SummarySalud Para Todos ("Health for All"), a partnership between a health clinic system and a community organization, coordinates outreach workers, known as promotoras, to help Mexican farm workers navigate the health care system and improve their health. Promotoras from the clinics work with physicians and one on one with patients before, during, and after visits to make sure they understand their diagnoses and treatment. Promotoras from the community organization hold classes and support groups to encourage healthier lifestyles and appropriate health care. Promotoras from both organizations work closely together on an ongoing basis. A preliminary review found that participants increased physical activity, improved dietary habits, and had higher satisfaction with their health care. Clinic staff also increased their cultural competence.Moderate: The evidence is based on pre- and post-implementation comparisons of self-reported information from surveys of program participants and clinic staff on various metrics related to physical activity, nutrition, patient satisfaction, and cultural competence.
Developing OrganizationsSunset Community Health Center
Both partner organizations are located in Yuma County, AZ.
Date First Implemented2007
Race and Ethnicity > Hispanic/latino-latina; Vulnerable Populations > Rural populations; Transients/migrants
Problem AddressedLack of health insurance and language and cultural barriers frequently prevent Mexican immigrants from accessing high-quality preventive and primary care, leading to higher rates of chronic diseases.
- Lack of insurance, leading to inadequate access to care: Mexican immigrants are less likely than U.S.-born Mexican Americans and non-Hispanic whites to access preventive and primary care services, in large part because of a lack of health insurance. In 2000, more than half (58 percent) of Mexican immigrants between the ages of 18 and 64 years old did not have health insurance and nearly half (45 percent) did not have a regular source of primary care.1
- Language and cultural barriers: Many Mexican immigrants have difficulty navigating the health care system because they do not speak English well and remain unfamiliar with the American system. In the Yuma Valley, many physicians come from other cultures (e.g., primarily Middle Eastern and Southeast Asian cultures), thus adding to the challenge of bridging cultural barriers with Mexican immigrant patients.
- Leading to more chronic health problems: Mexican Americans are twice as likely to have—and 50 percent more likely to die from—diabetes than are non-Hispanic whites.2 In addition, although as a group, Mexican Americans have a lower rate of heart disease than do non-Hispanic whites, many Mexican-American men remain at high risk of heart disease because of greater prevalence of key risk factors such as overweight or obesity and high cholesterol.3
Description of the Innovative ActivitySalud Para Todos, a partnership between a health clinic system and a community organization, coordinates promotoras to help Mexican farm workers navigate the health care system and improve their health. Promotoras from the clinics work with physicians and one-on-one with patients before, during, and/or after visits to make sure they understand their diagnoses and treatment. Promotoras from the community organization hold classes and support groups and meet with families to encourage participants to engage in healthier lifestyles and seek treatment for health problems. Promotoras from both organizations work closely together on an ongoing basis. Key program elements are described below:
- Extensive outreach and multiple ways to enroll: Participants are recruited through community outreach or enrolled when they receive health or social services at either organization.
- Recruitment through community outreach: Campesinos Sin Fronteras uses a range of strategies to recruit people who might benefit. Promotoras visit work sites, speak to other community organizations (e.g., other health agencies and clinics), participate in health fairs (where they also measure blood pressure, blood glucose, cholesterol, and body mass index), and put up posters at bus stops and other visible sites. As of May 2010, promotoras had attended 44 health fairs at which they conducted about 4,100 total screenings for blood pressure, glucose, body mass index, and cholesterol, and distributed more than 7,500 flyers advertising the program.
- Recruitment at point of service: Some individuals enter the program when they seek services at Campesinos Sin Fronteras or medical care at one of the four clinics run by Campesinos Sin Fronteras's partner, Sunset Community Health Center. Sunset physicians identify candidates based on their health needs and cultural background.
- Trained, culturally competent staff: All promotoras have been farm workers or are children of farm workers, so they are familiar with the culture and the challenges facing individuals in the community. All new Sunset promotoras undergo training designed to improve their understanding of Hispanic culture and how it may affect health. A 4-hour session covers general cultural components, Hispanic health beliefs, barriers to care, and strategies for eliciting patients' perspectives on illnesses and treatment. In addition, experienced promotoras conduct ongoing 4-hour cultural competency workshops for all Sunset staff (including medical and administrative employees) to familiarize the staff with Hispanic culture and how it may affect patients' health and treatment.
- Wide range of services focused on navigation and health promotion: Promotoras from each organization offer different types of support to the Mexican farm workers. Sunset promotoras focus on helping workers navigate the health care system and Campesinos Sin Fronteras promotoras focus on helping them engage in healthier lifestyles and seek treatment for health problems. Details on the activities of each group of promotoras follow:
- Health navigation support: To the extent possible, those enrolled in the program see the same Sunset promotora over time. This individual works with migrants to assist in navigating the health care system, much as a case manager would. Key activities include the following:
- One-on-one visit counseling: Before and/or after doctor visits, Sunset promotoras provide one-on-one counseling related to a patient's condition. Interactions often include explaining the causes and risk factors for a disease (typically chronic diseases such as heart disease, diabetes, or asthma), reviewing a medication's purpose and how to take it, and discussing treatment options. Promotoras prepare for the counseling sessions in collaboration with physicians and nurses. Each promotora works with roughly 10 patients each day. As of May 2010, Sunset promotoras had conducted 789 one-on-one sessions with patients about diabetes.
- Help during doctor visits: At patients' request, Sunset promotoras may accompany them to doctor visits to help them communicate with the physician and understand the diagnosis and recommended treatment, including their role in the treatment.
- Lifestyle management support: Campesinos Sin Fronteras promotoras focus on helping migrant workers engage in healthier behaviors and seek care for medical problems, as outlined below:
- Ongoing individual support: Each enrollee is assigned to a Campesinos Sin Fronteras promotora who meets with the individual at enrollment and provides ongoing one-on-one support. Interactions often include encouraging the workers to sign up for health education classes, inviting them to support groups, and putting them in touch with social service agencies. When participants enroll through Sunset, the Sunset promotora contacts a Campesinos Sin Fronteras promotora to take on this role.
- Health education classes: Campesinos Sin Fronteras promotoras hold a 12-week health education class for workers and their family members at the organization's community center. The course covers topics such as nutrition, cooking, physical activity, stress management, and depression management in a culturally relevant manner. For example, participants discuss nutrition in the context of foods common to the Mexican diet and talk about ways to avoid relying on unhealthy "comfort foods" to reduce stress and combat depression.
- Support groups: Campesinos Sin Fronteras promotoras run weekly support groups for migrant worker with particular health problems, such as diabetes, depression, and heart disease. As with the health education classes, program enrollees are encouraged to bring family members. As of May 2010, promotoras had conducted 82 group sessions on heart disease and 98 on diabetes.
- Coordinated followup, facilitated by database: Promotoras from both organizations remain in regular contact with program participants by phone to make sure they continue to attend doctor's appointments and receive desired services. Promotoras from each partner organization work together to address any obstacles to care that may arise, such as making sure participants do not have transportation problems or financial issues and can find a physician specialist. To facilitate such collaboration, the organizations maintain a shared database of all promotora encounters with enrollees, thus creating a record of every interaction that can be used to ensure enrollees receive appropriate services from each partner.
Context of the InnovationSunset Community Health Center, a nonprofit corporation, operates four community-based clinics that serve low-income individuals in Yuma County, AZ. Campesinos Sin Fronteras, a nonprofit, community-based organization, serves migrant and seasonal farmworkers and other members of the low-income Hispanic community in Yuma County by helping them access health information, treatment, and safe and affordable housing. The Salud Para Todos program grew out of a growing awareness among leaders and staff within both organizations, as well as input from farm workers themselves, of the barriers that local farm workers (who are primarily from Mexico) face in accessing high-quality health care services. These barriers include problems in scheduling and attending doctor's appointments, difficulties in understanding recommended treatments, and lack of availability of ongoing care management for chronic illnesses. Staff at both organizations believed that by joining forces and using the promotora model (which they previously used together in another program, as described in the next section), they could enhance these migrant workers' experiences at the medical clinics and help them establish better health-related habits and behaviors at home.
ResultsA preliminary review found that the program led to more physical activity, better dietary habits, and higher satisfaction among migrant workers; and to enhanced cultural competence among clinic staff.
Moderate: The evidence is based on pre- and post-implementation comparisons of self-reported information from surveys of program participants and clinic staff on various metrics related to physical activity, nutrition, patient satisfaction, and cultural competence.
- More exercise and better diet: Among 500 graduates of the Campesinos Sin Fronteras health education class, frequency of physical activity increased by 60 percent over the course of the 12-week program (from 2.8 to 3.9 times per week). Fruit intake increased by 69 percent (from 2.0 to 3.2 servings per day) and vegetable intake by 65 percent (from 1.9 to 3.4 servings per day). Soda consumption fell by 77 percent (from 1.15 to 0.46 servings per day).
- Higher satisfaction: Surveys conducted at one of Sunset's clinics in San Luis found that the percentage satisfied or highly satisfied with their care increased from 83 percent to 98 percent after program implementation. At the Somerton clinic, the percentage of satisfied or highly satisfied patients increased from 79 percent to 93 percent.
- Enhanced cultural competence among clinic staff: Among 56 clinic staff who attended the cultural competency workshops, including 23 medical professionals, 62 percent reported an improved ability to describe components of Hispanic culture. Similarly, 55 percent reported being better able to describe Hispanic health beliefs, and 64 percent reported an enhanced ability to practice cross-cultural communication.
Planning and Development ProcessKey steps in the planning and development process included the following:
- Building on existing links and prior work: Before Salud Para Todos, the two organizations had worked together on several previous programs—including a Health Resources and Services Administration Rural Health Outreach Grant to provide diabetes self-management support, the Border Health Strategic Initiative, and the Campesinos Diabetes Management Program—and would meet monthly to discuss their joint projects. The second diabetes program successfully used the promotora model to provide Hispanic community members, primarily retired farm workers, with ongoing support and education focused on medication, exercise, nutrition, stress management, and mental health issues. In addition, several staff members had worked or volunteered for both organizations at different times, and the groups often shared meeting space and logistical support. As a result of these ties and the organizations' shared goal of addressing the health needs of low-income residents, the framework for working together on a broader project already existed.
- Conducting initial planning: In 2005 and 2006, staff from the two groups continued to meet monthly and began working out the details of the program and applying for grant funding. Key attendees from Sunset included the medical director, chief executive officer, and a promotora who had worked with people with diabetes, while Campesinos Sin Fronteras representatives included the executive director, the programs director, and three promotoras. This group made several key decisions, including that Sunset would be subcontracted to hire additional promotoras and that the program would emphasize family involvement rather than simply helping the individual farm worker.
- Securing funding: In 2007, the U.S. Department of Health and Human Services' Office of Minority Health approved the proposal submitted by program developers to fund the program; see the Resources Used and Skills Needed section for more information.
- Hiring and training promotoras: In late 2007, Campesinos Sin Fronteras hired three promotoras, and in early 2008, Sunset hired two promotoras to work on Salud Para Todos. (These two promotoras were previous employees of Campesinos Sin Fronteras with prior experience as promotoras in the earlier diabetes program.) All new promotoras had to obtain state and national certification through the National Heart, Lung, and Blood Institute's (NHLBI's) Your Health, Your Life cardiovascular and diabetes curriculum, and to shadow more experienced promotoras before working independently.
- Forming university partnership to evaluate program: In 2007, the program partnered with the University of Arizona's College of Public Health Canyon Ranch Center for Prevention and Health Promotion to perform an independent evaluation of the program's effectiveness using pre- and post-implementation measures, indepth interviews, and patient satisfaction surveys.
- Developing curriculum: In 2007, program leaders and promotoras developed educational materials for the program, including pamphlets and audio-visual materials. They adapted much of the printed material from existing sources, such as the NHLBI's Your Heart, Your Life curriculum.
Resources Used and Skills Needed
- Staffing: The program employs five full-time promotoras, (three by Sunset and two by Campesinos Sin Fronteras). Additional employees from both organizations also participate in the program as part of their regular job responsibilities.
- Costs: Operating costs average roughly $250,000 a year, consisting primarily of salaries and benefits for the promotoras and printing fees for educational and promotional materials.
Funding SourcesOffice of Minority Health
The program is funded by a 3-year, $750,000 grant from the U.S. Department of Health and Human Services' Office of Minority Health.
Tools and Other ResourcesNHLBI's Your Heart, Your Life program is available at: http://www.nhlbi.nih.gov/health/prof/heart/latino/english/intro.htm.
Getting Started with This Innovation
- Build on existing partnerships: Keep an eye out for opportunities to work with existing partners on new projects to capitalize on existing relationships and expand capabilities.
- Share data documenting potential benefits: To secure support from key stakeholders (including skeptics), share published studies showing how the model can improve health outcomes.
- Choose promotoras carefully: Ideally, promotoras' backgrounds should match that of the target population as closely as possible. Promotoras will be more effective if they have firsthand experience with participants' home and work environments and if they understand participants' culture, language, and values.
Sustaining This Innovation
- Periodically review services from participants' perspective: Leaders within each partner organization regularly review the program from the perspective of those being served. For example, Campesinos Sin Fronteras staff continuously provide leadership and advocacy trainings to their promotoras to ensure that they are meet their clients' needs, and staff are all cross-trained in all the available programs. Sunset leaders strive to make their health clinics a place where they would personally like to receive care. To that end, both programs periodically review their operations from the patient's perspective, identifying and addressing problems at all key "touchpoints," from the initial visit to followup care.
Spreading This InnovationThe leaders of several other organizations in Arizona have contacted Salud Para Todos officials about starting up a similar program in their communities.
Contact the InnovatorFloribella Redondo
Campesinos Sin Fronteras
725 E. Main Street, Suite 1 B&C
P.O. Box 423
Somerton, AZ 85350
Sunset Community Health Center
115 North Somerton Avenue
Somerton, AZ 85350
Innovator DisclosuresMs. Redondo and Ms. Murrieta have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile.
References/Related ArticlesIngram M, Torres E, Redondo F, et al. The impact of promotoras on social support and glycemic control among members of a farmworker community on the US-Mexico border. Diabetes Educ. 2007;33 Suppl 6:172S-8S. [PubMed]
Original publication: September 15, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: August 27, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: July 23, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.