Training Child Care Inspectors to Deliver Health Messaging: A Quality Improvement Pilot Project.

Early childhood obesity is at epidemic proportions. Early child care providers have a unique opportunity to instill healthy eating and active living behaviors in children that can foster lifelong health. Academic-community partnerships that involve collaborations between child care centers, local public health departments, and universities provide one avenue to strengthening healthy eating and active living-related knowledge and skills among early child care providers. This quality improvement pilot intervention, titled Healthy Child Care Makes a Healthy Start, is one example of this type of collaboration. This quality improvement pilot project consisted of two complementary intervention components. Inspectors were trained to cofacilitate a strategic planning process with university researchers to help providers implement healthy eating and active living-related policy, system, and environment changes in their child care homes and centers. An average of five changes were implemented in participating child care locations. Inspectors also received training on health-related best practices and delivered 1-minute health messages to child care providers during routine inspection visits. This type of innovative partnership has the potential to leverage a currently existing relationship between child care providers and licensing and regulation inspectors and shift the relationship to include dissemination and implementation of health messaging in child care center and home settings.

Refinement of an educational toolkit to promote cervical cancer screening among Hispanic immigrant women in rural southern Georgia.

Cervical cancer incidence and mortality continue to affect Hispanic women in the U.S. disproportionately. Our project sought to refine a cervical cancer intervention designed for use by community health workers, or promotoras, in rural southern Georgia. We collaborated with Hispanic promotoras to refine a Spanish language educational flipchart featuring cervical cancer topic areas for use in screening promotion.

Salud es vida: development of a cervical cancer education curriculum for promotora outreach with Latina farmworkers in rural Southern Georgia.

We developed and evaluated a lay health worker curriculum intended to educate Hispanic farmworker women on cervical cancer, human papillomavirus (HPV), and the HPV vaccine. We pilot tested the curriculum in 2010 with 7 volunteer promotoras for readability, attractiveness, content, comprehension, cultural appropriateness, persuasion, structure and organization of lessons, balance between didactic and participatory activities, and ease of diffusion to community members. Peer-led cervical cancer prevention education is a practical option for low-income, Hispanic farmworker women in newer immigrant-receiving areas of the United States with fewer Spanish-speaking health professionals.

Eliminating inequities in health care: understanding perceptions and participation in an antiracism initiative.

Antiracism training for staff of health care institutions is a promising intervention strategy to address racial and ethnic disparities in health care. In 2001, Southern County Public Health Department (SCPHD) staff completed a mandatory Dismantling Racism (DR) training, and some continued with an optional DR process to challenge institutional racism within their agency. To explore factors influencing participation in optional DR activities (i.e., caucuses and Change Team), a process evaluation was conducted involving in-depth interviews with 28 SCPHD administrators and staff members, whose participation in the DR process varied. Findings demonstrate that familiarity with and receptiveness to the relationship between racism and health care inequities influenced participation in DR activities. Perceived relevance and impact of the DR process on the organization and staff were also major factors affecting participation. Improvements for implementing such efforts including the consideration of institutional power and other implications for addressing racial health care inequities through antiracism initiatives are discussed.

A community-based approach to translational research addressing breast cancer disparities.

Disparities in breast cancer survival rates suggest that biological processes contribute. Translational research addressing health disparities would benefit from using a community-based participatory approach (CBPR) to examine biological processes commonly seen as the proximal causes of illness as well as behavioral and social-ecological "causes of the causes" within an integrated conceptual framework. This paper describes a CBPR study that explored perceptions regarding breast cancer relevant behaviors, and the application of the study's results to develop translational research. Data from eight focus groups of African American (n = 29) and Caucasian women (n = 27) were analyzed, using the framework of the social-ecological model. Nutrition and physical activity were valued over screening and research participation. Treatment of illness was emphasized over prevention. Women's perspectives are presented within a framework that facilitated the collaborative development of translational research to examine associations among biological, behavioral, and societal processes contributing to disparities.

Considering organizational factors in addressing health care disparities: two case examples.

Policy makers and practitioners have yet to successfully understand and eliminate persistent racial differences in health care quality. Interventions to address these racial health care disparities have largely focused on increasing cultural awareness and sensitivity, promoting culturally competent care, and increasing providers' adherence to evidence-based guidelines. Although these strategies have improved some proximal factors associated with service provision, they have not had a strong impact on racial health care disparities. Interventions to date have had limited impact on racial differences in health care quality, in part, because they have not adequately considered or addressed organizational and institutional factors. In this article, we describe an emerging intervention strategy to reduce health care disparities called dismantling (undoing) racism and how it has been adapted to a rural public health department and an urban medical system. These examples illustrate the importance of adapting interventions to the organizational and institutional context and have important implications for practitioners and policy makers.

A structural approach to examining prostate cancer risk for rural southern African American men.

Physical, cultural, and social factors influence health risk and behavior, but few have explored how the environmental context affects African American men's prostate cancer screening and treatment. This paper describes a structural analysis of data from eight focus groups of rural, southern African American men (n=66). A structural approach highlights the interrelationships between individuals, the health service system, and community factors that directly and indirectly affect screening and treatment for prostate cancer. The availability of accurate and timely health information and health services, social norms regarding health and professional help-seeking, and the sociopolitical context shaped men's screening and treatment behaviors. These proximal and distal health factors affected men's prostate cancer knowledge, perceived risk, willingness to seek care and trust in the health service system. The findings suggest that prostate cancer screening and treatment occurs in a larger structural context that has important implications for help-seeking and health promotion.

Dismantling institutional racism: theory and action.

Despite a strong commitment to promoting social change and liberation, there are few community psychology models for creating systems change to address oppression. Given how embedded racism is in institutions such as healthcare, a significant shift in the system's policies, practices, and procedures is required to address institutional racism and create organizational and institutional change. This paper describes a systemic intervention to address racial inequities in healthcare quality called dismantling racism. The dismantling racism approach assumes healthcare disparities are the result of the intersection of a complex system (healthcare) and a complex problem (racism). Thus, dismantling racism is a systemic and systematic intervention designed to illuminate where and how to intervene in a given healthcare system to address proximal and distal factors associated with healthcare disparities. This paper describes the theory behind dismantling racism, the elements of the intervention strategy, and the strengths and limitations of this systems change approach.

A comparison of two Native American Navigator formats: face-to-face and telephone.

The study was designed to test the relative effectiveness of a Navigator intervention delivered face-to-face or by telephone to urban Native American women. The effectiveness of the intervention was evaluated using a design that included a pretest, random assignment to face-to-face or telephone group, and posttest. The Social Cognitive Theory-based intervention was a tailored education program developed to address individual risk factors for breast cancer. At posttest, self-reported mammograms in the past year increased from 29% to 41.3% in the telephone group and from 34.4% to 45.2% in the face-to-face group. There was no difference in change from pretest to posttest between the telephone and face-to-face groups. Navigators can be effective in increasing adherence to recommendations for screening mammography among urban American Indian women.

The efficacy of tailored print materials in promoting colorectal cancer screening: results from a randomized trial involving callers to the National Cancer Institute's Cancer Information Service.

In this large randomized trial among callers to the Cancer Information Service (CIS), tailored print materials were tested for efficacy in promoting colorectal cancer (CRC) screening (fecal occult blood test [FOBT], flexible sigmoidoscopy, or colonoscopy). All participants completed baseline interviews at the end of their usual service calls to the CIS, as well as short-term (6-month) and longer-term (14-month) telephone follow-up interviews. The study sample (n = 4,014) was restricted to English-speaking CIS callers 50 + years of age, who would be eligible for CRC screening at 14 months follow-up and did not call the CIS about CRC or CRC screening. Four experimental conditions were compared: a single untailored (SU) mailout of print material (the control condition); a single tailored (ST) mailout of print material; four (multiple) tailored (MT) mailouts of print materials spanning 12 months, all of which were tailored to information obtained at baseline; and four (multiple) retailored (MRT) mailouts also spanning 12 months, with retailoring of the print materials (mailouts 2, 3, and 4) based on updated information obtained from the 6-month follow-up interviews. Consistent with the main hypothesis of this trial, a significant linear trend across the SU, ST, MT, and MRT groups was found at 14 months (42%, 44%, 51%, and 48%, respectively, p = 0.05). Only for MT was there a significant difference compared with SU (p = 0.03) for the sample as a whole, while no differences were found for MT vs. MRT at 14 months. Significant moderator effects in the predicted direction were found among females, younger participants, and among those with a history of CRC screening, all of which involved the SU vs. MT MRT comparisons. Only among younger participants (ages 50-59) was there a difference between SU vs. ST at 14 months. Given these results, we conclude from this trial the following: (1) the MRT intervention failed to show added benefit beyond the MT intervention, (2) the significant intervention effects involving the MT and MRT conditions can be explained by tailoring and/or the longitudinal nature of both interventions, and (3) the most compelling evidence in support of tailoring was found for the ST condition among younger participants, where a significant need for interventions exists at the national level. Directions for future research are discussed in light of the results summarized above.

Reaching those most in need: a review of diabetes self-management interventions in disadvantaged populations.

There has been increased recognition of the importance of developing diabetes self-management education (DSME) interventions that are effective with under-served and minority populations. Despite several recent studies in this area, there is to our knowledge no systematic review or synthesis of what has been learned from this research. An electronic literature search identified five formative evaluations and ten controlled DSME intervention trials focused on under-served (low-income, minority or aged) populations. The RE-AIM (Reach, Efficacy, Adoption, Implementation, Maintenance) evaluation framework was used to evaluate the controlled studies on the dimensions of reach, efficacy, adoption, implementation, and maintenance. Fifty percent of the studies identified reported on the percentage of patients who participated, and the percentages were highly variable. The methodological quality of the articles was generally good and the short-term results were encouraging, especially on behavioral outcomes. Data on adoption (representativeness of settings and clinicians who participate) and implementation were almost never reported. Studies of modalities in addition to group meetings are needed to increase the reach of DSME with under-served populations. The promising formative evaluation work that has been conducted needs to be extended for more systematic study of the process of intervention implementation and adaptation with special populations. Studies that explicitly address the community context and that address multiple issues related to public health impact of DSME interventions are recommended to enhance long-term results.