Communicating to Engage: An Improvisational Theater-Based Communication Training Designed to Support Community-Academic Partnership Development.

PROBLEM: The potential for community-engaged research to address health inequity requires deliberate effort to create trusting and equitable community-academic partnerships. A lack of evidence-based opportunities for cultivating such partnerships remains a barrier. APPROACH: In 2017 and 2018, the authors designed, facilitated, and evaluated a mixed stakeholder training, Communicating to Engage, at 2 urban academic medical centers involved in the All of Us research program, Boston Medical Center and Mass General Brigham. The goal was to bring together researchers and community members to develop communication skills through improvisational theater-based co-learning. The curriculum was inspired by several evidence-based learning frameworks including community-based participatory research principles and improvisational theater techniques. A self-administered survey completed before and after the training session measured participants' communication skills using the Self-Perceived Communication Competence Scale (SPCCS) and comfort with specific communication styles as outlined in the program's training objectives. Paired t tests were used to measure changes in scaled responses among combined participants and separately among self-identified community members and researchers. OUTCOMES: Sixty-nine total participants across 6 workshops completed training evaluations. Overall, pre-post survey analysis demonstrated significant mean score improvement for both the SPCCS and comfort with specific communication styles. In stratified analysis, both community members (n = 26) and researchers (n = 38) reported significant improvement in scores related to comfort with specific communication styles. Only researchers, but not community members, had significant improvement in SPCCS scores. NEXT STEPS: The Communicating to Engage program brought community and researcher stakeholders together and demonstrated improvement in self-perceived communication styles, yet researcher participants benefited more than community participants. Future innovation is necessary to further target community stakeholder communication training needs. Mixed stakeholder improvisational theater-based learning provides deliberate opportunities to build new community-academic partnerships that may enhance health equity initiatives.

The Neighborhood Deprivation Index and Provider Geocoding Identify Critical Catchment Areas for Diabetes Outreach.

PURPOSE: In designing a Project ECHO™ type 1 diabetes (T1D) program in Florida and California, the Neighborhood Deprivation Index (NDI) was used in conjunction with geocoding of primary care providers (PCPs) and endocrinologists in each state to concurrently identify areas with low endocrinology provider density and high health risk/poverty areas. The NDI measures many aspects of poverty proven to be critical indicators of health outcomes. METHODS: The data from the 2013-2017 American Community Survey (ACS) 5-year estimates were used to create NDI maps for California and Florida. In addition, geocoding and 30-minute drive-time buffers were performed using publicly available provider directories for PCPs and endocrinologists in both states by Google Geocoding API and the TravelTime Search Application Programming Interface (API). RESULTS: Based on these findings, we defined high-need catchment areas as areas with (1) more than a 30-minute drive to the nearest endocrinologist but within a 30-minute drive to the nearest PCP; (2) an NDI in the highest quartile; and (3) a population above the median (5199 for census tracts, and 1394 for census block groups). Out of the 12 181 census tracts and 34 490 census block groups in California and Florida, we identified 57 tracts and 215 block groups meeting these criteria as high-need catchment areas. CONCLUSION: Geospatial analysis provides an important initial methodologic step to effectively focus outreach efforts in diabetes program development. The integration of the NDI with geocoded provider directories enables more cost-effective and targeted interventions to reach the most vulnerable populations living with T1D.

The Role of Elders in the Wellbeing of a Contemporary Australian Indigenous Community.

BACKGROUND AND OBJECTIVES: Traditional Elders are integral to the social structure of Australian Indigenous communities. Due to progressive loss of traditional way of life, however, the role of Elders has been eroding. This study aims to develop a conceptual model of the role of Elders in an Australian Indigenous community, with the goal of attaining strategies to strengthen the role of Elders. RESEARCH DESIGN AND METHODS: The study, conducted in a regional Indigenous community in Australia, adopted a community-based participatory approach. Design and focus of the project were informed by a community forum (Yarning Circle). One-on-one semistructured interviews and focus groups with community members were conducted by Indigenous researchers. Group concept mapping (GCM) was applied to elicit major themes in qualitative data, from the point of view of community members, and to derive a conceptual model of the role of Elders. RESULTS: Fifty members of the Indigenous community took part in interviews and focus groups. The participants' median age was 45 years (range 18-76 years); 31 (62%) were female. An additional 24 Indigenous community members took part in the data sorting task of GCM. GCM identified seven major aspects of the role of Elders, including Community relations, Passing down the knowledge, Dealing with racism and oppression, Building a better resourced community, Intergenerational connectedness, Safeguarding our identity, and Caring for our youth. DISCUSSION AND IMPLICATIONS: Elders fulfill many important roles in contemporary Indigenous communities. Our results can be used to assist the community to codesign a program to increase community wellbeing.

The in's and out's of science outreach: assessment of an engaging new program.

Many professors are interested in providing science outreach to local K-12 students, but may not have the time or resources needed to create an engaging presentation. The American Physiological Society supports outreach initiatives through programs such as the Physiology Understanding (PhUn) Week. Building on these activities, it was desired to create and assess an immersive and engaging Outreach Program in a disadvantaged K-12 student population. Three distinct modules were created on cardiovascular physiology, respiratory physiology, and oral health. All resources for these modules underwent peer review and publication, allowing other professors to easily execute their own outreach programming. The outreach modules were presented to 288 students in 3rd, 5th, 6th, and 7th grade classes. Implementation of the modules resulted in significant increases in student content knowledge, ranging from 32 to 57% improvement ( P < 0.001, dependent t-test), with an average increase of 46%. K-12 science teachers reported that the program was at an appropriate educational level, increased students' enthusiasm for science, and increased students' exposure to science careers. Additionally, the presenters of the Outreach Program were perceived to be enthusiastic, knowledgeable, and proficient at interacting with the students. On open-response survey items, the science teachers indicated a high level of satisfaction with the program and an enthusiasm for continued collaborations. These results indicate the importance of organized and interactive science activities for the success of a new Outreach Program.

Establishing an integrated gastroenterology service between a medical center and the community.

AIM: To combine community and hospital services in order to enable improvements in patient management, an integrated gastroenterology service (IGS) was established. METHODS: Referral patterns to specialist clinics were optimized; open access route for endoscopic procedures (including esophago-gastro-duodenoscopy, sigmoidoscopy and colonoscopy) was established; family physicians' knowledge and confidence were enhanced; direct communication lines between experts and primary care physicians were opened. Continuing education, guidelines and agreed instructions for referral were promoted by the IGS. Six quality indicators were developed by the Delphi method, rigorously designed and regularly monitored. Improvement was assessed by comparing 2010, 2011 and 2012 indicators. RESULTS: An integrated delivery system in a specific medical field may provide a solution to a fragmented healthcare system impaired by a lack of coordination. In this paper we describe a new integrated gastroenterology service established in April 2010. Waiting time for procedures decreased: 3 mo in April 30th 2010 to 3 wk in April 30th 2011 and stayed between 1-3 wk till December 30th 2012. Average cost for patient's visit decreased from 691 to 638 NIS (a decrease of 7.6%). Six health indicators were improved significantly comparing 2010 to 2012, 2.5% to 67.5%: Bone densitometry for patients with inflammatory bowel disease, preventive medications for high risk patients on aspirin/NSAIDs, colonoscopy following positive fecal occult blood test, gastroscopy in Barrett's esophagus, documentation of family history of colorectal cancer, and colonoscopy in patients with a family history of colorectal cancer. CONCLUSION: Establishment of an IGS was found to effectively improve quality of care, while being cost-effective.

'Trust and teamwork matter': community health workers' experiences in integrated service delivery in India.

A comprehensive and integrated approach to strengthen primary health care has been the major thrust of the National Rural Health Mission (NRHM) that was launched in 2005 to revamp India's rural public health system. Though the logic of horizontal and integrated health care to strengthen health systems has long been acknowledged at policy level, empirical evidence on how such integration operates is rare. Based on recent (2011-2012) ethnographic fieldwork in Odisha, India, this article discusses community health workers' experiences in integrated service delivery through village-level outreach sessions within the NRHM. It shows that for health workers, the notion of integration goes well beyond a technical lens of mixing different health services. Crucially, they perceive 'teamwork' and 'building trust with the community' (beyond trust in health services) to be critical components of their practice. However, the comprehensive NRHM primary health care ideology - which the health workers espouse - is in constant tension with the exigencies of narrow indicators of health system performance. Our ethnography shows how monitoring mechanisms, the institutionalised privileging of statistical evidence over field-based knowledge and the highly hierarchical health bureaucratic structure that rests on top-down communications mitigate efforts towards sustainable health system integration.

Community organizing practices in a globalizing era: building power for health equity at the community level.

In the postindustrial era, global economic processes have constrained the ability of local agencies, service providers, and civic groups to respond to systemic challenges in public health. Community health psychology can benefit by focusing on interventions through mediating structures that develop innovative methods of leveraging power in the context of globalizing economic forces. Promising methods include careful analysis of power within targeted policy domains and developing strategic alliances with others, so as to exercise social power to affect policy change. The case of ISAIAH, an organizing group based in Minnesota, illustrates innovative avenues for intervention in the context of globalization.

Looking within and beyond the community: lessons learned by researching, theorising and acting to address urban poverty and health.

Urban poverty and health inequalities are inextricably intertwined. By working in partnership with service providers and communities to address urban poverty, we can enhance the wellness of people in need. This article reflects on lessons learned from the Family100 project that explores the everyday lives, frustrations and dilemmas faced by 100 families living in poverty in Auckland. Lessons learned support the need to bring the experiences and lived realities of families to the fore in public deliberations about community and societal responses to urban poverty and health inequality.

All things to all people? The provision of outreach by community mental health teams for older people in England: findings from a national survey.

OBJECTIVE: The objective of this study is to identify the extent of outreach activity community mental health teams (CMHTs) for older people provide to mainstream services in light of the recommendations of the National Dementia Strategy. In particular, to determine the range of settings in receipt of support; to specify the form of this activity; to identify the professionals involved; and to explore the factors associated with the provision of such support. METHODS: A self-administered postal questionnaire was sent to all CMHTs in England. The reported arrangements were categorised and reviewed according to a taxonomy of outreach developed from the literature. RESULTS: Three hundred and seventy six (88%) of the CMHTs responded. Although nearly all teams undertook some outreach work, much of this was informal in nature. Nevertheless, the vast majority of teams had some formal outreach arrangements in at least one mainstream setting. Just less than three-quarters provided support (most typically education) to care homes, approaching half centres to day centres, and over a third to primary care practices, social services teams, home care providers and general hospitals, respectively. Link workers were the favoured means of supporting general hospital staff. Community mental health nurses were most commonly involved in providing outreach, and larger teams were more likely than smaller teams to have formalised arrangements. A significant minority of teams expressed concerns about their capacity to provide effective services. CONCLUSIONS: The findings suggest that both more resources and more evidence will be needed to meet the National Dementia Strategy's aim of improving care for older people with mental health problems in mainstream settings.

Reducing Alaska Native paediatric oral health disparities: a systematic review of oral health interventions and a case study on multilevel strategies to reduce sugar-sweetened beverage intake.

BACKGROUND: Tooth decay is the most common paediatric disease and there is a serious paediatric tooth decay epidemic in Alaska Native communities. When untreated, tooth decay can lead to pain, infection, systemic health problems, hospitalisations and in rare cases death, as well as school absenteeism, poor grades and low quality-of-life. The extent to which population-based oral health interventions have been conducted in Alaska Native paediatric populations is unknown. OBJECTIVE: To conduct a systematic review of oral health interventions aimed at Alaska Native children below age 18 and to present a case study and conceptual model on multilevel intervention strategies aimed at reducing sugar-sweetened beverage (SSB) intake among Alaska Native children. DESIGN: Based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) Statement, the terms "Alaska Native", "children" and "oral health" were used to search Medline, Embase, Web of Science, GoogleScholar and health foundation websites (1970-2012) for relevant clinical trials and evaluation studies. RESULTS: Eighty-five studies were found in Medline, Embase and Web of Science databases and there were 663 hits in GoogleScholar. A total of 9 publications were included in the qualitative review. These publications describe 3 interventions that focused on: reducing paediatric tooth decay by educating families and communities; providing dental chemotherapeutics to pregnant women; and training mid-level dental care providers. While these approaches have the potential to improve the oral health of Alaska Native children, there are unique challenges regarding intervention acceptability, reach and sustainability. A case study and conceptual model are presented on multilevel strategies to reduce SSB intake among Alaska Native children. CONCLUSIONS: Few oral health interventions have been tested within Alaska Native communities. Community-centred multilevel interventions are promising approaches to improve the oral and systemic health of Alaska Native children. Future investigators should evaluate the feasibility of implementing multilevel interventions and policies within Alaska Native communities as a way to reduce children's health disparities.

Patient Protection and Affordable Care Act; Exchange functions: standards for Navigators and non-Navigator assistance personnel; consumer assistance tools and programs of an Exchange and certified application counselors. Final rule.

This final rule addresses various requirements applicable to Navigators and non-Navigator assistance personnel in Federally-facilitated Exchanges, including State Partnership Exchanges, and to non-Navigator assistance personnel in State Exchanges that are funded through federal Exchange Establishment grants. It finalizes the requirement that Exchanges must have a certified application counselor program. It creates conflict-of-interest, training and certification, and meaningful access standards; clarifies that any licensing, certification, or other standards prescribed by a state or Exchange must not prevent application of the provisions of title I of the Affordable Care Act; adds entities with relationships to issuers of stop loss insurance to the list of entities that are ineligible to become Navigators; and clarifies that the same ineligibility criteria that apply to Navigators apply to certain non-Navigator assistance personnel. The final rule also directs that each Exchange designate organizations which will then certify their staff members and volunteers to be application counselors that assist consumers and facilitate enrollment in qualified health plans and insurance affordability programs, and provides standards for that designation.

The illusions and juxtapositions of commercial sexual exploitation among youth: identifying effective street-outreach strategies.

To explore sexually exploited youths' perspectives of how street outreach workers can effectively provide outreach and connections to services, we conducted qualitative interviews with 13 female participants, ages 14 to 22, in a Midwest U.S. city. Participants reported multiple types of exploitation, most first exploited by age 13, plus substance use and recurrent homelessness. Nearly all had a pimp, and all used the internet as a venue for sexual exploitation. Participants wanted outreach workers to use "soft words" to refer to exploitation. They expressed contradictory images of their "boyfriend" pimps and their exploitation. They wanted outreach workers to "provide resources," "be nonjudgmental," "listen," and "care." Street outreach can be one way to support sexually exploited youth but should occur in multiple settings.

Integrating tobacco cessation quitlines into health care: Massachusetts, 2002-2011.

QuitWorks is a Massachusetts referral program that links health care organizations, providers, and patients to the state's tobacco cessation quitline and provides feedback reporting. Designed collaboratively with all major Massachusetts health plans, QuitWorks was launched in April 2002. In 2010, approximately 340 institutions and practices used QuitWorks. Between April 2002 and March 2011, approximately 3,000 unique providers referred patients and 32,967 tobacco users received referrals. An analysis of QuitWorks data showed 3 phases in referrals between April 2002 and March 2011: referrals increased from April 2002 through November 2005, plateaued during December 2005 through January 2009, then substantially increased during February 2009 through March 2011. Factors responsible include partnerships with stakeholders, periodic program promotions, hospital activities in response to Joint Commission tobacco use measures, service evolutions, provision of nicotine replacement therapy for referred patients, and electronic referral options. QuitWorks' history demonstrates that tobacco cessation referral programs can be successfully sustained over time; reach substantial numbers of tobacco users, benefit providers and health care organizations; and contribute to sustainable systems-level changes in health care.

Distinguishing community benefits: tax exemption versus organizational legitimacy.

US policymakers continue to call into question the tax-exempt status of hospitals. As nonprofit tax-exempt entities, hospitals are required by the Internal Revenue Service (IRS) to report the type and cost of community benefits they provide. Institutional theory indicates that organizations derive organizational legitimacy from conforming to the expectations of their environment. Expectations from the state and federal regulators (the IRS, state and local taxing authorities in particular) and the community require hospitals to provide community benefits to achieve legitimacy. This article examines community benefit through an institutional theory framework, which includes regulative (laws and regulation), normative (certification and accreditation), and cultural-cognitive (relationship with the community including the provision of community benefits) pillars. Considering a review of the results of a 2006 IRS study of tax-exempt hospitals, the authors propose a model of hospital community benefit behaviors that distinguishes community benefits between cost-quantifiable activities appropriate for justifying tax exemption and unquantifiable activities that only contribute to hospitals' legitimacy.

A mixed-method exploration of functioning in Safe Schools/Healthy Students partnerships.

This paper presents a mixed-method approach to measuring the functioning of Safe Schools/Healthy Students (SS/HS) Initiative partnerships. The SS/HS national evaluation team developed a survey to collect partners' perceptions of functioning within SS/HS partnerships. Average partnership functioning scores were used to rank each site from lowest to highest. Sites with the most favorable perceptions of partnership functioning were defined as having average scores in the top 10% (n=10) and sites with the least favorable perceptions of partnership functioning were defined as having average scores in the bottom 10% (n=10). Qualitative data for these 20 sites were inductively open coded for emergent themes and analyzed for patterns using grounded theory approach. Six themes emerged that distinguished sites reporting the most favorable and least favorable perceptions of partnership functioning: partner engagement, facilitators, barriers, shared decision making, partnership structure, and sustainability. Sites reporting the most favorable perceptions of partnership functioning effectively utilized collaboration processes that facilitate coalition building, such as shared decision making, effective communication, and developing a clearly defined structure. Qualitative themes from this analysis provide evidence of validity for the partnership functioning scale used and illustrate distinguishing features between sites with the most favorable and least favorable perceptions of partnership functioning.

Involvement of consumers in studies run by the Medical Research Council Clinical Trials Unit: results of a survey.

BACKGROUND: We aimed to establish levels of consumer involvement in randomised controlled trials (RCTs), meta-analyses and other studies carried out by the UK Medical Research Council (MRC) Clinical Trials Unit across the range of research programs, predominantly in cancer and HIV. METHODS: Staff responsible for studies that were included in a Unit Progress Report (MRC CTU, April 2009) were asked to complete a semi-structured questionnaire survey regarding consumer involvement. This was defined as active involvement of consumers as partners in the research process and not as subjects of that research. The electronic questionnaires combined open and closed questions, intended to capture quantitative and qualitative information on whether studies had involved consumers; types of activities undertaken; recruitment and support; advantages and disadvantages of involvement and its perceived impact on aspects of the research. RESULTS: Between October 2009 and April 2010, 138 completed questionnaires (86%) were returned. Studies had been conducted over a 20 year period from 1989, and around half were in cancer; 30% in HIV and 20% were in other disease areas including arthritis, tuberculosis and blood transfusion medicine. Forty-three studies (31%) had some consumer involvement, most commonly as members of trial management groups (TMG) [88%]. A number of positive impacts on both the research and the researcher were identified. Researchers generally felt involvement was worthwhile and some felt that consumer involvement had improved the credibility of the research. Benefits in design and quality, trial recruitment, dissemination and decision making were also perceived. Researchers felt they learned from consumer involvement, albeit that there were some barriers. CONCLUSIONS: Whilst most researchers identified benefits of involving consumers, most of studies included in the survey had no involvement. Information from this survey will inform the development of a unit policy on consumer involvement, to guide future research conducted within the MRC Clinical Trials Unit and beyond.

Regular provision of outreach increases acceptance of cataract surgery in South India.

OBJECTIVES: The prevalence of visual loss and blindness from cataract remains high in India. Marginalized communities are frequently reached through outreach clinics. The aim of this study was to explore the hypothesis that regular outreach, held in the same location by the same provider, leads to greater acceptance of cataract surgery than outreach clinics that are irregular in terms of timing and location. METHODS: The study was integrated into outreach clinics run in two districts by Sankara Eye Centre, Coimbatore, Southern India. A semi-structured questionnaire was administered to patients who had attended outreach eye clinics and either accepted or not accepted the offer of cataract surgery. RESULTS: Overall acceptance of surgery was high (91.7%), being higher in the district with regular outreach (94.6%vs. 82.3%, P < 0.001). A total of 398 participants (240, 60% acceptors) were interviewed. Acceptors were more likely to live in smaller households and in supportive families than non-acceptors who lived in larger families which could not provide support and where transport and distance were also barriers (P .001). Attending regular outreach and having had first eye cataract surgery were independent predictors of acceptance in a logistic regression model. CONCLUSION: The findings indicate the importance of providers building trust by organizing regular outreach in the same location. Previous eye surgery was also a strong predictor of accepting cataract surgery. To promote universal access to health care, marginalized rural communities will continue to need outreach for some time to come.