Jill Guernsey de Zapien

The Impact of a Promotora on Increasing Routine Chronic Disease Prevention among Women Aged 40 and Older at the U.S.-Mexico Border

A randomized controlled intervention tested the effectiveness of a community health worker (CHW) program in increasing compliance with annual preventive exams among uninsured Hispanic women living in a rural U.S.-Mexico border area. During 1999-2000, household surveys were administered to women aged 40 and older. Uninsured women not receiving routine comprehensive preventive care were invited to participate in a free comprehensive clinical exam. Participants in the initial exam were eligible to participate in the CHW (promotora) intervention. Women were randomized to one of two intervention arms. One arm received a post-card reminder for an annual preventive exam, the other a postcard reminder and follow-up visit by a promotora. Receiving the promotora intervention was associated with a 35% increase in rescreening over the postcard-only reminder (risk ratio [RR] = 1.35, 95% confidence interval 0.95-1.92). Using promotoras to increase compliance with routine screening exams is an effective strategy for reaching this female population.

Using lay health workers: Case study of a community-based prenatal intervention

This article reports on the design and implementation of a prenatal outreach and education intervention for low income, Hispanic women living in three migrant and seasonal farmworker communities in Arizona. The program included three major elements: a Spanish language prenatal curriculum; a group of mature Hispanic women recruited from the target communities and trained as “Comienzo Sano” (healthy beginning) Promotoras (health promoters), and the organization of a support network of local health professionals. The rationale for the demonstration is reviewed, and the structure of the intervention is described. Factors which facilitated and constrained implementation of the program are identified, and guidelines are provided for other health care providers and health educators interested in developing similar programs.

Community health workers then and now: An overview of national studies aimed at defining the field

This article compares and contrasts 3 national studies of the US Community Health Worker (CHW) field spanning 15 years. Findings cover 4 areas of overlap among the 3 studies: CHW Demographics, Core Roles and Competencies, Training and Credentialing, and Career Advancement and Workforce Issues. Implications for the future development of research, practice, and policy are discussed. Authors observe that while health care reform has the potential for increasing funding and recognition of CHWs, it is essential that policies support the full range of CHW roles, including CHWs role as change agents, so that CHWs achieve their full potential to improve health outcomes, reduce health disparities, and work for social justice.

EVALUATION OF A PEER HEALTH WORKER PRENATAL OUTREACH AND EDUCATION PROGRAM FOR HISPANIC FARMWORKER FAMILIES

This article contains the findings from an evaluation of a prenatal education program to Hispanic migrant farmworker families using peer health workers. The focus of the evaluation was on establishing the validity of the intervention model in the target population. Data are presented on the program setting, characteristics of the clients served, and effects of the educational program on the clients and peer health workers. The evaluation identified factors that established confidence in the program model: (1) there were existing barriers to health care and health information; (2) the program served a culturally specific and disadvantaged population; (3) the prenatal curriculum was culturally sensitive; (4) the peer workers were accepted by the target community; and (5) the model did not threaten the medical community. The directions for future research are presented.

Community Health Workers and Community Advocacy: Addressing Health Disparities

The Community Health Worker model is recognized nationally as a means to address glaring inequities in the burden of adverse health conditions that exist among specific population groups in the United States. This study explored Arizona CHW involvement in advocacy beyond the individual patient level into the realm of advocating for community level change as a mechanism to reduce the structural underpinnings of health disparities. A survey of CHWs in Arizona found that CHWs advocate at local, state and federal political levels as well as within health and social service agencies and business. Characteristics significantly associated with advocacy include employment in a not for profit organization, previous leadership training, and a work environment that allows flexible work hours and the autonomy to start new projects at work. Intrinsic characteristics of CHWs associated with advocacy include their belief that they can influence community decisions, self perception that they are leaders in the community, and knowledge of who to talk to in their community to make change. Community-level advocacy has been identified as a core CHW function and has the potential to address structural issues such as poverty, employment, housing, and discrimination. Agencies utilizing the CHW model could encourage community advocacy by providing a flexible working environment, ongoing leadership training, and opportunities to collaborate with both veteran CHWs and local community leaders. Further research is needed to understand the nature and impact of CHW community advocacy activities on both systems change and health outcomes.

Predictors and a Framework for Fostering Community Advocacy as a Community Health Worker Core Function to Eliminate Health Disparities

OBJECTIVES Using a mixed-method, participatory research approach, we investigated factors related to community health worker (CHW) community advocacy that affect social determinants of health. METHODS We used cross-sectional survey data for 371 CHWs to assess demographics, training, work environment, and leadership qualities on civic, political, and organizational advocacy. We present advocacy stories to further articulate CHW activities. The data reported are from the recently completed National Community Health Workers Advocacy Study. RESULTS CHWs are involved in advocacy that is community-focused, although advocacy differs by intrinsic leadership, experience, training, and work environment. We propose a framework to conceptualize, support, and evaluate CHW advocacy and the iterative processes they engage in. These processes create opportunities for community voice and action to affect social and structural conditions that are known to have wide-ranging health effects on communities. CONCLUSIONS The framework presented may have utility for CHWs, their training programs, and their employers as well as funders and policymakers aiming to promote health equity.

Risk factors for squamous intraepithelial lesions (SIL) of the cervix among women residing at the US-Mexico border

It is now well established that cervical cancer is caused by oncogenic human papillomavirus (HPV) infections that commonly infect women worldwide. What remains to be understood are the factors that contribute to cervical cancer in the presence of HPV infection. We conducted a case‐control analysis of women recruited at the US‐Mexico border to simultaneously evaluate factors associated with 3 cytologic outcomes: atypical squamous cells of undetermined significance or atypical glandular cells of undetermined significance (ASCUS/AGUS), low grade squamous intraepithelial lesions (LSIL) and high grade squamous intraepithelial lesions (HSIL). A cross‐sectional binational study of 2,059 women ages 15–79 years was conducted between 1997 and 1998. A significant difference in the distribution of cytologic categories by country was observed (3.0% vs. 0.7% HSIL among Mexican vs. US women, respectively). The only factors independently associated with all 3 cytologic outcomes were HPV infection and viral load. A linear increase in risk with increasing viral load was observed for each of the 3 outcome variables, with the strength of this association increasing with cytology abnormality. In addition to HPV infection, parity and Mexico as a country of residence appear to be associated with LSIL and HSIL, respectively. Factors associated with cytologic outcomes in analyses limited to women with HPV infection were similar to results obtained in models where HPV infection was included as a covariate. Future work is needed to evaluate the predictive value of HPV viral load utilizing more specific and quantitative measures.

Design and results of the USA-Mexico border human papillomavirus (HPV), cervical dysplasia, and Chlamydia trachomatis study

OBJECTIVE Mexico has one of the highest mortality rates of invasive cervical cancer in the world. This is particularly true for the states in northern Mexico that border on the United States of America. In addition, Hispanics in the United States have higher rates than do non-Hispanics in the country. Therefore, a binational team was formed to focus on this problem and to determine the risk factors and prevalence of cervical dysplasia and human papillomavirus (HPV) infection, the sexually transmitted disease (STD) known to cause cervical cancer. Chlamydia trachomatis infection, a common STD and potential HPV cofactor, was also assessed. METHODS Research was conducted in 1997 and 1998 in the border region of two states, Arizona in the United States and Sonora in Mexico, applying a cross-sectional study of women attending clinics for routine gynecologic care. Clinical measurements included Pap smears, HPV infection by both polymerase chain reaction (PCR) and Hybrid Capture (HC), and C. trachomatis status by HC and enzyme-linked immunoassay (EIA). A total of 2,436 women were enrolled (mean age 33.3 years +/- 10.3 years). RESULTS The overall prevalence of abnormal cytology was 9.3%, with a significant difference in the prevalence in Mexico (11.4%) vs. the United States (6.6%). Of the participants, 14.5% of them tested positive for HPV by PCR, with no significant difference between the two countries, in spite of a lower behavioral risk profile for the Mexican women. Overall prevalence of C. trachomatis was found to be greater by HC than by EIA (8.2% vs. 3.0%), and in Mexico higher by both methods. CONCLUSIONS An important accomplishment of the project was the implementation of a quality control program for Pap smear collection, which resulted in a significant reduction in inadequate smears in Mexico. Despite numerous potential logistical barriers, the binational team successfully conducted a large-scale study in the border area and developed an infrastructure for future research.

Everyday violence, structural racism and mistreatment at the US-Mexico border

Immigration laws that militarize communities may exacerbate ethno-racial health disparities. We aimed to document the prevalence of and ways in which immigration enforcement policy and militarization of the US-Mexico border is experienced as everyday violence. Militarization is defined as the saturation of and pervasive encounters with immigration officials including local police enacting immigration and border enforcement policy with military style tactics and weapons. Data were drawn from a random household sample of US citizen and permanent residents of Mexican descent in the Arizona border region (2006-2008). Qualitative and quantitative data documented the frequency and nature of immigration related profiling, mistreatment and resistance to institutionalized victimization. Participants described living and working in a highly militarized environment, wherein immigration-related profiling and mistreatment were common immigration law enforcement practices. Approximately 25% of respondents described an immigration-related mistreatment episode, of which 62% were personally victimized. Nearly 75% of episodes occurred in a community location rather than at a US port of entry. Participant mistreatment narratives suggest the normalization of immigration-related mistreatment among the population. Given border security remains at the core of immigration reform debates, it is imperative that scholars advance the understanding of the public health impact of such enforcement policies on the daily lives of Mexican-origin US permanent residents, and their non-immigrant US citizen co-ethnics. Immigration policy that sanctions institutional practices of discrimination, such as ethno-racial profiling and mistreatment, are forms of structural racism and everyday violence. Metrics and systems for monitoring immigration and border enforcement policies and institutional practices deleterious to the health of US citizens and residents should be established.

HEALTHCARE ACCESS AND UTILIZATION AMONG WOMEN 40 AND OLDER AT THE U.S.-MEXICO BORDER: PREDICTORS OF A ROUTINE CHECK-UP

Mexican Americans are more likely to experience barriers to access and utilization of healthcare services than any other U.S. Hispanic group. In Mexico, where the majority of the population has access to care, the pressing issue is the underutilization of preventive services among adults. This study was conducted to assess access and utilization barriers among a U.S.-Mexico border population. A cross-sectional, population-based survey was conducted during 1999–2000 in a pair of contiguous U.S.-Mexico border communities. Household surveys were administered to U.S. and Mexican women, 40 years of age and older, to assess healthcare access and utilization, participation in chronic disease screenings, orientation toward prevention and personal history of chronic disease. Analysis indicates few statistically significant differences (p < 0.05) among access and utilization variables by country. Mexican participants were more likely to have a regular source of care and to have had a blood sugar test within the past 12 months. U.S. participants more often reported having had a Pap smear and mammogram during the previous year. Factors independently positively associated with having had a routine check-up during the past 12 months included age and having a regular provider or place to go when sick. Only going to the doctor when ill was independently inversely associated with routine check-ups in the past 12 months. Findings suggest that U.S. and Mexican border populations are similar with regard to healthcare access and utilization characteristics. Efforts to increase utilization of preventive health screenings among women are needed at the U.S.-Mexico border.