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Vida Sana/Healthy Life Intervention Program
Vida Sana: A Lifestyle Intervention for Uninsured, Predominantly
Spanish-Speaking Immigrants Improves Metabolic Syndrome
Indicators
Jacob Buckley
Brown University and
Clínica Esperanza/ Hope Clinic, 60 Valley St., Providence, R.I. 02909
Telephone-401-272-2123
Fax-272-7562
Shahla Yekta, PhD, MPH
University of Rhode Island, 80 Washington St., Providence, RI 02903
Telephone: 401-277-5149
Fax: 401-277-5408
Valerie Joseph, RN
Clínica Esperanza/Hope Clinic, 60 Valley St., Providence, RI 02909
Telephone: 401-272-2123
Fax: 401-272-7562
Heather Johnson, MLIS
University of Rhode Island, 80 Washington St., Providence, RI 02903
Telephone: 401-277-5149
Fax: 401-277-5408
Susan Oliverio, MD
Institute for Education on Health and Research, Inc.
http://www.thumbsupforhealth.org/
Rhode Island Hospital, Center for Primary Care, 02903
And Alpert Medical School of Brown University 02903
Anne De Groot, MD *Corresponding author
Clínica Esperanza/Hope Clinic, 60 Valley St., Providence, RI 02909
University of Rhode Island, 80 Washington St., Providence, RI 02903
EpiVax, Inc., 146 Clifford St., Providence, RI 02903
Telephone: 401-272-2123
Fax: 401-272-7562
dr.annie.degroot@gmail.com
Key Words: Hispanic, Latino, Health Disparities, Free Clinic, Uninsured, Life-style
Intervention, Social cognitive theory, Metabolic Syndrome, Diabetes, PreDiabetes,
Hypertension, Diabetes Prevention Project, DPP
Vida Sana/Healthy Life Intervention Program
Vida Sana: A Lifestyle Intervention for Uninsured, Predominantly
Spanish-Speaking Immigrants Improves Metabolic Syndrome
Indicators
Abstract
Metabolic syndrome is an increasingly common condition that can contribute to the
development of type 2 diabetes and cardiovascular disease. 35% of adults living in the United
States meet the criteria for having metabolic syndrome, with that number being even higher in
populations with health disparities. We describe a ‘healthy lifestyles’ program implemented at a
free clinic serving a predominantly Hispanic cohort of low-income, uninsured individuals living in
Providence, Rhode Island. The “Vida Sana/Healthy Life” (Vida Sana) program uses low literacy,
language-appropriate materials and trained peers to educate participants about healthy
lifestyles in a setting that also provided opportunities for social engagement. 192 of 126 (65.6%)
participants in Vida Sana completed 6 out of 8 sessions of the Vida Sana program over a 12-
month period. At the completion of the program, nearly 90% of Vida Sana/Healthy Life
participants showed an increase in their health literacy, and at least 60% of participants
decreased each of the risk factors (blood sugar, cholesterol, body mass index or waist
circumference) associated with metabolic syndrome.
Vida Sana/Healthy Life Intervention Program
Vida Sana: A Lifestyle Intervention for Uninsured, Predominantly
Spanish-Speaking Immigrants Improves Metabolic Syndrome
Indicators
Introduction
Metabolic syndrome is an increasingly common condition that can contribute to the
development of type 2 diabetes (T2D) and cardiovascular disease [1]. Nearly 35% of adults
living in the United States in 2014 meet the criteria for having metabolic syndrome. When
compared to patients without metabolic syndrome, these individuals are twice as likely to
experience adverse cardiovascular events, and are four times as likely to develop T2D [2-4].
The risk factors for metabolic syndrome include hypertension, abdominal obesity, elevated
fasting glucose, insulin resistance, triglycerides, and decreased high-density lipoprotein [5,6].
Metabolic syndrome disproportionately affects populations with health disparities, and the social
determinants that contribute to these disparities also contribute to the negative long-term
outcomes that many patients with metabolic syndrome experience [6-11].
In Rhode Island, individuals experiencing health disparities primarily identify themselves
as belonging to either an ethnic minority group and/or an immigrant population. In fact, many of
the estimated 25,000-35,000 undocumented immigrants living in Rhode Island are of Central
and South American origin [12-15]. In addition to ethnicity and citizenship status, most patients
from health disparities populations also report a low annual income as well as a lack of health
insurance, either due to residency restrictions or matters of affordability. Furthermore, these
individuals often experience linguistic barriers in clinical settings, which can significantly impact
their health literacy and access to quality care and other health-related resources [11,16,17].
Clínica Esperanza/Hope Clinic (CEHC) is a free clinic that serves a predominantly Latino
community in and around the Olneyville neighborhood of Providence, Rhode Island, where
Vida Sana/Healthy Life Intervention Program
41.1% of family incomes fall below the federal poverty level and roughly 29% of individuals are
uninsured [12, 18]. The clinic’s team of eight paid employees and over 200 healthcare
volunteers serves this local community and an extended community of low-income,
predominantly Spanish-speaking individuals who lack health insurance by providing free,
culturally-attuned, linguistically-appropriate healthcare. In addition to offering traditional health
services such as primary care and preventative screening, CEHC also offers health education,
training for entry-level healthcare workers, and a number of different health education and
prevention programs that allow CEHC patients to learn about healthier choices and work
towards reducing their risk for chronic disease [12,19].
The Vida Sana/Healthy Life (commonly referred to as Vida Sana) intervention is based
on the tenets of social cognitive theory, a behavioral intervention model that has been
recognized for its effectiveness in producing lasting change in similar populations with health
disparities [6,20,21]. Vida Sana uses materials developed by Dr. Susan Oliverio, of the Institute
for Education on Health and Research (http://www.thumbsupforhealth.org). Dr. Oliverio’s
“Thumbs Up!” metabolic syndrome workbook and associated presentation and discussion
materials were specifically developed for low English proficiency populations. The program was
further adapted by CEHC to be administered by peer educators known as Navegantes in
conjunction with social activities that would reinforce the workbook material. The Navegantes
are trained community health-workers who live in the communities that the Clinic’s patients also
live in, and represent similar ethnic backgrounds. In preparation for their role as peer educators,
the Navegantes participated in an extensive 10-week training program that provided them with
training in case management, community outreach, and health education specific to the
curriculum of the program [21-23].
The Navegantes covered the contents of the Thumbs Up! metabolic syndrome
workbooks during two hour sessions, once per week, over five weeks, in a highly interactive
“social club” that enabled participants to share their stories and participate in fun activities while
Vida Sana/Healthy Life Intervention Program
learning about the basic nutrition and metabolic syndrome risk factors described in the
workbook and presentation materials. The entire program spanned eight weeks, during which
time participants were screened for metabolic syndrome (at the initiation and close of the
program), received the Thumbs Up! nutritional education and (during the three weeks following
the close of the program) participated in health-focused social activities.
In this report, we provide an overview of the initial 12 months of the Vida Sana/Healthy
Life program, report the results for the first 192 participants, describe the challenges associated
with running the program, and identify plans for improvement. Based on the results described
here, the Vida Sana/Healthy Life program appears to effectively reduce metabolic syndrome risk
factors for participants who complete the majority of the sessions and may represent a low-cost
alternative to other more intensive lifestyle intervention programs aiming to improve long-term
health outcomes in health-disparities populations with linguistic barriers.
Methods
Vida Sana/Healthy Life Program Overview
The development of the Vida Sana/Healthy Life program was initially funded by
the AMA Foundation (2012) and has subsequently been supported by the Rhode Island
Department of Health (RI DOH, 2013-2014). With funding from the RI DOH, concurrent Vida
Sana programs were established at three active sites during the twelve-month period reported
here; some groups met at CEHC’s clinic location, others met at the Gloria Dei Lutheran Church
in downtown Providence as well as at the Open Table of Christ United Methodist Church in the
Washington Park neighborhood of Providence. Over a twelve-month period, 13 groups
completed the program, and of them, 11 were conducted primarily in Spanish. Program
participants were provided with linguistically-appropriate educational materials that were written
and illustrated in a manner that catered specifically to the needs of the average program
Vida Sana/Healthy Life Intervention Program
participant. Participants met weekly for two hours, for a total of eight weeks. Upon completion of
the program, participants provided with an honorarium (between $10-30 for the eight week
program) to compensate for their time and travel. Program completion was defined as the
attendance of at least six of the eight sessions, including at least one social session. At the
close of the program, participants completed a follow-up health survey and provided
measurements of their weight, body mass index (BMI), blood glucose, low-density lipoprotein
(LDL) cholesterol, waist circumference, and blood pressure. Participants were asked to follow
up a month after the end of the program, although not all were available to do so.
Participants
Participants were recruited from either CEHC or from two other local community
organizations (local churches). The programs were open to all interested individuals, although
participants were primarily comprised of either current CEHC patients or individuals who were
recruited during health screenings held at any of the three sites; individuals identified as either
meeting the criteria for having metabolic syndrome or being at-risk for developing it, were
informed about the program and invited to participate. Efforts were made to create groups of 10-
15 individuals, equally representative of men and women from a variety of age groups, ranging
from 16-79 years of age, although the median age of all participants was 51. While outreach
personnel made a concerted effort to recruit an equal number of men and women, the majority
of participants (73%) were female. Similarly, enrollment was open to all, although the majority of
participants were Hispanic, with 89% speaking Spanish as their primary language. Only 5% of
participants were born in the United States. See Figure 1 and Table 1 for graphical and tabular
demographic data of the participants in the Vida Sana program.
Vida Sana/Healthy Life Intervention Program
Human Studies
The procedure for data analysis and the resulting report for publication were
reviewed by the Ethical and Independent Review Services (E&I, Independence, Missouri) and
qualified for exemption 4 as defined in 45 CFR46.101(b). Prior to initiating the Vida Sana
program, participants provided consent to participate in the program and to have blood tests
performed. All participants were assigned an identification code (ID code). During the 12 month
period that was reviewed for this report, individual participant results were tabulated by
participant ID code in a password protected excel spreadsheet (no individual patient identifiers
were included in the spreadsheet). An analysis of the project data was performed at the
completion of the 12-month initial period of the project. Demographic information, health literacy
assessment results, and metabolic outcome measures were inaccessible to non-program
personnel.
Materials
All Vida Sana curriculum materials such as slides, books, and subsequent assessments
were designed for the low-health literacy, low English-language proficiency subjects and
information was presented using simple terminology accompanied by vivid photographs of
individuals participating in healthy activities. The health literacy assessment was developed by
Susan Oliverio (IEHR) who has experience designing educational materials for populations with
low health literacy. The materials were provided to participants in either English or Spanish and
all materials were written using simple (5th grade-level) language.
At the first visit, Navegantes administered a health literacy survey. The survey assessed
participants’ knowledge of chronic conditions such as T2D and cardiovascular disease, and also
Vida Sana/Healthy Life Intervention Program
asked participants to provide insight into their understanding of nutrition and other lifestyle
choices that might influence metabolic syndrome.
After completing the health literacy assessment, the Navegantes recorded the weight,
BMI, blood glucose, LDL cholesterol, waist circumference, and blood pressure of all
participants. During the first session and over the course of the next four meetings, the
Navegantes used the Vida Sana curriculum materials to introduce the participants to topics
related to health issues and lifestyle choices. The topics covered during the five didactic
sessions were nutrition, T2D, cardiovascular disease, and methods of chronic diseases
prevention and management. These five educational sessions (one per week) were followed by
two social sessions which served to reinforce what participants had learned previously, and a
final session that assessed the impact of the program on metabolic syndrome indicators. These
meetings were characterized by social activities such as a dance classes and health-literacy
bingo. Previous program participants were frequently invited to discuss their experience with the
program and their post-completion methods for living a healthy lifestyle.
During this last session, participants completed a follow-up health literacy assessment
and had their metabolic risk factors re-measured. The final session also featured a ‘graduation’
and distribution of certificates of achievement. Those who completed the program were also
given a small stipend that was based on the number of sessions completed (gift cards ranging
from $10 to $40 dollars), a pedometer, and a booklet reinforcing the key elements of the
program. Participants were encouraged to share their individual results with their healthcare
providers and to discuss plans for continuing to reduce their metabolic risk factors.
Data Collection and Analysis
Vida Sana/Healthy Life Intervention Program
The student’s t test for unpaired samples was used to compare the baseline metabolic
characteristics of participants who ultimately completed the program to those who did not. The
individual Vida Sana groups did not differ significantly in terms of outcomes, so the individual
group were pooled for the final analysis. Outcomes were measured by examining the percent
changed for each category between the baseline and eight-week time point for individuals who
participated in at least six out of the eight sessions.
Since participants had different starting points and goals for the program, outcomes
were described as ‘percent stable or improved’ and ‘percent and total amount changed’, for
each category. For example, some subjects were overweight and some were not, so not all
subjects were trying to lose weight. Follow-up measurements were gathered at time points
ranging between three and seven months after completion. Follow-up data was analyzed in a
similar fashion to eight-week data, examining the numbers of participants who remained stable
or improved between their completion and follow-up date, and how much those that improved
changed in that time.
Results
Over the twelve-month period reported here, 192 individuals participated in the 13
longitudinal eight-week programs. Of these participants, 126 (65.6%) completed the program
(defined as having participated in at least six of eight Vida Sana sessions). Program outcomes
were determined for those who completed the program. Across all metabolic factors, more than
60% of participants showed improvement in one or more measures, and nearly 90%
demonstrated improved health literacy. The eight-week changes in metabolic outcomes and
health literacy are shown in Figure 2; changes in measurements are described in Table 2 and
metabolic data is described in Table 3.
Vida Sana/Healthy Life Intervention Program
Because participants with a baseline systolic blood pressure of 120mmHg or lower are
considered to be within a healthy range, only participants whose baseline systolic blood
pressure was greater than 120 mmHg were counted in the blood pressure calculation. Out of
the total 192 participants, 69 individuals (36%) had elevated blood pressure at program outset,
and of those, 83% demonstrated an improved systolic blood pressure. Blood glucose
measurements were not always performed when the patients were fasting. However, non-
fasting (“random”) glucose levels improved for 63% of participants.
At the onset of the program, 54% of participants were considered to be obese (BMI of 30
or greater), and at the close of the eight-week program, the rate of obesity among all
participants decreased to 46.0%. The percentage of participants who met the criteria for
abdominal obesity (waist circumference >35 inches for women and >40 inches for men) was
reduced from 68% to 62%.
Of the 126 individuals who completed the program, 51 (41%) completed a follow-up
session one to seven months after the close of their session; metabolic factors consistently
improved or remained stable in participants throughout the range of follow-up times. In all
cases, risk factors for metabolic syndrome were reduced by a minimum of 34%, with the most
significant continued improvement being to participants’ systolic blood pressure, with 82%
follow-up individuals reporting an average reading of 127.8. Figure 3 shows metabolic
outcomes between the end of the program and the follow-up measurement for these
participants.
Discussion
During the 12 month Vida Sana program report period, at least 60% of participants
demonstrated stability or improvement after the eight-week intervention in each of the measured
outcomes, including weight, waist circumference, random blood glucose, LDL cholesterol, and
blood pressure. The average participant experienced a 3.7-pound weight loss (a reduction of
Vida Sana/Healthy Life Intervention Program
2.0% from baseline), which correlated with an average BMI decrease of 0.7 kg/m2, from 31.5 to
30.8. The average waist circumference decreased by nearly one inch (0.9 inches). Participants
decreased their random blood glucose and LDL cholesterol by 7.4 mg/dl and 5.2 mg/dl, on
average, respectively. Of those participants with a systolic blood pressure greater than 120
mmHg at baseline, the average change was a decrease of 5.6 mmHg. With respect to the
health literacy assessment, the average pre-assessment score was 72.1, and the average
follow up assessment was 90.0%, with approximately 83% of participants improving their health
literacy status.
Overall, the Vida Sana intervention program had a positive impact on measured
metabolic syndrome indicators during the 12 months reported here. Several limitations to this
report are worth noting. Participation in the program was not randomized, and there was no
comparison group. It is not possible to determine which of the components of the program (LEP
curriculum, interactive sessions, or nutritional information) most strongly influenced the
outcomes. The short program period also served as a limiting factor in collecting data, since the
eight-week timeframe did not provide a long enough period to observe significant changes in
metabolic risk factors. Blood glucose measurements were not performed after fasting, since the
program was designed to be convenient to the participants and the sessions usually took place
at the end of the day. Therefore, the blood sugar results were variable and not statistically
rigorous, but were nevertheless included in the results. Random blood glucose measurements
have been found to provide a fairly reliable correlation to glycemic control [24].
Funding for the program was also a significant limitation, since the number of hours that
Navegantes could devote to planning, preparation, and instruction was limited. Limited financial
resources also affected the extra benefits participants received such as incentives and the type
of food provided to participants during sessions. Participation rates might also have been higher
had the program included on-site childcare.
Vida Sana/Healthy Life Intervention Program
Despite these limitations, however, the results are comparable to a more comprehensive
lifestyle interventions, which usually require intensive participation over a six-month period
[6,21,22,23,25]. At the end of the intervention, the average Vida Sana participant had lost nearly
four pounds of body weight, while the average weight change observed in three other lifestyle
intervention studies was a loss of two to seven pounds [6,21,23]. The average change in waist
circumference after eight-week Vida Sana intervention was a decrease of 0.9 inches, whereas
the average change reported for two other lifestyle studies was a decrease of 0.5 to 2.5 inches
[23,25]. The average change in LDL cholesterol after the eight-week Vida Sana intervention was
a decrease of 5 mg/dl, compared to a decrease of 13 mg/dl for participants in another
intervention, which focused on culturally-appropriate health education for Spanish-speaking
individuals [20]. Few comparable intervention programs measured a difference in health literacy;
therefore, we are only able to compare results to one other study: 82.9% of Vida Sana
participants demonstrated improvements in health literacy, while Spanish-speaking participants
in another study showed a 69% improvement rate [20]. Other programs using similar health-
literacy tests reported seeing comparable increases in test scores and attributed some of the
metabolic improvements observed in participants to these gains in health literacy [6, 22, 25].
None of these results from the Vida Sana program or from other interventions in health-
disparities populations were as successful as those observed by the Diabetes Prevention
Program (DPP) Research Group, which was well funded, intensive, and included participants
who were from a substantially different socioeconomic population. Participants in the DPP
achieved a weight loss of approximately 15 lbs. and a net reduction in fasting blood glucose of 4
mg/dl at the six-month time point [26]. After the 2.8-year study, there was 58% reduction in the
incidence of diabetes for the lifestyle-intervention group compared with placebo [26]. Other
lifestyle-intervention programs in general community settings have been shown to decrease
weight and other metabolic risk factors but have not been as successful as the DPP study [27-
30].
Vida Sana/Healthy Life Intervention Program
Future Directions
Limitations on funding made it difficult to obtain additional validation of the impact of the
Vida Sana program. Future iterations of this program will include glycated hemoglobin (HbA1c),
and emphasize the importance of obtaining fasting blood glucose readings. Vida Sana peer
educators will also encourage participants to set manageable goals and to provide healthy
snacks at program meetings. Supplemental exercise programs will also be made available to
Vida Sana participants. Volunteer-run childcare services will also be provided to improve the
participant retention rate.
By focusing on a community-based model of culturally-sensitive, linguistically-
appropriate health education, the Vida Sana/Healthy Life program has produced promising
results during the twelve-months of the program reported here, and compares well with other
similar programs. This demonstrates the feasibility of shorter duration peer-led healthy lifestyle
intervention programs to reduce chronic diseases risk factors related to metabolic syndrome in
health-disparities populations, and demonstrates the efficacy of a social cognitive theory-based
approach.
Footnotes
Funding for the Vida Sana/Healthy Life program has been provided to CEHC by the
American Medical Association Foundation and the Rhode Island Department of Health (Center
for Health Equity and Wellness Program). The authors report no conflicts of interest.
Vida Sana/Healthy Life Intervention Program
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Table 1: Demographic Data of Participants (n=192)
Age and Gender
Number (%)
Age (mean years)
49.8
Female
140 (73%)
Continent/Region of Birth
North America
20 (10%)
Central America
54 (28%)
South America
7 (4%)
Caribbean
93 (48%)
Europe/Asia
5 (3%)
Africa
8 (4%)
Other
5 (3%)
Primary Language
Spanish
171 (89%)
English
12 (6%)
Creole
6 (3%)
French
2 (1%)
Portuguese
1 (1%)
Vida Sana/Healthy Life Intervention Program
Table 2: Changes in Measured Variables at 8 Weeks
Baseline,
mean (SD)
8 weeks,
mean (SD)
%
Stable/Improve
d
Change for those
that improved,
mean (SD)
Weight (n=126), lbs
180.0 (46.1)
176.4 (45.1)
80.2%
-6.0 (5.2)
BMI (n=126)
31.5 (7.7)
30.8 (7.5)
80.2%
-1.1 (1.0)
Waist
Circumference
(n=125), inches
38.7 (6.7)
37.8 (5.8)
80.8%
-2.2 (1.5)
Blood Glucose
(n=124), mg/dl
123.2 (50.7)
115.8 (48.4)
62.9%
-26.3 (27.5)
LDL Cholesterol
(n=125), mg/dl
190.6 (37.7)
185.4 (33.1)
60.0%
-19.1 (16.8)
Systolic BP (>120
onset) (n=69),
mmHg
139.1 (16.8)
133.5 (15.3)
82.6%
-11.1 (9.5)
Health Literacy
Test (n=117)
72.1%
(21.4%)
90.0% (10.7%)
88.9%
+22.2% (19.7%)
Table 3: Changes in Metabolic Variables at 1-7 Month Follow-up
8 weeks, mean
(SD)
Follow up,
mean (SD)
% Stable/
Improved
Change for those
that improved,
mean (SD)
Weight (n=51),
lbs
178.5 (58.1)
174.6 (52.7)
78.4%
-9.2 (18.2)
BMI (n=51)
30.8 (8.8)
30.2 (7.9)
78.4%
-1.6 (3.0)
Waist
Circumference
(n=50), in
37.4 (6.3)
37.4 (6.2)
56.0%
-2.0 (1.5)
Blood Glucose
(n=50), mg/dl
122.6 (48.4)
125.3 (49.7)
54.0%
-30.5 (34.7)
Vida Sana/Healthy Life Intervention Program
LDL Cholesterol
(n=50), mg/dl
187.9 (36.4)
198.5 (36.9)
34.0%
-14.8 (29.6)
Systolic BP
(>120 onset)
(n=27), mmHg
133.3 (14.3)
127.8 (13.5)
81.5%
-14.9 (8.1)
Figure 1. Demographic information for Vida Sana Participants: (A) Region of origin of Vida Sana participants.
(B) Age distribution of Vida Sana participants.
Figure 2. Percent of Vida Sana population stable or improved for measured variables after: (A) the 8 week
intervention and (B) the 1-7 month post-intervention follow up.
North America
10%
Central America
28%
South America
4%
Carribean
48%
Europe/Asia
3%
Africa
4%
Other
3% <=30
7%
31-40
15%
41-50
27%
51-60
36%
61-70
10%
>70
5%
AB
Vida Sana/Healthy Life Intervention Program
Figure 3. Percent decrease of each metabolic variable for those participants who improved in variable at the 8
week follow up time point.
