ACTIVATE Community Engagement Implementation Guide | Center for Reducing Health Disparities | UC Davis Health

UC Davis Center for Reducing Health Disparities in partnership with

Ampla Health

ACTIVATE Project Partners

 

ACTIVATE

2022-2023 Community Engagement Implementation Guide

 

The ACTIVATE Community Engagement Team is grateful for all the community partners who shared their personal experiences through their participation in focus groups and key informant interviews.

This collaborative project was funded by a private donation. We are grateful for the donor’s generous support in service of the advancement of telehealth and tele-mental health for historically underserved communities.

ACTIVATE was made possible through the collaboration of various partners in the agricultural community in the Northern Sacramento Valley, Ampla Health, UC Davis Center for Reducing Health Disparities, the Center for Information Technology Research in the Interest of Society and the Banatao Institute (CITRIS), and MITRE.

Lucy Candito – Patient Navigator; Neymi Leon – Lead Community Promotions Worker; Maria Soto –Community Promotions Worker; Adriana Sanchez – Community Promotions Worker; Adriana Castro – Community Promotions Worker; Cynthia Peshek, M.A. – Outreach Program Manager; Cindy Snelgrove, M.B.A./M.S.N./H.C.M., R.N., P.H.N. – Chief Clinical Services Officer; Catharin Manriquez–Former Lead Community Promotions Worker; Benjamín H. Flores, M.P.H. – Chief Executive Officer; Horacio Paras – Board Chair.

Community Partner - Brian Park

 

Sergio Aguilar-Gaxiola, M.D., Ph.D. – Director; Katherine Ferry – Project Manager; Karla Ornelas Hernandez – Senior Project Coordinator; Javier Morla Estrada, M.Sc. – Graduate Student Researcher; Andrea C. Nuñez – Chief Administrative Officer. Cassie Chandler, M.P.H.; Jeffrey Duong, Ph.D.; Gustavo Loera, Ed.D. – formerly of CRHD; Edward Kissam, Consultant.

 

David Lindeman, Ph.D. – Executive Director, CITRIS; Gale Berkowitz, Dr.P.H.– Associate Director, CITRIS; Katherine Kim, Ph.D. – Principal, MITRE Labs, Health Innovation Center; Melissa Bruno Valenzuela, M.P.H. – Senior Public Health Specialist, MITRE.

ABOUT THIS GUIDE

This guide is a handbook to help communities implement their own telehealth programs to support farmworker communities who are traditionally at-risk and vulnerable populations. This guide:

• Provides user-friendly steps for implementing ACTIVATE health education workshops in a new context;
• Describes lessons learned and best practices;
• Describes the process of development and implementation of ACTIVATE health education workshops utilized by UC Davis Center for Reducing Health Disparities, in partnership with Ampla Health and an agricultural grower; and
• Provides implementation tools such as evaluations.

 

The goal of ACTIVATE was to promote telehealth, tele-mental health, and remote monitoring as cost-effective strategies for health improvement—reaching and providing maximum benefit to at-risk and vulnerable populations.

 

Key principles of ACTIVATE:

• Develop a program that is efficient, cost- effective and evidence based. Promote equitable access to telehealth-enabled solutions, specifically addressing the needs of low-income, at-risk individuals.
• Address the wide variation of health care needs, resources, and capacity of California’s – and the nation’s – diverse population.
• Maximize public/private collaboration to ensure the greatest impact possible.
• Build upon existing networks and resources.
• Design a program to be replicated, rapidly scaled and sustainable.
• Consider the unique workforce and development needs of rural communities.
• Inform public policy and program design to ensure long-term sustainability of telehealth.

 

What is Telehealth?

DEFINING “TELEHEALTH”

In this document, telehealth refers to the provision of healthcare from a remote location by means of telecommunication technology.

Video Conferencing (Synchronous)

Live, two-way interaction between a patient and a provider using audiovisual telecommunications technology.

 

Phone Calls (Synchronous)

Live, verbal interaction between a patient and a provider over the phone.

 

Store-and-Forward (Asynchronous)

Transmission of medical information, such as digital images, documents, and pre-recorded videos, through an electronic communications system to a provider who uses the information to evaluate the case or render a service outside of a real-time or live interaction.

 

Remote Patient Monitoring (RPM)

Electronic transmission of personal health and medical data collection from a patient in one location to a provider in a different location for use in care and related support.

Example: Rural patients with hypertension or Type 2 diabetes can monitor their blood pressure or blood glucose through mobile apps.

Mobile Health (mHealth)

Clinical and public health services and education supported by mobile communication devices such as cell phones and tablet computers.

 

eConsult

A primary care provider (PCP) consults with a specialist via live video conferencing or store-and- forward.

 

ACTIVATE TIMELINE

 

JANUARY 2022

CRHD formed a partnership with Ampla Health, a 501 (c)3 nonprofit network of comuniyy based Federally Qualified Health Centers (FQHC) offering comprehensive health services in 6 counties in the Northern Sacramento Valley

 

AUGUST 2022

CRHD and Ampla Health promotoras conducted focus groups and interviews with farmworkers, growers, contractors, and health providers to examine attitudes and barriers toward telehealth and tele-mental health.

 

JANUARY 2023

CRHD developed a curriculum for a series of workshops for Latino agricultural workers that were designed to (1) increase use of telehealth and mental health services and (2) improve their connections to Ampla Health.

 

APRIL 2023

Promotoras reviewed the draft curriculum, suggested changes (through bidirectional communication) and led the revisions process. UC Davis Health professionally translated the curriculum into Spanish, and our teams reviewed the translation for local accuracy.

 

JUNE 2023

The curriculum was pilot tested onsite with farmworkers in Colusa County, California. Ampla Health’s extensive connections and demonstrated history of service to the agricultural community in the region was a critical factor in successfully partnering with a grower.

Promotoras facilitated workshops over a six-week period in June and July 2023 with a group of fifteen farmworkers. We monitored the implementation of the workshops in several ways, including observation of engagement of participants, observation of facilitation by promotoras, and regular communication with the grower.

 

AUGUST 2023

An evaluation of the project included the following steps:

• Measure attitudes about telehealth with the attitudes survey.
• Measure knowledge gained with knowledge pre-/post- tests.
• Assess participant engagement through structured observation.
• Assess Promotoras’ facilitation skills through structured observation.

 

ACTIVATE SCOPE AROUND THE STATE

 

CRHD’s work began in 2021 with research related to mental health in farmworker communities, existing telehealth and tele- mental health services in California’s Central Valley, and existing models for utilizing promotoras (i.e. community health workers) to engage farmworkers in health services. CRHD formed a partnership with Ampla Health, a 501 (c)3 nonprofit network of community based Federally Qualified Health Centers (FQHC) offering comprehensive health services in 6 counties in the Northern Sacramento Valley.

The partnership’s goal was to (1) co-design a training program for promotoras/community health workers and (2) conduct outreach and training to Latino farmworkers on the topics of telehealth and tele-mental health.

 

CONTEXT ABOUT TELEHEALTH AND MENTAL HEALTH FOR FARMWORKER COMMUNITIES

Farmworkers have increased vulnerability for mental distress due to low wages, threats to their immigration status, and risks associated with their work. The COVID-19 pandemic, floods, and wildfires have only exacerbated these stressors.

Mental health care—and telehealth in particular—is underutilized by Latino agricultural workers due to:

• geographical isolation,
• lack of internet / cell service,
• lack of culturally and linguistically appropriate services,
• lack of access to insurance or financial assistance due to immigration status, and
• stigmas about mental health.

 

The use of telehealth and tele-mental health services expanded since the pandemic due to numerous advantages for farmworkers:

• saving time,
• accessing health services without missing work and pay,
• eliminating transportation costs.

Despite this, focus groups and interviews found that farmworkers had limited awareness of telehealth and technology use as well as limited access to bilingual services.

 

“Just their attitudes. And I feel that the very first session, I saw how they were more laid back, not really answering questions, just listening to us. And then the second one that I did, they were more talkative and the very last one they were more comfortable sharing. So I think they opened up.”

—Ampla Health Promotora

ABOUT PROMOTORAS

Promotoras are community members who act as natural helpers and liaisons to meaningful information and resources for their neighbors and neighborhoods. As Vision y Compromiso, the largest promotora network in both California and the U.S., because promotoras share the same language, culture, ethnicity, status and experiences of their communities, promotoras are able to reduce the barriers to health education and services that are common for native-born and immigrant communities. The result is better health for more individuals, families, and communities.

The personal and professional experiences of promotoras come from the communities they serve, as they have a personal background in the culture, language, and lived experiences as community members.

Promotoras may hold various job titles including outreach workers, community advocates, health educators, patient navigators, and community promotions workers. Promotoras’ level of education ranges from a high-school diploma to college degree and beyond.

 

They may vary in proficiency levels of English and Spanish, and indigenous languages such as Mixteco, depending on their native language.

Roles of promotoras and their professional skills are not consistent across the profession, as their responsibilities and activities center on meeting the needs of the organization and the communities they serve.

 

LESSONS LEARNED FROM ACTIVATE

These lessons may be helpful to organizations planning to replicate the ACTIVATE project in their own communities:

• Health education sessions promoted favorable attitudes toward telehealth service use among project participants.
• Health education sessions created awareness about telehealth and mental health care service availability and use among project participants.
• The facilitation guide was well received and beneficial for participants and Ampla Health.
• The facilitation training supported the promotoras’ delivery of health education sessions through developing and practicing public presentation skills.
• ACTIVATE’s financial and promotional incentives were beneficial to motivating project participants to attend health education sessions.

 

On developing the health education curriculum content:

• Seeking input from all project partners, including the grower, enhances project buy-in and satisfaction.
• Incorporating new curriculum modules or significant changes necessitates a team member with curriculum design expertise, which some FQHCs might lack.
• Engaging promotoras in curriculum design leads to buy-in and yields a higher- quality facilitation guide. Adapting content tailored to local farmworkers’ needs is crucial.
• The process of reviewing and revising the professionally translated curriculum demands more effort than initially expected. A comprehensive review involving the promotora team familiar with adapting to the local language nuances is essential.

 

On effective health education content and strategies:

• Roleplay and simulation of telehealth visits between participants and promotoras helps demystify the telehealth process, boosting participants’ confidence for future interactions.
• Utilizing storytelling and examples in the facilitation guide makes telehealth and mental health concepts relatable and less intimidating.

 

On considerations for future curriculum revisions:

• Including a session on factors contributing to mental health issues is beneficial for Latino/a/x agricultural workers.
• The sixth workshop module must be adapted by each implementing agency to reflect the services of the project’s FQHC partner, with an emphasis on the FQHC’s offerings related to programs for uninsured and other hardly reached community members, such as sliding fees for services, transportation services and telehealth programs.
• Incorporate visual aids like infographics or images to enhance engagement and comprehension.

 

On promotora training:

• Allow more time for promotoras to practice and review workshop content.
• Equip promotoras with strategies to navigate sensitive discussions around personal mental health experiences shared by participants.
• Enhance training on asking effective open-ended questions related to mental health.

 

On community engagement:

• Involving a grower necessitates deep personal connections.
• within the agricultural community due to concerns about project impact and intentions.
• Time health education workshops to suit all stakeholders’ preferences for consistent attendance and minimal interference with farm operations.

 

The following Best Practices emerged from the ACTIVATE project:

• Engage promotoras in curriculum design, which ensures cultural and linguistic appropriateness.
• Provide training to promotoras in public speaking and workshop facilitation.
• Establish trust with participants through informal meetings before workshops begin.
• Include telehealth simulation and role-playing to promote participant buy-in.
• Offer incentives for workshop attendance to generate initial interest.
• Maintain professionalism and effective communication to build and sustain trust with all project partners.

 

 

Set the Stage

1. Engage the community
2. Establish timeline
3. Plan the resources

 

Develop Partnerships

1. Partner with a Federally Qualified Health Center (FQHC)
2. Review curriculum with promotoras
3. Develop and maintain partnerships with promotoras
4. Conduct formative research and design the intervention
5. Partner with a grower

 

Develop the Materials

1. Revise the curriculum for Module 6
2. Translate the facilitator’s guide
3. Pilot test the curriculum

Train the Promotoras

Facilitate the Workshops

Evaluate the Intervention

The results of the attitudes survey reveal that, on average, a greater number of participants more frequently agreed or strongly agreed with statements about the ease of using or learning how to use telehealth after attending health education sessions. This contrasts with their initial perceptions at the start of the project, where they expressed disagreement or had neutral perceptions about the ease of using telehealth.

 

—Excerpt from the Evaluation

Report of the ACTIVATE project

1A. ENGAGE THE COMMUNITY

 

It is vital to involve community partners throughout each step of project development and implementation. Community partners include farmworkers, growers, promotoras, and health center staff. Involving these partners creates buy-in and promotes the development of work products that reflect partners’ expertise and actual needs.

 

Strategies for Engaing Farmworker Communities

Build trust and model trustworthiness with community partners; acknowledge and recognize farmworkers’ fears and the barriers they face.

Go to where people live, work and gather.

Ensure all components of a project, including research, products, trainings, and activities, are culturally and linguistically appropriate to the farmworkers.

Develop relationships with trusted members of the agricultural community.

Taking the time to develop these relationships helps those implementing health education projects gain access to communities and provides champions for projects.

 

What is Community Engagement?

Defining “Community Engagement”

Community engagement is defined as “an ongoing, evolving, process of multi- directional communication with and for people to solve the problems and mitigate the concerns that matter to them. The process should be durable, long-lasting and equitable to all who participate. The ultimate goal is to learn, implement and disseminate the practices of equitable partnering, influence policies, programs, and practices for the betterment of the community.”

Community engagement is defined as “an ongoing, evolving, process of multi- directional communication with and for people to solve the problems and mitigate the concerns that matter to them. The process should be durable, long-lasting and equitable to all who participate. The ultimate goal is to learn, implement and disseminate the practices of equitable partnering, influence policies, programs, and practices for the betterment of the community.”

 

1B. ESTABLISH THE TIMELINE

Gantt charts are a great strategy for project management and organizing timelines. See the example ACTIVATE Gantt chart below. Special considerations on project timeline:

• Allow time to secure the partnership and form ties with the local agricultural community.
• Allocate enough time for professional translation of documents to avoid delays.
• Conduct the intervention during the season harvesting period and consider how crop rotation affects farmworkers’ travel and relocation during the different seasons.

 

Plan the Project: Month 1-3

Identify and Partner with a Grower: Month 4-6

Review ACTIVATE Curriculum with Promotora: Month 4

Conduct Formative Research: Month 4-5

*Necessary if the decision is to develop new curriculum instead of adopting the curriculum in this guide

 

Design the Intervention: Month 6

*Necessary if the decision is to develop new curriculum instead of adopting the curriculum in this guide

 

Adapt the Curriculum: Month 6 & Month 7

 

Translate the Curriculum and Review the Translation: Month 8

 

Pilot Test the Curriculum: Month 9

 

Train the Promotoras: Month 9

 

Implement the Workshops: Month 10-11

 

Evaluate the Intervention: Month 10-12

 

1C. PLAN THE RESOURCES

 

Consider budget items such as personnel, travel and mileage, equipment (e.g. laptops & recording devices), training expenses such as catering and printing materials, and office supplies.

Agencies conducting significant formative research (e.g. focus groups, pilot testing) may wish to budget for transcription software or services, and possibly professional translation services, if making significant additions or changes to the curriculum.

Incentives such as gift cards for local grocery stores, sun hats, and insulated lunch bags can increase participation in both the formative research and workshop implementation phases.

DETERMINE PERSONNEL

 

The table to the right outlines duties of key personnel.

These positions reflect what is needed for a project with one FQHC and one grower partner with a small farm (18 workers). Plan to scale up on both project management and project coordination accordingly for larger farming operations or multiple FQHC partnerships.

Along with making personnel decisions, consider hiring bilingual staff and providing them additional pay.

“I think incentives helped. They knew that if they came to the module, they would get a little treat. At first it was about the incentive. And then maybe after they [realized], hey, this stuff is beneficial, this stuff is good to know. And then they were happy with learning about it and sharing it with their coworkers.”

-Ampla Health Promotora

Technical Assistance Provider

Project Manager

FTE: 0.50

Sample Duties: Manage finance and budget, oversee staff, oversee contracts with funder contracts with funder and FQHC partner, ensure timely completion of deliverables and reporting, co-design workshop curriculum and other work products.

 

Project Coordinator:

FTE: 0.75

Sample Duties: Build and maintain partnerships with FQHC and grower, coordinate and facilitate meeting and focus groups, co-design curriculum in Spanish and English, create training materials, provide training to promotoras, coordinate purchasing of supplies, travel, services (e.g. translation, transcription) and expense reporting, co-write reports.

 

Evaluator

FTE: 0.25

Sample Duties: Design and facilitate focus groups and interviews, create evaluation instruments, write evaluation reports, present findings to various partners, contribute to curriculum and training design.

 

Lead Promotora

FTE: 0.20

Sample Duties:  Oversee performance and schedule of other promotoras, plus duties below.

 

Promotoras

FTE: 0.20

Sample Duties:

Participate in weekly meetings, review research findings, review curriculum and translation, participate in various trainings, participate in meetings with grower, facilitate workshops.

 

2A. PARTNER WITH FEDERALLY QUALIFIED HEALTH CENTERS (FQHC)

The Federally Qualified Health Centers (FQHC) partnership serves multiple purposes:

• Hiring promotoras to facilitate workshops
• Securing local partners to help design curriculum
• Introducing the technical assistance provider team to growers and farmworkers; and
• Providing a place to refer workshop participants for health services.

 

When forming partnerships, consider how the strengths of the partner agency will complement yours, including these factors.

1. Ties to the local agricultural community.

How can the FQHC connect you to the local agricultural community (both employers and farmworkers)? What subject matter expertise does the FQHC have in serving this population?

 

2. Structure of Promotora/Community Health Worker Program

FQHC partner have a well-established promotora or CHW program? What kind of training and skills can you expect the promotoras to have? What is their experience working with farmworkers and/or telehealth?

 

3. Agency’s readiness to utilize telehealth.

Does partner FQHC have an established telehealth program, including language interpretation for telehealth services? To what extent does workshop curriculum need to be tailored to correspond to the FQHC’s actual services?

4. Leadership buy-in to the initiative.

How can FQHC leadership provide access to knowledge about the FQHC’s operations?

2B. REVIEW CURRICULUM WITH PROMOTORAS

Provide time for technical assistance providers to determine if the curriculum requires additional topics, changes to the target population, or translation.

Follow the guidelines below to review the curriculum and help make decisions about which process to follow in adapting it.

 

Assess Possible Adaptation Needs of the Curriculum

Option 1:

1. Review curriculum with Promotoras
2. Minimal-to-no changes to curriculum
3. Adopt curriculum as is or incorporate changes to curriculum
4. Optional: Focus groups/pilot testing of curriculum

 

Option 2:

1. Review curriculum with Promotoras
2. Curriculum requires substantial changes (e.g., new topics, language, target audience)
3. Conduct formative research (focus groups) with target community
4. Identify health education topics that address community needs
5. Co-design new curriculum with promotoras
6. Pilot new curriculum with community members of target population

 

2C. DEVELOP AND MAINTAIN PARTNERSHIPS WITH PROMOTORAS

Promotoras are community members who act as natural helpers and liaisons to meaningful information and resources for their communities.

To develop promotoras’ trust in the partnership, they need to be integrated in every phase of the project. This could include encouraging their participation in brainstorming sessions, collaborating in the design of project materials, facilitating focus group discussions, incorporating their feedback on education materials and evaluation tools, participating in reflection discussions, and providing frequent/ regular project updates.

It is fundamental that promotoras be instituted as channels of communication between the implementing organization and community members. Promotoras are the access points to communities.

“The partnership with Ampla. I think that was key, the way we approached that. We built trust with the promotoras because I feel like our team understood that to get to the agricultural workers in a community directly, promotoras were key access points. So, I think we spent a lot of quality time to involve them in every step of the process. In building trust with them.”

—CRHD Management Staff

2D. CONDUCT FORMATIVE RESEARCH AND DESIGN THE INTERVENTION

Formative research uses qualitative and quantitative methods to provide information for researchers to plan intervention programs.

To conduct formative research for your intervention, collect demographic information about local farmworker communities including: languages spoken, countries of origin, socioeconomic status, current residency, distance to work and health services, and access to internet at home.

This data can be gathered from US Census and county reports. Also, promotoras, as trusted members of the community, are another excellent source of information.

Conduct focus groups and interviews with the target population if considering adding topics to your curriculum or substantially revising the curriculum.

“I think [the focus groups] gave us the idea of what to expect for these sessions and the farm workers that we would be giving these presentations to, [for example] the questions that we first asked them that they didn’t know about mental health or where to find help. I think it gave us a jumpstart where to get this information, exactly what to give them for the sessions.”

-Promotora

 

Considerations when Establishing a Focus Group:

1. Clearly define the health behavior addressed by the module.

For example, if available research indicates that nutrition is an important topic to address with Latino farmworkers, the implementing organization must precisely frame what the health behavior problem is (i.e. overconsumption of high sugar and salty foods) and a time horizon for the health behavior (i.e. during weekday meals). If it is unclear what the specific health behavior problem is, the implementing organization can use the formative research to identify it with key informant interviews.

 

2. Recruit participants that represent the target population and its demographic characteristics.

If the target population consists of diverse age ranges, gender identities or sexual orientations, ensure that you have at least separate interviews or focus groups that represent these sub-groups. Forming small focus groups of 4 to 6 participants, that represent one sub-group of sex and age, are easier to manage and analyze.

 

3. Be mindful of farmworkers’ rigorous work schedules.

Whenever possible, hold focus groups in the evenings, after regular work hours. Consider holding focus groups in community spaces such as conference rooms of health clinics, migrant centers, community organizations, or public libraries. We also recommend that participants be compensated with a meal and gift cards for their time and participation in the discussion.

 

4. Consider recording group discussions.

The implementing organization can decide if focus group discussions will be audio recorded for the purpose of ensuring farmworkers’ insights are captured as accurately as possible. Doing so will require obtaining written consent from the focus group participants. Emphasize repeatedly that all information will be kept confidential and any identifying information will be removed from the transcriptions of the recordings.

 

2E. PARTNER WITH A GROWER

Community partners -- promotoras, members of agricultural organizations, and allies of the agricultural community -- are the key to identifying growers in the local area of interest. In our intervention, the lead promotora from Ampla Health had extensive knowledge of growers, contractors, and farmworkers in the area as well as significant community trust.

 

Things to Consider When Approaching a Grower with a Proposal to Implement Workshops at Their Site

 

What? What is the goal of the project? Improve access to health care and mental health care services among Latino agricultural workers via telehealth services and the partner FQHC.

 

Why? Provide relevant local data that demonstrate the disparities in health care accessibility of Latino agricultural workers.

 

How? Through trusted Community Health Workers/Promotoras, farmworkers will receive participatory health education information about telehealth, mental health & wellbeing, and services offered by the partner FQHC.

 

Who? Who is involved? The implementing organization in partnership with the FQHC.

 

What? What are the benefits for the grower? Improvement of worker health and financial protection, increased output and employee loyalty, and social mission.

 

“The transparency was nice. The communication, whether it was at the shop or via email. I think that that’s important to me. And I think it would be important to anyone else going forward. I thought you guys did a really good job

at that. And also sticking to the schedule and being on time. I mean, there’s just a lot of people these days that think it’s okay to not be on time, and it’s a big pet peeve of mine.”

-Local Grower

 

How is trust maintained with the grower?

 

Maintaining trust with partners is an ongoing effort that will require professionalism, transparency, and efficient bilateral communication.

We suggest:

• Respecting partners’ time and being flexible to work around their availability.
• Creating transparency about the purpose for any type of information/data collection.
• Introducing all parties involved in the project.
• Keep the grower in the loop with project updates.
• Collaborating to create the workshop schedule and reviewing the workshop materials.
• Sending weekly email reminders on upcoming workshops dates, topics, and team members to be expected on site.

 

In our intervention, the team, including the promotoras, were invited by the grower to have lunch with the farmworkers to introduce the project, its mission, the topics, and to get to know the farmworkers. Meeting over a Convivencia, a cultural practice that symbolizes community in the Latino community, is an effective approach to demonstrate cultural sensitivity to the farmworkers. In sharing a meal together, we were able to connect more personally and welcome them to participate.

 

Design the Intervention

 

Use the data from the formative research to design your intervention. To develop the

ACTIVATE curriculum, we held workshops with promotoras to review the data from focus groups and key interviews and began to design the intervention together. These sessions enabled us to identify the key beliefs, strategies, knowledge, and information related to telehealth and tele- mental health that would provide the framework of the six workshops in our curriculum.

 

3A. REVISE THE CURRICULUM FOR MODULE 6

Tailor intervention according to services provided by the partner FQHC. This workshop is an important opportunity for farmworkers to ask the promotoras questions on medical coverage eligibility and address the following questions:

1. What services does the FQHC offer? (medical, specialty, urgent visits, vision, dental, mental health, telehealth.
2. Where are the clinics located? What counties?
3. Which health insurances does the FQHC accept? Are there any special coverage programs that the FQHC offers to those that are uninsured? If so, what are the eligibility requirements? (income, family size, identification documents, legal status)
4. What are the clinic’s hours of operation? Does the clinic offer after-hours care?
5. Does the clinic provide services for transportation, urgent care, referrals?

 

Revise the Curriculum Based on Intervention Design Discussions with Promotoras

When making substantial changes to the curriculum (e.g. adding modules), use the following processes:

1. Review the major beliefs, strategies, and information identified in the intervention design discussions with promotoras. Then, determine how much new content could be developed. We recommend 30-minute workshops to support minimal disruption to the farmworkers’ workday.

 

2. Discuss the number of workshop modules with project partners to ensure added content is an appropriate length. Keep in mind the seasonality of farm work when scheduling the workshops. Discuss the timeframe with the grower and promotoras.

 

3. Divide the added content into topics based on the thematic analysis and outline each workshop. We followed this workshop structure: welcome of participants and introduction of promotora/facilitator, an opening question about the topic, definition of key terms (such as “telehealth”), and review. We also found simulating a telehealth session (module 3) to be very effective.

 

3B. TRANSLATE THE FACILITATORS GUIDE

Once the Facilitator’s Guide is finalized, the next step is to

have it translated into Spanish by a certified translator. To ensure the content of the Facilitator’s Guide is culturally and linguistically appropriate to farmworkers, have promotoras take part in this process and propose replacements for and adapting to local language verbiage. The target level of the document should be elementary-grade proficiency to accommodate varying levels of education and literacy among farmworkers.

The example on the following page compares a literal translation as proposed by the translator versus the local translation and adaptation recommended by the promotoras.

Stages of Translation

English Content:

Some people avoid seeking help for their mental health because they are afraid the very personal information they disclose to their therapist or psychiatrist could be misused or shared with other people. But in reality, the information you share with these health care providers cannot be shared with others without your permission.

 

Literal Spanish Translation

Algunas personas evitan buscar ayuda para su salud mental porque tienen miedo de que la información muy personal que divulguen a su terapeuta o psiquiatra pueda utilizarse erróneamente o compartirse con otras personas. No obstante, en realidad, la información que comparta con estos proveedores de atención médica no puede compartirse con otros sin su permiso

 

Local Spanish translation proposed by promotoras (Adaptation)

Algunas personas evitan buscar ayuda para su salud mental porque tienen miedo de que la información personal que compartan con su terapista o psiquiatra pueda ser mal utilizada o pueda ser compartida con otras personas. En realidad, la información que comparta con estos proveedores de atención médica no puede compartirse con otros sin su permiso.

3C. PILOT TEST THE CURRICULUM

Pilot testing assesses the effectiveness, relevance, cultural and linguistic appropriateness, timing and pace, and delivery methods of the curriculum’s content before it is fully implemented. This process leads to more refined materials that better meet objectives.

Here’s a step-by-step guide on how to conduct a pilot test for the content of training:

• Define clear objectives of the pilot test. Focus on specific aspects of the workshop content you want to assess, such as the effectiveness of certain modules, activities, assessments, or delivery methods.
• Select participants who resemble the target audience of focus. Ensure that their backgrounds, knowledge levels, and learning needs align with the intended audience.
• Prepare training materials to simulate real-life training. Run through activities in real time to ensure that the materials are complete, accurate, and ready for testing.
• Adapt the pilot testing facilitation guide to your objectives.

 

“And also to know that one can ask [providers] what you want by video call or by phone instead of going there in person. Because one thinks, ‘No, we’ll have to go.’ I’m going to lose time from work so you’re not wasting your time. You use your lunch break, and they attend you and you no longer waste your time.”

—Farmworker

 

“I got something good from the presentation. Because like my partner mentioned, I felt that to go to a therapist, a psychologist, mental help, was because you’re going crazy but you don’t have to be crazy. You may be going through a bad time and you go and they can help you.”

—Farmworker Focus- Group Participant

 

[I liked] the information of the video calls. Is it information that is good to have or know? Yes, because as he says, there are times when you can’t go in person and by video call because they attend to you, you don’t lose work, you don’t drive you have to look for someone to bring you.

-Farmworker

 

3C. PILOT TEST THE CURRICULUM (CONTINUED)

Conduct the Pilot Test:

• Provide participants with an orientation to explain the purpose of the pilot test and its expected outcomes (i.e., evaluation and feedback).
• Present the training content to participants, using the same content, delivery methods, activities as intended for the full training.
• Encourage active participation and engagement during the pilot test to gauge participant involvement.
• Assess learning to measure participants’ understanding of the content.
• Gather feedback from participants via a focus group.
• Record discussion of participant feedback and transcribe it for later analysis

 

Analysis, Learning, and Revisions:

1. Analyze data to identify common trends, strengths, weaknesses, and areas for improvement.
2. Improve the training content using the feedback.
3. Document lessons learned from the pilot test, including successes, challenges, and insights gained.
4. Incorporate the improvements to prepare for full implementation.
5. TRAIN THE PROMOTORAS

 

This intervention requires that promotoras learn and practice a variety of skills for facilitating health education sessions to farmworkers. We suggest the implementing organization assess the levels of promotoras’ experience in health education, public speaking, and presentation skills early on. Then, conduct two training courses.

The first training is part of the formative research phase on facilitating focus groups discussions with farmworkers. The second training in the implementation phase on managing small group presentations/workshops.

Included in this report are the tools for two trainings:

• How to Effectively and Respectfully Facilitate Focus Group Discussions (FGDs)
• A Promotora’s Guide: How to Facilitate Small Group Presentations to Agricultural Workers.

 

Trainings should be a minimum of four hours and be practice-based (meaning the Promotoras rehearse the tools during the training and receive constructive feedback).

 

“I thought the way the training helped us deliver the presentations was very good.

Because this gave us the opportunity to give our opinion and show how it could”

-Promotora

 

5. FACILITATE THE WORKSHOPS

Prepare to implement. Plan a site visit before the first workshop to review the grower’s location and decide how and where to set up for workshops, noting any factors that might interfere with workshop delivery, such as noise from equipment and exposure to sun or insects. Plan to set up chairs in a semicircle where farmworkers can easily see the promotora facilitating and each other.

Schedule the workshops. For our intervention, workshops were delivered once per week and workers were given the option of attending at either 9:00 a.m. or 10:00 a.m. (to avoid summer heat).

 

“I think that, you know, just having them get up there and do it and practice the sessions that they were going to facilitate was effective, particularly where we practiced audience response. And we made up, you know, answers to when they asked open-ended questions, I thought that was really effective both not only for them to practice but also for us.”

-Promotora

 

Sample Materials List

-Facilitator’s Guide

-Key terms signs

-Gift cards

-Gift card tracking sheet

-Other incentives (hats, coolers)

-Evaluation Surveys

-Promotora Observation Tool

-Audience Observation Tool

-Pens

-Insect Repellent, sun hat, sunscreen, etc.

 

Check-In Midway

Plan to meet with both the promotoras and the grower hosting the workshops midway through implementation of workshops. For the grower, ask what feedback they’ve heard from workers about the workshops and ask if there have been any issues with workshops interfering with business operations. Discuss the plan for the remaining workshops. Meet with the promotoras as a group and discuss common themes from promotora observation and propose improvements.

 

Sample Schedule:

8:30-9:00 am : Set-up for workshop

 

9:00-9:15am: Welcome Participants and administer knowledge pre-test

 

9:15-9:45am: Present workshop, observe participants through structured observation tool, observe Promotoras through structured observation tool

 

9:45-10am: Administer knowledge post-test and provide incentives

 

“One sounds kind of weird, but it might be that there’s a little more cohesiveness amongst the group. Um, you know, because they all, not all of them have known each other for a long time. And so, again, this kind of this might just be the act of sitting in any workshop together, right? Like, like, like it’s almost like a team function, right? ... Obviously it’s only going to help, right? I mean, the more comfortable they are around one another, the more likely they’re going to be able to ask, you know, a coworker a question when maybe before they were apprehensive to because they didn’t know him that well or they weren’t that comfortable around him.”

-Local Grower

6. EVALUATE THE INTERVENTION

To evaluate the success of the health education workshops in achieving project objectives, the implementing organization must apply the survey, knowledge test, and evaluation tools developed in the ACTIVATE project. In addition, throughout the delivery of health education sessions, the implementing organization would also assess the level of participant engagement and promotora application of skills learned in training.

“I learned that I have not learned everything [about mental health]. With the story of the depressed girl, that those life events affect the mental health. And this teaches us to pay attention when we are going through something that we cannot understand or simply feel bad about it mentally. G to go to therapists or clinics to receive help.”

-Farmworker

A Step-by-Step Guide to Implementing Your Evaluation

Measure attitudes about telehealth with the attitudes survey. Administer the first survey before the start of the implementation (baseline) and after (end-line) through in-person administration. We recommend reading the surveys to participants and ensuring comprehension before recording participant responses.

Measure knowledge gained with knowledge pre-/post- tests. Implement knowledge tests before and after each session to gauge knowledge gained per session. Then, use that data to reinforce select knowledge

Assess participant engagement through structured observation. Two or more observers should complete the participant engagement forms during sessions and share the results with promotoras.

Assess promotoras’ facilitation skills through structured observation. Two or more observers should complete the facilitation skill forms during sessions and share the results with promotoras.

Even more noteworthy is the pronounced increase in perceived personal resources, such as “knowledge necessary to use telehealth,” which escalated from a strong disagreement (1.31) to an agreement (4.38)

-Excerpt from Evaluation Report of the ACTIVATE Project

How to Find Validated Scales for Evaluation of Additions to Curriculum

Finding validated attitude scales on health care seeking attitudes involves a systematic identification of existing measurement tools that have been rigorously tested and validated.

To find and select validated attitude scales for this purpose you should:

1. Clarify research objectives: Clearly define the health behavior addressed by the new module you seek to include in the health education sessions
2. Conduct a literature review: Conduct a literature review in relevant databases (e.g., PubMed, PsycINFO, Google Scholar) using relevant keywords related to health behavior you seek to change with health education
3. Assess validity and reliability: Once you identify potential attitude scales, carefully examine the validation and reliability information provided in the articles. Look for evidence of psychometric properties such as construct validity, content validity, convergent validity, and reliability (e.g., Cronbach’s alpha).
4. Check for references: In the articles where the scales are mentioned, explore the reference lists to find the original source of the scales, if applicable. This can lead you to the validated versions and guidelines for using them
5. Use measurement websites: Explore websites and repositories that specialize in psychological measurement tools. Examples include the Health and Psychosocial Instruments (HaPI) database or the Psychological Assessment Resources (PAR) website.
6. Assess Cultural Appropriateness: Consider the cultural context in which the attitudes on health behavior are being assessed. Ensure that the scales you choose are suitable and relevant for your target population and context.
7. Adapt if necessary: Depending on your research objectives and the population you’re studying, you might need to adapt the scale slightly to ensure cultural or context-specific relevance. Ensure that any modifications you make maintain the validity of the scale.
8. Pilot lot testing: Before using the scale in your main study, conduct a pilot test with a small sample to assess the clarity and understandability of the scale items for your target population.

 

Remember...

Finding and using validated attitude scales can provide you with a reliable and established way to measure healthcare seeking attitudes. However, thorough evaluation of the scales' psychometric properties and careful consideration of their appropriateness for your research context are crucial steps in the process.

 

BEST PRACTICES IMPLEMENTING THE PROGRAM

1. Engaging promotoras in curriculum design ensures cultural and linguistic appropriateness
2. Providing training to promotoras in public speaking and workshop facilitation.
3. Building trust with participants through informal meetings before workshops begin
4. Including telehealth simulation and role-playing to promote participant buy-in
5. Offering incentives for workshop attendance to generate initial interest.
6. Maintaining professionalism and effective bilateral communication to build and sustain trust with all project partners

 

“We got the opportunity to go over everything to practice and do the [presentations] upfront and do roleplays. And I also found it beneficial that you guys were asking questions as if you were the farmworker. And we had the opportunity to practice answering or being put on the spot questions to be expected that sometimes you don’t expect.”

-Promotora

 

“I don’t know if I would change anything. I guess the one thing, on health, it seems like [I would recommend] nutrition. I guess I’m still a firm believer that overall nutrition...that should be a topic that really could help the Hispanic community, [I] feel like a lot of them don’t know like that it’s okay to eat well.”

-Local Grower