Promoting Cardiovascular Health in Rural Hispanic Communities: Programmatic Recommendations

1. What Needs to be Included in ‘healthy heart’ community programs? Programmatic Recommendations from Rural Hispanic Immigrants Karen Peters, DrPH, Benjamin Mueller, MS, Marcela Garces, MD MSPH, Sergio Cristancho, PhD University of Illinois, IL Prevention Research Center College of Medicine – Rockford, National Center for Rural Health Professions Collaborating Partners and Residents of the Communities of: Belvidere, DeKalb, Rochelle, Rockford, IL

2. Objective and Specific Aims Objective: Pursuing the CHIRTN mission to contribute to cardiovascular health for all people through the conduct of prevention research and translation activities that promote cardiovascular health, we will implement cardiovascular health (CVH) interventions in underserved populations. Specific Aim s: • to understand how persons in communities of underserved populations perceive cardiovascular disease and stroke (CVD), and their associated risk factors such as hypertension, dyslipidemia, and obesity • using qualitative methods to evaluate perceptions of CVD and its risk factors and barriers to their prevention • in populations that are geographically, socially, economically, or ethnically underserved

3. CHIRTN Network • 1 of 4 CDC sponsored ‘Networks’ • Physical Activity Policy • Cancer Prevention and Control • Healthy Aging • CVH • Currently in 2nd year of 5 year funding cycle ($25K/center)

4. CHIRTN Network • Participating Universities: • Univ of Rochester – (lead) – Deaf • Univ of Colorado – Rural, Latino, families, aging • Univ of Washington – Urban, Asian • Univ of North Carolina – Urban-Rural African American • Univ of West Virginia – Appalachian • Univ of Illinois at Chicago – Rural Latino

5. Hispanics in Illinois • 1,530,262 Hispanics in Illinois (12.3%); • 1,253,670 Spanish speakers • 74.8%Mexican • 11.7% Caribbean • 2.6% Central American • 2.5% South American • 8.4% Other • 121.5% is the growth rate of Hispanics in Illinois between 1990-2000

7. Site-specific Methods/Roles • Communities identified via Alianza based on existing CBPAR projects • Hispanic Health Advisory Committees in each community: • Definition of target population (adults over 18) • Review/revision of protocol • Recruitment • Hosting event (food; childcare) • Reaction to and dissemination of community report – next steps • Community Research Team Involvement • Facilitation of focus groups • Demographic/screening survey at beginning • Provide health educational materials and ‘teaching moments’ during groups • Transcription/translation of data; creation of reports; link to CHIRTN • Presentation to Alianza

9. Core Questions • KNOWLEDGE OF DISEASE AND RISK • KNOWLEDGE OF PREVENTION III. HEALTH LITERACY IV. DISSEMINATION If we put you in charge of getting the word out to others about the importance of physical activity, controlling blood pressure, a healthy diet, smoking cessation, and other heart healthy behaviors, what would you do to make sure everyone knows about this?

10. Target Population • Location: 4 ‘rural’ communities in NW IL • Number of groups: 5 focus groups • (1 PhotoVoice) • Number of focus group participants: 64 • Age: 18-78; Avg. 35 • Gender: Mixed Groups – 70% female • Race/ethnicity: 100% Hispanic – all groups conducted in Spanish w/ bilingual facilitator • Length of residence in US: bimodal 35% LT 2 years; 65% GT 5 years • Length of residence in community: 45% LT 2 years; 55% GT 5 years

11. Target Population • 85% from Mexico (35% from rural areas) • Education (Avg: 9 years) Range 0-17 yrs • Married: 63% • Children: 88% (0-10, Avg 3) • Income: 75% under $20,000 • Health insurance: 46% Yes • Major Health Problems: Obesity (25%); HBP (22%); Psychological (20%); Diabetes (16%); High Cholesterol (14%) • Only 1 on heart medication • Family history of HD (40%) • Smoke: 5%; Exercise: 53%; Healthy Diet: 33%

12. Site-specific Analysis • Translation/Transcription – 2 reviewers • Coding, independently by 4 coders, then reconciliation • Entry into ATLAS • Query database based on major categories. Query reports contained all of the quotations that related to the assigned category/theme. • Examination of each query report for emerging themes, again independently and then with reconciliation • Development of broad conclusions for each category • Development of community reports and dissemination

13. Results: Programmatic Recommendations:I. What Programs Should Focus on Regarding Risk Factors (Diet and Physical Activity) • Promote Healthy Diet • how to prepare healthy food (Belvidere) “To be on a diet is hard because I don’t know how to follow it. I have to eat what I know how to cook.” (Rockford, Nueva Vida) • diet/menu plans for specific risk factors/diseases (DeKalb) • appropriate food portions (DeKalb) • affordable healthy eating “We think if we eat more expensive food, it means that we are eating healthier food and it is not true.” (Rochelle) “Some times I don’t have enough money to buy healthier food and I have to eat whatever I have.” (Rockford, La Voz Latina) • How to make eating healthy convenient, “Some times is easier to go to a convenient store and buy chips and soda than to go to the supermarket and buy a fruit or a vegetable.” (Rockford, La Voz Latina) • Information about what constitutes a balanced diet (Rockford, Nueva Vida)

14. Results: Programmatic Recommendations:I. What Programs Should Focus on Regarding Risk Factors (Diet and Physical Activity) • Promote Physical Activity • the importance of it (DeKalb) • instruction on how to do exercises appropriate to the particular individual (DeKalb) • How to incorporate exercise into all seasons “All these things added for example here in Illinois winter is very cruel and we cannot go out to run. We prefer to be warm and under a blanket. In summer time is ether work or because it is too hot. So that’s a big influence.” (Rockford, Nueva Vida)

15. Results: Programmatic Recommendations: I. What Programs Should Focus on Regarding Risk Factors Other • Cultural factors: that affect physical and mental health: • Adjustments to life in the US: working two or three jobs, the weather “sitting all day on a chair, lack of exercise because weather or because you work too much.” (Rockford, La Voz Latina) Acculturation “I think it is very difficult because there are a lot of factors like the ones we have mentioned such as economy, weather, time etc and I think some times we are depressed because of the things we left behind. The life style here is very different.” (Rockford, Nueva Vida) • Culture-specific Foods (Rockford, Nueva Vida) “I don’t know if it is a consequence but the cultural background is important. For example, we as Hispanics like greasy food and I think the lack of knowledge because people are not educated on the way we should eat and generally Hispanics don’t realize that we suffer a disease until the last moment.” (Rockford, Nueva Vida) • Explanations, instead of a list of dos and don’ts. “One of the many things you hear when you go to the doctor, and he talked to you and send you to the nutritionist and she says that you can eat this or not; however, they don’t explain to you why or why you shouldn’t consume a lot of sugar. They simply don’t explain you why you can eat this fruit or that one. They don’t say that it is because this fruit has sugar and your body can not deal with it.” (Rockford, La Voz Latina) • Economic risk factors “I think that a very important factor in Latin America is the economy. There are a lot of people who are aware of a disease and they know that need to get tests done. Unfortunately, they don’t have the money to get them and that causes a lot of limitations. When they have to go to the hospital is because they really have to, because is an emergency and usually the disease has developed or has advanced. Money is a big factor.” (Rockford, Nueva Vida)

16. Results: Programmatic Recommendations: II. What Programs Should Include (families, activities for kids, gender specific, locations) • Women only “I would like to have some activities for women . . . because all the times women have to be at home. We have to prepare the dinner, do laundry, care of our children and our husbands go to the soccer play. I think it is not fair for the women.” (Rochelle) • Women as the base. “Going back to the idea of that we have to get educated. In the Latin culture we know that women are the ones who buy the groceries and take them home, we know what our children are going to eat, what our husbands are going to eat that’s why we should get educated and pass on this information to our partner and kids and try to eat healthy.” (Rockford, La Voz Latina) • Women and children “because men do not like to go [to the gym] in Belvidere.”

17. Results: Programmatic Recommendations: II. What Programs Should Include(families, activities for kids, gender specific, locations) • The whole family (Belvidere) “There should be a place where kids, teens, adults and elderly can participate and pay more attention to health that’s the goal.” (Rockford, La Voz Latina) • Latino families (DeKalb) “There should be a place where we Hispanics can go because we are afraid of the places where Americans go. We are afraid and we don’t want to be in a different culture, we think that they are going to criticize us and that we are going to feel awkward because we don’t talk the same language.” (Rockford, Nueva Vida)

18. Results: Programmatic Recommendations: II. What Programs Should Include( families, activities for kids, gender specific, locations) • Organizations: churches, hospitals, clinics, community-based organizations • Workplace-based programs “I would also propose that in our work places such as factories, hospitals and schools to have a free blood test every year and every worker would receive his/her results.” (DeKalb) • Elementary school-based programs (DeKalb) “I would create a health class for children who are in elementary school because teenagers who are in high school do not care anything. If you teach something to children and you tell them “look it is important that you and your parent eat healthy food”, they would care about this.

19. Results: Programmatic Recommendations: III. Key Ingredients for Good Programs • Interactive: “I would like to talk face to face where we have the opportunity to ask questions.” (Belvidere) • Pass it on model - “I would like to know how I can help my father who is in Mexico.” Belvidere) • Child Care - “Almost all people have children and many times people do not do activities because do not have any body that takes care of their children” (Belvidere) • Culture appropriateness (messages, recruitment, dissemination of information that would attract Latinos) (Rochelle) • Family-focused: nights at the gym (Belvidere); family festivals (DeKalb)

20. Results: Programmatic Recommendations: III. Key Ingredients for Good Programs • Accessibility to all regardless of immigrant status, economic status, language: • A health center where people without resources have easy access. (DeKalb) • A gym or fitness center, that includes a medical office with free consults (Belvidere). “I think the first thing I would do is to create a health center because if we want to go here a gym, we can not get in. There ask you for ID and many people do not have ID. I would like to create a center like YMCA but that all Hispanic people may go in.” (DeKalb) • Free or affordable. Welcoming to Hispanics. • “A health center in the Hispanic community. It could be cheap and affordable prices for everybody who wants to see the doctors. It will also important the language because many people do not go to the doctor. People are afraid to talk because they do not speak English. If nobody helps me what I am going to do.” (DeKalb)

21. Results: Programmatic Recommendations: III. Key Ingredients for Good Programs • Parent involvement – “I think it is a good idea that parents educate more to their children and not just the school.” (DeKalb) • Sound leadership “It is important to be with a leader who would orient with the purpose of helping our family and friends.” (DeKalb) • Transportation (Rockford, La Voz Latina) • Program staff who speak Spanish and understand different cultures (Rockford, La Voz Latina). • Accurate, thorough, and accessible information. “Sometimes the programs on TV or advertisement are helping us but we do not have enough information in order to take care more about ourselves. If we had the right information, it would not have too many obese people and we would not have too many people with cardiovascular diseases.” (DeKalb)

22. Results: Programmatic Recommendations: III. Key Ingredients for Good Programs • Support/Education for navigating the healthcare system: “If you are diagnosed with a disease how to get a correct treatment by a particular doctor or if you have insurance by them but if the person doesn’t has to worry about how to get the money because he or she doesn’t want to die and has to find the money to cover all the expenses.” (DeKalb) • Flexibility “[programs should be flexible with different schedules because some people work in the morning and others at night. Also there should be a program where people can learn about the program and later transfer all that information and knowledge to other people because of the lack of teachers and trainers” (Rockford, Nueva Vida)

23. Results: Programmatic Recommendations: III. Key Ingredients for Good Programs • Mental Health Services “It would be nice to have a psychologist in the case that exercise and diet are not working because people get depress and in that moment they need help. With a psychologist or advisor you can get better and try other things and find solutions and keep you motivated.” (Rockford, Nueva Vida) • Social Support “I think it has to be like church. Where you can meet more people and go to the gym and make friends. They can make a schedule and go to exercise together. My mom said that “she was feeling alone” but if there is someone else that can help you and exercise together and have a schedule to go to the gym.” (Rockford, Nueva Vida) • Variety of Approaches “I think it is important to combine [approaches] because if you don’t have a TV or internet you can listen to the radio when you are driving. The “comadre a comadre” is one of the best because we can visualize what we are listening and all our senses are working and it is easier to remember what we have talked. I think the more activities and media are involved in the program the result are going to be better and reach more people.” (Rockford, Nueva Vida)

24. Acknowledgements: University of Illinois at Chicago, IL Prevention Research Center (U48 DP000048) Project EXPORT Center of Excellence in Rural Health NIH/NCMHD (5 P20 MD000524) National Center for Rural Health Professions UIC College of Medicine at Rockford University of Illinois Extension Community Health Advisory Committees (Belvidere, DeKalb, Rochelle,Rockford) Study Participants This presentation was supported by Cooperative Agreement Number 1-U48-DP-000048 from the Centers for Disease Control and Prevention. The findings and conclusions in this presentation are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. http://uic-ihrp.org/iprc