Promoting Hispanic Immigrant Health via Community Health Workers and Motivational Interviewing

Abstract

Hispanic immigrant health disparities are amongst the highest in the nation, especially related to obesity and access to health services. Healthy Fit (En Forma Saludable) is a health promotion program that leverages public health department infrastructure to address these disparities through the use of three key innovations explored in this paper: community health workers, motivational interviewing, and vouchers for free preventative health services. Community health workers trained in motivational interviewing conduct a health screening and then distribute preventive service vouchers and health resources as needed based on screening results. Vouchers cover breast, cervical, and colorectal cancer screening, and several vaccinations including flu and HPV. Resources to support exercise, a healthy diet, to quit smoking, and to reduce risky drinking are also distributed as needed. Community health workers then use motivational interviewing to address perceived barriers and strengthen intrinsic motivation to make use of the health resources. Integrating these strategies provides a low-cost approach to promote healthy behavior in an underserved immigrant population.

Hispanic immigrant health disparities are among the highest in the nation in regards to heart disease, cancer, high blood pressure, obesity, and tobacco use (Velasco-Mondragon, Jimenez, Palladino-Davis, Davis, & Escamilla-Cejudo, 2016). Several barriers to health for low-income, minority, and immigrant patients increase the prevalence of Hispanic health disparities - ultimately resulting in delayed diagnosis, increased (co-)morbidity, and mortality rates (Saad-Harfouche, et al., 2011; Schwingel, et al., 2016). Specifically, Hispanic community members are more likely to face challenging social determinants of health that interfere with healthy behavior and access to quality care, such as poverty, low education levels, language barriers, and an immigration status that does not qualify for Medicaid (Lazar & Davenport, 2018). This paper examines three innovative strategies designed to overcome the health disparities Hispanic immigrants face: the use of community health workers (CHWs), vouchers for preventative health services, and motivational interviewing (MI). These strategies were implemented in a health promotion program called Healthy Fit, which has reached over 2,500 participants.

Healthy Fit

Healthy Fit focuses on reducing risk of chronic diseases, such as cancer and cardiovascular disease, in El Paso, Texas. According to a 2017 U.S. Census, 82.8% of the population in El Paso, Texas identified as Hispanic or Latino with a median household income of $42,075, trailing the state median income of $56,565. Of the entire population in El Paso, 24.5% identified as foreign-born. Furthermore, 22.7% were identified as being below the poverty level, and among those below age 65, 21.2% are uninsured (U.S. Census Bureau, 2017). In Healthy Fit, CHWs recruit and screen a predominantly immigrant population at the Mexican consulate’s Ventanilla de Salud. The program targets individuals who are 18 years or older, uninsured, or are Medicaid beneficiaries; however, participants with insurance are not excluded. CHWs conducting the health screenings also recruit participants from community events and health fairs. CHWs also encourage participants to refer friends and family members via word-of-mouth, which helps to reach others of similar socioeconomic status.

Healthy Fit participants complete a baseline health screening which includes a demographic survey and health measurements, such as blood pressure, BMI, fat percentage. Based on screening eligibility, participants are then connected to a variety of health resources such as vouchers for free breast, cervical, and/or colon cancer screenings; vouchers for free vaccinations against HPV, flu, and pneumonia; tobacco cessation education, alcohol misuse education; as well as resources encouraging healthy eating and exercise. After reviewing the health measurements with the participant, CHWs share fotonovelas, health education comics developed at an elementary literacy level that contain helpful information about diet and exercise. The CHWs also review other health resources the participant may benefit from, such as exercise activities around the city that are free, or donation based.

CHWs then conduct a brief motivational intervention (MI) aimed at enhancing the participant’s intrinsic motivation to follow through and complete health behavior changes. The following sections explore in more detail how through the use of CHWs, vouchers and health resource referrals, and MI, the Healthy Fit program is able to address a variety of health barriers experienced by the Hispanic immigrant population.

Vouchers

Low-income Hispanics in El Paso face a multitude of financial barriers to healthcare and Healthy Fit addresses some of these by providing vouchers for free preventive health services funded by the city’s Department of Public Health’s Medicaid Waiver Program. Given that healthcare access is highly dependent on its affordability, low-income Hispanic community members are less likely to have health insurance coverage. This is due in part to being less likely to receive employer health insurance, as lower wage jobs do not typically offer insurance opportunities. Immigration status can also interfere with access to Medicaid and other public insurance programs (Lillie-Blantan & Hoffman, 2005; Edward & Hines-Martin, 2016). Being un(der)insured makes medical services more expensive, further preventing immigrants from seeking needed medical attention, ultimately resulting in worse health outcomes over time (Lopez-Sanders, 2017; Artiga & Diaz, 2019).

The vouchers provided through the Healthy Fit program address financial barriers to healthcare experienced by many Hispanic immigrant residents in El Paso because participants who are uninsured or who have a household income less than 200% of federal poverty level (irrespective of their citizenship statuses) are eligible to receive vouchers for necessary cancer screenings and/or vaccines through the Medicaid Waiver program. With cancer screenings (such as a mammograms) costing up to $250 without health insurance, the vouchers save participants significant preventive healthcare costs. Participants present the voucher at a program partner clinic to receive the services at no cost.

However, even with a voucher, participants still face several logistical barriers to seeking and receiving healthcare. Low-income immigrant families are more likely to be burdened with inconsistent access to transportation and have difficulties finding childcare for appointments. Additionally, undocumented immigrants may fear being arrested and detained while traveling to receive healthcare (Heyman, Núñez, Guillermina, Talavera, 2009). These barriers become reasons to not take advantage of Healthy Fit resources. The use of CHWs and MI help participants overcome these additional barriers that the vouchers do not address.

CHWs

One core set of barriers Hispanic immigrants face relates to language and culture. The limited number of culturally competent healthcare providers impacts quality of care (Centers for Disease Control and Prevention, 2016; Lazar & Davenport, 2018). Research suggests that when providing information on preventative measures, cancer, and disease management, CHWs are effective in helping community members navigate the healthcare system and overcome distrust of healthcare professionals (Steinberg, M.L., et al., 2006; Cupertino, A.P., et al., 2015). CHWs, also known as “promotoras de salud” in the Hispanic and Latino community, are “of the community” and therefore, well-positioned to reach other community members who may not otherwise pursue help or information about their health.

Healthcare professionals with high socioeconomic status often lack the lived experience needed to understand and connect with Hispanic immigrants. Relating to fellow community members through experience allows barriers to be addressed in a sensitive manner. Furthermore, research suggests that the emotional validation provided by CHWs due to lived experience helps to establish a trusting partnership which then ignites motivation (Reinschmidt, K.M., et al., 2006). CHWs are able to provide culturally appropriate strategies to addressing barriers (O’Brien, M.J., Halbert, C.H., Bixby, R., Pimentel, S., & Shea, J.A. 2010). For example, CHWs help guide participants to creating a plan that includes a list of people they are able to rely on for help, whether asking for a ride to an appointment or seeking childcare for the duration of the appointment. Furthermore, CHWs can increase access to healthcare by communicating sensitive information, advocating on a participant’s behalf, and ultimately creating a partnership with participants (Schwingel, et al., 2016; Saad-Harfouche, et al., 2011; Natale-Pereira, Enard, Nevarez, & Jones, 2011).

Motivational Interview (MI)

MI is a client centered interview technique intended to bring awareness to risky behaviors and increase the chances that the person will change their behavior by increasing intrinsic motivation (Miller & Moyers, 2006; Jelsma, Mertens, Forsberg, & Forsberg, 2015). Participants in Healthy Fit are able to be vulnerable with the CHW because the nature of MI is a collaborative conversation, allowing participants to freely and openly discuss questions or concerns about healthcare with someone they find less intimidating. CHWs serve as a bridge between the community and healthcare professionals due to their ability to empathize with participants while maintaining adherence to MI. Conversations are held in such a way that the participant should increase their motivation to make changes based on the values and beliefs they hold. Immigrant communities struggling with the unfamiliarity of the healthcare system, limited transportation, and fear of deportation may benefit from MI as the conversations seek to address potential barriers in depth with the CHW (Brandford, et al., 2018). For example, the depth of the MI conversation may lead a CHW to support a participant in identifying strategies to minimize deportation risk, such as by relying on a friend or family member to help with transportation.

MI has traditionally been performed by clinical professionals in the fields of mental health and substance abuse prevention. However, CHWs do not typically have a clinical background or a college degree. CHWs were trained to apply MI to address ambivalence towards making healthy behavioral changes, including utilization of the health resources provided to them. Thus, training CHWs in MI is an innovative aspect of Healthy Fit. Clinicians and professional MI trainers examine the quality of recorded CHW interviews using the Motivational Interviewing Treatment Integrity (MITI) coding system. Findings suggest MI adherence by CHWs improves over time and is achievable (Brandford, et al., 2018).

Healthy Fit participants engaging in MI choose to discuss a resource or health behavior change that is important to them but in which they feel ambivalent. Ambivalence is natural as the participant comes to terms with unhealthy behaviors and values they hold (e.g., health). Addressing ambivalence about change is important when creating a partnership because understanding contradictory behaviors helps the participant to accept a collaborative discussion and express change talk (McCarley, 2009). Change talk entails willingness to make a behavior change (e.g., losing weight) but may also be accompanied with sustain talk - providing reasons as to why they may want to remain the same (e.g., disliking exercise). While sustain talk should be expected by the CHW, it is also important to strategize a response which shifts the conversation back to change talk and their readiness to change (Manuel & Moyers, 2016).

CHWs emphasize the person’s autonomy in an effort to provide an encouraging conversation rather than a directive monologue focused on fixing or creating solutions that the participant did not create themselves, known as the righting reflex. Traditionally, CHWs are trained to educate and provide information to participants; however, doing so in a traditional manner does not encourage the participant’s autonomy. To maintain MI adherence, CHWs first ask permission before offering advice or information. If given permission, they share information and then check in with the participant on how they received that information and whether it is something they would like to further consider. Confrontation and persuasion are avoided, as they are usually met with resistance from the participant and can soften change talk (Resnicow & McMaster, 2012; Brandford, et al., 2018).

Conclusion

Programs such as Healthy Fit encourage resource utilization and address the healthcare needs of low-income Hispanics and immigrants in the El Paso community. Through the use of CHWs, participants connect with liaisons who serve as a bridge between healthcare providers and the community. Use of MI enriches the conversation between CHWs and participants, helping participants address health barriers. Furthermore, the use of MI with participants may increase motivation to make health behavior changes. Providing vouchers for various health screenings helps address the financial accessibility barrier as well. The combination of these strengths makes Healthy Fit a promising low-cost program which promotes wellness in an underserved immigrant population.