Carol R. Horowitz

Barriers to Buying Healthy Foods for People With Diabetes: Evidence of Environmental Disparities

OBJECTIVES A community coalition compared the availability and cost of diabetes-healthy foods in a racial/ethnic minority neighborhood in East Harlem, with those in the adjacent, largely White and affluent Upper East Side in New York City. METHODS We documented which of 173 East Harlem and 152 Upper East Side grocery stores stocked 5 recommended foods. RESULTS Overall, 18% of East Harlem stores stocked recommended foods, compared with 58% of stores in the Upper East Side (P <.0001). Only 9% of East Harlem bodegas (neighborhood stores) carried all items (vs 48% of Upper East Side bodegas), though East Harlem had more bodegas. East Harlem residents were more likely than Upper East Side residents (50% vs 24%) to have stores on their block that did not stock recommended foods and less likely (26% vs 30%) to have stores on their block that stocked recommended foods. CONCLUSIONS A greater effort needs to be made to make available stores that carry diabetes-healthy foods.

Community-Based Participatory Research From the Margin to the Mainstream Are Researchers Prepared?

Despite an increasing arsenal of effective treatments, there are mounting challenges in developing strategies that prevent and control cardiovascular diseases, and that can be sustained and scaled to meet the needs of those most vulnerable to their impact. Community-based participatory research (CBPR) is an approach to conducting research by equitably partnering researchers and those directly affected by and knowledgeable of the local circumstances that impact health. To inform research design, implementation and dissemination, this approach challenges academic and community partners to invest in team building, share resources, and mutually exchange ideas and expertise. CBPR has led to a deeper understanding of the myriad factors influencing health and illness, a stream of ideas and innovations, and there are expanding opportunities for funding and academic advancement. To maximize the chance that CBPR will lead to tangible, lasting health benefits for communities, researchers will need to balance rigorous research with routine adoption of its conduct in ways that respectfully, productively and equally involve local partners. If successful, lessons learned should inform policy and inspire structural changes in healthcare systems and in communities.

Community-based participatory research: opportunities, challenges, and the need for a common language.

In January of 2002, a call for papers featuring community-based participatory research (CBPR) was issued. The intent was to highlight the outstanding work being done in this area and the role CBPR can play in improving the care and outcomes of populations at-risk.1 What emerged from this call was more than what any of the editors expected, and has been illustrative of both the superb scholarship and community engagement occurring in CBPR and how much more can be done in refining and broadening the application of CBPR in what we do. The body of research submitted for consideration also highlights several important realities: 1) CBPR is appropriate and applicable across disciplines and within many diverse community settings; 2) the potential for CBPR to make meaningful contributions to improving the health and well-being of traditionally disenfranchised population groups and communities is very real and, in many instances, being realized; and 3) we need to do a better job of articulating CBPR to our peers and colleagues as “research-plus” that is both methodologically rigorous and that makes unique contributions not possible using other means. The 11 original research papers presented in this Special Issue came from an impressive pool of 81 submissions. And while CBPR may seem somewhat straightforward in theory, as these articles demonstrate, the degree to which CBPR is applied and how it is represented are far more diverse and varied. The peer review process and several editor meetings for this Special Issue brought out many of the challenges inherent in CBPR. How do we define community? What is a meaningful impact? How do we distinguish between community-placed and community-based research? How do we balance the importance of the research process with the importance of the research product or findings? Is there a methodologic threshold with which to determine whether a project is or is not CBPR? What is evident from the submissions is how broadly CBPR is being applied, geographically, within specific population groups and clinical scenarios, and methodologically. For example, Angell et al.2 and Stratford et al.3 both describe CBPR projects in rural settings, while van Olphen et al.,4 Horowitz et al.,5 and Masi et al.6 all describe urban-based research. Initiatives targeting specific vulnerable or at-risk populations are featured in work by Lauderdale et al.7 with older Chinese immigrants, by Lam et al.8 with Vietnamese-American women, and by van Olphen et al. with African-American women. Similarly, CBPR was clearly applicable in several different clinical scenarios, including chronic disease management of diabetes,5 asthma,9 and cancer treatment and prevention.10 The partners engaged in the community-based research also varied across projects and included faith-based organizations,4,10 neighborhood and community leaders,6,8 and social service and support agencies.2,3,7 Finally, the research topics and interventions themselves also reflected a wide spectrum of CBPR applications. Sloane et al. examined the degree of nutritional resources available within a community, whereas Masi et al. evaluated the application of internet-based technologies.5,11 The articles presented also reflect the broad scope of research in which CBPR can be applied methodologically. Angell et al. and Corbie-Smith et al. report on findings where CBPR was applied to randomized controlled trials,2,10 while van Olphen et al., Masi et al., and Lam et al., all report data from intervention studies with pre–post comparisons.4,6,8 Horowitz et al. and Lauderdale et al. represent good examples of CBPR applied to survey research,5,7 and Parker et al. demonstrate CBPR applied to a qualitative study.9 Finally, the article by Nyden provides an overview of CBPR and highlights many of the issues and struggles to institutionalizing and legitimizing CBPR within the broader research community from an academic perspective.12 As the science and field of CBPR advance to the next level, it is clear that several things need to occur. We need more formal training in CBPR that is more broadly available to both academically-based researchers and community members. Post-doctoral training programs such as the Kellogg Community Scholars Program13 need to be expanded beyond the current 3 schools of public health, and need to be integrated into other health professional schools and within other established fellowship and post-doctoral training programs. Additionally, career development awards sponsored by federal agencies and private philanthropies need to be amenable to proposals that engage the candidate in CBPR projects and ideally should promote this in their solicitation and review process. We also need to encourage scholarship, not only in the application of CBPR, but also in better understanding the nuances of the model, so that it can truly live up to its potential. This includes developing a common language for describing CBPR-related research in the health services literature, so that it can stand on its own merits and be appreciated for the contributions it brings to the field. One possible framework for this common language is introduced in Table 1 and is meant to serve as a resource for authors considering submission of CBPR projects to peer-reviewed journals. Finally, we need to gain a greater appreciation for CBPR as “research-plus” that is reflected in funding priorities, review criteria, community empowerment, and academic advancement. Table 1 Proposed Process for Describing Community-based Participatory Research Findings in Health Sciences Literature In summary, it is best to view this Special Issue as a reflection of both where we are as a research community and where we need to go. The 11 papers ultimately chosen for this issue represent a small fraction of the excellent work ongoing in many of our communities. Yet there is much more than can and should be done. As the gap in health access and health outcomes grows wider and is further defined by socioeconomics, race, language, country of origin, and other markers and designations inherent in a multicultural, multiethnic society, we need CBPR to help find the answers and sustainable solutions.

Racial and ethnic differences in factors associated with early postpartum depressive symptoms.

OBJECTIVE: To explore racial differences in reporting of early postpartum depressive symptoms. To explore whether racial differences in early postpartum experience (such as mothers health status and social context) might account for racial differences in reported postpartum depressive symptoms. METHODS: This was a telephone survey of 655 white, African-American, and Hispanic mothers between 2 and 6 weeks postpartum. Mothers reported on demographic factors, physical symptoms, daily function, infant behaviors, social support, skills in managing infant and household, access, and trust in the medical system. We explored racial differences in report of early postpartum depressive symptoms using bivariate and multivariate statistics. RESULTS: African-American and Hispanic women more commonly reported postpartum depressive symptoms (43.9% and 46.8%, respectively) than white women (31.3%, P < .001). Similar factors (physical symptom burden, lack of social support, and lack of self-efficacy) were associated with early postpartum depressive symptoms in white, African-American, and Hispanic mothers. In a comprehensive model including other demographic factors, history of depression, physical symptoms, daily function, infant behavior, social support, skills in managing infant and household, access, and trust, the adjusted odds ratio for reported postpartum depressive symptoms remained elevated for African-American women at 2.16 (95% confidence interval 1.26–3.70) and Hispanic women at 1.89 (95% confidence interval 1.19–3.01) as compared with white women. CONCLUSION: African-American and Hispanic mothers are at higher risk for reporting early postpartum depressive symptoms as compared with white mothers. Factors associated with these symptoms are similar among African-American, Hispanic, and white mothers. LEVEL OF EVIDENCE: II-2

Results of a Pilot Diabetes Prevention Intervention in East Harlem, New York City: Project HEED

OBJECTIVES Our community-academic partnership employed community-based participatory research to develop and pilot a simple, peer-led intervention to promote weight loss, which can prevent diabetes and eliminate racial/ethnic disparities in incident diabetes among overweight adults with prediabetes. METHODS We recruited overweight adults at community sites, performed oral glucose tolerance testing to identify persons with blood glucose levels in the prediabetes range, and randomized eligible people to a peer-led lifestyle intervention group or delayed intervention in 1 year. Outcomes, including weight, blood pressure, and health behaviors, were measured at baseline and 3, 6, and 12 months. RESULTS More than half of those tested (56%, or 99 of 178) had prediabetes and enrolled in the study. Participants were predominantly Spanish-speaking, low-income, undereducated women. The intervention group lost significantly more weight than the control group and maintained weight loss at 12 months (7.2 versus 2.4 pounds; P < .01). One fourth (24 of 99) of participants progressed to diabetes. CONCLUSIONS In underserved minority communities, prediabetes prevalence may be higher than previously reported. Low-cost, community-based interventions can succeed in encouraging weight loss to prevent diabetes.

The IGNITE network: a model for genomic medicine implementation and research

BackgroundPatients, clinicians, researchers and payers are seeking to understand the value of using genomic information (as reflected by genotyping, sequencing, family history or other data) to inform clinical decision-making. However, challenges exist to widespread clinical implementation of genomic medicine, a prerequisite for developing evidence of its real-world utility.MethodsTo address these challenges, the National Institutes of Health-funded IGNITE (Implementing GeNomics In pracTicE; www.ignite-genomics.org) Network, comprised of six projects and a coordinating center, was established in 2013 to support the development, investigation and dissemination of genomic medicine practice models that seamlessly integrate genomic data into the electronic health record and that deploy tools for point of care decision making. IGNITE site projects are aligned in their purpose of testing these models, but individual projects vary in scope and design, including exploring genetic markers for disease risk prediction and prevention, developing tools for using family history data, incorporating pharmacogenomic data into clinical care, refining disease diagnosis using sequence-based mutation discovery, and creating novel educational approaches.ResultsThis paper describes the IGNITE Network and member projects, including network structure, collaborative initiatives, clinical decision support strategies, methods for return of genomic test results, and educational initiatives for patients and providers. Clinical and outcomes data from individual sites and network-wide projects are anticipated to begin being published over the next few years.ConclusionsThe IGNITE Network is an innovative series of projects and pilot demonstrations aiming to enhance translation of validated actionable genomic information into clinical settings and develop and use measures of outcome in response to genome-based clinical interventions using a pragmatic framework to provide early data and proofs of concept on the utility of these interventions. Through these efforts and collaboration with other stakeholders, IGNITE is poised to have a significant impact on the acceleration of genomic information into medical practice.

Effective Recruitment of Minority Populations Through Community-Led Strategies

BACKGROUND Traditional research approaches frequently fail to yield representative numbers of people of color in research. Community-based participatory research (CBPR) may be an important strategy for partnering with and reaching populations that bear a greater burden of illness but have been historically difficult to engage. The Community Action Board, consisting of 20 East Harlem residents, leaders, and advocates, used CBPR to compare the effectiveness of various strategies in recruiting and enrolling adults with prediabetes into a peer-led, diabetes prevention intervention. METHODS The board created five recruitment strategies: recruiting through clinicians; recruiting at large public events such as farmers markets; organizing special local recruitment events; recruiting at local organizations; and recruiting through a partner-led approach, in which community partners developed and managed the recruitment efforts at their sites. RESULTS In 3 months, 555 local adults were approached; 249 were appropriate candidates for further evaluation (overweight, nonpregnant, East Harlem residents without known diabetes); 179 consented and returned in a fasting state for 1/2 day of prediabetes testing; 99 had prediabetes and enrolled in a pilot randomized trial. The partner-led approach was highly successful, recruiting 68% of those enrolled. This strategy was also the most efficient; 34% of those approached through partners were ultimately enrolled, versus 0%-17% enrolled through the other four strategies. Participants were predominantly low-income, uninsured, undereducated, Spanish-speaking women. CONCLUSIONS This CBPR approach highlights the value of partner-led recruitment to identify, reach out to, and motivate a vulnerable population into participation in research, using techniques that may be unfamiliar to researchers but are nevertheless rigorous and effective.

How do Urban African Americans and Latinos View the Influence of Diet on Hypertension

Uncontrolled hypertension and its complications continue to be major health problems that disproportionately affect poor minority communities. Although dietary modification is an effective treatment for hypertension, it is not clear how hypertensive minority patients view diet as part of their treatment, and what barriers affect their abilities to eat healthy diets. We conducted nine focus groups with 88 African American and Latino patients treated for hypertension to assess their knowledge, attitudes, behaviors, and beliefs concerning hypertension. Participants generally agreed that certain foods and food additives play an important role in the cause and treatment of hypertension. However, they found clinician-recommended diets difficult to follow in the context of their family lives, social situations, and cultures. These diets were often considered expensive, an unwelcome departure from traditional and preferred diets, socially isolating, and not effective enough to obviate the need for medications. These findings suggest the importance of culturally sensitive approaches to dietary improvements.

Project HEAL: Peer Education Leads to Weight Loss in Harlem

Background. Obesity and diabetes are epidemic in the predominantly minority Harlem community. To address them, a coalition of community and academic leaders tested the effectiveness of a peer-led weight loss course. Methods. The coalition developed Project HEAL: Healthy Eating, Active Lifestyles through extensive collaboration with community members and experts in nutrition, exercise, and peer education. We piloted the course in a local church and assessed its impact through pre and post course weights, self-reported behaviors and quality of life. Results. Twenty-six overweight and obese African American adults lost a mean of 4.4 pounds at 10 weeks, 8.4 pounds at 22 weeks, and 9.8 pounds at 1 year. Participants reported decreased fat consumption and sedentary hours, and improved health related quality of life. Conclusions. A peer-led, community-based course can lead to weight loss and behavior change. The minority communities most affected by obesity and diabetes may benefit from this low-cost, culturally appropriate intervention.

A community-centered approach to diabetes in east harlem

AbstractOBJECTIVE: Residents of East Harlem, an impoverished, nonwhite community in New York city (NYC), have up to 5 times the mortality and complication rates of diabetes compared with NYC residents overall. To determine potentially remediable problems underlying this condition, a community-based collaboration of health providers, community advocates, and researchers, surveyed East Harlem residents with diabetes to assess their knowledge, behaviors, barriers to care, and actions taken in response to barriers. DESIGN: Telephone interviews. SETTING: The 3 hospitals and 2 community clinics serving East Harlem. PARTICIPANTS: Nine hundred thirty-nine of the 1,423 persons (66%) with diabetes identified from these 5 healthcare sites with 2 or more ambulatory visits for diabetes during 1998 who lived in East Harlem. RESULTS: While most respondents (90%) said they know how to take their medicines, between 19% and 39% do not understand other aspects of their diabetes management. Many limit their diabetes care due to concerns about money (16% to 40%), and other barriers, such as language and transportation (19% to 22%). In multivariate analyses, Latinos (relative risk [RR]=0.77; 95% confidence interval [95% CI] 0.63 to 0.91) and those who do not keep a diabetic diet due to concerns about money (RR=0.85; 95% CI 0.70 to 0.99) had poorer health status. CONCLUSIONS: A community-based coalition was able to come together, identify areas of concern in diabetes care and assess the needs of adults with diabetes residing and obtaining care in East Harlem. The coalition found that even among those with access to care there remain significant financial barriers to good diabetes care, and a need to address and optimize how individuals with diabetes manage their disease.