Running head: PROMOTING MENTAL HEALTH 1 CBPR: Community and Promotoras Mental Health within Rural Latino Communities Elizabeth L. Johnson University of Florida
PROMOTING MENTAL HEALTH 2 Abstract This honors thesis explores both role and the involvement of faith based organizations (FBO) in addressing social isolation and promoting mental health in rural Latino communities. Research questions are: 1) How do manuals for community health workers address mental health bot h in training CHWs and in assisting the community?, 2) Are CHWs equipped with religious content when training for the promotion of mental health?, and 3) What do FBO leaders see as problems and recommendations for intervening with rural Latinos? This pil ot descriptive study reviewed CHW health promotion manuals found through electronic databases and by searching the gray literature. Then, interviews with FBO leaders ( n =15) in Levy County, Florida populated with Latinos, were performed, reviewed, and con tent analyzed. Results show that there is a lack of mental health content and religious interventions in CHW manuals. Also, FBO leaders indicated linguistic/cultural knowledge and building capacity, health and social inequities, geographic immobility, im migration issues, characteristics of the individual, and cultural disunity as central concerns. To promote mental health, subjects such as immigration status, financial support, and backing from authorities in the community need to be addressed. Not only should CHWs receive more mental health training, but faith based interventions should also be explored for effectiveness and possible implementation in health promotion for Latinos in rural areas. Keywords: promotora(s) community health worker, mental h ealth promotion, social isolation, immigrant Latino(s), rural population, low income
PROMOTING MENTAL HEALTH 3 CBPR: Community and Promotoras Mental Health within Rural Latino Communities Latinos have surpassed European immigration and are now the largest minority group in the United States (U.S. Census Bureau, 2006); many immigrants continue to settle in isolated, underserved rural areas near work sites, revealing a group that is in great need of mental health services (US/DHHS, 2001). Latino participation in research may be significantly enhanced by culturally appropriate approaches that include members of the community in the research process; one such appro ach is community based partici patory r esearch (CBPR) (Stacciarini, in press) collaborative approach to research that equitably involves all partners in the change that improves hea lth outcomes and results in the elimination of health disparities ( Israel, Schulz, Parker, & Becker, 1998, p. 177 ). In order to uphold the seven principles, CBPR should n the community, facilitate collaborative partnerships in all phases of the research, integrate promote a co learning and empowering process that attends to social inequalities, involve a cyclical and iterative process addresses health from both positive and ecological perspectives and (Israel et al ., 1998, p.178 180). The advantages of using CBPR to conduct research are that the investigator works with and for the community staying true to the wellness approach rather than an illness approach (Stacciarini, 2009).
PROMOTING MENTAL HEALTH 4 The purpose of this project was to further collaborate with the main research in the area of mental health promotion among rural Latinos. The main researcher, Dr. Stacciarini, initiated a community academic partnership in 2008 and created an advisory boar d ( n =8), which consists of active workers in the Latino community, in the rural area of Levy County (Stacciarini, in press). promotoras to promote mental health among rural, low income Latinos. A promotora is an 1) From here on, promotora and community health worker (CHW) will be used interchangeably. Dr. Stacci arini has performed several research steps including a mental health assessment of Latino mothers and children and a faith based organization survey. Specific aims of this honors exploratory descriptive pilot study are to: 1) conduct a review of literatur e of previously established curriculums for promotoras /CHWs and analyze content for promotion of mental health and prevention of mental illness and 2) analyze previously collected interviews what faith based organization (FBO) leaders to identify problems in the rural Latino community Methodology To achieve the first aim, the gray literature was searched in order to find health promotion manuals ( n =6) for CHWs/ Promotoras Gray literature simply refers to information that cannot be accessed using conventional methods such as databases and search engines and may include unpublished materials. Dr. Stacciarini provided a couple manuals, and a couple were found through referen ces within research articles; these articles were found through the promotoras
PROMOTING MENTAL HEALTH 5 acquired by emailing community workers at various health departments in the Midwest. The six analyzed manuals consist of: 1) Promotor(a) Community Health Manual: Developing a Community Based Diabetes Self management Program 2) Living 3) SONR ISA: A Curriculum Toolbox for Promotoras/Community Health Workers to Address Mental/Emotional Health Issues Associated with Diabetes 4) the Our Bodies Ourselves Gua de Capacitacin para Promotoras de Salud 5) the Poder es Salud/Power for Health manual, and 6) The Salud Manual To achieve the second aim, previously conducted interviews of FBO leaders were analyzed. The interviews ( n =15) performed with leaders from six churches in three different towns within Levy County were collected through purposive and snowball sampling. The main questions analyzed were: 1) What are the problems the community in Levy County faces?, 2) What type of support do you need to help the Latino community?, 3) What are your hopes for the Lati no community?, and 4) What are your reservations/concerns about the Latino community in Levy County? In order to maintain inter rater reliability and validity of our findings, another honors student and I analyzed the interviews separately and then valida ted the analysis with Dr. Stacciarini. Results Review of CHW Manual Literature Four of the six manuals explicitly addressed mental health promotion and illness prevention in varying degrees, with the SONRISA manual covering the topic in greatest detail. Mental health training for CHWs. Regarding mental health training, the SONRISA manual suggests that promotoras need to be trained in identifying and addressing mental and emotional health ( Reinschmidt & Chong, 2005 ). Likewise, A New Leaf advises that tra ining for
PROMOTING MENTAL HEALTH 6 playing are included; this allows trainees to use materials and counseling tools ( UNC Center for Health Promotion and Disease Prevention, 2007 ). Mental health promotion a nd burnout prevention for CHWs. One manual, in particular, appropriately addresses mental health promotion and work related burnout prevention for CHWs/ promotoras According to the SONRISA manual, promotoras need to acquire skills to maintain personal physical and emotional balance to avoid burnout and to render the best service possible to the client. It also provides a self assessment tool that helps the CHWs understand his or her strengths, weaknesses, goa ls, and needs (Reinschmidt & Chong, 2005). When discussing mental health education and the role of promotoras /CHWs in educating various target communities, the SONRISA manual again offers the most training and advic e. The manual explains that promotoras should give informational support including teaching about prevention and health management of depression and factors leading to depression; this education should also include both the biological origin and environme ntal influences on mental and/or emotional health. It is also wise to teach the SONRISA manual stress that different cultures have different ways of dealing wit h stress, specifically through expression and coping mechanisms. The manual also talks about the first signs of depression so that appropriate actions may be taken when they appear; some of the first signs are: change in sleep or eating habits, loss of en ergy, feelings of restlessness, decreased libido, loss of interest in usual activities, depressed mood, decreased concentration, and suicidal thoughts (Reinschmidt & Chong, 2005 ).
PROMOTING MENTAL HEALTH 7 Stress as a precursor to mental illness. The next research area identified concerns stress as an instigator of mental illness. CHWs are encouraged to educate about stress its manifestations and causes. Bonilla (2002) encourages Latina women to identify the most common triggers of stress and depression. Stress management class es and group discussions are also recommended. Goals should be aimed at reducing stressors, which will in turn help to ease the feelings of depression. The SONRISA ntions such as exercise, diet and nutrition, relaxation techniques, time management, social support, positive attitude and lifestyle, and remaining organized among others (Reinschmidt & Chong, 2005 ) Assessment and management of mental illness. The rese arch area that received the most attention from a variety of the manuals deals with assessment and management of mental illness and specifically depression. Reinschmidt and Chong (2005), authors of the SONRISA manual, suggests a relational approach from C HWs in order to prevent or help community members cope with depression; it is more helpful to focus on strengths rather than weakness and to include fun activities as interventions rather than long discussions of negative emotions. CHWs should share succe ss stories, improve follow up, and help patients stay in the healthcare system; they should be actively involved in procuring mental health systems where people who are not in crisis can seek help to prevent crises. Also, when dealing with mental health i ssues, it is important to mobilize support from family members, friends, and the community. The SONRISA manual introduces communication with a priest or clergy member as an intervention for mental or emotional distress. Finally, the SONRISA manual recomm ends equipping CHWs with a depression screening tool that systematically, and therefore not always precisely, measures a person mental health (Reinschmidt & Chong, 2005). In the same way, A New
PROMOTING MENTAL HEALTH 8 discusses risk and vulnerabil ity assessments that are necessary for swift interventions. An organization in the New Mexico area has diligently labored to create an online database of mental health services, citing service descriptions, languages offered, and costs to aid members of t he community in seeking help (La Comunidad Habla, 2002). The Our Bodies Ourselves manual, entitled Gua de Capacitacin para Promotoras de Salud (2002), have a community, neighbors, family, friends, and a doctor. The second worksheet is entitled n, their causes, and solutions or resources while using the comparison of a tree with its root, trunk, and leaves/fruit (Bonilla, 2002). As previously mentioned, the main interview questions analyzed were: 1) What are the problems the community in Levy County faces?, 2) What type of support do you need to help the Latino community?, 3) What are your reservations/concerns about the Latino community in Levy County?, and 4) What are your hopes for the Latino community? When analyzing these questions, six categories were identified: 1) linguistic/cultural knowledge and building capacity, 2) health and social inequities, 3) geographic mobility, 4) immigration, 5) characteristics of the individual, and 6) cultural unity. Problems and support needed in the community identified by FBO leaders. The overall results (see Figure 1) show that the problems identified by FBO leaders in Levy County correspond to the types of support they feel are needed to help the community. The health and so cial inequities/support category overwhelms the responses by the FBO leaders as they identify
PROMOTING MENTAL HEALTH 9 problems such as inadequate healthcare, alcoholism, drug addiction, discrimination, persecution, racism, lack of jobs, and lack of governmental support. As previ ously mentioned, the type of needs correspond to the same problems: support from authorities and county offices, financial support, medical support, and consistent support groups for the community. Geographic mobility, immigration, and linguistic/cultura l knowledge and building capacity are equally identified as problems in the Latino community. Linguistic/cultural knowledge and building capacity. This category refers to the linguistic challenges and the capacity of the individuals to further enhance t heir socioeconomic status in the community. Examples include the English Spanish language barrier, lack of services available in Spanish, the need to learn English, and lack of formal education. Health and social inequities/support This category refers to health and social situations, such as discrimination, lack of communication between different cultural communities, lack of health services/information, and lack of jobs, which place the Latino community at a disadvantage. Geog raphic mobility. This category is used to describe the lack of and need for transportation, public or private, and the geographic isolation of the Latino community. Immigration. This category pertains to undocumented status in the country and its imp lications; these include lack of legal documents, inability of illegal immigrants to obtain a for low wages. As in the problems and type of support identified, FBO leaders also have reservations about geographic immobility, lack of linguistic/cultural knowledge and building capacity, and health and social inequities. Also,
PROMOTING MENTAL HEALTH 10 immigration status issues generate fear in the community concerning legal documentation and anti immigration laws. Characteristics of the individual. When addressing reservations, a new category, c haracter types that may hinder the progress of the Latino community and includes refusal to learn a new language, familial irresponsibility, and lack of motivation for life improvement. The FBO leaders are concerned that some members of the Latino communi ty do not want to or refuse to learn a new language, some do not retain familial responsibility required to encourage and implement change, and that some simply will not have the motivation to improve quality of life and status. e community. Similarly to the other interview questions, FBO leaders hope for increased linguistic/cultural knowledge and building capacity, increased health and social support, and less stringent immigration laws. Cultural unity. As expressed by the FB O leaders, cultural unity is the primary hope for the Levy County Latino community; cultural unity denotes the hope that the Latino community will be unified within itself and within the mainstream culture; examples include destruction of communication bar riers that previously lead to disunity and cultural acceptance between communities within one geographical setting. Furthermore, FBO leaders hope that the community will have increased motivation to adapt to the U.S. culture, be united without religious b arriers, and that eventually the community as a whole can be united without discrimination or prejudice.
PROMOTING MENTAL HEALTH 11 Figure 1 Faith Discussion With a cursory review of the results, the mental health content found throughout the CHW manual literature appears encouraging, because it would seem that mental health issues and health promotion are being incorporate d and discussed; however, a deeper look exposes gaps in promotora training and community education. None of the manuals for training CHWs mentioned the effectiveness or outcomes of the programs/interventions. This information, though possibly accessible in other publications, would be helpful to the researcher in selecting manuals and/or interventions. With the exception of the SONRISA manual ( Reinschmidt & Chong, 2005) and one lesson plan within the Power for Health training curriculum ( Farquhar et al., 2003) the manuals reveal gaps in mental health training for CHWs. Of the manuals that do briefly mention mental health issues in CHW training and for community education, depression
PROMOTING MENTAL HEALTH 12 and stress are the only issues identified. There is a gap that exists in the resources for CHWs concerning a wide range of mental health issues; for example, how do you promote mental health when the mental illness has a genetic origin? No single manual was found that specifically and solely deals with mental health promoti on in rural, Latino communities as its primary aim. FBO leaders indicated discrimination, language barriers/communication, and lack of transportation as central concerns relating to social isolation among Latinos in rural Levy County. To promote mental health and prevent social isolation, subjects such as immigration status, financial support, and backing from authorities in the community need to be addressed in greater detail. Issues Encountered Limitations Because CBPR is specific to the community of focus, it is difficult to generalize research findings to a larger population. While it is extremely useful and relevant to that community, the findings may not be relatable when variables of other cultures are considered. Purposive and snowball sampli ng, which are subject to bias, were utilized when choosing participants for FBO leader interviews; many times, this selection method may be inadequate because the sample may not be representative of the larger target population. Issues The Spanish Englis h language barrier posed a problem throughout the honors research project, not only during the review of literature, but also during the interview analysis. While most manuals for Latino CHWs/ Promotoras are offered in English and Spanish, one manual was only published in Spanish. In order to understand the full context and detail of the manual, another honors student who speaks fluent Spanish read, translated, and interpreted the manual.
PROMOTING MENTAL HEALTH 13 During the pa st nine months, scheduling research meetings was difficult and required effective communication. Working with a group or team and being dependent upon others for completion of certain projects were adjustments but definitely good learning experiences. Re commendations for Further Research Concerning the research topic, t here is a need to develop an innovative intervention that (Stacciarini, 2009); FBO leaders may have a significant role in this process. Church is a place where Latinos have traditionally felt safe; incorporating FBOs as partners in mental health promotion may strengthen the interventions for rural isolated Latinos (Stacciarini, in press). When beginning this continuing research, it would be beneficial for future honor students sly performed research. In the same way, meeting with the advisory board in Levy County would most likely generate better understanding and aid the student in relating to the population of research. Learning Acquired As a result of this project, I became familiar with and empathetic to many issues and topics of which I previously felt ignorant. Prior to this research project, I had not considered at length the hardships faced by Latino immigrants; these include language barriers, immigration issues, lack of jobs, and health disparities that can all impact mental health. and initiative, provided an opportunity to submit an abstract, which was accepted for presentati on at the Southern Nursing Research Society (SNRS) 2011 Conference in Jacksonville, Florida I re analyzed the previously found literature to incorporate faith based interventions for
PROMOTING MENTAL HEALTH 14 the purpose of combining research with another student and presenting a poster at the conference. The purpose of the combined research was to assess potential for engagement with FBOs to develop mental health promotion interventions with rural Latinos (see Appendix A). Of the six manuals analyzed, three addressed spirituali ty and the role of the church in coping with stress or depression. Promotoras are encouraged to use spirituality as a motivational force at the beginning of support groups without promoting any one religion. They are also trained to lead spirituality bas ed support groups while incorporating scripture (Redondo, Torres, Castro, Villasenor, & Ingram 2008). The Our Bodies Ourselves manual acknowledges the role of the church in promoting mental health; it discusses the utilization of spirituality and religio n when there is a mental health problem (Bonilla, 2002). In controlling diabetes and depression, the SONRISA manual recommends using alone time/meditation/prayer to cope with stress, reach higher consciousness, rest, and be at peace. The diabetic with de pression can ask a priest or clergy to discuss feelings, and the church should convene meetings that address the issue of depression in the community (Reinschmidt, & Chong, 2005). While faith based activities are mentioned in 50 percent of the CHW/ promoto ras manuals, there appears to be a lack of detailed training and orientation to the prevention of mental illness and the incorporation of faith and faith based activities. As a result of this secondary research topic, I learned the extent to which faith p lays a significant role in the promotion of mental health. Summary The purpose of this continuing research project was to assess the literature on CHWs and resources given to low income, rural Latino communities to promote mental health. In addition, ana lyzing recommendations from FBO leaders aided in understanding the community in Levy County problems and needs. This experience has broadened my understanding of the research
PROMOTING MENTAL HEALTH 15 process and the hardships of immigrants living in rural areas of the United Stat es. The results show that a more intensive focus and interventions are needed regarding this population.
PROMOTING MENTAL HEALTH 16 References Bonilla, Z. E. (2002). Gua de capacitacin para promotoras de salud. Retrieved from Our Bodies Ourselves: http://www.ourbodiesourselves.org/uploads/pdf/porta.pdf Encarta World English Dictionary. (2009). Promotora. Retrieved from http://encarta.msn.com/dictionary_701708964/promotora.html Farquhar, S. A., Wiggins, N., Michael, Y. L., Luhr, G., Jordan, J., & Lop ez, A. (2003). Poder es salud / power for health initial capacitation series Portland, OR: Multnomah County Health Department. Israel, B.A., Schulz, A.J., Parker, E., & Becker, A.B. (1998). Review of community based research: Assessing partnership approaches to improve public health. Annual Review of Public Health 19 ,173 202. La Comunidad Habla. (2002). Retrieved from My Community NM: http://mycommunitynm.org/main/index .php La Comunidad Habla. (2002). The salud manual. Retrieved from My Community NM: http://mycommunitynm.org/main/salud_manual_main.php Redondo, F., Torres, E., Castro, I., Villasenor, A., & Ingram, M. (2008). Promotor(a) community health manual: Developing a community based diabetes self management program Somerton, AZ: Campesinos Sin Fronteras. Reinschmidt, K. M., & Chong, J. (2005). SONRISA: A curriculum toolbox for promotoras/community health workers to address mental/emotional health issues associated with diabetes Southwest Center for Community Health Promotion, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona.
PROMOTING MENTAL HEALTH 17 Stacciarini, J. M. (2009). A review of community based participatory research: A promising approach to address depression among Latinos? Issues of Mental Health Nursing, 30 (12), 751 757. Stacciarini, J.M. (in press). CBPR : Building partnerships with Latinos in rural areas for a wellness approach to mental health. Issues of Mental Health in Nursing. UNC Center for Health Promotion and Disease Prevention. (2007). healthy living. Retrieved from http://www.center trt.org/downloads/wisewoman/interventions/newleaf/New_Leaf_template.pdf U.S. Census Bureau. (2006). Ethnicity and Ancest ry Branch Population Division U.S. Census Bureau. Hispanics in the United States. Retrieved from the World Wide Web: http://www.census.gov/population/www/socdemo/hispanic/files/Internet_Hispanic_in_U S_2006.ppt#55,38 U.S. Department of Health and Human Ser vices. (2001). Mental health: Culture, race, and ethnicity a supplement to mental health. A report of the Surgeon General. Rockville, MD.
PROMOTING MENTAL HEALTH 18 Appendix A SNRS Conference Abstract CBPR : Partnering with Faith Based Organizations to Promote Mental Health among Isolated Latinos in Rural Areas Amanda Hernandez Elizabeth Johnson Jeanne Marie R. Stacciarini, RN, PhD Sandra Garzon College of Nursing: University of Florida Introduction: Utilizing community based participatory research (CBPR), the purpose of this study is to assess potential for engagement with faith based organizations (FBOs) to develop mental health promotion interventions with rural Latinos. Specific aims are to: 1) Describe religious content found in health promotion manuals for community health workers (CHWs), 2) describe evidence of integration of faith based activities to promote mental health; 3) describe Research questions are: 1) Are CHWs equipped with religious content when trained for promoting mental health?; 2) What faith based activities have been shown to promote mental health?; 3) What FBO leaders see as problems and recommendation for intervening with rural Latinos? Methods: This pilot descriptive study reviewed CHW health promotion manuals and research articles, found through electronic databases. Then, interviews with FBO leaders ( n =15) in rural areas populated with Latinos, were performed, reviewed, and content an alyzed. Results: There is a lack of religious content in manuals for CHWs. Only one manual incorporates prayer and support groups as coping mechanisms. Evidence from research articles supports faith as a coping mechanism/protective factor in mental healt h however, little was found on the use/effects of specific FBO interventions/activities. FBO leaders indicated discrimination, language barriers/communication, and lack of transportation as central concerns. To promote mental health, subjects such as immig ration status, financial support and backing from authorities in the community, need to be addressed. Discussion/Co nclusion: Faith based interventions should be explored for effectiveness and possibly implemented in health promotion manuals for CHWs. The re is a need to develop an Church is a place where Latinos have traditio nally felt safe; incorporating FBOs as partners in mental health promotion may strengthen the interventions for rural isolated Latinos.