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Powell N, Dalton H, Lawrence-Bourne J, Perkins D. Co-creating community wellbeing initiatives: what is the evidence and how do they work? Int J Ment Health Syst 2024; 18:28. [PMID: 39103881 DOI: 10.1186/s13033-024-00645-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 07/09/2024] [Indexed: 08/07/2024] Open
Abstract
BACKGROUND Addressing wellbeing at the community level, using a public health approach may build wellbeing and protective factors for all. A collaborative, community-owned approach can bring together experience, networks, local knowledge, and other resources to form a locally-driven, place-based initiative that can address complex issues effectively. Research on community empowerment, coalition functioning, health interventions and the use of local data provide evidence about what can be achieved in communities. There is less understanding about how communities can collaborate to bring about change, especially for mental health and wellbeing. METHOD A comprehensive literature search was undertaken to identify community wellbeing initiatives that address mental health. After screening 8,972 titles, 745 abstracts and 188 full-texts, 12 exemplar initiatives were identified (39 related papers). RESULTS Eight key principles allowed these initiatives to become established and operate successfully. These principles related to implementation and outcome lessons that allowed these initiatives to contribute to the goal of increasing community mental health and wellbeing. A framework for community wellbeing initiatives addressing principles, development, implementation and sustainability was derived from this analysis, with processes mapped therein. CONCLUSION This framework provides evidence for communities seeking to address community wellbeing and avoid the pitfalls experienced by many well-meaning but short-lived initiatives.
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Affiliation(s)
- Nicholas Powell
- Independent researcher. Formerly Centre for Rural and Remote Mental Health, University of Newcastle, Orange, NSW, Australia
| | - Hazel Dalton
- Rural Health Research Institute, Charles Sturt University, Orange, NSW, Australia.
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia.
- Healthy Minds Research Program, Hunter Medical Research Institute, Newcastle, NSW, Australia.
- Mental Health Policy Unit, Health Services Research Institute, University of Canberra, Canberra, ACT, Australia.
| | - Joanne Lawrence-Bourne
- Independent researcher. Formerly Centre for Rural and Remote Mental Health, University of Newcastle, Orange, NSW, Australia
| | - David Perkins
- Mental Health Policy Unit, Health Services Research Institute, University of Canberra, Canberra, ACT, Australia
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Bora NS, Brummel ML, O'Donnell JE, Smith KC. Collaboration for Health Equity: A Qualitative Assessment of Local Leaders in Community-Based Organizations, Health Care, and Public Health in Michigan. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2024:00124784-990000000-00293. [PMID: 38950426 DOI: 10.1097/phh.0000000000002013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024]
Abstract
A qualitative study was conducted using semi-structured interviews leaders in community-based organizations, health care, and local public health to understand organizational perspectives of collaboration for health equity and identify opportunities to improve collaboration. Twelve leaders were interviewed from March through May 2023 in Kent County, Michigan. All leaders saw collaboration as valuable for advancing health equity. Key themes that affected collaboration and could be a facilitator or barrier to advancing health equity in the community were inclusion, power, relationships, resources, and organizational traits. Leaders articulated the following factors as those that support collaboration for health equity: authentic inclusion, shared decision-making, taking time to foster trusting relationships, adequate resources to support the infrastructure needed for collaborations, organizational flexibility, and individual commitment. Building partnerships with these facilitators in mind may result in more robust, sustainable, and resilient collaboratives.
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Affiliation(s)
- Nirali S Bora
- Author Affiliations: Kent County Health Department, Grand Rapids, Michigan (Dr Bora, Mss Brummel, and O'Donnell); College of Human Medicine, Michigan State University, Grand Rapids, Michigan (Dr Bora); and Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Drs Smith and Bora)
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Fraley HE, Ramos de Oliveira C, Aronowitz T, Burton CW. Trauma-Informed Research With Emerging Adult Survivors of Sexual Violence. Clin Nurs Res 2024; 33:429-436. [PMID: 38685710 DOI: 10.1177/10547738241248861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
Health researchers have had increasing calls to include vulnerable populations in research to tailor inclusive evidence-based practice interventions. The inclusion of vulnerable populations in research is sensitive and complex. Sensitive topics such as dating and sexual violence are especially complex, with emerging adults the highest risk group for all forms of sexual violence and an especially hard-to-reach population for inclusion in research. Impacts of trauma, including physiological and psychological, complex needs of survivors, and potential for revictimization during interactions when participating in research must be considered. Researchers must be equipped with specialized, trauma-informed skills to safely and ethically conduct all aspects of research. Using the trauma-informed framework, the purpose of this paper is to discuss the complexities of conducting research with emerging adult survivors of sexual violence and to explore evidence-based approaches that can safely include this vulnerable population through the application of trauma-informed approaches. The use of evidence-based, trauma-informed research approaches tailored to engage this population in research can further help to develop effective interventions that are context-sensitive to emerging adults.
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Affiliation(s)
| | | | - Teri Aronowitz
- University of Massachusetts Chan Medical School, Worcester, USA
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Carson SL, Cameron F, Lee D, Zúñiga D, Poole K, Jones A, Herman C, Ramirez M, Harlow S, Johnson J, Agonafer EP, Hong CS, Brown AF. A collaboration team to build social service partnerships within a safety-net health system. BMC Public Health 2024; 24:654. [PMID: 38429651 PMCID: PMC10905940 DOI: 10.1186/s12889-024-18155-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 02/19/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND To facilitate safety-net healthcare system partnerships with community social service providers, the Los Angeles County Department of Health Services (LAC DHS) created a new collaboration team to spur cross-agency social and medical referral networks and engage communities affected by health disparities as part of a Sect. 1115 Medicaid waiver in Los Angeles County entitled Whole Person Care-Los Angeles (WPC-LA). METHODS This observational research reviews three years of collaboration team implementation (2018-2020) through Medicaid-reportable engagement reports, a collaboration team qualitative survey on challenges, facilitators, and recommendations for community engagement. Member reflections for survey findings were conducted with the collaboration team and LAC DHS WPC-LA leadership. RESULTS Collaboration team Medicaid engagement reports (n = 144) reported > 2,700 events, reaching > 70,000 individuals through cross-agency and community-partnered meetings. The collaboration team survey (n = 9) and member reflection sessions portrayed engagement processes through outreach, service assessments, and facilitation of service partnerships. The collaboration team facilitated community engagement processes through countywide workgroups on justice-system diversion and African American infant and maternal health. Recommendations for future safety net health system engagement processes included assessing health system readiness for community engagement and identifying strategies to build mutually beneficial social service partnerships. CONCLUSIONS A dedicated collaboration team allowed for bi-directional knowledge exchange between county services, populations with lived experience, and social services, identifying service gaps and recommendations. Engagement with communities affected by health disparities resulted in health system policy recommendations and changes.
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Affiliation(s)
- Savanna L Carson
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, 1100 Glendon Ave, Suite 1100, Los Angeles, CA, 90095, USA.
| | - Francesca Cameron
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, 1100 Glendon Ave, Suite 1100, Los Angeles, CA, 90095, USA
| | - Diamond Lee
- Los Angeles County Department of Health Services, 711 Del Amo Blvd, Torrance, CA, 90502, USA
| | - Diana Zúñiga
- Los Angeles County Department of Health Services, 711 Del Amo Blvd, Torrance, CA, 90502, USA
- Tres Lunas Consulting, 1509 Stanley Ave. #302, Long Beach, 90804, USA
| | - Kelli Poole
- Los Angeles County Department of Health Services, 711 Del Amo Blvd, Torrance, CA, 90502, USA
| | - Adjoa Jones
- Los Angeles County Department of Health Services, 313 N Figueroa St, Los Angeles, CA, 90012, USA
| | - Cristina Herman
- Los Angeles County Department of Health Services, 711 Del Amo Blvd, Torrance, CA, 90502, USA
| | - Mayra Ramirez
- Los Angeles County Department of Health Services, 711 Del Amo Blvd, Torrance, CA, 90502, USA
| | - Simone Harlow
- Los Angeles County Department of Health Services, 711 Del Amo Blvd, Torrance, CA, 90502, USA
| | - Jeannette Johnson
- Los Angeles County Department of Health Services, 711 Del Amo Blvd, Torrance, CA, 90502, USA
| | - Etsemaye P Agonafer
- Department of Health System Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Clemens S Hong
- Los Angeles County Department of Health Services, 711 Del Amo Blvd, Torrance, CA, 90502, USA
| | - Arleen F Brown
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, 1100 Glendon Ave, Suite 1100, Los Angeles, CA, 90095, USA
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Marcus R, Monga Nakra N, Pollack Porter KM. Characterizing Organizational Health Equity Capacity Assessments for Public Health Organizations: A Scoping Review. Public Health Rep 2024; 139:26-38. [PMID: 36891964 PMCID: PMC10905768 DOI: 10.1177/00333549231151889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023] Open
Abstract
OBJECTIVE Organizational health equity capacity assessments (OCAs) provide a valuable starting point to understand and strengthen an organization's readiness and capacity for health equity. We conducted a scoping review to identify and characterize existing OCAs. METHODS We searched the PubMed, Embase, and Cochrane databases and practitioner websites to identify peer-reviewed and gray literature articles and tools that measure or assess health equity-related capacity in public health organizations. Seventeen OCAs met the inclusion criteria. We organized primary OCA characteristics and implementation evidence and described them thematically according to key categories. RESULTS All identified OCAs assessed organizational readiness or capacity for health equity, and many aimed to guide health equity capacity development. The OCAs differed in regard to thematic focus, structure, and intended audience. Implementation evidence was limited. CONCLUSIONS By providing a synthesis of OCAs, these findings can assist public health organizations in selecting and implementing OCAs to assess, strengthen, and monitor their internal organizational capacity for health equity. This synthesis also fills a knowledge gap for those who may be considering developing similar tools in the future.
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Affiliation(s)
- Rachel Marcus
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Keshia M. Pollack Porter
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Ross J, Betancourt GS, Andrade EA, Klein A, Marrero L, Morales GA, Rivera S, Watnick DL, Patel VV. Collaborative PrEP Implementation Strategies for Latino Men Who have Sex with Men: A Health Center-Community Consensus Process. J Community Health 2023; 48:994-1003. [PMID: 37548892 PMCID: PMC10558404 DOI: 10.1007/s10900-023-01266-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2023] [Indexed: 08/08/2023]
Abstract
Community-based organizations (CBOs) deliver services in culturally-responsive ways, and could effectively partner with health centers to deliver HIV pre-exposure prophylaxis (PrEP) to Latino men who have sex with men (LMSM). However, few such models exist. We conducted a planning study in collaboration with three CBOs serving LMSM to identify optimal PrEP delivery strategies for health centers and CBOs to implement jointly. We established a Community Expert Panel (CEP) of eight client-facing CBO and health center staff. Over 6 months, the panel met monthly to identify collaborative strategies for PrEP delivery, using a modified Delphi method consisting of the following steps: (1) brainstorming strategies; (2) rating strategies on acceptability, appropriateness and feasibility; (3) review of data from qualitative focus group discussions with CBO clients; and (4) final strategy selection. The panel initially identified 25 potential strategies spread across three categories: improving communication between health centers and CBOs; using low-barrier PrEP options (e.g. telemedicine), and developing locally-relevant, culturally-sensitive outreach materials. Focus groups with CBO clients highlighted a desire for flexible options for PrEP-related care and emphasized trust in CBOs. The final package of strategies consisted of: (1) a web-based referral tool; (2) telemedicine appointments; (3) geographically-convenient options for lab specimen collection; (4) tailored print and social media; and (5) regular coaching sessions with CBO staff. Through a community-engaged process, we identified a package of PrEP delivery strategies that CBOs and health centers can implement in partnership, which have the potential to overcome barriers to PrEP for LMSM.
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Affiliation(s)
- Jonathan Ross
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, 3300 Kossuth Avenue, Bronx, NY, 10467, USA.
| | | | - Elí A Andrade
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, 3300 Kossuth Avenue, Bronx, NY, 10467, USA
| | - Augustus Klein
- Hunter Alliance for Research and Translation, Hunter College, New York, NY, USA
| | | | | | | | - Dana L Watnick
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Viraj V Patel
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, 3300 Kossuth Avenue, Bronx, NY, 10467, USA
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Johnston B, Ruffalo L, Nelson D, O'Connor S, Young S. Foundations of Community Engagement: A Series for Effective Community-Engaged Research. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2023; 19:11350. [PMID: 37822302 PMCID: PMC10562524 DOI: 10.15766/mep_2374-8265.11350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 06/22/2023] [Indexed: 10/13/2023]
Abstract
Introduction Medical students lack systematic exposure to community engagement. Community-engaged research (CEnR) is an effective approach to improve community health, and community-engaged physicians are better attuned to the community context of their patients' health and well-being. The Medical College of Wisconsin (MCW) Office of Community Engagement began offering the educational series Foundations of Community Engagement in 2021 to meet this need. Methods We developed and implemented a four-session series for medical students at MCW and the University of Nebraska Medical Center. A 1-hour session on the foundations of CEnR was held for all learners. Three 1-hour sessions dove deeper into CEnR principles for a self-selected cohort. These small-group sessions involved discussion between faculty and community partners and facilitated small-group discussion. Students completed evaluations after each session. Results A total of 160 students participated in the introductory session; 36 took part in the follow-up series. Survey response rates varied from 38% to 67% for each session. Overall, 87% of students in all sessions felt their session was worthwhile, with 85% of large-group and 96% of small-group respondents reporting they learned something they would use in their practice or profession. Qualitative responses included appreciation for addressing a curricular gap and desire for more time and more sessions to continue discussions. Discussion The program was effective at stimulating medical student self-reported gains in skills, attitudes, and future intentions regarding CEnR in an efficient manner. Effective programs that transfer positive CEnR skills and attitudes to future physicians can promote CEnR within academic medicine.
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Affiliation(s)
- Bryan Johnston
- Assistant Professor, Department of Family and Community Medicine, Medical College of Wisconsin
| | - Leslie Ruffalo
- Associate Professor, Department of Family and Community Medicine, Medical College of Wisconsin
| | - David Nelson
- Professor, Department of Family and Community Medicine, Medical College of Wisconsin
| | - Sarah O'Connor
- Program Director, Office of Community Engagement, Medical College of Wisconsin
| | - Staci Young
- Professor, Department of Family and Community Medicine, Director, Office of Community Engagement, and Senior Associate Dean for Community Engagement, Medical College of Wisconsin
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Chi C, Núñez A, Tuepker A. From sharing voices to making decisions: The case for centring community ownership in evaluation of health programme planning and management. Int J Health Plann Manage 2022; 37 Suppl 1:8-19. [PMID: 36100969 DOI: 10.1002/hpm.3571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 07/25/2022] [Accepted: 08/31/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Community participation in health programme planning has gained traction in public health in recent decades. When an idea enters the mainstream, it becomes vulnerable to overuse and dilution, and public health professionals claiming "community participation" may intentionally or unintentionally prevent more meaningful participatory action. The principle of community-centred planning is seldom integrated into programme evaluation. We have previously argued that, to prevent ambiguity and abuse, a stronger and more explicit idea of community ownership is useful. Un-like "participation", "ownership" leaves little room for dilution. METHOD This perspective piece explores a framework to support evaluating community ownership in planning, by emphasising decision-making power in health planning and management as a necessary element for evaluation alongside other outcomes. After defining the concept of community ownership, we identify and discuss challenges and research gaps related to implementing community ownership in health programme planning, management, and evaluation. Such issues include considering which communities have claims to programme ownership, alternative approaches to representation and participation that support ownership, gathering community values and preferences, and incorporating them into ongoing programme planning, management and evaluation. We consider methodological issues likely to arise when transitioning from gathering community voices - which is valuable but incomplete work - towards community decision making power in planning and evaluation. RESULTS We use cases from recent policy and research in Chile as examples to consider through the lens of this framework. Finally, we discuss some current constraints in implementing community ownership in healthcare planning and evaluation. CONCLUSION We encourage exploring how to practice evaluation in ways that will further our ability to be helpful professional supporters of community self-determination in finding their paths to health.
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Affiliation(s)
- Chunhuei Chi
- Center for Global Health, Global Health Program, Health Management and Policy Program, College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon, USA
| | - Alicia Núñez
- Department of Management Control and Information Systems, Faculty of Economics and Business, University of Chile, Santiago, Chile
| | - Anaïs Tuepker
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University/Center to Improve Veteran Involvement in Care, Portland, Oregon, USA
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Xanthopoulou PD, Mbanu J, Chevalier A, Webber M, Giacco D. Social Isolation and Psychosis: Perspectives from People with Psychosis, Family Caregivers and Mental Health Professionals. Community Ment Health J 2022; 58:1338-1345. [PMID: 35079917 PMCID: PMC9392710 DOI: 10.1007/s10597-022-00941-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 01/11/2022] [Indexed: 11/28/2022]
Abstract
This paper explores the subjective experiences of mental health practitioners, people with psychosis and carers, on social isolation and community integration of people with psychosis. Focus groups and one-to-one interviews with 80 adult participants across three sites in the UK were conducted. Audio recordings were transcribed and analysed using thematic analysis. Participants commented on various aspects that may cause social isolation or enable community integration, including institutional factors (lack of resources, hospitalisation impact), illness symptoms (e.g., paranoia; over-pathologising vs individual choice), stigma (particularly the psychosis label), and the importance of communities that foster agency and embrace change. Hospitalisation maybe be a cause for isolation and psychiatric wards should consider allowing for socialisation as a therapeutic tool. Initiatives should consider the social fabric of our communities, socioeconomic inequalities and stigmatisation. Building communities that are accepting, kind and flexible can create opportunities that could lead to independence from mental health services.
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Affiliation(s)
| | - Jennifer Mbanu
- Devon Partnership NHS Trust, Dryden Road, Exeter, EX2 5AF, UK
| | - Agnes Chevalier
- Unit for Social and Community Psychiatry, (WHO Collaborating Centre for Mental Health Service Development), Barts and the London School of Medicine, Queen Mary University of London, Newham Centre for Mental Health, London, E13 8SP, UK
| | - Martin Webber
- International Centre for Mental Health Social Research, Department of Social Policy and Social Work, University of York, York, YO10 5DD, UK
| | - Domenico Giacco
- Unit for Social and Community Psychiatry, (WHO Collaborating Centre for Mental Health Service Development), Barts and the London School of Medicine, Queen Mary University of London, Newham Centre for Mental Health, London, E13 8SP, UK.,Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
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Jiménez DJ, Sabo S, Remiker M, Smith M, Samarron Longorio AE, Williamson HJ, Chief C, Teufel-Shone NI. A multisectoral approach to advance health equity in rural northern Arizona: county-level leaders' perspectives on health equity. BMC Public Health 2022; 22:960. [PMID: 35562793 PMCID: PMC9100312 DOI: 10.1186/s12889-022-13279-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 04/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Multisectoral and public-private partnerships are critical in building the necessary infrastructure, policy, and political will to ameliorate health inequity. A focus on health equity by researchers, practitioners, and decision-makers prioritizes action to address the systematic, avoidable, and unjust differences in health status across population groups sustained over time and generations that are beyond the control of individuals. Health equity requires a collective process in shaping the health and wellbeing of the communities in which we live, learn, work, play, and grow. This paper explores multisectoral leaders' understanding of the social, environmental, and economic conditions that produce and sustain health inequity in northern Arizona, a geographically expansive, largely rural, and culturally diverse region. METHODS Data are drawn from the Southwest Health Equity Research Collaborative's Regional Health Equity Survey (RHES). The RHES is a community-engaged, cross-sectional online survey comprised of 31 close-ended and 17 open-ended questions. Created to assess cross-sectoral regional and collective capacity to address health inequity and inform multisectoral action for improving community health, the RHES targeted leaders representing five rural northern Arizona counties and 13 sectors. Select open-ended questions were analyzed using an a priori coding scheme and emergent coding with thematic analysis. RESULTS Although leaders were provided the definition and asked to describe the root causes of inequities, the majority of leaders described social determinants of health (SDoH). When leaders described root causes of health inequity, they articulated systemic factors affecting their communities, describing discrimination and unequal allocation of power and resources. Most leaders described the SDoH by discussing compounding factors of poverty, transportation, housing, and rurality among others, that together exacerbate inequity. Leaders also identified specific strategies to address SDoH and advance health equity in their communities, ranging from providing direct services to activating partnerships across organizations and sectors in advocacy for policy change. CONCLUSION Our findings indicate that community leaders in the northern Arizona region acknowledge the importance of multisectoral collaborations in improving health equity for the populations that they serve. However, a common understanding of health equity remains to be widely established, which is essential for conducting effective multisectoral work to advance health equity.
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Affiliation(s)
- Dulce J Jiménez
- Center for Health Equity Research, Northern Arizona University, PO Box 4065, Flagstaff, AZ, 86011, USA.
| | - Samantha Sabo
- Center for Health Equity Research, Northern Arizona University, PO Box 4065, Flagstaff, AZ, 86011, USA
| | - Mark Remiker
- Center for Health Equity Research, Northern Arizona University, PO Box 4065, Flagstaff, AZ, 86011, USA
| | - Melinda Smith
- Center for Health Equity Research, Northern Arizona University, PO Box 4065, Flagstaff, AZ, 86011, USA
| | | | - Heather J Williamson
- Center for Health Equity Research, Northern Arizona University, PO Box 4065, Flagstaff, AZ, 86011, USA
| | - Carmenlita Chief
- Center for Health Equity Research, Northern Arizona University, PO Box 4065, Flagstaff, AZ, 86011, USA
| | - Nicolette I Teufel-Shone
- Center for Health Equity Research, Northern Arizona University, PO Box 4065, Flagstaff, AZ, 86011, USA
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DeHaven MJ, Gimpel NA, Kitzman H. Working with communities: Meeting the health needs of those living in vulnerable communities when Primary Health Care and Universal Health Care are not available. J Eval Clin Pract 2021; 27:1056-1065. [PMID: 33051956 DOI: 10.1111/jep.13495] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/10/2020] [Accepted: 09/21/2020] [Indexed: 01/01/2023]
Abstract
RATIONALE, AIMS, AND OBJECTIVES The health care delivery model in the United States does not work; it perpetuates unequal access to care, favours treatment over prevention, and contributes to persistent health disparities and lack of insurance. The vast majority of those who suffer from preventable diseases and health disparities, and who are at greatest risk of not having insurance, are low-income minorities (Native Americans, Hispanics, and African-Americans) who live in high risk and vulnerable communities. The historical lack of support in the United States for Universal Health Care (UHC) and Primary Health Care (PHC)-with their emphasis on health care for all, population health, and social determinants of health-requires community health scientists to develop innovative local solutions for addressing unmet community health needs. METHODS We developed a model community health science approach for improving health in fragile communities, by combining community-oriented primary care (COPC), community-based participatory research (CBPR), asset-based community development, and service learning principles. During the past two decades, our team has collaborated with community residents, local leaders, and many different types of organizations, to address the health needs of vulnerable patients. The approach defines health as a social outcome, resulting from a combination of clinical science, collective responsibility, and informed social action. RESULTS From 2000 to 2020, we established a federally funded research programme for testing interventions to improve health outcomes in vulnerable communities, by working in partnership with community organizations and other stakeholders. The partnership goals were reducing chronic disease risk and multimorbidity, by stimulating lifestyle changes, increasing healthy behaviours and health knowledge, improving care seeking and patient self-management, and addressing the social determinants of health and population health. Our programmes have also provided structured community health science training in high-risk communities for hundreds of doctors in training. CONCLUSION Our community health science approach demonstrates that the factors contributing to health can only be addressed by working directly with and in affected communities to co-develop health care solutions across the broad range of causal factors. As the United States begins to consider expanding health care options consistent with PHC and UHC principles, our community health science experience provides useful lessons in how to engage communities to address the deficits of the current system. Perhaps the greatest assets US health care systems have for better addressing population health and the social determinants of health are the important health-related initiatives already underway in most local communities. Building partnerships based on local resources and ongoing social determinants of health initiatives is the key for medicine to meaningfully engage communities for improving health outcomes and reducing health disparities. This has been the greatest lesson we have learned the past two decades, has provided the foundation for our community health science approach, and accounts for whatever success we have achieved.
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Affiliation(s)
- Mark J DeHaven
- Academy for Research on Community Health, Engagement, and Services (ARCHES), University of North Carolina at Charlotte, Charlotte, North Carolina, USA
| | - Nora A Gimpel
- Department of Family and Community Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Heather Kitzman
- Robbins Institute for Health Policy & Leadership, Baylor Scott & White Health and Wellness, Dallas, Texas, USA
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Petiwala A, Lanford D, Landers G, Minyard K. Community voice in cross-sector alignment: concepts and strategies from a scoping review of the health collaboration literature. BMC Public Health 2021; 21:712. [PMID: 33849498 PMCID: PMC8042631 DOI: 10.1186/s12889-021-10741-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 03/30/2021] [Indexed: 11/19/2022] Open
Abstract
Background Health care access is an important driver of population health, and factors beyond health care also drive health outcomes. Recognizing the importance of the social determinants of health (SDOH), different actors in the health care, public health, and social service sectors are increasingly collaborating to improve health outcomes in communities. To support such collaboration, the Robert Wood Johnson Foundation developed a cross-sector alignment theory of change. According to the cross-sector alignment theory of change, community voice is critical for helping collaboratives address community health needs. Yet research on health collaboratives offers mixed guidance on how community voice should be understood and which community voice strategies are most effective. Methods This study addresses a gap in the literature with a systematic scoping review of research on health-oriented cross-sector collaboration and community voice. By scanning key academic journals, searching three academic databases, and obtaining documents from across our professional networks, we identified 36 documents that address community voice in health collaboratives. Results The review reveals several conceptions of community voice and a range of community voice strategies. We find that community voice strategies fall on a spectrum between two broad types of approaches: active and passive. These vary not only in the level of power shared between communities and collaborators, but also in the level of involvement required from the community, and this in turn has important implications for community collaboration strategies. We also find that while most strategies are discussed in the context of short-term collaboration, many also lend themselves to adoption in the context of sustainable collaboration and, ultimately, cross-sector alignment. Conclusion This review provides a characterization and conceptualization of community voice in health-oriented collaborations that provides a new theoretical basis for future research. Passive and active community voice strategies can be studied in more detail for their expected impact on health outcomes and disparities. Increased attention to active community voice and the resources it requires can help practitioners achieve improved health outcomes and researchers understand the pathways to health improvement through collaboration.
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Affiliation(s)
- Aliza Petiwala
- Georgia Health Policy Center, Andrew Young School of Policy Studies, Georgia State University, 55 Park Place 8th Floor, Atlanta, GA, 30303, USA.
| | - Daniel Lanford
- Georgia Health Policy Center, Andrew Young School of Policy Studies, Georgia State University, 55 Park Place 8th Floor, Atlanta, GA, 30303, USA
| | - Glenn Landers
- Georgia Health Policy Center, Andrew Young School of Policy Studies, Georgia State University, 55 Park Place 8th Floor, Atlanta, GA, 30303, USA
| | - Karen Minyard
- Georgia Health Policy Center, Andrew Young School of Policy Studies, Georgia State University, 55 Park Place 8th Floor, Atlanta, GA, 30303, USA
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13
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Harden SM, Balis LE, Strayer T, Wilson ML. Assess, Plan, Do, Evaluate, and Report: Iterative Cycle to Remove Academic Control of a Community-Based Physical Activity Program. Prev Chronic Dis 2021; 18:E32. [PMID: 33830914 PMCID: PMC8051858 DOI: 10.5888/pcd18.200513] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
PURPOSE AND OBJECTIVES Responsive methods and measures are needed to bridge research to practice and address public health issues, such as older adults' need for multicomponent physical activity. The objective of this study was to detail the longitudinal, quasi-experimental work that spans 5 years to describe outcomes across RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) dimensions of integrating a physical activity intervention for older adults into the Cooperative Extension System through the assess, plan, do, evaluate, report (APDER) cycle. INTERVENTION APPROACH The participant-level intervention is Lifelong Improvements through Fitness Together (LIFT), an 8-week, group dynamics-based, strength-training program with 16 in-person sessions. The implementation intervention applies the iterative APDER cycle based on feedback for each dimension of RE-AIM. Each year, the APDER cycle was used to embed data collection procedures at the instructor and participant level to reveal the next evolution of the program. EVALUATION METHODS Each evolution of LIFT was measured through a pretest and posttest quasi-experimental design. Data were collected on each RE-AIM dimension through participant surveys and functional fitness assessments, number and representativeness of trainees, and process evaluation. RESULTS Overall, LIFT was expanded to 4 states with 275 instructors, reaching 816 older adults; consistently improved functional fitness outcome measures; demonstrated strong program adherence; and was seen as feasible and enjoyable by instructors and participants. LIFT is now undergoing adaptations for virtual delivery as well as updating the exercise protocol to introduce yoga postures that target flexibility and balance. IMPLICATIONS FOR PUBLIC HEALTH Overall, ongoing adaptations were necessary to ensure the program continued to fit the mission, values, and resources of the delivery system. Public health implications to support the need for ongoing adaptation include embedding pragmatic measures of adaptations and RE-AIM into standard evaluation pathways and using iterative APDER cycles.
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Affiliation(s)
- Samantha M Harden
- Department of Human Nutrition, Foods, and Exercise, Virginia Polytechnic Institute and State University, Blacksburg, Virginia
- Virginia Tech, 1981 Kraft Dr, Blacksburg, VA 24060.
| | - Laura E Balis
- Department of Human Nutrition, Foods, and Exercise, Virginia Polytechnic Institute and State University, Blacksburg, Virginia
- University of Wyoming Extension, Lander, Wyoming
| | - Thomas Strayer
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, Tennessee
| | - Meghan L Wilson
- Bluefield College, Department of Biology, Bluefield, Virginia
- Edward Via College of Osteopathic Medicine, Department of Preventive Medicine and Public Health, Blacksburg, Virginia
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14
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Henderson S, Wagner JL, Gosdin MM, Hoeft TJ, Unützer J, Rath L, Hinton L. Complexity in partnerships: A qualitative examination of collaborative depression care in primary care clinics and community-based organisations in California, United States. HEALTH & SOCIAL CARE IN THE COMMUNITY 2020; 28:1199-1208. [PMID: 32052531 PMCID: PMC7318288 DOI: 10.1111/hsc.12953] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 12/02/2019] [Accepted: 01/14/2020] [Indexed: 05/09/2023]
Abstract
Partnering across health clinics and community organisations, while worthwhile for improving health and well-being, is challenging and time consuming. Even partnerships that have essential elements for success in place face inevitable challenges. To better understand how cross-organisational partnerships work in practice, this paper examines collaborations between six primary care clinics and community-based organisations in the United States that were part of an initiative to address late-life depression using an enhanced collaborative care model (Archstone Foundation Care Partners Project). As part of an evaluation of the Care Partners Project, 54 key informant interviews and 10 focus groups were conducted from 2015 to 2017. Additionally, more than 80 project-related documents were reviewed. Qualitative thematic analysis was used to code the transcripts and identify prominent themes in the data. Examining clinic and community organisation partnerships in practice highlighted their inherent complexity. The partnerships were fluid and constantly evolving, shaped by a multiplicity of perspectives and values, and vulnerable to unpredictability. Care Partners sites negotiated the complexity of their partnerships drawing upon three main strategies: adaptation (allowing for flexibility and rapid change); integration (providing opportunities for multi-level partnerships within and across organisations) and cultivation (fostering a commitment to the partnership and its value). These strategies provided opportunities for Care Partners collaborators to work with the inherent complexity of partnering. Intentionally acknowledging and embracing such complexity rather than trying to reduce or avoid it, may allow clinic and community collaborators to strengthen and sustain their partnerships.
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Affiliation(s)
- Stuart Henderson
- School of MedicineOffice of Research Evaluation UnitUniversity of CaliforniaDavis, SacramentoCAUSA
| | - Jenny L. Wagner
- School of MedicineOffice of Research Evaluation UnitUniversity of CaliforniaDavis, SacramentoCAUSA
| | - Melissa M. Gosdin
- Center for Healthcare Policy and ResearchUniversity of CaliforniaDavis, SacramentoCAUSA
| | - Theresa J. Hoeft
- Department of Psychiatry and Behavioral SciencesUniversity of WashingtonSeattleWAUSA
| | - Jürgen Unützer
- Department of Psychiatry and Behavioral SciencesUniversity of WashingtonSeattleWAUSA
| | | | - Ladson Hinton
- Department of Psychiatry and Behavioral SciencesUniversity of CaliforniaDavis, SacramentoCAUSA
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15
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Castillo EG, Ijadi-Maghsoodi R, Shadravan S, Moore E, Mensah MO, Docherty M, Aguilera Nunez MG, Barcelo N, Goodsmith N, Halpin LE, Morton I, Mango J, Montero AE, Koushkaki SR, Bromley E, Chung B, Jones F, Gabrielian S, Gelberg L, Greenberg JM, Kalofonos I, Kataoka SH, Miranda J, Pincus HA, Zima BT, Wells KB. Community Interventions to Promote Mental Health and Social Equity. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2020; 18:60-70. [PMID: 32015729 PMCID: PMC6996071 DOI: 10.1176/appi.focus.18102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
(Reprinted with permission from Current Psychiatry Reports (2020) 21: 35).
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16
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Castillo EG, Ijadi-Maghsoodi R, Shadravan S, Moore E, Mensah MO, Docherty M, Aguilera Nunez MG, Barcelo N, Goodsmith N, Halpin LE, Morton I, Mango J, Montero AE, Rahmanian Koushkaki S, Bromley E, Chung B, Jones F, Gabrielian S, Gelberg L, Greenberg JM, Kalofonos I, Kataoka SH, Miranda J, Pincus HA, Zima BT, Wells KB. Community Interventions to Promote Mental Health and Social Equity. Curr Psychiatry Rep 2019; 21:35. [PMID: 30927093 PMCID: PMC6440941 DOI: 10.1007/s11920-019-1017-0] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW We review recent community interventions to promote mental health and social equity. We define community interventions as those that involve multi-sector partnerships, emphasize community members as integral to the intervention, and/or deliver services in community settings. We examine literature in seven topic areas: collaborative care, early psychosis, school-based interventions, homelessness, criminal justice, global mental health, and mental health promotion/prevention. We adapt the social-ecological model for health promotion and provide a framework for understanding the actions of community interventions. RECENT FINDINGS There are recent examples of effective interventions in each topic area. The majority of interventions focus on individual, family/interpersonal, and program/institutional social-ecological levels, with few intervening on whole communities or involving multiple non-healthcare sectors. Findings from many studies reinforce the interplay among mental health, interpersonal relationships, and social determinants of health. There is evidence for the effectiveness of community interventions for improving mental health and some social outcomes across social-ecological levels. Studies indicate the importance of ongoing resources and training to maintain long-term outcomes, explicit attention to ethics and processes to foster equitable partnerships, and policy reform to support sustainable healthcare-community collaborations.
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Affiliation(s)
- Enrico G Castillo
- Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA.
- Center for Social Medicine and Humanities, UCLA, Los Angeles, CA, USA.
- Los Angeles County Department of Mental Health, Los Angeles, CA, USA.
| | - Roya Ijadi-Maghsoodi
- Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
- Division of Population Behavioral Health, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
- VA Health Service Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Sonya Shadravan
- Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Elizabeth Moore
- Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Michael O Mensah
- Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Mary Docherty
- Harkness Fellow in Healthcare Policy and Practice, New York State Psychiatric Institute, Columbia University, New York, NY, USA
| | - Maria Gabriela Aguilera Nunez
- Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Nicolás Barcelo
- Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Nichole Goodsmith
- Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Laura E Halpin
- Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Isabella Morton
- Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Joseph Mango
- Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
- Center for Health Services and Society, UCLA, Los Angeles, CA, USA
| | - Alanna E Montero
- Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
- Center for Health Services and Society, UCLA, Los Angeles, CA, USA
| | - Sara Rahmanian Koushkaki
- Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
- Center for Health Services and Society, UCLA, Los Angeles, CA, USA
| | - Elizabeth Bromley
- Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
- Center for Health Services and Society, UCLA, Los Angeles, CA, USA
- UCLA Department of Anthropology, Los Angeles, CA, USA
- Rand Corporation, Santa Monica, CA, USA
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Bowen Chung
- Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
- Center for Health Services and Society, UCLA, Los Angeles, CA, USA
- Rand Corporation, Santa Monica, CA, USA
- Los Angeles Biomedical Research Institute, Los Angeles, CA, USA
- Healthy African American Families II, Los Angeles, CA, USA
| | - Felica Jones
- Healthy African American Families II, Los Angeles, CA, USA
| | - Sonya Gabrielian
- Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
- VA Health Service Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Lillian Gelberg
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Family Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
- UCLA Jonathan Fielding School of Public Health, Los Angeles, CA, USA
| | - Jared M Greenberg
- Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
- VA Health Service Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Ippolytos Kalofonos
- Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
- Center for Social Medicine and Humanities, UCLA, Los Angeles, CA, USA
- UCLA International Institute, Los Angeles, CA, USA
| | - Sheryl H Kataoka
- Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
- Center for Health Services and Society, UCLA, Los Angeles, CA, USA
- Division of Child and Adolescent Psychiatry, UCLA, Los Angeles, CA, USA
| | - Jeanne Miranda
- Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
- Center for Health Services and Society, UCLA, Los Angeles, CA, USA
- UCLA Jonathan Fielding School of Public Health, Los Angeles, CA, USA
| | - Harold A Pincus
- Rand Corporation, Santa Monica, CA, USA
- Department of Psychiatry, Columbia University Medical Center, New York State Psychiatric Institute, NewYork-Presbyterian Hospital, Irving Institute for Clinical and Translational Research, New York, NY, USA
| | - Bonnie T Zima
- Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
- Center for Health Services and Society, UCLA, Los Angeles, CA, USA
- Division of Child and Adolescent Psychiatry, UCLA, Los Angeles, CA, USA
| | - Kenneth B Wells
- Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
- Center for Health Services and Society, UCLA, Los Angeles, CA, USA
- Rand Corporation, Santa Monica, CA, USA
- UCLA Jonathan Fielding School of Public Health, Los Angeles, CA, USA
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