A Comprehensive, Community-Based Coalition to Address Racial Disparities in Chronic Disease: REACH in Allegheny County, Pennsylvania

BACKGROUND

Funded by the Centers for Disease Control and Prevention Racial and Ethnic Approaches to Community Health Initiative, Live Well Allegheny: Lifting Wellness for African Americans (LWA) in Allegheny County, Pennsylvania, aims to enhance health equity by addressing chronic disease in six African American communities via three key strategies: nutrition, physical activity, and community-clinical linkages.

OBJECTIVES

This manuscript describes the coalition's partnership dynamics and evaluation methods with a focus on nutrition strategies.

METHODS

We have a network of committed partners implementing the strategies and we are evaluating our efforts using community asset mapping, county population-based survey data, qualitative process interviews, focus groups, and program performance measures.

RESULTS

The LWA coalition is the culmination of years of partnership building, which allows for more targeted activities related to health equity in the region. Thus far, the LWA coalition is thriving. The network of committed and talented partners in the nutrition strategy (healthy nutrition standards, food systems, and breastfeeding) reached 22 sites and more than 46,000 people during the first 2 years of the project. Process interviews conducted as part of the evaluation identified challenges and successes of implementation, and development of the coalition.

CONCLUSIONS

This comprehensive evaluation approach supports formative processes, evaluation metrics, and prolonged sustainability plans of this community-based coalition.

Preferences, beliefs, and attitudes about oral fluid and blood-based HIV self-testing among truck drivers in Kenya choosing not to test for HIV

Introduction

Clinical trials in sub-Saharan Africa support that HIV self-testing (HIVST) can increase testing rates in difficult-to-reach populations. However, trials mostly evaluate oral fluid HIVST only. We describe preferences for oral fluid vs. blood-based HIVST to elucidate prior trial results and inform testing programs.

Methods

Participants were recruited from a HIVST randomized controlled trial in Nakuru County, Kenya, which aimed to test the effect of choice between oral HIVST and facility-based testing compared to standard-of-care on HIV testing among truck drivers. We conducted in-depth interviews (IDIs) with purposively sampled trial participants who declined HIV testing at baseline or who were offered access to oral fluid HIVST and chose not to pick up the kit during follow-up. IDIs were conducted with all consenting participants. We first describe IDI participants compared to the other study participants, assessing the statistical significance of differences in characteristics between the two samples and then describe preferences, beliefs, and attitudes about HIVST biospecimen type expressed in the IDIs.

Results

The final sample consisted of 16 men who refused HIV testing at baseline and 8 men who did not test during follow-up. All IDI participants had tested prior to study participation; mean number of years since last HIV test was 1.55, vs. 0.98 among non-IDI participants (p = 0.093). Of the 14 participants who answered the question about preferred type of HIVST, nine preferred blood-based HIVST, and five, oral HIVST. Preference varied by study arm with four of five participants who answered this question in the Choice arm and five of nine in the SOC arm preferring blood-based HIVST. Six key themes characterized truckers' views about test type: (1) Rapidity of return of test results. (2) Pain and fear associated with finger prick. (3) Ease of use. (4) Trust in test results; (5) fear of infection by contamination; and (6) Concerns about HIVST kit storage and disposal.

Conclusion

We found no general pattern in the themes for preference for oral or blood-based HIVST, but if blood-based HIVST had been offered, some participants in the Choice arm might have chosen to self-test. Offering choices for HIVST could increase testing uptake.

Impact of COVID-19 on a Community Health Coalition and Its Residents in Allegheny County, Pennsylvania: Insights Into Adaptation From Focus Groups and Evaluation Reports

Live Well Allegheny: Lifting Wellness for African Americans (LWA2) is a coalition in Allegheny County, Pennsylvania, funded by the Centers for Disease Control and Prevention’s (CDC) Racial and Ethnic Approaches to Community Health (REACH) initiative. LWA2 consists of partner organizations addressing chronic disease prevention in six Black communities through nutrition, physical activity, and community–clinical linkage strategies. This analysis focuses on qualitative data exploring the influence of COVID-19 on coalition functioning and communities. We conducted focus groups with residents in REACH communities and collected evaluation reports from partner organizations. Three focus groups assessed awareness of and participation in the REACH initiative, feedback, and the impact of COVID-19 when applicable. An additional focus group included questions related to flu vaccine messaging and the COVID-19 vaccine. These data sources provided insight regarding how COVID-19 affected planned tasks. Evaluation team members analyzed focus groups and collated summaries as part of a larger comprehensive evaluation. Partner organizations experienced an increase in food stamp applications, delays in opening farmers’ markets, a shift to virtual preventive health programs, canceled in-person events, and programmatic interruptions that shifted long-term goals. Community resident concerns included difficulty accessing public transportation, decreased physical activity, fear of in-person interactions, and increased wait times for mental health services. Coalition members developed methods to continue functioning and sustaining program activities. Residents were able to engage differently with chronic illness prevention techniques. Reports from the ongoing analysis will be used to adapt coalition functioning.

Instituting Racial Equity: The Allegheny County Racial and Ethnic Approaches to Community Health Initiative

INTRODUCTION

In 2018, The Live Well Allegheny: Lifting Wellness for African Americans (LWA2) Initiative was developed to support six priority, Black communities in Allegheny County, Pennsylvania to address health equity in chronic disease. The LWA2 coalition members participated in ongoing anti-racism and racial equity sessions with a nationally recognized anti-racist facilitation team. The sessions included a 2-days experience in January 2020 along with follow up meetings throughout 2020.

METHODS

Surveys were administered to understand their perceptions related to anti-racism and oppression and subsequent actions as a result of the sessions. Additionally, we conducted nine in-depth interviews with organizational partners (January -May 2020) to evaluate the overall effectiveness of the coalition and inform future activities.

RESULTS

Ten participants completed the post session surveys. Seven out of 10 survey respondents felt they had a good understanding of how oppression (racism, sexism, capitalism) influenced their life and work. However, the majority indicated needing the tools to implement anti-racist strategies in their work. The in-depth interviews with organizational partners revealed that racial equity was of concern to all partners but there was variability in intentionality around racial equity as a core element of each organization's mission, goals and subsequent actions.

DISCUSSION

As a result of the interviews, coalition members developed a racial equity statement and theory of change for implementation in the coalition work and within individual organizations along with a plan for implementing an equity audit of the coalition. Coalitions of this kind should be intentional about implementing continuous strategies related to anti-racism for structural changes toward achieving racial equity in their overall work.

Skin Cancer Screening

Skin cancers are exceedingly common malignancies in the United States and include keratinocyte cancers, which have low mortality rates but are costly to treat, and melanomas, which can be deadly if diagnosed at later stages. Skin cancer screening for the general population has not received recommendation by the United States Preventive Services Task Force, given the paucity of clinical trial data documenting utility, yet there are sound arguments for the utility of risk-based screening, based on increased skin cancer risk. Such risk factors include skin type, high mole number, genetic susceptibility, and family or personal history of skin cancers. Screening can involve an inspection of the entire skin surface performed by a dermatologist or other health care provider, or self-screening, whereby individuals conduct an examination of their skin surface at home, which can be facilitated through the use of a mirror, as well as a family member or friend to facilitate skin inspection. Rates of physician screening as well as skin self-examination are low in the United States. This chapter reviews the current evidence and recommendations for skin cancer screening in the United States. It also reviews the current rates of screening, both overall and in higher-risk subgroups. The chapter discusses the recent evidence for the use of interventions to enhance skin cancer screening. It also presents some innovative use of new technology to increase skin cancer screening as well as future directions for this research.

Pharmacist Involvement in Addressing Public Health Priorities and Community Needs: The Allegheny County Racial and Ethnic Approaches to Community Health (REACH) Project

Community–clinical linkages are connections between community and clinical sectors to improve population health, and community-based pharmacists are well positioned to implement this strategy. We implemented a novel approach to community–clinical linkages in African American communities in which community-based pharmacists implement screenings for chronic disease and social determinants of health, make referrals to clinical and social services, and follow up with patients to support linkage to care in nontraditional health care settings. The community-based pharmacist navigation program works with multisector partners to increase referrals and access to existing health and social service programs. We used a mixed-methods evaluation approach to collect and analyze data on program characteristics and the linkage intervention. From February 2019 to March 2020, 702 African American community members received preventive health screenings, and 508 (72%) were referred to clinical and social services. Pharmacists demonstrated the ability to implement clinical preventive services in nontraditional health care settings and improve access to care through the provision of community–clinical linkages.

Applying a social-ecological lens to opinions about HIV self-testing among Kenyan truckers who declined to test: a qualitative study

HIV prevalence among truckers in Africa is high and testing rates suboptimal. With numerous African countries having approved HIV self-testing kits, more information on how to design acceptable and accessible self-testing programs for high-risk populations is necessary. We explored views about self-testing via in-depth interviews with 24 truckers participating in a randomised controlled trial who refused HIV testing. A social-ecological lens was used to guide data analysis and frame study findings. While most participants said that they would use an HIV self-test, perceived barriers and facilitators were identified at multiple levels. Many participants noted lack of time to test or obtain a self-test kit as a major barrier (intrapersonal) and varied in their views about self-testing with a partner (interpersonal). Participants offered programmatic/policy recommendations, suggesting that they preferred accessing self-test kits in settings where training could be provided. Participants believed they should be able to pick up multiple test kits at the same time and that the test kits should be free or low cost. These study findings will help guide the design of self-testing programs for truckers and other mobile populations.

Patients' Medical and Psychosocial Experiences After Detection of a CDH1 Variant With Multigene Panel Testing

PURPOSE

Germline CDH1 pathogenic variants (PV) are associated with hereditary diffuse gastric cancer and lobular breast cancer. Although prevalence of CDH1 PV is low in the general population, detection of these variants is increasing with the growing use of multigene panel testing. Little is known about the experiences of individuals tested for CDH1 variants in the multigene panel testing era.

METHODS

Participants recruited from the Prospective Registry of Multiplex Testing completed a cross-sectional self-report survey regarding CDH1 genetic testing experiences, medical management, and psychosocial adaptation.

RESULTS

Discordance existed in interpretations of CDH1 results; 13.3% of cases had disagreements in variant classifications among commercial laboratories, and 21.4% had disagreements between participant self-report and ClinVar classification. Survey data were available from 57 individuals reporting either PV (n = 16) or variants of uncertain significance (VUS; n = 41). Those with PV were more likely than those with VUS to report receiving a recommendation for prophylactic gastrectomy, although only 40.0% of those with PV received this recommendation. Participants with VUS were less satisfied with their health care providers' knowledge and reported less CDH1 knowledge, distress, and worry about discrimination. Participants with PV perceived greater breast cancer risks, but similar gastric cancer risks, as those with VUS.

CONCLUSION

Few individuals with CDH1 PV report receiving recommendations for prophylactic gastrectomy, and no differences in perceived gastric cancer risk were observed based on participants' CDH1 results, suggesting serious unmet informational needs.