Federal Assistance Programs Research Articles

Using concept mapping to co-create implementation strategies to address maternal-child food insecurity during the first 1000 days of life.

Food insecurity (FI) has short- and long-term effects on maternal and child health, with persistent inequities within under-resourced communities of colour (e.g., Hispanic and Non-Hispanic Black). Interventions to mitigate maternal-child FI must engage the voices of under-resourced communities of colour to improve implementation and tackle socio-ecological drivers of inequities, leading to positive maternal-child outcomes. This exploratory sequential mixed-methods study aimed to co-create implementation strategies to tailor a culturally sensitive intervention to address FI during the first 1000 days of life in under-resourced communities of colour in Las Vegas. A Community Advisory Board (CAB) engaged in a two-step participatory process. First, through the concept mapping, hierarchical cluster analysis organized 125 strategies into seven thematic areas: policy and advocacy, access to food and resources, built environment, education across systems, social and peer support, cultural congruency and trust, and wellness and mental health. Second, through consensus-building, strategies were combined by similarity (n = 94) and excluded if unrelated to health and nutrition (n = 9). The CAB reached a consensus on 22 strategies classified across three socio-ecological levels. Examples of strategies at the community level (n = 16) included increasing utilization of federal nutrition assistance programmes; at the service level (n = 4), integrating FI screenings and referral coordination systems across services; and at the individual level (n = 2), providing mentorship, education, and support for families and moms. The co-creation of a culturally sensitive intervention to reduce inequities in maternal-child FI during the first 1000 days of life requires multi-level strategies across three socio-ecological levels in under-resourced communities of colour in Las Vegas.

US federal resource allocations are inconsistent with concentrations of energy poverty.

Recent data from the US Energy Information Administration reveals that nearly one in three households in the United States report experiencing energy poverty, and this number is only expected to rise. Federal assistance programs exist, but allocations across states have been nearly static since 1984, while the distribution of energy poverty is dynamic in location and time. We implement a LASSO-based machine learning approach using sociodemographic and geographical information to estimate energy burden in each US census tract for 2015 and 2020. We then compare the allocation to states from the Low Income Home Energy Assistance Program to an optimized allocation. We allocate funds to the most burdened households, providing them with enough assistance to reduce their energy expenditures so that their household energy burden is equal to a new maximum allowable energy burden. This markedly shifts funds from the northern cold-weather states to the southern warm-weather states.

Assessing social equity of federal disaster aid distribution: A nationwide analysis.

In this study, we conduct the first comprehensive, nationwide assessment of social equity performance of multiple federal post- and pre-disaster assistance programs that differ in targeted recipients, project types, forms of aid, and funding requirements. We draw on the social equity and distributive justice theory to develop and test a set of hypotheses on the influence of program design and specificity on their aid distributional patterns and equity performance. The analysis uses panel data of about 3000 US counties to examine the relationship between a county's receipt of federal assistance and its recent disaster damage, socioeconomic, demographic, political, local government, and geographic characteristics in a two-stage random effects Tobit model. Expectedly, we find that post-disaster grants are largely driven by recent disaster damage, while damage is simultaneously influenced by local socioeconomic conditions. For all disaster programs, disproportionately more federal aid is allocated to populous counties. For programs geared toward state and local governments and targeting community recovery and mitigation, more aid is received by counties with better socioeconomic conditions. Conversely, for programs targeting individual relief and recovery, more aid is given to counties with lower incomes and greater social vulnerability. Results also indicate that counties located in high-risk regions receive greater outlays. These findings shed light on the varying degrees of social equity of federal disaster assistance programs tied to their cost-share requirement, funding caps, and inherent complexity of application procedures.

Demographic Characteristics, Perinatal Smoking Patterns, and Risk for Neonatal Health Complications Among Pregnant Smokers in the United States Who Begin Using Electronic Cigarettes During Pregnancy: A Descriptive Study Using Population-Based Surveillance Data.

Health agencies have called for research evaluating e-cigarette (EC) use in supporting prenatal smoking cessation. This study aimed to describe (1) the characteristics of smokers who begin using electronic cigarettes (ECs) during pregnancy, (2) how frequently smokers reduce or eliminate pre- and post-natal combustible cigarette (CC) use, and (3) the risk for neonatal health complications among smokers who initiate ECs during pregnancy. Pregnant women using CCs exclusively during prepregnancy, who participated in a U.S. surveillance study, were classified by their reported late-pregnancy smoking behavior as CC-exclusive users, EC initiators, or quitters. EC initiators were further subclassified as dual users (used both ECs and CCs) or EC replacers (used ECs exclusively). Of 29 505 pregnant smokers, 1.5% reported using ECs during the last three pregnancy months. Among them, 29.7% became EC-exclusive users. EC initiators were disproportionately non-Hispanic White. Relative to quitters, EC initiators had lower income, were less likely to be married, have intended pregnancies, receive first-trimester prenatal care, and participate in a federal assistance program. Compared to CC-exclusive users, EC initiators overall, and dual users specifically, were more likely to reduce pre- and post-natal CC usage relative to prepregnancy levels. EC initiators' risk for neonatal health complications fell between quitters and CC-exclusive users, though the differences were not statistically significant. Although EC initiators reduced CC use more than CC-exclusive users, only 29.7% reported complete CC cessation, and there was insufficient evidence of reduction in neonatal health complications relative to CC-exclusive users. Currently, ECs should not be considered a viable gestational smoking cessation strategy. Health agencies have identified a critical need for research evaluating the use of e-cigarettes in supporting prenatal smoking cessation. Using the U.S. Pregnancy Risk Assessment Monitoring System surveillance study data, we provide real-world evidence that prenatal e-cigarette initiation as a smoking cessation tool is used infrequently among pregnant CCs smokers. Most using e-cigarettes in the last 3 months of pregnancy also used CCs.

Association Between Rental Assistance Programs and Undiagnosed Diabetes Among U.S.

Rental assistance programs have been linked to better housing quality, stability, healthcare access, and reduced likelihood of uncontrolled diabetes. However, its direct association with diabetes screening is uncertain. To determine whether federal rental assistance programs are associated with lower odds of undiagnosed diabetes. We used a quasi-experimental approach, comparing outcomes among adults receiving rental assistance to those who entered assisted housing within 2 years after their health data were collected. We test the a priori hypothesis that rental assistance will be associated with decreased odds of undiagnosed diabetes. Participants in the National Health and Nutrition Examination Survey 1999-2018 who received rental assistance and who had diabetes. Current rental assistance participation, including specific housing programs. Undiagnosed diabetes based on having hemoglobin A1c ≥ 6.5% but answering no to the survey question of being diagnosed with diabetes. Among 435 eligible adults (median age 54.5 years, female 68.5%, non-Hispanic white 32.5%), 80.7% were receiving rental assistance programs at the time of the interview, and 19.3% went on to receive rental assistance within 2 years. The rates of undiagnosed diabetes were 15.0% and 25.3% among those receiving rental assistance programs vs. those in the future assistance group (p-value = 0.07). In an adjusted logistic regression model, adults receiving rental assistance had lower odds of undiagnosed diabetes (OR 0.52, 95% CI 0.28-0.94) than those in future assistance groups. Sex, race and ethnic group, educational level, and poverty ratio were not significantly associated with having undiagnosed diabetes, but individuals aged 45-64 years had significantly lower odds of undiagnosed diabetes (OR 0.21, 95% CI 0.08-0.53) compared with those aged 18-44. Rental assistance was linked to lower odds of undiagnosed diabetes, suggesting that affordable housing programs can aid in early recognition and diagnosis, which may improve long-term outcomes.

Potential inequities in access to in-person SHIP counseling services.

Counseling and education on Medicare coverage options are available through the federal State Health Insurance Assistance Program (SHIP), but little is known about the population that SHIP reaches. Cross-sectional study. Using a novel data source on SHIP counseling site locations, we characterized the availability of in-person SHIP counseling by zip code tabulation area (ZCTA) and used linear regression and t tests to evaluate whether SHIP counseling sites are disproportionately located in higher-income communities. Our sample included 1511 SHIP counseling sites. More than half (63%) of the localities in our sample have a SHIP site within the ZCTA or county. Twenty-four percent do not have a SHIP site within the county but have one in an adjacent county. The remaining 13% do not have a nearby SHIP site. There is a disproportionate number of individuals eligible for Medicare in localities without a SHIP site. Moreover, the population living in areas without in-person SHIP sites is more likely to have low income and fewer years of education than the population living in areas with a SHIPsite. These results suggest that there are areas where in-person SHIP service expansion or other additional navigation support may be warranted.

Racial/Ethnic Disparities in Renters’ Experiences with Maintenance Delays in the United States

Structural racism and individual discrimination contribute to racial inequalities in poor housing conditions in the United States. Less is known about whether and how structural racism and individual discrimination shape a parallel, but distinct, process that is also consequential for family wellbeing: experiencing housing unit maintenance delays. Maintenance delays transform acute problems into chronic stressors and increase exposure to physical hazards over time. Using the 2013 American Housing Survey, I examine racial/ethnic disparities in maintenance delays across non-Hispanic White, Black, Hispanic, Asian, and American Indian/Alaska Native renters. Given that 2.3 million low-income households rent using Housing Choice Vouchers (HCVs), a federal housing assistance program with requirements around repair timing, I also examine how renting with a voucher shapes maintenance delays. There are three principal findings. First, White renters are more likely to report timely repairs than either Black or Hispanic renters. Second, for Black renters, both structural racism experienced in rental markets and individual discrimination drive this disparity, whereas Hispanic renters’ diverging maintenance experiences are largely explained by pathways impacted by structural racism. Third, renting with an HCV is not associated with repair timeliness for any racial/ethnic group. Taken together, the findings suggest that racial/ethnic disparities in substandard housing emerge not only through unequal exposure to housing quality problems but also through unequal responses to these issues.

Food insecurity and health-related quality of life among a nationally representative sample of older adults: cross-sectional analysis

BackgroundFood insecurity is a significant health issue among older adults and contributes to poorer quality of life and mental health. However, limited evidence is available among older adults. Thus, the study evaluated the associations between food security and multiple outcomes related to health-related quality of life. We examined whether participants’ sex and participation in the federal Supplemental Nutrition Assistance Program (SNAP)/or receiving the Food Stamp program might modify these associations.MethodsCross-sectional analysis of the 2007–2012 National Health and Nutrition Examination Surveys (NHANES). A sample of 3,375 adults aged ≥ 60 years with household incomes ≤ 300% of the federal poverty level (FPBL). Food security was assessed using the 18-item US Household Food Security Survey Module and categorized as food security, marginal food security, and food insecurity. Outcomes were the CDC Health-Related Quality of Life measures (HRQOL-4).ResultsApproximately 8% experienced marginal food security and 12% experienced food insecurity. Over the past month, food insecurity was significantly associated with ≥ 16 days of poor physical health (OR 1.88, 95% CI 1.23, 2.85, P-trend = 0.005), ≥ 16 days of poor mental health (OR 2.22, 95% CI 1.50, 3.28, P-trend < 0.0001), and ≥ 16 days of feeling anxious (OR 3.33, 95% CI 2.30, 4.81, P-trend < 0.0001) after multivariate adjustment. The association between food insecurity and poor physical health was stronger in females (P-interaction = 0.02). There was no evidence for effect modification in any of these associations among those receiving benefits from the federal SNAP/Food Stamp program.ConclusionsFood insecurity was positively associated with multiple adverse health outcomes. Public health programs and policies targeted for older adults are needed to mitigate the extent of food insecurity to promote overall health and well-being.

Socioeconomic Status Diversity of Trainees and Faculty in Residency Programs: A Pilot Study in Plastic Surgery

The socioeconomic diversity of residents, fellows, and faculty members in any medical or surgical specialty is currently unknown making it difficult to understand socioeconomic status (SES) disparities and create programs to improve diversity. Additionally, the career trajectories of residents and faculty members who come from different SES backgrounds have not been explored. We have performed a survey-based research study to understand the SES composition and career trajectories of residents and faculty members within U.S. Plastic and Reconstructive Surgery (PRS) residency programs. An anonymous online survey was administered to 754 recipients within plastic surgery residency programs in the United States. Self-reported SES information such as household income prior to age 18 and parental education level was collected. Data regarding career trajectories was obtained through questions about away rotations and research productivity. A total of 196 fellows, and faculty members participated in the study, with an estimated survey respondent rate of 25.9%. Only 9.9% (10 of 101) of residents and fellows reported a childhood (under age 18) family income less than $40,000. When analyzing parental education and occupation (EO-status), 42.6% (43 of 101) of residents and fellows had at least 1 parent in an executive, managerial, or professional position with a doctorate/professional degree. Low-income and low EO-status were associated with increased utilization of federal and state assistance programs (p = 0.0001) and approval for AAMC's Fee Assistance Program (FAP) (p = 0.0001). Residents and fellows who identified as White were not as likely to be from low EO-status households as those who identified as Asian (OR 0.3 and p = 0.015 vs. OR 2.9 and p = 0.038). Residents and fellows from low EO-status backgrounds were more likely to take a gap in education (87% vs. 65.4%, p = 0.047) compared to their high EO-status peers. Notably, more current residents and fellows performed away rotations and had first-author publications during or before medical school compared to full professors (p = 0.0001). Understanding the backgrounds and career trajectories of trainees and faculty in medicine is essential, yet it has not been performed at the resident or faculty level. This survey is the first to demonstrate the lack of socioeconomic diversity in a specialty (PRS) and identifies variation in career trajectories among those from different SES backgrounds. Large-scale research efforts are necessary to understand current SES diversity and barriers encountered by trainees and educators from low-SES backgrounds in all medical and surgical specialties.

Spatial analysis of community service availability in rural Kentucky, United States.

This study examined community service provider (CSP) availability relative to neighborhood socioeconomic status and its association with health-related social needs in Eastern Kentucky, United States. We used GIS methods to generate 10-mile network service areas around addresses of 736 CSPs and 10,161 Medicaid and Medicare beneficiaries screened August 2018-April 2020 in 27-county study region. We observed wide variation in CSP availability and an inverse relationship between CSP availability and rates of unemployment, poverty, and federal Supplemental Nutrition Assistance Program. The CSPs appear to have higher availability in more affluent census block groups. We found a statistically significant negative relationship between CSP availability within 10 miles of a beneficiary's resident and the presence of food, housing, transportation needs. Our findings suggest that healthcare providers, government entities, and non-profit organizations should consider geographic accessibility to those most in need when making referral and funding decisions, particularly in rural communities.

Addressing food insecurity and intersectional health-related social needs at a federally qualified health centre during the COVID-19 pandemic: a case study

ABSTRACT The COVID-19 pandemic has exacerbated preexisting health-related social needs (HRSN) in communities already facing health disparities. Federally qualified health centres (FQHC) are well positioned to understand the unique needs of diverse communities and patients. This singular case study provides a novel look into one Massachusetts FQHC's experience addressing increased hunger and poverty in their patient population. Interviews with the FQHC staff and leadership explored perspectives on the centre's current practices to address food insecurity, barriers they face, and hopes for improving community health. Interviews were recorded, transcribed, and coded using grounded theory methods. Participants were equivocal about whether food insecurity was the largest problem patients are facing. They rather emphasised the intersectional nature HRSN, including housing instability, occupational health hazards, and unemployment. Stigma associated with utilising social services, HRSN screening disruptions, and capacity limitations were barriers to addressing the community's needs. Participants highlighted the importance of patient agency; allowing patients to choose for themselves how and where they spend money to meet their health needs. The need to invest in community-centred and culturally sensitive solutions was also emphasised. Longer-term interventions, such as application assistance to federal nutrition assistance programmes, were highly favoured over emergency aid. Addressing the root causes of poverty and health disparities was recognised as essential to improving community health both during and after the pandemic. Findings highlight the importance of fostering trust and supporting community-centred and justice-oriented interventions that go beyond emergency assistance and individualised care.

Making sense of eviction trends during the pandemic

Eviction filings have largely returned to their prepandemic levels in 2022 after a long period of being below trend. In this Economic Commentary, I describe the trends in eviction filings collected so far during the pandemic and pandemic-era policies aimed at mitigating the damage of the pandemic on housing stability. I show that restrictions on evictions, common early in the pandemic, are associated with lower levels of eviction filings; that recent rent-price growth is associated with higher levels of eviction filings; and that the timing of eviction trends varies in response to the federal emergency rental assistance program in a way that is consistent with the program’s design.

Association Between Rental Assistance Programs and Hemoglobin A1c Levels Among US Adults

Programs that provide affordable and stable housing, such as federal rental assistance, may be associated with improved mean blood glucose levels and related diabetes outcomes. To assess whether 2 different types of federal rental assistance programs are associated with glycated hemoglobin A1c (HbA1c) levels among middle-aged and older US adults. This cohort study used data from the National Health and Nutrition Examination Survey (NHANES) linked with US Department of Housing and Urban Development records of rental assistance participation. Adults aged 45 years or older who were receiving 2 types of rental assistance (project-based housing or housing vouchers) at the time of the NHANES interview and those who would receive rental assistance within the subsequent 2 years (waitlist group) were included. Data were collected from January 1999 to December 2016 and analyzed in October 2021. Rental assistance participation, including project-based housing (subsidized housing developments including public housing) and housing vouchers (tenant-based subsidies for private market housing). The primary outcome was continuous HbA1c level, a common measure of blood glucose reflecting diabetes control. Linear regression was used to estimate the association between the 2 rental assistance programs and HbA1c level. Logistic regression was used to assess the association between rental assistance programs and HbA1c cut points (prediabetes: 5.7% to ≤6.5%; diabetes: >6.5%; uncontrolled diabetes: ≥9% [to convert to proportion of total Hb, multiply by 0.01]). Analyses used weights created by the National Center for Health Statistics that adjust for linkage eligibility. Among 1050 adults in the study (41.6% aged ≥65 years; 70.1% female), 795 were receiving rental assistance at time of the NHANES interview (450 lived in project-based housing, and 345 had housing vouchers), and 255 received rental assistance within 2 years after the interview. Participants in project-based housing had lower HbA1c levels compared with individuals in the waitlist group (β, -0.290; 95% CI, -0.599 to 0.020), but the difference was not significant. No significant differences in HbA1c levels were found between those receiving housing vouchers and those in the waitlist group (β, 0.051; 95% CI, -0.182 to 0.284). Receiving project-based housing was associated with a reduced likelihood of uncontrolled diabetes (-3.7 percentage points; 95% CI, -7.0 to -0.0 percentage points) compared with being in the waitlist group. In this cohort study of a nationally representative sample of US adults, living in project-based, federally subsidized housing was associated with a reduced likelihood of uncontrolled diabetes. The findings suggest that affordable housing programs may be associated with improved diabetes outcomes.

Sociodemographic and Biological Factors of Health Disparities of Mothers and Their Very Low Birth-Weight Infants.

Background:Black mothers and their very low birth-weight infants in the United States have increased risk of adverse neonatal and maternal health outcomes compared with White mothers and infants. Disparities in adverse birth outcomes associated with sociodemographic factors are difficult to quantify and modify, limiting their usefulness in assessing intervention effects.Purpose:To test hypotheses that (1) the biological factors of maternal testosterone and cortisol are associated with sociodemographic factors and (2) both factors are associated with neonatal health and maternal mental health and healthy behaviors between birth and 40 weeks' gestational age.Methods:We used a descriptive, longitudinal design. Eighty-eight mothers and very low birth-weight neonates were recruited from a tertiary medical center in the United States. Data on sociodemographic factors and neonatal health were collected from medical records. Maternal mental health and healthy behaviors were collected with questionnaires. Maternal salivary testosterone and cortisol levels were measured using enzyme immunoassays. Data were analyzed primarily using general linear and mixed models.Results:High testosterone and/or low cortisol levels were associated with younger age, less education, enrollment in a federal assistance program, being unmarried, being Black, poorer neonatal health, and delayed physical growth. Low cortisol level was related to higher levels of depressive symptoms. Black mothers had fewer healthy behaviors than White mothers.Implications for Practice and Research:Findings confirm that biological factors are associated with sociodemographic factors, and both are associated with neonatal health and maternal mental health and healthy behaviors. We propose using sociodemographic and biological factors concurrently to identify risk and develop and evaluate ante- and postpartum interventions.Video abstract available at https://journals.na.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=59

Food security and diet quality in a racially diverse cohort of postpartum women in the USA.

Food insecurity has been associated with poor diet, but few studies focused on the postpartum period - an important time for women's health. We examined associations between food security and diet quality in postpartum women and assessed whether participation in federal food assistance programmes modified this potential relation. Using longitudinal data, we analysed the association between food security at 3 months postpartum and a modified Alternate Healthy Eating Index-2010 (AHEI) at 6 months postpartum (excluding alcohol). We conducted multivariable linear regressions examining associations between food security and AHEI. We assessed two food assistance programmes as potential effect modifiers. The sample included 363 postpartum women from the Nurture study, located in the Southeastern USA (2013-2017). Among women, 64·4 % were Black and 45·7 % had a high school diploma or less. We found no evidence of an interaction between food security and two federal food assistance programmes. In adjusted models, marginal, low and very low food security were not associated with AHEI. However, low (β: -0·64; 95 % CI -1·15, -0·13; P = 0·01) and very low (β: -0·57; 95 % CI -1·02, -0·13; P = 0·01) food security were associated with greater trans fat intake. Food security status was not associated with overall diet quality but was associated with higher trans fat (low and very low) and more moderate alcohol (marginal) intake. Future studies should assess the consistency and generalisability of these findings.

Creating diabetes guidelines for the individual not just the illness

For more than 30 years the American Diabetes Association (ADA) has developed and published recommendations and related documents for clinical practice for diabetes care. ADA's Standards of Medical Care in Diabetes document,1 referred to as the Standards of Care, is intended to inform clinicians, researchers, policy makers, payers (ie, federal and commercial insurance, and federal and states assistance programmes, and health maintenance organisations) of the components of diabetes care, general treatment goals, and tools to evaluate the quality of care.

Policy Implications of the COVID-19 Pandemic on Food Insecurity in Rural America: Evidence from Appalachia.

Rural communities are disproportionally affected by food insecurity, making them vulnerable to the consequences of supply disruptions caused by the COVID-19 pandemic. While access to food was initially diminished due to food supply disruptions, little is known about the mechanisms through which federal emergency assistance programs impacted food access in rural populations. Through a series of five focus groups in spring 2021, we examined the impact of the COVID-19 pandemic on food access in a rural Appalachian community in Kentucky. Data were analyzed using a Grounded Theory Approach. Findings revealed the following four primary themes: food scarcity in grocery stores; expanded federal food assistance; expanded community food resources; and expanded home gardening. Participants provided details regarding the way increased federal assistance, especially expanded benefits within the Supplemental Nutrition Assistance Program, allowed them to purchase greater quantities of nutritious food. This study unveils the specific impacts of the COVID-19 pandemic on one rural population, including the influence of some social determinants of health on food insecurity. Policymakers and stakeholders should recognize the layered protection of multiple federal emergency assistance programs against food insecurity and the potential for long-term population health promotion in rural areas.

Food Insecurity in the Food Allergic Population: A Work Group Report of the AAAAI Adverse Reactions to Foods Committee

Food allergies affect 32 million Americans. Restricted diets due to food allergies can be difficult to maintain especially when the household is food insecure. Food insecurity is defined as the inability to acquire food for household members due to insufficient money or resources for food. The COVID-19 pandemic has caused many people to face food insecurity for the first time with Latinx, Native American, and Black communities disproportionately affected. Because of the increase in food insecurity, this work group developed a survey regarding food insecurity screening. This survey was sent out to a random sample of American Academy of Allergy Asthma & Immunology members to assess food insecurity knowledge and practices. The majority of survey participants did not routinely screen their patients for food insecurity. The biggest barrier identified to screening was lack of knowledge of how to perform a screen and resources available when a patient screened positive. This work group report provides guidance on how to implement and perform a food insecurity screen, including federal resources and assistance programs.

Food Insecurity on College and University Campuses: A Context and Rationale for Solutions

Food Insecurity on College and University Campuses: A Context and Rationale for Solutions

Improving partnerships in rural communities: Organizing approaches for improved effectiveness and reach of rural nutrition programs

ABSTRACT How local initiatives organize to address community issues can impact project success. Hunger alleviation programs serving high poverty, rural populations rarely reach full participation and often do not coordinate services. This paper is a summary of findings from a three-year study of 15 regional partnerships working to improve participation in, and communication between federal assistance programs addressing childhood food insecurity in high poverty, rural areas. The regional partnerships explored organizing structures and collaborative outreach methods to improve program reach and involvement. Most partnership teams addressed community connections by organizing coalitions or working with existing coalitions. Partnership coalitions improved over the duration of this study by increasing attention to organizational structure, purpose, and group processes. In addition, all partnerships used technology and digital media to expand outreach, communication, and coordination. Results included expanded partnership collaboration, increased program participation, and expanded promotion through creative outreach strategies to engage community members.