Tobacco Cessation Services Through Community Health Workers for Spanish-Speaking Populations

Abstract

Partnerships were established with the University of Arizona’s Healthcare Partnership to train promotores—Spanish-speaking community health workers—as tobacco cessation counselors. Tobacco Free El Paso certified promotores to help identify tobacco users and offer tobacco cessation counseling services.

The project certified 89 participants, of whom 95% were promotores; 88% were Hispanic/Latino, 67% were females, and 62% indicated Spanish as their primary language. Participants who completed Técnicas Básicas, Treatment Specialist, and Déjate de ese Vicio certifications significantly increased self-confidence levels to deliver brief smoking cessation interventions (P < .05). Satisfaction scores (scale = 1–5) were also relatively high for each certification (Técnicas Básicas, mean = 4.8; Treatment Specialist, mean = 4.7; Déjate de ese Vicio, mean = 4.6). The results suggest that promotores understood the concepts and methodologies presented.

In 2003, the Paso del Norte Foundation of El Paso, Tex, reported that 18% of the city’s adult residents were smokers.1 Local health providers have limited time and are not always prepared or equipped to carry out tobacco cessation interventions. Low-income adults who lack health insurance often cannot pay the out-of-pocket expenses for private services to help them stop smoking. In addition, because 78% of El Paso’s population is Hispanic, it is important that smoking cessation services be both culturally sensitive and in Spanish.

With these considerations in mind, Tobacco Free El Paso was set up to find counselors to deliver tobacco cessation interventions through the Arizona Tobacco Cessation Training Model for promotores (curriculum was already established) and 2 viable partnerships, and establish training sessions. Grant monies were provided by the American Legacy Foundation and the W. K. Kellogg Foundation to purchase meals, drinks, and training and educational materials for all participants.

Program Description

In 2000, Tobacco Free El Paso was an American Legacy Foundation initiative committed to create reliable and accessible tobacco cessation services for low-income, predominant Hispanic populations. Throughout the years, we worked with local agencies such as Texas Tech University’s Community Partnership clinics and Centro San Vicente to train promotores (and other health care providers) to identify patients, and deliver a comprehensive tobacco cessation service that incorporated the use of nicotine replacement therapies as referred by the providers, and counseling sessions administered by promotores. Promotores were selected to provide tobacco cessation interventions to Spanish-speaking residents. Along the US–Mexican border, promotores are used primarily by health care and educational institutions to offer heath education classes on topics related to diabetes, to administer support groups, and to administer questionnaires to Spanish-speaking populations. For example, the El Paso clinics operated by Texas Tech University and Centro San Vicente have a small group of 1 to 6 paid promotores who work as instructors and counselors for their clinics. Most of the promotores in this region are volunteers.

Promotores are community health workers, or community outreach workers.2 Promotores are “respected members of their community who regardless of their academic background, provide health related services, and serve as key facilitators between providers and targeted communities.”2^(p1) Research related to promotores as tobacco cessation counselors is limited. However, Earp and Flax3 have shown that to patients in need of health education services, promotores are influential, credible, and supportive.

Tobacco Cessation Training

Tobacco Free El Paso took its curriculum from the University of Arizona’s Healthcare Partnership, which in 1996 developed a Spanish-language program to train counselors in tobacco cessation interventions.4 Tobacco Free El Paso’s training courses provide inclusive and culturally appropriate material in Spanish. The courses, each of which lasts about 5 days and began in 2003, offer 3 certifications: introductory (“Técnicas Básicas para Dejar el Tabaco,” or “Basic Skills to Stop Using Tobacco”), intermediate (Treatment Specialist), and advanced (“Déjate de ese Vicio,” or “Leave the Addiction”) (Table 1 ▶). To evaluate the program’s effectiveness, participants were given a self-confidence test before (pretest) and after (posttest) the course and a “satisfaction questionnaire” at the end of the course. The Likert scale was used to measure participants’ self-confidence and satisfaction with the course (1 = very low; 5= very high).

TABLE 1—

Topics Taught in Tobacco Free El Paso’s Tobacco Cessation Training Courses

Level 1: Técnicas Básicas para Dejar el Tabacoa	Level 2: Treatment Specialist	Level 3: Déjate de ese Viciob
Nicotine addiction	Alternative therapies	Spanish-language intensive intervention curriculum
History and statistics of tobacco use	Assessment instruments
Economic effects of smoking	Case study analysis
Minimal, brief, and intensive interventions	Client recruitment
Stages of change	Counseling
5 A’s, 5 R’s, and quit planc	Pharmacology
	Role playing

^a“Basic Skills to Stop Using Tobacco.”

^b“Leave the Addiction.”

^cThe 5 A’s are: Ask about tobacco use, Advise to quit, Assess willingness to make a quit attempt, Assist in the quit attempt, and Arrange a follow-up time. The 5 R’s are: Relevance, Risks, Rewards, Roadblocks, and Repetition. Quit plans are plans with patients that help them identify a date to begin their smoke-free life.

Invitations to participate in the courses were sent via fax, mail, and e-mail to nonprofit organizations and health clinics in El Paso, southern New Mexico, and Ciudad Juarez, Chihuahua, Mexico. Because participants were to commit to approximately 5 days of training, the courses were offered at central or onsite locations. The training sessions were scheduled Monday through Thursday from 9:00 am to 4:00 pm. Health care professionals showed interest and were invited to attend the courses as participants.

Clinic Partnerships

The courses were also offered to employees of Texas Tech University’s community partnership clinics and of Centro San Vicente clinic, both located in El Paso. These neighborhood clinics wanted to establish culturally sensitive, Spanish-language tobacco cessation trainings for their patients. These neighborhood clinics were trained by Tobacco Free El Paso with the borrowed Arizona tobacco cessation curriculum. After the training sessions, the clinics offered their patients access to affordable tobacco cessation counseling, referral, and screening services. Through these collaborative efforts, Tobacco Free El Paso was able to indirectly access under-served and uninsured patients who resided in El Paso and Hudspeth Counties with tobacco cessation services through their neighborhood clinics with recognized and trusted medical professionals (to include the promotores). Through additional funding from the American Legacy Foundation, training materials were purchased for both facilities to offset clinic costs.

Residents of these counties often received primary and preventative health care services at these community clinics. Centro San Vicente serves approximately 13 000 patients per year, most of whom are Hispanic (98%) and uninsured (68%).5 Texas Tech’s clinics serve 4000 to 6000 patients per year, with demographics similar to those of Centro San Vicente.

Discussion and Evaluation

Tobacco Free El Paso began the courses in August 2003. In the first month, 11 promotores were trained as tobacco cessation counselors. The participants found the courses to be comprehensive and easy to implement into their everyday work situations. Their verbal approval allowed us to invite other promotores and to facilitate more tobacco cessation training courses for the region.

Through August 2004, a total of 24 training courses, involving 89 participants, were administered. Of the 89 participants, 74 were certified for Técnicas Básicas; of these, 39 went on to receive Treatment Specialist certification and 34 were awarded Déjate de ese Vicio. As shown in Table 2 ▶, 87.8% were Hispanic/Latino, 39.2% were aged 36 to 49 years, 63.5% were female, 50% spoke only Spanish. A total of 95% of the participants were promotores and 5% were health care professionals.

TABLE 2—

Demographic Characteristics of Participants in Tobacco Free El Paso’s Certification Program (n = 74)

	No. (%) of Participants
Gender
Male	27 (36.5)
Female	47 (63.5)
Age, y
18–35	27 (36.5)
36–49	29 (39.2)
≥ 50	11 (14.9)
Missing data	7 (9.5)
Ethnicity
Hispanic/Latino	65 (87.8)
Multicultural/multiethnic	6 (8.1)
Missing data	3 (4.1)
Primary language
English only	4 (5.4)
English and Spanish	24 (32.4)
Spanish only	37 (50)
Missing data	9 (12.2)
Level of education (y)
High school (9–12)	36 (48.6)
College (13–16)	24 (32.4)
Postgraduate (≥ 17)	7 (9.5)
Missing data	7 (9.5)

Note. Baseline demographic information was collected from the 74 participants who completed the pretests administered during scheduled training sessions from August 2003 to August 2004.

Results from the pre- and posttests measuring self-confidence (results not shown) suggest that the participants understood the training material. As measured by repeated-measures analysis of variance (ANOVA), participants who completed all 3 certifications significantly increased their self-confidence sufficiently to deliver a brief smoking cessation intervention (P < .05). Mean satisfaction scores as measured on the Likert scale (1= definitely not confident to 5 = definitely confident) were high for recipients of each of the certifications (Técnicas Básicas para Dejar el Tabaco, 4.8; Treatment Specialist, 4.7; Déjate de ese Vicio, 4.6). Satisfaction scores indicated that participants felt the training material adequately prepared them to deliver tobacco cessation interventions.

The fact that the courses were easily accessible and free of charge probably increased attendance. The length of the courses, however, may have had a deterrent effect: attendance for the 2 higher levels (which each required 10–12 hours of instruction) was lower than for the first level (6–8 hours). To accommodate diverse work schedules, courses were reduced from 5-day training sessions to 1-, 2-, and 3-day sessions.

Next Steps

Promotores who have undergone the Arizona training with Tobacco Free El Paso will continue to offer tobacco cessation trainings using the “train the trainer” model borrowed from the Arizona tobacco cessation curriculum at the Texas Tech’s Community Partnership clinics, and at Centro San Vicente Main and Homeless clinics.

KEY FINDINGS

• The training sessions were simple to operate.

• The curriculum was understood by Spanish- and English-speaking participants.

• Time was a limiting factor for instructors and participants.

• Participants acquired knowledge and confidence to offer tobacco cessation interventions to communities in need.