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Addressing Emotional Wellness During the COVID-19 Pandemic: the Role of Promotores in Delivering Integrated Mental Health Care and Social Services

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Introduction: The disproportionate impact of the COVID-19 pandemic on Latino communities has resulted in greater reports of depression, anxiety, and stress. We present a community-led intervention in Latino communities that integrated social services in mental health service delivery for an equity-based response. Methods: We used tracking sheets to identify 1,436 unique participants (aged 5-86) enrolled in Latino Health Access's Emotional Wellness program, of whom 346 enrolled in the pre-COVID-19 period (March 2019-February 2020) and 1,090 in the COVID-19 period (March-June 2020). Demographic characteristics and types of services were aggregated to assess monthly trends using Pearson χ2 tests. Regression models were developed to compare factors associated with referrals in the pre-COVID-19 and COVID-19 periods. Results: During the pandemic, service volume (P < .001) and participant volume (P < .001) increased significantly compared with the prepandemic period. Participant characteristics were similar during both periods, the only differences being age distribution, expanded geographic range, and increased male participation during the pandemic. Nonreferred services, such as peer support, increased during the pandemic period. Type of referrals significantly changed from primarily mental health services and disease management in the prepandemic period to affordable housing support, food assistance, and supplemental income. Conclusion: An effective mental health program in response to the pandemic must incorporate direct mental health services and address social needs that exacerbate mental health risk for Latino communities. This study presents a model of how to integrate both factors by leveraging promotor-led programs.
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PREVENTING CHRONIC DISEASE
PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY
Volume 18, E53 MAY 2021
ORIGINAL RESEARCH
Addressing Emotional Wellness During the
COVID-19 Pandemic: the Role of
Promotores
in Delivering Integrated Mental
Health Care and Social Services
KyleJ.Moon1; GloriaItzelMontiel,PhD2; PatriciaJ.Cantero,PhD2; SairaNawaz,PhD,MPH1
Accessible Version: www.cdc.gov/pcd/issues/2021/20_0656.htm
Suggested citation for this article:
Moon KJ, Montiel GI,
Cantero PJ, Nawaz S. Addressing Emotional Wellness During the
COVID-19 Pandemic: the Role of Promotores in Delivering
Integrated Mental Health Care and Social Services. Prev Chronic
Dis 2021;18:200656. DOI: https://doi.org/10.5888/pcd18.200656.
PEER REVIEWED
Summary
What is already known on the topic?
Mental health needs have been exacerbated by the COVID-19 pandemic.
As a result, Latino communities experience disparate rates of stress, de-
pression, and anxiety.
What is addressed by this report?
Few studies explore
promotor
-led mental health interventions as strategies
to address service gaps in Latino communities. This article describes a
community-based intervention that integrates social services and mental
health services.
What are the implications for public health practice?
With ongoing COVID-19 surges and with vaccine distribution underway, a
critical need remains to respond with equity. Latino Health Access’s Emo-
tional Wellness program emphasizes the importance of delivering mental
health care integrated with social services and provides a model to re-
duce the effect of COVID-19 in socioeconomically disadvantaged com-
munities.
Abstract
Introduction
The disproportionate impact of the COVID-19 pandemic on
Latino communities has resulted in greater reports of depression,
anxiety, and stress. We present a community-led intervention in
Latino communities that integrated social services in mental health
service delivery for an equity-based response.
Methods
We used tracking sheets to identify 1,436 unique participants
(aged 5–86) enrolled in Latino Health Access’s Emotional Well-
ness program, of whom 346 enrolled in the pre–COVID-19 period
(March 2019–February 2020) and 1,090 in the COVID-19 period
(March–June 2020). Demographic characteristics and types of ser-
vices were aggregated to assess monthly trends using Pearson
χ
2
tests. Regression models were developed to compare factors asso-
ciated with referrals in the pre–COVID-19 and COVID-19 peri-
ods.
Results
During the pandemic, service volume (
P
< .001) and participant
volume (
P
< .001) increased significantly compared with the pre-
pandemic period. Participant characteristics were similar during
both periods, the only differences being age distribution, expan-
ded geographic range, and increased male participation during the
pandemic. Nonreferred services, such as peer support, increased
during the pandemic period. Type of referrals significantly
changed from primarily mental health services and disease man-
agement in the prepandemic period to affordable housing support,
food assistance, and supplemental income.
Conclusion
An effective mental health program in response to the pandemic
must incorporate direct mental health services and address social
needs that exacerbate mental health risk for Latino communities.
This study presents a model of how to integrate both factors by
leveraging
promotor
-led programs.
Introduction
Mental health needs of working-class Black and Latino communit-
ies have long been insufficiently met in the United States (1). The
COVID-19 pandemic has exacerbated mental health needs through
The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health
and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.
This publication is in the public domain and is therefore without copyright. All text from this work may be reprinted freely. Use of these materials should be properly cited.
www.cdc.gov/pcd/issues/2021/20_0656.htm • Centers for Disease Control and Prevention 1
unpredictability and uncertainty, physical distancing, social isola-
tion, loss of employment and income, mortality, and social suffer-
ing (2). Among US adults surveyed in June 2020, 52.1% of His-
panic adults reported at least 1 adverse mental or behavioral health
condition, compared with 37.8% of non-Hispanic White adults.
Hispanic adults reported higher prevalence of anxiety or depress-
ive disorder, trauma-related and stressor-related disorder, sub-
stance use to cope with stress, and suicidal ideation (3). These dis-
parities in mental health effects reflect the grief, bereavement, and
stress related to financial insecurity resulting from the pandemic in
Latino communities (4), which along with other racial and ethnic
minority communities, have been disproportionately affected by
COVID-19 as a result of structural racism (5).
Experts have called for local implementation (6) of community-
level mental health interventions and prevention efforts that integ-
rate financial relief and social services, promote social cohesion,
and provide culturally and linguistically tailored education on
COVID-19 and mental health (2,3). The American Psychological
Association has also called for a “reimagining” of the behavioral
health system as one that reaches people where they are, recog-
nizes wisdom in each community to solve its own problems, and
looks to innovative roles for new mental health practitioners who
are firmly rooted in their communities (6,7). Responding to these
calls to action, this study investigated the role of
promotores de
salud
(community health workers) in providing community-led
and integrated mental health care and social services in response to
the COVID-19 pandemic in Latino communities of Orange
County, California. Our findings may provide a model for integ-
rating equity in mental health interventions during and after the
pandemic.
Methods
Emotional Wellness program framework
Latino Health Access’s (LHA’s)
Bienestar Emocional
(Emotional
Wellness) program draws on principles of narrative therapy and
aligns with human-centered design, which prioritizes participant
engagement throughout the lifecycle of the program (8,9). The
program was developed by LHA
promotores
in partnership with a
marriage and family therapist trained in narrative therapy. Narrat-
ive therapy recognizes participants as authors of their own stories,
in which we are all participants in each other’s stories (10) and
empowers people to write a new story as a process to overcome
the inequities and oppressions of the dominant social narrative
(11). In this way, narrative therapy can link people with similar
stories, joining their voices together in shared purpose to improve
their mental and emotional well-being (10). Narrative therapy has
demonstrated success in overcoming stigma associated with ther-
apy and social position because it centers the person rather than
imposing a hierarchy, with the counselor as expert (11). A unique
feature of LHA’s program is that it is facilitated by
promotores
with ongoing training and support provided by a marriage and
family therapist.
The multipronged nature of the Emotional Wellness program ad-
dresses the spectrum of needs for the community, such that 1) nar-
rative therapy and peer support achieve culturally appropriate
mental health services, 2) services to overcome barriers to care ad-
dress more immediate health and social needs, and 3) community
advocacy and leadership are intended to address inequities by
shifting the policy environment (Figure 1). Because of the its
reach and grounding in human-centered design, along with the
trusted relationships
promotores
have with participants as pro-
gram facilitators and community members facing similar circum-
stances, the program was the appropriate vehicle for providing in-
tegrated care once COVID-19 hit communities in early March
2020. The Emotional Wellness program was enhanced to expand
delivery of mental health services while addressing social needs of
food and housing insecurity. Through these services, LHA en-
sured its mental health response was rooted in addressing the so-
cial inequities that created the conditions by which COVID-19
devastated working-class racial and ethnic minority communities
and exacerbated mental health stressors (12). The Emotional Well-
ness program adopted a population health approach to address be-
havioral health needs along a continuum, regardless of whether
participants had a mental or emotional health condition, providing
a range of services (6). As COVID-19 policies took effect (Figure
1), the Emotional Wellness program was well-positioned to ex-
pand to help vulnerable groups meet their immediate mental health
and social needs, while continuing to address the structural in-
equities exacerbated by the pandemic.
PREVENTING CHRONIC DISEASE VOLUME 18, E53
PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY MAY 2021
The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services,
the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.
2 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2021/20_0656.htm
Figure 1. Framework for Latino Health Access’s
Bienestar Emocional
(Emotional Wellness) program describing its 3 primary initiatives, their
components, and the associated timeline of related events. The program is
based in Orange County, California. Abbreviations: CARES, Coronavirus Aid,
Relief, and Economic Security Act; N-20-28, executive order issued by
Governor Newsom of California that allows local governments to impose
temporary limitations on residential and commercial evictions under COVID-
19-related financial distress.
Study design
Our observational study used de-identified tracking data collected
by LHA over 2 years (March 2019–June 2020). No sampling was
conducted, because the full universe of clients was needed to re-
flect changes in volume of services received (mental health and
social services) and referrals provided during the prepandemic and
pandemic periods. Because data were stripped of all identifiable
information with no linkage to the participants from whom it was
originally collected, the study did not constitute human subjects
research and therefore did not require internal review board ap-
proval.
Study site and participants
LHA, a nonprofit public health organization in Santa Ana, Califor-
nia, partners with Latinx communities in Orange County to ad-
vance health equity through a combination of culturally and lin-
guistically concordant direct services and upstream initiatives that
address social determinants of health through community-led
policy, systems, and environmental change. Programs are facilit-
ated by
promotores
, who are members of the community and thus,
have a wealth of local knowledge and expertise, understand the
lived experiences of those in the community, and have specialized
training in health promotion and community advocacy.
All participants in this study were drawn from LHA’s Emotional
Wellness program from March–June 2019 and January–June
2020, during which 1,436 unique participants were enrolled. All
participants were recruited from Orange County, California, with
participants representing 25 of the 34 cities and 50 of the 88 zip
codes in the county. Historic data showed that LHA participants
were predominantly female (72%), aged 18 or older (71%), Latino
(98%), uninsured (46%), foreign born (95%), Santa Ana residents
(78%), monolingual Spanish speakers (90%), and earned less than
$30,000 annually (85%) (13).
Procedure
Promotores
across all LHA programs referred participants to the
Bienestar Emocional
program whom they identified as having ex-
perienced or were currently experiencing trauma or domestic viol-
ence. Once enrolled, emotional wellness
promotores
conducted an
exploratory session to uncover the priority issues for the parti-
cipant and identify their most pressing social needs. Thereafter,
participants engaged in group sessions and one-on-one sessions
with a
promotor
by using a curriculum based on principles of nar-
rative therapy. During each session,
promotores
provided a range
of interventions, including education (navigating legal, medical,
education, penal, or immigration systems), peer support (dona-
tions, goal setting, identifying strengths and barriers, moral sup-
port, system support), leadership development (advocacy and indi-
vidual coaching), community building and engagement (group
projects, activities, volunteering), addressing barriers to service
use (application assistance, childcare, health care access, transla-
tion services, transportation arrangements), and referrals to legal,
social, and health services. All
promotores
were trained by a mar-
riage and family therapist to facilitate structured sessions through
the program curriculum. In addition,
promotores
received training
on mental health and community interventions from a bilingual
and bicultural therapist.
Once COVID-19 struck, service delivery changed: group sessions
convened via video conferencing, and one-on-one sessions were
carried out over the telephone. In March 2020, LHA rapidly ex-
panded its referrals to address social needs, with COVID-19 finan-
cial relief, nutrition assistance, and affordable housing support. As
such, participant volume also increased substantially during the
pandemic, because 1) social needs proliferated and 2)
promotores
organized an initial COVID-19 pandemic response by calling cur-
rent and prior LHA participants to understand their experiences
with the pandemic in real time. During these calls,
promotores
provided prevention information, education, and resources as well
as presented civic engagement opportunities to address the rising
housing crisis, the decennial census, and the 2020 Presidential
election with nonpartisan voter engagement messaging.
PREVENTING CHRONIC DISEASE VOLUME 18, E53
PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY MAY 2021
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the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.
www.cdc.gov/pcd/issues/2021/20_0656.htm • Centers for Disease Control and Prevention 3
Data collection and statistical analysis
During one-on-one sessions, data were captured by each
promotor
by using a 12-character unique identifier. Service providers re-
moved all personal information and shared the de-identified data
with Ohio State University researchers (K.J.M. and S.N.). Ana-
lyses were conducted to compare the effects of the pandemic on
provision of services. First, demographic characteristics were
compared for the sample of participants in the prepandemic
(March 2019–February 2020) and the pandemic (March
2020–June 2020) periods. Demographics included age, ethnicity,
sex, and geographic residence.
Second, analyses of services used were conducted at 2 levels, 1)
by service volume and type, and 2) by participant. For analyses by
participant, service use trends were controlled such that each parti-
cipant received a maximum of 1 of each service during a particu-
lar month. For example, if Participant A had 3 service encounters
for peer support and 1 service encounter for education during
March, Participant A received 2 services during March: peer sup-
port and education. The denominator for participant-based ana-
lyses was the number of unique participants in each month. We
used independent
t
tests to assess differences in service and parti-
cipant volume from the prepandemic to pandemic period. The
Pearson
χ
2 test of independence was used to identify significant
differences in demographic characteristics and service use by ser-
vice type and referral category. Yates’s continuity correction was
applied when any cell in the contingency table had a frequency
less than 10. Significance was established at α = .05; 95% CIs
were constructed for all proportions. To assess variation across the
ten months, an overall
P
value was computed, and a second com-
parison was computed between prepandemic (March 2019–Febru-
ary 2020) and pandemic (March 2020–June 2020) periods. The
third analysis involved the development of logistic regression
models to compare predictors of participants receiving referrals in
the prepandemic and pandemic periods. Participants with missing
data for 1 or more demographic variable(s) were excluded from
the regression models, as were participants enrolled during both
prepandemic and pandemic periods. We included 722 unique par-
ticipants in the analysis, of whom 210 were enrolled during the
prepandemic period and the remaining 512 during the pandemic
period. All analyses were performed by using R Statistical Soft-
ware, version 3.6.2 (R Foundation for Statistical Computing).
Results
We enrolled 1,436 unique participants in LHA’s Emotional Well-
ness program from March 2019 to June 2020. Of these, 660 parti-
cipants (46.0%) were excluded from demographic analyses be-
cause of missing data, leaving 776 unique participants, 57 of
whom were enrolled in the Emotional Wellness program during
both the prepandemic and pandemic periods. The magnitude of
missing data is largely due to the transition to virtual service deliv-
ery and the rapid expansion of the program in response to COVID-
19. Of the 776 unique participants, most were Latino (n = 763,
98.3%), female (n = 594, 76.5%), aged 25–44 (n = 400, 51.5%),
and from Santa Ana (n = 503, 64.8%) (Table 1). Group differ-
ences in sex (increased male participation during the pandemic
period,
P
< .001), age (decreased participation among people aged
5–17 [12.8% vs 4.1%,
P
< .001] and increased participation
among people aged 45–64 [30.1% vs 37.9%,
P
= .03] during the
pandemic period), and geographic residence (decreased participa-
tion from Anaheim [20.3% vs 14.3%,
P
= .03] and increased parti-
cipation from other cities [12.0% vs 22.2%,
P
< .001]) were signi-
ficant. Groups did not differ by ethnicity (98.1% Latino prepan-
demic vs 98.6% pandemic,
P
= .83).
Trends in use of services
From prepandemic to pandemic periods, the volume of services (
P
< .001) and participants (
P
< .001) increased significantly (Figure
2). Although the volume of participants was driven, in part, by the
promotores
’ COVID-19 outreach, the ratio of services to parti-
cipants increased, though not significantly, from an average of 4.0
in the prepandemic period to 4.3 in the pandemic period (
P
= .54),
meaning each participant received a greater number of services.
Figure 2. Service use among Latino Health Access’s Emotional Wellness
participants, showing trends in volume of services and participants during 10
months (March 2019–June 2020). The ratio of services to participants
increased from an average of 4.0 in the pre-COVID-19 period to an average of
4.3 in the COVID-19 period (
P
= .54). Significance was assessed by using an
independent
t
test.
Trends in referrals varied significantly in 8 of the 9 service cat-
egories in both periods (Table 2).When the COVID-19 pandemic
struck in full force in March 2020, a significant uptick in referrals
occurred for affordable housing (
P
< .001), financial assistance (
P
< .001), and food and nutrition assistance (
P
< .001). Paradoxic-
ally, referrals to mental health services declined steeply (
P
< .001)
as did referrals for health education and disease management (
P
<
.001) from the prepandemic to pandemic period.
PREVENTING CHRONIC DISEASE VOLUME 18, E53
PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY MAY 2021
The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services,
the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.
4 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2021/20_0656.htm
Regression models
Results from logistic regression analysis identified factors associ-
ated with the receipt of referrals (Model 1), receipt of referrals for
mental health services (Model 2), and receipt of referrals to ad-
dress social needs (Model 3) (Table 3). During the prepandemic
period, 179 (85.2%) received 1 or more referrals; 104 (58.1%) re-
ceived a referral for mental health services. In March 2020, 475
(92.8%) received 1 or more referrals, of which 20 (4.2%) were for
mental health services, and 416 (87.6%) to address social needs.
Of those receiving a referral for mental health services, 13 (65.0%)
received referrals to address both mental health and social needs.
During both prepandemic and pandemic periods, participants who
resided outside of Santa Ana were significantly less likely to re-
ceive a referral (odds ratio [OR] = −1.06 during prepandemic,
P
=
.001 vs −1.59 pandemic,
P
= .004). During the prepandemic peri-
od, participants receiving 1 to 3 services from LHA were signific-
antly less likely than those not receiving services from LHA to re-
ceive a referral for mental health services (OR = −1.91,
P
< .001).
Although still significant, the OR declined during the pandemic
period (−1.17,
P
= .02), meaning the likelihood of participants not
receiving mental health services decreased.
Discussion
Our study aimed to understand the ways in which
promotores
in-
corporated equity in a COVID-19 community mental health inter-
vention in the Latino communities of Orange County, California.
An equity response prioritizes the populations that are most af-
fected by health disparities and engages them in developing
strategies to address both the immediate needs and root causes of
these disparities. Our intervention leveraged principles of narrat-
ive therapy, integrated social services that addressed needs cre-
ated by structural inequities, and engaged participants in upstream
initiatives to address not only gaps in services but the conditions
that underlie these gaps. Although prior mental health initiatives
sought to improve cultural competency of interventions (7,14), the
intervention presented herein was unique in that it incorporated so-
cial services as a strategy to build equity in the delivery of
community-driven emotional wellness services (15). This integra-
tion drew on human-centered design by addressing the com-
munity’s social realities directly and centering the experiences of
the communities it intended to affect.
Data from our study provide evidence of the association between
social needs and mental health needs, because the pandemic peri-
od marked a rapid increase in the receipt of in-house mental health
and social services. Increases in the volume of services and parti-
cipants were likely the result of social and economic precarity: re-
duced work hours and unemployment (and thus, loss of income,
food insecurity, and housing instability) during the shelter-in-place
period and subsequent business closures. However, mental health
and disease management referrals sharply declined as social ser-
vice referrals increased. Before the pandemic, LHA provided pro-
gramming in diabetes self-management, obesity prevention, and
chronic pain management (16), all of which were
promotor
-led
with group and individual meetings. Like mental health needs, dis-
ease management needs did not disappear during the pandemic,
but because of the economic impact of COVID-19 on Latino com-
munities, it became pressing to provide the referrals and addition-
al services linked to the entrenched social determinants of health
that resulted in greater social needs for vulnerable populations
(12,17). Therefore, an equitable response to mental health during
the pandemic had to, at a minimum, also account for the social
needs and heightened stress that affected these communities. An
approach that only focuses on adapting mental health interven-
tions for Latino communities may fail without a more integrated
approach to care that accounts for social needs. Furthermore, data
from our study also suggests that housing, financial assistance, and
food are among the most important social needs in the rise of the
pandemic, and all 3 of these have been associated with mental
health and stability (4,18). In many cases, financial strain — and
the resulting poverty, increased exposure to violence, food insec-
urity, and reduced access to social safety nets — is the fundament-
al cause of mental health issues (18–20).
LHA Emotional Wellness participants were predominantly from
immigrant backgrounds, and a high proportion were uninsured,
which may have contributed directly to their reliance on
community-based organizations such as LHA for critical mental
health and social services for which they may have been ineligible
through mainstream systems. At the same time, it may also have
been these characteristics that drove a disproportionate need
among these participants, in comparison to nonimmigrant Latino
participants or those insured either through private insurance or
Medicaid. Nonetheless, because the
promotor
model relies on a
workforce with local knowledge and expertise, the model can be
generalizable to other communities and has already been tested as
a model for health education, health promotion, and programmat-
ic interventions to address health outcomes in other ethnic com-
munities in the United States and globally (21,22). Our study ad-
vances empirical knowledge on
promotor-
facilitated mental health
programming by 1) providing understanding of community-based
mental health interventions during the COVID-19 pandemic and
2) describing how leveraging a model built on strong community
trust can be an effective vehicle in providing integrated care for
mental health and social services. Because traditional health sys-
tems have proven less than effective in addressing the community
spread of COVID-19 (23), our study showed how
promotor
-led in-
terventions could rapidly address inequities arising from COVID-
PREVENTING CHRONIC DISEASE VOLUME 18, E53
PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY MAY 2021
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the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.
www.cdc.gov/pcd/issues/2021/20_0656.htm • Centers for Disease Control and Prevention 5
19 and associated policies, meet social needs, and reduce social
isolation, all while mobilizing the community to advocate against
racist policies related to housing, employment, and access to so-
cial services. LHA’s Emotional Wellness model illustrates how
long-term engagement with a community is needed to effectively
apply principles of human-centered design in health and social ser-
vice delivery models to advance equity. As the role of social de-
terminants of health in creating inequalities has become clear dur-
ing the COVID-19 pandemic (24), many health systems have
sought solutions, such as referral systems (25) or payment models
(26), to screen patients and link them to services in the com-
munity. Though these have been effective in increasing referral
rates, the acceptability of these services and their health effects has
not been well documented. Because LHA is present in the com-
munity, it has helped shape programs proposed by health systems
and public health and academic centers, establishing its unique
value as part of the COVID-19 response.
Our study has several limitations. We relied on participant track-
ing data that were collected virtually during the pandemic period,
resulting in missing data for demographic characteristics. A com-
parison of available data (services used, city, zip code) for parti-
cipants with missing data versus those included in the study pro-
duced no significant differences, and we therefore believe our res-
ults are generalizable to all LHA participants. The outcome for our
study was limited to use of services, and in the absence of a com-
parison group, we could not establish the effectiveness of the
Emotional Wellness program on health outcomes. Previous
promotor-
led interventions in mental health services faced similar
challenges, with favorable observations from ethnographic evalu-
ation but no significant improvements in health outcomes (7), un-
derscoring the need for further research to link interventions to
mental health outcomes. Additionally, we had no tracking data to
determine how many participants who received a referral ac-
cessed services at the referred agency. Given LHA’s long-standing
presence in Orange County, the organization has forged strong
community partnerships for referrals. Where possible,
promotores
established an initial call to a service provider and helped pro-
gram participants make the initial contact or appointment.
Promotores
also gave participants eligibility information for each
service and all contact information for partner agencies. Future in-
terventions are necessary to identify which social needs should be
addressed to improve mental health (27). Given LHA’s limited re-
sources, the authors had to rely on existing data to assess program
value and identify opportunities for improvement, adaptation, and
expansion as the community’s needs evolved. We, however, be-
lieve that the study’s benefits outweigh its limitations as the US
seeks effective models for addressing ongoing surges in the
COVID-19 pandemic and ensuring equitable roll-out of vaccines
to reach systematically disadvantaged populations (28,29). Effect-
ive communication strategies, with peer-to-peer vaccine education
and outreach, may be an effective strategy to address vaccine mis-
trust and misinformation in Latino communities. Such efforts are
likely to ease uncertainty and alleviate stress, and thus, may help
address mental health conditions associated with COVID-19 (2,3).
Our study showed how a community-based organization with
long-standing ties in the Latino community effectively expanded
its Emotional Wellness program to provide integrated mental
health care and social services to clients disproportionately af-
fected by the COVID-19 pandemic. Despite some limitations, the
study findings are informative for traditional health systems that
have struggled to address the health inequities that have been ex-
acerbated during the pandemic. Although social needs have taken
precedence, evidence of the mental health toll of the pandemic are
already well documented (3), and programs such as LHA’s Emo-
tional Wellness program are needed to reduce the pandemic’s im-
pact in systematically disadvantaged communities.
Acknowledgments
LHA’s Emotional Wellness Program receives contributions from
the Orange County Community Foundation, the Keith and Judy
Swayne Family Foundation, and the Health Care Foundation for
Orange County. The authors thank the
promotores
at LHA, who
have championed mental health equity in their work on the front-
lines of the COVID-19 pandemic, responding with the utmost
compassion and courage. No copyrighted material was used in this
article.
Author Information
Corresponding Author: Saira Nawaz, PhD, MPH, Ohio State
University, 381 Cunz Hall, 1841 Neil Ave, Columbus, OH 43210.
Telephone: 614-292-4691. Email: nawaz.16@osu.edu.
Author Affiliations: 1Center for Health Outcomes and Policy
Evaluation Studies, Ohio State University College of Public
Health, Columbus, Ohio. 2Latino Health Access, Santa Ana,
California.
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the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.
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the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.
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PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY MAY 2021
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the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.
8 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2021/20_0656.htm
Tables
Table 1. Demographic Characteristics of Participants (N = 722) in Latino Health Access’s Emotional Wellness Program During the COVID-19 Pandemic, Orange
County, Californiaa
Characteristic Pre-COVID-19 (March 2019-February 2020), n = 266bCOVID-19 (March 2020-June 2020), n = 567b
P
Valuec
Ethnicity
Hispanic/Latino 261 (98.1) [96.5–99.8] 559 (98.6) [97.6–99.6]
.83Other 261 (1.9) [0.2–3.5] 8 (1.4) [0.4–2.4]
Sex
Male 40 (15.0) [10.7–19.3] 146 (25.7) [22.2–29.3]
<.001Female 226 (85.0) [80.7–89.3] 421 (74.3) [70.7–77.8]
Age, y
5–17 34 (12.8) [8.8–16.8] 23 (4.1) [2.4–5.7) <.001
18–24 6 (2.3) [0.5–4.0] 9 (1.6) [0.6–2.6] .69
25–44 133 (50.0) [44.0–56.0] 298 (52.6) [48.4–56.7] .49
45–64 80 (30.1) [24.6–35.6] 214 (37.9) [33.9–41.9] .03
≥65 13 (4.9) [2.3–7.5] 22 (3.9) [2.3–5.5] .50
Location of residence
Santa Ana 180 (67.7) [62.0–73.3] 360 (63.5) [59.5–67.5] .24
Anaheim 54 (20.3) [15.5–25.1] 81 (14.3) [11.4–17.2] .03
Other 32 (12.0) [8.1–15.9] 126 (22.2) [18.8–25.6] <.001
a Fifty-seven participants were enrolled in both prepandemic and pandemic programs.
b Values are number (percentage) [95% CI] unless otherwise indicated.
c Pearson
χ
2 test of independence was used to determine significance, with Yates’ continuity correction applied when any cell had a frequency of <10.
P
value <.05
considered significant.
P
value assesses difference between prepandemic (March 2019-February 2020) and pandemic period (March 2020-June 2020).
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the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.
www.cdc.gov/pcd/issues/2021/20_0656.htm • Centers for Disease Control and Prevention 9
Table 2. Trends in Referrals to Mental Health and Social Services Among Participants (N = 722) in Latino Health Access’s Emotional Wellness Program During the
COVID-19 Pandemic, Orange County, Californiaa
Category
2019 2020
Overall
P
Valueb
Pre-
COVID-19
vs
COVID-19
P
Value
Mar,
n = 45
Apr,
n = 69
May,
n = 75
Jun,
n = 66
Jan,
n = 44
Feb,
n = 67
Mar,
n = 220
Apr,
n = 307
May,
n = 344
Jun,
n = 224
Affordable
housing
0 4.3
(0–9.2)
0 3.0
(0–7.2)
2.3
(0–6.7)
1.5
(0–4.4)
13.6
(9.1–18.2)
13.0
(9.3–16.8)
10.5
(7.2–13.7)
12.1
(7.8–16.3)
<.001 <.001
Financial
assistance
0 0 0 0 0 0 0.9
(0–2.2)
30.9
(25.8–36.
1)
61.0
(55.9–66.
2)
55.4
(48.8–61.
9)
<.001 <.001
Food and
nutrition
assistance
0 1.4
(0–4.3)
0 1.5
(0–4.5)
0 0 74.1
(68.3–79.
9)
61.6
(56.1–67.
0)
45.9
(40.7–51.
2)
49.6
(43.0–56.
1)
<.001 <.001
Health education
and disease
management
62.2
(48.1–76.
4)
34.8
(23.5–46.
0)
36.0
(25.1–46.
9)
7.6
(1.2–14.0)
15.9
(5.1–26.7)
4.5
(0–9.4)
0 2.0
(0.4–3.5)
4.4
(2.2–6.5)
7.1
(3.8–10.5)
<.001 <.001
Legal services
and advocacy
4.4
(0–10.5)
5.8
(0.3–11.3)
9.3
(2.7–15.9)
12.1
(4.2–20.0)
9.1
(0.6–17.6)
9.0
(2.1–15.8)
2.3
(0.3–4.2)
3.9
(1.7–6.1)
3.5
(1.5–5.4)
6.3
(3.1–9.4)
.02 <.001
Medical care 6.7
(0–14.0)
1.4
(0–4.3)
2.7
(0–6.3)
4.5
(0–9.6)
11.4
(2.0–20.7)
4.5
(0–9.4)
2.3
(0.3–4.2)
4.2
(2.0–6.5)
9.0
(6.0–12.0)
25.9
(20.2–31.
6)
<001 .002
Mental health
services
4.4
(0–10.5)
33.3
(22.2–44.
5)
28.0
(17.8–38.
2)
45.5
(33.4–57.
5)
72.7
(59.6–85.
9)
83.6
(74.7–92.
5)
12.3
(7.9–16.6)
6.8
(4.0–9.7)
2.3
(0.7–3.9)
6.7
(3.4–10.0)
<.001 <.001
Recreation 88.9
(79.7–98.
1)
34.8
(23.5–46.
0)
48.0
(36.7–59.
3)
40.9
(29.0–52.
8)
2.3
(0–6.7)
1.5
(0–4.4)
0.5
(0–1.3)
0.3
(0–1.0)
0 0 <.001 <.001
Other 2.2
(0–6.5)
7.2
(1.1–13.4)
2.7
(0–6.3)
4.5
(0–9.6)
0 3.0
(0–7.1)
0.9
(0–2.2)
2.9
(1.0–4.8)
5.5
(3.1–7.9)
3.1
(0.8–5.4)
.18 .93
a Values are percentage (95% CI) unless otherwise indicated.
b Pearson
χ
2 test of independence was used to determine significance, with Yates’ continuity correction applied when any cell had a frequency of <10.
P
value <.05
considered significant.
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10 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2021/20_0656.htm
Table 3. Regression Analysis of Likelihood of Referral to Mental Health or Social Services Among Participants (N = 722) in Latino Health Access’s Emotional Well-
ness Program During the COVID-19 Pandemic, Orange County, Californiaa
Predictors
Model 1: ≥1 Referral Model 2: Referred to Mental Health Services
Model 3: Referred to Social
ServicesPre-COVID-19 COVID-19 Pre-COVID-19 COVID-19
Sex
Female 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference]
Male −0.41 (−1.70 to 0.89) 0.06 (−0.67 to 0.85) −0.23 (−0.92 to 0.60) −0.64 (−1.76 to 0.27) 0.39 (−0.16 to 0.98)
Age, y
<65 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference]
≥65 −0.98 (−3.18 to 1.02) 17.04 (NA) −0.27 (−1.88 to 1.19) −14.78 (−268.94 to
28.79)
−0.06 (−1.21 to 1.43)
Location of residence
Santa Ana 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference]
Outside Santa Ana 0.70 (−0.33 to 1.80) −0.64 (−1.35 to 0.05) −1.06b (−1.66 to (−0.41) −1.59b (−2.83 to (−0.61) 0.21 (−0.29 to 0.73)
Number of Latino Health Access services
None 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference]
1–3 −20.95 (NA) −17.46 (−262.92 to
21.14)
−1.91c (−2.97 to (−1.00) −1.17d (−2.22 to (−0.24) −0.19 (−0.75 to 0.36)
4 or 5 −19.56 (−399.72 to
59.69)
−17.32 (−262.78 to
21.28)
−0.40 (−1.12 to 0.31) 0.28 (−0.58 to 1.11) −0.17 (−0.81 to 0.48)
Abbreviation: NA, not available.
a Values are odds ratio (95% CI). All models were developed as logistic regressions. Model 3, Social Services, was implemented in March 2020. Wald χ2 test was
used to determine significance.
b Significant at
P
< .01.
c Significant at
P
< .001.
d Significant at
P
< .05.
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... The impact on this group was exacerbated by uncertainty, social isolation, loss of employment and income, mortality, and social suffering. 1 Latinx youth make up one of the largest and fastest-growing ethnic minority populations of Latinx in the United-States (US) and suffer from higher rates of mental health issues than their peers. Among Latinx youth, 22% report depressive symptoms, which is higher than all other groups except Native American youth. 2 Despite this, Latinx youth are less likely to receive mental health treatment (8%) compared to their Caucasian peers (14%). ...
... 4 Despite the increased prevalence of mental health disorders among Latinx adolescents and their families, they encounter unmet mental health needs stemming from disparities in the availability, accessibility, and quality of mental health services. 1 Until we acknowledge and address these limitations of our healthcare system and the disparities in the social determinants of health, we continually fail to foster the social and emotional well-being of this vulnerable population. Consistently pursuing opportunities to tackle ingrained health injustices within our nation remains paramount. ...
... The role of peer support in behavioral health has promising outcomes, particularly when members of the community are trained in providing behavioral health services (A. Gonzalez et al., 2021;Moon, 2021;Sternberg et al., 2019). Including families in appointments, with the patient's consent, may increase the comfort level in the provider's office (O'Mahony & Clark, 2018). ...
Article
Introduction: In 2020, 18.4% of Hispanics experienced mental illness, yet only about a third received treatment compared with nearly half of non-Hispanic Whites. In Montana, where only 11% of the mental health needs are currently met, service utilization is low. The purpose of this study was to determine the perceptions of the Hispanic immigrant population in a rural state on mental health and professional service utilization. Methods: Using a descriptive phenomenological approach, we conducted semi-structured telephone interviews in Spanish. Audio recordings were transcribed, translated to English, and analyzed for themes. Results: We recruited a sample of 14 participants from Mexico, Ecuador, Colombia, and Venezuela ranging in age from 33 to 59. We identified five themes: definitions of mental health, maintaining mental health, familismo/socialization, stigma, and acculturation stress. Discussion: Novel findings point to the need for Spanish-language services focused on reducing stigma around mental illness and incorporating the importance of social connections.
... It has long been recognized that disparities in health care access and patient outcomes are associated with factors related to race, sex, gender, sexual orientation, primary language, and socioeconomic status (27). Epps and coauthors recognize that African Americans and other underrepresented racial and ethnic groups are often not included in health decision making and policy development (9). As a result, these public health experts describe steps undertaken to improve participation, joint decision making, and capacity building between an integrated academic health system and a community coalition to address complex health challenges with the aim of increasing the capacity of health systems to reduce the burden of COVID-19. ...
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This review examines the current reporting trends of program design, implementation, and evaluation of training programs for Latinx community health workers. Five scholarly databases were searched using a scoping review methodology to identify articles describing training programs for Latinx community health workers. The timeframe was 2009 to 2021. We identified 273 articles, with 59 meeting inclusion criteria. Researchers thematically coded the articles to identify reporting strategies related to program design, implementation, and evaluation. Findings suggest a lack of consensus in reporting elements critical to program resources, instructor qualifications, frequency and length of training implementation, theoretical background, and pedagogical tools associated with the training program. We offer detailed reporting recommendations of community health worker training programs to support the consistent dissemination of promising practices and facilitate the initiation of new programs for Latinx community health workers.
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Community-initiated health interventions fill important gaps in access to health services. This study examines the effectiveness of a community-initiated health intervention to improve diabetes management in an underserved community of color using a retrospective observational study, comparing a study intervention, the Latino Health Access Diabetes Self-Management Program (LHA-DSMP), with usual care. The LHA-DSMP is a 12-session community health worker (promotor/a) intervention developed and implemented by a community-based organization in a medically underserved area. Usual care was delivered at a federally qualified health center in the same geographic area. Participants were 688 predominantly Spanish-speaking Latinx adults with type 2 diabetes. The main outcome was change in glycemic control (glycosylated hemoglobin [HbA1c]) from baseline to follow-up. At 14-week follow-up, mean (95% CI) HbA1c decrease was -1.1 (-1.3 to -0.9; P < .001) in the LHA-DSMP cohort compared with -0.3 (-0.4 to -0.2; P < .001) in the comparison cohort. Controlling for baseline differences between cohorts, the adjusted difference-in-differences value in HbA1c was -0.6 (-0.8 to -0.3; P < .001) favoring the LHA-DSMP. A community-initiated promotor/a-led educational program for diabetes self-management is associated with clinically significant improvement in blood sugar control, superior to what was observed with usual medical care.
Full-text available
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The COVID-19 global pandemic highlights the necessity for a population health approach to identify and implement strategies across systems to improve behavioral health. Adopting a population health approach helps to address the needs of the total population, including at-risk subgroups, through multiple levels of intervention and to promote the public's behavioral health and psychological well-being.
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