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. Author manuscript; available in PMC: 2019 Aug 8.
Published in final edited form as: AIDS Educ Prev. 2015 Oct;27(5):465–473. doi: 10.1521/aeap.2015.27.5.465

Once a Navegante, Always a Navegante: Latino Men Sustain their Roles as Lay Health Advisors to Promote General and Sexual Health to their Social Network

Christina J Sun 1, Lilli Mann 1, Eugenia Eng 2, Mario Downs 1, Scott D Rhodes 1
PMCID: PMC6686176  NIHMSID: NIHMS1044794  PMID: 26485235

Abstract

Little is known about the sustainability of male and men’s-health-focused lay health advisors. HoMBReS Por un Cambio was a community-level social network intervention designed to improve sexual health among Latino men who were members of soccer teams. During the year after the intervention implementation, lay health advisors (Navegantes) continued to promote sexual health; over 84% (16 of the 19) Navegantes conducted 9 of 10 primary health promotion activities. Describing where to get condoms was the activity that the most Navegantes reported having conducted. Navegantes had broad reach with their social networks, although the number of Navegantes that conducted each activity differed across the categories of social network members (soccer team mates, non-team mates, and women). Results suggest that HIV-related health disparities may be addressed through lay health advisor interventions because they are sustained after the intervention ends and reach large numbers of community members.

Keywords: HIV, Latino, men’s health, community-based participatory research, sustainability, lay health advisor

Introduction

The Latino population is rapidly growing in the United States (US), particularly the southeastern US. Eight of the nine states with the largest Latino population growth from 2000 to 2010 (each doubling their Latino populations) were in the South, including North Carolina (NC; Pew Research Center, 2011). From 2000 to 2011, the overall US Latino population grew 47.5%, while in NC, the state with the seventh fastest growing Latino population, the Latino population grew by 120% (Pew Research Center, 2013).

The southeastern US is experiencing disproportionate HIV and sexually transmitted disease (STD) infection rates compared to other regions of the US (Centers for Disease Control and Prevention [CDC], 2013, 2015; Reif et al., 2014) and has been referred to as the “new” US HIV epicenter (Wiltz, 2014). Many southern states, including NC, consistently lead the US in reported cases of AIDS and other STDs (CDC 2013, 2015). In NC, the HIV incidence rate is 40% higher than the national rate (NC Department of Health and Human Services, 2012).

Latinos in the US are also disproportionately affected by HIV and other STDs. The rate of new HIV infections among Latinos in the US in 2010 was more than three times that of whites (CDC, 2012). Latinos accounted for 21% of all new infections in the US, despite representing 17% of the total US population (CDC, 2012; US Census Bureau, 2014). Similarly, the rates of chlamydia, gonorrhea, and primary and secondary syphilis among Latinos are two times the rate among whites (CDC, 2013). These rates in and of themselves are of great concern; and furthermore, having an STD increases susceptibility to HIV infection and infectiousness of HIV (Fleming & Wasserheit, 1999; Wasserheit, 1992).

One potential strategy that has shown effectiveness to address health disparities are lay health advisor (LHA) interventions (Ayala, Vaz, Earp, Elder, & Cherrington, 2010; Eng, Rhodes, & Parker, 2009; Mcquiston, Choi-Hevel, & Clawson, 2001; Rhodes, Foley, Zometa, & Bloom, 2007; Rhodes, Hergenrather, Bloom, Leichliter, & Montaño, 2009; Viswanathan et al., 2010). LHAs are generally community members who assist linking community members who lack adequate health care access to health providers and health service systems (Eng, Parker, & Harlan, 1997; Witmer, Seifer, Finocchio, Leslie, & Neil, 1995), and may do so by being part of the care team, providing education, conducting outreach, or serving as a navigator (Rhodes et al., 2007).

Little is known about the sustained efforts of LHAs after a project ends and very few studies have examined sustainability (Ayala et al., 2010; Eng et al., 2009; Rhodes et al., 2007). The purpose of this analysis is to examine the sustainability of HoMBReS Por un Cambio (Men for a Change), a male and men’s-health-focused LHA intervention. Like many other LHA interventions, HoMBReS Por un Cambio is implemented over a defined period of time (one year) during which LHAs, known as Navegantes (navigators), receive ongoing support from a program coordinator but has a goal of building community capacity and making a long-term impact on health behaviors and health outcomes. The purpose of this paper is to report on findings of a process evaluation. In this paper, we determine whether, and to what extent, Navegantes sustained their roles as LHAs one year after the completion of HoMBReS Por un Cambio implementation. Understanding Navegantes’ activities after formal support is no longer provided can help to explore the potential sustainability of LHA interventions.

Methods

Community-Based Participatory Research

HoMBReS Por un Cambio was developed, implemented, and evaluated utilizing community-based participatory research (CBPR). CBPR is an action-oriented research approach, which blends the lived experiences of community members and organization representatives with sound science, often resulting in interventions that are most relevant to communities and more likely to be sustained if effective (Israel, Schulz, Parker, & Becker, 1998; Minkler & Wallerstein, 2003; Rhodes, Malow, & Jolly, 2010). CBPR fully engages with communities and emphasizes equal ownership over the process and products and collaborative engagement by all members throughout the entire research process. HoMBReS Por un Cambio’s CBPR partnership consists of representatives from public health departments, AIDS service organizations, universities, Latino-serving community-based organizations (CBOs), and the local immigrant Latino community, who have all collaborated for over a decade (Rhodes, Duck, Alonzo, Daniel-Ulloa, & Aronson, 2013; Rhodes et al., 2010).

HoMBReS Por un Cambio

HoMBReS Por un Cambio is an enhanced intervention based on the efficacious intervention HoMBReS: Hombres Manteniendo Bienestar y Relaciones Saludables (Men: Men Maintaining Wellbeing and Healthy Relationships), which increased condom use and HIV testing among Latino men by harnessing the naturally existing social network of Latino soccer team mates (Rhodes et al., 2006, 2009). Team mates elect one LHA per team to serve as a Navegante. This Navegante completes an interactive 16-hour training, which includes an overview of the purpose of the intervention, explanation of the roles and responsibilities of Navegantes, and education about the prevention of HIV and STDs. After the training, each Navegante promotes sexual health among his soccer team-based social network through his role as a health advisor, an opinion leader, and a community advocate.

Enhancements made by the CBPR partnership were based on lessons learned from the evaluations of HoMBReS. Enhancements included the creation and addition of Spanish-language DVD segments (including topics such as the magnitude of HIV and STDs in Latino communities, the process of HIV testing at a local public health department, and living with HIV) to model behavior and trigger discussion; a tour of the local health department taken by Navegantes to increase their understanding of, trust in, and comfort with local processes of accessing and using services; an inauguration event with each soccer team to further the Navegante’s credibility; and 12 “themes of the month,” where each Navegante, with support and guidance from the program coordinator, plans and organizes group activities with his team mates focused on a different specific topic each month.

Measures

The overall study designed to evaluate HoMBReS Por un Cambio included the collection of survey data at three different times: at baseline, immediately after the intervention implementation (12 months after Navegante training), and one year after the intervention implementation (24 months after Navegante training). The program coordinator contacted the Navegantes to schedule a mutually convenient time to collect data.

Relevant to this analysis, we reported on sociodemographic characteristics (collected at baseline) and 10 health promotion activities that Navegantes conducted after the intervention implementation ended (collected one year after the intervention implementation). The Navegantes were trained to conduct 10 health promotion activities: (1) talking about health in general, (2) sexual health, or (3) individual sexual problems; (4) providing information about HIV and STDs; (5) describing where to get condoms; (6) providing information on the correct use of condoms; (7) providing referrals to a local CBO partner that offered HIV and STD testing, (8) the local health department, or (9) another health provider; and (10) showing any of the intervention DVD segments about HIV and STDs. These were measured by asking Navegantes survey questions and Navegantes reported whether they had or had not (yes or no) conducted each activity over the previous year with social network members in three categories: soccer team mates, community members who were not part of their soccer team (non-team mates), and women in their community. Participants also described where they conducted these activities: inside North Carolina (where the soccer teams were based); outside North Carolina, but inside the US; or outside the US.

Analysis

We calculated frequencies of Navegantes conducting each activity overall and by soccer team-based social network members, non-team mates, and women, and conducted the Kruskal-Wallis test to identify differences across the three categories of social networks. All analyses were conducted with Stata/IC 12.1.

All participants completed written informed consents. The Wake Forest School of Medicine Institutional Review Board approved study protocol and provided human subjects oversight.

Results

Navegante Characteristics

Nineteen Navegantes completed both the baseline and follow-up survey one year after intervention implementation ended (one Navegante was lost to follow-up). At baseline, Navegante mean age was 33.3 (range 25-49) years, and all self-identified as Latino and were native Spanish speakers with limited self-reported English skills. Fifteen were married or partnered and 9 had at least a high school education. Nearly all (n=17) were employed; of those employed, 14 were employed year round.

Health Promotion Activities Conducted by Navegantes One Year after Intervention Implementation Ended

One year after the intervention implementation ended, overall, over 84% (or 16 of the 19) Navegantes conducted at least 9 of the 10 different activities with their social network members (see Table 1). Across all categories of social network members, describing where to get condoms was the activity that the most Navegantes reported having conducted; and providing referrals to the local CBO partner was the activity the least number of Navegantes reported.

Table 1.

Number of Navegantes (n=19) who Conducted Activity by Social Network Category

Navegante activity Any
social
network
member		 Team
mate		 Non-
team
mate		 Women
Talked about health in general* 19 19 19 16
Talked about sexual health, risks, and realities* 19 19 19 16
Talked about individual sexual problems** 19 19 19 13
Provided information about HIV and STDs* 19 19 19 15
Described where to get condoms^ 19 19 19 17
Provided information on the correct use of condoms^ 19 18 18 15
Provided referrals to the local community-based organization partner 8 6 6 6
Provided referrals to local health department 18 18 17 12
Provided referrals to another health provider 16 15 14 11
Showed any of the intervention DVD segments about HIV and STDs 17 16 16 15
Open in a new tab
^

p < .20,

*

p < .05,

**

p < .01.

Soccer team-based social networks.

With members of their soccer team-based social networks, all Navegantes reported discussing health in general, sexual health, and individual sexual problems, providing information about HIV and STDs, and describing where to get condoms. All Navegantes also provided referrals to either the local CBO partner, the local health department, or other health providers to their soccer team-based social networks, although there were differences across where the referral made; 18 Navegantes provided referrals to the local health department; 15 to other health providers; and 6 to the local CBO partner. Providing information on the correct use of condoms and showing any of the DVD segments about HIV and STDs to members of their soccer team-based social networks were conducted by 18 and 16 of the 19 Navegantes, respectively.

Non-team mates.

In addition to engaging with their soccer team-based social networks, Navegantes also conducted many activities with non-team mates. With non-team mates, all Navegantes also discussed health in general, sexual health, and individual sexual problems, described where to get condoms, and provided information about HIV and STDs. Eighteen Navegantes reported providing information on the correct use of condoms. Seventeen Navegantes reported making referrals to the local health department while 14 reported making referrals to other health providers, and 6 reported making referrals to the local CBO partner. Additionally 16 Navegantes showed the intervention DVD segments about HIV and STDs to non-team mates. All Navegantes conducted these activities with non-team mates in the United States; 16 Navegantes conducted activities with non-team mates within NC only; 1, with non-team mates in NC and in other states in the US as well; and 1, with non-teammates within the US but outside of NC.

Women.

In general, fewer Navegantes reported having conducted activities with women; in fact, two Navegantes did not conduct any health promotion activities with women. Among those who did conduct activities with women, the largest number of Navegantes (n=17) reported describing where to get condoms. The next most frequently reported activities with women were talking about health in general and sexual health; the same 16 Navegantes conducted both of these activities. Fourteen Navegantes reported making referrals to the local CBO, the local health department, or other health providers to women. Navegantes were least likely to talk about individual sexual problems with women, reported by only 13 Navegantes. All activities with women were conducted in North Carolina.

Differences across social network categories.

There were significant differences in the types of activities conducted across the three social network categories. Navegantes were significantly less likely to report discussing health in general (p < .05), sexual health (p <.05), or sexual problems (p < .01) with women, and provide information about HIV and STDs (p <.05) to women (compared to both soccer team-based social networks and non-team mates). Navegantes were marginally significantly less likely to report describing where to get condoms (p = .13) and provide information on the correct use of condoms (p = .19) to women (compared to both soccer team-based social networks and non-team mates). There were no differences in the number of Navegantes who provided referrals to the local CBO partner, the local health departments, or other health providers.

Discussion

Overall, Navegantes continued their role as LHAs one year after the intervention implementation ended without any formal support from the program coordinator or study team. Nine of the 10 activities that they were trained to conduct were conducted by most Navegantes. This finding could indicate that the intervention met a real need of members of the social networks of the Navegantes.

There were differences in the how many Navegantes conducted the various health promotion activities. One of the activities conducted by the most Navegantes was discussing health in general, although their training was focused on sexual health. Their training in and skills and knowledge about accessing local HIV and STD testing, care, and treatment services may have generalized to accessing and using health care services broadly.

Providing referrals to the local CBO partner was conducted by the fewest number of Navegantes. This CBO is located in one specific area of the state and may not have been easily accessed by social network members; therefore, a referral to a local health department or other health provider may have been more appropriate. The Navegantes probably used their insider knowledge to make referrals that they thought were most appropriate and realistic for members of their social network to access. The insider knowledge of community members is extremely important in creating interventions that match community needs and one of the reasons our CBPR partnership is committed to working closely and in partnership with community members.

Although Navegantes also reached beyond their soccer team-based social networks to promote health to non-team mates and women, the types of activities conducted across the three categories of social network members did differ. No significant differences were found between activities with team mates and non-team mates. Navegantes were less likely to discuss health in general, sexual health, or individual sexual problems with and provide information about HIV and STDs to women compared to soccer team mates or non-team mates. One possible reason for this finding is there could be fewer women in their social networks, which could reduce the opportunities for Navegantes to talk to them. Latinos who immigrated to the new destination states in the South are often males traveling without women (Painter, 2008). Discussing individual sexual problems included STD symptoms, which women are less likely to have and are less visible compared to the symptoms men experience; therefore, these may have been biological and anatomical barriers to discussing sexual problems. There could also be discomfort experienced by the Navegantes or women to discuss individual sexual problems with members of the opposite sex, because of cultural values and gender norms (Cashman, Eng, Simán, & Rhodes, 2011; Hernandez, Zule, Karg, Browne, & Wechsberg, 2012; Hirsch, Higgins, Bentley, Nathanson, & Sites, 2002). Future iterations of this intervention could include modules on skills to communicate with women given these findings that Latino men do promote health with Latinas and previous research that Latino men are willing to be trained to reach Latinas (Vissman et al., 2009).

The results of this study should be interpreted with several limitations in mind. Relative to other types of studies and study designs, the sample size (number of Navegantes) is small; however, it is reflective of the number of lay health advisors in other health interventions among Latinos. In a review of Latino LHA interventions, the number of LHAs is generally small, few interventions involved men as LHAs, and when male LHAs are involved, the number of male LHAs ranged from 1 to 3 (Rhodes et al., 2007); therefore, in this study we were able to recruit, engage, and retain a hard to reach population.

The data collected may be biased with some activities overlapping by participant categories. The survey question did not clearly instruct participants to report on activities conducted with male non-team mate social network members and non-team mates could have included women. Furthermore, it is not possible to know when these activities were conducted. We only know that health promotion activities were conducted during the year after intervention implementation ended, but not the precise months they were conducted. It is possible that these activities were conducted inconsistently throughout the year. Future studies could measure frequency and recency of when each health promotion activity was conducted to address this limitation.

There were also changes in the compositions of the soccer teams, which may have affected the findings. Based on the program coordinator’s observations, Navegantes and their team mates do not necessarily remain on the same soccer team. Given these changes in the team rosters, it is even more impressive that the Navegantes continued their LHA roles with team mates and also engaged with non-team mates and women.

Finally, an outcome evaluation to describe the impact of the Navegantes’ sustained roles on the health and health behaviors of their social network members is needed. Notwithstanding, the results of this process evaluation and these analyses demonstrate that the Navegantes still engaged in their roles as LHAs after the intervention ended and without formal support.

Subsequent studies should collect more details about the activities Navegantes engaged in after the intervention implementation ended, their motivations to continue these health promotion activities, and what additional supports are needed to further sustain health promotion activities. Comparing these findings to a previous process evaluation of the HoMBReS intervention (Rhodes et al., 2012), the predecessor of HoMBReS Por un Cambio, Navegantes conducted the same activities during intervention implementation and one year after the intervention implementation ended; however additional activities could have been conducted outside of the ten measured in the survey instrument. Navegantes, who have spent a year building trust and a positive reputation as a source of knowledge about and link to health care services, may now be viewed as a general resource who can assist community members in accessing other resources not directly related to health care (e.g., education, transportation, or legal services) but are other important priorities. Navegantes may have responded to requests from their social network members or they may have proactively initiated these activities. These data could be collected with qualitative methods, including interviews or observations, and would complement these findings and allow for a more complete and rich understanding of the sustainability of LHA interventions. Answers to these questions could inform future interventions that train LHAs to promote health within communities that are often marginalized and underserved.

Conclusion

Lay health advisors, who were chosen for their natural helping capabilities and respect in the community, are committed to help their communities be healthier even after an intervention has ended. This male-led and male-focused LHA intervention had broad reach to both men and women, and within and beyond the soccer team-based networks where Navegantes were trained to promote sexual health. Continuing to support and develop community-level LHA interventions may be crucial to reducing health disparities, particularly among underserved and vulnerable populations that have traditionally lacked access to adequate care and face inequitable conditions.

Acknowledgment:

We would like to thank the participants for their efforts and commitment to their community’s health. We would like to acknowledge Jorge Elias Arellano for the title, which he came up with while reflecting on his own work as a Navegante in another lay health advisor intervention project.

Sources of Support: National Institutes of Health, National Institutes of Minority Health and Health Disparities (R24MD002774)

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