Promoting Community and Population Health in Public Health and Medicine: A Stepwise Guide to Initiating and Conducting Community-engaged Research.

Various methods, approaches, and strategies designed to understand and reduce health disparities, increase health equity, and promote community and population health have emerged within public health and medicine. One such approach is community-engaged research. While the literature describing the theory, principles, and rationale underlying community engagement is broad, few models or frameworks exist to guide its implementation. We abstracted, analyzed, and interpreted data from existing project documentation including proposal documents, project-specific logic models, research team and partnership meeting notes, and other materials from 24 funded community-engaged research projects conducted over the past 17 years. We developed a 15-step process designed to guide the community-engaged research process. The process includes steps such as: networking and partnership establishment and expansion; building and maintaining trust; identifying health priorities; conducting background research, prioritizing "what to take on"; building consensus, identifying research goals, and developing research questions; developing a conceptual model; formulating a study design; developing an analysis plan; implementing the study; collecting and analyzing data; reviewing and interpreting results; and disseminating and translating findings broadly through multiple channels. Here, we outline and describe each of these steps.

Engaged for Change: A Community-Engaged Process for Developing Interventions to Reduce Health Disparities.

The science underlying the development of individual, community, system, and policy interventions designed to reduce health disparities has lagged behind other innovations. Few models, theoretical frameworks, or processes exist to guide intervention development. Our community-engaged research partnership has been developing, implementing, and evaluating efficacious interventions to reduce HIV disparities for over 15 years. Based on our intervention research experiences, we propose a novel 13-step process designed to demystify and guide intervention development. Our intervention development process includes steps such as establishing an intervention team to manage the details of intervention development; assessing community needs, priorities, and assets; generating intervention priorities; evaluating and incorporating theory; developing a conceptual or logic model; crafting activities; honing materials; administering a pilot, noting its process, and gathering feedback from all those involved; and editing the intervention based on what was learned. Here, we outline and describe each of these 13 steps.

Does Neighborhood Risk Explain Racial Disparities in Low Birth Weight among Infants Born to Adolescent Mothers?

STUDY OBJECTIVE: To test associations and interactions between racial identification, neighborhood risk, and low birth weight disparities between infants born to African-American and white adolescent mothers. DESIGN: Retrospective cross-sectional study. Birth cases were geocoded and linked to census tract information from the 2010 US Census and the 2007-2011 American Community Survey. A "neighborhood risk" index was created using principal component analysis, and mothers were grouped into 3 neighborhood risk levels (low, medium, high). Multilevel models with cross-level interactions were used to identify variation in racial differences in low birth weight outcomes across neighborhood risk levels when controlling for maternal demographic characteristics and pregnancy behaviors (smoking, prenatal care use). SETTING: North Carolina, United States. PARTICIPANTS: Singleton infants (n = 7923 cases) born to non-Hispanic African American and white adolescent mothers from the North Carolina State Center of Health Statistics for 2011. MAIN OUTCOME MEASURES: Low birth weight. RESULTS: African American mothers were significantly more likely to have infants of low birth weight than white mothers in this sample (odds ratio = 1.89; 95% confidence interval, 1.53-2.34). Mothers that resided in areas of high neighborhood risk were significantly more likely to have infants of low birth weight than mothers residing in areas of low neighborhood risk (odds ratio = 1.55; 95% confidence interval, 1.25-1.93). Even when controlling for confounding factors, racial disparities in low birth weight odds did not significantly vary according to neighborhood risk level. CONCLUSION: Racial disparities can remain in low birth weight odds among infants born to adolescent mothers when controlling for maternal characteristics, pregnancy behaviors, and neighborhood risk.

Race, Socioeconomic Status, and Age: Exploring Intersections in Preterm Birth Disparities among Teen Mothers.

Few studies have examined disparities in adverse birth outcomes and compared contributing socioeconomic factors specifically between African-American and White teen mothers. This study examined intersections between neighborhood socioeconomic status (as defined by census-tract median household income), maternal age, and racial disparities in preterm birth (PTB) outcomes between African-American and White teen mothers in North Carolina. Using a linked dataset with state birth record data and socioeconomic information from the 2010 US Census, disparities in preterm birth outcomes for 16,472 teen mothers were examined through bivariate and multilevel analyses. African-American teens had significantly greater odds of PTB outcomes than White teens (OR = 1.38, 95% CI 1.21, 1.56). Racial disparities in PTB rates significantly varied by neighborhood income; PTB rates were 2.1 times higher for African-American teens in higher income neighborhoods compared to White teens in similar neighborhoods. Disparities in PTB did not vary significantly between teens younger than age 17 and teens ages 17-19, although the magnitude of racial disparities was larger between younger African-American and White teens. These results justify further investigations using intersectional frameworks to test the effects of racial status, neighborhood socioeconomic factors, and maternal age on birth outcome disparities among infants born to teen mothers.

Laying the groundwork for evidence-based public health: why some local health departments use more evidence-based decision-making practices than others.

We examined variation in the use of evidence-based decision-making (EBDM) practices across local health departments (LHDs) in the United States and the extent to which this variation was predicted by resources, personnel, and governance. We analyzed data from the National Association of County and City Health Officials Profile of Local Health Departments, the Association of State and Territorial Health Officials State Health Departments Profile, and the US Census using 2-level multilevel regression models. We found more workforce predictors than resource predictors. Thus, although resources are related to LHDs' use of EBDM practices, the way resources are used (e.g., the types and qualifications of personnel hired) may be more important.

Resilience of Vietnamese refugees: resources to cope with natural disasters in their resettled country.

OBJECTIVE: Study findings suggest that refugees are more vulnerable than the general population to mental disorders from disasters. This pilot study explored the nature of Vietnamese refugees' resilience to a potential natural disaster as a first step toward improving their disaster mental health. METHODS: Interviews were conducted with 20 ethnic Vietnamese and Montagnard adult refugees using a semistructured interview guide. Factors in resilience at both individual and family levels were examined. RESULTS: Our results indicated that these refugees had positive personalities and strong family cohesion. However, although a majority of the participants had experienced natural disasters, they lacked knowledge and specific strategies to cope with these events. The individual participants and their families lacked sufficient information, financial resources, emergency supplies, or social support for a natural disaster. CONCLUSIONS: Enhancing refugees' current strengths in responding to disasters, delivering them tailored emergency training, strengthening relationships between refugee service providers and refugee communities, and advocating for refugees' socioeconomic capacity building should be considered.

Exploring birth outcome disparities and the impact of prenatal care utilization among North Carolina teen mothers.

BACKGROUND: This study investigated the role of prenatal care utilization in explaining disparities in birth outcomes between African-American and White teen mothers in North Carolina. METHODS: This cross-sectional study analyzed birth record data for African-American and White teen mothers provided by the North Carolina State Center of Health Statistics for 2009 (n = 10,515). Hierarchical moderated multiple regression models were completed to explore associations between racial status, prenatal care utilization, and birth outcome disparities amid multiple demographic and medical risk factors. FINDINGS: Racial status as African American was identified as a significant predictor for lower birth weight and gestational age in each regression model when accounting for other demographic variables, medical risk factors, and prenatal care utilization. Results illuminate significant associations between higher prenatal care utilization levels and higher infant birth weight and gestational age for the overall teen population. However, these results did not identify protective effects in reducing racial disparities in birth weight or gestational age. CONCLUSION: Given these results, a more in-depth exploration of prenatal care client assessment, education, and alternative prenatal care models is warranted to identify strategies for reducing birth outcome disparities between these populations. These findings also suggest the need for further examination of other potential social and economic factors that explain racial disparities in birth outcomes between African-American and White teen populations.

Brothers Leading Healthy Lives: Outcomes from the pilot testing of a culturally and contextually congruent HIV prevention intervention for black male college students.

We used a treatment group-only design to pilot test a newly developed intervention to increase condom use among higher risk heterosexually active African American/black male college students. A community-based participatory research partnership developed the intervention called Brothers Leading Healthy Lives. Following an initial screening of 245 men, 81 eligible men were contacted for participation. Of the 64 men who agreed to participate, 57 completed the intervention and 54 of those completed the 3-month follow-up assessment, for a 93% completion rate. Results show significant changes between the baseline and 3-month follow-up assessments in behavioral outcomes, including reductions in unprotected sex, increase in protection during last intercourse, and fewer condom use errors. Most potential mediators (knowledge, attitudes, intentions, and condom use self-efficacy) also changed significantly in the expected direction. These demonstrated changes provide good evidence that men exposed to this intervention will see changes that reduce their risk for HIV.

Predictors of uncontrolled hypertension in the Stroke Belt.

Inadequate control of high systolic blood pressure in older adults has been largely attributable to poor control of overall hypertension (HTN). The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines emphasize the importance of controlling isolated systolic HTN in older adults. The study examined demographics, self-reported health information, and clinical measures as predictors of uncontrolled HTN among individuals taking antihypertensive medications. The Community Initiative to Eliminate Stroke, a stroke risk factor screening and prevention project, collected data in two North Carolina counties. Statistical modeling of predictors included odds ratios (ORs) and logistic regression analyses. Of the 2663 participants, 43.5% and 22.8% had uncontrolled systolic and diastolic HTN, respectively. African Americans were more likely to have uncontrolled systolic (60%) or diastolic HTN (70.9%) compared with whites (40% and 29.1%, respectively). Participants 55 years and older were more likely to have uncontrolled systolic HTN compared with younger individuals. Regression analyses showed that race (OR, 1.239; P=.00), age (OR, 1.683; P=.00), and nonadherence with medications (OR, 2.593; P=.00) were significant predictors of uncontrolled systolic HTN. Future interventions should focus on improving management of isolated systolic HTN in older adults and African Americans to increase overall control of HTN.

Predictors of congruency between self-reported hypertension status and measured blood pressure in the stroke belt.

BACKGROUND: Few studies have comprehensively investigated the validity of self-reported hypertension (HTN) and assessed predictors of HTN status in the stroke belt. This study evaluates validity self-reporting as a tool to screen large study populations and determine predictors of congruency between self-reported HTN and clinical measures. METHODS: Community Initiative to Eliminate Stroke project (n = 16,598) was conducted in two counties of North Carolina in 2004 to 2007, which included collection of self-reported data and clinical data of stroke-related risk factors. Congruency between self-reported HTN status and clinical measures was based on epidemiological parameters of sensitivity, specificity, and predictive values. McNemar's test and Kappa agreement levels assessed differences in congruency, while odds ratios and logistic regression determined significant predictors of congruency. RESULTS: Sensitivity of self-reported HTN was low (33.3%), but specificity was high (89.5%). Prevalence of self-reported HTN was 16.15%. Kappa agreement between self-report and clinical measures for blood pressure was fair (k = 0.25). Females, whites, and young adults were most likely to be positively congruent, whereas individuals in high risk categories for total blood cholesterol, low density lipoproteins, triglycerides, and diabetes were least likely to accurately capture their HTN status. CONCLUSION: Self-report HTN information should be used with caution as an epidemiological investigation tool.

Using community-based participatory research to prevent HIV disparities: assumptions and opportunities identified by the Latino partnership.

BACKGROUND: HIV disproportionately affects vulnerable populations in the United States, including recently arrived immigrant Latinos. However, the current arsenal of effective approaches to increase adherence to risk-reduction strategies and treatment within Latino populations remains insufficient. METHODS: Our community-based participatory research (CBPR) partnership blends multiple perspectives of community members, organizational representatives, local business leaders, and academic researchers to explore and intervene on HIV risk within Latino populations. We used CBPR to develop, implement, and evaluate 2 interventions that were found to be efficacious. RESULTS: We identified 7 assumptions of CBPR as an approach to research, including more authentic study designs, stronger measurement, and improved quality of knowledge gained; increased community capacity to tackle other health disparities; the need to focus on community priorities; increased participation and retention rates; more successful interventions; reduced generalizability; and increased sustainability. CONCLUSIONS: Despite the advancement of CBPR as an approach to research, key assumptions remain. Further research is needed to compare CBPR with other more-traditional approaches to research. Such research would move us from assuming the value of CBPR to identifying its actual value in health disparity reduction. After all, communities carrying a disproportionate burden of HIV, including immigrant Latino communities, deserve the best science possible.

Female sex work within the rural immigrant Latino community in the southeast United States: an exploratory qualitative community-based participatory research study.

BACKGROUND: Little is known about the structure and context of, and the risks encountered in, sex work in the United States. OBJECTIVE: This community-based participatory research (CBPR) study explored female sex work and the feasibility of conducting a larger study of sex work within the immigrant Latino community in North Carolina. METHODS: Twelve abbreviated life story interviews were conducted with Latina women who sold sex, other women who sold sex to Latino men, and Latino men who hired sex workers. Content analysis was used to analyze narrative data. RESULTS: Themes emerged to describe the structure of sex work, motivations to sell and hire sex, and the sexual health-related needs of sex workers. Lessons learned included the ease of recruiting sex workers and clients, the need to develop relationships with controllers and bar owners/managers, and the high compensation costs to reimburse sex workers for participation. CONCLUSIONS: Study findings suggest that it is possible to identify and recruit sex workers and clients and collect formative data within this highly vulnerable and neglected community; the prevention of HIV and STDs is a priority among sex workers, and the need for a larger study to include non-Latino men who report using Latina sex workers, other community insiders (e.g., bartenders), and service providers for Latina sex workers.

Ethnic and racial differences of baseline stroke knowledge in a "stroke belt" community.

Acute stroke is often a treatable condition; however, intervention is time dependent and typically should ensue within 3 hr from onset of symptoms. The ability of individuals to understand stroke risk factors to reduce individual risk and to recognize warning signs and symptoms of stroke as signals to initiate medical care is paramount to decreasing stroke-related morbidity and mortality. This descriptive study presents ethnic and racial differences of baseline stroke knowledge among residents (n = 1,904) of two North Carolina counties situated in the Stroke Belt. Findings suggest a global stroke knowledge deficit that is more pronounced among Hispanics. Future community stroke education campaigns need to consider various educational mediums and outlets to ensure inclusion of persons at highest risk for stroke. Suggestions are provided for possible content of future stroke knowledge and prevention campaigns.

Factors Influencing Depression and Anxiety among Black Sexual Minority Men.

The primary aim of this study was to examine the relationships between depression and anxiety, and ethnic and sexual identity development, and discrimination and harassment (DH) among Black sexual minority men. Additional aims were to determine whether an interaction effect existed between ethnic and sexual identity and whether coping skills level moderated these relationships. Using an observational cross-sectional design, 54 participants recruited through snowball sampling completed self-administered online surveys. Stepwise multiple regression analysis was used. Sixty-four percent of the variance in depression scores and 53% of the variance in anxiety scores were explained by DH and internalized homonegativity together. Thirty percent of the sample had scale scores indicating likelihood of depression and anxiety. Experience of DH and internalized homonegativity explained a large portion of the variability in depression and anxiety among Black sexual minority men. The study showed high prevalence of mental distress among this sample.

Meal patterns and food choices of young African-American men: understanding eating within the context of daily life.

Although young African-American men are at particularly high risk of developing hypertension at an early age, dietary interventions that have successfully reduced blood pressure among African-American adults have not been translated into programs for this group. Life contexts such as school enrollment, participation in competitive athletics, and employment influence the daily activities and meal patterns of African-American men. This study explored the activities of young African-American men to identify opportunities to increase healthful food choices. A purposive sample was recruited that included five groups of African-American men aged 15 to 22 years (N=106): high school athletes and nonathletes, college athletes and nonathletes, and nonstudents. A structured interview guided participants through a description of their activities, meal patterns, and food choices during the course of a typical weekday. Common elements emerged that provided a contextual view of the participant meal patterns and food choices. These elements were sports team participation, college employment, school as a food source, nonstudent status, and eating dinner at home. These findings suggest opportunities for the design of dietary interventions for young African-American men that take into consideration how school, athletics, and employment may influence opportunities to eat regular meals that include healthful foods.

Latino men who have sex with men and HIV in the rural south-eastern USA: findings from ethnographic in-depth interviews.

A community-based participatory research partnership explored HIV risk and potentially effective intervention characteristics to reduce exposure and transmission among immigrant Latino men who have sex with men living in the rural south-eastern USA. Twenty-one participants enrolled and completed a total of 62 ethnographic in-depth interviews. Mean age was 31 (range 18-48) years and English-language proficiency was limited; 18 participants were from Mexico. Four participants reported having sex with men and women during the past three months; two participants self-identified as male-to-female transgender. Qualitative themes that emerged included a lack of accurate information about HIV and prevention; the influence of social-political contexts to sexual risk; and barriers to healthcare services. We also identified eight characteristics of potentially effective interventions for HIV prevention. Our findings suggest that socio-political contexts must be additional targets of change to reduce and eliminate HIV health disparities experienced by immigrant Latino men who have sex with men.

What do men who serve as lay health advisers really do?: Immigrant Latino men share their experiences as Navegantes to prevent HIV.

HoMBReS was a lay health adviser (LHA) intervention designed to reduce sexual risk among recently arrived, nonEnglish-speaking Latino men who were members of a multicounty soccer league in central NC. Our community-based participatory research (CBPR) partnership collected, analyzed, and interpreted qualitative life-story narratives to characterize the roles of male LHAs known as Navegantes. Nine Navegantes were interviewed. Their mean age was 39 years (range: 26-62 years); six were from Mexico and three from El Salvador. Navegantes described the function and facilitators of serving as LHAs and identified leverage points for future HIV and STD prevention strategies. They highlighted psychosocial and sociocultural influences on HIV risk, settings for risky behavior, and personal changes from serving as Navegantes. This study provides preliminary evidence that an LHA approach is feasible and appropriate for Latino men, and can be effective in reaching men who might otherwise be difficult to reach.

Factors associated with misperception of weight in the stroke belt.

BACKGROUND: Understanding the reasons for overweight and obesity is critical to addressing the obesity epidemic. Often the decision to lose weight is based as much on one's self-perception of being overweight as on inherent health benefits. OBJECTIVE: Examine the relationships between self-reported health and demographic factors and measured health risk status and the misperception of actual weight status. DESIGN: Cross-sectional study of factors associated with self-perceived overweight status in participants who self-selected to participate in stroke risk factor screenings. Participants were asked, "Are you overweight?" before their body mass index (BMI) was determined from measured weight and self-reported height. Demographics including, sex, race, education, and location; and health status variables including level of exercise and history of high blood pressure and cholesterol were collected. RESULTS: Mean BMI for the group was 30 kg/m(2). Most women (53.1%) perceived themselves to be overweight, whereas most men (59.6%) perceived themselves not to be overweight. Factors related to misperception of weight status varied by actual BMI category. Among individuals with normal BMI, sedentary individuals had 63% higher odds of misperceiving themselves as overweight. Sedentary individuals with obese BMI were at 55% reduced odds of misperceiving themselves as normal weight. CONCLUSIONS: Active obese and overweight individuals may be more likely to incorrectly perceive themselves as normal weight, and thus misperceive their risk for stroke. Thus, it is not enough to only counsel individuals to be active. Physicians and other health professionals need to counsel their clients to both be active and to attain and maintain a healthy weight.

Strengthening community leadership: evaluation findings from the california healthy cities and communities program.

Collaborative approaches to community health improvement such as healthy cities and communities have the potential to strengthen community capacity through leadership development. The healthy cities and communities process orients existing local leadership to new community problem-solving strategies and draws out leadership abilities among residents not previously engaged in civic life. In an evaluation of the California Healthy Cities and Communities (CHCC) Program, leadership development was one of several outcomes assessed at the civic-participation level of the social ecology. Data collection methods included focus groups and surveys, semistructured interviews with coordinators and community leaders, and review of program documents. Findings suggest that the CHCC program enhanced capacity by expanding new leadership opportunities through coalition participation, program implementation, and civic leadership roles related to spin-off organizations and broader collaborative structures. Communities in rural regions were particularly successful in achieving significant leadership outcomes.

Neighborhood mapping and evaluation: a methodology for participatory community health initiatives.

OBJECTIVES: This paper describes the use of neighborhood mapping as a key element in an ecological study of a community-based urban infant mortality prevention program. We propose the use of neighborhood mapping in evaluation research to more fully examine the local context of community health programs. Mapping can be used to study community change and to describe community assets and structural, epidemiological, and social features of neighborhoods that may influence program implementation and outcomes. METHODS: Data on physical features were collected by community residents during street-by-street neighborhood walkthroughs. Other data sources included program records, Census, birth certificate, and state and city data. Analytic methods included geo-coding, exploratory factor analysis to create spatial density indicators of neighborhood features at the Census block group level, and analysis of associations between neighborhood features and outcomes. RESULTS: Point and chloropleth maps provide a powerful illustration of neighborhood features (e.g., vacant buildings), client distribution and participation, health outcomes, and change over time. Factor analysis indicated two salient clusters of non-residential land use: (1) legitimate daily usage (liquor stores and other businesses) and (2) non-legitimate daily use (houses of worship and vacant buildings). A composite scale was created to indicate overall risk related to physical neighborhood features. CONCLUSIONS: Neighborhood mapping is a powerful tool that brings participants and residents into the research process. Moreover, it can improve understanding of the role of neighborhood ecology in program implementation and outcomes.