Community-based Sites Research Articles

Impact of the introduction of rapid HIV testing in the Voluntary Counselling and Testing sites network of Catalonia, Spain

Rapid HIV antibody tests, which provide results within 15-60 minutes, can help reduce the number of unrecognized infections by improving access to testing facilities and increase the number of people tested who know their results. After an acceptability study, rapid HIV testing was first implemented in Catalonia in 2007 within the community-based Voluntary Counselling and Testing sites network. One year after implementation, an increase of 102.9% has been observed in the number of tests performed, ranging from 8.4% to 328.3% according to the site. Despite the important immediate impact of rapid HIV testing on the number of tests performed, there was no significant change in the proportion of tests that were positive. Rapid HIV testing can help increase access to testing, but it should be complemented with specific outreach programmes targeting the most vulnerable subgroups.

Exploring Primary Care Providers’ Interest in Using Patient Navigators to Assist in the Delivery of Tobacco Cessation Treatment to Low Income, Ethnic/Racial Minority Patients

We examined attitudes and practices regarding tobacco cessation interventions of primary care physicians serving low income, minority patients living in urban areas with a high smoking prevalence. We also explored barriers and facilitators to physicians providing smoking cessation counseling to determine the need for and interest in deploying a tobacco-focused patient navigator at community-based primary care practice sites. A self-administered survey was mailed to providers serving Medicaid populations in New York City's Upper Manhattan and areas of the Bronx. Provider counseling practices were measured by assessing routine delivery (≥80% of the time) of a brief tobacco cessation intervention (i.e., "5 A's"). Provider attitudes were assessed by a decisional balance scale comprising 10 positive (Pros) and 10 negative (Cons) perceptions of tobacco cessation counseling. Of 254 eligible providers, 105 responded (41%). Providers estimated 22% of their patients currently use tobacco and nearly half speak Spanish. A majority of providers routinely asked about tobacco use (92%) and advised users to quit (82%), whereas fewer assisted in developing a quit plan (32%) or arranged follow-up (21%). Compared to providers reporting <80% adherence to the "5 A's", providers reporting ≥80% adherence tended to have similar mean Pros and Cons scores for Ask, Advise, and Assess but higher Pros and lower Cons for Assist and Arrange. Sixty four percent of providers were interested in providing tobacco-related patient navigation services at their practices. Although most providers believe they can help patients quit smoking, they also recognize the potential benefit of having a patient navigator connect their patients with evidence-based cessation services in their community.

Palliative Care Research Issues and Methods: Pain Assessment, Prognostication, and CAM (518)

1.Discuss and critique research methods in terms of design, measurement, and implementation.2.Identify dilemmas and limits in specific areas of palliative care research through case examples.3.Apply methodological approaches in palliative care research learned in this session to their own projects. In this session, research concepts, methodological approaches, and questions will be discussed and participants will be invited to raise questions and critiques regarding the research. Three palliative care researchers will present on current topics in palliative care research methods in the following areas: pain identification and screening, prognostication, and complementary and alternative medicine (CAM) trials. Specific research methods in pain identification and prognosis will include case examples in design, measurement, and study implementation. Recent research focusing on routine pain screening and the implementation of quality indicators for symptom management will be addressed. A review of the characteristics of well-designed studies to evaluate the association of prognostic factors with survival and a discussion of alternative approaches to studying prognostication will also be presented. Studies of CAM will be examined with special emphasis on methodology employed in a massage therapy random controlled trial (RCT), including selection of control exposure, maintaining fidelity to study protocol, recruitment, planning for data missing not at random, the resulting evidence, and implications for future CAM studies in this population. Participants are encouraged to bring specific questions related to their own research interests and works in progress, such as recruitment, alternatives to randomization, selection of control groups, ethics/human subjects protection, respondent burden, maintaining fidelity to study protocols in dispersed community-based study sites, health service resources, as well as any other working ideas on current projects. Structure and Processes of Care

Building a National Research Network for Clinical Investigations in Otology and Neurotology

Practice-based research networks (PBRNs) are the preferred research setting for descriptive/epidemiologic studies and studies that explore the effectiveness of treatments for disease that are managed in community settings, away from the rubric of the academic medical center. A PBRN in otology/neurotology, established upon a sustainable research infrastructure, addresses the challenges of performing community-based research through enhanced support for data collection and facilitated research regulatory adherence. A strategic alignment of a PBRN with an established research infrastructure allows for successful implementation of a variety of study methodologies and a framework for successful competition for research funding in hearing and balance disorders. Our goal is to develop a centralized, high-quality research infrastructure that supports a dynamic research alliance between regional centers for research excellence, community physicians, allied health professionals, and patients. We describe herein current plans and progress toward the goal of developing a network of academic- and community-based research sites to facilitate the conduct of clinical research in hearing and balance disorders. We have formed a PBRN that we call the CHEER Network: Creating Healthcare Excellence through Education and Research. Creating healthcare excellence through education and research was proposed in response to a request for applications from the National Institute for Deafness and other Communication Disorders to further develop clinical research in otolaryngology, specifically focusing on disorders in hearing and balance. Our expectation is that a network organized and focused around regional research alliances between academic institutions and community practitioners will have broad appeal to community-based health care professionals and patients, resulting in enhanced communications, interoperability, and success in the conduct of high-quality multicenter clinical research in hearing and balance disorders.

Experiences in conducting multiple community-based HIV prevention trials among women in KwaZulu-Natal, South Africa

BackgroundSouth Africa, with its scientific capacity, good infrastructure and high HIV incidence rates, is ideally positioned to conduct large-scale HIV prevention trials. The HIV Prevention Research Unit of the South African Medical Research Council conducted four phase III and one phase IIb trials of women-initiated HIV prevention options in KwaZulu-Natal between 2003 and 2009. A total of 7046 women participated, with HIV prevalence between 25% and 45% and HIV incidence ranging from 4.5-9.1% per year. Unfortunately none of the interventions tested had any impact on reducing the risk of HIV acquisition; however, extremely valuable experience was gained, lessons learned and capacity built, while the communities gained associated benefits.ExperienceOur experience in conducting these trials ranged from setting up community partnerships to developing clinical research sites and dissemination of trial results. Community engagement included setting up community-based research sites with approval from both political and traditional leaders, and developing community advisory groups to assist with the research process. Community-wide education on HIV/sexually transmitted infection prevention, treatment and care was provided to over 90 000 individuals. Myths and misconceptions were addressed through methods such as anonymous suggestion boxes in clinic waiting areas and intensive education and counselling. Attempts were made to involve male partners to foster support and facilitate recruitment of women. Peer educator programmes were initiated to provide ongoing education and also to facilitate recruitment of women to the trials. Recruitment strategies such as door-to-door recruitment and community group meetings were initiated. Over 90% of women enrolled were retained.Community benefits from the trial included education on HIV prevention, treatment and care and provision of ancillary care (such as Pap smears, reproductive health care and referral for chronic illnesses). Social benefits included training of home-based caregivers and sustainable ongoing HIV prevention education through peer educator programmes.ChallengesSeveral challenges were encountered, including manipulation by participants of their eligibility criteria in order to enroll in the trial. Women attempted to co-enroll in multiple trials to benefit from financial reimbursements and individualised care. The trials became ethically challenging when participants refused to take up referrals for care due to stigma, denial of their HIV status and inadequate health infrastructure. Lack of disclosure of HIV status to partners and family members was particularly challenging. Some of the ethical dilemmas put to the test our responsibility as researchers and our obligation to provide health care to research participants.ConclusionConducting these five trials in a period of six years provided us with invaluable insights into trial implementation, community participation, recruitment and retention, provision of care and dissemination of trial results. The critical mass of scientists trained as clinical trialists will continue to address the relentless HIV epidemic in our setting and ensure our commitment to finding a biomedical HIV prevention option for women in the future.

Implementation of Mental Health Parity: Lessons From California

Implementation of Mental Health Parity: Lessons From California

Stroke literacy in Central Harlem

Awareness of stroke warning symptoms and risk factors (stroke literacy), as well as knowledge of available treatment options, may be poor in high-risk populations. We sought to evaluate stroke literacy among residents of Central Harlem, a predominantly African American population, in a cross-sectional study. Ten community-based sites in Central Harlem were identified between 2005 and 2006 for administration of a stroke knowledge survey. Trained volunteers administered in-person closed-ended questionnaires focused on stroke symptoms and risk factors. A total of 1,023 respondents completed the survey. African Americans comprised 65.7% (n = 672) of the survey cohort. The brain was correctly identified as the site where a stroke occurs by 53.7% of respondents, whereas the heart was incorrectly identified by 20.8%. Chest pain was identified as a symptom of stroke by 39.7%. In multivariable analyses, African Americans (odds ratio [OR] 2.20, 95% confidence interval [CI] 1.09-4.45) and Hispanics (OR 5.27, 95% CI 2.46-11.30) were less likely to identify the brain as the damaged organ in stroke. Hispanics were more likely to incorrectly identify chest pain as a stroke symptom, compared with whites (OR 3.40, 95% CI 1.49-7.77). No associations were found between calling 911 and race/ethnicity and stroke knowledge, although women were more likely than men to call 911 (OR 0.50, 95% CI 0.30-0.80). Significant deficiencies in stroke literacy exist in this high-risk population, especially when compared with national means. Culturally tailored and sustainable educational campaigns should be tested in high-risk populations as part of stroke public health initiatives.

Geographic Recruitment of Breast Cancer Survivors into Community-Based Exercise Interventions

There is increased interest in developing and disseminating health behavior interventions for cancer survivors. Challenges in these efforts include participant burden in traveling to central intervention sites and sustainability. The purpose of this article is to report various methods used to recruit breast cancer survivors into an exercise intervention that attempts to address both of these challenges. Letters were mailed within specific zip codes near community-based intervention sites in cooperation with state cancer registries. Additional recruitment methods included flyers at breast care clinics and support groups, mass media, and conferences. Of the 3200 women who responded, 82% (n = 2625) identified having heard about the study through state or hospital registry and 8% (n = 243) through print and broadcast media. Thirty-five percent (n = 103) of randomized women self-identified as having a minority racial background and 31.9% (n = 94) self-identified as African American. Comparisons of participant age and racial distribution to state cancer registries indicate similar age distribution but greater racial diversity among participants. These results support the use of population-based cancer registries to recruit survivors into community-based interventions and clinical trials.

Outcomes of National Community Organization Cardiovascular Prevention Programs for High-Risk Women

The purpose of this study was to reduce cardiovascular disease (CVD) risk in women by implementing a cardiovascular prevention health promotion program in faith- and community-based sites. The primary outcomes were reducing obesity and increasing physical activity. A longitudinal cohort of high-risk (age > 40, ethnic minority) women (n = 1,052) was enrolled at 32 sites across the USA. The pre- or post-educational intervention consisted of eight biweekly counseling sessions conducted over 4 months each addressing one of six of the major CVD risk factors (smoking, diabetes, hypertension, cholesterol, obesity, and physical inactivity) as well as signs and symptoms of a heart attack and stroke; plus 4–6 maintenance sessions over three additional months. A multifaceted approach delivered by lay and medically trained personnel involving medical screenings, health behavior counseling, risk behavior modification, and stage of change were determined at baseline and end of counseling or maintenance. Following list-wise deletion, data were analyzed on 423 women who completed all follow-up time-points. Overall, significant improvement was attained in most of 28 secondary outcomes but not in the primary outcomes. Knowledge and awareness of heart disease as the leading killer or women, all of the signs and symptoms of a heart attack, calling 911, and CVD risk factors increased significantly (p < 0.05) by 8.8%, 13.6%, 5.8%, and 10%, respectively. There was a 10% (p < 0.05) increase in participants attaining control for hypertension (blood pressure < 140/90) coupled with a significant reduction in mean blood pressure in the entire cohort. Knowledge of effective CVD risk modification strategies for all CVD risk factors increased significantly (p < 0.05), except for obesity. In addition, there were significant (p < 0.05) increases in forward movement in stage of change for each CVD risk factor (range +10% to +39%). Thus, a heart disease prevention intervention built around a model of community engagement, advocacy, self-efficacy, resource knowledge, and health promotion in faith- and community-based organizations is successful at improving cardiovascular knowledge and awareness outcomes in high-risk women. Limitations of our study include the high dropout rate, significant time demands on site coordinators, limited resources for program implementation, lack of morbidity and mortality endpoints, and failure to attain the primary outcomes of weight loss and physical activity. Future studies should not only assess the effect of community education interventions on lifestyle change and knowledge and awareness of participants but should also address program duration, cost, and resources required to attain improved outcomes.

Validity of Reported Varicella History as a Marker for Varicella Zoster Virus Immunity Among Unvaccinated Children, Adolescents, and Young Adults in the Post–Vaccine Licensure Era

We assessed the validity of reported varicella history as a marker for varicella zoster virus immunity among unvaccinated persons 1 to 29 years of age, and we examined varicella disease characteristics associated with varicella zoster virus immunity among those reporting positive histories. We conducted a cross-sectional study at 7 community-based sites in Philadelphia, Pennsylvania, between June 2004 and May 2006 and recruited 1476 participants 1 to 29 years of age who had not been vaccinated against varicella. Sensitivity, specificity, and positive predictive value were determined by comparing self-reported or parent-reported varicella histories from a standardized study interview with varicella zoster virus immunoglobulin G serological results for each participant. We performed multivariate logistic regression analyses to determine which disease characteristics best predicted seropositivity. The sensitivity of reported varicella history was highest (81%-89%) among participants > or =10 years of age, whereas specificity was highest among participants 1 to 4 years of age (99%) and > or =20 years (88%). Reported varicella history was highly predictive of seropositivity (>95%) only among participants > or =15 years of age. For participants 10 to 14 years of age, parental reports of a generalized itchy rash with 1 of the following were highly predictive of seropositivity: varicella transmission to another household member or being raised in a household with no other children. Among participants < or =9 years of age, no combination of disease characteristics was both highly predictive of seropositivity and common. The validity of reported varicella history varies according to age, and a reported history is no longer highly predictive of seropositivity among cohorts born since 1994 (participants < or =9 years of age). Universal varicella vaccination, regardless of history, for these children should be considered, as should simplified criteria for varicella zoster virus immunity among unvaccinated persons born before 1994.

Violence Exposure and the Association Between Young African American Mothers' Discipline and Child Problem Behavior

Children of adolescent mothers are at increased risk of violence exposure and behavior problems, which have been linked to mothers' disciplinary practices. This study examines how the effect of young African American mothers' discipline on their preschool-age children's externalizing and internalizing behavior varies by mother and child violence exposure. A sample of 230 African American mothers who gave birth as adolescents and their 3- to 6-year-old children were recruited from community-based day care and primary health care sites in the Washington, DC, metropolitan region. In-person interviews were conducted by trained research assistants who administered standard survey instruments. Hierarchical regression models revealed an interaction effect such that adolescent mothers' harsh disciplinary practices, specifically physical discipline strategies, were positively associated with young children's internalizing and externalizing behavior in the context of high or moderate, but not low, maternal violence exposure. Compared with less violence-exposed mothers, the harsh disciplinary practices of young African American mothers who have been exposed to high levels of violence are more strongly associated with their children's problem behavior. Practitioners should screen mothers for violence exposure in order to address potential issues of discipline and behavior problems.

Cost‐Effectiveness of Increasing Access to Mammography Through Mobile Mammography for Older Women

To compare the costs of mobile and stationary mammography and examine the incremental cost-effectiveness of using mobile mammography to increase screening rates. A cost-effectiveness analysis was performed using effectiveness data from a randomized clinical trial and modeling of costs associated with the mobile mammography intervention. The trial involved 60 community-based meal sites, senior centers, and clubs. Four hundred ninety-nine individuals were enrolled in the study, of whom 463 had outcome data available for analysis. Costs were calculated for stationary and mobile mammography, as well as costs due to differences in technology and film versus digital. Incremental cost-effectiveness (cost per additional screen) was modeled, and sensitivity analysis was performed by altering efficiency (throughput) and effectiveness based on subgroup data from the randomized trial. The estimated annual costs were $435,162 for a stationary unit, $539,052 for a mobile film unit, and $456, 392 for a mobile digital unit. Assuming mobile units are less efficient (50% annual volume), the cost per screen was $41 for a stationary unit, $86 for a mobile film unit, and $102 for a mobile digital unit. The incremental cost per additional screen were $207 for a mobile film unit and $264 for a mobile digital unit over a stationary unit. Although mobile mammography is a more effective way to screen older women, the absolute cost per screen of mobile units is higher, whereas the reimbursement is no different. Financial barriers may impede the widespread use of this approach.

Use of Picture Dictionaries to Promote Functional Communication in Students With Deafness and Intellectual Disabilities

A mismatch of communication modalities can occur between students who communicate using sign language and coworkers at community-based vocational sites who do not use sign language. This study investigated the use of picture dictionaries to facilitate note writing as a form of expressive communication for students who were deaf and had mild to moderate intellectual disabilities. Students were systematically taught to use their picture dictionaries to initiate requests using the system of least prompts and the environmental arrangement strategy. A multiple baseline probe design was used. All students were able to successfully use the picture dictionaries to promote communication initiations. Implications regarding using the picture dictionaries for communication and for improving spelling of target vocabulary are discussed.

A “Health Commons” Approach to Oral Health for Low-Income Populations in a Rural State

Oral health needs are urgent in rural states. Creative, broad-based, and collaborative solutions can alleviate these needs. "Health commons" sites are enhanced, community-based, primary care safety net practices that include medical, behavioral, social, public, and oral health services. Successful intervention requires a comprehensive approach, including attention to enhancing dental service capacity, broadening the scope of the dental skills of locally available providers, expanding the pool of dental providers, creating new interdisciplinary teams in enhanced community-based sites, and developing more comprehensive oral health policy. By incorporating oral health services into the health commons primary care model, access for uninsured and underserved populations is increased. A coalition of motivated stakeholders includes community leaders, safety net providers, legislators, insurers, and medical, dental, and public health providers.

A Long-Term Comprehensive Evaluation of a Family-Based Pediatric Weight Management Program Implemented in Multiple Community-Based and Hospital-Based Sites

A Long-Term Comprehensive Evaluation of a Family-Based Pediatric Weight Management Program Implemented in Multiple Community-Based and Hospital-Based Sites

Understanding paediatric resident−continuity preceptor relationships through the lens of apprenticeship learning

Apprenticeship learning is common in medical education, but is often situated in theoretical frameworks which highlight its cognitive but not its social dimension. We conducted an ethnographic case study of paediatric residents' learning relationships with their preceptors in a community-based paediatric continuity site. It included 5 months (100 hours) of direct observation, and semi-structured interviews with 10 residents (before and after observation) and 10 primary care paediatricians who served as their continuity preceptors (after observation). Interview transcripts and notes from observations were inductively coded and analysed for major themes. Our observations and reports of resident learning trajectories fit well with the concept of legitimate peripheral participation. Residents learned the everyday practice of primary care as they worked alongside experienced paediatricians in the continuity clinic. Although the direction of learning was towards central participation in patient care, residents learned during transient shifts to the periphery of practice. As a function of residents' increased participation, preceptors moved into more supportive roles. Residents were not only learners; at times they were teachers who facilitated preceptors' learning. Legitimate peripheral participation is a concept that helps to explain apprenticeship as a dynamic social relationship which shapes, and is shaped by, learning that takes place in clinical practice. Other concepts shed light on the bidirectional nature of apprenticeship learning.

Low Prevalence of Detectable HIV Plasma Viremia in Patients Treated With Antiretroviral Therapy in Burkina Faso and Mali

Sub-Saharan Africa has seen dramatic increases in the numbers of people treated with antiretroviral therapy (ART). Although standard ART regimens are now universally applied, viral load measurement is not currently part of standard monitoring protocols in sub-Saharan Africa. We describe the prevalence of inadequate virological response (IVR) to ART (viral load >or= 500 copies/mL) and identify factors associated with this outcome in 606 HIV-positive patients treated for at least 6 months. Recruitment took place in 7 hospitals and community-based sites in Bamako and Ouagadougou, and information was collected using medical charts and interviews. The overall prevalence of IVR in treatment-naive patients was 12.3% and 24.4% for pretreated patients. There were no differences in rates of IVR according to ART delivery sites and time on treatment. Patients living farther away [odds ratio (OR) = 2.48; 95% confidence interval (CI) 1.40 to 4.39], those on protease inhibitor or nucleoside reverse transcriptase inhibitor regimens (OR = 3.23; 95% CI 1.79 to 5.82) and those reporting treatment interruptions (OR = 2.36; 95% CI 1.35 to 4.15), had increased odds of IVR. Immune suppression (OR = 3.32, 95% CI 1.94 to 5.70) and poor self-rated health (OR = 2.00; 95% CI 1.17 to 3.41) were also associated with IVR. Sufficient expertise and dedication exist in public hospital and community-based programs to achieve rates of treatment success comparable to better-resourced settings.

Increasing Safe Syringe Collection Sites in New York State

This article describes expansion of options for safe syringe collection in New York State (NYS) in conjunction with efforts to enhance and expand access to hypodermic needles and syringes. Together with activities to educate the public and providers about the dangers of improperly disposed of syringes, the goals were to (1) develop community-based collection sites for individuals to safely dispose of used syringes and (2) improve accessibility of existing health-care facility-based collection sites. During the period of 2002 to 2006, 79 community-based collection sites were created. These sites collected an estimated 2.6 million used syringes during 2006. Significant increases in availability and use of health-care facility-based collection sites was also documented. Efforts to promote safe disposal in NYS are ongoing, informed by these findings.

Double Jeopardy: Depressive Symptoms and Rapid Subsequent Pregnancy in Adolescent Mothers

Adolescent mothers in the United States are twice as likely as adults to become depressed, and African Americans seem to be especially at risk. A recent meta-analysis showed that nearly 1 in 5 teen mothers had another pregnancy within 12 months, and nearly 40% within 2 years. Both rapid subsequent pregnancy and maternal depression are associated with an increased risk of child abuse and neglect, as well as impaired intellectual development and psychosocial functioning. This study evaluated depressive symptoms using the Center for Epidemiological Studies Depression Scale in 269 pregnant teenagers age 12-18 years who were seen at 5 community-based prenatal sites. The subjects-predominantly low-income African Americans-were interviewed 1 and 2 years after delivery. Nearly half of the 245 teens followed until 2 years postpartum had at least one subsequent pregnancy, and 10% had more than one. One-third of 24 participants had another pregnancy within 12 months. The mean interval between the index birth and first subsequent pregnancy was 11.4 months. The teens who had a subsequent pregnancy were more likely to have dropped out of school, to not use condoms consistently, and to claim a relationship with their infant's father. Subsequent pregnancies were significantly more frequent in teens having depressive symptoms at baseline, even after adjusting for numerous possible confounding factors. In addition, teens with depressive symptoms tended to have a subsequent pregnancy significantly sooner after the index birth compared to those without such symptoms. These findings suggest that, in teenage mothers, depression may be an important and independent risk factor for a subsequent pregnancy within 1 to 2 years of an index pregnancy. Because depression is treatable, it will be of interest to learn whether better recognition will lessen the risk of a rapid subsequent pregnancy.

Evaluation of a Telephone Advice Nurse in a Nursing Faculty Managed Pediatric Community Clinic

Introduction Nurse-managed health centers face increasing obstacles to financial viability. Efficient use of clinic resources and timely and appropriate patient care are necessary for sustainability. A registered nurse with adequate education and support can provide high-quality triage and advice in community-based practice sites. The purpose of this program evaluation was to examine the effect of a telephone advice nurse service on parent/caregiver satisfaction and access to care. Methods A quasi-experimental separate pre-post sample design study investigated parent/caregiver satisfaction with a telephone advice nurse in an urban pediatric nurse-managed health center. The clinic medical information system was used to retrieve client visit data prior to the service and in the first year of the program. Results Statistically significant differences were found on two items from the satisfaction with the advice nurse survey: the reason for calling ( P < .05), and the importance of being involved in decision making ( P < .05). Discussion A telephone advice nurse may increase both parent/caregiver and provider satisfaction and access to care.