Advancing Environmental Justice in the Community Using Charrette: A Case Study in Boston Chinatown.

Background: Community research partners in Boston Chinatown implemented a planning charrette as a part of a community-based participatory study focused on near highway research and public health action to mitigate traffic-related air pollution (TRAP). Charrettes are intensive workshops for solution-oriented design and planning used to bring together diverse stakeholders to address complex environmental health concerns. Methods: The planning charrette included three phases: (1) community meetings and resident interviews, (2) a planning charrette to address community health concerns and air pollution within larger community wellness goals, and (3) development of a Master Planning document with policy, project, and practice recommendations to guide future community advocacy. Outcomes: Intergenerational residents, community leaders, planners, researchers, and volunteers (N = 90) joined a day-long planning charrette to inform the Chinatown Master Plan. Workshops were informed by resident interviews focused on finding solutions to three resident identified priorities: Healthy Housing, Healthy Mobility, and Healthy Public Realm. Air pollution mitigation strategies were embedded in discussions around each priority area. Discussion: The charrette provided an opportunity for community stakeholders to voice concerns about TRAP as part of a new framework focused on health and wellness. Concerns about pedestrian safety, housing access, and expansion of green and recreational spaces were highlighted by participants as important areas for further development. Conclusions: Boston Chinatown residents reaffirmed their investment in the community by highlighting concerns about TRAP within the context of other health-related concerns. Charrettes offer a vehicle to advance environmental justice in communities through collective problem-solving and decision making.

Virtual Reality Simulated Learning Environments: A Strategy to Teach Interprofessional Students About Social Determinants of Health.

PURPOSE: Physician assistants (PAs) and medical degree students (MDs) often lack training in addressing the social determinants of health (SDOH). Social work students (SWs), meanwhile, have extensive SDOH training; however, few medical professionals have opportunities to engage in interprofessional training with SWs. This study examined the feasibility, acceptability, and students' perceptions of an interprofessional virtual reality (VR) simulated learning environment (SLE) for teaching health professions students about the SDOH. METHOD: In January 2020, 15 students at Boston University School of Medicine attended web-based video conferences focused on SDOH, health equity, and team-based care. Subsequently, student dyads participated in a case-based learning activity using an immersive VR SLE to develop teamwork skills. Evaluation included a postsurvey and a focus group examining their experiences in the course to gauge feasibility and acceptability. Thematic analysis of open-ended survey responses from the postsurvey and focus group data was conducted. RESULTS: A total of 8 VR simulations were run. Findings indicated both MD and PA students learned patient engagement strategies from SW students, who enhanced their health care leadership capacity. Participants found the means of instruction acceptable, valued the hands-on VR interprofessional training, and expressed interest in learning more about the scope of one another's roles and the community resources available to patients. CONCLUSIONS: VR SLE is a feasible and acceptable means of instruction. It allowed students to connect across programmatic and geographic boundaries in a collaborative working environment mimicking the team approach to care they will use in their professional life. This experience illustrated for students the strengths a multidisciplinary team has to offer.

COVID-19 shines a light on health inequities in communities of color: A youth-driven photovoice inquiry.

This manuscript reports on a youth-driven health assessment engaging youth of color in identifying community health priorities during the coronavirus disease 2019 (COVID-19) pandemic. Photovoice, a participatory visual ethnographic health assessment strategy, was used to explore the question: What does health or healthiness mean to you and/or your community? Youth captured images that represented their priorities. The photos were discussed using the SHOWed framework and analyzed thematically. Four themes related to community health were identified. Additionally, youth captured their narrative of COVID-19 as "a revealing force that highlights systemic inequities, driving individuals and communities to both cultivate their resilience and take healthcare into their own hands in response to government and policy level failures." Youth are acutely aware of the historical and structural inequities that create multi-level barriers to healthcare access. Health inequities existed long before the pandemic, but the current crisis requires us to examine ways to transform the healthcare landscape moving forward.

Health Lens Analysis: A Strategy to Engage Community in Environmental Health Research in Action.

Health Lens Analysis is a tool to facilitate collaboration among diverse community stakeholders. We employed HLA as part of a community based participatory research (CBPR) and action study to mitigate the negative health effects of TRAP and ultrafine particles (UFPs) in Somerville, MA. HLA is a Health in All Policies tool with previously limited implementation in a North American context. As part of the HLA, community and academic partners engaged residents from across near-highway neighborhoods in a series of activities designed to identify health concerns and generate recommendations for policies and projects to improve health over an 18-month planning period. Noise barriers, which may reduce TRAP exposure among residents in addition to reducing traffic noise, were seen as an acceptable solution by community stakeholders. We found HLA to be an effective means to engage stakeholders from across sectors and diverse community residents in critical discourse about the health impacts of near-roadway exposures. The iterative process allowed the project team to fully explore the arguments for noise barriers and preferred health interventions, while building a stakeholder base interested in the mitigation of TRAP, thus, creating a shared language and understanding of the issue.

Two communities, one highway and the fight for clean air: the role of political history in shaping community engagement and environmental health research translation.

BACKGROUND: This paper explores strategies to engage community stakeholders in efforts to address the effects of traffic-related air pollution (TRAP). Communities of color and low-income communities are disproportionately impacted by environmental threats including emissions generated by major roadways. METHODS: Qualitative instrumental case study design was employed to examine how community-level factors in two Massachusetts communities, the City of Somerville and Boston's Chinatown neighborhood, influence the translation of research into practice to address TRAP exposure. Guided by the Interactive Systems Framework (ISF), we drew on three data sources: key informant interviews, observations and document reviews. Thematic analysis was used. RESULTS: Findings indicate political history plays a significant role in shaping community action. In Somerville, community organizers worked with city and state officials, and embraced community development strategies to engage residents. In contrast, Chinatown community activists focused on immediate resident concerns including housing and resident displacement resulting in more opposition to local municipal leadership. CONCLUSIONS: The ISF was helpful in informing the team's thinking related to systems and structures needed to translate research to practice. However, although municipal stakeholders are increasingly sympathetic to and aware of the health impacts of TRAP, there was not a local legislative or regulatory precedent on how to move some of the proposed TRAP-related policies into practice. As such, we found that pairing the ISF with a community organizing framework may serve as a useful approach for examining the dynamic relationship between science, community engagement and environmental research translation. Social workers and public health professionals can advance TRAP exposure mitigation by exploring the political and social context of communities and working to bridge research and community action.

Recipient's unemployment restricts access to renal transplantation.

Equitable distribution of a scarce resource such as kidneys for transplantation can be a challenging task for transplant centers. In this study, we evaluated the association between recipient's employment status and access to renal transplantation in patients with end-stage renal disease (ESRD). We used data from the United States Renal Data System (USRDS). The primary variable of interest was employment status at ESRD onset. Two outcomes were analyzed in Cox model: (i) being placed on the waiting list for renal transplantation or being transplanted (whichever occurred first); and (ii) first transplant in patients who were placed on the waiting list. We analyzed 429 409 patients (age of ESRD onset 64.2 ± 15.2 yr, 55.0% males, 65.1% White). Compared with patients who were unemployed, patients working full time were more likely to be placed on the waiting list/transplanted (HR 2.24, p < 0.001) and to receive a transplant once on the waiting list (HR 1.65, p < 0.001). Results indicate that recipient's employment status is strongly associated with access to renal transplantation, with unemployed and partially employed patients at a disadvantage. Adding insurance status to the model reduces the effect size, but the association still remains significant, indicating additional contribution from other factors.

Effect of education on racial disparities in access to kidney transplantation.

Higher education level might result in reduced disparities in access to renal transplantation. We analyzed two outcomes: (i) being placed on the waiting list or transplanted without listing and (ii) transplantation in patients who were placed on the waiting list. We identified 3224 adult patients with end-stage renal disease (ESRD) in United States Renal Data System with education information available (mean age of ESRD onset of 57.1 ± 16.2 yr old, 54.3% men, 64.2% white, and 50.4% diabetics). Compared to whites, fewer African Americans graduated from college (10% vs. 16.7%) and a higher percentage never graduated from the high school (38.6% vs. 30.8%). African American race was associated with reduced access to transplantation (hazard ratio [HR] 0.70, p < 0.001 for wait-listing/transplantation without listing; HR 0.58, p < 0.001 for transplantation after listing). African American patients were less likely to be wait-listed/transplanted in the three less-educated groups: HR 0.67 (p = 0.005) for those never completed high school, HR 0.76 (p = 0.02) for high school graduates, and HR 0.65 (p = 0.003) for those with partial college education. However, the difference lost statistical significance in those who completed college education (HR 0.75, p = 0.1). In conclusion, in comparing white and African American candidates, racial disparities in access to kidney transplantation do exist. However, they might be alleviated in highly educated individuals.

Impact of substance abuse on access to renal transplantation.

BACKGROUND: With an ever-increasing demand for kidneys and limited supply pool, it is essential to understand the balance between utility and equity in transplant access. The goal of this project was to evaluate the association between recipient's substance abuse and renal transplant access in patients with end-stage renal disease (ESRD). METHODS: We used data from the United States Renal Data System. The primary variables of interest were abuse of alcohol, tobacco, or illicit drugs based on information from Centers for Medicare & Medicaid Services form 2728. We analyzed three outcomes in Cox model: (1) being placed on the waiting list for renal transplantation or transplanted (whichever occurred first); (2) first transplant in patients who were placed on the waiting list; and (3) graft loss or mortality after transplant. In addition, we performed subgroup analysis based on age, race, sex, diabetic status, and donor type. RESULTS: We analyzed 1,077,699 patients (age of ESRD onset 62.9±15.5 years, 54.1% males, 64.2% white, and 29.7% African American). When compared with those with no substance abuse, abusing all three substances was associated with reduced transplant access (hazard ratio 0.39, P<0.001 for wait listing/transplant; hazard ratio 0.67, P=0.019 for transplant). This trend was similar in most subgroups studied. CONCLUSION: We demonstrated that patients with ESRD abusing or dependent on tobacco, alcohol, or illicit drugs are less likely to be placed on the waiting list for kidney transplant; and once on the list are less likely to be transplanted. The possible utility justifications for such disparity and potential interventions are discussed.

Quality of life and psychosocial functioning of spouse/partner caregivers before and after liver transplantation.

Spouse/partner caregivers of liver transplant (LTx) patients play an important role both before and after transplantation. However, very little research has examined the quality of life (QOL), caregiving strain, and psychological functioning of these caregivers. In this study, we examined these outcomes and their correlates in 86 (49 pre-LTx, 38 post-LTx) spouse/partner caregivers. The physical QOL of caregivers was not impaired, and numerous caregiving benefits were identified (e.g., realizing what is important in life, discovering one's own inner strength, giving emotional support to the patient). However, a relatively high proportion of both pre-LTx and post-LTx caregivers had clinically low mental QOL (29% and 35%, respectively), low life satisfaction (45% and 32%, respectively), and high caregiving strain (59% and 81%, respectively). Both pre- and post-LTx caregivers, particularly women, had more total mood disturbance than a normative sample. Higher caregiving strain was significantly correlated with lower mental QOL, lower life satisfaction, and more mood disturbance. Overall, findings suggest that caregiving strain is prominent through the LTx spectrum. There is a need for prospective research to identify the patterns of caregiver outcomes over time and to examine the benefits of clinical interventions for caregivers.

Spouse caregivers of kidney transplant patients: quality of life and psychosocial outcomes.

CONTEXT: Most kidney transplant programs require patients to identify a primary caregiver who can assist them throughout the transplant process. Little is known about the quality of life, caregiving strain, and psychosocial functioning of these caregivers. OBJECTIVES: To characterize the psychosocial functioning of spouse/partner caregivers. DESIGN, SETTINGS, AND PARTICIPANTS: Cross-sectional survey administered to spouse/partner caregivers of patients before (n=33) and after (n=46) kidney transplantation at a transplant center in New England. MAIN OUTCOME MEASURES: Quality of life, life satisfaction, caregiving strain and benefit, mood, and social intimacy. RESULTS: Relative to normative samples and published data involving other transplant caregivers, caregivers of kidney transplant patients had favorable quality of life, life satisfaction, psychological, and social intimacy outcomes. Life satisfaction scores were significantly lower for caregivers before than after kidney transplantation, but otherwise the 2 cohorts did not differ significantly from each other. Most caregivers both before and after kidney transplantation reported clinically high levels of caregiving strain, as well as several caregiving benefits. CONCLUSION: Our data are consistent with results of other studies in showing that spouses experience considerable caregiving strain both before and after transplantation. However, caregivers of kidney transplant patients overall have good quality of life, life satisfaction, mood, and social intimacy. More prospective research is necessary to characterize better how these outcomes change over time throughout the transplant process.