Border Health Strategic Initiative
To confront the threat of diabetes on the U.S.-Mexico Border, representatives from border communities in Yuma and Santa Cruz Counties joined the Mel and Enid Zuckerman College of Public Health (MEZCOPH) to develop and test a comprehensive and sustainable model for community-oriented chronic disease prevention and control. Launched in October 2000, the Border Health Strategic Initiative (Border Health ¡SI!) model promoted individual prevention and control, while assisting communities to develop system-level strategies that support healthy behaviors. Central to the models success were promotores de salud, who not only provided services to individuals, but also engaged community members in addressing the health of their environment. Border Health SI! was a true collaboration between community and academic partners.
The former understood the needs and local issues of their community. The latter brought technical expertise in intervention design and evaluation. The synergy provided an energizing and inspirational experience for all involved. The vision of Border Health ¡SI! was to create a comprehensive chronic disease prevention and control model that will have the greatest impact on a community over an extended period of time. To realize this goal, the project operated under a set of guiding principles outlined below.
- Comprehensive: addresses multi-levels of prevention.
- Community-Oriented: strategies developed within the community.
- Acceptable to stake holders: involves community partnerships.
- Effective in fostering and sustaining change: strategies involve individual skill building and support.
- Evaluation: rigorous scientific assessment of processes and outcomes of change.
- Transportable: adaptable to other communities.
- Sustainable funding.
Under these guiding principles, Border Health ¡SI! encompassed a series of objectives or project components that comprise our goal toward a comprehensive and systems change approach to chronic disease.
Border Health ¡SI! programs:
- Special Action Groups - Help community design and implement policy.
- Patients - Increase the extent and efficacy of patient diabetes self-management through self-management, skill-building and patient-empowerment.
- Providers - Work with health care providers in community health centers to evaluate and improve the quality of their diabetes care.
- Families - Increase the range of primary prevention and diabetes support behaviors of family members of identified persons living with diabetes.
- Community - Increase primary prevention behavior among community members through improved nutrition and increased physical activity.
- Schools - Assist elementary and middle school to develop policy related to school-based nutrition and physical activity.
Curricula and publications related to each of these project areas can be found in a special supplemental issue of Preventing Chronic Disease.
School Health Index (SHI)
The SHI has been implemented in a tribal school and in 13 Arizona elementary schools, two middle schools and one high school located in Arizona border communities as part of the Border Health Strategic Initiative (BHSI), a USMBHC-ADHS initiative, and the AzPRC. Individual school action plans varied but most shared one component, to reduce in-school access to "unhealthy foods." Other plans included health curricula and physical education. Three of the five schools completing the SHI implemented an immediate policy change that prohibited unhealthy snacks/candy to be given as rewards or incentives. The following is a partial list of changes that have occurred in the schools:
- Walking clubs have been organized during non-class time;
- The student council is no longer selling unhealthy snacks after school; and
- Bake sales offer nutritious food options (e.g. fruit salad rather than peanut butter cookies).
Feedback from the evaluation indicated that the SHI process builds awareness on the level of school commitment to health. The major barrier found was time, both for individual teachers who needed their time for planning, and also for scheduling groups together to complete a module. Modifications that strengthen the SHI include an external coordinator, especially in schools with limited resources, and school incentives that encourage participation in the SHI. The SHI is a valuable tool for assisting elementary schools to make immediate policy changes resulting in a healthier environment for children. This is important along the Arizona border, where rates of type 2 diabetes are on the rise among children and adolescents and childhood obesity is a major concern. Primary prevention in the schools through healthier nutritional and physical activity policies can decrease the chances of high-risk Hispanic children being diagnosed with diabetes and encourage healthier lifestyle habits. Currently, the Douglas SAG has chosen unhealthy foods in schools as one of its priority policy topics and is working with its schools to implement such policies. The SHI is currently being implemented in Cochise, Santa Cruz, and Yuma counties as part of the Steps to a HealthierUS Initiative.
Building the Hualapai Indian Community's Capacity to Address Youth Wellness
A community based participatory research project designed to address obesity and chronic disease risk factors in elementary school children within the Hualapai Nation. A diverse community wellness team or task force representing the school, tribal administration, the court system, tribal enterprises and the health department, advise and consult with community lay health educators who worked with the school to implement the School Health Index, designed and implemented a formative assessment of local barriers to youth wellness, and designed and are implementing a school-based and family outreach physical activity intervention.
Prevention and Control of Diabetes
Education for people living with diabetes
In the past, the AzPRC has worked in partnership with Mariposa Community Health Center in Santa Cruz County and Sunset Community Health Center in Yuma County to develop and implement an intervention for their adult patients with diabetes. These interventions were designed to increase the patients’ knowledge of diabetes as well as their self-management of their illness. Trained community health workers played an important role in these programs. The AZPRC Prevention and Disease Control of Diabetes project partnered with the Chiricahua Community Health Center in Cochise County on a similar program. To view and download the curriculum, see curricula.
The patient component of this latest program includes:
Family Component: Diabetes and the Family/La Diabetes y La Unión Familiar
The AzPRC Family Component is based on the Diabetes and the Family/La Diabetes y La Unión Familiar diabetes family intervention that was designed and implemented as part of the Border Health Strategic Initiative (BHSí) model in Santa Cruz and Yuma Counties. The University of Arizona (including AzPRC staff) collaborated with two Arizona U.S.-Mexico Border agencies (Mariposa Community Health Center and Campesinos Sin Fronteras) to design, implement as a pilot, and evaluate a diabetes education program for families delivered by promotoras/es.
La Diabetes y La Unión Familiar is an integrated family diabetes intervention that addresses primary and secondary prevention of diabetes in a culturally appropriate way. It increases awareness of what constitutes healthy physical activity and food choices, encourages behavior change towards health, and teaches family communication and supportive behavior that increases perceived cohesion, conflict resolution and emotional expression within the family. The intervention consists of home visits, kick off and graduation events, five interactive educational sessions that can be presented in home visits or in multi-family group sessions, and pre- and post-test evaluations.
The development and piloting phases of the family diabetes curriculum were an innovative and unique aspect of the BHSí comprehensive diabetes intervention model. La Diabetes y La Unión Familiar was the first program that focused on the family as a whole (and also allowed for the inclusion of neighbors and friends) to support diabetes management and diabetes prevention.
Starting in 2005, the BHSí family diabetes education program and curriculum were adapted to the AzPRC comprehensive diabetes intervention research project in Douglas, AZ. The intervention now consists of an initial home visit, pre-test evaluations, a kick off event, five interactive educational sessions presented in multifamily group sessions, a graduation event, one follow-up home visit serving as progress check, and post- and three months follow-up evaluations. The educational materials were expanded to address frequent complications of diabetes, namely cardiovascular disease, and depression and stress (the later uses materials from the SONRISA curriculum that was developed by AzPRC staff in 2004/2005). The AzPRC family intervention was piloted in mid-2005. As of December 2006, AzPRC staff have implemented and evaluated 4 rounds of the family diabetes intervention component.
Steps Forward/Pasos Adelante
Steps Forward/Pasos Adelante is an educational curriculum designed to be facilitated by Community Health Workers (CHWs). The Steps Forward/Pasos Adelante curriculum is an adaptation of the National Institutes of Health, National Heart, Lung, and Blood Institute’s (NHLBI) program Your Heart, Your Life (Su corazón, su vida) and was created to promote chronic disease prevention, specifically diabetes and cardiovascular disease, in Latino populations through increasing physical activity and nutrition promotion. The Steps Forward/Pasos Adelante program expands the NHLBI’s Your Heart, Your Life (Su corazón, su vida) curriculum to include additional information about diabetes, community advocacy, emotional/mental health, and how to organize walking groups. The CHW-led walking groups are designed to engage participants in a coordinated effort to increase physical activity through social support. Toward the end of the 12 week program, the CHWs stop walking with the groups but encourage them to continue. This pattern of involvement is meant to encourage the participants to continue to walk together once the program ends. As of March 2007, approximately 1,000 people along the Arizona/Sonora border have participated in the program. To view and download the curriculum, see curricula.
Reconized by CDC as an Evidence Base Program: http://www.cdc.gov/prc/prevention-strategies/chronic-disease-risks.htm
Local Special Action Groups (SAGs)
The AzPRC engages the community through partnerships to help effect policy change and to more efficiently build community capacity. Many of the changes needed to improve health along the border are policy decisions. For example, policy is needed to create sidewalks and parks, change access to junk food in schools, and provide state funding to actually care for uninsured persons who screen positive for diabetes, or other chronic diseases. When action coalitions also become political coalitions, their health promotion interventions may be more effective and sustainable. AzPRC personnel have been key facilitators and evaluators, initially as part of the Border Health Strategic Initiative and continuing under new funding, of the local CABs, coalitions focusing on policy change related to diabetes prevention and control in Yuma, Santa Cruz and Cochise Counties. Local CAB initiatives have resulted in various policy changes, such as the awarding of two Community Development Block Grants for parks to the town of Gadsden and an unincorporated area of Yuma County. In Cochise County, the school superintendent re-introduced physical education as a direct result of local CAB action and, in some schools, the local CAB has been instrumental in removing soda vending machines. The local CABs are designed to link all of the Community Health Worker (CHW) and school components to a broad coalition of organizations from diverse sectors of the community. While the CHW interventions focus on specific community driven activities, the focus of the CABs is developing and implementing a policy agenda as well as monitoring outcomes and successes. The formalization of these coalitions in both Yuma and Santa Cruz Counties took place in 2001. In Douglas, the CAB was built from the foundation of the Diabetes Working Group in 2002. Health challenges such as diabetes, poverty, the sociocultural and economic dynamics of the border, inadequate access to health care, good nutrition, and opportunities to live physically active lifestyles along the U.S.-Mexico border are too complex for a single intervention, agency or service, working by itself, to effectively address. Such problems call for a coordinated response on the part of the whole community and the need to work through community coalitions. The AzPRC has joined and provided supportive leadership through community coalitions. Gathering different actors around a coalition table mounts a coordinated multifaceted response to a complex issue and resources can be effectively shared. For example, working through a partnership, the diabetes prevalence survey that initiated the Douglas CAB was completed without support from any single source. Agencies and community members, including AzPRC staff each contributed money, resources or labor.
Rural Health Outreach Grants
The AzPRC has a long history of partnering with various community-based organizations in Southern Arizona to improve health and well-being through interventions focusing on chronic disease prevention and control. Using a participatory model of evaluation, the AzPRC has collaborated in the development and evaluation of programs addressing diabetes, obesity, coronary heart disease, and partner violence. The Rural Health Outreach Grants, funded by the Health Services Research Administration, provide an example of this model, in which the AzPRC served as a sub-contractor with recipients of Rural Health Outreach Grants in Yuma, Ajo, Santa Cruz, Cochise, and Graham/Greenlee Counties. These grants created community consortiums, which provided diabetes outreach and self-management classes tailored to the needs of the specific community. The community health worker (CHW) model was utilized in four of the five grants. Evaluation was both qualitative and quantitative and included self-reported measures as well as biological markers such as HbA1c. These measures were created in collaboration with the partnering organizations and were utilized by the groups in both program development and sustainability.
Network analysis is a method for examining the relationships between individuals, groups, or organizations. It involves collecting information from network members, and those who perhaps should be part of the network, on the relationships each maintains with other members of the network. Once this information is collected, it is analyzed using one or more computer programs, such as UCINET. Network analysis procedures provide a method for examining the extent to which collaboration is actually occurring, who is collaborating with whom, in what ways, and how these relationships are evolving over time. The results can be reported back to network members, providing relationship scores for individual members and for the network as a whole. Results can also be displayed graphically, providing an instant picture of what the network looks like. Building collaborative partnerships has become increasingly recognized in public health as an important way for community-based organizations with limited resources to identify critical health needs, to provide and coordinate needed services, and in general, to enhance the overall capacity of a community to address its most pressing health and human service needs. Yet most communities have only a general and often vague understanding of whether or not their network-building efforts are actually resulting in stronger collaboration. Network analysis provides a powerful tool for community leaders to assess their network/partnership-building efforts in a systematic way that can be readily understood by both policy officials and health practitioners.
Legacy Foundation: Best Practices in Tobacco Control
This is a qualitative study of the administration and implementation of tobacco control programs designed specifically for Hispanic and Native American populations in four states, California, Arizona, New Mexico and Texas. Primary research activities include in-depth interviews with personnel at the state and community levels to assess programs' familiarity and use of CDC's Best Practices Guidelines for Tobacco Control and to document perceived strengths and weaknesses in program administration and implementation at the state and community level.
REACH 2010 Promotora Community Coalition Evaluation (Rio Grande Valley, Texas)
A comprehensive diabetes prevention and control program focusing on a clinical intervention with patients and providers, prevention in the schools and the local communities, and a system and environmental change intervention through the community coalition. The Border Health Strategic Initiative (BHSI) comprehensive model was based upon the REACH 2010 community model.
Steps to a Healthier US Initiative (Arizona)
This is a HHIS/CDC initiative. In 1998, the AzPRC began working with community partners in four border communities, Yuma, Santa Cruz, and Cochise Counties and the Tohono O’odham Nation to develop and evaluate Border Health ¡SI¡, a comprehensive model to address diabetes prevention and control. Border Health ¡SI¡ laid the groundwork for the Steps to a Healthier Arizona Initiative, funded by the CDC to the Arizona Department of Health Services (ADHS), which aims to help Americans live longer, better, and healthier lives by reducing the burden of diabetes, overweight, obesity and asthma. As part of Steps, AzPRC faculty and staff continue to work collaboratively with community partners in program development and evaluation. The AzPRC engages in a participatory model of evaluation in which all partners engage in the process of identifying program outcomes and measures, evaluation instruments, and data collection. The AzPRC works closely with Steps partners in the field and provides evaluation results on a regular basis to ensure that findings are integrated into program strategies. The AzPRC also collaborates with ADHS to address national evaluation and provides technical assistance to community partners.
Arizona Department of Health Services (ADHS) Nutrition and Physical Activity (NUPA) State Plan
The ADHS NUPA evaluation project is a collaboration between the AzPRC and ADHS to evaluate and assess the impact of the Nutrition and Physical Activity State Plan released in 2005. The project entails researching and forming an appendix of references from multiple other state nutrition and physical activity plans that would be used to revise the Arizona state plan.
In addition, an online survey aimed at key stakeholders will be circulated to determine usability and relevance of the State Plan. The data collected will then be used to update, improve, and revise the state plan. Key stakeholders are also being asked for a summary of programs targeting physical activity and nutrition to be included in a state level database.