Community-engagement to support cardiovascular disease prevention in disparities populations: three case studies

Cardiovascular diseases remain the leading cause of death in the United States, and are characterized by socioeconomic, geographic, ethnic, and gender disparities in risk, morbidity and mortality. In response, public health efforts have moved beyond approaches focusing on individual-level behavior change toward culturally appropriate community-focused efforts. In specific, engagement of community partners is now recognized as essential to facilitate changes at multiple levels to improve cardiovascular disease outcomes. This paper shares lessons learned to deepen appreciation for the unique challenges community-engagement in health disparities research entails, including variations in practice, time commitment, and complexity. This paper presents three case studies documenting community-engagement in the planning, implementation and evaluation processes. All projects collaborated with community partners in contexts with disproportionately high rates of cardiovascular disease but with distinct programmatic foci: the East Los Angeles, California project focused on improving access to fresh fruit and vegetables through corner store makeovers; the Boston, Massachusetts project reached out to and engaged Puerto Rican community members in a lifestyle intervention study; and the Lenoir County, North Carolina project engaged local restaurant owners and a range of community agencies in healthy lifestyle promotion activities. These cases provide examples of the unique solutions and approaches to issues common in doing community-engagement work

Obesity Risk among Preschoolers: The Role of Parental Stressors and Children’s Emotional Regulation Skills

Childhood obesity is associated with adverse health outcomes across the lifecourse. Accordingly, there is growing interest in psychosocial correlates of child obesity, including the role of stress and a child’s social-emotional development on obesity risk. This dissertation examined the association between two parental stressors, relationship quality and parenting stress, on preschooler’s emotional regulation skills and their obesity risk. Inspired by the Risky Families Model, the overarching theoretical argument and research questions this dissertation addresses is whether higher levels of parental stressors lead to poor emotional regulation skills of the child, and if poor emotional regulation skills contribute to increased risk of child obesity. In addition, this dissertation assessed whether certain parenting resources, including the number of household routines and socioeconomic resources, served as protective factors. I used data from the Early Childhood Longitudinal Study-Birth Cohort which provides a nationally representative sample of children born in the United States in 2001. To include a more comprehensive analysis of obesity risk, I examined 8 outcomes: frequency of family meals, soda consumption, fast food consumption, fruit consumption, vegetable consumption, sleep duration, odds of exceeding the 2 hour guideline for daily screentime and weight status (obese/not obese). I conducted multivariate Ordinary Least Squares regression , logistic regression, or negative binomial regression to show the relationship between 1) each parental stressor and a child’s emotional regulation skills, 2) a child’s emotional regulation skills and 8 obesity risk factors and 3) each parental stressor and the 8 obesity risk factors. For each analysis , I included measures of sociodemographic characteristics, socioeconomic resources, child-level characteristics and parent-level characteristics as covariates. Additionally, I tested whether protective factors moderated these associations including interaction terms. Analyses were based on an analytic sample of 4,000 co-residential mother-father dyads at the preschool wave. In general, the results suggested that parental stressors were associated with a child’s emotional regulation skills and obesity risk. However, these associations often became non-significant once parent-level characteristics that influence family functioning, or the general social-emotional climate of the household, were added to the models. Thus, the findings indicated that parent-level characteristics including maternal depressive symptomology, conflict resolution styles and the number of household routines may influence a child’s behavior and obesity risk above and beyond the specific stressors this dissertation focused on. In addition, the overall findings also suggest that the relationships between parental stressors and child outcomes vary by parental gender as the associations are stronger among mothers than fathers. The results did not support the hypothesis that parenting resources moderated the association between the parental stressors and a child’s emotional regulation skills, but there was partial support for moderation when examining the association between a child’s emotional regulation skills and the obesity risk factors. This dissertation contributes to the literature on psychosocial correlates of child obesity by highlighting the importance of examining familial characteristics that influence the general social-emotional climate of the household and the role of parents’ gender to better understand how the family environment and specific behaviors and practices influence early childhood health and development

Social Determinants of Health, Violent Radicalization, and Terrorism: A Public Health Perspective

Background: Terrorism-related deaths are at an all-time high as there were 32,685 and 29,376 terrorism-related deaths in 2014 and 2015, respectively. Terrorism is defined as the use of violence and intimidation in the pursuit of political aims. Terrorism is detrimental for mental health, premature mortality, and economic losses and undermines the central tenets of public health to improve the health and well-being of populations. Despite the impact terrorism has on avoidable morbidity and mortality, population health research largely overlooks social determinants of terrorism and risk factors that contribute to terrorist activities. Methods: Drawing from what is known about commonly studied social determinants of health topics, including the relationships between structural and interpersonal discrimination, social cohesion, and gang violence and health, we present a public health framework, rooted in the social determinants of health, for identifying potential factors influencing terrorism and violent radicalization. Results: Social determinants of health provide unique insight into how interpersonal and structural factors can influence risk for violent radicalization and terrorist activity. Each of the topics we review provides an entry point for existing public health and behavioral science knowledge to be used in preventing and understanding violent radicalization and terrorism. For example, anti-Muslim sentiment has promoted discrimination against Muslims, while also serving to marginalize and stigmatize Muslim communities. These conditions limit the social resources, like social cohesion, that Muslims have access to and make political violence more appealing to some. Conclusions: Public health can contribute much to the ongoing debate around terrorism. The field must take a more prevention-focused approach to the problem of terrorism. Failure to do so only perpetuates approaches that have not been successful

Feedback from the Field: Feasibility of the Perinatal Food Group Recall Form

Background: Maintaining a healthy weight can reduce risks of excessive weight gain during pregnancy and help prevent maternal and child obesity. Low-income women are high-risk for excessive weight gain during pregnancy. Nutrition counseling can help improve dietary habits, however, it is often provided by paraprofessionals who lack formal training in dietetics. There is a need for a brief dietary assessment form for paraprofessionals serving low-income perinatal women. Purpose: The purpose of this study was to provide feedback on the feasibility of the Perinatal Food Group Recall (PFGR) form among Comprehensive Perinatal Health Workers (CPHWs) serving low-income pregnant and post-partum mothers. Methods: Nine CPHWs at four clinics were asked to complete their regular dietary assessment form and then administer the PFGR. Key informant interviews with the nine paraprofessionals were conducted to obtain their feedback on the form. Results: The findings suggest that the form provides a feasible and easyto-administer dietary assessment tool for use by practitioners without formal dietetics training who serve clinics in low-income communities with heavy client flow. Conclusion: The form can facilitate the provision of nutrition counseling among low-income mothers and build capacity among community health workers

Whole Person Care in Under-resourced Communities: Stakeholder Priorities at Long-Term Follow-Up in Community Partners in Care.

ObjectiveDepressed individuals may require help from different agencies to address health and social needs, but how such coordination occurs in under-resourced communities is poorly understood. This study sought to identify priorities of Latino and African American depressed clients, explore whether service providers understand client priorities, and describe how providers address them.MethodsBetween October 2014 and February 2015, we interviewed 104 clients stratified by depression history and 50 representatives of different programs in health and social community agencies who participated in Community Partners in Care, a cluster-randomized trial of coalition-building approaches to delivering depression quality improvement programs. Clients were queried about their most pressing needs; program representatives identified their clients' needs and explained how they addressed them.ResultsPhysical and mental health were clients' top priorities, followed by housing, caring for and building relationships with others, and employment. While persistently depressed clients prioritized mental health, those with improved depression prioritized relationships with others. Program representatives identified housing, employment, mental health, and improving relationships with others as clients' top priorities. Needs assessment, client-centered services, and linkages to other agencies were main strategies used to address client needs.ConclusionDepressed clients have multiple health and social needs, and program representatives in under-resourced communities understand the complexity of clients' needs. Agencies rely on needs assessment and referrals to meet their clients' needs, which enhances the importance of agency partnership in "whole person" initiatives. Our results illustrate agency capacity to adopt integrated care models that will address clients' multiple needs through multi-sector collaboration and describe potential strategies to help reach the goal of whole person care

A Health Profile and Overview of Healthcare Experiences of Cambodian American Refugees and Immigrants Residing in Southern California

Asian Americans are understudied in health research and often aggregated into one homogenous group, thereby disguising disparities across subgroups. Cambodian Americans, one of the largest refugee communities in the United States, may be at high risk for adverse health outcomes. This study compares the health status and healthcare experiences of Cambodian American refugees and immigrants. Data were collected via questionnaires and medical records from two community clinics in Southern California (n = 308). Chi square and t-tests examined the socio-demographic differences between immigrants and refugees, and ANCOVA models compared the mean differences in responses for each outcome, adjusting for age at immigration, education level, and clinic site. Cambodian American refugees reported overall lower levels of health-related quality of life (all p's < 0.05 in unadjusted models) and self-rated health [unadjusted means (SD) = 18.2 (16.8) vs. 21.7 (13.7), p < 0.05], but either similar or more positive healthcare experiences than Cambodian American immigrants. In adjusted analyses, refugees had higher rates of diabetes and cardiovascular disease risk (e.g. heart condition and hypertension; p's < 0.05) compared to Cambodian American immigrants. There were minimal differences in self-reported health behaviors between the two groups. There is a need for more health promotion efforts among Cambodian American refugees and immigrants to improve their health outcomes and perceived wellbeing

Engaging Community Networks to Improve Depression Services: A Cluster-Randomized Trial of a Community Engagement and Planning Intervention

This paper explores the effects of a group-randomized controlled trial, Community Partners in Care (CPIC), on the development of interagency networks for collaborative depression care improvement between a community engagement and planning (CEP) intervention and a resources for services (RS) intervention that provided the same content solely via technical assistance to individual programs. Both interventions consisted of a diverse set of service agencies, including health, mental health, substance abuse treatment, social services, and community-trusted organizations such as churches and parks and recreation centers. Participants in the community councils for the CEP intervention reflected a range of agency leaders, staff, and other stakeholders. Network analysis of partnerships among agencies in the CEP versus RS condition, and qualitative analysis of perspectives on interagency network changes from multiple sources, suggested that agencies in the CEP intervention exhibited greater growth in partnership capacity among themselves than did RS agencies. CEP participants also viewed the coalition development intervention both as promoting collaboration in depression services and as a meaningful community capacity building activity. These descriptive results help to identify plausible mechanisms of action for the CPIC interventions and can be used to guide development of future community engagement interventions and evaluations in under-resourced communities