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The interprofessional team measured seven clinical outcomes [obesity, diabetes, hypertension, hypertriglyceridemia, low high-density lipoprotein cholesterol HDL-C levels, and depression], and using the Duke Health Profile, assessed the health-related quality of life HrQoL. Methods: The investigators used ly reported disease prevalence, an implementation model, and community needs-assessments to de an outreach healthcare delivery model. include a high prevalence of obesity The HrQol domain of low self-perceived health, relates to obesity, diabetes, low HDL, and depression.
Depression predicted all 11 domains of the HrQol. Conclusion: The prevalence of diabetes, hypertension, obesity, and depression remains epidemic. Mobile clinics increase access and address highly prevalent illnesses in the Colonias. The data collected can be used to address chronic disease and quality of life, focus care, and direct research in high-need underserved areas. The Colonia is defined by the Texas Secretary of State as an economically distressed area that lacks the basic living necessities, such as potable water and sewer systems, electricity, paved ro, and safe and sanitary housing.
While frequently found far from resources in unincorporated or rural areas of the counties, a few Colonias are found within city limits Figure 1 13. Figure 1. Colonia map in Hidalgo County.
Benefit Colonias 3. Dating back to the s, developers in the RGV used agriculturally worthless land, land in flood plains, or rural land, to create un-incorporated subdivisions that lacked basic infrastructure.
Families paid low down payments and rent, then built homes with what they could afford, often without indoor plumbing or electricity 14. Some Colonias grew and county commissioners and cities garnered money and services to build basic necessities. Other Colonias continue without county or city services and public health challenges, such as vector borne disease, flooding, and garbage build-up.
Although few studies examine the health of individuals in Colonias along the Texas-Mexico border, those that have, report poor healthcare access, high rates of diabetes 6. The Colonias that have been incorporated into the city and share the amenities of the city are often classified as green. In contrast, the rural Colonias are often islands of poverty separated by small ro 9 In Colonias geographically separated from critical healthcare resources, the cost of transportation and lack of family vehicles, fear of deportation, low socio-economic and education levels, and chronic illness remains a frequent challenge.
Colonias require increased healthcare access, but cost-effective, sustainable care and resources targeted at highly prevalent chronic illness remains under-developed. The team provides primary care services, mental health evaluations and treatment, social services, medication advice and reconciliation, and health and quality-of-life education to Colonia residents.
We present demographic characteristics of a self-selected cross-sectional cohort and report on the services provided and clinical and health related quality of life HrQol data. We describe the use of integrated interprofessional teams that serve as learning venues for students and faculty and report on baseline data that confirm the epidemic prevalence of chronic disease in underserved areas. The can be used to de future research, healthcare access, and services for the Coloniason the US-Mexico border. All patients ed a consent for care.
The team focused on screening for chronic illness, providing preventive care, and improving health education and quality of life in the region. A stepped wedge-cluster model allowed for progressive implementation into the two communities.
The STITCH consortium met to develop a logic model, a method of implementation and evidence-based interventions to address potential issues in the Colonias. County Commissioners met with the group to advise on the needs of the neighborhoods and serve as a conduit to the Colonia residents. A list of possible recommendations, based on reports, was used as a starting point for discussion Colonia focus groups were conducted to determine healthcare screening needs, topics of healthcare education interest, and optimal modes of healthcare delivery.
Approximately 30 members primarily women met in each local Colonia church. The list of identified needs created by the focus groups included: primary care services directed at highly prevalent chronic diseases hypertension, diabetes, obesity, hyperlipidemia, and depression as well as school physical exams, immunizations, and topics on preventive medicine.
Duke Health Profile scores demonstrate self-reported functional health status across 11 physical, social, and mental domains 22 The team used Duke Health Profile to guide the interprofessional team in managing care, to determine differences between Colonias, and to evaluate the relationship between HrQOL and chronic disease in the cohort. Prior to and after each session, the team met in a huddle to plan, implement, and evaluate care.
Providers nurse practitioners, physician assistants, family physician faculty and residents in training, PharmD providers, and other learners offered continuity-primary care with a focus on healthcare maintenance. The interprofessional teams developed healthcare plans that used clinical chemistryPHQ9, and Duke Health Profile. All patients received copies of their laboratory reports and HIPPA compliant follow-up, records, and charts were maintained centrally.
At Cameron Park, Methodist Health Ministries Wesley nurses and the Cameron County Proyecto Juan Diego, a not-for-profit community center that has been serving the Brownsville area since for nutrition and diabetes education, served as referral resources. There were fewer Indian Hills Colonia referral options and were located at least a 30 min drive from the Colonia.
Health education, counseling, and screening was provided onsite by nurses, community health workers, social workers, and advanced practice providers. The College of Education provided education and health literacy classes.
Consequent to imputation using MissForest we arrived at a final data set of observations for all variables of interest. Logistic regression models explain odds ratios in the face of more than one variable. We carried out a two-stage regression analysis logistic or linear depending on the dependent variable. In the second stage, we performed generalized linear mixed model analysis using the glmm package in R to enable hypothesis testing i.
Women represented The BMI of men averaged Obesity hypertension, lipids, age and sex are all related, consistent with known associations. Table 2. ificant predictors of clinical outcomes based on of generalized linear mixed models. Predictors of the 11 Duke Domains are listed in Table 3.
Although each clinical measure was an important predictor of a domain of HrQOL, the most consistent predictors, PHQ9 score, age, sex, weight, and diabetes reduced HrQol in all patients. Mean scores on the 11 domains of the Duke Profile are listed in Table 4.
Indian Hills Colonia residents ranked higher in perceived health. Table 3. The 11 Duke Health Profiles linear mixed model : predictors of 11 Duke Health Profiles from linear mixed model .
Although the prevalence of obesity as a national trend is slowing, the prevalence of obesity remains disproportionately high in Hispanics, and especially in Mexicans and Mexican Americans living on the US-Mexico border 12. Obesity, diabetes, hypertension, hypertriglyceridemia, low HDL, and depression were highly prevalent in our cohort. Males had a higher prevalence of hypertension, hypertriglyceridemia and lower HDL than females. The reason for these sex differences, however, are unclear.
Since many men in the Colonias work until late in the evening and on weekends, they are less likely to seek primary care services. It is also possible that the males who seek care are more than likely unable to work due to illness or injury and thus have worse health profiles. Alternatively, there may be socio-cultural reasons why the Hispanic males living in the Colonias do not seek healthcare. To address healthcare needs for all residents, it is important to determine ways to increase access for males. The support other well-known association between age, obesity, hypertension, hypercholesterolemia, hypertriglyceridemia, low HDL levels, and depression that we have considered in iterative changes to the implementation and evaluation of our model.
We added more resources for nutrition education and mental health services. We screened all patients, learners, providers and mental health specialists trained in screening, brief intervention and referral for treatment SBIRT. Social determinants of health, including job insecurity, poverty, lack of access to care, transportation, family violence, substance use, diet, language challenges, lack of education, immigrant status, acculturation and lack of trust may contribute to resident's depression and subsequently to HrQoL.
In subsequent years, we added a screen for Social Determinants of Health, although ificant changes will require more targeted research, new policies, laws, and the involvement of government resources. More research and implementation of programs to address depression and the root causes of depression are needed. It is possible that focusing on addressing the symptoms of depression may improve health related quality of life and possibly chronic disease.
Chronic illness affects the domains of functional, physical, and social quality of life, while age, sex and BMI remain important predicators of HrQOL. Poor self-perceived health is a measure of quality of life and is related to education, language differences, age, and mental illness 1619 Our cohort did not perceive their health as poor, despite the prevalence of chronic illness and other risk factors. Further research using sociocultural or social cognitive theories could further explain the reasons for this. It is possible that un-measured social determinants of health, poverty, lack of access to health care, language and cultural differences, as well as immigration status contribute to the level of self-perceived health in the Colonias.
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