A case study in academic-community partnerships: A community-based nutrition education program for Mexican immigrants

Abstract

Hispanics are the largest U.S. immigrant group and Mexican Americans are the largest U.S. Hispanic population. Hispanics, particularly Mexican Americans, are among the highest risk groups for obesity, placing them at increased risk for cardiovascular disease and certain types of cancer. Obesity lifestyle interventions incorporating Motivational Interviewing techniques and specific adaptations for the population of interest can have a significant impact on reducing health risks. This paper presents a community-engaged, culturally-sensitive nutrition and dietary counseling intervention conducted between 2016–2018 at the Consulate General of Mexico in New York City and reports preliminary findings regarding participant satisfaction and self-reported changes in eating and exercise habits. In addition, it describes the community and academic partners’ roles and processes in program development, discusses strengths and challenges posed by a multi-sector partnership and describes adaptations made using the Behavioral Model for Vulnerable Populations to increase the program’s sustainability and potential for scalability.

Introduction

Background

Hispanics are the largest U.S. immigrant group and Mexican Americans are the largest U.S. Hispanic population [1]. Mexican immigrants are soon to be the largest immigrant group in New York City (NYC) [2]. Hispanics, particularly Mexican Americans, are among the highest risk groups for obesity. Over 78% of U.S. Mexican women and 81% of U.S. Mexican men are either overweight or obese, compared to 60.9% and 73.2% among non-Hispanic whites (NHWs), respectively [3].

The high prevalence of obesity puts Mexican Americans at increased risk for cardiovascular disease (CVD) and its risk factors, including hypertension (HTN), metabolic syndrome, and type 2 diabetes mellitus, and for certain types of cancer, especially breast (postmenopausal), endometrial, prostate, and colon [4]. Hispanic individuals from Mexico have nearly two times the diabetes risk than NHWs [3]. A multitude of factors contribute to energy imbalance and weight gain, including energy-dense, nutrient-poor diets, and physical inactivity [3]. The process of acculturation has had a significant and negative impact on the Mexican American diet [5]; Hispanics are also one of the least physically active population groups [6].

Obesity lifestyle interventions can have a significant impact on reducing shared CVD and cancer risk. Five percent weight loss has been associated with numerous health benefits in several studies, including a reduced risk of developing diabetes and HTN, improved control of diabetes and HTN, and decreased risk factors for CVD; these studies also demonstrated improvements in insulin sensitivity and biochemical measures of hormone metabolism, which are hypothesized to play a role in the relationship between obesity and cancer [7].

COMIDA (Consumo de Opciones Más Ideales De Alimentos) (Eating More Ideal Food Options) is a community-engaged dietary counseling and education program led by an academic-community partnership, delivered in a community setting, and supported by partners representing a range of health and social service organizations that provide primary care screenings and referrals to community resources. COMIDA is delivered to community members who attend the New York Metropolitan area (NYMA) Ventanillas de Salud (VDS) (Health Windows) program and was developed in response to VDS visitors’ request for a nutrition education program. The VDS is a national, collaborative program between the Mexican government and over 400 U.S. non-profit and private agencies, working to increase access to health care and promote a healthy lifestyle among low-income U.S. Latinos at 50 national sites. The NYMA VDS is a local partnership housed and run by the Mexican Consulate in NYC that has as its lead academic partner Memorial Sloan Kettering Cancer Center’s (MSKCC) Immigrant Health and Cancer Disparities (IHCD) Center. The NYMA VDS has linkages with over 20 Mexican-serving organizations.

This paper presents preliminary findings regarding participant satisfaction and self-reported changes in eating and exercise habits following the COMIDA intervention. In addition, it describes key strategies for community-engaged partnership and intervention development, including delineating community and academic partners’ roles and processes in the development of the program’s components; using community-based personnel; and adapting the intervention to increase the program’s sustainability and potential for scalability.

COMIDA Intervention

COMIDA is a 12-week dietary counseling and education program designed to help participants make healthy eating and exercise choices. It is a multifaceted intervention that includes a baseline BMI measurement, an in-person individual or group dietary counseling session lasting approximately 45 minutes to one hour, an interviewer-administered dietary recall (for individual format only), a Spanish language low literacy diet and nutrition brochure, thrice weekly diet/exercise text messages (e.g., “Instead of snacking on chicharrones or other fried snacks, choose fruits and veggies with lime and chili”), low literacy Spanish-language written materials on neighborhood food resources, and the provision of measuring cups and spoons, a water bottle, and a MyPlate portion plate, and a follow-up BMI measurement and patient satisfaction survey at 3 months.

The COMIDA nutrition educational counseling is based on the USDA MyPlate program (available in Spanish) [8], is tailored to the Mexican population’s commonly eaten foods, is grounded in Social Cognitive Theory [9], and incorporates Motivational Interviewing [10] approaches. The counseling session consists of ten modules: 1) Beverages: Avoid Sodas, Artificial and/or Sugary drinks; 2) Vegetables, Fruit, and Fiber; 3) Grains, Tortillas, and Fiber; 4) Proteins: Diversify your Proteins and Choose Lean Ones; 5) Fried Food; 6) Junk Food and Sweets; 7) Fast Food Restaurants and Eating Out; 8) Be More Active: Exercise; 9) Final Activities, Food Selection (Weekly Ad) and Building Your Meal (‘Build Your Tortilla’) (experiential or ‘modeling’ activities, e.g. using a supermarket ad to choose foods and building a meal using food models); 10) Conclusion and Goal-Setting. Modules, which last 3 to 5 minutes each, include an introduction, the module topics, questions and activities for the participant about diet/exercise behaviors, and money-saving tips.

Methods

Spanish-speaking, overweight or obese individuals seeking services at the Ventanillas de Salud program at the Mexican Consulate in NYC were eligible for participation. Exclusion criteria included not being in the NYC area for the study duration, being pregnant and/or breastfeeding, the presence of a chronic disease such as cancer, kidney disease, liver disease, etc.; having dietary restrictions; not having a phone that accepts text messages; presence of a serious psychiatric or cognitive impairment, and/or having another family member already enrolled in COMIDA.

Trained study staff administered the individual COMIDA intervention between January 2016 and August 2018 and the group COMIDA intervention between May 2016 and August 2018. 3 months after the intervention, a 50-item follow-up survey created by the authors evaluated participants’ satisfaction with the intervention and changes in eating and exercise habits.

Preliminary Findings

For the individual COMIDA intervention, 205 people were approached for participation. Of these, 148 (72%) agreed to be screened, and 138 of those screened were eligible for participation. Between January 2016 and August 2018, 137 agreed to participate in COMIDA, 135 completed the intervention, and 127 were due for the 3-month follow-up assessment, among whom 76 completed the assessment. At follow-up, 70% rated the COMIDA program as ‘excellent’, 75% rated the COMIDA interventionists as ‘excellent’, 69% rated the text message tips as ‘excellent’; and 94% agreed that they were eating more healthfully, 86% agreed that they were eating affordable healthy food options, and 58% agreed that they were exercising more after participating in COMIDA.

For the group intervention, between May 2016 and August 2018, 83 were approached for participation, 60 (80%) agreed to be screened, among whom 50 were eligible for participation. 49 agreed to participate, 48 completed the intervention, and 38 were due for the 3-month follow-up, among whom 23 completed the assessment. At follow-up, 50% rated the program as ‘excellent’, 47% rated the community-based health educators (promotoras) as ‘excellent’, 57% rated the text message tips as ‘excellent’; and 80% agreed that they were eating more healthfully, 85% agreed that they were eating affordable healthy food options, and 65% agreed that they were exercising more after participating in COMIDA.

Strategies for Partnership and Intervention Development

The key aspects of the COMIDA intervention that potentially facilitated its success (detailed below) were: 1) Development and maintenance of partnerships; 2) Use of trained and community-based health educators (promotoras) and partnership community outreach staff; and 3) Iteratively modifying the intervention to decrease barriers to participation based on the Behavioral Model for Vulnerable Populations (BMVP) [11].

Partnership Development

The COMIDA program partnership included the following entities, a number of which are themselves formalized partnerships: minority serving institution-NCI-designated Cancer Center partnership (CCNY (City College of New York) – MSKCC (Memorial Sloan Kettering Cancer Center) U54 Partnership for Cancer Research, Training, and Community Outreach); government-academic partnership (NY Ventanillas de Salud (VDS) or ‘Health Windows’ program, a partnership between the Mexican Consulate in NYC, MSKCC’s Immigrant Health Disparities (IHCD) Center, and over 20 Mexican-serving organizations); community-based organizations (Mexican Coalition and Make the Road New York); and a community-academic partnership (Cornell Cooperative Extension, a key outreach system of Cornell University, with an extensive local presence and public mission that is responsive to New York community needs), which provided resource materials (see Table 1).

Table 1.

COMIDA Program Partnership Members.

Member	COMIDA Contributions
PCORE (Partnership Community Outreach-Research-Education) Core, outreach arm of CCNY-MSKCC U54 Partnership for Cancer Research, Training, and Community Outreach	Conducted needs assessment to inform COMIDA program design
	In concert with IHCD, provided clinicians for VDS program
	Provided interventionists who delivered COMIDA individual intervention
	Provided outreach staff to facilitate COMIDA partnership: community health outreach staff and researchers
MSKCC Immigrant Health and Cancer Disparities Center (IHCD)	In concert with PCORE, provided clinicians for VDS program
VDS Program in NYC	Provided weekly culturally tailored health education and screening programs to address CVD and cancer risk reduction and navigation into primary care for COMIDA’s target population: Mexican immigrants visiting the Consulate for consular services
	Provided COMIDA participants with resource referrals as needed (e.g. to entitlement offices, food resources, etc.)
Mexican Coalition and Make the Road New York	Provided health promotors (promotoras) who were trained to deliver COMIDA’s group intervention
Cornell Cooperative Extension	Provided resource materials, e.g. Eat Smart New York! Stretch Your Food Dollars pamphlets

Partners shared the common goal of improving the health and well-being of the community of interest. For example, the outreach arm of the U54 Partnership, PCORE (Partnership Community Outreach, Research, and Education), aims to increase community outreach programs to address cancer risk factors in underserved communities, including diet/obesity and physical inactivity. The mission of the VDS is to provide preventive care and promote healthy lifestyle habits in the Latino community. The mission of the Mexican Coalition is to strengthen individual, organization, and community capacities that allow the Latino, Mexican, and Mexican-American community to realize their full integration—civic, cultural, and political—within American society [12]. Make the Road New York’s Health Access Programs aim to guarantee equal rights, access, and improved healthcare for the 2.5 million New Yorkers with limited English proficiency [13].

In addition, partners were selected for their ability to contribute services that others could not. For example, the Mexican Coalition and Make the Road New York provided trained health promotors (promotoras) who delivered COMIDA’s group intervention, and the VDS, located in the NYC Mexican Consulate, provided a natural and trusted site at which to reach the program’s population of interest, Mexican immigrants.

Personnel

Promotoras de salud in Latino communities refer to community health workers, paraprofessionals who provide health education and research services in their own communities [14]. The promotora model has a decades-long history in Latin American countries and has been successfully replicated and adapted in the United States among Hispanic communities [15]. A growing body of literature has demonstrated promotoras’ cultural and linguistic effectiveness in conducting community health education and outreach within U.S. Hispanic communities [14].

The group format of COMIDA is delivered by trained Spanish-speaking promotoras from the Mexican Coalition and Make the Road New York. Mexican Coalition promotoras completed a 36-hour in-class curriculum on COMIDA plus 48 hours of field practice. The course is delivered in partnership with Hostos Community College and National Council of La Raza’s Comprando Rico y Sano (CRS) model [16] and prepares promotoras to engage in small community conversations on health-related topics, including nutrition. Make the Road New York promotoras were trained to assist with health insurance and food stamp enrollment, hospital bill negotiation, health system navigation, nutrition education and emergency food services.

Promotoras often share similar socio-economic characteristics and cultural norms with community members, creating a bridge between their communities and the formal healthcare system [14]. For example, in delivering the COMIDA intervention, promotoras effectively used self-disclosure to engage participants, e.g. telling personal stories about how they changed their own eating habits, identifying barriers and how they overcame them and thereby modeling how to affect change.

Several outreach-focused staff members from PCORE provided the “glue” between academic and community partners, including a Community Health Educator who develops and maintains relationships with community-based organization partners (such as the Mexican Coalition, Make the Road New York, and the Mexican Consulate). This staff member also delivered the individual format of COMIDA and was instrumental in providing trainings for the Mexican Coalition and Make the Road New York promotoras. IHCD also employs a full-time VDS Community Outreach Assistant, supported by the Mexican Consulate, who, in concert with IHCD clinicians, conducts weekly culturally tailored health education and screening programs to address CVD and cancer risk reduction. Weekly team meetings (including the outreach staff described and PCORE faculty members and research managers) and additional email or telephone check-ins allowed both community and academic partners to share their concerns and collaborate on COMIDA program design.

Implementation Approach: Behavioral Model for Vulnerable Populations

The approach used to implement and adapt the COMIDA intervention for the community of interest was informed by the Behavioral Model for Vulnerable Populations (BMVP) [11], developed to explain variables that impact health services utilization. The BMVP posits that the special needs and characteristics of vulnerable populations may impede utilization of healthcare and health-related services. We sought to identify predisposing and enabling factors salient to Mexican immigrants and modified the intervention accordingly (Figure 1).

Figure 1.

COMIDA Implementation Approaches targeting Predisposing and Enabling Factors in the Behavioral Model of Vulnerable Populations.

Predisposing factors.

Predisposing factors leading to a decrease in seeking healthcare and health-related services included limited English proficiency (97% of VDS visitors are limited English proficient), immigration status, acculturation level, and a high poverty level (76% of VDS participants live in poverty, 30% reported being unemployed).

An implementation log used to track participants’ reasons for refusal of the intervention showed that the most commonly cited reason was related to their financial/occupational status, i.e. “lack of time” due to “long working hours” (many participants worked late night shifts in the service industry) and “lack of childcare”. Because of this, educational information at their COMIDA visit was delivered in a modular format, with the most essential information presented first in case participants had to leave before completion. Further, to address the time burden on participants of returning for follow-up, study procedures were amended so that follow-up could be completed over the phone via self-report using digital scales distributed at the initial evaluation. In addition, staff made phone calls on evenings and weekends when participants were more likely to be off from work.

The Language Initiatives team at IHCD was a key partner in addressing language barriers in the COMIDA intervention. To ensure accuracy, readability, and cultural fidelity, the intervention was transcreated into Spanish by the director of the Language Initiatives team at IHCD, then back-translated into English by an outside translation agency, using well-established guidelines [17]. COMIDA staff who recruit participants and deliver the individual intervention are bilingual English and Spanish speakers, promotoras who deliver the group intervention are Spanish-speaking, and both COMIDA staff and promotoras have extensive experience working with the Mexican immigrant community. The intervention is delivered verbally and uses pictures as visual aids to depict nutrition facts to address low literacy. A nutritionist developed a healthy Mexican recipes booklet in response to participants’ requests.

Enabling factors.

Enabling factors that could facilitate healthcare and health related services-seeking behavior included self-help skills and the availability of social services.

To encourage the development of self-help skills, participants were given healthy eating tools as a part of the intervention, including measuring cups and spoons and digital scales. Water bottles were distributed to encourage the drinking of tap water after interventionists’ discovered that participants were unaccustomed to the public provision of free and safe water and were therefore buying bottled water, encroaching on their food budget. Unnecessary expenditures on bottled water in low-income households may contribute to food insecurity, which is also tied to obesity [18].

To address barriers to the utilization of social services stemming from unfamiliarity with public assistance programs, COMIDA interventionists also provided information about community programs and social service agencies covering a wide array of services, including those providing food and shelter, banking, and mental health services.

Discussion

The COMIDA pilot program is an example of how an academic-community partnership can work productively to develop a dietary counseling intervention that addresses the needs of the Mexican immigrant community. The program is grounded in evidence-based behavioral change approaches and provides a foundation for future studies with the potential to yield valid and generalizable results. Community-based organizations and programs such as the Mexican Coalition, Make the Road New York, and the VDS are important partners in addressing longstanding health disparities in immigrant communities, particularly for the undocumented who may be wary of traditional healthcare institutions such as hospitals and clinics [19]. Yet there is a paucity of literature that describes the process of developing service programs from conceptualization to implementation, especially papers that identify the strengths and challenges of intervention development in the context of an academic-community partnership.

The COMIDA collaboration features a number of strengths. First, the intervention was developed in response to community need made apparent through the community-engaged activities of PCORE and the VDS. In the planning stages, the COMIDA team incorporated evidence-based approaches grounded in SCT theory to address the problems of poor diet and overweight/obesity in the Mexican immigrant community. The Behavioral Model of Vulnerable Populations [11] informed modifications to the intervention protocol, which enhanced the ability of COMIDA to recruit and retain a hard-to-reach community. These adaptations also greatly increased the potential for further dissemination of the program without having to undergo substantial revisions. Another important strength was the training of Mexican Coalition promotoras to deliver the group intervention, which contributed to capacity building in a Mexican serving organization and allowed the program to have greater reach and sustainability. Partnering with the VDS also allows for potential intervention dissemination throughout the 50 national VDS sites and serves as a model for other community-embedded sites (e.g. schools, churches, community-based organizations, community centers, etc.).

The partnership model used to develop the COMIDA program also presented challenges. For instance, the partnership needed to manage the sometimes-different priorities of the partners as the program evolved from its initial pilot stage. PCORE faculty and project managers from prioritized adherence to the manualized intervention protocol to ensure fidelity and internal validity of evaluation results, which was sometimes at odds with community partners’ wish to shorten the intervention due to participants’ time constraints. An organizational structure that built in regular communication allowed both community and academic partners to share their concerns and make the adaptations described to accommodate both academic and community priorities, e.g. ordering the modules to ensure that participants who needed to leave early received the most impactful modules.

As the difficulty of translating public health research to real-world practice is increasingly acknowledged [20], more collaborative partnerships between university researchers and community organizations are needed to develop and evaluate effective interventions. An important lesson highlighted by the COMIDA program is the necessity of identifying trusted partners with shared goals who provide entrée into an underserved community. In addition, implementing a partnership structure specifically designed for cross-pollination (i.e., in which project collaborators are embedded within community organizations) supports and increases the likelihood of the success of collaborative projects.

The COMIDA pilot program provides an example of how an academic-community partnership can collaborate during all phases of development of a community-based public health intervention, from conceptualization through pilot implementation. In addition, it demonstrates how partnerships can work together to meet the specific needs of an underserved population using evidence-based and culturally responsive methods. Additional examples of academic-community partnerships are needed in the literature, particularly descriptive, process-oriented papers identifying strengths and challenges of such collaborations.