Community-Based Program on the U.S.-Mexico Border Reduces Chronic Disease Risks

Community health workers (CHWs, or promotores) help tailor and lead a chronic disease prevention program for Mexican-Americans living on the U.S.-Mexico border
Promotores deliver educational sessions targeting nutrition, physical activity, and other chronic disease and mental health risk factors, and form walking groups to promote activity
Significant improvements in body mass index; blood pressure, total cholesterol, and glucose levels; health-related quality of life; and depression are sustained after the intervention ends

Background

Socioeconomic characteristics of the U.S.-Mexico border area include high rates of poverty, unemployment, and lack of health insurance; inadequate public health infrastructure; and spotty access to health care. Hot climate; lack of sidewalks, recreational facilities, and lighting; roaming dogs; and other environmental factors contribute to inadequate physical activity in the area’s largely Mexican-American population. These residents eat significantly fewer than the recommended daily servings of fruits and vegetables than do non-Hispanic whites, and the rates of obesity and diabetes are higher for Mexican-Americans than for non-Hispanic whites (79% vs. 67% and 13% vs. 8%, respectively).^1,2 Few community programs address border residents’ need to reduce their chronic disease risks.

Context

Community health workers (CHWs) have been used worldwide to promote health; in Hispanic communities, CHWs (called promotores when referring to both women and men) have been successful in programs to improve access to care and screening.³ Promotores provide community knowledge, help make programs culturally appropriate, and substantially contribute to their implementation. In 2000, the researchers began assessing the approach of a promotora-facilitated program in U.S.-Mexico border communities and found that it could motivate people to reduce their risk of cardiovascular disease, diabetes, and other chronic diseases related to diet and physical activity.⁴
The program was part of a large-scale initiative to improve border health. The Initiative included components targeting clinicians, schools, persons with diabetes and their families, and the community; Pasos Adelante was the community component. The program was developed in partnership with the Mariposa Community Health Center in Nogales, Arizona, the Regional Center for Border Health, Inc., the Western Arizona Area Health Education Center, and faculty and staff at the University of Arizona Mel and Enid Zuckerman College of Public Health.

Methods & Results

The National Heart, Lung, and Blood Institute’s intervention, Su Corazon, Su Vida, is a 9-week peer-led cardiovascular disease prevention curriculum for Hispanic populations that had been shown to be effective in lowering weight and blood pressure and improving food choices.⁵ The curriculum was adapted by the promotores, PRC staff, and partners to include information about diabetes, community advocacy, organizing walking groups, and emotional and mental health. The resulting 12-week intervention consisted of weekly two-hour scripted classroom sessions led by promotores, who were also responsible for forming walking groups. At week 7, the promotores began to withdraw from the walking groups but encouraged participation to make the groups self-sustaining.
The 11 promotores lived in Douglas, Nogales, Somerton, or San Luis. Some of them were working for the partner agencies, and others were hired to work on Pasos Adelante. The promotores received about six hours of training on the instructional manuals and study protocols and attended a one-week training on Su Corazon, Su Vida and a one-day training on diabetes. During project implementation, the promotores sought additional training in diabetes, chronic disease, nutrition, and physical activity at regional and national conferences. The promotores recruited participants at health fairs, by making presentations at schools and church groups, and by going door-to door.
From 2000 – 2003, the program was implemented in the U.S.-Mexico border counties of Yuma and Santa Cruz, Arizona. Of 248 persons who began the program, 216 (87%) completed it. Overall, there were statistically significant (p < 0.05) dietary improvements in per week servings of soda (2.6 to 1.4), sweetened hot drinks (7.5 to 6.5), salads (4.5 to 6.2), fruits (8.8 to 11.7), and vegetables (5.3 to 7.8). Mean weekly minutes of moderate walking increased significantly from 73.7 to 138.1, as did fast walking from 77.5 to 108.9 (both p < 0.001).
From 2005 – 2008 the program was implemented in Douglas, Arizona, a U.S.-Mexico border town of about 10,000 adults, 86% of whom are Hispanic. Baseline physiologic measures (height, weight, waist and hip circumference, blood pressure, pulse, and fasting blood levels [glucose, cholesterol, and triglycerides]) and measures of depression and health-related quality of life were taken, repeated at program end, and repeated again 3 months post-program. 255 (83.6%) participants completed the program and 221 completed the 3 month post-program assessment. Compared to baseline, statistically significant (p< 0.05) mean improvements at program end were seen in body mass index (-0.199 kg/m2), blood pressure (systolic = -3.208 mm Hg and diastolic = -2.939 mm Hg), total cholesterol (-6.897mg/dL), mean physically unhealthy days (-1.8), and mean mentally unhealthy days (-2.5). Fewer participants rated their health as poor or fair (p < 0.002), and fewer had low depression scores (p < 0.03). At 3 months post-program, a -4.529 mean drop in glucose levels was noted and the other changes were sustained.^6,7
In the initial program, the participants were overwhelmingly female (88% in Yuma and 97% in Santa Cruz), had an average age of 49.5 years, and all but one were Hispanic. In the Douglas implementation, all participants were Hispanic and more than 90% were female. The average age at baseline was 52.2 years. The promotores reflected these demographic characteristics as well; in the initial study, all but one were women, and in the Douglas program all three were women.

Consequences and Potential Impact

Pasos Adelante may motivate Mexican-American women aged 40 years or older to adopt and sustain healthy lifestyle behaviors. Widespread use of the intervention may help decrease the health disparities for these women. Further, because women are the food preparers in many households, the knowledge and behaviors they gained from the program may affect broad family units. In addition, the appeal of the program to men and to all people younger than 40 needs further research.
The Pasos Adelante manual is available in English

and Spanish

, and community organizations and public health agencies continue to deliver the program along the U.S.-Mexico border and elsewhere. The model also has been adapted for a young, urban Latina population in Arizona and is being adapted in collaboration with a Mexican academic institution and the Sonora (Mexico) Ministry of Health for an urban, low-income population in northern Mexico.

References

Flegal K, Carroll M, Kuczmarski R, Johnson C. Overweight and obesity in the United States: prevalence and trends, 1960 – 1994. International Journal of Obesity and Related Metabolic Disorders 1998;22:39.
Hertz RP, Unger AN, Ferrario CM. Diabetes, hypertension, and dyslipidemia in Mexican Americans and non-Hispanic whites. American Journal of Preventive Medicine 2006;30(2):103-10.
Swider SM. Outcome effectiveness of community health workers: an integrative literature review. Public Health Nursing 2002;19:11-20
Staten LK, Scheu LL, Bronson D, Pena V, Elenes J. Pasos Adelante: the effectiveness of a community-based chronic disease prevention program. Preventing Chronic Disease 2005;2:1-11.
Balcazar HG, de Heer H, Rosenthal L, Aguirre M, Flores L, Puentes FA, Cardenas VM, Duarte MO, Ortiz M, Schulz LO. A promotores de salud intervention to reduce cardiovascular disease risk in a high-risk Hispanic border population, 2005-2008. Preventing Chronic Disease 2010;7:2
Staten LK, Cutshaw C, Davidson C, Stewart R, Reinschmidt K, Roe D. Pasos Adelante: effectiveness of a community health worker-led chronic disease prevention and control program in a US-Mexico border community. Preventing Chronic Disease. Forthcoming 2012.
Cutshaw C, Staten LK, Reinschmidt KM, Davidson C, Roe D. Effects of Pasos Adelante, a chronic disease prevention and control program, on health-related quality of life and depressive symptoms in a Latino border community. Preventing Chronic Disease. Forthcoming 2012.