Product Details

Author Information

Corresponding Author
Cynthia Lebron
University of Miami
Miller School of Medicine
Division General Internal Medicine
Miami, FL 33136
United States
p: 3052439680
clebron@med.miami.edu

Authors (listed in order of authorship):
Yisel Alonzo
University of Miami

Ernesto Reyes-Arrechea
University of Miami

Andrea Castillo
University of Miami

Olveen Carrasquillo
University of Miami

Sonjia Kenya
University of Miami

Brendaly Rodriguez
University of Miami

Product Description and Application Narrative Submitted by Corresponding Author

What general topics does your product address?

Public Health, Social & Behavioral Sciences

What specific topics does your product address?

Access to health care, Advocacy, Chronic disease, Community health , Community-based education, Cultural competency , Curriculum development, Diabetes, Health disparities, Health education , Mental health, Overweight/obesity, Prevention, Social determinants of health, Community Health Worker Role

Does your product focus on a specific population(s)?

Latino/Hispanic, Men, Women

What methodological approaches were used in the development of your product, or are discussed in your product?

Focus group , Qualitative research, Quantitative research, Randomized trial , Interview

What resource type(s) best describe(s) your product?

Manual/how to guide

Application Narrative

1. Please provide a 1600 character abstract describing your product, its intended use and the audiences for which it would be appropriate.*

This guide was created based on the input of the patients and experiences of the Cariño team members for use by community health workers (CHWs), health care providers, community members and others interested in implementing a CHW program. The Cariño program is part of the Miami Heart Healthy Initiative (MHHI), a study examining how CHWs can provide Hispanics/Latinos with type II diabetes with the necessary skills to make healthy lifestyle changes. Although the focus is on Hispanics/Latinos, many of the CHW approaches are applicable to other populations. This guide provides information about the tools used to deliver the program and the CHWs’ experiences when working with patients.

MHHI was created to address social determinants using a culturally appropriate approach - “promotora de salud” - as an intervention. The guide also describes the history and role of CHWs, and how CHWs and CHW managers can train for career development. It delves into the nuances of CHW/patient relationships, such as how to foster a trusting and collaborative partnership. It also presents the various methods used by CHWs in delivering health education. After jointly identifying the needs and challenges, CHWs would create strategies that address the needs of the patients and those strategies are presented as tips throughout the guide. For example, patients specifically requested a health insurance information session be presented during their support group. As a response to this request, CHWs sought out a health insurance representative to present during the group session. Additionally, the guide provides a tracking mechanism, created by CHWs to assist CHWs’ efforts and patient progress.
[A special note: All the pictures in this guide are original pictures taken by patients and CHWs at events hosted by MHHI].

2. What are the goals of the product?

The goal of the guide is to provide information and options about the ways CHWs can help Hispanics/Latinos manage diabetes and provides the community and health collaborators with tools and information that may assist in implementing a similar program with a higher probability of success.


This guide provides information about the tools used to deliver the program, experiences when working with patients, and the barriers CHWs encountered. The goal of this product is to document how the Cariño program was shaped by CHWs to be tailored to their patients. The CHWs found great tips from other guides and educational materials and wanted to add to the literature the techniques they used to foster positive relationship with their patients. Many of the current CHW materials address how to deliver a successful program, however what is unique about this guide is the perspective of a CHW. It describes how it is imperative to include the family unit in diabetes management since it requires lifestyle changes that would affect everyone and how social support can help patients follow the program. Another example that makes this guide unique are the descriptions of the components that went beyond the program design to express commitment to their patients such as sending birthday cards, having family picnics and holding a career workshop.

3. Who are the intended audiences or expected users of the product?

The guide is intended for the use by CHWs, health care providers, community members and others interested in implementing such programs. It is recommended for healthcare providers who are looking to implement a program with Hispanics/ Latinos with diabetes. Although this guide is tailored for Hispanics/Latinos with diabetes, the information can also be beneficial for programs that focus on diverse populations and other prevalent health issues. Audiences looking for strategies on how to engage and retain participants or how to create a trusting relationship with their patients will find this guide helpful. We expect users of this product to be from diverse community settings seeking materials from experienced CHW programs.

4. Please provide any special instructions for successful use of the product, if necessary. If your product has been previously published, please provide the appropriate citation below.

A great tip is to print this guide in color. When this guide was field tested with different audiences, many members acknowledged that it was easy to follow and attractive because of the way it is formatted and the visuals provided.

5. Please describe how your product or the project that resulted in the product builds on a relevant field, discipline or prior work. You may cite the literature and provide a bibliography in the next question if appropriate.

Type 2 diabetes mellitus disproportionately affects the Hispanic/Latino community. Hispanics/Latinos with diabetes are also more likely to experience cardiovascular risk factors such as high cholesterol and high blood pressure. CHWs are increasingly being used to address various health disparity conditions, including diabetes (1). The role of CHWs is to provide members of the community, who traditionally lack access to quality health care, with information and support from a culturally competent point of view that they can understand (2). Among their scope of activities are health education, patient navigation and advocacy services. In addition, CHWs help patients acquire/schedule medical appointments and empower individuals to navigate the health care system (3).

According to Love et al, “like a number of other chronic disease challenges, diabetes prevention and self-care are less dependent on "high-tech" clinical approaches than they are on "high-talk" efforts that provide social support, outreach, consistent follow-up, preventive care, community and family education, and community mobilization (2).” However, evidence of CHWs’ effectiveness from randomized controlled trials is limited. The Miami Healthy Heart Initiative (MHHI) is a clinical trial examining the impact of a one-year CHW-led intervention on diabetes outcomes among 300 Latinos with poorly controlled diabetes. The goal was to determine whether CHWs can help reduce cardiovascular disease risk among Hispanics/Latinos with uncontrolled diabetes in Miami, Florida. In addition, MHHI examined changes in medication adherence, diet and exercise, as well as confidence in overall diabetes management, patient-provider communication, and lifestyle changes (1). Evidence of the impact of CHWs intervention can help policymakers and program planners develop a more tangible and qualitative perspective on the intervention by highlighting specific instances of where the intervention succeeded and areas where challenges persisted.

6. Please provide a bibliography for work cited above or in other parts of this application. Provide full references, in the order sited in the text (i.e. according to number order). .

1. Carrasquillo O, Patberg E, Alonzo Y, Li H, Kenya S. Rationale and design of the Miami Healthy Heart Initiative: a randomized controlled study of a community health worker intervention among Latino patients with poorly controlled diabetes. Intl J Gen Med 2014; 7: 115–126.

2. Love MB, Gardner K, Legion V. Community Health Workers: Who they are and what they do. Health Educ 1997; 24: 510–522.

3. Centers for Disease Control and Prevention. Addressing chronic disease through community health workers: A policy and systems-level approach.
Atlanta, GA: Centers for Disease Control and Prevention; 2011. Available at http://www.cdc.gov/dhdsp/docs/chw_brief.pdf.

7. Please describe the project or body of work from which the submitted product developed. Describe the ways that community and academic/institutional expertise contributed to the project. Pay particular attention to demonstrating the quality or rigor of the work:

• For research-related work, describe (if relevant) study aims, design, sample, measurement instruments, and analysis and interpretation. Discuss how you verified the accuracy of your data.
• For education-related work, describe (if relevant) any needs assessment conducted, learning objectives, educational strategies incorporated, and evaluation of learning.
• For other types of work, discuss how the project was developed and reasons for the methodological choices made.

The MMHI is a randomized controlled trial of 300 Latino patients with diabetes. To qualify for MHHI, study patients had to be between 35–70 years of age, self-identify as Hispanic/Latino, have visited the clinic twice within the last year for diabetes care, and had their most recent hemoglobin A1c (HbA1c) = or > 8.0%. Patientsere recruited from Miami-Dade’s public hospital system in two ways. First, using the electronic medical records, we obtained a list of age-eligible patients having had at least two visits to the Jackson Memorial Hospital ambulatory clinics with a diagnosis of diabetes and the most recent laboratory result for HbA1c being greater than or equal to 8.0%. From this list, patients having Hispanic surnames were selected. The study research assistant contacted them with a recruitment letter and followed up with up to ten phone calls. Second, the health providers were sent letters informing them of the study and asking for referrals. Health providers were also informed at faculty meetings and university conferences.

Participants were randomized to either enhanced usual care or a CHW intervention called Cariño. Participants were stratified by sex during randomization to ensure males and females were equally distributed across both arms. Enhanced usual care included monthly mailings of educational materials and periodic retention phone calls. For participants in the Cariño arm of the study, CHW services included assistance with nonmedical social services, health education, and patient navigation in which the CHWs serve as a bridge between patients and the health care system. These services were delivered through home visits, phone calls, and group visits. CHWs delivered custom tailored education for diabetes management and cardiovascular disease prevention and administered it to best fit the individual needs. Group visits consisted of education and physical activity sessions. Education sessions were held on campus and covered a myriad of health issues and worked in part as a support group. Physical activity sessions were held at a local park chosen by participants where CHWs led participants in aerobic exercise and provided a pedometer and exercise bands to enhance the sessions. CHWs were encouraged to attend clinic visits with participants to focus on developing communication skills with physicians. At 12 months, all subjects had a follow-up examination. Outcomes are currently being analyzed. The intervention effects on outcomes (SBP, LDL, and HbA1c) will be evaluated using linear mixed models for continuous variables (primary outcomes) with categorical classification variables to index time intervals pre- and post-intervention as well as interventional groups.

There was a heavy emphasis on CHW and patient collaboration. The CHWs built relationships with their patients to facilitate the direction of the treatment plan. The principal investigators encouraged the CHWs to take ownership of the study intervention and mold it to their patients’ needs. In turn, the CHWs empowered the patients to make the program their own. CHWs and patients worked together to continuously modify the delivery of the program to make it more patient-centered.

8. Please describe the process of developing the product, including the ways that community and academic/institutional expertise were integrated in the development of this product.

MHHI was designed to address health concerns and needs from a community based perspective. The CHWs that were identified to work in this project were employed for their in depth knowledge of Hispanics living in Miami-Dade county and their strong interest in serving their community.

Two of the main contributors of the guide were both born and raised in the community they served. Before joining the project, one CHW was a former Best Buy salesman, while the other was a former high school teacher. Each CHW had personal experiences with diabetes and were searching for a way to improve the health of their community members suffering from this chronic disease. This guide provided an avenue in which to voice their collective successes and challenges as community health workers.

When MHHI was coming to a close, the research team felt that it was important to share with other CHWs what they had experienced. Cariño CHWs had spent 3 years navigating through the health care system, learning about community resources and identifying ways to keep their participants engaged. Many of those things they discovered from a variety of educational materials, other health care professionals, and through trial and error. As a result, the Cariño team decided to document their program in a way that is relatable and could be helpful to other CHWs in the field and/or entering the field of community health workers.

The guide was written in a span of two years. Year 1 consisted of weekly meetings in identifying and brainstorming the message the team wanted to relay. As time progressed, the development of the guide was divided into three parts: 1) CHW description and training, 2) Cariño overview and visits, and 3) Services, group session, and commitment. Two CHWs worked on 1) and 3) and the CHW manager worked on 2). CHWs incorporated stories about their experiences and techniques they used to make the program successful.

Year 2 consisted of field testing the guide. To ensure the research team included information relevant to other CHWs, Cariño field tested this guide three times among other CHWs and settings: 1) at the local level with CHWs from the South Florida Center for Reducing Cancer Disparities and ConnectFamilias, 2) at the regional level with Miami Dade Health Action Network, and 3) at the state level with The Florida Coalition of Community Health Workers. These CHWs came from different countries, work settings, and educational levels. These CHWs were employed by various organizations from academia to nonprofit organizations to community clinics, to name a few. Field tests were conducted in an open focus group format. Changes to the guide were made based on suggestions about format, content, and language. Changes were incorporated before each new field test and documented along the way. The program administrator also oversaw the project. When the content was complete, the principal investigator reviewed the material as well and provided feedback.

9. Please discuss the significance and impact of your product. In your response, discuss ways your product has added to existing knowledge and benefited the community; ways others may have utilized your product; and any relevant evaluation data about impact, if available. If the impact of the product is not yet known, discuss its potential significance.

This guide has the potential to be impactful for CHW programs. This guide incorporates information and data from varying sources and present it in a user friendly way. CHWs and administrators should find it helpful to learn about programmatic efforts, in addition to CHW history throughout the guide.

This guide presents information and data on how Hispanics have disproportionately suffered from diabetes, along with some cultural considerations when teaching diabetes management skills to Hispanics/Latinos. Through the guide, users will read about the history and background of CHWs such as the origins of the “barefoot doctors” in China and the US Department of Labor classification for community health workers.

The guide also outlines the roles and characteristics necessary for CHWs to be successful in their field. Users receive recommendations about training and networking. For example, information about the importance of CHWs being up to date with current social and health issues since this is a rapidly changing field, and providing information is a key component. Users can collect tips for how to assess their patients’ needs, conduct home visits and phone calls, and tailor support groups. There are also tips on the importance of making that first contact with their patients and how to build a rapport with patients. In addition, there are several notes on how to connect with hard to reach patients and how to build and maintain positive relationships. Users will also find strategies, agenda break downs, and other suggested materials helpful for their projects. There are also forms in the appendices to log interactions with patients. These forms were created by CHWs and used to keep files on their individual patients. CHW administrators reviewed these logs weekly to monitor patient development in the program, as well CHW outreach efforts.

The guide also outlines two types of barriers: 1) The barriers that kept patients from reaching the goals they set for themselves and 2) the barriers the CHWs experienced in facilitating patients in reaching their goals. CHWs and patients collaboratively identified the problem, developed solutions and created strategies to reach their goals. In order for CHWs to facilitate this process, a key element was demonstrating commitment and trust. CHWs were looking for a method to express this and they came up with concept of “cariñitos”. Examples of “cariñitos” were mailing birthday cards, randomly calling to see how the patient was doing and attending community events with their patient. This created personal impact and demonstrated a sign of genuine care. These cariñitos are outlined in the guide and examples are found in the appendices.

We believe our product has the potential to inform other CHW administrators on program design and assist CHWs in successful interactions with their patients.

10. Please describe why you chose the presentation format you did.

Our product was created in a user guide format as an instructional approach to present the wealth of information the CHWs had collected in an attractive, colorful way. One of our CHWs found a user-friendly design on Word Publisher. This allowed us to create incredible visuals, enhance the content, and include original pictures taken throughout the program. The format also demonstrates a unified way to provide content, testimony, and tips all on one page. The colorful design has been readily accepted by other CHWs in the field and has been remarked upon as easy to follow. This format also makes it convenient to share electronically via email/website or by printing.

11. Please reflect on the strengths and limitations of your product. In what ways did community and academic/institutional collaborators provide feedback and how was such feedback used? Include relevant evaluation data about strengths and limitations if available.

This guide’s critical strength is that it was created by CHWs for CHWs. It has a unique perspective that can only be given by someone who has worked in this particular field. In addition, there is a span of information taken from different sources and made into a user friendly guide. As mentioned earlier, the guide gives information on programmatic efforts so that it can contribute towards the design of a community-based project. A limitation of this guide is that it is specific to Hispanics living with diabetes. However, much of the information given can be tailored to any CHW project, regardless of population or disease.

Although this guide was created by the Cariño team, there were outside community health care providers who shared constructive feedback. One such key collaborator was Ms. Brendaly Rodriguez, the manager of the Community Engagement and Cultural Diversity Program at the Miami Clinical and Translational Science Institute. In addition, she is the co-chair of the Florida Community Health Worker Coalition. As a result of her experience and knowledge, she was able to advise us about valuable information for audience members and future users of the guide. Ms. Rodriguez also facilitated the three field tests. Locally, it was held at the University of Miami Miller School of Medicine with CHWs from Connect Families and Health Choice Network. At a regional level, it was field tested at Miami-Dade College during the Regional CHW Annual Symposium. And finally, at a state level, it was field tested during the Annual CHW Coalition Summit in Orlando, Florida. Some of the common feedback ranged from font size, color, layout of certain pages, pictures to include or not include, to the reading level, and how to best disseminate this product. The feedback we received from these field tests was incorporated into the design and content of the guide.

12. Please describe ways that the project resulting in the product involved collaboration that embodied principles of mutual respect, shared work and shared credit. If different, describe ways that the product itself involved collaboration that embodied principles of mutual respect, shared work and shared credit. Have all collaborators on the product been notified of and approved submission of the product to CES4Health.info? If not, why not? Please indicate whether the project resulting in the product was approved by an Institutional Review Board (IRB) and/or community-based review mechanism, if applicable, and provide the name(s) of the IRB/mechanism.

Miami Healthy Heart Initiative was informed by contemporary models of successful interventions aimed at improving health among racially and ethnically diverse communities. Within this framework are important elements of the chronic care model, including self-management support, clinical information systems, delivery system redesign, decision support, health care organization, and community resources.

The MHHI approach was also guided by the fact that as people spend almost all of their time residing within their communities, interventions that focus solely on care delivered within traditional health care systems may have a limited impact. In the project design, the patient’s community and environment, encompassing everything from governmental policies to community and health care organizations, are considered as levers to be addressed as part of a comprehensive intervention. For this reason, Cariño is primarily focused on community-level interventions in which the CHWs successfully link persons in underserved settings with approaches that can effectively improve their overall health.

Throughout the project, the CHWs regularly tailored the program based on the needs and input of their patients. Since the CHWs were familiar with and/or came from similar communities as their patients, CHWs were able to provide a culturally sensitive approach to delivering the study intervention. Throughout the program, patients were also encouraged to express their opinions and suggestions about how to strengthen Cariño, which gave the patient a sense of ownership within the program.

The guide was created with multi-level input directly from CHWs, from patients, from the Principle Investigator (PI) and from program management. When the idea of developing a CHW guide was offered, the CHWs knew that in order to keep the guide authentic, patients’ input was the key ingredient. As a result, the CHW introduced the idea of the guide to the patients at an educational group session. At this time, it was decided that there would be a brainstorming session where CHWs and patients would collaboratively design and outline the guide to highlight the impact of Cariño both from the CHWs’ and the patients’ vantage points. The CHWs treated this session as a focus group, recording and transcribing the information shared. Some of the topics covered during the focus group were:
• Nutrition and exercise improvement
• Group sessions/support group
• Patient/healthcare provider relationships
• Family education and its impact
• CHW and patient relationships
• Diabetes knowledge and management
• Social and mental health
• Understanding the healthcare system (navigation)
• CARINO duration and continuation

Furthermore, the Cariño team embodied principles of mutual respect by working together where the PI provided direction and guidance, management facilitated content on training and program design, CHWs provided knowledge on patient navigation and the patients provided critical information about the needs of the community.

The study protocol was approved by the University of Miami Institutional Review Board (Protocol #20090751). The study was also registered in the ClinicalTrials.gov registry.