Designing a Culturally Appropriate Group Navigation Model to Improve Mental and Emotional Health Equity for Spanish-Speaking Latina Women
Phase: NA
Conditions: Mental Health Wellness 1, Depression
Sponsor: University of New Mexico

1 
Designing a Culturally Appropriate Group Navigation Model to Improve Mental and Emotional Health 
Equity for Spanish-Speaking Latina Women 
NCT Number: 03901430  
Unique Protocol ID: 18-305 
Document Date: 03-30-2018
Principal Investigator 
Julia Meredith Hess, Ph.D., Prevention Research Center, UNM 
Research Team: 
Principal Community Mentor and Co-Investigator 
Guadalupe Fuentes, Centro Sávila 
Community Mentor 1  
Jacqueline Perez, LCSW, Centro Sávila/The Hopkins Center 
Community Mentor 2 
Alma Olivas, Centro Sávila 
Research Mentor 
Janet Page-Reeves, Ph.D., Family and Community Medicine, UNM 
Biostatistician 
Cameron Solomon, Ph.D. Prevention Research Center, UNM 
Community Partner Agency 
Centro Sávila 
Bill Wagner, Ph.D., MSW, Director 
Research Assistant 
Annette Carrion, UNM Student 

 
2 
Specific Aims  
 Hispanic women (Latinas) experience mental and emotional health (MEH) concerns and disorders 
that often go unrecognized by health providers, and even when recognized, Latinas have low-levels of 
treatment follow-through with biomedical modalities. Using a novel community-directed, solution-
based approach to increase access to existing services and nurture culturally meaningful social 
relationships, it is possible to address social determinants of health and reduce these disparities. 
The goal of this study is to implement such an approach conceptualized by a community health 
worker (CHW) to pilot an innovative, multi-level intervention to address social and structural 
determinants that negatively influence MEH disparities for Latinas from low-income households. The 
proposed research integrates CHW navigation with group peer support. Both of these strategies have 
been shown to be culturally appropriate and effective for improving a variety of health outcomes with 
this population. Our transdisciplinary, community-engaged team will use a convergent parallel mixed 
method research design to assess the feasibility of the intervention and its impact on six domains of 
interest: 1) emotional support, 2) informational support, 3) depression, 4) social isolation, 5) 
empowerment, and 6) social determinants needs. As part of our preparation for future extramural 
funding, we will include development of an advocacy plan for multi-level social change impact. 
   Aim 1. Create a group navigation model to improve mental and emotional health equity for Spanish-
speaking Latina women.  In a series of peer group sessions facilitated by Guadalupe Fuentes, a CHW 
who designed the model, we will create a culturally-appropriate, non-stigmatizing group intervention. 
The group process will allow participants to explore their own MEH, better understand the ways that 
mental health influences well-being and everyday dynamics of their lives, and to develop empowering 
knowledge and action plans through the support of other women. We will document group discussions, 
processes, and themes, gather information about women’s explanatory models of MEH, and administer 
a multidimensional survey to capture information about the domains of interest.  Through individual 
case management, Fuentes will work individually with women from the groups to identify their specific 
social and structural determinants needs, assist them to make an individual action plan, provide them 
with information about available resources, and help them navigate systems and access resources and 
services. We will document participant needs and navigation outcomes.  Hypotheses: Participation will 
decrease depression, social isolation, and social determinants needs, and increase emotional support, 
informational support, and women’s sense of empowerment. 
   Aim 2. Create an advocacy plan.  With data gathered in group meetings and individual navigation 
sessions, we will identify social and structural barriers that negatively influence participants’ MEH 
outcomes and ability to access resources and services. We will create an advocacy plan to address 
structural and policy barriers that can be implemented by CHWs and advocacy groups in the future. 
Hypotheses: We can identify factors that negatively influence the MEH and well-being of Latinas. We 
hypothesize that in the future, we can use this knowledge to develop a strategic plan with the potential 
to address socio-structural and policy barriers through advocacy. 
   Aim 3. Assess the feasibility of the intervention.  We will track recruitment, attrition, attendance at 
group sessions, and attendance at individual CHW navigation meetings. We will gather survey data and 
qualitative data to document participant experiences with and perceptions of the group process, 
working with the CHW, and the value of the intervention. Hypotheses: The intervention we pilot will be 
feasible, acceptable, valuable, and culturally appropriate. 
   Expected Outcome. This pilot study will use team science to test an intervention that emerged 
organically in the community and contribute to building the next generation of health disparities 
research using knowledge generated through solution-based investigation as the foundation for 
submitting an NIH R21 research proposal. 

 
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Significance   
    Latina MEH Disparities: New Mexico (NM) is one of five majority-minority states with 48% of the 
population identifying as Hispanic, a group that experiences poor health outcomes.1 Moreover, there is 
evidence of an “immigrant paradox” or “nativity effect,” wherein recent immigrants experience mental 
and emotional health (MEH) disorders at lower rates than native born Hispanics.2 However, others have 
cautioned that Hispanics/Latinos are not a monolithic group3 even within the immigrant community.  
More recent research has shown that social-structural conditions negatively influence the health of 
the immigrant population,4–7 with significant disparities in the realm of MEH.8,9 In particular, providers in 
Albuquerque’s International District have identified MEH as a significant concern among Spanish-
speaking Hispanic women (Latinas), especially those from the Mexican immigrant community. 
Through our research and community work with this population, members of our team have found that 
Latinas often: 1) misrecognize MEH symptoms and are unsure how they can be addressed through 
existing community resources, 2) require assistance identifying and navigating systems and services, 3) 
lack social and emotional support, and 4) experience personal disempowerment.  
   The growing acceptance of social determinants of health frameworks that move beyond individual 
health in primary care settings10 has been a huge advance in health research for improving health 
outcomes, especially in relation to addressing health disparities.6,7,11,12 However, it is clear that a social 
determinants framework must go beyond recognizing that social determinants exist to examining the 
mechanisms through which social determinants operate13 and how they contribute to decision-making 
within structural and policy arenas.14 In relation to MEH, although there are evidence-based guidelines 
for treating individuals, these fail to address social and structural factors that contribute to disease 
prevalence, or to sufficiently consider culture in intervention design. We believe that given disparities in 
Latina MEH in NM, it is important to take a different approach. Increasing Latina MEH equity requires 
understanding culturally- and experientially-based explanatory models of MEH, attending to social and 
structural determinants, and designing non-stigmatizing, culturally-appropriate strategies for working in 
the community to emphasize social connectivity, empowerment, advocacy for self and others, access to 
resources and services, and collective engagement to identify needed policy change.  
Innovation 
   The proposed project is innovative in a number of ways: 1) we use a project design that emerged 
organically from expertise in the community, 2) we integrate two successful and culturally appropriate 
approaches in a novel way, 3) we use a multi-level socioecological approach to address social and 
structural determinants, and 4) we incorporate future advocacy to address structural barriers. 
   Community-based Innovation: At the same time that Latina MEH is an enormous concern in NM, there 
are two contextual factors at play that offer opportunities for us to develop a novel way to address 
women’s concerns while promoting health equity. The proposed project will leverage existing resources 
and knowledge in an innovative, culturally-appropriate way. This strengths-based approach integrates 
wisdom and evidence from community work and research in NM related to CHWs and Latina social 
dynamics. We will implement a group navigation model that combines CHW-assisted navigation with 
peer group support. This approach was conceptualized by Principal Community Mentor and Co-
Investigator, Guadalupe Fuentes, a CHW with over 20 years’ experience. Fuentes recognizes the 
synergistic nature of factors that negatively influence MEH outcomes for Spanish-speaking Latinas, 
including social Isolation, depression, and other emotional disorders. In her CHW role, Fuentes has 
encountered Latinas with significant MEH that are not currently being addressed through the existing 
health care system. The novelty of this pilot is in recognizing and addressing these conditions as 
interrelated in order to develop strategies to counter disparities in treatment and access.  
   Building on the Existing CHW Model: In NM, a robust effort has been made to develop a systematic 
approach to helping people navigate health systems and access community resources through the 
creation of a variety of important CHW programs. These programs have been shown to successfully 

 
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address health needs of New Mexicans who would otherwise lack information about or access to 
resources and services.15–18 Currently, most NM CHW programs tend to involve interaction between a 
CHW and an individual client. The relationship between the CHW and the client can be very personal 
and in best-case scenarios, is culturally-appropriate. However, we believe that this interaction could be 
further strengthened by incorporating a group dynamic with the capacity to contextualize MEH within 
the context of peer validation and support for the recognition of the effect of everyday stressors. Our 
innovative model builds on existing CHW approaches, allowing women to receive both individual and 
group support to address their needs, while developing personal relationships and increasing 
understanding of social determinants that influence their lives.  
   Recognizing the Importance of the Social-Relational: Research among Latinos16,19,20 has demonstrated 
the centrality of social relationships and peer support as factors influencing Latina MEH. The proposed 
intervention will innovatively integrate CHW navigation with peer support using a novel structured 
dialogue approach16,20 that combines expert group facilitation with open-ended discussion to allow 
participants to share experiences and insights, and to define themes discussed with support from the 
facilitator. Structured dialogue can be empowering for women through the development of positive 
personal strategies for dealing with MEH.20 Examples of empowerment include strengthening 
interpersonal relationships, learning about and navigating systems to access resources, improving 
“literacy” of social and structural dynamics that influence individual, family and community health, and 
feeling socially connected.  
   Eliciting Explanatory Models (EM): Kleinman developed the elicitation of EM to understand how social 
worlds affect and are affected by illness.21 EM are now widely used in medical schools and clinical 
settings. Doctors ask, “What do you call this problem?” and “What do you believe is the cause of this 
problem?” in an effort to open dialogue with patients to reveal their understanding of illness and 
treatments. As a methodological innovation of the proposed project, a facilitator of the same cultural 
background as participants (Fuentes) who is also trained in Western conceptualizations of MEH, will 
elicit EM from participants in a group setting. Using structured dialogue, this process will allow 
participants to develop personal and collective MEH conceptual repertoires. As such, Fuentes will bi-
directionally translate understandings of MEH and facilitate identification of appropriate treatments. 
Approach 
   Theoretical Model: The model in the study is informed by socioecological approaches22 to address 
disparities and affect change at multiple levels as broadly constructed by a social and structural 
determinants of health framework.23 We included attention to change at the level of the individual, the 
social group, and external infrastructure (e.g. political, legal, economic and other social/institutional 
factors). Our pilot addressed social and structural determinants at each of these levels.  
   Research Design: We uses a convergent parallel mixed method research design24 to implement an 
intervention to affect six domains of interest in the lives of Latinas: 1) emotional support, 2) 
informational support, 3) depression, 4) social isolation, 5) empowerment, and 6) social determinants 
needs. Further, we will assess the feasibility of implementing this model with 30 participants. The 
intervention integrated navigation assistance and case management by a CHW with a peer support 
group. We gathered both qualitative and quantitative data using a variety of instruments and methods 
as described below, and we will integrate different types of data during analysis and interpretation. 
   Team Expertise & Roles: Our transdisciplinary team integrated expertise from anthropology, 
community-engaged research, social work, counseling, community navigation, and biostatistics, and we 
are well situated to conduct the proposed research. Julia Meredith Hess, PhD, the PI, is a cultural 
anthropologist and Research Assistant Professor of Pediatrics in the Prevention Research Center. She 
has over 20 years’ experience conducting community-engaged research with migrants and other 
marginalized people to improve health and well-being. Guadalupe Fuentes, Principal Community 
Mentor and Co-Investigator, was trained as a Special Education teacher in Aguascalientes, Mexico and 

 
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for 10+ years she has worked as a CHW in Albuquerque. Research Mentor, Janet Page-Reeves, PhD is an 
Associate Professor and cultural anthropologist in Family & Community Medicine. Cameron Solomon ss 
a statistician affiliated with the UNM Prevention Research Center. Annette Carrion is a UNM student 
who will be the project Research Assistant. Hess and Fuentes, with assistance from Page-Reeves and 
Solosmon, designed this study to examine the feasibility and efficacy of Fuentes’ proposed intervention 
model. Hess, in addition to overall direction of the study, will lead the qualitative components, assist 
with data collection, lead team analytical discussions, and be responsible for budgets and reporting. 
Fuentes will lead implementation of the intervention, including recruiting, facilitating the groups, and 
individual case management, and she will participate in collection and analysis of the data. Page-Reeves 
will meet regularly with Hess and Fuentes to discuss project activities and outcomes, assist with data 
collection, and participate in analytical team discussions. Solomon was responsible for statistical analysis 
of the quantitative data and will participate in team analytical discussions. Carrion will assist Fuentes to 
conduct the classes, collect data, enter survey and program data into REDCap, assist with qualitative 
coding, and participate in team analytic discussions. Community Mentor #1 Jackie Perez, LCSW, is the 
Director of The Hopkins Center counseling office, a facility operated by Centro Sávila, a nonprofit agency 
providing affordable mental health services to Spanish-speaking Latinos. Community Mentor #2 Alma 
Olivas, a CHW with expertise in advocacy work, is a senior CHW at Centro Sávila. Centro Sávila will be 
our community partner agency, and Bill Wagner, Director of Centro Sávila, will be our project’s liaison. 
Fuentes, Carrion, Perez and Olivas will work on this project under a contract with Centro Sávila. Perez 
will provide input for facilitation of groups and interpretation of any MEH concerns that arise. Olivas will 
provide support and input for the resource access component and for developing the advocacy plan. 
Wagner will provide oversight for the project contract with Centro Sávila.  
   Population: This project involved Spanish-speaking Latinas from low-income households. Participants 
was recruited from the International District and South Valley neighborhoods of Albuquerque and 
screened for language, self-reported ethnic identity as Latino/Hispanic, and self-reported income below 
250% of the Federal Poverty Level. The majority of the participants were Mexican immigrants with one 
participant who was from Central America and one who was a second generation Mexican immigrant. 
   Recruitment: During month #2 prior to the start of the intervention, Fuentes recruited 30 participants 
through the Pathways Program, the Simplemente Salud Clinic and Centro Sávila. In the course of regular 
meetings with clients who request a range of services, she identified identify and invite those who might 
benefit from the proposed model.  While particpants experessed interest int eh program, lower 
numbers than anticipated joined the study from the first 3 cohort. We therefore changed the 
implementation strategy to allow for two sequential cohorts, one in the Fall and and one in the Spring.  
   Intervention Implementation:  
        MONTH #1: Planning, logistics, & preparation.  
        MONTH #2: Recruitment.           
        MONTH #3: During month #3, each cohort of 10 participants participated in four two-hour classes 
held weekly and facilitated by Fuentes with assistance from Carrion. Class 1 included introductions and 
open-ended discussion of participants’ perspectives on and experiences with MEH challenges including 
eliciting explanatory models of illness using a structured dialogue approach. In Class 2, Fuentes 
presented information on concepts of MEH including anxiety, depression, and social isolation, and the 
group explored ways that participants’ own experience may align with these concepts. In Class 3 
participants identified and give name to their feelings and experiences and begin to consider services 
they might be interested in accessing. In Class 4, Alma Olivas provided information about relevant health 
care and other resources, for example, school counselors, domestic violence services, Centro Sávila, The 
Hopkins Center, couples counseling, UNM mental health services/counseling, and church support 
groups.  

 
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        MONTH #4: Over the first three weeks of month #4 of the intervention, the team conducted a 
preliminary analysis of class notes, observations and audio (described in the data analysis section below) 
to identify common themes and specific resource and service needs for each participant, and in week 4 
of month #4, reconvene the groups for Class 5 to discuss findings and individual experiences with 
accessing resources and services since Class 4 and individual participants will develop action plans.  
        MONTHS #5-7: Fuentes provided individual case management to assist participants to access 
resources and navigate systems to achieve goals identified in their individual action plans.  
        MONTH #8: We reconvened the groups for Class 6 to engage in a follow-up discussion of outcomes 
and to administer the post-survey. 
   Mixed method data collection.  
 
         Quantitative data collection: Data was 
stored in a database created in UNM’s secure 
data capture system, REDCap. We tracked 
recruitment, attrition, attendance at group 
sessions, and attendance at individual CHW 
navigation meetings. Pre-/Post-data was 
gathered at baseline (Class 1) and follow-up 
(Class 6) in the form of a multi-dimensional 
survey (see table). The survey will include: A) 
demographic questions to characterize 
participants, B) program evaluation/feasibility 
questions to document participant experiences 
with and perceptions of the group process, 
working with the CHW, and the value of the 
intervention, C) seven reliable instruments that 
have been validated in English and Spanish to 
measure the six domains of interest: a) 
emotional support, b) informational support, c) 
social isolation ; d) depression; e) ACES; and f) 
resiliency. 
         Qualitative data collection: Group class sessions were audio-recorded. Hess and/or Carrion 
attended Classes 1 and 6 for each cohort and take observational notes. Analytical notes taken during 
team meetings. Notes from individual case management sessions, individual resource action plans, and 
the Advocacy Plan will be documented and analyzed.  
     Data Analysis 
          Quantitative analysis: Descriptive statistics were presented for baseline participant characteristics: 
means and standard deviations or medians and quartiles for continuous measures, and frequencies and 
percentages for categorical measures. All instrument measures at baseline and follow-up were 
summarized with appropriate descriptive statistics. The seven quantitative measures from the PHQ-9, 
PROMIS support instruments, and PPS-R were reported as unadjusted mean scores and their 95% 
confidence intervals (CIs) at each of baseline and follow-up, as well as for the changes from baseline to 
follow-up. We predicted with a sample size of 30, we would be able to detect medium effect sizes 
(Cohen’s d=0.53) of instrument change scores between the two time points (unadjusted type I error rate 
α=0.05, power 1-β=0.80). SAS 9.4 will be used for all statistical analyses. 
         Qualitative analysis: We employed a constructivist grounded theory approach which is a well- 
known way to explicate processes, in this case change related to the intervention.31 Theory is 
“grounded” in the data themselves. Constructivist grounded theory therefore uses a combined inductive 
Construct 
Instrument # of Items 
Time 
point 
Demographic Info 
18 items 
B only 
Depression 
PHQ-9 
9 items 
B&F 
Emotional Support 
PROMIS 24,25 
8 items 
B&F 
Informational 
Support 
PROMIS26 
8 items 
B&F 
Social Isolation 
PROMIS25 
8 items 
B&F 
Resiliency 
CD-RISC 
25 items 
B&F 
Adverse Childhood 
Events 
ACES  
10 items 
F 
ACES Resiliency 
 ACES + 
Resiliency 
12 items 
B&F 
Eval & Feasibility 
  
8 items 
F 

 
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and deductive approach, coupled with the recognition that study participants and researchers ‘co-
construct’ data, thus making it a good fit for community-engaged research. As such, analyses require 
inclusion of participant perspectives and meaning to be fully developed.31 A key aspect of this approach 
is its iterative nature, thus analysis will be ongoing and begin at baseline. Beginning in Month 3, notes 
from audio recordings were checked for accuracy and imported into NVivo 11, a qualitative data analysis 
software program. Hess trained Carrion in qualitative coding techniques and all qualitative data will be 
independently coded by Hess and Carrion. Analysis began with 1) text-based coding, marking recurrent 
themes or statements, 2) as themes emerge, Hess and Carrion met to define and standardize them, 
agree on a structural framework and to determine how themes should be applied to  
coding, 3) Hess and Carrion used focused coding31 of prominent thematic clusters and constant 
comparison techniques to conduct preliminary analysis of prominent themes, 4) we conducted member 
checking32 through sharing these preliminary interpretations during Class 4, using methods  developed 
by CBPR researchers to elicit feedback and interpretation from the group, which we then incorporated 
into our analses.33,34 For Aim 1, qualitative analysis of narratives from class discussion and observational 
notes provided insights into women’s explanatory models of MEH to inform the case management and 
resource access phase of the intervention, the dynamics of the structured dialogue group process, how 
women develop and use action plans to navigate and access resources, how they explain and describe 
their experience in this process, and the extent to which empowering processes emerge. For Aim 2, we 
analyzed challenges and barriers identified by participants and identify potential strategies to promote 
institutional and policy changes that would positively affect MEH through advocacy. Aim 3 was assessed 
by looking at evaluation process data for participant perspectives on the feasibility, acceptability, value 
and cultural appropriateness of the intervention model. 
Results 
Intervention was acceptable 
and feasible. Increase in 
resiliency was our most robust 
quantitative finding. Social, 
emotional and informational 
empowerment scores 
improved, but not in statistically 
significant way. Depression 
scores worsened, which could 
reflect the effectiveness of the 
psychoeducation component. 
Qualitative results: participants’ 
experiences in the intervention 
underscored the importance of 
recognizing cultural differences 
in values and meaning related 
to MEH: 1) Self-advocacy and 
self-efficacy (learning how to 
say “no” or set limits as Latinas) 
; 2) Addressing violence (in 
domestic settings, in families, 
social violence) ; 3) Isolation and 
socializing (recognizing differences in U.S. v. Latin America) . Overall, the results demonstrated the 
importance of multilevel interventions that address mental health at multiple levels: 1) Individual: 
Research Timeline 
Month 
Activity 
1 
2 
3 
4 
5 
6 
7 
8 
9 
1
0 
1
1 
1
2 
Planning/Logistics 
 
 
 
 
 
 
 
 
 
 
 
 
Recruitment 
 
 
 
 
 
 
 
 
 
 
 
 
Cohort 1 (Classes 1-4) 
 
 
 
 
 
 
 
 
 
 
 
 
Quantitative Baseline Interview 
 
 
 
 
 
 
 
 
 
 
 
 
Cohort 2 (Classes 1-4) 
 
 
 
 
 
 
 
 
 
 
 
 
Cohort 3 (Classes 1-4) 
 
 
 
 
 
 
 
 
 
 
 
 
Analysis of Class Data  
 
 
 
 
 
 
 
 
 
 
 
 
Class 5 – Discuss Findings, 
Resource Access Plan 
 
 
 
 
 
 
 
 
 
 
 
 
Individual Case Management 
 
 
 
 
 
 
 
 
 
 
 
 
Class 6 – Follow-up to Discuss 
Outcomes 
 
 
 
 
 
 
 
 
 
 
 
 
Quantitative post-interview 
 
 
 
 
 
 
 
 
 
 
 
 
Data Analysis of Outcome Class 
 
 
 
 
 
 
 
 
 
 
 
 
NMPHA (Present Advocacy 
Plan) 
 
 
 
 
 
 
 
 
 
 
 
 
Report results in Community 
Venues 
 
 
 
 
 
 
 
 
 
 
 
 
Final Report for TREE Center 
 
 
 
 
 
 
 
 
 
 
 
 

 
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addressing stigma, recognizing the prevalence depression and anxiety, investing in self and life purpose, 
developing coping skills, self-esteem, agency/empowerment and emotional awareness. 2) Family: 
recognizing/helping other family members, redefining family in U.S. context; 3) Community: Providers-
knowing who to see, what questions to ask; Organizational—what organizations offer, which are 
accessible. Finally, these results can inform administrative/systems/policy change to improve mental 
health equity for Spanish-speaking Latina women. 
 
Conclusions 
The study showed that interventions designed by community members effectively address barriers to 
addressing MEH (sociocultural attitudes and responses to MEH, current context and effects on Latinas). 
The research broadened our understanding of how MEH is impacted by sociocultural, economic, and 
policy-level factors is necessary to create effective interventions for addressing MEH. Preliminary results 
offer insight into how multilevel change is needed to improve mental health equity. 
 
The recruitment process showed that potential participants recognized a great need for such 
interventions among Spanish-speaking Latinas, but stigma, as well as family and work obligations made 
it difficult for women to commit to the class at the outset. However, the benefits of attending the class 
have spread by word of mouth, if funding were to be found for continued intervention, it is certain that 
there would be robust participation. Another major limitation for this project and community-based 
work generally were the bureaucratic barriers/mismatch between the university and the community-
based organizations to ensure timely payment for the organization. Additionally, survey completion 
during class was a barrier. In the future, a plan to collect baseline and follow-up data in person would 
make the first session flow better and be less intimidating for participants. 
 
 

 
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