A CBPR-Enhanced Delphi Method: The Measurement Approaches to Partnership Success Case Study

As part of a 5-year study to develop and validate an instrument for measuring success in long-standing community-based participatory research (CBPR) partnerships, we utilized the Delphi method with a panel of 16 community and academic CBPR experts to assess face and content validity of the instrument's broad concepts of success and measurement items. In addition to incorporating quantitative and qualitative feedback from two online surveys, we included a 2-day face-to-face meeting with the Expert Panel to invite open discussion and diversity of opinion in line with the CBPR principles framing and guiding the study. The face-to-face meeting allowed experts to review the survey data (with maintained anonymity), convey their perspectives, and offer interpretations that were untapped in the online surveys. Using a CBPR approach facilitated a synergistic process that moved above and beyond the consensus achieved in the initial Delphi rounds, to enhance the Delphi technique and the development of items in the instrument.

Validation of the Measurement Approaches to Partnership Success (MAPS) Questionnaire

Conceptualizing and testing factors that contribute to the success of community-academic partnerships are critical to understanding their contributions to the health and well-being of communities. Most measures to date focus on factors that contribute to the development of new partnerships, and only a few have been adequately tested and validated. Methods. The Measurement Approaches to Partnership Success (MAPS) study followed a community-based participatory research (CBPR) approach and a multiphase process that included the construction and pilot testing of a questionnaire, and a national survey to validate the psychometric properties of the questionnaire in long-standing CBPR partnerships (existing ≥ six years). All members within partnerships were recruited to complete the survey (55 partnerships with 563 partners). We used confirmatory factor analysis (CFA), Cronbach's alpha statistics, and a pairwise correlations approach to assess discriminant and convergent validity, and assessed internal consistency, and test-retest reliability. Results. All MAPS Questionnaire dimensions demonstrated strong validity and reliability and demonstrated agreement over time. Conclusion. The MAPS Questionnaire includes seven dimensions and 81 items related to the MAPS conceptual model and provides a scientific, in-depth measurement tool that allows long-standing CBPR partnerships to evaluate their work toward achieving health equity.

Erratum: Building the foundation for equitable and inclusive research: Seed grant programs to facilitate development of diverse CBPR community-academic research partnerships - CORRIGENDUM

[This corrects the article DOI: 10.1017/cts.2022.495.].

Cultivating an Ecosystem: A Qualitative Exploration of Sustainability in Long-Standing Community-Based Participatory Research Partnerships

Background:

While sustainability is crucial to the success of community-based participatory research (CBPR) partnerships, there is a lack of conceptual clarity on what defines sustainability and what characterizes sustainability-promoting practices in long-standing (in existence ≥ 6 years) CBPR partnerships.

Objectives:

The aim of this article is to explore the definition of sustainability, as well as practices that influence sustainability from the perspectives of academic and community experts in long-standing CBPR partnerships.

Methods:

This qualitative analysis is part of Measurement Approaches to Partnership Success (MAPS), a participatory mixed methods validity study that examined “success” and its contributing factors in long-standing CBPR partnerships. Thematic analysis of 21 semi-structured interviews was conducted, including 10 academic and 11 community experts of long-standing CBPR partnerships.

Results:

The key defining components of sustainability we identified include: distinguishing between sustaining the work of the partnership and ongoing relationships among partners; working towards a common goal over time; and enduring changes that impact the partnership. We further identified strengthening and capacity building practices at multiple levels of the partnership that served to promote the sustainability of the partnership’s work and of ongoing relationships among partners.

Conclusions:

Sustainability can be understood as supporting an ecosystem that surrounds the beneficial relationships between academic and community partners. Ongoing evaluation and application of practices that promote the sustainability of partnership activities and relationships may strengthen the long-term effectiveness of CBPR partnerships in advancing health equity.

Cultivating an ecosystem: A qualitative exploration of sustainability in long-standing community-based participatory research (CBPR) partnerships

Background

While sustainability is crucial to the success of community-based participatory research (CBPR) partnerships, there is a lack of conceptual clarity on what defines sustainability and what characterizes sustainability-promoting practices in long-standing (in existence ≥ 6 years) CBPR partnerships.

Objectives

The aim of this article is to explore the definition of sustainability, as well as practices that influence sustainability from the perspectives of academic and community experts in long-standing CBPR partnerships.

Methods

This qualitative analysis is part of Measurement Approaches to Partnership Success (MAPS), a participatory mixed methods validity study that examined "success" and its contributing factors in long-standing CBPR partnerships. Thematic analysis of 21 semi-structured interviews was conducted, including 10 academic and 11 community experts of long-standing CBPR partnerships.

Results

The key defining components of sustainability we identified include: distinguishing between sustaining the work of the partnership and ongoing relationships among partners; working towards a common goal over time; and enduring changes that impact the partnership. We further identified strengthening and capacity building practices at multiple levels of the partnership that served to promote the sustainability of the partnership's work and of ongoing relationships among partners.

Conclusions

Sustainability can be understood as supporting an ecosystem that surrounds the beneficial relationships between academic and community partners. Ongoing evaluation and application of practices that promote the sustainability of partnership activities and relationships may strengthen the long-term effectiveness of CBPR partnerships in advancing health equity.

Cultivating an Ecosystem: A Qualitative Exploration of Sustainability in Long-Standing Community-Based Participatory Research Partnerships

BACKGROUND

While sustainability is crucial to the success of community-based participatory research (CBPR) partnerships, there is a lack of conceptual clarity on what defines sustainability and what characterizes sustainability-promoting practices in long-standing (in existence 6 years or longer) CBPR partnerships.

OBJECTIVES

The aim of this article is to explore the definition of sustainability, as well as practices that influence sustainability from the perspectives of academic and community experts in long-standing CBPR partnerships.

METHODS

This qualitative analysis is part of Measurement Approaches to Partnership Success, a participatory mixed methods validity study that examined "success" and its contributing factors in long-standing CBPR partnerships. Thematic analysis of 21 semistructured interviews was conducted, including 10 academic and 11 community experts of long-standing CBPR partnerships.

RESULTS

The key defining components of sustainability we identified include: distinguishing between sustaining the work of the partnership and ongoing relationships among partners; working towards a common goal over time; and enduring changes that impact the partnership. We further identified strengthening and capacity building practices at multiple levels of the partnership that served to promote the sustainability of the partnership's work and of ongoing relationships among partners.

CONCLUSIONS

Sustainability can be understood as supporting an ecosystem that surrounds the beneficial relationships between academic and community partners. Ongoing evaluation and application of practices that promote the sustainability of partnership activities and relationships may strengthen the long-term effectiveness of CBPR partnerships in advancing health equity.

Cultivating an Ecosystem: A Qualitative Exploration of Sustainability in Long-Standing Community-Based Participatory Research Partnerships

Background:

While sustainability is crucial to the success of community-based participatory research (CBPR) partnerships, there is a lack of conceptual clarity on what defines sustainability and what characterizes sustainability-promoting practices in long-standing (in existence ≥ 6 years) CBPR partnerships.

Objectives:

The aim of this article is to explore the definition of sustainability, as well as practices that influence sustainability from the perspectives of academic and community experts in long-standing CBPR partnerships.

Methods:

This qualitative analysis is part of Measurement Approaches to Partnership Success (MAPS), a participatory mixed methods validity study that examined “success” and its contributing factors in long-standing CBPR partnerships. Thematic analysis of 21 semi-structured interviews was conducted, including 10 academic and 11 community experts of long-standing CBPR partnerships.

Results:

The key defining components of sustainability we identified include: distinguishing between sustaining the work of the partnership and ongoing relationships among partners; working towards a common goal over time; and enduring changes that impact the partnership. We further identified strengthening and capacity building practices at multiple levels of the partnership that served to promote the sustainability of the partnership’s work and of ongoing relationships among partners.

Conclusions:

Sustainability can be understood as supporting an ecosystem that surrounds the beneficial relationships between academic and community partners. Ongoing evaluation and application of practices that promote the sustainability of partnership activities and relationships may strengthen the long-term effectiveness of CBPR partnerships in advancing health equity.

Antiracism and Community-Based Participatory Research: Synergies, Challenges, and Opportunities

Structural racism causes stark health inequities and operates at every level of society, including the academic and governmental entities that support health research and practice. We argue that health research institutions must invest in research that actively disrupts racial hierarchies, with leadership from racially marginalized communities and scholars. We highlight synergies between antiracist principles and community-based participatory research (CBPR), examine the potential for CBPR to promote antiracist research and praxis, illustrate structural barriers to antiracist CBPR praxis, and offer examples of CBPR actions taken to disrupt structural racism. We make recommendations for the next generation of antiracist CBPR, including modify health research funding to center the priorities of racially marginalized communities, support sustained commitments and accountability to those communities by funders and research institutions, distribute research funds equitably across community and academic institutions, amplify antiracist praxis through translation of research to policy, and adopt institutional practices that support reflection and adaptation of CBPR to align with emergent community priorities and antiracist practices. A critical application of CBPR principles offers pathways to transforming institutional practices that reproduce and reinforce racial inequities. (Am J Public Health. 2023;113(1):70-78. https://doi.org/10.2105/AJPH.2022.307114).

Building the foundation for equitable and inclusive research: Seed grant programs to facilitate development of diverse CBPR community-academic research partnerships

Introduction

The effectiveness of community-based participatory research (CBPR) partnerships to address health inequities is well documented. CBPR integrates knowledge and perspectives of diverse communities throughout the research process, following principles that emphasize trust, power sharing, co-learning, and mutual benefits. However, institutions and funders seldom provide the time and resources needed for the critical stage of equitable partnership formation and development.

Methods

Since 2011, the Detroit Urban Research Center, collaborating with other entities, has promoted the development of new community-academic research partnerships through two grant programs that combine seed funding with capacity building support from community and academic instructors/mentors experienced in CBPR. Process and outcomes were evaluated using mixed methods.

Results

From 2011 to 2021, 50 partnerships received grants ranging from $2,500 to $30,000, totaling $605,000. Outcomes included equitable partnership infrastructure and processes, innovative pilot research, translation of findings to interventions and policy change, dissemination to multiple audiences, new proposals and projects, and sustained community-academic research partnerships. All partnerships continued beyond the program; over half secured additional funding.

Conclusions

Keys to success included participation as community-academic teams, dedicated time for partnership/relationship development, workshops to develop equity-based skills, relationships, and projects, expert community-academic instructor guidance, and connection to additional resources. Findings demonstrate that small amounts of seed funding for newly forming community-academic partnerships, paired with capacity building support, can provide essential time and resources needed to develop diverse, inclusive, equity-focused CBPR partnerships. Building such support into funding initiatives and through academic institutions can enhance impact and sustainability of translational research toward advancing health equity.

Understanding the Benefit-Cost Relationship in Long-standing Community-based Participatory Research (CBPR) Partnerships: Findings from the Measurement Approaches to Partnership Success (MAPS) Study

As part of the Measurement Approaches to Partnership Success (MAPS) study, we investigated the relationship between benefits and costs of participation in long-standing community-based participatory research (CBPR) partnerships using social exchange theory as a theoretical framework. Three major findings were identified: (1) the concept of benefits and costs operating as a ratio, where individual benefits must outweigh costs for participation, applies to early stages of CBPR partnership formation; (2) as CBPR partnerships develop, the benefits and costs of participation include each other's needs and the needs of the group as a whole; and (3) there is a shift in the relationship of benefits and costs over time in long-standing CBPR partnerships, in which partners no longer think in terms of costs but rather investments that contribute to mutual benefits.

Mexican-Origin Women's Construction and Navigation of Racialized Identities: Implications for Health Amid Restrictive Immigrant Policies

This study examines how Mexican-origin women construct and navigate racialized identities in a postindustrial northern border community during a period of prolonged restrictive immigration and immigrant policies, and it considers mechanisms by which responses to racialization may shape health. This grounded theory analysis involves interviews with 48 Mexican-origin women in Detroit, Michigan, who identified as being in the first, 1.5, or second immigrant generation. In response to institutions and institutional agents using racializing markers to assess their legal status and policing access to health-promoting resources, women engaged in a range of strategies to resist being constructed as an "other." Women used the same racializing markers or symbols of (il)legality that had been used against them as a malleable set of resources to resist processes of racialization and to form, preserve, and affirm their identities. These responses include constructing an authorized immigrant identity, engaging in immigration advocacy, and resisting stigmatizing labels. These strategies may have different implications for health over time. Findings indicate the importance of addressing policies that promulgate or exacerbate racialization of Mexican-origin communities and other communities who experience growth through migration. Such policies include creating pathways to legalization and access to resources that have been invoked in racialization processes, such as state-issued driver's licenses.

Measurement Approaches to Partnership Success: Theory and Methods for Measuring Success in Long-Standing Community-Based Participatory Research Partnerships

BACKGROUND

Numerous conceptual frameworks have been developed to understand how community-based participatory research (CBPR) partnerships function, and multiple measurement approaches have been designed to evaluate them. However, most measures are not validated, and have focused on new partnerships. To define and assess the meaning of success in long-standing CBPR partnerships, we are conducting a CBPR study, Measurement Approaches to Partnership Success (MAPS). In this article we describe the theoretical underpinnings and methodological approaches used.

OBJECTIVES

The objectives of this study are to 1) develop a questionnaire to evaluate success in long-standing CBPR partnerships, 2) test the psychometric qualities of the questionnaire, 3) assess the relationships between key variables and refine the questionnaire and theoretical model, and 4) develop mechanisms and a feedback tool to apply partnership evaluation findings.

METHODS

Methodological approaches have included: engaged a community-academic national Expert Panel; conducted key informant interviews with Expert Panel; conducted a scoping literature review; conducted a Delphi process with the Expert Panel; and revised the measurement instrument. Additional methods include: conduct cognitive interviews and pilot testing; revise and test final version of the questionnaire with long-standing CBPR partnerships; examine the reliability and validity; analyze the relationship among variables in the framework; revise the framework; and develop a feedback mechanism for sharing partnership evaluation results.

CONCLUSIONS

Through the application of a theoretical model and multiple methodological approaches, the MAPS study will result in a validated measurement instrument and will develop procedures for effectively feeding back evaluation findings in order to strengthen authentic partnerships to achieve health equity.

A Participatory, Mixed Methods Approach to Define and Measure Partnership Synergy in Long-standing Equity-focused CBPR Partnerships

Understanding what contributes to success of community-based participatory research (CBPR) partnerships is essential to ensuring their effectiveness in addressing health disparities and health inequities. Synergy, the concept of accomplishing more together than separately, is central to partnership effectiveness. However, synergy specific to long-standing, equity-focused CBPR partnerships has not been closely examined. To address this, we defined and developed measures of partnership synergy as one dimension of a participatory mixed methods study, Measurement Approaches to Partnership Success (MAPS), to develop a validated instrument to measure success in long-standing CBPR partnerships. Framed by a conceptual model and scoping literature review, we conducted in-depth interviews with a national panel of academic and community experts in CBPR and equity to develop partnership synergy measures. Items were refined through an iterative process, including a three-stage Delphi process, comparison with existing measures, cognitive interviews, and pilot testing. Seven questionnaire items were developed to measure synergy arising from equitable partnerships bringing together diverse partners across power differences to promote equity. Defining and measuring synergy in the context of long-standing partnership success is central to understanding the role of synergy in collaborative approaches to research and action and can strengthen CBPR partnerships to promote healthy communities and advance health equity.

Independent and joint contributions of economic, social and physical environmental characteristics to mortality in the Detroit Metropolitan Area: A study of cumulative effects and pathways

OBJECTIVE

Previous studies have demonstrated associations between race-based residential segregation, neighborhood socioeconomic and physical environmental characteristics, and mortality. Relatively few studies have examined independent and joint effects of these multiple neighborhood characteristics and mortality, including potential mediating pathways. In this study we examine the extent to which associations between race-based residential segregation and all-cause mortality may be explained by multiple socioeconomic indicators and exposure to air pollutants.

METHODS

Drawing on data from multiple sources, we assessed bivariate associations between race-based residential segregation (operationalized as percent non-Hispanic Black), education (percent with graduate equivalency degree), poverty (percent below poverty), income inequality (GINI coefficient) and air pollution (ambient PM2.5) and age adjusted all-cause, all race mortality (henceforth all cause mortality) at the census tract level in the Detroit Metropolitan Area. We used inequality curves to assess the (in)equitable distribution of economic and environmental characteristics by census tract racial composition. Finally, we used generalized estimating equations (GEE) to examine independent and joint associations among percent NHB, education, income inequality, and air pollution to all-cause mortality, and test for mediating effects.

RESULTS

Bivariate associations between racial composition, education, poverty, income inequality, PM2.5 and all-cause mortality were statistically significant. Census tracts with higher concentrations of NHB residents had significantly lower educational attainment, higher poverty, and greater exposure to PM2.5. In multivariate models, education, income inequality and PM2.5 fully attenuated associations between racial composition and all-cause mortality.

CONCLUSIONS

Results are consistent with the hypothesis that race-based residential segregation is associated with heightened all-cause mortality, and that those effects are mediated by education, income inequality, and exposure to air pollution at the census tract level. Public health and cross-sector interventions to eliminate race-based residential segregation or to eliminate the maldistribution of educational and economic resources, and environmental exposures, across census tracts could substantially reduce regional inequities in all-cause mortality.

Moving Health Education and Behavior Upstream: Lessons From COVID-19 for Addressing Structural Drivers of Health Inequities

In this Perspective, we build on social justice and emancipatory traditions within the field of health education, and the field's long-standing commitment to building knowledge and shared power to promote health equity, to examine lessons and opportunities for health education emerging from the COVID-19 pandemic. Examining patterns that emerged as the pandemic unfolded in Metropolitan Detroit, with disproportionate impacts on African American and low-income communities, we consider conditions that contributed to excess exposure, mortality, and reduced access to critical health protective resources. Using a life course framework, we consider enduring impacts of the pandemic for health equity. Finally, we suggest several strategic actions in three focal areas-environment, occupation, and housing-that can be taken by health educators working in partnership with community members, researchers, and decision makers, using, for example, a community-based participatory research approach, to reduce adverse impacts of COVID-19 and promote long-term equity in health.

Impact of change over time in self-reported discrimination on blood pressure: implications for inequities in cardiovascular risk for a multi-racial urban community

Objectives: The 21st century has seen a rise in racism and xenophobia in the United States. Few studies have examined the health implications of heightened institutional and interpersonal racism. This study examines changes in reported discrimination and associations with blood pressure over time among non-Latino Blacks (NLBs), Latinos, and non-Latino Whites (NLWs) in an urban area, and variations by nativity among Latinos.Design: Data from a probability sample of NLB, Latino, and NLW Detroit, Michigan residents were collected in 2002-2003, with follow-up at the same addresses in 2007-2008. Surveys were completed at 80% of eligible housing units in 2008 (n = 460). Of those, 219 participants were interviewed at both time points and were thus included in this analysis. Discrimination patterns across racial/ethnic groups and associations with blood pressure were examined using generalized estimating equations.Results: From 2002 to 2008, NLBs and Latinos reported heightened interpersonal and institutional discrimination, respectively, compared with NLWs. There were no differences in associations between interpersonal discrimination and blood pressure. Increased institutional discrimination was associated with stronger increases in systolic and diastolic blood pressure for NLBs than NLWs, with no differences between Latinos and NLWs. Latino immigrants experienced greater increases in blood pressure with increased interpersonal and institutional discrimination compared to US-born Latinos.Conclusions: Together, these findings suggest that NLBs and Latinos experienced heightened discrimination from 2002 to 2008, and that increases in institutional discrimination were more strongly associated with blood pressure elevation among NLBs and Latino immigrants compared to NLWs and US-born Latinos, respectively. These findings suggest recent increases in discrimination experienced by NLBs and Latinos, and that these increases may exacerbate racial/ethnic health inequities.

Applying Experiential Action Learning Pedagogy to an Intensive Course to Enhance Capacity to Conduct Community-Based Participatory Research

Community-based participatory research (CBPR) is widely recognized as an effective approach to understand and address health inequities. Opportunities for public health practitioners and researchers to engage jointly with community partners in intensive colearning processes can build capacity for CBPR. Using active learning approaches that engage diverse partners can enhance partnership development, competence, and equity. Examination of such pedagogical approaches can strengthen understanding of their contributions to the effectiveness of CBPR capacity-building programs. This article describes a weeklong intensive course carried out by the Detroit Urban Research Center as the foundation for a yearlong training program to build the capacity of community-academic partnership teams to engage in CBPR in their own communities. The in-person CBPR course was developed and implemented by expert academic and community instructors and used an experiential action learning model that integrated CBPR principles and processes. We describe the course content and application of our collaborative, experiential action learning model to course design; present results from participant evaluation of course effectiveness, CBPR competence, and equitable partnership development; and examine the contributions of the pedagogical approach to outcomes central to successful CBPR. The participatory, formative course evaluation used multiple methods that included closed- and open-ended questionnaires to assess instructional effectiveness, participant competence on 12 core components of CBPR, and course impact on partner relationships. Evaluation findings suggest that an experiential action learning approach with attention to colearning, collaboration among diverse instructors and participants, and an environment that fosters and models equitable and trusting relationships can be effective in building CBPR capacity.

Success in Long-Standing Community-Based Participatory Research (CBPR) Partnerships: A Scoping Literature Review

Background. Community-based participatory research (CBPR) is increasingly used by community and academic partners to examine health inequities and promote health equity in communities. Despite increasing numbers of CBPR partnerships, there is a lack of consensus in the field regarding what defines partnership success and how to measure factors contributing to success in long-standing CBPR partnerships. Aims. To identify indicators and measures of success in long-standing CBPR partnerships as part of a larger study whose aim is to develop and validate an instrument measuring success across CBPR partnerships. Methods. The Joanna Briggs Institute framework and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guided searches of three databases (PubMed, CINAHL, Scopus) for articles published between 2007 and 2017 and evaluating success in CBPR partnerships existing longer than 4 years. Results. Twenty-six articles met search criteria. We identified 3 key domains and 7 subdomains with 28 underlying indicators of success. Six partnerships developed or used instruments to measure their success; only one included reliability or validity data. Discussion. CBPR partnerships reported numerous intersecting partner, partnership, and outcome indicators important for success. These results, along with data from key informant interviews with community and academic partners and advisement from a national panel of CBPR experts, will inform development of items for an instrument measuring CBPR partnership success. Conclusion. The development of a validated instrument measuring indicators of success will allow long-standing CBPR partnerships to evaluate their work toward achieving health equity and provide a tool for newly forming CBPR partnerships aiming to achieve long-term success.

Insuring Good Health: Outcomes and Acceptability of a Participatory Health Insurance Literacy Intervention in Diverse Urban Communities

BACKGROUND

The U.S. uninsured rate has dropped significantly since the passage of the Affordable Care Act (ACA), yet insurance coverage remains lower in historically marginalized communities than in the overall population. New consumer engagement approaches that involve these populations are needed. The purpose of this study was to evaluate the effectiveness of the Insuring Good Health Intervention, a website and video series designed to improve engagement with health insurance and ACA reforms. The study was designed and implemented using a community-based participatory research approach.

METHOD

We conducted a lagged-control cluster randomized controlled trial to evaluate Insuring Good Health with racially and ethnically diverse adults seeking services in medically underserved areas within the Detroit, Michigan metropolitan area. Outcomes were assessed at baseline and at 6 and 9 months postintervention, and including self-efficacy, knowledge, beliefs, and intention to seek help with insurance navigation and care.

RESULTS

Among 243 participants, mean age was 43.4 ( SD = 13) years, and all participants met federal guidelines for poverty. The study had an 86% response rate at 9-month follow-up ( n = 209). Compared with the lagged-control group, intervention participants had more positive beliefs concerning preventive care (estimate 0.51, standard error 0.16; p < .01), and intention to seek help with insurance navigation and care (estimate 0.43, standard error 0.17; p < .001) at 9-month follow-up. Hispanic participants benefitted the most from the intervention, including improved knowledge of health insurance eligibility over 9 months compared with other racial/ethnic groups (estimate -0.97, standard error 0.40, p < .01).

DISCUSSION

Insuring Good Health was associated with increased intention to seek help with insurance navigation and care, and improved beliefs around preventive care.

CONCLUSIONS

Insuring Good Health has the potential to be an important consumer engagement tool to reduce disparities in health insurance coverage and care seeking.

Enhancing Capacity of Community-Academic Partnerships to Achieve Health Equity: Results From the CBPR Partnership Academy

Community-based participatory research (CBPR) is an equitable partnership approach that links academic researchers, community organizations, and public health practitioners to work together to understand and address health inequities. Although numerous educational materials on CBPR exist, few training programs develop the skills and knowledge needed to establish effective, equitable partnerships. Furthermore, there are few professional development opportunities for academic researchers, practitioners, and community members to obtain these competencies in an experiential co-learning process. In response, the Detroit Community-Academic Urban Research Center developed the CBPR Partnership Academy, an innovative, yearlong capacity-building program facilitated by experienced community and academic partners, involving an intensive short course, partnership development, grant proposal preparation and funding, mentoring, online learning forums, and networking. Three diverse cohorts (36 teams) from 18 states and 2 tribal nations have participated. We describe the rationale and components of the training program and present results from the first two cohorts. Evaluation results suggest enhanced competence and efficacy in conducting CBPR. Outcomes include partnerships established, grant proposals submitted and funded, workshops and research conducted, and findings disseminated. A community-academic partner-based, integrated, applied program can be effective for professional development and establishing innovative linkages between academics and practitioners aimed at achieving health equity.

A conceptual framework for evaluating health equity promotion within community-based participatory research partnerships

Community-based participatory research (CBPR) approaches present strong opportunities to promote health equity by improving health within low-income communities and communities of color. CBPR principles and evaluation frameworks highlight an emphasis on equitable group dynamics (e.g., shared leadership and power, participatory decision-making, two-way open communication) that promote both equitable processes within partnerships and health equity in the communities with whom they engage. The development of an evaluation framework that describes the manner in which equitable group dynamics promote intermediate and long-term equity outcomes can aid partners in assessing their ability to work together effectively and improve health equity in the broader community. CBPR principles align with health equity evaluation guidelines recently developed for Health Impact Assessments (HIAs), which emphasize meaningful engagement of communities in decision-making processes that influence their health. In this paper, we propose a synergistic framework integrating contributions from CBPR and HIA evaluation frameworks in order to guide efforts to evaluate partnership effectiveness in addressing health inequities. We suggest specific indicators that might be used to assess partnership effectiveness in addressing health equity and discuss implications for evaluation of partnership approaches to address health equity.

Urban HEART Detroit: a Tool To Better Understand and Address Health Equity Gaps in the City

The Urban Health Equity Assessment Response Tool (Urban HEART) combines statistical evidence and community knowledge to address urban health inequities. This paper describes the process of adopting and implementing this tool for Detroit, Michigan, the first city in the USA to use it. The six steps of Urban HEART were implemented by the Healthy Environments Partnership, a community-based participatory research partnership made up of community-based organizations, health service providers, and researchers based in academic institutions. Local indicators and benchmarks were identified and criteria established to prioritize a response plan. We examine how principles of CBPR influenced this process, including the development of a collaborative and equitable process that offered learning opportunities and capacity building among all partners. For the health equity matrix, 15 indicators were chosen within the Urban HEART five policy domains: physical environment and infrastructure, social and human development, economics, governance, and population health. Partners defined the criteria and ranked them for use in assessing and prioritizing health equity gaps. Subsequently, partners generated a series of potential actions for indicators prioritized in this process. Engagement of community partners contributed to benchmark selection and modification, and provided opportunities for dialog and co-learning throughout the process. Application of a CBPR approach provided a foundation for engagement of partners in the Urban HEART process of identifying health equity gaps. This approach offered multiple opportunities for discussion that shaped interpretation and development of strategies to address identified issues to achieve health equity.

Independent and Joint Contributions of Fine Particulate Matter Exposure and Population Vulnerability to Mortality in the Detroit Metropolitan Area

Fine particulate matter is associated with adverse health outcomes. Exposure to fine particulate matter may disproportionately affect urban communities with larger numbers of vulnerable residents. We used multilevel logistic regression models to estimate the joint effects of fine particulate matter (PM_2.5) and population vulnerabilities on cardiopulmonary mortality (CPM). We estimated the health benefits of reductions in PM_2.5 across census tracts in the Detroit metropolitan area with varying levels of population vulnerability, using cluster-specific odds ratios scaled to reflect PM_2.5-attributable cardiopulmonary risk. PM_2.5 and population vulnerability were independently associated with odds of CPM. Odds of CPM and the number of deaths attributable to PM_2.5 were greatest in census tracts with both high PM_2.5 exposures and population vulnerability. Reducing PM_2.5 in census tracts with high PM_2.5 would lead to an estimated 18% annual reduction in PM_2.5-attributable CPM. Between 78–79% of those reductions in CPM would occur within census tracts with high population vulnerabilities. These health benefits of reductions in PM_2.5 occurred at levels below current U.S. reference concentrations. Focusing efforts to reduce PM_2.5 in the Detroit metropolitan area in census tracts with currently high levels would also lead to greater benefits for residents of census tracts with high population vulnerabilities.

Does Perceived Safety Modify the Effectiveness of a Walking-Group Intervention Designed to Promote Physical Activity?

PURPOSE

To examine whether perceived safety modified the effectiveness of the Walk Your Heart to Health (WYHH) intervention in promoting physical activity and reducing central adiposity in predominantly non-Latino black (henceforth black) and Latino communities.

DESIGN

Generalized estimation equations were used to assess modifying effects of perceived safety on the route and perceived neighborhood safety on (1) WYHH participation at 8 weeks and 32 weeks, (2) associations between participation and physical activity, and (3) associations between physical activity and central adiposity.

SETTING

Community-based and faith-based organizations in black and Latino communities.

PARTICIPANTS

There were 603 adults, aged 18 years and older, who were predominantly black, Latino, and female.

MEASURES

Participation and physical activity (piezoelectric pedometer) were measured at each walking session. Perceived safety on the route (questionnaire), perceived neighborhood safety (questionnaire), and waist circumference were measured at baseline, 8 weeks, and 32 weeks.

ANALYSIS

Secondary analysis of repeated measures using generalized estimation equations.

RESULTS

Retention was 90% at 8 weeks and 64% at 32 weeks. Perceived safety on the route, but not perceived neighborhood safety, dampened participation at 8 weeks but not 32 weeks. Consistent participation in the intervention increased physical activity and reduced central adiposity irrespective of perceived safety on the walking route or perceived neighborhood safety.

CONCLUSION

Efforts to improve safety in conjunction with interventions focused on increasing physical activity can work toward improving physical activity for blacks and Latinos, leading to a myriad of improved health outcomes including reduced central adiposity.

Independent Effects of Neighborhood Poverty and Psychosocial Stress on Obesity Over Time

The objective of the study was to examine the independent effects of neighborhood poverty and psychosocial stress on increases in central adiposity over time. Data are from a community sample of 157 Non-Hispanic Black, Non-Hispanic White, and Hispanic adults collected in 2002-2003 and 2007-2008, and from the 2000 Decennial Census. The dependent variable was waist circumference. Independent variables included neighborhood poverty, perceived neighborhood physical environment, family stress, safety stress, everyday unfair treatment, and a cumulative stress index. Weighted 3-level hierarchical linear regression models for a continuous outcome were used to assess the effects of neighborhood poverty and psychosocial stress on central adiposity over time. We also assessed whether psychosocial stress mediated the association between neighborhood poverty and central adiposity. Neighborhood poverty and everyday unfair treatment at baseline were independently associated with increases in central adiposity over time, accounting for the other indicators of stress. Perceptions of the neighborhood physical environment and cumulative stress mediated associations between neighborhood poverty and central adiposity. Results suggest that residing in neighborhoods with higher concentrations of poverty and exposure to everyday unfair treatment independently heighten risk of increased central adiposity over time. Associations between neighborhood poverty and central adiposity were mediated by perceptions of the neighborhood physical environment and by the cumulative stress index. Public health strategies to reduce obesity should consider neighborhood poverty and exposure to multiple sources of psychosocial stress, including everyday unfair treatment.

Neighborhood Context, Homeownership and Home Value: An Ecological Analysis of Implications for Health

While homeownership has been linked to positive health outcomes there is limited evidence regarding the conditions under which it may be health protective. We present a conceptual model linking homeownership to health, highlighting key potential pathways. Using the Detroit Metropolitan Area as a case study, and data from the American Community Survey (2009-2013; 5-years estimates) and Michigan Department of Community Health, we tested the following questions: (1) Is neighborhood percentage non-Hispanic Black (NHB) associated with homeownership? (2) Is neighborhood percentage NHB associated with health? (3) Is the association between percentage NHB and health mediated by homeownership? (4) Does neighborhood housing value modify associations between percentage NHB and health, or between homeownership and health? Percentage NHB was associated with homeownership and health outcomes; Associations between percentage NHB and mortality, but not disability, were partially mediated by neighborhood homeownership. Neighborhood housing value modified associations between neighborhood homeownership and both disability and mortality, but not between percentage NHB and health outcomes. Findings are consistent with the thesis that health-promoting effects of homeownership may be contingent upon house values. These results add to a limited body of evidence suggesting that variations in homeownership may contribute to persistent racial and socioeconomic health inequities.

Do Neighborhood Demographics Modify Walking Group Intervention Effectiveness in Urban Neighborhoods?

OBJECTIVES

We assessed the effects of neighborhood composition on effectiveness of the Walk Your Heart to Health (WYHH) intervention in promoting physical activity and reducing cardiovascular risk (CVR) in low-to-moderate-income, predominantly non-Latino Black (NLB) and Latino communities.

METHOD

Multilevel models assessed modifying effects of neighborhood composition on (1) WYHH adherence/participation at 8 weeks and 32 weeks, (2) associations between participation and steps, and (3) associations between steps and CVR.

RESULTS

Approximately 90% of participants were women. Neither neighborhood poverty nor racial composition modified intervention participation at 8 weeks. At 32 weeks, residents of high percentage-NLB neighborhoods that also had high poverty rates had reduced participation. Neighborhood composition did not modify associations between participation and steps or between steps and CVR. Neighborhood percentage poverty and NLB were positively associated with CVR.

CONCLUSION

Positive associations between participation in the WYHH program and physical activity, and CVR did not differ by neighborhood composition. Efforts to address challenges to long-term participation are warranted for residents of racially segregated, high-poverty neighborhoods. Residents of racially segregated neighborhoods with high concentrations of poverty experience disproportionately high risk for cardiovascular disease and can benefit from interventions such as WYHH that increase physical activity and reduce CVR.

NEIGHBOURHOOD POVERTY, PERCEIVED DISCRIMINATION AND CENTRAL ADIPOSITY IN THE USA: INDEPENDENT ASSOCIATIONS IN A REPEATED MEASURES ANALYSIS

This study examines the independent effects of neighbourhood context (i.e. neighbourhood poverty) and exposure to perceived discrimination in shaping risk of obesity over time. Weighted three-level hierarchical linear regression models for a continuous outcome were used to assess the independent effects of neighbourhood poverty and perceived discrimination on obesity over time in a sample of 157 non-Hispanic Black, non-Hispanic White and Hispanic adults in Detroit, USA, in 2002/2003 and 2007/2008. Independent associations were found between neighbourhood poverty and perceived discrimination with central adiposity over time. Residents of neighbourhoods with high concentrations of poverty were more likely to show increases in central adiposity compared with those in neighbourhoods with lower concentrations of poverty. In models adjusted for BMI, neighbourhood poverty at baseline was associated with a greater change in central adiposity among participants who lived in neighbourhoods in the second (B=3.79, p=0.025) and third (B=3.73, p=0.024) poverty quartiles, compared with those in the lowest poverty neighbourhoods. The results from models that included both neighbourhood poverty and perceived discrimination showed that both were associated with increased risk of increased central adiposity over time. Residents of neighbourhoods in the second (B=9.58, p<0.001), third (B=8.25, p=0.004) and fourth (B=7.66, p=0.030) quartiles of poverty were more likely to show greater increases in central adiposity over time, compared with those in the lowest poverty quartile, with mean discrimination at baseline independently and positively associated with increases in central adiposity over time (B=2.36, p=0.020). The results suggest that neighbourhood poverty and perceived discrimination are independently associated with a heightened risk of increase in central adiposity over time. Efforts to address persistent disparities in central adiposity in the USA should include strategies to reduce high concentrations of neighbourhood poverty as well as discrimination.

RACE AND THE DISTRIBUTION OF SOCIAL AND PHYSICAL ENVIRONMENTAL RISK: A Case Example from the Detroit Metropolitan Area

Since W. E. B. Du Bois documented the physical and social environments of Philadelphia's predominantly African American Seventh Ward over a century ago, there has been continued interest in understanding the distribution of social and physical environments by racial make-up of communities. Characterization of these environments allows for documentation of inequities, identifies communities which encounter heightened risk, and can inform action to promote health equity. In this paper, we apply and extend Du Bois's approach to examine the contemporary distribution of physical environmental exposures, health risks, and social vulnerabilities in the Detroit metropolitan area, one of the most racially-segregated areas in the United States. We begin by mapping the proximity of sensitive populations to hazardous land uses, their exposure to air pollutants and associated health risks, and social vulnerabilities, as well as cumulative risk (combined proximity, exposure, and vulnerability), across Census tracts. Next, we assess, quantitatively, the extent to which communities of color experience excess burdens of environmental exposures and associated health risks, economic and age-related vulnerabilities, and cumulative risk. The results, depicted in maps presented in the paper, suggest that Census tracts with greater proportions of people of color disproportionately encounter physical environmental exposures, socioeconomic vulnerabilities, and combined risk. Quantitative tests of inequality confirm these distributions, with statistically greater exposures, vulnerabilities, and cumulative risk in Census tracts with larger proportions of people of color. Together, these findings identify communities that experience disproportionate cumulative risk in the Detroit metropolitan area and quantify the inequitable distribution of risk by Census tract relative to the proportion of people of color. They identify clear opportunities for prioritizing communities for legislative, regulatory, policy, and local actions to promote environmental justice and health equity.

Conducting Action Research: Relationships between Organization Members and Researchers

Action research in an organizational setting draws researchers and the employees involved into a joint process aimed at meeting both research and intervention objectives. The active collaboration of participants has major implications for researcher roles, and the manner in which these role shifts are carried out has a significant effect on study outcomes. Few have concretely analyzed the issues faced by researchers and organization members as they assume shared roles in the action research process. This article treats the relational aspect of researcher-participant co-investigation as a methodological issue. The authors share aspects of their experience in implementing an action research project aimed at understanding and reducing the deleterious effects of occupational stress. Relationships between researchers and organization members are dynamic. As they develop over time, role-related tensions and differences may arise around the issues of values and interests, resources and skills, control, political realities, and rewards and costs. Each of these is addressed, using examples from the authors' recently completed 6-year study. Further, the action research study participants helped revise this article and that process taught the authors much about these methodological issues.

Local Actors' Frames of the Role of Living Conditions in Shaping Hypertension Risk and Disparities in a Colombian Municipality

Conditions in the social and physical environment influence population health and risk for CVD, including hypertension. These environmental conditions are influenced by the decisions of public officials, community leaders, and service providers. Examining the frames that local decision makers bring to understanding hypertension can provide important insights into the decisions that they make about strategies for addressing this problem in their jurisdiction. The goal of this study was to examine the frames that local decision makers in Quibdó, Colombia, bring to understanding hypertension risk, and in particular, whether and how they use frames that encompass associations between living conditions and hypertension risk. Data for this qualitative study were collected using a stratified sampling strategy. Semi-structured interviews were conducted in 2012 with 13 local decision makers and analyzed using a framework approach. Participants linked the structural conditions experienced in Quibdó, including displacement, limited economic opportunities, and the infrastructure of the city, to hypertension risk through multiple pathways, including behavioral risk factors for hypertension and physiologic responses to stress. They described the social patterning of these factors across socioeconomic, racial/ethnic, and gender hierarchies. Although several conditions associated with hypertension risk are widely distributed in the city's population, social processes of marginalization and stratification create additional disadvantages for those on the lower rungs of the social hierarchy.

Community Partner Perspectives on Benefits, Challenges, Facilitating Factors, and Lessons Learned from Community-Based Participatory Research Partnerships in Detroit

BACKGROUND

There is an extensive body of literature on community-based participatory research (CBPR) and the role of community-academic partnerships, much of which has involved community partners in the conceptualization and preparation of publications. However, there has been a relative dearth of solely community voices addressing these topics, given the other roles and responsibilities which community members and leaders of community-based organizations (CBOs) have.

PURPOSE

The purpose of this article is to share the perspectives of three long-time (>20 years) community partners involved in the Detroit Community-Academic Urban Research Center and its affiliated partnerships.

CONCLUSION

In this article, we community partners provide our assessment of the benefits and challenges in using a CBPR approach at the personal, organizational, and community levels; the factors that facilitate effective partnerships; and our lessons learned through engagement in CBPR. We also present specific recommendations from a community perspective to researchers and institutions interested in conducting CBPR.

Joint Associations of Residential Density and Neighborhood Involvement With Physical Activity Among a Multiethnic Sample of Urban Adults

Regular physical activity is associated with improvements in overall health. Although resident involvement in neighborhood social activities is positively associated with physical activity, neighborhood design features, including residential density, have varied associations with physical activity. Using data from a multiethnic sample of 696 adults in Detroit, Michigan, multilevel models were used to examine joint effects of residential density and resident involvement in neighborhood activities in relation to physical activity. We found a marginally significant negative interaction of higher residential density and resident neighborhood involvement. Higher residential density was negatively associated with physical activity, and resident neighborhood involvement was positively associated with physical activity. Our findings suggest that future work incorporate additional neighborhood and individual-level characteristics to understand the complexity of the association between the neighborhood environment, resident social engagement in the neighborhood, and physical activity.

Leader Behaviors, Group Cohesion, and Participation in a Walking Group Program

INTRODUCTION

Less than half of all U.S. adults meet the 2008 Physical Activity Guidelines. Leader behaviors and group cohesion have been associated with increased participation or adherence in sports team and exercise class settings. Physical activity interventions in community settings that encompass these factors may enhance intervention adherence. The purpose of this study is to examine the impact of Community Health Promoter leader behaviors and group cohesion on participation in a walking group intervention among racially/ethnically diverse adults in low to moderate-income communities in Detroit, Michigan.

DESIGN

Data for the current study were drawn from the Walk Your Heart to Health (WYHH) data set. WYHH was a multisite cluster RCT with a lagged intervention and outcome measurements at baseline and 4, 8, and 32 weeks. Pooled survey data from both intervention arms were used for the current study. Data were analyzed between August 2013 and October 2014.

SETTING/PARTICIPANTS

A total of 603 non-Hispanic black, non-Hispanic white, and Hispanic adults across five cohorts that began the 32-week WYHH intervention between March 2009 and October 2011.

INTERVENTION

The intervention was a 32-week walking group program hosted by community- and faith-based organizations and facilitated by Community Health Promoters. Walking groups met three times per week for 90 minutes per session. To promote participation in or adherence to WYHH, Community Health Promoters used evidence-based strategies to facilitate group cohesion. Group members assumed increasing leadership responsibility for facilitating sessions over time.

MAIN OUTCOME MEASURES

Participation in WYHH as measured by consistency of attendance.

RESULTS

Community Health Promoter leader behaviors were positively associated with participation in WYHH. Social but not task cohesion was significantly associated with consistent participation. Social cohesion may mediate the relationship between leader behaviors and walking group participation.

CONCLUSIONS

Providing leaders with training to build socially cohesive groups may help motivate individuals to continue participation in community-based physical activity programs.

Effectiveness of a walking group intervention to promote physical activity and cardiovascular health in predominantly non-Hispanic black and Hispanic urban neighborhoods: findings from the walk your heart to health intervention

OBJECTIVES

The purpose of this study was to evaluate the effectiveness of the Walk Your Heart to Health (WYHH) intervention, one component of the multilevel Community Approaches to Cardiovascular Health: Pathways to Heart Health (CATCH:PATH) intervention designed to promote physical activity and reduce cardiovascular risk among non-Hispanic Black and Hispanic residents of Detroit, Michigan. The study was designed and implemented using a community-based participatory research approach that actively engaged community residents, health service providers and academic researchers. It was implemented between 2009 and 2012.

METHOD

WYHH was a 32-week community health promoter-facilitated walking group intervention. Groups met three times per week at community-based or faith-based organizations, and walked for 45 to 90 minutes (increasing over time). The study used a cluster randomized control design to evaluate effectiveness of WYHH, with participants randomized into intervention or lagged intervention (control) groups. Psychosocial, clinical, and anthropometric data were collected at baseline, 8, and 32 weeks, and pedometer step data tracked using uploadable peisoelectric pedometers.

RESULTS

Participants in the intervention group increased steps significantly more during the initial 8-week intervention period, compared with the control group (β = 2004.5, p = .000). Increases in physical activity were associated with reductions in systolic blood pressure, fasting blood glucose, total cholesterol, waist circumference and body mass index at 8 weeks, and maintained at 32 weeks.

CONCLUSION

The WYHH community health promoter-facilitated walking group intervention was associated with significant reductions in multiple indicators of cardiovascular risk among predominantly Hispanic and non-Hispanic Black participants in a low-to-moderate income urban community. Such interventions can contribute to reductions in racial, ethnic, and socioeconomic inequities in cardiovascular mortality.

Independent and joint associations between multiple measures of the built and social environment and physical activity in a multi-ethnic urban community

Physical activity is associated with reduced risk of a number of health outcomes, yet fewer than half of adults in the United States report recommended levels of physical activity. Analyses of structural characteristics of the built environment as correlates of physical activity have yielded mixed results. We examine associations between multiple aspects of urban neighborhood environments and physical activity in order to understand their independent and joint effects, with a focus on the extent to which the condition of the built environment and indicators of the social environment modify associations between structural characteristics and physical activity. We use data from a stratified, multi-stage proportional probability sample of 919 non-Hispanic Black, non-Hispanic White, and Hispanic adults in an urban community, observational data from their residential neighborhoods, and census data to examine independent and joint associations of structural characteristics (e.g., street network connectivity), their condition (e.g., sidewalk condition), and social environments (e.g., territoriality) with physical activity. Our findings suggest that sidewalk condition is associated with physical activity, above and beyond structural characteristics of the built environment. Associations between some structural characteristics of the built environment and physical activity were conditional upon street condition, physical deterioration, and the proportion of parks and playgrounds in good condition. We found modest support for the hypothesis that associations between structural characteristics and physical activity are modified by aspects of the social environment. Results presented here point to the value of and need for understanding and addressing the complexity of factors that contribute to the relationships between the built and social environments and physical activity, and in turn, obesity and co-morbidities. Bringing together urban planners, public health practitioners and policy makers to understand and address aspects of urban environment associated with health outcomes is critical to promoting health and health equity.

Air pollution and respiratory symptoms among children with asthma: vulnerability by corticosteroid use and residence area

RATIONALE

Information on how ambient air pollution affects susceptible populations is needed to ensure protective air quality standards.

OBJECTIVES

To estimate the effect of community-level ambient particulate matter (PM) and ozone (O) on respiratory symptoms among primarily African-American and Latino, lower-income asthmatic children living in Detroit, Michigan and to evaluate factors associated with heterogeneity in observed health effects.

METHODS

A cohort of 298 children with asthma was studied prospectively from 1999 to 2002. For 14days each season over 11 seasons, children completed a respiratory symptom diary. Simultaneously, ambient pollutant concentrations were measured at two community-level monitoring sites. Logistic regression models using generalized estimating equations were fit for each respiratory symptom in single pollutant models, looking for interactions by area or by corticosteroid use, a marker of more severe asthma. Exposures of interest were: daily concentrations of PM<10μm, <2.5μm, and between 10 and 2.5μm in aerodynamic diameter (PM, PM, and PM respectively), the daily 8-hour maximum concentration of O (8HrPeak), and the daily 1-hour maximum concentration of O (1HrPeak).

RESULTS

Outdoor PM, PM, 8HrPeak, and 1HrPeak O concentrations were associated with increased odds of respiratory symptoms, particularly among children using corticosteroid medication and among children living in the southwest community of Detroit. Similar patterns of associations were not seen with PM.

CONCLUSIONS

PM and O at levels near or below annual standard levels are associated with negative health impact in this population of asthmatic children. Variation in effects within the city of Detroit and among the subgroup using steroids emphasizes the importance of spatially refined exposure assessment and the need for further studies to elucidate mechanisms and effective risk reduction interventions.

Neighborhood food environment role in modifying psychosocial stress-diet relationships

Exposure to highly palatable foods may increase eating in response to stress, but this behavioral response has not been examined in relation to the neighborhood food environment. This study examined whether the neighborhood food environment modified relationships between psychosocial stress and dietary behaviors. Probability-sample survey (n=460) and in-person food environment audit data were used. Dietary behaviors were measured using 17 snack food items and a single eating-out-of-home item. Chronic stress was derived from five subscales; major life events was a count of nine items. The neighborhood food environment was measured as availability of large grocery stores, small grocery stores, and convenience stores, as well as proportion of restaurants that were fast food. Two-level hierarchical regression models were estimated. Snack food intake was positively associated with convenience store availability and negatively associated with large grocery store availability. The measures of chronic stress and major life events were generally not associated with either dietary behavior overall, although Latinos were less likely to eat out at high levels of major life events than African Americans. Stress-neighborhood food environment interactions were not statistically significant. Important questions remain regarding the role of the neighborhood food environment in the stress-diet relationship that warrant further investigation.

Hypertension: development of a prediction model to adjust self-reported hypertension prevalence at the community level

BACKGROUND

Accurate estimates of hypertension prevalence are critical for assessment of population health and for planning and implementing prevention and health care programs. While self-reported data is often more economically feasible and readily available compared to clinically measured HBP, these reports may underestimate clinical prevalence to varying degrees. Understanding the accuracy of self-reported data and developing prediction models that correct for underreporting of hypertension in self-reported data can be critical tools in the development of more accurate population level estimates, and in planning population-based interventions to reduce the risk of, or more effectively treat, hypertension. This study examines the accuracy of self-reported survey data in describing prevalence of clinically measured hypertension in two racially and ethnically diverse urban samples, and evaluates a mechanism to correct self-reported data in order to more accurately reflect clinical hypertension prevalence.

METHODS

We analyze data from the Detroit Healthy Environments Partnership (HEP) Survey conducted in 2002 and the National Health and Nutrition Examination (NHANES) 2001-2002 restricted to urban areas and participants 25 years and older. We re-calibrate measures of agreement within the HEP sample drawing upon parameter estimates derived from the NHANES urban sample, and assess the quality of the adjustment proposed within the HEP sample.

RESULTS

Both self-reported and clinically assessed prevalence of hypertension were higher in the HEP sample (29.7 and 40.1, respectively) compared to the NHANES urban sample (25.7 and 33.8, respectively). In both urban samples, self-reported and clinically assessed prevalence is higher than that reported in the full NHANES sample in the same year (22.9 and 30.4, respectively). Sensitivity, specificity and accuracy between clinical and self-reported hypertension prevalence were 'moderate to good' within the HEP sample and 'good to excellent' within the NHANES sample. Agreement between clinical and self-reported hypertension prevalence was 'moderate to good' within the HEP sample (kappa =0.65; 95% CI = 0.63-0.67), and 'good to excellent' within the NHANES sample (kappa = 0.75; 95%CI = 0.73-0.80). Application of a 'correction' rule based on prediction models for clinical hypertension using the national sample (NHANES) allowed us to re-calibrate sensitivity and specificity estimates for the HEP sample. The adjusted estimates of hypertension in the HEP sample based on two different correction models, 38.1% and 40.5%, were much closer to the observed hypertension prevalence of 40.1%.

CONCLUSIONS

Application of a simple prediction model derived from national NHANES data to self-reported data from the HEP (Detroit based) sample resulted in estimates that more closely approximated clinically measured hypertension prevalence in this urban community. Similar correction models may be useful in obtaining more accurate estimates of hypertension prevalence in other studies that rely on self-reported hypertension.

Associations between socioeconomic status and allostatic load: effects of neighborhood poverty and tests of mediating pathways

OBJECTIVES

We examined relationships between neighborhood poverty and allostatic load in a low- to moderate-income multiracial urban community. We tested the hypothesis that neighborhood poverty is associated with allostatic load, controlling for household poverty. We also examined the hypotheses that this association was mediated by psychosocial stress and health-related behaviors.

METHODS

We conducted multilevel analyses using cross-sectional data from a probability sample survey in Detroit, Michigan (n = 919) and the 2000 US Census. The outcome measure was allostatic load. Independent variables included neighborhood and household poverty, psychosocial stress, and health-related behaviors. Covariates included neighborhood and individual demographic characteristics.

RESULTS

Neighborhood poverty was positively associated with allostatic load (P < .05), independent of household poverty and controlling for potential confounders. Relationships between neighborhood poverty were mediated by self-reported neighborhood environment stress but not by health-related behaviors.

CONCLUSIONS

Neighborhood poverty is associated with wear and tear on physiological systems, and this relationship is mediated through psychosocial stress. These relationships are evident after accounting for household poverty levels. Efforts to promote health equity should focus on neighborhood poverty, associated stressful environmental conditions, and household poverty.

A community-based participatory planning process and multilevel intervention design: toward eliminating cardiovascular health inequities

The elimination of persistent health inequities requires the engagement of multiple perspectives, resources, and skills. Community-based participatory research (CBPR) is one approach to developing action strategies that promote health equity by addressing contextual as well as individual-level factors, and that can contribute to addressing more fundamental factors linked to health inequity. Yet many questions remain about how to implement participatory processes that engage local insights and expertise, are informed by the existing public health knowledge base, and build support across multiple sectors to implement solutions. This article describes a CBPR approach used to conduct a community assessment and action planning process, culminating in development of a multilevel intervention to address inequalities in cardiovascular disease in Detroit, Michigan. The authors consider implications for future efforts to engage communities in developing strategies toward eliminating health inequities.

Context of entry and number of depressive symptoms in an older Mexican-origin immigrant population

We examined the association between context of entry into the United States and symptoms of depression in an older age Mexican-origin population. We found that context of entry was associated with the number of depressive symptoms reported in this population. Specifically, immigrants who arrived to the U.S. following the Mexican Revolution (1918-1928) reported significantly fewer depressive symptoms, and those who arrived following enactment of the Immigration Reform Control Act (1965-1994) reported significantly more symptoms of depression, compared to those who arrived in the Bracero era (1942-1964). These findings suggest that sociopolitical context at the time of immigration may be associated with long-term psychological well-being. They contribute to a growing body of literature that suggests that the context of immigration may have long-term implications for the health of immigrant populations. We discuss implications of our findings for understanding relationships between immigration policies and the health of Mexican immigrant populations.

Exposure to fine particulate matter and acute effects on blood pressure: effect modification by measures of obesity and location

BACKGROUND

Observational studies and controlled experiments have provided evidence that airborne particulate matter (PM) is capable of acutely increasing blood pressure (BP) in certain scenarios. The goal of this study was to evaluate whether and to what extent obesity and community location affect relationships between fine particulate matter (PM(2.5)) and blood pressure (BP) measures.

METHODS

Using data from a stratified random sample survey of adults conducted in 2002-3 in Detroit, Michigan, we tested body mass index (BMI) and waist circumference (WCIR) in separate models as effect modifiers of the relationship between PM(2.5) exposure and BP. We also tested interactions with community location. Models were adjusted for covariates with established pro-hypertensive effects.

RESULTS

PM(2.5) exposure was positively associated with increased pulse pressure (PP) for those categorised as obese (BMI> or =30) across lags 2 (beta 4.16, p<0.05) and 3 days (beta 2.55, p<0.05) prior to BP measure. WCIR similarly modified the effect of exposure to PM(2.5) on PP (beta 4.34, p<0.003). The observed effects were enhanced in the community with closer proximity to local emissions of PM(2.5), and for residents classified as obese (BMI> or =30) or with WCIR above high-risk cuts points.

CONCLUSIONS

This community-based study suggests that positive associations between PM(2.5) exposure and PP and systolic BP are enhanced in areas proximate to sources of PM (2.5) emissions. These patterns were observed for all residents, but were more visible and consistent among those who were obese. Research is needed to examine the mechanistic pathways by which air particles interact with obesity and location to affect BP, and inform community interventions to reduce the population burden of hypertension and related co-morbidities.

Community-based participatory research: a capacity-building approach for policy advocacy aimed at eliminating health disparities

There have been increasing calls for community-academic partnerships to enhance the capacity of partners to engage in policy advocacy aimed at eliminating health disparities. Community-based participatory research (CBPR) is a partnership approach that can facilitate capacity building and policy change through equitable engagement of diverse partners. Toward this end, the Detroit Community-Academic Urban Research Center, a long-standing CBPR partnership, has conducted a policy training project. We describe CBPR and its relevance to health disparities; the interface between CBPR, policy advocacy, and health disparities; the rationale for capacity building to foster policy advocacy; and the process and outcomes of our policy advocacy training. We discuss lessons learned and implications for CBPR and policy advocacy to eliminate health disparities.

Community organizing network for environmental health: using a community health development approach to increase community capacity around reduction of environmental triggers

The Community Organizing Network for Environmental Health (CONEH), a project of Community Action Against Asthma, used a community health development approach to improve children's asthma-related health through increasing the community's capacity to reduce physical and social environmental triggers for asthma. Three community organizers were hired to work with community groups and residents in neighborhoods in Detroit on the priority areas of air quality, housing, and citizen involvement in the environmental project and policy decision-making. As part of the evaluation of the CONEH project, 20 one-on-one semi-structured, in-depth interviews were conducted between August and November 2005 involving steering committee members, staff members, and key community organization staff and/or community members. Using data from the evaluation of the CONEH project, this article identifies the dimensions of community capacity that were enhanced as part of a CBPR community health development approach to reducing physical and social environmental triggers associated with childhood asthma and the factors that facilitated or inhibited the enhancement of community capacity.

The one-pager: a practical policy advocacy tool for translating community-based participatory research into action

The multiple and diverse perspectives, skills, and experiences inherent in community-academic partnerships make them uniquely positioned to educate policy makers and advocate for health equity. Effective communication tools are critical to successfully engage in the policy-making process. Yet few resources emphasize the development and use of practical tools for translating community-based participatory research (CBPR) findings into action. The purpose of this article is to describe a CBPR process for developing and using a one-page summary, or "one-pager," of research findings and their policy implications. This article draws on the experience of the Healthy Environments Partnership (HEP), a community-academic partnership in Detroit, Michigan. In addition to describing these processes, this article includes a template for a one-pager and an example of a one-pager that was written for and presented to federal policy makers.

Social, economic, and political processes that create built environment inequities: perspectives from urban African Americans in Atlanta

Growing evidence suggests that the built environment features found in many high-poverty urban areas contribute to negative health outcomes. Both built environment hazards and negative health outcomes disproportionately affect poor people of color. We used community-based participatory research and Photovoice in inner-city Atlanta to elicit African Americans' perspectives on their health priorities. The built environment emerged as a critical factor, impacting physical and mental health outcomes. We offer a conceptual model, informed by residents' perspectives, linking social, economic, and political processes to built environment and health inequities. Research, practice, and policy implications are discussed within an environmental justice framework.