Erratum: Building the foundation for equitable and inclusive research: Seed grant programs to facilitate development of diverse CBPR community-academic research partnerships - CORRIGENDUM.

[This corrects the article DOI: 10.1017/cts.2022.495.].

Building the foundation for equitable and inclusive research: Seed grant programs to facilitate development of diverse CBPR community-academic research partnerships.

Introduction: The effectiveness of community-based participatory research (CBPR) partnerships to address health inequities is well documented. CBPR integrates knowledge and perspectives of diverse communities throughout the research process, following principles that emphasize trust, power sharing, co-learning, and mutual benefits. However, institutions and funders seldom provide the time and resources needed for the critical stage of equitable partnership formation and development. Methods: Since 2011, the Detroit Urban Research Center, collaborating with other entities, has promoted the development of new community-academic research partnerships through two grant programs that combine seed funding with capacity building support from community and academic instructors/mentors experienced in CBPR. Process and outcomes were evaluated using mixed methods. Results: From 2011 to 2021, 50 partnerships received grants ranging from $2,500 to $30,000, totaling $605,000. Outcomes included equitable partnership infrastructure and processes, innovative pilot research, translation of findings to interventions and policy change, dissemination to multiple audiences, new proposals and projects, and sustained community-academic research partnerships. All partnerships continued beyond the program; over half secured additional funding. Conclusions: Keys to success included participation as community-academic teams, dedicated time for partnership/relationship development, workshops to develop equity-based skills, relationships, and projects, expert community-academic instructor guidance, and connection to additional resources. Findings demonstrate that small amounts of seed funding for newly forming community-academic partnerships, paired with capacity building support, can provide essential time and resources needed to develop diverse, inclusive, equity-focused CBPR partnerships. Building such support into funding initiatives and through academic institutions can enhance impact and sustainability of translational research toward advancing health equity.

Dose-Lowering in Contrast-Enhanced MRI of the Central Nervous System: A Retrospective, Parallel-Group Comparison Using Gadobenate Dimeglumine.

BACKGROUND: Concerns over gadolinium (Gd) retention encourage the use of lower Gd doses. However, lower Gd doses may compromise imaging performance. Higher relaxivity gadobenate may be suited to reduced dose protocols. PURPOSE: To compare 0.05 mmol/kg and 0.1 mmol/kg gadobenate in patients undergoing enhanced MRI of the central nervous system (CNS). STUDY TYPE: Retrospective, multicenter. POPULATION: Three hundred and fifty-two patients receiving 0.05 (n = 181) or 0.1 (n = 171) mmol/kg gadobenate. FIELD STRENGTH/SEQUENCES: 1.5 T and 3.0 T/precontrast and postcontrast T1-weighted spin echo/fast spin echo (SE/FSE) and/or gradient echo/fast field echo (GRE/FFE); precontrast T2-weighted FSE and T2-FLAIR. ASSESSMENT: Images of patients with extra-axial lesions at 1.5 T or any CNS lesion at 3.0 T were reviewed by three blinded, independent neuroradiologists for qualitative (lesion border delineation, internal morphology visualization, contrast enhancement; scores from 1 = poor to 4 = excellent) and quantitative (lesion-to-brain ratio [LBR], contrast-to-noise ratio [CNR]; SI measurements at regions-of-interest on lesion and normal parenchyma) enhancement measures. Noninferiority of 0.05 mmol/kg gadobenate was determined for each qualitative endpoint if the lower limit of the 95% confidence interval (CI) for the difference in precontrast + postcontrast means was above a noninferiority margin of -0.4. STATISTICAL TESTS: Student's t-test for comparison of mean qualitative endpoint scores, Wilcoxon signed rank test for comparison of LBR and CNR values; Wilcoxon rank sum test for comparison of SI changes. Tests were significant for P < 0.05. RESULTS: The mean change from precontrast to precontrast + postcontrast was significant for all endpoints. Readers 1, 2, and 3 evaluated 304, 225, and 249 lesions for 0.05 mmol/kg gadobenate, and 382, 309, and 298 lesions for 0.1 mmol/kg gadobenate. The lower limit of the 95% CI was above -0.4 for all comparisons. Significantly, higher LBR and CNR was observed with the higher dose. DATA CONCLUSION: 0.05 mmol/kg gadobenate was noninferior to 0.1 mmol/kg gadobenate for lesion visualization. EVIDENCE LEVEL: 2 TECHNICAL EFFICACY: Stage 3.

Knowledge of Health Insurance Terms and the Affordable Care Act in Racially and Ethnically Diverse Urban Communities.

Confusion around health insurance reforms persist. The purpose of this study was to assess demographic differences in Affordable Care Act (ACA) and health insurance knowledge in a multi-ethnic urban sample. Data came from 243 adults from racial/ethnic communities. Participants were asked about elements of health insurance and the ACA. Generalized linear and logistic regression models were used to examine relationships between demographic predictors and knowledge domains. Female gender (p < 0.05) and Latino/Hispanic race/ethnicity (p < 0.001) were most predictive of lower eligibility knowledge, while non-citizen with residency status (p < 0.001) and other/not declared residency status (p < 0.001) were most predictive of lower insurance coverage knowledge. No demographic factors predicted enrollment knowledge. Latino/Hispanic race/ethnicity (p < 0.01) was most predictive of not knowing that more people can get insurance because of the ACA. In conclusion, there is variation in health insurance and ACA-related knowledge in multi-ethnic populations. More compatible health communication interventions are needed to support outreach to key demographic groups.

Insuring Good Health: Outcomes and Acceptability of a Participatory Health Insurance Literacy Intervention in Diverse Urban Communities.

BACKGROUND: The U.S. uninsured rate has dropped significantly since the passage of the Affordable Care Act (ACA), yet insurance coverage remains lower in historically marginalized communities than in the overall population. New consumer engagement approaches that involve these populations are needed. The purpose of this study was to evaluate the effectiveness of the Insuring Good Health Intervention, a website and video series designed to improve engagement with health insurance and ACA reforms. The study was designed and implemented using a community-based participatory research approach. METHOD: We conducted a lagged-control cluster randomized controlled trial to evaluate Insuring Good Health with racially and ethnically diverse adults seeking services in medically underserved areas within the Detroit, Michigan metropolitan area. Outcomes were assessed at baseline and at 6 and 9 months postintervention, and including self-efficacy, knowledge, beliefs, and intention to seek help with insurance navigation and care. RESULTS: Among 243 participants, mean age was 43.4 ( SD = 13) years, and all participants met federal guidelines for poverty. The study had an 86% response rate at 9-month follow-up ( n = 209). Compared with the lagged-control group, intervention participants had more positive beliefs concerning preventive care (estimate 0.51, standard error 0.16; p < .01), and intention to seek help with insurance navigation and care (estimate 0.43, standard error 0.17; p < .001) at 9-month follow-up. Hispanic participants benefitted the most from the intervention, including improved knowledge of health insurance eligibility over 9 months compared with other racial/ethnic groups (estimate -0.97, standard error 0.40, p < .01). DISCUSSION: Insuring Good Health was associated with increased intention to seek help with insurance navigation and care, and improved beliefs around preventive care. CONCLUSIONS: Insuring Good Health has the potential to be an important consumer engagement tool to reduce disparities in health insurance coverage and care seeking.

Use of Storytelling to Increase Navigation Capacity Around the Affordable Care Act in Communities of Color.

BACKGROUND: Improving health insurance coverage and retention in communities of color is a national priority and new approaches are needed. OBJECTIVES: To describe 1) the formation of Insure Detroit, a community-based participatory research (CBPR) partnership aimed at addressing health insurance and Affordable Care Act (ACA) literacy challenges in economically disadvantaged areas, 2) the development of Insuring Good Health, a novel, multimedia, health information technology-focused intervention to address the health aims of the partnership, and 3) the evaluation plan for the intervention. METHODS: Insure Detroit, a partnership between researchers and community-based organizations, was established. Principles of CBPR were followed closely in the conduct of this project. The Insure Detroit partnership developed the intervention and evaluation plan through an iterative process. The Insuring Good Health intervention is multilingual and composed of a responsive website. It includes nine short, animated videos informed by storytelling techniques that communicate key learning points pertaining to health insurance navigation and use. LESSONS LEARNED: Lessons learned included narrowing learning points for the intervention, balancing the volume of work to comply with the study timeline, and balancing the political climate with the development of the intervention. CONCLUSIONS: The Insure Detroit partnership demonstrates that a CBPR approach can develop media-based health communications to address health insurance literacy. Our experiences highlight that CBPR principles that encourage shared decision making and co-learning can result in high-quality, innovative interventions that have the potential to resonate well with communities of color.

Health Insurance Challenges in the Post-Affordable Care Act (ACA) Era: a Qualitative Study of the Perspective of Low-Income People of Color in Metropolitan Detroit.

Low-income people of color are at risk of remaining uninsured due to a variety of factors. This study examined Affordable Care Act (ACA)-related and other health insurance enrollment experiences, observations, navigation needs, and experiences maintaining health insurance coverage among low-income communities of color in an economically disadvantaged community (Metropolitan Detroit). We conducted nine focus groups (n = 87) between May and June 2015. Participants were recruited through community-based organizations serving our key populations of interest. Using an inductive thematic analysis approach, codes and themes were generated. Findings from six themes demonstrated that although health insurance is perceived as important, confusion and frustration persist around health plan benefits and coverage, eligibility requirements and key provisions of the ACA, and enrollment. Individuals face difficulties justifying the cost of health insurance. More focused insurance outreach efforts are needed to achieve the ultimate goal of improving the health of low-income communities of color.

Geographic Variation in Medicaid Acceptance Across Michigan Primary Care Practices in the Era of the Affordable Care Act.

Coverage and access have improved under the Affordable Care Act, yet it is unclear whether recent gains have reached those regions within states that were most in need of improved access to care. We examined geographic variation in Medicaid acceptance among Michigan primary care practices before and after Medicaid expansion in the state, using data from a simulated patient study of primary care practices. We used logistic regression analysis with time indicators to assess regional changes in Medicaid acceptance over time. Geographic regions with lower baseline (<50%) Medicaid acceptance had significant increases in Medicaid acceptance at 4 and 8 months post-expansion, while regions with higher baseline (≥50%) Medicaid acceptance did not experience significant changes in Medicaid acceptance. As state Medicaid expansions continue to be implemented across the country, policy makers should consider the local dynamics of incentives for provider participation in Medicaid.

Primary care appointment availability and nonphysician providers one year after Medicaid expansion.

OBJECTIVES: With insurance enrollment greater than expected under the Affordable Care Act, uncertainty about the availability and timeliness of healthcare services for newly insured individuals has increased. We examined primary care appointment availability and wait times for new Medicaid and privately insured patients before and after Medicaid expansion in Michigan. STUDY DESIGN: Simulated patient ("secret shopper") study. METHODS: Extended follow-up of a previously reported simulated patient ("secret shopper") study assessing accessibility of routine new patient appointments in a stratified proportionate random sample of Michigan primary care practices before versus 4, 8, and 12 months after Medicaid expansion. RESULTS: During the study period, approximately 600,000 adults enrolled in Michigan's Medicaid expansion program, representing 57% of the previously uninsured nonelderly adult population. One year after expansion, we found that appointment availability remained increased by 6 percentage points for new Medicaid patients (95% CI, 1.6-11.1) and decreased by 2 percentage points for new privately insured patients (95% CI, -0.5 to -3.8). Over the same period, the proportion of appointments scheduled with nonphysician providers (nurse practitioners or physician assistants) increased from 8% to 21% of Medicaid appointments (95% CI, 5.6-20.2) and from 11% to 19% of private-insurance appointments (95% CI, 1.3-14.1). Median wait times remained stable for new Medicaid patients and increased slightly for new privately insured patients, both remaining within 2 weeks. CONCLUSIONS: During the first year following Medicaid expansion in Michigan, appointment availability for new Medicaid patients increased, a greater proportion of appointments could be obtained with nonphysician providers, and wait times remained within 2 weeks.

Prospective Cohort Study of Nephrogenic Systemic Fibrosis in Patients With Stage 3-5 Chronic Kidney Disease Undergoing MRI With Injected Gadobenate Dimeglumine or Gadoteridol.

OBJECTIVE: The purpose of this study was to determine the incidence of nephrogenic systemic fibrosis (NSF) in patients with chronic kidney disease (CKD) and moderate-to-severe impairment of kidney function who had not previously been exposed to gadolinium-based contrast agents (GBCAs) or referred to undergo contrast-enhanced MRI with gadobenate dimeglumine or gadoteridol. SUBJECTS AND METHODS: Two multicenter prospective cohort studies evaluated the incidence of unconfounded NSF in patients with stage 3 CKD (estimated glomerular filtration rate [eGFR] in cohort 1, 30-59 mL/min/1.73 m(2)) or stage 4 or 5 CKD (eGFR in cohort 2, < 30 mL/min/1.73 m(2)) after injection of gadobenate dimeglumine (study A) or gadoteridol (study B). A third study (study C) determined the incidence of NSF in patients with stage 4 or 5 CKD who had not received a GBCA in the 10 years before enrollment. Monitoring for signs and symptoms suggestive of NSF was performed via telephone at 1, 3, 6, and 18 months, with clinic visits occurring at 1 and 2 years. RESULTS: For studies A and B, the populations evaluated for NSF comprised 363 and 171 patients, respectively, with 318 and 159 patients in cohort 1 of each study, respectively, and with 45 and 12 patients in cohort 2, respectively. No signs or symptoms of NSF were reported or detected during the 2 years of patient monitoring. Likewise, no cases of NSF were reported for any of the 405 subjects enrolled in study C. CONCLUSION: To our knowledge, and consistent with reports in the literature, no association of gadobenate dimeglumine or gadoteridol with unconfounded cases of NSF has yet been established. Study data confirm that both gadoteridol and gadobenate dimeglumine properly belong to the class of GBCAs considered to be associated with the lowest risk of NSF.

Primary care appointment availability for new Medicaid patients increased after Medicaid expansion in Michigan.

The Affordable Care Act expands health insurance coverage to millions of Americans, but the availability of health care services for the newly insured population remains uncertain. We conducted a simulated patient (or "secret shopper") study to assess primary care appointment availability and wait times for new patients with Medicaid or private insurance before and after implementation of Michigan's Medicaid expansion in 2014. The expansion, which was made possible through a section 1115 waiver, has a unique requirement that new beneficiaries must be seen by a primary care provider within 60-90 days of enrollment. During a period of rapid coverage expansion in Michigan, we found that appointment availability increased 6 percentage points for new Medicaid patients and decreased 2 percentage points for new privately insured patients, compared to availability before the expansion. Wait times remained stable, at 1-2 weeks for both groups. Further research is needed to determine whether access to primary care for newly insured patients will endure over time.

Community-based participatory research: a capacity-building approach for policy advocacy aimed at eliminating health disparities.

There have been increasing calls for community-academic partnerships to enhance the capacity of partners to engage in policy advocacy aimed at eliminating health disparities. Community-based participatory research (CBPR) is a partnership approach that can facilitate capacity building and policy change through equitable engagement of diverse partners. Toward this end, the Detroit Community-Academic Urban Research Center, a long-standing CBPR partnership, has conducted a policy training project. We describe CBPR and its relevance to health disparities; the interface between CBPR, policy advocacy, and health disparities; the rationale for capacity building to foster policy advocacy; and the process and outcomes of our policy advocacy training. We discuss lessons learned and implications for CBPR and policy advocacy to eliminate health disparities.

The one-pager: a practical policy advocacy tool for translating community-based participatory research into action.

The multiple and diverse perspectives, skills, and experiences inherent in community-academic partnerships make them uniquely positioned to educate policy makers and advocate for health equity. Effective communication tools are critical to successfully engage in the policy-making process. Yet few resources emphasize the development and use of practical tools for translating community-based participatory research (CBPR) findings into action. The purpose of this article is to describe a CBPR process for developing and using a one-page summary, or "one-pager," of research findings and their policy implications. This article draws on the experience of the Healthy Environments Partnership (HEP), a community-academic partnership in Detroit, Michigan. In addition to describing these processes, this article includes a template for a one-pager and an example of a one-pager that was written for and presented to federal policy makers.

Health policy approaches to population health: the limits of medicalization.

Because of a strong tendency to "medicalize" health status problems and to assume that their primary solution involves medical care, policymakers often focus on increased financial and geographic access to personal health services in policies aimed at populations that are vulnerable to poor health. This approach has produced real public health gains, but it has neglected key social and economic causes of health vulnerability and disparities. Although access to care is a necessary component of population health, concerted policy action in income security, education, housing, nutrition/food security, and the environment is also critical in efforts to improve health among socially disadvantaged populations.

Drawing from Freirian empowerment methods to develop and use innovative learning maps: increasing enrollment of uninsured children on Detroit's eastside.

In 2001, virtually every child on Detroit's eastside was eligible for health coverage, yet approximately 3,000 children remained uninsured. The primary aim of the Eastside Access Partnership (EAP), a community-based participatory research collaboration, was to increase enrollment of uninsured children in state programs. To achieve this aim, one of the approaches that EAP is using is the innovative Learning Map titled Choosing the Healthy Path, which was developed in collaboration with Root Learning, Inc. Although Learning Maps were originally developed to assist corporations in implementing strategic change, their integration of visualization and interactive dialogue incorporates Freirian principles of empowerment education, making them a viable option for providing meaningful learning opportunities for community residents. This article presents the collaborative process involving the University of Michigan, local community-based organizations, community members, and Root Learning consultants to develop a visual map that enables community residents to understand and overcome the barriers that prevent them from obtaining health insurance for their children.

Challenges and facilitating factors in sustaining community-based participatory research partnerships: lessons learned from the Detroit, New York City and Seattle Urban Research Centers.

In order to address the social, physical and economic determinants of urban health, researchers, public health practitioners, and community members have turned to more comprehensive and participatory approaches to research and interventions. One such approach, community-based participatory research (CBPR) in public health, has received considerable attention over the past decade, and numerous publications have described theoretical underpinnings, values, principles and practice. Issues related to the long-term sustainability of partnerships and activities have received limited attention. The purpose of this article is to examine the experiences and lessons learned from three Urban Research Centers (URCs) in Detroit, New York City, and Seattle, which were initially established in 1995 with core support from the Centers for Disease Control and Prevention (CDC). The experience of these Centers after core funding ceased in 2003 provides a case study to identify the challenges and facilitating factors for sustaining partnerships. We examine three broad dimensions of CBPR partnerships that we consider important for sustainability: (1) sustaining relationships and commitments among the partners involved; (2) sustaining the knowledge, capacity and values generated from the partnership; and (3) sustaining funding, staff, programs, policy changes and the partnership itself. We discuss the challenges faced by the URCs in sustaining these dimensions and the strategies used to overcome these challenges. Based on these experiences, we offer recommendations for: strategies that partnerships may find useful in sustaining their CBPR efforts; ways in which a Center mechanism can be useful for promoting sustainability; and considerations for funders of CBPR to increase sustainability.

Training welfare caseworkers in service excellence: increasing children's Medicaid coverage.

Many low-income children who are eligible for public sector health insurance remain uninsured. There are many barriers to enrolling these children, but one key issue is parents' reluctance to use the services of the local enrollment agency, which is usually the welfare office. The Eastside Access Partnership, a community-academic coalition on the Eastside of Detroit, addressed the problem of uninsured-but-eligible children through a variety of interventions focused on (1) enhancing community members' understanding of the enrollment process and (2) reducing institutional barriers to enrollment. One of these interventions addressed the institutional barriers by developing a customer service excellence training program for welfare caseworkers. The training program curriculum, which was developed following the principles of community-based participatory research, included extensive input from community residents, welfare agency staff, and academic researchers. The training sessions received positive evaluations from participants and agency executives. A more thorough evaluation of the project is under way.