A Pipeline Program to Address the South African Crisis in Human Resources for Health.

BACKGROUND: The WHO Africa Region faces a shortage of health workers due to inadequate production of health workers and emigration of physicians and nurses to wealthier countries. South Africa and the United States share a history of discriminatory policies and practices resulting in groups that are under-represented amongst health professionals. One US response is the Area Health Education Centers Program (AHEC), a pipeline program to recruit members of under-represented groups into the health professions. OBJECTIVES: (1) Compare and contrast the United States' AHEC model with that developed in South Africa by Stellenbosch University Faculty of Medicine and Health Sciences SA AHEC in partnership with Morehouse School of Medicine in the United States. (2) Describe a formative evaluation of the Stellenbosch AHEC Program. Methods: Four hundred students (grades 7-12) and 150 teachers participated in SA AHEC with the goal of preparing the students to better compete for university admission. Students received after-school tutoring, holiday schools, and counselling on study skills, health careers, and university entry. Educators received continuing professional education, classroom observation, and feedback. The program was evaluated through a series of interviews and focus groups involving AHEC staff, educators, and parents and caregivers. RESULTS: Program strengths included educator training, collaboration, and increased student maturity, motivation, and academic success. Challenges included limited time with students, the location of some sites, and the educators' need for more engagement with AHEC staff and schools. Quarterly workshops were conducted to address challenges. Over 50% of program alumni are currently enrolled in institutions of higher education. Students will be tracked to determine whether they are able to complete their health professions studies and return to the communities where they grew up, or to similar communities. CONCLUSIONS: With appropriate adaptation and attention to context, it might be possible to implement similar programmes in other African countries. The comparison of the United States and South African models suggested that more parent and teacher participation in an advisory capacity might help to avoid some challenges.

Racial and ethnic disparities in smoking prevalence in Israel and the United States: progress to date and prospects for the future.

An article in this journal in 2016 demonstrated that smoking prevalence among Arab men in Israel is greater than among their Jewish counterparts born in Israel, while the reverse is true among Arab and Jewish Israeli women. This is reflected in lung cancer mortality rates. In the U.S., smoking prevalence in the mid-1960s was 20% higher in African American men than in white men, but has since decreased in both groups, and smoking prevalence in the two groups is now nearly identical. The black-white disparity in lung cancer mortality rates has been reduced by more than half as compared to its zenith in the early 1990s. The strategies employed to achieve these gains will continue to be important going forward, and successful strategies employed in Israel in addressing smoking in the male Arab population will be of increasing interest in the U.S. as its Arab population increases.

Social networks as predictors of colorectal cancer screening in African Americans.

BACKGROUND: Early detection can reduce colorectal cancer (CRC) mortality by 15%-33%, and screening is widely recommended for average-risk adults beginning at age 50 years. Colorectal cancer mortality rates are higher in African Americans than in whites, while screening rates are somewhat lower. Individual social networks can reduce emotional and/or logistical barriers to health-promoting but distasteful procedures such as CRC screening. The aim of this study was to examine social network interactions, and their impact on CRC screening among African Americans. We hypothesized a positive association between social network index (SNI) scores and CRC screening. METHODS: In a community intervention trial with four arms, we previously demonstrated the efficacy of a small group educational intervention to promote CRC screening among African Americans. This intervention outperformed a one-on-one educational intervention, a reduced out-of-pocket expense intervention, and a control condition. In the present analysis, we compared the SNI scores for participants in the small group intervention cohort with a comparison group comprised of the other three cohorts. Social networks were assessed using the Social Network Index developed by Cohen. RESULTS: Small group participants had a significantly higher network diversity score (Mean difference 0.71; 95% CI, 0.12-1.31; p=0.0017) than the comparison group. In the second component of the SNI score - the number of people talked to over a two week period - the small group intervention cohort also scored significantly higher than the comparison group. (Mean difference, 9.29; 95% CI, 3.963-14.6266; p=0.0004). CONCLUSIONS: The findings suggest that social interaction and support was at least partially responsible for the relatively high post-intervention screening rate in the small group intervention participants. Education in small groups could foster strong social networks. Strong and positive network diversity and a large number of people in social networks may enhance CRC screening rates among African Americans.

Persons Who Failed to Obtain Colorectal Cancer Screening Despite Participation in an Evidence-Based Intervention.

In a previous report, we demonstrated the efficacy of an educational intervention focused on increasing colorectal cancer screening rates among African Americans. Despite participating in the intervention, however, nearly two-thirds of participants did not seek and receive screening. Participants were African-Americans over age 49 (N = 257) who had not been screened for colorectal cancer according to guidelines. At baseline, participants completed tests measuring fatalism, perceived stress, self-esteem, attitudes/benefits/barriers, social support, and social network diversity. Those who completed the educational intervention were followed up by telephone to learn if they had been screened. We compared the scores on the psychometric tests of the participants who had been screened against the scores of those who had not. Only the mean scores on the attitudes, benefits, and barriers scale distinguished participants who had been screened from those who had not (p = 0.0816 on bivariate testing and p = 0.0276 in the logistic regression model). Social interaction among participants or social cognitive learning may have played a role in determining which participants were screened, but we were not able to demonstrate this. The major factor distinguishing participants who were not screened was their attitude toward screening at baseline. There is a subset of African Americans who are persistently resistant to screening, and their perspective in this regard must be addressed if colorectal cancer disparities are to be reduced.

Reducing Disparities by way of a Cancer Disparities Research Training Program.

BACKGROUND: For minority populations, there is a continuing disparity in the burden of death and illness from cancer. Research to address this disparity should be conducted by investigators who can best understand and address the needs of culturally diverse communities. However, minorities are under-represented in health-related research. The goal of this project was to develop and evaluate an approach to motivating and preparing master's degree students for careers dedicated to cancer disparities research. METHOD: A Cancer Disparities Research Training Program (CDRTP) was initiated in 2010. The program consists of coursework, practicum experiences, and research opportunities. Assessment of the curriculum is based on monitoring achievement of evaluation indicators and included a mixed-method approach with included both quantitative and qualitative approach. RESULTS: In its first three years, the program graduated 20 trainees, all of whom were minorities (18 African Americans and two Asians). When asked about career goals, two-thirds of the trainees indicated interest in pursuing careers in research in cancer prevention and control. The trainees expressed high satisfaction with the courses, instructor, materials, and curriculum. Although trainees had suggestions about course details, evaluations overall were positive. Across focus groups, three recurrent themes emerged regarding activities to enhance the trainee experience: having a wider variety of topics, more guest speakers, and field trips. CONCLUSION: The CDRTP was intended to recruit students - primarily African Americans - into research on prevention and control of cancer disparities. Although final evaluation of the program's overall outcome will not be available for several years, this preliminary evaluation indicates early program success.

Toward the Elimination of Colorectal Cancer Disparities Among African Americans.

BACKGROUND: In the USA, race and socioeconomic status are well-known factors associated with colorectal cancer incidence and mortality rates. These are higher among blacks than whites and other racial/ethnic groups. METHODS: In this article, we review opportunities to address disparities in colorectal cancer incidence, mortality, and survivorship among African Americans. RESULTS: First, we summarize the primary prevention of colorectal cancer and recent advances in the early detection of the disease and disparities in screening. Then, we consider black-white disparities in colorectal cancer treatment and survival including factors that may contribute to such disparities and the important roles played by cultural competency, patient trust in one's physician, and health literacy in addressing colorectal cancer disparities, including the need for studies involving the use of colorectal cancer patient navigators who are culturally competent. CONCLUSION: To reduce these disparities, intervention efforts should focus on providing high-quality screening and treatment for colorectal cancer and on educating African Americans about the value of diet, weight control, screening, and treatment. Organized approaches for delivering colorectal cancer screening should be accompanied by programs and policies that provide access to diagnostic follow-up and treatment for underserved populations.

Lessons Learned from Three Models that Use Small Grants for Building Academic-Community Partnerships for Research.

Despite the direct contribution of community-engaged research towards effective translation, establishing strong and sustained community academic research partnerships remains a challenge. The Atlanta Clinical and Translational Science Institute's Community Engagement Research Program (CERP) has developed and implemented three models for using small grants to seed new community academic partnerships for research: 1) community-initiated health projects with faculty partners, 2) dissemination of discoveries to community partners, and 3) building collaborative research capacity. In this paper, we describe each model in terms of its purpose, funding level, funding period, proposal requirements, selection criteria and faculty involvement. Resulting partnerships are described, along with benefits and challenges from faculty and community perspectives, and lessons learned in using these mechanisms to promote community-engaged research. These models may aid others attempting to promote community-engaged research for the purpose of narrowing the gap between research, practice and ultimately, impact on community health.

Exploration of barriers and facilitators to publishing local public health findings: A mixed methods protocol.

BACKGROUND: Worldwide, the US accounts for a large proportion of journals related to public health. Although the American Public Health Association (APHA) includes 54 affiliated regional and state associations, little is known about their capacity to support public health scholarship. The aim of this study is to assess barriers and facilitators to operation of state journals for the dissemination of local public health research and practices. METHODS: A mixed methods approach will be used to complete the 12-month study. Affiliate websites will be accessed through the APHA membership portal to evaluate organizational infrastructure and ascertain the presence/absence of a journal. The leader of each affiliate will be contacted via email containing a link to a 12-question on-line survey to collect his/her perceptions of scholarly journals and the publication of local health data. To determine barriers and facilitators to publication of local public health findings, 30-minute semi-structured telephone interviews will focus on the infrastructure of the association, perceptions of the leader about the journal (if in place), and its operation. ANTICIPATED RESULTS: We anticipate that 54 affiliate websites will be reviewed to complete the extraction checklist, that 74% of affiliate leaders will respond to the survey, and that 11 semi-structured interviews will be conducted. A limited number of state/regional public health associations will operate journals and a small percentage of those without journals may express an interest in implementing them. Barriers to operation of journals may include lack of resources (i.e., personnel, funding), and low prioritization of publication of state and local public health findings. Facilitators may include strong affiliate-academic relationships, affiliate leadership with experience in publications, and affiliate relationships with state and local departments of health. CONCLUSIONS: The research proposed in this protocol may stimulate other state public health associations and other academic public health programs to follow suit; it would not be the first time that an observational research study served as an intervention.

Community-based participatory research principles for the African American community.

BACKGROUND: Numerous sets of principles have been developed to guide the conduct of community-based participatory research (CBPR). However, they tend to be written in language that is most appropriate for academics and other research professionals; they may not help lay people from the community understand CBPR. METHODS: Many community members of the National Black Leadership Initiative on Cancer assisting with the Educational Program to Increase Colorectal Cancer Screening (EPICS) had little understanding of CBPR. We engaged community members in developing culturally-specific principles for conducting academic-community collaborative research. RESULTS: We developed a set of CBPR principles intended to resonate with African-American community members. CONCLUSIONS: Applying NBLIC-developed CBPR principles contributed to developing and implementing an intervention to increase colorectal cancer screening among African Americans.

Prostate Cancer Screening and Mortality in Blacks and Whites: A Hospital-based Case-Control Study.

BACKGROUND: Prostate cancer incidence and mortality are substantially higher in Black than in white men. Prostate cancer screening remains controversial. This study was conducted to assess the impact of, and racial differences in, prostate cancer screening on prostate cancer mortality. METHODS: This was a case-control study of Black and White men in eight hospitals. Cases were deaths related to prostate cancer; controls were hospital-based subjects that were frequency-matched to cases based on age and race. Multivariable logistic regression was used to test the association between screening and prostate cancer mortality. RESULTS: Cases had fewer PSA (prostate-specific antigen) tests than controls (1.73 vs. 3.98, p<0.001). White controls had higher rates of PSA tests than other sub-groups. There was no difference in PSA testing between Black cases and controls. Mean co-morbidity was 10.3 in cases and 2.63 in controls. Prostate cancer mortality was 55 to 57% lower among the screened persons. Individuals who died of prostate cancer related causes were less likely to have received PSA testing (OR=0.65; 95% Cl 0.56-0.75). CONCLUSIONS: The odds of dying from prostate cancer were lower among white men receiving screening tests. Having less co-morbidity was associated with lower odds of mortality in both races. This study raises the possibility that screening for prostate cancer with the PSA test may be more effective in white than in Black men.

An academic-public health department partnership for education, research, practice, and governance.

Public health departments and medical schools are often disconnected, yet each has much to offer the other. There are 4 areas in which the 2 entities can partner; in Atlanta, Georgia, the Morehouse School of Medicine (particularly its Prevention Research Center or PRC) and the Fulton County Department of Health and Wellness have demonstrated partnership in each area. With respect to teaching, the 2 have collaborated on clerkships for medical students and rotations for preventive medicine residents. In research, Morehouse faculty and health department staff have worked together on projects. In service, the 2 entities have been able to put into practice interventions developed through their joint research efforts. In governance, the health department has a representative on the PRC board, while the PRC principal investigator serves on the Fulton County Board of Health. Benefits have accrued to both entities and to the communities that they serve.

Black white disparities in receiving a physician recommendation for colorectal cancer screening and reasons for not undergoing screening.

There is consensus that all adults over 50 years of age, regardless of gender, race, or ethnicity, should receive a physician recommendation for colorectal cancer (CRC) screening. Disparities in CRC screening result in poorer health outcomes for blacks than for whites. The purpose of this study was to determine whether there are black-white differences in receiving a physician recommendation for CRC screening and reasons for undergoing screening. With 12,729 U.S. adults ages 50 to 74 included in the analysis, Whites were more likely than blacks to report receiving a physician recommendation for CRC screening. Based on age-adjusted odds ratio, one out of three blacks were less likely to report receiving a CRC screening recommendation from their physician (OR=0.68, 95% CI 0.57,0.81). This association persisted after adjusting for socioeconomic and other health-related factors (OR=0.61; 95% CI 0.53,0.71). This study suggests that additional steps need to be taken to reduce cancer health disparities.

Efficacy to effectiveness transition of an Educational Program to Increase Colorectal Cancer Screening (EPICS): study protocol of a cluster randomized controlled trial.

BACKGROUND: African Americans have the highest incidence and mortality and are less likely than whites to have been screened for colorectal cancer (CRC). Many interventions have been shown to increase CRC screening in research settings, but few have been evaluated specifically for use in African-American communities in real world settings. This study aims to identify the most efficacious approach to disseminate an evidence-based intervention in promoting colorectal screening in African Americans and to identify the factors associated with its efficacy. METHODS/DESIGN: In this study, investigators will recruit 20 community coalitions and 7,200 African-Americans age 50 to 74 to test passive and active approaches to disseminating the Educational Program to Increase Colorectal Cancer Screening (EPICS); to measure the extent to which EPICS is accepted and the fidelity of implementation in various settings and to estimate the potential translatability and public health impact of EPICS. This four-arm cluster randomized trial compares the following implementation strategies: passive arms, (web access to facilitator training materials and toolkits without technical assistance (TA) and (web access, but with technical assistance (TA); active arms, (in-person access to facilitator training materials and toolkits without TA and (in-person access with TA). Primary outcome measures are the reach (the proportion of representative community coalitions and individuals participating) and efficacy (post-intervention changes in CRC screening rates). Secondary outcomes include adoption (percentage of community coalitions implementing the EPICS sessions) and implementation (quality and consistency of the intervention delivery). The extent to which community coalitions continue to implement EPICS post-implementation (maintenance) will also be measured. Cost-effectiveness analysis will be conducted. DISCUSSION: Implementing EPICS in partnership with community coalitions, we hypothesized, will result in more rapid adoption than traditional top-down approaches, and resulting changes in community CRC screening practices are more likely to be sustainable over time. With its national reach, this study has the potential to enhance our understanding of barriers and enablers to the uptake of educational programs aimed at eliminating cancer disparities. TRIAL REGISTRATION: http://www.ClinicalTrials.gov NCT01805622.

Community health workers support community-based participatory research ethics: lessons learned along the research-to-practice-to-community continuum.

Ethical principles of community-based participatory research (CBPR)--specifically, community engagement, mutual learning, action-reflection, and commitment to sustainability--stem from the work of Kurt Lewin and Paulo Freire. These are particularly relevant in cancer disparities research because vulnerable populations are often construed to be powerless, supposedly benefiting from programs over which they have no control. The long history of exploiting minority individuals and communities for research purposes (the U.S. Public Health Service Tuskegee Syphilis Study being the most notorious) has left a legacy of mistrust of research and researchers. The purpose of this article is to examine experiences and lessons learned from community health workers (CHWs) in the 10-year translation of an educational intervention in the research-to-practice-to-community continuum. We conclude that the central role played by CHWs enabled the community to gain some degree of control over the intervention and its delivery, thus operationalizing the ethical principles of CBPR.

The Southeastern U.S. Collaborative Center of Excellence in the Elimination of Disparities (SUCCEED): reducing breast and cervical cancer disparities for African American women.

This supplement highlights the efforts of Morehouse School of Medicine's Prevention Research Center and its partners to reduce the disparities experienced by African American women for breast and cervical cancer in Georgia, North Carolina and South Carolina. The project (entitled the Southeastern U.S. Collaborative CEED, or SUCCEED) is supported by a Centers for Disease Control and Prevention (CDC) grant to establish a Center of Excellence in the Elimination of Disparities (CEED). This introductory paper provides an overview describing the project's goals and core components and closes by introducing the adjoining papers that describe in more detail these components. The program components for SUCCEED include providing training and technical assistance for implementing evidence-based interventions for breast and cervical cancer; supporting capacity-building and sustainability efforts for community-based organizations; promoting the establishment of new empowered community coalitions and providing advocacy training to cancer advocates in order to affect health systems and policies.

Driving to better health: cancer and cardiovascular risk assessment among taxi cab operators in Chicago.

While a number of investigations of the health of taxi cab drivers have been conducted in Europe, Asia, and Africa, virtually none have been conducted in the United States. We undertook a survey of taxi cab operators in the Chicago area to understand better their health status and health promotion practices. The survey was completed by a convenience sample of 751 Chicago taxi drivers. Taxi drivers had low rates of insurance coverage, fruit and vegetable consumption, and physical activity compared with the general Chicago population. Participation in cancer screening tests was also lower for this group. A high proportion of taxi drivers are immigrants. They tend to be highly educated and report a readiness to engage in more health-promoting behaviors. Further research is needed to develop a targeted intervention for this population.

Operationalization of community-based participatory research principles: assessment of the national cancer institute's community network programs.

OBJECTIVES: We examined how National Cancer Institute-funded Community Network Programs (CNPs) operationalized principles of community-based participatory research (CBPR). METHODS: We reviewed the literature and extant CBPR measurement tools. On the basis of that review, we developed a 27-item questionnaire for CNPs to self-assess their operationalization of 9 CBPR principles. Our team comprised representatives of 9 of the National Cancer Institute's 25 CNPs. RESULTS: Of the 25 CNPs, 22 (88%) completed the questionnaire. Most scored well on CBPR principles of recognizing community as a unit of identity, building on community strengths, facilitating colearning, embracing iterative processes in developing community capacity, and achieving a balance between data generation and intervention. CNPs varied in the extent to which they employed CBPR principles of addressing determinants of health, sharing power among partners, engaging the community in research dissemination, and striving for sustainability. CONCLUSIONS: Although the development of assessment tools in this field is in its infancy, our findings suggest that fidelity to CBPR processes can be assessed in a variety of settings.

Faith-based partnerships in graduate medical education: the experience of the Morehouse School of Medicine Public Health/Preventive Medicine Residency Program.

Faith-based organizations can be strategic partners in addressing the needs of low-income and underserved individuals and communities. The Morehouse School of Medicine (MSM) Public Health/Preventive Medicine Residency Program (PH/PMR) collaborates with faith-based organizations for the purpose of resident education, community engagement, and service. These partners provide guidance for the program's community initiatives and health promotion activities designed to address health inequities. Residents complete a longitudinal community practicum experience with a faith-based organization over the 2-year training period. Residents conduct a community health needs assessment at the organization and design a health intervention that addresses the identified needs. The faith-based community practicum also serves as a vehicle for achieving skills in all eight domains of the Public Health Competencies developed by the Council on Linkages and all six Accreditation Council for Graduate Medical Education (ACGME) Core Competencies. The MSM PH/PMR Program has engaged in faith-based partnerships for 7 years. This article discusses the structure of these partnerships, how partners are identified, funding sources for supporting resident projects, and examples of resident health needs assessment and intervention activities. The MSM PH/PMR Program may serve as a model to other residency and fellowship programs that may have an interest in developing partnerships with faith-based organizations.

Innovative ways of integrating public health into the medical school curriculum.

This is one of six short papers that describe additional innovations to help integrate public health into medical education; these were featured in the "Patients and Populations: Public Health in Medical Education" conference. They represent relatively new endeavors or curricular components that had not been explored in prior publications. Although evaluation data are lacking, it was felt that sharing a description of the methods use by Morehouse School of Medicine to integrate public health in the curriculum would be of value to medical educators.