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.

Diabetes is a community issue: the critical elements of a successful outreach and education model on the U.S.-Mexico border.

BACKGROUND: Diabetes is reaching epidemic proportions on the U.S.-Mexico Border, and culturally competent diabetes education is not available in many communities. CONTEXT: People with diabetes often do not have access to regular medical care, cannot afford medication, and lack the community infrastructure that supports self-management practices. Self-management education and support have great potential to impact diabetes control in this environment. METHODS: To address this need, partners of the Border Health Strategic Initiative (Border Health iSI!) collaboratively developed a culturally relevant diabetes outreach and education program. The model included a five-week series of free diabetes education classes that assisted participants in gaining the knowledge and skills necessary to be physically active, control diet, monitor blood sugar, take medications, and be aware of complications. Central to the model was the use of community health workers - or promotores de salud - to conduct outreach, participate in patient education, and provide individual support. CONSEQUENCES: Program participants achieved significant improvements in self-management behaviors and HbA1c, random blood glucose, and blood pressure levels. INTERPRETATION: Quantitative and qualitative evaluation helped to identify the essential elements of a successful program, including partnership of providers, community diabetes classes, promotores outreach and support, linkage between diabetes education and clinical care, and program evaluation.

Pasos Adelante: the effectiveness of a community-based chronic disease prevention program.

BACKGROUND: Implementing programs that target primary prevention of chronic diseases is critical for at-risk populations. Pasos Adelante, or "Steps Forward," is a curriculum aimed at preventing diabetes, cardiovascular disease, and other chronic diseases in Hispanic populations. Pasos Adelante is adapted from the National Heart, Lung, and Blood Institute's cardiovascular disease prevention curriculum, Su Corazon, Su Vida, and includes sessions on diabetes and community advocacy and incorporates walking clubs. CONTEXT: The Pasos Adelante curriculum was implemented in two Arizona, United States-Sonora, Mexico border counties. Key issues in these communities are safety, access to recreational facilities, climate, and cultural beliefs. METHODS: Pasos Adelante is a 12-week program facilitated by community health workers. The program includes interactive sessions on chronic disease prevention, nutrition, and physical activity. Evaluation of the program included precurriculum and postcurriculum questionnaires with self-reported measures of physical activity and dietary patterns. Approximately 250 people participated in the program in Yuma and Santa Cruz counties. CONSEQUENCES: Postprogram evaluation results demonstrate a significant increase in moderate to vigorous walking among participants and shifts in nutritional patterns. INTERPRETATION: The Pasos Adelante program demonstrates that an educational curriculum in conjunction with the support of community health workers can motivate people in Arizona/Sonora border communities to adopt healthy lifestyle behaviors.