Journal of Latina/o Psychology

2016, Vol. 4, No. 2, 8397

2015 American Psychological Association

2168-1678/16/$12.00 http://dx.doi.org/10.1037/lat0000051

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Health Promotion Among Latino Adults: Conceptual Frameworks,

Relevant Pathways, and Future Directions
Leticia Arellano-Morales

John P. Elder

University of La Verne

San Diego State University

Erica T. Sosa

Barbara Baquero

University of Texas at San Antonio

University of Iowa

Carmela Alcntara
Columbia University
Health promotion programs for Latinos can play a key role in increasing their awareness and early detection of prevalent diseases. However, these programs must integrate
cultural factors and also recognize the significant diversity among Latinos. Thus, the
current article provides practitioners with an understanding of health promotion for
Latinos by building upon the work of Elder, Ayala, Parra-Medina, and Talavera (2009).
Relevant pathways and future directions for health promotion for Latinos are also
discussed.
Keywords: Latinos, health promotion, conceptual frameworks, health interventions

Despite health initiatives to eliminate health

disparities and improve the nations health,
there is ample research indicating that Latinos
continue to experience health disparities (Ruiz,
Campos, & Garcia, 2016). For example, Latinos
have lower death rates for most leading causes
of death and lower prevalence of cancer and
heart disease than White/European Americans.
However, Latinos demonstrate higher death
rates from diabetes (51%) and chronic liver
disease and cirrhosis (48%), and have higher
prevalence of diabetes (133%) and obesity
(23%) than White/European Americans

(Dominguez et al., 2015). Unfortunately, Latinos also continue to experience mental health
disparities, in comparison to their White/
European American counterparts (AguilarGaxiola et al., 2012; Cook, McGuire, & Miranda, 2007; Rosales Meza, & ArellanoMorales, 2014; U.S. Department of Health &
Human Services [DHHS], 2001; Vega, Rodriguez, & Gruskin, 2009). Latinos with mental
disorders are less likely than White/European
Americans to utilize mental health services
(Alegra et al., 2008). Once they enter treatment, they are also more likely to receive services that are inadequate than White/European
Americans (Alegra et al., 2008; Cook et al.,
2007), resulting in premature termination
(DHHS, 2001).
Health and mental health disparities among
Latinos are the product of complex genetic,
biological, psychosocial, and economic factors.
Communication barriers that are due to organizational and structural malfunctions within
health care settings, as well as barriers within
medical encounters create health disparities
among Latinos (Betancourt, Carrillo, Green, &
Maina, 2004; Betancourt & Flynn, 2009). Although health care reform, such as the Patient

This article was published Online First December 14,

2015.
Leticia Arellano-Morales, Department of Psychology,
University of La Verne; John P. Elder, Institute for Behavioral and Community Health, San Diego State University;
Erica T. Sosa, Department of Kinesiology, Health, & Nutrition, University of Texas at San Antonio; Barbara Baquero, Department of Community and Behavioral Health
Prevention Research Center, University of Iowa; Carmela
Alcntara, School of Social Work, Columbia University.
Correspondence concerning this article should be addressed to Leticia Arellano-Morales, Department of Psychology, University of La Verne, 1950 Third Street, LA
Verne, CA 91750. E-mail: larellano@laverne.edu
83

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84

ARELLANO-MORALES ET AL.

Protection and Affordable Care Act of 2010,

has aided in reducing the number of uninsured
Latinos (DHHS, 2014b), Latinos experience
limited health care coverage that impacts their
preventive health care utilization. Regrettably,
health programs seldom reach vulnerable populations, including many immigrants, the poor, and
disadvantaged populations, such as Latinos. Given
the health and mental disparities of Latinos, public
health models for disease prevention and health
promotion with elements of health equity, justice,
community-based participatory research (CBPR),
and social action research are essential (Daniel,
2010; Torres et al., 2013; Valenzuela, McDowell,
Cencula, Hoyt, & Mitchell, 2013; Watson, Kaltman, Townsend, Goode, & Campoli, 2013). In
addition, effective translational research and
dissemination is warranted to inform practitioners and policymakers regarding the need for
improved health and mental health care for Latinos (Aguilar-Gaxiola et al., 2002, 2012).
Research indicates that intensive health education and promotion programs specifically designed for Latinos are effective tools for communicating health information and sustaining
healthy behavioral change (Alcalay, Alvarado,
Balcazar, Newman, & Huerta, 1999; Castro,
Balcazar, & Cota, 2008; Elder et al., 2009).
However, an overlooked area within Latino
health promotion is the transnational context.
Recent studies indicate that the transnational
context contributes to behavioral health (e.g.,
depression, distress), and health behaviors such
as smoking (Alcntara, Chen, & Alegra, 2015;
Alcntara, Molina, & Kawachi, 2015;
Grzywacz et al., 2006; Torres, 2013), but further research is warranted.
Practitioners must possess a thorough understanding of Latinos and their community, and
attend to salient cultural variables to guide the
selection of their health promotion efforts and
avoid a one-size fits-all pitfall (Castro et al.,
2008; Elder et al., 2009). In addition, these
health promotion programs must adjust their
program activities based upon levels of acculturation and consider linguistic, literacy, gender
relevance, and other cultural factors.
Therefore, the current article aims to provide
practitioners with an understanding of health
promotion for Latinos. We build upon the work
of Elder et al. (2009) in their review of health
communication with Latinos, and discuss relevant pathways and future directions for health

promotion for Latinos. Because health promotion programs for Latinos vary based upon their
needs and geographical location, we provide
examples of culturally-tailored health interventions from four distinct regions of the U.S. (e.g.,
South Carolina, Pennsylvania, Texas, California) and health areas that are amenable to
change (e.g., physical activity, nutrition, diabetes, depression). However, unlike Elder et al.
(2009), the current article discusses issues of
mental health and the role of transnational ties
and its effect upon the health and mental health
of Latinos.
Health Promotion Frameworks
Health promotion programs for Latinos can
play a key role in increasing their awareness and
early detection (Cristancho, Peters, & Garces,
2014; Vega et al., 2009). While these programs
aid in reducing health disparities among Latinos, enacting healthy behavioral changes is difficult (Castro et al., 2008). Conditions for optimal health behavior are often difficult for many
Latinos, particularly those with stressful living
situations. Nonetheless, health promotion programs for Latinos are possible and their efficacy
is dependent upon the provision of health information that motivates and sustains changes in
health behavior (Alcalay et al., 1999; Balcazar
et al., 2006; Castro et al., 2008; Cristancho et
al., 2014; Elder et al., 2009).
Castro et al. (2008) indicate that such change
must occur within a culturally relevant manner
through the use of program activities that build
upon their cultural strengths and mobilize interpersonal and environmental resources within an
integrated manner. These strengths can include
cultural values such as familismo, personalismo, respeto, and confianza (Buki, Salazar, &
Pitton, 2009; Torres et al., 2013). Health promoters cannot assume that the messages and
materials developed for mainstream audiences
are effective for every individual (Torres et al.,
2013). Rather, the design of health promotion
interventions for Latinos should be grounded on
the contemporary health needs and desires of
the local community. Empirically- based health
promotion research and empirically validated
interventions for Latinos should guide these efforts to promote healthy behavioral change
(Castro et al., 2008). In addition, these programs
must adjust program activities based upon lev-

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HEALTH PROMOTION

els of acculturation and also consider linguistic,

literacy, gender relevance, and other cultural
factors (for a review of program planning, development, and evaluation of health promotion
in Latino populations see Castro et al., 2008).
Organizations that serve Latino populations,
such as schools, community centers, and faithbased organizations are often the settings in
which these interventions take place, as well as
participants homes (Elder et al., 2009; Woodruff, Candelaria, & Elder, 2010). Health promotions for Latinos must also incorporate community-based efforts that include community
partners within the design, data collection, dissemination, and action planning. CBPR efforts
are paramount, given the significant health barriers within Latino immigrant communities, due
to their disenfranchisement, isolation, and mistrust (Valenzuela et al., 2013). For instance,
CBPR efforts are helpful in addressing the
health and mental health needs of Latino immigrants within nontraditional settlement areas,
such as North Carolina (Tran et al., 2014), Ohio,
(Valenzuela et al., 2013) and Montana (Letiecq
& Schmalzbauer, 2012).
Theories of behavior change are often based
upon middle-class norms (Krumeich, Weijts,
Reddy, & Meijer-Weitz, 2001) and their applicability to Latinos is questionable, particularly
among first-generation Latinos because they fail
to consider the importance of the family (Elder
et al., 2009). Among the few frameworks that
have been proposed to investigate Latino health,
Borrell (2005) highlighted the need to consider
racial identification and its impact on how Latinos are exposed to individual, psychosocial,
and contextual stressors that subsequently impact their health and well-being (Borrell, 2005).
The family-community model by Mendoza and
Fuentes-Afflick (1999) provides a framework
for examining the impact of immigration on
childrens health within the context of the family, community, and cultural factors and how
they relate to physical and functional health.
Similarly, Castro, Shaibi, and Boehm-Smith
(2009) propose an expanded ecodevelopmental
model that considers cultural variables at the
individual level and how those variables interact with other multiple levels to create systemic
risks for disease. Each of these models provides
innovative approaches to examine and promote
Latino health. Key features of these models are
presented in Table 1. These elements are essen-

85

tial to better direct health promotion programs

for different levels, including program planning, development, and evaluation. However,
for the purpose of this article, McGuires (1989)
communication persuasion model is used to illustrate how practitioners can design and evaluate health communication efforts for the Latino community.
Health Communication Sources
McGuires (1989) communication persuasion
model offers a pragmatic framework for both
designing and evaluating health communication
efforts and modifying these efforts for Latinos
(Elder et al., 2009). McGuires framework is
divided into inputs and outputs. Communication inputs that are applicable to Latinos may
significantly differ from those that appeal to the
majority population. Inputs can be seen as independent variables, in other words, those that
are under the control of the designers and planners of specific health communication efforts.
Inputs include the real or inferred source of
the communication. If program participants perceive that health care providers lack cultural
awareness, these providers may be ignored and
perceived as a less credible message source.
Thus, bicultural and bilingual staff who possess
cultural competence are essential to ascribe trust
among participants and maintain their program
involvement (Castro et al., 2008). For instance,
many health promotion programs have utilized
promotoras as adjuncts to program recruitment
and implementation because they offer personalized support and reduce the likelihood that
participants will misunderstand health promotion communication and increase their acceptance of the communication (Elder et al., 2009;
Larkey, 2006; Reinschmidt et al., 2006).
Health Communication Message Framing
The second input variable is the message
itself (McGuire, 1989). A basic tenet of culturally responsive health promotion is that messages must be presented within the language of
the audience. However, a common challenge for
health providers is the issue of language and
health literacy (Buki et al., 2009), particularly
among recent Latino immigrants with limited
English proficiency or Latinos with low levels
of education. Literacy issues are also confounded when health instructional approaches

Year

2005

2009

2009

Model

Borrell
(Framework for the Effect of
Racial Identity among
Latinos)

Mendoza and Fuentes-Afflick

(Family-Community Health
Promotion Model)

Castro, Shaibi, & Boehm-Smith

(Eco-developmental Model)

Table 1
Frameworks to Examine Latino Health

Identifies socio-environmental
factors that influence
childrens health.
Informs the development of
effective, economically
feasible health interventions
that will have long-term
effects on socio-environmental
factors.
Aids in the conceptualization and
design of culturally tailored,
multi-level diabetes prevention
interventions for racial/ethnic
minority populations.

To better understand the

heterogeneity among Latinos
in terms of stressors and health
outcomes.
Identifies key individual
characteristics, psychosocial
factors and contextual factors
that affect health and
well-being.

Aims

The expanded eco-developmental

model can be used to help guide
the increased focus on defining
features of racial/ethnic minority
sub-groups.

Provides an understanding of the

effect of race among the racial
identification of Latinos within
U.S. Census categories.
Social stratification is reinforced
through racial categorization,
therefore, it is best to develop
effective programs and policies to
advance the understanding of
health.
Racial categorization may
significantly predict health status
and well-being.
Provides a conceptual framework for
developing and researching
hypotheses about Latino children
and families.
Changes in health perceptions create
a feedback loop to individual and
familial health practices.

Applications

Key Factors

Provides a contemporary understanding

of the complexity of factors involved
when addressing critical and highly
prevalent health conditions for
Latinos.

Incorporates the concepts of family and

cultural health traditions and
emphasizes the family-community
complex to understand the
unexpectedly low rates of adverse
health outcomes among some groups
of poor children.

Identifies how the racial categorization

of Latinos is dynamic and
emphasizes the need to examine a
life-course pattern of accumulated
negative exposures that can be
transmitted throughout generations.

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86
ARELLANO-MORALES ET AL.

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HEALTH PROMOTION

and materials are designed for relatively educated individuals with high English literacy.
Furthermore, Spanish materials that are direct
translations from English are often inappropriate, since they lack linguistic and cultural relevance. Other Spanish translations tend to be
written at a high reading level, yielding them
inappropriate for low-level readers (Elder et al.,
2009). In addition to the content of a message,
its feel must be consistent with the values of
familismo, simpata, and allocentrism, with a
tone and images that are relevant to these dimensions (Sampson et al., 2001). To address
these issues, Buki et al. (2009) developed a
Checklist of Design Elements for the Development of Cancer Education Print Materials for
Latina/o Audiences (CEMLA). Using socialcognitive theory, the CEMLA provides a costeffective systematic and practical tool to develop culturally and linguistically appropriate
cancer education materials for Latinos.
Health Communication Channels
of Communication
The third input variable within health promotion programs for Latinos is the channel or
medium of communication (McGuire, 1989).
Multiple communication channels are employed, such as face-to-face communication, bilingual mass media, and other mediums. For
instance, mass media have included telenovelas
(soap operas), public service announcements,
radio programs, motivational videos, and telephones. In addition, other mediums have included the use of brochures, recipe booklets,
photonovelas (stories using photographs), and
workbooks to increase their awareness of risk
factors and health knowledge (Balcazar et al.,
2006; Castro et al., 2008; Cristancho et al.,
2014; Elder et al., 2009).
Health Communication Audience
The fourth input variable is the audience or
the receiver of the communication (McGuire,
1989). Audience characteristics that frame the
health promotion effort for Latinos include cultural sensitivity and recognition of the diversity
of Latinos (Ramirez et al., 1999). For many
Latinos, behavioral change will occur within the
context of the family, since they are often primary sources of social support, particularly

87

among recent immigrants (Elder et al., 2009). In

addition, health promotion programs must consider the specific roles of each family member,
since the involvement of the family is critical
(Castro et al., 2008). For instance, health promotion messages may be multifaceted, and
combine fear appeals with encouragement to
place personal health in the context of the family and culture (Elder et al., 2009).
Health Communication Outputs
Lastly, McGuire (1989) indicates that outputs
range from those that are very broad and proximal to the communication effort to those that
are more distal and involve a smaller number of
individuals. Outputs begin with the (a) exposure
to or reach of the message, followed by (b)
attention to the message, its (c) comprehension,
(d) agreement with or forming a favorable attitude toward it, (e) changing behavior, and (f)
maintaining this behavioral change (McGuire,
1989). As can be inferred, outputs form an
inverse pyramid in terms of the number of individuals that are impacted at each level. Moreover, this conceptualization of health communication outputs may conveniently lead to the
design of evaluation approaches, including determining which media have the widest range or
exposure to the development of surveys that can
determine attitude, knowledge, and behavioral
change. The Methods to Reach Latinos section
provides a discussion of McGuires (1989) input variables with special characteristics of Latino communities, such as the sources within the
settings and the diverse methods previously utilized to reach Latinos.
Methods to Reach Latinos
Organizations
Within Latino culture, language, family, and
religion are often paramount. Interestingly,
these are factors potential points of entry for
health promotion and mental health service delivery. Organizations that serve Latino populations are often instrumental in recruiting research participants, providing needed health
services, and building health-related knowledge
among underserved populations, such as
schools, Head Start centers, and faith-based organizations (Elder et al., 2009). Schools provide

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88

ARELLANO-MORALES ET AL.

a wealth of resources and are geographically

located within the neighborhoods they serve.
For these reasons, school-based programs can
circumvent common barriers among Latino parents who participate in these programs (GarciaDominic et al., 2010). Schools also provide a
captive audience and are influential channels
for health promotion. When school-based
programs are culturally tailored and provided
in the child and familys preferred language,
they are more likely to be effective. For example, the Bienestar diabetes prevention program was culturally tailored for a Mexican
American community and effectively reduced
childrens fasting capillary glucose levels and
increased their physical activity (Trevio et
al., 2004).
In addition to school-based educational programs, schools can house resources for underserved Latino communities, such as schoolbased health centers and shared use agreements.
School-based health centers bridge the gap in
health access among Latinos and other underserved populations. These centers also offer
age-appropriate services, including dental
health care, health education and promotion,
and mental/behavioral health care (DHHS,
2014a). These services are often provided as a
partnership between schools and community
health care centers and can help eliminate disparities in access to health care among Latino
children and their families. Shared-use agreements also enable schools to open their physical activity facilities to the community while
avoiding high financial or legal risk. For instance, the City of San Antonio established
shared-use agreements with two school districts that enabled the city to fund modification to the school districts existing resources,
in which the school district subsequently provides access to community members during
after school hours.
Nonschool-based programs, such as Head
Start and faith-based health programs, are also
beneficial for Latinos. Family based approaches
can be very effective when disseminated
through Head Start centers. For instance, the
Mranos program engaged approximately 80%
of parents in their home-based intervention,
largely due to the structure of Head Start and
demonstrated positive results in childrens
physical activity (Yin et al., 2012). Faith-based
organizations are an integral part of the Latino

community, and are a source for many Latinos

who seek food assistance, counseling, and other
services. They are also beneficial in the health
promotion of Latinos. For example, Building a
Healthy Temple and other faith-based health
promotion programs engaged the Latino community through its existing relationships with
the churches (He et al., 2013). A needs assessment among Latino faith leaders found
that most congregants believed diabetes and
obesity were critical health issues in their
congregation and that the church could play a
key role in addressing those issues (He et al.,
2013).
Health and Mental Health-Care Clinics
The health clinic (both primary care and specialty care [e.g., mental health clinic]) has traditionally served as one of the primary settings
for engaging Latinos in health promotion and
disease management. While the Affordable
Care Act solidified the importance of the primary care clinic to national health (Goodson,
2010; Hofer, Abraham, & Moscovice, 2011),
impediments to effective patient-provider communication and health promotion remain for
Latinos (Aklin & Turner, 2006; Snowden,
Masland, Peng, Lou, & Wallace, 2011). Language barriers are distinctly important among
Latinos, since those with limited English proficiency are more likely than their counterparts to
use language assistance programs, and/or rely
upon Spanish translated health promotion materials.
Individual factors such as cultural stigma (especially concerning mental illness), and socioeconomic factors such as literacy levels and
educational attainment are also important determinants of the receipt of appropriate preventive
and medical care. With the Affordable Care Act
there is promise for improved approaches for
integrated systems of care (Holden et al., 2014)
for Latinos and opportunities to decrease their
mental health disparities, particularly since they
are more likely to report mental health problems
within primary care settings than mental health
settings. Also, because primary care settings
offer the opportunity for comprehensive medical and mental health care on site, there are
significant benefits for Latinos, such as increased compliance and follow-up due to increased collaboration among professionals and

HEALTH PROMOTION

decreased stigma of mental illness (Holden et

al., 2014).

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Communities With Few Latino-Oriented

Organizations
In new destination communities there are
limited community-based organizations with
the capacity and resources to respond to Latinos. This has hindered their integration into
these communities and contributed to their social-economic disparities. New destination
communities have responded in two ways: (a)
through traditional settings such as churches
and schools, and (b) the development of new
businesses by Latino immigrants in response to
the needs of Latino communities (Allegro &
Grant Wood, 2013; Ayala, Baquero, Laraia, Ji,
& Linnan, 2013; Hill, 2010; Jordan, 2012). As a
result, traditional settings, such as churches and
schools, have added additional services and new
businesses have revitalized these communities.
For example, churches have added Spanishlanguage religious services and recruited bilingual church-community liaisons to reach out the
community and develop programs and services.
In many instances, churches become the community resource for Latinos within new destination communities. Schools, particularly elementary schools, have identified bilingual
teachers or created Spanish liaison positions
within their school districts to serve new students and their monolingual parents or parents
who are unfamiliar with the U.S. educational
system.
Latino entrepreneurs who moved to these
new destination communities have also created new businesses to respond to the demands for Latino products and services. Food
stores and restaurants first emerged within
these new communities to cater to the food
preferences of Latinos. Food stores are not
only locations where Latinos can purchase
familiar foods from their country of origin,
but locations where Latinos can also access
information about their new community and
conduct other business, such as check cashing, translation services, or sending remittances to their country of origin (Allegro &
Grant Wood, 2013; Ayala et al., 2013; Hill,
2010; Jordan, 2012).

89

Channels of Communication for Health

Promotion With Latinos
Promotora/Face-to-Face Approaches
Female community health workers, also
known as promotoras or promotoras de salud
(Balcazar et al., 2006), are beneficial in improving the health, knowledge, and behaviors of
Latinos and play a critical role in the research
process (Johnson, Sharkey, Dean, St. John, &
Castillo, 2013; Rhodes, Foley, Zometa, &
Bloom, 2007). Their success is often attributed
to their roles as community advocates, role
models, health advisors, and providers of social
support (Larkey, 2006; Reinschmidt et al.,
2006). As members of their local communities,
they engender greater confianza, function as
cultural brokers, and provide personalized support. Promotora programs are provided within
various facilities, such as community centers,
schools, churches, personal homes, and other
locations and address a wide range of health
topics (Rhodes et al., 2007). For instance, in
their literature review of promotoras, Rhodes et
al. (2007) found that a larger proportion of
studies focused on cancer prevention and
screening (38%), but other interventions also
included prenatal health, cardiovascular disease, as well as asthma management.
Despite successful outcomes, promotora programs are not without limitations. Most promotoras within these studies are female and few
interventions specifically focus upon Latino
men (Philip, Shelton, Erwin, & Jandorf, 2012;
Rhodes et al., 2007; Wagoner, Downs, Alonzo,
Daniel-Ulloa, & Rhodes, 2015), and largely focus upon Mexican Americans within the Southwest. Uniform differences in the design of promotora-based interventions also exist, due to
their geographical locations. For instance, programs in the Southwest are more likely to train
promotoras in traditional education roles while
programs in other regions are more likely to
train promotoras to function as cultural brokers
or intermediaries to help bridge health services
and other organizational systems (Elder et al.,
2009). Lastly, significant time is needed for
training and sustainability and potential decay
of acquired skills are also possible (see Swider,
Martin, Lynas, & Rothschild, 2010; Woodruff
et al., 2010 for the recruitment, training, retention, and performance of promotoras).

90

ARELLANO-MORALES ET AL.

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Mass Media and Emerging Channels

For decades, Latinos have participated in
broadly-based mass media intervention studies,
from the Stanford 5 City Program (Winkleby,
Fortmann, & Rockhill, 1993) to the VERB campaign (Huhman et al., 2005). Most mass media
campaigns, however, have not specifically targeted Latino communities. One of the most
notable exceptions to this general observation is
the work of Ramirez and her colleagues in the
San Antonio/South Texas region. For example
Ramirez and McAlister (1988) developed the A
Su Salud program for cancer prevention in
South Texas. Much of the cancer prevention
information for A Su Salud was delivered via
narrowcast, by which promotoras convened
TV watch groups of participants to view select
televised programs emphasizing behavioral risk
reduction. McAlister et al. (1992) demonstrated
the effectiveness of broader use of mass media
in the promotion of smoking cessation among
Latinos. Given the much broader demand for
Spanish language media today, concurrent with
the explosion of social media use, a major acceleration in research on mass media in Latino
health promotion can be expected. This is presently manifested through small grants funded
by Ramirez group from their Salud America!
program that is a part of a Robert Wood Johnson Foundation initiative (see http://saludamerica.org).
Culturally Tailored Health Promotion
Interventions With Latinos
Health promotion programs for Latinos vary
based upon their needs and geographical location. Thus, the following section provides examples of culturally tailored health interventions from four distinct regions of the U.S. (e.g.,
South Carolina, Pennsylvania, Texas, California) and health areas that are amenable to
change (e.g., physical activity, nutrition, diabetes, depression).
Physical Activity Promotion
The high prevalence of physical inactivity
among Latinos contributes to their risk for the
development of cardiovascular disease. To engage Latinas in physical activity and increase
their awareness of cardiac and metabolic risk,

the 2-year intervention Un Corazon Saludable:

A Healthy Heart was developed (Harralson et
al., 2007). Risk factors included body mass index (BMI), waist-to-hip ratio, abdominal obesity, and blood pressure, as well as depressive
symptoms and perceived social support. Participants were recruited from existing programs at
an urban community-based organization that
served low income Latinos in Philadelphia, PA.
Bilingual salsa aerobics and culturally-sensitive
health education modules were provided at a
Latino-owned gym located within an urban
Puerto Rican neighborhood for 12 weeks during
the first year and 16 weeks during the second
year.
Decreased BMI, abdominal obesity, and depressive symptoms and improvements in selfreported health were observed among program
completers (52%, n 118). Focus groups were
also conducted to identify barriers and facilitators to exercise. Facilitators included weight
management, improvement in self-esteem and
mood, enhancement of appearance, health,
well-being, and increased social support. However, family obligations and transportation were
identified as barriers to exercise. Focus group
data also indicated that depression, domestic
violence, poverty, housing, and adolescent truancy impacted their self-care and health promotion. Given the high rates of childhood obesity
among Latino children, future programs should
consider involving family members in physical
activity, such as a mother-child exercise class.
This type of family involvement is beneficial by
increasing their healthy habits and also empowers urban Latinas to take control of their health
(Harralson et al., 2007).
Nutrition Interventions
The recent influx of Latinos into the Midwest, and the rural context, have limited the
availability to develop and implement effective
health prevention and disease control interventions that work within these settings. However,
in the South, Vida Sana Hoy y Maana, a feasibility intervention study was developed to increase fruit and vegetable intake among Latino
immigrants (Ayala et al., 2013). Ayala and colleagues (2013) collaborated with nontraditional
locations for their intervention, such as foodstores (tiendas) to reach Latinos within North
Carolina. Tiendas are places that Latinos trust

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HEALTH PROMOTION

and frequent to obtain food and services. Four

tiendas were randomized to a 2-month intervention with a delayed control condition. The primary outcome of the study was self-reported
daily fruit and vegetable intake among a sample
of customers. The intervention consisted of
food marketing and environmental change strategies. Employees and managers were trained to
promote fruit and vegetables sales, and the intervention staff implemented a food marketing
campaign and worked with the tienda staff to
modify the environment to promote the sale of
fruits and vegetables.
Findings indicated successful outcomes, such
as achieving a high fidelity (Baquero, Linnan,
Laraia, & Ayala, 2014), and increased daily
intake of fruits and vegetables among customers
in the intervention tiendas, compared to the
delayed control tiendas (Ayala et al., 2013). In
addition, at the store level, a group-by-time
interaction was observed for availability of
fresh and canned vegetables. In this case, the
researchers explored the characteristics of the
community and environment and engaged with
local stakeholders to determine adequate intervention methods and locations to implement the
intervention. In new destination communities,
such as the South, Southeast, and Midwest, limited traditional infrastructures to effectively
serve Latinos pose different challenges to reach
and promote health among new destination Latino immigrants, thus, innovative and alternative intervention strategies should be considered.
In traditional destination communities, such
as Texas and Arizona, nutrition interventions
have successfully reached Latinos to promote
changes in their diet, physical activity, and to
improve health indicators. For instance, the intervention Mi Casa, Mi Salud (My House, My
Health; de Heer et al., 2015) applied best practices from the CDC Task Force on Community
Preventive Services and utilized promotoras to
facilitate access to community resources, provided cooking classes, grocery stores tours, and
coffee talks to promote healthy heart nutrition
practices. The intervention activities lasted four
months and significantly improved health behaviors and body composition indicators. Findings also indicated that greater attendance to
program activities was key to the interventions
success (de Heer et al., 2015). In a similar study,
Staten and colleagues (2012) conducted Pasos

91

Adelante (Steps Forward), a 12-week intervention, to promote nutrition and physical activity
through the use of promotoras. The intervention
design also integrated social ecological strategies endorsed by the CDC Task Force on Community Preventive Services. Pasos Adelante
significantly decreased self-reported body composition, blood pressure, and cholesterol (Staten
et al., 2012). In traditional destination communities, available resources, community capacity,
and large Latino communities facilitate the implementation of evidence-based interventions
and successful application of large community
trials. This evidence suggests that promotoras,
strong community ties, and culturally specific
strategies, are important factors to consider
when designing and implementing interventions
for Latinos (Ayala & the San Diego Prevention
Research Center Team, 2011; Keller & Cantue,
2008).
Diabetes Control Interventions
Given the high rates diabetes in South Texas,
especially among Mexican Americans, interventions in this area are critical. The Starr
County Border Health initiative included two
interventions along the Texas-Mexico border
(Brown & Hanis, 2014). The yearlong intervention included 12 weekly educational sessions
and biweekly support groups, whereas the
8-week intervention included eight 2-hr educational sessions, three 2-hr support groups, and
guidance from a nurse case manager. One
unique feature of this intervention was the inclusion of a research dietitian, nurse, and promotora within its intervention teams. In contrast
to other studies, the promotoras were primarily
for logistical support and recruiting study participants because formative research suggested
that study participants preferred for health professionals to provide the educational sessions
rather than the promotoras.
Outcomes of the Starr County Border Health
Initiative were promising. Participants who attended at least half of their sessions decreased
A1C by an average of 1.7 percentage points
compared with an average of four percentage
points among the highest attendees. High participation was partially attributed to program
implementation in Spanish (90% of the sample
selected Spanish as their preferred language);
the provision of transportation, flexible sched-

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ARELLANO-MORALES ET AL.

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uling, and ongoing communication between

participants and promotoras (Brown & Hanis,
2014). In addition, the initiative was culturally
sensitive and addressed cultural myths related
to diabetes, and values such as fatalism. These
aspects of the intervention are appropriate,
given the unique profile of disadvantaged residents along the Texas-Mexico border (Mier et
al., 2012).
Mental Health Interventions
There are limited promotora-based interventions for Latinos that focus upon the area of
mental health (Hernandez & Organista, 2013;
Unger, Cabassa, Molina, Contreras, & Baron,
2013). However, within California, Hernandez
and Organista (2013) extended the work of Unger et al. (2013), who evaluated the effectiveness of a fotonovela entitled Secret Feelings, to
increase knowledge of depression and treatment
among a sample of 142 adult Spanish-speaking
Latinas who were at risk for depression and low
health literacy. Participants were recruited
through a large multiservice community clinic
located within the San Francisco, CA area; sixty-seven were randomized to the control group
and 75 were randomized into the experimental
group. The experimental group was exposed to
the fotonovela that included a story of a depressed middle-aged mother who modeled how
to seek treatment and how to discuss her mental
health concerns with her family. Control group
participants were exposed to a discussion of
family communication and intergenerational relationships. Pre-post data indicated significant
gains for the experimental group in their depression-related knowledge, self-efficacy to identify
the need for treatment, and reduced stigma toward antidepressants (Hernandez & Organista,
2013).
Hernandez and Organista (2013) attribute the
programs success to the use of a multiservice
delivery site that allowed for collaboration with
promotoras, the provision of childcare, assistance to participants who experienced difficulties completing pre- and postintervention measures, and a group format that allowed the
participants to read aloud their fotonovela.
These improvements are important for low
health literate Latinas who are at risk for depression as well as Latino men. Fotonovelas are
potentially effective mental health tools that

provide health information for a stigmatized

condition such as depression, and may potentially motivate Latinos to seek help (Hernandez
& Organista, 2013; Unger et al., 2013).
Implications for Sustainability and
Replicability: Transnational Extensions
Many Latinos actively maintain transnational
ties, defined as frequent and enduring social, economic, political, or cultural ties between two or
more countries, most notably through economic
remittances, with annual totals to Latin America
and the Caribbean in the billions of dollars, and
travel to their home country (Office of Travel and
Tourism Industries, 2010; Portes, 2003; World
Bank, 2011). However, prior research on Latino
health and health promotion has often neglected
the transnational context and its influence on
health and health behavior. Yet, recent evidence
suggests that the transnational context (both the
type and frequency of transnational contact) contributes to behavioral health (e.g., depression, distress), health behaviors such as smoking, selfrated health, and overall distress levels among
Latino adult immigrants, (Alcntara, Chen, et al.,
2015; Alcntara Molina, et al., 2015; Torres,
2013; Viruell-Fuentes & Schulz, 2009). This research also suggests that gender may pattern these
associations, such that Latinas may experience
increased odds of negative health outcomes, such
as depression, in the context of greater transnational contact such as return visits (Alcntara,
Chen, et al., 2015; Alcntara, Molina, et al., 2015).
Importantly, for health promotion, these findings suggest that a necessary but often overlooked
contextual influence on Latino health and health
promotion is the transnational context. Thus, contemporary socioecological models of Latino
health promotion will benefit from greater consideration of the importance of ties that reside outside
domestic borders to health behavior. A transnational extension of contemporary models of health
promotion provides ample opportunity to (a) better understand how transnational ties may serve as
resources or vulnerabilities that in turn impact
health practices; (b) determine how gender, race/
ethnicity, and socioeconomic status, and other factors such as the geopolitical context and technological innovations may shape transnational
practices and health behavior; and (c) develop
lifestyle and preventive health interventions that
are sustainable across contexts; this may be par-

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HEALTH PROMOTION

ticularly important for Latino migrants residing in

the United States for whom transnational ties are
important.
Although there are ongoing debates regarding
the novelty, prevalence, density, and durability of
transnational ties (Levitt & Jaworsky, 2007), the
development of a research and practice agenda
that considers the interplay of transnational factors, and other contextual factors, on Latino health
and health promotion over the life course, is essential. This consideration is important to develop
a behavioral workforce that can meet the health
needs of contemporary migrants living in a globalized America. Thus, there is a pressing need for
qualitative and quantitative research on transnational ties and health promotion. For example,
comparative studies of international migration and
internal migration that capitalize on the mass disruptions in technology, communication, and transportation of the 21st century, may provide key
insights into the dynamic relationships between
transnational ties, place, and health behavior, and
will also help identify novel sites for health promotion. These insights may lead to the development and subsequent testing and implementation
of health promotion preventive strategies and interventions within geographic settings with high
transnational contact such as border cities and
towns (de Heer et al., 2013, 2015), and near
settings that are primary sites for transnational
contact such as telephone centers, and international money transfer centers. The implementation
of effective preventive and intervention health
promotion strategies in transnational settings may
be far reaching and have broad implications for
disease prevention among first-generation and
second-generation Latinos. However, the development, testing, and identification of sustainable and
replicable communication strategies across contexts may be key to designing health promotion
interventions for Latinos that extend beyond domestic borders and reflect the realities of an increasingly globalized world.
Conclusion
Health education and promotion programs that
are specifically designed for Latinos are effective
tools for communicating health information and
sustaining healthy behavioral change (Alcalay et
al., 1999; Elder et al., 2009). While health promotion efforts for Latinos have employed multiple
communication channels, the need for continued

93

innovation is essential to enable Latinos to take

optimal advantage of Internet-based as well as
video, audio, and written formats (Elder et al.,
2009). Health promotion practitioners and researchers should also continue to utilize promotoras to improve the health of Latinos and to aid in
the research process (Johnson et al., 2013; Rhodes
et al., 2007; Valenzuela et al., 2013). However,
male promotores are needed to address the unique
health needs of Latino men (Rhodes et al., 2007;
Wagoner et al., 2015).
Different regional and socioeconomic realities
further extend the complexities of the Latino experience within the U.S., and program developers
must consider these factors within the development of their interventions (Betancourt et al.,
2004; Betancourt & Flynn, 2009), particularly
since appropriate infrastructures are often needed
within new geographical destinations for Latino
immigrants (Kandel & Parrado, 2005; Valenzuela
et al., 2013). In addition, the transnational context
of Latinos also warrants attention. There is an
exciting opportunity to develop and test the effectiveness of health promotion preventive strategies
that can be implemented in geographic settings
with high transnational contact, such as border
cities and other settings that are primary sites for
transnational contact such as telephone centers
and international money transfer centers. The development, testing, and identification of sustainable communication strategies across contexts
may be key to designing health promotion interventions for Latinos that extend beyond domestic
borders.
Given the health and mental disparities of
Latinos, there is a significant need for health
equity and social justice. Community-based
participatory research and efforts can aid in the
reduction of health disparities, since they aid in
achieving health equity and effectively address
the needs of Latinos through community action
and empowerment (Aguilar-Gaxiola et al.,
2012; Watson et al., 2013). However, despite
the empirical evidence suggesting health and
mental health disparities among Latinos, efforts
to eliminate these disparities through the use of
translational research into policy and practice
is scant. Effective translational research and
dissemination is warranted to inform practitioners and policymakers regarding the need
for improved health and mental health care
for Latinos, and to create sustainable change

94

ARELLANO-MORALES ET AL.

within local, state, and federal levels (Aguilar-Gaxiola et al., 2002, 2012).

This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Abstracto
Programas de promocin de la salud para los Latinos
pueden tener un papel clave en el aumento de su
conocimiento y la deteccin temprana de las enfermedades prevalentes. Sin embargo, estos programas
deben integrar factores culturales y reconocer la significativa diversidad entre los Latinos. Por lo tanto, el
presente artculo ofrece profesionales con un marco de
la promocin de la salud para los Latinos a travs del
trabajo conducido por Elder et al. (2009). Tambin se
discuten las marcos pertinentes y la futura orientaciones
de promocin de la salud para los Latinos.

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Received February 24, 2015
Revision received September 17, 2015
Accepted October 7, 2015