BACKGROUND AND LITERATURE REVIEW Limited English-proficient Latinos are a rapidly grow- ing and vulnerable population in the United States with respect to health disparities. Language, socioeconomic status, immigration status, limited knowledge of the health care system, and cultural barriers contribute to their unequal access to quality health care. Many Latinos in the United States are working in low-paying jobs, less likely to have health insurance or a source of ongoing health care, and more likely to report their health status as “fair or poor” rather than “good or excellent” (National Center for Health Statistics, 2002). By 2004, the Latino population had grown to 40.5 million, representing 14.2% of the U.S. population (U.S. Census Bureau, 2004c). In Chicago, the site of this service demonstration program, Latinos made up 27.4% of the population in 2004 (U.S. Census Bureau, 2004a). However, only 5.8% of health care providers in the United States are Hispanic (U.S. Census Bureau, 2004b). As a result, this population receives health care primarily from non-Hispanic providers, who often lack the language skills and cultural understanding needed to provide opti- mal care. This systemwide problem has contributed to a growing underserved population for whom health care disparities exist (Centers for Disease Control & Prevention, 2004). Community Health Workers: A Primary Health Care Strategy Primary health care, promoted worldwide since the 1978 Declaration of Alma-Ata (World Health Organization, 1978), is a system-level approach that involves multisec- toral collaboration to promote health for all through the development of health care that is accessible, socially acceptable, culturally appropriate, affordable, equitable, and sustainable (McElmurry & Keeney, 1999, 2006 Pan American Health Organization, 2003). An important primary health care strategy for providing affordable, accessible, acceptable, and culturally appropriate health programs is the incorporation into health care systems of CHWs (McElmurry, Tyska, & Parker, 1999), also known by a number of other terms such as lay health advisors and health promoters (Andrews, Felton, Wewers, & Heath, 2004). Community health workers are trusted, respected community members who are seen as helpful and respon- sive to the needs of others (Satterfield, Burd, Valdez, Hosey, & Eagle Shield, 2002). They receive special training to enable them to serve as health educators and mobilize their communities to improve their health and environments (Swider & McElmurry, 1990). Community health workers have been widely used in Latin America (Elder et al., 2005 McElmurry, Marks, & Cianelli, 2002) and the United States, especially with ethnic minority populations (Andrews et al., 2004 Elder et al., 2005 Family Strengthening Policy Center, 2006 Lewin et al., 2005). As community members, CHWs are cultural insiders who know the health beliefs and practices common to their community. Patients view CHWs as similar to them- selves, which may enhance CHWs’ ability to influence patients’ health care decision making and behavior (Satterfield et al., 2002). From their position as commu- nity insiders, CHWs provide health-related services including health education, case finding and manage- ment, transport or interpreter services, and community outreach (Earp & Flax, 1999 Zuvekas, Nolan, Tumaylle, & Griffin, 1999). Typically, paid or volunteer CHWs function in the community within community-based health care settings or in public health departments. Their primary functions are to provide culturally appropriate health education and help the community understand and 294 HEALTH PROMOTION PRACTICE / April 2009 The Authors Beverly J. McElmurry, EdD, FAAN, is a professor of Public Health Nursing and associate dean, Global Health Leadership Office, University of Illinois at Chicago College of Nursing, in Chicago, Illinois. Linda L. McCreary, PhD, RN, is a research assistant professor of Public Health Nursing at the University of Illinois at Chicago College of Nursing, in Chicago, Illinois. Chang G. Park, PhD, is a senior research specialist at the University of Illinois at Chicago College of Nursing in Chicago, Illinois. Lori Ramos, MA, MPH, is the executive director at the Chicago Global Donors Network and was, at the time of the demonstration program, executive director of Centro San Bonifacio in Chicago, Illinois. Enrique Martinez, MD, is a chief medical officer for Ambulatory Specialty Services and Primary Care Clinics at the John H. Stroger Jr. Hospital of Cook County in Chicago, Illinois. Rajesh Parikh, MD, MPH, is the director of Education and Professional Development at the Illinois Primary Health Care Association, and, during the demonstration project, director of the Illinois Area Health Education Program in Chicago, Illinois. Kelly Kozik, BS, RD, LD, CDE, is a clinical coordinator, Cook County Network Diabetes Program, at the Cook County Bureau of Health Services in Chicago, Illinois. Leon Fogelfeld, MD, is the head, Division of Endocrinology, at Rush University Medical Center and chief, Division of Endocrinology, at John H. Stroger Jr. Hospital of Cook County in Chicago, Illinois. at OhioLink on January 6, 2012 hpp.sagepub.com Downloaded from

access the health care system appropriately (University of Arizona, 1998). Community health workers have been shown to effec- tively screen and educate at-risk community members about health promotion practices, increase knowledge of chronic illness and prevention, improve self-care and medication compliance, improve outcomes for patients, increase the proportion of referred patients who attend follow-up appointments, and reduce health care costs through appropriate use of health care facilities. CHWs also act as bridges between their communities and the health care system, often serving as cultural brokers between clients of ethnic minority groups and majority-group health care providers (Corkery, Palmer, Schechter, Frisher, & Roman, 1997 Felix-Aaron, Bone, Levine, & Rubin, 2002 Goicoechea-Balbona, 1997 Satterfield et al., 2002 Wasserman et al., 2006). Furthermore, CHWs pro- vide training in cultural sensitivity for health care providers from the majority group (Corkery et al., 1997 Felix-Aaron et al., 2002 Flax & Earp, 1999 Hill, Bone, & Butz, 1996 Poss, 1999). In most cases, CHWs perform multiple roles (Norr, McElmurry, & Misner, 1999). Several review articles provide a comprehensive overview of the published con- ceptual and research literature addressing the role of CHWs in community settings (Andrews et al., 2004 Lewin et al., 2005 Nemcek & Sabatier, 2003 Swider, 2002 Witmer, Seifer, Finocchio, Leslie, & O’Neil, 1995) and with persons with diabetes (American Association of Diabetes Educators, 2003). However, there has been little research into the role of CHWs in clinical settings serving ethnic minority group members. In the clinical setting, CHWs serve a dual role as cultural bridges: They both enhance patients’ understanding of how to negotiate the clinical arena and increase health care providers’ understanding of their patients’ culturally determined health beliefs and practices. PROGRAM DEVELOPMENT: MULTISECTORAL COLLABORATION This article describes the development, outcomes, and lessons learned from multisectoral collaboration to imple- ment the primary health care–based Bridges to Health (BTH) program. The collaborative group included physi- cians, registered nurses (RNs), registered dieticians, certi- fied diabetes educators (CDEs), public health specialists, researchers, educators, and community developers from four diverse organizations: the Illinois Health Education Consortium, a not-for-profit private nongovernmental organization University of Illinois at Chicago College of Nursing, a research-intensive public university Cook County Bureau of Health Services, a large publicly owned health care center and Centro San Bonifacio, a grass- roots, community-based organization that promotes self- empowerment within immigrant Latino communities of Chicago. Building on Centro San Bonifacio’s community- based Health Promoter (HP) program (Ramos, Sanchez, & Ramos, 1999), BTH was developed to bring an existing cadre of HPs into the clinical setting to serve as “bridges to health,” providing culturally appropriate diabetes edu- cation for LEP Latinos in five ambulatory care sites of the Cook County Bureau of Health Services Network Diabetes Program (NDP). In addition, BTH was developed to increase the cultural and linguistic competence of the health care providers in the clinical setting by providing Spanish language and cultural competency training for Cook County Bureau of Health Services health care providers. Program Description: Strategies to Improve Care and Reduce Disparities Community health worker interventions can target one or more of three outcomes: individual behavior change, community change, and organizational change (Eng & Young, 1992). Following the recommendation of the Committee on Future Directions for Behavioral and Social Sciences Research at the National Institutes of Health (Singer & Ryff, 2001) that interventions should function at multiple levels, BTH focused on both the individual and the organizational levels. At the individual level, BTH provided culturally tailored diabetes patient education in Spanish, along with Spanish language skills and cultural competency training for health care providers. At the organizational level, BTH provided cultural workshops for clinic staff and other providers, as well as introduced HPs into the clinical area to act as cultural bridges between other health care providers and patients. The BTH program was unique because of its comprehensive, multilevel primary health care approach to improving care and reducing health disparities experienced by LEP Latino diabetes patients by increasing accessibility and acceptability of care. This was accomplished by providing culturally appropriate patient services and increasing the cultural and linguistic competence of health care providers. Implemented from 2001 to 2004, BTH developed and provided both patient-directed and provider-directed services that together had a positive effect on the health of LEP Latino patients with diabetes. First, to address patients’ needs, a group of five HPs, with one designated as the HP coordinator, were recruited and given specific McElmurry et al. / COLLABORATIVE PRIMARY HEALTH CARE PROGRAM 295 at OhioLink on January 6, 2012 hpp.sagepub.com Downloaded from