A Multicomponent Health Education Campaign Led by Community Health Workers to Increase Influenza Vaccination among Migrants and Refugees.

OBJECTIVES: To evaluate the impact of a Community Health Worker (CHW)-led influenza campaign on knowledge and attitudes about vaccination in Latinx migrant and refugee populations. METHODS: Twelve online workshops were conducted with 183 participants and 24 CHWs between January 12 and May 12, 2021. Participants were Latinx families living in underserved communities throughout Washington state. The initiative also included radio, animated videos, advertisements, social media, and educational materials. RESULTS: Analysis of pre and post workshop surveys from 155 participants showed statistically significant improvements in all questions about the definition of influenza, symptoms, and risks: and in 7 of 9 questions about treatments and vaccines. Analysis of 2 open-ended questions showed increases in words key to understanding influenza, such as "virus," "illness," "death," and "contagious." There were significant increases in rates of participants identifying vaccination and antibiotics as cures for influenza. CONCLUSIONS: CHW-led workshops can be an effective way to increase knowledge about influenza and influenza vaccine. Future curriculum should emphasize the difference between viruses and bacteria, and the use of vaccination for prevention as opposed to treatment for illness.

Counting the Unsung by Promoting Participation in the 2020 US Census: A Survey of Migrant Workers in Washington State.

INTRODUCTION: Participation in the United States Census is critical for determining congressional representation and federal funding, but in every census there are groups systematically undercounted due to socioeconomic and demographic factors. Migrants and refugees are a group particularly threatened by being undercounted, including Hispanic migrant workers living in more rural areas. METHODS AND RESULTS: To gather information to promote migrant participation in the census, the Community Health Worker Coalition for Migrants and Refugees in Washington state conducted a systematic survey of 71 migrant workers in seven urban and suburban Washington communities. The results showed that while most participants had heard of the census, basic knowledge about the census was limited and people wanted more information. CONCLUSIONS AND RECOMMENDATIONS: A strong, coordinated outreach approach should be carried out to educate people in migrant communities about the census. This may involve one-on-one structured conversations, radio telenovelas, and community conversations organized by the trusted leaders.

Correlation of Oral Health Education by Community Health Workers with Changes in Oral Health Practices in Migrant Populations in Washington State.

INTRODUCTION: An important question for oral health education is whether knowledge gained during lay-led workshops is retained and applied in daily practice. This study assessed the knowledge retention and changes in oral health practices several months after oral health education workshops were held for migrant farmworkers by Community Health Workers (CHWs). METHODS AND RESULTS: Follow-up surveys were conducted with 32 participants 1 to 43 months post participation (60% between 6 and 21 months). The results showed a high degree of retention, in such areas as general oral health knowledge, and brushing/flossing frequency and technique among this sample. There was no relationship between length of time since the educational workshop and knowledge retained or behaviors changed. CONCLUSIONS AND RECOMMENDATIONS: An interactive, lay-led oral health education program run by CHWs can be an effective way to deliver sustained improvements in oral health knowledge and changes in oral health practice in migrant populations.

Using the County Health Rankings Framework to Create National Percentile Scores for Health Outcomes and Health Factors.

INTRODUCTION: As a means of conceptualizing population health, the County Health Rankings & Roadmaps program developed a methodology to rank counties within each state on Health Outcomes and Health Factors. We built on this framework by introducing an additional application that utilized national percentile scores and population size weighting to compare counties on a national, rather than a state, level. METHODS: We created national percentile scores for 3078 US counties and used population size weighting in our calculations so that values for counties with larger populations would be weighted more heavily than values for counties with smaller populations. RESULTS: We demonstrated how this application can be used to 1) compare counties nationally, 2) examine clustering and variability among counties, and 3) compare the health of states and regions. To underscore its utility, we included an example application by Kaiser Permanente. As a form of method validation, the results of this application are in line with other ranking systems (eg, US News and World Report and United Health Foundation; ρ = 0.39 to 0.91, p < 0.001). DISCUSSION: This application can be used by communities and organizations that may be interested in comparing the health of counties, service areas, and regions in which they operate. We included additional considerations and highlighted some limitations for those interested in utilizing this application. CONCLUSION: By comparing counties nationally and utilizing population size weighting, community partners can focus on areas that may be of greatest need in moving toward a national Culture of Health.

Patient Perspectives on Addressing Social Needs in Primary Care Using a Screening and Resource Referral Intervention.

BACKGROUND: Interest is growing in interventions to address social needs in clinical settings. However, little is known about patients' perceptions and experiences with these interventions. OBJECTIVE: To evaluate patients' experiences and patient-reported outcomes of a primary care-based intervention to help patients connect with community resources using trained volunteer advocates. DESIGN: Qualitative telephone interviews with patients who had worked with the volunteer advocates. Sample and recruitment targets were equally distributed between patients who had at least one reported success in meeting an identified need and those who had no reported needs met, based on the database used to document patient encounters. PARTICIPANTS: One hundred two patients. INTERVENTIONS: Patients at the study clinic were periodically screened for social needs. If needs were identified, they were referred to a trained volunteer advocate who further assessed their needs, provided them with resource referrals, and followed up with them on whether their need was met. APPROACH: Thematic analysis was used to code the data. KEY RESULTS: Interviewed patients appreciated the services offered, especially the follow-up. Patients' ability to access the resource to which they were referred was enhanced by assistance with filling out forms, calling community resources, and other types of navigation. Patients also reported that interacting with the advocates made them feel listened to and cared for, which they perceived as noteworthy in their lives. CONCLUSIONS: This patient-reported information provides key insights into a human-centered intervention in a clinical environment. Our findings highlight what works in clinical interventions addressing social needs and provide outcomes that are difficult to measure using existing quantitative metrics. Patients experienced the intervention as a therapeutic relationship/working alliance, a type of care that correlates with positive outcomes such as treatment adherence and quality of life. These insights will help design more patient-centered approaches to providing holistic patient care.

A Community-Wide Collaboration to Reduce Cardiovascular Disease Risk: The Hearts of Sonoma County Initiative.

PURPOSE AND OBJECTIVES: Collaboration across multiple sectors is needed to bring about health system transformation, but creating effective and sustainable collaboratives is challenging. We describe outcomes and lessons learned from the Hearts of Sonoma County (HSC) initiative, a successful multi-sector collaborative effort to reduce cardiovascular disease (CVD) risk in Sonoma County, California. INTERVENTION APPROACH: HSC works in both clinical systems and communities to reduce CVD risk. The initiative grew out of a longer-term county-wide collaborative effort known as Health Action. The clinical component involves activating primary care providers around management of CVD risk factors; community activities include community health workers conducting blood pressure screenings and a local heart disease prevention campaign. EVALUATION METHODS: The impact of the clinical improvement efforts was tracked using blood pressure data from the 4 health systems participating in HSC. Descriptive information on the community-engagement efforts was obtained from program records. Lessons learned in developing and maintaining the collaborative were gathered through document review and interviews with key informants. RESULTS: Favorable trends were seen in blood pressure control among patients with hypertension in the participating health systems: patients with controlled blood pressure increased from 58% in 2014 to 67% in 2016 (P < .001). Between 2017 and 2019, the community engagement effort conducted 99 outreach events, reaching 1,751 individuals, and conducted 1,729 blood pressure screenings, with 441 individuals referred to clinical providers for follow-up care. HSC scored highly on 6 essential elements of an effective coalition and achieved a degree of sustainability that has eluded many other collaboratives. IMPLICATIONS FOR PUBLIC HEALTH: Factors contributing to the success of HSC include 1) starting small and focused to build trust among participants and demonstrate value, 2) working within the framework of a larger effort, and 3) providing long-term, open-ended backbone support.

Engaging patients in primary care design: An evaluation of a novel approach to codesigning care.

OBJECTIVE: Recognition is growing that to create truly patient-centred care, health-care organizations need to partner with patients around care design. More research into the benefits of engaging patients and the most effective ways of partnering with them is needed. METHODS: This study assessed the process and impact of a collaborative effort to design a new clinic service that balanced the number of patient and clinical provider/staff codesigners involved and recruited patients to represent diverse perspectives. Data sources included interviews with participants, event observation and participant surveys. RESULTS: Our evaluation found that including patients as equal partners improved the design process by infusing a real-world, patient perspective. The pre-event orientation and interactive methods used in the event fostered positive collaboration, as well as personal growth for the patient codesigners. CONCLUSION: This study demonstrated the feasibility and benefits of including a roughly equal number of patients and clinical providers/staff in design events and ensuring that the patients represent diverse perspectives.

Improving oral health in migrant and underserved populations: evaluation of an interactive, community-based oral health education program in Washington state.

OBJECTIVES: Oral health is one of the greatest unmet health needs of migrant farmworkers and many migrant workers lack basic oral health knowledge. This paper presents evaluation results for an oral health education program designed to both increase knowledge concerning oral health practices and to gain a better understanding of the knowledge, attitudes and behaviors regarding oral health among migrant workers. METHODS: We used a pre-post uncontrolled design to assess the impact of the education program on participant knowledge about oral health practices. Changes in knowledge were assessed using a paper and pencil survey given to participants before the session began (pre) and at the end of the session (post). The pre-post survey was supplemented by qualitative information in the form of participant self-reported barriers and facilitators, and figure drawings illustrating their feelings about the state of their own oral health. RESULTS: There were 311 participants in 12 workshops held in 2017 throughout Washington State. There were statistically significant increases in knowledge for all of the pre/post survey questions. Questions with particularly large improvements included: the results of having a mouth infection, factors causing oral health problems, and whether children in low-income families experience more tooth decay. CONCLUSIONS: An interactive, lay-led oral health education program can be an effective way to increase oral health knowledge in migrant populations. Recommendations for similar programs include using interactive approaches to engage participants, being open to learning and changing your own thinking, and using lay leaders for the education sessions.

Dose as a Tool for Planning and Implementing Community-Based Health Strategies.

A major challenge in community-based health promotion is implementing strategies that could realistically improve health at the population level. Population dose methodology was developed to help understand the combined impact of multiple strategies on population-level health behaviors. This paper describes one potential use of dose: as a tool for working collaboratively with communities to increase impact when planning and implementing community-level initiatives. Findings are presented from interviews conducted with 11 coordinators who used dose for planning and implementing local efforts with community coalitions. During early-stage planning, dose was used as a tool for strategic planning, and as a framework to build consensus among coalition partners. During implementation, a dose lens was used to revise strategies to increase their reach (the number of people exposed to the intervention) or strength (the relative change in behavior for each exposed person) to create population-level impact. A case study is presented, illustrating how some community coalitions and evaluators currently integrate dose into the planning and implementation of place-based healthy eating and active living strategies. Finally, a planning checklist was developed for program coordinators and evaluators. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives, which is sponsored by Kaiser Permanente, Community Health.

Using Population Dose to Evaluate Community-level Health Initiatives.

Successful community-level health initiatives require implementing an effective portfolio of strategies and understanding their impact on population health. These factors are complicated by the heterogeneity of overlapping multicomponent strategies and availability of population-level data that align with the initiatives. To address these complexities, the population dose methodology was developed for planning and evaluating multicomponent community initiatives. Building on the population dose methodology previously developed, this paper operationalizes dose estimates of one initiative targeting youth physical activity as part of the Kaiser Permanente Community Health Initiative, a multicomponent community-level obesity prevention initiative. The technical details needed to operationalize the population dose method are explained, and the use of population dose as an interim proxy for population-level survey data is introduced. The alignment of the estimated impact from strategy-level data analysis using the dose methodology and the data from the population-level survey suggest that dose is useful for conducting real-time evaluation of multiple heterogeneous strategies, and as a viable proxy for existing population-level surveys when robust strategy-level evaluation data are collected. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives, which is sponsored by Kaiser Permanente, Community Health.

A Community-Level Initiative to Prevent Obesity: Results From Kaiser Permanente's Healthy Eating Active Living Zones Initiative in California.

INTRODUCTION: A growing number of health systems are leading health promotion efforts in their wider communities. What impact are these efforts having on health behaviors and ultimately health status? This paper presents evaluation results from the place-based Kaiser Permanente Healthy Eating Active Living Zones obesity prevention initiative, implemented in 2011-2015 in 12 low-income communities in Kaiser Permanente's Northern and Southern California Regions. METHODS: The Healthy Eating Active Living Zones design targeted places and people through policy, environmental, and programmatic strategies. Each Healthy Eating Active Living Zone is a small, low-income community of 10,000 to 20,000 residents with high obesity rates and other health disparities. Community coalitions planned and implemented strategies in each community. A population-dose approach and pre and post surveys were used to assess impact of policy, program, and environmental change strategies; the analysis was conducted in 2016. Population dose is the product of reach (number of people affected by a strategy divided by target population size) and strength (the effect size or relative change in behavior for each person exposed to the strategy). RESULTS: More than 230 community change strategies were implemented over 3 years, encompassing policy, environmental, and programmatic changes as well as efforts to build community capacity to sustain strategies and make changes in the future. Positive population-level results were seen for higher-dose strategies, particularly those targeting youth physical activity. Higher-dose strategies were more likely to be found in communities with the longest duration of investment. CONCLUSIONS: These results demonstrate that strong (high-dose), community-based obesity prevention strategies can lead to improved health behaviors, particularly among youth in school settings. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives, which is sponsored by Kaiser Permanente, Community Health.

Changes in Consumer Purchases in Stores Participating in an Obesity Prevention Initiative.

INTRODUCTION: From 2011 to 2014, small stores in three communities participated in a community-wide obesity prevention initiative. The study aimed to determine how participation in the initiative influenced store environments and consumer purchases. STUDY DESIGN: Pre- and post-intervention without control. Structured observations of the store environments and intercept surveys of adult shoppers at all stores, and of children at two stores, conducted at baseline and follow-up. Manager/owner interviews regarding perceived impacts of the intervention conducted at follow-up. SETTING/PARTICIPANTS: Shoppers at nine small stores in three diverse, low-income communities in Northern California. INTERVENTION: The store interventions were determined locally with combinations of strategies such as product displays, healthier options, marketing and promotion, store layout, and facility improvements that were implemented to varying degrees at each site. MAIN OUTCOME MEASURES: Changes in store environments and purchases of select foods and beverages. RESULTS: Stores experienced consistent, but not always significant, declines in purchases of sweets and chips and increases in purchases of fruits and vegetables at select stores. Decreases in purchases of targeted sugar-sweetened beverages were offset by increases in purchases of other sugar-sweetened beverages. Changes in store environments and promotional activities varied widely from store to store and corresponded to variations in changes in purchasing. The owners/managers perceived benefits to their bottom line and community/customer relations, but challenges were identified that may account for the varied degree of implementation. CONCLUSIONS: Substantive improvements in fruit and vegetable availability and promotion were needed to achieve a measurable impact on purchases but reducing purchases of unhealthy foods, like sweets and chips, required a less consistent intensive effort. These findings suggest it may be challenging to achieve the consistent and targeted implementation of changes and ongoing promotional efforts at a large enough proportion of stores where residents shop that would be required to get measurable impacts at the community level. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives, which is sponsored by Kaiser Permanente, Community Health.

Evaluation of the Learning to Integrate Neighborhoods and Clinical Care Project: Findings from Implementing a New Lay Role into Primary Care Teams to Address Social Determinants of Health.

INTRODUCTION: Health systems increasingly recognize the impact of social determinants of health such as access to housing, transportation, and nutritious food. Lay health workers have been used to address patients' social determinants of health through resource referral and goal setting in targeted populations, such as individuals with diabetes. However, we know of no studies that evaluate this type of role for a general primary care population. OBJECTIVE: To assess the implementation and impact of the Community Resource Specialist (CRS) role in Kaiser Permanente Washington. METHODS: We analyzed data from staff interviews, patient focus groups, clinic site visits, patient surveys, the electronic health record, and administrative sources. RESULTS: Satisfaction with CRSs was high, with 92% of survey respondents choosing "very satisfied" or "somewhat satisfied." Of patients with a resource referral and follow-up encounter, 45% reported using the resource (n = 229) and 86% who set a goal and had a follow-up encounter (n = 218) progressed toward their goal. Primary care teams reported workload easing. Patients who used CRSs and participated in focus groups reported behavior changes and improved health, although no changes were detected from electronic health records or patient survey data. Key learnings include the need to clearly define the CRS role, ensure high visibility to clinical staff, and facilitate personal introductions of patients (warm handoffs). CONCLUSION: Adding an individual to the primary care team with expertise in community resources can increase patient satisfaction, support clinicians, and improve patients' perceptions of their health and well-being.

The Immunity Community: A Community Engagement Strategy for Reducing Vaccine Hesitancy.

Parental concerns about vaccine safety have grown in the United States and abroad, resulting in delayed or skipped immunizations (often called "vaccine hesitancy"). To address vaccine hesitancy in Washington State, a public-private partnership of health organizations implemented and evaluated a 3-year community intervention, called the "Immunity Community." The intervention mobilized parents who value immunization and provided them with tools to engage in positive dialogue about immunizations in their communities. The evaluation used qualitative and quantitative methods, including focus groups, interviews, and pre and post online surveys of parents, to assess perceptions about and reactions to the intervention, assess facilitators and barriers to success, and track outcomes including parental knowledge and attitudes. The program successfully engaged parent volunteers to be immunization advocates. Surveys of parents in the intervention communities showed statistically significant improvements in vaccine-related attitudes: The percentage concerned about other parents not vaccinating their children increased from 81.2% to 88.6%, and the percentage reporting themselves as "vaccine-hesitant" decreased from 22.6% to 14.0%. There were not statistically significant changes in parental behaviors. This study demonstrates the promise of using parent advocates as part of a community-based approach to reduce vaccine hesitancy.

Study protocol for "Healthy Hearts Northwest": a 2 × 2 randomized factorial trial to build quality improvement capacity in primary care.

BACKGROUND: Little attention has been paid to quality improvement (QI) capacity within smaller primary care practices which comprise nearly half of all primary care settings. Strategies for external support to build such capacity include practice facilitation (PF), shared learning opportunities, and educational outreach. Although PF has proven effectiveness, little is known about the comparative effectiveness of combining these strategies. Here, we describe the protocol of the "Healthy Hearts Northwest" (H2N) study, a randomized trial designed to address these questions while improving risk factors for cardiovascular disease. METHODS/DESIGN: The targeted enrollment is 250 smaller primary care practices across Washington, Oregon, and Idaho. The study is utilizing a two-by-two factorial design to assess four different combinations of practice support: PF alone, PF with educational outreach, PF with shared learning opportunities, or PF with both. A mixed methods approach is being used for evaluation and will include data from (1) baseline and follow-up practice and staff surveys; (2) baseline and quarterly clinical performance measurement from each practice on four cardiovascular risk factors: appropriate aspirin use, blood pressure control, lipid management and smoking cessation support; and (3) a quality improvement capacity assessment (QICA) survey used by external practice facilitators to guide improvement efforts. DISCUSSION: Results from this study will inform future large-scale practice improvement initiatives by providing comparisons of promising external practice support strategies and advance our understanding of how to build QI capacity in primary care. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02839382.

Primary Care Clinicians' Perspectives on Reducing Low-Value Care in an Integrated Delivery System.

CONTEXT: Perceptions about low-value care (eg, medical tests and procedures that may be unnecessary and/or harmful) among clinicians with capitated salaries are unknown. OBJECTIVE: Explore clinicians' perceived use of and responsibility for reducing low-value care by focusing on barriers to use, awareness of the Choosing Wisely campaign, and response to reports of peer-comparison resource use and practice patterns. METHODS: Electronic, cross-sectional survey, distributed in 2013, to 304 salaried primary care physicians and physician assistants at Group Health Cooperative. MAIN OUTCOME MEASURES: Attitudes, awareness, and barriers of low-value care strategies and initiatives. RESULTS: A total of 189 clinicians responded (62% response rate). More than 90% believe cost is important to various stakeholders and believe it is fair to ask clinicians to be cost-conscious. Most found peer-comparison resource-use reports useful for understanding practice patterns and prompting peer discussions. Two-thirds of clinicians were aware of the Choosing Wisely campaign; among them, 97% considered it a legitimate information source. Although 88% reported being comfortable discussing low-value care with patients, 80% reported they would order tests or procedures when a patient insisted. As key barriers in reducing low-value care, clinicians identified time constraints (45%), overcoming patient preferences/values (44%), community standards (43%), fear of patients' dissatisfaction (41%), patients' knowledge about the harms of low-value care (38%), and availability of tools to support shared decision making (37%). CONCLUSIONS: Salaried clinicians are aware of rising health care costs and want to be stewards of limited health care resources. Evidence-based initiatives such as the Choosing Wisely campaign may help motivate clinicians to be conscientious stewards of limited health care resources.

Promoting Policy, Systems, and Environment Change to Prevent Chronic Disease: Lessons Learned From the King County Communities Putting Prevention to Work Initiative.

CONTEXT: Initiatives that convene community stakeholders to implement policy, systems, environment, and infrastructure (PSEI) change have become a standard approach for promoting community health. OBJECTIVE: To assess the PSEI changes brought about by the King County, Washington, Communities Putting Prevention to Work initiative and describe how initiative structures and processes contributed to making changes. DESIGN: The impact evaluation used a logic model design, linking PSEI changes to longer-term behavioral impacts in healthy eating active living and tobacco use and exposure. Qualitative methods, including stakeholder interviews and surveys, were used to identify initiative success factors. SETTING: Communities Putting Prevention to Work activities occurred throughout King County, with a focus on 7 low-income communities in South Seattle/King County. PARTICIPANTS: The focus communities had a combined population of 652 000, or 35% of the county total, with lower incomes and higher rates of physical inactivity, tobacco use, poor diet, and chronic disease. INTERVENTION: Twenty-four PSEI strategies were pursued by organizations in sectors including schools, local governments, and community organizations, supported by the public health department. There were 17 healthy eating active living strategies (eg, enhancements to school menus, city planning policies) and 7 tobacco strategies (eg, smoke-free policies in schools, housing, and hospitals). MAIN OUTCOME MEASURE: PSEI changes made and numbers of residents reached. RESULTS: Twenty-two of the 24 strategies achieved significant progress toward implementing PSEI changes. The most common success factor was a "dyad" consisting of a dedicated technical assistance provider-either an outside consultant or public health department staff-working closely with a champion from the participating organizations to bring about PSEI changes. CONCLUSIONS: An initiative structure that creates and supports external consultant/internal organizational champion dyads in key community sectors offers a promising approach that may be adopted by similar community health efforts in the future.

Biomarkers of Insecticide Exposure and Asthma in Children: A National Health and Nutrition Examination Survey (NHANES) 1999-2008 Analysis.

Pesticide exposure is a potential risk factor for increased asthma prevalence among children. The authors used National Health and Nutrition Examination Survey (1999-2008) biomarker data to evaluate dialkylphosphate (DAP) urinary concentrations, serum dichlorodiphenyldichloroethylene (DDE), and asthma among school-aged children (Mexican American, Non-Hispanic Black, Non-Hispanic White). Poisson logistic regression included age, sex, nativity, poverty index ratio, tobacco smoke exposure, and body mass index covariates. No association was found between DAP (N=2,777) and asthma outcomes; adverse effect of DDE (N=940) was suggested for Current Wheeze. Subgroup analyses identified positive associations with some asthma outcomes among Non-Hispanic Blacks, whereas inverse associations were identified among Mexican Americans. Results support previous associations observed among children's DDE exposure and wheeze. Characterization of risk factors for pesticide exposure and disease recognition among Mexican Americans is needed.

Population-based comparison of biomarker concentrations for chemicals of concern among Latino-American and non-Hispanic white children.

Differences in cultural and economic status may place ethnic subgroups of children at higher risk for exposure, leading to heightened health risks, and health inequities. Although Latino-Americans represent 22% of all children in the United States, few studies have explored within-group differences in their exposure to toxicants. Using socio-demographic and biomarker data from the National Health and Nutrition Examination Survey from 1999 to 2008, we characterized determinants of health and estimated geometric means of environmental contaminant biomarkers (blood concentrations of lead and mercury, serum concentrations of dichlorodiphenyldichloroethylene [p,p'-DDE] and cotinine, and urinary metabolites of organophosphate [OP] pesticides and polycyclic aromatic hydrocarbons [PAHs]) among 4,257 Mexican American (MA), 677 Other Latino-American (OL), and 3,370 Non-Hispanic White (NHW) children. MAs had the lowest levels of health insurance coverage and regular access to health care, and largest household size compared to NHWs and OLs. MAs had higher levels of p,p'-DDE, lead, and cadmium while OLs had higher estimates of mercury relative to other groups. MAs had higher urinary metabolite concentrations of 2-hydroxynaphthalene; otherwise MAs and OLs had lower concentrations of PAHs. NHWs had higher levels of cotinine and dimethylthiophosphate. For other OP metabolites, differences among groups were less clear. Lead and p,p'-DDE exposure differences likely reflect later and less regulatory control of these chemicals in Latin America. Additionally, poor quality housing with lead paint is more common in economically disadvantaged subpopulations. Dietary habits are possible sources of differential cadmium, mercury, and organophosphate exposure. Cotinine exposure differences by income and U.S.- vs. foreign-born may represent increased acculturation. These results, coupled with additional research on exposure sources may contribute to refinement of environmental health promotion programs for the fast-growing Latino-American population.