Multicultural Community Health Promoters Program

State: GA Type: Model Practice Year: 2004

Health disparities experienced by immigrants and refugees are most striking among women. In response to requests from refugee women, the DeKalb County Board of Health trained fifteen community health promoters (CHP) representing five refugee communities in Clarkston, Georgia where one-third of the population is foreign-born. The CHP committed to reaching 40 families during each year. The Community Health Promoters Program goals are to train refugee and immigrant health promoters to: 1) Conduct health education classes in their native language; 2) Serve as a health information resource and liaison; 3) Advocate for better health care for their community; and 4) Empower community members to advocate for their health rights. The impact goals stated that as a result of the CHP Program members of their communities would 1) Know about lifestyle and environmental factors which threaten their health and well-being; 2) Access available community health resources; and 3) Practice lifestyle behaviors that promote health and well-being. Outcome data collected through monthly reports and case studies indicate that the CHP are providing health information in their communities, conducting health education classes and serving as liaisons between their community members and the health care system. It is too early to adequately document behavior change in the target populations reached by the CHP; however, case studies indicate a trend towards impact in the areas of nutrition and fitness. Replication of the program requires a partnership between the local board of health, agencies serving the refugee community and the refugee community itself. A facilitator team sensitive to the community and trained in popular education methods is essential. Resources must be in place to support a Program Coordinator, the costs of training and stipend payments for the CHP.
The Community Health Promoters Program (CHPP) responds to the health disparities found among immigrants and refugees which are most striking among women. The resettlement process focuses on jobs for men and school for children, leaving the women marginalized in these new and strange surroundings. Although, women are marginalized, they are still responsible for the health of their families. In view of this fact, marginalizing them decreases their families’ accessibility to the healthcare system. Another reason for the greater impact of health disparities among women is that in many of their home countries learning and socializing between men and women are not allowed. The comfort level of the women and their families is higher when activities are conducted in single sex environments. The CHPP responds to the health needs of the refugee community by training women from within their own communities to promote health and to be a liaison to the healthcare system. The 2001 Institute of Medicine report stated that health promoters were an important strategy for reducing disparities. Approximately 40 local women have received the Community Health Leadership Training and have initiated projects within their own communities such as English as a second language for Somali women, driver’s education for Afghan women, business cooperatives for African women and youth mentoring African youth. These projects were identified by the women themselves as activities that would improve their health and well-being in America.
Agency Community RolesThis CHPP would not be possible without a collaborative relationship between the Board of Health and the community. There have been three major partners in this collaborative: 1. Refugee Women’s Network, a grassroots non-profit agency providing leadership training to refugee women on a national level, 2. Clarkston Community Center, a grassroots community effort to develop a community center in Clarkston, GA, one of the most diverse communities in the Southeast United States, and 3. DeKalb County Board of Health, the local county public heath agency. All three partners worked together to write the grant that secured the funding. RWN took responsibility for recruitment and communication with the women. DCBOH was responsible for the training and implementation of the program. CCC provided the venue, stipend payments and administrative oversight. The relationship between the partners is an equalitarian relationship, with each partner taking responsibility for their piece of the program. The partners meet on a regular basis and make decisions regarding training, implementation, monitoring and evaluation as a team. It should be added that the CDC has also been a partner through the provision of a Preventive Medicine Resident who spent her year assisting in the training design as well as developing and overseeing the evaluation.  Costs and ExpendituresThe CHPP was supported with a $150,000 grant from the Healthcare Georgia Foundation for a two-year period. This includes the $30,000 salary costs of the Project Director as a half-time employee at the DCBOH, the manual development, training, supplies and stipends. RWN staff put in approximately 10 hours per week and the CCC about the same for administrative oversight. The CDC Resident contributed 15-20 hours per week of her time as well. A major in-kind contribution was the women’s time during training as they did not start receiving their stipends until they actually began their CHP responsibilities. Each CHP is being paid a monthly $100.00 stipend. At current levels of funding, the stipend payments will last until December 2005.  ImplementationA group of 15 women were recruited and selected from an already established base of refugee and immigrant women to participate in the Community Health Promoter training program. Fifty hours of training were implemented over a three-month period from September 2003 to December 2003. Women were trained in grassroots community development, nutrition and fitness, chronic disease, women’s health, mental health, and healthcare services and resources. Each woman received a Health Promoter Manual developed by the CHHP team with them. As of January 1, 2004, these 15 women began working as Community Health Promoters. Their responsibilities included volunteering two to three hours per week, conducting informal needs assessments to understand the health problems in their communities, raising people’s awareness about health issues, providing health education, and sharing information regarding the healthcare system. The CHP also determined the methodologies that they would use to fulfill their job such as visiting newcomers and new families to find out their health needs; having informal conversations in homes, at cultural events, or while waiting for MARTA; holding small group gatherings in homes and other places; using stories, role-plays, songs, poems, dance and art work as a means of teaching about health; and conducting community health fairs in collaboration with healthcare providers. Currently, the implementation team meets with the women on a monthly basis for the purpose of sharing stories, reporting, evaluating, continuing education, participating in fitness sessions, and receiving stipend payment.
The training was evaluated through the regular ongoing evaluations by asking the women to rate their comprehension level and to make any recommendations or suggestions regarding the training. Evaluation forms and the results are available to anyone seeking to replicate this model. During training, a knowledge post-test of was also given to the participants at each meeting. These forms assessed participant knowledge on the key concepts taught at the previous training session. With repeat testing, knowledge of foods high in fat content remained constant, as did knowledge of foods high in salt. Although, a decline in knowledge of foods high in salt content occurred with the first repeat testing the knowledge level recovered on the second repetition. Twenty-five percent of the women were missing during the session on foods high in salt content. Repeat testing of chronic diseases knowledge, showed a non-statistically significant improvement. The inability of the women to name more than one food high in fat or salt may have been because of language or cultural barriers. The language barrier made it difficult to ask open-ended questions. Questions with multiple-choice answers may have helped the women. However, this was not observed when changing from open-ended to multi-choice answers for nutrition and foods high in fat or salt content. The women also had low knowledge levels for women’s health issues. The outcomes of the program are being measured through case studies which are recorded on a monthly basis. These case studies will be aggregated and a content analysis will be done to determine impact of the health promoters on each ethnic community and on the community as a whole.
SustainabilityThe women are committed and enthusiastic about their new role in their communities. They have stated that they would continue to perform their health promotion duties even if they did not receive stipends. The response from the community has also been favorable. Community members now call and seek these women on a regular basis to assist them with any health-related issue. The women have expanded their involvement with the DCBOH by getting involved with a new refugee mental health clinic and performing various translation functions. In some ways the commitment of the women, their communities and the partners involved will sustain the program. Additional support is being sought for the continuation of the program through grants. The program team continues to work together to seek these additional funds. The Office of Refugee Resettlement of DHHS has expressed real excitement about this innovative approach to refugee health and may provide funds in the future. Program staff maintain an ongoing relationship with this office and encourage their personnel to attend the training whenever possible. It is the desire not only to sustain the program but to expand it by reaching other refugee and immigrant communities in the greater Atlanta area. Although the DCBOH has experienced budget cuts, the administration is committed to the program and is seeking to make the program director a regular DCBOH employee rather than a consultant dependant on grant monies. This expresses a profound commitment on the part of the DCBOH. Lessons LearnedThese are some of the lessons learned from the experience: allow the participants to determine those health topics which are most significant for their communities; allow participants to determine their role; recruit ethnic groups in teams of two to four participants; allow ethnic teams to work together so that they can assist each other with language and subject comprehension; use a small group-large group methodology (working in small groups and reporting back in the large group); keep the training interactive and animated; use as many self-discovery methodologies as possible; build from the knowledge base of the participants; be flexible and patient with the needs of the participants; and adjust the schedule as necessary to accommodate various events and holidays.  Key Elements ReplicationCertain factors that are essential for replication of this program include a close relationship with the refugee community and refugee agencies so that there is ample trust, a true equalitarian partnership between the Board of Health and grassroots agencies working with refugees and immigrants, a profound understanding of the Freirian methodology of popular education, an ability to adjust schedules as deemed necessary by the participants, and facilitators that understand and communicate well with members of diverse communities.