Addressing Heart Health in Hispanic Communities by Integrating Community Health Workers
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The H.E.A.R.T. project in El Paso, Texas, aimed to reduce cardiovascular disease (CVD) risk factors among Hispanic families through community health worker (CHW) interventions. Both phases of the project involved planning and implementing culturally-tailored health education programs focused on enhancing healthy behaviors and community engagement. Outcomes showed significant improvements in health metrics and self-efficacy regarding healthy lifestyle choices among participants.
Addressing Heart Health in Hispanic Communities by Integrating Community Health Workers
- 1. Community Based Participatory Research Project Health Education and Assessment Research Team H.E.A.R.T. September 27, 2013 El Paso, Texas
- 2. Affiliation People El Paso, Texas, Lower Valley Community 300 Participants and their families (Phase I) 754 Participants and their families (Phase II) Community Health Advisory Leadership Council Community Members Community Health Worker Coalition Pema Garcia and Community Health Workers (CHWs) City of El Paso Parks and Recreation Department Jose Rodriguez University of Texas Houston El Paso Regional Campus – School of Public Health Hector Balcazar, Lee Rosenthal, Victor Cardenas, Sherrie Wise, Alisha Hayden, Monica Chavez Centro San Vicente Melissa Aguirre, Lorraine Hernandez YWCA El Paso del Norte Region Sandra Braham, Elke Cumming, Anita Rockett, Diana Hastings, Guillermo Flores, Bertha Torres, Paty Diaz, Bertha Gonzalez El Paso Community College Leticia Flores, Souraya Hajjar The University of Texas at El Paso Maria Duarte, Sandor Dorgo, Cecilia Ochoa, Ximena Burgos, Julio Ramirez National Institutes of Health National Institute of Minority Health and Health Disparities Grant: R24 MD001785
- 3. Phase I: Planning Phase II: Implementation ◦ Planning the large-scale Intervention ◦ Integrating CHWs in a partner CBO ◦ Conducting the Intervention ◦ Building the CHW Coalition
- 4. Phase I: Planning (2005 – 2008) •Identification of a health problem in a low-income El Paso area by Community Health Advisory Leadership Council •Pilot CHW Intervention •Planning of the H.E.A.R.T. Phase 2 Project Phase II: Implementation (2008 – 2013) •To conduct an intervention to address lifestyle and environmental factors that relies on a CHW culturally-tailored model •To foster the sustained integration of the CHW model in CBOs to improve healthy behaviors
- 5. Zip Code 79907 Zip Code 79915 El Paso County Total Population 55,132 40,057 820,790 Hispanics, % 52,803 (95.8%) 38,024 (94.9%) 81.4% Spanish Spoken at Home ages >5, % 44,289 (87.6%) 33,195 (85.6%) 71% Median Age, years 32.8 35.8 31.2 Median Household Income $29,347 $25,966 36,015
- 6. • Heart disease leading cause of death in US (~600,000 per year) & Texas (CDC, 2011) • More than 1 in 3 American adults have 1 or more types of Cardiovascular diseases (CVD) (Roger et al, 2012) • High Blood Pressure – 76 400 000 • Coronary Heart Disease – 16 300 000 • Among Mexican Americans age 20 and older • Hypertension: 27.8 % men; 28.9 % women • High cholesterol: 50.1 % men; 46.5 % women • Overweight & obesity: 77.5 % men; 75.1 % women
- 7. • Clinical - BMI > 30 kg/m2 - High Blood pressure - Total serum cholesterol > 240 mg/dL - Diabetes • Behavioral • Low intake fruits and vegetables • Diet high in saturated fat • Lack of physical activity
- 8. 1) To conduct an intervention that relies on CHWs to decrease CVD risk factors among Hispanic families 2) To foster the sustained integration of the CHWs in CBOs to improve healthy behaviors, and ultimately decrease CVD risk factors 3) To develop supportive policy environment for sustain the CHW workforce
- 9. Health Education Assessment and Research Team Project
- 10. Domain Change Agents/ Stakeholders Domain Objective To establish a multidisciplinary team to deliver programs and services aimed at reducing CVD risk factors Methods Strengthen Partnership and Community Health Advisory Leadership Council (CHALC) Established Memorandum of Understanding (MOU) with partners Outcome CHALC and Partnership were strengthened CHW were integrated in YWCA El Paso del Norte Region
- 11. Trusted members of the community Have a close understanding of the community they serve Prepared to take leadership roles Build individual and community capacity by increasing health knowledge and self- sufficiency through: ◦ outreach ◦ community education ◦ informal counseling ◦ social support ◦ advocacy. American Public Health Association, 2008by Paulina Matias, TX
- 12. Integration of CHW at partner agency, YWCA Paso del Norte Region Training of CHW ◦ Employer regulations ◦ Professional development ◦ Research Ethics ◦ Data collection and data entry ◦ Curriculum implementation ◦ Training certifications
- 13. Domain Individual Level/Family Domain Objective 2 To conduct an intervention to address lifestyle in the Lower Valley of El Paso, Texas that relies on a CHW culturally-tailored model in order to: Specific Aims 2.1) increase awareness and utilization of programs by Hispanic families living in the target community; 2.2) increase healthy behaviors including intentions and self-efficacy; 2.3) decrease CVD risk factors among Hispanic families Methods Plan and implement a large-scale intervention
- 14. Curriculum Specialist •Inventory of wellness programs at partners agencies 40 participants (Focus groups) •Pilot intervention 754 participants •Large scale intervention
- 15. Lifestyle/Nutrition Your Heart Your Health Charlas Cooking Demonstrations Environmental/Nutrition Grocery Store Tours Lifestyle/Fitness Aerobics Swimming Zumba Environment/Exercise Walking Groups Soccer and Basketball CHW Promotores de Salud
- 16. • Curriculum: 16 week CHW-led intervention • NHLBI “Your Health Your Heart” CHW friendly curriculum • Heart-healthy grocery store tours • Heart-healthy cooking demonstrations • Charlas (“coffee chats”) • Scheduled activities at the Parks • Weekly walking groups • Weekly Zumba and Latin dance classes • Family soccer
- 17. • Conducted by three Community Health Workers, Paso del Norte Region YWCA employees • Took place at • Health fairs within the target community • Schools within the target community • Was conducted door-to-door within designated zip codes (79907 & 79915)
- 18. Demographic, anthropometric, and behavioral measures (self-efficacy and intentions) Data Collection pre- and post-intervention ◦ Time 1 (T1): Baseline ◦ Time 2 (T2): After 16 week intervention ◦ Time 3 (T3): 4 months after intervention
- 19. 754 Participants BehavioralDemographics CVD Risk Measures Clinical SES Intentions Self-efficacy Community Health Workers Lifestyle- Fitness Lifestyle- Nutrition Environment- Nutrition Environment -Exercise Data Collection and Intervention
- 21. Age, mean ± SD 44.0 ±12.9 Female (n, %) 511 (84.5) Birthplace Mexico 386 (63.8) United States 216 (35.7) Language spoken for survey Spanish 517 (84.9) English 92 (15.1) Household Income <$15,0000 328 (54.7) $15,000 - $25,000 132 (22.0) >$25,000 140 (23.3) No Health Insurance 309 (51.3) Married/Living with a partner 340 (56.4) Separated/Divorced 126 (20.9) Widow 33 (5.47) Years of Education, mean ± SD 12.1 ± 3.7 Employed 234 (38.9)
- 22. CVD Risk Factor T1 (Range) n=604 T2 (Range) n=339 p value T1 to T2 T3 (Range) n=173 p value T1 to T3 Weight, lb 177.4 (93.8-330) 175.1 (101.6-327.6) <.0001* 173.10 (110.6-280.0) 0.0008* BMI, kg/m2 31.3 (16.0-54.7) 30.7 (17.0 - 48.88) 0.0003* 30.5 (18.34-49.5) 0.3945 (N/S) Waist Circum, cm 38.6 (25-61) 37.5 (25 - 61) <.0001* 37.8 (28-59) 0.0246* Hip Circum, cm 44.1 (30.5-65) 43.5 (33 - 62) <.0001* 43.2 (34.8-61) 0.0008* Systolic BP, mm Hg 126.9 (91-214) 124.7 (76 - 187) 0.0244* 125.3 (95.7-205.7) 0.0236* Diastolic BP, mm Hg 76.7 (52.7-115) 75.2 (55 - 103) 0.0025* 74.7 (49.7-110.7) <.0001* CVD Risk Index 5.54 (0-9) 3.65 (0 - 8) <.0001* N/A ( * =significant; N/S= not significant). Covariates included in the analysis: gender, years of education, household income, years living in the U.S., & age. T1= Time 1 (Baseline); T2= Time 2 (4-month follow up); T3 = Time 3 (8 month follow up).
- 23. Intentions and Self-efficacy Behaviors of Hispanics participating in the HEART project Behaviors Variable T1 n=604 T2 n=339 p value (T1-T2) Intentions1 Avoid eating fast food more than once a week 8.9975 9.2692 0.0077 Cook using less salt 9.2774 9.4882 0.0259 Avoid eating foods rich in sodium 9.1476 9.3728 0.0287 Self-efficacy2 Can buy and prepare healthy foods for my family 8.4496 9.1953 <.0001* Can eat at least 5 servings of fruits and vegetables 8.2258 8.9053 <.0001* Can cook using less fat 8.8282 9.4349 <.0001* Can avoid eating fast food more than once a week 8.2559 8.8609 <.0001* Can cook using less salt 8.4223 9.2337 <.0001* Can avoid eating foods rich in sodium 8.1956 9.0888 <.0001* Can do at least 30 min of exercise 3 times week 8.7214 9.3521 <.0001* 1Likert scale, 1=strongly disagree, 10= strongly agree; 2Likert scale, 1= Not at all confident, 10= absolutely confident. Covariates included in the analysis: gender, years of education, household income, years living in the U.S., and age. T1= Time 1 (Baseline); T2= Time 2 (4-month follow up).
- 24. Domain Organizational /Policy Objective 3 To foster the sustained integration of the CHW/PS model in (CBOs) and public sector settings in El Paso, Texas through building organizational experience of and knowledge regarding the importance of culturally-tailored lifestyle and environmental interventions in order to increase service utilization, improve healthy behaviors, and ultimately decrease CVD risk factors. Activities Developed a CHW Coalition CHW Retreat Outcome CHW Strategic Plan
- 25. Paso del Norte CHW/Promotora Workforce Coalition" was created. Coalition’s strategic directions for CHW workforce advancement include: ◦ 1) Policy and Publicity ◦ 2)Training and Skills Development ◦ 3) Research and Evaluation
- 27. To review local, state and national developments in CHW policy; especially those impacted by health care reform
- 28. Participants and their families Community Health Workers HEART Project Partners National Institutes of Health National Institute on Minority Health and Heart Disparities (NIH Grant: R24 MD001785)