Research articleImpact of Peer Nutrition Education on Dietary Behaviors and Health Outcomes among Latinos: A Systematic Literature Review
Introduction
Latinos are the largest minority group in the United States, accounting for over 12% of the population, and they are expected to be nearly 25% of the population by 2050. (Although the terms Latino and Hispanic are often used interchangeably in the literature, the authors will refer to this ethnic group solely as Latino.) Over 40% of Latinos are foreign born, with almost half residing in California and Texas. Latinos represent over 20 different countries of origin from Central America, South America, the Caribbean, and Europe. Over 22% of Latinos live in poverty, compared with 8.2% of non-Latino white individuals. Contributing to poor socioeconomic status are higher unemployment rates, lower-status employment, and lower educational attainment among Latinos compared to non-Latino white individuals.1, 2
Latinos have less access to nutritionally adequate and safe food. Compared to 7.8% of non-Latino white individuals, almost 20% of Latinos are food insecure.3 Food insecurity has been linked to poor dietary quality, low quantity of food, and overweight/obesity. The high incidence of risk factors and chronic diseases among Latinos including obesity, type 2 diabetes and cardiovascular disease4, 5, 6 is exacerbated by lower physical activity levels compared to the rest of the population.7, 8
Community health workers (CHWs) have been defined as “community members who work almost exclusively in community settings and serve as connectors between health care consumers and providers to promote health among groups that have traditionally lacked access to adequate care.”9, 10 In the area of nutrition education, the term “peer educator” is commonly used. In the public health literature, the term “community health worker” has become the term of choice, although other terms such as promotora are also employed. When describing studies in this review, the authors use the term as reported in the original article.
Community health workers are expected to come from communities of the same socioeconomic status as those they serve, and to have similar cultural and social life experiences as their target clients. The nomenclature used to describe CHWs varies greatly in the scientific literature. Community health workers have been referred to as promotoras, lay health workers, community health advisors, paraprofessionals, patient navigators, outreach workers, aides, peer educators, and peer counselors, without having clear, specific definitions of these terms. The term used does not appear to be solely a function of the discipline studied or tasks performed.
Ideally, CHWs should have experienced a similar condition (eg, diabetes) or practiced the same behavior (eg, breastfeeding) that they are addressing and/or should have provided key support to a close friend or relative with the condition or practicing the behavior of interest.9, 10, 11, 12 The Chronic Care Model11 posits that CHWs play a crucial role linking communities with the health care system. Community health workers can perform multiple tasks, including disease and case management, the simple transfer of health information, support with medical appointments (eg, making appointment, transportation, presence during appointment), and support for health promotion.12
The documentation of the use of paraprofessionals to deliver social and health services in the United States began in the 1960s. Indeed, the use of nutrition education paraprofessionals was formally institutionalized through the creation of the Expanded Food and Nutrition Education Program (EFNEP) in the early 1960s13 and has greatly expanded through the Food Stamp Nutrition Education Program (FSNE).14 In developing countries, CHWs have been and continue to be used extensively to address diverse problems including infant mortality and corresponding causal factors (malnutrition, measles and other communicable diseases, diarrhea, respiratory infections), as well as human immunodeficiency virus (HIV), tuberculosis, and malaria in the general population.10, 15 Demonstration projects and small-scale programs in the United States and other developed countries have shown that CHWs are effective at improving diverse outcomes including infant feeding, immunizations, HIV prevention/self-management, diabetes self-management, and breast cancer screening rates.10, 15, 16 However, the impact of peer nutrition educators has not been systematically reviewed.
A recent report from a conference on peer-led approaches to dietary change in the United Kingdom reviewed 3 studies grouped into 3 categories: (1) older people living in shelters; (2) mother and infants (emphasis on weaning foods); and (3) individuals with diabetes.17 All studies targeted low-income individuals. The author concluded that these peer-led interventions can have positive impacts on knowledge, confidence, and attitudes, and small improvements in diet change. However, this conclusion should apply only to the infant feeding study as there were no positive results reported from the diabetes and elderly studies. For the latter 2 studies, the internal validity is highly questionable because of high attrition rates and limited statistical power. There are no published reviews addressing the effectiveness of CHWs who deliver nutrition education to Latinos. However, a systematic review published over a decade ago evaluated the impact of peer nutrition education. These findings are summarized in the following section.
In 1995 Contento et al examined the effectiveness of nutrition education at improving knowledge, attitudes, and behaviors across the life span.13 Their review included 217 experimental or quasi-experimental studies with adequate documentation of instrument reliability and validity. The authors included a chapter on the impact of training of paraprofessionals (EFNEP and WIC nutrition aides, school food service staff) and professionals (school teachers, nutritionists, health professionals) on their nutrition education effectiveness. Based on 2 controlled studies,18, 19 the authors concluded that well-developed training programs are effective at increasing paraprofessionals' general nutrition knowledge and breastfeeding knowledge, attitudes, and self-efficacy (for teaching breastfeeding). The review strongly supports a positive impact of paraprofessionals on nutrition knowledge, attitudes, and behaviors of target audiences.13 However, little emphasis was placed on Latino target audiences, which is understandable since the major growth of the Latino community nationwide is relatively recent and few studies were available at the time when their review was published.
The objectives of this systematic review are to: (1) assess the impact of peer education/counseling on type 2 diabetes, breastfeeding, and other nutrition knowledge, attitudinal, and behavioral outcomes among Latinos; (2) discuss the policy implications of findings; and (3) identify gaps in knowledge and future research needs. This review covers studies based on federal nutrition education programs (EFNEP and FSNE), as well as demonstration nutrition education programs.
Section snippets
Methodology
A systematic literature search (Figure 1) was conducted by: (1) searching Internet databases (PubMed); (2) conducting backward searches using reference lists from articles of interest; (3) manually reviewing the archives of the Center for Eliminating Health Disparities among Latinos (CEHDL); (4) searching the Journal of Nutrition Education and Behavior; and (5) directly contacting researchers in the field. The PubMed search was conducted using the following key words and combinations:
Diabetes Peer Counseling
Among Latinos, implementing lifestyle modifications to follow current diabetes self-management recommendations is often challenging.21 Moreover, the lack of culturally competent diabetes education programs that incorporate appropriate language, beliefs, values, costumes, and food preferences hinders the efficacy of existing programs. An emerging approach to improve self-management has been the incorporation of CHWs as part of the diabetes care team. Although several projects are already
Conclusions
This systematic review of experimental and quasi-experimental studies provides evidence that peer nutrition education has a positive influence on diabetes self-management and breastfeeding outcomes, as well as on general nutrition knowledge and dietary intake behaviors among Latinos in the United States. These findings are consistent with studies conducted with non-Latino white and black individuals, which suggests that it is important to formally incorporate peer nutrition educators as part of
Acknowledgment
The development of this article was funded by the Connecticut Center of Excellence for Eliminating Health Disparities among Latinos (CEHDL) (NIH-National Center on Minority Health and Health Disparities grant # P20MD001765). This work is dedicated to all our Latino communities, for their past, present, and future contributions.
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The development of this article was funded by the Connecticut Center of Excellence for Eliminating Health Disparities among Latinos (CEHDL) (NIH-National Center on Minority Health and Health Disparities grant # P20MD001765).