supervise lead promotoraactivities within the SPSC-NCLR project. The leadpromotora participated in a series of training activities.These activities included (a) a 32-hour training at NCLRheadquarters using the “Your Heart, Your Life” curricu-lum; (b) 18 hours of training by lead promotoras to localteams of promotoras with the “Your Heart, Your Life”curriculum; (c) a 2-day training to promotoras at theNational Promotoras Conference conducted by leadpromotoras; (d) participation in promotora trainingactivities and continuing education at the NCLRNational Conference; and (e) participation in monthlyconference calls with the SPSC-NCLR team (NHLBI,NCLR, and UNT-SPH partners).

Pledges (Compromisos)

One important outcome evaluated was the extent towhich pledges were fulfilled by the end of year 1 of theproject implementation phase (2000-2001). Thesepledges (see Table 2) represent the commitment thatlead promotoras and their agencies made to deliver pro-ject activities utilizing the funding allocations given toeach of the community sites. Table 2 shows the indica-tors as the gold standard for evaluating success.

The SPSC-NCLR projects trained 29 promotoras todeliver health education to Latino families. Thesepromotoras had at least a high school education andpreferred speaking Spanish. The trend in promotoraprogram delivery was similar between sites: Out of atotal of 29 promotoras, 11 delivered the program in Chi-

72 HEALTH PROMOTION PRACTICE / January 2006

TABLE 2Promotora Pledges and Results of Activities Under Contract

Pledges Chicago, IL Escondido, CA Española, NM

Number of trained promotoras Proposed: 15 Proposed: 15 Proposed: 7committed to training for delivering Number: 11 Number: 11 Number: 7the program

Number of families recruited Proposed: Between 75-150 Proposed: Between 75-100 Proposed: Between 105-140to receive SPSC education Number: 79 Number: 49 Number: 60(at least 50% of the sessionsof curriculum or manual)

Provide follow-up activities Proposed: 50% of families Proposed: 50% of families Proposed: 50% of familiesAchieved: 100% Achieved: 83% Achieved: 100%

Number: 79 Number: 41 Number: 60

Provide referrals When possible When possible When possible

Organize and participate in a Proposed: 6 Proposed: 6 Proposed: 5number of community events Achieved Achieved Achieved

Collect testimonials 3 testimonials 3 testimonials 3 testimonialsCompleted Completed Completed

NOTE: SPSC = Salud Para Su Corazón.

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cago (proposed 15), 11 in Escondido (proposed 15), and7 in Española (proposed 7). These figures represent a73% rate of success for Chicago, an 80% rate forEscoñdido, and a 100% rate for Española.

The number of families recruited who received theSPSC family heart-health education (minimum 50% ofa seven-session program) in Chicago, Escondido, andEspañola represented 100% (79 families/75 proposed),65% (49 families/75 proposed), and 57% (60 families /105 proposed) rates of success, respectively.

The pledge to conduct follow-up activities with atleast 50% of the families yielded very good results intwo communities—Chicago (79 families) and Española(60 families)—achieving 100% follow-up success rates.The other site, Escondido, achieved an 83% follow-upsuccess rate (41 out of 49 families).

Referral activity data were not available and there-fore could not be evaluated, and consequently, a pledgereference standard was not established for this activity.Promotoras were able to conduct 100% of the suggestednumber of community activities and collections of testi-monials. All sites delivered a variety of communityevents as part of the SPSC-NCLR program.

Promotora Knowledge and Skills

Pretest and posttest promotora heart-health knowl-edge and self-skill behavior scores were obtained forone site. Differences in pre-post test scores were diffi-cult to determine with the two other sites because oftheir open-ended versus closed format for evaluatingknowledge and skills. The closed-format pre-post testscores reported a score of 74% for the pretest and 100%correct for the posttest (n = 11). Statistically significantresults of the self-assessment skills of promotora knowl-edge and performance as community health educatorsare shown in Figures 2 and 3.

Promotoras showed significant improvement as indi-cated by the percent of promotoras responding“always” in basic knowledge of health, basic knowledgeof how to take care of the heart, and knowing abouthealth services in the community (Figure 2).Promotoras significantly improved their performanceafter 1 year by being better listeners; increasing activi-ties of planning, organizing, and delivering classes andgroup presentations; increasing acceptance of positivecriticism; and augmenting the actions of encouragingpeople to express their own opinions (Figure 3).

Family Heart-Health Education

Figure 4 illustrates the results of the percentage ofheart-health education sessions Latino familiesreceived from promotoras at the three different sitesusing the “Your Heart, Your Life” curriculum. Thepromotoras pledge to teach at least 50% of seven ses-sions of the “Your Hearth, Your Life” curriculum (ses-sions 6 and 7 were delivered as one). Chicago reportedimplementation rates of more than 50% in five training

sessions. “Are you at risk for heart disease?” had thehighest rate at 100%. Escondido reported 100% imple-mentation of five sessions, and New Mexico reported100% implementation in all seven sessions of the “YourHeart, Your Life” curriculum. The diabetes session wasconsidered optional.

All educational sessions for the three communitysites were delivered within a 2 to 3 month period. Edu-cation sessions were delivered by promotoras severaltimes a week, once a week, or every other week.Promotoras used a variety of teaching techniques thatincluded self-discovery, empowerment, and value clar-ification based on storytelling, poems and songs, cul-tural symbolism, hands-on activities and practicums,role-play and simulation, food demonstration and fooddisplays, audiovisuals, and community health talks(charlas). Follow-up contacts were made in the form of

Balcazar et al. / SALUD PARA SU CORAZÓN 73

FIGURE 2 Differences in Pre-Post Promotora KnowledgeScores (N = 29)NOTE: Self-assessment knowledge: 1 = basic knowledge of health;2 = basic knowledge of how to take care of heart; 3 = knowing abouthealth services in the community. Pre-post changes are statisti-cally significant at p < .05.

FIGURE 3 Differences in Pre-Post Promotora PerformanceSkills Scores (N = 29)NOTE: Self-assessment performance skills: 1 = listening to whatpeople say; 2 = planning, organizing, presenting a class/group dis-cussion; 3 = accepting positive criticism; 4 = encouraging people toexpress their own opinions. Pre-post changes are statistically sig-nificant at p < .05.

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home visits or by telephone after the completion of theeducational sessions. The educational sessions and thefollow-up contacts for all participating Latino familiesfrom the three community sites were conducted withina 6-month period. The purpose of the follow-up con-tacts was to reinforce the educational activities learnedin the program.

Family Risk Factors Assessment

An assessment of CVD risk factors was conducted bypromotoras and recorded for each of the 188 participat-ing families using the family health card data collectiontool. Results of four major risk factors for heart diseaseare shown in Figure 5. Across all sites, 37% of familiessmoke cigarettes, 41% consider themselves as beingoverweight, 32% have been told they have diabetes, and52% reported a lack of physical activity. As shown inFigure 5, differences in the distribution of these riskfactors vary by site.

Cost Analysis

To determine costs of the SPSC-NCLR program, ameasure was developed estimating the total number ofhours of activity for promotoras in each community.Total promotora hours for each community included timedevoted to training, family program delivery, follow-upwith families, and promotora activities at communityevents as shown in Table 3. The $11,000 granted to eachcommunity was divided by total promotora hours todetermine an average cost per promotora hour. Asshown in Table 3, using this measure, the cost per houraveraged $10.77 across the three communities involvedin the project and ranged from a low of $8.79 at the NewMexico site to $13.29 at the California site.

Promotora Testimonials

Participants praised the promotoras from the SPSC-NCLR program for their teaching and for showing themhow to incorporate health education into their dailylives. The following two testimonials came from pro-gram participants:

I have learned from the promotoras how to eat healthy.They have taught me to eat balanced meals. I reallyenjoy when she visits me at home, and I also enjoygoing to the classes.

Receiving the classes was a very positive experi-ence for me and my family. The promotora was ableto answer our questions and made the class veryinteresting and fun. I now want to keep my heartworking well.

CBO Reponses

Participating CBOs were asked to complete an evalu-ation to gather information about their opinions, ideas,satisfaction, disappointments, suggestions, and hopes

related to the project. CBO representatives had positivecomments about the program. One CBO representativecommented that since they began working with the pro-gram, their promotoras say that they have become moreconscious of the quality of the food that they provide attheir events and are very satisfied with the progress,promotora support, and the project’s contribution tobuilding capacity. Another CBO representativereported that “the program provides its promotoraswith the opportunity to see how their efforts can benefitthe community, it gives them a sense of empowerment,and it increases their leadership skills.” Furthermore,this same CBO representative indicated being very sat-isfied with the participation of other community con-tacts to promote program goals, support promotoras,and verify the usefulness of the Cuéntamelo evaluationtool. The representatives from the third CBO said thatthe promotoras program has allowed their organizationto expand its range of services to include health promo-tion efforts in other health-related areas.

74 HEALTH PROMOTION PRACTICE / January 2006

FIGURE 4 Family Heart-Health Education SessionsParticipationNOTE: N = 188 families: Chicago, IL = 79; Escondido, CA = 49;Española, NM = 60. Sessions taught: (a) Are you at risk for heartdisease? (b) Be more physically active; (c) What you need to knowabout high blood pressure, salt, and sodium; (d) Eat less fat, satu-rated fat, and cholesterol; (e) Maintain a healthy weight; (f) Makeheart-healthy eating a family affair; (g) Enjoy living smoke free; and(h) Diabetes (optional).

FIGURE 5 Family Risk Factors AssessmentNOTE: N = 188 families: Chicago, IL = 79; Escondido, CA = 49;Española, NM = 60.

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Balcazar et al. / SALUD PARA SU CORAZÓN 75

�DISCUSSION

In this article, we report the findings of specific com-ponents of a comprehensive outreach promotora pro-gram to promote heart-healthy behaviors among Lati-nos. Using several evaluation tools, the results showedthat the promotora approach utilized in the SPSC-NCLRprojects worked based on evidence obtained from thefollowing indicators: changes in promotora’s pre-postknowledge and performance skills, progress towardtheir pledge goals in terms of training promotoras,recruiting and teaching families, providing follow-up,and organizing or participating in community events.

The training of promotoras was a very successfulcomponent of the program. Many hours of supervisionand training were given to the lead promotoras by theteam and CBOs. Training emphasized capacity build-ing, team building, evaluation, and sharing activities.The in-depth training of the lead and field promotoraswas based on the “Your Heart, Your Life” curriculum.This curriculum offers a variety of culturally andlanguage-appropriate instructional methods includingvalue clarification and cultural symbolism. One ofthe important elements of the training that is empha-sized is to engage promotoras in the development ofself-discovery through readings of poems and sharing ofpersonal stories of the life of the promotoras and the val-ues they have for community involvement.

Lead promotoras were able to train 29 fieldpromotoras to work directly with Latino families. The29 promotoras developed further competencies as aresult of teaching families. Important promotora skillslearned included elements of leadership and manage-ment (listening to people; accepting positive criticism;encouraging people to express opinions; and planning,organizing, and presenting class/group discussions).

The train-the-trainer model was very effectivelyapplied in the three different settings where promotoraslive and work. Promotoras became good role modelsand teachers (Corkery et al., 1997; Navarro et al., 1998).

Establishing promotora pledges at the beginning ofthe project and using those pledges to guide and evalu-ate activities/successes under contractual agreementsproved to be a very positive experience for all partnersinvolved. This process enabled lead promotoras, CBOs,and partners (NHLBI, NCLR, and UNT-SPH) to be morerealistic about what could be accomplished and evalu-ated with funding allocations for each site ($11,000 for aperiod of 1 year). The total number of promotorasrecruited and trained per site in addition to the totalnumber of families recruited, educated, and followedup within each project are important indicators of suc-cess for this initial year of implementation of the pro-jects. Additional activities of referral, organization, andparticipation in community activities are also positiveelements of promotora outreach activities delivered inthe participating Latino communities.

Promotoras provided health promotion and educa-tional activities to 188 families. The results showed thattrained promotoras can engage Latino families in ahealth education program. In addition, as part of theintervention activities, promotoras were able to identifyCVD risk factors for participating families.

Limitations

An important limitation in implementing the threeprojects was the lack of sufficient resources needed toallow for the development of organizational supportmechanisms to reinforce the efforts of the promotoras intheir communities. Promotoras were asked to field testthe newly developed evaluation tools, use them for col-

TABLE 3Costs of Salud Para Su Corazón Local Implementation Projects

Chicago, IL Escondido, CA Española, NM Total

Local promotora training hoursa 62 62 62 186

Family program delivery hoursb 679 675 957 2,311

Family follow-up hoursc 200 51 180 3,064

Community event hoursd 44 40 52 136

Total promotora hours 985 828 1,251 3,064

Community grant $11,000 $11,000 $11,000 $33,000

Program cost per promotora houre $11.17 $13.29 $8.79 $10.77

a. Training hours included a 2-day National Promotoras Conference training of lead promotoras, 18 hours of training to local promotorasteams, 2 hours per continuing education session per month, and 1-hour monthly conference calls.b. Program delivery included eight 2-hour sessions per family times the local percentage of sessions completed by families.c. Family follow-up assumes 2 hours for each home visit and 1 hour per telephone contact.d. Community event hours assumes 2 hours per activity.e. Amount of community grant(s) divided by total promotoras hours.

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lecting the data, and implement the program. Thesetasks were difficult to accomplish simultaneously in atimely fashion during a 1-year period. This process cre-ated inconsistency and a lack of completeness and clar-ity in collecting the data. The nature and extent of thepromotoras’ interactions with families did not alwayslend themselves to easy documentation. More time wasneeded to develop a level of comfort with theevaluation forms.

Unfortunately, because of funding limitations, it wasnot possible to evaluate the extent to which projectactivities associated with providing follow-up, refer-rals, and community events to promote heart healthyielded improvements in the number of new patient’sscreened and changes in lifestyle behaviors amongLatino families that did not participate in the promotorasessions. The findings of these projects are not intendedto be representative of all Latino communities; how-ever, they provide insights into what a promotora-basedcommunity strategy with a participatory process canaccomplish. The evaluation phase of the SPSC-NCLRprojects for year-2 funding (2002-2003) includes impactmeasures for assessing changes in heart-healthy life-style behaviors among program participants. This eval-uation is currently in progress.

�CONCLUSIONS

Findings from year-1 implementation of SPSC-NCLRprograms indicate that promotora-based partnershipscan be comprehensive, and the approach is feasible inlow-income Latino communities. Project achievements,along with feedback from promotoras and CBOs, led tothe identification of specific areas for considerationwhen implementing community outreach promotoraprograms. These include the following: (a) Team build-ing engaged the group to function effectively for com-munity action and to foster ownership; (b) balancinghow things would get done and what would get donewas a key guiding principle; (c) capacity building, pro-viding learning experiences and building skills, is keyto energizing the promotoras; (d) evaluation created aparticipatory process for providing ongoing assessmentto help determine the value of the work of the promo-toras and strengthen project implementation; (e) shar-ing the project with others provides an opportunity formarketing, further expansion, new learning, and usabil-ity; and (f) development of cost measures provided anopportunity to estimate an average cost per promotorahour. This assessment of delivering outreach services toLatino families can then be used by other promotoraprojects to compare costs of local implementationprojects similar to the SPSC-NCLR program.

REFERENCES

Alcalay, R., Alvarado, M., Balcazar, H., Newman, A., & Huerta, E.(1999). Salud Para Su Corazón: A community-based Latino cardio-vascular disease prevention and outreach model. Journal of Com-munity Health, 24, 359-379.

Alcalay, R., Alvarado, M., Balcazar, H., Newman, E., & Ortiz, G.(2000). Evaluation of a community-based Latino heart disease pre-vention program in metropolitan Washington, D.C. InternationalQuarterly of Community Health Education, 3, 191-204.

Balcazar, H., Alvarado, M., Alcalay, R., Huerta, E., & Ortiz, G.(1999). Salud Para Su Corazón: A model program to promote car-diovascular health in Latinos. Medico Interamericano, 18(1), 18-23.

Balcazar, H., Alvarado, M., Alcalay, R., Schindeldecker, M.,Newman, E., Huerta, E., et al. (2001). Salud Para Su Corazón: Eval-uating cardiovascular health outreach activities in the Latino com-munity. Medicine of the Americas, 2, 4-11.

Castro, F., Elder, J., Coe, K., Tafoya-Barraza, H., Moratto, S., Camp-bell, N., et al. (1995). Mobilizing churches for health promotion inLatino communities: Campañeros en la salud. Journal of theNational Cancer Institute Monograms, 18, 127-135.

Corkery, E., Palmer, C., Foley, M., Schechter, C., Frisher, L., &Roman, S. (1997). Effect of a bicultural community health workeron completion of diabetes education in a Hispanic population.Diabetes Care, 20(3), 254-257.

Eng, E., Parker, E., & Harlan, C. (1997). Lay health advisor interven-tion strategies: A continuum from natural helping to paraprofes-sional helping. Health Education & Behavior, 24, 413-417.

Flores, E., Castro, F., & Fernandez-Esquer, M. (1995). Social theory,social action, and intervention research: Implications for cancerprevention among Latinos. Monograms of the National CancerInstitute, 18, 101-108.

Kegler, M., Stern, R., Whitecrow-Ollis, S., & Halinka, L. (2003).Assessing lay health advisor activity in an intervention to preventlead poisoning in Native American children. Health PromotionPractice, 4, 189-196.

Meister, J., Warrick, L., de Zapien, J., & Word, A. (1992). Using layhealth workers: Case study of a community-based prenatal inter-vention. Journal of Community Health, 17, 37-51.

Minkler, M., & Wallerstein, N. (2003). Community-based partici-patory research for health. San Francisco: Jossey-Bass.

Moreno, C., Alvarado, M., Balcazar, H., Newman, E., Ortiz, G., &Forrest, M. (1997). Heart disease education and prevention pro-gram, targeting immigrant Latinos: Using focus group responses todevelop effective interventions. Journal of Community Health, 22,435-450.

National Heart, Lung, & Blood Institute. (1996). Latino communitycardiovascular disease prevention and outreach initiative. Back-ground report. Bethesda, MD: Public Health Service, NationalInstitutes of Health.

National Heart, Lung, & Blood Institute. (2002). Promotores: Ener-gizing local communities for heart health. Findings from SaludPara Su Corazón implementation projects. Washington, DC: U.S.Department of Health & Human Services.

Navarro, A., Senn, K., McNicholas, L., Kaplan, R., Roppe, B., &Campo, M. (1998). Por la vida model intervention enhances use ofcancer screening tests among Latinas. American Journal of Preven-tive Medicine, 15(1), 32-41.

Pandey, D. K., Labarthe, D. R., Goff, D. C., Chan, W., & Nichaman,M. Z. (2001). Community-wide coronary heart disease mortality inMexican Americans equals or exceeds that in non-HispanicWhites: The Corpus Christi Heart Project. American Journal ofMedicine, 110(2), 81-87.

Perez-Stable, E., Juarbe, T., & Moreno-John, C. (2001). Cardiovas-cular disease. In M. Aguirre-Molina, C. Molina, & R. Zambrana(Eds.), Health issues in the Latino community (pp. 245-276). SanFrancisco: Jossey-Bass.

Rainwater, D. L., Mitchell, B. D., Comuzzie, A. G., VandeBerg, J. L.,Stern, M. P., & MacCluer, J. W. (2000). Association among 5-yearchanges in weight, physical activity, and cardiovascular disease

76 HEALTH PROMOTION PRACTICE / January 2006

at SAN DIEGO STATE UNIV LIBRARY on November 4, 2010hpp.sagepub.comDownloaded from

risk factors in Mexican Americans. American Journal of Epidemi-ology, 152(10), 974-982.

Stern, M. P., & Wei. M. (1999). Do Mexican Americans really havelow rates of cardiovascular disease? Preventive Medicine, 29, S90-S95.

Witmer, A., Seifer, S., Finocchio, L., Leslie, J., & O’Neil, E. (1995).Community health workers: Integral members of the health carework force. American Journal of Public Health, 85, 1055-1058.

Balcazar et al. / SALUD PARA SU CORAZÓN 77

The Authors

Hector Balcazar, PhD, is the assistant dean and a professorin the Division of Health Promotion and Behavioral Sci-ences at the University of Texas School of Public Health,El Paso Regional Campus at Houston.

Matilde Alvarado, RN, MSN, is the coordinator of theMinority Health Education and Outreach Programs in theOffice of Prevention, Education, and Control at the NationalHeart, Lung, and Blood Institute/National Institutes ofHealth in Bethesda, Maryland.

Mary Luna Hollen, PhD, RD, is a research assistant profes-sor in the Department of Social and Behavioral Sciences atthe School of Public Health, Health Science Center, Univer-sity of North Texas in Fort Worth.

Yanira Gonzalez-Cruz, MPH, is the chief operating officerof the Hispanic-Serving Health Professions Schools pro-gram in Washington, D.C.

Odelinda Hughes, is a promotora de salud at Centro SanVicente in El Paso, Texas.

Esperanza Vasquez, is a promotora de salud at Centro SanVicente in El Paso, Texas.

Kristine Lykens, PhD, is an assistant professor in theDepartment of Health Management and Policy at the Schoolof Public Health, Health Science Center, University of NorthTexas in Fort Worth.

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