Prepared for the Office of Health Disparities, Colorado Department of Public Health and Environment
Amendment 35 Program Evaluation Group
•
The Colorado Health Disparities Grants Program,
January 2006 – July 2008: a retrospective evaluation
January 2009
Contents
Executive Summary.........................................................................................................................1
Background......................................................................................................................................3
Methods ...........................................................................................................................................4
Summary of Reach ..........................................................................................................................7
Success Stories ..............................................................................................................................11
Limitations.....................................................................................................................................17
Recommendations .........................................................................................................................18
Appendix 1. Health Disparity Priorities in Cancer, Cardiovascular and Pulmonary Diseases .....19
Appendix 2. Implementation by Disease Category .......................................................................21
Appendix 3. Project List and Strategies…. ……………………………………………………...33
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Executive Summary Introduction In the November 2004 election, Coloradans approved constitutional Amendment 35 to increase the cigarette tax by $0.64 per pack and dedicate the revenues for health-related purposes. Starting in January 2006, the Office of Health Disparities (OHD) began awarding a portion of these revenues in the form of competitive grants to prevent, diagnose and treat tobacco-related illnesses (cancer, cardiovascular disease, and pulmonary disease) among Colorado’s ethnic and racial minority populations. Through July 2008, the OHD awarded $9,085,319.00 for 34 projects. The Amendment 35 Program Evaluation Group (APEG), at the University of Colorado Denver, was asked to evaluate the award portfolio as a whole and provide recommendations regarding funding directions and data collection needs. APEG compiled and analyzed data that were reported to OHD, organized by disease, target population, and intervention strategies. Portfolio Distribution by Disease, Population, and Strategy
Cardiovascular disease projects received nearly half of awards (15/34) and funds (47%). The next largest category was "crosscutting" projects that addressed multiple diseases (15 projects, 41% of funds). Cancer projects received three awards and 9% of funds. One pulmonary disease project received 3% of funds. The portfolio included at least some activity for every ethnic and racial minority population.
• Half of the projects (53% of funds) were intended to serve Latinos. • Eight projects (27% of funds) targeted more than one racial and ethnic minority. • Four projects (5% of funds) were intended to serve African Americans. • Three projects (9% of funds) aimed to serve Native Americans. • Two projects (6% of funds) were intended to serve Asians and Pacific Islanders.
Most funded projects used multiple strategies to meet their objectives. Almost all projects (33) delivered health education or awareness, or both. Individual-level activities to promote awareness of health risks, healthy behaviors, screening and health management programs reportedly reached 37,893 Coloradans. Similar messages via media (radio, television, newspaper) made 987,300 impressions. Health education classes and programs served 34,850 individuals directly and delivered 75,300 media impressions. More than one-third of projects (17) provided patient care services such as disease management, access to care, treatment, patient navigation and interpretation/translation. Other strategies included screening (13 projects), risk factor reduction (12), referrals (8), and Promotoras or community outreach workers (6). Indirect delivery approaches included provider or health care worker education (12), cultural competency (3), data collection and analysis (12), and partnerships/collaboration (4). Most projects took place in community settings such as health fairs, clinics, faith-based locations, schools, recreation centers, and a beauty salon. Disease-Specific Findings Cardiovascular Disease. Most projects focused on diabetes-related conditions among Latinos, delivering direct education to a reported 26,263 people, risk factor reduction through nutritional or
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physical activity programs to a reported 57,204 people, and community outreach/Promotoras for informational, educational and screening services to a reported 19,508 people. Cancer. Three projects addressed cancer. One project distributed cervical cancer awareness materials to 1,896 people at health fairs, and delivered an estimated 16,000 impressions through public service announcements. The targeted population was Asian and Pacific Islander women. Educational efforts through outreach, workshops and community forums reached a reported 1,347 people. Educational workshops about cancer prevention were provided to Asians and Pacific Islanders. Education regarding prostate cancer screening was provided to African American men; regional data along with general cancer information were provided to regional action teams. Fifty-two African American adults gained access to care through transportation for prostate screening. Asians and Pacific Islanders received screening and patient navigation services; in some cases, linguistically matched navigators accompanied women to cervical cancer screening exams. Pulmonary Disease. In one project addressing pulmonary disease, approximately 1,500 Asians and Pacific Islanders received screening for asthma and allergies. Crosscutting. Crosscutting projects reached African American, Latino, Native American, and multiple racial and ethnic minority groups (REM) populations through a wide variety of programs and activities. Multiple strategies were used to influence healthy behavior, which included awareness (reached 30,532), education (reached 7,240 directly and 75,300 through media) and risk factor reduction (reached 6,710). Crosscutting projects reported the use of mass media strategies, reach into youth and families, and activities aiming to close gaps in disparities by providing health care training and educational opportunities to minorities. Conclusions
• Substantial numbers of Coloradans received information about cardiovascular disease and multiple disease risk factors, delivered in culturally congruent ways and through community members with perceived credibility. Reliable reach estimates are unavailable due to inconsistencies in grantee reporting. Data quality can be improved through periodic training on topics such as logic models, SMART objectives, and evaluation tools.
• Most projects (28 of 34) used multiple direct delivery strategies, frequently combining education and training with awareness (and/or other strategies) or employing multi-pronged approaches such as screening and referral.
• Fifteen projects provided patient services such as disease management, access to care, treatment, patient navigation, and translation. Most of these efforts were in cardiovascular disease and crosscutting projects.
• Funding was concentrated in certain populations, diseases, or intervention delivery strategies. Explicit rationales for funding concentrations will enable evaluation to assess the alignment of funding with priority needs and funder purposes.
• Need-based opportunities may exist for programs addressing cardiovascular disease and diabetes among African Americans and Native Americans, as well as cancer and pulmonary disease among several populations. Decisions to increase funding diversity should weigh the tradeoffs of addressing many problems vs. concentrating on a few problems.
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Background
In the November 2004 election, Coloradans approved constitutional Amendment 35 (A35) to increase the cigarette tax by $0.64 per pack and specify use of the revenues for health-related purposes. The Colorado Department of Public Health and Environment (CDPHE) receives 16% of these funds to address the prevention, early detection, and treatment of tobacco-related diseases, specifically cancer, cardiovascular disease (including diabetes and other precursors), and pulmonary disease. Fifteen percent of the funds targeting tobacco-related diseases is distributed through competitive awards through the Office of Health Disparities (OHD) to address tobacco related illnesses among racial and ethnic minority populations. Awards are made upon recommendation by the Minority Health Advisory Commission (MHAC) and approval by the Board of Health.
The Amendment 35 Program Evaluation Group (APEG), at the University of Colorado Denver, was asked to analyze the portfolio of OHD-funded projects from program inception in January 2006 through June 2008, and address the following questions:
• What is the estimated reach of the funded projects into minority populations? • How do funded projects align with identified health disparities? • How were funded projects implemented? • What reach or implementation data are unavailable? • What are some identified successes? • What key lessons were learned from these funded projects?
This report describes the APEG evaluation process and results.
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Methods Guiding Frameworks
APEG designed the analysis of OHD-funded projects within two frameworks:
• Elements of the RE-AIM model • Program Delivery Strategies
RE-AIM Reach and Implementation The RE-AIM model of Russell Glasgow1 and others recommends that an intervention’s impact be evaluated by considering its Reach, Effectiveness, Adoption, Implementation, and Maintenance. For the current evaluation, APEG focused on Reach and Implementation, which can be measured retrospectively without waiting for long-term effects such as reduced disease or death, and can be summarized across many projects. We applied the following definitions to the abstraction and review process:
Reach Number of individuals known to have received an intervention designed to improve their health and/or lower their disease risk. Reach does not include people who are trained to deliver an intervention.
Implementation The processes of delivering an intervention, including who delivered it, where, how, and how much was delivered.
Program Delivery Strategies
Like the populations they served, OHD-funded projects were highly diverse in the objectives they pursued and the approaches they applied. To summarize this diversity, we identified program delivery strategies that were implemented by multiple projects and grouped them by direct or indirect delivery mode. Direct delivery aims an intervention or activity directly at patients or individual community members. Examples include a blood-lipid screening project for Latinas in the San Luis Valley, and an exercise class for African American residents of northeast Denver. Direct delivery projects allow the possibility of counting the number of people reached, and, in some cases, describing participant characteristics.
Indirect delivery targets groups, organizations, or infrastructures to adopt an intervention and deliver it to patients or community members. Examples include training physicians to use a specific protocol when treating patients, and development of community collaborations to enhance access to care and referrals. The reach of indirect delivery strategies is often hard to measure. For example, using the example of physician training to use a new patient protocol, the number of patients the physician used the protocol with must be collected. In the case of community collaborations, it is difficult for organizations to measure how many new people were reached due to the collaboration.
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The following strategies were identified from APEG review of projects and were applied to data abstraction:
Direct Delivery Strategies
Strategy Activities
Awareness / Media Advertising campaigns, handouts. Focus: brings attention to an illness, services, or resources.
Access to Care Fee reduction, vouchers, transportation services for patients. Focus: activities that directly help patients get services by eliminating or reducing specific, known barriers to those services.
Education / Training Health education for patients or community members. Focus: brings specific new knowledge or skills to individuals
Screening Screen individuals for specific illnesses or risk factors. Focus: detect illness for further follow-up care; detect risk factors to prevent onset or progression of illness or disease.
Risk Factor Reduction Weight loss or exercise programs, nutrition programs, smoking cessation, sun protection. Focus: engage individuals in specific activities to prevent illness or reduce risk factors.
Disease Management Patient navigation, case management, self-management programs. Focus: for patients who already have a disease or illness, programs aim to prevent worsening symptoms, exacerbations, or improve use of resources.
Treatment Provide specific appropriate treatment. Focus: treat individuals for cancer, cardiovascular disease, or pulmonary disease.
Community Outreach Worker / Promotora
Community member responsible for raising awareness of health and educational information and programs Focus: engage individuals in health information and promotion through culturally congruent community member.
Referral Recommending a patient or community member to follow-up care, usually after screening for disease or risk factors. Can also include referrals to community services or resources following assessment of eligibility or appropriateness. Focus: direct patients to appropriate follow up care or service.
Translation / Interpretation
Facilitating communication from one language form into its equivalent, in another language form Focus: Reduce language barriers in health education and access.
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Indirect Delivery Strategies
Strategy Activities
Collaboration/ Partnership
Build or enhance joint efforts with other agencies, organizations, or businesses. Focus: improve coordination, develop combined resources, and establish working relationship between or among entities to enhance overall capacity.
Education / Training Training of clinicians, providers or other health care workers; continuing education. Focus: brings specific new knowledge or skills to health care workers, either lay or professional.
Infrastructure Acquire equipment, staff/personnel, supplies, administrative skills or systems, or other resources. Focus: build capacity or infrastructure to improve intervention delivery, expand reach, or enhance resources.
Data collection / Analysis
Collect or analyze primary or secondary data. Focus: new data collection activities or review existing data to assess need, scope, or descriptive information about a population related to programming.
Policy Develop, ratify or implement policies. Focus: policies that promote health, reduce exposure to harm, or build capacity.
Data abstraction and analysis
OHD grantees submit quarterly and annual progress reports. APEG developed a Microsoft® Access database to abstract data and review projects uniformly across A35 funding sources. Data on reach and implementation were abstracted from annual reports, or, in cases where annual reports were unavailable, from quarterly reports and proposals. Available data were entered from 57 annual reports (of 65 expected), supplemented where necessary by quarterly reports and proposals. Entered data were organized into tables by disease and strategy and were compared with source documents to clarify ambiguities, address questions, conduct further data cleaning, and resolve inconsistencies. The data were then analyzed to estimate reach and identify themes regarding implementation.
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January 2006 - June 2008
Asian $557,143
(6%)
Native American $848,477 (9%)
African American, $454,263(5%)
REM*$2,446,652
(27%)
Latino
$4,778,817
(53%)
Figure 1. Funding by target population
* Projects targeting more than one racial and ethnic minority group (REM).
Cardiovascular Disease $4,262,673 (47%)
Cancer $856,068 (9%)
Pulmonary Disease $239,624 (3%)
Crosscutting, $3,726,960 (41%)
Figure 2. Funding by Disease
Summary of Reach
During January 2006 through June 2008, OHD awarded approximately $9 million to 34 projects (Table 1).
Table 1. OHD Awards by Year
Period Total New or Continuation January – June 2006 $1,333,663 new (n=18) July 2006-June 2007 $2,907,426 continuation (n=17) July 2006-June 2007 $2,543,564 new (n=16) July 2007-June 2008 $2,300,666 continuation (n=15)
Total $9,085,319 Figure 1 shows the distribution of funds by target population. Projects focusing on Latinos received approximately half of funds, and projects addressing more than one racial and ethnic minority (REM) received approximately one-fourth of funds.
Figure 2 shows the distribution of funds by disease. (Projects addressing more than one disease are described as crosscutting.) Most projects addressed cardiovascular disease or were crosscutting.
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Figure 3 shows the distribution of projects by direct delivery strategy. Education and training were the most frequently employed strategies across diseases, followed by awareness, screening, and risk factor reduction.
Number of Projects by Disease and Strategy
0 5 10 15 20 25 30
Education/Training
Awareness
Disease Management
Screening
Risk-factor reduction program
Referrals
Community Outreach Worker/ Promotora
Patient Navigation
Translation
Media (Awareness)
Media (Education)
Access to Care
Treatment
Stra
tegy
Number of Projects
CVD (n=15)Cross-cutting (n=15)Cancer (n=3)COPD (n=1)
Tables 2 and 3 show numbers of people reportedly reached. Results are organized by direct delivery strategies and disease (Table 2) or target population (Table 3). The numbers in these tables are estimates, and over-counting cannot be ruled out, particularly for education, awareness and risk factor reduction strategies (data limitations are described in the Limitations section of this report). Tables 2 and 3 include media impressions, reported in (parentheses), which represent the estimated number of times messages are viewed in a population. Media campaigns typically deliver a message multiple times to increase the likelihood that the content registers on audience members, so the number of impressions does not represent the number of individuals reached. Media impression reporting was inconsistent and sometimes not reported. Totals by column are not shown because of the likelihood that individuals were reached by more than one strategy. Data limitations prevent reliable estimation of total reach across OHD-funded projects. A plausible approach is to estimate reach under two opposite assumptions – that every strategy reached a different individual (highest estimate), or that every strategy reached the same group of people (lowest estimate). This approach sets the range at approximately 57,000 to 195,696 Coloradans. Actual reach could be lower, due to possible over-counting (although it’s highly unlikely that every project served the same group of people). Actual reach cannot be higher unless some projects omitted some reach in their reports. The true number probably falls within the range, although where it lies is impossible to determine.
Figure 3. Strategies used by funded projects
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The most wide-reaching delivery strategies reported were risk factor reduction, awareness, and education/training. Cardiovascular disease and crosscutting risk factors were the most common targets. Latinos were reportedly reached by all direct delivery strategies. African Americans were reached mostly through awareness and education / training strategies, Native Americans through awareness and risk factor reduction, and Asians and Pacific Islanders through awareness strategies and some screening.
1 Total reach by disease is not shown because one individual may have been reached by multiple strategies.
Table 2.1 Reported Reach by Strategy and Disease (number of projects)
Cancer (n=3)
CVD (n=15)
COPD (n=1)
Cross-cutting (n=15) Total
Access to Care 52 60 112Awareness (media)
1,896 (16,000*)
5,465 (971,300**)
30,532 37,893 (987,300)
Outreach / Promotoras 19,508 1,606 21,114Disease Management 2,502 415 2,917Education / Training (Media)
1,347 26,263 7,240 (75,300***)
34,850 (75,300)
Patient Navigation 60 4,683 608**** 5,351Referrals 5 145 821 971Risk-factor Reduction 57,204 6,710 63,914Screening 143 10,361 1,500 406 12,410Translation / Interpretation 8 37 45Treatment 1,214 1,214* represents estimated reach of public service announcements circulated through newspapers ** represents awareness impressions estimates through newspaper (9,000), television (960,000) and radio (1,500) *** Includes an estimated 15,000 weekly radio show listeners and 63,000 television show viewers **** total was not reported
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Figure 4. Number of Projects by County
Table 3.2 Reported Reach by Strategy and Population
African
American (n=4)
Latino (n=17)
Asian (n=2)
Native American
(n=3)
Racial/ Ethnic
Minorities (n=8) Total
Access to Care 52 60 112Awareness (media)
1,175 29,440 (971,300*)
1,896 (16,000**)
882 4,500 37,893 (987,300)
Outreach / Promotoras 19,636 1,478 21,114Disease Management 2,847 70 2,917Education / Training (media)
4,737 26,731 (75,300***)
344 65 2,973 34,850 (75,300)
Patient Navigation 100/wk.**** 4,683 60 608 5,351Referrals 963 5 3 971Risk-factor Reduction 57,198 326 6,390 63,914Screening 110 10,596 1,654 50 12,410Translation / Interpretation 45 45Treatment 1,214 1,214*represents awareness impressions estimates through newspaper (9,000), television (960,000) and radio (1,500) ** represents estimated reach of public service announcements circulated through newspapers *** Includes an estimated 15,000 weekly radio show listeners and 63,000 television show viewers **** total was not reported
OHD-funded projects were active in 41 of 64 counties (figure 4), with the largest numbers in Denver, Adams, Arapahoe, Jefferson, and Pueblo counties.3
2 Total reach by population is not shown because one individual may have been reached by multiple strategies. 3 Figure 4 excludes four statewide projects and two projects that did not provide regional data.
10 to 15
4 to 9
2 to 3
1
0
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Success Stories The Office of Health Disparities (OHD) selected four projects to provide anecdotal highlights of the work they conducted through OHD awards. These grantees represent projects with varying organizational structures, including two community-based organizations, a university-based program, and a local affiliate of a national not-for-profit health organization. The Amendment 35 Program Evaluation Group (APEG) collected project highlights through a written questionnaire and follow-up telephone interviews. This section of the report summarizes organizational enhancement and individual "success stories" reported by the four projects.
Summary of Organizational Enhancement
The four grantees reported that the Health Disparities Grants program enhanced their organizations in the following ways. Building Capacity The grantees consistently reported that OHD funding enhanced their organizational capacity.
• One grantee noted that staff learned skills that made it possible “to increase the infrastructure of the program.”
• Another grantee reported having gained “significant experience and skills working with [disparate] populations.”
• Grantee organizations were enhanced through formation of “new partnerships and collaborations.”
Sustaining Success Grantees reported that taking part in the Health Disparities Grants Program helped their organizations seek additional sources of funds. “We are now better prepared to apply for such grants,” said one grantee. “It has helped to obtain grants, because the OHD funding adds credibility to the program,” another said. Grantees generally agreed that the positive impacts on their programs were sustained after OHD funding ended. Impacting Communities Several grantees said OHD funding had an impact beyond their individual projects, such as maintaining collaborations among community organizations after project completion. Other community impacts were seen through participants of exercise classes bonding with one another, networking and continuing physical activities like mall walking. One project reported that after the health disparities grant funding ended, they were able to obtain alternate funding to maintain exercise classes and now have over 100 regular attendees in addition to having developed new community projects.
“It was a positive capacity-building experience for us.” – OHD Grantee
“The … program is sustained and continues to grow through grants received. Regularly scheduled workshops continue without being canceled. We strive to have continuity of the program to serve the Latino community in Colorado.” – OHD Grantee
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Por Tu Familia: Challenging the Latino Community to Change Lives Por Tu Familia: Retando a Nuestra Comunidad Latina a Cambiar Sus Vidas
The Latino population is disproportionately affected by serious health problems such as diabetes. They are more likely to be uninsured, to face barriers to health promotion and prevention information, and to be overweight. A Multi-Pronged Approach The American Diabetes Association in Colorado developed an innovative project to educate the Latino community about diabetes and cardiovascular disease, based on an existing model for Latino outreach, Por Tu Familia. Funding from the Office of Health Disparities made it possible for the American Diabetes Association to expand the focus of Por Tu Familia, promoting awareness through media, to include educational workshops and screening services. This project served twenty counties throughout Colorado. Por Tu Familia was designed to be appropriate for the Latino community, with educational materials provided in Spanish and outreach occurring in churches where participants would feel comfortable. But this project also challenged the Latino community to learn about what they could do to improve their health and how to access services from clinics. The project’s three main activities are described below.
• Awareness: A promotora-led awareness campaign was implemented through 120 churches and Spanish-language mass media. These activities helped people understand diabetes and encouraged participation in educational workshops. Participants also learned how to access health care services at low-income clinics.
• Screening: Cholesterol and glucose screenings were offered to people attending the workshops. An important part of the services was follow-up to those who needed treatment.
• Educational Workshops: Forty-one evidence-based workshops took place in low income clinics and community health centers. Registered dieticians provided information about nutrition, diabetes, and cardiovascular disease, and exercise classes were given.
Project Impact Por Tu Familia has reached more than 18,000 Latinos in the state of Colorado through educational workshops and screening services– and even more through the awareness campaign. American Diabetes Association staff report that the project has benefitted them personally, as they have become more physically active to set a good example for participants. Before, said Julissa Soto, “None of us exercised. Now we’re all runners.” Contact: Julissa Molina Soto, Amer. Diabetes Assn., Assoc. Dir. of Latino Outreach,
2480 W. 26th Ave # 120B, Denver, CO 80211 Telephone 720- 855-1102 X 7027
Diagnosing Diabetes: Por Tu Familia Helps a Community Member
A gentleman was screened for glucose and cholesterol levels. He was waiting with his wife and infant daughter for the results of his screening. His glucose level was over 300, and the cholesterol level was high as well. When he received the results, he was referred to the local clinic. We followed up with him a month later. He had been diagnosed with diabetes and was working on managing it. A few months later, Our Lady of Guadalupe hosted another Por Tu Familia workshop, and the gentleman came with his family to thank the program for all it does and to say his diabetes was under control thanks in large part to the education of the program.
Colorado has been the only state operating under this model. Now other states are trying to duplicate the model used in Colorado. – Reported by Julissa Molina Soto, Associate Director of Latino Outreach
A Por Tu Familia participant at a clinic.
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Healthy Body, Healthy Spirit: Changing Lives, One Person At A Time
Diabetes and heart disease are significant health problems in Pueblo County, Colorado: The prevalence of diabetes is higher than in the rest of Colorado, and Latinos in particular face higher rates of diabetes. Lack of physical activity, obesity, dietary habits, poverty, and minority status are all contributors to diabetes and heart disease. Healthy Body, Healthy Spirit addressed disparities related to diabetes and heart diseases through an evidence based curricula called the Diabetes Prevention Program that focuses on dietary changes and physical activity. Glucose and cholesterol screenings held in churches helped educate participants about their health status. Educational classes were presented by health educators. These classes offered the opportunity to share with other participants and provided activities with a spiritual component. The program also held three physical activity classes a week for eighteen weeks.
Many Pueblo residents benefitted from participation in Healthy Body, Healthy Spirit • More than 340 residents attended classes. • 73% of regular participants lost weight. • Nearly a quarter of participants decreased
their body weight by 5% or more. • There were significant decreases in BMI,
waist/hip ratio, systolic blood pressure, total cholesterol, LDL, and triglyceride levels.
Contact: Carol Foust, Colorado State University- Pueblo, Chair and Professor, 2200 Bonforte Blvd. Pueblo, CO. 81001 Telephone 719-549-2337
A Participant Transforms Her Life Program staff received a call from a physician who just couldn’t believe the significant impact that Healthy Body, Healthy Spirit had on his patient’s overall health. The participant had been overweight for the past 20 years. Through Healthy Body, Healthy Spirit, she lost 55 pounds. She no longer needed her cholesterol medication, her blood pressure medication was reduced significantly, and her A1c level went way down. “She just significantly improved her physical health,” said Carol Foust, the project director. “And, of course, you can imagine she felt way better, she was happier, she was more active.”
“[Participants] have created these bonds. A lot of them go to class together, but then they meet and they walk at the mall … We now have a garden project, and some of those people in those classes are getting involved in our community garden project … it’s just amazing, the kinds of networking.” – Carol Foust, Healthy Body, Healthy Spirit director.
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CAHEP Addresses Health Disparities While Raising the Bar on Cultural Competency
Many health care needs are unmet or underserved among the Asian American/Pacific Islander (AAPI) population in Colorado. Cultural and linguistic barriers make it hard for members of this population to access health care services. The community faces higher rates of emergency department visits, hospitalizations, and higher asthma mortality. Few data are available regarding pulmonary disease prevalence among the community. Colorado Asian Health Education and Promotion (CAHEP) addressed health disparities with OHD funding. The main objectives were to enhance understanding among AAPI individuals about asthma and other chronic illnesses, increase access to screening and early detection of diseases and to identify cultural competency gaps and training needs among healthcare providers. Through community-based participatory methods and engagement of community
leaders, CAHEP reached into AAPI communities and provided services to a
diverse population representing multiple countries (India, Thailand, China, Korea, The Philippines, Vietnam, Laos and others). CAHEP provided allergy and asthma screening to more than 1,500 people at more than 44 community health fairs, as well as diabetes and TB
screenings. Of those screened through CAHEP’S efforts, 62.7% of the people reached were uninsured and 45.3% had family income less than $25,000 annually.
Multi-Level Successes
• Individuals in need of health care services were reached.
o more than 1,500 people screened for asthma and allergies o routinely saw people who had not had a physical exam for10-15 years o a high proportion who had never accessed the standard health care system o 135 people who needed follow-up services but did not have health insurance o 37 uninsured people who had test results indicating
disease • Participants were assisted with access to culturally congruent and
affordable follow up care. • Deep reach into the community was made possible by the trust
built with the agency. • CAHEP created strong networks and groups within communities. • Interviews and surveys of more than 150 health care providers
increased understanding of cultural and language barriers. • Training needs were identified. • Screening information with demographic data was collected.
Contact: Alok Sarwal, Ph.D. Colorado Asian Health Education and Promotion, Executive Director 6795 E.
Tennessee Ave #220 Denver, CO. 80224 Telephone 303-300-5263
Without the CAHEP screening event, these individuals would likely not have known about the need for diagnostic care and the fact that asthma or other disease might be present. --According to Dr. Alok Sarwal
“The trust has been built, and they know that we are giving quality, really high quality services with our medical staff …They also know that we will not abandon them after the screening is done.” –Dr. Alok Sarwal, Executive Director, CAHEP
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Training the Trainer
The Center for African American Health trained 19 community and staff members to facilitate chronic disease awareness and education, enhancing the organization’s capacity to implement subsequent Chronic Disease Management programs.
The Center for African American Health: Tackling Cardiovascular Disease
in the Denver Metro African American Community
In Colorado, the African American population has the highest rate of death from heart disease, 1.5 times the state average. This is due in part to cultural factors that influence dietary and exercise beliefs and behaviors.
Highlights of Project Successes • Partnerships were formed with several
organizations, including the Denver Bronco Alumni Association, to develop culturally relevant CVD programming for African American men.
• The project provided culturally appropriate and engaging educational opportunities with more than 100 participants in the CVD awareness education workshops.
Partnership with Denver Broncos Alumni Association
Through its annual survey, the program found that African American men have less knowledge of CVD risk factors than women. To address this, the African American Man’s Playbook was created through a partnership with the Denver Broncos Alumni Association, which incorporated a football theme that appealed to men. The brochure gives "quarter-by-quarter" information on CVD and tips that men need to have a healthful life.
“We are most proud of our ability to get the word out and raise awareness about heart disease, and reach people in unique categories.”
“Health fairs are conducted in a culturally appropriate and engaging way,
and people are really anxious to come to our events.”
Lucille Johnson, Director for Health Initiatives, Center for African American Health
Education and Awareness through Workshops
In the African American community, cardiovascular disease (CVD) is a health topic that needs to be talked about, but people don’t want to talk about. In partnership with the Colorado Neurological Institute and the Colorado Prevention Center, education and awareness workshops were conducted. The workshops started in faith-based settings but have expanded to other settings and even include the 80 Bombardier engineers from the Denver International Airport.
During the 2006 Annual Health Fair, youth step groups were charged with the task to create a step routine incorporating cardiovascular health messages. These routines were innovative, creative, and appealed to all age groups.
Denver International Airport’s 80 Bombardier Engineers
Contact: Grant Jones, Center for African American Health at the Metro Denver Black Church Initiative, Executive Director, 3601 Martin Luther King Blvd Denver, CO 80205 Telephone 303-355-3423.
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Limitations The results in this report are subject to the following limitations:
• Projects were required to submit quarterly progress reports and a final report. While these reports often included sufficient details for monitoring progress, they were not designed to provide reach or implementation, which are the main targets of the current evaluation. The requirements also did not include reporting of strategies. Beginning in July 2008 (FY09), new reporting requirements should facilitate improved understanding of reach and implementation across the OHD program.
• In some reports, data on reach and implementation lack contextual clarity, are missing, or are ambiguous. As a consequence, APEG could not conclusively estimate reach for some projects, or their implementation could not be readily summarized. In such cases, APEG reviewers exercised judgment about the quality of data to determine whether it could be abstracted or would be omitted. Some reach data may appear under the wrong strategy due to ambiguous information about the activity.
• For some projects, the methods of collecting reach data likely counted individual participants more than once, resulting in duplication. In addition, the need to abstract some data from multiple reports raises the possibility of double counting. Reviewers used additional report information where possible to avoid entering duplicate data. Where we remained uncertain, we included reach data at the risk of overestimating reach.
• Reach through media are strictly estimates and were not uniformly reported. • Reported data provided by the grantees were accepted as accurate and truthful without
further verification. • Where race/ethnicity was not reported, we classified the data based on other information
in reports and the stated project objectives.
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Recommendations The OHD A35 funding portfolio for the funded periods February 2006 through June 2008 emphasized cardiovascular disease projects, education and awareness strategies, and Latino populations. These emphases may be appropriate, but no explicit rationale was provided. Future portfolio choices and funding distribution will be more thoroughly evaluable if they are based on explicit intentions, criteria, and priorities. For example, OHD and MHAC could decide to focus future funding based on a problem’s severity, the availability of effective strategies to address it, the size of the affected population, a need to make a large impact on some but not all problems, or other criteria. Or, future funding could be dispersed, in order to serve all ethnic and racial populations equitably, build capacity equitably, align funding with population sizes or the size of their needs, etc. Whether focused or dispersed, intentional approaches to grant making require thoughtful planning. Clearly identified funding goals and objectives will not only improve programming but will also make more robust evaluation possible. Current reporting requirements prevent analysis of funding allocations by strategy. The potential benefits of this information might include knowledge of costs associated with specific strategies, as well as more detailed knowledge of overall funding distributions. These benefits should be weighed against the additional grantee burdens that would be imposed by the necessary budget and reporting modifications. Grantee reporting was inconsistent during the period evaluated. Periodic training on topics such as logic models, SMART objectives and evaluation tools could improve the quality of proposals and enhance data collection while also enhancing organizational capacity. The APEG measurement toolkit, which was provided to grantees after the evaluation period, is expected make reach and implementation data reporting more complete and consistent in the future. While all projects should report reach and implementation data to ascertain outcomes, criteria are needed for deciding whether some projects should undergo additional evaluation. In general, the goal of additional program evaluation should be to guide future project funding decisions. Examples of criteria include potentially large impact if a small project were more widely implemented, the need to develop a new strategy where existing approaches have failed, or the allocation of large dollar amounts to one project.
19
Appendix 1.
Health Disparity Priorities in Cancer, Cardiovascular and Pulmonary Diseases
APEG reviewed state and major national plans and recommendations related to cancer, cardiovascular and pulmonary disease in order to identify strategic priorities among minority populations. The following ten plans were reviewed: • Turning Point Initiative • Colorado Health Disparities Report (2005) • Colorado Health Disparities Conference • Colorado Heart Healthy and Stroke Free: Reaching the future 2005-2010 • Colorado Action Plans for
o Asthma o Cancer o Diabetes o Physical Activity & Nutrition
• USHHS Initiative to Eliminate Health Disparities • Healthy People 2010 This report focuses on diseases and conditions chosen for retrospective summary by the Minority Health Advisory Commission (MHAC) on Oct. 5, 2007. The priorities identified in Colorado and nationally are displayed by population in Table 4. The numbers of OHD funded projects addressing each disease/condition are included, along with the frequency of funded projects addressing more than one racial and ethnic minority. The priorities outlined in this table are also referred to in Appendix 2, Implementation by Disease Category section of this report.
20
Table 4. Office of Health Disparities strategic priorities, by population
and number of funded projects*
Latino
African American Asian
Native American
REM**
Cancer death (overall) 555555 1 Breast cancer death Cervical cancer 1 Prostate cancer 1 Colon cancer death Lung cancer Asthma management 1 Cardiovascular disease (heart disease & stroke) 13 3 1 1 1
Diabetes 15 1 2 1 Healthy life style choices (nutrition, physical activity) 17 2 3 5
Obesity 6 1 3 2 Diversity & cultural competence in health professions 1 3
* number of funded projects addressing identified disparity (projects may address more than one priority) ** The REM (racial and ethnic minorities) column lists projects addressing more than one racial or ethnic minority Colorado Priority; US & Colorado Priority; US priority
21
Appendix 2.
Reach and Implementation by Disease Category Implementation data included settings, intervention content, delivery methods, and intensity (how often or how much). Two limitations are noted here:
• To be effective, awareness strategies often repeat messages to the same audience in different ways. Many projects reported counts of delivered items (e.g., brochures) or audience size, not whether multiple dissemination approaches were used to reach the same people.
• Education and training were common strategies, but information was generally not reported on content, delivery method, or dose.
Disease Specific Findings
Cardiovascular Disease
Overview: Heart disease is the leading cause of death among Colorado minorities. African Americans consistently had the highest death rate*. Furthermore, diabetes, healthy behavior/lifestyle (physical activity and nutrition) and obesity are all considered health disparate diseases and conditions for Latino, African American, and Native American populations nationally. Through the Office of Health Disparities, 15 projects were funded during partial funding period in FY 2006 and the FY 2007 – 2008. All of the projects were funded for two years with six projects starting in fiscal year 2006 and nine projects starting in fiscal year 2007. Thirteen of those projects focused more specifically on diabetes, a precursor to cardiovascular disease (CVD). Populations targeted were consistent with the priority diseases and conditions identified for racial and ethnic minorities in Colorado (Table 4); however, Latinos were the focus of 12 projects and constituted the majority of those targeted. Two projects targeted Native Americans, and one project targeted African Americans. Direct Cardiovascular Disease Strategies: Reach and Implementation. Grantees implemented a wide variety of activities to reach patients and community members with their interventions. Many addressed diabetes through physical activity and nutrition. Examples of activities include a televised cooking show, diabetes case management, and hip-hop dance classes. Reach was abstracted from reports and categorized by strategy and population (Table 5). It is important to note that the reach data presented are best estimates. Many projects reported having
* Colorado Department of Public Health and Environment Office of Health Disparities, Racial and Ethnic Health Disparities in Colorado 2005
22
served communities with high proportions of their target group reside (such as Denver metro area neighborhoods with up to 80 percent Hispanic/Latino residents, and Pueblo County where Hispanic/Latino residents made up a reported 44 percent of the population), however, several project reports lacked participants’ demographic details. It is likely that some of these projects actually reached multiple racial and ethnic minorities (REM). In the absence of participant racial/ethnic reporting, reach totals were assigned to the population specified in the proposal as the target population. Interpretation of reported reach data should also take the likelihood of double counting into consideration. In many cases, the methods used to capture and report reach data were ambiguous and it appeared to reviewers that individuals were counted each time they participated in an activity or event (such as attending a physical activity session in a risk factor reduction program) rather than being counted once as a program participant. This resulted in the likelihood of individuals being counted repeatedly, and elevated numbers of individuals reached reported. In addition, it should be noted that implementation details regarding the content, setting, frequency, and duration of the activities were not consistently reported. Table 5 summarizes the reported reach for cardiovascular disease projects by strategy and target population.
Multi-pronged direct delivery approaches were used in many of the CVD projects. The projects targeting African Americans and Native Americans combined awareness, educational and screening strategies. The projects addressing CVD among Latinos collectively applied eleven direct delivery strategies. Highlights of certain strategies are discussed below. Awareness Awareness strategies were used by 10 of the 15 cardiovascular disease projects and were frequently combined with education. Activities included the distribution of information on diabetes and cardiovascular disease through mass media such as television, radio, and
Table 5. Reported Reach of Cardiovascular Disease Projects, by Strategy and Target Population
Target Population Strategy
(number of projects)
African American Latino Asian Native
American Racial/Ethnic
Minorities Totals
Access to care (1) 60 60Awareness (10) (media) (2)
1,025 3,940(971,300*)
500 5,465(971,300)
Outreach / Promotoras (5) 19,508 19,508Disease Management (4) 2432 70 2,502Education/Training (13) 100 26,163 26,263Patient Navigation (2) 4,683 4,683Referral (6) 142 3 145Risk-factor Reduction (8) 57,124 80 57,204Screening (9) 22 10,278 11 50 10,361Translation (1) 8 8Treatment (2) 1,214 1,214*represents awareness impressions estimates through newspaper (9,000), television (960,000) and radio (1,500)
23
newspaper. One project addressed Latinos about diabetes prevention and control, delivering 144 television spots during a nine-week period and 13 half-hour radio programs. These activities had an estimated 957,300 media impressions. Another project distributed information in a newspaper with an estimated circulation of 9,000 and through a televised cooking show with a reported 5,000 viewers. Other awareness activities included the distribution of printed material and presentations in various community settings (health fairs, churches, schools, etc.) One project reported reaching 1,025 African Americans through health fair activities including a cardiovascular disease exhibit and oral presentation by Denver Broncos Alumni. Pamphlets were distributed at powwows and other community events reaching 500 Native Americans. A project provided health issues and community resource information reaching 3,300 Latinos through church outreach and community activities; however, few details were reported regarding the health information provided. It is important to acknowledge the difficulty of determining and interpreting reach numbers with awareness strategies, as reach is often duplicated and difficult to measure. A count of informational material distributed at a health fair is often used as a surrogate for the number of individual participants. This lends itself to duplication of reach estimates as it is unknown how many participants read the material or how many may have collected more than one piece of informational material. Community Outreach Worker/Promotora. Community Outreach Workers and Promotoras conducted outreach and health promotion activities targeting Latinos. Activities were conducted in faith-based settings for three of the five projects. Activities also took place in hospitals, schools, health fairs, and homes. The total reach among Latinos through community outreach workers and Promotoras was 19,508. One project reported reaching 18,789 individuals with promotora-led workshops on the causes, symptoms, prevention, and management of diabetes. However, it is not clear whether the number reached by this project represents unduplicated individuals or multiple contacts with the same individual. Pre and post-tests were used to measure knowledge gained by participants in workshops and evaluations of the workshops were conducted. Promotoras and Community Outreach Workers can be used for a number of differing endpoints, including outreach into a community, language and cultural assistance or providing credible culturally specific education/awareness or resources. Evaluation of community outreach and the use of Promotoras requires project specific objectives and detailed implementation data including goals of the community outreach worker/Promotora, the program being implemented (if it is based on a model), where and how often activities were implemented, the services they are promoting, and method of delivery. One grantee reported detailed implementation information and reached several distinct groups of Latinos, including dairy farmers, families, and business people, and members of a women’s health coalition. The content included information about healthy oils for cooking and the relationship between diabetes and kidney disease. This project reported that outreach workers had 133 contacts in community settings, 118 contacts with families, 8 instances of translation services, and 4 presentations or community health fairs.
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Disease Management Classes, support groups, and case management were delivered in clinic or community settings by four grantees. One project offered diabetic management support groups reaching 2,250; however, few details of implementation were available for this project. Culturally competency service provision was incorporated into one project through disease management classes in Spanish and another project that provided case management based on culturally appropriate "best practices." Three of the four grantees offering disease management reported the frequency of their activities: one project provided case management in four 90-day sessions, another program held a series of eight classes, and the third project reported a total of 231 patient visits. Education/Training Education and training was the most frequently utilized strategy to address CVD. Educational activities were delivered in 13 projects with varying formats reaching a reported total of 26,263 individuals (26,163 were Latino). One of the thirteen projects reported a reach of 19,489 through activities implemented in faith-based settings, implementation details were not provided. Other educational activities included small group discussions on diabetes in homes of community members and an 18-week education course on diabetes prevention and heart disease in faith-based settings. Three grantees specified that they tracked attendance at educational activities through sign-in sheets or other tracking tools. In addition, two projects conducted pre/post tests, one of which found a statistically significant increase in diabetes knowledge. Risk-Factor Reduction Risk factor reduction programs, most of which took place in community settings, included nutritional or physical activity opportunities such as meal planning for diabetics, hip-hop dancing, and a cooking class. Most programs implemented risk-factor reduction activities through a series of classes, such as one project’s six-session weight loss group (no reach reported) and another project’s five-week swimming lesson program (reported reach was 16 youth). One project reported reaching more than 50,000 individuals through community fitness centers; however, it is likely that the reach number is elevated due to counting each visit to a fitness facility. Screening and Referral Screening services for cholesterol, blood pressure, BMI, glucose, and diabetes risk reportedly reached 10,361 individuals. Implementation methods varied across projects; project activities included providing one-time screenings for cholesterol, blood pressure, and glucose, as well as referral services, while another project conducted monthly screenings in clinic settings along with presentations. A project providing diabetes screening offered risk assessments to health fair participants, finger-stick tests for at risk individuals and referral services. Six of the nine screening projects also provided referrals or treatment. Referrals were made for a total of 145 patients for services such as primary care, diabetic education, mental health, and lab work. The three screening projects not making referrals combined screening with other strategies such as risk-factor reduction, education, or disease management.
25
Other Direct Delivery Strategies: Access to care, which included supplying insulin, insulin pens, medication, and diabetic shoes to patients, was provided to 60 Latinos and treatment was provided to 1,214 patients in clinic and community settings. Patient navigation services reached 4,683 Latinos. Services included referrals and assistance during provider visits and from patient health advocates. Indirect Delivery Strategies: The indirect strategies implemented by cardiovascular disease projects included provider education, data analysis and review, and infrastructure.
• Six projects collected data through surveys or needs assessments (focus groups, key informant interviews).
• Promotoras, patient health advocates and health care professionals received diabetes, cardiovascular disease, and cultural competency education through eight projects.
• Six grantees implemented activities related to their programs’ infrastructure (formation of a community advisory board, establishing a fitness room and computer lab, and obtained new fitness equipment and additional computers).
Successes reported by grantees: “Participants in our Home Health parties showed a knowledge increase of 80% averaged over the whole group. We consider this intervention format to be the most effective strategy we employ because of the duration of contact between the Promotora and a group (often with numerous members of a family), and the depth of information that is able to be shared and customized to the persons present.”
–Sisters of Color United for Education “An important part of our goal to increase community participation at the newly renovated Fulton Heights facility was to hold an advisory board meeting which was accomplished and which continues to contribute to the success of the center. The advisory board is made up of local residents who provide invaluable advice and ideas to utilize in the program activities.”
–Pueblo County Government
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Crosscutting Projects
Overview: Crosscutting projects address multiple diseases or aim to influence health/lifestyle behaviors that impact more than one of the tobacco-related illnesses. Obesity, lack of physical activity, and dietary factors are associated both with incidence and outcomes of cardiovascular disease (including diabetes) and certain cancers. An example of a crosscutting project would be to reduce obesity and risk of obesity related conditions through nutritional education and physical activity opportunities. Fifteen crosscutting projects were funded through OHD during the fiscal years 2006-2008. Several projects address precursors to diseases or conditions identified as health disparities in Colorado and displayed in Table 4. Crosscutting Strategies Reach and Implementation: The vast array of crosscutting projects does not allow them to be collectively evaluated. Overall, projects aimed to improve health and reduce risk and incidence of disease through knowledge, healthy behavior and lifestyle opportunities, raising awareness and providing education. The reach of each crosscutting strategy for minority populations is shown in Table 6. Awareness, education and training and risk factor reduction strategies reported considerable numbers of participants reached directly, as seen in the table.
27
Awareness Awareness strategies were incorporated into five projects, all of which used multiple strategies often combining awareness activities with education and/or collaboration activities. Large awareness reach numbers are seen, particularly for Latinos and REM populations. These numbers mainly reflect the dissemination of information through radio announcements and distribution of informational materials such as brochures, nutritional information, and cookbooks at community events. Overall, reach data suggests that general health, physical activity and nutritional information along with disease specific (diabetes and prostate cancer) awareness messages were made available to large numbers of minority populations in Colorado through OHD funded crosscutting projects. This was especially true in larger proportions of Latino and REM populations. Much of the reporting during this funding period lacked detailed implementation data such as types of materials and frequency of information delivery. Education and Training Education and training were the most frequently used strategies among the crosscutting disease category. This strategy was used in seven direct reach projects, two of which included mass media. In addition, three projects used education and training targeting health care workers. The eight education and training strategies with direct reach involved health promotion and health behavior educational opportunities. Some specific projects’ report of reach included: more than 2,000 children and parents receiving nutritional and exercise opportunities at field day events, Native Americans received colon cancer education and culturally specific nutritional information in workshops and informational booths, motivational education regarding closing
Table 6. Reported Reach of Crosscutting Projects, by Strategy and Target Population
Target Population
Strategy (number of projects) African
American Latino Asian Native American
Racial/ Ethnic
Minorities Total
Awareness (5) 150 25,500 382 4,500 30,532Outreach / Promotoras (2) 128 1,478 1,606Disease Management (1) 415 415Education /Training (10) (media) (3)
4,131 568 (75,300)*
3 65 2,473 7,240(75,300)
Patient Navigation (2) (100/week)** 608 608Referral (1) 821 821Risk-factor Reduction (4) 74 246 6,390 6,710Screening (2) 88 318 406Translation / Interpretation (4) 37 37* Includes an estimated 15,000 weekly radio show listeners and 63,000 television show viewers * Excludes 100 people/ week receiving cardiovascular disease and diabetes liaison services because the number of weeks was not included.
28
the gap on medical education was delivered to 3,000 African Americans, and African American women (1,000) participated in monthly seminars, each with different topics. Another effort to address the gap in medical training for minorities provided the opportunity for 52 students to access trainings, workshops, and shadow a health care worker in a mentoring fashion. One project developed a 30-minute culturally specific educational video of interviews with ten African American health leaders. The video, followed by discussion sessions, has been played for stakeholders and at various community forums. Mass media programs were used to provide education and training in three cross-cutting projects; Spanish language educational programs over the radio reported reaching an estimated 15,000 people weekly, and televised programs were aired on channel 12 in Spanish and English, in clinic waiting rooms, and at health and cultural events. Although reach was not reported, the grantee noted that Nielsen Surveys report that channel 12 reaches 60,300 Hispanics in the Denver metro area. Mass media methods can only provide estimates of reach. The intensity (how often an individual tuned in, how long) and the impact (whether or not there was an increase in knowledge or a change in behavior) on those reached are impossible to measure. Indirect reach in the strategy of education and training target intermediate audiences such as health care providers, with the intention that the training provided will be used in practice to reach the individual patient or community member. Education and training strategies were used in this method in three projects: one provided patient navigators and community outreach workers with core classes, one trained a case manager, and the third provided cultural competency training to 219 health and social service workers. Similar to awareness strategies, ascertaining reach and implementation in education and training activities can be difficult. Collecting individual data and demographics is often dependant on the method of delivery, the setting and the data collection material. As stated in previous sections of this report, duplication in reported reach is likely. Risk Factor Reduction Four projects provided opportunities for reducing the risk factor of diseases through physical activity and/or nutritional programs. Examples of these activities included 8 Latinos participating in a seniors exercise program, and community activity programs (which included youth). It is important to note that these reach numbers may reflect the same individual participants reported in other strategies, such as education and training or awareness. Screening African American women (88) received blood pressure screening during community education sessions. Blood sugar, blood pressure, and lipid measurement screenings were provided for 318 Latino women at health fairs, clinics and occupational settings. Several considerations to be taken into account when evaluating the implementation of screening strategies include the type of screening conducted, the purpose of screening, how the results will be used, if referral systems are in place and whether the participant has access to care if needed.
29
Certain screening procedures are diagnostically informative such as a colonoscopy, whereas others may be patient education and information such as a single point in time blood pressure or body mass index. It is important to know if the screening results will be used diagnostically, for data collection or simply patient awareness of health conditions and monitoring. In the event that the results warrant further diagnostic procedures or treatment, it is important the participant has the capacity to follow up. One project conducted by the San Juan Basin Health Department reported regarding its screening services: “When needed, Promotoras have advised and assisted their clients in seeking follow-up care and have suggested appropriate sites for services. In addition to making referrals, Promotoras often make the appointment and accompany their client to the service provider…Follow-up calls have been made to check on referral actions that show many clients are keeping their appointments with the clinic.” Other Direct Delivery Crosscutting Strategies
• Community Outreach Workers and Promotoras were used in two projects; 1,478 REM participants were surveyed and referred to services, and 128 Latinos received health concern assessments.
• Disease management and patient navigation services collectively assisted 1,123 African Americans, Latinos and REM populations in patient education, care coordination and liaison services.
• Translation and interpretation services were provided to 37 Latinos (other projects reported using translation and interpretations services, however, insufficient reach information was provided).
Indirect Service Strategies: Many crosscutting projects used indirect delivery approaches to develop or enhance their projects. Organizational infrastructure was often developed with activities like database preparation, tracking mechanisms, hiring and processes implemented. Advocacy and Policy strategy was reported involving a community policy review for environmental change strategies for healthful food and physical activity. Collaboration and partnering was demonstrated through activities such as creating a community advisory group or partnerships for screening services. Surveys were conducted for needs assessments and evaluation purposes. One project used data collected through surveys and interviews to measure television program satisfaction and determine improvement methods. Focus groups with 50 Native Americans were conducted to assess the communities’ knowledge, attitudes and behaviors regarding nutrition and physical activity. Successes reported by grantees: “I am by far most thankful for those that I have met in the program. Being a first-generation college student and growing up in a home where English is not even spoken, the pursuit of going all the way to medical school has seemed quite bleak to me at times. When my fellow applicants seem to have fathers and aunts who are doctors and are available to give them the push they need, I felt that I had no one and often questioned myself whether I was pursuing the right
30
dream…I feel that there is a force behind me now…I am constantly reminded of how fortunate I am to have been given the chance to be a part what the office has offered.”
-The University of Colorado Denver Health Sciences Center’s Undergraduate Pre-Health Program (Excerpt from participant essay about gaining cultural capital/self-confidence).
“On the positive side, NAPO experienced collaboration from the various Native American programs in the surrounding Denver Metro Area. Relationships were renewed and new friendships were established. The community have banded together in the fight for health and wellness. The projects developed from these relationships will have a lasting effect on the American Indian Community.”
- Native American Cancer Research
Cancer Projects
Overview: African Americans have a disparately high death rate from cancer, especially of the breast, prostate, lung and colon. Asian/Pacific Islander and Latina women have disparately high cervical cancer death rates. *Three cancer projects were initially funded for two years; however, one was terminated after year one. Types of cancer: One project focused on prostate cancer among African Americans, one addressed cervical cancer among Asian, Pacific Islander, and medically underserved women, and another created seven regional action teams to address cancer disparities. Reach and Implementation: Each cancer project was implemented using multiple strategies. Many of the activities implemented took place in community settings such as health fairs, while other activities took place in clinical settings. The number of patients or community members reached by cancer projects is shown in Table 7.
* Colorado Department of Public Health and Environment Office of Health Disparities, Racial and Ethnic Health Disparities in Colorado 2005
31
Educational activities were conducted by each of the three cancer projects and consisted of workshops, community forums, and community outreach. It was reported that 1,347 individuals were reached through education strategies, which includes 469 African Americans, 37 Somalis, and 500 REM.
Awareness of cervical cancer targeting Asian and Pacific Islander (API) women was promoted through public service announcements in newspapers and the distribution of printed materials at health fairs. Nearly 18,000 individuals were reportedly reached (16,000 through media public service announcements). Linguistic navigators accompanied 60 women to pap screenings. Two projects collectively provided 143 cervical cancer screenings. One project reported that follow-up and referral activities were provided for five women, however, no additional information about how the implementation of those activities was provided.
Indirect service strategies addressing cultural competency and infrastructure were also used. Health care providers, interpreters, and educators (18) received cultural competency training as part of one project, English as a Second Language (ESL) teacher (3) were trained on health literacy curriculum, and 60 ESL students received health literacy training. Another project involved 17 community leaders and health professionals in regional action teams and town hall meetings (7 held).
Successes reported by grantees:
“I didn’t know what prostate cancer was until this conversation. This conversation made me aware of dangerousness of this disease.”
“It is important that African-American men get screened every year.”
“I learned that it is imperative to be tested since cancer does not have to cause pain. It can be a silent killer.”
“After our conversation, I have realized that I need to be checked and also it is wise to be detected early.”
–It Takes a Village
Table 7. Reported Reach of Cancer Projects, by Strategy and Target Population
Population Strategy (number
of projects)
African American Latino
Asian Pacific
Islander Native
AmericanRacial/ Ethnic
Minorities Total
Access to care (1) 52 52Awareness (1) (media) (1)
1,896(16,000*)
1,896(16,000)
Education/ Training (3) 506 341 500 1,347Patient Navigation (1) 60 60Referrals (1) 5 5Screening (1) 143 143* represents estimated reach of public service announcements circulated through newspapers
32
Pulmonary Disease
Overview: In the United States, asthma among Latinos and African Americans has been identified as a high priority need, and lung cancer in African Americans was also identified as a disparate condition.
One project was funded addressing chronic obstructive pulmonary disease (COPD). This project targeted Asians and Pacific Islanders and used a multi-pronged approach combining screening with data collection and cultural competency training strategies. Direct Service Strategies and Reach: The direct delivery screening strategy targeted Asian/Pacific Islanders. This project expanded into several communities reaching several identified populations; Indian (17%), Korean (15%), Lao-Hmong (14%), Filipino (9%), Vietnamese (9%), Thai (8 %), and Chinese (6%). Allergy and asthma screenings were provided (1,500 screened and 1,217 were considered clinically complete). Reach was reported with demographics of age, gender, education and health insurance status. This data capture is useful in many arenas including describing disease prevalence, participation rates in screening efforts, and health care provider information. Indirect Service Strategies: This project applied the indirect strategy approach of data collection. Data were obtained during screening (demographics and health history) and a health care provider needs assessment was conducted. The project aimed to identify the cultural competency and technical assistance needs of health care providers serving the API population. Cultural competency training strategies were also addressed through development and piloting of a competency survey. Implementation: When evaluating the implementation of screening and data collection activities, it is important to consider the quality of data captured, the types of screening conducted, and the settings in which these activities took place. The implementation of the screening activities was well described. Screening consisted of a comprehensive questionnaire for asthma and allergies, peak flow and skin testing. The project reported conducting 1,500 screenings; however, 1217 were determined to be clinically complete. Screenings were conducted at 44 community health fairs in the Denver Metro area and Colorado Springs. Needs assessments were conducted with more than 50 providers in an effort to understand gaps and barriers. The survey was piloted to 36 of the participating providers with at least 1% of their patient population being API.
Success reported by grantee: “Services reached a number of individuals who likely experienced reduced access to health services due to low socio-economic status, language barriers and the lack of health insurance.” –Colorado Asian Health Education and Promotion
33
Appendix 3.
Project List and Strategies
34
Organization Project Name
Acce
ss to
Car
e
Awar
enes
s*
Colla
bora
tion/
Partn
ersh
ip Da
ta Co
llecti
on/
Analy
sis
Dise
ase M
anag
emen
t
Educ
ation
/ Tra
ining
**
Infra
struc
ture
Patie
nt Na
vigati
on
Polic
y
Prom
otora
/ Outr
each
W
orke
r
Risk
Fac
tor R
educ
tion
Refer
ral
Scre
ening
Tran
slatio
n/ Int
erpr
etatio
n Tr
eatm
ent
American Diabetes Association Por Tu Familia: the Latino Outreach Program of the ADA- Colorado Area x x x x x
Asian Pacific Development Center Community-Based Participation for the Reduction of Asian Cervical Cancer x x x x x
A Woman’s Worth Health Disparities Education x x Brother Jeff’s Cultural Center Guide to Cultural Competency
Education/Training Video x
Center for African American Health
Focus on Cardiovascular Disease x x x x
Clinica Tapeyac, Inc Preventing Diabetes, Cardiovascular Disease x x x x x x x
Colorado Asian Health Education and Promotion
Early Detection, Prevention, and Education of Pulmonary Disease in Asian-Pacific Islander Population
x x x
CSU- Pueblo Healthy Body, Healthy Spirit x x x Denver Health and Hospital Authority
Reducing Health Disparities through Community Outreach and Patient Navigation
x x x x
Denver Health and Hospital Authority
WHEN Partnership x x x x x
Denver Indian Health and Family Services
“Hozho Go,” Lose Big, Win Bigger x x x x
It Takes A Village, Inc. Get H.I.P (Healthy and Informed about your Prostate) x x x
Jefferson County Dept of Health & Environment
La Buena VIDA (Victory in Diabetes Awareness) x x x x x
35
Organization Project Name
Acce
ss to
Car
e
Awar
enes
s*
Colla
bora
tion/
Partn
ersh
ip Da
ta Co
llecti
on/
Analy
sis
Dise
ase M
anag
emen
t
Educ
ation
/ Tra
ining
**
Infra
struc
ture
Patie
nt Na
vigati
on
Polic
y
Prom
otora
/ Outr
each
W
orke
r
Risk
Fac
tor R
educ
tion
Refer
ral
Scre
ening
Tran
slatio
n/ Int
erpr
etatio
n Tr
eatm
ent
Kaiser Permanente Thriving Communities: Healthy Eating and Active Living, Health Disparities x x
Kit Carson County Health and Human Services
Disparities Outreach Program x x x
Mesa County Health Department Spanish-Language, Multi-Media Health Outreach in Mesa County x x x x x
Native American Cancer Research Native American Prevention of Obesity x x x x x x Penrose St. Francis Health Foundation
Addressing Cancer Related Health Disparities Through Regional Action Teams x x
Plan de Salud Del Valle Patient Health Advocates (PHA) used to reduce the Effects of Diabetes and to increase the prevalence of cardiovascular screening and healthy behaviors
x x x x
Pueblo County Government Department of Housing and Human Services
Salado No Mas x x x x x
Regional Institute for Health and Environmental Leadership
Eliminating Health Disparities through Culturally Competent Health Leadership x x x
Rural Solutions Improving Access to Cardiovascular Care for the Latino Population in Northeast Colorado
x x x x x
Salud y Vida for the Latino Community (English)
"Maya's Secrets for Healthy Living" TV program- in English x x x x
Salud y Vida for the Latino Community
"Maya's Secrets for Healthy Living" TV program- in Spanish x x
36
Organization Project Name
Acce
ss to
Car
e
Awar
enes
s*
Colla
bora
tion/
Partn
ersh
ip Da
ta Co
llecti
on/
Analy
sis
Dise
ase M
anag
emen
t
Educ
ation
/ Tra
ining
**
Infra
struc
ture
Patie
nt Na
vigati
on
Polic
y
Prom
otora
/ Outr
each
W
orke
r
Risk
Fac
tor R
educ
tion
Refer
ral
Scre
ening
Tran
slatio
n/ Int
erpr
etatio
n Tr
eatm
ent
St. Mary's Family Medicine Center and Residency Program
A Strategy of Education and Advocacy to Improve the Prevention, Screening, and Treatment of Diabetes in Mesa County Latinos
x x x x x x x
San Juan Basin Health Department
Southwest Latino Health Promotion Project x x x x x x x x
San Luis Valley Regional Medical Center
Reducing Health Disparities in Diabetes in the San Luis Valley x x x x x
Sisters of Color United for Education
Latinos Eliminating Access Disparities x x x x x x
Southern Ute Tribe Health Services Division
Healthy Weight Program for Women of the Southern Ute Indian Tribe x x x
Summit Prevention Alliance La Vida Sana x x x x x UCDHSC Camine! Clinics Assisting with More
Interventions in Nutrition and Exercise x x x x
UCDHSC Office of Diversity Undergraduate Pre-Health Program x x
University Physicians, Inc. Training for Multicultural Care and Research: Toolkits to Promote Cultural Competency in Cancer, Cardiovascular, and Pulmonary Disease Care
x
Weld County Department of Public Health
Decreasing Diabetes Disparities in Weld County x x x x x x
*Awareness strategies include media **Education/Training strategies include media and projects with direct or indirect educational/training activities
