The following primary objectives were shared by all participating CHCs: 1) increase CVD knowledge and heart-healthy practices; 2) increase participation in physical activity; 3) decrease blood pressure, cholesterol levels, blood glucose levels, and body mass index (BMI); 4) increase awareness and knowledge through community-based health promotion activities; and 5) increase involvement and support for Salud para su Corazón from local agencies and organizations. To meet these objectives, all 4 CHCs implemented Salud para su Corazón by identifying community strengths and appropriately adapting methods employed by previous programs for use in their respective communities (3-6).

GCHC uses several components within the center to integrate self-management interventions into the center's medical practice. Center components include patients, promotores, medical providers, certified diabetes educators, medical support staff, administrators, and the board of directors. The training for Salud para su Corazón is integrated into the medical providers' referral system after the patient is referred to the promotores.

The clinical directives for implementing the promotores model at GCHC can be summarized as follows: 1) community outreach by promotores facilitates patient appointments with the medical staff (physician visit) facilitates patient appointments with the medical staff (physician visit), and appointments are scheduled; 2) an assessment plan is developed by the medical staff; 3) medical staff initiate educational directives (issuing verbal and printed instruction); 4) a treatment plan is developed that includes laboratory assessment, medication, care plan, and referral to the promotores program; 5) the promotores program includes group classes (Su Corazón, Su Vida [Your Heart, Your Life] supported by the Salud para su Corazón-HRSA program) and individual support; and 6) follow-up is provided by both medical and promotores staff as needed.

The Salud para su Corazón-HRSA initiative adopted several approaches to community participation and capacity building. It established collaboration among select staff from NHLBI and HRSA and researchers from the University of Texas School of Public Health, El Paso Regional Campus, to provide consultation, mentorship, and guidance to CHC staff, promotores, and other personnel involved with project activities at the community level. This team delivered Salud para su Corazón resources and materials to all 4 CHCs to support delivery of community education. For example, it conducted monthly calls for the duration of the project with key staff and lead promotores from each CHC to review progress and to provide an opportunity to discuss any aspect of the projects.

All of the CHCs conducted a series of well-defined and structured promotores training activities, following protocols similar to those previously implemented in other Salud para su Corazón programs (3-6). These training protocols consisted of approximately 16 to 18 hours of training to complete the Your Heart, Your Life curriculum lessons. Lead promotores who had been previously trained in the Your Heart, Your Life manual delivered the training activities to promotores new to the Salud para su Corazón program. Lead promotores from all 4 CHCs provided leadership and served as role models and mentors for the newly trained promotores.

Promotores de salud from each CHC delivered 8 lessons from Your Heart, Your Life, which uses various educational approaches and relevant materials. More information about the curriculum can be found elsewhere (3-7). Table 2 provides an overview of the health education program at each site. All 4 centers implemented a 1-group, pretest-posttest study design. Promotores' primary responsibility was to recruit Hispanic participants through the CHCs' clinical and community outreach systems. Recruitment strategies included referrals by the medical team, advertisement of the program at the CHCs, and outreach to neighborhood and community sites near the CHCs. Educational sessions were delivered several times a week, once a week, or every other week for a total intervention period of 2 to 3 months.

As part of program activities for the Salud para su Corazón-HRSA initiative, each CHC conducted media and community outreach events to enhance the work of the promotores at the community level (3,8). CHCs organized different activities to enrich the programs in their communities. In addition to media and community outreach events, the CHCs developed partnerships with various local health clinics, health departments, schools, and community-based organizations to support program activities.

We conducted an evaluation workshop in El Paso to present CHC principles and strategies for data collection and to integrate an evaluation component into the Salud para su Corazón-HRSA program. To test whether the program met its health objectives, the CHCs agreed to conduct the program and to assess behavioral and clinical outcomes at 4 intervals: at baseline and at 3 months, 6 months, and 12 months after the intervention. Actual data collection varied among sites (Table 2). Clinical measures included weight, BMI, low-density lipoprotein (LDL) cholesterol level, high-density lipoprotein (HDL) cholesterol level, triglyceride level, glycated hemoglobin (HbA1c), and systolic and diastolic blood pressure. Behavioral data were collected by using My Family Habits Scale, a 35-item, self-reported, valid and reliable instrument, which has been tested in previous Salud para su Corazón promotores programs (3-6). NCHS also included an assessment of physical activity. Behavioral data using My Family Habits Scale are presented for NCHS only (behavioral data from other sites were not available). The main objective of the evaluation was to examine changes in clinical measures from baseline to 3 different points after delivery of the intervention (3, 6, and 12 months) because the effect of Salud para su Corazón on clinical outcomes had not been explored previously.

Data on sociodemographic characteristics were not collected uniformly across sites and therefore were not included in the statistical analyses. For the purposes of evaluation, we combined clinical data from 2 CHCs (CSV and GCHC) because of their similar timing of assessments and similar integration of clinical and community outreach activities that used promotores. Behavioral and clinical data for NCHS are presented separately. Data from MCHC, which assessed outcomes after 2 months of follow-up, did not yield significant changes in clinical outcomes and are not presented here.

We used a 2-sample paired t test to evaluate differences from baseline to 6 months  and from baseline to 12 months  for CSV and GCHC. Repeated-measures 1-way analyses of variance were used to evaluate matched sample comparisons between baseline and 2 follow-up points (3 and 6 months after the intervention) for NCHS.

The improvements in heart-healthy behaviors observed by NCHS were consistently documented in previous Salud para su Corazón studies, lending credibility to the efficacy of the promotores program in a clinical setting (3-6). The positive changes further observed in some clinical outcomes (eg, LDL cholesterol level, triglyceride level, waist circumference, diastolic blood pressure, weight, and HbA1c) suggest that integrating community outreach with a clinical protocol that links medical diagnosis, referrals, and community health group education is a promising strategy for culturally competent and effective health service delivery (9,10).

Limitations in design and methods temper interpretation of results. Additional empirical testing with more integrated and sophisticated intervention approaches is needed (10). Nevertheless, both behavioral and clinical outcomes provided the impetus for investing in a promotores infrastructure at the clinics to address CVD health disparities among Hispanics (11). We hope to achieve consistency in research methods and to integrate evaluation protocols as part of the delivery of health care and intervention services in the region.

The investment in promotores is a step toward building community coalitions and partnerships to support work in various sectors of the health care system (12). The Salud para su Corazón-HRSA initiative succeeded in taking the first step toward developing an infrastructure to support the promotores workforce in the US-Mexico border region.

One key element of the NHLBI-HRSA initiative was pilot testing several integrated clinic-type models of care that link promotores to the medical system at the clinical level. The GCHC illustrates the integration of promotores made possible through the support of the initiative.

Several key components of success of this clinical promotores integration include 1) open and frequent communication; 2) wide organizational acceptance of promotores; 3) regular staff meetings (in which promotores participate) to assess progress and identify issues; 4) extensive training of promotores; 5) thorough documentation; 6) management support; 7) provider involvement including training, recruitment, support, and participation; and 8) regular assessment of patient satisfaction and feedback. Finally, the GCHC has identified several benefits of its promotores program. The benefits to the provider include more efficient use of time, reinforcement of the treatment plan, assessment of social needs and concerns, extension of physician services, identification of health advocate and additional clinic and service referrals, and improved patient control of diabetes. Benefits to the patient include more time dedicated to education, increased awareness of the need to adhere to treatment plans, individualized care, improved access to care, specific needs met by appropriate referrals, and improved health outcomes.

The study has limitations related to research design and to methods of data collection and evaluation. The Salud para su Corazón-HRSA initiative was not able to implement a more sophisticated study design. This limitation is faced by many community-based organizations, including CHCs, because of the great need to provide direct community outreach and clinical services to their clients. Additionally, CHCs did not collect sociodemographic and other pertinent information that may confound intervention effects because of resource limitations (ie, not having personnel at the CHCs to support data collection). As a result, less emphasis and priority were given to research and to adequate collection of data to support the CHCs' Salud para su Corazón-HRSA programs.

Challenges still exist in implementing standardized research protocols. Data collection tools were difficult to standardize. We were unable to consolidate the development of a complete database that could match each participant with all data points needed for all variables of interest (ie, age, sex, socioeconomic status, acculturation status, marital status, and educational level). As a consequence of this limitation, the evaluation is constrained by the difficulty in conducting analyses of confounding factors. Therefore, these results should be interpreted with caution. Expertise in evaluation and statistical analyses needs to be an intricate part of the infrastructure being developed for CHCs as community outreach activities are integrated with clinical encounters. The implementation of electronic records appears to be a promising strategy.

Finding the right balance between allowing flexibility with the design and the intervention (including data collection procedures) and infusing a well-developed, science-based approach is a major challenge in these types of health promotion and disease prevention initiatives. Community-based participatory research is a promising approach that needs to be strengthened with CHCs when promotores are working in conjunction with the medical system to combat heart disease and address CVD risk factors among Hispanic populations living in the US-Mexico border region (13).

We offer recommendations based on the experience of the Salud para su Corazón-HRSA initiative to enhance the capacity of CHCs and their providers to ensure that the promotores model can be sustained in their community settings.