Health Fairs Program Manual

Health Fairs Program Manual

Michael Dalious Health Fairs Coordinator La Clínica del Pueblo

2831 15th Street, NW |‌ Washington, DC 20009-4607 T (202) 462-4788 |‌ F (202) 667-3706 |‌ www.lcdp.org

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La Clínica del Pueblo Health Fairs Program Manual

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Direct funding for the health fairs program in 2008 has come from the District of Columbia’s Department of Health, the Mayor’s Office for Latino Affairs, and the MedStar Research Institute. This manual and the study of the health fairs program were funded by the DC Department of Health’s Preventative Health Block grant (DOH ID# 8H0127) and La Clínica del Pueblo in collaboration with the George Washington University. Direct supervision of the study was provided by Dr. Daniel Hoffman, Professor of Epidemiology and Biostatistics with George Washington University’s School of Public Health. ACKNOWLEDGEMENTS La Clínica del Pueblo is proud to present this manual for the health fairs program for the Latino community of the Washington, DC Metropolitan Area. The development of this manual has been a cumulative effort begun by the work of Dr. Juan Romagoza, the modern day founder of La Clínica del Pueblo. For 20 years, Dr. Romagoza reached out to the Latino community to both educate and serve. His vision of health care access as a basic human right continues to be the driving force of all health fairs. Dr. Juan Romagoza The Community Health Outreach Department was created within La Clínica del Pueblo in 2006 to continue the outreach work performed by Dr. Romagoza. Key collaborators to the health fairs program from these years include Kristen Boehne, Eudom Ixthayul, Sarah Koch, Lillian Meza, Sorangel Posada, Carolina Torres, and Blanca Tobar. In 2008, the Health Fairs program also greatly benefited from the work of our two interns, Amy Robandt and Caroline Rosenberg. Rigorous scientific support for the program has been obtained from the US Department of Health through their US Preventative Services Task Force organized by the Agency for Healthcare Research and Quality, and from the following institutions:

National Heart, Lung and Blood Institute

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La Clínica del Pueblo and the Latino community would also like to recognize the continuing work of our dedicated community health promoters and volunteers, without whom the health fairs would not be possible.

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CONTENTS Acronyms………………………………………………………………….. 6 Foreword…...………………………………………………………………. 7 PROGRAM DESCRIPTION……………………………………………………….8 La Clínica del Pueblo Synopsis……………...…………………………….. 9 Community Health Outreach Department Synopsis………………………. 10 Problem Statement…………………………………………………………. 11 Program Objectives and Activities………………………………………… 12 Target Population…………………………………………………………... 13 Planning Considerations……………………………...……………………. 15 CORE HEALTH FAIR SERVICES………..……………………………………… 17 Registration………………………………………………………………… 18 Screening Sessions……………………………………………………........ 20 Body Mass Index Screening………………………………………. 20 Blood Pressure Screening…………………………………………. 21 Plasma Glucose Screening………………………………………… 22 Total Cholesterol Screening………………………………………. 23 Counseling Sessions………………………………………………………. 24 Nutrition Counseling……………………………………………… 24 Exercise Counseling………………………………………………. 30 Heart Health Counseling………………………………………….. 32 Diabetes Counseling………………………………………………. 34 Cancer Counseling………………………………………………… 39 Colorectal Cancer…………………………………………. 40 Prostate Cancer……………………………………………. 41 Breast Cancer……………………………………………… 42 Cervical Cancer……………………………………………. 43 Exit Counseling……………………………………………………………. 44 Health Insurance Counseling……………………………………………… 45 ADDITIONAL SERVICES……………………………………………………….. 46 HIV Counseling and Testing………………………………………………. 47 Glaucoma Screening……………………………………………………….. 47 Other Health Services……………………………………………………… 47 Non-Health Related Services……………………………………………….48 Children’s Center……………………………………………………………48 POST HEALTH FAIR SERVICES………………………………………………... 49 Patient Navigation System………………………………………………….50 Program Evaluation………………………………………………………... 51 Logic Model………………………………………………………………...52 Recommendations…………………………………………………………. 53

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APPENDICES……………………………………………………………………... 54 Appendix A………… 2008 Health Fair Statistics………………………… 55 Appendix B ………... 2008 Health Fair Venues…………………………... 60 Appendix C ………... Health Fairs Program Schedule……………………. 61 Appendix D…………Health Promoter Agreement……………………….. 62 Appendix E………… Health Fairs Program Flyer…………………………64 Appendix F………… Registration Sheet………………………………….. 66 Appendix G…………¼ Page Participant Results Sheet………………….. 68 Appendix H…………Body Mass Index Tables…………………………... 69 Appendix I…………. Nutrition Handouts………………………………… 71 Appendix J…………. Exercise Handouts…………………………………. 73 Appendix K…………Heart Health Handouts…………………………….. 75 Appendix L…………Diabetes Handouts…………………………………. 77 Appendix M………...Cancer Handouts…………………………………... 79 Appendix N…………Exit Counseling “Your Health Levels”……………. 83 Appendix O…………What are Heart Disease and Stroke?......................... 84 Appendix P………….How Can I Reduce High Blood Pressure?................ 88 Appendix Q…………How Can I Lower High Cholesterol?........................ 92 Appendix R………… All about Pre-Diabetes……………………………...96 Appendix S………… Mental Health Resources Handout………………… 100 Appendix T………… Community Clinics in Washington DC……………. 101 Appendix U…………Community Clinics in Maryland and Virginia…….. 103 ENDNOTES……………………………………………………………………….. 105

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ACRONYMS ACS ADA AHA AHRQ BSE BMI CBE CHOD DC DOH HDL HIV LCDP LDL NHLBI NIH NCEP OLA SES STI USPSTF

American Cancer Society American Diabetic Association American Heart Association Agency for Healthcare Research and Quality Breast self-examination Body mass index Clinical breast examination Community Health Outreach Department District of Columbia’s Department of Health High density lipoprotein Human immunodeficiency virus La Clínica del Pueblo Low density lipoprotein National Heart, Lung and Blood Institute National Institute of Health National Cholesterol Education Panel The Mayor’s Office for Latino Affairs Socioeconomic status Sexually transmitted infection United States Preventive Services Task Force

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FOREWORD The intent behind the creation of this manual is threefold. First, the manual serves to document La Clínica del Pueblo’s 25 years of experience with health fairs. In this time, the health fairs have evolved to meet the unique needs of the Latino community in the Washington, DC Metropolitan Area. In documenting our experiences, we aim to acknowledge the hard work of all those who have supported the program. Secondly, the manual is considered a tool for LCDP staff to formalize the health fair procedures and medical protocols. This manual will be used to ensure that all health fair activities are supported by the current medical research and recommendations, and that all activities are implemented in a uniform manner to provide high standard screening and counseling sessions to all health fair participants. Finally, this manual has been assembled to share our cumulative experiences and best practices with our funders and other communitybased organizations interested in promoting health access among the Latino community. This manual is considered a living document. In the future, the program will continually adapt to the changes within the Latino community and their health needs. Over the years, we have observed shifts in Latino residential densities, country of origins, and various other factors that affect the health needs of the community. As such, the health fairs program and this manual will continually adapt to the circumstances of the community. The advancements in medical research and changes in screening and counseling recommendations will also be adopted to ensure that the program incorporates emerging best practices. New recommendations from the United States Preventive Services Task Force (USPSTF) and other contributing organizations will be continuously reviewed in order to provide the best service possible and to align with current health care practices.

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PROGRAM DESCRIPTION

“While the diversity of the American population is one of the Nation’s greatest assets, one of its greatest challenges is reducing the profound disparity in health status of America’s racial and ethnic minorities.” ~National Center on Minority Health and Health Disparities

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LA CLÍNICA DEL PUEBLO La Clínica del Pueblo's mission is to provide culturally appropriate  health services to persons in the Latino community regardless of their  ability to pay. La Clínica del Pueblo was founded in 1983 in response to the growing medical and mental health care needs of Central American refugees escaping their warntorn countries during the 1980s. For many of these individuals, getting access to any type of medical care was nearly impossible due to their status as refugees and the cultural and language barriers that come with immigrating to another country. La Clínica was started in direct response to the health care needs of these immigrants and began as a one-room clinic, one night per week, by a volunteer doctor. Despite its brief hours of operation between 8:00 pm to 5:00 am during its initial days, La Clínica was always full of patients who would brave the cold of winter and the heat of summer because this was the only place where they felt comfortable and where they were treated with respect and dignity. La Clínica’s services are now offered in a newly renovated, state-of-the-art clinic located at the crossroads of the Columbia Heights, Mt Pleasant, and Adams Morgan neighborhoods in the District of Columbia. In 2007, over 7,500 clients were seen during 55,000 client visits. A staff of almost 80 employees coordinates over 100 volunteers, the majority of whom are bilingual and culturally competent. Client Population • 86% of La Clínica's clients are recent Latino immigrants from Central and South America; 55% are originally from El Salvador. • Over 90% have no health insurance and have incomes below the poverty level. • More than 50% have less than a seventh grade education. • Over 90% are most comfortable communicating in Spanish. • 77% of La Clínica's clients live in the District of Columbia; 19% live in Maryland; and 4% live in northern Virginia. • 62% are female; 20% are under the age of twenty.

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COMMUNITY HEALTH OUTREACH DEPARTMENT (CHOD) Goal – Reduce the health disparities experienced within the Latino community in the Washington, DC Metropolitan Area. The objectives of the Community Health Outreach Department (CHOD) of La Clínica del Pueblo are: 1) To educate the Latino community of the risk factors and symptoms of chronic illnesses including diabetes, cardiovascular disease, obesity, and cancer in order to change behaviors that negatively affect the mental and physical health of the community while enforcing positive culturally appropriate behaviors. 2) To orient Latinos to the culturally appropriate medical services and health insurance programs available to them. 3) To integrate preventative services into medical care by providing exercise and cooking classes, a diabetic patients club, and educational sessions to the Latino community. 4) To advocate for the right to equal access to health services for underserved populations through participating in a variety of citywide coalitions and councils. In order to achieve these objectives, CHOD has developed several innovative programs that focus on behavioral change including: the health fairs program; a comprehensive diabetes education and management program—including exercise and cooking classes; a cancer prevention program; and a heart health program. All of the department’s programs are supported by a specially trained group of health promoters. This group consists of individuals from within the Latino community who are trained by LCDP staff as health promoters. The health promoters provide culturally appropriate health screenings and educational sessions in community health fairs and other educational opportunities in Spanish.

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PROBLEM STATEMENT Medical anthropologists who study the political economy of health care access for ethnic minorities in the United States identify several barriers to health care access including cost, language, educational level, cultural beliefs, and legal status.i The literature indicates that the origins of health care barriers stem both from the neoliberal US health care system as well as the cultural beliefs and practices of immigrating Latinos. The barriers not only reduce health care access, but also lead to delayed and often substandard care that negatively impacts the health outcomes of ethnic minorities. As the Latino population is the fastest growing subgroup in the United States as of 2008, there are rising concerns that this group will increasingly place excess stress on the US health care system. As the population ages, elderly Latinos who have not had access to preventative health care will present higher levels of advanced chronic illnesses that are expensive to treat and negatively affect their quality of life. In a study of the state of Latino health in the District of Columbia, McClure and Jerger collect comprehensive baseline data on Latinos’ health status, knowledge, and access to care.ii Through a collaborative and community-based effort, they were able to identify and assess the barriers to health care access of Latinos living in Washington, DC. Key Health Care Findings: • 41.5% of respondents had no form of health insurance • 32% of respondents had not seen a doctor in more than two years Key Socioeconomic Findings: • 25% of respondents reported receiving a high school degree or GED • 62% of respondents reported having an annual household income below $25,000 • 31% of respondents reported cost as their primary reason for not accessing health care • 59% of respondents reported speaking only Spanish McClure and Jerger’s findings indicated that Latinos in Washington, DC experience even higher barriers than the average Latino living in the United States. The national average for uninsured Latinos is 18% and nationally only 35% of Latinos earn an annual household income of less than $25,000 per year. Likewise, 59% of Latinos nationally reported having a high school degree or GED and only 40% reported speaking only Spanish. As a result, 36% of Latinos in DC report their health as poor or fair, while only 16% of Latinos and 13% of Whites nationally report their health as poor or fair. As such, actions must be taken to decrease the health disparities experienced by Latinos living in Washington, DC. The efforts must acknowledge the barriers in existence and aim to circumnavigate them in the short-term and eliminate them in the long-term.

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PROGRAM OBJECTIVES AND ACTIVITIES The current anthropological literature suggests three main approaches to improving health care access for Latinos despite the heterogeneous population.iii First and foremost, the provision of affordable or no-cost health insurance can immediately reduce the health care costs barrier that limits Latino access to health care. Secondly, training medical professionals in cultural competency allows them to understand the beliefs and behaviors of Latinos and better serve the Latino population. Finally, educating Latinos about their health risks and their rights to health care assists Latinos in their health care utilization decision making processes. The provision of health insurance and culturally competent providers are both the short-term solutions to increasing health care access and together with increasing education and income levels, they serve as the long-term strategy for eliminating ethnic inequalities in the US health care system. The recommendations from the McClure and Jerger study largely coincide with the anthropological literatureiv, suggesting: active enrollment of Latinos in available health insurance plans—one of which is provided free of charge to low income Latinos; bilingual health education focusing on key health issues including obesity, diabetes, cancer, and health care access; and increased investment in Latino-serving clinics, as their providers have been observed to be more culturally competent. These recommendations and the observations of the state of Latino health in the Washington, DC Metropolitan Area have shaped the health fairs program. The objective of the health fairs is not to replace medical services, but rather to encourage individuals in the Latino community to become concerned about their health and to direct them to health care services and insurance programs. This objective is attended through the implementation of four principle activities, all of which are supported by the literature as means to circumnavigating barriers to health care access. 1) Counseling sessions are provided to educate participants about chronic illnesses and the benefits of preventive and palliative services. 2) Screenings are provided to identify participants at high risk for chronic illness, so that these individuals pay special attention to the counseling messages and seek out preventive and palliative health care services. 3) Participants without a primary care physician and participants that have abnormal screening results for one or more chronic disease indicators are referred to a culturally appropriate clinic and follow-up calls are made to ensure they were able to make an appointment. 4) Eligible participants are enrolled in the DC Alliance HealthCare insurance program. These activities may reduce health disparities by overcoming barriers to health care access. In the short-term, Latinos gain access to preventive and palliative health care services that increase their quality of life. In the long-term, as Latinos gain access to health insurance and have rising levels of income and education, they will be better able to continually access health care services and ultimately have an improving quality of life.

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TARGET POPULATION As La Clínica del Pueblo’s mission is oriented towards the Latino community and funding for the program comes from the Mayor’s Office for Latino Affairs (OLA) and the District of Columbia’s Department of Health for Integral Health for Latinos, all health fairs target the Latino population. The program’s goal is to reduce health disparities by connecting more Latinos to health service. In this sense, the target Latino population includes those who do not have health insurance and/or do not have regular access to health services. Among the Latino population, socio-economic determinants of income and immigration status play a large role in the ability to access health services. For this reason the health fairs target low-income, recently-immigrated Latinos. According to OLA and the official Census figures in 2002, of the District's 564,326 residents, 53,289 (9.4 percent) are Latino, although due to census undercounting the figure is estimated to be closer to 13 percent.v Latinos in the District demonstrated a 56 percent growth rate from 1990 to 2002, making them the fastest growing ethnic minority in the District. By the year 2010, the District will have an estimated 70,000 Latino residents. Residency patterns for Latinos show a concentration in Wards 1 and 4, with marginal increases in Wards 5 and 6, and declines in Wards 2 and 8. Almost half (46.3 percent) of DC Latinos live in Ward 1 neighborhoods. Within Ward 1, three clusters (Kalorama Heights/Adams Morgan/Lanier Heights, Mount Pleasant/Columbia Heights/Pleasant Plains/Park View, and Howard University/Cardozo/Shaw/Le Droit Park) have a Latino population of 10 percent or more. The same case is within Ward 4 for Logan Circle/Shaw cluster; and within Ward 4 for Brightwood/Manor Park/Takoma and Brightwood Park/Crestwood/Petworth/16th St. Heights. Much of DC's Latino population growth is due to immigration rather than fertility. Latino population growth from 1970 to 2000 reflects the newcomer characteristics of the population, including the concentration of Latinos in certain neighborhoods, high proportion in productive and reproductive age groups, unstable sex ratios, linguistic isolation, and extended family structures. According to OLA, over one-third of DC Latinos identified their country of origin as being in Central America, the vast majority from El Salvador. This pattern is in stark contrast to the rest of the Latino population in the US, which is mainly of Mexican, Puerto Rican, Dominican or Cuban heritages. It is estimate that the proportion of the Latino population in Washington, DC that is undocumented ranges from 5 percent to 15 percent of the total Latino population.

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Hispanic Population in the District of Columbia, 2000 Source: Mayor’s Office for Latino Affairs Demographic and health care information obtained from health fair participants in 2008 supports the Census figures and confirms that the health fairs program is effectively reaching its target population. Most notably, of the 2008 participants, 68% reported that they did not have health insurance, and 54% reported that in the past year they did not access health care services. Appendix A contains the full report of 2008 health fair statistics. Special considerations are taken in the planning of health fairs to ensure that culturally appropriate services are provided to the target population. Additionally, several assumptions of the population are made when determining screening necessities and are described in the sections were they apply. The United States Preventive Service Task Force (USPSTF) recognizes that clinical or policy decisions involve more considerations that their accumulated evidence alone. When determining screening protocols the USPSTF acknowledges that clinicians and policy makers must individualize decision-making to the specific situation, but should do so with an understanding of the evidence they present.vi Throughout this manual, several considerations based on the preceding population are made that modify the services offered. These modifications are noted along with their justifications in each case.

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PLANNING CONSIDERATIONS Venue – The venue for a health fair can be as important as the content of the event in terms of the ability to positively intervene in the lives of the participants. • The venue needs to be in an area of high Latino concentration (all health fairs within the district are planned in areas of high Latino density according to the Mayor’s Office for Latino Affairs “Washington DC Hispanic Population.”vii) • Health fairs must be distributed throughout the Washington, DC Metropolitan Area to provide services to a greater majority of the Latino community. • The venue is also chosen for its accessibility (It is a place where Latinos normally congregate). • The venue needs to have sufficient space to house all services, providing private areas for HIV screening and adequate space between services to provide confidentiality. • The community partner responsible for the venue is required to assist in announcing the health fair to the surrounding Latino community. Appendix B contains the health fair venues from 2008. Timing – Timing is another important consideration in the planning of health fairs. • Health fairs must be timed during periods when the Latino community is free from work and other social responsibilities (for the Latino community this means holding the majority of health fairs on the weekends alternating between Saturday and Sunday. Smaller events can be held during weekday evenings.) • Health fairs are also timed during the period when Latinos are most active in community activities (The health fair schedule runs from March to November, which avoids the coldest part of the year when Latinos are less active in the community.) • In order to serve all participants, health fairs range from 3 to 6 hours in length. • The frequency of the health fairs is another important consideration. As the health fairs aim to connect recently-arrived Latinos with health services, it is important to continually return to areas with growing number of Latino immigrants. However, the health fairs are not meant to replace health services and therefore need to be spaced temporally and advertised to new populations in order to avoid dependence. Appendix C contains the generalized health fairs schedule. Health Fair Personnel – The closer the health promoter is to the health fair participant in terms of socioeconomic status and cultural background the more effective their communication will be with participants. • Health promoters are recruited from within the Latino community. (PLEASE NOTE: There is no racial discrimination in this process, as individuals from any racial or ethnic background who speak Spanish and are familiar with Latin American culture are welcomed to participate in the program.) • As it is recognized that health promoters whom originate from the target population are highly effective in both creating a welcoming atmosphere and simply communicating health messages, there is no minimum level of education required to be a participant in La Clínica del Pueblo

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the program. However, health promoter candidates are required to show a strong interest in serving their community, which is often very strong because they themselves have recently been in the situation of those they will be serving. All new and returning health promoters are required to participate in a six day health promotion training given by LCDP staff in February prior to the start of the health fair year. On-going training sessions are provided throughout the year to reinforce the initial training sessions and to train health promoters on additional topics that will increase their knowledge for the health fairs and benefit them personally. Paid but more importantly appreciated! All health promoters that complete the training are monetarily compensated for their time during the health fairs. However, the principle motivation for participating in the program is the sense of pride that comes from serving the community. LCDP staff reinforce this sense of pride by informing the health promoters of the benefits of their work, as indicated by the evaluation. Health promoters are also give ample opportunities to volunteer in additional health outreach events organized by LCDP staff.

Appendix D contains the health promoter agreement. Partnering Organizations – In order to multiply our impact in the community, we partner with community-based organizations such as churches, schools, commercial centers, and community centers that are able to provide a venue and contacts within the community. We also partner with service provision organizations such as Planned Parenthood, Latin American Youth Center, DC Department of Health, OLA, and FIDMi-Tierra, which are able to provide additional services during the health fair. Due to the diversity among the participating organizations, the following norms have been established. • Venue sponsors may not deny access to any individual on grounds of race, sexual orientation, or language abilities. • Venue Sponsors and/or the Health Fairs Coordinator may deny access to individuals who are deemed by them to be dangerous or disruptive. • Service provision organizations must have 501(c)3 status or be a non-partisan branch of the government. • Service providers must respect the beliefs of the venue sponsors (i.e. service organizations that promote family planning services are occasionally asked to promote only those services that are found to be acceptable by the church sponsors). Health Fair Announcements – All health fairs are publicized within the Latino community. • Flyers are produced by either the venue sponsor or the Health Fairs Coordinator and distributed in La Clínica del Pueblo and within the target community in the two weeks leading up to the event. • Experience has shown that the most effective flyer distribution method is to enlist the support of a community leader, such as a church or school leader, to distribute the flyers to potential participants. These trusted individuals are aware of the services offered during the health fairs and are able to influence community members to attend the event. • The Health Fairs Coordinator is also responsible for announcing the fairs in a growing network of media channels including television, radio and newspaper outlets.

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Appendix E contains a sample health fair flyer.

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CORE HEALTH FAIR SERVICES

“If it hadn’t been for La Clínica del Pueblo, I never would have known how serious my diabetes was.” ~ Douglas Rivera Health fair participant

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The following core health fair services are provided at all health fairs. Participant registration is always completed first and the exit counseling session follows all core services. The Health Fairs Coordinator reserves the right to modify the order of the screening and counseling services depending on participant flow and space constraints. REGISTRATION The first station of every health fair is the registration table, where information—as listed in Box 1—is obtained from the participant and the order of the services are explained to the participant. Box 1 The following information is obtained from every participant in this order. • Name • Address • Telephone Number • Date of Birth • Age • Sex • Race/Ethnic Group • Country of Origin • Level of education • How long the participant has resided within the United States • If they speak Spanish • If they speak English • If they have medical insurance • If they have visited a clinic in the past 12 month within the United States • If they suffer from an illness • If so, what type of illness do they currently suffer from? • If they smoke • If they would like to stop smoking • If they have ever had one of the following exams o Colonoscopy o Pap-smear o Mammogram o Prostate Exam All information obtained from participants is held confidentially by LCDP staff. The information is used to monitor and improve the health fairs program and to contact participants that are referred to medical services.

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Participation Authorization Upon completion of the questionnaire, all participants are required to sign the registration sheet acknowledging the statement in Box 2. Box 2 Authorization: I hereby authorize La Clínica del Pueblo to conduct a series of free tests designed to detect certain risks posed to my health. I understand that these tests are not definitive, and that I would need to consult a doctor for a definitive diagnosis and for any treatment needed. I hereby release and exonerate La Clínica del Pueblo of any responsibility or liability that could result from these tests. Appendix F contains the registration sheet used for all health fairs. Each registration sheet has an accompanying ¼ page where the participant’s test results are noted, so that the participant retains a copy of all test results when they hand in the registration sheet at the exit counseling session. On the front side of this page, the participant’s name and test date are recorded along with the screening results for Body Mass Index, Blood Pressure, Plasma Glucose Level, and Total Cholesterol Level. On the reverse side of this page, the participant is provided a guide to help them interpret their screening results and four ways to prevent high blood pressure. Appendix G contains the ¼ page that the participant retains with their screening results.

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HEALTH SCREENINGS This section describes the screening performed at the health fairs. Health fair participants are encouraged to complete all screenings and their results are interpreted after all screenings have been completed. None of the screenings are considered definitive nor are they the basis for a diagnosis. The screenings are used to identify participants with higher risk of chronic disease, so that they may be referred to preventive and palliative health care services. BODY MASS INDEX SCREENING The U.S. Preventive Services Task Force (USPSTF) recommends the screening of all adults for obesity and the referral of obese adults to counseling (B recommendation).viii On the basis on this recommendation, all health fair participants are screened for obesity using the Body Mass Index (BMI) screening test. BMI, calculated as weight in kilograms divided by height in meters squared, is compared to pre-established obesity levels (<25 normal; 25-29.9 overweight; 30-34.9 obese class I; 35-39.9 obese class II; >40 obese class III). To calculate BMI, the participant’s weight and height is recorded, and the corresponding BMI is derived from a BMI table.ix A floor scale is used to weigh participants and a tape measure affixed to a wall is used to measure the height of the participants. Participants with thick heeled shoes are asked to remove their shoes for both procedures. Additionally, if the individual is carrying anything with them or has an excessive amount of objects in their pockets, they are asked to set them down before being weighed. Participants with a BMI between 30 and 39.9 (obesity classes I and II) are referred to highintensity counselingx including both exercise and nutrition components by the exit counselor. This recommendation is based on the USPSTF findings that high-intensity counseling— including diet and exercise components—together with behavioral interventions can produce modest, sustained weight loss which in turn leads to improved glucose metabolism, lipid levels, and blood pressure (B recommendation). Participants with a BMI exceeding 39 (obesity class III) are referred to both high-intensity counseling and medical services by the exit counselor.xi Appendix H contains the BMI tables used in the health fairs.

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BLOOD PRESSURE SCREENING The USPSTF recommends screening for high blood pressure in adults aged 18 or older based on the ease of blood pressure monitoring and the benefits of early detection and treatment (A recommendation).xii The USPSTF states that hypertension is “a very prevalent condition that contributes to significant adverse health outcomes, including premature deaths, heart attacks, renal insufficiency, and stroke.”xiii They continue by stating, “The USPSTF found good evidence that treatment of high blood pressure in adults substantially decreases the incidence of cardiovascular events.” Both pharmacological and nonpharmacological treatments of hypertension are available and are effective within the Latino community. On the basis of the USPSTF recommendation, all participants are screened for high blood pressure. The blood pressure of all participants is taken with the OMRON Automatic Blood Pressure Monitor with Arm Cuff (Model HEM-711AC). The manufacture’s directions for proper use are followed for all screenings. An extra large blood pressure cuff is used to take the blood pressure of participants that have an arm circumference between 13 to 17 inches. In the event of two sequential error messages, the Health Fairs Coordinator, a nationally-certified Emergency Medical Technician, records the participant’s blood pressure manually using a stethoscope and sphygmomanometer. Participants with a blood pressure exceeding either a systolic of 130mm Hg or diastolic of 85mm Hg are informed of four nonpharmacological treatment methods for reducing high blood pressure including: reduced dietary sodium intake, weight loss, increased physical activity, and reduced alcohol intake.xiv Participants with a blood pressure exceeding either a systolic of 140mm Hg or diastolic of 90mm Hg are referred to medical services for confirmation and the subsequent treatment of hypertensionxv. These participants are also informed of four nonpharmacological treatment methods for reducing high blood pressure including: reduced dietary sodium intake, weight loss, increased physical activity, and reduced alcohol intake.xvi Emergency Protocol At the direction of La Clínica’s Medical Director, all participants that have a blood pressure exceeding 210 mm HG systolic or 120 mm Hg diastolic are asked to wait five minute, after which a second manual reading is performed by the Health Fairs Coordinator. If the participant’s blood pressure remains above the previously indicated level, the Health Fairs Coordinator activates the Emergency Medical System by calling 911 or notifying onsite Emergency Medical Services and reports the hypertensive emergency.

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PLASMA GLUCOSE SCREENING The USPSTF recommends screening for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg (B recommendation).xvii However, since a baseline blood pressure cannot be established in the single reading at the health fair, the high prevalence of hypertension in the Latino community, and the low invasiveness of the non-fasting plasma glucose screening, all participants are screened for type 2 diabetes by means of a plasma glucose level test. Plasma glucose level screenings are performed through a contract with Health Pact, Inc using the One Touch Ultra® glucameter. The manufacture’s directions for proper use are followed for all screenings. Health Pact staff note whether the participant is fasting or non-fasting. In the health fairs context, fasting participants are those who have not eaten in the twelve hours preceding the screening. All other participants are considered non-fasting. Participants with a non-fasting plasma glucose level exceeding 140 mg/dl or a fasting plasma glucose level of 126 mg/dl are referred to medical services by the exit counselor.xviii Emergency Protocol Hyperglycemia At the direction of La Clínica’s Medical Director, all participants that have a plasma glucose level exceeding 250 mg/dl and are non-symptomatic are advised to eat a small dinner and follow-up with a physician as soon as possible. If the participant’s plasma glucose is exceeding 250 mg/dl and the participant presents with shortness of breath, breath that smells fruity, nausea and vomiting and/or a very dry mouth, the Health Pact staff member performing the test notifies the Health Fairs Coordinator, who activates the Emergency Medical System by calling 911 or notifying onsite Emergency Medical Services and reports the hyperglycemic emergency. Hypoglycemia At the direction of La Clínica’s Medical Director, all participants that have a plasma glucose level below 70 mg/dl and are non-symptomatic are advised to follow-up with a physician as soon as possible. If the participant’s plasma glucose is below 70 mg/dl and the participant presents with any of the following symptoms the Health Pact staff member performing the test notifies the Health Fairs Coordinator, who activates the Emergency Medical System by calling 911 or notifying onsite Emergency Medical Services and reports the hypoglycemic emergency. • • • • • •

Shakiness Dizziness Sweating Hunger Headache Pale skin color

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Sudden moodiness or behavior changes Clumsy or jerky movements Seizure Difficulty paying attention, and/or confusion Tingling sensations around the mouth

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TOTAL CHOLESTEROL SCREENING The USPSTF recommends screening for lipid disorders in (1) men aged 35 and older (A recommendation) and (2) men aged 20 to 35 and women 20 and older if they are at increased risk for coronary heart disease (B recommendation).xix Due to the lifestyle of low SES immigrant Latinos which includes poor dietary intake and low levels of physical activity, all participants are considered to be at increased risk for coronary heart disease and are screened for total cholesterol. The USPSTF has declared total cholesterol as an independent predictor of coronary heart disease risk.xx The National Cholesterol Education Panel, in their ATP III guidelines, state “if non-fasting test is done and total cholesterol is greater than 200 mg/dl, a fasting lipoprotein profile is recommended.”xxi The preferred screening method includes a breakdown between high density lipoproteins (HDL) and low density lipoproteins (LDL). However in the health fairs, total cholesterol screening is used as an affordable screening to indicate risk and refer participants for fasting lipoprotein profiles. Total cholesterol level screenings are performed through a contract with Health Pact, Inc using the ACCU-CHEK InstantPlus® Cholesterol tester. The manufacture’s directions for proper use are followed for all screenings. Participants with a total cholesterol level exceeding 200 mg/dl are referred by the exit counselor to medical services for a fasting lipoprotein profile.xxii

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HEALTH COUNSELING The following section describes the counseling sessions provided to all participants. Sessions are given in a one-to-one or small group setting. Each session is meant to last no longer than ten minutes, including participant participation. The sessions provide targeted health messages that are aimed to promote behavioral change in diet, exercise, and medical services utilization. However, the short-term indicator used to measure the success of these sessions is an increase in health knowledge. In this sense the more immediate goal of the sessions is to augment the knowledge and to foster discussion of health topics among the target population. The health promoters responsible for these sessions are trained in participatory education methods and provided with materials specifically developed for use in LCDP’s health fairs program. The health promoter is responsible for understanding all of the information in this section, however, in each session the health promoter tailors the information presented to best communicate with the participant. Thus all information presented here is not communicated in each session. NUTRITION COUNSELING The USPSTF recommends behavioral dietary counseling for patients with known risk factors for cardiovascular and diet-related chronic disease (B recommendation).xxiii As previously stated, all health fair participants are considered to be at increased risk for coronary heart disease and also diet-related chronic disease—most notably type 2 diabetes—due to socioeconomic status and thus are counseled on components of a healthy diet. All participants receive a five to ten minute nutritional counseling session where they are taught how to distinguish the major food groups, the recommended daily intake of each food group, the main nutritional component of each food group, and the importance of that component to their health. The health promoter relates the theoretical food pyramid to the daily habits of the majority of immigrant Latinos and ends by reviewing the “Nutrition Facts” label that appears on packaged foods. In this session, the health promoter uses real packaged foods with labels and artificial whole foods such as vegetables and meats to visually communicate the topic. The health promoter also has an 18” x 24” poster board that contains all of the topics presented during the session, and each participant receives an 8 1/2” x 11” handout with the same information. Information for this session came from the ADAxxiv, AHAxxv, and USDAxxvi. Objectives 1. Explain the Food Pyramid a. Grains and carbohydrates b. Vegetables and fruits c. Dairy and meats d. Fats, sweets, and oils 2. Determine what is a healthy serving size 3. Discuss what foods and food habits to avoid 4. Teach participants how to read the Nutrition Labels and make healthier food choices

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Materials 18” x 24” poster Handouts of poster material Play and packaged foods Content 1. Explain the Food Pyramid The Food Pyramid shows us how to balance our diets. The base of the pyramid is the largest and is made of grains and carbohydrates. This means that more of our daily diet should come from this category of foods. The second level is broken into vegetables and fruits, which should make up the second largest part of our daily diets. The third level includes dairy and meat products, which means we should consume less of these items in our daily diet. Lastly, the top of the Food Pyramid is made up of fats, sweets, and oils. We should consume a limited amount of these types of foods. Question for participants: Think to yourselves about what foods you have eaten in the last 24 hours. As we discuss the Food Pyramid, ask yourself these questions: What types of food do I eat a lot of? What types of food do I not eat enough of? a. Grains and carbohydrates Question for participants: Which of the food items on this table would fall into the grains and carbohydrates category? What are some other foods in the grain group? Any food made from wheat, rice, oats, cornmeal, barley or another cereal grain is a grain product. Bread, pasta, oatmeal, breakfast cereals, tortillas, and rice are examples of grain products. Question for participants: Why do we need grains and carbohydrates in our diet? How many servings of grains should we eat each day? Carbohydrates give us the energy we need to go throughout our day. The recommended number of servings depends on your age, sex, and type of work you do each day. Adults who do physical labor or exercise regularly may eat more. Generally 6-11 servings per day are recommended. b. Vegetables and fruits Question for participants: Which of the food items on this table would fall into the vegetable and fruit category? What are some other foods in the vegetable and fruit group? Any vegetable counts as a member of the vegetable group. Any fruit or 100% fruit juice counts as part of the fruit group. Vegetables and fruits may be raw or cooked; fresh, frozen, canned, or dried/dehydrated; and may be whole, cut-up, or mashed. Spinach, peas, zucchini, pineapple, grapes, and bananas are examples of vegetable and fruit products. Question for participants: Why do we need vegetables and fruits in our diet? How many servings of vegetables and fruits should we eat each day? Vegetables and fruits provide vital nutrients such as vitamin C and fiber for the health and maintenance of your body. Eating a diet rich in fruits and vegetables may reduce your risk of stroke, cardiovascular diseases, and type-2 diabetes, and may protect against certain cancers, such as mouth, stomach, and colon-rectum cancer. The recommended number of servings

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depends on your age, sex, and type of work you do each day. Adults who do physical labor or exercise regularly may eat more. Generally 3-5 servings of vegetables and 2-4 servings of fruit per day are recommended. c. Dairy and meats Question for participants: Which of the food items on this table would fall into the dairy and meats category? What other foods are in the dairy and meats group? All fluid milk products and many foods made from milk are considered part of this food group. Most milk group choices should be fat-free or low-fat. All foods made from meat, poultry, fish, dry beans or peas, eggs, nuts, and seeds are considered part of this food group. Most meat and poultry choices should be lean or low-fat. Question for participants: Why do we need dairy and meat in our diet? How many servings of dairy and meats should we eat each day? Consuming milk and milk products can help build and maintain bone mass and reduce the risk of osteoporosis in later life. This is especially important for children and adolescents. Foods in the milk group provide nutrients such as calcium, protein, and Vitamin D that are vital for health and maintenance of your body. Meat, poultry, fish, dry beans and peas, eggs, nuts, and seeds supply many nutrients, such as protein, B vitamins, and iron. Proteins help build bones, muscles, cartilage, skin, and blood. B vitamins play a vital role in the function of the nervous system, aid in the formation of red blood cells, and help build tissues. Iron is used to carry oxygen in the blood. Many teenage girls and women in their child-bearing years have iron-deficiency anemia, and they should eat foods high in iron (meats) and vitamin C. The recommended number of servings depends on your age, sex, and type of work you do each day. Adults who do physical labor or exercise regularly may eat more. Generally 2-3 servings of dairy products and 2-3 servings of meats per day are recommended. Question for participants: If you or someone in your family is a vegetarian, what foods should they eat to get the nutrients they need from this food group? Protein sources from the meat and beans group for vegetarians include eggs, beans, nuts, nut butters, peas, and soy products (tofu, tempeh, veggie burgers). d. Fats, sweets, and oils Question for participants: Which of the food items on this table would fall into the fats, sweets, and oils category? What other foods are in the fats, sweets, and oils group? Solid fats are solid at room temperature, like butter and shortening. Solid fats come from many animal foods and some vegetable oils. Some common solid fats are butter, beef, chicken, and pork fat (lard), and shortening. Foods high in solid fats include: • • •

many cheeses cream bacon

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sausage poultry skin cookies, donuts, and other pastries

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Sweets include sugars and syrups that are added to foods or beverages during processing or preparation. This does not include naturally occurring sugars such as those that occur in milk and fruits. Foods that contain most of the added sugars in American diets are: • • • • •

sodas or soft drinks candy cakes cookies ice cream, pudding, and sweetened yogurt

Oils are fats that are liquid at room temperature, like the vegetable oils used in cooking. Oils come from many different plants and from fish, and oils from plant sources (vegetable and nut oils) do not contain any cholesterol. Extra virgin olive oil is the healthiest oil you can buy, followed by virgin olive oil and canola oil. Peanut, corn, and sesame oils are less healthy because they contain more polyunsaturated and saturated fats. Question for participants: Why do we need fats, sweets, and oils in our diet? How many servings of fats, sweets, and oils should we eat each day? Because oils contain essential fatty acids, they should be consumed in limited amounts. To lower risk for heart disease, cut back on foods containing saturated fats, trans fats, high fructose corn syrup, and cholesterol. Generally less than 2-3 servings of fats, sweets, and oils are recommended per day. Fats and oils can be used for flavoring, but should be limited. Sweets should be eaten sparingly, perhaps as a reward to yourself. 2. Determine what is a healthy portion and serving size When you sit down to eat lunch or dinner, how much food you eat is also important. When we talk about a portion, we mean how much food is on your plate. For example, McDonalds serves large portions of hamburgers, french fries, and sodas. When we talk about a serving, we mean an amount of food that is approximately the size of the palm of your hand. Everyone’s serving size will be slightly different, for example, children should eat smaller servings than adult men. Question for participants: How many servings are… Grains: In a sandwich?=2 In 1 cup of rice?=2 In a large tortilla?=4 In general, 1 slice of bread or ½ cup of cooked rice, cooked pasta, or cooked cereal is the equivalent of 1 serving from the grains group. Vegetables: In 1 cup of broccoli?=1 In one large ear of corn?=1 In a small salad?=1/2 One cup of raw or cooked vegetables or 2 cups of raw leafy greens is considered 1 serving from the vegetable group. Fruits: In a large apple?=2 In ½ a cup of raisins or prunes?=1 In a large banana?=1 One cup of fruit or 100% fruit juice, or ½ cup of dried fruit is the equivalent of 1 serving from the fruit group. Dairy: In 3 scoops of ice cream?=1 In 1 8oz glass of milk?=1 In 1 slice of hard cheese?=1/2 One cup of milk or yogurt or 1 ½ ounces of natural cheese is the equivalent of 1 serving from the milk group.

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Meats: In 1 lean hamburger?=2-3 In 1 can of tuna?=3-4 In ½ a cup of cooked beans?=2 In ½ a small chicken breast?=3 One egg, ¼ cup cooked dry beans, or 1 tablespoon of peanut butter is the equivalent of 1 serving from the meat and beans group. Fats, sweets, and oils: In 1 can of soda?=1-2 In 1 glazed donut?=1-2 In 1 medium order of fries?=2-3 3. Discuss what foods and food habits to avoid Question for participants: Who here eats at fast-food restaurants? How often? A lot of us eat at fast-food restaurants because it is inexpensive and convenient. Unfortunately, meals from fast-food chains, as well as other pre-packaged foods (such as Ramen noodles) often contain high levels of fats, sodium, and carbohydrates, and they are lacking in vitamins, minerals and other nutrients our bodies need. 4. Teach participants how to read the Nutrition Labels and make healthier food choices Question for participants: As we have been talking about the different food groups, has anyone noticed something about their diet they could change in order to eat a more balanced diet? A good start to improving your diet is to look at the Nutrition Labels on the packaged food you buy at the grocery store. On the right-hand side of the label you will see percentages based on the recommended 2000 calorie diet. People who do hard physical labor may eat more than 2000 calories per day, but in general, 2000 calories per day is a good recommendation. Look at the fats, cholesterol, sugars, and carbohydrates and notice what percent of your daily diet that product will fill. Try comparing different brands for lowers levels of sodium, fats, or sugars. Question for participants: Who would like to put together a balanced meal using our food items? For breakfast? Lunch? Dinner? (continue discussing nutrition recommendations while participants put together meals) Other recommendations to incorporate healthier foods into your daily diet: • Try substituting a whole-grain product for a refined product – such as eating whole-wheat bread, brown rice, or whole-wheat pasta. • Buy fresh fruit and vegetables in season. They cost less and are likely to be at their peak flavor. • Stock up on frozen vegetables for quick and easy cooking in the microwave. • Try a salad for lunch. Go light on the salad dressing. • Include chopped vegetables in pasta sauce or lasagna. • Keep a bowl of whole fruit on the table, counter, or in the refrigerator. • Buy fruits that are dried, frozen, and canned (in water or juice) as well as fresh, so that you always have a supply on hand. • At breakfast, top your cereal with bananas or peaches. • At lunch, pack a tangerine, apple, or grapes to eat. • At dinner, add crushed pineapple, mandarin oranges, or grapes in a tossed salad. • Drink a glass of fat-free or low-fat milk at meals. La Clínica del Pueblo

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• • • • •

If you usually drink whole milk, switch gradually to fat-free milk, to lower saturated fat and calories. Choose the leanest cuts of meat for beef and pork, and extra lean ground beef. Buy skinless chicken parts, or take off the skin before cooking. Trim away all of the visible fat from meats and poultry before cooking. Broil, grill, roast, poach, or boil meat, poultry, or fish instead of frying, and drain off any fat that appears during cooking.

Appendix I contains the Nutrition handouts given to all health fair participants.

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EXERCISE COUNSELING Regular physical activity has been found to prevent cardiovascular disease, hypertension, Type 2 Diabetes, obesity, and osteoporosis, and the benefits of physical activities are seen at even modest levels of activity—30 minutes per day on most days of the week.xxvii However, the USPSTF has found insufficient evidence to recommend for or against behavioral counseling to promote physical activity (I recommendation). LCDP offers aerobic and yoga classes to patients and these classes have proven to be effective interventions for motivated patients struggling with chronic disease management. The implementation of this educational session is aimed to motivate individuals to enroll in exercise classes at LCDP and/or make small changes in their physical activity level. Information for this session came from the AHA.xxviii Objectives 1. Identify why exercise is important in maintaining or improving overall health 2. Dispel myths or excuses about the need for exercise 3. Provide examples of small ways to introduce exercise into a daily routine, including setting goals and exercising with a friend 4. Connect participants to local fitness classes or opportunities for exercise Materials 18” x 24” Poster Handout of poster material Content 1. Identify why exercise is important in maintaining or improving overall health Question for participants: How often do you exercise a week? What does exercise do for our health? It is recommended that you exercise 30 minutes a day, 5 days a week. Exercising regularly has many benefits, including: • Reducing the risk of heart disease by improving blood circulation throughout the body • Keeping weight under control • Improving blood cholesterol levels • Preventing and managing high blood pressure • Preventing bone loss • Boosting energy level • Helping manage stress • Improving the ability to fall asleep quickly and sleep well • Countering anxiety and depression • Increasing muscle strength and the ability to do other physical activities • In older people, helping delay or prevent chronic illnesses and diseases associated with aging, and maintaining quality of life and independence longer 2. Dispel myths or excuses about the need for exercise Question for participants: If you don’t exercise regularly, why not? (Ask for excuses) a. “I’m tired at the end of the day” La Clínica del Pueblo

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b.

c.

d. e.

= Exercising regularly will increase your energy. “I don’t have time” = Try to schedule 30 minutes of exercise into your day, or even break it up into two 15-minute exercises. Once you become accustomed to the routine, it will become easier. “I do physical labor at work” = A lot of physical labor (such as construction or cleaning) involves repetitive movements that can be damaging to your body. Good exercise can build strength and flexibility to help your body repair itself. “I’m too old to exercise” = Continued exercise helps prevent chronic diseases in older people, and allows you to remain more active in your community. “I don’t like exercising” = There are many ways to exercise, so you can choose something you enjoy doing, such as dancing, soccer, swimming, yoga, cycling, and running.

3. Provide examples of small ways to introduce exercise into a daily routine Question for participants: What types of exercise do you enjoy? What changes could you make in your daily life to be more active? • Go out for a short walk before breakfast, on your lunch break, or after dinner. Start with 5-10 minutes and work up to 30 minutes. • Walk or bike to the store instead of driving. When walking, pick up the pace from leisurely to brisk. • Stand up while talking on the telephone. • Park farther away at the shopping mall and walk the extra distance. • Take the stairs instead of the elevator, or get off a few floors early and take the stairs the rest of the way. • Join a fitness center near your job. Work out before or after work to avoid rush-hour traffic, or drop by for a mid-day workout. • Get off the bus a few blocks early and walk the rest of the way to work or home. • Play your favorite music while exercising, something that motivates you. • Dance with someone or by yourself. • Set goals and reward yourself for accomplishing them • Invite a friend or family member to exercise with you Question for participants: Who do you know that would benefit from or be interested in exercising with you? 4. Connect visitors to local fitness classes or opportunities for exercise Questions for participants: Do you know of any gyms, fitness centers, or community recreation centers near you? Participants are advised of the exercise program run by LCDP. Appendix J contains the Exercise handouts given to all health fair participants.

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HEART HEALTH COUNSELING An educational session that elaborates the effects of obesity, high blood pressure, and high cholesterol on heart health has been developed to ensure that participants understand the significance of the results from the previous screenings. Previously, similar sessions were provided as part of the exit counseling for individuals who had elevated test results. However, due to the high prevalence of chronic disease in the participant population, efforts are now made to educate all participants on the topic of Heart Health as an increasingly preventative measure. Information for this session came from the AHA.xxix Objectives 1. Identify the structure and function of the heart 2. Explain heart disease and the factors that increase risk a. BMI and obesity b. Blood pressure c. Cholesterol 3. Provide examples of how visitors can decrease risks Materials 18” x 24” Poster Handout of poster material Heart model Artery model with Cholesterol Brain model Cholesterol model Content 1. Identify the structure and function of the heart Question for participants: What do you know about the heart? The heart is a muscle the size of a fist that pumps blood filled with nutrients and oxygen through the arteries to the other organs of the body. Blood circulates throughout the body and returns to the heart through the veins to repeat the process. The heart pumps approximately 5 liters (20 cups) of blood per minute. Show visitors how to find their pulse. 2. Explain the factors that increase the risk of heart disease (heart attacks) Question for participants: Does anyone know the leading cause of death in the US? What is heart disease? Heart disease is the leading cause of death of Americans, followed by cancer and stroke. Approximately 94 people in the Latino community die each day of heart diseases (NCLR, 2005). Question for participants: What are some of the risk factors for heart disease? a. BMI and obesity Question for participants: How do we determine obesity? Obesity is too much body fat. To determine if a person is overweight or obese we compare their height and weight using the Body Mass index. Encourage visitors to find their BMI score. Obesity increases your risk of heart disease because the heart has to work harder to circulate

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blood throughout the body, and the extra body fat collects in the blood and begins to block arteries, which can eventually cause a heart attack or stroke. Obesity also increases the risk of various types of cancer and contributes to other health problems such as arthritis or sleep disorders. b. Blood pressure Question for participants: What is blood pressure? Blood pressure is the force of blood against the walls of your arteries. This pressure is what circulates blood throughout the body. Blood pressure is easy to measure, and the reading gives two scores. The first (systolic) is the pressure of blood when the heart beats. The second (diastolic) is the pressure of the blood when the heart rests. A healthy reading is 120/80. If you have between 120-140 or 80-90 you have borderline high blood pressure. If you have a reading above 140 or 90, you may have high blood pressure. This is an indicator of heart trouble, which puts you at risk for heart disease, stroke, kidney problems, and blindness. c. Cholesterol Question for participants: What is cholesterol? Cholesterol is a soft waxy substance that comes from the liver and from the foods you eat. Good cholesterol produced by the liver helps to get rid of fat. Bad cholesterol comes from the food you eat. This cholesterol builds up in your blood vessels, collects in your arteries, and can obstruct blood flow, causing a heart attack. This makes the heart work harder and increases your risk of blood clots and heart attack. Cholesterol levels can be measured with a blood test. 3. Provide examples of how visitors can decrease risks Question for participants: How can you reduce your risk of heart disease? a. Maintain a healthy weight b. Exercise regularly c. Avoid foods high in salt, saturated fats, and cholesterol (cheese, butter, whole milk, ice cream, red meat, egg yolks, chicken with skin, donuts and other pastries), and eat more fruits (2-4 servings) and vegetables (3-5 servings) d. Quit smoking e. Consume less alcohol f. Visit your doctor regularly Appendix K contains the Heart Health handouts given to all health fair participants.

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DIABETES COUNSELING All participants receive a ten minute educational session in which they learn about the different types of diabetes and the risk factors and symptoms associated to diabetes. The session draws off of previously presented information in the nutrition, exercise, and heart health sessions. Participants are encouraged to discuss their current understanding of and experiences with diabetes. Health promoters use this understanding to communicate diabetic preventive and management strategies. Information for this session came from the ADA.xxx Objectives 1. Define diabetes and explain the four types 2. Identify risk factors and symptoms of diabetes 3. Discuss how diabetes and other health issues are related 4. Dispel myths surrounding diabetes 5. Provide examples of lifestyle changes in order to prevent the onset of diabetes or to improve the management of diabetes Materials 18” x 24” Poster Handout of poster material Content 1. Define Diabetes and explain the four types Question for participants: What is diabetes? What do you know about diabetes? What would you like to learn about diabetes? Diabetes is a disease in which the body does not produce or properly use insulin. Insulin is a hormone that is needed to convert sugar, starches and other food into energy needed for daily life. Although the cause of diabetes is unknown, both genetics and environmental factors such as obesity and lack of exercise play a role. When glucose (sugar) builds up in the blood instead of going into cells, it starves your cells for energy. Over time, high blood glucose levels can damage your heart, kidneys, eyes, and nerves. Question for participants: Do you know anyone with diabetes? There are 23.6 million children and adults in the United States, or 7.8% of the population, who have diabetes. While an estimated 17.9 million have been diagnosed with diabetes, unfortunately, 5.7 million people (or nearly one quarter) are unaware that they have the disease. Diabetes is the fifth-deadliest disease in the United States, and it has no cure. There are four variations of diabetes: a. Type 1 develops when the body does not produce insulin. It was previously known as juvenile diabetes, and is usually diagnosed in children and young adults b. Type 2 results from insulin resistance (a condition in which the body fails to properly use insulin), combined with relative insulin deficiency. Type 2 accounts for about 90% to 95% of all diagnosed cases of diabetes. c. Gestational diabetes occurs in women during late pregnancy. It develops in 2% to 5% of all pregnancies but disappears when a pregnancy is over. Women who have had

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gestational diabetes or have given birth to a baby weighing more than 9 pounds are at an increased risk for developing type 2 diabetes later in life. d. When a person's blood glucose levels are higher than normal but not high enough for a diagnosis of type 2 diabetes, they are diagnosed with pre-diabetes. Approximately 57 million Americans have pre-diabetes, in addition to the 23.6 million with diabetes. 2. Identify risk factors and symptoms of diabetes The prevalence of diabetes is at least 2-4 times higher among African American, Hispanic/Latino, American Indian, and Asian/Pacific Islander women than among white women. The risk for diabetes also increases with age. Most people with diabetes have additional health problems or risk factors such as high blood pressure and cholesterol that increase one's risk for heart disease and stroke. More than 65% of people with diabetes die from heart disease or stroke. Question for participants: What are the symptoms of diabetes? When checking for diabetes or pre-diabetes, what symptoms should you look for? General symptoms of diabetes • • • • • • •

Frequent urination Excessive thirst Extreme hunger Unusual weight loss Increased fatigue Irritability Blurry vision

Question for participants: How do we determine if someone has diabetes? There are a number of tests that can determine whether or not a patient has pre-diabetes or diabetes. If you are fasting, a blood glucose level between 100 and 125 mg/dl signals prediabetes, and a level of 126 mg/dl or higher signals diabetes. If you are not fasting, a blood glucose level is between 140 and 199 mg/dl signals pre-diabetes, and a blood glucose level at 200 mg/dl or higher signals diabetes. Question for participants: Why is your blood glucose level important? Does anyone know what may happen if it is too low or too high? When you have low blood glucose (sugar) levels you may experience Hypoglycemia. Hypoglycemia is a condition of diabetes that is potentially very dangerous, and may cause a seizure. The symptoms of hypoglycemia include: • • •

Shakiness Dizziness Sweating

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• • • • • • •

Hunger Headache Difficulty paying attention, or confusion Tingling sensations around the mouth Clumsy or jerky movements Pale skin color Sudden moodiness or behavior changes, such as crying for no apparent reason

When you have high blood glucose (sugar) levels you may experience Hyperglycemia. Hyperglycemia occurs when the body has too little insulin, or when the body can't use insulin properly. This can occur when you eat more or exercise less than planned. The stress of an illness, such as a cold or flu, or family conflicts could also be the cause. Hyperglycemia may cause Ketoacidosis, a diabetic coma, which is life-threatening and needs immediate treatment. Symptoms include: Shortness of breath Breath that smells fruity Nausea and vomiting A very dry mouth 3. Discuss how diabetes and other health issues are related Question for participants: What other health problems are related to diabetes? • • • •

Untreated diabetes can lead to serious complications, including: Heart disease and stroke - Adults with diabetes have heart disease death rates about 2 to 4 times higher than adults without diabetes. • Kidney disease - Diabetes is the leading cause of kidney failure, accounting for 44% of new cases in 2005. • Blindness - Diabetic retinopathy causes 12,000 to 24,000 new cases of blindness each year, making diabetes the leading cause of new cases of blindness in adults 20-74 years of age. • Amputations - More than 60% of non-traumatic lower-limb amputations occur in people with diabetes. a. Diabetes and cholesterol: Diabetes tends to lower "good" HDL cholesterol and raise triglyceride and "bad" LDL cholesterol levels, which increases the risk for heart disease and stroke. •

b. Diabetes and high blood pressure: High blood pressure increases the risk of coronary heart disease (which leads to heart attack) and stroke, especially when it's present with other risk factors, such as diabetes. When a person has high blood pressure and diabetes, his or her risk for cardiovascular disease doubles. c. Diabetes and obesity: Even moderate weight loss helps control blood glucose levels, reduces blood pressure and cholesterol, reduces risk for cardiovascular disease, and can even help prevent diabetes in people with pre-diabetes. La Clínica del Pueblo

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d. Diabetes and smoking: Smoking raises your risk of a heart attack, and may trigger a blood clot to form. A clot may either further narrow the blood vessel or completely block it. This damage can worsen foot ulcers and lead to blood vessel disease and leg and foot infections. If you have diabetes, smoking is even worse because you're: More likely to get nerve damage and kidney disease. Three times more likely than nonsmokers are to die of cardiovascular disease. More likely to raise your blood sugar level, making it harder to control your diabetes. 4. Dispel myths surrounding Diabetes • • •

Myth #1 You can catch diabetes from someone else. No. Although we don’t know exactly why some people develop diabetes, we know diabetes is not contagious. It can’t be caught like a cold or flu. There seems to be some genetic link in diabetes, particularly type 2 diabetes. Lifestyle factors also play a part. Myth #2 People with diabetes can't eat sweets or chocolate. If eaten as part of a healthy meal plan, or combined with exercise, sweets and desserts can be eaten by people with diabetes. They are no more “off limits” to people with diabetes than they are to people without diabetes. Myth #3 Eating too much sugar causes diabetes. No. Diabetes is caused by a combination of genetic and lifestyle factors. However, being overweight does increase your risk for developing type 2 diabetes. If you have a history of diabetes in your family, eating a healthy meal plan and regular exercise are recommended to manage your weight. Myth #4 People with diabetes should eat special diabetic foods. A healthy meal plan for people with diabetes is the same as that for everyone – low in fat (especially saturated and trans fat), moderate in salt and sugar, with meals based on whole grain foods, vegetables and fruit. Diabetic and “dietetic” versions of sugar-containing foods offer no special benefit. They still raise blood glucose levels, are usually more expensive and can also have a laxative effect if they contain sugar alcohols. 5. Provide examples of lifestyle changes in order to prevent or improve Diabetes Question for participants: How can you reduce your risk of developing diabetes? If you are pre-diabetic, or you have diabetes, what can you do to manage your blood glucose levels? People with diabetes have to take extra care to make sure that their food is balanced with insulin and oral medications, and exercise to help manage their blood glucose levels. This might sound like a lot of work, but your doctor can help you create a meal plan that is best for you. a. Nutrition

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Blood sugar control isn't just about your sugar intake, it’s about carbohydrate intake as well. The more carbohydrates you take in, the more your blood glucose goes up. By adjusting your insulin to balance the amount of carbohydrates in your diet, you can maintain the right blood sugar balance in your diet and reduce your risk of complications from diabetes. Question for participants: What foods contain carbohydrates? Carbohydrates are found in many foods including: • • • • • • • •

Breads, cereals and pastas and vegetables Rice and other grains Beans Milk and yogurt Fruit Juice Sugar Honey, syrup and molasses

Foods like meat, fish, eggs, oils, cheese, butter and margarine contain very few carbohydrates, but you should still watch your fat intake with these items. In order to reduce blood pressure and cholesterol, eat a diet low in saturated fats and trans fats. b. Exercise Weight control, regular physical activity, and diet help manage glucose levels in the blood, as well as lower blood pressure and cholesterol. It is recommended that you exercise 30 minutes a day, five times a week. c. General Healthcare When you're sick or under stress, your body releases hormones that help it fight disease. Unfortunately, these hormones raise blood sugar levels and interfere with the effects of insulin. As a result, when you are sick, your blood glucose can rise to dangerous levels and cause a diabetic coma. When sick, you will still need to continue medicine for your diabetes. You need them because your body makes extra glucose when you are sick. Always consult with your doctor before discontinuing medications. Appendix L contains the Diabetes handouts given to all health fair participants.

CANCER COUNSELING All participants receive a five to ten minute counseling session focused on the four treatable forms of cancer when detected in their early stages. The health promoter uses organ models with

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cancerous pathologies to demonstrate cancerous growths. The health promoter also has an 18” x 24” poster board that contains all of the topics presented during the session, and each participant receives an 8 1/2” x 11” handout with the same information. Information for this session came from the ACS.xxxi Objectives 1. Define what is cancer and explain the four detectable and treatable types a. Colorectal b. Prostate c. Breast d. Cervical Within each type of cancer: 2. Identify potential risk factors 3. Discuss symptoms and early detection 4. Provide examples of how participants can decrease their risks of cancer Materials 18” x 24” Poster Handout of poster material Colon model with pathologies Prostate model with pathologies Breast model with pathologies Cervix model with pathologies Content 1. Define what is cancer and explain the four types Questions for participants: Can someone tell us what is cancer? What do you know already about cancer? What questions do you have about cancer? Does anyone have a personal experience with cancer? Cancer is a disease in which cells in part of the body start to reproduce uncontrollably. Although there are many types of cancer, they all begin with the growth of abnormal cells. Cancer that is not treated can lead to serious disease and death. Cancer can be caused by external factors (such as smoking) as well as internal factors (such as genetics), and it can affect anyone.

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COLORECTAL CANCER Health promoter demonstrates where the colon is in the body and the direction in which it works (From lower right quadrant, up to the rib cage, across the stomach area, and back down the left side). Colorectal cancer is the development of abnormal cells in the colon or the rectum. It is the 2nd most commonly diagnosed cancer among Latino men and women. 2. Identify potential risk factors a. Age b. Family history of colorectal cancer or bowel disease c. Obesity d. Diet high in fat and red meat e. Alcohol and tobacco use f. Diabetes 3. Discuss symptoms and early detection Question for participants: If you had colorectal cancer, what would be the signs to look for? a. Stomach pain or cramping b. Changes in bowel movements, such as diarrhea or constipation, or a reduction in the diameter of stool c. A constant feeling of having to defecate d. Rectal bleeding or blood in the stool These changes aren't always caused by cancer. However, if you notice any of these symptoms, it is important that you speak with a doctor right away. Cancer treatment is most effective when the cancer detection and treatment occur early. 4. Provide examples of how participants can decrease their risks of cancer Question for participants: What can you do to prevent colorectal cancer? a. Exercise regularly and maintain a healthy weight b. Consume less alcohol and tobacco c. Eat a balanced diet high in fruits and vegetables d. Seek testing from your doctor, including colonoscopy, sigmoidoscopy, and fecal occult blood tests (FOBT) beginning at age 50 (USPSTF A recommendation and supported by the ACS)

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PROSTATE CANCER Question for participants: What is the prostate and what does it do? What do you know about prostate cancer? The prostate gland is found just below the bladder, in front of the rectum. This gland contains cells that produce part of the liquid that protects and nourishes sperm. Prostate cancer is the development of abnormal cells in the prostate, and is the most commonly diagnosed cancer among Latino men. 2. Identify potential risk factors a. Age b. Family history of prostate cancer c. Obesity d. Diet high in fat and red meat e. Alcohol and tobacco use 3. Discuss symptoms and early detection Question for participants: If you had prostate cancer, what would be the signs to look for? a. Feeling the need to urinate frequently b. Difficulty or pain during urination c. Blood in the urine d. Trouble having or keeping an erection (impotence) e. Constant pain in the lower back, pelvis, or upper thighs These changes aren't always caused by cancer. However, if you notice any of these symptoms, it is important that you speak with a doctor right away. Cancer treatment is most effective when the cancer detection and treatment occur early. 4. Provide examples of how participants can decrease their risks of cancer Question for participants: What can you do to prevent prostate cancer? a. Seek blood and rectal exams from a doctor once a year after the age of 50 (USPSTF D Recommendation; Procedure supported by ACS) b. If you have a family history of prostate cancer, begin yearly screenings after the age of 40 (USPSTF D recommendation; Procedure supported by ACS) c. Eat a balanced diet high in fruits and vegetables d. Consume less alcohol and tobacco

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BREAST CANCER Question for participants: What do you know about breast cancer? Does breast cancer only affect women? Breast cancer is the development of abnormal cells in the ducts, the lobules, or other breast tissues. It is the most commonly diagnosed cancer and the leading cause of cancer death among Latina women, but it is also important to know that it can also affect men. Statistic: Latina women are 20% more likely to die from breast cancer than non-Latina women with the same diagnosis at the same stage of disease. This may be a result of less access or utilization of timely, high-quality treatment. -Cancer Facts & Figures for Hispanics/Latinos 2006-2008, American Cancer Society 2. Identify potential risk factors a. Gender (women are at a higher risk than men) b. Age c. Family history of breast cancer d. Early start of menstruation (before the age of 12) e. Obesity f. Alcohol and tobacco use 3. Discuss symptoms and early detection Question for participants: If you had breast cancer, what would be the signs to look for? a. A noticeable lump or change in the physical appearance of the breast b. Swelling or skin irritation of the breast or nipple c. Pain or discharge from the nipple These changes aren't always caused by cancer. However, if you notice any of these symptoms, it is important that you speak with a doctor right away. Cancer treatment is most effective when the cancer detection and treatment occur early. 4. Provide examples of how participants can decrease their risks of cancer Question for participants: What can you do to prevent breast cancer? a. Exercise regularly and maintain a healthy weight b. Consume less alcohol and tobacco c. Pay attention to the appearance and feeling of your breasts, and report any changes to a doctor (Note: Breast self-examinations are no longer promoted USPSTF I recommendation, BSE not supported by ACS) d. Seek a mammogram test once a year (after age 40) (USPSTF B recommendation and supported by ACS) Participants are advised to call 1-800-ACS-2345 (1-800-227-2345) to speak with someone about cancer. This toll-free number provides cancer information in both English and Spanish from the American Cancer Society.

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CERVICAL CANCER Question for participants: What is the cervix? What do you know about cervical cancer? The cervix is the lower part of the uterus that connects to the vagina. Cervical cancer is the development of abnormal cells in the lining of the cervix, and is the 4th most commonly diagnosed cancer among Latina women. 2. Identify potential risk factors a. Human papilloma virus (HPV) infection This is the most important risk factor for cervical cancer. HPV is a group of 100 types of viruses that may cause genital warts or cancer of the cervix. HPV is passed from one person to another during vaginal, anal, or oral sex. Risk factors for HPV infection: i. Having sex at a young age ii. Having unprotected sex iii. Having sex with many partners iv. Having sex with men who have had many partners v. Having sex with uncircumcised men b. Family history of cervical cancer c. Multiple pregnancies d. Sexually-transmitted infections (STI’s) e. HIV/AIDS f. Alcohol and tobacco use 3. Discuss symptoms and early detection Question for participants: If you had cervical cancer, what would be the signs to look for? a. Abnormal vaginal discharge b. Abnormal vaginal bleeding (not your regular period) c. Bleeding or pain after sex These changes aren't always caused by cancer. However, if you notice any of these symptoms, it is important that you speak with a doctor right away. Cancer treatment is most effective when the cancer detection and treatment occur early. 4. Provide examples of how participants can decrease their risks of cancer Question for participants: What can you do to prevent cervical cancer? a. Use condoms during sex to protect yourself from HPV, HIV, and other STI’s b. All women should begin having Pap smears approximately 3 years after they start having sex (vaginal intercourse), but no later than age 21 (USPSTF A recommendation and supported by ACS).xxxii c. A HPV vaccine has been approved for girls and young women age 9 to 26. This vaccine prevents two types of HPV that cause 70% of all cervical cancers, and two types of HPV that cause 90% of all genital warts. d. Consume less alcohol and tobacco Appendix M contains the Cancer handouts given to all participants

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EXIT COUNSELING Upon the completion of all screening and counseling sessions, the participant receives a one-onone counseling session with a health promoter. The health promoter first reviews the registration sheet to obtain information of the previous health service utilization by the participant. The health promoter then reviews the results of all the screenings with the participant, indicating the significance of the numbers and makes referrals to medical services if the participant has elevated screening results. The health promoter will also ask if the participant has any specific questions concerning the screenings, the counseling sessions, or any other health or social service-related questions. If further information is requested, the health promoter at the exit counseling session has at their disposal several educational handouts concerning health related issues and a list of health clinics in Washington, DC and in the areas of Maryland and Virginia surrounding Washington, DC. If the participant requires a referral, the health promoter reviews the list of providers available in the area where the participant lives and refers the participant to a provider that offers the service required. All handouts are included in Appendices O through U. Appendix O What are Heart Disease and Stroke? Appendix P How Can I Reduce High Blood Pressure? Appendix Q How Can I Lower High Cholesterol? Appendix R All About Pre-Diabetes Appendix S Mental Health Resources Handout Appendix T Community Clinics in Washington, DC Appendix U Community Clinics in Maryland and Virginia

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HEALTH INSURANCE COUNSELING Health fair participants that cannot afford private insurance may be eligible for government subsidized programs that have been designed to help keep individuals in Washington, D.C. healthy and insured. The following information is presented to interested participants. DC HealthCare Alliance The DC HealthCare Alliance (Alliance) program is designed to provide medical assistance to needy District residents who are not eligible for federally-financed Medicaid benefits. This includes non-disabled childless adults, non-qualified aliens and some individuals who are overincome for Medicaid. The Alliance program provides comprehensive health services, including preventative, primary, acute, and chronic care services such as clinic services, emergency care, immunizations, in-patient and out-patient hospital care, physician services, and prescription drugs. Requirements for eligibility include: live in the District of Columbia; not eligible for Medicaid; and have income (before taxes) at or below 200% of the federal poverty level. Required documents for the Alliance application include: proof of DC residence and proof of income. DC HealthCare Alliance applications are available for enrollment at all health fairs for eligible participants. La Clínica del Pueblo is also an Alliance enrollment site. Medicare Medicare is a health insurance program for: • people age 65 or older, • people under age 65 with certain disabilities, and • people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant). Medicare includes: Hospital Insurance - helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. Beneficiaries must meet certain conditions to get these benefits. Medical Insurance - helps cover doctors' services and outpatient care. It also covers some other medical services that Hospital Insurance doesn't cover, such as some of the services of physical and occupational therapists, and some home health care. Prescription Drug Coverage - Everyone with Medicare can get this coverage that may help lower prescription drug costs and help protect against higher costs in the future.

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ADDITIONAL SERVICES

“Despite advances in screening, diagnosis, and treatment, sexually transmitted infections remain an important cause of morbidity and mortality in the United States.” ~United States Department of Health and Human Services

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HIV SCREENING AND COUNSELING The USPSTF strongly recommends screening for human immunodeficiency virus (HIV) in all adolescents and adults at increased risk for HIV infection (A recommendation). A person is considered at increased risk for HIV infection if he or she reports 1 or more of the following risk factors:xxxiii • Men who have sex with men after 1975 • Men and women who have unprotected sex with multiple partners • Past or present drug users • Men and women who exchange sex for money or drugs or have sexual partners who do • Individuals whose past or present partners were HIV infected, bisexual, or injection drug users • Persons being treated for sexually transmitted diseases (STDs) • Persons with a history of blood transfusion between 1978 and 1985 • Persons who request an HIV test despite reporting no individual risk factors (probability of non-disclosure of high risk behaviors) Based on the USPSTF recommendations, all participants that disclose one or more of the individual risk factors or request a HIV test are encouraged to get tested for HIV during the health fair (if HIV testing and counseling is available—services are provided at approximately half of the health fairs by LCDP’s HIV Department) or are directed to a HIV testing facility. MENTAL HEALTH COUNSELING A screening method for depression is currently being developed. The health promoters serving as exit counselor will be responsible for identifying participants that may be experiencing depression, mitigate the stigma associated to depression, advise them on the availability of mental health services, and refer them to the appropriate services (USPSTF B recommendation). GLAUCOMA SCREENING Glaucoma screening is provided at several health fairs per year by the Friends of the Congressional Glaucoma Caucus. The USPSTF found insufficient evidence to recommend for or against screening adults for glaucoma (I recommendation). However, the Latino population’s high incidence of type 2 diabetes—a risk factor for glaucoma—and the low invasiveness of the screening coupled with infrequent utilization of ophthalmological services places Latinos at higher risk of glaucoma and warrants the screening. OTHER HEALTH SERVICES Additional health services many be provided during health fairs by partnering organizations depending on their availability. These services include but are not limited to vaccinations, family planning and contraceptive counseling, STI screening and counseling, additional mental health

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counseling, and substance abuse counseling. The services provided must be deemed beneficial to the health fair participant population. NONHEALTH RELATED SERVICES As health fairs draw large numbers of underserved Latinos, services including but not limited to financial, legal, and social services may also be offered by partnering organizations at the health fairs. Participants are encouraged to participate in health related services before participating in other services; however, participants are never required to participate in services in which they are not interested. CHILDREN’S CENTER In order to improve the health fair experience for parents, a children’s center is constructed at every health fair where parents can leave their children under the supervision of LDCP health promoters or volunteers as they go through all screening and counseling sessions. The children’s center is centrally located so that parents can keep an eye on their children without having the parents juggling children during the screenings. The creation of the children’s center has lead to an improvement in service quality for parents and the welcoming nature of the health fair. The children are provided a variety of materials to color and play. Recent emphasis has been placed on providing nutritional information to the children in the form of coloring books that teach healthy eating habits. Drawings of foods that can be colored, cut out, and pasted on paper plates are also provided and the health promoters and volunteers are encouraged to talk with the children about a healthy and balanced diet as they play. The intent is that the children and their parents upon leaving the health fair with the child’s creations will be prompted to talk about what they learned, and thus reinforce the lessons.

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POST HEALTH FAIR SERVICES “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” ~Martin Luther King, Jr.

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PATIENT NAVIGATION SYSTEM On the first business day following the health fair all of the information from the registration sheets is entered into a database. Based on this information, individual participant reports are generated for each participant that was referred to medical services. With these reports, containing all demographic and screening information, a health promoter calls all referred participants to ascertain if they were able to make an appointment with a provider approximately three to five day after the health fair. The purpose of these calls is first to provide additional information and support to ensure that participants are able to make a medical appointment, and secondly to monitor the health utilization behavioral change due to the health fairs. Possible call scenarios • If the participant reports that they have made an appointment, the health promoter congratulates them, wishes them well, and the process stops. • If the participant expresses interest in making a medical appointment but was not able to, the health promoter will give the participant additional information, and will continue to call the individual until they have been able to make an appointment. • If the participant expresses that they are not interested in making a medical appointment regardless of the advice from the health promoter, the health promoter will record the reason given for not making an appointment and the process ends with that call. • If the participant is unable to be contacted on the first call, the health promoter will wait two to five days and return the call. • If the participant is unable to be contacted in two sequential calls, the process stops. All information attained from the follow-up calls is also entered into the database system. This information includes whether or not the telephone number was a functioning number, if the participant answered the phone, if the participant decided to make a medical appointment or not, where the appointment was made, and for what services the appointment was made. Information about other actions taken and remarks made to the health promoter are also captured.

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EVALUATION Focus The primary method of evaluating the health fairs program is through assessing the percent of health fair participants that have changed their medical service consumption patterns – increased number of medical visits. This is monitored through the participant follow-up calls. Secondary means of evaluation to monitor the increase of knowledge and behavioral change include verbal interviews with participants as they are exiting the health fair, feedback given to the health promoter making the follow-up calls and from the health promoters themselves at the end of each fair when LCDP staff, health promoters, and volunteers meet to discuss the positive and negative aspects of the fair. Data Collection Data is collected primarily from participant registration sheets and follow-up calls. This information is used to determine the demographic characteristics of health fair participants and to establish their pre- and post-health fair utilization of medical services. Subjective data obtained from participants through interviews and surveys is also collected to complement the objective data. All data is held confidentially by LCDP staff in a database program indefinitely and on paper for one full year for verification processes. Analysis and Interpretation Database software is used to analysis the objective data and generates reports as seen in Appendix A. Subjective data sets are combined monthly to supplement the objective data. A significant amount of the data recorded is self-reported by the participants. All data that is self-reported is indicated as such in all reports. Reporting Monthly, quarterly and annual reporting monitors inputs, outputs and outcomes of the program. The health fair statistics that are presented in Appendix A represent the full range of information that is reported annually. Monthly, internal output and outcome reports are produced to ensure the proper implementation of the program. Quarterly, external reports are produced for funding agencies that reflect input, output and outcome levels. Logic Model A logic model has been developed to describe all inputs, outputs, and outcomes of the program. The model allows LCDP staff to ensure that the program inputs result in the planned outputs and that the evaluation is focused on the realization of outcomes while ensuring the proper use of inputs.

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RECOMMENDATIONS In the foreword, this manual was presented as a living document; one that will continually adapt to meet the changing needs of the Latino community and new health care developments. In completing the introspective process of documenting the health fairs program, several potential changes have also been discovered. They include: Improved Educational Materials 1) Creating a Health Promoter Training Manual based on the educational content of the health fairs and other LCDP educational programs, with greater emphasis on participatory education methods. 2) Developing additional health insurance informational materials and increase the involvement of health insurance providers in the health fairs. Improved Referral Process 3) Updating and reorganizing the community clinic lists in Washington, DC, Maryland, and Virginia. (This task, as of 12/10/08, is being undertaken by a group of George Washington University graduate students who are participating in a community service program, ISCOPES.) 4) Providing direct referrals to clinics in the immediate area of the health fair, by means of an intake worker present during the health fair. 5) Varying the follow-up calls between day and evening times to increase the contact success rate. Improved Monitoring and Evaluation Systems 6) Adding an outcome-oriented evaluation to the existing process-oriented evaluation, where the desired long-term outcomes are monitored through the use of pre- and post-health fair knowledge and behavior surveys and longitudinal studies of health fair participants to track health behavior and health care utilization trends. 7) Obtaining additional funding, through improved documentation, monitoring, and evaluation of all health fair activities, to expand the program to new locations and reach additional individuals in need of health care services. Through all of the improvements to the health fairs program, it is essential to not forget the initial concept of the health fairs. As Dr. Juan Romagoza stated “health care is a basic human right.” In this light, the barriers that prevent health care access are seen as violating that right. As such, all changes are made in attempt to improve the program’s ability to circumnavigate and when possible eliminate barriers to health care access and increase the quality of life for the Latino community in the Washington, DC metropolitan area.

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APPENDICES

“Health Promoters build individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support, and advocacy.” ~District of Columbia Primary Care Association

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Appendix A

2008 Health Fair Statistics

Reported by: Michael Dalious Health Fairs Coordinator La Clínica del Pueblo

March -- November 2008

Number of Events* Complete events Partial events 20 4 * Complete events include all core services and the completion of registration forms Number of Participants Complete events 1402

Partial Events ~650

Total >2000

Following Statistics based on Complete events State Distribution of Events DC MD VA Total 14 5 1 20 70% 25% 5%

Note: Information is self-reported Total numbers vary due to the late introduction of some questions and incomplete participant responses

Residence of Participants DC MD VA 664 538 181 48% 39% 13%

Other 5 0%

Total 1388

DC Residences by Zip Code 20001 20002 20005 41 12 11 6% 2% 2%

20007 6 1%

20008 28 4%

20009 145 22%

20012 24 4%

20016 16 2%

20017 7 1%

20018 16 2%

Other 40 6%

Total 664

Age Distribution <18 18-25 50 196 4% 14%

26-35 362 26%

36-45 308 22%

46-55 256 18%

56-65 147 11%

Sex Distribution Male Female

Total

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20010 159 24%

20011 159 24%

>65

Total 1396

77 6%

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806 58%

594 42%

Ethnic Groups African Latino American 1029 24 94% 2% Country of Origin El Salvador Guatemala 526 227 38% 16%

Ecuador 26 2%

Columbia 20 1%

1400

Caucasian (White) 29 3%

Asian 13 1%

Other 2 0%

Total 1098

Mexico 129 9%

Peru 102 7%

Honduras 100 7%

USA 85 6%

Dominican Republic 16 1%

Other 6 0%

Total 1385

Bolivia 42 3%

Nicaragu a 30 2%

Education level (at least one year in category) Primary 427 34%

Secondary 641 51%

University 181 14%

Total 1249

5 to 10 312 25%

> 10 392 31%

Average number of years in school 9 years

Years in the United States <1 120 9%

1 to 5 447 35%

Total 1271

Average number of years in the US 9.6

Language Ability (Note: Small Sample Size due to late introduction of the question) Speaks Speaks Spanish Total English Total 192 201 88 201 96% 44% Health Insurance Yes No 444 938 32% 68%

Total 1382

Have visited a clinic in the past year Yes No Total 635 760 1395 46% 54%

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Have attended previous LCDP Health Fairs Yes No Total 120 837 957 13% 87%

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Currently suffering from an illness Yes No Total 323 778 1102 29% 71% Illnesses currently suffered High Cholesterol 67 21%

High Blood Pressure 56 17%

Diabetes 55 17%

Pain 25 8%

No

Total 331

Asthma 20 6%

Gastritis 18 6%

Athritis 16 5%

Total 323

Smokers Yes 84 25%

Want to Quit * 67 80%

246 74%

* Percentage is of smokers who want to quit smoking

Cancer Screenings (performed prior to health fair / self-reported) Colon Cancer Screenings (Colonoscopy or Sigmoidoscopy and/or FOBT) Participants in screening age range (50-70 yrs) Yes No Total 47 213 260 18% 82% Breast Cancer Screenings (Mammogram) Women in screening age range (≥ 40 yrs) Yes No Total 178 107 285 62% 38%

Cervical Cancer Screenings (Pap Smear) Women in screening age range (14 -- 70 yrs) Yes No Total 245 182 427 57% 43%

Prostate Cancer (DRE and/or PSA) Men in screening age range (50 -- 70 yrs) Yes No Total 53 83 136 39% 61%

Screenings (Preformed during health fair / reported by health fair staff) Body Mass Index (Kg/M²) Normal ≤ 24

Overweight 25 -- 29

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Obese 30 -- 39

Extremely Obese ≥ 40

Total

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401 30%

595 45%

Blood Pressure (mmHg) High Systolic ≥ 140 Total 322 1372 23%

307 23%

22 2%

High Diastolic ≥ 90 145 11%

Plasma Glucose Level (mg/dl / Non-fasting) High Glucose ≥ 140 Total 114 1326 9%

1326

Total 1372

Total Cholesterol Level (mg/dl) High Cholesterol ≥ 200 Total 237 1276 19%

Follow-up with Participants Advised to seek health care based on screenings and/or lack of cancer screenings Yes No Total 591 811 1402 42% 58%

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Able to be contacted after health fair Yes No Total 304 287 591 51% 49% Participants not able to be contacted because telephone number did not work Total 65 591 11% Participants not able to be contacted because there was no answer Total 222 591 38% Contacted participants that self-reported making a medical appointment Yes No * Total 155 149 304 51% 49% * The two main reasons given for not making medical appointments were participant concern about costs and lack of time to go to an appointment. Extrapolation of appointments made * Yes No Total 301 290 591 * Based on the appointment rates of participants contacted

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Appendix B

LA CLÍNICA DEL PUEBLO Health Fairs 2008 Date March 25, 2008 March 29, 2008 April 6, 2008 May 10, 2008 May 18, 2008 May 31, 2008 June 7, 2008 June 29, 2008 July 26, 2008 July 31, 2008 August 2, 2008 August 7, 2008 August 10, 2008 August 30, 2008 September 4, 2008 September 21, 2008 October 4, 2008 October 5, 2008 October 11, 2008 October 19, 2008 November 2, 2008 November 15, 2008

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Place Neighbors Consejo 3118 16th St. NW Washington, DC 20009 Foundry United Methodist Church 1500 16th Street NW Iglesia Adventista del 7 día de la Capital 4800 16th St. NW Washington, DC 20011 Iglesia Zion 1007 Merrimac Dr. Langley Park, MD Nuestra Señora Reina de las América 2200 California St. NW Sacred Heart School 1625 Park Road NW All Souls Church 1500 Harvard St NW National HIV Testing Day - La Union 1401 University Blvd E. Hyattsville, MD Sargent Shriver's Elem. School 12518 Greenly Drive, Silver Spring, MD Immunization Drive Reeves Center 2000 14th NW Youth Health Fair (LAYC) 1419 Columbia Rd, NW Immunization Drive Reeves Center 2000 14th NW OLA Verano Latino 2008 3149 16th St NW Langley Park Community Center 1500 Merrimac Drive, Langley Park, MD Immunization Drive Reeves Center 2000 14th NW 7th Day Adventist Church of Central Washington DC 4917 Georgia Ave NW The Holy Family 1007 Merrimac Dr. Langley Park, MD Binational Health Week 3149 16th St NW Binational Health Week 3415 Markham St, Annandale, VA Oyster Bilingual School 2801 Calvert St. NW Family Fair (DC Armory) 2001 E Capital St, SE All Souls - Diabetes Health Fair 1500 Harvard St NW

Time 10am-2pm

Organizer LCDP

11am-3pm

Fathers

1pm-5pm

LCDP

10am-1pm

LCDP

10am-2pm

LCDP

11am-2pm

OLA / WASA

10pm-3pm

Fathers

12pm-4pm 10am-3pm

LCDP CASA LCDP

4pm-7pm

OLA

12pm-4pm

Fathers

4pm-7pm

OLA

10am-4pm

OLA

10am-3pm

LCDP

4pm-7pm

OLA

10am-3pm

LCDP

10am-2pm

LCDP

10am-3pm

OLA

12pm-5pm

OLA

9:30am12:30pm 11am-6pm

LCDP Telemundo

10am- 3pm

LCDP

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Appendix C Health Fairs Program Schedule

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Appendix D AGREEMENT FOR HEALTH PROMOTERS This Agreement for providing outreach services and health education is made this ___________ day of __________, 200__ by and between La Clinica del Pueblo, Inc., a District of Columbia corporation (“LCDP”) and ___________________________________________ (the “Contractor”). 1. Recitals a. LCDP, in connection with its operations as a health care provider, requires Health Promoters (promotores de salud) to facilitate the delivery of services to LCDP’s patients and clients. b. Contractor is an experienced health promoter (promotor de salud) and is willing to provide outreach services and health education to community members as an independent contractor to LCDP subject to the terms and conditions of this Agreement. Wherefore, in consideration of the mutual promises and terms set forth in this Agreement, LCDP and Contractor agree as follows: 2. Term of Agreement. Contractor agrees to serve as an independent, non-exclusive provider of outreach services and health education to LCDP for the period _______, 20___ to December 31, 20___. 3. Status as Independent Contractor. As an independent contractor to LCDP, Contractor’s compensation under this Agreement will be paid without deduction for, or withholding, of federal, social security, state or local taxes. Contractor shall be responsible for all taxes and other legally required payments to governmental authorities arising out of Contractor’s engagement by LCDP. Contractor shall not be eligible to participate in, or receive benefits from, any employee benefit plan applicable to employees of LCDP. 4. Termination. Either party may terminate this Agreement effective upon written notice to the other, or the contract will terminate at the end of its term. 5. Services to be Performed. Contractor agrees to conduct outreach activities and provide culturally appropriate health education services to community members based on La Clinica’s Community Health Outreach Department’s curricula. Contractor agrees to fulfill his or her responsibilities as pursuant to this Agreement in accordance with the following conditions and requirements: a. Contractor should attend all training deemed necessary for their participation in the health fair events, and/ or charlas (interactive health talks) program b. Contractor shall prominently display an ID card and shall dress appropriately

c. Contractor staffing health fairs should perform the tasks assigned by Health Fairs Coordinator. d. Contractors staffing health fairs should arrive half an hour earlier to the event to set up and should stay until the end of the event in order to help clean up e. Contractors conducting charlas in the community should arrive 45 minutes earlier to the place where the charla will take place. f. Contractors shall participate in meetings pertaining to each of the projects that they are providing services for: health fairs, and/or charlas. 6. Compensation. LCDP will compensate contractors as follows: a. A $ 50.00 stipend per event for staffing a health fair, when the contractor has been contacted by the Health Fair Coordinator. If a contractor comes to a health fair without having been contacted by the Health Fair Coordinator, s/he will not be compensated for services provided at such particular event. b. Contractor providing charlas in the community for projects related to the National Council of La Raza will be paid $ 30.00 per charla. c. To be compensated contractor must invoice La Clínica by the 25th of each month for services provided since the 25th of the previous month. 7. Confidentiality/HIPAA. Contractor understands that in the course of his or her work, Contractor may learn the identity and other information concerning clients and/or personnel of LCDP. Contractor agrees that all such information is to be treated as confidential. Contractor understands that LCDP is a “Covered Entity” as defined by and in accordance with the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), and that Contractor is acting as LCDP’s “Business Associate” for purposes of compliance with HIPAA. Contractor agrees to provide Services in compliance with the Business Associate Contract Addendum attached hereto as Exhibit A. The provisions of this Paragraph survive termination of this Agreement. 8. Prohibition on Assignment. This Agreement shall not be assigned by either party without the express written consent of the other party. Contractor Name:

SSN:

Address: Phone:

Fax:

Cellular:

E-mail: .

Contractor

By: La Clínica del Pueblo, Inc

(Title)

Appendix E

Appendix F

Appendix G

Appendix H

Appendix I

Appendix J

Appendix K

Appendix L

AppendixM

Appendix N

Appendix O

Appendix P

Appendix Q

Appendix R

Appendix S

Si quiere más información de salud mental habla con su médico o llama a: • La Clínica del Pueblo (línea de Salud Mental) – 202-448-2838 • Mary’s Center – 202-483-8196 • Departamento de Salud Mental en DC – 202-673-2058 • Women’s Center / Centro de la Mujer – 202-293-4580 ¿Está en crisis de salud mental? Llame a la línea telefónica de ayuda de Washington DC disponible las 24 horas: 1 (888) 793-4357 Llame a la línea telefónica de CrisisLink disponible 24 horas: 1 (888) 628-9454 Si es víctima de un asalto sexual o violación, llame a la línea telefónica de DC Rape Crisis disponible 24 horas: (202) 333-PARE (7272)

If you need more information about mental health talk with your doctor or call: • La Clínica del Pueblo (Mental Health line) – 202-448-2838 • Mary’s Center – 202-483-8196 • DC Department of Mental Health – 202-673-2058 • Women’s Center – 202-293-4580 Are you experiencing a mental health crisis? Call the Washington DC Helpline available 24 hours a day: Call CrisisLink available 24 hours a day:

1 (888) 793-4357

1 (888) 628-9454

If you are a victim of sexual assault or rape, call the DC Rape Crisis Hotline available 24 hours a day: (202) 333-7272 Appendix T

Clínicas Comunitarias de Washington DC Centro Católico 1618 Monroe St NW Washington, DC 20010 Teléfono: 202-939-2400 Atienden pacientes nuevos De MD,DC y VA.

Columbia Road Health Services 1660 Columbia Rd Washington, DC 20009 Teléfono: 202-328-3717 Atienden a residentes de DC.

Community of Hope 2250 Champlain St. NW Washington, DC 20009 Teléfono: 202-232-9022

Mary’s Center

Upper Cardozo Clinic 3020 14th St NW Washington, DC 20010 Teléfono: 202-745-4300 Atienden a residentes de DC.

Whitman-Walker Clinic Elizabeth Taylor Medical Center 1701 14th St NW Washington, DC 20010 Teléfono: 202-939-7690

Zaccheus Free Medical Clinic 1525 7th St Nw Washington, DC 20001 Teléfono: 202-265-2400 Atienden nuevos pacientes

2333 Ontario Rd NW Washington, DC 20024 Teléfono: 202-483-8196 Atienden pacientes de MD VA y DC.

La Clinica del Pueblo 2831 15th Street, NW Washington, DC 20009 Telefono: 202-448-2854 Atienden pacientes de MD VA y DC.

ANACOSTIA (Ward 6) 1328 W Street, SE Washington, DC 20020

Teléfono: 202/610-7160 WIC: 202/610-5491 Fax: 202/610-7164

Abierto: Lunes, Miercoles, Viernes 8:15am-8:00pm Martes, Jueves 8:15am-4:45pm

Health Center Manager: Janet Jackson Atienden pacientes nuevos MD, DC y VA. SOUTHWEST (Ward 2)** 850 Delaware Ave., SW Washington, DC 20024 Teléfono: 202/548-4520 Fax: 202/548-4538 Abierto: Lunes-Viernes, 8:15 AM - 4:45 PM Health Center Manager: Gretchen Wooten Atienden pacientes nuevos MD, VA, DC. WALKER-JONES (Ward 2) CLINCIA Y SERVICIO DE FARMACIA 1100 First Street, NW Washington, DC 20001 Teléfono: 202/354-1120 Fax: 202/354-1150 Abierto: Lunes- Viernes, 8:15 AM - 4:45 PM Health Center Manager: Libbie Buchele Atienden pacientes nuevos MD, DC y VA. PHOENIX CENTER (Ward 3) DC General Hospital 1900 Massachusetts Ave. SE Suite 1242 Washington, DC 20003 Teléfono: 202/548-6500 Fax: 202/548-6534 Abierto: Lunes-Viernes, 8:15 AM - 4:45 PM Health Care Manager: Melinda O’Brien Atienden pacientes nuevos MD, DC y VA. CONGRESS HEIGHTS (Ward 8) 3720 Martin Luther King Jr. Avenue

Washington DC 20032 Teléfono: 202/279-1800 Fax: 202/279-1834 Abierto: Lunes-Viernes, 8:15 AM - 4:45 PM Health Center Manager: Mary Beth Levin Atienden pacientes nuevos MD, DC y VA. HUNT PLACE (Ward 7)** 4130 Hunt Place, NE Washington, DC 20019 Teléfono: 202/388-8160 Fax: 202/388-8746 Abierto: Lunes-Viernes, 8:15 AM - 4:45 PM Health Center Manager: Darrin Bowden Atienden pacientes nuevos MD, DC y VA. WOODBRIDGE (Ward 5) 2146 24th Place, NE Washington, DC 20018 Teléfono: 202/281-1160 Fax: 202/281-1191 Abierto: Lunes-Viernes, 8:15 AM - 4:45 PM Health Center Manager: Priscilla Porter

Atienden pacientes nuevos MD, DC y VA.

SERVICIO DE FARMACIA Upper Cardozo Clinic 3020 14th St. NW Washington, DC 20010 Teléfono: 202/745-4300 Abierto: Lunes, Martes, Jueves, Viernes 8:30 AM – 12:30 PM, 1:30 PM – 5:00 PM; Miercoles 11:00 AM – 3:30 PM, 4:30 PM- 7:00 PM Atienden pacientes nuevos MD, DC y VA.

Appendix U Gaithersburg Community Clinic, Inc. 17 E. North Summit Ave Gaithersburg, MD 20877 301-216-0880 www.cciweb.org Se habla Español Lunes-Viernes 8:30am-4:30pm Sábado de 8:30- 12:00 p.m. Germantown Mercy Health Center 12900 Middlebrook Road Germantown, MD 20874 240/773/0300 Se habla Español www.mercyhealthclinic.org Hyattsville Community Clinic, Inc. 7676 New Hampshire Ave. Hyattsville, MD 20783 301-431-2972 www.cciweb.org Se Habla Español Lunes-Viernes 8:30am-3:00pm Sabados solo para niños 8:30-11:00 Wheaton Proyecto Salud 2424 Reedie Dr. Wheaton, MD 20902 301-962-6173 Se habla español www.montgomerycountymd.gov Lunes-Jueves 8:30am-8:30pm Viernes 8:30-4:30 * Se atienden pacientes solo de Montgomery Clínica de Jóvenes (12-24 años) 7005 Carroll Ave. Takoma Park, MD 20912 301-565-0914 www.connectwithteens.com

Clínicas Comunitarias de Maryland Se habla Español Lunes-Viernes 11:00-6:00p:m Silver Spring Community Clinic, Inc. 8210 Colonial Lane Silver Spring, MD 20910 301-585-1250 www.cciweb.org Se habla Español Lunes, miércoles y Jueves 8:30 am-4:30 pm Holy Cross Hospital Health Center 7987 Georgia Ave Silver Spring, MD 20910 301-562-5600 www.holycrosshealth.org Lunes-Viernes 9:00am-5:00pm Centro Católico 1015 University Blvd. E Silver Spring, Md 20903 301-434-3999 www.centrocatolicohispano.org Se habla Español Lunes-Jueves 8:30-5:00p:m Viernes 8:30-12:00m. People’s Community Wellness Center 3300 Briggs Chaney Rd Silver Spring, MD 20904 301-847-1172 www.pcw.onehealthylife.org Montgomery Volunteer Dental Clinic New Hampshire Ave. #115 Silver Spring, MD 20904 301-384-9795 Lunes-Viernes 9:00am-5:00pm (cerrado 12:00-1:00) Mobile Medical Care, Inc. Clínica Móvil Llame para lugares y horarios

301-493-2400 www.mobilemedicalcare.org Clínicas de Salud, Hospitales y Agencias de Servicios Sociales en Virginia Alexandria Neighborhood Health Services Pediatric Center/Centro de Niños 3804 Executive Ave, D-1 Alexandria, VA 22305 (703) 535-5419 Medicina Adulta y Salud de las Mujeres 2 E. Glebe Rd Alexandria, VA 22305 (703) 535-5568 3er Jueves de cada mes cerrado 7:30am-11:00am Lunes, Miércoles, Viernes 7:30am-5:00pm Martes y Jueves 7:30am-7:00pm Atienden a los pacientes de MD, DC, y VA. Salud de la Familia y Salud Mental 3802 Executive Ave, D-1 Alexandria, VA 22305 www.anhsi.org Lunes, Miercoles 8:30am-5:30pm Martes 8:30am-7:30pm/Jueves 1:30pm-7:30pm Flora K. Casey Health Center 1200 N. Howard Street Alexandria, VA 22204 (703) 519-5979 Lunes 7:30am-4:30pm Mount Vernon 8350 Richmond Highway, Suite 233 Alexandria, VA 22306 (703) 704-5203 Lunes/Miércoles 8:00am-3:30pm Martes 10:00am-6:00pm Viernes 7:30am-12:00pm Arlington Dept of Human Services 1800 N Edison St. Arlington, VA 22207 (para salud mental): 1725 N George Mason Dr. Arlington, VA 22205

Arlington Department of Human Services (Servicios para la Familia) 3033 Wilson Boulevard Suite 200B Arlington, VA 22201 (703) 228-4992 Lunes-Viernes 8:00am-5:00pm Atienden solo a residentes de Arlington, excepto las enfermedades de transmisión sexual (aceptan pacientes de DC y MD). Arlington Free Clinic 2926 Columbia Pike Arlington, VA 22204 (703) 979-1400 Lunes-Viernes 10am-4pm Joseph Willard Health Center 3750 Old Lee Highway Fairfax, VA 22030 (703) 246-7100 Lunes/Miercoles 8:00am-3:00pm Jueves 10:00am-6:00pm, Viern. 7:30am-12:00pm Vacunas solamente Fairfax County Health Center 6245 Leesburg Pike, Suite 500 Falls Church, VA 22044 703-534-8343 www.fairfaxcounty.gov Fairfax City Health Department 6245 Leesburg Pike Suite 500 Falls Church, VA 22044 (703) 534-8343 Lunes/Miercoles 8:00am-3:30pm Jueves 8:00am-6:00pm, Viernes 7:30am-12:00pm Herndon-Reston Health Center 1850 Cameron Glenn Drive, Suite 100 Reston, VA 22090 (703) 481-4242 Lunes/Miercoles 8:00am-3:15pm Martes 10:00am-5:45pm, Viernes 7:30am-11:45pm

Personal Bilingüe, Servicios de Vacunos, Maternidad, Dental, Familiar, y más. Springfield Health Department 8136 Old Kene Mill Rd., Suite A100 Springfield, VA 22152 703-569-1031 www.fairfaxcounty.gov Lunes/Miercoles 8:00am-3:30pm Martes 10:00am-6:00pm, Viernes 7:30am12:00pm

Personal Bilingüe Solo atienden a residentes de Fairfax. NVCC Medical Center 6699 Springfield Center Dr. Springfield, VA 22150 (703) 822-6698 Lunes-Viernes 8:30am-5:00pm

i

Dalious, Michael 2008 Barriers to Latino Health Care Access: An anthropological literature review. Transcript available from the Community Health Outreach Department of La Clínica del Pueblo. ii McClure, Heather and Kristin Jerger 2005 The State of Latino Health in the District of Columbia. Published by the Council of Latino Agencies, Washington, D.C. iii Dalious, Michael 2008 Barriers to Latino Health Care Access: An anthropological literature review. Transcript available from the Community Health Outreach Department of La Clínica del Pueblo. iv Ibid. v Mayor’s Office of Latino Affairs. Document available at: www.ola.dc.gov Viewed 12/12/08. vi U.S. Department of Health & Human Services. Agency for Healthcare Research and Quality. The U.S. Preventive Services Task Force. Available at http://www.ahrq.gov/clinic/USpstfix.htm#Recommendations. Viewed 9/26/08. vii Washington DC Hispanic Population. Mayor’s Office of Latino Affairs. Document available at: www.ola.dc.gov Viewed 12/12/08. viii The U.S. Preventive Services Task Force (USPSTF) assigns one of five letter grades to each of its recommendations (A, B, C, D, or I). The USPSTF changed its grade definitions based on a change in methods in May 2007. GradeDefinitionSuggestions for PracticeAThe USPSTF recommends the service. There is high certainty that the net benefit is substantial.Offer or provide this service.BThe USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.Offer or provide this service.CThe USPSTF recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is at least moderate certainty that the net benefit is small.Offer or provide this service only if other considerations support the offering or providing the service in an individual patient.DThe USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.Discourage the use of this service.I Statement The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms. U.S. Department of Health & Human Services. Agency for Healthcare Research and Quality. The U.S. Preventive Services Task Force. Available at http://www.ahrq.gov/clinic/USpstfix.htm#Recommendations. Viewed 9/26/08. ix BMI table used at health fairs is a slightly modified table available from the National Institute of Health. Available at www.nhlbi.nih.gov/guideleines/obesity/bmi_tbl.htm. Viewed 9/26/08. x High-intensity counseling is defined by the USPSTF as person-to-person meetings more than once a month for at least the first 3 months. xi The USPSTF supports surgical interventions in cases of class III obesity. xii U.S. Department of Health & Human Services. Agency for Healthcare Research and Quality. The U.S. Preventive Services Task Force. Available at http://www.ahrq.gov/clinic/USpstfix.htm#Recommendations. Viewed 9/26/08. xiii Ibid. xiv Ibid. xv The USPSTF defines Hypertension as a blood pressure exceeding 140 mm Hg systolic and/or 90 mm Hg diastolic on at least 2 visits over a period of 1 to several weeks. xvi The USPSTF and AHA have identified these four nonpharmacological treatments for the reduction of high blood pressure. xvii U.S. Department of Health & Human Services. Agency for Healthcare Research and Quality. The U.S. Preventive Services Task Force. Available at http://www.ahrq.gov/clinic/USpstfix.htm#Recommendations. Viewed 9/26/08. xviii The USPSTF defines type 2 diabetes as a non-fasting plasma glucose level exceeding 140 mg/dl or a fasting plasma glucose level of 126 mg/dl. xix U.S. Department of Health & Human Services. Agency for Healthcare Research and Quality. The U.S. Preventive Services Task Force. Available at http://www.ahrq.gov/clinic/USpstfix.htm#Recommendations. Viewed 9/26/08. xx U.S. Department of Health & Human Services. Agency for Healthcare Research and Quality. The U.S. Preventive Services Task Force. Available at http://www.ahrq.gov/clinic/uspstf/uspschol.htm Viewed 9/26/08. xxi NCEP/ATP III guidelines (JAMA 2001 May 16;285(19):2486), editorial can be found in JAMA 2001 May 16;285(19):2508, commentary can be found in JAMA 2001 Nov 21;286(19):2400. xxii The American Heart Association deems individuals that have a total cholesterol level over 200 mg/dl at higher risk for heart attacks and strokes. Information attained from “Do you know what your cholesterol level means?” Available at http://www.americanheart.org/downloadable/heart/119618151049911%20CholLevels%209_07.pdf Viewed 9/26/08.

xxiii

U.S. Department of Health & Human Services. Agency for Healthcare Research and Quality. The U.S. Preventive Services Task Force. Available at http://www.ahrq.gov/clinic/USpstfix.htm#Recommendations. Viewed 9/26/08. xxiv American Diabetes Association. Information available at www.diabetes.org. Viewed 10/12/08. xxv American Heart Association. Information available at www.americanheart.org. Viewed 10/12/08. xxvi United States Department of Agriculture. Information available at www.usda.gov. Viewed 10/12/08. xxvii U.S. Department of Health & Human Services. Agency for Healthcare Research and Quality. The U.S. Preventive Services Task Force. Available at http://www.ahrq.gov/clinic/USpstfix.htm#Recommendations. Viewed 9/26/08. xxviii American Heart Association. Information available at www.americanheart.org. Viewed 10/12/08. xxix Ibid. xxx American Diabetes Association. Information available at www.diabetes.org. Viewed 10/12/08. xxxi American Cancer Society. Information available at www.cancer.org. Viewed 10/12/08. xxxii The USPSTF concurs with the American Cancer Society on the necessity and frequency for Pap smears. xxxiii U.S. Department of Health & Human Services. Agency for Healthcare Research and Quality. The U.S. Preventive Services Task Force. Available at http://www.ahrq.gov/clinic/uspstf/uspshivi.htm. Viewed 9/26/08.