Alicia L. Salvatore

Community-Based Participatory Research: Lessons Learned from the Centers for Children's Environmental Health and Disease Prevention Research

Over the past several decades there has been growing evidence of the increase in incidence rates, morbidity, and mortality for a number of health problems experienced by children. The causation and aggravation of these problems are complex and multifactorial. The burden of these health problems and environmental exposures is borne disproportionately by children from low-income communities and communities of color. Researchers and funding institutions have called for increased attention to the complex issues that affect the health of children living in marginalized communities—and communities more broadly—and have suggested greater community involvement in processes that shape research and intervention approaches, for example, through community-based participatory research (CBPR) partnerships among academic, health services, public health, and community-based organizations. Centers for Children’s Environmental Health and Disease Prevention Research (Children’s Centers) funded by the National Institute of Environmental Health Sciences and U.S. Environmental Protection Agency were required to include a CBPR project. The purpose of this article is to provide a definition and set of CBPR principles, to describe the rationale for and major benefits of using this approach, to draw on the experiences of six of the Children’s Centers in using CBPR, and to provide lessons learned and recommendations for how to successfully establish and maintain CBPR partnerships aimed at enhancing our understanding and addressing the multiple determinants of children’s health.

Community-based intervention to reduce pesticide exposure to farmworkers and potential take-home exposure to their families.

The US EPA Worker Protection Standard requires pesticide safety training for farmworkers. Combined with re-entry intervals, these regulations are designed to reduce pesticide exposure. Little research has been conducted on whether additional steps may reduce farmworker exposure and the potential for take-home exposure to their families. We conducted an intervention with 44 strawberry harvesters (15 control and 29 intervention group members) to determine whether education, encouragement of handwashing, and the use of gloves and removable coveralls reduced exposure. Post-intervention, we collected foliage and urine samples, as well as hand rinse, lower-leg skin patch, and clothing patch samples. Post-intervention loading of malathion on hands was lower among workers who wore gloves compared to those who did not (median=8.2 vs. 777.2 μg per pair, respectively (P<0.001)); similarly, median MDA levels in urine were lower among workers who wore gloves (45.3 vs. 131.2 μg/g creatinine, P<0.05). Malathion was detected on clothing (median=0.13 μg/cm2), but not on skin. Workers who ate strawberries had higher malathion dicarboxylic acid levels in urine (median=114.5 vs. 39.4 μg/g creatinine, P<0.01). These findings suggest that wearing gloves reduces pesticide exposure to workers contacting strawberry foliage containing dislodgeable residues. Additionally, wearing gloves and removing work clothes before returning home could reduce transport of pesticides to worker homes. Behavioral interventions are needed to reduce consumption of strawberries in the field.

Using community-based participatory research to design and initiate a study on immigrant worker health and safety in San Francisco's Chinatown restaurants.

BACKGROUND Restaurant workers have among the highest rates of work-related illness and injury in the US, but little is known about the working conditions and occupational health status of Chinese immigrant restaurant workers. METHODS Community-based participatory research (CBPR) was employed to study restaurant working conditions and worker health in San Franciscos Chinatown. A community/academic/health department collaborative was formed and 23 restaurant workers trained on research techniques and worker health and safety. A worker survey instrument and a restaurant observational checklist were collaboratively developed. The checklist was piloted in 71 Chinatown restaurants, and the questionnaire administered to 433 restaurant workers. RESULTS Restaurant workers, together with other partners, made substantial contributions to construction of the survey and checklist tools and improved their cultural appropriateness. The utility of the checklist tool for restaurant-level data collection was demonstrated. CONCLUSIONS CBPR holds promise for both studying worker health and safety among immigrant Chinese restaurant workers and developing culturally appropriate research tools. A new observational checklist also has potential for restaurant-level data collection on worker health and safety conditions.

Studying and Addressing Urban Immigrant Restaurant Worker Health and Safety in San Francisco’s Chinatown District: A CBPR Case Study

With its emphasis on empowerment, individual and community capacity building, and translating research findings into action, community-based participatory research (CBPR) may be particularly advantageous in work with urban immigrant populations. This paper highlights eight ways in which CBPR has been shown to add value to work with urban underserved communities. It then describes the background, context, and methods of an ecological CBPR project, the Chinatown Restaurant Worker Health and Safety Study, conducted in San Francisco, California, and draws on study processes and outcomes to illustrate each of the eight areas identified. Challenges of using CBPR, particularly with urban immigrant populations, briefly are described, drawing again on the Chinatown study to provide illustrative examples. We discuss lessons learned, through this and other studies, for the effective use of CBPR with urban immigrant populations. We conclude that despite its challenges, this transdisciplinary, community-partnered and action-oriented approach to inquiry can make substantial contributions to both the processes and the outcomes of the research.

Adapting to Context in Community-Based Participatory Research: “Participatory Starting Points” in a Chinese Immigrant Worker Community

Community-based participatory research (CBPR) is increasingly being used to better understand and improve the health of diverse communities. A key strength of this research orientation is its adaptability to community contexts and characteristics. To date, however, few studies explicitly discuss adaptations made to CBPR principles and processes in response to community context and partners’ needs. Using data from our CBPR study, the San Francisco Chinatown Restaurant Worker Health and Safety Project, and drawing from literature on immigrant political incorporation, we examine the links between the contexts of the Chinese immigrant worker community, adaptations made by our collaborative, and study outcomes. In particular, we explore the concepts of contexts of reception and participatory starting points, which may be especially relevant for partnerships with immigrant communities whose members have historically had lower rates of civic and political participation in the US. We discuss contextual findings such as worker partner accounts of language barriers, economic and social marginalization, and civic skills and participation, as well as subsequent adaptations made by the partnership. We also describe the relative effectiveness of these adaptations in yielding equitable participation and building partners’ capacity. We conclude by sharing lessons learned and their implications for CBPR and partnerships with immigrant communities more broadly.

Wage Theft as a Neglected Public Health Problem: An Overview and Case Study From San Francisco’s Chinatown District

Wage theft, or nonpayment of wages to which workers are legally entitled, is a major contributor to low income, which in turn has adverse health effects. We describe a participatory research study of wage theft among immigrant Chinatown restaurant workers. We conducted surveys of 433 workers, and developed and used a health department observational tool in 106 restaurants. Close to 60% of workers reported 1 or more forms of wage theft (e.g., receiving less than minimum wage [50%], no overtime pay [> 65%], and pay deductions when sick [42%]). Almost two thirds of restaurants lacked required minimum wage law signage. We discuss the dissemination and use of findings to help secure and enforce a wage theft ordinance, along with implications for practice.

Food insecurity and chronic diseases among American Indians in rural Oklahoma: The THRIVE study

Objectives To examine food insecurity and cardiovascular disease-related health outcomes among American Indians (AIs) in rural Oklahoma. Methods We surveyed a cross-sectional sample of 513 AI adults to assess food insecurity domains (i.e., food quality and quantity) and obesity, diabetes, and hypertension. Results Among AIs surveyed, 56% reported inadequate food quantity and 62% reported inadequate food quality. The unadjusted prevalence of diabetes (28.4% vs 18.4%), obesity (60.0% vs 48.3%), and hypertension (54.1% vs 41.6%) was higher among participants with inadequate food quantity than among those with adequate food quantity. These associations did not reach statistical significance after adjustment for age, gender, study site, education, and income. The unadjusted prevalence of obesity (60.7% vs 45.8%), diabetes (27.3% vs 18.8%), and hypertension (52.5% vs 42.5%) was higher among those with inadequate food quality than among those with adequate food quality, even after adjustment for age, gender, study site, education, and income. Conclusions Tribal, federal, and state policymakers, as well as businesses and nonprofit organizations, must collaboratively take aggressive action to address food insecurity and its underlying causes, including improving tribal food environments, reducing barriers to healthy foods, and increasing living wages.

Beyond Health Equity: Achieving Wellness Within American Indian and Alaska Native Communities

The author discusses the need for the improvement of health disparities among Native Americans living in the U.S (or American Indians and Alaska Natives). Topics include the life expectancy of Native Americans, which is the lowest of any racial or ethnic group in the U.S., the efforts of tribal communities and the National Institutes of Health (NIH) to implement the Interventions for Health Promotion and Disease Prevention in Native American Populations initiative, and the mistrust for medical research of many tribal communities.

Health in My Community: Conducting and Evaluating PhotoVoice as a Tool to Promote Environmental Health and Leadership Among Latino/a Youth

Background: The PhotoVoice method has shown substantial promise for work with youth in metropolitan areas, yet its potential for use with Latino youth from agricultural areas has not been well documented.Objectives: This project was designed to teach environmental health to 15 high school youth while building their individual and community capacity for studying and addressing shared environmental concerns. The project also aimed to test the utility of PhotoVoice with Latino agricultural youth.Methods: Fifteen members of the Youth Community Council (YCC), part of a 15-year project with farmworker families in Salinas, CA, took part in a 12-week PhotoVoice project. Their pictures captured the assets and strengths of their community related to environmental health, and were then analyzed by participants. A multi-pronged evaluation was conducted.Results: YCC members identified concerns such as poor access to affordable, healthy foods and lack of safe physical spaces in which to play, as well as assets, including caring adults and organizations, and open spaces in surrounding areas. Participants presented their findings on radio, television, at local community events, and to key policy makers. The youth also developed two action plans, a successful 5K run/walk and a school recycling project, still in progress. Evaluation results included significant changes in such areas as perceived ability to make presentations, leadership, and self-confidence, as well as challenges including transportation, group dynamics, and gaining access to people in power.Conclusion: The PhotoVoice method shows promise for environmental health education and youth development in farmworker communities.

A randomized, controlled study of a rural sanitation behavior change program in Madhya Pradesh, India

Poor sanitation and open defecation are thought to be a major cause of diarrhea and intestinal parasite infections among young children. In 1999, India launched the Total Sanitation Campaign with the goal of achieving universal toilet coverage in rural India by 2012. This paper reports on a cluster-randomized, controlled trial that was conducted in 80 rural villages in Madhya Pradesh to measure the effect of the program on toilet access, sanitation behavior, and child health outcomes. The study analyzed a random sample of 3,039 households and 5,206 children under five years of age. Field staff collected baseline measures of sanitation conditions, behavior, and child health, and re-visited households 21 months later. The analysis finds that implementation of the program activities was slower than the original timeline (only 35 percent of villages were triggered more than six months before the follow-up survey). Nevertheless, the Total Sanitation Campaign successfully increased toilet coverage by 19 percent in intervention villages compared with control villages (41 percent v. 22 percent), while reported open defecation decreased by 10 percent among adults (74 percent v. 84 percent). The intervention also led to some improvements in water quality and protozoan infection, but consistent improvements were not observed across multiple child health outcomes (diarrhea, helminth infections, child growth). However, the exposure period was likely to have been too short to result in any benefit of the sanitation interventions on child health. Given the large improvements in toilet construction documented, an additional follow-up survey with a longer period of exposure would yield valuable information on the effects of improved sanitation conditions on health outcomes.