The City of Houston Health Department (HHD) has public health jurisdiction for the Houston geographic area. The City of Houston Health Department (HHD) provides public health services and seeks to use innovative methods to meet the community's needs with the mission of working in partnership with the community to promote and protect the bhealth and social well-being. HHD is the first health department in Texas and the second in a large U.S. city to earn national public health accreditation through the Public Health Accreditation Board (PHAB). The City of Houston employs over 22,000 staff members, including more than 1,100 staff in the Houston Health Department.
Houston, Texas is the fourth largest city in the United States with an estimated population of 2.2 million individuals and is over 627 square miles. Houston is located within Harris County which has a total population of 4.3 million individuals. Houston is a minority-majority city with people of color comprising over 68% of the population, including 44% Hispanic and 24% Black. Over the last decades, development patterns in Houston have resulted in a low-density development, e.g. sprawl. Like other cities of this size and sprawl, Houston residents face many challenges resulting in disparate social and health outcomes. The leading Public Health issues are heart disease and obesity which are symptomatic of opportunities for healthy eating, physical activity and underlying socio-economic disparities. Heart disease is the leading cause of death and disability in Houston, Texas.
As for educational attainment, 31% have a Bachelor's degree or beyond. English is spoken at home by 52% of residents while 38% speak Spanish and 10% other languages. Native-born Houstonians comprise 69% of the population while 31% are foreign-born. In Houston, nearly 16% of adults have diabetes, compared to the national average of 9.4%, and another 9% report having been diagnosed with prediabetes. In addition, 32% of adults live with obesity, which significantly increases their risk for developing type 2 diabetes. Despite being a city with significant medical acumen and resources in the powerhouse Texas Medical Center, diabetes and other chronic disease continue to pose a significant health issue for Houston. Seven of the ten leading causes of death in Houston are chronic diseases. Diabetes is the 7th leading cause of death in the US and the 6th leading cause of death in Houston.
Urbanization is a global phenomenon with nearly 70% of the world's population expected to reside in urban settings by 2050 according to the UN Department of Economic and Social Affairs. Simultaneously, diabetes prevalence rates are on the rise, resulting in significant human and economic tolls. This combination and the unique characteristics and infrastructure of urban areas that can increase the risk for diabetes were the catalysts for Novo Nordisk developing and implementing the Cities Changing Diabetes program. Cities Changing Diabetes operates as a public-private partnership between Novo Nordisk and local governments in 18 countries around the world. In the US, the program currently operates in one city: Houston, Texas.
Through an extensive quantative and qualitative research process, 5 major objectives for improving diabetes prevention, detection, care and management emerged:
Improve diabetes literacy
Help people prioritize their personal health
Increase provider, insurer and employer collaboration
Improve connections for people with diabetes with their community
Ibmprove navigation for patients to better use prevention, detection, and care resources.
These objectives have been partially achieved through the establishment of ongoing multi-sector Action Work Groups of community volunteers who have developed an online Houston Diabetes Resource Center; a faith and diabetes initiative; a peer support initiative; an initiative to encourage employers to adopt the CDC's National Diabetes Prevention Program; and a diabetes disaster preparedness plan.
The specific factors leading to the success of this practice were giving ownership of the practice to members of the community to develop concepts and activities that could work for them, and dedicated volunteers from a diverse array of more than 120 community-based organizations, businesses, and the Houston Department of Health.
The public health impact of the practice is yet to be determined, in terms of behavior change or reductions in diabetes prevalence.
The Web site for the Houston Department of Health is: https://www.houstontx.gov/health/index.html. The Web site for the Houston Diabetes Resource Center, an outcome of the practice, is: https://houstondiabetes.org/.
The public health issue being addressed is undiagnosed and diagnosed diabetes and prediabetes, with the intent to improve awareness of factors placing people in Houston at risk for diabetes and helping them get access to information and resources that could help them get tested for diabetes and take appropriate action if diagnosed with diabetes of prediabetes.
In Houston, nearly 16% of adults have diabetes, compared to the national average of 9.4%, and only another 9% report having been diagnosed with prediabetes. (The CDC reports that the vast majority of adults with prediabetes – about 89% -- are undiagnosed and unaware.) In addition, 32% of adults live with obesity, which significantly increases their risk for developing type 2 diabetes. Seven of the ten leading causes of death in Houston are chronic diseases. Diabetes is the 7th leading cause of death in the US and the 6th leading cause of death in Houston.
In 2015, in the metro Houston area, there were estimated to be 553,000 people with diagnosed diabetes, 196,000 with undiagnosed diabetes, and 1,800,000 with prediabetes (with as many as 89% of them undiagnosed). We estimate that we have reached 10% of these populations through the work of the partners in our model program.
The model practice used is the Cities Changing Diabetes change model Map-Share-Act that involves all stakeholders in understanding, developing, implementing and funding solutions. In Houston, to better understand the problem of diabetes in the city, the coalition sought expertise from two spheres: 1) Academic expertise to conduct a study on community-level vulnerability to diabetes. Houston Health Department and Novo Nordisk collaborated with UT School of Public Health to conduct both quantitative and qualitative research to understand the factors that exist in Houston that make people vulnerable to developing type 2 diabetes. 2) Community stakeholders participated in a series of 12 community roundtables that brought together different sectors faith- and community-based organizations; employers; health plans; and medical/health care organizations to better understand the contours of the problem of diabetes in Houston, existing resources, and gaps and needs. In addition, the roundtables helped identify grassroots leaders in the community who would be instrumental in pulling through the process of developing, implementing, funding and sustaining local collaborative interventions.
Cities Changing Diabetes launched in Houston in November 2014 with a comprehensive analysis of the major gaps and vulnerabilities associated with diabetes. Soon after it launched, the program invested more than a year researching the diabetes epidemic in Houston. A community-wide assessment identified the populations most at risk for developing the disease and compared them to Houstonians already diagnosed with diabetes.
This work led to the formation of five Action Work Groups with more than 75 diverse members representing approximately 60 faith-based organizations, government, health insurance companies, medical providers, employers and non-profit entities.
The focus areas for the five Action Work Groups were:
1. Enhance awareness and education to improve diabetes literacy
2. Improve navigation for patients to better use prevention, detection, care and management resources
3. Improve collaboration by providers, insurers and employers to improve patient trust
4. Help people prioritize personal health over other life demands
5. Improve the connections between people at risk for diabetes, with diabetes and caregivers and their community
Cities Changing Diabetes – Houston developed the virtual Houston Diabetes Resource Center (HDRC). HDRC serves as a one-stop shop” website for consumers, providers and employers and houses important resources for diabetes prevention, detection and care. Also, four other initiatives have been established by the community Action Teams:
Peer Support Initiative: Connects employer, provider and community partners to create peer support networks for people with diabetes
Faith and Diabetes Initiative: Helps houses of faith develop diabetes prevention and awareness efforts for their congregations
Employer National Diabetes Prevention Program: An effort to improve the availability of the National Diabetes Prevention Program among community providers and engage employers in adopting the program
Disaster and Preparedness Plan: Spurred on by Hurricane Harvey and its devastation in Houston, a disaster preparedness plan for people with diabetes and chronic disease has been developed.
In 2016, the Robert Wood Johnson Foundation awarded a $2.4 million grant to UTHealth to support collaboration, evaluation and sharing best practices from Cities Changing Diabetes. The grant supported the creation of the Healthy Cities Research Hub, a virtual hub that focus on the social and environmental conditions that impact health in urban settings throughout North America. Research efforts will span three Cities Changing Diabetes cities – Houston, Mexico City and Vancouver.
The objectives of the model practice are: improve diabetes literacy; help people prioritize their personal health; increase provider, insurer and employer collaboration; improve connections for people with diabetes with their community; and improve navigation for patients to better use prevention, detection, and care resources.
Houston stakeholders, led by Houston Health Department, came together to explore how to reach community members with prediabetes and diabetes who were disconnected from the healthcare system.
In addition to Houston Health Department other organizations joined the local steering committee: American Diabetes Association, American Association of Diabetes Educators, Harris County Health Department, Harris County Medical Society, City of Houston HR Department, Hispanic Health Coalition, Asian American Health Coalition, Houston Business Coalition on Health, The Fountain of Praise, and Institute for Spirituality and Health.
Sharing and Action involved a 400-participant coalition, including health systems, health plans, employers, faith-based and community-based organizations. Based on the research and roundtables with these organizations, Action Workgroups were formed to address 5 needs: improve diabetes literacy; help people prioritize their personal health; increase provider, insurer and employer collaboration; improve connections for people with diabetes with their community; and improve navigation for patients to better use prevention, detection, and care resources. Five projects have been implemented: 1) on-line diabetes resource center with navigation by trained Community Health Workers; 2) in-person and on-line peer support programs; 3) CDC-funded effort to improve employer participation in the Diabetes Prevention Program; 4) diabetes prevention and management education through faith-based organizations using a train-the-trainer model; and 5) creation of a disaster preparedness plan for people with diabetes and chronic disease.
On June 16, 2016, Cities Changing Diabetes Houston unveiled new research showing three kinds of vulnerability to diabetes across communities and specified 14 social and cultural factors that reinforce them. The quantitative survey research, conducted by the University of Texas Health Science Center at Houston (UTHealth) School of Public Health and sponsored by Novo Nordisk, indicated that across vulnerable populations, the key social and cultural factors include the perception of change and transition (77.6%), the feeling of being financially constrained (44.8%), the adherence to nourishing traditions (42.4%), the use of cars for long commutes (41.6%) and the experience of time poverty (40%). The research was presented on June 16, 2016, at a Cities Changing Diabetes Houston Town Hall event.
Various insights into vulnerability for type 2 diabetes and diabetes-related complications emerged from the research, the most important of which are highlighted below. These insights have been used by the Action Teams as well as the Houston Department of Health, to think differently about factors affecting diabetes risk, beyond demographics:
Change and transition: Perceived changes and transitions at societal and community level as well as individual level lead to uncertainties and a sense of instability. Expanding cities such as Houston are, by definition, in flux and often unstable, which can easily exaggerate existing social stressors: for example, existing services change, move or are shut down, with concrete consequences for those relying on them. Change and transition in Houston are experienced both practically (e.g. where a new influx of people crowds a neighborhood), and psychologically (e.g. where that influx causes distress in residing individuals). Furthermore, the changing faces of neighborhoods and society concern many, though some felt that things were improving.”
Nourishing traditions: In Houston, the notion of food as a ‘nourishing tradition' has a profound impact on the way food is perceived and what certain meals and dishes mean for community coherence. Heritage is strongly interwoven with food in Houston, and traditional foods carry meaning beyond nutrition and diet. For many participants, food and food-related rituals constitute an essential social connector that relates people to a common identity. These foods and related rituals are also perceived as ‘comfort' food. Therefore, cooking and offering these foods creates a sense of community and connectivity and providing this kind of food becomes a way of caring for oneself, others and a common culture or heritage. However, because these foods and beverages are seen as part of a cultural identity that cannot and should not be changed, there is also a common justification among participants that following certain habits, whether healthy or not, is warranted.
Time poverty: The concept of ‘time poverty' is highly relevant in a city such as Houston, where long working hours combined with long commutes and living in neighborhoods where basic amenities are not readily accessible.
Time poverty fundamentally impacts the way people live their lives. It impacts social relations, neighborliness, healthy living strategies, etc. and it is embedded into everyday life and practices: the way people work, live and eat. It is a kind of cultural time poverty. Among some of the participants, a longing for more social activities and social interactions in the community is interlinked with the notion of cultural time poverty.
Being time-poor means having to carefully manage free time, and often requires ‘trade-offs' in order to complete everyday tasks. Thus, a hierarchy of demand (or need) is created, into which work, daily chores, management and, ultimately, leisure activities are organized. In order to create a situation in which diabetes and other chronic conditions can be successfully prevented, sufficient time and energy must be allocated to healthier living, and this should be reinforced beyond the individual at organizational and institutional levels.
Peer appearance: The comparison of ‘self' and ‘other' is a fundamental way in which people make sense of their immediate social environment. As a result, normative body images shift in settings where body size increases or decreases in a significant proportion of a group of people.
But in scenarios where body weight across a group changes noticeably, the classification of self as ‘not as bad', ‘healthier than', ‘fitter than', etc. can have a detrimental effect on weight perception and management. When the normative body images change, so do the perceptions of what a ‘healthy body' might look like. Many Houston participants make references to the bodies of others as ‘big' (just like their own), or ‘even bigger' (where they feel noticeably slimmer than peers). As is the case with ‘nourishing traditions', the relative notion of self in relation to peer appearance serves as justification for and validation of the status quo in Houston.
Preliminary quantitative data analysis from program evaluation of the Faith & Diabetes conducted by TMF Health Quality Institute (Quality Improvment Organization for Texas) for Centers for Medicare and Medicaid indicates that thee grassroots learning collaborative involving 14 houses of faith from Christian, Muslim and Hindu denominations is implementing the six-week Diabetes Self-Management Education and Supports program in the congregations faster and with a higher retention rate than the usual site partners for the Quality Improvement Organization (hospitals and FQHCs). In Q1 and Q2 2018 two cohorts of 50 individuals representing 30 Muslim, Christian and Hindu communities with 100K+ members have been trained
14 6-week DSMES courses delivered so far with 134 participants.
Also, qualitative research performed by the Healthy Cities Research Hub at UTHealth School of Public Health from interviews with program organizers, the two cohorts of trainees and the community participants indicate the following success factors for the program:
A neutral convening organization to serve as a training site and follow-up on implementation with a dedicated FTE
Connections made explicit between faith and health
Enough people to work as a team, divide up work, and capitalize on respective strengths. People collaborated across faith organizations to make this work
Engaged faith leadership demonstrate/model commitment to the initiative
Faith Leadership made space and time available for holding classes.
The five initiatives in Cities Changing Diabetes - Houston are sustainable because they were funded by the local organizations who participated in the crowdsourcing of solutions to the research. They brainstormed interventions, designed them further, pursued local funding (in-kind and federal grants from CDC and CMS) and were responsible for implementation. By design, no programmatic funding for Cities Changing Diabetes were given by Novo Nordisk, other than minimal seed funding for HDRC. Novo Nordisk only funded the research and the community engagement process.
From the very get-go, the two major partners Houston Health Department and Novo Nordisk created an environment that brought multiple sectors together to collaborate on this effort. The stakeholders were encouraged to develop initiatives that were aligned with their particular organizational priorities but do so in partnership with other organizations, in particular, other sectors. While this self-organizing process was "messy" and 'chaotic" at times, it created a can-do culture within Cities Changing Diabetes Houston.
Each of the five initiatives are sustainable beyond the 4th year of Cities Changing Diabetes as the backbone organizations for each initiative has allocated staff, reprioritized budgets, received multi-year funding or created the program entirely in-kind and through volunteers.
For instance, a Houston area technology firm has assumed the responsibility of managing and developing the web community that connects people with diabetes, caregivers, healthcare professionals and employers to evidence based solutions and local programs. The technology firm is mapping the success criteria for the website from the perspective of each of the twelve steering committee members, before creating a plan for how to develop new site features and functions, and presenting that plan to potential funders (local health systems, employers and philanthropy).