Cecilia B Rosales
- Associate Dean, Community Engagement and Phoenix Programs
- Professor, Public Health
- Member of the Graduate Faculty
Dr. Rosales serves as Associate Dean for Community Engagement & Outreach and Associate Dean for Phoenix Campus. In addition, she is a tenured Professor and Department Head of Public Health Practice & Translational Research in Phoenix.
The Associate Dean for Community Engagement & Outreach provides mentoring and support for College of Public Health personnel, students, and prospective students to develop and engage in community-based programs, service learning activities and research. Communicates the importance of community-public health partnerships to a diverse set of partners, including community members, academic affiliates, government agencies, and organizations (public and private) with a health and/or a social justice focus. She strives to develop community-campus partnerships that result in shared power in decisions related to research, infrastructure, and training programs.
Within our mission to build and sustain healthier communities within Arizona, the position of Associate Dean can do so by supporting community groups through partnerships, which are mutually beneficial, reciprocal and respectful. As a land grant institution and aligned with MEZCOPH mission, the position is committed to engagement with both internal and external partners, explore the many ways faculty, adjunct educators, staff, and students impact the daily lives of residents of Arizona through outreach, discovery and engaged scholarship. Engagement and outreach enhances the quality of life for residents across Arizona, the border region, tribal nations, and globally.
Dr. Rosales has 30 years’ experience in the areas of program development and implementation, public health administration and policy, and health disparities research related to the Southwest and border region. Her understanding of the region has resulted in a unique contribution to the body of knowledge associated with border and binational health in general, and has strengthened community-based participatory research and collaboration in the Southwest.
She is known for her deep understanding of the context in which the public health infrastructure can be strengthened at the local, state, national and binational level to address the issues of health disparities in this region.
Dr. Rosales serves as the private sector co-chair of the Health Services Committee of the Arizona-Mexico Commission. She also served as a member of the U.S.-Mexico Border Health Commission representing Arizona for 10 years. The Border Health Commission, the Arizona-Mexico Commission, the Border Governors and the state health departments in Arizona and Sonora have benefited from her innovative and creative strategies for strengthening the public-health infrastructure in this region.
Dr. Rosales has developed a strong academic and community network created through her years of research, practice and service. Dr. Rosales strives to bring and work together with a multidisciplinary and binational cadre of interested parties, including academics, non-profit, and other governmental officials.
Dr. Rosales is a member of the Advisory Board for the National Ventanillas de Salud (Health Windows) program. The Advisory Board received the Ohtli Award from the Mexican Government in 2018 for improving the quality of life for low-income and immigrant Mexican populations in the U.S. by improving access to basic preventive health services.
Since 2016, the Primary Prevention Mobile Health Unit program, which grew from the Ventanillas de Salud, provides free preventive health services to the uninsured and underinsured. Today, the program has 11 Mobile Health Units in Chicago, Dallas, Denver, Las Vegas, Los Angeles, Miami, New York, Orlando, Phoenix, Raleigh, and Tucson. Dr. Rosales is Principal Investigator and Director of the Primary Prevention Mobile Health Unit program in Arizona and works with a team of interprofessional students and faculty from the UA Health Sciences in Phoenix and Tucson to provide outreach and preventive services to community.
Since the COVID-19 pandemic in 2020, Dr. Rosales and the Mobile Health Unit team have worked diligently within the community to educate on the COVID-19, provide testing and vaccination as well as continuing to provide basic health screenings, among other services to the hard to reach and communities of color within the state. Through internal funding from the University of Arizona Health Sciences, Dr. Rosales established the MOVE-UP initiative. The goal is to improve COVID-19 vaccination uptake and reduce health inequities in vulnerable, hard to reach populations using mobile units that administer vaccines, provide education on COVID-19 transmission and prevention strategies to protect family members living in the same household. The mobile units also provide primary and preventive care and refer to other health and social services as appropriate. Collaborating with the Arizona Department of Health Services, Mexican Consulate Offices in Arizona, county health departments, and rural health providers can bring these educational, technological resources and vaccines to the community as opposed to having hard to reach residents come to us in Phoenix or Tucson.
Dr. Rosales completed 2021, in collaboration with El Colegio de Sonora and the Secretaria de Salud de Sonora, a 5-year National Institutes of Health grant titled, Tools and practices to decrease cardiovascular disease and complications in the diabetic population of Mexico. The research project aimed to test the effectiveness of certain tools and practices to decrease cardiovascular disease and complications from diabetes. The goal is to scale up the intervention to the national level within Mexico and along the US-Mexico border region.
Currently, Dr. Rosales is Co-Principal Investigator on the multidisciplinary “Binational Studies of the Environment and Asthma in Mexico and the United States” (BEAMS) Program, which seeks to characterize environmental factors that prevent childhood asthma by building on a powerful natural experiment. Our preliminary data show that despite similar genetic ancestries and a negligible geographic distance (<100 miles), Mexican children born in Nogales, Sonora have drastically lower asthma prevalence and higher levels of microbial exposure compared to Mexican American children born in Tucson, AZ. Dr. Rosales will oversee the Mexican arm of the study in collaboration with Dr. Gudelia Rangel from El Colegio de la Frontera Norte and the Secretaria de Salud of Sonora.
Dr. Rosales brings a passionate commitment to the elimination of health disparities, mentoring of students, and encouraging the pursuit of health sciences majors and interprofessional opportunities for students. She also supports the integration of community and public health into all missions of the UA, UA Health Sciences and MEZCOPH. In addition, provides leadership, guidance and assistance to the Dean of MEZCOPH and Associate Deans, Department Chairs, and Center Directors on public health education, service, and research programs within MEZCOPH at the University of Arizona.
- M.D. MS Epidemiology
- University of Arizona, Tucson, Arizona
- Mel & Enid Zuckerman College of Public Health (2016 - Ongoing)
- Mel & Enid Zuckerman College of Public Health (2016 - Ongoing)
- Mel and Enid Zuckerman College of Public Health, University of Arizona (2014 - 2016)
- Mel and Enid Zuckerman College of Public Health, University of Arizona (2011 - 2015)
- Division of Community, Environment and Policy, Policy and Management Section, Mel and Enid Zuckerman College of Public Health, University of Arizona (2005 - 2016)
- Victoria Foundation, Dr. Loui Olivas Distinguished Leadership in Higher Education Award
- Victoria Foundation, Fall 2020
- Pete Garcia Los D-backs Ambassadors Community Leadership Award
- Diamondbacks Organization, Fall 2019
- OHTLI Award
- Mexican government for, Fall 2018
- Chicanos Por La Causa-Cause for Change Honoree
- Chicanos Por La Causa, Summer 2016
- Most Influential Women in Arizona Business
- Arizona Business Magazine, Summer 2016
- Pueblo High School Hall of Fame Recipient
- Pueblo High Alumni Foundation, Fall 2015 (Award Finalist)
- Dr. Cesar E Chavez Community Service Award
- Arizona State University Chicano/Latino Faculty & Staff Association, Spring 2015 (Award Finalist)
- Change Champion Award
- Public Health Institute, Fall 2014
- Profiles of Success, Latino Excellence in Health & Sciences
- Valle del Sol, Fall 2013
- UA Alumni Association Club President Award
- UA Alumni Association, Fall 2013
Border and binational health, farmworker health, social corporate responsibility, health disparities,
US Mexico Border Policy and Binational Collaboration, Policy and Management, Service Learning
DissertationPHPM 920 (Spring 2022)
Master's ReportPHP 909 (Spring 2022)
Public Hlth Policy+MgmntPHPM 574 (Spring 2022)
DissertationPHPM 920 (Fall 2021)
Master's ReportPHP 909 (Fall 2021)
Master's ReportPHP 909 (Summer I 2021)
Master's ReportPHP 909 (Spring 2021)
Public Hlth Policy+MgmntPHPM 574 (Spring 2021)
Independent StudyPHP 599 (Fall 2020)
Master's ReportPHP 909 (Fall 2020)
Public Hlth Policy+MgmntPHPM 574 (Fall 2020)
DissertationHPS 920 (Spring 2020)
Honors ThesisPHP 498H (Spring 2020)
Master's ReportPHP 909 (Spring 2020)
Public Hlth Policy+MgmntPHPM 574 (Spring 2020)
DissertationHPS 920 (Fall 2019)
Honors ThesisPHP 498H (Fall 2019)
Master's ReportPHP 909 (Fall 2019)
Master's ReportPHP 909 (Summer I 2019)
DissertationPHPM 920 (Spring 2019)
Honors ThesisPHP 498H (Spring 2019)
Master's ReportPHP 909 (Spring 2019)
Public Hlth Policy+MgmntPHPM 574 (Spring 2019)
DissertationHPS 920 (Fall 2018)
DissertationPHPM 920 (Fall 2018)
Honors ThesisPHP 498H (Fall 2018)
Master's ReportPHP 909 (Fall 2018)
Master's ReportPHP 909 (Summer I 2018)
DissertationPHPM 920 (Spring 2018)
Master's ReportPHP 909 (Spring 2018)
Public Hlth Policy+MgmntPHPM 574 (Spring 2018)
DissertationPHPM 920 (Fall 2017)
Master's ReportPHP 909 (Fall 2017)
Public Hlth Policy+MgmntPHPM 574 (Fall 2017)
DissertationCPH 920 (Summer I 2017)
Master's ReportCPH 909 (Summer I 2017)
DissertationCPH 920 (Spring 2017)
Independent StudyCPH 699 (Spring 2017)
Master's ReportCPH 909 (Spring 2017)
Public Hlth Policy+MgmntCPH 574 (Spring 2017)
DissertationCPH 920 (Fall 2016)
Independent StudyCPH 499 (Fall 2016)
Master's ReportCPH 909 (Fall 2016)
Public Hlth Policy+MgmntCPH 574 (Fall 2016)
Master's ReportCPH 909 (Summer I 2016)
DissertationCPH 920 (Spring 2016)
Master's ReportCPH 909 (Spring 2016)
Public Hlth Policy+MgmntCPH 574 (Spring 2016)
- Carvajal, S. C., Carvajal, S. C., Zapien, J. G., & Rosales, C. B. (2016). Emergent Public Health Issues in the US-Mexico Border Region. Frontiers Media SA. doi:10.3389/978-2-88945-047-3
- Sabo, S. J., Nicolette, T., Jill, d. Z., & Rosales, C. B. (2014). Entre Fronteras (Between Borders): The Power of Service-Learning in Cultural Exchange and Social Action in the United States -Mexico Borderlands. eBook ISBN: 978-989-98013-7: Heritage 2014 Proceedings of the 4th International Conference on Heritage and Sustainable Development.
- Arranda, P., Ortega, I., Rosales, C. B., Sabo, S. J., De Zapien, J. G., & Zapien, A. (2013). Migracion y atenciion a la salud de los Jornalero agricolas. In Alternativas en la crisis para la transformacion de las politicas sociales en Mexico. Hermosillo, Mexico: Fundación Konrad Adenauer.More infoArranda P, Ortega I, Rosales C, de Zapien J, Sabo S, Zapien A. (2013) Migracion y atención a la salud de los Jornalero agricolas. In Alternativas en la crisis para la transformación de las políticas sociales en México, México/Hermosillo, El Colegio de Sonora, CIAD, Fundación Konrad Adenauer
- Aceves, B., Ruiz, M., Rosales, C., Madhivanan, P., Ingram, M., Garcia, D. O., Denman, C. A., & Aceves, B. (2021). Mental health and diabetes self-management: assessing stakeholder perspectives from health centers in Northern Mexico.. BMC health services research, 21(1), 177. doi:10.1186/s12913-021-06168-yMore infoPeople living with diabetes have an increased risk of developing mental health issues. Mexico has observed a high prevalence of people living with diabetes suffering from mental health issues, such as anxiety and depression. Self-management programs have demonstrated promise in helping participants address and prevent not only physiological health complications but mental health issues as well. This qualitative study aimed to understand the mental health benefits of a diabetes self-management intervention for health centers in Northern Mexico and opportunities for improvement through assessing stakeholder perspectives..Trained research staff used a semi-structured questionnaire guide to conduct all interviews and focus groups from February-May 2018. Individual interviews (n = 16) were conducted face-to-face at four health center sites among all health center directors and key staff located throughout the state of Sonora. One focus group (n = 41) was conducted at each of the four health centers among intervention participants. Directed content analysis was used to establish themes by understanding relationships, identifying similar experiences, and determining patterns across datasets..In total 57 health center directors, health center staff, and intervention participants were involved in the interviews and focus groups across the four health centers. Overall the analysis identified four themes throughout the data, two were categorized as benefits and two as improvements. The primary themes for participant benefits were an increase in self-efficacy and social support to manage their chronic conditions. These were evident from not only participant perspectives, but health staff observations. Conversely, increased family involvement, and increased mental health integration and services within diabetes care were identified themes for opportunities to improve the intervention to be more inclusive and holistic..All stakeholders observed the benefits for intervention participants and opportunities for more inclusivity of the family and integration as well as an increase in mental health services. The themes identified demonstrated a need to more proactively enhance and utilize diabetes self-management as a means to improve mental health outcomes among people living with diabetes in Mexico. This is an opportunity to employ a more comprehensive approach to diabetes self-management, and integrate mental health services into overall diabetes care..www.ClinicalTrials.gov, identifier: NCT02804698 . Registered on June 17, 2016.
- Rosales, C., Hounkpatin, W. A., Ehiri, J. E., Djrolo, F., & Alaofe, H. (2021). Knowledge, attitude, practice and associated factors among patients with type 2 diabetes in Cotonou, Southern Benin.. BMC public health, 21(1), 339. doi:10.1186/s12889-021-10289-8More infoType 2 diabetes (T2D) is becoming an epidemic with significant disability and premature death in Sub-Saharan Africa, including Benin. However, little is known about the level of knowledge, attitude, and practice (KAP) necessary for diabetic patients to enhance therapeutic outcomes and prevent diabetes complications. The study aimed to assess patients' KAP levels and identify the factors associated in Cotonou, southern Benin..A cross-sectional study was conducted from July to August 2019 among 300 diabetic patients from four health centers. Data was collected using validated questionnaires. KAP levels were determined by calculating the scores, and multivariate logistic regression was used to explore factors influencing KAP scores..About 53, 52, and 47% of all patients had good knowledge, attitude, and practice towards diabetes. In logistic regression, factors such as being female, married, educated, government/non-government employee, and longer duration of diabetes were significantly associated with good knowledge. Being married, having a longer duration of diabetes, and good knowledge were significantly associated with a good attitude while being educated, having a longer duration of diabetes, and good knowledge with good practice..Lack of knowledge, poor attitude, and inadequate practice were found in this surveyed community, suggesting a need for structured educational programs to assist diabetic patients. However, education should be considered a priority for male, newly diagnosed, and uneducated patients.
- Wolkin, A., Tonda, J., Rosales, C., Romero-steiner, S., Medal, I. R., Lara, J., Lainz, A. R., Gomez, M. G., Flynn, M. A., Feldstein, F., Dominguez, K., & Dicent-taillepierre, J. (2021). An Innovative United States-Mexico Community Outreach Initiative for Hispanic and Latino People in the United States: A Collaborative Public Health Network.. Public health reports (Washington, D.C. : 1974), 136(3), 287-294. doi:10.1177/0033354920972699More infoCollaborative partnerships are a useful approach to improve health conditions of disadvantaged populations. The Ventanillas de Salud (VDS) ("Health Windows") and Mobile Health Units (MHUs) are a collaborative initiative of the Mexican government and US public health organizations that use mechanisms such as health fairs and mobile clinics to provide health information, screenings, preventive measures (eg, vaccines), and health services to Mexican people, other Hispanic people, and underserved populations (eg, American Indian/Alaska Native people, geographically isolated people, uninsured people) across the United States. From 2013 through 2019, the VDS served 10.5 million people (an average of 1.5 million people per year) at Mexican consulates in the United States, and MHUs served 115 461 people from 2016 through 2019. We describe 3 community outreach projects and their impact on improving the health of Hispanic people in the United States. The first project is an ongoing collaboration between VDS and the Centers for Disease Control and Prevention (CDC) to address occupational health inequities among Hispanic people. The second project was a collaboration between VDS and CDC to provide Hispanic people with information about Zika virus infection and health education. The third project is a collaboration between MHUs and the University of Arizona to provide basic health services to Hispanic communities in Pima and Maricopa counties, Arizona. The VDS/MHU model uses a collaborative approach that should be further assessed to better understand its impact on both the US-born and non-US-born Hispanic population and the public at large in locations where it is implemented.
- Yeo, S., Rosales, C., Okechukwu, A., Magrath, P., Hounkpatin, W. A., Ehiri, J., & Alaofe, H. (2021). Cultural Considerations for the Adaptation of a Diabetes Self-Management Education Program in Cotonou, Benin: Lessons Learned from a Qualitative Study.. International journal of environmental research and public health, 18(16), 8376. doi:10.3390/ijerph18168376More infoBackground: Type 2 diabetes (T2D) poses a disproportionate burden on Benin, West Africa. However, no diabetes intervention has yet been developed for Benin's contexts. This study aimed to explore specific cultural beliefs, attitudes, behaviors, and environmental factors to help adapt a diabetes self-management program to patients with T2D from Cotonou, in southern Benin. Methods: Qualitative data were collected through focus group discussions (FDGs) involving 32 patients with T2D, 16 academic partners, and 12 community partners. The FDGs were audio-recorded, transcribed verbatim from French to English, and then analyzed thematically with MAXQDA 2020. Results: Healthy food was challenging to obtain due to costs, seasonality, and distance from markets. Other issues discussed were fruits and vegetables as commodities for the poor, perceptions and stigmas surrounding the disease, and the financial burden of medical equipment and treatment. Information about local food selections and recipes as well as social support, particularly for physical activity, were identified, among other needs. When adapting the curriculum, gender dynamics and spirituality were suggested. Conclusions: The study demonstrates the need for culturally sensitive interventions and a motivation-based approach to health (spiritual and emotional support). It also lays the groundwork for addressing T2D contextually in Benin and similar sub-Saharan African countries.
- Zapata-garibay, R., Rosales, C., Rangel, G., Lopez-galvez, N., Gonzalez-fagoaga, E., & Aceves, B. (2021). Virtual Seminar on Coronavirus 2019 for the US-Mexico Border Region: Building Opportunities for Communication and Collaboration.. Journal of Immigrant and Minority Health, 1-4. doi:10.1007/s10903-021-01190-yMore infoWhile the US-Mexico border region has had increasing restrictions due to coronavirus 2019 (COVID-19), the economically and socially integrated region continues to facilitate necessary movement between the two countries. Binational partners representing universities, government, and health delivery worked together to develop a COVID-19 Virtual Seminar for the US-Mexico Border Region, which consisted of weekly sessions in Spanish designed to better facilitate communication and collaborative systems between border states. In total 835 participants registered for the virtual seminar with attendance ranging from 394 in Session 1 to 269 in Session 6. From evaluation surveys (n = 297), organizers observed a large plurality of healthcare professionals, followed by students, researchers, and government employees. The seminar's contribution to increasing collaborative and communication systems identified major needs in the region surrounding surveillance and monitoring; increased resources for migrant shelters to control outbreaks; an increase in personal protective equipment; tracking binational cases.
- Zapata-garibay, R., Rosales, C., Rangel, G., Lopez-galvez, N., Gonzalez-fagoaga, E., & Aceves, B. (2021). Virtual Seminar on Coronavirus 2019 for the US-Mexico Border Region: Building Opportunities for Communication and Collaboration.. Journal of Immigrant and Minority Health, 23(4), 1-4. doi:10.1007/s10903-021-01190-yMore infoWhile the US-Mexico border region has had increasing restrictions due to coronavirus 2019 (COVID-19), the economically and socially integrated region continues to facilitate necessary movement between the two countries. Binational partners representing universities, government, and health delivery worked together to develop a COVID-19 Virtual Seminar for the US-Mexico Border Region, which consisted of weekly sessions in Spanish designed to better facilitate communication and collaborative systems between border states. In total 835 participants registered for the virtual seminar with attendance ranging from 394 in Session 1 to 269 in Session 6. From evaluation surveys (n = 297), organizers observed a large plurality of healthcare professionals, followed by students, researchers, and government employees. The seminar's contribution to increasing collaborative and communication systems identified major needs in the region surrounding surveillance and monitoring; increased resources for migrant shelters to control outbreaks; an increase in personal protective equipment; tracking binational cases.
- Zapien, J. D., Wagoner, R., Rosales, C., Lopez-galvez, N., Ernst, K., Canales, R. A., Burgess, J. L., & Beamer, P. (2021). Longitudinal assessment of kidney function in migrant farm workers.. Environmental research, 202, 111686. doi:10.1016/j.envres.2021.111686More infoChronic kidney disease of unknown etiology (CKDu) is an epidemic that affects young agricultural workers in several warm regions of the world. However, there is a lack of monitoring of kidney issues in regions with extremely warm environments such as the Northwest of Mexico, a semi-arid region with a growing agricultural industry, where migrant and seasonal farm workers (MSFWs) travel to work in the fields. The objective of this study was to longitudinally assess kidney functioning of MSFWs in relation to pesticide exposure, heat stress and dehydration in a large-scale farm in Mexico. We enrolled 101 MSFWs, of whom 50 were randomly selected to work in an organic certified area and 51 were randomly selected to work in a conventional area. We also enrolled 50 office workers within the same region as a reference group. We collected urine and blood samples from all workers in addition to demographic, behavioral, and occupational characteristics. The physiological strain index (PSI) was used to estimate workers' heat strain. Sampling was conducted at pre-harvest (March) and late in the harvest (July). Linear mixed models were built with the estimated glomerular filtration rate (eGFR) as the dependent variable. We found a significant decrease in kidney function in MSFWs compared to office workers. By the late harvest, one MSFW developed kidney disease, two MSFWs suffered a kidney injury, and 14 MSFWs were at risk of a kidney injury. We found that the eGFR in MSFWs decreased significantly from pre-harvest (125 ± 13.0 mL/min/1.73 m2) to late harvest (109 ± 13.6 mL/min/1.73 m2) (p < 0.001), while no significant change was observed in office workers. The eGFR was significantly lower in MSFWs who worked in the conventional field (101.2 ± 19.4 mL/min/1.73 m2) vs the organic field (110.9 ± 13.6 mL/min/1.73 m2) (p = 0.002). In our final model, we found that dehydration was associated with the decrease of eGFR. We also found an interaction between heat strain and job category, as a significant decline in eGFR by job category (conventional/organic MSFWs and office workers) was related to an increase in heat strain. This suggests that pesticide exposure needs to be considered in combination with heat stress and dehydration. This study provides valuable information on kidney function in MSFWs, and it shows the importance of early long-term monitoring in farm workers in other regions where CKDu has not been evaluated yet.
- Zapien, J. G., Vasquez, M. D., Rosales, C. B., Nuno, T., Ingram, M., Gonzalez-fagoaga, J. E., Denman, C. A., Cornejo, E., Bell, M. L., Anderson, E. J., & Aceves, B. (2021). Meta Salud Diabetes for cardiovascular disease prevention in Mexico: a cluster-randomized behavioural clinical trial.. International journal of epidemiology, 50(4), 1272-1282.. doi:10.1093/ije/dyab072More infoHealthy lifestyle interventions offered at points of care, including support groups, may improve chronic disease management, especially in low-resource populations. We assessed the effectiveness of an educational intervention in type 2 diabetes (T2D) support groups to reduce cardiovascular disease (CVD) risk..We recruited 518 participants to a parallel, two-arm, cluster-randomized, behavioural clinical trial across 22 clinics in Sonora, Mexico, between August 2016 and October 2018. We delivered a 13-week secondary prevention intervention, Meta Salud Diabetes (MSD), within the structure of a support group (GAM: Grupo de Ayuda Mutua) in government-run (community) Health Centres (Centros de Salud). The primary study outcomes were difference in Framingham CVD risk scores and hypertension between intervention (GAM+MSD) and control (GAM usual care) arms at 3 and 12 months..CVD risk was 3.17% age-points lower in the MSD arm versus control at 3 months [95% confidence interval (CI): -5.60, -0.75, P = 0.013); at 12 months the difference was 2.13% age-points (95% CI: -4.60, 0.34, P = 0.088). There was no evidence of a difference in hypertension rates between arms. Diabetes distress was also lower at 3 and 12 months in the MSD arm. Post-hoc analyses showed greater CVD risk reduction among men than women and among participants with HbA1c < 8..MSD contributed to a positive trend in reducing CVD risk in a low-resource setting. This study introduced an evidence-based curriculum that provides T2D self-management strategies for those with controlled T2D (i.e. HbA1c < 8.0) and may improve quality of life.
- Aceves, B., Zapien, J. G., Rosales, C., Nieto, C., Ingram, M., & Aceves, B. (2020). Non-communicable disease prevention in Mexico: policies, programs and regulations.. Health promotion international, 35(2), 409-421. doi:10.1093/heapro/daz029More infoNon-communicable diseases (NCD), such as diabetes and cardiovascular disease, have become a leading cause of the death in Mexico. The federal government has addressed this issue through developing NCD prevention plans, regulations and policies (PRPs) that seek to address social and environmental factors, which was led by the National Institute of Public Health and Ministry of Health in concert with various non-governmental organizations. This review aims to synthesize and summarize national NCD prevention PRPs addressing social and environmental factors passed from 2010 to 2016, and to assess the extent to which these efforts successfully addressed factors contributing to the epidemic. In total nine federal NCD prevention PRPs were identified from a scan that examined executive and legislative PRPs, which identified five documents. A scoping review was conducted for evaluation studies and reports corresponding to these PRPs. The majority of PRPs focused on nutrition, specifically the access and promotion of food. Studies and reports demonstrated that taxation on energy-dense low-nutrient foods and sugar-sweetened beverages were the most effective. Other PRPs had various issues with implementation, mostly related to adherence and resources available. Overall, there lacked evidence of evaluative work on several NCD prevention PRPs, specifically assessing implementation and effectiveness. Additionally, PRPs did not sufficiently address integration of clinical, social, environmental approaches and access to physical activity. While the Mexican federal government has taken the initial steps to address the multifactorial causes of NCD, firm political commitment and investment of significant resources are still needed.
- Asaolu, I. O., Rosales, C., Okusanya, B. O., Okechukwu, A., Kimaru, L. J., Ehiri, J. E., & Asaolu, I. O. (2020). Medical cannabis for the reduction of opioid dosage in the treatment of non-cancer chronic pain: a systematic review.. Systematic reviews, 9(1), 167. doi:10.1186/s13643-020-01425-3More infoMedical cannabis (MC) is currently being used as an adjunct to opiates given its analgesic effects and potential to reduce opiate addiction. This review assessed if MC used in combination with opioids to treat non-cancer chronic pain would reduce opioid dosage..Four databases-Ovid (Medline), Psyc-INFO, PubMed, Web of Science, and grey literature-were searched to identify original research that assessed the effects of MC on non-cancer chronic pain in humans. Study eligibility included randomized controlled trials, controlled before-and-after studies, cohort studies, cross-sectional studies, and case reports. All databases were searched for articles published from inception to October 31, 2019. Cochrane's ROBINS-I tool and the AXIS tool were used for risk of bias assessment. PRISMA guidelines were followed in reporting the systematic review..Nine studies involving 7222 participants were included. There was a 64-75% reduction in opioid dosage when used in combination with MC. Use of MC for opioid substitution was reported by 32-59.3% of patients with non-cancer chronic pain. One study reported a slight decrease in mean hospital admissions in the past calendar year (P = .53) and decreased mean emergency department visits in the past calendar year (P = .39) for patients who received MC as an adjunct to opioids in the treatment of non-cancer chronic pain compared to those who did not receive MC. All included studies had high risk of bias, which was mainly due to their methods..While this review indicated the likelihood of reducing opioid dosage when used in combination with MC, we cannot make a causal inference. Although medical cannabis' recognized analgesic properties make it a viable option to achieve opioid dosage reduction, the evidence from this review cannot be relied upon to promote MC as an adjunct to opioids in treating non-cancer chronic pain. More so, the optimal MC dosage to achieve opioid dosage reduction remains unknown. Therefore, more research is needed to elucidate whether MC used in combination with opioids in the treatment of non-cancer chronic pain is associated with health consequences that are yet unknown..This systematic review was not registered.
- Thomson, C. A., Rosales, C., Rodriguez, M., Okusanya, B. O., Lott, B. E., Kram, N. A., Ehiri, J. E., & Anderson, E. J. (2020). Interventions to increase uptake of Human Papillomavirus (HPV) vaccination in minority populations: A systematic review.. Preventive medicine reports, 19, 101163. doi:10.1016/j.pmedr.2020.101163More infoMinority youth represent a unique population for public health interventions given the social, economic, and cultural barriers they often face in accessing health services. Interventions to increase uptake of Human Papillomavirus (HPV) vaccination in minority youth have the potential to reduce disparities in HPV infection and HPV-related cancers. This systematic review assesses the effectiveness of interventions to increase HPV vaccine uptake, measured as vaccine series initiation and series completion, among adolescents and young adults, aged 9-26 years old, identifying as a racial and ethnic minority or sexual and gender minority (SGM) group in high-income countries. Of the 3013 citations produced by a systematic search of three electronic databases (PubMed, Embase, and Web of Science) in November 2018, nine studies involving 9749 participants were selected for inclusion. All studies were conducted in the United States and were published from 2015 to 2018. Interventions utilized education, vaccine appointment reminders, and negotiated interviewing to increase vaccination. Participants were Black or African American (44.4%), Asian (33.3%), Hispanic or Latinx (22.2%), American Indian or Alaska Native (11.1%), and SGM (22.2%). Studies enrolled parent-child dyads (33.3%), parents alone (11.1%), and youth alone (55.6%). Vaccine series initiation ranged from 11.1% to 84% and series completion ranged from 5.6% to 74.2% post-intervention. Educational and appointment reminder interventions may improve HPV vaccine series initiation and completion in minority youth in the U.S. Given the lack of high quality, adequately powered studies, further research is warranted to identify effective strategies for improving HPV vaccine uptake for minority populations.
- Zapien, J. D., Wagoner, R., Rosales, C., Ospina, M., Lopez-galvez, N., Canales, R. A., Calafat, A. M., & Beamer, P. I. (2020). Evaluating imidacloprid exposure among grape field male workers using biological and environmental assessment tools: An exploratory study.. International journal of hygiene and environmental health, 230, 113625. doi:10.1016/j.ijheh.2020.113625More infoImidacloprid is a neonicotinoid insecticide commonly injected through agricultural drip irrigation systems to reduce the population of vine mealybugs (P. ficus) in grape farms. There is a growing concern of potential human health effects of imidacloprid, however, there is limited information on the exposure to imidacloprid in farm workers. Imidacloprid exposure was evaluated in this exploratory study of 20 male migrant grape workers sampled five days after imidacloprid was injected in the irrigation system during winter and summer seasons. We administered a questionnaire on work activities, exposure characteristics, and socio-demographics and collected personal air, hand wipe, and spot urine samples. Heat exposure was also assessed. Spearman's correlation coefficients and Wilcoxon rank-sum tests were utilized to evaluate associations and differences in imidacloprid exposures with socio-demographic, occupational, and environmental characteristics. All participants had less than a high school education and about half identified an Indigenous language as their primary language. Although not detected in air samples, imidacloprid was detected in 85% of the hand wipes (median: 0.26: 0.41 μg/wipe, range: 0.05-7.10 μg/wipe). The majority of participants (75%) had detectable urinary concentrations of imidacloprid (median: 0.11 μg/g creatinine, range: 0.05-3.90 μg/g of creatinine), and nearly all (95%) had detectable urinary concentrations of 5-hydroxy-Imidacloprid (5-OH-IMI), a metabolite of imidacloprid (median: 1.28 μg/g creatinine, range: 0.20-27.89 μg/g creatinine). There was a significant correlation (p < 0.001) between imidacloprid in hand wipes and urinary imidacloprid and 5-OH-IMI (rs: 0.67 for imidacloprid and 0.80 for 5-OH-IMI). Hand temperature was significantly and positively correlated (p < 0.05) with imidacloprid concentration on hand wipes (rs: 0.70), and urinary biomarkers (rs: 0.68 for imidacloprid, and 0.60 for 5-OH-IMI) suggesting that working in high temperatures may influence the exposure and absorption of imidacloprid. Thus, research on farm workers would benefit in the future by evaluating imidacloprid exposure in relation to heat stress and other occupational factors.
- Aceves, B., Zapien, J. G., Rosales, C., Ocejo, A. G., Ingram, M., Denman, C. A., Cornejo-vucovich, E. C., Castro-vasquez, M. D., & Aceves, B. (2019). The Meta Salud Diabetes Implementation Study: Qualitative Methods to Assess Integration of a Health Promotion Intervention Into Primary Care to Reduce CVD Risk Among an Underserved Population With Diabetes in Sonora, Mexico.. Frontiers in public health, 7, 347. doi:10.3389/fpubh.2019.00347More infoBackground: Within health promotion research, there is a need to assess strategies for integration and scale up in primary care settings. Hybrid interventions that combine clinical effectiveness trials with implementation studies can elicit important contextual information on facilitators and barriers to integration within a health care system. This article describes lessons learned in developing and implementing a qualitative study of a cluster-randomized controlled trial (RCT) to reduce cardiovascular disease (CVD) among people with diabetes in Sonora, Mexico, 2015-2019. Methods:The research team worked cooperatively with health center personnel from 12 Centers that implemented the intervention. The study used observations, stakeholder meetings, case studies, staff interviews and decision maker interviews to explore issues such as staff capacity, authority, workflow, space, and conflicting priorities, as well as patients' response to the program within the clinical context and their immediate social environments. Applying a multi-layered contextual framework, two members of the research team coded an initial sample of the data to establish inclusion criteria for each contextual factor. The full team finalized definitions and identified sub nodes for the final codebook. Results: Characteristics of management, staffing, and the local environment were identified as essential to integration and eventual adoption and scale up across the health system. Issues included absence of standardized training and capacity building in chronic disease and health promotion, inadequate medical supplies, a need for program monitoring and feedback, and lack of interdisciplinary support for center staff. Lack of institutional support stemming from a curative vs. preventive approach to care was a barrier for health promotion efforts. Evolving analysis, interpretation, and discussion resulted in modifications of flexible aspects of the intervention to realities of the health center environment. Conclusion: This study illustrates that a robust and comprehensive qualitative study of contextual factors across a social ecological spectrum is critical to elucidating factors that will promote future adoption and scale up of health promotion programs in primary care. Application of conceptual frameworks and health behavior theory facilitates identification of facilitators and barriers across contexts. Trial registration: www.ClinicalTrials.gov, identifier: NCT02804698 Registered on June 17, 2016.
- Carr, T. F., Beamer, P. I., Rothers, J., Stern, D. A., Gerald, L. B., Rosales, C. B., Van Horne, Y. O., Pivniouk, O. N., Vercelli, D., Halonen, M., Gameros, M., Martinez, F. D., & Wright, A. L. (2019). Prevalence of Asthma in School Children on the Arizona-Sonora Border. The journal of allergy and clinical immunology. In practice, 5(1), 114-120.e2.More infoMexican-born children living in the United States have a lower prevalence of asthma than other US children. Although children of Mexican descent near the Arizona (AZ)-Sonora border are genetically similar, differences in environmental exposures might result in differences in asthma prevalence across this region.
- Contreras, O. A., Sandoval-rosario, M., S, M., Rosales, C. B., Oval-rosario, O., Mercado, C., Cunningham, T. J., Contreras, O. A., & Barbour, K. E. (2019). The Association between Depression and Diabetesand Associated Risk Factors by Racial/Ethnic Statusamong Adults in Arizona: Arizona Behavioral RiskFactor Surveillance System, 2014-2017. Diversity and equality in health and care, 16(2). doi:10.36648/2049-5418.104.22.168More infoObjective: The purpose of our study was to examine the association between depression with diabetes, current smokers, and overweight or obesity among adults in four racial/ethnic groups: non-Hispanic whites (NHWs), non-Hispanic African Americans/blacks (NHAA/blacks), Hispanics, and American Indians/Alaskan Natives (AI/ANs), in Arizona. Methods: Data from the 2014-2017 Arizona Behavioral Risk Factor Surveillance System was used to examine the association between self-reported provider-diagnosed depression and self-reported provider-diagnosed diabetes and associated risk factors for each racial/ethnic group (n=31,671). The analysis was extended to test whether current smoking status or overweight or having obesity status modified the association between depression and diabetes among all Arizona adults. Weighted adjusted prevalence ratios (APRs) accounting for potential confounders were estimated using Cox’s proportional hazards regression analysis. Results: For all Arizona adults after adjusting for potential confounders, the prevalence of diabetes (APR =1.60: 95% confidence interval=1.43-1.72), current smoking status (APR=1.04: 1.02-1.07), and overweight or obesity status (APR=1.07:1.03-1.11) was greater among adults with depression versus without depression. For NHWs (APR=1.63:1.47-1.80), Hispanics (APR=1.71:1.39-2.12), and AI/ANs (APR=1.44:1.11-2.05) the prevalence of diabetes was greater among adults with depression versus without depression. In addition, the association between depression and diabetes was greater for current smokers and those overweight or with obesity than their counterparts in all Arizona adults (p
- Tonda, J., Svarch, A., Rosales, C., Lara, J., Jaramillo, A. M., Gomez, M. G., & Anderson, E. J. (2019). Together for Health: An Initiative to Access Health Services for the Hispanic/Mexican Population Living in the United States.. Frontiers in public health, 7, 273. doi:10.3389/fpubh.2019.00273More infoA disproportionately small percentage of the Hispanic/Mexican population in the United States has adequate access to health services, which decreases quality of life at both the individual and community levels. In addition, it increases risk for preventable diseases through insufficient screening and management. The Mexican Section of the U.S./Mexico Border Health Commission, in efforts to address barriers to accessing preventive health care services for vulnerable populations, launched the initiative Juntos por la Salud (JPLS) that offers health promotion and disease prevention services to Hispanics living in and around 11 U.S. metropolitan cities via mobile health units. This paper presents a descriptive analysis of the JPLS initiative and potential positive impact it has had in reducing barriers faced by the Hispanic population. JPLS screens and provides referrals to primary care services to establish a medical home and has the potential to reduce health care costs in a high-risk population through education and timely health screenings.
- Bojorquez, I., Rosales, C., Angulo, A., de Zapien, J., Denman, C., & Madanat, H. (2018). International migration and dietary change in Mexican women from a social practice framework. Appetite, 125, 72-80.More infoMigration from lower- and middle-income to high-income countries is associated with dietary change, and especially with the adoption of a modern, less healthy diet. In this article we analyze the dietary changes experienced by Mexican migrants, employing as a theoretical framework the concept of social practice. According to this framework, practices integrate material elements, meanings and competences that provide their conditions of possibility. Practices are shared by members of social groups, and interact with other competing or reinforcing practices. Between 2014 and 2015, we conducted semi-structured interviews with 27 women, international return migrants living in Tijuana, Mexico. The interview guide asked about history of migration and dietary change. We found three main areas of dietary change: from subsistence farming to ready meals, abundance vs. restriction, and adoption of new food items. The first one was associated with changes in food procurement and female work: when moving from rural to urban areas, participants substituted self-produced for purchased food; and as migrant women joined the labor force, consumption of ready meals increased. The second was the result of changes in income: participants of lower socioeconomic position modified the logic of food acquisition from restriction to abundance and back, depending on the available resources. The third change was relatively minor, with occasional consumption of new dishes or food items, and was associated with exposure to different cuisines and with learning how to cook them. Public health efforts to improve the migrants' diets should take into account the constitutive elements of dietary practices, instead of isolating individuals from their social contexts.
- Carvajal, S. C., Huang, S., Zapien, J. G., Staten, L. K., Rosales, C., Huang, S., Denman, C. A., Cornejo, E., Chang, J., Carvajal, S. C., & Bell, M. L. (2018). Behavioral and subjective health changes in US and Mexico border residing participants in two promotora-led chronic disease preventive interventions.. Health education research, 33(6), 522-534. doi:10.1093/her/cyy037More infoChronic diseases are the primary health burden among Mexican-origin populations and health promotion efforts have not been able to change negative population trends. This research presents behavioral and subjective health impacts of two related community health worker (CHW) interventions conducted in the US-Mexico border region. Pasos Adelante (United States) and Meta Salud (Mexico) are 12-13 week CHW-led preventive interventions implemented with Mexico-origin adults. Curricula include active learning modules to promote healthy dietary changes and increasing physical activity; they also incorporate strategies to promote social support, empowerment and group exercise components responsive to their communities. Questionnaire data at baseline (N = 347 for Pasos; 171 for Meta Salud), program completion and 3-month follow-up were analyzed. Results showed statistically significant improvements in multiple reported dietary, physical activity and subjective health indicators. Furthermore, at follow-up across both cohorts there were ≥10% improvements in participants' meeting recommended physical activity guidelines, consumption of whole milk, days of poor mental health and self-rated health. While this study identifies some robust health improvements and contributes to the evidence base for these interventions current dissemination, the lack of change observed for some targeted behaviors (e.g. time sitting) suggests they may have stronger overall impacts with curricula refinement.
- López-Gálvez, N., Wagoner, R., Beamer, P., de Zapien, J., & Rosales, C. (2018). Migrant Farmworkers' Exposure to Pesticides in Sonora, Mexico. International journal of environmental research and public health, 15(12).More infoExpanding agribusiness in Sonora, a state in Northern Mexico, has increased the demand for temporary migrant agricultural workers. Sonora is one of the top states in Mexico for pesticide utilization. We conducted an exploratory study to evaluate exposure to organophosphate (OP) and pyrethroid pesticides among migrant farmworkers. A sample of 20 migrant farmworkers was recruited from a large commercial grape farm during the harvest season. We administered a questionnaire on work activities, exposure characteristics, and socio-demographics. We collected urine samples to quantify pesticide metabolite concentrations. Most participants were originally from the state of Chiapas, Mexico, none had completed high school, and about half spoke an indigenous language as well as Spanish. The majority of participants had detectable concentrations of pyrethroid and organophosphate biomarkers. Geometric mean creatinine-adjusted concentrations for 3-phenoxybenzoic acid (1.83 µg/g), trans-3-(2,2-dichlorovinyl)-2,2-dimethylcyclopropane carboxylic acid (0.88 µg/g), 4-fluoro-3-phenoxybenzoic acid (0.94 µg/g), 3,5,6-trichloro-2-pyridinol (3.56 µg/g), and para-nitrophenol (0.63 µg/g) were significantly higher than in the general United States' population and Mexican Americans. Our results also suggest that migrant farmworkers in this region are exposed to pesticides at higher levels than other farmworkers' studies. Farmworkers' age, language, training on personal protective equipment, time at the farm, and season, were significant exposure determinants.
- Sabo, S., Denman Champion, C., Bell, M. L., Cornejo Vucovich, E., Ingram, M., Valencia, C. I., Castro Vasquez, M. d., Gonzalez Fagoaga, J. E., Guernsey De Zapien, J. E., & Rosales, C. B. (2018). Meta Salud Diabetes study protocol: a cluster-randomised trial to reduce cardiovascular risk among a diabetic population of Mexico. BMJ Open, 3(8), 1-10. doi:10.1136/bmjopen-2017-020762
- Sabo, S., Denman Champion, C., Bell, M. L., Cornejo Vucovich, E., Ingram, M., Valenica, C., Castro Vasquez, M. D., Gonzalez-Fagoaga, E., Geurnsey de Zapien, J., & Rosales, C. B. (2018). Meta Salud Diabetes study protocol: a cluster-randomised trial to reduce cardiovascular risk among a diabetic population of Mexico. BMJ open, 8(3), e020762.More infoNorthern Mexico has among the highest rates of cardiovascular disease (CVD) and diabetes in the world. This research addresses core gaps in implementation science to develop, test and scale-up CVD risk-reduction interventions in diabetics through a national primary care health system.
- Carvajal, S. C., Huang, S., Zapien, J. G., Staten, L. K., Rosales, C., Huang, S., Denman, C. A., Cornejo, E., Chang, J., Carvajal, S. C., & Bell, M. L. (2017). Health behavior changes in Latino US-Mexico border residing adults participating in chronic disease preventive interventions. The European health psychologist, 19.More infoBackground: Non-communicable diseases are the leading cause of death among Mexican-origin adults. There is growing evidence for the effectiveness of community health worker led group interventions in lowering risk. This study aims to examine the behavioral and perceived health impacts of one such intervention tested in a US border community--Pasos Adelante, and contrasts those findings with those of its Northern Mexico adapted and delivered intervention, Meta Salud. The former is a Centers for Disease Control disseminated intervention based on its clinical impact, but little is known about which behavioral change objectives have been successfully addressed. Methods: The primary data comes from the largest cohort to date for evaluating Pasos (N =347); participants were recruited from community and clinical settings. Pasos was developed from a social cognitive theory-based intervention with extensive adaptations based on community participatory methods. Questionnaire data at baseline, conclusion of program, and at 6-month post program initiation were analyzed (e.g., generalized linear logistic mixed models). Findings: Pasos participants reported more physical activity (e.g., meeting CDC guidelines), healthier dietary choices and more positive perceived health at both post program assessments. Across both interventions, participants showed improved indicators of physical activity, whole milk consumption, sugary drink consumption, fruit consumption, mental health and self-rated health (ps
- Contreras, O. A., Rosales, C. B., Gonzalez-Fagoaga, E., Valencia, C. I., & Rangel, M. G. (2017). Impacting Binational Health through Leadership Development: A Program Evaluation of the Leaders across Borders Program, 2010-2014. Frontiers in public health, 5, 215.More infoWorkforce and leadership development is imperative for the advancement of public health along the U.S./Mexico border. The Leaders across borders (LaB) program aims to train the public health and health-care workforce of the border region. The LaB is a 6-month intensive leadership development program, which offers training in various areas of public health. Program curriculum topics include: leadership, border health epidemiology, health diplomacy, border public policies, and conflict resolution.
- Rangel Gomez, M. G., Tonda, J., Zapata, G. R., Flynn, M., Gany, F., Lara, J., Shapiro, I., & Rosales, C. B. (2017). Ventanillas de Salud: A Collaborative and Binational Health Access and Preventive Care Program. Frontiers in public health, 5, 151.More infoWhile individuals of Mexican origin are the largest immigrant group living in the U.S., this population is also the highest uninsured. Health disparities related to access to health care, among other social determinants, continue to be a challenge for this population. The government of Mexico, in an effort to address these disparities and improve the quality of life of citizens living abroad, has partnered with governmental and non-governmental health-care organizations in the U.S. by developing and implementing an initiative known as -Health Windows-(VDS). The VDS is located throughout the Mexican Consular network and aim to increase access to health care and health literacy, provide health screenings, and promote healthy lifestyle choices among low-income and immigrant Mexican populations in the U.S.
- Rosales, C. B., Zapien, J. G., Changn, J., Ingram, M., Fernandez, M. L., Carvajal, S. C., Carvajal, S. C., Staten, L. K., Zapien, J. G., & Fernandez, M. L. (2017). Perspectives on a US–Mexico Border Community’s Diabetes and “Health-Care” Access Mobilization Efforts and Comparative Analysis of Community Health Needs over 12 Years. Front Public Health, 10(5), 152. doi:10.3389/fpubh.2017.00152More infoThis paper describes a community coalition-university partnership to address health needs in an underserved US-Mexico border, community. For approximately 15 years, this coalition engaged in community-based participatory research with community organizations, state/local health departments, and the state's only accredited college of public health. Notable efforts include the systematic collection of health-relevant data 12 years apart and data that spawned numerous health promotion activities. The latter includes specific evidence-based chronic disease-preventive interventions, including one that is now disseminated and replicated in Latino communities in the US and Mexico, and policy-level changes. Survey data to evaluate changes in a range of health problems and needs, with a specific focus on those related to diabetes and access to health-care issues-identified early on in the coalition as critical health problems affecting the community-are presented. Next steps for this community and lessons learned that may be applicable to other communities are discussed.
- Rosales, C. B., de Zapien, J. E., Chang, J., Ingram, M., Fernandez, M. L., Carvajal, S. C., & Staten, L. K. (2017). Perspectives on a US-Mexico Border Community's Diabetes and "Health-Care" Access Mobilization Efforts and Comparative Analysis of Community Health Needs over 12 Years. Frontiers in public health, 5, 152.More infoThis paper describes a community coalition-university partnership to address health needs in an underserved US-Mexico border, community. For approximately 15 years, this coalition engaged in community-based participatory research with community organizations, state/local health departments, and the state's only accredited college of public health. Notable efforts include the systematic collection of health-relevant data 12 years apart and data that spawned numerous health promotion activities. The latter includes specific evidence-based chronic disease-preventive interventions, including one that is now disseminated and replicated in Latino communities in the US and Mexico, and policy-level changes. Survey data to evaluate changes in a range of health problems and needs, with a specific focus on those related to diabetes and access to health-care issues-identified early on in the coalition as critical health problems affecting the community-are presented. Next steps for this community and lessons learned that may be applicable to other communities are discussed.
- Rosales, C., Packard, S., Osuchukwu, O., Oren, E., Nuηez, M., Hawkins, E., Gonzalez-salazar, F., Ehiri, J. E., & Aviles, J. G. (2017). Latent Tuberculosis Infection Screening Acceptability among Migrant Farmworkers. International Migration, 55(5), 62-74. doi:10.1111/imig.12275More infoLatent tuberculosis (TB) infection is routinely diagnosed using the tuberculin skin test (TST). New methods of detection more specific than TST such as QuantiFERON TB Gold In-Tube (QFT-GIT) have been developed but evidence remains limited on their acceptability among migrant farmworkers. This article examined the acceptability of screening tests among migrant farmworkers working on the Arizona-Mexico border. We conducted a cross-sectional survey of migrant farmworkers via questionnaire. Of 83 participants interviewed, 53 (63.9%) believed that TB was a serious disease that could result in death and 59 (71.1%) considered TB a health concern in their community. Sixty-four participants (77.1%) rated QFT-GIT test as performing better than TST. Our study demonstrates preference for QFT-GIT results over TST, and highlights migrant farmworkers’ considering themselves at risk of TB and TB as a health concern. Policies that create easy access and culturally appropriate, affordable healthcare for this vulnerable population should be encouraged.
- Valencia, C. I., Asaolu, I. O., Ehiri, J. E., & Rosales, C. (2017). Structural barriers in access to medical marijuana in the USA-a systematic review protocol. Systematic reviews, 6(1), 154.More infoThere are 43 state medical marijuana programs in the USA, yet limited evidence is available on the demographic characteristics of the patient population accessing these programs. Moreover, insights into the social and structural barriers that inform patients' success in accessing medical marijuana are limited. A current gap in the scientific literature exists regarding generalizable data on the social, cultural, and structural mechanisms that hinder access to medical marijuana among qualifying patients. The goal of this systematic review, therefore, is to identify the aforementioned mechanisms that inform disparities in access to medical marijuana in the USA.
- Valencia, C. I., Ernst, K., & Rosales, C. B. (2017). Tuberculosis Treatment Completion in a United States/Mexico Binational Context. Frontiers in public health, 5, 118.More infoTuberculosis (TB) remains a salient public health issue along the U.S./Mexico border. This study seeks to identify the social and structural factors, which are associated with TB disease burden in the binational geographic region. Identification of barriers of treatment completion provides the necessary framework for developing evidence-based interventions that are culturally relevant and context specific for the U.S./Mexico border region.
- Zapata-garibay, R., Rosales, C. B., Rangel-gomez, M. G., Hirata-okamoto, R., & Guerrero, R. (2017). The Leaders across Borders Certification Program—A Systemic Multiple Level Observation of Groups Analysis Approach to Measure Effective Leadership: A Case Study. Frontiers in Education, 2. doi:10.3389/feduc.2017.00052More infoLeadership measurement, feedback and development have grown in importance for the field of management. The Mexico-US Border defined as the area of land within 100 kilometers (62.5 miles) north and south of the international boundary, shares common challenges, and requires the development of multicultural change agents who conduct binational actions toward the improvement of public health and quality of life of the population in the region. Leaders Across Borders (LaB) was established in 2010 as an advanced certified binational leadership development program aimed at building the capacity of public health, health care and other community sector leaders working to improve the health of the communities in the Mexico–US Border region. Leadership as a social interaction process requires leader skills development to achieve goals promoting unity and reducing polarization to optimize interactions between all resources, thus improving teamwork. Therefore, measurement and feedback model of general values and beliefs that guide effective behavior, not only individual personality assessments need to drive a proactive learning and action plan development to improve interactions in a team, thus optimizing leadership. Starting 2014, we administered a new model named Systemic Multiple Level Observation of Groups (SYMLOG) to measure the values and beliefs that guide the behavior of learners and team facilitators. We also evaluated the effectiveness of each team of the program and established benchmarks and action plans to optimize interactions and communication between all the learners during the 8-month program. This leads to a stronger systemic network upon graduation from the program. The SYMLOG approach measured initial and improved situations of individual leadership and team performance effectiveness because of the LaB Program training and skills development sessions. The SYMLOG also provided positive feedback to each participant, which had a direct impact on the optimization of members´ interactions of all teams, as well as developing effective leadership values and behaviors of participants. This paper presents a case study of this application, the challenges in the design and implementation of the SYMLOG measurement model and the results obtained for last three cohorts 2014-2016 of Leaders Across Borders program.
- , ., , ., , ., , ., , ., , ., , ., , ., , ., , ., , ., , ., , ., , ., , ., , ., , ., , ., , ., , , ., et al. (2016). Tackling NCD in LMIC: Achievements and Lessons Learned From the NHLBI-UnitedHealth Global Health Centers of Excellence Program.. Global heart, 11(1), 5-15. doi:10.1016/j.gheart.2015.12.016More infoEffectively tackling the growing noncommunicable disease (NCD) burden in low- and middle-income countries (LMIC) is a major challenge. To address research needs in this setting for NCDs, in 2009, National Heart, Lung, and Blood Institute (NHLBI) and UnitedHealth Group (UHG) engaged in a public-private partnership that supported a network of 11 LMIC-based research centers and created the NHLBI-UnitedHealth Global Health Centers of Excellence (COE) Program. The Program's overall goal was to contribute to reducing the cardiovascular and lung disease burdens by catalyzing in-country research institutions to develop a global network of biomedical research centers. Key elements of the Program included team science and collaborative approaches, developing research and training platforms for future investigators, and creating a data commons. This Program embraced a strategic approach for tackling NCDs in LMICs and will provide capacity for locally driven research efforts that can identify and address priority health issues in specific countries' settings.
- Gunn, J. K., Rosales, C. B., Nunez, A. V., Gunn, J. K., Gibson, S. J., Ehiri, J. E., & Christ, C. (2016). Prenatal exposure to cannabis and maternal and child health outcomes: a systematic review and meta-analysis.. BMJ open, 6(4), e009986. doi:10.1136/bmjopen-2015-009986More infoTo assess the effects of use of cannabis during pregnancy on maternal and fetal outcomes..7 electronic databases were searched from inception to 1 April 2014. Studies that investigated the effects of use of cannabis during pregnancy on maternal and fetal outcomes were included..Case-control studies, cross-sectional and cohort studies were included..Data synthesis was undertaken via systematic review and meta-analysis of available evidence. All review stages were conducted independently by 2 reviewers..Maternal, fetal and neonatal outcomes up to 6 weeks postpartum after exposure to cannabis. Meta-analyses were conducted on variables that had 3 or more studies that measured an outcome in a consistent manner. Outcomes for which meta-analyses were conducted included: anaemia, birth weight, low birth weight, neonatal length, placement in the neonatal intensive care unit, gestational age, head circumference and preterm birth..24 studies were included in the review. Results of the meta-analysis demonstrated that women who used cannabis during pregnancy had an increase in the odds of anaemia (pooled OR (pOR)=1.36: 95% CI 1.10 to 1.69) compared with women who did not use cannabis during pregnancy. Infants exposed to cannabis in utero had a decrease in birth weight (low birth weight pOR=1.77: 95% CI 1.04 to 3.01; pooled mean difference (pMD) for birth weight=109.42 g: 38.72 to 180.12) compared with infants whose mothers did not use cannabis during pregnancy. Infants exposed to cannabis in utero were also more likely to need placement in the neonatal intensive care unit compared with infants whose mothers did not use cannabis during pregnancy (pOR=2.02: 1.27 to 3.21)..Use of cannabis during pregnancy may increase adverse outcomes for women and their neonates. As use of cannabis gains social acceptance, pregnant women and their medical providers could benefit from health education on potential adverse effects of use of cannabis during pregnancy.
- Ortega, M. I., Sabo, S., Aranda Gallegos, P., De Zapien, J. E., Zapien, A., Portillo Abril, G. E., & Rosales, C. (2016). Agribusiness, Corporate Social Responsibility, and Health of Agricultural Migrant Workers. Frontiers in public health, 4, 54.More infoLiving conditions and health of migrant farmworkers could benefit from a health promotion model based on corporate social responsibility (CSR).
- Rosales, C. B. (2016). Agribusiness, Corporate Social Responsibility and Health of Agricultural Migrant Workers. Frontiers in Public Health, 4(54), 10. doi:10.3389/fpubh.2016.00054
- Rosales, C. B. (2016). Developing a Network of Community Health Workers: Improving the Lives of Migrant Farmworkers. Open Journal of Social Sciences, 4, 14. doi:http://dx.doi.org/10.4236/jss.2016.410011
- Rosales, C. B. (2016). Editorial: Emergent Public Health Issues in the US–Mexico Border Region. Frontiers in Public Health, 4(93), 10. doi:https://doi.org/10.3389/fpubh.2016.00093
- Rosales, C. B. (2016). Prevalence of Asthma in School Children on the Arizona-Sonora Border. The Journal of Allergy and Clinical Immunology: In Practice, 5(1), 6. doi:http://dx.doi.org/10.1016/j.jaip.2016.07.001
- Rosales, C. B. (2016). The effects of prenatal cannabis exposure on fetal development and pregnancy outcomes: a protocol. BMJ, 5(3), 10.
- Rosales, C. B., Carvajal, S., & de Zapien, J. E. (2016). Editorial: Emergent Public Health Issues in the US-Mexico Border Region. Frontiers in public health, 4, 93.
- Denman, C. A., Bell, M. L., Cornejo, E., de Zapien, J. G., Carvajal, S., & Rosales, C. (2015). Changes in health behaviors and self-rated health of participants in Meta Salud: a primary prevention intervention of NCD in Mexico. Global heart, 10(1), 55-61.More infoMeta Salud was a community health worker-facilitated intervention for the prevention of noncommunicable diseases in Northern Mexico.
- Gunn, J. K., Rosales, C. B., Center, K. E., Nuñez, A. V., Gibson, S. J., & Ehiri, J. E. (2015). The effects of prenatal cannabis exposure on fetal development and pregnancy outcomes: a protocol. BMJ open, 5(3), e007227.More infoThe effects of exposure to marijuana in utero on fetal development are not clear. Given that the recent legislation on cannabis in the US is likely to result in increased use, there is a need to assess the effects of prenatal cannabis exposure on fetal development and pregnancy outcomes. The objective of this review is to assess the effects of prenatal exposure to cannabis on pregnancy outcomes (including maternal and child outcomes).
- Sabo, S., de Zapien, J., Teufel-Shone, N., Rosales, C., Bergsma, L., & Taren, D. (2015). Service learning: a vehicle for building health equity and eliminating health disparities. American journal of public health, 105 Suppl 1, S38-43.More infoService learning (SL) is a form of community-centered experiential education that places emerging health professionals in community-generated service projects and provides structured opportunities for reflection on the broader social, economic, and political contexts of health. We describe the elements and impact of five distinct week-long intensive SL courses focused on the context of urban, rural, border, and indigenous health contexts. Students involved in these SL courses demonstrated a commitment to community-engaged scholarship and practice in both their student and professional lives. SL is directly in line with the core public health value of social justice and serves as a venue to strengthen community-campus partnerships in addressing health disparities through sustained collaboration and action in vulnerable communities.
- Carvajal, S. C., Mcclelland, D. J., Zapien, J. G., Torres, E., Rubio-goldsmith, R., Rosales, C., Rodriguez, K., Redondo, F., Meister, J. S., Mcclelland, D. J., Kibor, C., Ingram, M., & Carvajal, S. C. (2014). Stress and sociocultural factors related to health status among US-Mexico border farmworkers.. Journal of immigrant and minority health, 16(6), 1176-82. doi:10.1007/s10903-013-9853-1More infoThis study examines factors relating to farmworkers' health status from sociocultural factors, including stress embedded within their work and community contexts. A cross-sectional household survey of farmworkers (N = 299) included social-demographics, immigration status descriptors, and a social-ecologically grounded, community-responsive, stress assessment. Outcomes included three standard US national surveillance measures of poor mental, physical, and self-rated health (SRH). Logistic regression models showed that higher levels of stress were significantly associated (Ps < .001) with increased risk for poor mental health and poor physical health considering all variables. Stress was not associated with SRH. Regarding two of the three outcomes, mental health and physical health, stress added explanatory power as expected. For poor SRH, a known marker for mortality risk and quite high in the sample at 38%, only age was significantly associated. Clinical and systems-level health promotion strategies may be required to mitigate these stressors in border-residing farmworkers.
- Denman, C. A., Rosales, C., Cornejo, E., Bell, M. L., Munguía, D., Zepeda, T., Carvajal, S., & Guernsey de Zapien, J. (2014). Evaluation of the community-based chronic disease prevention program Meta Salud in Northern Mexico, 2011-2012. Preventing chronic disease, 11, E154.More infoMeta Salud is a community health worker-facilitated intervention in Hermosillo, Sonora, Mexico, and was adapted from Pasos Adelante, a similar evidence-based intervention developed for a Latino population in the United States-Mexico border region. The objective of this study was to examine outcomes for Meta Salud and compare them with outcomes for Pasos Adelante.
- Langellier, B. A., Guernsey de Zapien, J., Rosales, C., Ingram, M., & Carvajal, S. C. (2014). State Medicaid expansion, community interventions, and health care disparities in a United States-Mexico border community. American journal of public health, 104(8), e94-e100.More infoWe investigated whether access to and use of health care services increased among residents of a low-income, predominantly Mexican American border community affected by the expansion of Arizona's Medicaid program in 2001 and multiple community-level programs and policies.
- Rosales, C. B., Coe, K., Ortiz, S., Gámez, G., & Stroupe, N. (2014). Social justice, health, and human rights education: challenges and opportunities in schools of public health. Public health reports (Washington, D.C. : 1974), 127(1).
- Sabo, S. J., Shaw, S. J., Ingram, M. -., Teufel-Shone, N. I., Carvajal, S., De Zapien, J. G., Rosales, C. B., Redondo, F., Garcia, G., & Rubio-Goldsmith, R. (2014). Everyday Violence , Structural Racism and Mistreatment at the US-Mexico Border. Social Science and Medicine, 109, 66-74.More infoSabo S, Shaw S, Ingram M, , Teufel Shone N, Carvajal S, de Zapien J, Rosales C, Redondo F**, Garcia G**, . Rubio-Goldsmith R. Everyday Violence , Structural Racism and Mistreatment at the US-Mexico Border. Social Science and Medicine.
- Sabo, S., Shaw, S., Ingram, M., Teufel-Shone, N., Carvajal, S., de Zapien, J. G., Rosales, C., Redondo, F., Garcia, G., & Rubio-Goldsmith, R. (2014). Everyday violence, structural racism and mistreatment at the US-Mexico border. Social science & medicine (1982), 109, 66-74.More infoImmigration laws that militarize communities may exacerbate ethno-racial health disparities. We aimed to document the prevalence of and ways in which immigration enforcement policy and militarization of the US-Mexico border is experienced as everyday violence. Militarization is defined as the saturation of and pervasive encounters with immigration officials including local police enacting immigration and border enforcement policy with military style tactics and weapons. Data were drawn from a random household sample of US citizen and permanent residents of Mexican descent in the Arizona border region (2006-2008). Qualitative and quantitative data documented the frequency and nature of immigration related profiling, mistreatment and resistance to institutionalized victimization. Participants described living and working in a highly militarized environment, wherein immigration-related profiling and mistreatment were common immigration law enforcement practices. Approximately 25% of respondents described an immigration-related mistreatment episode, of which 62% were personally victimized. Nearly 75% of episodes occurred in a community location rather than at a US port of entry. Participant mistreatment narratives suggest the normalization of immigration-related mistreatment among the population. Given border security remains at the core of immigration reform debates, it is imperative that scholars advance the understanding of the public health impact of such enforcement policies on the daily lives of Mexican-origin US permanent residents, and their non-immigrant US citizen co-ethnics. Immigration policy that sanctions institutional practices of discrimination, such as ethno-racial profiling and mistreatment, are forms of structural racism and everyday violence. Metrics and systems for monitoring immigration and border enforcement policies and institutional practices deleterious to the health of US citizens and residents should be established.
- Zuckerman, E., Sonora, H., Rosales, C., R, S., G, A., & C, R. (2014). Rocky Mountain Spotted Fever, A Reemerging Disease in Arizona and Sonora- Case Study. Journal of Case Reports and Studies, 2(3). doi:10.15744/2348-9820.1.601More infoRocky Mountain spotted fever, Rickettsia Rickettsii (RMSF) is a reoccurring disease in Arizona and Sonora and a public health problem due to the high risk medical complications it provokes. In the region it is transmitted by the bite of the Rhipicephalus sanguineus tick, found in dogs. This tick transmits Rickettsia rickettsii bacteria. Following an incubation period of 3-14 days, it causes acute, non-specific effects early on (fever, headache and rash) that -if not diagnosed and treated in time can be serious or cause death. Death is primarily associated with two factors: (a) delay in diagnosis, and (b) doxycycline, a highly effective antibiotic treatment which is inexpensive and simple to administer is delayed. If doxycycline is not provided before the 5 th day after the symptoms begin, the patient can worsen and present with dark purple spots on the body, mostly hands and soles, wrists and ankles as well as have heart, hepatitis, renal, central nervous symptoms and other multiple organ complications. RMSF should be considered a medical priority and a public health problem at the regional level with a network of underlying factors. To prevent and control RMSF in Arizona and Sonora, public health interventions will need to address medical challenges associated with a number of social, political, and environmental factors.
- Carvajal, S. C., Carvajal, S. C., Miesfeld, N., Chang, J., Zapien, J. G., Fernandez, M. L., Rosales, C. B., Staten, L. K., Zapien, J. G., Reinschmidt, K. M., Fernandez, M. L., & Chang, J. T. (2013). Evidence for Long-Term Impact of Pasos Adelante: Using a Community-Wide Survey to Evaluate Chronic Disease Risk Modification in Prior Program Participants. Int J Environ Res Public Health, 10(10), 4701-17.. doi:10.3390/ijerph10104701More infoEffective community-level chronic disease prevention is critical to population health within developed and developing nations. Pasos Adelante is a preventive intervention that aims to reduce chronic disease risk with evidence of effectiveness in US-Mexico residing, Mexican origin, participants. This intervention and related ones also implemented with community health workers have been shown to improve clinical, behavioral and quality of life indicators; though most evidence is from shorter-term evaluations and/or lack comparison groups. The current study examines the impact of this program using secondary data collected in the community 3-6 years after all participants completed the program. A proportional household survey (N = 708) was used that included 48 respondents who indicated they had participated in Pasos. Using propensity score matching to account for differences in program participants versus other community residents (the program targeted those with diabetes and associated risk factors), 148 natural controls were identified for 37 matched Pasos participants. Testing a range of behavioral and clinical indicators of chronic disease risk, logistic regression models accounting for selection bias showed two significant findings; Pasos participants were more physically active and drank less whole milk. These findings add to the evidence of the effectiveness of Pasos Adalente and related interventions in reducing chronic disease risk in Mexican-origin populations, and illustrate the use of innovative techniques for using secondary, community-level data to complement prior evaluation research.
- Carvajal, S. C., Carvajal, S. C., Rosales, C. B., Rubio-goldsmith, R., Sabo, S., Sabo, S. J., Ingram, M., Mcclelland, D. J., Redondo, F., Torres, E., Romero, A. J., Romero, A. J., O'leary, A. O., Sanchez, Z., Zapien, J. G., Zapien, J. G., O'leary, A. O., & Mcclelland, D. J. (2013). The border community and immigration stress scale: a preliminary examination of a community responsive measure in two Southwest samples. Immigration Minority Health, 2, 427-36. doi:10.1007/s10903-012-9600-z.
- Carvajal, S. C., Miesfeld, N., Chang, J., Reinschmidt, K. M., de Zapien, J. G., Fernandez, M. L., Rosales, C., & Staten, L. K. (2013). Evidence for long-term impact of Pasos Adelante: using a community-wide survey to evaluate chronic disease risk modification in prior program participants. International journal of environmental research and public health, 10(10).More infoEffective community-level chronic disease prevention is critical to population health within developed and developing nations. Pasos Adelante is a preventive intervention that aims to reduce chronic disease risk with evidence of effectiveness in US-Mexico residing, Mexican origin, participants. This intervention and related ones also implemented with community health workers have been shown to improve clinical, behavioral and quality of life indicators; though most evidence is from shorter-term evaluations and/or lack comparison groups. The current study examines the impact of this program using secondary data collected in the community 3-6 years after all participants completed the program. A proportional household survey (N = 708) was used that included 48 respondents who indicated they had participated in Pasos. Using propensity score matching to account for differences in program participants versus other community residents (the program targeted those with diabetes and associated risk factors), 148 natural controls were identified for 37 matched Pasos participants. Testing a range of behavioral and clinical indicators of chronic disease risk, logistic regression models accounting for selection bias showed two significant findings; Pasos participants were more physically active and drank less whole milk. These findings add to the evidence of the effectiveness of Pasos Adalente and related interventions in reducing chronic disease risk in Mexican-origin populations, and illustrate the use of innovative techniques for using secondary, community-level data to complement prior evaluation research.
- Carvajal, S. C., Rosales, C., Rubio-Goldsmith, R., Sabo, S., Ingram, M., McClelland, D. J., Redondo, F., Torres, E., Romero, A. J., O'Leary, A. O., Sanchez, Z., & de Zapien, J. G. (2013). The border community and immigration stress scale: a preliminary examination of a community responsive measure in two Southwest samples. Journal of immigrant and minority health / Center for Minority Public Health, 15(2).More infoUnderstanding contemporary socio-cultural stressors may assist educational, clinical and policy-level health promotion efforts. This study presents descriptive findings on a new measure, the border community and immigration stress scale. The data were from two community surveys as part of community based participatory projects conducted in the Southwestern US border region. This scale includes stressful experiences reflected in extant measures, with new items reflecting heightened local migration pressures and health care barriers. Stressors representing each main domain, including novel ones, were reported with frequency and at high intensity in the predominantly Mexican-descent samples. Total stress was also significantly associated with mental and physical health indicators. The study suggests particularly high health burdens tied to the experience of stressors in the US border region. Further, many of the stressors are also likely relevant for other communities within developed nations also experiencing high levels of migration.
- Carvajal, S., Carvajal, S., Rosales, C. B., Rosales, C. B., Raquel, G. R., Raquel, G. R., Sabo, S., Sabo, S., Ingram, M. -., Ingram, M. -., McClelland, D., McClelland, D., Redondo, F., Redondo, F., Torres, E., Torres, E., Romero, A. J., Romero, A. J., O'Leary, A. O., , O'Leary, A. O., et al. (2013). The Border Community and Immigration Stress Scale: A Preliminary Examination of a Community Responsive Measure in Two Southwest Samples. Journal of Immigrant & Minority Health, 2(15), 427-436.More infoThis article is based on earlier research on Migrant Farmworker health in Yuma, Arizona. The article was first published on-line in 2012, then in print in 2013.
- Chang, J., Guy, M. C., Rosales, C., de Zapien, J. G., Staten, L. K., Fernandez, M. L., & Carvajal, S. C. (2013). Investigating social ecological contributors to diabetes within Hispanics in an underserved U.S.-Mexico border community. International journal of environmental research and public health, 10(8).More infoHispanics bear a disproportionate burden of diabetes in the United States, yet relations of structural, socio-cultural and behavioral factors linked to diabetes are not fully understood across all of their communities. The current study examines disparities and factors associated with diabetes in adult Hispanics of Mexican-descent (N = 648) participating in a population survey of an underserved rural U.S.-Mexico border community. The overall rate of diabetes prevalence rate in the sample, based on self-report and a glucose testing, was 21%; much higher than rates reported for U.S. adults overall, for all Hispanic adults, or for Mexican American adults specifically. Acculturation markers and social determinants of health indicators were only significantly related to diabetes in models not accounting for age. Older age, greater BMI (>30), greater waist-to-hip ratio as well as lower fruit and vegetable consumption were significantly related to increased likelihood of diabetes when all structural, cultural, behavioral, and biological factors were considered. Models with sets of behavioral factors and biological factors each significantly improved explanation of diabetes relative to prior social ecological theory-guided models. The findings show a critical need for diabetes prevention efforts in this community and suggest that health promotion efforts should particularly focus on increasing fruit and vegetable consumption.
- Rosales, C. (2013). The Enigma of the Stigma of Hair Loss: Why is Cancer-Treatment Related Alopecia so Traumatic for Women?. Open Cancer Journal, 6, 1-8.More infoCoe, K., Staten, L., Rosales, C., & Swanson, M. (2013). The Enigma of the Stigma of Hair Loss: Why is Cancer-Treatment Related Alopecia so Traumatic for Women?. Open Cancer Journal, 6, 1-8.
- Rosales, C., Carvajal, S. C., Kibor, C., McClelland, D. J., Ingram, M., de Zapien, J. G., Torres, E., Redondo, F., Rodriguez, K., Rubio-Goldsmith, R., Meister, J., & Rosales, C. B. (2013). Stress and Sociocultural Factors Related to Health Status Among US-Mexico Border Farmworkers. Journal of immigrant and minority health / Center for Minority Public Health.More infoThis study examines factors relating to farmworkers' health status from sociocultural factors, including stress embedded within their work and community contexts. A cross-sectional household survey of farmworkers (N = 299) included social-demographics, immigration status descriptors, and a social-ecologically grounded, community-responsive, stress assessment. Outcomes included three standard US national surveillance measures of poor mental, physical, and self-rated health (SRH). Logistic regression models showed that higher levels of stress were significantly associated (Ps
- Rosales, C., Sugeng, A. J., Beamer, P. I., Lutz, E. A., & Rosales, C. B. (2013). Hazard-ranking of agricultural pesticides for chronic health effects in Yuma County, Arizona. The Science of the total environment, 463-464.More infoWith thousands of pesticides registered by the United States Environmental Protection Agency, it not feasible to sample for all pesticides applied in agricultural communities. Hazard-ranking pesticides based on use, toxicity, and exposure potential can help prioritize community-specific pesticide hazards. This study applied hazard-ranking schemes for cancer, endocrine disruption, and reproductive/developmental toxicity in Yuma County, Arizona. An existing cancer hazard-ranking scheme was modified, and novel schemes for endocrine disruption and reproductive/developmental toxicity were developed to rank pesticide hazards. The hazard-ranking schemes accounted for pesticide use, toxicity, and exposure potential based on chemical properties of each pesticide. Pesticides were ranked as hazards with respect to each health effect, as well as overall chronic health effects. The highest hazard-ranked pesticides for overall chronic health effects were maneb, metam-sodium, trifluralin, pronamide, and bifenthrin. The relative pesticide rankings were unique for each health effect. The highest hazard-ranked pesticides differed from those most heavily applied, as well as from those previously detected in Yuma homes over a decade ago. The most hazardous pesticides for cancer in Yuma County, Arizona were also different from a previous hazard-ranking applied in California. Hazard-ranking schemes that take into account pesticide use, toxicity, and exposure potential can help prioritize pesticides of greatest health risk in agricultural communities. This study is the first to provide pesticide hazard-rankings for endocrine disruption and reproductive/developmental toxicity based on use, toxicity, and exposure potential. These hazard-ranking schemes can be applied to other agricultural communities for prioritizing community-specific pesticide hazards to target decreasing health risk.
- Carvajal, S. C., Rubio-goldsmith, R., Romero, A. J., Torres, E., Sanchez, Z., Sabo, S., Rubio-goldsmith, R., Rosales, C., Romero, A. J., Redondo, F., O'leary, A. O., Mcclelland, D. J., Ingram, M., Desapien, J., & Carvajal, S. C. (2012). The Border Community & Immigration Stress Scale and Associations to Health Outcomes. Journal of Immigrant and Minority Health.
- Ortega, M., Rosales, C., de Zapien, J. G., Aranda, P., Castañeda, A., Saucedo, S., Montaño, C., & Contreras, A. (2012). Migration, agribusiness and nutritional status of children under five in Northwest Mexico. International journal of environmental research and public health, 9(1).More infoThe aim of this study was to examine the nutritional status of children of Mexican migrant worker families under five years of age within the context of global food markets. The sample included 404 children less than five years old from farms and agricultural communities in northwest Mexico. Prevalence of stunting and underweight of children appeared very similar to that of indigenous children from the national sample survey (difference 0.9 and 1.6 percentage points, respectively). Compared to the national sample of Mexican children, stunting and underweight seemed higher in migrant children (difference 17.7 and 4.5 percentage points, respectively), but wasting, an indicator of both chronic and acute undernutrition, appeared to indicate a process of nutritional recuperation. Migrant children living in poverty and suffering from chronic undernutrition, poor performance and scarce education opportunities, can be expected to eventually become agricultural workers with low productivity and poor general health. Consumer's demands on social and environmental standards of fresh food production in developed countries could be an opportunity to impact the lives of migrant agricultural workers, their families and communities.
- Rosales, C., Ortega, M. I., De Zapien, J. G., Paniagua, A. D., Zapien, A., Ingram, M., & Aranda, P. (2012). The US/Mexico border: a binational approach to framing challenges and constructing solutions for improving farmworkers' lives. International journal of environmental research and public health, 9(6).More infoMexican migrant and seasonal farmworkers in the US-Mexico border region face health hazards and occupational risks and are becoming commonly known in the public health literature. According to several studies, farmworkers have high levels of chronic diseases such as diabetes and respiratory problems, are at risk for infectious diseases, and experience among the highest incidences of work-related injuries of any profession. The findings from two studies are considered and presented with the objective of contributing to an overall understanding of migrant farmworkers as a workforce moving across national boundaries and affected by the work environments and health stressors both shared and unique to each context. We propose a binational approach to comprehensively address the health problems and socioeconomic challenges faced by migrant and seasonal farmworkers. In this paper we present the results of two distinct but complementary studies of farmworker health on the Arizona-Sonora border.
- Stroupe, N., Rosales, C. B., Ortiz, S. E., Gamez, G., & Coe, K. (2012). Social justice, health, and human rights education: challenges and opportunities in schools of public health.. Public health reports (Washington, D.C. : 1974), 127(1), 126-30. doi:10.1177/003335491212700117
- Rosales, C. B., Nuno, T., Dieke, A., Galvez, F. N., Dutton, R. J., Guerrero, R., Dulin, P., Jiménez, E. A., Granillo, B., & de Zapien, J. G. (2011). U.S.-Mexico cross-border workforce training needs: survey implementation. Journal of injury & violence research, 3(1).More infoSince the tragic events experienced on September 11, 2001, and other recent events such as the hurricane devastation in the southeastern parts of the country and the emergent H1N1 season, the need for a competent public health workforce has become vitally important for securing and protecting the greater population. Objective: The primary objective of the study was to assess the training needs of the U.S. Mexico border states public health workforce.
- Hayden, M. H., Uejio, C. K., Walker, K., Ramberg, F., Moreno, R., Rosales, C., Gameros, M., Mearns, L. O., Zielinski-Gutierrez, E., & Janes, C. R. (2010). Microclimate and human factors in the divergent ecology of Aedes aegypti along the Arizona, U.S./Sonora, MX border. EcoHealth, 7(1).More infoThis study examined the association of human and environmental factors with the presence of Aedes aegypti, the vector for dengue fever and yellow fever viruses, in a desert region in the southwest United States and northwest Mexico. Sixty-eight sites were longitudinally surveyed along the United States-Mexico border in Tucson, AZ, Nogales, AZ, and Nogales, Sonora during a 3-year period. Aedes aegypti presence or absence at each site was measured three times per year using standard oviposition traps. Maximum and minimum temperature and relative humidity were measured hourly at each site. Field inventories were conducted to measure human housing factors potentially affecting mosquito presence, such as the use of air-conditioning and evaporative coolers, outdoor vegetation cover, and access to piped water. The results showed that Ae. aegypti presence was highly variable across space and time. Aedes aegypti presence was positively associated with highly vegetated areas. Other significant variables included microclimatic differences and access to piped water. This study demonstrates the importance of microclimate and human factors in predicting Ae. aegypti distribution in an arid environment.
- Rosales, C. B., Coe, M. K., Stroupe, N. R., Hackman, A., & de Zapien, J. G. (2010). The Culture of Health Survey: a qualitative assessment of a diabetes prevention coalition. Journal of community health, 35(1).More infoIn the past two decades, the fields of public health and social services have increasingly turned toward collaborative and community-based approaches to address complex health and social issues. One aspect of these approaches has been the development and implementation of community coalitions. Coalitions have been used to successfully address a wide range of issues, including cancer prevention, tobacco use, HIV/AIDS, youth violence, heart disease, diabetes, and sexual exploitation of youth runaways. In south Tucson, Arizona the SEAH coalition was developed to address diabetes and substance abuse prevention. Using a qualitative interview guide, the Culture of Health Survey, this study was aimed at identifying community perceptions of the coalition and its effectiveness in the areas of community leadership, partnerships, trust, and movement towards positive change. We also sought to document the dissemination, throughout a community, of information on the activities and functioning of a community based coalition and whether or not it was seen as one that held fast to the community values and not to individual agendas. Results highlight the importance of outreach, education, trust, and partnerships in promoting diabetes prevention through a community coalition.
- Rosales, C., Robinson, K. L., Ernst, K. C., Johnson, B. L., & Rosales, C. B. (2010). Health status of southern Arizona border counties: a Healthy Border 2010 midterm review. Revista panamericana de salud pública = Pan American journal of public health, 28(5).More infoThe region on the United States (US) side of the US-Mexico border consists of 44 counties in four states; populations on both sides of the border have similar health problems. Healthy Border 2010: An Agenda for Improving Health on the US-Mexico Border (HB 2010) is a binational agenda of health promotion and disease prevention for individuals in the region. This study reports on the health status of the four southern Arizona border counties.
- Ruiz, M. R., Rosales, C., Mayorga, M. T., & Ingram, M. (2009). The Animadora Project: identifying factors related to the promotion of physical activity among Mexican Americans with diabetes.. American journal of health promotion : AJHP, 23(6), 396-402. doi:10.4278/ajhp.08021915More infoThere is a dearth of information about factors related to physical activity among Mexican-Americans with diabetes. Self-efficacy and social support are associated with physical activity; however, little is known about their roles within different cultural groups..Focus groups were used to identify factors that motivated walking..Two Mexican-American communities located in Tucson, Arizona..Individuals who attended diabetes education..A community-based provider organized walking groups with people who previously attended diabetes classes. Walkers participated in focus groups exploring themes related to their experiences..Self-efficacy, social support, and collective efficacy. Grounded theory was used to analyze focus group results using two rounds of analysis; the first identified references to self-efficacy and social support, and the second added collective efficacy as a theoretic basis for walking..Among 43 eligible participants, 20 participated in focus groups. Social support was expressed as commitment and companionship. Walkers demonstrated a high level of self-efficacy for walking. Development of group identity/social cohesion was also a motivator to walk. Collective efficacy emerged as an applicable theoretic model encompassing these themes and their interrelationship..Collective efficacy, or the belief that the group can improve their lives through collective effort, is a viable theoretic construct in the development of physical activity interventions targeting Mexican-Americans with diabetes.
- Fenn, J., Rosales, C., & Logue, C. (2007). "Sir insulin monk versus the evil Diana betes": a program addressing type 2 diabetes education and prevention in youth. The Diabetes educator, 33(3), 455-459.More infoThe purpose of this article is to share an innovative method of integrating community resources into a program designed to deliver age-appropriate and culturally appropriate diabetes education to youth. The educational program involves an interactive dialogue that engages school-aged children in an active process of learning about diabetes. School or community-based settings provide the best venue for presenting information to youth on diabetes. In addition, peer education is an excellent method of creating interest among youth. Many adults have received diabetes education simply by observing the program. This program has become an appealing and interactive method of delivering type 2 diabetes prevention information to children of all ages.
- Cowan, L., Esteban, E., McElroy-Hart, R., Kieszak, S., Meyer, P. A., Rosales, C., Applegate, M., Mada Vélez, G., Arias-Ortiz, J., & Rubin, C. (2006). Binational study of pediatric blood lead levels along the United States/Mexico border. International journal of hygiene and environmental health, 209(3).More infoTo evaluate lead exposure among children living in border communities, the states of Arizona and New Mexico in the United States (US), and the states of Sonora and Chihuahua in Mexico collaboratively requested that the Centers for Disease Control and Prevention (CDC) provide technical assistance to document pediatric blood lead levels (BLLs) in children living along this part of the US/Mexico border. Two studies were conducted to evaluate BLLs of children aged 1-6 years. In 1998, 1210 children were tested in the Arizona/Sonora study; in 1999, 874 children were tested in New Mexico/Chihuahua. Overall geometric mean BLL was 32.5 microg/l (95% Confidence Interval 31.5-33.5) with BLLs ranging from below limit of detection to 320.0 microg/l. Mean BLLs were higher among children living on the Mexican side of the border (43.2 microg/l) compared to those on the US side (22.3 microg/l). Mean BLLs ranged from 14.9 to 31.2 microg/l at the US sites and from 26.9 to 55.2 microg/l at the Mexican sites. This study used a convenience sample and cannot be considered representative of the general population. Nonetheless, the range of mean BLLs among the sites and especially the higher mean BLLs among children living in the border communities in Mexico suggests different exposures to lead and warrants further attention.
- Weinberg, M., Lucas, C. A., Falcon, V. C., Morales, P. K., Lopez, L. A., Gutierrez, A. E., Gonzalez, E. R., Flisser, A., Valle, E. N., Rodriguez, A., Hernandez, G. A., Rosales, C., Ortiz, J. A., Landen, M., Vilchis, H., Leal, F. L., Ortega, L., Conyer, R. T., Waterman, S. H., , Rawlings, J. A., et al. (2003). The U.S.-Mexico Border Infectious Disease Surveillance project: establishing bi-national border surveillance.. Emerging infectious diseases, 9(1), 97-102. doi:10.3201/eid0901.020047More infoIn 1997, the Centers for Disease Control and Prevention, the Mexican Secretariat of Health, and border health officials began the development of the Border Infectious Disease Surveillance (BIDS) project, a surveillance system for infectious diseases along the U.S.-Mexico border. During a 3-year period, a binational team implemented an active, sentinel surveillance system for hepatitis and febrile exanthems at 13 clinical sites. The network developed surveillance protocols, trained nine surveillance coordinators, established serologic testing at four Mexican border laboratories, and created agreements for data sharing and notification of selected diseases and outbreaks. BIDS facilitated investigations of dengue fever in Texas-Tamaulipas and measles in California-Baja California. BIDS demonstrates that a binational effort with local, state, and federal participation can create a regional surveillance system that crosses an international border. Reducing administrative, infrastructure, and political barriers to cross-border public health collaboration will enhance the effectiveness of disease prevention projects such as BIDS.
- Rosales, C., Philen, R. M., Ortega, L., Kieszak, S., Brock, J. W., Barr, D. B., & Balluz, L. S. (2001). Investigation of systemic lupus erythematosus in Nogales, Arizona.. American journal of epidemiology, 154(11), 1029-36. doi:10.1093/aje/154.11.1029More infoIn 1996, a citizens group in Nogales, Arizona, reported to the Arizona Department of Health their concerns about a possible excess prevalence of systemic lupus erythematosus (SLE) due to exposure to environmental contamination in the area. The authors conducted a two-phase study in which the objectives of phase I were to identify potential SLE cases and to determine the prevalence of SLE and the objectives of phase II were to identify potential risk factors associated with the development of SLE and to evaluate the possible association between SLE and environmental exposure to pesticides and inorganic compounds. Participants included 20 confirmed cases and 36 controls. The authors found the prevalence of SLE to be 103 cases per 100,000 population (95 percent confidence interval: 56, 149), two to seven times higher than the prevalence in the US population. They detected elevated levels of 1,1-dichloro-2,2-bis-(p-chorophenyl)ethylene and organophosphate metabolites among cases and controls. In both, levels were higher than the reference mean for the US population. The authors found no statistical association between elevated levels of pesticides and disease status. Their results show that the prevalence of SLE in Nogales is higher than the reported prevalence in the US population and that both cases and controls had past exposure to chlorinated pesticides and have ongoing exposure to organophosphates.
- Rosales, C., Philen, R. M., Petersen, N. J., Ortega, L., & Bass, J. K. (2001). What's being used at home: a household pesticide survey.. Revista panamericana de salud publica = Pan American journal of public health, 9(3), 138-44. doi:10.1590/s1020-49892001000300002More infoSince very little is known about the health effects that household pesticides have on children, we conducted this survey to identify what pesticides are being used in the home, where they are being used and stored, and what methods are used for their disposal..In the spring of 1999 we conducted a survey in a community in the state of Arizona, in the United States of America, on the border with Mexico. To be eligible to participate in the survey, households had to have used a pesticide in the 6 mo prior to the survey and to have at least one child under the age of 10 years. We gathered general information on pesticide usage, storage, and disposal, in addition to specific information about each of the pesticides currently being used and/or stored in the home..In the 107 households surveyed, we found 148 pesticide products, for a mean of 1.4 per household. Half of the pesticides were stored less than 4 feet (1.22 m) from the ground, at a level a child could reach. Seventy percent of all the pesticides were stored inside the home, with the kitchen being the storage room most often mentioned. The kitchen was also the room where most of the pesticides were used, with 69% of the respondents saying they had used at least one pesticide there..From our research we conclude that it will be important to continue to investigate all avenues of pesticide exposure in order to fully evaluate childhood exposures. Understanding household pesticide use and developing a model of exposure will help in this process. Profiles of the use, storage, and disposal of products will also guide the development of effective education and poison prevention programs in the community.
- Lopez-Galvez, N., Wagoner, R., Canales, R. A., Guernsey De Zapien, J. E., Rosales, C. B., & Beamer, P. (2019, August). Imidicloprid Exposure in Grape Workers. Joint meeting of ISES/ISIAQ. Kaunas, Lithuania: International Society of Exposure Science.
- Aranda, P., Ortega, I., Rosales, C. B., de Zapien, J., Beamer, P., Lopez-Galvez, N., & Wagoner, R. (2017, Fall). Heat and Hydration Assessment of Migrant Grape-Workers in Sonora, Mexico. International Society of Exposure Science Conference. Research Triangle Park, NC.
- Aranda, P., Ortega, I., Rosales, C. B., de Zapien, J., Beamer, P., Wagoner, R., & Lopez-Galvez, N. (2017, Fall). A Pilot Study on Migrant Grape Workers Exposure to Pesticides in Sonora, Mexico. International Society of Exposure Science Conference. Research Triangle Park, NC.
- Rosales, C. B., De Zapien, J. G., Sabo, S., Ingram, M., Cornejo, E., & Denman, C. (2017, Fall). Importance of implementation science in translation of evidence based health promotion programming in Mexico. American Public Health Association Annual Meeting. Atlanta, Georgia: American Public Health Association.
- Sugeng, A. J., Canales, R. A., Lutz, E. A., Rosales, C. B., & Beamer, P. (2015, October). Modeling the Transport of Agricultural Pesticides into Farmworkers’ Homes. International Society of Exposure Science. Henderson, NV.
- Sabo, S., Teufel-Shone, N. I., Rosales, C. B., & De Zapien, J. G. (2014, July). Entre Fronteras (Between Borders): the power of service learning in cultural exchange and social action in the US-Mexico borderlands. 4th International Conference of Heritage and Sustainable Development. Guimares, Portugal: UNESCO.
- De Zapien, J. G., Denman, C., Cornejo, E., Staten, L., Carvajal, S. C., & Rosales, C. B. (2013, November). Meta salud: Building binational collaboration with community health workers for prevention of chronic disease. APHA.
- Gomez, S., Celaya, M., Silk, M., England, B., De Zapien, J. G., Rosales, C. B., Dawley, D., Andrade, R., Tobar, M. -., Healy, E., & Taren, D. L. (2013, November). Parent ambassador program: A model for expanding the public health workforce to effect school wellness plans. American Public Health Association Annual Meeting. Boston MA: American Public Health Association.
- Hanna, J. J., Gonzalez Fagoaga, J. E., Rangel, G., & Rosales, C. B. (2018, November). Health Awareness for Underserved Hispanic/Latino Populations through a Primary Prevention Mobile Health Unit. American Public Health Association Annual Meeting. San Diego, California: American Public Health Association.
- Ingram, M., Denman, C., Aceves, B., Ocejo, A., Cornejo, E., de Zapien, J. G., & Rosales, C. B. (2018, November). Role of implementation science in addressing chronic disease on a global scale. APHA Annual Meeting. San Diego, CA: American Public Health Association.
- Carvajal, S. C., Jean, C., Sam, S., De Zapien, J. G., & Rosales, C. B. (2013, November). Diabetes disparities in Latino adults in US-Mexico border: Are social context-related stressors contributing?. APHA.
- Carvajal, S. C., Jean, C., Sam, S., De Zapien, J. G., & Rosales, C. B. (2014, November). AZCHW Coalition: History, Process, and Outcomes. APHA.
- Sugeng, A. J., Canales, R. A., Lutz, E. A., Rosales, C. B., & Beamer, P. I. (2014, October). Using Chemical Characteristics to Explain Agricultural Pesticide Transport Pathways from the Field into Homes. International Society of Exposure Science. Cincinnati, OH: International Society of Exposure Science.
- Sugeng, A., Canales, R. A., Lutz, E. A., Rosales, C. B., & Beamer, P. I. (2014, October). Using chemical characteristics to explain transport pathways of agricultural pesticides from the field into homes. International Society of Exposure Science. Cincinnati, OH.
- Sugeng, A., Sugeng, A. J., Canales, R. A., Canales, R. A., Lutz, E. A., Lutz, E. A., Rosales, C. B., Rosales, C. B., Beamer, P. I., & Beamer, P. I. (2014, October). Exploring the Influence of Household and Housing Characteristics on Transport of Agricultural Pesticides into Farmworkers' Homes. International Society of Exposure Science. Cincinnati, OH.
- Bravo-Clouzet, R., Heckert, K. A., Ehiri, J. E., Rosales, C. B., Attakai, A. -., Guerrero, R., Andrade, R., & Taren, D. L. (2013, November). New frontiers in global health leadership: Building strong health systems to respond to non-communicable diseases – a versatile training toolkit for professionals and graduate students. American Public Health Association Annual Meeting. Boston MA: American Public Health Association.
- Sabo, S. J., De Zapien, J. G., Ingram, M. -., Rosales, C. B., & Carvajal, S. (2013, November). Everyday violence of immigration related ethno-racial profiling and mistreatment: A mixed methods approach to understanding immigration policy as a structural determinants of health. American Public Health Association Annual Meeting. Boston, MA: American Public Health Association.More infoPublic health scholars have called for research into the impact of state level immigration policies on the public's health and have recognized these policies may exacerbate existing racial and ethnic disparities among immigrant populations and their co-ethnics. Objective: The purpose of this study was to apply the theory of everyday violence to explore immigration policy and militarization of the US-Mexico border as a structural determinant of health. Methods: Through qualitative and quantitative data, the prevalence and type of direct and indirect experiences of immigration related ethno- racial profiling, mistreatment and resistance to institutionalized victimization were explored among 499 Mexican border farmworkers during the years 2005-2007. Results: Farmworkers were predominately US citizens and permanent residents with more than two decades working in US agriculture. Approximately 25% described a personally experienced and/ or witnessed immigration related mistreatment encounter, categorized as verbal, physical and or psychological mistreatment by an immigration official. Approximately 75% of all mistreatment encounters occurred in a non US-port of entry community location, and more than half were experienced personally and or reported by female farmworkers who were 30% of the total sample. Conclusion: Farmworkers described living and working in a highly militarized environment, whereby immigration related ethno-racial profiling and mistreatment were common immigration law enforcement practices. This paper argues for the inclusion of immigration policy that sanctions the institutional practices of discrimination, such as ethno-racial profiling and mistreatment by immigration officials, as a structural determinant of health and a form of everyday violence.
- Sabo, S. J., Rosales, C. B., De Zapien, J. G., Change, J., & Carvajal, S. (2013, November). Diabetes disparities in Latino adults in US-Mexico border: Are social context-related stressors contributing?. American Public Health Association Annual Meeting. Boston, MA: American Public Health Association.More infoMexican-descent persons living at the border have high rates of diabetes. Health consequences are further exacerbated by SES and health care access disparities, and within Arizona, an intense socio-political environment associated with immigration enforcement. This work examines context-relevant stressors as well as a more general stress and mental health problems, in relating to diabetes. The participants are from proportional household samples of adult Latino farmworkers (Southwest Arizona; N=299) and of Latino adults (Southeast Arizona; N = 648). The data were part of community-based participatory research involving diverse partnerships of academics, promotoras and other community advocates, and other public health professionals requesting surveillance, programmatic and policy-related data. Response rates were over 85%, a testament to the community partnerships and strong community rapport. Except for social-ecologic stress (1st sample only; from the Border Community and Immigration Stress Scale) and glucose (2nd sample only), measures were derived from standard behavior/health surveillance instruments. In the farmworker sample 16% reported physician diabetes diagnosis, while in the other sample the rate was 21% (including 1% detected from the glucose test alone). These rates are about 2-3 times that for non-Hispanic whites in the US, and 25-50% higher than the national rates for Latino or Mexican American adults. Models tested in both samples showed among stress and mental health indicators, only the BCISS related to significantly excess (AOR=1.7) risk for diabetes. Efforts to reduce diabetes should consider a broad range of culturally and context-relevant stressors, and consider ways to intervene on the individual, group and policy level.
- Sabo, S., Ingram, M., De Zapien, J. G., Rosales, C. B., & Carvajal, S. C. (2013, November). Everyday violence of immigration related ethno-racial profiling and mistreatment: A mixed methods approach to understanding immigration policy as a structural determinants of health.. APHA.
- Taren, D. L., Taren, D. L., De Zapien, J. G., De Zapien, J. G., Teufel-Shone, N. I., Teufel-Shone, N. I., Rosales, C. B., Rosales, C. B., Sabo, S., Sabo, S., Foote, J. A., Foote, J. A., Bergsma, L. J., Bergsma, L. J., Heckert, K. A., Heckert, K. A., Raine, S., Raine, S., Lutz, E. A., & Lutz, E. A. (2013, June). Creating an Environment that has Service Learning Integrated into the Curricula. Innovations for Public Health Education, Columbia University.