Practice Notes: Strategies in Health Education

The Practice Notes section is intended to keep readers informed about health educa-tion practice around the country. It is an attempt to spread the word about exemplarystrategies, initiatives, and programs and share successes in overcoming obstacles orchallenges. Periodically, articles presenting perspectives on practice-related issues arealso included in Practice Notes.

The Practice Notes in this special issue are focused onhealth disparities. These notes provide unique examples

of efforts to reduce health disparities across diversecommunities. The first presents the challenges and suc-

cesses in developing an occupational health curriculum toimprove the health and safety of young Latino workers in aborder community. Another highlights an effort to involve

barber and beauty shops in bringing health resources to anAfrican American community. Finally, a technical assistance

model is presented that is designed to enhance injuryprevention programs in Native American tribal communities.

Program: Occupational Health and Safety Educationfor Hispanic Workers at the Border

Sponsor: National Institute for Occupational Safety and Health (NIOSH)Cooperative Agreements Under the Southwest Center for Agricultural HealthInjury Prevention and Education, University of Texas Health Center at Tyler,

and the Southwest Center for Occupational and Environmental Health,University of Texas at Houston Health Sciences Center

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Health Education & Behavior, Vol. 33 (4): 425-432 (August 2006)DOI: 10.1177/1090198106288199© 2006 by SOPHE

Objective

This project was designed as a needsand assets assessment to develop and eval-uate a culturally appropriate, bilingual(Spanish/English), high school−level, occu-pational health and safety curriculum, specif-ically targeted for Latinos in a bordercommunity.

Assessment of Needs

Two vulnerable worker populations oftenunderrepresented in occupational healthresearch are young and Hispanic workersin the United States. Hispanics are sub-stantially younger on average than non-Hispanics, resulting in a substantiallyhigher proportion in the 18-to 24-year-old

range—a group likely to be working andparticularly vulnerable to workplace haz-ards. Hispanic workers are overrepresentedin the categories of manual work andservice occupations (Richardson, Ruser, &Suarez, 2003). In fact, Hispanic construc-tion workers have almost twice the risk ofmortality because of occupational injurieswhen compared with their non-Hispaniccounterparts. Hispanic men in the southernstates have the nation’s highest uninten-tional fatal occupational injury rate(Richardson, Loomis, Bena, & Bailer,2004). Reported odds for injury forHispanic adolescents working in SouthTexas are high for agriculture, restaurant,and construction (Weller, Copper, & Basen-Engquist, 2003). Work safety curriculahave been developed in several states butnot for Hispanic workers (Web sites: www.lohp.org, www.losh.ucla.edu, and main.edc.org). Applied research that promotescommunity partnerships to coordinate abroad-based school health promotion inter-vention represents a promising expansionfor school-based programs and for expan-sions of approaches to occupational healthand safety among Hispanic workers.

Program Strategy

The curriculum developed for Spanish-speaking workers included three phases:(a) needs and assets assessment via focusgroups and interviews, (b) resource assess-ment and curriculum development, and(c) curriculum refinement.

Needs and assets assessment: Six focusgroups consisting of 52 participants (highschool administrators, teachers, parents,students, and farmworkers) were held toprovide feedback about the high school−level occupational health and safety cur-riculum. The focus group protocol includedassessment of building capacity such asclassroom space and necessary audiovisualaids, curriculum development, and teachers’and administrators’ motivation.

Curriculum development: The collabo-ration between the School of PublicHealth, University of Texas (BrownsvilleRegional Campus) and the Labor Occu-pational Health Program, University ofCalifornia at Berkeley was established.After an extensive search, several English,but no bilingual, curricula were found.Several curricula were selected as primaryresources for this project. Permission wasobtained from all above organizations foruse and/or adaptation of materials, andappropriate materials from these sourceswere selected.

Curriculum refinement: An “educatortaskforce” consisting of general equiva-lency degree (GED) teachers, scienceteachers, GED program counselors, andhigh school administrators was formed to recommend modifications of coursematerials appropriate for high school−levelworkers. They made recommendations forspecific activities to ensure literacy level,cultural, and language appropriateness.The course materials were translated intoSpanish and back translated into English.The final product was a bilingual curricu-lum entitled Work Safely—Trabaje conCuidado. It consisted of eight 60-minutelessons and included topics such as hazardrecognition, injury prevention strategies,child labor laws, sexual harassment, work-ers’ compensation rights, and communica-tion skills needed to discuss work-relatedsafety concerns.

The curriculum is interactive, requiringstudent participation in activities such asmapping safety hazards of common entry-level work sites, developing and prioritiz-ing strategies to protect workers from thesehazards, and practicing communication ofwork-related safety concerns through role-playing. The curriculum was pilot tested intwo different South Texas cities, amonglaid-off workers in a GED program andamong migrant farmworker students. Inaddition, the curriculum is being tested ata regular high school with 113 studentsattending a work study program.

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Evaluation Approach

The educators’ task force completedevaluations before and after the workshop.A follow-up evaluation was conducted viatwo focus groups with participants afterthe workshop. They considered barriersfor implementation (at regular high schoolprograms and high school equivalencyprograms), made suggestions for futuretrainings, and expressed willingness toparticipate in pilot testing. After pilot test-ing of the curriculum materials, data arebeing collected to assess the process ofimplementation in those two initial sites.The second “pilot study” at the regulareducation high school is also under way. A6-week follow-up survey and several focusgroups will be conducted.

Implications for Practitioners

The curriculum may be a useful educa-tional bilingual intervention targetingyoung Hispanic workers. Reaching youngHispanic workers attending high school orGED programs is a promising approachproviding occupational health education.Teachers and administrators were enthusi-astic about participating in the develop-ment of the first bilingual curriculum fortheir students. However, those consideringuse of such curricula should be sensitiveto the multiple demands educators are fac-ing today. At GED programs, teachersmay have more time to provide additionaltraining that enhances the students’ educa-tion. The potential avenue for occupa-tional health and safety curricula atregular high schools may be in programsthat are linked to job training. The part-nership approach has been widely usedamong curriculum developers and mayhelp sustain programs as well.

For more information, contact MarthaSoledad Vela Acosta, MD, MS, PhD,

Assistant Professor, Division of Environ-mental and Occupational Health Sciences,University of Texas School of PublicHealth, 80 Fort Brown RAHC Building1.220D, Brownsville, TX 78526; phone:(956) 882-5163; fax: (956) 882-5152;e-mail: martha.s.vela.acosta@uth.tmc.edu;http://myprofile.cos.com/msvelaacosta.

Acknowledgments

This investigation is funded by NationalInstitute for Occupational Safety andHealth (NIOSH) Cooperative Agreementsunder the Southwest Center for Agricul-tural Health Injury Prevention and Educa-tion, University of Texas Health Center atTyler (U50 OH07541) and by the South-west Center for Occupational and Envi-ronmental Health (T42/CCT610417-11)University of Texas at Houston HealthSciences Center.

References

Richardson, D. B., Loomis, D., Bena, J., &Bailer, A. J. (2004). Fatal occupationalinjury rates in southern and non-southernstates, by race and Hispanic ethnicity.American Journal of Public Health,94(10), 1756-1761.

Richardson, S., Ruser, J., & Suarez, P. (2003).Hispanic workers in the United States: Ananalysis of employment distributions, fataloccupational injuries, and non-fatal occu-pational injuries and illnesses. Safety isSeguridad: A workshop summary (2003).Washington, DC: National Academy Press.Retrieved December 2005, from http://www.nap.edu/books/0309087066/html/43.html

Weller, N. F., Copper, S., & Basen-Engquist, K.(2003, August). The prevalence and pat-terns of occupational injury among SouthTexas high school farmworkers. TexasMedicine, pp. 52-57.

Practice Notes 427

Program: Take a Health Professional to the People: A CommunityOutreach Strategy for Mobilizing African American Barber Shops and

Beauty Salons as Health Promotion Sites

Sponsor: EXPORT Health Center at the Center for Minority Health,Graduate School of Public Health, University of Pittsburgh

Objectives

In September 2002, the U.S. Departmentof Health and Human Services launched“Take a Loved One to the Doctor Day,” anational effort to promote health and well-ness in the African American (A-A) com-munity. The Center for Minority Health(CMH) at the Graduate School of PublicHealth, University of Pittsburgh, adoptedthis model and tailored it to meet local needsby partnering with seven barbershops, twobeauty salons, and more than 100 healthprofessionals (HPs) to create what is nowknown as “Take a Health Professional to thePeople Day.” The focus of this partnershipwas to provide screenings and health infor-mation to patrons and transform these shopsand salons into health promotion sites.

Assessment of Needs

The national health initiative HealthyPeople 2010 has two main goals—increasing quality and years of life andeliminating health disparities. Despitemuch progress in improving the health ofAmerican citizens, disparities betweenA-A health and the general populationcontinue to exist. In a city with nationallyranked hospitals and health care traininginstitutions, Pittsburgh’s A-A community,like so many around the country, contin-ues to be affected by preventable diseases,including cancer, cardiovascular disease,HIV, and diabetes. Socioeconomic, political,and cultural factors combine to influencehealth beliefs and behaviors. It is importantthat health messages be delivered witha strategy that considers those factors.

Prevention efforts that are culturally rele-vant and that incorporate the social normsand values of the A-A community may beeffective, particularly if they are deliveredby trusted and respected communitymembers and institutions. In the A-A com-munity, barber shops and beauty salonsserve as gathering places and centers ofinformation exchange. Research indicatesthat barber shops and salons are viablevehicles for health education and healthpromotion interventions and are importantcommunity outreach sites. The idea ofusing trusted community-based institutionsto promote health and wellness has its rootsin social network and social support theory.

Program Strategy

Barber shops and beauty salons wereselected from a list of approximately 120,based on similarities of demographicprofiles from the 2000 census. Recruitmentof shops and salons began with phonecalls to each owner to make appointmentsfor formal introductions and pitch theidea. The strategy of “sampling the prod-uct” by getting a haircut proved instru-mental in establishing relationships.

To recruit health professionals, aWeb-based registration form was createdand the link sent via e-mail with a letterof invitation to participate in Take a . . .Day to researchers, physicians, nurses,community-based health organizations,federally qualified health centers, the localhealth department, nursing sororities, andschools of health sciences at the Universityof Pittsburgh and other neighboring collegesand universities.

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Practice Notes 429

CMH deployed health professionalsand students of all types into the A-A com-munity via this network of shops andsalons. Two CMH staffers were at each siteto observe the interactions between shop/salon employees, customers, and HPs,recording what they saw and heard using anabbreviated “observational protocol”instrument. Standard services provided ateach shop included blood pressures (BPs),“Ask the Pharmacist,” and referrals to andinformation on local health care providers.

Unique to this effort was the partner-ship with a competing university’s Schoolof Nursing and our university School ofPharmacy. These schools used this initia-tive to give their students “field placementand cultural confidence” training by plac-ing them in these sites under the supervi-sion of a professor or proctor.

In addition, one of our shops partneredwith a daycare center next door, and theRonald McDonald Van of Children’sHospital conducted full exams on thechildren.

The most significant highlight of theday was our attempt to engage A-A menin the barbershop to get a free prostateexamination in the shop. We were suc-cessful in reaching nine customers whoreceived either a PSA, DRE, or both.

CMH engaged the shops, salons, andtheir customers by making the atmospherefestive and inviting with the use of balloons,food, and water provided by our supermar-ket partner, and plenty of picture taking.

Evaluation Approach

Effectiveness of this project was evalu-ated through various process measuressuch as participant satisfaction, includingshops/salons and health professionals, mediacoverage, increased health professional

participation, and diffusion of innovationmeasures, such as number of inquiries fromother shops and programs to duplicate ourefforts.

Implications for Practitioners

“Take a Health Professional to thePeople Day” represents an innovativemethod of community engagement forhealth promotion and health educationand demonstrates a novel approach tousing barber shops and beauty salons asboth health promotion sites and venuesfor community-based training of healthproviders with a follow-up mechanismbuilt in. In addition, the field placementopportunity will be developed in an“Adopt-a-Shop” model to allow CMH toact as a conduit for various schools ofhealth sciences for ongoing community-based training.

Last, CMH believes that this type ofinfrastructure is necessary for future suc-cessful research activities with and in theA-A community.

This program is supported by NIH/NCMHD Grant P60 MD-000-207-02.For more information, please contactMario C. Browne, MPH, CAC, ProjectDirector, Center for Minority Health,Graduate School of Public Health,University of Pittsburgh, 125 Parran Hall,130 DeSoto Street, Pittsburgh, PA 15261;phone: (412) 624-5665; fax: (412) 624-8679; e-mail: mbrowne@cmh.pitt.edu;Web address: www.cmh.pitt.edu. You mayalso contact Angela Ford, PhD, AssociateDirector, Center for Minority Health,GSPH, University of Pittsburgh; e-mail:afford@cmh.pitt.edu; or Stephen Thomas,PhD, Director, Center for MinorityHealth, GSPH, University of Pittsburgh;e-mail: sbthomas@cmh.pitt.edu.

Program: Providing Technical Assistance to Tribal Entitiesto Build Local Capacity for Injury Prevention

Sponsors: Indian Health Service, University of North Carolina Schoolof Public Health, Department of Health Behavior and Health

Education and the Injury Prevention Research Center

Objectives

The Indian Health Service (IHS) InjuryPrevention Program has established a TribalInjury Prevention Cooperative AgreementsProgram (TIPCAP) to build the capacityof American Indian and Alaska Nativecommunities to develop, implement, andevaluate injury prevention programs. Ini-tiated in the fall of 2000, the IHS allo-cated $50,000 per year for up to 5 years ofsupport for TIPCAP sites.

Because of variation in the TIPCAPsites’ program capacity, technical assistancewas required to bridge the gap betweenneeds and resources. IHS augmented thesupport provided by TIPCAP project offi-cers and contracted with faculty and stafffrom the University of North Carolina(UNC) at Chapel Hill School of PublicHealth to provide tailored technical assis-tance that would move the programs towardself-sufficiency in implementing effectiveinjury prevention activities (Neufeld, 1978).

Assessment of Needs

American Indians/Alaska Natives (AIs/ANs) have the highest unintentionalinjury rates and suicide rates in the UnitedStates (National Center for Injury Preven-tion and Control, 1998). The AI/AN age-adjusted injury death rate is 2.6 times theoverall U.S. rate, and AI/AN mortalitybecause of motor vehicle crashes is 3.3times that of the U.S. population (RegionalDifferences in Indian Health, 2003). TheAI/AN injury mortality rate varies acrossthe country, with some rates four to fivetimes that of the general population(Smith & Robertson, 2000). Although thegap between mortality rates for the general

population and AIs/ANs has decreasedsince the 1980s, the difference remainssubstantial (Trends in Indian Health 2000-2001, 2004).

Program Strategy

UNC staff provided ongoing assistanceto 30 TIPCAP sites over a 5-year period.The technical assistance process began withan assessment of each site’s plan to developa program to reduce injuries. Assessmentactivities included document review,on-site visits, and structured-interview con-ference calls. Additional technical assistanceactivities included developing and imple-menting an annual 2-day training work-shop, producing a project newsletter, andproviding administrative support to IHSheadquarters and field staff. After UNCidentified specific needs for knowledge orskill development, technical assistancewas tailored to deliver information andprovide learning activities that could beconducted during site visits and/or dis-cussed during conference calls. Trainingworkshops and newsletter articles werespecifically designed to increase knowl-edge and build skills related to the sites’program challenges. UNC also devel-oped tools to assist program coordina-tors, including project-reporting templates,planning/evaluation worksheets, seat beltuse observational protocol, monitoringtables, and budget-monitoring spread-sheets. UNC and IHS staff encouragedthe implementation of comprehensiveintervention approaches through a combi-nation of education, enforcement, andenvironmental-change strategies to pro-mote safe behaviors and situations. Themost common interventions included

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Practice Notes 431

educational campaigns and equipmentdistribution to increase use of child pas-senger safety seats, seat belts, bicycle hel-mets, and smoke alarms. Some sites alsosought to pass and/or enforce tribal ordi-nances to address the use of child safetyseats, seat belts, helmets, and impaired-driving checkpoints.

Evaluation Approach

Evaluation of each TIPCAP program’schange in capacity was obtained fromprogress reports, continuation applications,conference call/site visit summaries, andannual project coordinator/project officersurveys. To better document and track thesemeasures, we developed a logic model,created a monitoring database, and codedthe information abstracted from multiplesources into five program components:(1) support/setting, (2) staff capability,(3) management, (4) injury preventioninterventions, and (5) impacts/outcomes.

Implications for Practitioners

The logic model and database proveduseful for organizing programmatic infor-mation from 30 sites over 5 years. The logicmodel facilitated the provision of clear, con-sistent, and comprehensive technical assis-tance. It also enabled project team membersto report site activities to IHS headquartersstaff annually in an organized manner.

There are advantages to contractingwith external organizations for technicalassistance. They often have more currenttechnical knowledge, are able to producerapid results, and have a broader array ofskills and expertise on staff. In addition,external organizations do not supervisethe program, therefore staff may feel freeto reveal program weaknesses and exploresolutions (Neufeld, 1978).

To provide tailored technical assistance,we recommend understanding the fundingagency goals; having relevant experience

with the content and the communities;emphasizing rapport building; continuouslyreflecting on how services are provided; andcommunicating the program progress,responsibilities, and recommendations inways that are clear, consistent, and realistic.

For more information, please contactCarolyn Crump, PhD, Research AssistantProfessor, Department of Health Behaviorand Health Education, Campus Box 7506,University of North Carolina, Chapel Hill,NC 27599-7506; phone: (919) 966-5598;e-mail: Carolyn_Crump@unc.edu. Forinformation about the IHS Injury Preven-tion Program, see information on Webpage: http://www.ihs.gov/medicalprograms/injuryprevention/.

Order of authors: Carolyn E. Crump,PhD; Robert J. Letourneau, MPH; MargaretM. Cannon, MPH.

References

National Center for Injury Prevention andControl. (1998). National Center forHealth Statistics vital system for numbersof deaths. Atlanta, GA: Author.

Neufeld, G. R. (1978). Technical assistance inhuman services: An overview. In M. L. T.Sturgion, A. Ziegler, R. Neufeld, &R. Wiegerink (Eds.), Technical assis-tance: Facilitating change (pp. 19-38).Bloomington: Development Training Center,Indiana University.

Regional Differences in Indian Health, 2000-2001. (2003). Rockville, MD: U.S.Department of Health and HumanServices, Indian Health Service, Office ofPublic Health, Office of Program Support,Division of Program Statistics.

Smith, R., & Robertson, L. (2000). Unintentionalinjury. In E. Rhoades (Ed.), American Indianhealth: Innovations in health care, promo-tion, and policy (pp. 244-259). Baltimore,MD: Johns Hopkins University Press.

Trends in Indian Health 2000-2001. (2004).Rockville, MD: U.S. Department of Healthand Human Services, Indian Health Service,Office of Public Health, Office of ProgramSupport, Division of Program Statistics.

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PRACTICE NOTES EDITORIAL COMMITTEE

Lisa D. Lieberman, PhD, CHES, President, Healthy Concepts, and Evaluation Specialist,Inwood House Research Group, New York; and Barbara Hager, MPH, CHES, Director,Division of Health Education and Promotion, Arkansas Department of Health.

SUBMISSION INFORMATION

Abstracts for Practice Notes and all correspondence concerning abstract reviewshould be sent to Lisa D. Lieberman, Healthy Concepts, 29 Ardsley Drive, New City, NY10956. Submissions can be mailed (include one hard copy and disk in Word format orWord Perfect) or sent by e-mail attachment to llhealth@optonline.net in Word format.Published manuscript length is approximately 300 words (excluding headings and con-tact information). Submitted manuscripts may be up to 700 words and will be edited forlength and clarity. Include the following: name of initiative or program, contact person,sponsoring agency or agencies, address, and phone number. The program descriptionshould include the following headings: Objectives, Assessment of Needs, ProgramStrategy (e.g., risk reduction, community organizing, media advocacy, disease manage-ment, policy advocacy, coalition building, social support, etc.), Evaluation Approach,and Implications for Practitioners (including descriptions of any special challenges orunique circumstances that the project has overcome). Authors should not include eval-uation results because Practice Notes is intended to describe processes and programs,not to assess outcomes. Submissions will be judged on applicability and utility to thehealth education practitioner, clarity of objectives, innovativeness and creativity, existenceof evaluation plan, and potential replicability. Additional artwork, graphs, or tables maybe submitted in camera-ready form.