Geographic disparities associated with travel to medical care and attendance in programs to prevent/manage chronic illness among middle-aged and older adults in Texas.

INTRODUCTION: Accessing care is challenging for adults with chronic conditions. The challenge may be intensified for individuals needing to travel long distances to receive medical care. Transportation difficulties are associated with poor medication adherence and delayed or missed care. This study investigated the relationship between those traveling greater distances for medical care and their utilization of programs to prevent and/or manage their health problems. It was hypothesized that those traveling longer distances for medical care attended greater chronic disease management programs. METHODS: Thirty six thousand households in nine counties of central Texas received an invitation letter to participate in a mailed health assessment survey in English or Spanish. A total of 5230 participants agreed to participate and returned the fully completed survey. To investigate distance traveled for medical services and participation in a chronic disease management program, the analyses were limited to 2108 adults aged ≥51 years with one or more chronic conditions who visited a healthcare professional at least once in the previous year. Other variables of interest included residential rurality, health status, and personal characteristics. The data were first analyzed using descriptive and bivariate analyses. Then, an ordinal logistic regression model was fitted to identify factors associated with longer distances traveled to medical services. Additionally, a binary logistic regression model was fitted to identify factors associated with attending a chronic disease self-management program. RESULTS: Among 2108 adults, rural participants (p<0.001), those with more chronic conditions (p<0.001), and those attending a chronic disease program (p=0.037) reported traveling further distances to medical services. Participants with limited activity (p<0.001), those from urban counties (p=0.017), and those who traveled further (p=0.030) were more likely to attend a chronic disease program. CONCLUSION: While further distances to healthcare providers was found to be a protective factor based on the utilization of community-based resources, rural residents were less likely to attend a program to better manage their chronic conditions, potentially choosing to use long distance travel to address urgent medical needs rather than focusing on prevention and management of their conditions. Important policy and programmatic efforts are needed to increase reach of chronic disease self-management programs and other community services and resources in rural areas and to reduce rural inequities.

Does injury prevention education initiate household changes in a Spanish-speaking minority population?

Young children from low income families are among the most affected population of unintentional injury. This non-randomized longitudinal study examined knowledge for home and child safety with an injury prevention training offered to parents of children who reside in the Rio Grande Valley of Texas. Eighty eight parents received the training and pre-and post-test surveys were used to measure knowledge outcomes. A follow-up survey was conducted 2 months after the educational intervention to identify how many parents reported household and safety behavior changes as a result of the training. The most significant change in behavior, as it pertains to the household, was related to locking and storage of dangerous cleaning chemicals. Other significant changes in behavior were in areas that directly related to the child such as learning how to swim, use of sun block and fire safety in the home. This study suggests that tailored trainings can improve parent knowledge and change in behaviors for the promotion of safety activities to avoid risks for unintentional injuries. Further, the study identified certain at-risk areas that need to be addressed from an educational perspective. These areas include bicycle and water safety; specifically, the use of protective gear when bicycling; understanding and adhering to traffic rules when bicycling; and, the dangers of drowning in small quantities of water.

Mexican-American children's perspectives: neighborhood characteristics and physical activity in Texas-Mexico border colonias.

The qualitative study described in this article investigated perceptions about environmental factors influencing physical activity (PA) among children from underserved neighborhoods known as colonias in the U.S.-Mexico border. Ten focus groups were conducted with 67 Mexican-American colonia children ages 8 to 13 living in one of the poorest border counties in the U.S. Analyses indicated that PA among children was influenced by neighborhood characteristics, including litter, speeding cars, unleashed dogs, and dark streets. The children also underlined intrapersonal and social environmental factors. Findings may inform policy makers and public health professionals about ways to promote PA among underserved children through urban planning and programs focusing on PA-supportive infrastructure, neighborhood safety, and family- and home-based physical activities.

Role and working conditions of nurses in public health in Mexico and Peru: a binational qualitative study.

AIM: This exploratory study conducted in Mexico and Peru investigated nurses' perceptions about their role in public health and working conditions. BACKGROUND: Health reform efforts in many countries are redefining the role of health professionals in public health. Little is known about the role of nurses working in public health contexts in Latin America. METHOD: Fourteen focus groups were conducted in Mexico and Peru with 82 nurses working in government-sponsored community health centres. Data were analysed using a content analysis technique. FINDINGS: Themes identified were: nurses' job descriptions in public health settings; organisational factors influencing the nurses' work, and influence of academic and social image factors. CONCLUSION: Management barriers and limited training influences the role and working conditions of public health nurses in Mexico and Peru. IMPLICATIONS FOR NURSING MANAGEMENT: The professional role of nurses working in public health in Latin America is not well defined because of the health-care system infrastructure and the lack of a clear public health nurse job description. Further research is needed to better understand the role of public health nurses and strengthen their training, particularly in relation to nursing management encompassing abilities for decision-making processes and public health program planning and evaluation.

Incorporating what promotoras learn: becoming role models to effect positive change.

Promotoras (community health workers) play an important health promotion role and must be continuously trained, but little is known about how much of their learning they actually put into practice. This non-randomized, longitudinal study examined knowledge and home environmental outcomes of an asthma and healthy homes training offered to promotoras using a train-the-trainer model. Eighty-five promotoras received the training and pre- and post-test surveys were used to measure training outcomes. Results showed a statistically significant increase in asthma and healthy home-related knowledge (P < .001). At 12-months post-intervention, a majority of the promotoras (69%) reported they made household changes to improve their indoor environment as a result of the training. This study suggests that effective trainings can improve promotoras knowledge and behaviors for the promotion of healthy homes in the community. Further evaluation is needed to investigate whether these trainings allow promotoras to serve as role models within their communities "by educating through example" and thereby enhance their credibility as health educators.

The impact of asthma health education for parents of children attending head start centers.

Parents of children who attend Head Start Centers are key participants in the health promotion and care of their own children. This non-randomized, longitudinal study aimed to test the effectiveness of an educational intervention based on the asthma and healthy homes curriculum targeting parents of Head Start children with or without an asthma diagnosis. One hundred and fifteen parents of children in Head Start Centers received an educational intervention at their corresponding sites, additionally pre- and post-test surveys were administered to measure educational intervention outcomes. A follow-up survey was conducted 6 months after the educational intervention was offered. Results showed a statistically significant increase in asthma and healthy home-knowledge (p < 0.001) in several areas. At 6 months post-intervention (54.4 %) (61 participants) were contacted and 98.4 % of made changes in their households as a result of their training. This study suggests that education can improve knowledge and change behaviors for the well-being of the residents of that household.

Ethnic and health correlates of diabetes-related amputations at the Texas-Mexico border.

OBJECTIVE: To examine the association between diabetes-related lower-extremity amputation (LEA) and ethnicity, age, source of payment, geographic location, diabetes severity, and health condition in adults with diabetes mellitus type 2 living in border and non-border counties in Texas, United States of America, and to assess intra-border region geographic differences in post-LEA treatment. METHODS: This correlational study was based on secondary data from the 2003 Texas Inpatient Hospital Discharge Data. The sample consisted of individuals 45 years of age and older with type 2 diabetes who had undergone a nontraumatic LEA (n = 5,865). Descriptive statistics and logistic regression analyses were applied. RESULTS: The following characteristics were predictors of LEA: being Hispanic or African American, male, ≥ 55 years old, and a Medicare or Medicaid user, and living in a border county. Persons with moderate diabetes and those who suffered from cardiovascular disease or stroke also had higher odds of undergoing an LEA. Post-LEA occupational therapy was significantly less prevalent among border residents (9.5%) than non-border residents (15.3%) (P < 0.001). CONCLUSION: Understanding the factors that influence diabetes-related LEA may lead to early detection and effective treatment of this disabling consequence of diabetes along the U.S.-Mexico border.

Anatomy of culturally sensitive interventions promoting nutrition and exercise in hispanics: a critical examination of existing literature.

Compared with non-Hispanic Whites, Hispanics experience a disproportionate burden of chronic diseases. Understanding the factors influencing the success of health programs in Hispanics requires a clearer examination of the principles and components of tailored interventions. This research comprises a comprehensive literature review of randomized controlled trials testing nutrition and exercise interventions tailored for Hispanics and an examination of how these interventions were constructed. The review of 18 interventions meeting study criteria suggests that most tailored programs promoting nutrition and exercise in Hispanics are theory driven and are informed by formative research. Also, the findings indicate that salient culturally sensitive intervention components are (a) bilingual and bicultural facilitators and materials, (b) family-based activities, (c) literacy-appropriate materials, and (d) social support. A clear understanding of Hispanic cultural values is also required. Further empirical examination is warranted to determine the factors mediating or predicting the efficacy of culturally sensitive health programs for Hispanics.

Confronting the diabetes disparity: a look at diabetes, nutrition, and physical activity programs in the Lower Rio Grande Valley.

Diabetes prevalence is higher along U.S.-Mexico border than in nonborder regions, and numerous community-based organizations are addressing this diabetes disparity through prevention and management programs. However, the nature, scope, and effectiveness of these efforts and programs are not well documented. This study aims at identifying key characteristics of diabetes programs in a Texas-Mexico border region with a predominately Hispanic, underserved population. A survey is administered to 84 community-based organizations in the Lower Rio Grande Valley (LRGV); 25 organizations respond. Nineteen programs related to diabetes and healthy lifestyle behaviors are identified in the LRGV. The majority of the programs are based on guidelines of national and state professional associations and agencies; target low-income and minority populations; are offered at no cost; and include program evaluation activities. Future research should examine the effectiveness, as well as the fidelity of the guidelines, of diabetes programs in the border region.

Assessing diabetes practices in clinical settings: precursor to building community partnerships around disease management.

Many recommended best practices exist for clinical and community diabetes management and prevention. However, in many cases, these recommendations are not being fully utilized. It is useful to gain a sense of currently utilized and needed practices when beginning a partnership building effort to ameliorate such practice problems. The purpose of this study was to assess current practices in clinical settings within the Brazos Valley in preparation for beginning a community-based participatory research project on improving diabetes prevention and management in this region. Fifty-seven physicians with admission privileges to a regional health system were faxed a survey related to current diabetes patient loads, knowledge and implementation of diabetes-related best practices, and related topics. Both qualitative and quantitative examination of the data was conducted. Fifteen percent of responding providers indicated they implemented diabetes prevention best practices, with significant differences between primary-care physicians and specialists. Respondents indicated a need for educational and counseling resources, as well as an increased health-care workforce in the region. The utilization of a faxed-based survey proved an effective means for assessing baseline data as well as serving as a catalyst for further discussion around coalition development. Results indicated a strong need for both clinical and community-based services regarding diabetes prevention and management, and provided information and insight to begin focused community dialogue around diabetes prevention and management needs across the region. Other sites seeking to begin similar projects may benefit from a similar process.

Sociodemographic and healthcare characteristics of Colonia residents: the role of life stage in predicting health risks and diabetes status in a disadvantaged Hispanic population.

An assessment of the risk or diagnosis of diabetes in a random sample of 386 adult border residents found 46% obese, 12% at risk for diabetes, and 18% diagnosed with diabetes. While obesity was associated with greater diabetes risk, > 50% of obese adults reported not being told of their diabetes risk. Independent of other characteristics, boomers were at increased risk (OR 3.88) for diabetes. Comorbidities increased the risk for actual diabetes diagnosis (OR 4.79). Skipping medications increased risk of developing diabetes (OR 2.98). Disadvantaged obese boomers are at particular risk, warranting culturally appropriate interventions before onset of chronic illnesses.

The impact of a communitywide smoke-free ordinance on smoking among older adults.

INTRODUCTION: Clean-air and smoke-free ordinances have been shown to reduce the prevalence of smoking among the overall population, but their effects on the smoking prevalence among older adults deserves further attention. We examined changes in self-reported cigarette smoking and in attitudes toward smoking after the implementation of such ordinances in Fort Collins, Colorado, in 2003. METHODS: Communitywide health status surveys were mailed out to northern Larimer County residents recruited via random-digit dialing in 2001 and 2004. Secondary data analysis was conducted for respondents living in Fort Collins, comparing the entire sample with a subsample of adults aged 50 years or older. Univariate analyses were used to determine differences in self-reported cigarette smoking between the groups across the 2 surveys. Multivariate logistic regression models estimated differences in smoking status and in attitudes toward acceptability of public smoking between the 2 survey administrations, controlling for demographic correlates. RESULTS: Smoking rates among older respondents failed to change, despite significant decreases in smoking rates in the entire adult population. Furthermore, attitudes toward smoking in public did not change between the 2 surveys for either of the groups. CONCLUSION: Different factors may influence the decision to stop smoking for older adults and younger adults. We recommend the use of multiple approaches on different ecological levels to ensure that communitywide antismoking intervention efforts reach all population segments.

Health-related quality of life among Mexican Americans living in colonias at the Texas-Mexico border.

Understanding influences on health-related quality of life (HRQL) is critical in order to track and improve the health of poor, vulnerable populations and reduce health disparities. However, studies assessing HRQL of minorities are relatively scarce. The purpose of this study was to document personal and socioenvironmental correlates to HRQL. The study population is Mexican Americans in the Texas-Mexico border region living in colonias - unincorporated, impoverished settlements with substandard living conditions along the U.S.-Mexico border. Mexican Americans living in colonias are one of the most disadvantaged, hard-to-reach minority groups in the United States. We used data from the Integrated Health Outreach System Project collected in 2002 and 2003. Our sample included 386 participants randomly selected and interviewed face-to-face with a structured survey. We measured HRQL and examined personal and socioenvironmental correlates. Unadjusted and adjusted (multivariate) logistic regression models were used for data analyses. We found that border Mexican Americans living in colonias were of similar mental health status compared to the general population of the United States, but worse off in terms of physical health. Poor education and long-term residency in colonias were predictors of lower physical health. Women reported worse mental health than men. Length of time living in a colonia, co-morbidity status, and perceived problems with access to healthcare was associated with poorer mental health status. This study provides information for health professionals and policymakers and underscores the need to provide better preventive and medical services for underserved populations. Major findings indicate the need for additional research centered on further exploration of the impact of economic, cultural, and social influences on HRQL among severely disadvantaged populations.

Nutrition provided to Mexican-American preschool children on the Texas-Mexico border.

The purpose of this study was to assess whether nutrients offered to border Mexican-American preschool children met the Recommended Dietary Allowances. Nutrient contents of two dietary patterns were examined in this study, one composed exclusively of home foods and one containing a combination of both home and school foods. The sample consisted of 198 Mexican-American preschoolers living on the Texas-Mexico border, who were recruited using a convenience sampling technique. A self-administered, precoded 24-hour recall questionnaire was used. Nutrient values of home foods were collected during a weekend day, and nutrient values containing a combination of both home and school foods were collected during a weekday. Fisher's exact test or chi2 test and t test were used for analyses. Mean nutrient contents of foods provided to the border Mexican-American children exceeded recommendations for total energy (P<0.001), total fat (P<0.001), saturated fat (P<0.001), carbohydrates (P<0.001), protein (P<0.001), sodium (P<0.001), and niacin (P<0.001). Foods offered were also significantly insufficient in fiber (P<0.001), vitamin A (P<0.001), and potassium (P<0.001). Nutrition interventions targeting low-income border Mexican-American families should emphasize the need and importance of providing children with diets that meet the Recommended Dietary Allowances.

Mexican Americans with type 2 diabetes: perspectives on definitions, motivators, and programs of physical activity.

INTRODUCTION: Research documents that Mexican Americans bear excess health risk because of physical inactivity and have higher morbidity and mortality rates from chronic diseases than do other ethnic groups. Factors influencing physical activity in this minority population, however, are not well understood. This study examines perceptions of physical activity in a population of Mexican Americans who have type 2 diabetes and live in the Texas-Mexico border region and identifies motivators and barriers to physical activity in this group. METHODS: This study used a qualitative research design and employed six focus groups comprising 39 Mexican Americans with type 2 diabetes who live in the Texas-Mexico border region. A team of bilingual Mexican American researchers systematically reviewed and analyzed focus group data by means of qualitative data analysis software. The study was conducted during 2005-2006. RESULTS: Most participants considered physical activity to be related not only to exercise but also to occupational and home activities. Walking was the preferred type of activity. Motivators to physical activity included family support and the sense of well-being derived from physical activity. Barriers to physical activity included individual and environmental factors, such as lack of time, physical pain, depression, being overweight, unsafe neighborhoods, and lack of facilities. Participants suggested that the ideal intervention would be low in cost, family-based, close to home, and led by bilingual instructors. CONCLUSION: Health promotion efforts to prevent or reduce the effects of chronic disease among Mexican Americans with type 2 diabetes in the Texas-Mexico border region should focus on implementing neighborhood-based, family-oriented walking interventions.

Levels and correlates of exercise in a border mexican american population.

OBJECTIVE: To examine personal and environmental correlates of exercise among Mexican Americans living in the Texas-Mexico border region. METHODS: The study was based on data from a community health assessment conducted in 2 counties at the Texas-Mexico border region. A random-digit-dialed community survey was used in this cross-sectional study (n=933). RESULTS: A majority of border Mexican Americans (52%) did not exercise at all. Gender, age, and self-rated health were statistically significant correlates to exercise. CONCLUSIONS: Understanding personal and environmental factors that influence physical activity and exercise in this minority population is critical for the development of culturally sensitive health interventions.

The caregiving experience among Hispanic caregivers of dementia patients.

This research reviewed studies that investigated factors influencing the caregiving experience among informal Hispanic caregivers of dementia patients. This review identified 24 journal articles published between 1985 and 2003. Variables studied were depression and social support. In addition, methodological issues were detected such as sampling bias and multiple measurements. This review concluded that there is a need for an extensive, in depth research of the caregiving experience among Hispanics and further research needs are discussed.

Relative Association of Multi-Level Supportive Environments on Poor Health among Older Adults.

Background: The aging of the United States population poses significant challenges to American healthcare and informal caregiving systems. Additional research is needed to understand how health promotion programs and policies based on a socio-ecological perspective impact the health and well-being of older persons. The purpose of this study was to investigate personal characteristics and supportive environments associated with poor health among older individuals aged 65 and over. Methods: This study used a cross-sectional design and was guided by a conceptual framework developed by the authors to depict the relationship between personal characteristics and environments associated with poor health status. Environment types included in this study were family, home, financial, neighborhood, and healthcare. The sample was comprised of 1319 adults aged 65 years and older residing in Central Texas. From a random selection of households, participants were administered a mail-based survey created by a community collaborative effort. Descriptive statistics and three binary logistic regression models were fitted to examine associations with poor health status (i.e., physical, mental, and combined physical/mental). Results: Two personal characteristics (number of chronic conditions and educational level) were consistently related (p < 0.05) to health outcomes. Supportive family, home, financial, neighborhood, and health care environmental factors were shown to be related (p < 0.05) to various aspects of physical or mental health outcomes. Conclusions: Multidimensional factors including personal characteristics and protective environments are related to health status among older individuals. The unique roles of each environment can help inform public health interventions to create and enhance support for older adults to engage in healthful activities and improve their physical and mental health.

The Benefits and Challenges of Managing Asthma in Hispanic Families in South Texas: A Mixed-Methods Study.

BACKGROUND: Understanding the experience of Hispanic parents of children diagnosed with asthma can be useful in the delivery of effective and meaningful asthma education. In order to assess the needs of Hispanic families with asthmatic children in South Texas, investigators utilized a combination of qualitative and quantitative research methods. OBJECTIVES: This study aimed (1) to assess the impact of asthma in the quality of life of Hispanic children and their families and (2) to identify barriers and challenges to asthma management as perceived by parents of children diagnosed with asthma. METHODS: A mixed-methods study included a quality-of-life survey and focus group discussions. The Children's Health Survey for Asthma (CHSA) was completed by 90 parents of children with asthma. Three focus groups were conducted with 15 low-income, Hispanic parents of asthmatic children to assess their needs and experience in managing the disease. RESULTS: Results from the CHSA showed that asthma significantly affects the quality of life of children with asthma and their families, particularly the emotional dimensions and the child's physical health. Fifty-three percent of the children had visited the emergency room, and 51% had been hospitalized due to asthma. One out of five parents had missed work, and 27% of children had missed school in the past 2 weeks due to the child's asthma. In the focus group discussions, the key themes emerging included lack of asthma knowledge, the burden of disease for asthmatic children and their families, and the importance of asthma education and self-management behaviors for asthma control. CONCLUSION: One of the main challenges faced by Hispanic families with asthmatic children is the lack of asthma-related knowledge to help understand and control their children's disease. Lack of knowledge and self-management skills lead to significant stress and anxiety among children with asthma and their parents. Results highlight that while asthma has an effect on the quality of life of children and their families, particularly on the emotional health domain, a wide dissemination of asthma management education in different settings might help prevent asthma attacks and improve symptom control among those suffering from this disease along the US-Mexico border.

Diabetes Screening and Prevention in a High-Risk, Medically Isolated Border Community.

INTRODUCTION: A project in a Texas border community setting, Prevention Organized against Diabetes and Dialysis with Education and Resources (POD2ER), offered diabetes prevention information, screening, and medical referrals. The setting was a large, longstanding flea market that functions as a shopping mall for low-income people. The priority population included medically underserved urban and rural Mexican Americans. Components of the program addressed those with diabetes, prediabetes, and accompanying relatives and friends. BACKGROUND: People living in the Lower Rio Grande Valley (LRGV) face challenges of high rates of type 2 diabetes, lack of knowledge about prevention, and inadequate access to medical care. Recent statistics from actual community-wide screenings indicate a high diabetes prevalence, 30.7% among adults in the LRGV compared with 12.3% nationwide. METHODS: A diverse team composed of public health faculty, students, a physician, a community health worker, and community volunteers conceived and developed the project with a focus on cultural and economic congruence and a user-friendly atmosphere. The program provided screening for prediabetes and diabetes with a hemoglobin A1c test. Screening was offered to those who were at least 25 years of age and not pregnant. When results indicated diabetes, a test for kidney damage was offered (urinary albumin-to-creatinine ratio). A medical appointment at a community clinic within a week was provided to those who tested positive for diabetes and lacked a medical home. Health education modules addressed all family members. DISCUSSION: The project was successful in recruiting 2,332 high-risk people in 26 months in a community setting, providing clinic referrals to those without a doctor, introducing them to treatment, and providing diabetes prevention information to all project participants. Implications for research and practice are highlighted. CONCLUSION: This study shows that a regular access point in a place frequented by large numbers of medically marginalized people in a program designed to eliminate cultural and economic barriers can succeed in providing a hard-to-reach community with diabetes prevention services. Aspects of this program can serve as a model for other service provision for similar populations and settings.