The impact of diabetes is devastating along the U.S.-Mexico Border. The rate of diabetes mortality in the border region is nearly 50% higher than in the rest of the country (1), and Hispanics are two to three times more likely to suffer from serious secondary complications (2,3). Self-management behaviors, such as diet, physical activity, and glucose self-monitoring are fundamental to avoiding the long-term complications of diabetes (4). For many individuals, however, self-management behaviors constitute drastic lifestyle changes for which there is little external support. In a managed-care setting, Hispanics were shown to exhibit poor diabetes control when compared with non-Hispanic whites (5).

Diabetes education can have a positive impact on self-management behaviors and glycemic control, particularly when accompanied by intensive follow-up support (6). Diabetes classes delivered in a community setting have been shown to be effective in achieving glycemic control among adults with type 2 diabetes, and this mode of delivery is likely to increase the cultural relevancy and appropriateness of educational techniques in addition to providing greater access to hard-to-reach populations (7). Community partnerships also have the potential to enhance cultural relevance and positively impact self-management and clinical outcomes (8).

There are overwhelming challenges to providing formal diabetes education in border communities. Individuals without insurance do not have access to diabetes education services. For individuals with insurance, few certified diabetes educators (CDEs) live and work in border communities and they may not speak Spanish. Programs that provide interpretation or translation are often not culturally relevant to Hispanics.

This paper describes the patient component of the Border Health Strategic Initiative (Border Health ¡SI!) funded by the Centers for Disease Control and Prevention (CDC), which used the community health worker model to provide culturally competent diabetes education in two Arizona border communities in Yuma and Santa Cruz counties. A detailed description of Border Health ¡SI! is included in this issue of Preventing Chronic Disease (9) along with several companion papers addressing other components of the model (10-18). More information on the rationale and effectiveness of the community health worker model in addressing diabetes can be found in the CDC Division of Diabetes Translation's position statement (available from http://www.cdc.gov/diabetes/projects/comm.htm).

Individual ability to manage diabetes cannot be separated from community context and support for diabetes care (19). Both Yuma and Santa Cruz Counties are rural and more than 90% Hispanic; Yuma County has a large migrant/farmworker community. The region is medically underserved. Lack of insurance, seasonal employment of farmworkers, and fear and discrimination related to immigration present challenges to establishing a regular source of care (20). Patients with diabetes often cross the border to Mexico for medical care, making it difficult to maintain continuity of care.

Residents not eligible for Medicaid programs can rarely afford diabetes medication. Individuals with insurance often do not have pharmaceutical coverage and must decide whether to buy food or medicine. Patients share medication or resort to taking it only when they are feeling badly. While diabetes programs may make glucose monitors available, few resources cover the cost of glucose-monitoring strips.

The border environment does not support good nutrition and physical activity. Few recreational areas, parks, or sidewalks exist in these rural areas to facilitate walking. Summer heat, inadequate lighting, dangerous walking surfaces, and wild dogs pose additional challenges. Although southern Yuma County is a farming community, and the city of Nogales (in Santa Cruz County) is a throughway for produce from Mexico, healthy foods such as fresh fruits and vegetables are high-priced and often unavailable. Furthermore, the health messages taken for granted in urban areas rarely reach farmworkers who work 12-hour days in isolated areas.

The social network that can potentially support self-management is often not in place. The elderly may have family members who migrate to follow the harvesting season or move to urban areas. Many extended family members live in Mexico. Diabetes patients may become isolated and depressed as they experience increasing health problems.

Because of these barriers, education programs must be culturally competent. Vital to the diabetes education program was the use of promotores de salud. Promotores are indigenous to the communities in which they work and provide a bridge between the health care delivery system and the community. In addition to health information, they provide social support and advocate for patients to gain access to health and social services (21). In one diabetes education program, the use of promotores in a Hispanic community was shown to increase the rate of completion (22).

The process of implementing the Border Health ¡SI! patient education component over three years in two communities provided a rich opportunity to learn from successes and challenges. In spite of diminishing resources, both programs maintained a strong commitment to providing diabetes education to the underserved. Both communities expressed increased demand for the classes, which was difficult to manage in Yuma because the program moved one group of participants through one series of classes before starting another. At times, classes in Yuma had more than 40 people. Santa Cruz began offering classes in the evening to respond to those who worked during the day.

Santa Cruz had the advantage of a CDE who had worked in the community for years. The Yuma health educator left halfway through the program. The promotores then took responsibility for teaching the classes under the supervision of the hospital CDE. Participant outcomes were maintained when the promotores began teaching.

This program responded to a need for accessible, culturally competent diabetes education and demonstrated how communities can galvanize local capacity to respond to an overwhelming lack of resources. Local providers contributed free eye and foot exams and promotoras took over the diabetes education classes when the health educator left the community.

Partnership of providers. Crucial to success was the partnership of diverse organizations that enabled the programs to confront challenges of the border environment on multiple levels. The CHCs had access to the target population, but they would not have been able to recruit and retain participants without the promotores. In both communities, the hospital was critical in providing expertise and in accessing resources.

Community diabetes classes. Holding classes at a community site in a series with a specific group of participants appears to contribute to program completion. This may be because participants have a greater sense of commitment and enjoy belonging to a group. Santa Cruz was extremely fortunate to have a committed, culturally competent and expert CDE. In rural communities where CDEs are not available, promotoras can be trained to provide diabetes education. It is vital, however, that they have backup and support from a qualified person.

Promotores outreach and support. Program outcomes would not have been achieved without promotores. Promotores are fundamental in ensuring that participants initiate and complete classes, gain access to resources, and adopt self-management practices.

Linkage between diabetes education and clinical care. Providing access to health care, examinations, and medications is a challenge that should be addressed early on. For this reason alone, community collaboration is essential. Creating formal relationships with clinical providers may enhance health outcomes. The patient empowerment card was one attempt to establish a formal relationship, and the card was popular with program participants. Strategies to ensure that providers use the card need to be implemented and the impact on care needs to be evaluated.

Program evaluation. Conducting meaningful program evaluation — especially with limited resources — was a challenging but key element of the patient education component. Consistent with the participatory model of evaluation, the academic partner was not an outsider to but rather an integral member of the team and a stakeholder in its success. Within this framework, evaluation became a tool of program development, encouraging partners to define concretely the desired outcomes of the program, to make the effort to collect the necessary information, and to integrate feedback into program strategies. The influence of evaluation on Border Health ¡SI! included 1) designing a series of diabetes education classes (rather than an open-door policy) to create group cohesion and support, 2) establishing a greater focus on including family members in the education and care process, and 3) developing strategies to increase patient-provider communication. Both Border Health ¡SI! communities used evaluation results to sustain program activities beyond the funding period, one through institutional support and the other through other grant funding.

In these two marginalized border communities, the Border Health ¡SI! diabetes education and outreach program had a positive influence on the ability of individuals to adopt self-management practices and improve health outcomes. It is important to note that as a component of the comprehensive Border Health ¡SI!, the education and outreach program was linked to a policy action group that addressed challenging environmental issues related to diabetes (15,16). Participation in a policy-focused group enabled program partners and community leaders to discuss systemic problems, leverage additional resources, and address prevention on a community level.