Volunteers from 19 countries serve as health promoters in Montgomery County’s Multicultural Health Promoters Program. The health promoters program started in September 2000 to provide assistance to the county’s large and diverse immigrant population in applying for the Maryland Children’s Health Insurance Program (MCHP). According to the 2000 census, 27 percent of the county’s total population is foreign-born. It soon became apparent that the health promoters were in an ideal position to serve as referral sources and as health educators to the growing number of foreign-born residents.
Montgomery County Public Health Services conducts monthly training classes so that the health promoters can provide health education on important topics, such as household safety, nutrition, exercise, asthma, and diabetes. The health promoters have assisted 966 children to enroll in MCHP and have provided referral and health education services to almost 5,000 people. Next year, the Department will expand training to improve the health promoters’ ability to serve as effective health advocates for their communities. The Department is also developing plans for incorporating the health promoters into its emergency preparedness planning, so that they can efficiently disseminate language-appropriate information to their communities during a public health emergency.
The number of volunteers has increased from 35 to 48, with most remaining in the program from one year to the next. Tests before and after training show that training increases the health promoters’ knowledge of MCHP and Medicaid. Their ability to enroll large numbers of children in MCHP demonstrates the success of the program. The goals of the program are to improve the health of recent immigrant families by training native speakers from different countries to help enroll members of their communities in various publicly funded health programs.
When the federal government began the Children’s Health Insurance Program (CHIP) in 1999, the Montgomery County Department of Health and Human Services knew that there were a large number of immigrants whose children would be eligible for the MCHP but who would not be aware of the program or know how to enroll. Using traditional outreach approaches, such as brochures and fliers in English, would not be effective in reaching these immigrant families. Since many were from Central and South America, the department decided to adopt a model frequently used in those regions. For generations, many Latin Americans received vital health education from lay members of their community who were trained as health promoters. The Department recruited members from those communities to train as health promoters to reach as many children as possible to enroll in MCHP to ensure that all had medical care.
The Department’s Administrative Care Coordination Unit (ACCU) is responsible for helping county residents enroll in the Medicaid managed care program, Health Choice. When MCHP was implemented, the ACCU had only three outreach workers, only one whom spoke Spanish. The three outreach workers attended health fairs and other community events to enroll children in MCHP. The Department knew that this would not be sufficient to reach the large number of recent immigrant families. To reach these families, the ACCU studied how health care is accessed in their home countries. As the number of immigrants from Latin America and other parts of the world increased, the Department of Health and Human Services (DHHS) adopted the model of indigenous health promoters to reach these new immigrants, not only to enroll their children in MCHP, but also to serve as neighborhood contacts for health education and information.
Agency Community RolesThe Montgomery County Department of Health and Human Services, Public Health Services is the local health agency. Public Health Services’ ACCU is responsible for helping enrollees in HealthChoice to access services. The ACCU is also responsible for community outreach for HealthChoice and for MCHP enrollment. The ACCU recruits and trains the health promoters. Each new health promoter is required to attend 24 hours of training, followed by four hours of additional training monthly. The Maryland Department of Health and Mental Hygiene (DHMH) provides funding for a small monthly stipend of $50 for each health promoter.
The Multicultural Health Promoters Program collaborates with a wide array of community organizations. The health promoters attend numerous health fairs sponsored by community-based organizations such as churches, hospitals, and ethnic service organizations. They reach parents in the schools by attending back-to-school nights, kindergarten orientations, and other school events. Public health staff collaborates with many community groups to expand the health promoters program. For example, a local African and Haitian immigrant congregation has asked the program to train some of their members to be health promoters. One of the local mayors has also requested that the Department train some of its residents as well.
The program is collaborating with many groups, including local hospitals, fire and rescue services, DHHS health promotion and child safety services, and others to conduct a multicultural health fair for families in June 2004. Each year the Department holds a recognition ceremony for the health promoters. The County Executive shows his support for the program by thanking the health promoters at this ceremony.
Costs and ExpendituresWhen the ACCU realized that it would need to develop a new approach to reach hard-to-reach populations, especially the non-English-speaking immigrant communities, for Medicaid managed care and MCHP enrollment, staff consulted with the Department’s Health Promotion Program, which was using Latino health promoters to educate Latinos in the lower section of the county on health issues. The ACCU adopted this model but expanded it to include Asian and African immigrants and African Americans as health promoters, who were recruited from the upper portion of the county.
The health promoters were recruited through announcements in church bulletins and in the local paper; flyers circulated in the communities, public housing and WIC sites; and through word of mouth. When the initial group of 35 health promoters was recruited, a central training site was selected that was accessible by public transportation. ACCU developed a training curriculum manual. Funding was obtained from the DHMH to pay each health promoter a small monthly stipend. The health promoters received 24 hours of training. The Multicultural Health Promoters’ tasks are:
To locate hard-to-reach families without health insurance and help them apply for MCH.
To educate the community on existing health resources in the county and other services for low-income residens.
To empower residents to become advocates for their communities.
ImplementationWhen the ACCU realized that it would need to develop a new approach to reach the hard-to-reach populations, especially the non-English-speaking immigrant communities, for Medicaid managed care and MCHP enrollment, staff consulted with the Department’s Health Promotion Program, which was using Latino health promoters to educate Latinos in the lower section of the county on health issues. The ACCU adopted this model, but expanded it to include Asian and African immigrants and African American health promoters, who were recruited from the upper portion of the county. The health promoters were recruited through announcements in church bulletins and in the local paper, flyers circulated in the communities, public housing and WIC sites, and through word of mouth.
When the initial group of 35 health promoters was recruited, a central training site was selected that was accessible by public transportation. ACCU developed a training curriculum manual. Funding was obtained from the DHMH to pay each health promoter a small monthly stipend. The health promoters received 24 hours of training.
The Multicultural Health Promoters’ tasks are to locate hard-to-reach families without health insurance and help them apply for MCHP, to educate the community on existing health resources in the county and other services for low-income residents, and to empower residents to become advocates for their communities.
To this end, some health promoters use the media to outreach to their community. Several Latino health promoters have talked about their program on a local Spanish-language radio station. A Chinese health promoter writes articles for a Chinese newsletter. The ACCU team writes an English/Spanish newsletter that provides health information targeted at a sixth grade reading level, which is distributed through community churches, restaurants, and ethnic grocery stores.
Process Evaluation: Strategy assessment: The objective of the Multicultural Health Promoters Program is to improve the health status of low-income, uninsured county residents by assisting them in accessing health care and other needed services and in providing one-on-one health education.
Challenges: It has been a challenge to recruit African Americans for the Health Promoters program. Despite vigorous recruitment efforts, the program has been able to attract only two black health promoters, leaving a gap in addressing the health needs in this community. The program will continue to explore options to attract this community, but are limited by staff and budgetary constraints.
Another challenge is how to expand the number of health promoters and have sufficient funds to continue to pay the small monthly stipend. As an incentive for participation and retention in the program, the health promoters receive $20 for each meeting and $30 for each monthly report. Babysitting and lunch are also provided for approximately 55 health promoters. It may be necessary to eliminate the babysitting and lunch in order to have enough funds to increase the number of health promoters. Another option is to partner with another group, which will pay for the stipends in exchange for training their residents to be health promoters.
Outcome Evaluation: Some measures of the program’s success are the increase in the number of participants, the increase in the diversity of the participants, and their retention rate. The number of health promoters has increased from 35 to 48, with participants from 19 different countries. The retention rate is 80 percent. The number of individual clients that the health promoters provided health education services, MCHP enrollment assistance, or referral to health care services increased 175 percent--from 1,794 in FY02 to 4,937 in FY03. The multicultural health promoters helped 526 residents apply for MCHP.
SustainabilityState funding is expected to continue in the future. However, due to budget cutbacks for FY05, costs will be reduced by conducting the classes in free rather than rented space, eliminating the babysitting service during the training classes, and reducing expenditures for lunch during the classes. Community interest in the Health Promoters program continues to grow. Each year, new residents volunteer to become health promoters. The number of minority groups participating continues to increase, as community groups find out about the health promoters and want to have people from their culture who speak their language trained as health promoters. Local governments and churches have expressed interest in having their members trained as health promoters to serve their populations. Community support is strong for this grassroots approach to improving health outcomes.
Lessons LearnedBased on feedback from the annual Health Promoters program evaluation surveys, it was determined that the program needed to change to fully address the health care needs the health promoters identified in their communities. For the first three years, training focused on the MCHP program and community resources, with a monthly presentation on a health promotion topic. The expectation was that the health promoter would disseminate this information to their communities: at work, in their neighborhoods, and at churches. Based on feedback from the surveys, the focus of the program was changed in the fourth year to include developing leadership skills to strengthen the health promoters’ ability to advocate for their communities. The challenge to meet this need within two months was monumental: it entailed developing a curriculum that would give the health promoters communication skills and education techniques to enable them to give community presentations and to plan community events. This new focus also gives the Health Promoters an opportunity for personal growth as well as the chance to expand their visibility in the community.
Key Elements ReplicationThe program can be replicated in other communities with large immigrant populations. Building a level of trust is the underlying supportive factor to the successful recruitment of volunteers from diverse hard-to-reach populations. Also needed is designated staff capable of developing the curriculum and teaching a group of adult learners. The curriculum was translated into Spanish, allowing the bilingual staff to teach the program in Spanish.
To address the needs of the other volunteers with limited English proficiency, materials for each session are mailed out at least a week in advance to allow them time to assimilate the information. This program has proven to be labor intensive and time-consuming for the three staff members preparing the monthly sessions. Among the tasked associated with the program are developing the curriculum and lesson plans, gathering materials as handouts, scheduling health promoters for community events, as well as answering telephone calls from the health promoters who have questions from their encounters in the community.
Funding is a key issue in the sustainability of the program. Some of the costs of the program can be covered by funds that the federal government provides to the state health departments for outreach for Medicaid and MCHP enrollment. When the program was new, there was more money than could be used for such extras as food for lunch and babysitting services. But with the program’s success came the need to replicate it in other areas. With no additional funding to do so, the program will need to cut back on these extras. Looking toward the future, the health department will need to cultivate more community partnerships to share the expense of expanding this program.