Programs and Communities

Diabetes, a common chronic condition, effects many individuals causing poor quality of life, expensive medical bills, and devastating medical complications. While health care providers try to manage diabetes during short office visits, many patients still struggle to control their diabetes at home. Lack of diabetes self-management (DSM) is a potential barrier for people with diabetes having to maintain healthy hemoglobin A1cs (HgA1c).

In hopes of addressing this concern, an evidenced-based intervention; diabetic education and phone calls, using the chronic care model as its framework was implemented. The intervention targeted people with type II diabetes at a transitional care setting. Measured variables included HgA1c and DSM. Statistically significant improvements were seen in reported physical activity. Average improvements were seen in HgA1c and DSM after three months of diabetes self-management education (DSME). Attrition, cultural sensitivity, and increasing DSME hours should be further evaluated for future projects.

Background and Purpose: Over 30 million people in the United States (U.S.) have diabetes mellitus, which comprises about 9% of the population, and about 90% of individuals with diabetes have type 2 diabetes (Centers for Disease Control and Prevention [CDC], 2017). Adults with type 2 diabetes at a local internal medicine clinic were consistently having high glycated hemoglobin (HbA1C) levels, demonstrated by data collected from the electronic health record (EHR), and there was no ordering process for referring patients to diabetes management education and support (DSMES) services. The purpose of this project was to improve glycemic control, demonstrated by lower HbA1C levels, and reach a diabetes education attendance rate of 62.5% at an internal medicine clinic in Chandler, Arizona.

Methods: An electronic health record (EHR) template was created and brief staff training was completed to connect patients with diabetes in the community to a local formal diabetes education program. HbA1C levels were measured before and three months after adults with education program. HbA1C levels were measured before and three months after adults with type 2 diabetes mellitus (T2DM) received physicians’ orders for a DSMES program, and rates of attendance to the program were calculated. Data was collected through the EHR and through feedback from the DSMES program. Descriptive statistics were used in data analysis.

Outcomes: The participants’ results did not demonstrate significant differences in pre-referral and post-referral HbA1C results after they were ordered DSMES services (p = .506). The proportion of education attendance (30%) was lower than the project goal of 62.5%, but increased from the clinic baseline.

Conclusions: EHR template implementation for referral to DSMES may increase rates of formal diabetes education and improve glycemic control. Larger sample sizes, longer project periods, alternative methods of communication, and increased follow-up of participants may be required to produce significant results.

Background: The global prevalence of all types of diabetes increased from 108 million in 1980 to 422 million in 2014 (Nazir et al., 2018). The Centers for Disease Control and Prevention (2017) ranks diabetes as the 7th leading cause of death in the United States with an estimated annual expense of $327 billion. Within the rural setting, patients typically have less resources available for the treatment and self-management of their diseases. It is important to explore self-management techniques that can be utilized by patients with type 2 diabetes living in rural areas. Research demonstrating the importance of education, exercise, diet, glucose monitoring, medications, and supportive measures is prominent throughout the literature.

Objective: The purpose of this Doctor of Nursing Practice (DNP) applied project is to investigate the effects of delivering biweekly text messages containing diabetes self-management education (DSME) materials to patients in an effort to support successful self-care.

Methods: During an 8 week period, DSME was provided via text messaging, bi-weekly (Sunday and Wednesday), to 23 rural participants with type 2 diabetes, in a family clinic in Payson, Arizona. Participants were asked to complete the Skills, Confidence, and Preparedness Index both pre- and post-intervention to evaluate their knowledge of diabetes self-management.

Results: Twenty-three adults aged 52 to 78 years (M = 64.91) participated in the project. Of the participants, 57% (13/23) were female. The majority of participants had T2DM diagnosis less than 10 years (M=13.8 years). There was a statistical difference between the pre- and post-Skills, Confidence and Preparedness Index questionnaire (p < .001) indicating an improvement in self-efficacy scores post- intervention.

Conclusion: DSME delivered via text message is a cost-effective way to increase patients' self-efficacy and potentially improve their ability to successfully self-manage their disease.

The City of Phoenix (Arizona, USA) developed a Tree and Shade Master Plan and a Cool Roofs initiative to ameliorate extreme heat during the summer months in their arid city. This study investigates the impact of the City's heat mitigation strategies on daytime microclimate for a pre-monsoon summer day under current climate conditions and two climate change scenarios. We assessed the cooling effect of trees and cool roofs in a Phoenix residential neighborhood using the microclimate model ENVI-met. First, using xeric landscaping as a base, we created eight tree planting scenarios (from 0% canopy cover to 30% canopy cover) for the neighborhood to characterize the relationship between canopy cover and daytime cooling benefit of trees. In a second set of simulations, we ran ENVI-met for nine combined tree planting and landscaping scenarios (mesic, oasis, and xeric) with regular roofs and cool roofs under current climate conditions and two climate change projections. For each of the 54 scenarios, we compared average neighborhood mid-afternoon air temperatures and assessed the benefits of each heat mitigation measure under current and projected climate conditions. Findings suggest that the relationship between percent canopy cover and air temperature reduction is linear, with 0.14 °C cooling per percent increase in tree cover for the neighborhood under investigation. An increase in tree canopy cover from the current 10% to a targeted 25% resulted in an average daytime cooling benefit of up to 2.0 °C in residential neighborhoods at the local scale. Cool roofs reduced neighborhood air temperatures by 0.3 °C when implemented on residential homes. The results from this city-specific mitigation project will inform messaging campaigns aimed at engaging the city decision makers, industry, and the public in the green building and urban forestry initiatives.

The urban thermal environment varies not only from its rural surroundings but also within the urban area due to intra-urban differences in land-use and surface characteristics. Understanding the causes of this intra-urban variability is a first step in improving urban planning and development. Toward this end, a method for quantifying causes of spatial variability in the urban heat island has been developed. This paper presents the method as applied to a specific test case of Portland, Oregon. Vehicle temperature traverses were used to determine spatial differences in summertime ~2 m air temperature across the metropolitan area in the afternoon. A tree-structured regression model was used to quantify the land-use and surface characteristics that have the greatest influence on daytime UHI intensity. The most important urban characteristic separating warmer from cooler regions of the Portland metropolitan area was canopy cover. Roadway area density was also an important determinant of local UHI magnitudes. Specifically, the air above major arterial roads was found to be warmer on weekdays than weekends, possibly due to increased anthropogenic activity from the vehicle sector on weekdays. In general, warmer regions of the city were associated with industrial and commercial land-use. The downtown core, whilst warmer than the rural surroundings, was not the warmest part of the Portland metropolitan area. This is thought to be due in large part to local shading effects in the urban canyons.

Problem: The prospect that urban heat island (UHI) effects and climate change may increase urban temperatures is a problem for cities that actively promote urban redevelopment and higher densities. One possible UHI mitigation strategy is to plant more trees and other irrigated vegetation to prevent daytime heat storage and facilitate nighttime cooling, but this requires water resources that are limited in a desert city like Phoenix.

Purpose: We investigated the tradeoffs between water use and nighttime cooling inherent in urban form and land use choices.

Methods: We used a Local-Scale Urban Meteorological Parameterization Scheme (LUMPS) model to examine the variation in temperature and evaporation in 10 census tracts in Phoenix's urban core. After validating results with estimates of outdoor water use based on tract-level city water records and satellite imagery, we used the model to simulate the temperature and water use consequences of implementing three different scenarios.

Results and conclusions: We found that increasing irrigated landscaping lowers nighttime temperatures, but this relationship is not linear; the greatest reductions occur in the least vegetated neighborhoods. A ratio of the change in water use to temperature impact reached a threshold beyond which increased outdoor water use did little to ameliorate UHI effects.

Takeaway for practice: There is no one design and landscape plan capable of addressing increasing UHI and climate effects everywhere. Any one strategy will have inconsistent results if applied across all urban landscape features and may lead to an inefficient allocation of scarce water resources.

Research Support: This work was supported by the National Science Foundation (NSF) under Grant SES-0345945 (Decision Center for a Desert City) and by the City of Phoenix Water Services Department. Any opinions, findings, and conclusions or recommendations expressed in this material are those of the authors and do not necessarily reflect the views of NSF.

Outdoor human comfort is determined for the remodelled downtown of Tempe, Arizona, USA, an acclaimed example of New Urbanist infill. The authors desired to know whether changes were accompanied by more comfortable conditions, especially in hot, dry summer months. The physiological equivalent temperature provided an assessment of year-round outdoor human comfort. Building compactness and tree shade that became part of the changes in the downtown provided more overall daytime human comfort than open nearby streets; however some downtown sites were less comfortable at night, but below 40°C, a threshold for human comfort in this desert environment.

Cities are systems that include natural and human-created components. When a city grows without proper planning, it tends to have low environmental quality. If improving environmental quality is intended, people’s opinion should be taken into account for a better acceptance of urban management decisions. In this study, we assessed people’s perception of trees by conducting a survey with a controlled sample of citizens from the city of Morelia (west-central Mexico). Citizens liked both native and exotic tree species and rejected mainly exotic ones. Preference for trees were related to tree attributes; such as size. Trees that dropped leaves or tended to fall were not liked. The most-mentioned tree-related benefits were oxygen supply and shade; the most mentioned tree-related damages were accidents and infrastructure damage. The majority of respondents preferred trees near houses to increase tree density. Also, most respondents preferred trees in green areas as well as close to their houses, as they consider that trees provide oxygen. The majority of the respondents thought more trees were needed in the city. In general, our results show that although people perceive that trees in urban areas can cause damages, they often show more interest for the benefits related to trees and consider there should be more trees in cities. We strongly suggest the development of studies that broaden our knowledge of citizen preferences in relation to urban vegetation, and that further policy making takes their perception into account when considering creating new urban green areas, regardless of their type or size.

Communities in Phoenix are confronted with numerous challenges that adversely affect human health and safety, with disproportionate impacts on low-income communities. While some challenges are being addressed at the city level, new alliances at the neighbourhood level are initiating community development programmes and projects. This article reports on an intervention study carried out in collaboration with community representatives, city staff, and non-profit organisations to mitigate adverse effects of urban sprawl in the Sky Harbour Neighbourhood in Phoenix. Participatory research was conducted to design and test a tree and shade intervention. Challenges associated with navigating community desires and broader principles of sustainable development are discussed. The study offers a replicable and adaptable intervention research design aimed at empowering communities to meet urban challenges.

Creating a Healthier, More Livable and Prosperous Phoenix

Phoenix is poised to become the next great American City. The Tree and Shade Master Plan presents Phoenix’s leaders and residents a roadmap to creating a 21st Century desert city. The urban forest is a keystone to creating a sustainable city because it solves many problems with one single solution. By investing in trees and the urban forest, the city can reduce its carbon footprint, decrease energy costs, reduce storm water runoff, increase biodiversity, address the urban heat island effect, clean the air, and increase property values. In addition, trees can help to create walkable streets and vibrant pedestrian places. More trees will not solve all the problems, but it is known that for every dollar invested in the urban forest results in an impressive return of $2.23 in benefits.

Phoenix has a strong foundation on which to build the future. Phoenix residents value natural resources and have voted repeatedly to invest in the living infrastructure. For instance, the Phoenix Parks and Preserve Initiative was passed twice with over 75 percent voter approval. This modest sales tax has purchased land for the Sonoran Preserve, funded habitat restoration efforts along Rio Salado, built new parks and planted hundreds of new trees. These projects and others like it provide the base for a healthy urban forest. Trees and engineered shade have the potential to be one of the city’s greatest assets and the Tree and Shade Master Plan provides the framework for creating a healthier, more livable and prosperous Phoenix.

The Urban Forest – Trees for People

The urban forest is a critical component of the living infrastructure. It benefits and attracts residents and tourists alike to live, work, shop and play in the city. Phoenix’s urban forest is a diverse ecosystem of soils, vegetation, trees, associated organisms, air, water, wildlife and people. The urban forest is found not only in parks, mountain preserves and native desert areas, but also in neighborhoods, commercial corridors, industrial parks and along streets. The urban forest is made up of a rich mosaic of private and public property that surrounds the city and provides many environmental, economic, and social benefits.

In order for the urban forest to be a profitable investment, Phoenix must do more than just plant trees. The entire lifecycle of the tree must be addressed because the current planting, maintenance, and irrigation practices are preventing many trees from providing their maximum return on investment. The Tree and Shade Master Plan provides a detailed roadmap to address these issues, as well as many others, with realistic and incremental steps. To succeed, this plan requires a long-term investment from the residents and leaders of Phoenix.

Trees are Solution Multipliers

Solution multipliers solve numerous problems simultaneously. Trees are a perfect example of a solution multiplier because when planted and maintained correctly, they can provide many economic, environmental, and social benefits. According to the US Forest Service, trees benefit the community by: providing a cooling effect that reduces energy costs; improving air quality; strengthening quality of place and the local economy; reducing storm water runoff; improving social connections; promoting smart growth and compact development; and creating walkable communities (US Forest Service and Urban & Community Forestry). Trees are high-yield assets; for example, the City of Chicago values its trees at $2.3 billion dollars. Trees have a documented return on investment (ROI) in Arizona of $2.23 for every $1 invested (US Department of Agriculture Forest Service). This demonstrates the important role that trees have within the city's economy. This is why it is critical to manage and invest in the urban forest; the health of the urban forest is closely linked to the economic health of the city.

Maintainable Infrastructure

Phoenix is a desert city that has a history of several decades of drought. In order to achieve a healthy urban forest we must use water wisely. Currently, 60 percent of Phoenix’s water is used outdoors, mainly for landscape irrigation. According to the City of Phoenix’s Water Services Department, Phoenix has an adequate sustainable water supply to meet the State of Arizona’s 100-year assured water supply standard. This includes growth in Phoenix’s system water demand over the next 20 years or more. Nonetheless, to achieve a maintainable urban forest, water must be used more efficiently. This is done with high-efficiency irrigation systems, use of drought-tolerant plant material, strategic placement of shade corridors and continued education. In order for a healthy urban forest to exist, it must be coupled with strong water management.

Implementation

The Urban Forest Infrastructure Team and the Parks and Recreation Department are charged with coordinating and maintaining the Tree and Shade Master Plan. Many City departments will implement the plan as they work to fulfill their own missions. The Tree and Shade Master Plan will not only provide a framework to achieve an average 25 percent tree canopy coverage by 2030 but will also help to achieve many goals and policies from the Green Phoenix Initiative and the voter ratified General Plan.

The plan proposes incremental steps to achieve the 2030 vision and canopy goal. The City of Phoenix is beginning to put a process in place to preserve, maintain, and redevelop the urban forest. This plan intends to increase the quality of life and economic vitality of the city by recommending ways to create a sustainable urban forest for future generations.