Social and Behavioral Determinants of Health Assignment #4: Social Policy Paper

General instructions:1. Type the paper in Microsoft Word or Rich Text Format. (Other formats will NOT be accepted.)2. Upload your paper to Blackboard by 11:59 PM on the due date in the syllabus. I strongly suggest that you also email the paper to YOUR school or personal email account in case Blackboard loses it. Emailing it to yourself provides a time stamp in case there is a controversy.3. Do not put your name anywhere in your paper or use your name as the document name when you save your paper electronically. (I correct papers anonymously to do so without bias. Blackboard remembers your name and can match you to your score when I am done.)4. Organize your paper in the sections that I have below so I can apply the rubric.5. Use scientific references only (unless specifically stated otherwise). Use APA style references in text and at the end of the document (see the syllabus for more info). 6. Get help from the O’Leary reference librarian, Sara Marks, if you are unsure how to use UML library databases or conduct searches (see the syllabus for more info).7. Make sure to read the rubric at the end of this paper for tips.

1. Background (5 points). Select a health issue. This should be a type of physical or psychological disease or injury. Describe the US impact of this health problem. You may want to include:

o Number of people with the diseaseo Number of new cases/deaths/disabilities that result from this disease every yearo Financial costs and lost productivity due to this diseaseo Projected future trends for this disease.

Describe the major physiological and behavioral risk factors for this disease. Provide citations for the facts that you include (at least 3 different citations).

Clear description of 1. Health concern and impact, 2. Risk factors, 3. Correct citations for scientific references.

Select a health issue: Type II Diabetes.

Describe the US impact of this health problem. You may want to include:o Number of people with the diseaseo Number of new cases/deaths/disabilities that result from this disease every yearo Financial costs and lost productivity due to this diseaseo Projected future trends for this disease.

Type II diabetes is a disease from the group of the diabetes (type I, type II, Gestational and other types related to pancreatic diseases or genetic conditions such a development of diabetes in youth). The two most common manifestations are type I diabetes, which occurs when the pancreas reduces the rate of insulin production and type II diabetes that occurs when the body’s cells begin to reduce the response to the insulin produced in the pancreas. In both cases, glucose levels begin to increase in the bloodstream and eventually begin to damage the blood vessels,

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kidneys and nerves1. This illness is known for being a “silent” chronic disease characterized by the high levels of blood glucose capable of compromising the cardiovascular system or being able to cause blindness. This disease can also cause liver and kidney failure. Type II diabetes can even be a cause of amputations in people suffering from the disease.

Type II diabetes is the most common form of diabetes that normally starts attacking people around 40 years of age or people with family history of diabetes, overweight or obese, and also people who have sedentary lifestyles and its development is described as follows:

In human body, the ingested food is converted into glucose that enters the bloodstream where insulin produced by the pancreas converts it into energy and then is assimilated. Diabetes is a metabolic disorder that tends to occurs in people who are overweight or sedentary.

It is important to notice that there is no cure for diabetes. Nevertheless it can be prevented with adequate diet and frequent physical activity and exercise. On the other hand, once the disease is acquired, it can also be controlled with medication, exercise and diet. A good control can greatly help in the prevention of diabetes’ complications related to heart and circulatory system, eyes, kidneys and nerves. The map below shows the concentration of diabetes cases in the US.

The illness affects almost 9% of the population which means 28.8 million persons are suffering from it and there are 8.1 million of whom may be undiagnosed and unaware of their condition.

1 Gordon, C., Walker, M., & Carrick-Sen, D. (2013). Exploring risk, prevention and educational approaches for the non-diabetic offspring of patients with type 2 diabetes - a qualitative study. Journal Of Advanced Nursing, 69(12), 2726-2737. doi:10.1111/jan.12162

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Moreover, in 2010 1.9 million new cases of diabetes were diagnosed in people aged 20 years or older then 1.7 million new cases of diabetes were diagnosed in U.S. adults in 2012. Two years earlier; the prevalence of type 2 diabetes is on the rise2. If current trends continue, 1 of 3 U.S. adults will have diabetes by 20503. Figure 1 shows the tendency in diabetes cases in the US.

In 2007 the disease was ranked the seventh of the most common cause of death in the United States4, currently it ranks the sixth. Even when it is preventable with an opportune intervention (can be eliminated or reduced with time and effort), the number of cases has tripled since then. Studies have found that only about 35% to 40% of people with diabetes who died had diabetes listed anywhere on the death certificate and about 10% to 15% had it listed as the underlying cause of death5.

By 2012, the estimated cost of diagnosed diabetes was around $245 billion, $176 billion for direct medical costs and $69 billion in reduced productivity, being 40% higher than the relative costs from the year 2000.

Describe the major physiological and behavioral risk factors for this disease.2 Longhurst, Adrienne. September, 2014. Healthline Networks Inc. Type II diabetes statistics and facts.http://www.healthline.com/health/type-2-diabetes/statistics#43 Center for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion Diabetes, Successes and Opportunities for Population-Based Prevention and Control. http://www.cdc.gov/chronicdisease/resources/publications/aag/ddt.htm4 Center for Disease Control and Prevention. 2011. Diabetes, Successes and Opportunities for Population-Based Prevention and Control http://www.cdc.gov/chronicdisease/resources/publications/aag/ddt.htm5 American Diabetes Asociation. Statistic about diabetes. http://www.diabetes.org/diabetes-basics/statistics/#sthash.KGhTKD6O.dpuf

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A person exhibiting any of the following characteristics or risk factors has a high probability of developing type II diabetes6:

People over 45 years old. Obese or overweight persons whose BMI above 30 kg/m2. People with family members who have type II diabetes Sedentary people who do not exercise, have a disability and/or with low physical activity. People with low HDL cholesterol or high triglycerides People with waist circumference over 35 inches. People who smoke People who present symptoms of having prediabetes.

Among the risk factors these are categorized as major physiological and behavioral risk factors:

o Physiological risk factor: Being overweight or obese.o Psychological risk factor: Stresso Behavioral risk factor: Under or over sleep time.

Obesity and type II diabetes:

Being overweight or obese plays a role in the majority of cases of type II diabetes. The progression from overweight to obese increases the risk for the development of type II diabetes. As a person becomes more obese, they enter a more insulin resistant state, leading to impaired glucose tolerance, which can potentially lead to the development of type II diabetes.Stress and type II diabetes:

A study conducted by The Center for Health and Social Care Research from Sheffield Hallam University, suggests that activation of the physiologic stress response from chronic exposure to stressors like low socioeconomic status, severe mental health problems, or aggressive behavior increases the risk of type II diabetes. The article makes a comprehensive review of the literature on the link between the disease and psychosocial factors focusing on prospective studies of the risk for developing diabetes.

The review found an increased risk for type II diabetes in people: exposed to stressful working conditions or traumatic events, with depression, with personality traits or mental health problems that put them in conflict with others, of low socioeconomic status, either currently or in childhood, and in racial/ethnic minority populations, independent of current social status.

Sleep time and type II diabetes

6 Clark, J. (2014). Lifestyle recommendations for people at increased risk of type 2 diabetes. Nurse Prescribing, 12(3), 143-146. http://eds.b.ebscohost.com.libproxy.uml.edu/eds/pdfviewer/pdfviewer?sid=8e74c3a1-5365-4968-bec2-6a442022b8b8%40sessionmgr198&vid=2&hid=119

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A recent study concluded there is a relationship between sleep duration and type II diabetes. Short and long sleeping times are associated with a higher risk of developing the disease. The results suggest that sleep duration may represent a novel risk factor for type II diabetes.

Chronic partial sleep deprivation as a consequence of voluntary bedtime restriction is an endemic condition in modern society. In 2004, more than 30% of adults between the ages of 30 and 64 years old reported sleeping less than 6 hours per night. Factors responsible for this situation include increases in environmental light, longer work days/longer commuting time, an increase in evening and night work, an increase in television use, and the advent of the personal computer and the Internet.

Another study suggests that chronic partial sleep deprivation, a behavior that is specific to the human species and appears to have become more prevalent during the past few decades, may increase the risk of type II diabetes. However, the underlying mechanisms of this presumed adverse influence of sleep deprivation on glucose metabolism is not well understood. Some data suggests that short-term partial sleep restriction could lead to insulin resistance by increasing sympathetic tone, raising evening cortisol concentrations, and decreasing cerebral glucose utilization. These findings suggest that long-term sleep deprivation may predispose individuals to evident clinical diabetes.

A study conducted by the National Institutes of Health7 suggests that patients with type II diabetes are 52% more likely to develop major depressive disorder than the general population. However, the study identified that there is no reciprocity in the fact i.e. depression does not cause diabetes.

The following table shows the percentage of diabetes cases in Massachusetts.

This table shows the mortality incidence due to diabetes in the state

7 Janes GR. Ambulatory Medical Care for Diabetes. 2nd ed. Bethesda, MD: National Institutes of Health; 1995.

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Provide citations for the facts that you include (at least 3 different citations). Clear description of 1. Health concern and impact, 2. Risk factors, 3. Correct citations for scientific references.

Gordon, C., Walker, M., & Carrick-Sen, D. (2013). Exploring risk, prevention and educational approaches for the non-diabetic offspring of patients with type 2 diabetes - a qualitative study. Journal Of Advanced Nursing, 69(12), 2726-2737. doi:10.1111/jan.12162

Chaput, J., Després, J., Bouchard, C., Astrup, A., & Tremblay, A. (2009). Original Article: Sleep duration as a risk factor for the development of type 2 diabetes or impaired glucose tolerance: Analyses of the Quebec Family Study. Sleep Medicine, 10919-924. doi:10.1016/j.sleep.2008.09.016

Stress and Type 2 Diabetes: A Review of How Stress Contributes to the Development of Type 2 Diabetes. (2015). Annual Review of Public Health, 441.

Naranjo, D., Fisher, L., Areán, P., Hessler, D., & Mullan, J. (2011). Patients with type 2 diabetes at risk for major depressive disorder over time. Annals Of Family Medicine, 9(2), 115-120. doi:10.1370/afm.1212

Viswanathan, V., Wadud, J. R., Madhavan, S., Rajasekar, S., Kumpatla, S., Lutale, J., & Abbas, Z. G. (2010). Comparison of post amputation outcome in patients with type 2 diabetes from specialized foot care centres in three developing countries. Diabetes Research And Clinical Practice, 88146-150. doi:10.1016/j.diabres.2010.02.015

Stanford, K. I., & Goodyear, L. J. (2014). Exercise and type 2 diabetes: molecular mechanisms regulating glucose uptake in skeletal muscle. Advances In Physiology Education, 38(4), 308. doi:10.1152/advan.00080.2014

2. Social determinant of health (10 points).

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You can pick a social determinant from our reading (race, sex, gender, poverty, work environment, socioeconomic position, sexuality, geography, etc.) or that you are aware of through your research or personal experience (disability, ageism, etc.).

Explain how this social determinant impacts the health outcome you selected in Part 1. o Describe how the disease is patterned by the social determinant you selected

(provide actual statistics showing which groups are most and least impacted by the disease).

o Describe how the patterning of the disease by social determinants raises the overall burden of that disease in the US population.

Explain the pathway to disease. How does the social determinant you are describing affect the physiological and behavioral risk factors for the disease that you described in Part 1?

Provide citations for the facts that you include (at least 3 different citations). Explain 1. Social Determinant, 2. Disease patterns by this determinant, 3. Pathways to disease, 4. Correct citations for scientific references.

Pick a social determinant from our reading (race, or that you are aware of through your research or personal experience (disability, ageism, etc.).

Social determinant selected: Race: Type II diabetes among Latin American population.

Explain how this social determinant impacts the health outcome you selected in Part 1. Describe how the disease is patterned by the social determinant you selected (provide actual

statistics showing which groups are most and least impacted by the disease).

According The American Journal of Medicine, the Latino population in the United States has a greater prevalence of metabolic abnormalities and type II diabetes compared with non-Hispanic whites. Compared with non-Hispanic whites, Latinos tend to be generally more obese, and are less likely to achieve control of parameters such as Glycated hemoglobin8, blood pressure, and lipid levels.

Overall, the magnitude of the problem of type II diabetes in Latinos is large, worrisome, and getting worse. Some of the ethnic differences in the prevalence between Latinos and whites have

8 It is a form of hemoglobin that is measured primarily to identify the average plasma glucose concentration over prolonged periods of time. In diabetes mellitus, higher amounts of glycated hemoglobin, indicating poorer control of blood glucose levels, have been associated with cardiovascular disease, nephropathy, and retinopathy. Monitoring HbA1c in type 1 diabetic patients may improve outcomes. Larsen ML, Hørder M, Mogensen EF (1990). "Effect of long-term monitoring of glycosylated haemoglobin levels in insulin-dependent diabetes mellitus". N. Engl. J. Med. 323 (15): 1021–5.

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a genetic basis (attributed by metabolic syndrome)9, but socioeconomic and cultural factors have a greater influence.

Among the conditions that increase Latino’s (particularly immigrant) predispositions to risk factors are:

Most of the time they leave their homelands under precarious, exhaustive, and stressful condition that compromise their health.

An unstable immigration status often generates a great state of anxiety and stress impairing their emotional state.

A native diet rich in sugars and fats. Increasing their risk for becoming overweight or obese. Extent labor schedules (sometimes double shift) and long distances to cover mostly by public

transportation forcing them to reduce sleep time and also keep them away from having a balanced meal, which is often replaced with fast food.

Family nucleus disconnection increases levels of anxiety, stress and, sometimes enhances depression.

Sending money back to their home country inhibits them to attend a preventive intervention program to type II diabetes.

Describe how the patterning of the disease by social determinants raises the overall burden of that disease in the US population.

Latin Americans may keep higher ranks among the population with type II diabetes due to the following reasons:

Migration from Latin American countries will be higher than migration from other continents due to the proximity between them and the US border. They will have an easier access.

There is no evidence that the economic and social conditions of most of Latin American countries improve in the short term, consequently there should not be a reason of reduction of the number of immigrants into the US.

For most of the immigrant Latinos the legalization procedures are slow and normally take several years to normalize. Consequently the stress and anxiety levels in the population become chronic.

Language and skills limitations, labor displacement is complicated for Latinos in US, getting worse they need to send money back home compromising their economic situation. They normally experience limited access to information about chronic diseases and opportune medical interventions.

9 Metabolic syndrome is a disorder of energy utilization and storage, diagnosed by a co-occurrence of three out of five of the following medical conditions: abdominal (central) obesity, elevated blood pressure, elevated fasting plasma glucose, high serum triglycerides, and low high-density cholesterol (HDL) levels. Metabolic syndrome increases the risk of developing cardiovascular disease and diabetes. Some studies have shown the prevalence in the USA to be an estimated 34% of the adult population, and the prevalence increases with age. The most important factors are genetics. Pollex, R.L.; Hegele, R.A. (2006). "Genetic determinants of the metabolic syndrome". Nat Clin Pract Cardiovasc Med 3 (9): 482–9.

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The first generations of Latinos are increasing their age, which is one of the type II diabetes risk factors.

Latinos tend to keep their dietary habits and eating traditions for more than two generations increasing their risk of obesity and the risk of acquiring type II diabetes.

The following graph explains how Latinos see themselves after several generations living in the US:

Explain the pathway to disease. How does the social determinant you are describing affect the physiological and behavioral risk factors for the disease that you described in Part 1?.

In the United States, the prevalence of adults who are overweight or obese is higher in Latinos compared with non-Hispanic whites. In addition, data from the National Health and Nutrition Examination Survey (NHANES) indicate that the prevalence of type II diabetes mellitus is consistently greater in racial/ethnic minority groups, such as Latinos, compared with non-Hispanic whites. Between 1988 to 1994 and 2005 to 2006, the prevalence of diabetes increased from 9.6% to 12.6% in the adult Latino population. According to Pew Hispanic Center, an estimate of 17% of all Hispanics and 22% of all Hispanic youths ages 16 to 25 are unauthorized immigrants. Besides, approximately 41% of all foreign-born Hispanics and 58% of foreign-born Hispanic youths are estimated to be unauthorized immigrants. Probably for those Latinos in US the pathway for their development of the disease could follow the following steps10:

A person gets into the country alone, without his close nuclear family normally with an uncertain migratory status that increases his anxiety and depression levels.

10 PEW RESEARCH CENTER. 2013. Between Two Worlds: How Young Latinos Come of Age in America. http://www.pewhispanic.org/2009/12/11/between-two-worlds-how-young-latinos-come-of-age-in-america/.

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A native diet with strong influences of his country of origin rich in sugar and fats, combined with a low profile in nutritional education does not allow him to identify good sources of nutrition.

Long distances to cover to get to his workplace and long working shifts, makes most of the Latinos to reduce his hours of sleeping and also to abuse fast food and sodas.

Anxiety generated due to his migratory status, bad nutrition habits, and reduced sleeping time trigger overweight and obesity risk factors that eventually initiate the development of type II diabetes.

A chronic vicious circle develops in this process.

Provide citations for the facts that you include (at least 3 different citations). Explain 1. Social Determinant, 2. Disease patterns by this determinant, 3. Pathways to disease, 4. Correct citations for scientific references.

López-Jaramillo, P., Sánchez, R. A., Diaz, M., Cobos, L., Bryce, A., Parra-Carrillo, J. Z., & ... Zanchetti, A. (2014). [Latin American consensus on hypertension in patients with diabetes type 2 and metabolic syndrome]. Arquivos Brasileiros De Endocrinologia E Metabologia, 58(3), 205-225.

López-Jaramillo, P., Sánchez, R. A., Díaz, M., Cobos, L., Bryce, A., Parra-Carrillo, J. Z., & ... Zanchetti, A. (2014). Documento de consenso: Consenso latinoamericano de hipertensión en pacientes con diabetes tipo 2 y síndrome metabólico. Clinica E Investigacion En Arteriosclerosis, 2685-103. doi:10.1016/j.arteri.2013.11.008

Cusi, K., & Ocampo, G. L. (2011). Unmet Needs in Hispanic/Latino Patients with Type 2 Diabetes Mellitus. The American Journal Of Medicine, 124(Supplement), S2-S9. doi:10.1016/j.amjmed.2011.07.017

Valencia, W. M., Oropesa-Gonzalez, L., Hogue, C., & Florez, H. J. (2014). Diabetes in Older Hispanic/Latino Americans: Understanding Who Is at Greatest Risk. Generations, 38(4), 33-40.

PEW RESEARCH CENTER. 2013. Between Two Worlds: How Young Latinos Come of Age in America. http://www.pewhispanic.org/2009/12/11/between-two-worlds-how-young-latinos-come-of-age-in-america/.

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3. Public health initiative (10 points). Describe a program designed to reduce the social disparity you described in Part 2.

o This program can be a law, regulation, policy, environmental change, or behavioral intervention.

o Be careful—many initiatives that are designed to improve health actually end up increasing health disparities. The point of this exercise is to decrease health disparities and (hopefully) not make anyone’s health worse.

o This program can be something tried in the past, used in the present, or proposed for the future.

o You must provide scientific evidence supporting the usefulness of this approach in reducing social inequality. Use the scientific evidence to explain how (at least theoretically) this intervention would improve health.

o Please go beyond individual behavior change. Do not make your intervention an educational program in which you only tell the disadvantaged group about actions that they can take to improve their health. Think bigger than that.

Describe how this reduction in social disparity can result in reductions in health inequalities and improvements in population health regarding the health problem addressed in Part 1.

Provide some insight about possible negative effects of the implementation of this policy Provide citations for the facts that you include (at least 2 different citations). 1. Properly defines strategy, 2. Explains how the strategy might impact health, 3. Considers negative impacts, 4.

Correct citations for scientific references.

Describe a program designed to reduce the social disparity you described in Part 2. This program can be a law, regulation, policy, environmental change, or behavioral intervention.

According (Ockene and Tellez, 2012)11 “Tailoring, or adapting interventions to specific individuals or populations, is important to address unique barriers to behavior change and has been shown to be successful in various communities”. Their experience in the Lawrence project can be emulated in the proposed program but its effectivity may get increased if the behavioral intervention incorporates this elements:

The complete concept to be implemented would be: A community-based, multi-institutional type II diabetes and lifestyle intervention-healthy foods and physical activity in workplace.

It is considered that the one of the best environments to focus an intervention for type II diabetes would be the work places. A multi – institutional community based behavioral intervention using a work place and ethnic approach may be able to impact in a large number of persons in risk, particularly if it is settled on large urban communities that concentrate a large amount of immigrants. Most of the people within the age-risk factors, regardless of their origin have a work place. Therefore an intervention that considers involving multiple institutions can minimize disparities.

11 Ockene IS, Tellez TL, Rosal MC. 2012. Can a Culturally Tailored Diabetes Program Effectively ReduceDiabetes Risk in a Low-Income Latino Population?, et al. Outcomes of a Latino community-based intervention for the prevention of diabetes: The Lawrence Latino Diabetes Prevention Project.

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A program can be developed considering the participation of the community, local entrepreneurs, and business; Food stores and restaurants in order to promote the availability in local and ethnic nutritious food and also to increase the interactivity of members with the same ethnic roots and increasing the amount of physical activity in workplaces in order to reduce the occurrence of type II diabetes among ethnic minorities and immigrants.

There is evidence that isolation and the leak of social network predicts death12. Consequently, the program include the promotion of ethnic and cultural based activities, sport competitions and folkloric fairs and exhibitions to promote not only social interaction among members of the same ethnic group. But also to promote a component of the availability of healthy and ethnic food in local stores and the benefits of the consumption of healthy food, water, fruits and, fresh vegetables. Also to present the importance of increasing physical activity to reduce the occurrence of type II diabetes.

The cultural and social – ethnic interaction would be managed through the municipal authorities. On the other hand, physical activity, healthy eating and the availability ethnic food programs would be handled through the workplaces but coordinated both programs through the local public health department. The intervention would also consider a component of promotion and marketing (radio, TV, posters and other informative and publicity material).

The implementation of the community-ethnic base nutritional and physical activity program among workers would reduce any public health disparity because the program will promote the interaction of individuals not only from the same ethnic group. Also with another ethnic groups through sport activities, cultural performance and folkloric fairs.

The work places will be participating as an ethnic group coordinators and information facilitators not only of the activities to perform but also information related to nutrition, type II diabetes, healthy lunches at work place, and increasing physical activity subprograms.

Key components of this ethnic-community workplace intervention are:

o Community ownership of the program.o Ethnic and cultural sensitivity and interaction.o Increasing physical activity through sports and competitions.o Partnership with different community stakeholders as local business, companies,

food stores, and restaurant participation.o Integration of new immigrants into the community, reducing their level of stress,

loneliness, segregation, and increasing their knowledge of nutrition, chronic diseases, culture, and networking.

12 Berkman Lisa, Kawachi Ichiro. 2000 Social Epidemiology. Chapter 7 pp 142.

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o Local and municipal authorities’ involvement in reducing type II diabetes, reducing health disparities by including all ethnic workforce without privileges or preferences and also minimizing cultural and ethnic differences and conflicts.

o The reduction of chronic diseases occurrence by the promotion of social interaction among ethnic groups, the reduction of stress level in workforce, development of healthy food eating habits, Also the increase of physical activity in persons in risk of type II diabetes.

o At the individual level, reducing the consumption of sodas, high carbohydrates, and fat fast foods among ethnic groups of workers and new immigrants.

o The reduction of isolation, loneliness and depression among workers.

These are some of the possible negative effects of the implementation of this intervention.

Work places may not find it profitability incentive to engage in a physical activity program. Workers’ attention on the program may distract them from their work duties. There is a possible risk of creating inter racial friction by some misunderstanding or conflict

generated during a sport competition. Grocery stores and restaurants may not find profitability in selling healthy or ethnic food. The program may be misinterpreted as an incentive to stimulate illegal immigration into the

country.

Describe how this reduction in social disparity can result in reductions in health inequalities and improvements in population health regarding the health problem addressed in Part 1.

By promoting interaction between individuals of the same ethnic group the levels of stress, isolation and depression tend to diminish contributing to reduce the occurrence of type II risk factors.

The interaction between individuals with the same or similar roots, language or identity background facilitates the exchange of knowledge related to the improvement of nutrition and the importance of physical activity in reducing type II diabetes risk factors.

Involving the participation of workplaces and offices facilitates to identify individuals under risk but also facilitate that the intervention reach all workers by equity without getting preference for a specific group.

Involving the communities contribute to the development of the ethnic folklore and cultural programs, which is an excellent way to promote healthy food and nutrition habits. In addition it helps to distribute information regarding physical activity importance.

According Kawachi and Berkman (2000), for the successful of the intervention need to considerate the following elements:

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Frequency of the contact: Workers need to be motivated and induced to be in contact with the other members of their ethnic group and also in participating in the activities.

Multiplexity and diversity: The program need a component of diversity and creativity to keep the participants and the members of the community eager to participate in the activities

Duration: The program needs to be running for a long period in order to be able to modify the behavior in terms of eating and exercising.

Reciprocity: All the stakeholder need to be profitable in order to keep them active in the program.

Provide citations for the facts that you include (at least 2 different citations). 1. Properly defines strategy, 2. Explains how the strategy might impact health, 3. Considers negative impacts, 4. Correct citations for scientific references.

Mead, E. L., Gittelsohn, J., Roache, C., Corriveau, A., & Sharma, S. (2013). A Community-Based, Environmental Chronic Disease Prevention Intervention to Improve Healthy Eating Psychosocial Factors and Behaviors in Indigenous Populations in the Canadian Arctic. Health Education & Behavior, 40(5), 592-602.

Berkman Lisa, Kawachi Ichiro. 2000 Social Epidemiology. Chapter 7

Varekamp, Inge. Verbeek, Jos H, van Dijk, Frank J. H. November 2006. International Archives of Occupational and Environmental Health, Volume 80, Issue 2, pp 87-97. How can we help employees with chronic diseases to stay at work? A review of interventions aimed at job retention and based on an empowerment perspective. http://link.springer.com/article/10.1007/s00420-006-0112-9

Ockene IS, Tellez TL, Rosal MC. 2012. Can a Culturally Tailored Diabetes Program Effectively Reduce Diabetes Risk in a Low-Income Latino Population?, et al. Outcomes of a Latino community-based intervention for the prevention of diabetes: The Lawrence Latino Diabetes Prevention Project.

4. Obstacles (5 points).

Provide information about an obstacle that hampers the initiative you describe in section 3. This obstacle could entail aspects such as

o Difficulty in implementing the interventiono Opposition from public opinion or vested interestso Political considerations

Provide suggestions about reasonable ways that public health professionals might overcome this obstacle. These suggestions may include such topics as technical fixes, public health advocacy, public education.

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Provide 2 citations for these concepts. I would prefer scientific references. However, since I realize that many of these concepts are delving into the realm of political and social science (and many of you have not had experience in researching this type of information) I will accept news articles (either print or online sources) that make your points (for this section only). 1. Clearly explains an obstacle, 2. Suggests a reasonable procedure to overcome this problem, 3 . Correct citations for scientific or news references

Provide information about an obstacle that hampers the initiative you describe in section 3. This obstacle could entail aspects such as

Difficulty in implementing the intervention

According Vivian, Colbert and Remington in Lessons Learned from a Community Based Lifestyle Intervention for Youth at Risk for Type II diabetes, one of the obstacles is that many families from underserved communities have limited access to healthy foods, parks and recreational areas, which makes maintaining a healthy lifestyle challenging.

Normally immigrant workers’ lifestyle gravitates around their workplace and transportation. At the end of the day exhaustion and boredom is so intense that the individual prefers to sleep before doing any physical or even recreational activity.

Another obstacle is the language. When the person gets older it is more difficult to learn a new language, especially when technical terminology is involved; In this case medical, nutritional and sometimes legal terminology. This obstacle may limit the person for understanding the importance of nutrition and physical activity in reducing type II diabetes risk factors approach.

Opposition from public opinion or vested interests

There are racial and ethnic differences in attitudes about health and healthcare, and perceptions of racial and ethnic discrimination in healthcare. A study found that race and ethnic disparities at the site of the usual source of care persisted even after controlling for individuals' attitudes about health and healthcare, and their perceptions about racial and ethnic discrimination in healthcare. One of the problems of discrimination is its tendency to generalization without caring about any other condition of the marginalized person.

Political considerations

Several newspaper articles indicates that the health issues on immigration (a topic close related with race) is still unsolved and difficult to predict their results, particularly related to health insurance coverage even when this topic is considered relevant during presidential campaigns.Additional problems related on immigrant is that there is no consistency between current immigration laws and health laws, creating even more uncertainty among people who are

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already experiencing some of the type II diabetes risk factors that limits them to initiate an opportune intervention.

Ways to overcome the obstacles.

An intervention to prevent type II diabetes risk factors should be implemented considering the appropriate language and literacy levels of the population targeted. It should be necessarily to consider multilanguage personnel to manage the intervention.

One of the aspects that cause social and political instability in most of the Latin American countries is the narco-activity. By reducing the consumption rate in the US would help to improve the socio-political panorama of those nations, which contribute significantly to reducing migration.

It may probably work to create a parallel national social intervention exposing how US was created by immigration and ethnic diversity.

Correct citations for scientific or news references

Gaskin DJ, Arbelaez JJ, Brown JR, Petras H, Wagner FA, et al. Examining racial and ethnic disparities in site of usual source of care. J Natl Med Assoc. 2007;99:22–30. [PMC free article] [PubMed]

Minkler M, Blackwell AG, Thompson M, Tamir H. Community-based participatory research: implications for public health funding. Am J Public Health. 2003;93:1210–1213. [PMC free article] [PubMed]

Ockene IS, Tellez TL, Rosal MC. 2012. Can a Culturally Tailored Diabetes Program Effectively Reduce Diabetes Risk in a Low-Income Latino Population?, et al. Outcomes of a Latino community-based intervention for the prevention of diabetes: The Lawrence Latino Diabetes Prevention Project.

National Immigration Law Center. January, 2013. Current Immigration Reform Proposals Fail to Ensure That Aspiring Citizens Will Have Access to Health and Nutrition Programs.http://www.nilc.org/hlthcareimmreform2013.html Obama Immigration Move Won't Solve Health Issueshttp://www.huffingtonpost.com/2015/02/26/obama-immigration-action_n_6760432.html

Immigration hot topic for Republican candidateshttp://www.statesman.com/news/news/inmigracion-tema-candente-para-los-aspirantes-repu/nkhpF/Project Criteria; Total points = 35

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Novice(0-70%)

Developing(80%)

Proficient(90%)

Exceptional(100%)

Background(5 points)

Aspects are missing or all 3 are unclear or less appropriate.

All 3 aspects are present; two are unclear or less appropriate.

All 3 aspects are present; one is unclear or less appropriate.

Clear description of 1. Health concern and impact, 2. Risk factors, 3. Correct citations for scientific references.

Social Determinant of Health(10 points)

Aspects are missing or 3+ are unclear or less appropriate.

All 4 aspects are present; two are unclear or less appropriate.

All 4 aspects are present; one is unclear or less appropriate.

Explain 1. Social Determinant, 2. Disease patterns by this determinant, 3. Pathways to disease, 4. Correct citations for scientific references.

Public Health Initiative(10 points)

Aspects are missing or all 3 are unclear or less appropriate.

All 3 aspects are present; two are unclear or less appropriate.

All 3 aspects are present; one is unclear or less appropriate.

1. Properly defines strategy, 2. Explains how the strategy might impact health, 3. Considers negative impacts, 4. Correct citations for scientific references.

Obstacle(10 points)

Aspects are missing or all 3 are unclear or less appropriate.

All 3 aspects are present; two are unclear or less appropriate.

All 3 aspects are present; one is unclear or less appropriate.

1. Clearly explains an obstacle, 2. Suggests a reasonable procedure to overcome this problem, 3 . Correct citations for scientific or news references.

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