Cultivating a cycle of trust with diverse communities in practice-based research: a report from PRIME Net.

PURPOSE: Practice-based research networks (PBRNs) are increasingly seen as important vehicles to translate research into practice, although less is known about the process of engaging diverse communities in PBRN research. The objective of this study was to identify strategies for successfully recruiting and retaining diverse racial/ethnic communities into PBRN research studies. METHODS: This collaborative, multisite study engaged 5 of the 8 networks of the PRImary care MultiEthnic Network (PRIME Net) consortium that conducts research with traditionally underrepresented/underserved populations. We used a sequential, qualitative research design. We first conducted 1 key informant interview with each of 24 researchers experienced in recruiting research participants from 5 racial/ethnic communities (African American, Arab/Chaldean, Chinese, Hispanic, and Native American). Subsequently, we conducted 18 focus groups with 172 persons from these communities. RESULTS: Participants' comments indicated that successful recruitment and retention of underrepresented populations in PBRN studies is linked to the overall research process. This process, which we termed the cycle of trust, entailed developing and sustaining relationships of trust during 4 interrelated stages: before the study, during study recruitment, throughout study conduct, and after study completion. Participants identified a set of flexible strategies within each stage and called for close engagement with clinic and community partners. CONCLUSIONS: Our participants suggest that approaches to research that lay a foundation of trust, demonstrate respect for community members, and extend beyond the enrollment and data collection phases are essential to enhance the participation of diverse populations in PBRN research. These findings offer the PBRN community a guide toward achieving this important goal.

Injuries after Hurricane Katrina among Gulf Coast Evacuees sheltered in Houston, Texas.

INTRODUCTION: After Hurricane Katrina and a decline in the living conditions at a major temporary shelter in New Orleans, Louisiana, residents were offered transport to a Mega-Shelter in Houston, Texas. Approximately 200,000 Gulf Coast residents were transported to Houston's Astrodome/Reliant Center Complex for appropriate triage and transfer to other shelter facilities. The Katrina Clinic was quickly organized to treat evacuees with acute injuries and illnesses as well as chronic medical conditions. Clinic physicians documented 1130 hurricane-related injuries during Katrina Clinic's operational interval, September 1-22, 2005. METHODS: This article documents the nature, extent, and location of injuries treated at that clinic. We compare the frequency of injury among Katrina evacuees who visited the clinic to that of injuries among clinic outpatient records recorded in a nationally representative database. Using the Barell Matrix system and codes from the International Classification of Diseases, Ninth Revision, we classify Katrina injuries by body region and nature of injury; we also document the large number of hurricane-related immunizations distributed at the temporary outpatient clinic. RESULTS: The results show a 42% higher injury proportion among Katrina evacuees and that approximately half of all of the evacuees required immunizations. Lower leg extremity injuries were among the most frequent injuries. DISCUSSION: Future planning for hurricanes should take into account nonfatal injuries requiring medical treatment and other supportive care.

Houston's medical disaster response to Hurricane Katrina: part 2: transitioning from emergency evacuee care to community health care.

After Hurricane Katrina hit the Gulf Coast on August 29, 2005, thousands of ill and injured evacuees were transported to Houston, TX. Houston's regional disaster plan was quickly implemented, leading to the activation of the Regional Hospital Preparedness Council's Catastrophic Medical Operations Center and the rapid construction of a 65-examination-room medical facility within the Reliant Center. A plan for triage of arriving evacuees was quickly developed and the Astrodome/Reliant Center Complex mega-shelter was created. Herein, we discuss major elements of the regional disaster response, including regional coordination, triage and emergency medical service transfers into the region's medical centers, medical care in population shelters, and community health challenges.

Houston's medical disaster response to Hurricane Katrina: part 1: the initial medical response from Trauma Service Area Q.

After Hurricane Katrina hit the Gulf Coast on August 29, 2005, thousands of ill and injured evacuees were transported to Houston, TX. Houston's regional disaster plan was quickly implemented, leading to the activation of the Regional Hospital Preparedness Council's Catastrophic Medical Operations Center and the rapid construction of a 65-examination-room medical facility within the Reliant Center. A plan for triage of arriving evacuees was quickly developed and the Astrodome/Reliant Center Complex mega-shelter was created. Herein, we discuss major elements of the regional disaster response, including regional coordination, triage and emergency medical service transfers into the region's medical centers, medical care in population shelters, and community health challenges.

Dietary intake of homeless women residing at a transitional living center.

Women who are homeless experience health problems due to many factors, including poor nutrition. This paper describes a nutritional assessment of women who are homeless living at a transitional living center in an urban setting. A rapid food screener was used to assess fat, fruit and vegetable, and fiber intake, and focus group analysis was used to assess nutritional attitudes and dietary behaviors. We found that the dietary intake of shelter residents does not meet the USDA recommendations in several key areas. We also found that shelter residents considered shelter cafeteria food to be inadequate in terms of taste, nutritional quality, and choices, and they believed the shelter diet contributed to chronic diseases and their symptoms. We conclude that addressing these barriers to good nutrition may help people who are homeless prevent and manage chronic illness.

A cohort study of injuries in migrant farm worker families in South Texas.

PURPOSE: This cohort study estimated the frequency of and risk factors for work injuries among migrant farmworker families over a two-year period. METHODS: The cohort consisted of 267 families. Bilingual interviewers asked mothers to respond for their family soliciting demographic, psychosocial, employment, and work-related injury information. Cox regression was used to examine risk factors for first injury events. RESULTS: Of the 267 families, nearly 60% migrated and 96% of these completed the follow-up interviews. These families represented about 310 individuals each year who had participated in farmwork on average 6 days a week, 10 hours a day, for 2.7 months in the past year. Twenty-five work-related injuries were reported with an overall rate of 12.5/100 FTE (95% C.I., 8.6-19.0). Working for a contractor increased the hazard ratio, and use of car seat belts and working for more than one employer during the season decreased it. CONCLUSIONS: If person-time at risk for injuries is taken into account the reported injuries are substantial. Because the injuries were quite diverse, specific interventions may have to focus on improved working conditions (physical and economic), ergonomic modifications, and enhanced enforcement of existing regulations.

Comparative description of migrant farmworkers versus other students attending rural south Texas schools: substance use, work, and injuries.

CONTEXT: Little is known about substance use, work characteristics, and injuries of youth from migrant farmworker families. Some evidence suggests that migrant youth may be at greater risk for substance use and work-related injuries than nonmigrant youth. PURPOSE: The aim of this study is to compare substance use, employment, and injury data from migrant and nonmigrant youth residing in rural South Texas. METHODS: Anonymous cross-sectional survey data were collected from 7,302 middle and 3,565 high school students during a regular class. Classification as a migrant student occurred if the student responded positively to: "Does your family move around the state or nation to pick fruits or vegetables for work?" RESULTS: About 5% of South Texas middle and high school students reported belonging to a migrant family. Compared to nonmigrant students, migrant youth were more likely to report frequent substance use. Youth belonging to migrant families were less likely to work for pay on weekends but more likely to work for pay on weekday mornings before school. These youth were also more likely to have ever been injured while working than nonmigrant students. CONCLUSIONS: These results demonstrate a need for additional interventions in this most vulnerable rural population. Specifically, targeted educational programs to enhance the occupational safety and health of migrant youth, further research into effective substance abuse treatment and prevention programs in rural areas, and enhancement of child labor laws are recommended.

Comparative description of migrant farmworkers versus other students attending South Texas schools: demographic, academic, and health characteristics.

Little is known about academic performance, health, and social functioning of youth from migrant farmworker families. This study was designed to compare demographic, academic, health, and social data between migrant and nonmigrant youth residing in South Texas. Anonymous cross-sectional survey data were collected from 6954 middle and 3565 high school students. About 5% of South Texas middle and high school students reported belonging to a migrant family. Compared with nonmigrant students, migrant youth were more likely to miss and arrive late to school, sleep in class, and study fewer hours weekly. Migrant students reported fewer hours of nightly sleep, fewer hours spent with their friends, and more minor illnesses than nonmigrant youth. These results demonstrate the need for interventions specifically targeted to this vulnerable adolescent population.

School-year employment among high school students: effects on academic, social, and physical functioning.

This study describes the effects of different weekly work intensity levels on adolescent functioning in a sample of 3,083 high school students in rural South Texas, where economically disadvantaged and Hispanic youth are heavily represented. Anonymous surveys were conducted in 10th- and 12th-grade students' classrooms in 1995. The following effects were associated with long hours of weekly employment during the school year: (1) decreased performance/engagement in school and satisfaction with amount of leisure time, and (2) increased health risk behaviors and psychological stress. The effects of school-year work on academic factors and health behaviors differed by grade, but not by race/ethnicity, parent education, or race/ethnicity and parent education considered together. It was concluded that parents and professionals should continue to monitor the number of weekly hours that students work during the school year.

The prevalence and patterns of occupational injury among south Texas high school students.

High school students frequently work long hours during the school year, increasing their risk of injury. Few studies have examined the relation between work injury and weekly work hours. This paper describes injuries among students in South Texas, where economically disadvantaged Hispanic students are heavily represented. Anonymous surveys were collected from 3565 secondary students in 23 schools. Self-reported data included weekly work hours and type of injury and job when injured. A dose-response effect was observed: increasing weekly work hours were related to injury (1-10 hours, adjusted odds ratio [AOR] = 1.0; 11-20 hours, 1.4; 21+ hours, 1.5), P < .000. The AOR for restaurant work was 3.2; for construction, 3.0; for factory, office, or skilled labor, 2.9; for agriculture, 2.8; for yard work, 2.0; and for babysitting (1.0). Males (OR = 1.5) were more prone to injury. High-intensity weekly work increased the likelihood of injury. Prevention efforts should be targeted to youth to reduce work injuries.

Labor and Related Injuries among Schoolchildren in Palestine: Findings from the National Study of Palestinian Schoolchildren (HBSC-WBG2006).

Background. Labor related injuries among Palestinian schoolchildren are a significant undocumented public health concern. This study aimed at documenting the prevalence and nature of work related injuries among schoolchildren as well as identifying sociodemographic factors that predict these injuries. Methods. A cross-sectional survey included 15,963 children of whom 6458 (40.8%) completed an optional package related to labor. Students aged 12-18 years self-completed the international WHO collaborative HBSC valid questionnaires between April and May of 2006. Results. Approximately 73.8% of the students who filled the optional package reported working during the last 12 months, of whom 79.1% sustained a work related injury. Work injuries were significantly higher among boys, younger children, and children enrolled in UNRWA schools and living in Gaza Strip (P < 0.05). Children working ≥3 hours/day were more likely to experience injuries, 1.73 (95% CI, 1.53-1.95), than those working ≤3/day. About half of the children worked in retail trade (51.5%), agriculture (20.0%), and cleaning (11.4%). Injury type was related to the type of work performed. Conclusions. The high prevalence of injuries among working Palestinian schoolchildren confirms its severity as a public health problem. To reduce occupational injuries, policymakers and professionals should develop intervention programs that target the public and health providers.

Use of community engagement strategies to increase research participation in practice-based research networks (PBRNs).

PURPOSE: Practice-based research networks (PBRNs) are increasingly encouraged to use community engagement approaches. The extent to which PBRNs engage clinic and community partners in strategies to recruit and retain participants from their local communities (specifically racial/ethnic communities) is the focus of this study. METHODS: The design was a cross-sectional survey of PBRN directors in the United States. Survey respondents indicated whether their research network planned for, implemented, and has capacity for activities that engage clinic and community partners in 7 recommended strategies organized into study phases, called the cycle of trust. The objectives of the national survey were to (1) describe the extent to which PBRNs across the United States routinely implement the strategies recommended for recruiting diverse patient groups and (2) identify factors associated with implementing the recommended strategies. RESULTS: The survey response rate was 63%. Activities that build trust often are used more with clinic partners than with community partners. PBRNs that adopt engagement strategies when working with clinic and community partners have less difficulty in recruiting diverse populations. Multivariate analysis showed that the targeting racial/ethnic communities for study recruitment, Clinical and Translational Science Award affiliation, and planning to use community engagement strategies were independent correlates of PBRN implementation of the recommended strategies. CONCLUSION: PBRNs that successfully engage racial/ethnic communities as research partners use community engagement strategies. New commitments are needed to support PBRN researchers in developing relationships with the communities in which their patients live. Stable PBRN infrastructure funding that appreciates the value of maintaining community engagement between funded studies is critical to the research enterprise that values translating research findings into generalizable care models for patients in the community.

Reports of persistent change in the clinical encounter following research participation: a report from the Primary Care Multiethnic Network (PRIME Net).

PURPOSE: Following anecdotal reports of unexpected patient and/or clinician behavior change in the primary care encounter in a previous study, we conducted this study to learn more about the short- and long-term effects on clinician and/or patient behavior from participation in a practice-based research network (PBRN) study. METHODS: Clinicians in two PBRN studies of Acanthosis nigricans were surveyed and interviewed 3 to 6 months following one study and surveyed 3 to 5 years following a second study. We gathered data on clinicians' reports of behavior change in the encounter, the persistence of those changes, and the likely causes of reported changes. RESULTS: Eighty-six percent of clinicians in the short-term and 79% in the long-term samples reported more frequent diagnostic efforts, and 68% and 54%, respectively, reported more frequent preventive counseling after participation in the studies. Interview data suggested that several factors contributed to this reported behavior change: increased clinician knowledge, availability of a feasible tool to support counseling, change in patient receptivity/motivation, and creation of a new context for counseling. CONCLUSIONS: Reports of behavior change in the primary care encounter associated with a PBRN study suggest that PBRNs may be effective vehicles for education, translation, and practice change in addition to their value in research.

Acanthosis Nigricans: high prevalence and association with diabetes in a practice-based research network consortium--a PRImary care Multi-Ethnic network (PRIME Net) study.

BACKGROUND: Previous work has established a surprisingly high prevalence of acanthosis nigricans (AN) and its association with increased risk of type 2 diabetes in a Southwestern practice-based research network (PBRN). Our objective was to establish whether this high prevalence of AN would be present in other areas. METHODS: We examined the prevalence of type 2 diabetes and its risk factors and the prevalence of AN among patients aged 7 to 65 years who had been seen by one of 86 participating clinicians in a national PBRN consortium during a 1-week data collection period. In a subsample of nondiabetic matched pairs who had or did not have AN, we compared fasting glucose, insulin, and lipid levels. RESULTS: AN was present in 19.4% of 1730 patients from among all age ranges studied. AN was most prevalent among persons with more risk factors for diabetes. Patients with AN were twice as likely as those without AN to have type 2 diabetes (35.4% vs 17.6%; P < .001). In multivariable analysis, the prevalence ratio for diabetes was 2.1 (95% CI, 1.3-3.5) among non-Hispanic whites with AN and 1.4 (95% CI, 1.1-1.7) among minority patients with AN. In a subsample of 11 matched pairs, those with AN had higher levels of insulin and insulin resistance. CONCLUSIONS: We found high rates of AN among patients in primary care practices across the country. Patients with AN likely have multiple diabetes risk factors and are more likely to have diabetes.

Internet-based training in a practice-based research network consortium: a report from the Primary Care Multiethnic Network (PRIME Net).

BACKGROUND: Continuing growth of the research spectrum of practice-based research networks (PBRNs) creates a need (1) for new approaches to training clinicians in research protocols and (2) to standardize clinician data collection. Each existing training method has shortcomings when used in geographically dispersed PBRNs. We describe here the use and costs of Internet-based training in support of a research protocol across a PBRN consortium. METHODS: Clinicians in 4 PBRNs in the PRIME Net consortium participated in training for a study of acanthosis nigricans (AN). We compared results of pre- and posttraining assessments of knowledge and ability to correctly diagnosis AN. We also calculated costs for placement of the training on the Internet. RESULTS: Among 103 participating clinicians, statistically significant increases in knowledge acquisition were demonstrated for all but 2 of the individual topics and in total scores on the assessments. AN diagnostic sensitivity increased from 52% to 99% to 96% to 100%, whereas specificity increased from 70% to 96% to 74% to 97%. Total costs for the web aspects of the training were $3732. CONCLUSION: The Internet can be an effective and feasible alternative method for training clinicians in support of PBRN research.

Substance use and occupational injuries among high school students in South Texas.

This cross-sectional study examined the association between self-reported nonfatal occupational injuries among high school students in South Texas and their self-reported general use of substances. Data were collected using a self-administered, anonymous questionnaire (n = 3365). The independent variables included alcohol, marijuana, cocaine, inhalant, and steroid use. The dependent variable was occupational injury. Adjusting for grade, sex, ethnicity, and work intensity, odds ratios were calculated using logistic regression. Supporting an association with each substance, odds ratios consistently strengthened as use increased. Additional research is merited given the scant number of previous studies. The associations for inhalant (OR, 5.61) and steroid (OR, 7.63) use argue for their inclusion in future research.

Work-related injury among south Texas middle school students: prevalence and patterns.

BACKGROUND: Work experiences among early adolescents are largely undocumented. Our purpose was to document the prevalence of work and work-related injury among lower-income Hispanic South Texas middle school students. METHODS: Anonymous surveys were conducted in classrooms of sixth- through eighth-grade students, and 3,008 students reported current or recent employment. RESULTS: The prevalence of work was 56%; mean weekly work hours were 7.7. Increasing weekly work hours were significantly related to work injury (11-20 hours, odds ratio [OR], 1.5; 95% confidence interval [CI], 1.1-1.9; 21+ hours, OR, 2.4; 95% CI, 1.8-3.2, compared with 1-10 hours). The odds of injury were highest for agriculture (OR, 4.4; 95% CI, 3.3-6.0), followed by restaurant (OR, 3.8; 95% CI, 2.7-5.4), construction (OR, 3.6; 95% CI, 2.4-5.2), and yard work (OR, 1.7; 95% CI, 1.4-2.2). CONCLUSION: Working more than 20 hours weekly increased the likelihood of injury among middle school students. Parents and professionals should monitor weekly school-year work hours.

Lifetime inhalant use among alternative high school students in Texas: prevalence and characteristics of users.

This cross-sectional study describes the prevalence of lifetime inhalant use and identifies demographic, psychosocial, and other risk behavior characteristics of students reporting lifetime inhalant use. The sample consisted of 354 students attending alternative high schools (dropout prevention/recovery schools) in Texas. The prevalence of lifetime inhalant use was 27.7%. After controlling for potentially confounding factors, students reporting lifetime inhalant use were less likely to be financially supported by their parents/guardians, more likely to use alcohol/tobacco, marijuana, and cocaine, and more likely to carry weapons and consider suicide. Study results may allow school officials, parents, researchers, and health care providers to gain a better understanding of inhalant use among students at risk for dropping out of school, a group which has not been extensively studied by previous researchers.