The purpose of this literature review is to evaluate the research exploring the utilization of culturally sensitive nutrition education, specifically studies incorporating promotoras (community health workers) among Latino populations in the U.S. Due to the high prevalence of obesity and its associated diseases among Latinos, there is an urgency to identify interventions that successfully incorporate culturally sensitive interventions in order to better communicate with these individuals.

1. Nutrition Education, Promotoras, & the Latino/a Population
By
Rocío González
A Senior Project submitted
In partial fulfillment of the requirements for the degree of
Bachelor of Science in Nutrition
Food Science and Nutrition Department
California Polytechnic State University
San Luis Obispo, CA
March 2016

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Abstract
The purpose of this literature review is to evaluate the research exploring the utilization
of culturally sensitive nutrition education, specifically studies incorporating promotoras
(community health workers) among Latino populations in the United States (U.S.). A mix of
income and education inequities create challenging barriers to preventative care and nutrition
education resulting in disproportionately unhealthy adults within the Latino population, as
compared to the greater U.S. population. The prevalence of overweight, obesity, diabetes
mellitus, and other diseases is higher among Latinos. Due to the high prevalence of obesity and
its associated diseases among Latinos, there is an urgency to identify interventions that
successfully incorporate culturally sensitive interventions in order to better communicate with
these individuals. One mechanism is by utilizing promotoras through interventions. Two
government-funded programs, Expanded Food and Nutrition Education Program (EFNEP) and
Supplemental Nutrition Assistance Program-Education (SNAP-ED), have demonstrated results
in the improvement of healthy behaviors in individuals, and also incorporate peer educators
(promotoras) into their health education curriculum. Promotoras and public health workers have
worked together to empower and educate community members. Promotoras combine cultural
strengths and practices to promote healthy behaviors. Further research is needed to better
understand nutrition education strategies that are both culturally sensitive and effective in the
adult Latino population.

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Introduction
The Latino population in the United States (U.S.) has grown from 8 million in 1965, to
nearly 57 million in 2015—making up the nation's largest ethnic minority at 18% of the
population (Pew Research Center, 2015). Projections for the 2060 U.S. population estimates
Latinos will makeup 30% of the population (Colby & Ortman, 2015). Furthermore, 77% of
Latino adults are overweight or obese (Ogden, Carroll, Kit, & Flegal, 2013). Obesity is one of
the leading drivers of preventable chronic diseases and healthcare costs in the U.S (The State of
Obesity, 2015). The estimated annual healthcare costs of obesity-related illness make up an
alarming $190.2 billion or nearly 21% of annual medical spending in the U.S. (Cawley &
Meyerhoefer, 2012). Thus, reducing obesity in the U.S.’s largest ethnic minority population can
help lower medical costs and reduce the risk of developing a wide range of chronic-diseases.
There is a pressing need for effective intervention approaches to prevent obesity among the
growing Latino population.
An essential component to reduce obesity and its associated health problems in
communities of color is cultural competence, or culturally appropriate care. In other words, the
ability of providers to effectively deliver health care services that meet the social, cultural, and
linguistic needs of patients. Due to the high prevalence of obesity among Latinos, there is an
urgency to identify interventions that successfully incorporate culturally sensitive interventions
in order to better communicate with these individuals.
The purpose of this literature review is to evaluate the research exploring the utilization
of culturally sensitive nutrition education, specifically studies incorporating promotoras
(community health workers) among Latino populations. The prevalence of nutrition-related
conditions and poor health outcomes among Latinos in the U.S. will be discussed. Various

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nutrition education intervention programs designed to reduce the prevalence of obesity in the
Latino population will be described and research examining the effectiveness of the programs
will be summarized.
Latinos in the United States
Latinos represent a unique population residing in the U.S. While most are largely of
Mexican descent, their cultures and circumstances are significantly different from that of White
non-Latino Americans. However, it is important to note that the Latino community is by no
means a homogenous one. This review refers to the Latino community as a whole unless
otherwise specified, but there may be extensive differences based on specific country of origin,
nativity, language and other variables. Latinos in the U.S. face significant risk-factors and
predispositions to chronic diet-related diseases.
According to the federal Office of Management and Budget, a Hispanic or Latino is “a
person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or
origin, regardless of race” (as cited in U.S. Census Bureau). Among Latino subgroups, Mexicans
are the largest, making up 64% of the Latino population; Following Mexicans were Puerto
Ricans (9.4%), Salvadorans (3.8 %), Cubans (3.7%), Dominicans (3.1%), Guatemalans (2.3%),
and the remaining 13.7% were people of other Latino origins (U.S. Census Bureau, 2012).
Growth and Demographics
According to the Pew Research Center (2015), roughly 57 million Latinos are living in
the U.S., representing approximately 18% of the U.S. total population, and making people of
Latino origin the nation's largest ethnic or race minority. In addition, the projected 2060 Latino
population of the U.S. is estimated to reach 120 million (Colby & Ortman, 2014). Based on this
projection, the Latino population will constitute 30% of the nation’s population by that date. See

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Figure 1. Since 2010, the U.S. has contained one of the highest populations of Latinos
worldwide; ranking 2nd to Mexico (120 million) who is the only country with a larger Latino
population than the United States (U.S. Census Bureau, 2014).
Figure 1. The U.S. Latino Population. This figure illustrates the Latino population in 2012 and the projected
population in 2060. From The State of Obesity (2015).
Income and Poverty
Latino households in the U.S. experience disproportionate levels of poverty and have
lower household income than their White, non-Latino counterparts (DeNavas-Walt & Proctor,
2015). In 2014, the median income of Latino households ($42,491) was significantly lower than
their White, non-Latino counterparts ($60,256). Further, the poverty rate among Latinos in 2014
was 23%, which is more than double that of non-Latino Whites (11%) (See Figure 2) and 10% of
Latinos lived in deep poverty (incomes below 50% of the federal poverty threshold), compared
to 7% of the total population (DeNavas-Walt & Proctor, 2015). This income gap may partly be
explained by educational differences.

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Figure 2. Population Living Below the Poverty Line. This figure illustrates the comparison between the percentage
of the Latino population living below the poverty line and the percentage of the White population living below the
poverty line in the U.S. From The State of Obesity (2015).
Education Attainment
The Centers for Disease Control (CDC) released the Health Disparities and Inequalities
Report in 2011 that claimed ethnic disparity in both income and education, compared with non-
Latino whites, was greatest for Latinos (CDC, 2011). In 2013, only 15% of Latinos (ages 25 to
29) had a bachelor’s degree or higher (Pew Research Center, 2015). In comparison, about 40%
of whites (ages 25 to 29) had a bachelor’s degree or higher (as did 20% of Blacks and 60% of
Asians) (Pew Research Center, 2015).
To further illustrate this disparity, the UCLA Chicano Studies Research Center analyzed
data from the 2000 U.S. Census, and named their findings the Latino Education Pipeline (Yosso
& Solorzano, 2006). As depicted by Figure 3, out of every 100 Latino elementary school
students, only 8 graduate with an undergraduate degree. Of these 8 graduates, only 2 will go on
to earn a graduate or professional degree, and less than 1 student will eventually receive a
doctorate (Yosso & Solorzano, 2006). Current barriers contributing to a lack of higher education
access: socioeconomic barriers and a lack of social capital, a lack of a sense of belonging on
campus, increased tuition and a lack of financial aid, and mentoring experiences (Nora & Crisp,
2009).

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Figure 3. The Latina/o education pipeline. This figure illustrates the national graduation outcomes for Latina/o
elementary- school students. FromLaw, Social policy, and the Latina/o Education Pipeline (Romero, 2012)

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The connection between education and income. The Bureau of Labor Statistics (2016)
analyzed data from 2015 that identified the connection between earnings and unemployment
rates by educational attainment. As evidenced by Figure 4, the higher the education a person
receives, the more likely they are to earn a high income, which has the potential to influence
health. In fact, an issue brief released by the Virginia Commonwealth University in 2015
explored education’s connection to health (Virginia Commonwealth University Center on
Society and Health, 2015). According to the brief, people with less education face serious health
conditions such as shorter lives, greater prevalence of illnesses and disabilities, more risk factors,
generate higher medical care costs, and experience more psychological stress (Virginia
Commonwealth University Center on Society and Health, 2015). As a result of low income and
poverty rates, coupled with education inequalities, perpetuates poor health outcomes within
Latino populations in the U.S.
Figure 4. Earnings and unemployment rates by educational attainment. This figure illustrates unemployment rates in
2015, categorized by educational attainment. It also compares the median weekly earnings in 2015, categorized by
educational attainment. From the Bureau of Labor Statistics (2016).

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Poor Health Outcomes
Poor health outcomes within the Latino population undermine the community and the
health care system. The 2011 CDC report, Health Disparities and Inequalities, demonstrates that
Latino populations suffer higher mortality rates than other populations. As depicted by Figures 5
and 6, the prevalence of diet- related chronic diseases such as obesity is 1.2 times higher in
Latinos than non-Latino Whites (Blackwell, Lucas, & Clarke, 2014) and 65% more likely than
non-Latino Whites to have diabetes, 55 percent more likely to have end-stage renal disease
(Centers for Disease Control, 2012), and 45 percent more likely to die from diabetes (Murphy,
Xu, & Kochanek, 2013).
Figure 5. Obese or Overweight Adults. This figure illustrates the comparison between obese or overweight Latino Adults and
obese and overweight White Adults in the U.S. From The State of Obesity (2015).

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Figure 6. Obese or Overweight Adults. This figure illustrates the comparison between obese or overweight Latino Adults and
obese and overweight White Adults in the U.S. From The State of Obesity (2015).
Disparities in the nation’s healthcare infrastructure and workforce. The Department of
Health and Human Services (DHHS) released a report in 2011 stating ethnic minorities are more
likely than non-Latino Whites to experience poorer quality patient-provider interactions, a
disparity pronounced among the 24 million adults who have a limited English speaking
proficiency, such as immigrant Latinos (National Center for Education Statistics, 2009). The
DHHS report recognized diversity as a key element in patient-centered healthcare. This report
projects the ability of the healthcare workforce to address health outcomes will depend on
cultural competence and diversity (DHHS, 2011).
Potential Solutions from Latino Health Leaders
In conjunction with Trust For America's Health and Salud America!, Greenberg Quinlan
Rosner Research conducted ten individual, in-depth interviews with Latino public health leaders
across the U.S. (The State of Obesity, 2015). Participants within the study consisting of
academic professionals, health professionals, community leaders, and business leaders. The

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purpose of these interviews was to seek community guidance to find solutions in preventing
obesity among Latino communities. The interviews specifically assessed various health barriers
and the interviewees identified priority solutions such as education, culture, and shared
ownership (The State of Obesity, 2015).
Education
The Latino health leaders described that often times solutions to reduce obesity in their
community include placing resources promoting physical activity, such as parks (The State of
Obesity, 2015). The leaders emphasized that although resources for physical activity is
important, simply placing resources promoting physical activity is not enough. Rather, the Latino
health leaders ranked health education as more important because it gave people the tools and
information about resources to combat economic constraints. The Latino health leaders called for
physical activity resources to go hand-in-hand with education campaigns. These campaigns must
focus on both promoting healthy diets and physical activity. In addition, these campaigns need to
show how eating healthy and being active can be fun, lower stress, and decrease the risk for diet-
related chronic diseases (The State of Obesity, 2015).
Culture
The Latino health leaders also claimed that cultural issues might contribute to obesity
(The State of Obesity, 2015). For example, even though many Latino families attempt to
preserve their cultural food traditions, health problems arise when they begin adopting and
acculturating to American culture habits. These habits include including driving more and
walking less, larger portion sizes, and purchasing more processed foods. The leaders all agreed
on one huge concern, the unhealthy American habits adopted by Latino immigrants continue to
negatively impact their health (The State of Obesity, 2015).

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In addition, even though nutrition and physical activity information is available in both
Spanish and English, there is a concern about receiving useful information in a helpful and
supportive way (The State of Obesity, 2015). The health leaders stressed the importance of
tailoring education approaches in ways that make health education relevant to people's daily lives
(The State of Obesity, 2015). One way to do this is by tailoring nutrition education to the
participant’s specific culture. Culturally sensitive programs must involve modifications beyond
the “surface,” such as language and ethnically matched providers, but also be cognizant of “deep
structure” characteristics of the Latino culture such as sub-groups (Mexicans, Puerto Ricans,
Cubans), acculturation levels (first generation born in the U.S. and recent immigrants), values
(family-oriented and respect), traditions (religion and gender roles), and practices (relationship-
oriented is more important than being time and task-oriented) (Broyles, Brennan, Herzog, Kozo,
& Teras, 2011; Carteret, 2011).
Shared Ownership
One of the most important barriers to effectiveness of obesity-prevention initiatives
identified by the Latino health leaders is a lack of empowerment, placing a barrier on the
community members from having ownership of the programs (The State of Obesity, 2015). The
Latino health leaders believe that a systemic or widely successful replicable model to create
empowerment and leadership within local communities does not exist. As a result, programs are
not sustainable (The State of Obesity, 2015).
Improving Nutritional Health in Latino Communities: Challenges & Solutions
With a number of poor health outcomes and education and income inequities, there is a
pressing need to improve nutritional health in the growing Latino populations, which can lead to
better health outcomes.

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Challenges
Efforts focused on diet-related health issues, such as obesity, can be difficult to combat
in Latino communities (Johnson, Sharkey, Dean, St John, & Castillo, 2013). Some of these
challenges include: Maintaining trust and understanding the community residents who are
noticeably different from the research team; Working with logistical challenges of participants
(e.g., employment conflict and transportation challenges) in order to minimize drop-out rate and
complete assessments in a timely manner; Recruiting from a specific group and to minimize
drop-out rate; Effectively adapting culturally appropriate and reliable measures of dietary
exposures for data collection, protocols, and instruments; Understanding behaviors health
related. In addition, it is essential to conduct research in a method that is respectful of the
community and residents’ norms, values, and traditions, while at the same time maintaining the
rigor needed for academia (Johnson et al., 2013). In order to maintain respectfulness towards the
community, it is important to note that participants/patients value social interactions and cultural
competency (Teufel-Shone, Drummond, & Rawiel, 2005; Hansen et al., 2005).
Promotoras: Utilizing Latino Community Health Workers to Reach Vulnerable Populations
A community-academic partnership where university-based researchers develop a
partnership with promotoras is one way to address these challenges in a culturally-competent
manner. Promotores de Salud is a Spanish term that translates to Health Promoter. A female
health worker may be referred to as a Promotora, a male as a Promotor, and the plural of both is
Promotores. For the purpose of this literature review, the term promotora will be used, to reflect
the predominantly female community health worker population in the research discussed.
The promotoras are known as the bridged between their communities and health and
social service providers (Albarran, Heilemann, & Koniak-Griffin, 2014; Balcazar, Alvarado, &

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Ortiz, 2011; Eng, Parker, & Harlan, 1997; Hilfinger, Parra-Medina, Sharpe, Treviño, Koskan, &
Morales-Campos, 2013). They are often called peer educators, patient navigators, community
health workers, outreach workers, or lay health educators. (Hurtado, Spinner, Yang, Evensen,
Windham, & Ortiz, 2014). Promotoras do not provide healthcare services directly, instead, they
offer culturally tailored education, social support, help with improving communication between
patients and health professionals, and help patients overcome barriers in acquiring appropriate
healthcare (Albarran et al, 2014; Johnson, Sharkey, Dean, St John, & Castillo, 2013). According
to the U.S Department of Health and Human Services, promotoras play an essential role in
promoting community-based health education and prevention in a manner that is both culturally
and linguistically appropriate. Promotoras often share the same ethnicity, language,
socioeconomic status, and life experience of the community members they serve (Office of
Minority Health, 2014).
Characteristics and Values of Promotoras. Highly recognized leaders of the promotora-
led model include Latino Health Access (LHA) in Santa Ana, the statewide association Visión y
Compromiso (VyC), and the Esperanza Community Housing Corporation in Los Angeles
(ECHC). These recognized leaders surveyed 125 promotoras to share their opinions about what
makes the promotora model so effective at engaging communities (LHA, VyC, & ECHC, 2011).
The goal was to identify the characteristics that distinguish promotoras from other community
workers who share these same roles (i.e. a community organizer or patient navigator). From this
data, ten primary characteristics and values have been identified and are summarized in Figure 7.

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Figure 7. Primary Characteristics and Values of Promotoras. This table describes the top ten characteristics promotoras are
meant to uphold. From LHA et al. (2011).
A culmination of these distinct characteristics is what makes promotoras effective (LHA
et al, 2011). Since promotoras share similar life experiences as the participants and are often
members of the community, they are easily accessible to participants. In addition, promotoras
are often trusted with topics beyond the promotoras scope, such as domestic violent or substance
abuse in the family. Promotoras are able to serve the families based on their needs and are
compassionate enough to listen to their pain. By doing so, they remain flexible to build quality
relationships and help others create positive change in their lives (LHA et al, 2011).
Another crucial characteristic LHA et al. (2011) summarized is that promotoras are
innate experts of their community because they combine cultural strengths and practices to work
with and not against the culture. Promotoras communicate complex ideas by speaking without
technical jargon, arrogance and interpreters. For example, they are able to explain how social and

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economic determinants of health influence diabetes disease management by using simple and
relatable examples (LHA et al, 2011).
A characteristics that differs promotoras from other health professionals is their ability to
serve as a bridge between healthcare and their community (LHA et al, 2011). This two-way
bridge operates by bringing information about health care to the community and providing
information from the community back to the institutions, such as hospital, researchers etc. This
way, programs and services developed by the institution are actually the ones the community
wants and needs. All of these characteristics allow promotoras to be an effective guide for
community transformation lives (LHA et al., 2011).
Promotora Interventions to Minimize Nutritional Disadvantages of Latinos in the U.S.
Due to the education and income inequalities Latinos face in the U.S, numerous nutrition-
related conditions can be anticipated. In general, the public health workforce has identified the
high prevalence of various health conditions among Latinos and has developed government-
funded programs and community-based interventions to decrease the gap between current
nutrition education and the need for culturally relevant curriculum. For example, two
government-funded programs, Expanded Food and Nutrition Education Program (EFNEP) and
Supplemental Nutrition Assistance Program-Education (SNAP-ED), incorporate peer educators
(promotoras) into their health education curriculum. In addition, nutrition education
demonstrations programs have begun to involve community health workers (promotoras) among
Latino populations, four of which are randomized control trials.
The Expanded Food and Nutrition Education Program (EFNEP)
The Expanded Food and Nutrition Education Program (EFNEP) collects resources from
the federal, state, and local government to reach two specific groups: 1. Low-income families

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with young children and 2. Low-income youth (National Institute of Food and Agriculture
[NIFA], 2016). NIFA reported that EFNEP supports approximately half a million adults every
year. About 74% of EFNEP families are of an ethnic minority and about 41% of EFNEP families
are Latino. Additionally, 85% of EFNEP families reported an income at or below 100% of
poverty, earning $24, 250 per year, or less, for a family of four. There is not data provided about
the income of Latinos who participate in EFNEP. This program relies on a research-based
learning model, facilitated by peer-educators who are members of the communities that they
support. EFNEP’s peer-education model utilizes peer educators to deliver a series of hands-on,
interactive lessons to program participants. The lessons are evidence-based and the peer
educators are typically recruited from the local community. These peer-educators also recruit
participants and their families through referrals, neighborhood contacts, and community
organizations and agencies (NIFA, 2016).
EFNEP effectiveness and its benefit. The effectiveness of EFNEP at improving dietary
habits has been evaluated through various reports, research studies, and cost-benefit analyses. A
2016 report evaluated the success of the program and showed that EFNEP participation is
associated with improved dietary habits (NIFA, 2016). Numerous studies and reports examining
the impact of EFNEP on nutrition-related outcomes have also determined the following
improvements in: dietary intake (Luccia, Kunkel, & Cason, 2003; NIFA, 2016), nutrition
knowledge (Arnold & Sobal, 2000; NIFA, 2016; Townsend, Johns, Shilts, & Farfan-Ramirez,
2006), food practice (Arnold et al, 2000; Townsend et al, 2006), and food insecurity (Burney &
Haughton, 2002; Dollahite, Olson, & Scott-Pierce 2003).
Cost–benefit studies have also been conducted to determine other benefits of EFNEP
regarding health care costs and work productivity studies confirm that EFNEP is a program that

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prevents nutrition-related illnesses and diseases (Block Joy, Pradhan, & Goldman, 2006; Burney
& Haughton, 2002; Rajgopal, Cox, Lambur, & Lewis, 2002; Schuster et al, 2003; Wessman &
Betterley 2000). Moreover, some research studies have even documented economic benefits of
EFNEP, such as improvements in employment (Burney & Haughton, 2002; Wessman &
Betterley 2000) and education (Wessman & Betterley, 2000). The cost–benefit analyses
conducted by Block Joy et al. (2006), evaluated the impact of the EFNEP program on reducing
medical costs. Overall, the study found that EFNEP resulted in a savings of $14.67 in medical
care costs for every $1.00 spent. Block Joy et al (2006) also discovered that EFNEP could reduce
long-term medical costs. For EFNEP graduates who maintained optimal nutrition behavior for
over 5 years, California saved at least $3.67 dollars per person in future medical treatment costs
(Rajgopal et al, 2002). These studies confirmed that EFNEP saves the state and taxpayers
money.
Overall, the results of the studies discussed confirm benefits experienced by all EFNEP
participants, and the benefits EFNEP has for Latino beneficiaries. Unfortunately, researchers
have not analyzed differences among sub-groups by isolating data for Latinos and comparing it
to all EFNEP beneficiaries. Further research is needed to identify if EFNEP can benefit Latinos
as much as it benefits all EFNEP beneficiaries. Also, since almost half (41%) of EFNEP
participants are Latino and only 27% of EFNEP peer educators are from Latino descent (NIFA,
2016), further research is necessary to identify barriers and provide solutions to the uneven
distribution of Latino peer educators working for EFNEP.
The Supplemental Nutrition Assistance Program-Education (SNAP-Ed).
The Supplemental Nutrition Assistance Program (SNAP) website descries SNAP as a
U.S. nutrition assistance program that includes an optional nutrition education portion known as

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SNAP–Education (SNAP-Ed), for low-income families. This nutrition education portion
promotes healthy eating consistent with the Dietary Guidelines for Americans and MyPlate to
SNAP beneficiaries. The nutrition education content varies from state to state, but can include
one-on-one counseling, small group education, and food and nutrition social marketing
campaigns (Landers, 2007).
SNAP-Ed and Community Health Workers. SNAP-Ed can also involve the use of
nutrition education peer educators. Unfortunately, though Latino-specific SNAP-Ed programs
(Perez-Escamilla & Putnik 2007) and theoretical impact evaluation efforts exist (Guthrie,
Stommes, & Voichick, 2006; Taylor-Powell, 2006; Townsend et al., 2006), there are no
published studies or reports that specifically analyze the involvement of SNAP-Ed community
health workers. Thus, further research is necessary to evaluate the effectiveness of Latino/a
community health workers (promotoras) among Latino SNAP beneficiaries, compared to general
nutrition education or non-Latino/a community health workers.
The SNAP gap. A noteworthy fact is that Latino households are less likely to receive
SNAP benefits than White, non-Latino client households. As noted by Figure 8, researchers have
found a gap between the number of Latinos eligible for SNAP and the number of Latinos
actually receiving the benefits (Nord, Andrews, & Carlson, 2009; Bread for the World, 2014).

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Figure 8. SNAP Participants by Latinos in 2011. This image shows the gap between Latinos eligible for SNAP and Latino
receiving the benefits. From the Promotor Model: A Model for Building Healthy Communities (2011).
Research is necessary to identify if promotoras might be a part of the multifaceted
solution to improve the discrepancy between Latinos receiving benefits and Latinos eligible for
receiving SNAP benefits.
Demonstration Programs-Individual
Government-funded initiatives are not the only programs exploring the utilization of
promotoras. The following are nutrition education demonstration programs that incorporate
community health workers (promotoras), three of which were randomized controlled trials.
The program Pasos adelante or “Steps Forward,” implemented by Staten, Scheu,
Bronson, Pena, and Elenes (2005), used a generic health-focused curriculum. Pasos adelante or
“Steps Forward” is a 12-week educational program led by promotoras. The curriculum is
adapted from the National Heart, Lung, and Blood Institute cardiovascular disease prevention
program, Su Corazón, Su Vida (Your Heart, Your Life) (Bethesda, 2000). Pasos adelante was
implemented in two counties located near the U.S. and Mexico border in Arizona with 216
participants who completed the program (Staten et al., 2005). The impact of the program was

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assessed using pre- and post curriculum questionnaires regarding self-reported measures of
physical activity and dietary intake patterns. Participants who actively participated in the
program increased their physical activity, lowered their consumption of soft drinks, and
increased their intake of fruits and vegetables. The researchers concluded that a health-focused
curriculum combined with the help of promotoras can guide and motivate people to take up
healthy habits. However, one weakness of the program is its lack of retention from employed
participants, smokers, and people with asthma. The 32 participants who did not complete the
program were significantly more likely to be employed and to have asthma. Additionally, more
smokers were among those who did not complete the program. Another drawback the
researchers noted was a lack of male participants. More research and programs need to be
developed to appeal to these individuals (Staten et al., 2005).
Elder, Ayala, Campbell, Arredondo, Slymen, and Baquero et al. (2006) used an
individualized approach on a health education curriculum, consisting of a promotora facilitator
and follow-up homework assignments. The randomized controlled trial conducted examined the
impact of two behavior-change interventions used to reduce dietary fat and increase fiber. The
authors analyzed the 1-year impact of 357 Spanish speaking Latinas. The 14-week randomized
control trial consisted of the following three groups: 1. Received nutrition counseling from
promotoras, weekly home visits or telephone calls, and weekly newsletters uniquely tailored to
the participants. The content contained tailored homework assignments to help them reach their
health goals. 2. Received weekly newsletters uniquely tailored for each participant to reach their
health goals. 3. Control group, received 12 generic newsletters covering the same heath-related
content. The measurement of the impact was assessed at baseline, 12 weeks, 6 months, and 12
months post-intervention. The intervention outcomes were based on 24-hour dietary recalls and

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anthropometric measures. At 12 weeks, participants in the intervention with promotoras had
consumed significantly lower intakes of total fat, saturated fat, glucose, and fructose when
compared to the other intervention group and the control group. By 12 months, there were no
detectable dietary intake differences between groups, concluding that interpersonal contact with
promotoras was necessary in order to achieve long-term success (Elder et al., 2006).
Cocina Saludable, or “The Healthy Kitchen,” capitalized from the fact that certain family
members hold respected positions within the Latino family and community; and only hired those
particular individuals for the role of promotoras (Taylor, Serrano, Anderson, & Kendall, 2000).
The nutrition education program was implemented in two southern Colorado counties among
337 low-income Latina mothers of preschool children (Taylor, Serrano, Anderson, & Kendall,
2000). La Cocina Saludable was designed according to the Stage of change Model. Latina
grandmothers and grandmother figures (abuelas) were selected as promotoras to deliver 5
nutrition education sessions. Each abuela underwent training related to accurate nutrition
information and built confidence in their teaching skills. The knowledge and skills of the abuelas
were assessed pre-, post-, and follow-up. The evaluation of the program participants consisted of
pre- and post- class questionnaires. These questionnaires evaluated immediate changes in
knowledge, self-reported behaviors, and skills of the intervention group. A survey was mailed at
6 months post-intervention to assess retention of information related to the intervention;
unfortunately, the return rate was only 24% because this population’s known for their dislike of
taking tests. At 6 months, significant improvements were documented for self-reported
knowledge/skills related to nutrition, diet, and food safety, thus, these improvements were
retained at 6 months. The significance of these results is slightly limited because of a lack of
control group and a low return rate of the survey post-intervention (Taylor et al., 2000).

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Faucher and Mobley (2010) decided to primarily focus their pilot study on portion
control for weight loss. The randomized controlled pilot study was conducted at a community
clinic-based setting, among 19 low-income Mexican-American women. This 20-week nutritional
intervention, led by a certified nurse-midwife and a promotora, consisted of four 2-hour classes.
Initial baseline weight was obtained along with a self-administered survey regarding personal
health information. The control group received a physical examination and nutrition education
on portion control and exercise from both the promotora and primary care provider. The
intervention group received the same standard care plus an additional four classes focused on
portion control. Final analyses identified more weight loss in the intervention group than women
in the control group, but this difference was not statistically significant. The curriculum was
tailored to be culturally sensitive by using foods specific to Mexican-American families,
emphasized nutrition for the whole family, and provided incentives such as a refrigerator magnet
with a motivational message about weight loss written in Spanish (Faucher et al., 2000).
Unfortunately, the incorporation of cultural relevance was only “surface level” and did not
incorporate enough “deep structure” characteristics of the participants culture. This discrepancy
might be due to funding; future research should include greater efforts to appropriately tailor an
intervention if they are going to state it is culturally sensitive.
Keller and Cantue (2008) utilized the potential social power of promotoras in order to get
more people to exercise. The 36-week randomized control trial was designed to evaluate the
effects of two frequencies (3 vs. 5 days per week) of walking on reducing cardiovascular risk in
18 obese Mexican-American women. Each participant was randomly assigned to one of two
treatment groups: Group I had 3 days per week of walking or Group II which had 5 days per
week of walking. The promotora scheduled weekly sessions for the participants to walk at the

24. 24
local neighborhood community center, where the participants could either join the promotora or
walk on their own. The program included promotoras to be culturally relevant, and also allowed
participants to map walking routes for safety, invite friends for social support, and also included
time for socializing and snacks. There were also monthly nutrition education sessions that
focused on low-fat dietary intake and low-fat food preparation methods. Results showed
significant improvements in BMI trends and lower lipid levels from baseline in both intervention
groups. One weakness of the study was its attrition rates; at 12 weeks, the drop-out rate was 28%
and at 36 weeks, it grew to 52% (Keller & Cantue, 2008). Another weakness was the lack of a
control group without a promotora, to further assess if the role of promotoras was a factor in
improved health outcomes.
Kim, Koniak-Griffin, Flaskerud, and Guarnero (2004) decided to focus on reducing
overall cardiovascular risk in the Latino immigrant population. The researchers recruited 12
promotoras from the local Los Angeles community and were trained to teach 3 classes on
nutrition and other healthy habits. These promotoras taught a general health curriculum to a total
of 256 Latino adults, who were recruited through the promotora’s social networks. All
participants filled out a questionnaire at baseline and 94% filled out a questionnaire1 month post-
intervention. Analyses showed significant increases in participant scores from baseline to follow-
up in various lifestyle behaviors such as healthy eating, physical activity, and engagement in
smoke-free behavior. Thus, this intervention concluded that it decreased cardiovascular risk of
participants. This study also showed that promotoras were an easy and effective healthcare
delivery strategy for health promotion, specifically among the Latino immigrant population
(Kim, et al., 2004). This study was not detailed enough in its description of how its culturally
relevant curriculum differed from generic health curriculum.

25. 25
Folic acid consumption was the focus of a pilot study conducted by deRosset, Mullenix,
Flores, Mattia-Dewey, and Mai (2014), that also utilized promotoras. This study was conducted
among 303 Latinas in North Carolina. Each promotora received 60 hours of training and met
with research staff biweekly to monitor their outreach and education efforts. The study consisted
of four components: a baseline survey, an educational workshop, a 2-month follow-up telephone
call, and a 4-month post-intervention survey. Analyses showed that self-reported daily
multivitamin consumption increased from 24% at baseline to 71% four months post-intervention.
In addition, awareness of folic acid increased from 78% at baseline to 98% four months post-
intervention. During the same timeframe, knowledge of the role of folic acid in the prevention of
birth defects increased from 82% to 92%. The effects of this study revealed that the promotora
model may be effective in reaching Latina women with the message regarding the importance of
folic acid. A limitation in this study was its lack of control group (deRosset et al., 2014).
One research team, Albarran, Heilemann, and Koniak-Griffin (2014), analyzed the
perspectives of promotoras who participated in a randomized control trial. The parent study
analyzed a 6-month intervention that used the promotora model to see if it reduced the risk of
long-term diseases related to cardiovascular disease. A total of 18 overweight/obese immigrant
Latina participants received 8 classes delivered by promotoras over a 2-month period (Albarran
et al., 2014). The curriculum was based on an adapted form of Su Corazón, Su Vida or “Your
Heart, Your Life,” from the National Heart, Lung, and Blood Institute cardiovascular disease
prevention program (Bethesda, 2000). After the 2-month educational period, individual coaching
was implemented consisting of four home visits and four telephone calls over four months
(Albarran et al., 2014). The follow up was designed to reinforce class contact and to assist the
participant in reaching he goals. The participants described the promotoras as helpful by

26. 26
motivating them by providing easy to use tools, support, and knowledge. These participants
viewed their ability to adhere to habits as a connection to their emotional and psychological
health; they also claimed to view the promotoras as a type of counselor who consistently
supported them emotionally and socially. The intervention was emotionally therapeutic for these
participants. Thus, the research team recommended that: 1. Behavioral interventions should
include a strong component of mental and emotional well-being. 2. Promotoras should be
trained on emotional, psychological health, basic counseling skills, and mental health referral
sources (Albarran et al., 2014).
Cherrington, Willig, Agne, Fowler, Dutton, and Scarinci (2015) claimed that sometimes
promotoras feel pressured to be experts in health. These researchers attempted to relieve this
discrepancy by including an interactive and informational DVD in their intervention, along with
promotoras. This promotora-delivered intervention was meant to promote weight loss among
Latinos in Alabama. The program is called ESENCIAL Para Vivir or “Essential for Life”, and
attempts to incorporate cultural beliefs, attitudes and perspectives of Latinas, mostly Mexican.
The intervention is rooted in Self-Determination Theory (SDT) and is designed to promote
independent motivation for weight-related behaviors by enhancing individuals’ sense of
autonomy, competence, and relatedness to others. The intervention lasted 8 weeks and consisted
of six group sessions and two individual sessions. In order to promote social support, spouses
were invited to the orientation session and the entire family was invited to attend the graduation
ceremony. The promotoras led discussions that focused on identifying personal as well as
family-level values related to health and wellness. Other topics included diabetes prevention,
healthy nutrition, physical activity promotion, and group activities. The DVD the intervention
included was used by promotoras to address myths and misinformation related to weight,

27. 27
nutrition, and health habits. In addition, participants were given a separate workout DVD. The
participants claimed the workout DVD was a convenient way for women to exercise at home if
they did not feel safe exercising outside or could not hire childcare. Of the 28 women that
completed the program, only 22 women had complete biometric data at eight weeks, and 21
women had complete data at 6 months. Analyses are described for women with complete
biometric data. The intervention resulted in statistically significant weight loss at eight weeks,
but not at 6 months post intervention. Significant increase in levels of moderate physical activity,
and dietary practices improved and remained significant at eight weeks and six months post-
intervention. In addition, depression symptoms also improved (Cherrington et al., 2015).
Koniak-Griffin, Brecht, Takayanagi, Villegas, Melendrez, and Balcázar (2015) focused
on a Lifestyle Behavior Intervention based on a study by Bethseda et al. (2000) among Latina
immigrants. Koniak-Griffin et al. assessed whether 223 overweight/obese immigrant Latinas in a
community setting would demonstrate change in dietary habits and increase their physical
activity after the intervention. The researchers also assessed the acceptability and feasibility of
the 6-month program by assessing retention rates and participation in classes and home visits.
The program was called Mujeres Sanas y Precavidas or “Healthy Women Prepared for Life”,
and consisted of group sessions plus individual counseling (Koniak-Griffin et al., 2015). The first
2 months consisted of 8 weekly classes based on Su Corazón, Su Vida or “Your Heart, Your
Life.” It is a culturally-relevant, promotora-led educational program developed for Latinos,
created by the National Heart, Lung and Blood Institute (Bethesda, 2000). After the two months,
individual coaching began with a total of four home visits and four telephone calls delivered for
four months (Koniak-Griffin et al., 2015). Questionnaires were administered at baseline, and at
six- and nine-month follow-ups; as were lipids and blood pressure assessments performed by a

28. 28
registered nurse of Mexican descent. At nine months, outcomes showed significant
improvements in dietary habits, waist circumference, and physical activity as well as
significantly increased knowledge of heart disease compared to those in the control group. These
outcomes supported the practicality and positive outcomes of a promotora facilitated Lifestyle
Behavior Intervention in the community with overweight/obese immigrant Latinas (Koniak-
Griffin et al., 2015).
Demonstration Programs-Family Oriented.
Research has shown a high efficacy in family-based obesity prevention interventions
(Epstein, Paluch, Roemmich, & Beecher, 2007). In addition, researchers have concluded the
importance of familism in Latino culture across country of origin (Halgunseth, Ispa, & Rudy,
2006) and evidence that parenting style is associated with child eating patterns and obesity
among Latinos (Arredondo, Elder, Ayala, Campbell, Baquero, & Duerksen, 2006; Faith,
Scanlon, Birch, Francis, & Sherry, 2004). The following demonstration programs were designed
to be family-centered with a focus on parenting, one of which was a randomly controlled trial.
The critical need for culturally relevant interventions necessary to address obesity among
Latino children, who have a greater risk of obesity and diabetes than non-Latino white children
was studied by Ogden et al. (2014). Falbe, Cadiz, Tantoco, Thompson, and Madsen (2015)
understood this need and conducted a randomized control trial that was the first culturally
tailored program to show significant weight loss among Latino children. Researches tested the
impact of a 10-week family-oriented and culturally tailored obesity intervention groups during
health appointments. Participants were 55 Spanish-speaking parent-child teams that were
assigned to either the program Active and Healthy Families (AHF) or standard care. Children
were eligible if they met the following requirements: received care in a federally qualified health

29. 29
center, were aged 5 to 12 years, had a BMI in the 85th percentile or higher, and had not
participated in AHF. The intervention included biweekly 2-hour group sessions delivered by a
team made up of three health professionals: registered dietitian, physician, and a promotora.
Both the promotoras and dietitian were bilingual, native Spanish speakers. See Figure 9. The
physicians also understood Spanish, one was fluent in Spanish and the other physician spoke
basic Spanish. Between group sessions, the promotoras called families twice to check on
progress, answer questions, and remind families about the next session. The sessions covered
various topics such as parenting, television screen time, consumption of sugar-sweetened
beverages, physical activity, emotional eating, and stress related to mixed-family immigration
status. Before each session, a medical assistant measured children's vitals for assessment (Falbe
et al., 2015).
Figure 9 AHF Team (Triad): Community Health Worker (Promotora), Physician, and Nutritionist. Retrieved from Falbe et
al.(2015)
In addition, the program with Falbe et al. (2015) was culturally tailored in several ways: a
promotora was included; sessions emphasized foods and beverages commonly consumed by

30. 30
Latinos, such as pan dulce, tortillas, Sunny Delight; families also received a culturally
appropriate recipe book and snacks during the group sessions; AHF also targeted cultural
perceptions and practices, such as viewing overweight children as healthy, hesitancy to deny
children additional helpings, and using food as a reward; and a curriculum on immigration was
added. The intervention encouraged open discussion between the parent and child, except during
advanced topics, such as immigration status, parenting and family dynamics, and child’s weight,
where the child partook in physical activity while the parent received counseling. The parent-
child teams received take-home items such as a pedometer, water pitcher, and portion controlled
cereal bowl. During their last session, families the child received a physical activity item of their
choice, such as a soccer ball (Falbe et al., 2015). These strategies exhibit the researchers
commitment to cultural competency. For example, sometimes Latino immigrants were raised
experiencing extreme poverty, thus, an overweight child is deemed as “healthy” because they
have enough to eat. Promotoras can communicate and debunk this cultural perception in a
respectable manner.
After 10 weeks, children in the intervention group had decreased in body weight and the
control group increased in body weight (Falbe et al., 2015). Essentially, the intervention group
lost weight, while those in the control group gained weight. Children assigned to the intervention
group also had improvements in BMI and triglycerides when compared to the control group, but
no differences between groups in fasting blood glucose or blood pressure. There was no
significant change in parent weight for either the intervention or control group, suggesting that
more research is needed to identify the best intervention for adults (Falbe et al., 2015).
Balcazar, Alvarado, Hollen, Gonzalez-Cruz, and Pedregon (2005) used a family-oriented
approach to obesity prevention. The outreach program, Salud para Su Corazón or “Health for

31. 31
your Heart,” was implemented by the National Council of La Raza. The research team evaluated
its effectiveness in relation to improving healthy behaviors among 223 Latino families. The
intervention consisted of 2 two-hour lessons, home visits, and telephone calls for a total of 6
months. The curriculum was led by promotoras who were already employed by the community-
based organizations participating in the study. The promotoras were trained via 50 hours of
curriculum exposure, attendance of a 2-day national promotoras conference, and monthly
updates. The families participating completed surveys regarding healthy behaviors before and
after the program. The program was associated with higher participation in physical activity and
reduced weight, cholesterol, and fat intake. Indicators included changes in the promotoras pre
and post knowledge and performance skills, progress towards their personal goals after training,
and providing follow-up to participants, and organizing or participating in community events. By
using several evaluation tools, the authors showed that a promotora approach was successful
(Balcazar et al., 2005).
The research team, Ayala, Ibarra, Horton, Arredondo, Slymen, and Engelberg, et al.
(2015), merged a promotora-led model with an entertainment education portion designed to
improve the dietary behaviors and intake of predominantly Mexican-origin families. Participants
were made up of 180 Latina mothers who were randomly assigned to either the intervention or
the control. The family-based program, Entre Familia or “Between family” was conducted in
Imperial County California along the U.S.-Mexico border. The intervention consisted of a
Spanish language sitcom-style DVD series that followed a Mexican family while they tried to
improve their eating habits and faced everyday challenges. A family manual was also developed
to supplement the DVD, and was meant to help participants understands the objectives of the
visit, during which, promotoras used the DVD series and family manual to lead sessions for

32. 32
effective delivery of information and social support. Outcome evaluation determined that
mothers in the intervention showed significant increases in vegetable intake, and the use of
strategies to increase dietary fiber intake and decrease dietary fat intake 4 months post-baseline,
when compared to the control group. The children in the intervention increased the variety of
fruits and vegetables consumed and reduced intake of fast food, in comparison to the control
(Ayala et al., 2015). This study added to the existing research supporting the incorporation of
promotora models to promote behavior change in Latino communities.
Summary and Future Research
Culturally relevant nutrition education can facilitate an increase in positive behavior
change to improve health outcomes among the growing U.S. Latino population. At a basic level,
cultural relevancy is a necessary component for Latino individuals because of the changing
demographics of the U.S. The massive increase in size of the Latino population suggests that
there is value in constructing health promotion interventions that incorporates “deep structure”
characteristics about Latinos. However, the sheer number of Latinos in the U.S. is not reason
enough to create culturally sensitive health curriculum. The motivation to create these
interventions is also derived from the significant poverty, income, and education inequalities that
contribute to an immense number of poor health outcomes. Barriers are also especially
prominent in Latinos communities, where language, traditions and customs can be roadblocks to
accessing health prevention resources. One approach in the multifaceted solution to reduce poor
health outcomes faced by Latinos is the utilization of promotoras (community health worker),
along with culturally competent nutrition education.
Government-funded programs, such as EFNEP and SNAP-Ed utilized peer educators
(promotoras) as a mechanism to reach more people. These programs proved to be effective

33. 33
among all beneficiaries, however, more research is needed to identify if Latinos benefit from the
program as much as the other beneficiaries.
The strength of the studies reviewed who incorporating promotoras de salud or “health
promoters” is that promotoras were both valued and empowered through their role as cultural
advisers between their own community and the formal health care system. When public health
researcher—who are outsiders to a specific community—arrive and attempt to teach the
community new customs, they can run the risk of receiving resistance from community
members. However, when researchers empower everyday women and men from those
communities, who are often stereotyped by society as “unskilled laborers” (National Hispanic
Media Coalition, 2012), a favorable outcome can arise for both parties. The researcher is able to
connect with the specific target group and the promotora is valued for her innate cultural
competency, a skill that can neither be learned nor taught.
Two studies, Elder et al. (2006) and Staten et al. (2005), used similar but different
approaches in their culturally relevant intervention. Elder et al. utilized promotoras to
incorporate an individualized approach to their health curriculum by using a one-on-one
counseling setting. However, Staten et al. used a generalized health education curriculum,
facilitated by a promotora, in a group setting. Elder et al. had a lower retention rate than Staten
et al., 79% and 87%, respectively. Even though Elder et al. incorporated a more individualized
approach with one-on-one counseling, it may be possible that the less individualized approach
had lower attrition rates due to the social component of a group setting, which is can be a
component of cultural values.
A limitation in the studies reviewed includes their lack of anthropometric data and a
heavy reliance on questionnaires or surveys. There were a large number of studies (deRosset et

34. 34
al., 2014; Elder et al., 2006; Kim et al., 2004; Staten et al., 2005; & Taylor et al., 2000) that only
used questionnaires or surveys, and only a few studies which used weight as an outcome
indicator. Keller et al.(2008) identified significant weight loss among participants, and Faucher
et al.(2010) also identified a difference in weight loss among participants, although not
statistically significant. Cherrington et al.(2015) identified weight loss near the end of the
intervention, however, six months post intervention, and results were no longer significant. The
success of an intervention decreased months after the promotora was no longer interacting with
the participants, indicating that future research must implement a promotora model in long term
studies. The study conducted by Konak-Griffin et al. (2015) was the only study to identify
weight results nine months after the intervention ended. This may be because Konak-Griffin et
al. was one of the only studies to incorporate encouragement through follow-up phone calls from
the promotoras throughout the intervention and after it ended (Koniak-Griffin et al). It is
important to note that Latino participants value social interactions and cultural competency
(Teufel-Shone, Drummond, & Rawiel, 2005; Hansen et al., 2005). This suggests participants
responded positively to the interpersonal contact, which means that interventions may need to
extend the interpersonal contact in order to achieve long-term success. Additionally, across all
studies, there was no control group without a promotora to compare the data. More research is
needed to compare and intervention outcome between a promotora-led curriculum and a general
researcher-led curriculum. Future research that incorporates both subjective data, such as surveys
and questionnaires, and objective data, such as anthropometric measurements, is needed.
Additionally, most of the promotora facilitated interventions were short term (weeks to months),
more resources and investors are necessary to fund long term studies incorporating promotoras.

35. 35
The promotoras play essential role in promoting health and wellness within their
community. By building bridges between nutritional health recommendations and Latinos,
culturally competent health promotion interventions have a better understanding of what it means
to be a “Latino/a in the United States,” a concept generic nutrition education does not often
recognize. These findings should be considered when selecting or developing health and
nutrition educational materials or interventions for Latino families.

36. 36
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