Running head: CULTURALLY COMPETENT BEHAVIORAL WEIGHT LOSS

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A culturally competent behavioral weight loss program for adult Latinos with a BMI >30kg/m2
Nadia Ledesma
Arizona State University

	
  

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Abstract
This study answers the question, “In Adult Hispanic BMI ≥ 30 (P), how does
development of a weight loss program that utilizes Motivational Interviewing (I) compared to
counseling and educational materials only (C) affect weight loss over the period of three months
(T).” There are limited published systematic reviews and randomized control trials to evaluate
the effectiveness of Motivational Interviewing (MI), in conjunction with diet and exercise to
promote weight loss. Participants (n = 5) were Latino patients of a local community health care
center who were overweight and medically at risk due to unhealthy lifestyles that were
determined through a screening test. The 4-week clinical pathway program used motivational
interviewing in one-on-one sessions every other week, and implemented the “Your Heart, Your
Life” curriculum the other weeks. One expected outcome included lower anthropometric
measurement numbers of participants’ WL, BMI, WC, and BP. Another expected outcome was
an increase in physical activity. Participants were also expected to earn a higher score on a posttest about nutrition and healthy living. A paired t-test and power analyses were used to assess its
effectiveness. Results indicated significant decrease in weight loss (t [5] = 3.68, p = .0211,
Cohen’s dz=1.647). For heart healthy habits, there were significant increases all three categories:
weight management (t [5] = - 3.36, p = .0211), cholesterol and fat (t [5] = - 3.138, p =.035, salt
and sodium (t [5] = - 4.899, p = .008). In addition, there was an increase in knowledge (t [5] = 4.000, p = .016). Every participant showed small gains. Future implications should include more
participants, including males, a control group, innovative activities that help to motivate a
community of learners and more flexibility in allotted time for interventions.

	
  

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Chapter 1 Introduction
Background and Significance
Epidemiology. According to the American Heart Association (AHA), American College
of Cardiology (ACC), Task Force on Practice Guidelines and the Obesity Society (TOS) and
U.S. Preventative task force (USPSTF) more than 78 million adults suffered from obesity from
the year 2009 to 2010 (Jensen et al., 2014). The World Health Organization (WHO) statistics
show that by 2015 2.3 billion adults will be overweight and that at least 700 million will be
obese. The WHO and the National Institute of Health (NIH) have defined overweight as having a
BMI between 25.0 and 29.9 kg/m2; and obesity as having a BMI greater than 30.0 kg/m.
Environmental factors such as of high-caloric-density food, the cost of fruits and vegetables and
genetic predisposition are two factors that have contributed to the epidemic rise in obesity
(Jensen et al., 2013).
Description of the population. The Latino Community is the fastest growing minority group
representing 15% of the US population. This will increase to an estimate of 25% by 2050 (Corsino et al.,
2012; Sandoval, Harris, Jennings, Hinyard, & Banks, 2012). When comparing major ethnic groups in

the United States, statistics show that the Latino community is the most affected by obesity.
Between 1991 and 1998 obesity among Latinos has increased by 80% (Sandoval et al., 2012).
Statistics show that 21% of Latinos have a higher occurrence of obesity compared to non-Hispanic
Whites (Corsino et al., 2012; Nguyen, Markides, & Winkleby, 2011). Moreover, 77% of Hispanic women
compared to 61% of non-Hispanic white women living in the United States have a body mass index
(BMI) ≥ 25 kg/m2 (Araiza, Velenzuela, & Gance-Cleveland, 2012 ; Lindberg et al., 2012) .
Unfortunately, obesity is not the only risk factor surrounding the Latino community. The
majority of Latinos who live in lower socioeconomic communities do not participate in physical activity,
have poor portion control and an increase alcohol intake and tobacco use (Sandoval et al., 2012).
	
  

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Literature has found that all the variables mentioned above contribute and increase weight gain.

Sandoval et al. (2012) found that 28% of Latinos compared to 23% of white did not participate in
physical activities. Furthermore, 80% of Latinos were found not to eat the recommended
servings of fruits and vegetables. The foods prepared in Latino families are higher in saturated
fat, cholesterol and sugars.
Health Implications. Obesity has been strongly correlated in the development of chronic
conditions such as diabetes, hypertension and heart disease (Drieling, Ma, & Stafford, 2011). In addition,
evidence confirms a direct relationship between persons of low socioeconomic status (SES) and obesity
secondary to the lack of access to healthcare, environmental factors such as: lack of access to healthy
foods, increase consumption of high-calorie low-nutrient foods and limited safe places to exercise
(Araiza, Velenzuela, & Gance-Cleveland, 2012 ; Drieling et al., 2011; Lindberg et al., 2012).

Fiscal Implications. It was reported that obese individuals accrued more than 147 billion
dollars in medical cost in 2008 (Jensen et al., 2013). Statistics show that obese persons incur a
46% more in inpatient cost, 27% more in physician visits and outpatient cost and have an 80%
increase spending on prescriptions (Drieling, Ma, & Stafford, 2011 ; Jensen et al., 2014).
Internal Evidence. As a result, there is a desperate need for obesity management in the
Latino community. Wesley Health Center is located in South West, Arizona and Eighty-three
percent of patients seeking medical attention at WHC are Hispanic and eighty-seven percent are
at the one-hundred percent or below the poverty level (Wesley Health Center, 2013). At this
time, WHC only provides programs dealing with DM, HTN and prenatal care. The current
treatment method for obesity treatment at WHC begins with the identification of a BMI greater
than 30kg/m2. This is followed by brief counseling provided by a physician and then the patient
is referred out to a health educator.

	
  

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Therefore, this project sought after adopting a culturally sensitive weight loss program in
aim to develop a clinical pathway that integrated motivational interviewing techniques, exercise,
and nutritional awareness in order to reduce life limiting comorbidities associated with obesity.
Problem Statement
Obesity contributes to 147 billion per year and 10% of the total annual medical
expenditures. In addition, Obesity is associated with increase risk of mortality secondary to the
development of risk factors such as: diabetes, cardiovascular disease, digestive disorders and
some cancers (Araiza, Velenzuela, & Gance-Cleveland, 2012 ; Drieling et al., 2011; Lindberg et
al., 2012). Therefore, culturally competent lifestyle modifications programs that emphasize
weight loss through physical activity and nutritional awareness are at the cornerstone to reducing
risk factors among economically disadvantaged Hispanics. Given the increase risk of obesity in
the Hispanic population it is imperative to institute programs that are culturally competent and
cost effective to provide aid to those suffering to overcome weight loss due to the lack of income
and inability to consider the challenges of the Hispanic population.
Lindberg et al. (2012) found that lifestyle modification programs do not influence weight
loss in Hispanic populations when compared to non-Hispanic White, English-Speaking
participants. In addition, various studies found that a majority of the weight loss programs did
not take into consideration the challenges of the Latino population. This was shown by slower
weight loss among Latino participants. Lindberg et al. (2012) found that the programs lacked
cultural concerns, education, implementation strategies and socioeconomic factors. Corsino et
al. (2012) also found that finding a weight loss program tailored towards the Latino community
was challenging since there have not been many programs that have been researched. Both

	
  

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Corsino et al. (2012) and Lindberg (2012) found that weight loss programs lacked acculturation
and sensitivity.
Motivational Interviewing (MI) is a method that has been proven to help with addictive
disorders (DiLillo & West, 2011). Current research finds that the same outcome can be obtained
with achieving weight loss. MI is a technique that has been proven to be effective in maintaining
weight loss. Maintaining weight loss is a difficult process that requires hard-work, patience and
discipline. MI is a technique that works one on one with the individual. This one on one process
involves identifying, articulating, and strengthening reasons for and rectifying them (Armstrong
et al., 2011 ; DiLillo & West, 2011). Motivational interviewing is a way of identifying current
and future problems by being empathic, supporting self-determination and enhancing selfefficacy to set the patient up for success (Armstrong et al., 2011 ; DiLillo & West, 2011).
Current weight loss programs utilize a variety of behavioral techniques such as;
individuals ability to regulate behavior by setting goals, behavior-change plans, developing
problem-solving skills, and intensive group and lifestyle counseling (Albarran et al., 2014 ;
Drieling et al., 2011 ; Lindberg et al., 2012) but fail to incorporate motivational interviewing as
an intervention. Only one study was found to utilize Motivational Interviewing in the Latino
Community and reports to have significant results (Corsino et al., 2012). Although, research
justifies that motivation is an strong indicator for weight loss adherence (Armstrong et al., 2011 ;
DiLillo & West, 2011 ; Teixeira et al., 2012) MI is a fairly new strategy and not widely used in
the Latino community. MI is a technique that has been proven to be helpful in conjunction with
dietary modification and physical activity (Armstrong et al., 2011).
PICOT Question

	
  

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This inquiry has led to the clinically relevant PICOT question, “In Adult Hispanic BMI ≥
30 (P), how does development of a weight loss program that utilizes Motivational Interviewing
(I) compared to counseling and educational materials only (C) affect weight loss over the period
of three months (T).
Search Strategy
An exhaustive search was performed using PubMed, CINAHL and PsycInfo. Keywords
included; Hispanic, weight reduction, weight loss, obesity, motivational interviewing. By setting
certain limits such as limiting to research conducted within 5 years, inclusion of only scholarly
articles and combining each of this terms with either Mexican Americans, Latinos, Hispanic
Americans, and obesity“ AND” or “OR” it yielded more manageable yield of less than 200
references in each database. Connecting these terms with Motivational Interviewing yielded less
than 15 references in each database (Appendix A, B and C).
Articles were selected based on the following exclusion criteria studies published prior to
2010, doctoral dissertation studies targeting only one particular race, participants , 18 years old,
and patients who were either pregnant or with a diagnosed psychiatric disorder. Studies that were
researched included BMI ≥ 25, Latino community, MI or models of behavior change and
community weight loss programs.
Extensive research based on the aforementioned inclusion and exclusion criteria resulted
in sixty studies where only ten were chosen. After further review of the original sixty articles,
fifty of them were tossed aside due to lack of supporting evidence, inadequate documentation,
unsubstantial statistical data, and inconclusive results. The ten original research articles chosen
met the previously established inclusion criteria and were supportive and relevant to proving the

	
  

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stated PICOT question. Each study was reviewed and the data needed to support the PICOT
question was organized into tables for clear analysis and review (See Appendix G).
Evidence Synthesis
Currently there are a limited amount of systematic reviews and randomized control trials
that evaluate the effectiveness of MI in conjunction with diet and exercise to promote weight loss
in the Adult Hispanic Population. The literature within the past five years only exposes one level
one systematic review (Armstrong et al., 2011), two level II RCTs (Balcazar et al., 2010;
Gustafson et al., 2009). Seven level III studies that include five cohort studies (Araiza et al.,
2012; Balcazar et al., 2015; Corsino et al., 2012; Hardcastle et al., 2012; Lindberg et al., 2012),
one cross sectional study (Sandoval et al., 2012) and one qualitative study (Albarran et al., 2014).
Although the current literature is not relatively strong, all ten systemic reviews revealed a direct
relationship between weight loss and the use of MI techniques in conjunction with physical
activity and diet modification.
Purpose
The primary care clinic located in South West Phoenix, Arizona serves primarily
uninsured low socioeconomic Hispanic individuals. Health care providers (Physicians, Advanced
Nurse Practitioners, Registered Nurse, Medical Assistants, health educators and Behavioral
Specialist) play an integral part in addressing the obesity epidemic. The Latino community is
made up of various ethnicities, though two out of three Latinos are of Mexican descent
(Sandoval et al., 2012).
It is important to take into consideration that the majority of Wesley Health Center
(WHC) population is uninsured and of poor socioeconomic status. Araiza et al. (2012) found that
obesity is correlated with low socioeconomic status and Latinos/Hispanics are typically younger,

	
  

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less educated, unemployed, working in high risk occupations, live in poverty and live in larger
households. It has been reported that Mexican women who live below the poverty line are at a
13% higher risk to be overweight or obese (Faucher & Mobley, 2010). There are multiple
common themes that have been found to contribute to the rate of obesity in the Mexican
American population. These common denominators include : culture and social influences, lack
of knowledge about nutrition, portion control, risk factors (tobacco use, increase alcohol intake)
insufficient consumption of fruits and vegetables, reduced physical activity, mental health,
limited literacy and numeracy, Mexican traditions, differences in physical environment (safety,
recreational facilities) and healthy food accessibility due to low-income (Albarran, Heilemann, &
Koniak-Griffin, 2014 ; Araiza et al., 2012 ; Corsino et al., 2012 ; Drieling et al., 2011; Faucher &
Mobley, 2010 ; Lindberg et al., 2012 ; Sandoval et al., 2012).
The purpose of this project is to implement a culturally competent behavioral weight loss
program that will be successful in promoting lifestyle modification, inspire weight loss and
reduce risk factors in the Latino community. The objective is to institute a behavioral weight loss
program that integrates MI, physical activity and nutritional awareness.
Chapter 2 Applied Clinical Project: Methods & Results
Chapter two will illustrate the conceptual/theoretical model (Appendix D) and the
evidence based model (Appendix E) and its application (Appendix F) that guided the entire
project and intervention. In addition, the following chapter will show the methods of the
scholarly project by: protection of human subjects and recruitment, setting, participants,
intervention, measures, data collection and analysis plan and proposed budget. In conclusion of
the chapter, it will discuss the project results and comparison to other literature including the
strengths and limitations of the project.

	
  

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Evidence Base Practice Model
There are various models available to the clinicians that are intended to help facilitate
evidence based change in practice. For the purpose of this research, the Model for Evidence
Based Practice Change is used. This model allows for guidance through the development and
integration of change within a healthcare community. The end result is change within an
established practice. The model is broken down into six steps. Through the six steps a problem
is identified. Best practice evidence is then gathered to support the need for change. Then all
evidence is critically analyzed. Next step is to design a plan to promote change. Once the
appropriate changes are made, evaluate the results. Lastly, if appropriate, integrate and make
permanent change within the practice (Melnyk & Fineout-Overholt, 2014). The logical model
seen in (Appendix F) is an application of the evidence model approach to develop and integrate
change within the community.
Conceptual Theory
The social cognitive theory has been used to guide interventions aimed to increase
nutritional habits and increase physical activity. The social cognitive theory recognized that
behavior change is influenced by individual factors (cognitive, affective, biological), social and
physical environment (Linke, Robinson, & Pekmezi, 2013). A crucial element of the social
cognitive theory is self-efficay that is defined as the driving force behind behavior change. Selfefficacy has been found to be driven by mastery experiences, social modeling, improving
physical and emotional states and verbal persuasion. Strategies that are utilized to reach optimal
intensity and motivate behavior change are pedometers, step logs and diaries (Linke et al., 2013).
Conceptual Framework

	
  

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The conceptual model that will be implemented is the Salud Para Su Corazon – National
Council of La Raza Promotora Model (SPSC-NCLR) for promoting heart-healthy behaviors
among Latinos (Balcazar et al., 2006). SPSC-NCLR is a promotora outreach model that
incorporates several key components: (1) theory-driven elements that guided the original SPSC
project including participatory and social action research (2) the community-based organizations
(CBOs); (3) culturally enriched process dimensions incorporated in the planning, development,
implementation, and evaluation of the promotora approach; (4) the train-the trainer model of
promotoras; (5) the dynamic relation that include health, community, and economic
development; employment and training; and outreach activities such as forums and national
meetings (Balcazar et al., 2006)
Community Health Workers (CHW’s) are commonly vital to the success of SPSCNCLR. CHW is the liaison that delivers lifestyle behavior programs in at risk populations.
CHW’s are known as Promotoras in the Hispanic and Latin community. Systematic literature
reviews has found that Promotoras not only deliver information and emotional support but they
significantly impact Latino communities at risk for cardiovascular disease, Diabetes and obesity
by improving eating habits, physical activity and anthropometric measures (body mass index,
weight, waist circumefernce), lipoprotein profiles and decreases in blood pressure (Balcazar et
al., 2006 ; Koniak-Griffin et al., 2015).
The study model (Balcazar et al., 2006) tracks important factors to gauge the
effectiveness of the study. The aim of the SPSC-NCLR model is to monitor changes in heart
health knowledge and attitudes. The study model also tracks the delivery of the curriculum and
educational sessions delivered by the promotoras to Latino Families. In order to implement
these permanent behavioral changes the study delivers a series of community educational

	
  

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activities. Finally the study provides the outcome evaluated by the changes in heart-healthy
behaviors reported by Latino family participants.
Methods
Ethics. Permission to initiate this program was obtained from the Arizona State
University Institutional Review Board (IRB). The promotora’s and staff recruited participants
and if agreed to participate in the program the project leader obtained consent.
Setting. Wesley Health Center (WHC) is an establishment that provides health care to the
underserved populations including: migratory and seasonal agricultural workers, the homeless,
and residents of public housing. In the fiscal year of 2012 to 2013 WHC provided services to a
total of 20,518 patients. Of those patients, 14% were insured and 86% were uninsured. The
population is composed of 69%, female; 31%, male; 83%, Hispanic; and 87% are at 100% or
below the Federal Poverty Level. WHC provides services related to family medicine, pediatrics
and obstetrics. The clinic is made up of physicians, nurse practitioners and medical students
(Wesley Health Center, 2013).
Organizational Culture. WHC is a Federally Qualified Health Center (FQHC), 501 (c)
3 Nonprofit / Non-Governmental organization, its mission is to empower positive change by
working together (WHC, 2013). WHC is an organization that has served the underprivileged
community since the 1950’s and continues to abide by their mission and values through offering
programs, activities, and health services to all individuals that are of low socioeconomic status in
aims to bridge the gap of health disparities in a population that would not have access to such
services (WHC, 2013). WHC is an organization that is home to many underprivileged
individuals and hopes to continue to work together with students, volunteers, institutions and

	
  

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implement evidence based practice that supports the fight against obesity, hypertension, diabetes
and coronary artery disease.
Participants. The participants eligible for the behavioral weight loss program are adults
>18 to 65 years of age, Spanish speaking within the Wesley health center system, with a BMI
>30 kg/m2. The sample (n = 5) consisted of 100% women, 100% Latino and 100% Spanish speaking.
The ages ranged from 32 to 62 years, with a mean age of 45.

Program Intervention. IRB approval was finalized in September (See Appendix G),
participants were recruited the last week of September and beginning of October at Wesley
Health Center. Participants were recruited for screening by study staff who solicited patients in
the clinic or by referral from a primary care provider. Fliers titled Healthy Rhythm “Ritmo
Saludable” were posted in the waiting room, recommending that patients speak with their
healthcare provider if they are interested in participating in the study.
Spanish speaking CHW’s contacted potential participants by phone and explained the
program and asked if individuals were interested in participating. Participants were asked to
agree to attend a weekly course of 2 hours for 3 weeks and 3 individual 1 hour sessions. If
participants were interested they met with the project leader and a CHW to sign consent forms.
Once consented, an individual session was held were height and weight were taken and Body
Mass Index calculated as well as blood pressure, waist circumference all which were taken by
project leader. The 5 A’s Behavioral Change Model was administered by the CHW’s and
emphasized topics such as; healthy food choices, portion control, healthy eating, managing
emotional eating and increasing physical activity with the goal of walking 10,000 steps a day.
Participants were contacted by phone to notify them of the start date and time of the sessions.
The official start date was October 1st, 2015. The group sessions were led by the
promotora and the project leader. The group session instituted the Your Heart, Your Life (Su
	
  

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Corazon Su Vida) curriculum. The Su Corazon Su Vida curriculum is a culturally relevant,
promotora managed educational program developed for Latino communities by the National
Heart, Lung and Blood Institute (National Heart, Lung, and Blood Institute, 2008). The program
aims to promote healthy lifestyle behaviors (diet and physical activity) for reduction of
cardiovascular disease risk. The standard content of the curriculum is eleven two hour sessions.
Ten minutes of each class incorporated instructor led stretching techniques. Individual sessions
were made available if a participant missed a group session. After each group session an
individual session was scheduled at the participant’s request that was designed to reinforce class
content, institute the 5’As behavioral model that will support and motivate behavior change.
There were 3 individual teaching sessions and phone calls to remind participants of the group
sessions and schedule individual sessions. There were two cooking courses where participants
learned how to plan, choose, and prepare healthy diets for traditional Latino meals. To promote
physical activity a pedometer was given to the participants to achieve a goal of 10,000 steps per
day. Evidence based practice shows significant positive results with the use of the pedometer
influencing physical activity (Bravata et al., 2007).
Outcome Measures. The data will be collected at baseline and at the last individual
session. The measures to be analyzed will be dietary habits, body weight, height and waist
circumference, blood pressure and knowledge of cardiovascular disease. These categories will be
assessed by administration of my health habits questionnaire. The questionnaire was initially
developed in Spanish as part of the National, Heart, Lung and Blood Institute’s initiative for
Latino Cardiovascular Disease Prevention, and underwent translation to English. Several Su
Corazon, Su Vida studies report acceptable internal consistency (Balcazar et al., 2006 ; Balcazar

	
  

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et al., 2010 ; Koniak-Griffin et al., 2015), Internal consistency for Koniak-Griffin et al. (2015)
sample was satisfactory with a Cronbach’s α = .79.
Dietary habits will be assessed by a 25 – item questionnaire of my health habits
associated with salt and sodium consumption, cholesterol and fat consumption and weight
management. Item responses are on a 4-point scale (1 = never to 4 = all the time). The
questionnaire includes items that address healthy food choices, portion control and emotional
eating. Examples include “Do you eat more when you feel stressed”, “Do you eat low fat
cheese”, and “Do you add salt to fruit.”
Body weight will be measured using a digital weight scale. The participants will be asked
to remove their shoes and jacket and/or sweater. Per the recommendations of the CDC (Center
for Disease Control Prevention, 2013) the participants will be asked to stand in the center of the
scale platform with their hands at their sides looking straight ahead. Height will be measured via
a stadiometer with a fixed vertical backboard and an adjustable headpiece. The participants will
be asked to remove any hair accessories, they are asked to stand up straight against the
backboard with both feet flat on the platform, with heels together and toes apart, ensuring that
the head, shoulders and heals are touching the backboard (Center for Disease Control, 2013).
Waist circumference will be evaluated by using a Gulick tape measure following the National
Obesity Expert Panel Report guidelines (NHLBI, 2000). Blood pressure measurements will be
obtained using the guidelines of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure.
Knowledge of heart disease will be assessed by “My health habits” 14-item
questionnaire, administered at the beginning and after the 3 weeks of classes. Participants will be
asked to respond using a (1= yes, 2 = no and 3 = Don’t Know) format. Examples of questions are

	
  

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“Can high waist measures increase your risk of heart disease”, “Can eating foods that are high in
sodium increase your risk for high blood pressure” and “Does lard have a low amount of
saturated fat.”
Data Collection. Once consent is obtained at the first individual session, the project
leader will administer the physical readiness questionnaire (PAR-Q). If the participant answers
no to all the measures, the participants will be able to participate in the program immediately. If
the participant answers yes to any of the questions or is over the age of 69 years of age, clearance
will have to be provided by the healthcare provider. When and if able to participate after
administration of the PAR-Q, anthropometric measures such as height and weight will be taken
and Body Mass Index calculated by project leader, as well as blood pressure and waist
circumference. At that time a pretest will also be administered. At the end of the program height
and weight will be taken to calculate BMI, blood pressure and waist circumference and a posttest
will be administered.
Analysis Plan. A paired t-test was used to evaluate the effectiveness of the pre and posttest differences from the Heart Health Habits questionnaire, and analyze the new anthropometric
measures of body weight, body mass index, waist circumference, and blood pressure.
Cost and Benefit Analysis. The proposed budget of the program included pedometers,
twenty pedometers were purchased for a total of $150.00. Two Cooking classes were provided
for a total of $120.00 including a $ 30.00 dollar gift card given to the cooking instructor.
Photocopying and instruments will be a total of $50.00. Indirect costs such as lights, telephones
and office space will be provided by Wesley Health Center. The total sum of this clinical
scholarship project will be $300 dollars (See Appendix H).
Results

	
  

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Twelve participants were identified from recruitment efforts and expressed interest in the
study. Of those, only 5 (n=5) completed the program and were included in the report. Obstacles
included transportation, day care, work, and having to leave the country. All participants were
female, despite recruitment strategies targeted at male participants. All participants resided in
Phoenix, Arizona, and were patients of Wesley Health Center.
Results indicated significant decrease in weight loss (t [5] = 3.68, p = .0211, Cohen’s
dz=1.647). For Heart Health Habits, there were significant increases in all three categories:
weight management (t [5] = - 3.36, p = .0211), cholesterol and fat (t [5] = - 3.138, p =.035, salt
and sodium (t [5] = - 4.899, p = .008). In addition, there was an increase in knowledge (t [5] = 4.000, p = .016). Data are summarized in Table 1 and 2. A paired t-test was used to assess the
effectiveness of the program with reference to changes in	
  weight, BMI, waist circumference and
blood pressure. Results of paired-samples t-tests for changes revealed decreases in all four
measurements. However, only one of the four measures had a decrease that was statistically
significant. Weight decreased significantly (t [5] = 3.68, p = .0211) from pretest (M = 107.73,
SD = 34.56) to posttest (M = 106.20, SD = 33.97). The BMI decrease from pretest (M = 41.54,
SD = 8.50) to posttest (M = 41.38, SD 8.22) was not statistically significant (t [5] = 1.18, p =
.3030). Decrease in waist circumference was negligible. Blood pressure decreased from pretest
systolic (M = 6.40, SD = 4.35) to post systolic (M = 135.20, SD = 15.20) and was statistically
significant (t [5] = 3.01, p = .030). However, blood pressure diastolic pre (M = 94.40, SD =
11.26) and diastolic post (M = 8.40, SD = 7.92) showed no significant difference (t [5] = 2.37, p
= .077).
Paired t-tests in the following categories demonstrated statistical significance: salt and
sodium consumption, cholesterol and fat consumption, and weight management. Salt and sodium

	
  

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consumption (t [5] = - 4.899, p = .008) from pretest (M = 2.4000, SD =.38168) to posttest (M =
3.066, SD = .23040) decreased significantly. Cholesterol and fat consumption decreased
significantly (t [5] = 4.89, p = .008) from pretest (M = 2.200, SD = 1.043) to posttest (M = 2.73,
SD = .7226), and weight management decreased significantly (t [5] = -3.497, p = .025) from
pretest (M = 2.700, SD = .4643) to posttest (M = 3.150, SD = .2404).
Paired t-test for the results from Heart Health Habit lessons revealed statistical
significance for heart disease (t [5] = - 4.004, p = .016) from pretest (M = 9.60, SD =1.341) to
posttest (M = 12.00, SD = .0000). For confidence in cooking healthy meals demonstrated
statistical significance (t [5] = - 3.500, p = .025) from pretest (M = 2.60, SD =.8944) to posttest
(M = 4.000, SD = .0000).
Discussion
The purpose of this behavioral weight loss program was to teach aspects of a healthy
lifestyle for at-risk Hispanic populations. Change was achieved through a clinical pathway that
emphasized motivational interviewing during one-on-one sessions. Specifically, interaction
focused on behavior, physical activity, and diet modification. Synthesis of the literature
demonstrated that Your Heart, Your Life is an appropriate health educational tool that is
culturally competent to promote weight loss, healthy eating and increased physical activity in the
Latino community. This scholarly project was led through the application of the social cognitive
theory, SPSC-NCLR promotora model and the evidence based practice model that aided in
delivering the Su Corazon, Su Vida.
While, this study had its limitations, it effectively established that the Your Heart, Your
Life curriculum is successful in increasing knowledge and that motivational interviewing was
effective in modifying behavior change. The pre and post-test evaluation demonstrated

	
  

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significant improvements in knowing heart healthy habits. Yet, there were no significant or
breakthrough changes. Feedback from the participants stated that promotoras were essential in
motivating them and promoting behavioral lifestyle modification.
Conclusion
The purpose of this behavioral weight loss program is to promote a healthy lifestyle and
prevent life threatening cardiovascular diseases in at risk Hispanic populations. This program
hopes to promote change through an interdisciplinary approach that focuses on behavior,
physical activity and diet modification. Synthesis of the literature demonstrates that Your Heart,
Your Life is an appropriate health educational tool that is culturally competent to promote weight
loss, healthy eating and increased physical activity in the Latin community. This scholarly
project has been led through the application of the social cognitive theory, SPSC-NCLR
promotora model and the evidence based practice model that will aid in delivering the Su
Corazon, Su Vida curriculum as well as lead the individual sessions in the Latino community.
Chapter 3 Organizational/Health Policy Impact & Sustainability
Chapter 3 will discuss the potential impact of the project on the clinical site, as well as
demonstrate financial implications of the project. It will also discuss the impact of current policy,
role as a leader, sustainability plan for project, implications for further application and describe
gaps identified during project.
Impact of project at clinical site. Participants benefited from the program by learning
skills like how to set realistic goals and gaining heart healthy habits through increasing physical
activity, cooking heart healthy meals, and learning how to read and understand food labels.
Using a promotora in establishing this clinical pathway made the program sustainable and
feasible to implement and practice change. Speaking Spanish and acculturating Latino traditions

	
  

CULTURALLY COMPETENT BEHAVIORAL WEIGHT LOSS

20

motivated all five participants to complete the program. Stakeholders recognized the value of a
promotora as a resource and their impact on individuals with health disparities and
comorbidities. They are interested in this clinical pathway as a way to continue gaining
momentum for their patients who need motivation, education, and confidence in changing their
present lifestyles.
Financial Implications. Balcazar et al. (2006) determined the cost of a promotora by
developing a measure that considered estimating the total number of hours of activity for
promotoras in a community. Total invested hours for a promotora included time devoted to
training, family program delivery; follow up with families, and promotora activities at
community events. The average cost per hour for a promotora time was $10.77. Funds were not
available to support this wage, based on the hours worked; however, promotoras agreed to
volunteer their time and expertise. In this evidence based project the aim was to seek two
promotoras willing to volunteer their time, and they were each given a $10 gift card for their
work. Direct costs of the program included purchasing twenty pedometers at a total of $150.00.
Two cooking classes were provided for a total of $120.00, including a $30.00 gift card presented
to the cooking instructor. Photocopying and instruments totaled approximately $50.00. Indirect
costs such as lights, telephones and office space were provided by Wesley Health Center. The
total sum of this clinical scholarship project was $300 dollars (see Appendix Q).
Current Policy. Significant and worthy results were found in this evidence based
scholarly project. Although the feasibility of the sustainability of this project is not high and can
only be done with volunteer CHWs, dedication and enthusiasm cannot be compromised. In order
for CHWs (promotoras) to facilitate quality services and increase health knowledge through a
range of activities, they must be compensated. Evidence based practice has proven that CHWs

	
  

CULTURALLY COMPETENT BEHAVIORAL WEIGHT LOSS

21

improve the health of populations (Health Resources in Action of Boston for the Maricopa
County Department of Public Health, 2013). At this time there is no funding to support CHWs.
However, they are now widely acknowledged through the Affordable Care Act (ACA) and
recognized for the contribution and impact that they will have on triple aim reform (Health
Resources in Action of Boston for the Maricopa County Department of Public Health, 2013).
Role as a leader. Qualities of leadership emerge when qualities of relationships are
made. Attributes like trust, ethics, integrity and growth are essential in effectively projecting a
desired vision; therefore, communication is essential. Being a leader means seeing the whole,
not just its parts. Porter-O’Grady and Malloch (2015) refer to structure as a tree that depends on
its overall shape for survival. The branches, trunk and leaves are what sustain its balance and
harmony. Finding the balance is achieved by finding just enough structure to support the
integrity of the industry. When hospitals and health care centers expand, so come more patients,
which results in hiring more staff. If more structure is built, then more support will be needed in
order to sustain future innovative programs, such as what has been successful in this study.
As an innovative Doctor of Nursing Practice (DNP) leader, an enormous amount of
responsibility is acquired and expected. A leader is a knowledgeable person who has substantial
influence in an organization’s culture. An innovative DNP makes ethical and sustainable
decisions when building consensus for creating systemic change. Promotora-led programs work
because of the acculturation of the both workers and participants.
Sustainability Plan. Implications for future study include training practices for
promotoras, using innovative communication technology, electronic apps that give health care
providers access to connect with within minutes, and a suitable app to conduct face-to-face
contact with a promotora (ex. Skype, FaceTime, etc). The intake process would require ice

	
  

CULTURALLY COMPETENT BEHAVIORAL WEIGHT LOSS

22

breakers and “getting to know you” activities, and building a “sense of community” with the
group. Additionally, incorporating easy to use mobile tracking devices to count steps will
encourage physical activities. Although a cost and benefit analysis must be completed before
moving forward, it is vital to continue innovative programs designed to improve healthy habits.
A mechanism to sustain awareness and activity beyond the required four weeks is also essential
to individual success.
Implications for application. The implications for future practice include a method of
licensure and compensation for promotora services and a larger number of participants should be
recruited, including males. There must also be a control group. Further, there must be flexibility
in adjusting interventions for longer periods of time, as needed. Finally, qualitative input from
the participants would benefit future programs.
Gaps in the project. Results of the study correlated with success of the literature and the
evidence synthesis. Significant results indicated that participants learned relevant information on
healthy eating. While the study was unable to measure physical activity, participants were
engaged in goal setting and increasing physical activity while incorporating pedometers into their
exercise routine. Review of the literature emphasizes the use of promotoras in Latino
communities. As valuable resources, they are used to help reduce health disparities in patients.
Promotoras use a variety of teaching techniques that include self-discovery, empowerment, and
value clarification based on storytelling, cultural symbolism, hands-on activities, role-playing
and community health talks (Balcazar et al., 2006). Promotoras work alongside health
professionals in lifestyle health promotion.
Conclusion

	
  

CULTURALLY COMPETENT BEHAVIORAL WEIGHT LOSS

23

The success and limitations of the study begin with the recruitment and retention of the
participants, respectively. Having the Wesley Health Center and its workers agree to assist in
creating a promotora-led program on healthy habits was the first step. The healthcare providers
knew the need for such a program and were excited to develop a clinical pathway of motivational
interviewing for changing habits in their community. The participants projected feelings of
excitement, motivation, and interest in improving their lifestyle. Chang et al. (2009) found that
recruitment and retention are vital in a population of racial and ethnic minorities that are of low
income and are seeking to implement behavioral lifestyle modifications. Utilizing an adaptive
and comprehensive approach, the recruitment included partnerships with not only the health care
providers, but with the staff of WHC. One key element was the flexibility of the promotora in
meeting the participants at home, during the weekend, and allowing children to attend the
appointments, or meeting them at the closest coffee shop or restaurant (Warner et al., 2013). The
major disappointment was retention. Only five of twelve participants completed the project,
despite signing a Commitment Form at the beginning of the program. Many stated that they were
not able to attend the courses secondary to lack of transportation, childcare, insufficient funds,
and family and personal issues. In future studies, recommendation would be to adhere to the
strategies provided by Parra-Medina et al. (2004), such as hiring staff from the community that
reflect the participant’s cultural backgrounds, provide free transportation and child care, and
focus on classroom activities that promote a community of participants achieving the same goals.

	
  

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References
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Barnes, R. D., White, M. A., Martino, S., & Grilo, C. M. (2014). A randomized controlled trial
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Svetkey, L. P. (2012). The Latino health project: pilot testing a culturally adapted
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DiLillo, V., & West, D. S. (2011). Motivational interviewing for weight loss. , 34, 861-869.
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overweight and obesity in adults. , 63, 2985-3023.
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factors and Latino body mass index: A cross sectional study in Missouri. , 23, 1750-1767.
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The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in
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CULTURALLY COMPETENT BEHAVIORAL WEIGHT LOSS
Appendix A
EBSCO	
  search	
  strategy	
  

	
  

28

CULTURALLY COMPETENT BEHAVIORAL WEIGHT LOSS
Appendix B
PubMed Search Strategy

	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  

29

CULTURALLY COMPETENT BEHAVIORAL WEIGHT LOSS
Appendix C
ProQuest Search Strategy

	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  

	
  

30

CULTURALLY COMPETENT BEHAVIORAL WEIGHT LOSS
Appendix D
Conceptual/theoretical model

	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  

	
  

31

CULTURALLY COMPETENT BEHAVIORAL WEIGHT LOSS
Appendix E
Evidence based model	
  

	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  

	
  

32

CULTURALLY COMPETENT BEHAVIORAL WEIGHT LOSS
Appendix F
Application

	
  

33

CULTURALLY COMPETENT BEHAVIORAL WEIGHT LOSS

34

Appendix G
IRB Approval

The IRB approved the protocol from 9/2/2015 to 9/1/2016 inclusive. Three weeks before
9/1/2016 you are to submit a completed Continuing Review application and required attachments
to request continuing approval or closure. If continuing review approval is not granted before the
expiration date of 9/1/2016 approval of this protocol expires on that date. When consent is
appropriate, you must use final, watermarked versions available under the “Documents” tab in
ERA-IRB. In conducting this protocol you are required to follow the requirements listed in the
INVESTIGATOR MANUAL (HRP-103).
	
  
	
  
	
  

	
  

CULTURALLY COMPETENT BEHAVIORAL WEIGHT LOSS
Appendix H
Schedule Proposal

	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  

35

CULTURALLY COMPETENT BEHAVIORAL WEIGHT LOSS
Appendix I
Site Authorization Letter

	
  
	
  

	
  

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37

Appendix J
Demographics
Table 1
Demographics
Participants

Age

Gender

Family Hx of DM

Family Hx of CAD

1.

44

F

NO

NO

2.

42

F

YES

NO

3.

62

F

NO

YES

4.

48

F

NO

NO

5.

32

F

YES

NO

	
  

	
  

	
  

CULTURALLY COMPETENT BEHAVIORAL WEIGHT LOSS

38

Appendix K
Table of Statistical Results
	
  
Table 2
Paired-samples t-test Results for Weight and BMI
Pretest

95% CI Mean Difference

Posttest

M

SD

M

SD

n

Lower limit, Upper Limit

df

t

p

Weight

107.73

34.56

106.20

33.97

5

.37561, 2.67639

4

3.68

.0211*

BMI

41.54

8.50

41.38

8.22

5

-.21610, .53610

4

1.18

.3030*

Outcome

	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  

CULTURALLY COMPETENT BEHAVIORAL WEIGHT LOSS

39

Appendix L
Table of Statistical Results

Table 2
Paired-samples t-test Results for Sys/Diastolic blood pressure and Health habits
Pretest

95% CI Mean Difference

Postest

Outcome

M

SD

M

SD

n

PreSys-

141.60

18.02

135.20

15.20

5

94.40

11.26

86.00

6.48

2.700

.46435

3.150

2.200

1.043

2.400

Lower limit, Upper Limit

df

t

p

1.01627,-11.78373

4

3.301

.030

5

-1.43975, 1823975

4

2.370

.077

.2404

5

-.80732, -.09268

4

-3.497

.025

2.733

.7226

5

-1.00524, -.06143

4

-3.138

.035

.3816

3.0667

.2304

5

-1.04449, -.28884

4

-4.899

.008

9.600

1.34164

12.000

.0000

5

-4.06587, -.73413

4

-4.000

.016

2.600

.89443

.40000

.0000

5

-2.51058, -.28942

4

-3.500

.025

PosDias
PreDiasPosDias
PreWM PostWM
PreCF PostCF
PreSS PostSS
PreKnw PostKnw
Preknw
conf Postknw
conf

	
  
	
  
	
  
	
  
	
  

	
  

CULTURALLY COMPETENT BEHAVIORAL WEIGHT LOSS
Appendix M
Materials Used in the Intervention

	
  

40

CULTURALLY COMPETENT BEHAVIORAL WEIGHT LOSS
Appendix M
Materials Used in the Intervention

	
  

41

CULTURALLY COMPETENT BEHAVIORAL WEIGHT LOSS
Appendix M
Materials Used in the Intervention

	
  

42

CULTURALLY COMPETENT BEHAVIORAL WEIGHT LOSS
Appendix N
Materials Used in the Intervention

	
  

43

CULTURALLY COMPETENT BEHAVIORAL WEIGHT LOSS
Appendix N
Materials Used in the Intervention

	
  

44

CULTURALLY COMPETENT BEHAVIORAL WEIGHT LOSS
Appendix N
Materials Used in the Intervention

	
  

45

CULTURALLY COMPETENT BEHAVIORAL WEIGHT LOSS

46

Appendix O
Instrument

	
  
	
  
	
  
	
  
	
  

CULTURALLY COMPETENT BEHAVIORAL WEIGHT LOSS
Appendix O
Survey
	
  

	
  

47

CULTURALLY COMPETENT BEHAVIORAL WEIGHT LOSS
Appendix O
Survey

	
  

48

CULTURALLY COMPETENT BEHAVIORAL WEIGHT LOSS
Appendix O
Survey

	
  

49

CULTURALLY COMPETENT BEHAVIORAL WEIGHT LOSS
Appendix O
Survey

	
  

50

CULTURALLY COMPETENT BEHAVIORAL WEIGHT LOSS
Appendix O
Survey

	
  

51

CULTURALLY COMPETENT BEHAVIORAL WEIGHT LOSS
Appendix P
Table of Content

	
  

52

CULTURALLY COMPETENT BEHAVIORAL WEIGHT LOSS
Appendix Q
Budget
Direct

Cost

Promotoras (Gift Card)

10$

Pedometers (12)

150$

Cooking Instructor

30$

(Gift Card)
Groceries

120$

Photocopying/Instruments

50$

Indirect

Cost

Light, telephones, office

0$

space
Sum
	
  
	
  
	
  

	
  

300.00$

53