Vivir Mejor! (Live Better!) System of Diabetes Prevention and Care

Evidence-level

Effective (About evidence-level criteria)

Description

Mariposa Community Health Center (MCHC), is a Federally Qualified Health Center (FQHC) providing healthcare in the border town of Nogales, Arizona. With a population of around 20,000, Nogales is 95% Hispanic/Latino, according to U.S. Census Bureau data and is located in Santa Cruz county with its total population about 84% Hispanic.

According to several government agency reports, about 20 percent of the nation's population is Hispanic/Latino. Prior to COVID-19, their death rate was about 24% lower than in Whites and the leading causes of death in this racial/ethnic group was heart disease and cancer. However, diabetes experts note that this population has a 50% chance of developing type 2 diabetes, developing it at a younger age, and experiencing higher rates of both kidney failure and diabetes-related blindness.

A 2020 American Heart Association report reviewing cardiovascular statistics revealed that Hispanic men, women, youth, and children have a high prevalence of many of the medical conditions leading to heart disease and stroke, such as diagnosed and undiagnosed diabetes, obesity, high cholesterol, and high blood pressure.

Because the average Hispanic/Latino age is nearly 15 years younger than Whites, prevention steps are anticipated to have a high impact on future disease rates, especially since this group represents the largest U.S. racial/ethnic minority population and is growing at the fastest rate.

With the increasing disparities in Hispanic/Latino-specific health statistics emerging over a decade ago, in 2011 MCHC formed the Vivir Mejor! (Live Better!) System of Diabetes Prevention and Care Consortium, a multi- sector partnership that focuses on preventive care that originally included a Critical Access Hospital, a food bank, a university, the Southeastern Arizona Area Health Education Center (SEAHEC), and several other non-profit organizations. Under MCHC's continued leadership, current consortium members University of Arizona Prevention Research Center, Pinal Hispanic Council, a behavioral health provider, the AHEC, the community center, the Nogales Community Food Bank, women's club and the community's development center. The MCHC-led a consortium has been a three-time Rural Health Care Services Outreach Program grantee.

In 2012, grant work focused on further establishing an integrated system of diabetes care for their Hispanic/Latino diabetic patients using an approached that included state-of-the-art continuing medical education (CME) for primary care clinicians. For patients, enhanced self-management tools and increased family involvement/supports were added.

For selected participants, promoteras were able to enter clinical data via a specialized tool within the clinic's electronic health record allowing for improved tracking of grant outcome measures. Because this population is difficult to reach, key to bridging program barriers were promotoras-led education and community engagement efforts along with clinician engagement.

MCHC's 2015 grant focused on healthy eating by offering increased access to healthier foods and education about exercise in addition to hands-on interactive education on food preparation, along with an emphasis on changing food-choice habits paired with information on weight reduction.

Among the incentives provided for program completion were food boxes containing diabetes-appropriate food and provided by the contracted consortium partner, the Nogales Community Food Bank (NCFB).

MCHC was a Health Improvement Special Project (HISP) grantee and involved in a project that focuses on cardiovascular disease prevention in a target group age 50-74 years and incorporates the use of the previously available CDC heart age calculator.

Each of MCHC's grants has built on the successes of the previous grant outcomes. The use of culturally-sensitive, evidenced-based curricula and models of care that concentrate on diabetes, obesity, and more recently, heart health have all contributed to the success of Vivir Mejor. Other factors are:

• Lay leaders: Sometimes referred to as lay health educators or lay health advisors, lay leaders are not fully trained CHW's, but do share sameness of experiences and sameness of community as the patients they assist. Specific to MCHC's outreach programs, lay leaders are previous participants-turned volunteers who are trained by the Mariposa promotoras and receive stipends to provide multi-topic education classes and conduct interactive learning sessions. In the MCHC model, they expand beyond the clinic's patients and provide community outreach and education.
• Meta Salud: Based in social cognitive theory, self-efficacy, skill development and reduction in barriers needed for healthy behavior changes.
• Pasos Adelante (Steps Forward): 12-week- program which includes interactive sessions on chronic disease prevention, nutrition, and physical activity and facilitated by Promotoras de Salud.
• Promotoras de Salud: Promotoras are community health workers (CHWs) who can also function patient navigators for chronic disease management. These specialty workers have been at the core of MCHC's work for 3 decades.

Services offered

Some sample services offered from 2012-present:

• Vivir Mejor! education topics using evidence-based Pasos Adelante in a once weekly session:
  • What is Diabetes? Nutrition & Diabetes, Heart & Diabetes, What am I Eating? Complications of Diabetes, Foot Care, The Effects of Stress, Counting Carbs
• Physical activity classes included yoga, aerobic exercise, body strengthening, and Rhumba
• Nutrition counseling with a Certified Diabetes Educator
• Food budgeting classes
• Provider trainings, including a day-long conference on motivational interviewing, provided by the 2012-2105 grant.

Specific components of the 2018-2021 grant are:

• Cooking classes
• Walking groups
• Digital activity tracker
• Behavioral health services
• Heart age calculator use

Results

2012-2015 grant cycle outcomes:

• Healthy eating habits

According to post-test results, both groups improved HbA1c results:

• Though the average HbA1c remained unchanged after 3 years, those with the highest values demonstrated significant improvements:
  • 63 patients with HbA1c ≥ 9% decreased by 1.2%
  • 99 patients with HbA1c ≥ 8% decreased by 0.7%
• Overall success led to creation of Mariposa Care Plus to translate the promoteras/navigator model to hypertension and asthma

Also due to its success, the model expanded to include several other chronic disease prevention categories. Results will be shared at completion of those projects in the next several years.

For more information about the Vivir Mejor! program:

Kunz, S., Ingram, M., Piper, R., Wu, T., Litton, N., Brady, J., Knudson, A.(2017). Rural Collaborative Model for Diabetes Prevention and Management: A Case Study. Health Promotion Practice. Abstract

Kunz, S., Ingram, M., Piper, R., Ochoa, S., Sander, A., Navarro, C., McKenzie, S. The Vivir Mejor! Consortium: A Rural, US-Mexico Collaborative Model to Prevent and Treat Diabetes. J Health Care Poor Underserved. 2016. 27 (4A), 39-45.

Challenges

Challenges faced by Vivir Mejor! include:

• Patient retention
• Scheduling issues, in that participants often would not call to cancel appointments
• Difficulty in contracting potential consortium partners

Replication

In order to create a similar program, it is important to:

• Engage and regularly communicate with consortium partners
• Experienced outreach workers to recruit participants
• Key to participant retention: Incentives; friendly, trustworthy staff; reminder calls

Contact Information

Rosie Piper, Health Promotion Coordinator
Mariposa Community Health Center
520.375.6050
RPiper@mariposachc.net