A framework for building comprehensive cancer center's capacity for bidirectional engagement.

PURPOSE: Community engagement has benefits for cancer centers' work and for its researchers. This study examined the experiences and perceptions of community engagement by members of the Case Comprehensive Cancer Center (Case CCC) to create and implement a framework to meet the needs of the entire cancer center. METHODS: This study included three phases: 1) Semi-structured interviews with 12 researchers from a basic science program to identify needs and suggestions for the support of community engagement; 2) Preliminary interview results informed the development of a survey of 86 cancer center members' about their awareness of and readiness to integrate community outreach and engagement into their research; and 3) The Case CCC Office of Community Outreach and Engagement reviewed the results from phases 1 and 2 to develop and then utilize a framework of engagement opportunities. RESULTS: In the interviews and surveys, cancer center members recognized the importance of community engagement and expressed an interest in participating in COE-organized opportunities for bidirectional engagement. While participation barriers include communication issues, limited awareness of opportunities, and competing priorities, members were open to learning new skills, changing approaches, and utilizing services to facilitate engagement. The framework outlines engagement opportunities ranging from high touch, low reach to low touch, and high reach and was used to develop specific services. CONCLUSION: This study identified varying needs around community engagement using an approach aimed at understanding the perspectives of a community of scientists. Implementing the framework enables reaching scientists in different ways and facilitates scientists' recognition of and engagement with opportunities.

Common Social and Health Disparities Contribute to Racial Differences in Ambulatory Impairment in Multiple Sclerosis.

BACKGROUND: We previously reported more rapid accrual of ambulatory impairments in Black compared to White individuals with relapsing remitting multiple sclerosis (RRMS) and higher body mass index (BMI). Hypertension and lower neighborhood socioeconomic status (SES) were associated with greater impairment, irrespective of race. We hypothesize that these common social and health inequities may explain a substantial portion of the racial differences in ambulation in American individuals with RRMS. METHODS: Causal mediation analyses investigated baseline and change-over-time mediators of ambulatory impairment differences between 1795 Black and White individuals with RRMS using a retrospective cohort study comprised of electronic health record data from 8491 clinical encounters between 2008 and 2015 where Timed 25-Foot Walk (T25FW) speeds without assistive devices were recorded. The hypothesis was that BMI, neighborhood SES, and hypertension were possible mediators. RESULTS: At baseline, Black individuals with RRMS (n = 175) had significantly slower T25FW speeds (5.78 vs 5.27 ft/s), higher BMI, a higher prevalence of hypertension, and they were more likely to live in lower-income neighborhoods than White individuals (n = 1,620). At baseline, a significant proportion (33.7%; 95% CI, 18.9%-59.4%) of the T25FW difference between Black and White individuals was indirectly due to a higher BMI (12.5%), hypertension burden (9.5%), and living in lower-income neighborhoods (11.2%). Once baseline mediation relationships were accounted for, there were no significant longitudinal mediation relationships. CONCLUSIONS: The findings implicate social and health disparities as prominent drivers of ambulatory differences between Black and White individuals with RRMS, suggesting that wellness and health promotion are essential components of MS care, particularly for Black individuals.

Smoking and cessation behaviors in patients at federally funded health centers - United States, 2014.

BACKGROUND: Federally funded health centers (HCs) provide care to the most vulnerable populations in the U.S., including populations with disproportionately higher smoking prevalence such as those with lower incomes. METHODS: This study compared characteristics of adult HC patients, by cigarette smoking status, and assessed smoking cessation-related behaviors using 2014 Health Center Patient Survey data; analysis was restricted to adults with data on cigarette smoking status (n = 5583). Chi-square and logistic regression analyses were conducted. RESULTS: Overall, 28.1 % were current smokers and 19.2 % were former smokers. Current smokers were more likely to report fair/poor health (48.2 %) and a high burden of behavioral health conditions (e.g., severe psychological distress 23.9 %) versus former and never smokers. Most current smokers reported wanting to quit in the past 12 months (79.0 %) and receiving advice to quit from a healthcare professional (78.7 %). In a multivariable model, age <45, non-white race, COPD diagnosis, and past 3-month marijuana use were significantly associated with desire to quit. Few former smokers (15.2 %) reported using cessation treatment, though use was higher among those who quit within the previous year (30.6 %). CONCLUSIONS: Although most current smokers reported a desire to quit, low uptake of evidence-based treatment may reduce the number who attempt to quit and succeed. Given the burden of tobacco use, future efforts could focus on identifying and overcoming unique personal, healthcare professional, or health system barriers to connecting them with cessation treatments. Increasing access to cessation treatments within HCs could reduce smoking-related disparities and improve population health.

"The coupons and stuff just made it possible": economic constraints and patient experiences of a produce prescription program.

Although produce prescription (PRx) programs have been shown to improve fruit and vegetable (FV) consumption, few studies have examined how economic constraints influence participant experience. We conducted a qualitative study of patient experience of a 3-month PRx program for hypertension (PRxHTN) including 3 safety-net clinics and 20 farmers' markets (FMs). We interviewed 23 PRxHTN participants using semistructured guides to understand their program experiences. Interviews were audio-taped, transcribed, and analyzed to identify a priori and emergent themes. PRxHTN participants completing qualitative interviews were mostly middle-aged (mean: 62 years) African American (100%) women (78%). Economic hardship as a barrier to maximum program participation and sustainability was a main theme identified, with three subthemes: (i) transportation issues shaped shopping and eating patterns and limited participant ability to access FMs to utilize PRxHTN vouchers; (ii) limited and unstable income shaped participant shopping and eating behavior before, during, and after PRxHTN; and (iii) participants emphasized individual-level influences like personal or perceived motivations for program participation, despite significant structural constraints, such as economic hardship, shaping their program engagement. Future PRx programs should bolster economic and institutional supports beyond FM vouchers such as transportation assistance, partnering with local food banks and expansion to local grocery stores offering year-round FV access to support sustained behavior change. Additionally, structural competency tools for providers may be warranted to reorient focus on structural influences on program engagement and away from potentially stigmatizing individual-level explanations for program success. These efforts have potential to enhance the translation of PRx programs to the needs of economically vulnerable patients who struggle to manage chronic illness and access basic nutrition.

Dietary Impact of Produce Prescriptions for Patients With Hypertension.

INTRODUCTION: Little is known regarding the impact of produce prescriptions within the context of hypertension visits at safety net clinics. We evaluated intervention effectiveness on patient usage of farmers markets and dietary change related to fruit and vegetable consumption. METHODS: Health Improvement Partnership - Cuyahoga worked with 3 clinics to integrate, implement, and evaluated a produce prescription for hypertension (PRxHTN) program. PRxHTN involves 3 monthly, nonphysician provider visits, comprising blood pressure measurement, nutrition counseling, and four $10 farmers market produce vouchers, for hypertensive adult patients screening positive for food insecurity. Dietary measures were collected at visits 1 and 3. Voucher use was tracked via farmers market redemption logs. RESULTS: Of the 224 participants from 3 clinics, most were middle-aged (mean age, 62 y), female (72%), and African American (97%) and had a high school education or less (62%). Eighty-six percent visited a farmers market to use their produce vouchers, with one-third reporting it was their first farmers market visit ever. Median number of farmers market visits was 2 (range: 0-6), and median number of vouchers redeemed was 8 (range: 0-12). Among the subsample with follow-up survey data (n = 137), significant improvement in fruit and vegetable consumption was observed as well as a decline in fast food consumption. CONCLUSION: PRxHTN participants visited at least 1 farmers market, reported increases in provider communication related to diet, and exhibited significant changes in dietary behavior. PRxHTN can serve as a strong model for linking safety net clinics with farmers markets to promote community resource use and improve fruit and vegetable consumption among food-insecure patients with hypertension.

Attitudes and Risk Perceptions Toward Smoking Among Adolescents Who Modify Cigar Products.

Objective: To examine high school youths' perceptions of health risks, and personal and parental attitudes toward cigarette, cigar, and marijuana use among youth who use or modify cigars. Participants: The 2013 Cuyahoga County Youth Risk Behavior Survey used a two-stage cluster sample design to randomly sample public high schools and classrooms. Students in selected classrooms were eligible; 16,855 students completed the survey. Main Outcome Measures: This study examines the association between risk perceptions of and youths' personal and parental attitudes toward smoking cigarettes, cigars, and marijuana with current use of cigars, cigarillos or little cigars (CCLCs) or modified CCLCs (ie, freaking or blunting). Results: 23.5% of youth reported current use of CCLCs in some way; 11.0% reported current freaking and 18.5% reported current blunt use. CCLC users tended to be male and Black. Perceiving all smoking behaviors as risky, wrong, or wrong by parents reduced odds of using CCLCs. After multivariate analysis, Blacks had increased odds of using CCLCs if they perceived smoking cigarettes as harmful, which was not found among other race/ethnicity categories. Having parents who believed that smoking CCLCs is wrong increased the odds of youth freaking or blunting among all CCLC users. Odds of blunting was greater for those who believed CCLCs were more risky among all CCLC users. Conclusions: Findings suggest that CCLC users may think cigars are safer than cigarettes, and that modifiers may think their use is safer and more in line with their parents' views than non-modified CCLCs.

Developing multidimensional measures of healthy food access among low-income adults in Cleveland, Ohio, USA.

OBJECTIVE: Access to nutritious foods is key to achieving health promotion goals. While there is evidence that nutritious food access is complex, measures assessing multiple domains of access, including spatial-temporal, economic, social, service delivery and personal, are lacking. The current study evaluates psychometric properties of scales designed to measure perceptions of multiple domains of nutritious food access among low-income populations. DESIGN: A cross-sectional survey was conducted in 2015. Eighty-one items were selected or developed to represent five domains of nutritious food access for food shopping overall and specific to shopping at farmers' markets. Evaluation of the items included exploratory factor analysis within each domain and internal consistency reliability for each of the sub-scales. SETTING: Data were collected in seventeen urban neighbourhoods in Greater Cleveland, Ohio, USA that have high levels of poverty. All participants had access to at least one farmers' market within 1·6 km (1 mile) of their home to standardize spatial access to nutritious foods. SUBJECTS: Adults (n 304) receiving Supplemental Nutrition Assistance Program benefits. RESULTS: Each domain included multiple sub-domains: spatial-temporal (four), service delivery (two), economic (two), social (three) and personal (three), for a total of fourteen subdomains. The internal consistency reliability for one of the sub-domains was outstanding (>0·90), seven were excellent (0·80-0·89), five were very good (0·70-0·79) and one scale had poor reliability (0·58). CONCLUSIONS: Multiple sub-domains of nutritious food access can be assessed using short measures that have been tested for internal consistency. These measures are suitable for assessing the complex phenomena of nutritious food access among low-income populations.

Evaluation of the use of audio-enhanced personal digital assistants to survey Latino migrant farmworkers.

We describe the feasibility of audio-enhanced personal digital assistants (ADPAs) for data collection with 60 Latino migrant farmworkers. All participants chose to complete APDA surveys rather than using paper-and-pencil. No one left the study prematurely: two (3%) data cases were lost due to technical difficulties. Across all data .27% missing data were observed: nine missing responses on eight items. Participants took 19 minutes on average to complete the 58-question survey. The factor most influential for completion was education level. APDA methodology enabled both English- and Spanish-speaking Latino migrant farmworkers to become active research participants with minimal loss of data.

A randomized controlled trial for the primary prevention of osteoporosis among preadolescent girl scouts: 1-year outcomes of a behavioral program.

OBJECTIVE: To provide 1-year outcomes for a randomized controlled trial of a behavioral-educational intervention for the primary prevention of osteoporosis among 247 preadolescent girls. METHODS: Girl Scout troops were randomly assigned to one of two intervention groups-a group comprising girls only (n = 73) and girls with their mothers (n = 94)-and a healthy-lifestyles control group (n = 80). Multilevel (hierarchical) models were employed to account for clustering of girls within troops. RESULTS: Among girls who met the recommended levels of Ca at baseline, those in the intervention were significantly more likely to maintain or improve their intake at follow-up compared to controls. No significant group differences were found for changes in WBPA. CONCLUSIONS: A behavioral intervention for the primary prevention of osteoporosis holds promise for maintaining adequate Ca intake among preadolescent females.

Parental monitoring, negotiated unsupervised time, and parental trust: the role of perceived parenting practices in adolescent health risk behaviors.

PURPOSE: To compare two different parenting practices (parental monitoring and negotiated unsupervised time) and perceived parental trust in the reporting of health risk behaviors among adolescents. METHODS: Data were derived from 692 adolescents in 9th and 10th grades (x = 15.7 years) enrolled in health education classes in six urban high schools. Students completed a self-administered paper-based survey that assessed adolescents' perceptions of the degree to which their parents monitor their whereabouts, are permitted to negotiate unsupervised time with their friends and trust them to make decisions. Using gender-specific multivariate logistic regression analyses, we examined the relative importance of parental monitoring, negotiated unsupervised time with peers, and parental trust in predicting reported sexual activity, sex-related protective actions (e.g., condom use, carrying protection) and substance use (alcohol, tobacco, and marijuana). RESULTS: For males and females, increased negotiated unsupervised time was strongly associated with increased risk behavior (e.g., sexual activity, alcohol and marijuana use) but also sex-related protective actions. In males, high parental monitoring was associated with less alcohol use and consistent condom use. Parental monitoring had no affect on female behavior. Perceived parental trust served as a protective factor against sexual activity, tobacco, and marijuana use in females, and alcohol use in males. CONCLUSIONS: Although monitoring is an important practice for parents of older adolescents, managing their behavior through negotiation of unsupervised time may have mixed results leading to increased experimentation with sexuality and substances, but perhaps in a more responsible way. Trust established between an adolescent female and her parents continues to be a strong deterrent for risky behaviors but appears to have little effect on behaviors of adolescent males.