Michael A. Yonas

Aligning the Goals of Community-Engaged Research: Why and How Academic Health Centers Can Successfully Engage With Communities to Improve Health

Community engagement (CE) and community-engaged research (CEnR) are increasingly viewed as the keystone to translational medicine and improving the health of the nation. In this article, the authors seek to assist academic health centers (AHCs) in learning how to better engage with their communities and build a CEnR agenda by suggesting five steps: defining community and identifying partners, learning the etiquette of CE, building a sustainable network of CEnR researchers, recognizing that CEnR will require the development of new methodologies, and improving translation and dissemination plans. Health disparities that lead to uneven access to and quality of care as well as high costs will persist without a CEnR agenda that finds answers to both medical and public health questions. One of the biggest barriers toward a national CEnR agenda, however, are the historical structures and processes of an AHC—including the complexities of how institutional review boards operate, accounting practices and indirect funding policies, and tenure and promotion paths. Changing institutional culture starts with the leadership and commitment of top decision makers in an institution. By aligning the motivations and goals of their researchers, clinicians, and community members into a vision of a healthier population, AHC leadership will not just improve their own institutions but also improve the health of the nation—starting with improving the health of their local communities, one community at a time.

Perceptions of neighborhood collective efficacy moderate the impact of maltreatment on aggression.

This study examined the moderating influence of positive neighborhood factors such as social cohesion and informal social control (collective efficacy), on the relationship between child maltreatment and aggressive behavior at age 12. Caregiver (N = 861) and youth (N = 823) dyads were interviewed when youth were aged 12 as part of a longitudinal study of child abuse and neglect (LONGSCAN). Caregivers and youth provided reports of youth externalizing behaviors while caregivers provided perceptions of collective efficacy. Child Protective Services records and youth’s self-report of abuse experiences provided information on history of maltreatment. Multivariate analyses examined the moderating effect of collective efficacy on the influence of child abuse and neglect on youth externalizing behaviors. Neighborhood factors did moderate the association between earlier neglect and aggression at age 12, such that youth who experienced neglect, but not abuse, had lower externalizing scores in neighborhoods with higher levels of collective efficacy. Neighborhood-level factors such as collective efficacy should be considered as protective in preventing externalizing behaviors for youth who have experienced maltreatment.

The art and science of integrating Undoing Racism with CBPR: challenges of pursuing NIH funding to investigate cancer care and racial equity.

In this nation, the unequal burden of disease among People of Color has been well documented. One starting point to eliminating health disparities is recognizing the existence of inequities in health care delivery and identifying the complexities of how institutional racism may operate within the health care system. In this paper, we explore the integration of community-based participatory research (CBPR) principles with an Undoing Racism process to conceptualize, design, apply for, and secure National Institutes of Health (NIH) funding to investigate the complexities of racial equity in the system of breast cancer care. Additionally, we describe the sequence of activities and “necessary conflicts” managed by our Health Disparities Collaborative to design and submit an application for NIH funding. This process of integrating CBPR principles with anti-racist community organizing presented unique challenges that were negotiated only by creating a strong foundation of trusting relationships that viewed conflict as being necessary. The process of developing a successful NIH grant proposal illustrated a variety of important lessons associated with the concepts of cultural humility and cultural safety. For successfully conducting CBPR, major challenges have included: assembling and mobilizing a partnership; the difficulty of establishing a shared vision and purpose for the group; the problem of maintaining trust; and the willingness to address differences in institutional cultures. Expectation, acceptance and negotiation of conflict were essential in the process of developing, preparing and submitting our NIH application. Central to negotiating these and other challenges has been the utilization of a CBPR approach.

Intimate partner violence among HIV-positive persons in an urban clinic

Abstract While the intersection of HIV/AIDS and intimate partner violence (IPV) has gained increased attention, little focus has been given to the relationship among minority men and men who have sex with men (MSM). This pilot study, conducted at an urban clinic, explores the IPV experiences of HIV-positive persons involved in both heterosexual and homosexual relationships. Fifty-six HIV-positive individuals were interviewed to assess for verbal, physical, and sexual IPV, and for HIV-related abuse and attitudes regarding routine IPV screening. Approximately three quarters (73%) of the sample reported lifetime IPV and 20% reported current abuse. Physical IPV (85%) was cited the most by abused participants. IPV rates were highest among African-Americans and MSM. More than one-fourth (29%) of those abused felt the abuse was related to their HIV status. A majority of participants favored IPV screening by providers, but felt it might increase risk of IPV. IPV and its association to HIV are significant issues among this sample. Findings support the need for developing new programs that address these epidemics simultaneously.

Urban youth violence: Do definitions and reasons for violence vary by gender?

This study explored how young boys and girls living in low income urban neighborhoods defined and described reasons associated with youth violence. Five focus groups were conducted with 29 youth between the ages of 8 and 12 recruited from four selected study neighborhoods. Participants were asked to describe youth violence. Appropriate probes were used to explore similarities and differences by gender with regard to the reasons for violence. Definitions of youth violence were consistent across participants and included verbal threats, physical contact, and often the use of a weapon. Several common reasons for violence were found among both boys and girls; romantic relationships, respect, idle time, gangs.cliques, and witnessing violence. Reasons for violence unique to boys include fighting about issues related to money and illicit drugs. Gossip was identified as a reason specific to why girls engage in violence. Youth violence was perceived as a common problem impacting the lives of the boys and girls in this study. Although many of the reasons identified for violence are similar among boys and girls, select gender differences do exist. Future research and prevention efforts to address youth violence should engage young people in efforts to understand and address this important public health topic.

“Do You Want Somebody Treating Your Sister Like That?”: Qualitative Exploration of How African American Families Discuss and Promote Healthy Teen Dating Relationships

The article discusses a study conducted between December 2007 and March 2008 that involved 19 gender-stratified focus groups with African American parents and adolescents from Allegheny County, Pennsylvania, to explore the process and content of parent—adolescent communication about sex. Discussions about intimate partner violence (IPV) and healthy relationships emerge inductively as critical topics in these conversations. The authors use a grounded theory approach to content analysis to identify and organize themes related to discussions on these topics. A total of 125 participants from 52 families are recruited for the study. Family history of child sexual abuse often motivates discussions. Mothers are described as the primary parent discussing sexual issues with children. Fathers primarily role model ideal male partnership behavior for sons and daughters. Parents seek to prevent daughters from experiencing sexual abuse or emotional manipulation by partners and focus on instilling a sense of responsibility to and respect for romantic partners in sons. Parents prioritize and express the need for tools to influence their adolescent’s socialization as romantic partners. Mothers and fathers approach this process differently. Family-focused interventions to prevent unhealthy relationships can build on parent’s efforts.

Enhancing Dissemination and Implementation Research Using Systems Science Methods

BackgroundDissemination and implementation (D&I) research seeks to understand and overcome barriers to adoption of behavioral interventions that address complex problems, specifically interventions that arise from multiple interacting influences crossing socio-ecological levels. It is often difficult for research to accurately represent and address the complexities of the real world, and traditional methodological approaches are generally inadequate for this task. Systems science methods, expressly designed to study complex systems, can be effectively employed for an improved understanding about dissemination and implementation of evidence-based interventions.PurposeThe aims of this study were to understand the complex factors influencing successful D&I of programs in community settings and to identify D&I challenges imposed by system complexity.MethodCase examples of three systems science methods—system dynamics modeling, agent-based modeling, and network analysis—are used to illustrate how each method can be used to address D&I challenges.ResultsThe case studies feature relevant behavioral topical areas: chronic disease prevention, community violence prevention, and educational intervention. To emphasize consistency with D&I priorities, the discussion of the value of each method is framed around the elements of the established Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework.ConclusionSystems science methods can help researchers, public health decision makers, and program implementers to understand the complex factors influencing successful D&I of programs in community settings and to identify D&I challenges imposed by system complexity.

Use of standing orders for adult influenza vaccination a national survey of primary care physicians.

BACKGROUND Influenza vaccination of adults remains below recommended levels. Standing orders programs (SOPs) that allow nonphysician medical staff to assess eligibility and administer vaccines without an individualized physicians order are a proven method to increase vaccination rates. However, recent data on their use are not available. PURPOSE Investigators surveyed primary care physicians nationwide in 2009 to assess factors related to awareness and use of SOPs. METHODS Using the AMA Master List, a stratified random sample of U.S. family physicians (n=820) and general internists (n=820) was selected to receive a mailed questionnaire. The inclusion criterion was providing primary care to adults in an office-based practice. The primary outcome measure, analyzed in 2010, was consistent use of SOPs. RESULTS The survey response rate was 67% (1015/1517). Forty-two percent of respondents who immunized adults in their practices reported consistent use of SOPs. Those physicians differed in several dimensions, including awareness of recommendations and regulations regarding SOPs for vaccines, size and type of practice, number and level of training of clinical staff, attributes of the staff. The two variables in logistic regression models that were associated with the highest likelihood of using SOPs were awareness of recommendations to use them (OR=3.0; 95% CI=2.2, 4.1) and agreement with their effectiveness (OR=2.7, 95% CI=1.9, 3.8). CONCLUSIONS Fewer than half of physicians report using SOPs for influenza vaccination, a number that is not much higher than it was about a decade ago. Approaches to increase use of SOPs are needed.

A Picture's Worth a Thousand Words: Engaging Youth in CBPR Using the Creative Arts

Background: Engaging youth and incorporating their unique expertise into the research process is important when addressing issues related to their health. Visual Voices is an arts-based participatory data collection method designed to work together with young people and communities to collaboratively elicit, examine, and celebrate the perspectives of youth. Objectives: To present a process for using the creative arts with young people as a participatory data collection method and to give examples of their perspectives on safety and violence. Methods: Using the creative arts, this study examined and illustrates the perspectives of how community factors influence safety and violence. Visual Voices was conducted with a total of 22 African-American youth in two urban neighborhoods. This method included creative arts-based writing, drawing, and painting activities designed to yield culturally relevant data generated and explored by youth. Qualitative data were captured through the creative content of writings, drawings, and paintings created by the youths as well as transcripts from audio recorded group discussion. Data was analyzed for thematic content and triangulated across traditional and nontraditional mediums. Findings were interpreted with participants and shared publicly for further reflection and utilization. Conclusion: The youth participants identified a range of issues related to community factors, community safety, and violence. Such topics included the role of schools and social networks within the community as safe places and corner stores and abandoned houses as unsafe places. Visual Voices is a creative research method that provides a unique opportunity for youth to generate a range of ideas through access to the multiple creative methods provided. It is an innovative process that generates rich and valuable data about topics of interest and the lived experiences of young community members.

Conceptual frameworks for developing and comparing approaches to improve adolescent motor-vehicle safety.

This paper presents practical frameworks for developing and comparing approaches to improve adolescent motor-vehicle safety by merging concepts from the fields of developmental psychology and injury prevention and combining these with elements of a policy-analysis approach. Together, these models offer conceptual foundations for identifying intervention strategies to prevent crashes, reduce injuries in crashes, and reduce the long-term consequences of crashes and crash-related injury. In addition to helping generate ideas for interventions, the model can be used for making decisions about alternative interventions through consideration of value criteria such as effectiveness, cost, freedom, equity, stigmatization, preferences, and both technologic and political feasibility. Using these models, multidisciplinary groups concerned with youth development, engineering, law enforcement, education, and policy development can find common ground in addressing the complex issue of teen driving safety and develop, in a systematic and rational manner, approaches tailored to the circumstances and values of the settings in which they work.