Promotor(a)s, the organizations in which they work, and an emerging paradox: how organizational structure and scope impact promotor(a)s' work.

OBJECTIVE: To analyze how organizational structures and scope (geographic and programmatic) generate dissonance between the organization and its workers, creating a paradox with policy implications for access to health care in hard-to-reach populations. The workers are lay community health workers called promotor(a)s. The organizations are community based organizations in which the promotor(a)s work, either as volunteers, part-time or as full-time wage staff. METHOD: Ethnographic study of 12 organizations and their promotor(a)s. Data gathering included interviews with organization directors, promotor(a)s, service providers working with the organizations, and community residents served by the organizations and workers. In addition, promotor(a)s were observed in the course of their work. Sampling was a non-probability, snowball procedure for identifying the organizations and the workers within them. RESULTS: A paradox is emerging between (a) promotor(a)s who perceive their work to be locally focused and tightly integrated with the communities they serve and live in, and (b) the employing organizations that are expanding in geographical and programmatic scope because the work promotor(a)s do is in increasing demand by agencies and funding sources external to the communities served. The paradox potentially threatens to undermine and transform the work and working environment of the promotor(a)s. The challenge is to find a balance that will sustain a workable and working relationship among the organization, the workers, and the communities served. CONCLUSION: Care is needed in setting out policies that translate the paradox into greater congruence among organization, workers and communities. Policy needs discussed focus on (a) worker training, (b) worker employment and deployment, and (c) funding source recognition of the paradox.

Community health worker training and certification programs in the United States: findings from a national survey.

OBJECTIVE: To analyze trends and various approaches to professional development in selected community health worker (CHW) training and certification programs in the United States. We examined the expected outcomes and goals of different training and certification programs related to individual CHWs as well as the community they serve. METHOD: A national survey of CHW training and certification programs. Data collection was performed through personal interviews, phone interviews and focus groups. Data sources included public health officials, healthcare associations, CHW networks, community colleges, and service providers. Initial screening interviews resulted in in-depth interviews with participants in 19 states. We applied human capital theory concepts to the analysis of the rich qualitative data collected in each state. RESULTS: CHW programs in the U.S. seem to have been initiated mainly due to lack of access to healthcare services in culturally, economically, and geographically isolated communities. Three trends in CHW workforce development were identified from the results of the national survey: (1) schooling at the community college level - provides career advancement opportunities; (2) on-the-job training - improves standards of care, CHW income, and retention; and (3) certification at the state level - recognizes the work of CHWs, and facilitates Medicaid reimbursement for CHW services. CONCLUSION: Study findings present opportunities for CHW knowledge and skill improvement approaches that can be targeted at specific individual career, service agency, or community level goals. Trained and/or certified community health workers are a potential new and skilled healthcare workforce that could help improve healthcare access and utilization among underserved populations in the United States.

Diabetes Screening and Prevention in a High-Risk, Medically Isolated Border Community.

INTRODUCTION: A project in a Texas border community setting, Prevention Organized against Diabetes and Dialysis with Education and Resources (POD2ER), offered diabetes prevention information, screening, and medical referrals. The setting was a large, longstanding flea market that functions as a shopping mall for low-income people. The priority population included medically underserved urban and rural Mexican Americans. Components of the program addressed those with diabetes, prediabetes, and accompanying relatives and friends. BACKGROUND: People living in the Lower Rio Grande Valley (LRGV) face challenges of high rates of type 2 diabetes, lack of knowledge about prevention, and inadequate access to medical care. Recent statistics from actual community-wide screenings indicate a high diabetes prevalence, 30.7% among adults in the LRGV compared with 12.3% nationwide. METHODS: A diverse team composed of public health faculty, students, a physician, a community health worker, and community volunteers conceived and developed the project with a focus on cultural and economic congruence and a user-friendly atmosphere. The program provided screening for prediabetes and diabetes with a hemoglobin A1c test. Screening was offered to those who were at least 25 years of age and not pregnant. When results indicated diabetes, a test for kidney damage was offered (urinary albumin-to-creatinine ratio). A medical appointment at a community clinic within a week was provided to those who tested positive for diabetes and lacked a medical home. Health education modules addressed all family members. DISCUSSION: The project was successful in recruiting 2,332 high-risk people in 26 months in a community setting, providing clinic referrals to those without a doctor, introducing them to treatment, and providing diabetes prevention information to all project participants. Implications for research and practice are highlighted. CONCLUSION: This study shows that a regular access point in a place frequented by large numbers of medically marginalized people in a program designed to eliminate cultural and economic barriers can succeed in providing a hard-to-reach community with diabetes prevention services. Aspects of this program can serve as a model for other service provision for similar populations and settings.

Embracing the local: enriching scientific research, education, and outreach on the Texas-Mexico border through a participatory action research partnership.

Cameron Park, Texas, is a colonia (an isolated, unincorporated rural settlement without municipal improvements) on the Texas-Mexico border in the Lower Rio Grande Valley, in Cameron County near Brownsville, Texas. Cameron Park has a population of 5,961 residents, 99.3% of whom are Hispanic. The annual median income is 16,934 US dollars, about one-half of the state median. Fifty-eight percent of families generally and 68% of those with children younger than 5 years have incomes below poverty level. Cameron Park resides geographically in a region where agriculture has been, and continues to be, a dominant industry, a fact consistent with the intensive use of pesticides and increased potential for air, water, and ground contamination. The practice of good environmental health is extremely difficult under these conditions. In 1999 the Texas A&M University Center for Housing and Urban Development's Colonias Program and the Center for Environmental and Rural Health teamed up to create an environmental health education and outreach program called the Cameron Park Project (CPP). The CPP focused on how to reduce potential environmental exposures associated with human illness by providing residents with scientifically sound information on positive health practices and how to deal with environmental hazards. In this article we discuss the research methodology used in the CPP, a methodology specifically chosen to address four challenges presented by colonias to conducting valid and reliable research.

Walk together children with no wasted steps: community-academic partnering for equal power in NIH proposal development.

BACKGROUND: Community-based participatory research (CBPR) approaches equitably involve community members and researchers throughout the research process. A developing literature examines problems in CBPR partnerships, but less is written about community groups using CBPR to access university resources to address community-prioritized health concerns. OBJECTIVE: We sought to examine issues in two stages of a National Institutes of Health (NIH)-funded CBPR partnership: (1) joint proposal preparation, and (2) grant administration. METHODS: We used a case study approach to analyze data (partner dialogs, meeting notes, interviews, and press coverage) from a longstanding community-academic partnership. RESULTS: The partnership received NIH Partners in Research Program funding. During joint proposal preparation, issues included (1) learning to practice operating principles, such as "talking in ways that all people can understand," (2) streamlining proposal design to facilitate communication with community members, and (3) addressing inequities inherent in community-academic budget sharing. During the administration phase, issues included (1) community partner struggles with administrative requirements, (2) inequities in indirect cost (IDC) allocations, and (3) the impact of a natural disaster. CONCLUSION: Separately funded CBPR grants can contribute to community partner development, but make substantive demands on small, grassroots community organizations. Funders should consider taking more responsibility in developing community resources and infrastructure to ensure that grassroots community groups have the power to be equal partners. More accurate accounting of costs and benefits of CBPR to vulnerable communities should be in place to ensure communities receive adequate return on the time they invest in partnering with universities.

CBPR as community health intervention: institutionalizing CBPR within community based organizations.

BACKGROUND: A community-academy partnership was created with a commitment to developing a program for institutionalizing community-based participatory research (CBPR) capacity within community-based organizations (CBOs), with the intention to enhance CBOs' existing capabilities to understand and improve community health. OBJECTIVES: This article presents the design and conceptual foundations for a year-long CBPR education and training program in which CBO teams learn research design, discuss the principles of CBPR, design and implement a community health-related research project tailored to their program and community, conduct analyses, and initiate integration of the results into the organization and community. One objective is to integrate a commitment to and the practice of CBPR within CBOs' program and policies. METHODS: An initial partnership was created between the Center for Border Health, El Paso, and Texas A&M University School of Rural Public Health, College Station. Three additional CBOs then joined the partnership and participated in the CBPR education and training program consisting of four stages: (1)3 intensive months devoted to learning about and creating a research design; (2) 6 months for implementation of the design; (3) 2 months for analyses, interpretation, and consolidation of results into one or more final products; and (4) 1 month for development of protocols for integrating research results into community health development. RESULTS: In the first iteration, an interactive process evaluation was conducted during each program stage, plus a final year-end exit interview with each participating CBO. Evaluation demonstrated strong positive results and specific lessons learned. A proposal incorporating the lessons learned was presented to the funding source. A second iteration has been funded, with monies included to develop a formal outcome evaluation.

Environmental risk factors of disease in the Cameron Park Colonia, a Hispanic community along the Texas-Mexico border.

OBJECTIVES: This report summarizes the results of a cross-sectional study in Cameron Park in 2000-2001 to identify disease prevalence and health concerns among colonia residents and to identify environmental exposures to potentially adverse environmental conditions. RESULTS: Asthma and allergies were among the most prevalent respiratory diseases reported in both adults and children of Cameron Park. Other diseases affecting the community in higher numbers included diabetes and heart disease/high blood pressure. Among children, the most prevalent health conditions were asthma, followed by lung diseases, allergies, and to a lesser degree, skin rashes. CONCLUSIONS: These data can be useful in developing education and intervention programs to address the public health and medical issues impacting residents in the Cameron Park Colonia of Texas.