Partnering with communities to achieve health equity: Experiences, challenges and elements for succe

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Partnering with communities to achieve health
equity Experiences, challenges and elements for
success

• Susanne Montgomery, PhD, MPH Professor and
  Director of Community Partnership and Outreach
  Core
• Juan Carlos Belliard, PhD, MPH Assistant
  Professor
• Zaida Cordero-MacIntyre, PhD Assistant Professor
• Lorna Kendrick, PhD, RN Associate Professor

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Health Disparities vs. Health Care Disparities

• Health Disparities
• Differences in the incidence, prevalence,
  mortality, and burden of diseases and other
  adverse health conditions that exist among
  specific population groups in the United States
  (National Institute of Health, 2000)

• Health Care Disparities
• Differences in the quality of healthcare that
  are not due to access-related factors or clinical
  needs, preferences, and appropriateness to
  intervention (IOM, 2003, p. 32)

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Health Disparities Examples

• Breast cancer
• Diabetes
• Prostate cancer
• Cardiovascular disease
• Many, many more

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Causes for Disparities

• Access to health care
• Socio-economic status
• Discrimination
• Cultural incompetence
• Lack of minority health professionals
• Lifestyle and environment
• Personal health beliefs
• Biological factors

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How do we address health disparities?
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Elimination of Health Disparities

• Requires multidisciplinary scientific approach
• Increase number of health professionals and
  health providers from minority or medically
  underserved populations
• Develop partnerships between schools,
  institutions, and communities
• Accelerate fundamental translation and clinical
  biomedical research on health disparity diseases

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Loma Linda University Center for Health
Disparities and Molecular Medicine
LLU SM
LLU SPH
Marino De Leon, PhD, Director
Community Partnership and Outreach Core
Research Core
Research Training and Education Core
Biomedical and Translational Research
Outreach and Education in Medically Underserved
Communities
Training and Educational Programs for High
School, College, Medical, and Graduate Students
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A New Rationale Oxidative Stress

• Oxidative Stress is a new rationale identified in
  addressing biological factors associated with
  health disparity diseases
• Oxidative stress is the balance between the rate
  at which oxidative damage is induced and the rate
  at which oxidative damage is repaired and removed
  (www.genox.com)

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Oxidative Stress and Health Disparities
.A
Dietary Habits/Lifestyle Environment/Genet
ics
ASCOS (Augmented State of Cellular Oxidative
Stress)
Stress/Antioxidant Survival Pathways
Genomic Alterations
Cell Dysfunction
Cancer
Stroke
Diabetes
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Community Partnership and Outreach Core (CPOC)

• Coordinates public health community outreach
  activities
• for CHDMM by
• Conducting collaborative community work with
  Latino and Black communities, particularly
  Latinos
• Addressing accountability by utilizing strategies
  respectful of community cultural norms, beliefs
  and practices
• Increasing partnership-based engagement with
  dissemination of results of community outreach
  projects
• Increasing translational work between community
  and academia

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CPOC Objectives

• Mission of CPOC
• To reach out, engage, and sustain involvement
  with racial / ethnic groups to improve the health
  and well-being of diverse populations and
  communities in San Bernardino County
• There are 3 core objectives to be accomplished by
  CPOC

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Goals/Objectives of CPOC

• Objective 1 To expand community health
  promotion and education outreach for prostate
  cancer prevention and diabetes education among
  the medically underserved
• Objective 2 To provide outreach and development
  of a community-based participatory health
  planning process for Latinos
• Objective 3 To bridge the health worldviews gap
  by engaging community stakeholders, clinics,
  medical groups, and academic institutions in
  interactive discussions on health topics.

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Teaming community partnerships with basic sciences

• Community Action Model (CAM)
• Challenges traditional paradigms that concentrate
  on deficits and instead builds on asset-focused
  methods
• Empowers and mobilizes community members to
  address factors perpetuating inequalities
• Partnership between community and health planners
  to assist in eliminating health disparities
  within minority population
• Examples of Community Health Planning Processes
  Implementing Model
• Latino Health Collaborative (LHC)
• African American Health Institute (AAHI) and
  other AA CBOs

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Health Disparities A possible model
Health Outcomes
SES  Education Occupation Income Subjective
SES SES Inequality
Psychological Influences Resilience/Reserve
Capacity Negative Affect (anxiety, depression,
hostility) Lack of Control Negative
Expectations Perceived Discrimination Reactive
Responding
Access to Medical Care
Health Cognitive FX Physical FX
Exposure to Carcinogens Pathogens
Disease
Health Related Behaviors
Disease Trajectories Recovery Relapse Secondary
Events
Race and Gender
Environmental Resources Constraints Neighborhood
Factors Social Capital Work Situation Family
Environment Social Support Discrimination
CNS Endocrine Response Allostatic Load
Mortality
L i f e C o u r s e
Source Adler, 2006
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Collaborators

• Dr. JC Belliard, Associate Professor, SPH Global
  Health Dept.
• Herbal study
• Board member of Latino Health Collaborative (LHC)
• Dr. Zaida Cordero-MacIntyre, Assistant Professor,
  SPH Nutrition Dept.
• Diabetes prevention and intervention study
• Dr. Lorna Kendrick, Associate Professor, School
  of Nursing
• Collaborates with Dr. Montgomery in replicating
  pilot testing for peer navigator manual for Los
  Angeles AA men
• Assists in seeking external funding for a
  community trial to evaluate approach
• Dr. Padma Uppala, Associate Professor, SPH
  Environmental Health Dept.
• Basic scientist
• Collaborates with Dr. Montgomery to increase
  informed decision making about participation in
  breast cancer clinical trials among AA women
• Dr. Serena Tonstad, Director of SPH Preventive
  Care Program
• Gestational Diabetes
• new collaborator

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Research Assistants

• Dr Montgomery
• -- Keyonna King (Various Projects)
• Dr Belliard
• -- Adriana Arzate (Herbal Study)
• -- Melissa Preciado (Herbal Study)
• Dr Cordero-MacIntyre
• -- Emmanuel Ojo (Diabetes Study)
• -- Lorena Salto (Diabetes Study)
• Dr Uppala
• -- Jill Cabansag (Breast Cancer)

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Diabetes Prevention Interventions Study

• Began recruitment process
• Twenty-six participants finished study as of May
  2008
• Another 16 participants were enrolled in program
  in Feb 2008 completed in May 2008
• Blood laboratory analysis to assess blood sugar
  control, Dual X-ray absorptimetry DXA scans
  performed to assess body composition
• Test will be repeated again at 3 months
• Diabetes education sessions now in progress
• Includes provision of blood sugar monitoring
  machine
• Study already approved by Loma Linda University
  IRB
• Approval date March 2, 2008
• Radiation Safety Office approved use of DXA in
  Feb 2008

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Prostate Cancer Pilot Study

• Peer navigators trained to use Peer Navigator
  Training Manual for informed decision-making
  around prostate cancer screening
• Developed a peer navigator curriculum and pilot
  tested it with four 2-hour sessions
• Pilot test conducted with AA men
• Manual well received by participants in study

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Results of Pilot Study

• Respondents felt more prepared and enjoyed
  informal peer navigator approach
• Suggestion to add AA health professionals to at
  least one of the sessions with MD to answer
  clinical questions
• Advised about best locations and format
• Who to target/include
• Best places and times

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Herbal Study

• Two-hundred one surveys administered at community
  clinic sites assessing levels of use of herbal
  remedies among Latinos who access modern health
  systems
• Both herbal users and non-herbal users reported
  having confidence in modern medicine
• These findings suggest that medical pluralism is
  common among this particular patient population
• Herbal use is predicted by lower levels of
  acculturation (Spanish as preferred language),
  and access to health insurance
• Data analysis revealed
• 84.18 of patients reported using herbs
• Strongest predictors of herbal use were fluency
  in English, traditional health beliefs, and
  health insurance coverage

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• Understanding the health beliefs and practices of
  Latino patients is increasingly important for
  healthcare providers develop a partnership
  approach to delivering holistic and culturally
  appropriate health care
• Various presentations to health care providers
  and lectures to future health care providers on
  campus and in area have been made and will
  continue
• These presentations serve as a feedback mechanism
  from clinicians to prepare for next phase, which
  will focus on educational material development

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Translational Community Research Projects
Current Updates

• Collaborating with several CBOs on outreach
  surrounding diabetes prevention and interventions
• Tremendous health issue for our local community
  with diabetes rates much above national average
• Most of these new projects are in IRB application
  stage or conducting formative research

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Translational Community Research Projects Breast
Cancer

• Breast cancer clinical trials education for Black
  women in the Inland Empire (funder Susan G.
  Komen Foundation) -- in IRB/planning stage
• A study of barriers to breast cancer mammography
  in AA women 16 qualitative interviews, 156
  surveys (funder internal LLU dissertation
  support) at report stage
• Barriers to mammography project recently
  completed data collection
• 16 qualitative and 156 quantitative surveys on
  mammography related issues (barriers and provider
  communication)
• Local screening rates far higher than U.S.
  average hypothesized it is a likely function of
  aggressive community outreach

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Translational Community Research Projects
Diabetes

• A gratitude intervention to promote compliance
  with health behaviors among pre-diabetic
  Hispanics in America (funder NIH seed money and
  internal LLU dissertation support) thus far 100
  screened 25 recruited, 16 enrolled with baseline
  data.
• A study of predictors of intention and
  performance of physical activity in pregnant
  Hispanic women with gestational diabetes (funder
  LLU seed grant program) -- in IRB stage
• Prevention of obesity among Hispanic toddlers
  enrolled in WIC (funder USDA) Qualitative pilot
  data completed, continuation application to USDA
  submitted

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Translational Community Research Projects
Prostate Cancer

• Results from Training Manual pilot study
  revealed
• Perceived cultural, language and theme
  appropriateness with AA men was high
• Working to find funding for formal full-scale
  CBPR research trial
• Evaluating curriculum in a rigorous fashion
• Approved for funding with a high score
  application to CDC ultimately not funded due to
  budget cuts
• Results of project and other prostate related
  issues continue to be disseminated to various
  professional and CBOs
• reaching a total of 400 persons

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Translational Community Research Projects Latino
Health Collaborative (LHC)

• Dr. Belliard received a 150,000 grant from
  Kaiser Permanentes Community Benefits Program
• Funds will support a planning grant that focuses
  on evaluating access to specialty care issues in
  San Bernardino and adjacent cities
• Additional initiatives include
• Pipeline Coalition of Inland Empire that convenes
  educators, workforce development professionals
  and others interested in health profession
  diversity
• Awaiting funding from California Endowment to
  organize regional Workforce Diversity Conference
• Assisted by LHC Executive Director Edward McField

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Latino Health Collaborative

• Dr. Belliard continues to serve on Latino Health
  Collaborative Board supports organization with
  research resources
• Minority Health digital library provides latest
  reports and peer reviewed articles on Latino
  health
• This service provided to community entities
  seeking information and current data to affect
  policy change and to aid in grant proposal
  writing
• Kaiser Permanente grant used to coordinate
  community-based capacity building, awareness and
  advocacy
• Help to match community members to local clinics
  that will offer diagnostic care services to aid
  in early diagnosis of disease diagnostic care
  services can be difficult to obtain

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Latino Health Assessment

• A 300,000 grant proposal (submitted by LHC and
  prepared by Mr. McField with Drs Belliard and
  Montgomery) was initially accepted by San
  Bernardino First Five, which would have funded
  the implementation of Latino Health Assessment
• With continued partnership, more funds are being
  sought to conduct this large assessment
• Planning sessions for a comprehensive county-wide
  strategic plan continue between various
  stakeholders such as
• San Bernardino County Health Department
  leadership
• Loma Linda University faculty

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CPOC Community Outreach

• Health Disparities Community Forums
• Hosted a series of community forums using the
  Unnatural Causes documentary aired by PBS in
  April 2008
• A new series of Health Disparities forums are
  planned in which students, faculty, community
  members, and policy makers can discuss strategies
  to address health disparities in the region
• Sessions are free to the public and offered on
  LLU campus as well as in the community
• LHC able to secure additional funding for these
  forums
• Health Disparities Student Task Force
• Dr. Montgomery serves as faculty advisor
• A campus-wide student effort to better understand
  health disparities from a variety of
  perspectives
• Care, biology, community, and psychosocial
• Task force conducts several campus-wide events
  each year
• About 20 students are active in task force
• Annually reach several hundred students through
  events

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CPOC Community Outreach
Minority health resource library featuring
current sources including local and national
data -- Supports CHDMM goal of creating a diverse
team of research scientists, staff, students, and
healthcare providers working with community
organizations to identify, understand, and
address health disparities Designs for Health
televised public health series -- SPH Dean Dr.
David Dyjack recently developed Designs for
Health, an 8-week televised public health program
funded by a 35,000 grant from Pfizer
Foundation. -- Estimated to reach 2.5 million
homes archived on the LLU-SPH website -- Drs
Belliard and Montgomery participate and present
on program
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• Fill the Pipeline
• Regional recruiting programs to attract high
  school students and undergraduate minorities into
  health professions
• Preparing future Latino health professionals
  through training core, outreach and research
  activities
• Partnerships
• LLU teaming with Riverside County Dept of Public
  Health
• Environmental asthma presentations to high school
  students and parents in eastern Riverside County
• Reaches approximately 400 Spanish speaking
  residents and high school students

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Lessons Learned Experiences

• ASK and Engage so many noted no one ever
  asked
• Valuable suggestions provided by community
  collaborations
• Well-received response to outreach projects by
  community and their respective CBOs
• Acquired knowledge about barriers and
  communication critical to decreasing health
  disparities
• Increased partnership-based engagement of
  collaborative research by disseminating results
  among the community

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Lessons Learned Challenges

• No or limited funding available to continue
  promising research projects
• Real engagement and partnership takes time
• Longer project period needed to display changes
  or show successes of various programs and
  research
• Both health care providers and the minority
  community lack education about cultural norms
  (providers) and medical practices (community),
  creating barriers in communication
• Health care providers often see learning about
  cultural norms as fluff and a barrier to their
  research. Attitude one of Lets just get it over
  with.

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Lessons Learned Elements of Success

• Increased awareness about accountability issues
  among the community, health care providers, and
  academia
• A major increase in the translational work
  conducted in collaboration with the community by
  CPOC
• Partnership-based approach successful in creating
  community outreach activities and projects to
  further decrease the health disparities gap
• Feedback mechanisms used by CBOs, health care
  providers, and academic institutions help to
  better understand the minority populations they
  continue to serve.
• Trust is developing and collaboration is
  increasing
• Students are enthusiastic, hopefully leading to a
  new generation of H.D ambassadors
• Slowly more academics are beginning to see
  community engagement as not just another NIH
  project hurdle, but a key element in research

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Acknowledgements

• NIH / NCMHD Grant P20MD001632
• NIH / NIGMS Grant R25GM060501
• Loma Linda University School of Medicine
• Loma Linda University School of Public Health
• Special thanks to Keyonna King for her patient
  support and hard work in preparing this
  presentation.