Changes in empowerment: effects of participation in a lay health promotion program

Health ambassadors in the workplace: a health promotion intervention mobilizing middle managers and RE-AIM evaluation of outcomes

Background

The workplace provides an ideal setting for health promotion, as adults spend most of their day at work. Middle managers hold a strategic position to lead workplace health promotion. This study evaluates the outcomes of an intensive intervention training middle managers to promote health in the workplace.

Methods

A workshop was designed and conducted to train female middle management employees to construct, implement, and evaluate a health promotion program in their workplace. Semi-structured interviews were carried out post-intervention to assess workplace health promotion outcomes according to the RE-AIM framework, and identify variables contributing to success. Additionally, questionnaires were distributed pre and post-program assessing personal health and self-efficacy changes.

Results

Eighteen participants from 13 government offices, who serve 19,560 employees, completed the training course. Nine workplaces had workplace health promotion programs in progress 12 months after the course had ended, of which 8 made health promotion changes in organizational policy. Workplace RE-AIM scores showed that 8 workplaces were high or partial performers, and 5 were low or non-performers. Factors that increased the likelihood of successful interventions included management support, steering committee, comprehensive programming, conducting a needs assessment and flexibility in program implementation in the presence of challenges. Post course, participants reported increased health knowledge related to workplace health promotion (p < 0.001), and increased health promotion self-efficacy (p < 0.05).

Conclusions

Training and continued guidance of middle managers resulted in the design and successful implementation of workplace health promotion interventions. A RE-AIM based assessment was found to be an effective method for evaluating multi-content workplace health promotion programs.

Registered at ClinicalTrials.gov, https://www.clinicaltrials.gov, registration number:

NCT03295136, registration date: 24/09/2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11609-8.

Development and Validation of a Parental Health-Related Empowerment Scale with Low Income Parents

Objectives: Consistent with empowerment theory, parental empowerment acts as a mechanism of change in family-based interventions to support child health. Yet, there are no comprehensive, validated measures of parental health-related empowerment to test this important perspective. Informed by empowerment theory and in the context of a community-based obesity intervention, we developed a self-report measure of parental health-related empowerment and tested its preliminary validity with low-income parents. Methods: The Parental Empowerment through Awareness, Relationships, and Resources (PEARR) is a 21-item scale designed to measure three subdimensions of empowerment including resource empowerment, critical awareness, and relational empowerment. In the fall of 2017 or the fall of 2018, low-income parents (n = 770, 88% mothers) from 16 Head Start programs in Greater Boston completed the PEARR. The resulting data were randomly split into two equal samples with complete data. The factorial structure of the PEARR was tested in the first half of the sample using principal component analysis (PCA) and exploratory factor analysis (EFA) and subsequently confirmed with the second half of the sample using confirmatory factor analysis (CFA). Internal consistency coefficients were calculated for the final subscales. Results: Results from the PCA and EFA analyses identified three component factors (eigenvalues = 8.25, 2.75, 2.12) with all items loading significantly onto the hypothesized subdimension (β > 0.59 and p < 0.01). The three-factor model was subsequently confirmed with the second half of the sample using CFA (β > 0.54 and p < 0.01). Fit indices met minimum criteria (Comparative Fit Index = 0.95, Root Mean Square Error of Approximation = 0.05 (0.05, 0.06), Standardized Root-Mean-Square Residual = 0.05). Subscales demonstrated strong internal consistency (α= 0.83–0.90). Conclusions: Results support initial validity of a brief survey measuring parental empowerment for child health among Head Start parents. The PEARR can be utilized to measure changes in parental empowerment through interventions targeting empowerment as a mechanism of change.

Evaluation of Empowerment in Health Promotion Interventions: A Systematic Review

Although empowerment is one of the core principles of the World Health Organization's approach to health promotion, there are no standards, best practice recommendations, or guidelines for evaluating empowerment within interventions. For the development of effective empowerment promoting interventions, adequate study designs, methods, and indicators for assessing empowerment are essential. In order to better understand which evaluation procedures have been used so far, and which advantages and disadvantages are connected to them, we systematically reviewed empowerment-based health promotion interventions. We included 26 studies, which use a broad variety of quantitative, qualitative, and mixed-methods designs and various data collection methods; qualitative and mixed-methods designs predominated. The quantitative measurement instruments are heterogeneous: Mainly self-designed or modified scales are applied. All studies consider indicators reflecting individual competencies and motivations, whereas indicators capturing the organizational and political components of empowerment are less common. Involving target group members in the development of evaluation procedures and combining different data sources are mentioned as specific steps to improve the quality of data collection. Given the flexible and context-dependent nature of empowerment approaches, the development of a "gold standard" for its evaluation seems unrealistic. However, the analyzed studies can be used to deduce recommendations that may help to conduct high-quality evaluations of empowerment, for example, mixed-methods designs, participation of target groups, and reflective loops within the research team.

Empowerment in Rural Viet Nam: Exploring Changes in Mothers and Health Volunteers in the Context of an Integrated Nutrition Project

Empowerment is often cited as a fundamental component of health promotion strategies. Anecdotes suggest that Save the Children's integrated nutrition project empowers local women and health volunteers. The aim of this research was to document the degree to which this is being accomplished. Using qualitative methodologies, we conducted a cross-sectional assessment to compare self-reported changes in identified empowerment domains among 17 program health volunteers and 20 mothers involved in a child nutrition intervention and among five Women's Union leaders and five mothers in a non-intervention comparison commune. Intervention mothers reported increased knowledge, confidence, and information sharing about child-care and feeding, while non-intervention mothers reported minimal changes in these domains. Both intervention health volunteers and non-intervention Women's Union leaders expressed improvements in knowledge, confidence, and relationships with community members. In this study we found that the relative increases in empowerment were greater for mothers than for health volunteers. Intervention mothers reported more sharing of information on child relationships with community members than Women's Union leaders. The increased information sharing has positive implications for spread of key messages to families that did not directly participate in intensive feeding and the sustainability of the intervention's impact. Future research should focus on developing culturally specific concepts of empowerment to better understand the effects of empowerment efforts. This study's identification of empowerment domains will inform future empowerment studies in Vietnam.

I Could Live other Places, but This is Where I Want to Be: Support for Natural Helper Initiatives

Charlotte REACH 2010 is an example of a multi-level intervention with the goal of reducing cardiovascular disease (CVD) and diabetes. Structured within a socio-ecological framework, lay health advisors are the link between the multi-level programs. An exploratory assessment was conducted using focus group methodology. Nine focus groups were conducted with the Charlotte REACH LHAs, residents who had participated in REACH program activities, and residents who had not participated in REACH activities. Results reveal two prominent themes: improvements in health practices and community competence. Both LHAs and community participants improved their knowledge of health enhancement behaviors, developed health enhancement skills and behaviors, and noted personal, familial, and community wide health improvements. Community competence was also observed with regard to community commitment, communication of health issues, and expanded social support networks. The results of this qualitative evaluation suggest the effectiveness of incorporating natural helper models as part of larger multi-level initiatives.

Implementing a Natural Helper Lay Health Advisor Program: Lessons Learned from Unplanned Events

Programs that train natural helpers, or members of the community to whom others naturally turn for help, to be lay health advisors (LHAs) have proliferated throughout the United States; evaluations of these programs, however, are uncommon. The goal of this exploratory study was to understand how the natural helper LHA approach, as operationalized by the North Carolina Breast Cancer Screening Program (NC-BCSP), was translated from idea into practice. Data from document review and in-depth interviews with 24 LHAs and four of their coordinators were used to compare theory-based program plans with actual practice. Results suggest that although in large part the natural helper model was followed, program implementation departed from program plans in several unanticipated ways in the areas of (a) recruitment, (b) program direction, and (c) LHA activities. Differences illustrate the tensions between theory and practice and between community and program planners that may be inherent in a natural helper program, and highlight the need to include community members and program participants in all aspects of planning.

Adolescents and parental caregivers as lay health advisers in a community-based risk reduction intervention for youth: baseline data from Teach One, Reach One

The purpose of the current study is to describe the demographic, behavioral, and psychosocial characteristics of adolescent and caregiver lay health advisers (LHAs) participating in an intervention designed to reduce risk behaviors among rural African-American adolescents. Teach One, Reach One integrates constructs from the Theory of Planned Behavior and Social Cognitive Theory. It acknowledges that changing the sexual behaviors of African-American adolescents requires changing one's knowledge, attitudes, normative beliefs about the behavior of peers, and self-efficacy regarding adolescent sexual behavior, parent-teen communication about sex, and healthy dating relations among adolescents. Study participants completed baseline questionnaires assessing demographics and psychosocial determinants (knowledge, attitudes, perceived social norms, and self-efficacy) of sexual behaviors. Sixty-two adolescent and caregiver dyads participated. Caregivers included biological parents, legal guardians, or other parental figures. Strengths and areas in need of improvement were determined using median splits. Few adolescents had initiated sex. Their strengths included high levels of open parent-teen communication; positive attitudes and normative beliefs regarding both sex communication and healthy dating relationships; and high knowledge and self-efficacy for healthy dating behaviors. Areas needing improvement included low knowledge, unfavorable attitudes, poor normative beliefs, and low self-efficacy regarding condom use. Caregiver strengths included positive attitudes, normative beliefs, and self-efficacy for sex communication; positive attitudes and self-efficacy for condom use; and low acceptance of couple violence. Areas needing improvement included low levels of actual communication about sex and low knowledge about effective communication strategies and condom use. The current study highlights the value of assessing baseline characteristics of LHAs prior to intervention implementation, as it enables a better understanding of the key characteristics necessary for planning and implementing interventions, as well as engaging in targeted training activities.

Evaluation of a pilot promotora program for Latino forest workers in southern Oregon

BACKGROUND

Forest work, an occupation with some of the highest injury and illness rates, is conducted primarily by Latino immigrant workers. This study evaluates a pilot program where promotoras (lay community health educators) provided occupational health and safety trainings for Latino forest workers.

METHODS

Evaluation methods included a focus group, post-tests, and qualitative feedback.

RESULTS

Community capacity to address working conditions increased through (i) increased leadership and community access to information and resources; and (ii) increased worker awareness of workplace health and safety rights and resources. Fear of retaliation remains a barrier to workers taking action; nevertheless, the promotoras supported several workers in addressing-specific workplace issues.

CONCLUSIONS

For working conditions to significantly improve, major structural influences need to be addressed. A long-term, organizationally supported promotora program can play a key role in linking and supporting change at the individual, interpersonal and community levels, contributing to and supporting structural change.

Barriers and facilitators for promotoras' success in delivering pesticide safety education to Latino farmworker families: La Familia Sana

Despite widespread use of lay health advisor (LHA) programs, factors related to success of LHAs remain largely unexamined. This study describes experiences and personal transformations of LHAs (promotoras de salud) in a pesticide safety education program targeting farmworker families in North Carolina, using postintervention in-depth interviews conducted with 17 LHAs. LHAs identified assets and barriers that affected their success. LHAs also described increases in self-efficacy and empowerment resulting in perceived improvements in ability to teach and impact their community. Such positive changes are essential benefits to the LHAs. Evaluations that address these topics are needed to better understand continuity and attrition in LHA programs.

Empowering peer group leaders for HIV prevention in Malawi

PURPOSE

Behavioral change interventions using peer group leaders are effective and widely used, but few studies have examined how being a peer group leader affects the leaders. This study describes how participants felt being a peer group leader affected their lives.

DESIGN

This descriptive qualitative study interviewed 18 experienced peer group leaders who had conducted a multisession human immunodeficiency virus (HIV) prevention peer group intervention in rural Malawi.

METHODS

We used inductive content analysis and comparisons within and between cases.

FINDINGS

Three major themes were identified. All leaders said they experienced personal changes in their knowledge, attitudes, or HIV prevention behaviors. They described interacting with family, neighbors, and friends, and speaking at church or community meetings, to discuss HIV prevention issues. They increased their self-efficacy to engage others in sensitive HIV prevention issues, developed a self-identity as a change agent, and came to be recognized in their community as trustworthy advisors about HIV and acquired immunodeficiency syndrome. These three themes, taken together, form the meta-theme of psychological empowerment.

CONCLUSION

Being a peer group leader empowered the leaders as change agents for HIV prevention and had impacts in the community after the intervention ended, potentially increasing the long-term effectiveness and cost effectiveness of peer group interventions.

CLINICAL RELEVANCE

Healthcare workers and community volunteers who led HIV prevention sessions continued HIV prevention activities in the community and workplace after the program ended. Training health workers as volunteer HIV prevention leaders offers a strategy to bring HIV prevention to limited-resource settings, despite health worker shortages.

Informal occupational safety information exchange among Latino migrant and seasonal farmworkers

Latino farmworkers in North Carolina are a hard-to-reach population that faces diverse occupational health risks, including pesticide exposure. Health and safety education efforts often employ lay health advisor or promotor(a) de salud models in which farmworker community members are trained to provide health education. As a frequently tight-knit and isolated group, farmworkers may be well suited to serve as resident lay health advisors. This paper presents data collected from a nonrandom sample of Latino farmworkers living in North Carolina regarding the natural level of occupational safety information exchange among Latino farmworkers, specifically pesticide safety information. The data affirm that farmworkers informally exchange occupational safety information with one another, with the level of exchange increasing during the agricultural season. Consequently, if trained, the data suggest that farmworkers might be situated to provide in situ occupational health and safety education to their peers. This remains to be systematically tested and evaluated.

Esperanza y Vida: training lay health advisors and cancer survivors to promote breast and cervical cancer screening in Latinas

The use of lay health advisors (LHAs) to promote community-based health education programs is well documented and is considered an effective way to reach underserved communities. Esperanza y Vida (Hope & Life) is an educational outreach program to increase breast and cervical cancer screening for diverse Latinas. It incorporates Latino LHAs (men and women) and cancer survivor role models, sobrevivientes, in the program delivery. An interactive training program, conducted by bilingual staff across three sites (Little Rock, Arkansas; Buffalo, New York and New York City) included 74 sobrevivientes and LHAs who were recruited and trained. All training attendees completed an initial application assessing socio-demographics, experience and availability as well as, true/false surveys at the beginning (pre-) and end of the training (post-) measuring knowledge levels of breast and cervical cancer health. Data analysis indicated a significant increase of both breast and cervical cancer knowledge for attendees trained as LHAs (pre = 60%; post = 80%; p = 0.000), whereas sobrevivientes had a higher baseline knowledge of breast health (74%), and therefore did not show a significant increase following training (79%). However, sobrevivientes did display a significant increase in cervical cancer knowledge (p = 0.003). These findings demonstrate the impact of training and how LHAs may be recruited at different levels of knowledge and experience and be successfully trained in key program elements. Moreover, results indicate that sobrevivientes may be impacted differently, or require variations in training approaches. This information can be useful in developing and customizing curriculum for future lay health training programs.

Engaging with marginalized communities: the experiences of London health trainers

AIMS

Health trainers represent a new occupational role within the NHS which has been developing since 2006, when the first 'early adopter' sites were funded by the Department of Health. Health trainers are 'lay' people recruited to engage 'harder-to-reach' people from their communities, offering one-to-one support to enable them to make the healthy lifestyle changes of their choice. The aim of this study was to explore the experiences and approaches adopted by health trainers in engaging with marginalized communities.

METHODS

This paper describes an exploratory study using in-depth semi-structured interviews with 10 currently employed health trainers with diverse backgrounds, forms of employment and interpretation of role, drawn from seven London primary care trusts (PCTs) or boroughs.

RESULTS

The study found tensions between the lay identity of health trainers and their adoption of a formalized role. Health trainers emphasized their similarities but underestimated their often significant differences to their communities. Health trainers based in community or voluntary groups found engagement easier than those based in PCTs, and saw engagement as an end in itself, through its creation of opportunities for health.

CONCLUSIONS

There remains a lack of clarity about the role of the health trainer. Lay workers are not necessarily part of the marginalized communities they are expected to engage, while their ability to do so is compromised by the professional culture of the NHS and its approach to community engagement. Health trainers based in the community or voluntary sector appear to offer greater potential for engaging communities and providing those communities with practical opportunities for health gain.

Community participation and psychological empowerment: testing reciprocal causality using a cross-lagged panel design and latent constructs

Empowerment theory provides both a value orientation for community-based research and practice, and a conceptual framework for understanding and evaluating interventions. One critical question in empowerment theory involves whether a reciprocal (bidirectional) relationship exists between community participation (CP) and psychological empowerment (PE). This study applied structural equation modeling (SEM) with two waves of survey data from a cross-lagged panel design to test reciprocal and unidirectional causal relations between latent variables representing CP and PE. Participants (n = 474) were randomly selected neighborhood residents and organizational members from the United States. Four models were tested using SEM: (a) a baseline model with autoregressive paths, (b) a model with autoregressive effects and CP predicting future PE, (c) a model with autoregressive effects and PE predicting future CP, and (d) a fully cross-lagged model. Results indicated that CP influenced future PE; however, reciprocal causality was not found to occur between the variables. Implications of the study for empowerment theory and community-based practice are described, and directions for future research discussed.

The role of community health workers (CHWs) in health promotion research: ethical challenges and practical solutions

This article aims to describe the role of community health workers (CHWs) in health promotion research and address the challenges and ethical concerns associated with this research approach. A series of six focus groups are conducted with project managers and investigators (n = 5 to 11 per session) who have worked with CHWs in health promotion research. These focus groups are part of a larger study funded by the National Institutes of Health titled "Training in Research Ethics and Standards" (Project TRES). Participants are asked to describe their training needs for CHWs with respect to human subject protections as well as to identify associated challenges regarding research practice (i.e., recruitment, random assignment, protocol implementation, etc.). Findings reveal a number of challenges that investigators and project managers encounter when working with CHWs on research projects involving the community. These include characteristics inherent to CHWs such as education level and personal beliefs about their own community and its needs, institutional regulations regarding research practice, and problems inherent to research studies such as training materials and protocols that cannot account for the complexity of conducting research in community settings. Investigators should carefully consider the role that CHWs have in their communities before creating research programs that depend on the CHWs' existing social networks and their propensity to be natural helpers. These strengths could lead to compromises in research requirements for random assignment, control groups, and fully informed consent.

Outcome effectiveness of the lay health advisor model among Latinos in the United States: an examination by role

The objective of this study was to examine lay health advisor (LHA) programs designed to promote health among US Latinos and the extent to which educator-only versus educator-plus-bridge programs differed in designs and outcomes achieved. Two independent coders reviewed 128 published articles on LHAs yielding information at two levels: (i) study design and participant and LHA characteristics from 61 studies that broadly compared educator-only versus educator-plus-bridge programs and (ii) implementation features and outcomes from 17 randomized controlled trials or quasi-experimental studies with outcome data. LHA programs have been widely used with Latinos in certain US regions; our findings indicate that LHAs are effective intervention agents. We identified differences between educator-only and educator-plus-bridge LHA programs, although the small number of educator-plus-bridge programs with outcome data limited comparisons. Major gaps remain in research targeting Latino subgroups other than Mexican immigrants/Mexican Americans. Sufficient research has evaluated LHA programs among Latinos on their ability to achieve health behavior and/or health status changes. In the future, more of a focus on organizational and policy changes is warranted. Questions remain about diversity in LHAs' characteristics and roles, which influence not only outcomes but also program sustainability and dissemination.

Overcoming language and literacy barriers in safety and health training of agricultural workers

The workforce in all areas of United States agriculture and forestry is becoming increasingly diverse in language, culture, and education. Many agricultural workers are immigrants who have limited English language skills and limited educational attainment. Providing safety and health training to this large, diverse, dispersed, and often transient population of workers is challenging. This review, prepared for the 2010 Agricultural Safety and Health Council of America/National Institute for Occupational Safety and Health conference, "Be Safe, Be Profitable: Protecting Workers in Agriculture," is divided into five sections. First, we describe the occupational and demographic characteristics of agricultural workers in the United States to highlight their safety and health training needs. Second, we summarize current research on the social and cultural attributes of agricultural workers and agricultural employers that affect the provision of safety and health training. Worker and employer attributes include language, literacy, financial limitations, work beliefs, and health beliefs. Third, we review current initiatives addressing safety and health training for agricultural workers that consider worker language and literacy. These initiatives are limited to a few specific topics (e.g., pesticides, heat stress); they do not provide general programs of safety training that would help establish a culture of workplace safety. However, several innovative approaches to health and safety training are being implemented, including the use of community-based participatory approaches and lay health promoter programs. Fourth, the limited industry response for safety training with this linguistically diverse and educationally limited workforce is summarized. Finally, gaps in knowledge and practice are summarized and recommendations to develop educationally, culturally, and linguistically appropriate safety and health training are presented.

Ethnographic evaluation of a lay health promoter program to reduce occupational injuries among Latino poultry processing workers

We evaluated a lay health promoter program providing occupational health and safety education to immigrant Latino poultry processing workers in western North Carolina. While such programs are advocated for addressing the health education deficits of immigrant and disadvantaged populations, their application in occupational health has been limited to farmworkers. A community-university partnership recruited and trained promoters to deliver lessons on musculoskeletal injuries, slips and falls, and workers' rights to workers individually or in small groups in the community. Evaluation showed 841 workers received education during a 28-month period. Using ethnographic data, an evaluation showed that promoters' work led to changes in behavior and attitudes in the community. Promoters also reported substantial changes in self-esteem and independence. Promoters' supervisors reported challenges and strategies experienced by the promoters. Promoter programs in occupational health and safety are feasible approaches to supplement training provided in the workplace.

Using lay health promoters in occupational health: outcome evaluation in a sample of Latino poultry-processing workers

Lay Health Promoters (LHPs) are widely used in community health education, but their use and evaluation in occupational health has been limited to farm workers. Evaluation data were collected from 30 randomly selected Latino poultry processing workers who had an encounter with an LHP who delivered Maria's Story, an occupational health lesson about cumulative trauma disorders (CTDs). Participants had good recall of Maria's Story. Most participants (n = 18, 60%) could identify the primary occupational health exposure linked to CTDs, more than 50% of participants (n = 16) could recall one or more ways of preventing CTDs, and 43.3% (n = 13) described in detail recommended treatments. Nearly one-half (n = 12) reported an occupational health behavior change after hearing Maria's Story. The results of this study suggest that LHPs may be effective in promoting occupational health and reducing occupational health disparities among ethnic minorities in high-risk occupations.

Delivery of health services to migrant and seasonal farmworkers

Farmworkers are low-paid, uninsured employees in an extremely hazardous industry, and they provide an essential service for U.S. society. This review evaluates the delivery of health services to farmworkers. It describes the farmworker population in the United States, noting characteristics (e.g., migratory and immigration status) that limit their access to and utilization of health services. It describes the health services needs of this population, including occupational health, mental health, oral health, and chronic disease treatment. Cultural, structural, legal, financial, and geographic barriers to health services utilization are described. Existing research on health services utilization among farmworkers is discussed. Programs that have been developed to address the barriers to health services utilization among farmworkers are reviewed. Finally, research needed to improve knowledge of farmworker health services utilization is suggested. These research needs include formal evaluations of existing programs and basic research to characterize the health services utilization patterns of farmworkers.

Processes and capacity-building benefits of lay health worker outreach focused on preventing cervical cancer among Vietnamese

The authors organized a lay health worker (LHW) outreach program with Vietnamese women that produced significant increases in Pap testing. The program was conducted by five partner agencies and 50 LHWs and involved 1,005 women. This article reports on the roles of the agencies and coordinators, the selection of LHWs, the processes LHWs used in identifying and recruiting participants, the ways they conducted their outreach work, and their strategies for maintaining participation. The article also reports on the LHWs' perspectives about how they benefited and what they found to be most rewarding and challenging about being a LHW. Based on the analysis of this information, the authors present a conceptual framework for understanding how different contextual factors shape the processes and capacity-building benefits of LHW outreach, describing four contextual domains that shape LHW outreach: the sociocultural domain and organizational domain, which overlap in the programmatic domain, all of which are framed by the structural domain. This analysis provides an approach for understanding how lay health work is shaped by a broader context.

Dental Services for Migrant and Seasonal Farmworkers in US Community/Migrant Health Centers

CONTEXT

Migrant and seasonal farmworkers are recognized as a medically underserved population, yet little information on need, access, and services is available-particularly with regard to oral health care.

PURPOSE

This study describes the facilities, services, staffing, and patient characteristics of US dental clinics serving migrant and seasonal farmworkers, and identifies trends and issues that may impede or improve dental care access and service.

METHODS

National databases were used to identify community and migrant health centers providing oral health care to migrant and seasonal farmworkers. Mailed surveys collected information on clinic history, operational details, services provided, patient demographics, employment and resource needs, and perceived barriers to care.

FINDINGS

Among the 81 respondents (response rate 41%), hours of operation varied from 1 evening a week to more than 40 hours a week; 52% had no evening hours. Almost all the clinics offered preventive, diagnostic, and basic restorative dental services, and roughly two thirds also offered complex restorative services. Patients most frequently sought emergency dental care (44%) followed by basic restorative services (32%) and preventive services (26%). The dentist position was the most difficult to fill, and new funding sources were cited as the most important resource need. Respondents perceived cost of services, lack of transportation, and limited clinic hours as primary barriers to care.

CONCLUSIONS

While some barriers to care have been almost universally addressed (eg, language), there is evidence that some impediments remain and may present significant obstacles to a broad improvement in oral health care for migrant and seasonal farmworkers.

Acculturative stress, anxiety, and depression among Mexican immigrant farmworkers in the midwest United States

No previous studies have examined the psychological functioning of immigrant farmworkers in the midwest United States. The purposes of the present study were threefold: (1) to assess the prevalence levels of anxiety and depression in a sample of Mexican immigrant farmworkers in the midwest United States; (2) to explore the relationships among acculturative stress, anxiety, and depression; and (3) to examine the variables that best predict anxiety and depression. The overall sample revealed elevated levels of anxiety and depression. Immigrant farmworkers with heightened levels of acculturative stress reported high levels of anxiety and depression. Family dysfunction, ineffective social support, low self-esteem, lack of choice in the decision to immigrate and live a migrant farmworker lifestyle, high education levels, and low levels of religiosity were significantly associated with high levels of anxiety and depression. The overall findings suggest that Mexican immigrant farmworkers who experience elevated levels of acculturative stress may be "at risk" for experiencing high levels of anxiety and depression. The findings highlight the importance of establishing prevention and treatment services for migrant farmworkers that aim to increase levels of emotional support, self-esteem, and coping skills.

Preventing occupational exposure to pesticides: using participatory research with latino farmworkers to develop an intervention

Pesticide exposure is an occupational health hazard for migrant farmworkers. The US-EPA Worker Protection Standard (WPS) mandates training programs to prevent or reduce exposure. WPS implementation in a local context requires understanding individual, workplace, and community environmental factors that lead to exposure and influence intervention effectiveness. Participatory research within the PRECEDE-PROCEED planning framework was used to design a WPS training program for Mexican farmworkers in North Carolina cucumber and tobacco production. Research with farmworkers, farmers, health care providers, and Cooperative Extension agents identified modifiable behaviors and environmental factors, as well as structural and regulatory barriers requiring intervention. Data were gathered and analyzed through individual and group interviews, community forums, an advisory board, and a partnership between academic researchers and a community-based organization. The intervention's dominant features are (a) focus on key health behaviors, (b) relevance to local conditions, and (c) attention to issues of control in the workplace. Participatory research is effective for designing a health intervention where diverse social, cultural, political, and regulatory issues affect farmworkers' risk of exposure.

Cervical cancer among Hispanic women: assessing the impact on farmworkers

The purpose of this paper was to review the literature on Hispanic populations to outline: 1) demographics; 2) general health status; 3) cervical cancer incidence and mortality; 4) Pap smear screening rates; and 5) barriers to preventive care services. The methods: MEDLINE, Med66, Med75, and Med85 files, from 1966 to 1999, were searched for key words Hispanic health, cervical cancer and Hispanics, cervical cancer and Mexico, migrants and health, agricultural occupational health, farmworkers and cancer, and farmworker health. AGRICOLA (1982-98) was searched for key words farmworker health, agricultural workers and health, and agriculture and cancer. The results show that Hispanic immigrant women may have cervical cancer incidence rates ranging between the California rates for 1991-93 (19.8/100,000) and for Mexico in 1990 (115-220 per 100,000). Mortality rates for the same periods were 3.9/100,000 and 16.11/100,000 respectively. While survey results report Hispanic Pap smear rates above 70%, these surveys count urban women who do not share the barriers to care experienced by poor rural Hispanics. Since validated self-reports of survey responses are 20-50% lower than reported lower rates and Pap smear screening persist in Hispanic Pap evaluations and are reflected in higher morbidity and mortality from cervical cancer. That targeted community interventions have been successful in raising Pap smear rates among poor Spanish-speaking women. Such interventions should be a priority for preventive health care policy and practice.

Dental Decay in Southern Illinois Migrant and Seasonal Farmworkers: An Analysis of Clinical Data

CONTEXT

Migrant and seasonal farmworkers are a population at risk for oral health problems. Data on the oral health conditions of migrant and seasonal farmworkers' permanent teeth are particularly lacking.

PURPOSE

To document the relative rates of treated and untreated dental decay in a sample of southern Illinois migrant and seasonal farmworkers who had sought care at a farmworker health center dental clinic.

METHODS

Existing migrant health dental clinic records from 1995-2002 were reviewed. Final sample size was 650. Data for decayed, missing, and filled tooth surfaces were recorded using both anatomical recording and treatment notes.

FINDINGS

Sixty-nine percent of migrant farmworkers had at least 1 decayed (untreated) tooth surface, and more than half had 3 or more decayed surfaces.

CONCLUSIONS

Results indicate that untreated dental decay is significant among migrant and seasonal farmworkers who seek care at this dental clinic. Recommendations include addressing barriers to care, improved monitoring of dental health conditions, and further research to better document the treatment needs of this population.

Effectiveness of community health workers for promoting use of safety eyewear by Latino farm workers

BACKGROUND

To evaluate The Community Health Worker "promotor de salud" (CHW) model is evaluated as a tool for reducing eye injuries in Latino farm workers.

METHODS

In 2001, 786 workers on 34 farms were divided into three intervention blocks: (A) CHWs provided protective eyewear and training to farm workers; (B) CHWs provided eyewear but no training to farm workers; (C) eyewear was distributed to farm workers with no CHW present and no training.

RESULTS

Pre- and post-intervention questionnaires demonstrated greater self-reported use of eyewear in all blocks after the intervention (P < 0.0001), with Block A showing the greatest change compared to B (P < 0.0001) and C (P = 0.03); this was supported by field observations. Block A showed the greatest improvement in knowledge on questions related to training content.

CONCLUSION

CHWs were an effective tool to train farm workers in eye health and safety, improving the use of personal protective equipment and knowledge.

Stress Among Migrant and Seasonal Farmworkers in Rural Southeast North Carolina

CONTEXT

Although funding to enhance the delivery of health care among migrant farmworkers has primarily focused on urgent care issues within this population, the etiology of mental health risks and perceived stress is poorly understood.

PURPOSE

To identify the type and severity of stress perceived by migrant and seasonal farmworkers in rural southeast North Carolina.

METHODS

During the pre-agricultural season in 2002, 151 migrant and seasonal farmworkers completed the 39-item Migrant Farmworker Stress Inventory (MFWSI) in either English or Spanish.

FINDINGS

Fifty-one percent (n = 77) of the respondents perceived themselves at a high level of stress (mean score above 80 of "caseness") that may subsequently put them at greater risk for experiencing psychological difficulties. The stressors highly ranked (mean>2.5 in a maximum of 4, with "extremely stressful" in a 5-point Likert scale 0 to 4) were related to their mobile lifestyle, language barriers, insecure job and legal status, financial restraint, and long working hours. Also, drug and alcohol use in the migrant community was found to be one of the significant sources of stressors. Variables influencing high levels of stress include education, social support, religion, marital status, and age. Despite a relatively high level of perceived stress, the majority of respondents (71.5%) viewed their physical health as either "good" or "excellent."

CONCLUSIONS

Findings from the study suggest the availability of social support systems may provide significant insight into developing appropriate health services for migrant and seasonal farmworkers and their families.

Promising outreach practices: enrolling low-income children in health insurance programs in California

Strategies used by outreach workers to successfully enroll underserved and uninsured California children into low cost health insurance programs such as MediCal and Healthy Families are examined. Outreach workers are particularly effective in enrolling and retaining hard to reach populations, especially immigrant families, in health programs. Skilled in grassroots communications and members of the communities they serve, outreach workers are key to building viral community support. Effective outreach depends on the selection of outreach workers with appropriate personal characteristics and then training them in a number of core competencies. This article analyzes the main avenues used by outreach workers within the First Things First demonstration project: person-to-person contact, utilization of existing of institutions, and public communication strategies. Structural and systemic barriers remain to enrolling children in public health insurance programs that exceed the scope of outreach workers. Thus, effective outreach programs should address both structural issues and staff selection and training.

Immigrant women implementing participatory research in health promotion

Few studies on women's health include immigrant women as participants, and fewer are conducted by immigrant women themselves. In this article, the authors present a model that allowed their full participation as researchers and authors. They describe their experiences using participatory research methods with Hispanic women in multiple ways to reach out to isolated women, collect data about community needs, and provide health education. They explore the advantages and challenges of being trained for both researcher and health educator roles, describe opportunities to use this approach to assess service needs, and discuss the potential for personal empowerment. They also report on the time commitment that such a bilingual project requires. In the process of interviewing marginalized women, they realized how much health promotion and participatory research complement each other. The authors conclude that combining participatory research with health promotion activities has promise to contribute toward increased empowerment of immigrant communities.

"If they don't ask about condoms, I just tell them": a descriptive case study of Latino lay health advisers' helping activities

Health care practitioners have increasingly turned to lay health advisers (LHAs) to deliver health promotion and disease prevention supportive activities to underserved populations. Yet, published evaluations of the LHA programs or the manner in which LHAs deliver information are rare. An important aspect of program evaluation includes understanding the role of the LHA in the community as described by the LHAs in the field. The purpose of this article is to report the results of a component of a larger evaluation of an LHA program for preventing HIV/AIDS among recently immigrated Mexicans in North Carolina. Specifically, the authors use a descriptive case study design to report on the perceptions of the LHAs related to program objectives. The findings suggest that the LHAs are meeting the program objectives and are confident in their role as LHAs.

Exploring the mental health of Mexican migrant farm workers in the Midwest: psychosocial predictors of psychological distress and suggestions for prevention and treatment

The purposes of the present study were threefold: (a) to assess the prevalence levels of anxiety and depression in a sample of Mexican migrant farm workers in the midwestern United States; (b) to explore the relationships among acculturative stress, anxiety, and depression; and (c) to examine the variables that best predict anxiety and depression. The overall sample revealed elevated levels of anxiety and depression. Migrant farm workers with heightened levels of acculturative stress were more likely to report high levels of anxiety and depression. Family dysfunction, ineffective social support, low self-esteem, lack of agreement with the decision to migrate, high education levels, high levels of acculturative stress, and high levels of anxiety were significantly associated with high depression levels. The overall findings suggest that migrant farm workers who experience elevated levels of acculturative stress may be at risk for experiencing high levels of anxiety and depression. The findings highlight the importance of establishing prevention and treatment services for migrant farm workers that aim to increase levels of emotional support, self-esteem, and coping skills.

Psychosocial predictors of anxiety among immigrant Mexican migrant farmworkers: implications for prevention and treatment

This study examined predictors of anxiety symptomatology among immigrant Mexican migrant farmworkers in the Midwest. Its purposes were to assess the prevalence of anxiety symptoms, to examine the relationship between acculturative stress and anxiety, and to determine the variables that best predict anxiety. Heightened levels were found for overall anxiety and in the cognitive, affective, and physiological expressions of anxiety. Elevated acculturative stress, low self-esteem, ineffective social support, lack of control and choice in living a migrant farmworker lifestyle, low religiosity, and high education were significantly related to high anxiety. Findings suggest that migrant farmworkers who experience elevated acculturative stress are susceptible to the development of anxiety-related disorders and highlight the importance of establishing prevention and treatment services for migrant farmworkers.

Cognitive, affective, and physiological expressions of anxiety symptomatology among Mexican migrant farmworkers: predictors and generational differences

Scant research has examined the mental health of migrant farmworkers in the United States. The purposes of the present study were threefold: to assess the prevalence levels of anxiety symptoms in a sample of Mexican migrant farmworkers in the Midwest United States; to examine the relationship between acculturative stress and anxiety; and to determine the variables that significantly predict anxiety. High levels were found for overall anxiety and in the cognitive, affective, and physiological expressions of anxiety. Elevated acculturative stress, low self esteem, ineffective social support, lack of control and choice in the decision to live a migrant farmworker lifestyle, low religiosity, and high education were significantly related to high anxiety levels. The overall findings suggest that Mexican migrant farmworkers who experience high acculturative stress may be at risk for developing anxiety-related disorders. The findings highlight the necessity of establishing prevention and treatment services for migrant farmworkers that increase levels of emotional support, self esteem, and coping skills.

Process Evaluation Methods of a Peer-Delivered Health Promotion Program for African American Women

The Eat Well, Live Well (EWLW) Nutrition Program was a community-based, dietary change program delivered by peer educators to low-income African American women. To ensure that the program was delivered as intended, a process evaluation was conducted to determine the extent to which the content was accurate and comprehensive. The methodology included developing checklists for each of the intervention sessions, audiotaping randomly selected sessions, and independently rating the audiotapes. Overall comprehensiveness of the content delivered by the peer educators was 91.42%. Cohen’s kappa () for each data collection interval ranged from 0.95 to 0.97. Overall accuracy of information delivered was 88.52%. A process evaluation as described for the EWLW program is essential for peer-led health promotion programs and necessary to ensure program integrity. Practice implications are discussed.

Peer education project with persons who have experienced homelessness

This paper describes an unconventional health education project implemented by nurse practitioners in a nurse-managed clinic serving persons who are homeless. The nurse practitioners perceived that there were a number of potential barriers to providing health education to the homeless patients. These barriers included the fact that this patient population is part of a marginalized subculture affected by a variety of overwhelming social problems. An additional barrier was that the nurses often differed from their homeless patients in terms of race, gender, socioeconomic status, formal education, culture, and life experience. The nurse practitioners designed the Peer Health Education Project (PHEP) to try to overcome some of these barriers. The purpose of the PHEP was to increase the health education knowledge and empowerment of persons who had experienced homelessness so that they could serve as peer health educators with others who were living on the streets. The project model was based on the philosophy of Paulo Freire (1973). The peer health educators served as both leaders and participants in each education session. The educators set the agenda and the nurses acted as facilitators. The project was successful in preparing peer educators. Other indicators of the success of the project included increased empowerment, self-esteem, dignity, hope self-confidence, and community participation of the peer educators.

Enhancing community participation in intervention research: farmworkers and agricultural chemicals in North Carolina

The participation of affected communities in the development of public health intervention research improves project sustainability and effectiveness by making projects more relevant and acceptable to the communities. This article presents a multimode, multidomain model approach for community participation in different project components, which ensures the benefits of participation without requiring the same level of participation in every activity or by every community sector. A case study is used to illustrate the model, describing procedures for establishing and maintaining farmworker participation in developing an intervention to reduce exposure to chemicals. Farmworkers are a poor and underserved population for which the empowering and culturally appropriate benefits of community participation are especially needed. However, this population presents challenges for participatory health projects: geographic dispersion, ethnic diversity, lack of organization, sense of powerlessness, and communication and transportation difficulties. The lessons learned in this case extend the method and theory of community participation.

Early detection of cervical cancer among Native American women: a qualitative supplement to a quantitative study

The North Carolina Native American Cervical Cancer Prevention Project was a 5-year (1989-1995) National Cancer Institute-funded, community-based, early detection of cervical cancer intervention implemented among two Native American tribes in North Carolina: the eastern band of the Cherokee Indians and the Lumbee. The initial quantitative analysis of the intervention showed modest effects and found that the intervention had different effects in the two communities. Due to the equivocal findings, a retrospective qualitative study was conducted. The qualitative study found that two types of factors influenced the intervention's results. The first were project and intervention characteristics, and the second were community and cultural factors over which the project had no control. The community and cultural factors took two forms: enhancers, which contributed to greater intervention effect, and attenuators, which created barriers to success. Examples of each factor are presented, and implications for cervical cancer detection among Native American women are discussed.

Changing women: the narrative construction of personal change through community health work among women in Mexico

A major premise of health education is that people can and do change their lives. Personal changes and the events that precipitate them are often told in a form of narrative and are accompanied by a new sense of oneself. This research draws on the study of narratives and women's community activism to explore processes of personal change in women's activism as community health workers in Mexico. The research is a case study based on in-depth semistructured interviews. Two major categories of narratives of change emerged: change of the self and little or no change. Within these categories, changes are defined as development of the self, becoming a new and different person, actualization of the self, and little or no change. Although women experience significant changes, their changes are based on normative female identities. Implications for the study of narratives and personal change in health education are discussed.

HRSA's Models That Work Program: implications for improving access to primary health care

The main objective of the Models That Work Campaign (MTW) is improving access to health care for vulnerable and underserved populations. A collaboration between the Bureau of Primary Health Care (BPHC) at the Health Resources and Services Administration (HRSA) and 39 cosponsors--among them national associations, state and federal agencies, community-based organizations, foundations, and businesses--this initiative gives recognition and visibility to innovative and effective service delivery models. Models are selected based on a set of criteria that includes delivery of high quality primary care services, community participation, integration of health and social services, quantifiable outcomes, and replicability. Winners of the competition are showcased nationally and hired to provide training to other communities, to document and publish their strategies, and to provide onsite technical assistance on request.