David W. Lounsbury

Introduction to special issue on social ecological approaches to community health research and action.

We have the potential to make new, substantive contributions to resolving our most pressing community health problems. However, to do so we must adopt a philosophy of science that is directed towards understanding the dynamic complexity and full contextual reality surrounding these issues. A social ecological approach to science is ideally suited to this challenge. This framework is systems-oriented and defines research problems in terms of structures and processes, generating research outcomes that give insight into the dynamic interaction of individuals with their environment across time and space. Though community psychology is built upon social ecological principles, researchers from other disciplines have also noted its utility and implemented interventions based on this framework. In our introductory article to this special issue on social ecological approaches to community health research and action, we present a brief review of the theoretical foundations of the social ecological approach, present highlights from our selected manuscripts, and conclude with some reflections about the need to build further capacity to conduct effective social ecological research to foster community health and well-being.

Forms of social support and their relationships to mental health in HIV-positive persons

A baseline assessment for an HIV health services study recruited 626 people living with HIV/AIDS (PLWHA) in New York city who participated in an interview querying social support, health status, substance use, and mental health. Data were modeled using hierarchical classes (HICLAS) analysis. HICLAS discriminated items reflecting general support and assistance vs. support from an important person in ones life who was named in addition to other family members and friends. HICLAS then identified respondents who reported that they had general support and assistance, support from an important person, both types, or neither type of support. Having one or more important persons as part of the respondents social network was associated with more positive mental (but not physical) health than having only general support and assistance, or no support at all. Results argue for differentiating support obtained through ones relationship with an important person.

Disparities in Access to Over-the-Counter Nicotine Replacement Products in New York City Pharmacies

OBJECTIVES We surveyed the availability of tobacco products and nonprescription nicotine replacement therapy (NRT) in pharmacies in New York City, stratified by the race, ethnicity, and socioeconomic status (SES) of the surrounding neighborhoods to determine whether disparities in availability existed. METHODS Surveyors visited a random sample of retail pharmacies to record the availability of tobacco products and nonprescription NRT. We used census data and geographic information systems analysis to determine the SES of each neighborhood. We used logistic modeling to explore relations between SES and the availability of NRT and tobacco products. RESULTS Of 646 pharmacies sampled, 90.8% sold NRT and 46.9% sold cigarettes. NRT and cigarettes were slightly more available in pharmacies in neighborhoods with a higher SES. NRT was more expensive in poorer neighborhoods. CONCLUSIONS Small disparities existed in access to nonprescription NRT and cigarettes. The model did not adequately account for cigarette access, because of availability from other retail outlets. These results may explain some of the excess prevalence of cigarette use in low-SES areas.

The Role of Parenting Practices in the Home Environment among Underserved Youth

BACKGROUND The home environment, which includes parenting practices, is an important setting in which children develop their health behaviors. We examined the role of parenting practices in the home environment among underserved youth. METHODS We examined baseline data of a family-focused pediatric obesity intervention. Parenting practices (monitoring, discipline, limit setting of soda/snacks [SS] and screen media [SM], pressure to eat, and reinforcement) and availability of fruits/vegetables (FV) and sugar-sweetened beverages (SSBs), family meals, television (TV) watching during meals, TVs in the home, owning active video games/sports equipment, and household food security were assessed in 301 parent/caregivers of overweight/obese children (ages 7-12 years; BMI≥85th percentile). Associations were evaluated using Spearmans rank correlation coefficients and logistic regression models adjusted for potential confounders. RESULTS Parents/caregivers (ages 22-67 years) were largely Hispanic/Latino (74.1%), female (92.4%), and reported high levels of limit setting SS and low levels of pressure to eat. Parent age, gender, country of birth, and years living in the United States accounted for differences among several parenting practices. Adjusted logistic regression models identified several statistically significant associations, including: Monitoring was positively associated with availability FV (odds ratio [OR]=2.19; 95% confidence interval [CI], 1.25, 3.82); limit setting SS was inversely associated with availability of SSBs (OR=0.40; 95% CI, 0.21, 0.75); and limit setting SM was inversely associated with TV viewing during family meals (OR=0.51; 95% CI, 0.31, 0.85). Nearly 40% of our population was food insecure, and food insecurity was positively associated with pressure to eat (OR=1.77; 95% CI, 1.01, 3.15). CONCLUSIONS Parenting practices play an important role in the home environment, and longitudinal studies are needed to examine these associations in the context of family-focused pediatric obesity interventions.

Beliefs About Participating in Research Among a Sample of Minority Persons Living with HIV/AIDS in New York City

Despite substantial data documenting the challenges in recruiting racial and ethnic minorities into research studies, relatively little is known about the attitudes and beliefs toward research that are held by racial and ethnic minorities living with HIV/AIDS. The present study assessed the research attitudes and beliefs of a racially and ethnically diverse group of persons living with HIV/AIDS, with research broadly defined as either psychosocial, behavioral, or clinical. Also assessed were factors that would encourage or discourage them from participating in a research study. Six hundred twenty-two participants were recruited from 22 points of service in New York City; data were gathered through a single in-person structured interview conducted in Spanish or English. Findings from a series of quantitative analyses indicated that attitudes about research were primarily neutral or positive, and different attitude and belief patterns were associated with different preferences regarding what would or would not incline one to participate in a research study. Results suggest that minorities with HIV/AIDS are open to the possibility participating in research; however, they also suggest that receptivity to research may not be uniform and indicated a variety of specific research design and implementation options that investigators should consider in order to ensure sufficient access and interest in participation.

Understanding social forces involved in diabetes outcomes: a systems science approach to quality-of-life research

PurposeThe field of quality-of-life (QOL) research would benefit from learning about and integrating systems science approaches that model how social forces interact dynamically with health and affect the course of chronic illnesses. Our purpose is to describe the systems science mindset and to illustrate the utility of a system dynamics approach to promoting QOL research in chronic disease, using diabetes as an example.MethodsWe build a series of causal loop diagrams incrementally, introducing new variables and their dynamic relationships at each stage.ResultsThese causal loop diagrams demonstrate how a common set of relationships among these variables can generate different disease and QOL trajectories for people with diabetes and also lead to a consideration of non-clinical (psychosocial and behavioral) factors that can have implications for program design and policy formulation.ConclusionsThe policy implications of the causal loop diagrams are discussed, and empirical next steps to validate the diagrams and quantify the relationships are described.

SBIRT Implementation for Adolescents in Urban Federally Qualified Health Centers

BACKGROUND Alcohol, tobacco, and other drug use remains highly prevalent among US adolescents and is a threat to their well-being and to the public health. Evidence from clinical trials and meta-analyses supports the effectiveness of Screening, Brief Intervention and Referral to Treatment (SBIRT) for adolescents with substance misuse but primary care providers have been slow to adopt this evidence-based approach. The purpose of this paper is to describe the theoretically informed methodology of an on-going implementation study. METHODS This study protocol is a multi-site, cluster randomized trial (N=7) guided by Proctors conceptual model of implementation research and comparing two principal approaches to SBIRT delivery within adolescent medicine: Generalist vs. Specialist. In the Generalist Approach, the primary care provider delivers brief intervention (BI) for substance misuse. In the Specialist Approach, BIs are delivered by behavioral health counselors. The study will also examine the effectiveness of integrating HIV risk screening within an SBIRT model. Implementation Strategies employed include: integrated team development of the service delivery model, modifications to the electronic medical record, regular performance feedback and supervision. Implementation outcomes, include: Acceptability, Appropriateness, Adoption, Feasibility, Fidelity, Costs/Cost-Effectiveness, Penetration, and Sustainability. DISCUSSION The study will fill a major gap in scientific knowledge regarding the best SBIRT implementation strategy at a time when SBIRT is poised to be brought to scale under health care reform. It will also provide novel data to inform the expansion of the SBIRT model to address HIV risk behaviors among adolescents. Finally, the study will generate important cost data that offer guidance to policymakers and clinic directors about the adoption of SBIRT in adolescent health care.

Using the Interactive Systems Framework to Support a Quality Improvement Approach to Dissemination of Evidence-Based Strategies to Promote Early Detection of Breast Cancer: Planning a Comprehensive Dynamic Trial

Dissemination efforts must optimize interventions for new settings and populations. As such, dissemination research should incorporate principles of quality improvement. Comprehensive Dynamic Trial (CDT) designs examine how information gained during dissemination may be used to modify interventions and improve performance. Although CDT may offer distinct advantages over static designs, organizing the many necessary roles and activities is a significant challenge. In this article, we discuss use of the Interactive Systems Framework for Dissemination and Implementation to systematically implement a CDT. Specifically, we describe “Bronx ACCESS”, a program designed to disseminate evidence-based strategies to promote adherence to mammography guidelines. In Bronx ACCESS, the Intervention Delivery System will elicit information needed to adapt strategies to specific settings and circumstances. The Intervention Synthesis and Translation System will use this information to test changes to strategies through “embedded experiments”. The Intervention Support System will build local capacities found to be necessary for intervention institutionalization. Simulation modeling will be used to integrate findings across systems. Results will inform on-going policy debate about interventions needed to promote population-level screening. More generally, this project is intended to advance understanding of research paradigms necessary to study dissemination.

Establishing a General Medical Outpatient Clinic for Cancer Survivors in a Public City Hospital Setting

ABSTRACTINTRODUCTIONMany cancer centers and community hospitals are developing novel models of survivorship care. However, few are specifically focused on services for socio-economically disadvantaged cancer survivors.AIMSTo describe a new model of survivorship care serving culturally diverse, urban adult cancer patients and to present findings from a feasibility evaluation.SETTINGAdult cancer patients treated at a public city hospital cancer center.PROGRAM DESCRIPTIONThe clinic provides comprehensive medical and psychosocial services for patients within a public hospital cancer center where they receive their oncology care.PROGRAM EVALUATIONLongitudinal data collected over a 3-year period were used to describe patient demographics, patient needs, and services delivered. Since inception, 410 cancer patients have been served. Demand for services has grown steadily. Hypertension was the most frequent comorbid condition treated. Pain, depression, cardiovascular disease, hyperlipidemia, and bowel dysfunction were the most common post-treatment problems experienced by the patients. Financial counseling was an important patient resource.DISCUSSIONThis new clinical service has been well-integrated into its public urban hospital setting and constitutes an innovative model of health-care delivery for socio-economically challenged, culturally diverse adult cancer survivors.

Importance of substance use and violence in psychosocial syndemics among women with and at-risk for HIV

ABSTRACT Women in the US continue to be affected by HIV through heterosexual contact. Sexual risk behaviors among women have been associated with a syndemic, or a mutually reinforcing set of conditions, including childhood sexual abuse (CSA), depression, substance use, violence, and financial hardship. Baseline data from a cohort of women with and at-risk for HIV (N = 620; 52% HIV+) were analyzed with Poisson regression to assess evidence for additive, independent and interactive effects among syndemic conditions in relation to reported sexual risk behaviors (e.g., unprotected and transactional sex) over the past 6 months, controlling for age and HIV status. The number of syndemic conditions was incrementally associated with more types of sexual risk behaviors. For example, women with all five syndemic conditions reported 72% more types of risk behaviors over 6 months, as compared to women without any syndemic conditions. Compared to women with no syndemic conditions, women with three syndemic conditions reported 34% more and women with one syndemic condition reported 13% more types of risk behaviors. Endorsing substance use in the past 6 months, reporting CSA, and experiencing violence as an adult were independently associated with 49%, 12%, and 8% more types of risk behaviors, respectively compared to women without these conditions. Endorsing both substance use and violence was associated with 27% more types of risk behaviors. These associations were not moderated by HIV status. Understanding specific relationships and interactions are needed to more effectively prioritize limited resources in addressing the psychosocial syndemic associated with sexual risk behavior among women with and at-risk for HIV. Our results identify interrelated psychosocial factors that could be targeted by intervention studies aiming to reduce high-risk sex in this population.