1 Mental Health Assessment of Low Income Latino Women and Children in Rural Area: Ana Cristina Rosa University of Florida
COLLECTION 2 Abstract The specific aims of this honors research are to : (1) describe evidence on the role and training of promotoras in the Latino community, (2) describe promotoras Logs Entries recorded during data collection of a mental health assessment amongst rural Latino women and children, and (3) develop ideas on how to train promotoras to max imize their effectiveness It was a pilot descriptive study The research is vital to shape the future training of Promotoras who will be delivering a mental health intervention with the rural Latino community in North Central Florida The literature re view found that Promotora led interventions have resulted in improved health management The logs filled out by Promotoras after administering a mental health assessment on Latino women and children were analyzed and revealed strengths and weaknesses of P romotoras Programs need to take advantage of strengths of compassion and community knowledge and f uture training should include education on how to best deliver interventions and distribute resources
COLLECTION 3 According to t he U.S. Department of Hea lth and Human Services (2001) mental health is a vital aspect of personal well being, family relationships, and success ful contributions to society Despite its importance, many do not receive mental health services, especially Latinos residing in rural communities (Rural Assistance Center, 2010). Latinos are the largest minority group in the United States and a group that is in great need of mental health services (The U.S. Department of Health and Human Services, 2001) The population in this study is composed of Latino women and children in rural communities that immigrated to this country less than 10 years ago particularly to Levy County FL. The burden of leaving one s country due to poverty or political prosecutio n added to the process of acculturation puts a great deal of strain on the mental health of the Latino population ; yet, they have little access to mental health services (The U.S. Department of Health and Human Services, 2001) Mental health services ar e a resource that is scarce in rural communities due to a lack of funds (Rural Assistance Center, 2010 ) The purpose of this honors research study is to (1 ) describe evidence on the role and training of P romotoras in the rural Latino community, (2) desc ribe P Log Entries recorded during data collection of a mental health assessment amongst rural Latino women and children in North Florida, and (3) propose ideas to be included in P romotoras training to maximize their effectiveness within the comm unity The L og E ntries analyzed in this honors research are the l ogs filled out by Promotoras in the research entitled Using Community Based Participatory Research (CBPR) to Address Depression in Rural Low income Latino Mothers and Children performed by was to perform a mental health assessment using Promotoras and to find a culturally appropriate and innovative solution to address the lack of mental health services in Latino women and
COLLECTION 4 children residing in rural areas using CBPR principles. This honors project was a sub study of Methods This was a descriptive study composed of three different phases: (1) finding evidence on the role and training of P romotoras in the Latino community, (2) describing P romotoras Log Entries recorded during data collection of a mental health assessment amongst rural Latino women and children ages 8 17 and (3) developing ideas on how to train P romotoras to maximize their effectiveness. The terms P romotora community health worker and lay health advisor are all similar terms that describe an outreach worker who is responsible for raising awareness of health and educational issues In this honors research the term Promotora will be used to encompass all three terms. In order to complete Phase I and describe role and training in the Latino community a search was conducted in electronic data bases such as PubMed PsycINFO and Google Scholar. The data f ound in the research articles and program descriptions was compiled into a matrix format (See Appendix A ) and later summarized into a table. In order to understand Phase II of this honors project is important to understand the research entitled Using Community Based Participatory Research (CBPR) to Address Depression in Rural Low income Latino Mothers and Children In this research study P romotoras were sent to the homes of Latino women and children that had immigrated to this country less than 10 years ago. While in the home of the participants, the Promotoras performed a mental health assessment that included assessments on depression, s elf esteem and stressors. After the Promotora left the home of the participant she filled out a structured log form detailing her observations. The Log E ntries (See Appendix B ) were content
COLLECTION 5 analyzed, to describe P perceptions about the data collection of a mental health assessment amongst rural Latino women and children ages 8 17 in North Florida. The Promotoras completed 45 L og E ntries detailing their encounters with the mother and child of each family. The Log E ntries were analyzed by three students in order to ensure reliability. In Phase III t he data analysis from Phase II was used to make recommendations for the future training o f Promotoras The recommendations will be used to train Promotoras that will b e conducting mental health assessments and interventions in a Latino population residing in a rural community. Results Phase I This author found two studies that have been conducted that use Promotoras to perform mental health assessments and interventions One program implemented a Promotora centered mental health intervention while the qualitative analysis of this study was published, the quantitative analysis has not been published ( Getrich Heying, Willging, Waitzkin, 2007) The se cond program is in the process of forming a toolbox for P romotoras to use in order to assess depression in clients with chronic illness such as diabetes (Reinschmidt & Chong, 2007). However, Promotoras ha ve been used extensively in diabetes education, cardiovascular screening, and many other health promotion areas and th ese literature findings were summarized (See Table 1), to support a National Institutes of Health grant application for Dr. Stacciarini Promotoras roles. The literature describes five m ajor roles of Promotoras : educator, case manager, role model, program facilitator, and advocate (Andrea, et al., 2008; Cherrington, et al., 2008) The roles varied according to the need and purpose of the program The role most often identified
COLLECTION 6 was that of an educator They provide education on a variety of topics such as diabetes management and screening for breast and cervical cancer ( Culica, Walton, Harker, & Prezio, 2008; Fernndez, et al., 2009). Some programs assigned Promotoras the role of c ase managers (Andrea, et al., 2008; Cherrington, et al., 2008) Promotoras were also entrusted with a caseload of clients and asked to monitor the ir glucose levels and make judgments on whether they needed further education or if they needed an appointmen t with their primary care provider ( Culica, Walton, Harker, & Prezio, 2008) Promotoras are also r ole models in their communities; they model healthy behaviors such as getting yearly mammograms, checkups, exercising, and eating healthy (McCloskey, 2009) T hey advocate for members of their community by organizing community presentations and are also the main force behind many health programs (Kelly, Lesser, Peralez Dieckmann, & Castilla, 2007) They are often capable of filling roles that are typically filled by higher level personnel ( Culica, Walton, Harker, & Prezio, 2008) Promotoras t rai ning. The training Promotoras received varied greatly from program to program The length, intensity, topics and methods associated with the training was modified to suit the need of each individual program Programs that were research based included training on the research process, objectives, and recruitment process (Andrea, et al., 2008; Farquhar, et al., 2008) Some studies include training on leadership, advocacy, community organizing, cultural competency, and communication skills (Andrea, et al., 2008; Cherrington, et al., 2008; McCloskey, 2009) The length and intensity of training varied according to the curriculum The amount of hours ranged from eig ht hours in the classroom with some field work to over 240 hours in the classroom and in the field A combination of training methods such as lectures, group discussion, presentations, role play, one on one trai ning, and on the job training were identifie d
COLLECTION 7 (Andrea, et al., 2008; Perez, Findley, Mejia, & Martinez, 2006 ) Programs also provided education on the technical skills that were necessary for the job such as monitoring blood glucose levels, dealing with diabetic emergencies, asthma management and c onducting interviews (Andrea, et al., 2008; Cherrington, et al., 2008) Promotora led interventions and outcomes. Promotoras implemented a variety of interventions that all had generally positive outcomes ( Culica, Walton, Harker, & Prezio, 2008; Fernande z, et al., 2009; Perez, Findley, Mejia, & Martinez, 2006 ) In one program where they functioned as case managers f or clients with diabetes, the participants in th e program had improved control over their disease as measured by hemoglobin A1C levels after the Promotora intervention ( Culica, Walton, Harker, & Prezio, 2008) They assembled community presentations on topics relevant to the community such as domestic violence and health promotion (Kelly, Lesser, Peralez Dieckmann, & Castilla, 2007) They remo ved barriers to healthcare by facilitating access to health care and social services and through health promotion ( McCloskey, 2009; Reinschmidt, et al., 2006) One program used Promotoras to enroll families in health insurance, promote immunizations and p rovide education on asthma management (Perez, Findley, Mejia, & Martinez, 2006). These were families that would otherwise have had little to no access to healthcare. Gaps in Promotora research. The literature review yielded interesting results; however, there were several gaps The main gap is the lack of research on Promotora led interventions in mental health Promotoras are a practical way to provide services to communities that have no other access to health care Despite this, they are a resource t hat is not being taken advantage of. The gap that was most
COLLECTION 8 related to this honors research was the lack of documentation o f programs that focus on mental health that utilize Promotoras Table 1 Major Findings of Literature Review Research Area Major Findings Role of P romotora Five major roles: educator, case manager, role model, program facilitator, and advocate. Roles, responsibilities and training varied greatly across programs. The roles varied according to the program and most were flexible. Training of P romotora Training varied to suit the needs of the program. Programs that are research based tend to include training on the research process, objectives, and recruitment process. Some studies include training on leadership, advocacy, community organizing, cultural competency, and communication skills. Length of training varied. Ex. 2 day workshops, 80 hours total, 60 hours over 6 months, etc. Training methods varied. Most used a combination of methods. Ex. Lectures, group discussion, presentations, sociodramas, role play, one on one training, and on the job training. Each program provided technical training on the subjects they expected the promotoras to teach. Some programs provi Interventions provided by P romotora They made follow up phone calls, provided referrals, and updated the medical team when necessary. Assembled community presentations on topics relevant to t he community such as domestic violence and health promotion. Individual educational visits with participants. Provided education to the public on the area that their program specialized in. Facilitate access to health care and social services. Outcomes of P romotora Interventions Effective in reaching rural community members that would otherwise have no access to healthcare. Removed barriers to healthcare. Effective in increasing health promotion and disease prevention.
COLLECTION 9 Phase II T he data in the L og entries w ere summarized into 4 categories: social desirability, family dynamics, needed interventions, and lack of understanding regarding the instruments Social d esirability. Promotoras often documented that they felt participants were not being honest answering the instruments used for the mental health assessment According to their perceptions, er instead of answering truthfully A Promotora noted in one of the logs that a mother answered one of the questions in the depression questionnaire that she was never sad but she was crying and appeared sad as she completed the assessment In a different instance the mother answered in the questionnaire that there was no history of domestic violence in the household but the Promotora knew from her connection to the community that there was a history in the household Unfortunately, social desir ability bias as perceived by the Promotoras would be something that would skew the results of the data collected. Family dynamics. The Promotoras were also able to provide valuable insight into the family dynamics They reported on the relationship betwee n family members and on the environment the assessment was conducted in. The Promotoras were also able to modify their technique, plans and even the setting of the assessment in order to benefit the participant On one occasion, a Promotora entertained t he children of one of the mothers in order to give the mother peace and quiet so that she could complete the interview. At a different instance a Promotora completed icipant.
COLLECTION 10 Promotoras were able to observe family dynamics and use their findings to help the participants and to complete a thorough assessment. Needed interventions. The mental health assessment included a questionnaire on depression; this questionnaire a sked about topics such as anhedonia and suicidal ideation A protocol was set up so that if a mother or child received a dangerous score on the questionnaire or answered that he or she was having thoughts of hurting themselves the Promotora could immediat ely get them help The Promotora did this on one occasion and was able to set up an appointment for the mother with a local bilingual/bicultural therapist However, there were other occasions when the participant would deny suicidal ideation and would not receive a high score on the depression scale but the Promot o ra perceived that this person was in crisis or in need of help The Promotora received no training on what to do in these occasions In these instances the Promotoras would often provide a n intervention by talking to the participants and letting them vent about their problems and would then offer the participants the phone number to the crisis center just in case they decided to use the help On their own volition, the Promotoras would pro vide an intervention when they thought was necessary. Lack of understanding regarding the instruments. A considerate effort was made to ensure that the questionnaires used were culturally appropriate Despite these efforts some participants still had dif ficulty with some of the terms and questions The Promotoras were able to help the participants answer the questionnaires by explaining questions to them and defining words for them. Promotoras will also be able to help
COLLECTION 11 the researcher make more effective tools by telling the researcher what words the participants had problems with and make suggestions for more appropriate language. Phase III The L og E ntries completed by the Promotoras provided valuable insight into their strengths and their weaknesses Promotoras commented on what they observed and on what they felt The analys i s of the Logs were then used to fulfill the third aim of this honors research which was to propose ideas to be included in promotoras training to maximize their effectiveness wit hin the community. strengths of compassion and community knowledge need to be acknowledged and encouraged Promotoras are an invaluable asset because they know the community and come from the community Therefore, it is important for the rese arch time to use this strength and trust the Promotora to make judgments on whether or not an intervention is necessary It is also important to help Promotoras in this endeavor by providing them with the tools that they need to do the best job possible Training on available resources and on therapeutic communication would help Promotoras decide what kind of an intervention is necessary Promotoras would then have the training to talk participants in a therapeutic manner and then refer them to the appro priate agency if it is necessary Promotoras performing mental health assessments and interventions would also benefit from education on complete and objective data recording Many of the L ogs written by the Promotoras were brief and left the researcher s with some questions Promotoras need education on documenting their observations and if they think or feel something they need to document what led them to think or feel this
COLLECTION 12 Professionalism and confidentiality are vital tools for Promotoras conducting mental health assessments. A Promotora commented in one of the L ogs that she felt uncomfortable interviewing one of the participants because they were members of the same church In this instance, training on how to behave in a professional man ner and how to convey to the participants that what goes on between them during an intervention is confidential would have been invaluable to her Mental health is a topic that many people are not comfortable discussing due to the stigma attached; therefo re, educating Promotoras on professionalism and confidentiality could lead to a more honest and comfortable assessment and intervention Role in Research Th is honors project was completed in t hree consecutive phases The literature review was conducted during Phase I over a 4 week time period PubMed PsycInfo and Google Scholar databases were searched for any article related to Promotoras Latinos and mental health After the second week the search was broadened to include all articles related to Pro motoras and Latinos due to the lack of articles related to Promotoras, Latinos and mental health Each article found for the literature review was summarized into a matrix format (See Appendix A) The matrix was then used to create a table (Table 1) regar ding the major findings of the role and training of Promotoras their interventions and the outcome of their interventions. Phase II of this honors project was the analysis of the L ogs completed by the Promotoras Phase III was the utilization of th e data analysis to create a list of suggestions for the future training of Promotoras completing mental health assessments in Latino women and children residing in a rural community contributing to future interventions and research studies Learning Proce ss
COLLECTION 13 The completion of a literature review is a challenge In order to find every article related to Promotoras and mental health it was vital to learn how to navigate well in the databases Despite a thorough search, there is a chance that relevant articles may have been missed There is also the problem that there are many different terms used that describe an outreach worker The terms promotora community health worker, and lay health advisor were searched for but there may have been some resear ch studies that used a different title for their outreach worker It was also a challenge to try and locate all articles that were related to mental health or that had at least one small component related to mental health Every effort was made to locate all articles related to P romotoras and mental health but it is impossible to know how many articles may have been missed In order to ensure that the greatest amount of articles that were relevant were located various search engines were used, many diff erent terms were included in the search, and all articles that were found were read even when the abstract did not reveal that it might be a relevant article. A lthough P romotoras were trained on how to document their observations clearly and objectively reinforcement and practice are necessary. There were many L ogs that contained an inference made by the Promotora ; however, the L og did not contain the details that led her to come to this conclusion Therefore, there is the chance that vital information was not included in the L ogs In addition to this there is a chance that the information that was written in the logs was misinterpreted by the readers The three separate readers analyzed each log independently before coming together to discuss the content in order to reduce bias and in crease reliability Nonetheless without talking to the Promotoras and asking them what they meant by what they documented in the Logs total accuracy cannot be measured. Recomme ndations for Future Students
COLLECTION 14 When working on honors research it is recommended that students pick a topic of interest and form a timeline and a plan Honors research is a big endeavor that will require a great investment of time Therefore, it is vital t hat the student choose a topic that he or s he can become passionate about changes It will not seem to be a big undertaking ; it will be seen as a project that the student wants to spend time on However, even if it is a topic that the student is passionate about, it cannot be denied that it is a huge undertaking In order to be successful it is important that at the very beginning the student set goals and then designs a plan on how he or she plans to meet these goals Following this process, the student may increase their chances of successfully completing their honors research. Conclusion This honors research identified evidence on the role and training of Promotoras in research interventions and programs. It described the information documented in the Logs written by Promotoras after a mental health assessment. Also, w ays to empower Promotoras in order to ensure their success in administering mental health assessment s to Latino women and children residing in rural North Central Florida were listed
COLLECTION 15 References Andrea, C., Guadalupe, A., Halle, A., Scarinci, I., Allison, J., Corbie Smith, G. (2008). Applying the community health worker model to diabetes management: Us ing mixed methods to assess implementation and effectiveness. Journal of Health Care for the Poor and Underserved, 19 (4), 221 228. Retrieved on July 21, 2009 from PubMed database. Cherrington, A., Ayala, G., Amick, H., Allison, J., Corbie Smith, G., Scari nci, I. (2008). Implementing the community health worker model within diabetes: management: Challenges and lessons learned from programs across the United States. The Diabetes Educator, 34 (5), 824 833. Retrieved July 21, 2009 from PubMed database. Culica, D., Walton, J., Harker, K., Prezio, E. (2008). Effectiveness of a community health worker as sole diabetes educator: Comparison of CoDE with similar culturally appropriate interventions. Journal for the Healthcare of the Poor and Underserved, 19 (4). Getri ch, C ., Heying, S ., Willging, C ., Waitzkin, H (2007 ). An ethnography of clinic "noise" in a community based, promotora centered mental health intervention. Social Science & Medicine, 65 (2), 319 330. Retrieved July 2, 2009 from PubMed database. Farquhar, A., Wiggins, N., Michael, Y., Luhr, G., Jordan, J., Lopez, A. (2008). "Sitting in different chairs:" Roles of the community health workers in the Poder es Salud/Power for Health project. Education for Health, 21 (2). Ferna ndez, M., Gonzales, A., Tortolero Luna, G., Williams, J., Saavedra Embesi, M., Chan, W., Vernon, S. (2009). Effectiveness of Cultivando La Salud: A Breast and cervical cancer screeningpromotion program for low income Hispanic women. American Journal of Public Health, 99(5) Retrie ved on July 25, 2009 from PubMed database.
COLLECTION 16 Kelly, P., Lesser, J., Peralez Dieckmann, E., Castilla, M. (2007). Community based violence awareness. Issues in Mental Health Nursing, 28, 241 253. McCloskey, J. (2009). Promotores as partners in a community base d diabetes intervention program targeting Hispanics. Family and Community Health, 32 (1). Retrieved on July 26, 2009 from PubMed Database. Perez, M., Findley, S.,Mejia, M., Martinez, J. (2006). The Impact of community health worker training and programs in New York City. Journal of Health Care for the Poor and Underserved,17(1). Retrieved on July 21, 2009 from PubMed database. Reinschmi dt, K., Chong, J. (2007 ). SONRISA: a curriculum toolbox for promotores to address mental health and diabetes. Preventing Ch ronic Disease, 4 (4). Retrieved July 7, 2009 from PubMed database. Reinschmidt, K., Hunter, J., Fernandez, M., Lacy Mart inez, C., Guernsey de Zapien, J., Meister, J. (2006). Understanding the success of promotoras in increasing chronic disease screening. Journal of Health Care for the Poor and Underserved, 17 (2). Retrieved on July 21, 2009 from PubMed database. Rural Assist ance Center. (2010). Mental Health. Retrieved February 18, 2010 from http://www.raconline.org/info_guides/mental_health/ U.S. Department of Health and Human Services. (2001). Mental Health: Culture, Race, and Ethnicity A Supplement to Mental Health: A Report of the Surgeon General Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.
COLLECTION 17 Appendix A Matrix for Literature Review Citation PURPOSE Subjects Data N=? Characteristics Design/ Sample Source/ Year Data collected INTERVENTIONS COMPARISONS OUTCOMES Promotoras Instrument Training Roles
COLLECTION 18 Appendix B Using CBPR to Address Depression in Rural Low Income Latino Mothers and Children Research Assistant Log some questions to log the process health ide ntifier information names, address, phone number, school names) must not be included in this log. Approximate time spent with mother________________ and time spent with child __________ 1) Did you experience any problems during the data co llection process (e.g. interruptions during the data collection, understanding of the instruments language)? ( ) No ( ) Yes. Describ 2) How was the interaction with the mother who answered the instruments? ( ) Easy. Explain ( ) Difficulty. Explain 3) ( ) Neutral ( ) Positive. Explain ( ) Negative. Explain 4) Did the mother ask question (s) about the research? ( ) No ( ) Yes. Types of questions 5) verbal communication? ( ) Happy ( ) Calm/not anxious ( ) Anxious ( ) Cry (after some time) ( ) Cry (several times) ( ) Concerned with other things. Explain ( )Other 6) Did th e mother ask question (s) about the instruments? ( ) No ( ) Yes. Types of questions
COLLECTION 19 7) How was the interaction with the child who responded to the instruments? ( ) Easy. Explain ( ) Difficulty. Explain 8) earch? ( ) Neutral ( ) Positive. Explain ( ) Negative. Explain 9) verbal communication? ( ) Happy ( ) Calm/not anxious ( ) Anxious ( ) Cry (after some time) ( ) Cry (several times) ( ) Concerned with other things. Explain ( ) Others 10) Did the child ask question (s) about the research? ( ) No ( ) Yes. Types of questions 11) Did the child ask question (s) about the instruments? ( ) No ( ) Yes. Types of questions 12) Anything else about the process of data collection? (e.g. referrals)