Prior to 2019, the Frontera counseling session was a time to go over screening results with clients and encourage them to adopt habits meant to mitigate any abnormal findings identified via screening. Health-related goals were set with some clients, but it was not a standardized process and they were not SMART goals. It was also a time to connect clients with location-specific resources meant to facilitate the provision of healthcare for those with inadequate funds or lack of health insurance. For example, the Indigent Program/Medical Financial Assistance Program in Maverick County (Eagle Pass) provides medical financial assistance as a function of need (MaverickCountyHospitalDistrict). Following a strategic planning session at the beginning of 2019, the organization identified the implementation of SMART goals during the counseling session as a top priority for the betterment of client health.
SMART goals have been proven to improve self-efficacy in diabetic populations, as well as in other environments (e.g. students in academic environments) (Giroux et al., 2014; Lawlor, 2012). There is greater gravity to setting a goal of ‘I will walk in my neighborhood for 30 minutes, 3 times a week for the next 4 weeks’ rather than ‘I will try to walk more.’ Setting specific time periods and deadlines helps give form to the typical amorphous diet-related and exercise-related goals set during counseling sessions (i.e. ‘I will eat less junk food’). This creates much-needed organization and structure as patients attempt to make life-altering changes that are often quite difficult to maintain, let alone initiate.
The majority of goals created with clients were either diet-related or exercise-related (or both). This was appropriate as the chronic health conditions this population encounters (i.e. hypertension, diabetes, obesity) can often be partially addressed by diet and exercise interventions. For hypertension, the DASH (Dietary Approaches to Stop Hypertension) diet, a diet which is rich in fruits, vegetables, and low-fat dairy foods, has been found to be effective as a first-line therapy for stage 1 isolated systolic hypertension (Moore, Conlin, Ard, Svetkey, & Group, 2001). The DASH diet has also been found to be an effective nutritional strategy to prevent cardiovascular disease in hypertensive individuals (Siervo et al., 2015). Similarly, the Mediterranean diet has been touted as having a potentially beneficial effect on type 2 diabetes prevention and treatment (Georgoulis, Kontogianni, & Yiannakouris, 2014). On the other side of the coin, “exercise remains a cornerstone therapy for the primary prevention, treatment, and control of [hypertension]” and physical activity has been recognized as a ‘vital component’ in the prevention and management of type 2 diabetes (Association, 2004; Pescatello et al., 2004). Thus, implementing diet and exercise-related goals had the potential to positively impact client health in a significant way.
Additionally, these health screenings attracted a significantly greater proportion of women as compared to men. Anecdotally, the men that did attend the health screenings were often brought (sometimes against their will) by their wife or girlfriend. This prompted recognition of a potential demonstration of machismo. Machismo, though used to personify a variety of connotations, is often used to describe a man that is tough, strong, non-emotional, and with no need to attend a community health screening (Fragoso & Kashubeck, 2000; Getrich et al., 2012). This observation serves as a testament to the importance of understanding the cultural context in which healthcare is being provided and adapting the provision of that healthcare to adequately reach the desired population.
Overall, the initial findings of this project are promising, supporting the continued use of SMART goals in Frontera counseling sessions. Among those clients contacted for follow-up, almost two-thirds reported longitudinal adherence to their SMART goal(s). Most goals set with clients were diet-related, closely followed by exercise-related goals. However, no one type of goal was found to be more efficacious in longitudinal adherence than other types of goals. This supports the development of SMART goals with a focus chosen by the client, rather than targeted towards a specific health behavior (i.e. diet, exercise) by a Frontera counselor. The implementation of SMART goals also provided greater structure to the counseling session, imparting skills that students can use during their future training and, ultimately, practice.
Of concern, only 47.9% of clients in this sample who provided a valid phone number (58 of 121) were able to be contacted for follow-up. Personnel at Frontera events should communicate the follow-up process to clients and encourage clients to share functional phone numbers, should they wish to be contacted. Moving forward, follow-up should be targeted towards clients with concerning test results and/or no source of primary care to ensure utilization of location-specific health care resources recommended to clients during Frontera health screenings.
Limitations
This project has several limitations. First, the follow-up results were dependent on client-reported outcomes. With no in-person follow-up, there was no way to verify if clients had actually been adhering to their SMART goal. Second, follow-up was only able to be achieved with a small portion of the client population. Though the random sample of clients was meant to represent approximately 10% of the total population served during 2019 (150 out of 1,500), follow-up was only achieved with 58 (38.7%) of those 150 clients. Though not certain, there is the potential that those clients who answered the phone were willing to talk about their goal adherence because they had actually made progress toward their goal (i.e. self-selection bias). In other words, clients who had not adhered to their SMART goal were less likely to want to talk about their progress, so they declined to continue when called for follow-up.