Deborah J. Bowen, Ph.D. - US grants

DESCRIPTION (provided by applicant): While there has been "a dramatic increase in the attention and resources devoted to partnership or collaborative approaches to public health goals in the US," few of these efforts have focused on improving the mental health of communities. In this proposal we are seeking funds to establish the Boston Community Academic Mental Health Partnership (B-GAMHP). This partnership brings together consumers, family members and academic based researchers to develop community based participatory action research in mental health. We have defined our community as adults struggling with severe and persistent mental disorders (SPMI) and children struggling with severe emotional disturbance (SED) in Boston. This is an area of critical importance for while there are many academic mental health researchers in Boston, few avenues exist for consumers and family members to be a significant part of the research process. Our long term goal is to create a mechanism through which community members can inform and participate in all aspects of the research process; from question generation, to the design and conduct of research studies, the interpretation of results, and dissemination. The specific aims of this proposal are: 1) to develop the B-CAMHP; 2) to conduct a pilot study of consumer perspectives of psychiatric emergency care; and 3) to identify and develop future research proposals and sustainability efforts for the B-CAMHP. In developing the B-CAMHP we will hold regular meetings of the partners in order to develop a mission statement, operating guidelines, and to articulate shared common long-term goals. We will explore ways to expand the B-CAMHP with additional key community stakeholders. We will hire and train 4-6 consumer research assistants to participate in the B-CAMHP, conduct interviews and data analysis, and work on all aspects of the pilot study. We have chosen to focus the pilot study for this proposal on psychiatric emergency care. We have identified the lack of consumer and community input as an important gap in the research and literature on the use of psychiatric emergency services. Our preliminary study design involves the use of trained consumer interviewers to conduct a series of 30 interviews with users of psychiatric emergency care and their families. This proposal presents a unique opportunity to facilitate the continuation of this important work based on existing collaborations and partnerships and is a critical step in establishing the ongoing partnership between the community of people struggling with severe mental illness and their families, and the academic community in Boston. These efforts are steps towards achieving the change needed to expanding our knowledge to better inform the development a system of care that best meets the needs of consumers, their family members and other stakeholders.

[unreadable] DESCRIPTION (provided by applicant): American Indian/Alaska Native (AI/AN) populations are generally considered to suffer from the most dramatic disease and behavior health disparities of any non-White racial/ethnic group in the US. Few interventions to accomplish these goals have been tested. One potential point of intervention in AI/AN communities is through the workplace because workplaces provide access to AI/AN people, supported by communications and financial infrastructures. In 2003, the Department of Health and Human Services issued a call to action to the nation's employers to implement workplace health promotion interventions aimed at chronic diseases. We have created and piloted a package for the general population that is specifically designed to be implemented in the workplace. Our comprehensive package builds on the evidence collected by 2 federal task forces, the U.S. Preventive Services Task Force and the Task Force on Community Preventive Services. It recommends 15 practices that employers should implement in the workplace that fall into the broad domains of health insurance benefits, policies, programs, and communication and tracking systems. The 15 practices are aimed at helping employees increase the following 7 specific behaviors: 1) colon cancer screening, 2) healthy eating, 3) influenza immunization, 4) mammography use, 5) Pap smear use, 6) physical activity, and 6) tobacco cessation treatment. The working environments, needs, and structures of the lives of AI/AN people, in conjunction with the health disparities they suffer from, call for formative research to create and test such an intervention. Thus, the specific aims of this proposal are to create a package of proven health promotion interventions that is culturally appropriate in AI/AN workplace settings; test the feasibility of implementing this package in 4 different types of AI/AN workplaces; and evaluate its acceptability and usability. Our findings from the pilot study employers and their responsiveness to our approach and recommendations suggested that we are serving a largely unmet need - a need that will be even greater in Indian Country. Critical to the success of the proposed study, we have also found that the intervention developed in the pilot study could be successfully delivered by project interventionists from a community partner, with oversight from the academic partners. Community participation is critical to the success of research efforts involving Indian communities and to the acceptance and dissemination of new approaches. This project will be important to public health in several ways. It targets a disparities population, Native American people. It uses a public health channel for the implementation of proven interventions, workplaces. Finally, it will further develop an intervention model that can be used in multiple settings, and used to change multiple risk factors for chronic disease. [unreadable] [unreadable] [unreadable]

DESCRIPTION (provided by applicant): Obesity occurs disproportionately in women of lower socioeconomic status (SES), especially in industrialized countries. Rising rates of obesity have been linked to higher rates of cardiovascular disease, cancer, diabetes, and other chronic and life threatening diseases in both men and women. Weight gain in women during middle age (age 30-50) is frequent and of particular concern because of the consequences for later health and because of the important role these women play in their households. Among Hispanics, higher rates of obesity are associated with higher SES, similar to what has been found in poorer countries, historically. Most obesity prevention programs based on individual behavior change have not been successful in achieving long-term healthy weight. Attention is shifting to more complex environmental and societal contributions to adiposity, including central adiposity, to help identify multi-level and multi-causal pathways and to target interventions to high risk groups. Improved understanding is needed of the mechanisms by which established risk factors for increased body mass index (BMI) operate along the SES gradient (inverse for Caucasians, and positive for Hispanics). The main aim of this project is to better understand and evaluate the putative causal pathways between SES and BMI in middle-age women. Data from this project would assist in reducing the number of intervention channels and provide clues on how to reach these women and their household members to influence weight change through the mechanisms that mediate the SES disparities in risk of obesity. Ultimately, excess weight is caused by energy imbalance, with higher caloric input than output. However why this should occur at different rates according to different levels of SES is not known. We shall test key explanations for the SES and overweight/obesity relationship in a population-based cohort of 1000 women age 30-50, with oversampling of Hispanic women in a major urban area, based on a conceptual model by Mackenbach.1-3 By augmenting the recruitment to enhance the representation of women of Hispanic ethnicity, we will be able to conduct analyses within the group who are non-Hispanic white and separately, within the group who are of Hispanic origin. Specific aims are as follows: 1. To evaluate the mediating cross-sectional effects of a) material resources (e.g., walkability of neighborhood, availability of healthy foods;cost of food);b) psychosocial context (e.g., body image, norms of family and culture);and c) stress process (e.g., mood, sleep disturbance, cortisol) in the relationship between SES, weight-related behaviors (physical activity &eating patterns) and BMI in middle-age women 2. To evaluate the relationship between SES and change in weight over a 3-year period 3. To evaluate longitudinally the mediating effects of material resources, psychosocial context, and the stress process in the relationship between SES, BMI and central adiposity in middle aged women. PUBLIC HEALTH RELEVANCE Possible explanations for the observation that gradients over time in increased weight for height differ according to socioeconomic status are not well understood, and may differ by ethnicity or other socio- cultural factors. We propose, in middle aged Caucasian and Hispanic women, to study mechanisms including social, psychological, and biological factors, and the intersection of these factors in explaining the observed associations of obesity risk with socioeconomic status. Data from this project would assist in reducing the number of intervention foci and provide clues on how to reach these women and their household members to influence weight change through the mechanisms that mediate the socioeconomic disparities in risk of obesity.

DESCRIPTION (provided by applicant): The mission of the Partners in Health and Housing Prevention Research Center (PHH-PRC) at Boston University School of Public Health (BUSPH) is to improve the health and well being of public housing residents. To accomplish this, BUSPH has partnered with the Boston Housing Authority (BHA), the Boston Public Health Commission (BPHC) and the Community Committee for Health Promotion (CCHP), a community-based organization of public housing residents and advocates. This partnership has trained public housing residents, known as Resident Health Advocates (RHAs), in all 24 BHA family developments. The goals of the PHH-PRC are: 1) to build, improve and expand the capacity of the PHH-PRC infrastructure to support PHH-PRC activities;2) to assess the public health concerns and needs of public housing residents;3) to design and perform prevention research in the public housing setting;4) to identify and educate community leaders among residents of public housing about ways to improve the health of residents;5) to create practice opportunities in Boston public housing developments for public health students;6) to expand an effective partnership among BUSPH,-BHA and BPHC to address the public health needs of public housing residents;7) to sustain successful prevention programs for public housing residents through integration into ongoing programs of partner agencies;8) to communicate and disseminate PHH- PRC findings;and 9) to document PHH-PRC successes, identify areas where improvement is needed, and revise objectives to optimize potential for realizing PHH-PRC goals and National PRC Goals. The PHH-PRC partners work together to develop all research projects. The proposed PHH-PRC Core Research project will examine the effectiveness of a program of RHA-assisted navigation of public housing residents into disease treatment and health promotion programs. Public housing residents have lower health status than the general population and are also more likely to be members of racial, ethnic and socioeconomic minorities. Thus, the activities proposed for the PHH-PRC address the Healthy People 2010 goals of increasing health status and of reducing health disparities. RELEVANCE (See instructions): The Partners in Health and Housing Prevention Research Center seeks to improve the health and well-being of public housing residents. We have trained public housing residents to be Resident Health Advocates (RHAs) and we are proposing to study whether RHAs can significantly increase the participation of public housing residents in ongoing disease prevention and health promotion programs.

Project Summary/Abstract Genetics reports on 22 areas of clinical practice guidelines on how to use genetic tests, based on data that clinical outcomes are enhanced or improved by regular use. Current practice guidelines from ACMG provide referral indications for cancer predisposition assessment. Identifying patients with high genetic risk for breast, ovary, colon, or other cancers has important clinical ramifications for an individual's healthcare, but genetic risk if often not identified because of testing barriers at several levels. Barriers at the provider level include inadequacies in risk recognition, patient referrals and availability of genetic professionals to provide counseling in a traditional testing paradigm. Barriers at the level of the patient include poor understanding of the availability and benefits of testing and inadequate access to testing services. How to best implement appropriate genomic testing and follow-up care into an operating healthcare system is not known. Issues of communication, clinical flow, reportable actions, and transmission of information and support are of critical importance, and must change and grow to accommodate the new information contained within genomic testing. Studies to date of the implementation process have been conducted in high resourced facilities, under optimal conditions, often not at the system level. Aims include: 1. Compare the efficacy and implementation of two strategies for identifying members of a primary care clinic's population who have a family or personal history of cancer and offering high-risk individuals to obtain genetic testing for cancer susceptibility mutations in a randomized trial. The two methods are: 1) Point of Care (POC) approach: A tablet-based screening for family/personal history of cancer will be offered to all patients aged 25- 65 coming in for a routine appointment at the clinic. 2) Direct Patient Engagement (DPE): Letters will be sent to all individuals aged 25-65 in a clinic's population, inviting them to visit a web site for screening for family /personal history of cancer. In both strategies, those determined to be high-risk will receive online education about genetic testing and an invitation to obtain such testing through a web-based platform. Outcomes will be the fraction of the active clinic patient population that completes screening and the fraction of the active clinic patient population that undergoes testing. 2. Identify changes, problems, and inefficiencies in clinical flow and interactions during and after the implementation of genomic testing for cancer risk across primary care clinics. 3. Evaluate the effects of two methods of implementation of genomic screening for cancer risk on patient, provider, and health system leader reports of benefits and harms, satisfaction, perceived quality of care, including across gender, racial/ethnic, socioeconomic, and genetic literacy divides. 4. Evaluate the value (cost-effectiveness) and affordability (budget impact) of each screening strategy.

Project Summary Physical activity has been associated with several chronic disease markers for the past 25 years, and countless studies have tested interventions to improve physical activity of sedentary populations. Most of these intervention studies have attempted to improve physical activity behaviors by changing individual level drivers of activity, like motivation, attitudes, and self-efficacy for being active. Unfortunately, these efforts to change activity levels are often not sustained beyond the initial intervention period. One possible cause of this lack of sustainability is that insufficient attention was paid to environmental factors that facilitate physical activity. Thus, attention is shifting to more complex environmental and social contributions to physical activity, with the aim of identifying multi-level strategies to better target interventions to groups that need help. Very few tests of changing environment levels to increase physical activity exist in the literature. A focus on interventions at environmental levels, as called for by recent reviews as well as reports from the Institute of Medicine, might provide the long-term sustainable change that is needed to change physical activity in low-income populations. This project seeks to test a new multi-level, multi-component package to increase moderate intensity physical activity levels of people living in public housing developments. Our aims are to evaluate the effects of an intervention package focused on the environment level to produce changes in moderate physical activity among public housing residents. Furthermore, we will evaluate the added effects of an efficacy-tested individual-level eHealth phone program to produce further changes in moderate intensity physical activity. The design of this study is a prospective, cluster randomized controlled trial, with housing developments as the units of randomization. In this four group, factorial, cluster randomized controlled trial, we will compare an environmental intervention alone (E only), an individual intervention alone (I only), an environmental plus individual intervention (E+I), all against a control group. Mediation and moderation of our intervention will be assessed. Lastly, we will assess factors from the Consolidated Framework for Implementation Research domains to examine future implementation of a multi-level physical activity intervention among key informants in public housing developments.