La Buena VIDA (Victory in Diabetes Awareness): A Promotor Approach to Diabetes Education and Lifestyle Modification targets the documented under/uninsured Latino population in Jefferson County, Colorado. The Latino and Hispanic population is growing very rapidly in Colorado and Jefferson County is following the trend. Colorado’s population was 18.2 percent Hispanic or Latino in 2000, which was a 75 percent increase in ten years. Jefferson County’s population is ten percent Hispanic. All other minorities make up approximately four percent. At the same time, 34.4 percent of the Hispanic population in Colorado is uninsured which is 41.6 percent of the total uninsured population of Colorado. These numbers do not take into consideration the underinsured. In Colorado, the death rate of diabetes is 37.5 per 100,000 for Latinos while the state average death rate of diabetes is 18.3 per 100,000 – showing the disparity that the Latino population is almost twice as vulnerable of dying of diabetic complications, such as cardiovascular disease. Jefferson County Department of Health and Environment (JCDHE) targets this population in order to reduce and eventually eliminate the health disparity.
La Buena VIDA addresses, in one aspect or another, all ten of the Essential Public Health Services. In particular, the program focuses on the growing obesity epidemic nationwide which leads to the growing prevalence of diabetes; works toward decreasing multiple barriers to access to care, in particular cultural and language barriers; advocates increasing the number of individuals from the target population who are screened for diabetes and cardiovascular disease; addresses the health disparity present in the Latino population when it comes to diabetes; educates with a hope to increase awareness of the disease and prevention methods; and acts as a tool to increase trust between this hard-to-reach population and our health care system.
The key objectives are to provide the Latino community of Jefferson County with a general understanding and awareness of diabetes and its risk factors and complications, particularly in regards to cardiovascular health; to increase the number of individuals from the Latino community who are screened for diabetes and cardiovascular disease in Jefferson County; and to provide the Latino community with a general understanding of how lifestyle changes, including diet and physical activity, affect the onset and progression of cardiovascular disease risk factors, focusing on diabetes and obesity.
Complex relationships among both physiological and social determinants of health exist within the Latino community, such as family history of diabetes, obesity, socioeconomic circumstances, language, and medical insurance. Unfortunately the result is that more Latinos have type 2 diabetes but fewer Latinos follow diabetes standards of care resulting in increased diabetic complications and death. An estimated 18.2 million people in the United States have diabetes, 5.2 million of them just do not know it yet. Type 2 diabetes accounts for 90 to 95 percent of all diagnosed diabetic cases. One reason for this epidemic is that 61 percent of the U.S. adult population is overweight or obese. Jefferson County mirrors this trend. In 2003 Jefferson County’s obesity rate continued to increase, surpassing the Healthy People 2010 target of 15 percent. Over eight percent of the adult Latino population in Colorado is reported having been diagnosed with diabetes (White/non-Hispanic adults reported 4.4 percent). As of 2000, Jefferson County was 10 percent Latino with an estimated 20,333 persons having diabetes and the actual number probably numbering more due to the disease being greatly underdiagnosed. The 2003 Jefferson County Community Health Assessment identified that nine percent of the Jefferson County population reported being without insurance and Hispanics are a group that has the lowest rate of insurance coverage. The County’s only Federally Qualified Health Center is busy managing post-diagnosed clients.
La Buena VIDA is following in the footsteps of some very established and successful programs as it reaches out to the underserved Latino population through the promotora (community health worker) model. The Planned Parenthood Federation of America, Inc. has utilized the promotora model in a variety of communities and populations nationwide and has seen the benefits for the community and the promotores. They particularly note the positive impact of their educational outreach for their minority or immigrant populations thanks to this culturally-sensitive, trust-building, and cost-effective approach to the individual, noting a definite increase in the utilization of preventive services among the target population. The programs provided jobs for local residents within the target population, provided opportunities to learn about health careers, established role-models for under/un-employed individuals, and provided leadership training, ultimately incorporating the underserved individuals into the health care community. For the community health system, the study showed a decrease in emergency room visits, hospital visits, the length of time patients stayed in the hospital, and the number of complications from certain illnesses in areas where promotora programs were implemented. Since the model focuses on individual’s needs, it has been proved to decrease the barriers to medical care and increase the trust between the target population and the health care delivery system. The health workers and basic train-the-trainer method were proven to be a cost-effective intervention that had potential in being integrated into primary, secondary, and tertiary prevention systems.
La Buena VIDA's unique use of the promotora model is in the attention on follow-up with the clients. Instead of only utilizing the community connection for awareness and advertisement, our promotores stay with the client for six months to encourage and instill permanent lifestyle changes to help prevent diabetes.
Agency Community RolesAs a local health department, JCDHE, depends on and prides itself on how it works with local, state, and national organizations in order to reach out to as many people as it can, share ideas, minimize duplication of services, and share resources. The American Diabetes Association (ADA) has a Latino outreach program called Por Tu Familia. La Buena VIDA staff have a strong professional relationship with their director regarding their promotora model, their informational resources, and the services they provide resulting in collaboration. The program works closely with MCPN providers and registered dieticians in a two-way referral system for education and management.
Additionally, La Buena VIDA collaborates with non-profits that target a similar or overlapping target population around the county in order to exchange services. They can provide participants and a venue for a class and we can include their organization in our bank of resources that we suggest to our other clients. This has included such organizations as Planned Parenthood, local school English as a Second Language classes, and organizations that address domestic violence, child abuse, and homelessness. Internally, the program works with other programs within JCDHE that either specifically target the Latino population to increase awareness to those clients whom we are already in contact with as well as supplementing the outreach of other programs that might be having trouble reaching out to the Latino portion of their target population. Program partners play a role in outreach, training, promotion, follow-up, continuous care, and sustainability for the program. By incorporating partners in all aspects of the program, the possibility of duplicating services is decreased, while clientele is increased. By emphasizing the mutual give and take relationship we encourage with partners and stakeholders, the program increases the interest and support from these groups to help the program grow and succeed.
Costs and ExpendituresFunding sources for the program include The Office of Health Disparities, Colorado Department of Public Health and Environment (CDPHE). The total revenue received from CDPHE was $56,885 for the first six months. JCDHE covered the difference bewteen the total program costs and the total revenue received from CDPHE ($21,520) and the time of the Public Health Supervisor to write the grant initially.
The total cost for the program in the first six months was $78,405. Seventy-eight percent of the total program costs go toward salaries and benefits of the staff ($60,765). The program staff includes one FTE for a health educator, 1.6 FTE for promotores, 0.3 FTE for the public health nursing supervisor, 0.25 FTE for public health nurses, and 0.05 FTE for the registered dietician. Total operational costs equaled $8,471. Education and training material (including office and medical supplies) totaled approximately $2,700.00. Staff training and education cost the program $355.00. Since the program is based on the promotora model and staff is expected to go out into the community to do outreach and make community contacts, travel and mileage is an important component, coming to approximately $800.00.
ImplementationAfter securing a funding source, JCDHE spent the first three months hiring and training the staff, and designing the classes and program. Position advertising for promotores had to be approached differently than other positions. The Health Educator position was initially listed as a Public Health Nurse, but when no bilingual English/Spanish candidates applied, the grant was reevaluated and it was determined by JCDHE that the job could be executed by a Health Educator with public health nurses playing a lesser role. Upon hire, the Health Educator compiled a resource library to help the promotores learn more about diabetes, diet, and physical activity.
The county bought an bilingual slideshow on diabetes from the American Association of Diabetic Educators from which the staff took pieces to design a culturally appropriate, prevention focused, hour-long presentation. The Health Educator wrote, designed, and translated all forms and tracking logs to be used throughout the six-month lifestyle modification program. Also, within the first six months of implementation, the Health Educator determined what data would be necessary to track and designed Excel databases for data management. With the help of the health department’s communications staff, the staff produced a logo, brochure, poster, and flyer – all bilingual. The staff worked together in order to incorporate all their knowledge and past experiences in order to better approach the target community.
In order to design and implement a successful and sustainable community program, La Buena VIDA began building partnerships starting during the grant planning stage. The grant writer met with local community groups to gain support for the program. The Health Educator took over making and maintaining these partnerships throughout the implementation process. The local American Diabetes Association chapter has a Latino outreach director who was very supportive and offered to help train promotores and provide diabetes information. There is a strong partnership between JCDHE and the local Federally Qualified Health Center, Metro Community Network Provider (MCPN). JCDHE lightens their burden by providing more extensive preventive education to their clients, and they provide primary care providers, diagnostics, and management support to JCDHE's clients who are either diagnosed during the La Buena VIDA program or were previously diagnosed but not connected to a provider. La Buena VIDA also partnered and collaborated with Jefferson County Department of Health and Environment clinics for referrals and screenings.
About two months prior to the first class, La Buena VIDA finalized all promotional materials and the promotores began going out into the community, speaking with business owners, meeting with franchise managers, and distributing informational brochures. Each connection led them to another connection, often word of mouth being their most effective means of outreach. People started calling, clinics started referring, and by September the first class was held and the promotores began meeting with those clients one-on-one in October. The program is continuously adapting and modifying its outreach techniques and teaching methods as the program learns more about the target population and receive feedback from clients, the promotores, and other partners.
Objective 1:To provide the Latino community of Jefferson County with a general understanding and awareness of diabetes, the risk factors and complications of diabetes, particularly in regards to cardiovascular health.
Hire and train additional promotor.
Staff will present information through educational booths at 2 community events.
Staff will conduct 6 formal classes to community groups.
Health Educator will work with JCDHE’s Health Communications staff in designing promotional materials.
Promotores will partner with community centers and businesses to distribute and display promotional materials.
Materials will be displayed in 20 community centers and businesses.
Staff will present information through educational booths at 4 additional community events.
Staff will conduct 10 formal classes to community groups.
Materials will be displayed in 20 community centers and businesses – chosen based on effectiveness of material distribution of previous year.
YEAR 4:Hire and train additional promotor.
Staff will present information through educational booths at 6 community events.
Staff will conduct 12 formal classes to community groups.
Materials will be displayed in 20 community centers and businesses – chosen based on effectiveness of material distribution of previous year.
Outcome: La Buena VIDA has made contact and performed some form of outreach to over 50 community businesses and organizations. La Buena VIDA has received over 80 referrals from our outreach contacts. Promotores have distributed over 2400 English brochures, 3100 Spanish brochures, and over 1500 flyers to increase awareness. Promotores have presented information on diabetes in 17 different classes in 6 months to 97 individuals. Promotores have presented information on the program and diabetes prevention at 14 different venues through discussions with staff or booths for the public.Objective 2: To increase the number of individuals from the target population who are screened for diabetes and cardiovascular disease in Jefferson County.
To have screened 50 individuals through JCDHE or another provider and re-screened after five months.
YEAR 3:To have screened 65 individuals through JCDHE or another provider and re-screened after five months.
YEAR 4:To have screened 75 individuals through JCDHE or another provider and re-screened after five months.
Outcome: La Buena VIDA has seen 26 individuals screned for diabetes and cardiovascular disease over a six month time period. Eleven individuals were found to have high cholesterol and 5 individuals had high fasting blood glucose. 75 percent of La Buena VIDA's clients are considered Obese and 18 percent were considered overweight according to their BMI.Objective 3: To provide the Latino community with a general understanding of how lifestyle changes, including diet and physical activity, affect the onset and progression of cardiovascular disease risk factors, focusing on diabetes and obesity.
Promotores will conduct one-on-one visits with 50 clients and help the client set reasonable goals to modify lifestyle habits as well as discuss personal barriers that the client experiences while trying to reach his/her goals.
50 clients will meet with a Registered Dietician as part of their 6 month program.
YEAR 3:Maintain prmotor caseload established in year one of 25 clients/1 FTE (promotor). (65 clients will go through 6-month program).YEAR 4:Maintain promotor caseload established in previous year of 25 clients/1 FTE (promotor).
SustainabilityLa Buena VIDA chose the promotora model because it has been proven to be extremely cost-effective. La Buena VIDA has already completed the start-up phase so the majority of the expenditures now go to staff salaries and screenings. As La Buena VIDA grows and succeeds, it will become a model of lifestyle modification in an effort to reduce a health disparity and prevent diabetes and cardiovascular disease, so that in the future it can continue to be funded through national, state, local, and private grants. In order to accomplish this goal, it must remain a crucial program in the community in the eyes of partners and stakeholders. The registered dieticians around the county are relieved to have a program they can refer their clients to that might need more sustained counseling to delay complications or reduce their risk of diabetes. The public health nurses working in the JCDHE clinics are relieved to have an effective program to refer their clients to when they do not feel they can provide adequate time on behavior modification education.
The American Diabetes Association has been supportive of the program as it shares a similar mission to their statewide, Latino outreach program on diabetes awareness. The Colorado Department of Public Health and Environment has clearly labeled the health disparity surrounding diabetic (preventive and clinical) care in the Latino population in their state plans and fully support the program's endeavors to ameliorate the problems. As long as the program shares the burden of the growing epidemic of obesity, the growing number of uninsured, and the prevalent health disparity within the growing Latino population with partners, we will support each other to maintain the programs.
Lessons LearnedLessons learned include: Word of mouth referrals have been found to be the most beneficial means of attracting clients from our target population who are not tied in with a primary care provider. The class evaluation is analyzed by the health educator and any problems are communicated to the promotores who are teaching the classes. The pre-/post-tests do not seem to be the best way to track information learned by the clients attending the class due to various differences in education and past use of multiple choice tests in the target population.