La vida en la frontera: protocol for a prospective study exploring stress and health resiliencies among Mexican-origin individuals living in a US-Mexico border community.

BACKGROUND: Mexican-origin adults living near the U.S.-Mexico border experience unique and pervasive social and ecological stressors, including poverty, perceived discrimination, and environmental hazards, potentially contributing to the high burden of chronic disease. However, there is also evidence that residents in high-density Mexican-origin neighborhoods exhibit lower prevalence rates of disease and related mortality than those living in other areas. Understanding the factors that contribute to health resiliencies at the community scale is essential to informing the effective design of health promotion strategies. METHODS: La Vida en la Frontera is a mixed-methods participatory study linking a multi-disciplinary University of Arizona research team with Campesinos Sin Fronteras, a community-based organization founded by community health workers in San Luis, Arizona. This paper describes the current protocol for aims 2 and 3 of this multi-faceted investigation. In aim 2 a cohort of N≈300 will be recruited using door-to-door sampling of neighborhoods in San Luis and Somerton, AZ. Participants will be surveyed and undergo biomarker assessments for indicators of health and chronic stress at three time points across a year length. A subset of this cohort will be invited to participate in aim 3 where they will be interviewed to further understand mechanisms of resilience and wellbeing. DISCUSSION: This study examines objective and subjective mechanisms of the relationship between stress and health in an ecologically diverse rural community over an extended timeframe and illuminates health disparities affecting residents of this medically underserved community. Findings from this investigation directly impact the participants and community through deepening our understanding of the linkages between individual and community level stress and chronic disease risk. This innovative study utilizes a comprehensive methodology to investigate pathways of stress and chronic disease risk present at individual and community levels. We address multiple public health issues including chronic disease and mental illness risk, health related disparities among Mexican-origin people, and health protective mechanisms and behaviors.

Establishing voluntary certification of community health workers in Arizona: a policy case study of building a unified workforce.

BACKGROUND: Community health workers (CHWs) are widely recognized as essential to addressing disparities in health care delivery and outcomes in US vulnerable populations. In the state of Arizona, the sustainability of the workforce is threatened by low wages, poor job security, and limited opportunities for training and advancement within the profession. CHW voluntary certification offers an avenue to increase the recognition, compensation, training, and standardization of the workforce. However, passing voluntary certification legislation in an anti-regulatory state such as Arizona posed a major challenge that required a robust advocacy effort. CASE PRESENTATION: In this article, we describe the process of unifying the two major CHW workforces in Arizona, promotoras de salud in US-Mexico border communities and community health representatives (CHRs) serving American Indian communities. Differences in the origins, financing, and even language of the population-served contributed to historically divergent interests between CHRs and promotoras. In order to move forward as a collective workforce, it was imperative to integrate the perspectives of CHRs, who have a regular funding stream and work closely through the Indian Health Services, with those of promotoras, who are more likely to be grant-funded in community-based efforts. As a unified workforce, CHWs were better positioned to gain advocacy support from key health care providers and health insurance companies with policy influence. We seek to elucidate the lessons learned in our process that may be relevant to CHWs representing diverse communities across the US and internationally. CONCLUSIONS: Legislated voluntary certification provides a pathway for further professionalization of the CHW workforce by establishing a standard definition and set of core competencies. Voluntary certification also provides guidance to organizations in developing appropriate training and job activities, as well as ongoing professional development opportunities. In developing certification with CHWs representing different populations, and in particular Tribal Nations, it is essential to assure that the CHW definition is in alignment with all groups and that the scope of practice reflects CHW roles in both clinic and community-based settings. The Arizona experience underscores the benefits of a flexible approach that leverages existing strengths in organizations and the population served.

Non-communicable disease prevention in Mexico: policies, programs and regulations.

Non-communicable diseases (NCD), such as diabetes and cardiovascular disease, have become a leading cause of the death in Mexico. The federal government has addressed this issue through developing NCD prevention plans, regulations and policies (PRPs) that seek to address social and environmental factors, which was led by the National Institute of Public Health and Ministry of Health in concert with various non-governmental organizations. This review aims to synthesize and summarize national NCD prevention PRPs addressing social and environmental factors passed from 2010 to 2016, and to assess the extent to which these efforts successfully addressed factors contributing to the epidemic. In total nine federal NCD prevention PRPs were identified from a scan that examined executive and legislative PRPs, which identified five documents. A scoping review was conducted for evaluation studies and reports corresponding to these PRPs. The majority of PRPs focused on nutrition, specifically the access and promotion of food. Studies and reports demonstrated that taxation on energy-dense low-nutrient foods and sugar-sweetened beverages were the most effective. Other PRPs had various issues with implementation, mostly related to adherence and resources available. Overall, there lacked evidence of evaluative work on several NCD prevention PRPs, specifically assessing implementation and effectiveness. Additionally, PRPs did not sufficiently address integration of clinical, social, environmental approaches and access to physical activity. While the Mexican federal government has taken the initial steps to address the multifactorial causes of NCD, firm political commitment and investment of significant resources are still needed.

Women's Health Leadership to Enhance Community Health Workers as Change Agents.

Objectives A community health worker (CHW) is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. While natural leadership may incline individuals to the CHW profession, they do not always have skills to address broad social issues. We describe evaluation of the Women's Health Leadership Institute (WHLI), a 3-year training initiative to increase the capacity of CHWs as change agents. Methods Pre-/postquestionnaires measured the confidence of 254 participants in mastering WHLI leadership competencies. In-depth interviews with CHW participants 6 to 9 months after the training documented application of WHLI competencies in the community. A national CHW survey measured the extent to which WHLI graduates used leadership skills that resulted in concrete changes to benefit community members. Multivariate logistic regressions controlling for covariates compared WHLI graduates' leadership skills to the national sample. Results Participants reported statistically significant pre-/postimprovements in all competencies. Interviewees credited WHLI with increasing their capacity to listen to others, create partnerships, and initiate efforts to address community needs. Compared to a national CHW sample, WHLI participants were more likely to engage community members in attending public meetings and organizing events. These activities led to community members taking action on an issue and a concrete policy change. Conclusions Leadership training can increase the ability of experienced CHWs to address underlying issues related to community health across different types of organizational affiliations and job responsibilities.

A community health worker intervention to address the social determinants of health through policy change.

Public policy that seeks to achieve sustainable improvements in the social determinants of health, such as income, education, housing, food security and neighborhood conditions, can create positive and sustainable health effects. This paper describes preliminary results of Acción para la Salud, a public health intervention in which Community health workers (CHWs) from five health agencies engaged their community in the process of making positive systems and environmental changes. Academic-community partners trained Acción CHWs in community advocacy and provided ongoing technical assistance in developing strategic advocacy plans. The CHWs documented community advocacy activities through encounter forms in which they identified problems, formulated solutions, and described systems and policy change efforts. Strategy maps described the steps of the advocacy plans. Findings demonstrate that CHWs worked to initiate discussions about underlying social determinants and environment-related factors that impact health, and identified solutions to improve neighborhood conditions, create community opportunities, and increase access to services.

Aquí Entre Nos (Just Between Us): Engagement of Hotel Housekeepers During Sociopolitical and Environmental Change.

BACKGROUND: Aquí Entre Nos (Between Us) is a community-based participatory research project to engage rural, ethno-racially diverse hotel housekeepers in a right to work state during a time of national anti-immigrant policy, wildfires and emergence of a global pandemic. OBJECTIVES: We aimed to (1) build trust and social support with the hotel housekeeping community, (2) learn about the occupational health, safety, and workers' rights challenges, strategies, and solutions held by workers, and (3) develop a workforce-driven research and action agenda to improve labor and health conditions. METHODS: Participatory mixed methods rooted in popular education are described to form an advisory board and engage the workforce. LESSONS LEARNED: Trusted relationships built through community organizing around immigration, housing, and minimum wage were critical to engage and drive a worker centered research agenda. CONCLUSIONS: Despite challenges, housekeeper advisors defined a research agenda that addressed immediate-and long-term needs of the workforce.

Establishing a professional profile of community health workers: results from a national study of roles, activities and training.

Community Health Workers (CHWs) have gained national recognition for their role in addressing health disparities and are increasingly integrated into the health care delivery system. There is a lack of consensus, however, regarding empirical evidence on the impact of CHW interventions on health outcomes. In this paper, we present results from the 2010 National Community Health Worker Advocacy Survey (NCHWAS) in an effort to strengthen a generalized understanding of the CHW profession that can be integrated into ongoing efforts to improve the health care delivery system. Results indicate that regardless of geographical location, work setting, and demographic characteristics, CHWs generally share similar professional characteristics, training preparation, and job activities. CHWs are likely to be female, representative of the community they serve, and to work in community health centers, clinics, community-based organizations, and health departments. The most common type of training is on-the-job and conference training. Most CHWs work with clients, groups, other CHWs and less frequently community leaders to address health issues, the most common of which are chronic disease, prevention and health care access. Descriptions of CHW activities documented in the survey demonstrate that CHWs apply core competencies in a synergistic manner in an effort to assure that their clients get the services they need. NCHWAS findings suggest that over the past 50 years, the CHW field has become standardized in response to the unmet needs of their communities. In research and practice, the field would benefit from being considered a health profession rather than an intervention.

The Culture of Health Survey: a qualitative assessment of a diabetes prevention coalition.

In the past two decades, the fields of public health and social services have increasingly turned toward collaborative and community-based approaches to address complex health and social issues. One aspect of these approaches has been the development and implementation of community coalitions. Coalitions have been used to successfully address a wide range of issues, including cancer prevention, tobacco use, HIV/AIDS, youth violence, heart disease, diabetes, and sexual exploitation of youth runaways. In south Tucson, Arizona the SEAH coalition was developed to address diabetes and substance abuse prevention. Using a qualitative interview guide, the Culture of Health Survey, this study was aimed at identifying community perceptions of the coalition and its effectiveness in the areas of community leadership, partnerships, trust, and movement towards positive change. We also sought to document the dissemination, throughout a community, of information on the activities and functioning of a community based coalition and whether or not it was seen as one that held fast to the community values and not to individual agendas. Results highlight the importance of outreach, education, trust, and partnerships in promoting diabetes prevention through a community coalition.

Taking a broad approach to public health program adaptation: adapting a family-based diabetes education program.

Diabetes health disparities among Hispanic populations have been countered with federally funded health promotion and disease prevention programs. Dissemination has focused on program adaptation to local cultural contexts for greater acceptability and sustainability. Taking a broader approach and drawing on our experience in Mexican American communities at the U.S.-Mexico Border, we demonstrate how interventions are adapted at the intersection of multiple cultural contexts: the populations targeted, the community- and university-based entities designing and implementing interventions, and the field team delivering the materials. Program adaptation involves negotiations between representatives of all contexts and is imperative in promoting local ownership and program sustainability.

The Meta Salud Diabetes Implementation Study: Qualitative Methods to Assess Integration of a Health Promotion Intervention Into Primary Care to Reduce CVD Risk Among an Underserved Population With Diabetes in Sonora, Mexico.

Background: Within health promotion research, there is a need to assess strategies for integration and scale up in primary care settings. Hybrid interventions that combine clinical effectiveness trials with implementation studies can elicit important contextual information on facilitators and barriers to integration within a health care system. This article describes lessons learned in developing and implementing a qualitative study of a cluster-randomized controlled trial (RCT) to reduce cardiovascular disease (CVD) among people with diabetes in Sonora, Mexico, 2015-2019. Methods:The research team worked cooperatively with health center personnel from 12 Centers that implemented the intervention. The study used observations, stakeholder meetings, case studies, staff interviews and decision maker interviews to explore issues such as staff capacity, authority, workflow, space, and conflicting priorities, as well as patients' response to the program within the clinical context and their immediate social environments. Applying a multi-layered contextual framework, two members of the research team coded an initial sample of the data to establish inclusion criteria for each contextual factor. The full team finalized definitions and identified sub nodes for the final codebook. Results: Characteristics of management, staffing, and the local environment were identified as essential to integration and eventual adoption and scale up across the health system. Issues included absence of standardized training and capacity building in chronic disease and health promotion, inadequate medical supplies, a need for program monitoring and feedback, and lack of interdisciplinary support for center staff. Lack of institutional support stemming from a curative vs. preventive approach to care was a barrier for health promotion efforts. Evolving analysis, interpretation, and discussion resulted in modifications of flexible aspects of the intervention to realities of the health center environment. Conclusion: This study illustrates that a robust and comprehensive qualitative study of contextual factors across a social ecological spectrum is critical to elucidating factors that will promote future adoption and scale up of health promotion programs in primary care. Application of conceptual frameworks and health behavior theory facilitates identification of facilitators and barriers across contexts. Trial registration: www.ClinicalTrials.gov, identifier: NCT02804698 Registered on June 17, 2016.

From program to policy: expanding the role of community coalitions.

BACKGROUND: Diabetes mortality at the United States-Mexico border is twice the national average. Type 2 diabetes mellitus is increasingly diagnosed among children and adolescents. Fragmented services and scarce resources further restrict access to health care. Increased awareness of the incidence of disease and poor health outcomes became a catalyst for creating community-based coalitions and partnerships with the University of Arizona that focused on diabetes. CONTEXT: Five partnerships between the communities and the University of Arizona were formed to address these health issues. They began with health promotion as their goal and were challenged to add policy and environmental change to their objectives. Understanding the meaning of policy in the community context is the first step in the transition from program to policy. Policy participation brings different groups together, strengthening ties and building trust among community members and community organizations. METHODS: Data on progress and outcomes were collected from multiple sources. We used the Centers for Disease Control and Prevention's Racial and Ethnic Approaches to Community Health (REACH) 2010 Community Change Model as the capacity-building and analytic framework for supporting and documenting the transition of coalitions from program to policy. CONSEQUENCES: Over 5 years, the coalitions made the transition, in varying degrees, from a programmatic focus to a policy planning and advocacy focus. The coalitions raised community awareness, built community capacity, encouraged a process of "change in change agents," and advocated for community environmental and policy shifts to improve health behaviors. INTERPRETATION: The five coalitions made environmental and policy impacts by engaging in policy advocacy. These outcomes indicate the successful, if not consistently sustained, transition from program to policy. Whether and how these "changes in change agents" are transferable to the larger community over the long term remains to be seen.

A Comparison of Methods for Capturing Patient Preferences for Delivery of Mental Health Services to Low-Income Hispanics Engaged in Primary Care.

BACKGROUND: Consideration of patient preferences regarding delivery of mental health services within primary care may greatly improve access and quality of care for the many who could benefit from those services. OBJECTIVES: This project evaluated the feasibility and usefulness of adding a consumer-products design method to qualitative methods implemented within a community-based participatory research (CBPR) framework. RESEARCH DESIGN: Discrete-choice conjoint experiment (DCE) added to systematic focus group data collection and analysis. SUBJECTS: Focus group data were collected from 64 patients of a Federally-Qualified Health Center (FQHC) serving a predominantly low-income Hispanic population. A total of 604 patients in the waiting rooms of the FQHC responded to the DCE. MEASURES: The DCE contained 15 choice tasks that each asked respondents to choose between three mental health services options described by the levels of two (of eight) attributes based on themes that emerged from focus group data. RESULTS: The addition of the DCE was found to be feasible and useful in providing distinct information on relative patient preferences compared with the focus group analyses alone. According to market simulations, the package of mental health services guided by the results of the DCE was preferred by patients. CONCLUSIONS: Unique patterns of patient preferences were uncovered by the DCE and these findings were useful in identifying pragmatic solutions to better address the mental health service needs of this population. However, for this resource-intensive method to be adopted more broadly, the scale of the primary care setting and/or scope of the issue addressed have to be relatively large.

Addressing Hearing Health Care Disparities among Older Adults in a US-Mexico Border Community.

UNLABELLED: Hearing loss is associated with cognitive decline and impairment in daily living activities. Access to hearing health care has broad implications for healthy aging of the U.S. POPULATION: This qualitative study investigated factors related to the socio-ecological domains of hearing health in a U.S.-Mexico border community experiencing disparities in access to care. A multidisciplinary research team partnered with community health workers (CHWs) from a Federally Qualified Health Center (FQHC) in designing the study. CHWs conducted interviews with people with hearing loss (n = 20) and focus groups with their family/friends (n = 27) and with members of the community-at-large (n = 47). The research team conducted interviews with FQHC providers and staff (n = 12). Individuals experienced depression, sadness, and social isolation, as well as frustration and even anger regarding communication. Family members experienced negative impacts of deteriorating communication, but expressed few coping strategies. There was general agreement across data sources that hearing loss was not routinely addressed within primary care and assistive hearing technology was generally unaffordable. Community members described stigma related to hearing loss and a need for greater access to hearing health care and broader community education. Findings confirm the causal sequence of hearing impairment on quality of life aggravated by socioeconomic conditions and lack of access to hearing health care. Hearing loss requires a comprehensive and innovative public health response across the socio-ecological framework that includes both individual communication intervention and greater access to hearing health resources. CHWs can be effective in tailoring intervention strategies to community characteristics.

Network structure and attitudes toward collaboration in a community partnership for diabetes control on the US-Mexican border.

PURPOSE: This study seeks to provide an examination of a health policy network operating in a single, small community along the US-Mexican border. The purpose of the paper is to discuss why and how this network evolved, and then to present findings on how the network was structured. Analysis will focus especially on agency involvement, or "embeddedness" in the network, and its relationship to attitudes held by network members regarding trust, reputation, and perceived benefit. DESIGN/METHODOLOGY/APPROACH: Data were collected from 15 public and nonprofit agencies trying to work collaboratively to influence local policy and services regarding the prevention of obesity-related chronic disease, especially diabetes. Embeddedness was measured in three different ways and both confirmed and unconfirmed networks were assessed. Network analysis methods were utilized as well as nonparametric correlation statistics. FINDINGS: The network was found to be densely connected through unconfirmed linkages, but much less so when these links were confirmed. Strongest findings were found for shared information. Measures of agency embeddedness in the network were strong predictors of agency reputation, but findings for trust and perceived benefit were generally weak. ORIGINALITY/VALUE: From a practice perspective, the study points to the problems in building and sustaining community-based chronic disease health networks, especially in a small community with substantial health needs. The research also contributes to theory on embeddedness and to methodology for collecting and analyzing data on community health networks.

Changes in health behaviors and self-rated health of participants in Meta Salud: a primary prevention intervention of NCD in Mexico.

BACKGROUND: Meta Salud was a community health worker-facilitated intervention for the prevention of noncommunicable diseases in Northern Mexico. OBJECTIVES: This analysis examined changes in perceived health, eating habits, and physical activity immediately and 3 months after the intervention. The impact on the resulting behavioral and psychological factors are reported. METHODS: This was a nonrandomized intervention study with 1 baseline and 2 post-intervention follow-ups. Outcome evaluation consisted of anthropometric measurements, laboratory tests, and a lifestyle questionnaire. RESULTS: The most consistent patterns were increases in metabolic equivalent of task values expended per day from baseline to post-intervention (difference = 996; 95% confidence interval [CI]: 81 to 1,912) and to 3-month follow-up (difference = 1,073; 95% CI: 119 to 2,028); greater likelihood of meeting Centers for Disease Control and Prevention daily exercise recommendations, with an increase from 49% to 60% at post-intervention (OR: 1.6, 95% CI: 1.0 to 2.4) and 63% at follow-up (OR: 1.7, 95% CI: 1.7 to 2.7); lesser likelihood for consuming whole milk, from 38% to 59% (OR: 2.9, 95% CI: 1.8 to 4.7); fewer daily servings of packaged foods, from 0.72 to 0.57 (difference = -0.16; 95% CI: -0.28 to -0.03); fewer days of poor mental health, from 9.3 to 5.8 (difference = -3.4; 95% CI: -5.1 to -1.7); and greater likelihood for reporting good self-rated health, from 41% to 54% post-intervention (OR: 2.1, 95% CI: 1.3 to 3.6) and 57% at follow-up (OR: 2.5, 95% CI: 1.5 to 4.4). Changes in other outcomes, although in the expected direction of association, were not statistically significant. CONCLUSIONS: The study identified important strategies for making feasible dietary changes in the consumption of whole milk, sugary drinks, and packaged foods, yet there is still a need to identify strategies for improving consumption of healthy foods. There was stronger evidence for ways of improving physical activity as opposed to other outcome measures. Overall, it highlights the importance of behavioral and psychosocial factors as key intervention targets in preventing noncommunicable diseases in low- and middle-income countries.

Taking a community-based participatory research approach in the development of methods to measure a community health worker community advocacy intervention.

BACKGROUND: Public health advocacy is by necessity responsive to shifting sociopolitical climates, and thus a challenge of advocacy research is that the intervention must by definition be adaptive. Moving beyond the classification of advocacy efforts to measurable indicators and outcomes of policy, therefore, requires a dynamic research approach. OBJECTIVES: The purposes of this article are to (1) describe use of the CBPR approach in the development and measurement of a community health worker (CHW) intervention designed to engage community members in public health advocacy and (2) provide a model for application of this approach in advocacy interventions addressing community-level systems and environmental change. METHODS: The Kingdon three streams model of policy change provided a theoretical framework for the intervention. Research and community partners collaboratively identified and documented intervention data. We describe five research methods used to monitor and measure CHW advocacy activities that both emerged from and influenced intervention activities. DISCUSSION: Encounter forms provided a longitudinal perspective of how CHWs engaged in advocacy activities in the three streams. Strategy maps defined desired advocacy outcomes and health benefits. Technical assistance notes identified and documented intermediate outcomes. Focus group and interview data reflected CHW efforts to engage community members in advocacy and the development of community leaders. APPLICATION OF LESSONS LEARNED: We provide a model for application of key principles of CPBR that are vital to effectively capturing the overarching and nuanced aspects of public health advocacy work in dynamic political and organizational environments.

The impact of a promotora on increasing routine chronic disease prevention among women aged 40 and older at the U.S.-Mexico border.

A randomized controlled intervention tested the effectiveness of a community health worker (CHW) program in increasing compliance with annual preventive exams among uninsured Hispanic women living in a rural U.S.-Mexico border area. During 1999-2000, household surveys were administered to women aged 40 and older. Uninsured women not receiving routine comprehensive preventive care were invited to participate in a free comprehensive clinical exam. Participants in the initial exam were eligible to participate in the CHW (promotora) intervention. Women were randomized to one of two intervention arms. One arm received a post-card reminder for an annual preventive exam, the other a postcard reminder and follow-up visit by a promotora. Receiving the promotora intervention was associated with a 35% increase in rescreening over the postcard-only reminder (risk ratio [RR] = 1.35, 95% confidence interval 0.95-1.92). Using promotoras to increase compliance with routine screening exams is an effective strategy for reaching this female population.

Everyday violence, structural racism and mistreatment at the US-Mexico border.

Immigration laws that militarize communities may exacerbate ethno-racial health disparities. We aimed to document the prevalence of and ways in which immigration enforcement policy and militarization of the US-Mexico border is experienced as everyday violence. Militarization is defined as the saturation of and pervasive encounters with immigration officials including local police enacting immigration and border enforcement policy with military style tactics and weapons. Data were drawn from a random household sample of US citizen and permanent residents of Mexican descent in the Arizona border region (2006-2008). Qualitative and quantitative data documented the frequency and nature of immigration related profiling, mistreatment and resistance to institutionalized victimization. Participants described living and working in a highly militarized environment, wherein immigration-related profiling and mistreatment were common immigration law enforcement practices. Approximately 25% of respondents described an immigration-related mistreatment episode, of which 62% were personally victimized. Nearly 75% of episodes occurred in a community location rather than at a US port of entry. Participant mistreatment narratives suggest the normalization of immigration-related mistreatment among the population. Given border security remains at the core of immigration reform debates, it is imperative that scholars advance the understanding of the public health impact of such enforcement policies on the daily lives of Mexican-origin US permanent residents, and their non-immigrant US citizen co-ethnics. Immigration policy that sanctions institutional practices of discrimination, such as ethno-racial profiling and mistreatment, are forms of structural racism and everyday violence. Metrics and systems for monitoring immigration and border enforcement policies and institutional practices deleterious to the health of US citizens and residents should be established.

Stress and sociocultural factors related to health status among US-Mexico border farmworkers.

This study examines factors relating to farmworkers' health status from sociocultural factors, including stress embedded within their work and community contexts. A cross-sectional household survey of farmworkers (N = 299) included social-demographics, immigration status descriptors, and a social-ecologically grounded, community-responsive, stress assessment. Outcomes included three standard US national surveillance measures of poor mental, physical, and self-rated health (SRH). Logistic regression models showed that higher levels of stress were significantly associated (Ps < .001) with increased risk for poor mental health and poor physical health considering all variables. Stress was not associated with SRH. Regarding two of the three outcomes, mental health and physical health, stress added explanatory power as expected. For poor SRH, a known marker for mortality risk and quite high in the sample at 38%, only age was significantly associated. Clinical and systems-level health promotion strategies may be required to mitigate these stressors in border-residing farmworkers.

Evidence for long-term impact of Pasos Adelante: using a community-wide survey to evaluate chronic disease risk modification in prior program participants.

Effective community-level chronic disease prevention is critical to population health within developed and developing nations. Pasos Adelante is a preventive intervention that aims to reduce chronic disease risk with evidence of effectiveness in US-Mexico residing, Mexican origin, participants. This intervention and related ones also implemented with community health workers have been shown to improve clinical, behavioral and quality of life indicators; though most evidence is from shorter-term evaluations and/or lack comparison groups. The current study examines the impact of this program using secondary data collected in the community 3-6 years after all participants completed the program. A proportional household survey (N = 708) was used that included 48 respondents who indicated they had participated in Pasos. Using propensity score matching to account for differences in program participants versus other community residents (the program targeted those with diabetes and associated risk factors), 148 natural controls were identified for 37 matched Pasos participants. Testing a range of behavioral and clinical indicators of chronic disease risk, logistic regression models accounting for selection bias showed two significant findings; Pasos participants were more physically active and drank less whole milk. These findings add to the evidence of the effectiveness of Pasos Adalente and related interventions in reducing chronic disease risk in Mexican-origin populations, and illustrate the use of innovative techniques for using secondary, community-level data to complement prior evaluation research.