Practicing Hope: Enhancing Empowerment in Primary Health Care through Community-based Participatory Research.

The World Health Organization's (WHO's) Declaration of Alma Ata in 1978 made Primary Health Care (PHC) the official health policy of all WHO member countries, stressing the importance of multisectoral collaboration and community empowerment as critical for delivering quality primary healthcare and public health services to achieve social justice and health equity. Over forty years later, a divide remains between seeing individual patients in the traditional biomedical model and addressing population-level social determinants of health. One promising approach for the intentional and active integration of multi-sectoral partnering practices and community empowerment into Primary Health Care is the use of community-based participatory research (CBPR). The power of CBPR lies in its systematic approach to facilitating equitable collaboration of partners based on community priorities and strengths and is increasingly recognized for improving health equity outcomes. This paper highlights the use of CBPR as a promising practice for healthcare organizations to bridge the gap between the traditional individual patient focus and the comprehensive primary healthcare approach from WHO. We use a narrative case study from A Ministry of Sharing (AMOS) Health and Hope, a PHC organization in Nicaragua, to illustrate the use of the CBPR model as an implementation framework that facilitated the transformation of structures, policies, and practices as AMOS created multi-sector partnerships and embraced community empowerment as part of its strategic and comprehensive approach to health equity.

Leveraging Arts for Justice, Equity, and Public Health: The Skywatchers Program and Its Implications for Community-Based Health Promotion Practice and Research.

Arts have long addressed the conditions that cause ill health, such as poverty, social inequality, and structural racism, and have recently taken on increased significance for public health. This article illuminates the potential for cross-sector collaboration between community-based health promotion and community-engaged arts to address the social determinants of health and build neighborhood assets at multiple levels of the social-ecological model. It features Skywatchers, a collaborative community arts ensemble of artists and residents of the culturally rich but economically poor Tenderloin neighborhood in San Francisco, California, and its original values-based "relational, durational, conversational, and structural" methodology focused on process over product and leveraging arts for justice and equity. Now, 10 years into its work, Skywatchers offers lessons about building reciprocal relationships, cocreating artworks, and promoting arts-based advocacy to improve the conditions that foster poor health in the neighborhood. The article discusses implications for community-based health promotion practice that delineate commitments and challenges shared between the two fields, their distinct roles and tools, and the potential for more widespread partnerships. It concludes with implications for policy and advocacy and a vision for expanded community-based participatory research to better understand the impact of arts on community health and well-being.

A Participatory, Mixed Methods Approach to Define and Measure Partnership Synergy in Long-standing Equity-focused CBPR Partnerships.

Understanding what contributes to success of community-based participatory research (CBPR) partnerships is essential to ensuring their effectiveness in addressing health disparities and health inequities. Synergy, the concept of accomplishing more together than separately, is central to partnership effectiveness. However, synergy specific to long-standing, equity-focused CBPR partnerships has not been closely examined. To address this, we defined and developed measures of partnership synergy as one dimension of a participatory mixed methods study, Measurement Approaches to Partnership Success (MAPS), to develop a validated instrument to measure success in long-standing CBPR partnerships. Framed by a conceptual model and scoping literature review, we conducted in-depth interviews with a national panel of academic and community experts in CBPR and equity to develop partnership synergy measures. Items were refined through an iterative process, including a three-stage Delphi process, comparison with existing measures, cognitive interviews, and pilot testing. Seven questionnaire items were developed to measure synergy arising from equitable partnerships bringing together diverse partners across power differences to promote equity. Defining and measuring synergy in the context of long-standing partnership success is central to understanding the role of synergy in collaborative approaches to research and action and can strengthen CBPR partnerships to promote healthy communities and advance health equity.

Seizing the Moment: Policy Advocacy to End Mass Incarceration in the Time of COVID-19.

The mass human and economic casualties wrought by the COVID-19 pandemic laid bare the deep inequities at the base of the disproportionate losses and suffering experienced by diverse U.S. populations. But the urgency and enormity of unmet needs requiring bold policy action also provided a unique opportunity to learn from and partner with community-based organizations that often are at the frontlines of such work. Following a review of Kingdon's model of the policy-making process, we illustrate how a partnership in a large California county navigated the streams in the policy-making process and used the window of opportunity provided by the pandemic to address a major public health problem: the incarceration of over 2 million people, disproportionately African American and Latinx, in overcrowded, unsafe jails, prisons, and detention centers. We highlight tactics and strategies used, challenges faced, and implications for health educators as policy advocates during and beyond the pandemic.

Growing Equity and Health Equity in Perilous Times: Lessons From Community Organizers.

Although a growing body of evidence underscores the contributions of community-based participatory research, community coalitions and other community engagement approaches to addressing health equity, one of the most potent forms of engagement-community organizing-has attracted far less attention in our field. Yet, organizing by and for communities, to build power, select issues, develop and use strategies, and take action to address the goals they collectively have set, may offer important lessons for public health professionals in these fraught times. We share, largely in their own words, the experiences and reflections of ~140 grassroots organizers across the United States who attended regional convenings of organizers in 2017, planned and run by four leading community capacity and base-building organizations, and where diverse organizers shared strategies that work, challenges faced, and the deep concerns among their already often disenfranchised communities in the contemporary sociopolitical and cultural context. After briefly reviewing some of community organizing's core tenets and complexities, we share our qualitative research methods and key findings about the primary cross-regional concerns raised (mass incarceration, voter suppression, and immigrant rights), the themes that emerged (e.g., centering leadership by women of color and of using a health lens to frame community issues), as well as the challenges faced (e.g., the retraumatization often experienced by organizers and the difficulties in building alliances between groups "that have been taught to distrust each other"). We conclude by discussing how many of the promising practices and lessons shared by the community organizers might enhance our own field's health equity-focused efforts, particularly if we take seriously one of their most bedrock messages: that there can be no health equity without racial equity and social justice, and that to get to health equity, we must first address equity writ large, particularly in troubling times.

Learning From Coalitions' Efforts to Promote Equity and Justice.

Coalitions and collaboratives are working to address many of the most pressing contemporary health and social issues. The articles in this special issue provide numerous insights into these complex collaborative processes across different contexts and focal issues. All emphasize and scrutinize the strategies that groups are using in their work. These strategies seek to navigate not only conventional notions of effectiveness but also the challenges of pursuing greater equity and justice. In this concluding article, we distill some of the key insights from these articles as a collective. This special issue on collaborating for equity and justice can serve as a launching point for new efforts by coalitions and researchers pursuing policy, systems, and structural changes, particularly those intent on addressing root causes of health and social disparities.

Healthy Retail as a Strategy for Improving Food Security and the Built Environment in San Francisco.

In low-income neighborhoods without supermarkets, lack of healthy food access often is exacerbated by the saturation of small corner stores with tobacco and unhealthy foods and beverages. We describe a municipal healthy retail program in San Francisco, California, focusing on the role of a local coalition in program implementation and outcomes in the city's low income Tenderloin neighborhood. By incentivizing selected corner stores to become healthy retailers, and through community engagement and cross-sector partnerships, the program is seeing promising outcomes, including a "ripple effect" of improvement across nonparticipating neighborhood stores.

Retailers' perspectives on selling tobacco in a low-income San Francisco neighbourhood after California's $2 tobacco tax increase.

BACKGROUND: California's tobacco tax increased by $2.00 per pack in 2017. Although such increases are among the most effective tobacco control strategies, little is known about their impact from the perspective of corner store owners in low-income neighbourhoods with high concentrations of tobacco outlets. METHODS: We interviewed 38 corner store owners and managers in San Francisco's Tenderloin, the district with the city's highest tobacco outlet density, 60-90 days following implementation of the tax increase. Questions focused on perceptions of the impact of the higher tobacco tax on their revenues, customers and tobacco company promotions. We used qualitative content analysis to identify, compare and reconcile key themes. RESULTS: Most retailers reported a decline in cigarette sales, with customers buying fewer cigarettes, switching to cheaper brands or other products like marijuana, or trying to quit smoking. Retailers described challenges associated with running a small business and selling tobacco and concerns about selling a product that is 'bad' for customers' health. Contrary to expectation, tobacco companies appeared to be offering few product promotions in this neighbourhood. CONCLUSIONS: Small, independent retailers' concerns, about selling tobacco and about the health and well-being of customers, suggest that such retailers may be important allies in tobacco control efforts,particularly those focused on the point-of-sale.

Merchant Attitudes Toward a Healthy Food Retailer Incentive Program in a Low-Income San Francisco Neighborhood.

In low-income urban communities across the United States and globally, small stores frequently offer processed foods, sodas, alcohol, and tobacco but little access to healthy products. To help address this problem, the city of San Francisco created a healthy food retailer incentive program. Its success depends, in part, on retailers' willingness to participate. Through in-person interviews, we explored attitudes toward the program among store owners or managers of 17 nonparticipating stores. Eleven merchants were uninterested in the program due to negative past experiences trying to sell healthier products, perceived lack of customer demand, and fears that meeting program requirements could hurt profits. Six merchants expressed interest, seeing demand for or opportunity in healthy foods, foreseeing few difficulties in meeting program requirements, and regarding the assistance offered as appealing. Other municipalities considering such interventions should consider merchants' perspectives, and how best to challenge or capitalize on retailers' previous experiences with selling healthy foods.

Bringing Healthy Retail to Urban "Food Swamps": a Case Study of CBPR-Informed Policy and Neighborhood Change in San Francisco.

In urban "food swamps" like San Francisco's Tenderloin, the absence of full-service grocery stores and plethora of corner stores saturated with tobacco, alcohol, and processed food contribute to high rates of chronic disease. We explore the genesis of the Tenderloin Healthy Corner Store Coalition, its relationship with health department and academic partners, and its contributions to the passage and implementation of a healthy retail ordinance through community-based participatory research (CBPR), capacity building, and advocacy. The healthy retail ordinance incentivizes small stores to increase space for healthy foods and decrease tobacco and alcohol availability. Through Yin's multi-method case study analysis, we examined the partnership's processes and contributions to the ordinance within the framework of Kingdon's three-stage policymaking model. We also assessed preliminary outcomes of the ordinance, including a 35% increase in produce sales and moderate declines in tobacco sales in the first four stores participating in the Tenderloin, as well as a "ripple effect," through which non-participating stores also improved their retail environments. Despite challenges, CBPR partnerships led by a strong community coalition concerned with bedrock issues like food justice and neighborhood inequities in tobacco exposure may represent an important avenue for health equity-focused research and its translation into practice.

Improving Latino Youths' Environmental Health Literacy and Leadership Skills Through Participatory Research on Chemical Exposures in Cosmetics: The HERMOSA Study.

To increase environmental health literacy (EHL) and leadership skills in Latino youth in Salinas, CA., we worked from 2012-2015 with 15 members of the CHAMACOS Youth Community Council (YCC), an outreach arm of a longitudinal study of impacts of environmental chemicals on children's health. The YCC program provided hands-on research experiences related to Endocrine Disrupting Chemicals (EDCs) in cosmetics and their possible health effects. We use participatory research principles and Bloom's Taxonomy of Educational Objectives to describe the development of EHC and leadership in the youth co-researchers. Using data from multiple qualitative sources, we explore the youths' engagement in a wide range of research and action processes. Promising outcomes, including perceptions of improved youth self-esteem, EHL, leadership, and career orientation are discussed, as are challenges, such as time constraints and high priority youth concerns not addressed by the study. Implications for other youth-engaged participatory science and leadership programs are presented.

A community-engaged infection prevention and control approach to Ebola.

The real missing link in Ebola control efforts to date may lie in the failure to apply core principles of health promotion: the early, active and sustained engagement of affected communities, their trusted leaders, networks and lay knowledge, to help inform what local control teams do, and how they may better do it, in partnership with communities. The predominant focus on viral transmission has inadvertently stigmatized and created fear-driven responses among affected individuals, families and communities. While rigorous adherence to standard infection prevention and control (IPC) precautions and safety standards for Ebola is critical, we may be more successful if we validate and combine local community knowledge and experiences with that of IPC medical teams. In an environment of trust, community partners can help us learn of modest adjustments that would not compromise safety but could improve community understanding of, and responses to, disease control protocol, so that it better reflects their 'community protocol' (local customs, beliefs, knowledge and practices) and concerns. Drawing on the experience of local experts in several African nations and of community-engaged health promotion leaders in the USA, Canada and WHO, we present an eight step model, from entering communities with cultural humility, though reciprocal learning and trust, multi-method communication, development of the joint protocol, to assessing progress and outcomes and building for sustainability. Using examples of changes that are culturally relevant yet maintain safety, we illustrate how often minor adjustments can help prevent and treat the most serious emerging infectious disease since HIV/AIDS.

The Collective Impact Model and Its Potential for Health Promotion: Overview and Case Study of a Healthy Retail Initiative in San Francisco.

As resources for health promotion become more constricted, it is increasingly important to collaborate across sectors, including the private sector. Although many excellent models for cross-sector collaboration have shown promise in the health field, collective impact (CI), an emerging model for creating larger scale change, has yet to receive much study. Complementing earlier collaboration approaches, CI has five core tenets: a shared agenda, shared measurement systems, mutually reinforcing activities, continuous communication, and a central infrastructure. In this article, we describe the CI model and its key dimensions and constructs. We briefly compare CI to community coalition action theory and discuss our use of the latter to provide needed detail as we apply CI in a critical case study analysis of the Tenderloin Healthy Corner Store Coalition in San Francisco, California. Using Yin's multimethod approach, we illustrate how CI strategies, augmented by the community coalition action theory, are being used, and with what successes or challenges, to help affect community- and policy-level change to reduce tobacco and alcohol advertising and sales, while improving healthy, affordable, and sustainable food access. We discuss the strengths and weaknesses of CI as a framework for health promotion, as well as the benefits, challenges, and initial outcomes of the healthy retail project and its opportunities for scale-up. Implications for health promotion practice and research also are discussed.

Labor unions: a public health institution.

Using a social-ecological framework, we drew on a targeted literature review and historical and contemporary cases from the US labor movement to illustrate how unions address physical and psychosocial conditions of work and the underlying inequalities and social determinants of health. We reviewed labor involvement in tobacco cessation, hypertension control, and asthma, limiting articles to those in English published in peer-reviewed public health or medical journals from 1970 to 2013. More rigorous research is needed on potential pathways from union membership to health outcomes and the facilitators of and barriers to union-public health collaboration. Despite occasional challenges, public health professionals should increase their efforts to engage with unions as critical partners.

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.