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Volume
2:
No. 1, January 2005
ESSAY
Challenges
and Opportunities in Border Health
Joel Rodríguez-Saldaña, MD
Suggested citation for this article: Rodríguez-Saldaña J. Challenges and opportunities
in border health. Prev Chronic Dis [serial online] 2005
Jan [date cited]. Available from: URL:
http://www.cdc.gov/pcd/issues/2005/
jan/04_0099.htm.
Approximately 11.5 million people reside in the 42 counties and 39
Mexican municipalities located along the U.S.-Mexico border, and
86% of those people reside in 14 pairs of sister cities, metropolitan areas
divided by the international border (1). Border residents share similar
resources and environmental problems: issues of great concern include air
quality, water quantity and quality, and animal control. The communities
along the border are economically and socially interdependent, with more
than 1 million legal northbound crossings every day. The need to establish
cooperation between the United States and Mexico for improving health has
led to collaborative initiatives between the public and private sectors
(1). The principal health problems at the U.S.-Mexico border
are characterized by disparities in health systems (2), which
result from the lower health standards and socioeconomic conditions of
Mexican border communities compared with U.S. border communities.
Health-system disparities produce differences in and barriers to health
care access and use (3,4). Documented cases that
demand the creation of programs across the U.S.-Mexico border show different
rates in the prevalence of infectious disease, including hepatitis A,
salmonella, tuberculosis, dengue fever, and Helicobacter pylori
infection
(5,6). The magnitude and relevance of infectious disease as a major concern
along the U.S.-Mexico border have prompted the establishment of binational agreements, such as the U.S.-Mexico Border Infectious Disease
Surveillance Project, with the purpose of enhancing the effectiveness of
infectious disease prevention (7). On the other hand, populations on both
sides of the border share the impact of diseases — such as obesity and
diabetes — resulting from similar lifestyle changes. The prevalence rate for
diabetes along the U.S.-Mexico border is nearly 50% higher than the rate for
the rest of the United States, and Hispanics are more vulnerable to suffering
the burden of chronic complications because of genetic, economic, social,
behavioral, and psychological factors.
This issue of Preventing Chronic Disease includes an introduction
and overview (8) as well as additional articles on the Border
Health Strategic Initiative (Border Health ¡SI!), a comprehensive
community approach to diabetes prevention and control primarily
concentrated in Yuma and Santa Cruz counties in Arizona. Border Health ¡SI! is based on models of community
capacity building and community change and was established through a partnership
between several border community groups and the University of Arizona. In
addition to being comprehensive and community oriented, Border Health ¡SI!
was designed to be acceptable to
stakeholders, effective in fostering and sustaining change, adaptable to
other communities, sustainable after funding, and process and
outcome focused.
To reduce the incidence of diabetes among individuals with
impaired glucose tolerance, Border Health ¡SI! has emphasized the
management of risk factors such as obesity through lifestyle changes
(e.g., nutritional counseling, increased physical activity, modest weight
loss). The program has also focused on community-based diabetes care
provided by a multidisciplinary team that targets patients with diabetes,
their families, and their health care providers. Community-health outreach
workers called promotores de salud have been instrumental in
implementing interventions designed to change personal health risk factors.
The introductory article also describes the formation of community-based
coalitions called Special Action Groups (SAGs), whose primary goal is to
identify and implement plans for policy and environmental change. Meister
et al (9) provide details on how the SAGs in two communities were formed and
how they promoted activities to support physical activity and nutrition, and Steinfelt (10) reports on her experience as the community coordinator
responsible for orchestrating SAG activities. Other articles in this issue,
described below, provide examples of target populations.
Ingram et al report on the effectiveness of a series of diabetes
education classes to assist participants in gaining knowledge and skills
necessary to be physically active, control diet, monitor blood sugar, take
medications, and be aware of complications (11). Promotores de salud
play a key role in conducting outreach, participating in patient education,
and providing educational support in an overall framework in which
individual ability to manage diabetes is not separated from community
context and support for diabetes care. Community health centers administered
the program and provided a coordinator. Academic partners provided technical
assistance and conducted evaluations. The culturally competent curriculum
employed a variety of teaching methods to educate participants on how
diabetes affects the body. In addition, program staff measured blood
glucose, weight, and blood pressure at each of five weekly classes.
Improvements in self-management behaviors, HbA1c, random blood
glucose, and blood pressure were documented after five weeks. The authors
conclude that successful implementation of a program like Border Health ¡SI!
includes five essential elements: basic diabetes education, peer outreach
and support, integration of diabetes and clinical care, access to medical
care and medication, and sustainability.
Teufel-Shone et al (12) describe how the University of Arizona and two
community health agencies collaborated to design, pilot, and assess the
feasibility of a lay health-outreach, worker-delivered diabetes education
program for families. The culturally appropriate program addressed family
food choices, physical activity, behavior change, communication, and support
behaviors. Seventy-two families participated, and pre- and post-evaluations
showed an increase in knowledge of diabetes risk factors and an increase in
family efficacy to change food and activity behaviors.
Staten et al report their findings after implementing the School Health
Index (SHI) in 13 schools in two counties along the U.S.-Mexico border as
part of Border Health ¡SI! between 2000 and
2003 (13). The alarming increase in childhood obesity is a contributing
factor to the escalating rate of type 2 diabetes among adolescents. Although
the school environment is shown to neglect promotion of
physical activity (e.g., by eliminating or not offering physical education
classes) and good nutrition (e.g., by selling candy in vending machines), it offers opportunities to combat
obesity and diabetes. The SHI is a team-based program launched by the
Centers for Disease Control and Prevention in 2000 as a self-assessment and
planning tool for health promotion. The SHI enables schools to identify
strengths and weaknesses of physical activity and nutrition policies and
programs and to develop action plans for improving student health. Border
Health ¡SI! supported the hiring and training of an external (i.e., not
part of the school system) SHI coordinator in each county who
worked with the schools to implement the SHI, develop action plans, and
monitor progress. Process and participation varied from school to school,
but most schools
made at least one immediate
change in the school environment to promote student health. Analysis of short-term and intermediate outcomes
of the SHI at
these schools will be of great additional value.
Staten et al also report on Pasos Adelante, a curriculum designed
in cultural context aimed at preventing diabetes, cardiovascular disease,
and other chronic diseases in Hispanic populations (14). The 12-week program
was facilitated by promotoras de salud in two
counties along the Arizona-Sonora, Mexico border. Sessions included physical
activity. Walking clubs were established that could continue after the
program concluded. Approximately 250 people participated in Pasos
Adelante. Analysis of
pre- and post-program questionnaires demonstrated a significant increase in
moderate to vigorous walking among participants as well as positive changes
in nutritional patterns. The success of the Pasos Adelante curriculum shows that a culturally
appropriate educational program can motivate people in border communities to
adopt healthier lifestyle behaviors.
In a related article on original research, Abarca et al (15) illustrate how community indicators
were used to assess
nutrition in communities targeted by Border
Health ¡SI!.
Local grocery store purchases were selected as an indicator, and a
structured 26-question interview was developed and administered to grocery store managers. In addition, the investigators gathered data from milk
distributors serving these communities. Results showed that food items with a higher
fat and higher caloric content were favored. The authors suggest that barriers to acceptance of
healthier food items include lack of knowledge concerning healthy
foods and their prices. They conclude that more interventions are needed to
change dietary patterns, improve overall health, and prevent and control
diabetes in these communities.
Schachter et al report their findings on implementing national
diabetes guidelines in five border-community health centers (two in Arizona
and three in Texas) (16). Each center selected their top four or five
indicators of diabetes care and performed baseline audits of medical records
in a minimal sample of 12 to 15 charts. Percentage level of compliance for
each indicator was compared with the average percentage level of overall
diabetes care compliance for each community health center. Priorities varied
from clinic to clinic, but the majority of indicators showed improvement.
All participating centers expressed interest in improving performance. Only
three centers, however, were audited again 24 months later: two maintained or
increased improvements, and one lost ground. As reported in other studies
(17), translating guidelines into practice is easier said than done:
“Between the health care we have and the care we could have lies not just a
gap, but a chasm” (18).
Although there is increasing evidence of improvements in diabetes care,
not all people with diabetes are experiencing these benefits
(19). Addressing the complexities of diabetes management, improving the
established systems of care, and recognizing the decisive role of personal,
social, and economic factors on diabetes care for each individual with
diabetes are the greatest health challenges of our time. The
U.S.-Mexico border is a unique example of the interaction of global
interdependence: the challenges of providing formal diabetes education in
border communities are overwhelming (11). It would be desirable for this
interdependence to produce better standards of living and health for all,
but evidence confirms that this is not the case (1). The Border
Health Strategic Initiative is an illustrative example of a long and
successful record of collaborative work, with defined goals, including
process and outcome analysis. Resolution of the many challenges that the
emerging epidemic rates of diabetes presents at the U.S.-Mexico border will
certainly apply to other scenarios of health disparity.
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Author Information
Corresponding author: Joel Rodríguez-Saldaña, MD, Research Center, Servicios
de Salud de Hidalgo, Avenida México 300, Pachuca Hidalgo 42039 México.
Telephone: 011(52)771-71-80770. E-mail: joelrds@internet.com.mx.
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