“If you didn’t write it down it didn’t happen!” Using Participatory Evaluation to Tell CHW Stories
Promotora Stories from the Arizona Sonora Border
Since the launch of Arizona’s first promotores program, Comienzo Sano (Health Start) in 1987, researchers in Southern Arizona have collaborated with Arizona Border communities to collaboratively evaluate promotores programs. Comienzo Sano provided prenatal outreach and education to women in Yuma County, and is now the single promotores program to be sustained as a line item in the Arizona Department of Health Services budget. The documentation of maternal health outcomes played a huge role in making the argument to fund ongoing promotores prenatal services to rural and underserved communities throughout Arizona. The success of Comienzo Sano underscores the power of both evaluation and collaboration. In this essay, I describe two examples of participatory evaluation with promotores programs.
Campesino Diabetes Management Program (CDMP)
The CDMP was created by Campesinos Sin Fronteras (CSF), a promotores program in Somerton, Arizona, that was founded in 1999 to serve the farmworker community. From its inception, CSF was tackling diabetes as a major threat to the health and well-being of farmworker families. CSF began by providing diabetes self-management education, and for me, evaluation seemed pretty straightforward. I suggested that we document changes in self-management behavior using a pre/post questionnaire with participants, and that we use client clinical records to see if their glucose levels improved. The evaluation showed that the program was effective, and I credited the promotores classes, but I was missing a great deal of the why and the how! Fortunately, the promotores were one step ahead of me. The director of CSF had been the first promotora hired by Comienzo Sano, and based on that experience she was clear with her staff that if they weren’t writing down everything they did, then they could not claim they did it. I remember sitting in the meeting room in Yuma and seeing a gigantic notebook on the table. In response to my inquiry, they told me it represented all their work of the past year: flyers, sign-in sheets, newspaper articles, notes! From this I learned 1) that promotores are very effective in documenting their work, and 2) that evaluation with promotores meant helping them tell their story. To capture all of this, I suggested that I interview all of the promotores to find out how they did their work and what they thought about it. The result was the “Promotor/a Community Health Manual: Developing a community-based diabetes self-management program.” The manual, which is available online, is by and for promotores “who are dedicated to this difficult work to continue to address this disease and improve living conditions in their communities.”
This health promotion program targeting women of child-bearing age was designed by promotores at the Mariposa Community Health Center, located in the border community of Nogales, Arizona. Consistent with the principles of participatory evaluation, we worked collaboratively to develop both the program and the evaluation plan. For example, the promotores recruited women to formative focus groups in which we discussed what was important to them. From these, we identified specific behaviors that we wanted to focus on and measure. For example, rather than evaluating every dietary behavior, we decided that focusing on reducing consumption of soda and increasing the use of healthy oil in cooking and consumption of fruits and vegetables would be the most impactful. In this way, we made sure that the program activities were related to the evaluation measures. The promotores administered the pre/post questionnaires because we knew that participants would be most likely to be honest with these women with whom they had developed trust and compassion.
As with many promotores health promotion curricula, Salud Sí pre/post questionnaires and health measures showed positive results. We always wondered, however, if the women maintained their healthy behaviors once they were no longer in the classes. Because we continued to work together on many projects, several years later we decided to go back and find women who had been in the program and ask them. Because the promotores maintained their relationships with community members, we were able to find almost all of the women we had chosen randomly from the participant contact database. We found that the lessons to improve their family’s diet had become lifelong habits, and that the women continued to see benefit. Physical activity, however, was much harder because women no longer had the social support and the physical space to come together and exercise. Recognizing this, Mariposa continues to provide yoga and other classes to the community today.
Challenges and Lessons Learned
The success of these examples is not meant to suggest that evaluation is easy. Evaluation requires resources and time that the promotores would rather focus on the needs of community members. Over time, however, we developed mutual trust and respect for the value of each other’s work. I spent time with the programs so that I could learn about the programs firsthand, and I helped to administer the evaluation tools so that I could see how awkward and difficult the questions could be. Here are some of our lessons learned:
- Always combine qualitative with quantitative methods. Photos, observations, interviews, and focus groups show you the why and how of the program.
- Be flexible with evaluation. This way you can learn something unexpected, and you don’t waste time with efforts that aren’t working.
- Evaluation is about sharing, not judging. By focusing on telling the story, I found that there was always something to learn and something positive to tell.
- This focus on sharing means that evaluation can contribute to a better program.
iIngram, M., Piper, R., Kunz, S., Navarro, C., Sander, A., & Gastelum, S. Salud Sí: A case study for the use of participatory evaluation in creating effective and sustainable community-based health promotion. Journal of Family and Community Health. 2012: 35(2): 130-138.
iiRedondo, F., Torres, E., Castro, I., Villaseñor, A., & Ingram, M. Promotora Community Health Manual: Developing a Community-Based Diabetes Self-Management Program. 2010: CES4-Health.info
iiiTorres, E., & Ingram, M. Con el favor de Diós: the role of promotoras/community lay health workers as spiritual helpers in supporting diabetes self-management among Mexican Americans. Counselling and Spirituality. 2009: 28(1); 109-128.
ivIngram, M., Torres, E., Redondo, F., Bradford, G., Wang, C., & O’Toole, M. The impact of promotoras on social support and glycemic control. The Diabetes Educator. 2007: 33(Supp6):172S-178S.