Minority Peer Educator Project

Executive Summary

Overview

The Texas AgriLife Extension Service has developed a peer educator program to train older minorities to teach their age mates at congregate nutrition sites. The primary goal of the project was to bring relevant health, nutrition and mental health information to older minority participants of Senior Nutrition Sites. This project was funded by the U.S. Department of Health and Human Services, Office of Human Development Services. Project collaborators were the Texas Department on Aging and the National Center for Rural Elderly, University of Missouri. The project began October 1988 and ended July 1990.

Background

Texas has the fifth largest age 60 plus population in the United States including about twenty-one percent of all U.S. Hispanic elders. Research indicates more health problems among Hispanic and Black minority elders than Anglos, with low income further increasing health risk for all elders. Specific physical health concerns include nutritional problems, obesity, disability, diabetes, hypertension, heart disease and stroke; specific mental health concerns include lower morale and life satisfaction

While these problems persist among minority elders, they infrequently seek help or information from existing community services, health care providers or traditional educational programs such as community education or the community colleges. This lack of help seeking may be largely due to illiteracy, language, and cultural perceptions which do not view education as part of a problem solving process. Finding a mechanism to reach low income minority elders was critical if their health and quality of life were to be improved.

One service that reached 10 percent of the minority elderly population was the Texas Department on Aging’s Congregate Meal Program which, through a hot noon meal, provided participants with one third of the Recommended Daily Allowance of nutrients. 177,657 meals were served at meal sites throughout Texas during 1987; twenty-four percent of the meals were served to minority elderly. Nearly all participants were characterized by social and economic need.

The congregate meal site was selected as the location for reaching the minority elderly population. All sites were required to have 15 minutes of nutrition education per month by the Texas Department on Aging. A strategy was needed that would involve older participants in credible, culturally relevant and research based education, delivered in a coordinated sequence which would reinforce and encourage the use of health promoting practices

Approach

A peer education strategy was developed for use in the congregate meal sites. Peer education occurs when someone who belongs to a group takes an educational leader role with that group or when someone who has characteristics similar to the group is accepted in an educational leader role. The key here was acceptance. The indigenous group member would be more likely to have the group’s acceptance than the non-member who had similar age and cultural characteristics. However, a non-member might gain acceptance and become an effective educational leader. The peer educators would be a link between their peer group and sources of health, nutrition, and mental health information (Extension agents, physicians, psychologists, nurses, dietitians, etc.). Peers would be closer with their group in terms of language and culture.

Involving older adults in recruiting, teaching and counseling their peers was not a new concept. Peer programs have reached the hard-to-reach through informal neighborhood based meetings, housing projects, and in community schools and senior centers. These programs have been effective in delivering information and in increasing the self confidence and involvement of peer leaders. Adopting a peer education strategy could increase the involvement of the older minority participants in seeking solutions to problems encountered in later life. Peer educators could facilitate learning and encourage the use of information to prevent disease and/or manage chronic health problems.

Although proponents of nutritional education for older Americans have repeatedly suggested many appropriate strategies for implementing effective nutritional education programs, there were no available educational materials which targeted minority elderly, especially Blacks and Hispanics. Most nutrition education materials were developed for professionals or staff to use in teaching meal site participants. Some formats included lecture/discussion with participation activity but most materials were printed in English at a literacy level beyond that of many meal site participants. Because television was an information source used widely by minorities, video taped materials were identified as the method to support peer educators with technical information.

Materials

An interdisciplinary approach involving health, nutrition and mental health information was used to develop four video tapes to support the peer educators. Each tape was a story about a minority family which focused on a major health or mental health problem posing risk to the population. The story was developed in six 5-minute segments to allow short lessons to be given by the peer educators on each segment. The stories were “true-to-life” and involved family members of all ages, though the focus was on the older person’s health situation. The two topics for Black elders were hypertension and late onset diabetes. The two topics for Hispanic elders were depression following widowhood and overweight as a risk for high blood pressure. The videos for Hispanic elders were in Spanish only.

The problems addressed were identified from research literature and from interviews and surveys conducted with the Texas Department on Aging’s Minority Elderly Task Force, County Extension Agents, Senior Nutrition Site Managers, and Area Agency on Aging Staff. Focus groups with older minority participants and service providers validated information needs.

The scripts were developed by the project director with support from Nutrition Specialists in the Texas AgriLife Extension Service, Texas A&M University, Nutrition Specialists in the 1980 Extension Program at Prairie View A&M University, and Nutrition and Minority Specialists at the Texas Department on Aging. Scripts were also reviewed by physicians, nurses and members of the Minority Elderly Task Force.

Additional support materials developed included a flip chart for each of the six lessons with the three teaching points printed in large type. Publicity posters featuring the characters in each story were also developed.

Implementation

The project brought together two agencies concerned with the well being of the elderly. The Texas Department on Aging provides funding for services to older adults under the Older Americans Act. The Texas AgriLife Extension Service as part of the Texas A&M System provides research based education outside the university classrooms for all ages. County Extension Agents–Family and Consumer Sciences, professional adult educators who have backgrounds in nutrition, health, human development and gerontology, worked with Senior Nutrition Site Managers at the local level to implement the project. The project goals and objectives are given below.

The project goals were:

1. To develop the capabilities of County Extension Agents in organizing, implementing and evaluating the impact of a minority peer education program at the Texas Department on Aging funded congregate meal sites with site manager support.
2. To enhance the delivery of sound and relevant health, nutrition and mental health education to minority participants at meal sites.

Four major objective areas were established to meet the project’s goals.

1. County Extension Agents who participated in the training program would:
   • Establish minority peer educator programs at meal sites.
   • Evaluate the effectiveness of the minority peer education program.
   • Demonstrate the program’s effectiveness to other County Extension Agents in their district in the second stage of training.
   • Use the program to increase minority elderly educational participation.
2. Meal site managers who work with County Extension Agents would:
   • Accept and support peer educators as team members.
   • Encourage other meal site managers in their area to adopt the program.
3. Peer Educators would:
   • Increase knowledge in content areas to be taught.
   • Value their role as peer educator.
   • Teach six lessons to minority peers.
4. Minority elders who participate in peer educator programs would:
   • Increase in knowledge of dietary and lifestyle practices (i.e., reducing fat, sodium, increasing exercise) which reduce personal health risks.
   • Increase morale.
   • Value peer educators as a source of information.

Results

Sixteen counties piloted the four programs during the fall of 1989. In addition, one location in Missouri piloted the program during this time. County Extension Agents–Family and Consumer Sciences and Nutrition Site Managers were trained in methods to select, train and support the peer educators. They were provided support materials related to the health, nutrition and mental health content of the videotaped stories and on group discussion techniques.

Thirty-six peer educators (working in teams of two to four) were selected and trained to implement one of the four programs. During the fall of 1989, over 1400 older minorities participated in the program series led by these peer educators. The level of interest and meaningfulness of the program content was rated by a sample of participants as high. Peer educators had a high level of acceptance overall and were considered effective by participants and by the County Extension Agents and Nutrition Site Managers.

Program results were based on indepth pre- and post-program interviews with a sample of program participants from 8 of the 16 pilot sites in Texas. Forty-nine participants (25 Black and 24 Hispanic) formed the sample upon which results were based. These participants had participated in at least four of the six lessons given by the peer educators. Interviews were conducted in English with Black elders and in Spanish with Hispanic elders by three project evaluation assistants.

Participants and peer educators indicated that the educational video stories were “realistic,” “interesting,” and “helpful.” One participant stated that she had learned about “how to control salt—that’s what’s so dangerous.” Respondents identified closely with the family theme used in each of the videos. One respondent stated: “I enjoyed the family and their discussions and arguments and the headstrong woman with diabetes.”

The educational nature of the video stories was commented on with regard to health and food matters. Many respondents indicated that the program contained “good advice” and “good ideas” about “how to get people to do things.”

Knowledge gains were assessed at the individual level through the pre- and post-interviews with participants. Information had to be recalled without prompts from the interviewers. Pre- and post-responses were compared to determine gain.

For sample groups from both treatments, some knowledge gain occurred in every aspect of three major areas: weight control, hypertension and diabetes. Some gain occurred in the area of depression, which was included in only the Hispanic videos.

The largest gain seen for the entire group of 49 respondents was in the area of weight control. 31 persons (18 Black, 13 Hispanic) showed increased understanding of what helps an individual lose weight. The second largest gain appeared in the hypertension component. Almost half (8 Blacks, 16 Hispanics) showed increased knowledge regarding control of high blood pressure. Smaller gains occurred when respondents were asked how high blood pressure diabetes work in the body. Only four individuals gained knowledge in this area.

Behavior changes made or planned regarding diet, exercise and coping strategies were determined through questions asked before and after the program series. Changes in foods eaten and exercise were self reported. Almost half of the respondents (9 Black, 14 Hispanic) reported in the post interview that they were limiting salt, fat, sugar and/or the amount of food eaten.

Just under half of all respondents indicated a change in regard to diet. Twenty-four indicated that they “should change” or “plan to change or have changed” their diets. Persons planning to change or having changed included those who said they were on some kind of diet at the time of the first interview. This suggests that food patterns are not static among older minority persons, and that change, even though it may not be solely related to the peer project, did occur.

Regarding exercise, about one-third indicated an increase in the time spent walking. All but one of these individuals has participated in the Hispanic treatment. Over one-third of the respondents (8 Blacks, 8 Hispanics) indicated increased ability to handle emotional losses.

The Philadelphia Geriatric Center Morale Scale was administered before and after the treatment to 49 persons. Twenty-three of the forty-nine persons showed increases; 15 of 49 showed decreases; and 11 had the same score. The variation found in individual scores was within the range reported in other studies and did not seem to be related to any aspect of the educational treatment. Because the sample size from each site was small, differences across sites or by treatment were not considered.

Both County Extension Agents and Nutrition Site Managers indicated the success of the program in reaching nutrition site participants. As stated by one agent: “This program is ideal for a senior center. This program motivated seniors to get involved in health issues and to communicate with one another stories about themselves. This helps in community building. The peer educators were not looked upon as teachers but as aides in helping to understand diabetes, high blood pressure, diets, etc.”

Agents and Site Managers indicated that the selection and confidence of the peer educators and the appropriate selection of a nutrition site were key factors to the program’s success. Selection of the peer educators was most successful when agent and site manager worked together. Most agents and managers indicated that the training they provided to peer educators did increase their confidence. Data from peer educator interviews support this.

In regard to site selection, difficulty occurred where the Hispanics spoke English more than Spanish, where the chosen peer educator didn’t know Spanish well, and where Anglos seemed to resent the program designed especially for Hispanics. Also indicated as a factor was the support provided by the agent and the nutrition site manager for the program. Where ongoing support by both agent and nutrition site manager was given, program effectiveness was increased.

Dissemination

Efforts to disseminate the project in both Texas and nationally included a dissemination training reaching 145 Extension Agents and Nutrition Site Managers and presentations, reaching over 3846 people, to the Department on Aging, State Aging Conferences in Texas and Missouri, Missouri Department of Health, Southern Region Extension Conference and other groups. Participants in the Southern Region Extension Conference indicated high interest in acquiring and using the program in their states. Articles were published in Nutrition Today and The Aging Digest and project descriptions were registered with the National Resource Center on Minority Aging Populations and the Center for Rural Elderly. A workshop was presented at the 1991 annual meeting of the American Society on Aging.

Implications

The primary implication of the results reported in this demonstration project is that peer education using minority elders and supported by visual research based educational materials can be an effective method of providing nutrition education at senior nutrition sites for minority elders. Further implications relating to program implementation are listed below:

1. County Extension Agents–Family and Consumer Sciences are a key resource in implementing minority peer educator programs, providing research based support and leadership development for peer educators.
2. Nutrition Site Managers are a key factor in the success of a minority peer educator project. Support by this cooperator is necessary for effective peer recruitment and support during program implementation.
3. County Extension Agents and Nutrition Site Managers can be most effective in nutrition education delivery through peer educators when they have a common personal and time commitment to fulfill their roles in the program.
4. Peer education using minority elders is one method of effectively extending the educational outreach of the Extension Service. Peer educators reach beyond the intended audience to other community and family members.
5. The older minority audience characteristics must be considered when selecting peer educators and resource materials. Where Spanish is spoken, Spanish speaking peer educators and materials in Spanish must be used. Where English is spoken as a predominate public language by older Hispanic, English must be used.
6. Peer educators are more effective when certain key characteristics are present including: willingness to learn, flexibility, dependability, mutual respect by peer group and self confidence.
7. Peer educator programs which provide a coordinated sequence of meaningful lessons can positively affect older minorities’ knowledge about health, nutrition and mental health.
8. Videotaped stories about minority families facing health dilemmas which are resolved through the application of research based health, nutrition and mental health information are effective educational materials in peer led programs.
9. Peer-led videotaped instruction is most effective in an environment where sight and hearing needs of elders and the individual interest of the participants in learning about health, nutrition and mental health are considered by site managers who have the most influence where the program is implemented and who is involved.
10. Future development of videotaped stories for elder education needs to consider the cost of professional talent, the time required for quality production and support costs for properties, cast and crew.