Partner Engagement
To address the health problem of overweight obesity among Hispanic immigrant adults on the US-Mexico border, a community advisory board (CAB) will be established that is representative of the community. Formation of a CAB aligns with the Community Based Participatory Research (CBPR) approach in involving communities in the planning and implementation of health interventions, formalizing a partnership between academic and community organizations (Newman et al., 2011). The CAB will consist of a representative from the organizations identified in the table above. The provided list is a preliminary formation and may be reconsidered as risk factors, barriers, and assets are identified and the scope of the project is refined. The CAB is primarily intended to serve as a leadership structure to the community partnership and guides the implementation processes vital to the success of the partnership. Processes identified by Newman and colleagues will be implemented to form the advisory board, execute activities, and continuously evaluate progress and goals (Newman et al., 2011). Operating procedures include setting an agenda, rotating roles as note-taker to document minutes, agreeing on meeting times and location, and rotating meeting locations to ensure partners maintain engagement and ownership of the program.
Intervention mapping steps will be followed to provide the CAB with tools necessary to make decisions and move from planning, implementing, and evaluating a successful health program. The PRECEDE model will be followed to assess the needs, risk behaviors, and determinants of the community causing the risk problem. Another tool to help identify the factors at various levels environment is the Root Cause Analysis. This tool uses a participatory process to identify the root causes of an identified problem, again aligning with the community based participatory approach, by brainstorming ideas and grouping those ideas into broader categories. Adapted from the Healthy Wisconsin Leadership Institute, the Root Cause Analysis attempts to identify the causes of overweight and obesity among Hispanic immigrants, rather than the symptoms associated with the problem. Following the analysis, existing resources and assets will also be identified to provide a comprehensive picture of the needs and assets that could be leveraged in the community.
Model Entry
The health problem of overweight and obesity, which is Phase 2 of the risk model, will be explored to identify personal behaviors, environmental factors and determinants that are causally associated with obesity. The target population is Hispanic adults, specifically immigrants, living in the border region of El Paso, Texas.
Health Problem
The obesity epidemic in the United States continues to grow despite the evidence of negative health impacts and rising medical costs. For adults, overweight is considered a body mass index (BMI) of 25-29.9 and obese is a BMI of 30 or greater (Tung & McDonough, 2015). In 2016, 39.8% of US adults were obese with the highest prevalence among Hispanics, 47%, and non-Hispanic blacks, 46.8% (Hales, Carroll, Fryar, & Ogden, 2017; Tung & McDonough, 2015). In Texas, the prevalence of overweight and obesity was 34.7% and 33.4%, respectively (‘BRFSS Prevalence & Trends Data ‘, 2018). In El Paso, Texas, 28.5% of adults were obese and 67.2% were overweight (‘Obesity Prevention Dashboard,’ 2018). Unfortunately, overweight and obesity prevalence is expected to increase, with minority populations disproportionately affected (Agha & Agha, 2017).
In 2008, obesity related costs an estimated $147 billion and a range of $3.38 to $6.38 billion in lost productivity and job absenteeism (Finkelstein, Trogdon, Cohen, & Dietz, 2009).
At-Risk Population
At-risk populations for overweight and obesity include Hispanics with low socioeconomic status, low education, and low income Specifically, Hispanic immigrants are at an increased risk as they become more acculturated to Western beliefs, attitudes, and adopt potentially unhealthy behaviors (Tung & McDonough, 2015). In 2014, over 11 million immigrants from Mexico lived in the US with approximately 21% settling in Texas (Zong & Batalova, 2016). The Hispanic population is increasing rapidly, has the highest and fastest growing prevalence rate of obesity compared to other ethnic groups.
The immigrant population is less likely to understand English and therefore experience communication barriers, have lower educational attainment and income and are more likely to be uninsured (Zong & Batalova, 2016), increasing their risk for adverse health outcomes. . Barriers to accessing health care include poor English proficiency and a fear of deportation, for those residing in the US illegally (Zong & Batalova, 2016). Over 400,000 Hispanics live in unincorporated neighborhoods along the Texas border (Anders et al., 2010). These types of communities usually lack potable water supply systems, adequate sewage systems, paved roads, and decent, safe housing (Anders et al., 2010).
Quality of Life Indicators
Obesity is associated with poor quality of life health measures such as poor aerobic capacity (i.e. shortness of breath), back and joint pain causing reduced mobility, and increased risk for secondary health issues (Agha & Agha, 2017). Obesity increases risks for chronic health conditions such as cardiovascular diseases, stroke, type 2 diabetes, some types of cancers, and metabolic syndromes and drastically increases relative risk of death (Agha & Agha, 2017). The first four conditions listed here are also the leading causes of death (Tung & McDonough, 2015). In addition, obesity may cause complications during pregnancy and infertility issues (Agha & Agha, 2017).
Other quality of life indicators include increased medical costs and decreased productivity. Based on findings from a systematic review in 2008, compared to normal weight persons, overweight persons spent $266 and obese persons spent $1,723 more in direct medical costs (Tsai, Williamson, & Glick, 2011). Other indirect costs include lost productivity, insurance claims, and premature mortality (Goettler, Grosse, & Sonntag, 2017).
To determine if these quality of life indicators, increased risk for chronic conditions and medical costs, are important among the target community, in-depth interviews will be conducted with key community members and health workers. Brief surveys may also be used to gather more information.
Risk Factors
Inadequate physical activity remains a primary causal factor in the growing overweight and obesity epidemic across the nation and among Hispanics. In 2013, only 20% of all US adults met the national recommendations for physical activity (Towne Jr et al., 2018). However, only 17% of Hispanic adults met those guidelines and the relationship was inversely associated with income level (Towne Jr et al., 2018). Engaging in regular physical activity improves overall health and reduces risk for weight gain and chronic diseases (Ickes & Sharma, 2012).
Another strong causal risk factor is poor nutrition and dietary habits, with minimal consumption of fruits and vegetables. Specifically for immigrant populations, the nutritional transition theory specifically explains the diminished health outcomes as a result of immigrants transitioning to a high-calorie, high-fat diet in the new country compared to the diets high in fruit and vegetable consumption in the host county (Delavari, Sønderlund, Swinburn, Mellor, & Renzaho, 2013).
Both of these risk behaviors are associated with acculturation, as an immigrant continues to replace host-country behaviors with behaviors and attitudes from a new culture (Alidu & Grunfeld, 2018). Immigrants who reside in the US for at least 10 years, and are therefore more acculturated, have a higher BMI compared to immigrants who have lived in the US for less than 10 years (Goel, McCarthy, Phillips, & Wee, 2004). BMI in foreign-born immigrants approaches US-born counterparts with more time living in the US (Goel et al., 2004; Hubert, Snider, & Winkleby, 2005). Immigrants who are less acculturated are more likely to have healthier diets with higher fruit and vegetable consumption (Ghaddar, Brown, Pagán, & Díaz, 2010) and generally exhibit low rates of correct weight perception, weight dissatisfaction, weight loss intention and weight loss success (New, Xiao, & Ma, 2013). Since acculturation impacts the adoption of health behaviors that impact weight, it is important to consider acculturation when identifying risk behaviors and environmental factors impacting obesity.
Environmental Factors
In addition to individual risk behaviors, environmental factors may also contribute to obesity. Taking an ecological level perspective to identify factors as the interpersonal organization, community, and society level will allow for a comprehensive picture of risk factors to be addressed and effecetively reduce or prevent the health problem of obesity.
Interpersonal level factors influencing the risk for obesity include the lack of support from family and social support networks in discouraging individuals from engaging in regular physical activity. Another factor is the lack of trust and poor communication between recent immigrants with healthcare providers or other services providers.
Organizational level factors include the lack of poor organizational infrastructure or partnerships in providing resources to the community.
Other factors may fit into either the community or society level of environmental factors, such as limited access to healthy food choices and inadequate places to exercise (Zong & Batalova, 2016). Infrastructure inhibiting physical activity may include neighborhoods without sidewalks or parks, street lights, or paved roads (Zong & Batalova, 2016). Neighborhood walkability also influences a person’s ability to engage in physical activity (Towne Jr et al., 2018). Walkability is determined by a neighborhood having a safe center or main street, mixed income with affordable housing, parks and public spaces, pedestrian signage, and complete streets. As previously mentioned, many immigrants live in unincorporated communities that lack these characteristics (Anders et al., 2010). Availability and access to healthy food options, or food deserts, are another environmental factor increasing risk for obesity. In addition to this lack of healthy food options, there are more fast food restaurants located in primarily low-income and minority communities. There is also evidence of more aggressive marketing of sugar sweetened beverages and other unhealthy food options in these types communities.
