Community-based Participatory Approach Research Articles

Perceptions of agrodiversity and seed-saving practices in the northern Andes of Ecuador

BackgroundAs concerns about agrodiversity loss and its impact on food security increase, interest in seed-saving practices and motivations has risen, especially in regions characterized by ancestral farming. Agroecology practitioners in the northern Andes of Ecuador (n = 65) participated in this study to describe (1) the dynamics of intergenerational agrodiversity, (2) perceptions of relevance of the crops they grow, (3) criteria for characterizing the differences between conventional and non-conventional seeds, and (4) their seed-saving practices.MethodsThis exploratory study incorporated a community-based participatory research approach using mixed methods. We conducted (1) a timeline mapping for exploring the dynamics of intergenerational agrodiversity and (2) structured interviews to explore the perception of relevance of crops grown to identify criteria for characterizing conventional and non-conventional seeds and for identifying seed-saving practices. We computed ranks and frequencies from free listing data derived from the interviews to detect the most salient patterns for crop diversity and seed-saving practices. A principal component analysis was performed to illustrate crops distribution within the study area.Results and discussionBased on the timeline-mapping tool, we found that participants perceive an intergenerational loss of agrodiversity. Data derived from free listing determined that salient crops differ in each location of the study area, mostly due to geographic (altitude, climate), market factors, and crop management limitations. Responses from open-ended interview questions revealed that farmers discriminate conventional from non-conventional seeds using yield, adaptation to local conditions, pest tolerance, taste, and crop management as criteria. Analysis of free listing data determined that the most salient reported practices related to seed saving were soil fertility management, seed selection, safe seed storage, tilling and rowing, and weeding.ConclusionsThis study contributes to raising awareness of intergenerational agrodiversity loss and replacement with modern crops. We found the relevance of crops and practices is subject to cultural and environmental context, and few agricultural practices are exclusively used for seed saving. Further, farmers clearly discriminate conventional from non-conventional seeds based on advantages and disadvantages, cultural motivation, and produce destination. The community-based participatory approach resulted in positive engagement from participants and promoted commitment from farmers to preserve agrodiversity and support practices at the community level.

A Community-Based Participatory Approach to Understanding HIV/AIDS in the Ethiopian Community

ABSTRACTThe rate of HIV/AIDS in Washington, D.C remains at epidemic levels and is most prevalent in the black community, with foreign-born blacks accounting for an increasing proportion of HIV infections in the Washington DC area. The Ethiopian community is among the subgroups that are especially impacted by HIV/AIDS. Yet, seldom does research on the epidemiology of HIV/AIDS break data into diverse subgroups, accounting for the distinct needs based on cultural or ethnic differences. This paper reports on the qualitative findings from a community participatory action research study that involved interviewing 60 Ethiopian-immigrants and nine community-based providers about their attitudes toward HIV/AIDS, and to elicit their ideas about how to improve HIV/AIDS prevention, promotion, and treatment approaches targeting the Ethiopian community. Findings show that stigma remains the largest barrier to accessing HIV/AIDS treatment among Ethiopians in the Washington, D.C. area. Therefore, strategies to reduce HIV/AIDS must address stigmatizing beliefs and be met with cultural sensitivity when developing community prevention and treatment outreach programs designed to reduce HIV/AIDS among Ethiopians.

Service-Related Barriers and Facilitators in an Early Childhood System of Care: Comparing the Perspectives of Parents and Providers.

Systems of care (SOCs) have the potential to enhance underserved families' access to integrated health and support services. Most scholarship on SOCs has involved school-aged children and adolescents. Thus, research is needed to better understand barriers to, and facilitators of, families' access to services during early childhood. The present study included a community-based participatory approach in understanding services for families of children under age six years with severe emotional and behavioral problems. We analyzed data from two focus groups with caregivers (n = 7) and three focus groups with service providers (n = 22). Our thematic analysis of participants' responses revealed five primary barriers to family service access, including challenges associated with transition planning. In comparison, participants described four primary facilitators of family service access, including providers' adoption of "whole-family" service delivery approaches. Findings indicated areas of convergence and divergence in caregivers' and providers' responses. We discuss limitations and potential implications.

Risk Perception and Human Health Risk in Rural Communities Consuming Unregulated Well Water in Saskatchewan, Canada.

Rural communities dependent on unregulated drinking water are potentially at increased health risk from exposure to contaminants. Perception of drinking water safety influences water consumption, exposure, and health risk. A community-based participatory approach and probabilistic Bayesian methods were applied to integrate risk perception in a holistic human health risk assessment. Tap water arsenic concentrations and risk perception data were collected from two Saskatchewan communities. Drinking water health standards were exceeded in 67% (51/76) of households in Rural Municipality #184 (RM184) and 56% (25/45) in Beardy's and Okemasis First Nation (BOFN). There was no association between the presence of a health exceedance and risk perception. Households in RM184 or with an annual income >$50,000 were most likely to have in-house water treatment. The probability of consuming tap water perceived as safe (92%) or not safe (0%) suggested that households in RM184 were unlikely to drink water perceived as not safe. The probability of drinking tap water perceived as safe (77%) or as not safe (11%) suggested households in BOFN contradicted their perception and consumed water perceived as unsafe. Integration of risk perception lowered the adult incremental lifetime cancer risk by 3% to 1.3 × 10-5 (95% CI 8.4 × 10-8 to 9.0 × 10-5 ) for RM184 and by 8.9 × 10-6 (95% CI 2.2 × 10-7 to 5.9 × 10-5 ) for BOFN. Probability of exposure to arsenic concentrations >1:100,000, negligible cancer risk, was 23% for RM184 and 22% for BOFN.

Bringing Research to Life: A Review of Leavy’s Research Design

In this review, I examine the contents, themes, and possibilities of Patricia Leavy’s Research Design: Quantitative, Qualitative, Mixed Methods, Arts-Based, and Community-Based Participatory Approaches. Specifically, I outline the (1) contents of the book in relation to its development of research methodology and potential for use in research methods classes, and (2) the usefulness of this text for bettering and diversifying pedagogical approaches to social research methods. Further, I discuss limitations in the work in terms of possibilities for future additions or expansions teachers may add to the use of this book in courses. In conclusion, I offer overall thoughts on the work and its place within courses concerning the process of social research methodology.

Reclaiming Indigenous Planning as a Pathway to Local Water Security

Access to drinkable water is essential to human life. The consequence of unsafe drinking water can be damaging to communities and catastrophic to human health. Today, one in five First Nation communities in Canada is on a boil water advisory, with some advisories lasting over 10 years. Factors contributing to this problem stretch back to colonial structures and institutional arrangement that reproduce woefully inadequate community drinking water systems. Notwithstanding these challenges, First Nation communities remain diligent, adaptive, and innovative in their efforts to provide drinkable water to their community members. One example is through the practice of source water protection planning. Source water is untreated water from groundwater or surface water that supplies drinking water for human consumption. Source water protection is operationalized through land and water planning activities aimed at reducing the risk of contamination from entering a public drinking water supply. Here, we introduce a source water protection planning process at Muskowekwan First Nation, Treaty 4, Saskatchewan. The planning process followed a community-based participatory approach guided by trust, respect, and reciprocity between community members and university researchers. Community members identified threats to the drinking water source followed by restorative land management actions to reduce those threats. The result of this process produced much more than a planning document but engaged multiple community members in a process of empowerment and self-determination. The process of plan-making produced many unintended results including human–land connectivity, reconnection with the water spirit, as well as the reclaiming of indigenous planning. Source water protection planning may not correct all the current water system inadequacies that exist on many First Nations, but it will empower communities to take action to protect their drinking water sources for future generations as a pathway to local water security.

Participatory farm diversification and nutrition education increase dietary diversity in Western Kenya.

Our study assessed the effectiveness of a community‐based participatory approach in increasing micronutrient adequacy of diets of women and young children through agricultural activities and nutrition education in Vihiga County, Western Kenya. Outcome indicators include the mean dietary diversity score (DDS), the percentage of women and children reaching minimum dietary diversity (MDD), and micronutrient adequacy (mean adequacy ratio). The project consisted of(a) a diagnostic survey covering agrobiodiversity and nutrition, (b) participatory development of activities to improve nutrition, (c) a baseline survey covering dietary intakes, (d) participatory implementation of the developed activities, and (e) an endline survey covering dietary intakes. The diagnostic survey was conducted in 10 sublocations of Vihiga County, which were pair‐matched and split into five intervention and five control sublocations. The intervention sublocations developed activities towards improving nutrition. Before implementation, a baseline survey collected the dietary intake data of 330 women–child pairs in the intervention and control sublocations. To support the activities, communities received agriculture and nutrition training. After 1 year of implementation, an endline survey collected dietary intake data from 444 women–child pairs in the intervention and control sublocations. Impact was assessed using the difference‐in‐difference technique. Highly significant positive impacts on children's mean DDS (treatment effect = 0.7, p < 0.001) and on the share of children reaching MDD (treatment effect = 0.2, p < 0.001) were shown. Higher dietary diversity can be explained by the development of subsistence and income‐generating pathways and increased nutrition knowledge. Participatory farm diversification and nutrition education were shown to significantly increase dietary diversity of young children in Western Kenya.

Participatory planning and monitoring of protected landscapes: a case study of an indigenous rice paddy cultural landscape in Taiwan

Landscapes can be regarded as ‘a culture–nature link.’ Many examples of ‘living’ landscapes in the world are rich in natural and cultural values and have proven sustainable over centuries because of their maintenance by local communities. Satoyama, a traditional socio-ecological production landscape, provides a functional linkage between paddy fields and the associated environment with many ecosystem services. The idea of landscape conservation and paddy field revitalization was introduced into Taiwan’s amended Cultural Heritage Preservation Act in 2005 as a new legal instrument entitled ‘Cultural Landscape.’ To help stakeholders from governmental authorities and local communities apply this new instrument, this action research employed a community-based landscape and participatory approach to put relevant international concepts into practice. Learning from culturally grounded indicators of resilience in social–ecological systems, the study adopted a set of indicators of resilience in socio-ecological production landscapes and seascapes to successfully help residents evaluate the management of a designated Cultural Landscape through a series of local workshops. The case study shows that a landscape and participatory approach can be welcomed by rural people and can create a new style for ‘living’ protected landscapes in Taiwan’s nationally protected area system.

Development of the iCook 4-H Curriculum for Youth and Adults: Cooking, Eating, and Playing Together for Childhood Obesity Prevention

The objective was to describe the development process of a curriculum (iCook 4-H) targeted to low-income, rural, and/or diverse youths and their adult primary meal preparer to promote cooking, eating, and playing together. Lessons learned highlighted the importance of grounding the curriculum in Social Cognitive Theory and applying the experiential 4-H learning model using a multiphased, community-based participatory approach with cyclical development and evaluation, and key modifications made for dissemination and distribution. Findings across 4 testing phases over 6 years and 5 states demonstrated the time-intensive, cyclical process that required flexibility with fidelity to form a hands-on, interactive curriculum.

Ethical considerations for conducting sexual and reproductive health research with female adolescents engaged in high-risk behaviours in China

BackgroundChinese female adolescents engaged in sex trade and substance use are often criminalized and stigmatized. As a result of these cultural, legal and political constraints, ethical concerns can discourage investigators from engaging these adolescents in research. This paper aims to address the ethical tensions between protection and inclusion in conducting sexual and reproductive health (SRH) research with adolescents engaged in high-risk behaviours. Processes of moral reasoning, and examples and practical mechanisms in managing such ethical challenges were presented in the hope of advancing the research ethics policies and practice with adolescents. MethodsWe extracted ethical issues from three previously conducted SRH studies involving 517 Chinese female adolescents. Utilizing the principles of justice, beneficence, and respect for persons as articulated in the Belmont Report as a framework, we thematically summarised the key ethical considerations regarding inclusion and protection, then examine the ethical tensions and solutions within the local context. ResultsFindings suggest that the balance between protection and inclusion can be achieved by both considering the evolving decision-making capacity of adolescents as well as the level of risk. A community-based participatory approach shows promise in advancing adolescent engagement and empowerment. Ethically robust approaches contribute to the greater relevance and validity of the findings. ConclusionsOur studies suggest that it is crucial to achieve adolescents’ meaningful involvement in all levels of research and interventions, researchers need to shift their perspectives of the target population from subjects to key stakeholders in design and implementation of research.

Connection to the land as a youth-identified social determinant of Indigenous Peoples\u2019 health

BackgroundSocial determinants of Indigenous health are known to include structural determinants such as history, political climate, and social contexts. Relationships, interconnectivity, and community are fundamental to these determinants. Understanding these determinants from the perspective of Indigenous youth is vital to identifying means of alleviating future inequities.MethodsIn 2016, fifteen Yellowknives Dene First Nation (YKDFN) youth in the Canadian Northwest Territories participated in the 'On-the-Land Health Leadership Camp'. Using a strength- and community-based participatory approach through an Indigenous research lens, the YKDFN Wellness Division and university researchers crafted the workshop to provide opportunities for youth to practice cultural skills, and to capture the youth’s perspectives of health and health agency. Perspectives of a healthy community, health issues, and health priorities were collected from youth through sharing circles, PhotoVoice, mural art, and surveys.ResultsThe overall emerging theme was that a connection to the land is an imperative determinant of YKDFN health. Youth identified the importance of a relationship to land including practicing cultural skills, Elders passing on traditional knowledge, and surviving off the land. The youth framed future health research to include roles for youth and an on-the-land component that builds YKDFN culture, community relations, and traditional knowledge transfer. Youth felt that a symbiotic relationship between land, environment, and people is fundamental to building a healthy community.ConclusionOur research confirmed there is a direct and critical relationship between structural context and determinants of Indigenous Peoples’ health, and that this should be incorporated into health research and interventions.

The Church Challenge: A community-based multilevel cluster randomized controlled trial to improve blood pressure and wellness in African American churches in Flint, Michigan.

Chronic disease carries high morbidity and mortality in the United States, with large racial and ethnic disparities observed in chronic disease. Physical activity and healthy food are vital for chronic disease prevention yet challenging to access in economically distressed areas. Public health prevention efforts have become particularly prominent within faith-based organizations over the last three decades. This manuscript describes the protocol of the Church Challenge, a multilevel cluster-randomized controlled nutrition and physical activity trial across 24 churches to reduce blood pressure by 6 mmHg among 576 residents in Flint, MI. The Church Challenge was developed using community-based participatory approaches and is rooted in a church-based program developed by and for primarily African-American Flint church congregations. This three-level intervention addresses health at the community (level 3), church (level 2), and individual (level 1) to reduce blood pressure, reduce chronic disease risk, and promote health equity and wellbeing in Flint. Churches are randomized in a 1:1 ratio to a 16-week physical activity and nutrition program or a 4-session health and wellness workshop. Flint is not a unique community but has a history of traumatic community wide events; even now, the public health infrastructure continues to be a challenge and distract residents from focusing on their health. This trial is highly significant and innovative because it uses a combination of evidence-based practices simultaneously supporting health behavior change for individuals and their faith organizations, and evaluates multilevel efforts to sustain long-term health promotion activities in vulnerable communities like Flint.

Results of ALIVE: A Faith-Based Pilot Intervention to Improve Diet Among African American Church Members

Results of ALIVE: A Faith-Based Pilot Intervention to Improve Diet Among African American Church Members Elizabeth Lynch, PhD, Erin Emery-Tiburcio, PhD, Sheila Dugan, MD, Francine Stark White, MDiv, Clayton Thomason, JD, LaDawne Jenkins, MA, Catherine Feit, Elizabeth Avery-Mamer, MA, Yamin Wang, MA, Laurin Mack, PhD, and Alan Ragland, DMin What Is the Purpose of This Study? • The ALIVE intervention is a church-based dietary intervention to increase vegetable consumption among African American church members that was designed by a partnership between researchers, African American pastors, and church leaders in the Chicagoland area. • The ALIVE intervention reflected local community knowledge and values because it was designed and delivered by pastors and church members using a community-based participatory research approach. • The ALIVE study measured the feasibility of implementing and evaluating the ALIVE intervention. What Is the Problem? • African Americans have a higher prevalence of cardiovascular disease than other racial groups. Improving diet in African Americans could reduce this disparity. • Dietary interventions have been less successful with African Americans than other subgroups possibly owing to insufficient cultural tailoring and skepticism about medical research among African Americans. • A promising cultural tailoring strategy is to conduct interventions in the trusted setting of the Black church. A number of dietary interventions have been conducted in Black churches and many have resulted in increased vegetable consumption but few have been designed and/or conducted in partnership with church community members. • A community-based participatory approach to intervention development and implementation has the potential to increase church member engagement and intervention effectiveness. What Are the Findings? • The ALIVE intervention resulted in a mean increase of one vegetable serving over 9 months as well as improvements in total diet quality and reductions in weight and blood pressure. • ALIVE was successfully adapted to a range of church settings. Who Should Care Most? • African American congregations. • Health professionals. • Researchers and community members interested in reducing health disparities. [End Page 3] Recommendations for Action • Health disparity researchers should use a community-based participatory research approach to develop culturally tailored interventions to improve health equity. • Programs aimed at reducing health disparities and promoting wellness should leverage preexisting social structures and values within subgroups to promote education and motivation for health behavior change. [End Page 4] Elizabeth Lynch Department of Preventive Medicine, Rush University Medical Center Erin Emery-Tiburcio Department of Behavioral Sciences, Rush University Medical Center Sheila Dugan Department of Physical Medicine and Rehabilitation, Rush University Medical Center Francine Stark White Third Baptist Church of Chicago Clayton Thomason Department of Preventive Medicine, Rush University Medical Center LaDawne Jenkins Department of Preventive Medicine, Rush University Medical Center Catherine Feit Department of Preventive Medicine, Rush University Medical Center Elizabeth Avery-Mamer Department of Preventive Medicine, Rush University Medical Center Yamin Wang Department of Preventive Medicine, Rush University Medical Center Laurin Mack Department of Behavioral Sciences, Rush University Medical Center Alan Ragland Third Baptist Church of Chicago Copyright © 2019 Johns Hopkins University Press

A Pilot Study of a Culturally Tailored Lifestyle Intervention for Chinese American Cancer Survivors.

Although Asian Americans generally have the lowest cancer incidence rates and mortality rates, cancer is the leading cause of death among Asian Americans. The goal of this pilot study was to engage Chinese American cancer survivors (CACS) in systematic changes toward desired health behaviors through a healthy lifestyle intervention delivered by a community-based organization. The Reach out to ENhanceE Wellness (RENEW) program workbook was translated into Mandarin Chinese with additional physical activity (PA) and dietary information that are culturally appropriate (RENEW-C). Fifty-five Chinese cancer survivors were recruited from the greater Houston area to participate in this 50-week program and 50 of them completed both the baseline and postintervention surveys in 2013 and 2014, respectively. Paired sample t tests were used to assess changes in 5 groups of outcomes: (1) patient knowledge (measured by Health Education Impact Questionnaire [heiQ]), (2) dietary intake (Automated Self-Administered 24-Hour [ASA24] Dietary Assessment Tool), (3) PA (Community Healthy Activities Model Program for Seniors [CHAMPS]), (4) body mass index, and (5) quality of life (36-item Short-Form Survey [SF-36]). Compared with the baseline, participants reported significantly higher consumption of vegetables and higher frequency of PAs at the postintervention survey. They also showed improved mental health and lower limitation in doing their work or other activities due to physical health or emotional problems. Despite the small sample size, this pilot study demonstrated the effectiveness of using a community-based participatory approach in a healthy lifestyle intervention tailored for CACS.

Hoop House Gardening in the Wapekeka First Nation as an Extension of Land-Based Food Practices

Rural Indigenous communities in Canada’s North face many challenges getting regular access to nutritious foods, primarily because of the high cost of market food, restricted availability of nutritious foods, and lack of government support for nutritious food programs. The consequences of food insecurity in this context are expressed in high rates of diabetes, heart disease, and childhood obesity. Many Indigenous communities are responding to issues related to healthy food access by attempting to rebuild local food capacity in their specific regions. Important first steps have been taken in developing local food initiatives, yet whether these initiatives are improving northern food security remains to be seen. We explore this question by working with the Oji-Cree First Nation in the community of Wapekeka, northern Ontario, to construct a hoop house and develop a school-based community gardening program. Using a community-based participatory approach, we determined that hoop house and gardening initiatives in rural, northern settings have the potential to build up local food production, develop the skills and knowledge of community members, engage youth in growing local food, and align with land-based food teachings. We show that despite widespread and multidimensional community hardships, there was considerable community buy-in and support for the project, which gives hope for future development and provides important insight for those seeking to initiate similar gardening, hoop house, or greenhouse initiatives in northern Indigenous communities.

Community-based participatory approach to identify factors affecting diet following migration from Africa: The Hawaash study

Introduction: African women who migrate to the USA have a rich tradition of using herbs and spices to promote health. We conducted formative research on nutritional practices among East and North African women in the USA, focusing on whether traditional herbs and spices could support adherence to the Dietary Guidelines for Americans. Methods: In all, 48 adult African women living in San Diego, California participated in focus groups in July 2015. Inclusion criteria were 18 years or older, and able to answer focus group questions in one of five languages: Somali, Arabic, Amharic, Swahili or English. Results: Participants identified 62 unique spices and herbs that are traditionally used in meal preparation for flavour and health benefits. Participants also reported awareness that nutrients, foods, food groups and approaches to growing and preparing foods are important considerations for healthy diet. Barriers to healthy eating included costs, constraints around growing food in a different soil and climate than Africa, family size and the widespread availability of fast food. Groups identified opportunities for collaborations with researchers through educational programmes, and recommended seed and recipe exchanges that promote healthy eating across culturally heterogeneous African communities. Conclusion: A culturally informed behavioural intervention focused on spices and herbs would be feasible and accepted by African women in San Diego. This intervention may support adherence to the Dietary Guidelines for Americans during the nutrition transition and broader dissemination of practices that promote health across heterogeneous communities of Africans living in the USA.

Sistas Taking a Stand for Breast Cancer Research (STAR) Study: A Community-Based Participatory Genetic Research Study to Enhance Participation and Breast Cancer Equity among African American Women in Memphis, TN.

African American women are substantially underrepresented in breast cancer genetic research studies and clinical trials, yet they are more likely to die from breast cancer. Lack of trust in the medical community is a major barrier preventing the successful recruitment of African Americans into research studies. When considering the city of Memphis, TN, where the percentage of African Americans is significantly higher than the national average and it has a high rate of breast cancer mortality inequities among African American women, we evaluated the feasibility of utilizing a community-based participatory (CBPR) approach for recruiting African American women into a breast cancer genetic study, called the Sistas Taking A Stand for Breast Cancer Research (STAR) study. From June 2016 and December 2017, African American women age 18 and above were recruited to provide a 2 mL saliva specimen and complete a health questionnaire. A total of 364 African American women provided a saliva sample and completed the health questionnaire. Greater than 85% agreed to be contacted for future studies. Educational workshops on the importance of participating in cancer genetic research studies, followed by question and answer sessions, were most successful in recruitment. Overall, the participants expressed a strong interest and a willingness to participate in the STAR study. Our findings highlight the importance of implementing a CBPR approach that provides an educational component detailing the importance of participating in cancer genetic research studies and that includes prominent community advocates to build trust within the community.

The Role of Elders in the Wellbeing of a Contemporary Australian Indigenous Community.

Traditional Elders are integral to the social structure of Australian Indigenous communities. Due to progressive loss of traditional way of life, however, the role of Elders has been eroding. This study aims to develop a conceptual model of the role of Elders in an Australian Indigenous community, with the goal of attaining strategies to strengthen the role of Elders. The study, conducted in a regional Indigenous community in Australia, adopted a community-based participatory approach. Design and focus of the project were informed by a community forum (Yarning Circle). One-on-one semistructured interviews and focus groups with community members were conducted by Indigenous researchers. Group concept mapping (GCM) was applied to elicit major themes in qualitative data, from the point of view of community members, and to derive a conceptual model of the role of Elders. Fifty members of the Indigenous community took part in interviews and focus groups. The participants' median age was 45 years (range 18-76 years); 31 (62%) were female. An additional 24 Indigenous community members took part in the data sorting task of GCM. GCM identified seven major aspects of the role of Elders, including Community relations, Passing down the knowledge, Dealing with racism and oppression, Building a better resourced community, Intergenerational connectedness, Safeguarding our identity, and Caring for our youth. Elders fulfill many important roles in contemporary Indigenous communities. Our results can be used to assist the community to codesign a program to increase community wellbeing.

Accompaniment in a Mexican immigrant community: Conceptualization and identification of biopsychosocial outcomes

ABSTRACTTaller de Jose (TDJ) offers accompaniment in a Mexican neighborhood in Chicago, helping service participants navigate health, judicial, and social service systems. Using a community-based participatory approach, the current study conceptualizes the accompaniment service and identifies psychosocial outcomes. Focus groups with service participants and staff were conducted, using a grounded theory approach. The data provides support for a conceptual model of accompaniment based on interdisciplinary knowledge in ministry, social work, and public health; and a consideration of social context, values, and outcomes such as increased social support, knowledge of community resources, and improved self-efficacy.

The 6 A’s Global Transitional Care Model for Addressing Hospital-to-home Care Fragmentation

Introduction: An acute illness or injury can be life altering. However, few systems of care are organized to support individuals in the transition home from the acute hospital. Fragmented transitions in care lead to preventable complications, disability and depression. Care transitions without adequate planning and follow-up after an acute illness or injury is increasing the global disease burden. Methods: Our aim was to design a transitional care model appropriate for both developed and developing countries. We conducted a mixed methods study guided by the socioecological model that has a theory-base for understanding interacting levels of influence societal, community, institutions, social, family on individual behaviors and outcomes. We synthesized peer-reviewed and grey literature to identify national and regional infrastructure, health care and community-based strategies, involvement of family, and meaningful patient outcomes examined in transitional care models with demonstrated effectiveness. Our policy analysis for twelve countries three low-, middle- and high-income examined healthcare finance, availability and access to services, payment or policies for caregiver leave of absence, and products and technology that support independent living. Eighteen key informant interviews with healthcare and community leaders in six countries were conducted to assess the knowledge, attitudes and practices regarding hospital-to-home care transitions. Results: Key informants in each low-, middle- and high-income country acknowledged the challenges with fragmentation and opportunities to improve care coordination. Although fewer supportive policies were legislated in developing countries, several national strategic plans acknowledged key areas for development such as improving access to care or health information technology. These perspectives, policies and the evidence-to-date led to the development of the 6 A’s global transitional care model to address the fragmentation in care and improve outcomes. The essential components of the 6 A’s model are to assess, advise and educate patients and families, arrange follow-up, services and supports, access and attend organized follow-up, adopt self-management strategies and positive behaviors, and achieve the greatest quality of life measured outcomes. Discussions: The 6 A’s model was designed to be implemented in the hospital assess, advise, arrange and after hospital discharge in the community attend, adopt, achieve and the components are balanced for accountability between healthcare providers, patients and families. While each setting may present with unique challenges for implementation, our formative research indicates that local creative solutions are possible once the need and buy-in are established. Conclusions: The 6 A’s model is largely dependent on care redesign or re-alignment of existing resources and skills training. Local policies and perspectives will need to be considered for each implementing environment. Lessons: Scale-up of transitional care models tested in high-income countries to lower resourced areas will not be feasible. The 6 A’s holds promise as a global model that can be considered within local contexts. Limitations: Although our research engaged representatives and included literature from a diverse selection of countries, key informants were advocates for improving integrated person-centred care. Future research: Implementation research using a community-based participatory approach with attention to the six health system building blocks is recommended for the 6 A’s global transitional care model.