Journal of Community Health

Teaching Community Health Needs Assessment to First Year Medical Students: Integrating with Longitudinal Clinical Experience in Rural Communities Abstract Community health education is especially important for physicians who will practice in rural communities. However, the majority of efforts to teach community and population health in medical school appear in later years and focus on non-rural contexts. This article presents data from a formative evaluation of a newly developed curricular component on population health and community health assessment for first year medical students in a rural longitudinal clinical preceptorship. Curricular elements included: a classroom lecture and review of online community health databases, an individual homework assignment and a classroom debriefing session. In a sample of 210 students, pre- and post-course surveys and exam questions assessed gains in awareness and skills over the course period. Analyses of data aggregated over four academic years (2013–2014 to 2016–2017) showed that first year medical students reported significant increases in familiarity with online resources (29.5% pre vs. 94.8% post, p < .001), understanding the importance of community health assessments (67.5% pre vs. 96.7%, p < .001), knowing how to plan a community health assessment (20.0% pre vs. 90.5%, p < .001), and awareness of Affordable Care Act expectations for community health assessments (12.4% pre vs. 82.4% post, p < .001). Further, students performed well on exam questions and reported that this component fit well with the objectives of the rural longitudinal clinical preceptorship course. Later-year education should reinforce early learnings and future studies involving long-term follow-up of physicians could assess the impact of early exposure to community health education on physician behaviors.

Barriers to Purchasing Condoms in a High HIV/STI-Risk Urban Area Abstract The Centers for Disease Control and Prevention (CDC) have identified Atlanta, Georgia as a high-risk environment for STI/HIV infection. Condoms are an inexpensive and effective method for preventing STI/HIV infection. The majority of individuals acquire their condoms through purchase, rather than through free condom distribution programs. However, individuals purchasing condoms in stores encounter numerous barriers. This study assessed the environmental and physical barriers surrounding condom purchases in stores in downtown Atlanta. The findings revealed a combination of high environmental and physical barriers, low visibility of condoms in stores and limited selection of safer sex supplies. In the most densely populated area of the city, stores which sold condoms were few (n = 25), equating to 1 store per ~ 7000 people. In 80% of stores, personnel were required in order to access the condoms. In 28% of stores, condoms were hidden underneath the counter. The majority of stores offered only one brand of male condoms with a limited selection of lubricants and no dental dams or internal condoms. Barriers and discomfort surrounding purchasing condoms can contribute to embarrassment, which has a negative impact on condom acquisition and ultimately on condom use. Efforts must be made to lower barriers in Atlanta and make condoms more readily available to high-risk populations. Community advocacy has been effective in removing barriers to condoms. Access can furthermore be improved by: installing condom vending machines in public locations, offering self-check-out in stores that do not have physical barriers and encouraging individuals to order condoms online.

Local Disparities in Breastfeeding Initiation and Duration: A Cross-Sectional Population-Based Survey in Ten Chicago Community Areas Abstract Breastfeeding confers substantial health benefits to women and infants. While disparities in breastfeeding persist in the United States, the extent of these disparities at the local level is unclear. This study aimed to identify local level and racial/ethnic breastfeeding disparities within Chicago. A community-based representative survey including questions on breastfeeding was conducted in Chicago. We estimated the proportion of women who breastfed their last child for any length of time and who breastfed at 6 months by neighborhood and maternal characteristics. We performed Rao-Scott corrected chi-squared tests to analyze factors hypothesized to be associated with breastfeeding. Between March 2015 and September 2016, 641 women with at least one live birth completed the survey. We found no differences by community area in the breastfeeding initiation or breastfeeding for at least 6 months. Puerto Rican women had the lowest prevalence of breastfeeding initiation and continuation at 6 months in contrast to Mexican women who reported the highest prevalence of these practices. We found breastfeeding disparities between Puerto Rican and Mexican Hispanic subgroups. Policies and programs aimed at increasing breastfeeding should prioritize groups that are least likely to initiate breastfeeding or most likely to breastfeed for a limited duration.

The Patient Protection and Affordable Care Act and Utilization of Preventive Health Care Services Among Asian Americans in Michigan during Pre- and Post-Affordable Care Act Implementation Abstract Since the implementation of the Patient Protection and Affordable Care Act (ACA), significant increases in the percent of insured United States residents has steadily increased. Studies have shown that there is an increase in preventative services usage and a decrease in chronic disease burden with increased access to insurance. However, very little has been studied about how the implementation of ACA has impacted utilization of health services and health status among Asian Americans. In this study, we recruited 427 Asian Americans who attended health fairs and examined (1) changes in health care coverage and utilization of preventive health services before and after ACA, (2) health status on chronic disease risk factors, (3) comparing health services utilization by insurance status and types of insurance, and (4) identifying relationships between health care utilization and demographic factors. Study results indicate that even though the percentage of insured Asian Americans in Michigan increased significantly over study periods, health care utilization and chronic disease burden did not change significantly. The insured tended to utilize preventive health services more than the uninsured, but the types of insurance did not affect health care utilization. Gender and having a primary care physician were significant predictors in determining health care utilization. There is a need in this population for language-appropriate and culturally-sensitive education about the importance and availability of preventive services, which could improve adherence to preventive health services, thereby reducing health disparities.

An Educational Intervention to Improve Provider Screening for Syphilis Among Men Who Have Sex with Men Utilizing an Urban Urgent Care Center Abstract Rates of syphilis are increasing in the United States especially among men who have sex with men (MSM). The purpose of this project was to implement an educational intervention based on the 2015 CDC Sexually Transmitted Diseases (STD) Treatment Guidelines for urgent care providers with an emphasis on identifying MSM sexual behavior and appropriate screening for syphilis. An urgent care center was identified as a location where men seek care and where STD testing was occurring. After a baseline provider focus group to identify barriers to STD testing, a patient survey was created and given to clients to increase identification of MSM behaviors and to prompt providers to order syphilis testing. In addition, an educational intervention was implemented to improve provider and staff screening for syphilis. The intervention occurred between September 2015–December 2015. A total of 1341 males were seen with 1067 surveys collected. The mean age was 35.6 and 57.4% were Hispanic. Overall, 72 (5.4%) males identified as MSM. Approximately 50% of all MSM identified had RPRs (n = 37) sent and of these 13.5% (n = 5) tested positive for syphilis. The focus group among urgent care providers and staff identified barriers to syphilis testing. Targeted screening of males using a self-administered questionnaire is acceptable to urgent care populations and may assist in identifying MSM which in turn may help to facilitate syphilis screening and other relevant STI testing pertinent to this population.

A Qualitative Study about Creating Smoke-free Home Rules in American Indian and Alaska Native Households Abstract Smoke-free homes can reduce exposure to secondhand smoke (SHS) and support smoking cessation. The current study seeks to understand perspectives, including barriers and facilitators, on smoke-free homes among five American Indian/Alaska Native (AI/AN) communities. Guided by a national work group of tribal partners, ten focus groups were conducted with AI/AN adult smokers and nonsmokers (n = 95) in Alaska, California, Michigan and Oklahoma, stratified by smoking status. The majority of participants lived in single unit detached homes (70.5%). Most of the nonsmokers had a smoke-free home rule (92.9%) and a majority of smokers did as well (64.7%). The most common reasons for smoke-free home rules were protecting children and grandchildren, including children with health problems. Challenges to a smoke-free home included weather and visitors who smoked, along with the inconvenience of going outside, the habit of smoking inside, the need to watch a young child, safety concerns, and smokers who break the rules. Respecting rules and respecting elders emerged as important themes. Traditional use of tobacco in the home was viewed as quite distinct from recreational or everyday use. Over half (58.2%) reported never using tobacco for ceremonial, prayer or traditional reasons in their homes. Given unique considerations for the adoption of smoke-free homes in AI/AN communities, particularly regarding the use of sacred tobacco for traditional, ceremonial, or medicinal purposes, it is important to learn which barriers and facilitators are similar to the general population and which may be unique to tribal communities in the U.S.

Self-Justifications for Unsafe Sex Among Incarcerated Young Men Who Have Sex with Men and Are Living with HIV: Results from a New York City Jail-Based Pilot Intervention Abstract Young men who have sex with men (YMSM), especially African American and Latinx YMSM, accounted for the highest proportion of new HIV diagnoses in 2016. Minorities and persons living with HIV are over-represented in correctional settings. To influence risk behaviors of incarcerated YMSM who are living with HIV, New York City Health + Hospitals adapted, implemented, and evaluated an evidence-based intervention (EBI)—Personalized Cognitive Counseling—as a pilot program for YMSM, aged 20–29 in New York City jails from May 2015 to July 2016. Thirty-four participants recalled a memorable episode of unprotected anal intercourse (UAI), discussed the episode and resulting thoughts and feelings, identified the self-justifications that facilitated the episode, and discussed possible behavior modifications when presented with similar situations in the future. The top endorsed self-justifications for UAI included that they already had UAI with this person, condomless sex feels more natural, not wanting to lose the opportunity for sex, that substance use influenced their thinking, and not wanting to think about HIV transmission. HIV knowledge improved slightly, as measured by the 18 item HIV-KQ-18 HIV Knowledge Questionnaire, from a pre-intervention average of 15.17 (SD = 3.05) to post-intervention average of 16.48 (SD = 1.64) (p < 0.05). Learning the self-justifications that justice-involved MSM have for having UAI is beneficial for targeting future health promotion interventions. Despite challenges inherent in the jail setting, HIV behavioral EBIs are feasible and they can improve HIV knowledge and encourage exploration of self-justifications for risky behavior.

Risk-Taking Behaviors and Sexual Violence Among Secondary School Students in Tanzania Abstract There is limited district level data on drug or alcohol use as well as sex and reproductive history among secondary school students in Tanzania to inform prevention efforts. To address this, we conducted a survey of 2523 secondary school students in 2 districts (Bahi and Mpwapwa) and the Dodoma municipal area in Tanzania. Overall, fifty three percent were female and 67% were between the ages of 15 and 17 years old. Students in the Dodoma Municipality district self-reported the highest prevalence of forced sex, sex for gifts or money, and drug use. Students in the Bahi district reported the highest prevalence of alcohol use. Males reported a higher prevalence of consensual sex, contraception use, and alcohol and drug use compared to females, the latter of whom reported a higher prevalence of forced sex. Most students’ indicated that their primary source of sex and reproductive health information was their teachers. These results suggest the need for tailored interventions among secondary school students in the Dodoma region in Tanzania.

The Changing Characteristics of African-American Adolescent Suicides, 2001–2017 Abstract African-American (AA) adolescents (13–19 years of age) have disproportionately higher rates of suicide. In this study, to explore the nature of suicidal deaths and suicide attempts in African- American adolescents, we utilized the Youth Risk Behavior Surveys (YRBS) and the Web-Based Injury Statistics Query and Reporting System (WISQARS) database from years 2001 to 2017. The rate of AA male suicides increased by 60% and for AA females increased by 182% from 2001 to 2017. Suicides were the second leading cause of death for AA adolescents. Additionally, in 2017 alone, 68,528 AA males and 94,760 AA females made suicide attempts serious enough that they had to be treated by health professionals. Males were most likely to use firearms (52%) or to hang/suffocate themselves (34%) to commit suicide. Females used hanging/suffocation (56%) or firearms (21%) to commit suicides. The ten states with the greatest number of AA adolescent suicides (2015–2017) were: Georgia, Texas, Florida, North Carolina, Ohio, Illinois, Michigan, Pennsylvania, New York, and Missouri. There is an urgent need to further explore the changing nature and epidemiology of AA adolescent suicides and to study for whom and under what circumstances interventions can reduce suicides and suicidal behaviors in AA adolescents.

NIH-Funded CBPR: Self-Reported Community Partner and Investigator Perspectives Abstract The community-based participatory research (CBPR) approach across health contexts has matured greatly over the last 20 years. Though contributions to the literature on the development and effectiveness of CBPR interventions have grown, the number of publications on the function and evaluation of actual community-research partnerships has not kept pace. To help address that gap, we searched National Institutes of Health archival data and identified a set of 489 CBPR projects including collaboration-building, exploratory/pilot, research, and program project grants. We found community partner contact information commonly was absent from grant records and contacted principal investigators (PIs) for community-partner contact information. Subsequently, we built upon established measures to ask principal investigators and community partners for their perceptions of participation in NIH-funded CBPR projects. Many principal investigators and community partners reported existing collaborations—between academicians and community organizations as well as among community organizations. Partners tended to agree on the appropriateness of funding levels to accomplish projects and on the community partners’ ability to recruit and retain participants, collect data, and implement interventions. Partners differed in perceptions of participation in research design, data analyses, manuscript and presentation production, and dissemination of findings. Suggestions include collection of lead community partner information without undue burden and increased standard education and involvement of community organizations in research vocabulary and practices.