Addressing Heart Health in Hispanic Communities by Integrating

Community Health Workers

Community Based Participatory Research Project

Health Education and Assessment Research TeamH.E.A.R.T.

September 27, 2013

El Paso, Texas

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

Community Based Participatory Research Project (2005 – 2013)

National Institutes of HealthNational Institute of Minority Health and Health Disparities

Grant: R24 MD001785

Phase I: Planning

Phase II: Implementation ◦ Planning the large-scale Intervention◦ Integrating CHWs in a partner CBO ◦ Conducting the Intervention ◦ Building the CHW Coalition

H.E.A.R.T. Project Overview

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

Community Based Participatory Research

Zip Code79907

Zip Code79915

El PasoCounty

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

U.S.-Mexico Border Region

• 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

Phase I (2005 – 2008)

• 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

Phase 1 OutcomesCardiovascular Disease Risk Factors

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

Phase IIObjectives

Phase II: Implementation (2008 – 2013)Goal: Implement a CHW Model to address CVD risk factors

Health Education Assessment and Research Team Project

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

Objective 1

Community Health Workers

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, 2008

by Paulina Matias,

TX

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

Community Health Workers

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

Objective 2

Curriculum Specialist

• Inventory of wellness programs at partners agencies

40 participants(Focus groups)

• Pilot intervention

754 participants

• Large scale intervention

Development of Intervention

Lifestyle/NutritionYour Heart Your Health

CharlasCooking Demonstrations

Environmental/Nutrition

Grocery Store Tours

Lifestyle/FitnessAerobics

SwimmingZumba

Environment/Exercise

Walking GroupsSoccer and Basketball

CHWPromotores de

Salud

Lifestyle/Environment ProgrammeMy Heart My Community

Intervention • 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

Recruitment of Participants

• 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)

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

Measures

754 Participants

BehavioralDemographics

CVD RiskMeasures

Clinical

SESIntentions

Self-efficacy

Community Health Workers

Lifestyle-Fitness

Lifestyle-Nutrition

Environment-Nutrition

Environment-Exercise

Data Collection and Intervention

H.E.A.R.T. In Action

Age, mean ± SD 44.0 ±12.9Female (n, %) 511 (84.5)BirthplaceMexico 386 (63.8)United States 216 (35.7)Language spoken for surveySpanish 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 ± 3.7Employed 234 (38.9)

Characteristics of ParticipantsN = 604

CVD Risk FactorT1

(Range) n=604T2

(Range) n=339

p valueT1 to

T2

T3 (Range) n=173

p valueT1 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

Preliminary Results

( * =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).

Intentions and Self-efficacy Behaviors of Hispanics participating in the HEART project

Behaviors VariableT1

n=604T2

n=339p 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).

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 CoalitionCHW Retreat

Outcome CHW Strategic Plan

Objective 3

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

Outcome

Strategic Planning for the CHW Workforce

To review local, state and national developments in CHW policy; especially those impacted by health care reform

NEXT STEPS:Fall 2013 CHW/PS CoalitionMeeting Planned

AcknowledgementsParticipants and their familiesCommunity Health Workers

HEART Project Partners

National Institutes of Health National Institute on Minority Health and Heart Disparities

(NIH Grant: R24 MD001785)

QUESTIONS?