"I'm not going to be a guinea pig:" Medical mistrust as a barrier to male contraception for Black American men in Los Angeles, CA.

BACKGROUND: Racial disparities in unintended pregnancy and contraceptive use in the United States are not mediated by access to family planning services alone. Rather, a history of medical mistrust underlies Black Americans' adoption of new medical technologies, inclusive of contraception. Efforts to develop hormonal male contraceptives need to incorporate Black Americans' experiences and perspectives so that new contraceptives enable their reproductive goals and promote gender equity. STUDY DESIGN: Working with our community-based partner, Healthy African American Families in Los Angeles, California, we conducted six 60-minute focus group discussions with 39 Black men over age 18, in ongoing heterosexual relationships, to explore attitudes towards and willingness to use hormonal male contraceptives. RESULTS: Just over one-third (35%) of respondents reported willingness to use or rely on hormonal male contraceptives. The majority held negative attitudes about hormonal male contraceptives, citing concerns about side effects and safety. Several respondents expressed mistrust of the medical community and medical research, noting that hormonal male contraceptives could be used against Black communities; several expressed unwillingness to trial hormonal male contraceptives without years of testing. However, all groups described scenarios where they would use them despite stated concerns. CONCLUSIONS: Black men's hypothetical willingness to use hormonal male contraceptives is limited by medical mistrust, which may be overcome by their concerns about the unreliability of current options or the contraceptive behaviors of female partners. Nevertheless, addressing Black Americans' history of medical mistreatment and exploitation will be essential for hormonal male contraceptives to positively contribute to Black men's reproductive options and agency. IMPLICATIONS: While the development of reversible, hormonal male contraception intends to fulfill unmet global needs for contraception, the utility of these hormonal male contraceptive methods among Black men living on low incomes in Los Angeles, California cannot be fully realized until developers address and overcome historical and ongoing medical mistrust.

Food insecurity among nursing students: A mixed methods study.

BACKGROUND: College students are among 48.1 table million Americans who experience food insecurity, affecting aspects of daily living, health, and academic performance. This study sought to assess food security in nursing students to determine the prevalence and significance of this issue. METHODS: A mixed-methods descriptive design was utilized to collect and analyze data through an online survey of junior and senior undergraduate nursing students. Both qualitative and quantitative questions were related to personal experience with food insecurity. RESULTS: Approximately 40% of students responded that they were Sometimes/Often worried that food would run out before the next income arrived. In addition, 52% of the participants Sometimes/Often could not afford an adequate amount of food, and 35% reported having a shortage of food. CONCLUSION: University leadership, College of Nursing administrators, and nursing faculty should be aware of food insecurity among their students and identify strategies to assess and decrease this issue.

African American Women's Perceptions of Cardiovascular Disease After Myocardial Infarction: A Phenomenological Inquiry.

BACKGROUND: The primary cause of death among African American women older than 50 years is cardiovascular disease. Cardiovascular disease affects more than 16.8 million Americans and occurs when plaque builds up in the arteries that provide blood to the heart. This often leads to a partial or complete blockage, causing a myocardial infarction (heart attack). There is limited research regarding the lived experiences of African American women before and after a myocardial infarction. OBJECTIVE: The purpose of this qualitative study was to explore the experiences of African American women living in the southern region of the United States who have experienced a myocardial infarction. METHODS: A hermeneutic phenomenological framework guided the study. Semistructured, audiotaped interviews were conducted to elicit narratives from 7 participants. Interview data were transcribed verbatim and then coded and analyzed using Colaizzi's phenomenological analysis framework. RESULTS: The findings revealed 6 major themes: life before myocardial infarction, causes of my myocardial infarction, myocardial infarction warning signs, life after myocardial infarction, cardiac rehabilitation, and family support. Lifestyle changes must be implemented to prevent a second blockage. Attending cardiac rehabilitation and incorporating regular physical exercise are recommended to help prevent further heart damage and to improve quality of life.

Depression Remission From Community Coalitions Versus Individual Program Support for Services: Findings From Community Partners in Care, Los Angeles, California, 2010-2016.

Objectives. To explore effects of coalitions (Community Engagement and Planning [CEP]) versus technical assistance (Resources for Services [RS]) for depression collaborative care and the effects of social determinants on long-term remission outcomes. Methods. We randomized 95 health care and community programs in Los Angeles County, California, to CEP or RS. In 2010, 1246 depressed (Patient Health Questionnaire [PHQ-8] ≥ 10) adults enrolled and were invited for baseline and 6-, 12-, and 36-month surveys. Of 598 3-year completers, 283 participated at 4 years (2016). We examined effects of CEP versus RS, social factors (e.g., family income, food insecurity) on time to and periods in clinical (PHQ-8 < 10) and community-defined (PHQ-8 < 10 or PHQ-2 < 3; mental health composite score [MCS-12] > 40, or mental wellness) remission during the course of 3 years, and at 4 years. Results. We found that CEP versus RS increased 4-year depression remission and, for women, community-defined remission outcomes during the course of 3 years. Social factors and clinical factors predicted remission. Conclusions. At 4 years, CEP was more effective than RS at increasing depression remission. Public Health Implications. Coalitions may improve 4-year depression remission, while addressing social and clinical factors associated with depression may hold potential to enhance remission.

Clinical Practice Recommendations for Pediatric Dyslipidemia.

The leading cause of mortality in the United States is atherosclerotic cardiovascular disease (ASCVD). Atherosclerotic lesions begin during childhood and can place individuals at greater risk for ASCVD. Providers play an active role in preventing the progression of risk factors and future ASCVD events through appropriate clinical management of genetic and acquired dyslipidemias in the pediatric population. Health care providers need to be aware of current recommendations related to screening for dyslipidemia, lifestyle modification strategies, pharmacologic treatment, and guidelines for ongoing monitoring. Most patients with mild to moderate dyslipidemia can be managed by a primary care provider. It is imperative that providers understand the pathophysiology, screening methods, and available treatment options to effectively manage the condition. Frequent reassessment of family history and adherence to lifestyle modifications and pharmacologic interventions is essential for effective treatment.

How can we help African American substance users stop smoking? client and agency perspectives.

Research is needed to better understand barriers to smoking cessation and sustained abstinence among racial/ethnic minority polydrug users. We conducted community dialogue groups involving 49 clients in substance use treatment programs with predominantly ethnic minority clientele and individual dialogues/interviews with seven program providers (stakeholders). Most clients were African American, under 40 years old, women, current smokers, and high school graduates. Smoking cessation services in these programs were considered inadequate and community programs insufficiently culturally tailored and economically and geographically inaccessible. Participants discussed individual "willpower" and choice; agency tobacco-related programs and policies; the relationships between smoking, smoking cessation, and treatment goals; and steps needed to reshape agency services and policies to provide greater support for smoking cessation in this at-risk population.

The Community and Patient Partnered Research Network (CPPRN): Application of Patient-Centered Outcomes Research to Promote Behavioral Health Equity.

Objective: We describe the rationale, development, and progress on the Community and Patient Partnered Research Network (CPPRN). The CPPRN builds on more than a decade of partnered work and is designed to promote health equity by developing partnered research on behavioral health and social risk factors in Los Angeles and New Orleans. Setting: A community-academic partnership across Los Angeles County and New Orleans. Methods: Review of rationale, history, structure, activities and progress in applying community partnered participatory research (CPPR) to CPPRN. Findings: Patient and community stakeholders participated in all phases of development, including local and national activities. Key developments include partnered planning efforts, progress on aggregating a large, de-identified dataset across county agencies, and development of an information technology-supported screening approach for behavioral and social determinants in health care, social, and community-based settings. Conclusion: The CPPRN represents a promising approach for research data networks, balancing the potential benefit of information technology and data analytic approaches while addressing potential risks and priorities of relevant stakeholders.

Lessons on Patient and Stakeholder Engagement Strategies for Pipeline to Proposal Awards.

The Patient Centered Outcomes Research Institute (PCORI) supports patient-centered clinical comparative effectiveness research (CER) including health disparities and engagement portfolios. In 2013, PCORI launched the Pipeline to Proposal (P2P) mechanism to support development of novel patient- and stakeholder-centered partnerships focused on designing clinical CER funding proposals. By providing a tiered structure of successive small contracts and technical assistance, the P2P mechanism encourages development of new research partnerships among diverse stakeholders. As a comparatively new field, patient-centered outcomes research (PCOR) has few well-delineated methods for engaging patients and other non-scientists in effective teams with academics or clinicians to develop and implement rigorous, scientific research proposals. Community partnered participatory research (CPPR) provides a useful framework for structuring new partnerships. In this article we highlight the origins, development, and prospects of three current examples of funded P2P initiatives based in New Orleans and Los Angeles. We outline how these projects - Prisoner to Patient, the NOLA Partnership, and Resilience Among African American Men - use CPPR principles. We also describe how they have collaborated with, and contributed to, a two-way learning and knowledge exchange among members of the PCORI-funded Community and Patient Partnered Research Network. Lessons learned may be applicable to other groups planning to create new partnerships focused on implementing PCOR.

Comparative Effectiveness of Coalitions Versus Technical Assistance for Depression Quality Improvement in Persons with Multiple Chronic Conditions.

Significance: Prior research suggests that Community Engagement and Planning (CEP) for coalition support compared with Resources for Services (RS) for program technical assistance to implement depression quality improvement programs improves 6- and 12-month client mental-health related quality of life (MHRQL); however, effects for clients with multiple chronic medical conditions (MCC) are unknown. Objective: To explore effectiveness of CEP vs RS in MCC and non-MCC subgroups. Design: Secondary analyses of a cluster-randomized trial. Setting: 93 health care and community-based programs in two neighborhoods. Participants: Of 4,440 clients screened, 1,322 depressed (Patient Health Questionnaire, PHQ8) provided contact information, 1,246 enrolled and 1,018 (548 with ≥3 MCC) completed baseline, 6- or 12-month surveys. Intervention: CEP or RS for implementing depression quality improvement programs. Outcomes and Analyses: Primary: depression (PHQ9 <10), poor MHRQL (Short Form Health Survey, SF-12<40); Secondary: mental wellness, good physical health, behavioral health hospitalization, chronic homelessness risk, work/workloss days, services use at 6 and 12 months. End-point regressions were used to estimate intervention effects on outcomes for subgroups with ≥3 MCC, non-MCC, and intervention-by-MCC interactions (exploratory). Results: Among MCC clients at 6 months, CEP vs RS lowered likelihoods of depression and poor MHRQL; increased likelihood of mental wellness; reduced work-loss days among employed and likelihoods of ≥4 behavioral-health hospitalization nights and chronic homelessness risk, while increasing faith-based and park community center depression services; and at 12 months, likelihood of good physical health and park community center depression services use (each P<.05). There were no significant interactions or primary outcome effects for non-MCC. Conclusions: CEP was more effective than RS in improving 6-month primary outcomes among depressed MCC clients, without significant interactions.

Maintaining Internal Validity in Community Partnered Participatory Research: Experience from the Community Partners in Care Study.

Objective: With internal validity being a central goal of designed experiments, we seek to elucidate how community partnered participatory research (CPPR) impacts the internal validity of public health comparative-effectiveness research. Methods: Community Partners in Care (CPIC), a study comparing a community-coalition intervention to direct technical assistance for disseminating depression care to vulnerable populations, is used to illustrate design choices developed with attention to core CPPR principles. The study-design process is reviewed retrospectively and evaluated based on the resulting covariate balance across intervention arms and on broader peer-review assessments. Contributions of the CPIC Council and the study's design committee are highlighted. Results: CPPR principles contributed to building consensus around the use of randomization, creating a sampling frame, specifying geographic boundaries delimiting the scope of the investigation, grouping similar programs into pairs or other small blocks of units, collaboratively choosing random-number-generator seeds to determine randomized intervention assignments, and addressing logistical constraints in field operations. Study protocols yielded samples that were well-balanced on background characteristics across intervention arms. CPIC has been recognized for scientific merit, has drawn attention from policymakers, and has fueled ongoing research collaborations. Conclusions: Creative and collaborative fulfillment of CPPR principles reinforced the internal validity of CPIC, strengthening the study's scientific rigor by engaging complementary areas of knowledge and expertise among members of the investigative team.

Partnering with African American Churches to Create a Community Coalition for Mental Health.

Community partnered participatory research (CPPR) emphasizes community engagement, respect, and empowerment as guiding principles to promote mental health equity. This article describes the "Vision" stage of a CPPR-informed model to implement evidence-based practices for depression in two African American churches in Harlem, New York. Essential parts of the Vision include engagement of stakeholders and collaborative planning. The engagement process increased awareness about the project via a community-focused mental health symposium. The collaborative planning stage resulted in creating a multi-disciplinary Community Coalition for Mental Health, establishing the Coalition's values, agreeing to change the initial chosen study intervention from Interpersonal Counseling to Mental Health First Aid, and developing a website to disseminate the group's work. Key lessons learned from our partnered process are: 1) support from the lead pastor is crucial; 2) balancing community and academic interests can be challenging; 3) icebreaker activities foster relationships and reinforce CPPR principles; 4) multiple communication channels can enhance community participation; and, 5) should organize data in ways that make them easier to interpret.

Engaging African American Veterans with Health Care Access Challenges in a Community Partnered Care Coordination Initiative: A Qualitative Needs Assessment.

Background: Little has been written about engaging potentially eligible members of a health care system who are not accessing the care to which they are entitled. Knowing more about the experiences of African American Veterans who regularly experience health care access challenges may be an important step toward equitable, coordinated Veterans Health Administration (VHA) care. This article explores the experiences of African American Veterans who are at risk of experiencing poor care coordination. Design: We partnered with a community organization to recruit and engage Veterans in three exploratory engagement workshops between October 2015 and February 2016. Participants and Setting: Veterans living in South Los Angeles, California. Main Outcome Measures: Veterans were asked to describe their experiences with community care and the VHA, a division of the US Department of Veterans Affairs (VA). Field notes taken during the workshops were analyzed by community and academic partners using grounded theory methodology to identify emergent themes. Results: 12 Veterans and 3 family members of Veterans participated in one or more engagement workshops. Their trust in the VA was generally low. Positive themes included: Veterans have knowledge to share and want to help other Veterans; and connecting to VA services can result in positive experiences. Negative themes included: functional barriers to accessing VA health care services; insensitive VA health care environment; lack of trust in the VA health care system; and Veteran status as disadvantageous for accessing non-VA community services. Conclusions: Veterans living in underserved areas who have had difficulty accessing VA care have unique perspectives on VA services. Partnering with trusted local community organizations to engage Veterans in their home communities is a promising strategy to inform efforts to improve care access and coordination for vulnerable Veterans.

Participatory Technology Development to Enhance Community Resilience.

Objective: To assess the feasibility of a novel, partnered technology development process to co-create mobile health applications (apps) addressing community health priorities, using psychoeducation of cognitive behavioral therapy (CBT) principles for enhancing resilience as an example. Design: Stakeholder engagement, workgroups, pilot feasibility study using mixed methods during October 2013 through January 2016 over three phases: 1) defining the vision of the project and increasing technical capacity, 2) co-development and pilot testing of the app, and 3) planning for sustainability. Setting: An academic-community partnership in South Los Angeles, California. Participants: Eight stakeholders; 30 pilot participants from the community. Main Outcome Measures: Qualitative analysis of audio-recordings of the app development process and stakeholder interviews, surveys of stakeholders' perception of the development process, app use data, and feedback from pilot participants. Results: The participatory technology development process resulted in creation and pilot-testing of a resiliency-focused text messaging app. Of the 1,107 messages sent, 23 out of 30 (77%) app users responded to explore interactive content. Stakeholders reported increased perceived competency in creating mobile apps and that the process fostered a culture of co-leadership. There was also sustained engagement in mobile app development by stakeholders beyond the initial project period. Conclusions: This is the first study, to our knowledge, to demonstrate the feasibility of participatory technology development, an approach involving direct participation in the development, tailoring and maintenance of a mobile app by a broad set of stakeholders with high representation from racial/ethnic minorities from an under-resourced community. Participatory technology development is a promising approach for creating sustainable, relevant and engaging health technologies across different technological, clinical and community settings.

Community Partnership in Precision Medicine: Themes from a Community Engagement Conference.

Background: Patient and community engagement in under-resourced communities is a key issue for precision medicine research. We report proceedings from a community-academic partnered conference in Los Angeles to promote community understanding of precision medicine and generate engagement recommendations. Methods: Planning group review of planning, presentations, and audience discussions from facilitator notes and participant survey data from a one-day conference. Findings: Community-academic planning broadened community participation and presentations. More than 80% of survey participants indicated they would participate in the national precision medicine initiative, and most were willing to share diverse sources of data. Discussions identified trust concerns related to historical research abuses, data privacy, potential effects of findings on health care, personal safety, research procedures, the time-frame for benefit, and confusion about different initiatives. Concerns were balanced by belief in science to improve health. Recommendations included a community partnered participatory approach with support for local community and academic teams to engage stakeholders with written/online resources and partnered workgroups addressing key concerns. Conclusion: Conference participants expressed high willingness to participate in precision medicine studies, but discussions highlighted trust and transparency issues and suggested community partnered research with local capacity building.

Sexual Health Behavior and Mental Health Among Older African American Women: The Sistahs, Sexuality, and Mental Health Well-Being Project.

BACKGROUND: In Los Angeles County, the rates of sexually transmitted infections and diseases among African Americans represent a significant public health disparity. Older African American women are at particular risk as they are more likely to engage in high-risk sexual behaviors and report social isolation and loneliness than their younger counterparts. However, the literature on the relationship between sexual health and mental health in this group is limited. The purpose of this study was to use a community-based participatory research (CBPR) approach to better understand sexual health behaviors and mental health among African American women over 50 years of age who reside in South Los Angeles. MATERIALS AND METHODS: This project was divided into two phases. Phase I (January-March 2017) of the project consisted of four dialog/focus groups (N = 45) (ages: 50-80; Mage = 67). The purpose of Phase II (April 2017) was to present study results from Phase I to the community via a community-based conference, as well as gather feedback and generate discussion about the next steps for community prevention/intervention. RESULTS: Women reported that they did not feel comfortable discussing sexual practices with their physician, partners, and friends. Most women identified depression, loneliness, and self-esteem issues as reasons for engaging in high-risk sexual behaviors. During Phase II, potential intervention avenues emerged to address issues such as lack of physician-patient communication, lack of community support, and dialogs about sex. CONCLUSIONS: The use of CBPR greatly enhanced our knowledge of the core issues surrounding sexual health and mental health among older African American women.

Initiating Dialogue in Community-Partnered Participatory Research to Address Obesity in South Los Angeles.

In South Los Angeles, a community-engaged research project on obesity was initiated between a translational research institute seeking to build community-based or partnered participatory research (CBPR/CPPR) capacity, and a community partner with extensive experience. This manuscript describes the partnership-building process and discusses results from a bi-directional knowledge transfer event.

Comparative Effectiveness of Two Models of Depression Services Quality Improvement in Health and Community Sectors.

OBJECTIVE: The effectiveness of community coalition building and program technical assistance was compared in implementation of collaborative care for depression among health care and community sector clients. METHODS: In under-resourced communities, within 93 programs randomly assigned to coalition building (Community Engagement and Planning) or program technical assistance (Resources for Services) models, 1,018 clients completed surveys at baseline and at six, 12, or 36 months. Regression analysis was used to estimate intervention effects and intervention-by-sector interaction effects on depression, mental health-related quality of life, and community-prioritized outcomes and on services use. RESULTS: For outcomes, there were few significant intervention-by-sector interactions, and stratified findings suggested benefits of coalition building in both sectors. For services use, at 36 months, increases were found for coalition building in primary care visits, self-help visits, and appropriate treatment for community clients and in community-based services use for health care clients. CONCLUSIONS: Relative to program technical assistance, community coalition building benefited clients across sectors and shifted long-term utilization across sectors.

A Community-Partnered, Participatory, Cluster-Randomized Study of Depression Care Quality Improvement: Three-Year Outcomes.

OBJECTIVE: Community Partners in Care, a community-partnered, cluster-randomized trial with depressed clients from 93 Los Angeles health and community programs, examined the added value of a community coalition approach (Community Engagement and Planning [CEP]) versus individual program technical assistance (Resources for Services [RS]) for implementing depression quality improvement in underserved communities. CEP was more effective than RS in improving mental health-related quality of life, reducing behavioral health hospitalizations, and shifting services toward community-based programs at six months. At 12 months, continued evidence of improvement was found. This study examined three-year outcomes. METHODS: Among 1,004 participants with depression who were eligible for three-year follow-up, 600 participants from 89 programs completed surveys. Multiple regression analyses estimated intervention effects on poor mental health-related quality of life and depression, physical health-related quality of life, behavioral health hospital nights, and use of services. RESULTS: At three years, no differences were found in the effects of CEP versus RS on depression or mental health-related quality of life, but CEP had modest effects in improving physical health-related quality of life and reducing behavioral health hospital nights, and CEP participants had more social- and community-sector depression visits and greater use of mood stabilizers. Sensitivity analyses with longitudinal modeling reproduced these findings but found no significant differences between groups in change from baseline to three years. CONCLUSIONS: At three years, CEP and RS did not have differential effects on primary mental health outcomes, but CEP participants had modest improvements in physical health and fewer behavioral health hospital nights.