The greater Denver Latino Cancer Prevention/Control Network. Prevention and research through a community-based approach

A rapid realist review of patient engagement in patient-oriented research and health care system impacts: part one

BACKGROUND

Patient-oriented research affords individuals with opportunities to genuinely contribute to health care research as members of research teams. While checklists and frameworks can support academic researchers' awareness of patient engagement methods, less guidance appears available to support their understanding of how to develop and maintain collaborative relationships with their patient partners. This knowledge is essential as patient partners report that the social atmospheres of research teams significantly impacts the quality of their experiences. This study sought to develop theory regarding how academic researchers support and sustain patient engagement in patient-oriented research.

METHODS

A six-step, rapid realist review was conducted: (1) research question development, (2) preliminary theory development, (3) search strategy development; (4) study selection and appraisal, (4) data extraction, analysis and synthesis (5) identification of relevant formal theories, and (6) theory refinement with stakeholders. Findings were additionally distilled by collective competence theory.

RESULTS

A program theory was developed from 62 international studies which illuminated mechanisms supporting academic researchers to engage patient partners, contexts supporting these mechanisms, and resources that enabled mechanism activation. Interaction between seven contexts (patient-oriented research belief, prior interaction with a healthcare system, prior interaction with a particular academic researcher, educational background of patient partner, prior experience with patient-oriented research, study type, and time lived in a rural-urban setting) and seven mechanisms (deciding to become involved in patient-oriented research, recognizing valuable experiential knowledge, cultural competence, reducing power differentials, respectful team environment, supporting patient partners to feel valued, and readiness to research) resulted in an intermediate outcome (sense of trust). Trust then acted as an eighth mechanism which triggered the final-level outcome (empowered patient-centred lens).

CONCLUSIONS

Our theory posits that if patient partners trust they are a member of a supportive team working alongside academic researchers who authentically want to incorporate their input, then they are empowered to draw upon their experiential knowledge of health care systems and contribute as researchers in patient-oriented research. Our theory extends conceptual thinking regarding the importance of trust on patient-oriented research teams, how patient partners' trust is shaped by team interactions, and the role that academic researchers have within those interactions.

Community-Engaged Approaches for Minority Recruitment Into Clinical Research: A Scoping Review of the Literature

Underrepresentation of racial and ethnic minority populations in clinical research persists in the United States, highlighting the unmet ideals of generalizability and equity of research findings and products. Previous systematic reviews exploring various facets of this phenomenon concluded that community engagement with minority groups may effectively promote recruitment and retention, but the ways in which community-engaged approaches have been used for recruitment have not been examined. We performed a scoping review of the literature to identify studies of community-engaged recruitment processes. The search resulted in 2842 articles, of which 66 met inclusion criteria. These articles demonstrated a relatively large literature base of descriptive studies conveying details of community engagement approaches to enhance recruitment of minority research participants. We summarize key aspects of current practices across the spectrum of community engagement. A gap in the literature is the relative lack of the comparative studies among different engagement strategies.

Development and Feasibility of a Community-Based, Culturally Flexible Colorectal Cancer Prevention Program

Comprehensive cancer centers are an important community resource for cancer prevention education in their catchment areas. Colorectal cancer remains one of the most commonly diagnosed cancers in the United States, making prevention a priority. Colorectal cancer prevention targets include lifestyle modifications that are influenced by cultural norms, such as diet change, physical activity and screening behavior. Cancer centers must tailor prevention efforts to multiethnic catchment areas. This paper describes the development and feasibility of a comprehensive cancer center's approach to community-based colorectal cancer prevention in Houston, Texas, specifically targeting Hispanic and Asian populations. Sites were recruited through a city-wide network of partnerships between the community relations department in the hospital and community organizations. The program consisted of three workshop-style classes per community site. Each class had a similar overall structure, but cultural and site-specific adaptations were made for each group. A total of 33 classes were taught at nine distinct community sites to 1054 participants over 9 months. This program structure may be adapted for the future dissemination of other cancer prevention tools to communities in the area.

A community-academic partnership to explore informational needs of African American women as a primer for cancer clinical trial recruitment

Background: African Americans (AAs) are less likely to participate in cancer clinical trials (CCTs) despite experiencing disproportionately higher rates of cancer mortality. As a way to address these ongoing disparities, this study sought to qualitatively explore informational needs regarding CCTs among AA women and identify message considerations for educational information targeting AA women and their community. Methods: Three focus groups were conducted in which AA women viewed a DVD created as a decisional tool for CCT participation and provided feedback regarding content. Results: Results indicated general fear regarding CCTs, which is partially attributable to the impact of historic research abuses, lack of information regarding CCTs, and lack of cultural relevance of the education and outreach materials for AA communities. Recruitment of AAs to CCTs may be enhanced by educational and outreach approaches that increase awareness of CCTs as well as involvement of the AA community in developing such interventions. Conclusion: Interventions should include the perspectives of AA women, as key stakeholders and decision-makers for their family and provide research information in a multimedia format that will facilitate family discussion and decision-making regarding CCTs.

Process evaluation of health fairs promoting cancer screenings

Background

Low income and uninsured individuals often have lower adherence to cancer screening for breast, cervical and colorectal cancer. Health fairs are a common community outreach strategy used to provide cancer-related health education and services.

Methods

This study was a process evaluation of seven health fairs focused on cancer screening across the U.S. We conducted key-informant interviews with the fair coordinator and conducted baseline and follow-up surveys with fair participants to describe characteristics of participants as well as their experiences. We collected baseline data with participants at the health fairs and telephone follow-up surveys 6 months following the fair.

Results

Attendance across the seven health fairs ranged from 41 to 212 participants. Most fairs provided group or individual education, print materials and cancer screening during the event. Overall, participants rated health fairs as very good and participants reported that the staff was knowledgeable and that they liked the materials distributed. After the fairs, about 60% of participants, who were reached at follow-up, had read the materials provided and had conversations with others about cancer screening, and 41% talked to their doctors about screening. Based on findings from evaluation including participant data and coordinator interviews, we describe 6 areas in planning for health fairs that may increase their effectiveness. These include: 1) use of a theoretical framework for health promotion to guide educational content and activities provided, 2) considering the community characteristics, 3) choosing a relevant setting, 4) promotion of the event, 5) considerations of the types of services to deliver, and 6) evaluation of the health fair.

Conclusions

The events reported varied in reach and the participants represented diverse races and lower income populations overall. Most health fairs offered education, print materials and onsite cancer screening. Participants reported general satisfaction with these events and were motivated through their participation to read educational materials or discuss screening with providers. Public health professionals can benefit from this process evaluation and recommendations for designing and evaluating health fairs.

Characterization of the Hispanic or latino population in health research: a systematic review

The size and diversity of the Hispanic population in the United States has dramatically increased, with vast implications for health research. We conducted a systematic review of the characterization of the Hispanic population in health research and described its implications. Relevant studies were identified by searches of PubMed, Embase Scopus, and Science/Social Sciences Citation Index from 2000 to 2011. 131 articles met criteria. 56% of the articles reported only "Hispanic" or "Latino" as the characteristic of the Hispanic research population while no other characteristics were reported. 29% of the articles reported language, 27% detailed country of origin and 2% provided the breakdown of race. There is great inconsistency in reported characteristics of Hispanics in health research. The lack of detailed characterization of this population ultimately creates roadblocks in translating evidence into practice when providing care to the large and increasingly diverse Hispanic population in the US.

Comparing traditional and participatory dissemination of a shared decision making intervention (ADAPT-NC): a cluster randomized trial

BACKGROUND

Asthma is a common disease that affects people of all ages and has significant morbidity and mortality. Poor outcomes and health disparities related to asthma result in part from the difficulty of disseminating new evidence and care delivery methods such as shared decision making (SDM) into clinical practice.

METHODS/DESIGN

This non-blinded study will randomize 30 primary care clinics in NC stratified by four PBRNs. We will test dissemination across these practices using a facilitator-led participatory approach to dissemination (FLOW), a novel method of participatory dissemination involving key principles of community-based participatory research, and a more typical "lunch and learn" dissemination method. Specifically, we will use cluster randomization to assign each of the 30 practices to one of three arms: (1) control, no dissemination; (2) traditional dissemination, one didactic session a year and distribution of educational material; and (3) FLOW dissemination. We hypothesize that at the unit of randomization, the clinic, patients in the FLOW dissemination arm will be more likely to share in their treatment decisions compared to patients in the traditional dissemination or control arms. All outcomes will be measured at the level of the clinic. Adoption of the SDM approach will be evaluated by 1) asthma exacerbations, 2) level of patient involvement in the decision making process, and 3) qualitative assessments from patients and providers.

TRIAL REGISTRATION

The trial was registered on January 27, 2014 through the United States National Institutes of Health's ClinicalTrials.gov NCT02047929 and funded by the Patient-Centered Outcomes Research Institute (PCORI).

Using the Medical Research Council framework for the development and evaluation of complex interventions in a theory-based infant feeding intervention to prevent childhood obesity: the baby milk intervention and trial

INTRODUCTION

We describe our experience of using the Medical Research Council framework on complex interventions to guide the development and evaluation of an intervention to prevent obesity by modifying infant feeding behaviours.

METHODS

We reviewed the epidemiological evidence on early life risk factors for obesity and interventions to prevent obesity in this age group. The review suggested prevention of excess weight gain in bottle-fed babies and appropriate weaning as intervention targets; hence we undertook systematic reviews to further our understanding of these behaviours. We chose theory and behaviour change techniques that demonstrated evidence of effectiveness in altering dietary behaviours. We subsequently developed intervention materials and evaluation tools and conducted qualitative studies with mothers (intervention recipients) and healthcare professionals (intervention deliverers) to refine them. We developed a questionnaire to assess maternal attitudes and feeding practices to understand the mechanism of any intervention effects.

CONCLUSIONS

In addition to informing development of our specific intervention and evaluation materials, use of the Medical Research Council framework has helped to build a generalisable evidence base for early life nutritional interventions. However, the process is resource intensive and prolonged, and this should be taken into account by public health research funders. This trial is registered with ISRTCN: 20814693 Baby Milk Trial.

Effect of health care disparities on screening

Significant declines in the incidence and mortality rates of cervical cancer have occurred in the United States since the introduction of the Papanicolaou (Pap) test. Unfortunately, a reduction in the burden of cervical cancer is not equal across all ethnic and racial groups; significant disparities exist. Disparities are reflected not only in mortality and incidence rates, but also in screening rates. We review barriers to screening and effective approaches towards overcoming them. As minority populations increase over the next few decades, it becomes ever more urgent to employ interventions that will reduce the burden of cervical cancer among diverse groups.

A small grants program to involve communities in research

A key tenet of community-based participatory research is that communities be involved in all facets of research, from defining the problem to identifying solutions, to assisting in the research, and to participating in the publication of results. In this study, we instituted a small grants program for community participation. A Request for Applications (RFA) was developed and circulated widely throughout the Valley. The RFA sought proposals to address health disparities in cancer education, prevention, and treatment among Hispanics living in the Valley. Funds available were $2,500.00-3,500.00 for 1 year's worth of work. To help evaluate the progress of the RFA community projects according to the perspectives of the Community Advisory Board (CAB), an open-ended, semi-structured interview was created and administered by a former staff member to CAB members. In 4 years, ten small grants proposed by community members were funded. Funds allocated totaled approximately $25,000. Interviews with CAB members indicated that the RFA program was perceived positively, but there were concerns about sustainability. Our community grants program resulted in the implementation of several novel cancer prevention programs conducted by a variety of community organizations in the Lower Yakima Valley.

The science of primary health-care improvement: potential and use of community-based participatory research by practice-based research networks for translation of research into practice

There is a need for new approaches to supplement the existing methods of taking research from bench to bedside and from bedside to practice. Community-based participatory research (CBPR) is an emerging model of research that enhances ongoing clinical research by involving key stakeholders, including community members and patients. A practice-based research network (PBRN) is a group of primary care practices devoted principally not only to the primary care of patients, but also with a mission to investigate questions related to community-based practice and to improve the quality of primary care. Traditionally, PBRN research has not included patients or community members, while CBPR has excluded health providers as key stakeholders. Typical overlap topics of PBRN and CBPR research are health-care disparities, prevention, chronic disease management and mental health. The inclusion of CBPR within a PBRN has been identified as an important next step with the potential to significantly enhance the research process. This review focuses on bringing together the ideals of CBPR and PBRNs in order to tackle intractable problems such as disparities in health-care access and outcomes and translate these results into practice. Specifically, the CBPR PBRN approach can: (1) guide the research process so that studies more closely match the needs of all stakeholders (including providers, patients and community members); (2) assist in the development of the research protocol and identification of research methodologies so that the study is more amenable to participants; (3) facilitate recruitment of research participants; (4) enrich the data collection and analysis; and (5) allow rapid translation of results from the study back into clinical practice and the community. Once these mechanisms have been clearly elucidated, their widespread adoption will positively impact overall health at both a local and national level.

Preventing cervical cancer in the Latina population

Cervical cancer causes great morbidity and mortality worldwide and in the United States. Infection with oncogenic human papillomavirus (HPV), the etiological agent of almost all cervical cancer cases, is common among sexually active women in the United States. Over the past 5 decades, the implementation of Papanicolaou screening programs in the United States has led to a significant decrease in cervical cancer cases. However, notable disparities in the incidence and mortality of cervical cancer and cervical screening rates among Hispanics in the United States remain. If current disparities persist without intervention, the Latina population in the United States may remain at a higher risk of developing and dying from cervical cancer. We discuss disparities in cervical cancer screening, incidence, and mortality among the Latina population, as well as the barriers that may propagate these disparities. We also address how these barriers can be overcome through the coordination of outreach programs and widespread prophylactic HPV vaccination to reduce cervical cancer disparities in Latinas.