u.s.-mexico border health: a medically underserved community hector balcazar, ms., phd, ut school of...
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U.S.-Mexico Border Health: A Medically Underserved Community
Hector Balcazar, MS., PhD,UT School of Public HealthHealth Science Center HoustonEl Paso Regional Campus
Presenter Disclosures
Dr. Hector Balcazar
No relationships to disclose
Research Training Dissemination
❶Why Is the U.S.- Mexico Border Important For Assuring Health Equity?
❷Assess Unique Social Determinants of Health Within a Social Justice Framework
❸What Interventions To Develop? Presented at the American Public Health Association 140th Annual Meeting
San Francisco, California
Why The U.S.-Mexico Border? Hispanics largest minority Living in Two Worlds (Countries)- Many Worlds Very heterogeneous Moving everywhere in the U.S.- Great contributors
to economy (many not appreciated) Many “invisible populations”, migrant workers,
temporary, unauthorized, bilingual, bicultural Resilient and Active Participants in Decision-
Making Very vulnerable- (low education, low SES, low
social and economic capital/ no wealth)- wear-tear- for how long can this continue?
Paradoxically there are large health systems in the Border and yet large number of uninsured
U.S.-Mexico Border Region
Health Insurance“In the United States, Texas has the highest proportion of residents without health insurance (28.5%); The situation in EI Paso County is even more severe with almost 40% of adults lacking any health insurance. The high rate of uninsured in this region reflects the high rates among Hispanics; over 45% of Hispanics are uninsured as compared to less than 15% of non-Hispanics.”
Ref: A status report on the health of people in El Paso County, TX and Dona Ana County, NM, CBHR BRFSS 2005
2. Overweight and Obesity
Ref: A status report on the health of people in El Paso County, TX and Dona Ana County, NM, CBHR BRFSS 2005
3. Diabetes
Ref: A status report on the health of people in El Paso County, TX and Dona Ana County, NM, CBHR BRFSS 2005
9
Texas Projected Population Increases by Race/Ethnicity, 2000-2040*
0
5,000,000
10,000,000
15,000,000
20,000,000
25,000,000
30,000,000
35,000,000
40,000,000
2000 2010 2020 2030 2040
YEAR *Uses 0.5 migration scenario. Texas State Data Center - Off ice of
the State Demographer, Institute for Demographic and Socioeconomic Research, College of Business, University of
Texas at San Antonio.
Pop
ulat
ion
Hispanic
Black, non-Hispanic
White, non-Hispanic
TOTAL
10
Texas Projected Diabetes Cases 2000 - 2040*
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
2000 2010 2020 2030 2040
Nu
mb
er
of
Dia
be
tes
Ca
se
s
YEAR *Uses 2007 diabetes prevalence by race/ethnicity from BRFSS and population data from the Texas State Data Center - Office of the State Demographer, Institute for Demographic and Socioeconomic Research. Uses 0.5
migration scenario.
Hispanic (Prevalence = 12.3%) Black, non-Hispanic (Prevalence = 12.9%)
White, non-Hispanic (Prevalence = 8.5%) TOTAL (Prevalence = 10.3%)
CBPR- Tell An Initial Story from Baseline: Family History of Disease
50.8
66.8
44.7
67.2
0
10
20
30
40
50
60
70%
of
Yes
Intervention Group Control Group
Family History of Heart Disease Family History of Diabetes
51% of the intervention group and 45% of the control group reported having a relative with cardiovascular disease. In both groups, 67% of the participants reported having a relative with Diabetes.
Metabolic Syndrome & Diabetes
Metabolic Syndrome is an indicator or risk for cardiovascular disease. It is associated with six characteristics: adbominal obesity, disturbance in the blood fat levels, raised blood pressure, glucose intolerance, proinflammatory state, prothrombotic state.
47.8
31.6
48.4
25.2
0
5
10
15
20
25
30
35
40
45
50
%
Intervention Group Control Group
Metabolic Syndrome (> 3 risk factors) Diabetes (self-reported)
Nearly half of the intervention group and 40% of the control group had more than 3 risk factors for metabolic disease.
Nearly 1/3 of the intervention group and ¼ of the control group reported having diabetes.
Use of Medication
More than 40% of participants in both groups used medication to control blood pressure. Nearly 30% used medication to reduce blood cholesterol, and 25% of the intervention group and 22% of the control group used medication to control diabetes.
25
42.1
29
22.1
41.9
27.3
0
5
10
15
20
25
30
35
40
45
%
Intervention Group Control Group
Use of Diabetes Medication Use of Hypertensive Medication Use of Cholesterol Medication
Data From Cameron County Texas• Data from Cameron County Hispanic
Cohort from 2003-2008, of 2000 Mexican American Adults aged 18 or older
• Close to 70% had 1 or more conditions such as diabetes, hypertension, hypercholesterolemia
• Weighted Prevalence: Diabetes 30.7%, Hypertension 30.5%, Hypercholesterolemia 48.2%
• More than half of participants with diabetes (55.8%) were untreated among whom 29.9% had insurance and 10% had their diabetes diagnosed
• Of the drugs being taken for diabetes, 28% appeared to be of Mexican origin
• Lack of health affected several measures
Research Training Dissemination
❷Assess Unique Social Determinants of Health Within a Social Justice Framework
Presented at the American Public Health Association 140th Annual Meeting
San Francisco, California
Research Training Dissemination
Contextual-level understanding of
determinants
Why We Haven’t Made More Progress in Addressing/Eliminating Health Disparities?
Need Understand Multiple Social & Ecological Determinants
Environmental Factors Biopsychosocial Factors
Epidemiological profile Transborder Mobility Limited or no existing
services Legal and economic
barriers Low SES Immigration issues Lack of infrastructure border culture Low educational
attainment/goals Low community
empowerment/self-efficacy
Acculturation issues
Gender roles Health beliefs Health literacy Religiosity &
Spirituality Health behavior
norms (substance abuse; sexual risk)
Familism Fatalism Stigma
Norms affecting health decision-making
Hispanic Health Paradox (vulnerability and resilience)
Population genetic factors
Positive and negative lifestyle factors (nutrition, exercise, substance abuse, drug use & mode of delivery
Understanding Contextual Factors• Transborder mobility is a fact-
29.9% once a month, 20.4% once a week (324 mobile versus 678 non-mobile)
• Non-mobile respondents have higher social economic status than their mobile counterparts
• Mobile respondents have fewer economic resources, travel to Juarez for various goods and services
• Similar high levels of familismo, ethnic pride
• Mobile more likely to speak Spanish, be educated in Mexico, reside in U.S. for a shorter period
• Border crossing also included accessing services in Mexico and purchasing food and medications
Contextualizing Barriers To Care:Co-Morbidities Along US-Mexico Border
StructuralTransportation
Cognitive BarriersPatient-Provider
How are these factors related to individuals seeking health care when they have a series of co-morbidities? Work submitted for publication!
FinancialDifficulty paying
So- what is the social justice framework? Does it exists?
Not Yet!
How to Ensure Equitable, Sustainable and Long-Range Interventions- Working with New New Paradigms
Greater Demands On Prevention and Intervention Services
Old-Traditional
We Need Change- Real Change in Examining border specific characteristics and elucidate heterogeneity of border Hispanics-
New Paradigms
Research Training Dissemination
“My granddad said that in 1922, they came to study us, they are still studying us…a lot of paper, but no product…research for the sake of research, doesn’t do us any good”
Community Advocate at
Meeting How can we promote
health as a system that connects ethics with new research endeavors in communities?
How can we facilitate translation & dissemination of research?
Challenges
Research Training Dissemination
Empowerment at all levels of social ecological framework
Understand multiple social & ecological determinants
Integrate community representation in all facets of research
EthicalBenchmarks
Ethical Evaluation of Fairness: Equity, Efficiency, AccountabilityEthical Evaluation of Fairness: Equity, Efficiency, Accountability
Scientific Evaluation: Efficacy & EffectivenessScientific Evaluation: Efficacy & EffectivenessScientific
Benchmarks
A combined health disparity framework using ethical & scientific evaluations
Research Training Dissemination
❸What Interventions To Develop?
Presented at the American Public Health Association 140th Annual Meeting
San Francisco, California
New Era Of Ethics,
Efficiency, Effectiveness
Policy
Promote Awareness – Appreciation for Heterogeneity of
Hispanics
Research –Evaluation
Integration of Systems For
Social Change
Make Systems of health care more
accessible, affordable and accountable
Practice-Advocacy
New Paradigm for Health Equity
Strengthening the Community Approach
Build Community Models- Bring Social-Economic PoliciesBegin The Journey of Intersection between health and wellness, prevention-controlOne approach: The Community Health Worker Model, bring costs down, more access, better quality of care
by Paulina Matias, TX
Individuals
CHW Model
Border CommunitiesSociety
Synergy and Cooperation: CHW Model Influencing Change in
Border Communities
Family
The HEART Participant’s EnvironmentBalcazar et al. 2012 Prev Chronic Dis Vol 9 (11_0100)
www.kentonthemove.org/img/Socio-EcologicalMod..
Policy Agents: Policy makers
Community Agents: Community members, leaders
Organizations Agents: YWCA, Parks and Rec Dept., CHALC, UT
—El Paso, UT-SPH, Centro San Vicente, EPCC
InterpersonalAgents: CHWs, family, friends, social networks
IndividualAgents: HEART participant
Evaluation
Interven
tion
CBPR Context
Final Reflections
How do move forward integrated and well-defined community – population health interventions for a variety of Hispanic subgroups?Need to address complexity!Need to move beyond assumptions-border
fluidity- new dynamics i.e. use of health systems in both countries, medicationsLearn from resilience- family dynamics, Social capital, Ethics- Social Justice not a Cliche
THANKS To HHDRC and TEAM
Work Supported by P20MD002287 NIH- NIMHHD
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