Transcript ESAP Evaluation: Harlem and the Bronx - de

Harlem Community Academic Partnership:
Community Based Participatory Research
A Multilevel Outcome Analysis Following a Multicomponent Intervention in Treatment and
Comparison Communities
David Vlahov, PhD, RN
UCSF School of Nursing
Overview of HCAP Process
►
Mission Statement: to Promote Health in Harlem.
►
Principles of Partnership: e.g., Reciprocity
►
Bylaws: Organization for a Sustained Effort; Steering Committee
meets monthly; Intervention Work Groups (IWG) more often
►
Conceptual Model: Social Determinants of Health;
Multilevel Influences, Multi-component Interventions
►
Needs Assessment: Qualitative, Quantitative, Priority Setting
►
HCAP Goal: “Should be easier to get help for problems with drugs
than it is to get drugs themselves”.
Urban Research Center
Community Action Board (CAB) of the URC
Community Liaison
Principal Investigator
CDC assignee
Community members and organizations
Research
Interventions
Co-Investigators
H-CAP mission statement
The Harlem CAP is committed to:

Ensuring the active reciprocal relationship between the
Harlem community and the Urban Research Center

Promoting public health research to benefit the
community through increasing health awareness and
by promoting better health outcomes

Using participatory research to develop a partnership
with community-based organizations, public health
agencies, educational and other relevant institutions to
study and improve community health.
H-CAP operating principles
“The Board’s community partners
shall serve as a resource to the
research staff on the unique daily
living conditions, needs, strengths,
and community dynamics of the
Harlem community and other related
geographical areas.”
H-CAP operating principles
“The Researchers shall serve as a resource to
community organizations and residents to
conduct training on the principals of research
including grant-writing, the institutional review
board process, informed consent, and the
methodology of how to collect, analyze,
interpret, report and disseminate data to
enhance the individual and/or organizational
capacity to conduct research that benefits the
community.”
H-CAP operating principles
“On all of its products, the researchers will
acknowledge the contribution of, consult with,
and invite to collaborate as co-author (when
appropriate) all partners that participate in the
research.
The Researchers have an obligation to
disseminate findings in a timely manner
through community forums, community
newsletters and other community events.”
Social ecological model of health
Social and Economic Policies
Institutions
Neighborhoods and Communities
Living Conditions
Social Relationships
Individual Risk Factors
Genetic/Constitutional
Factors
Pathophysiologic
Pathways
Environment
Individual/Population
Health
Kaplan 2000
General model of social determinants
Social Factors
Personal Factors
Access to
Services
Individual
risk factors
Disease
Quality of
living area
Stress
Adoption of
Preventive
Behavior
Discrimination
Social
Support
Outcome
Self Regulation/
Management
Fundamental Factors: Money, Power, Prestige
Galea et al. Health Educ Behav 2002;29(3):296-311
Health
Overview of HCAP Process
►
Mission Statement: to Promote Health in Harlem.
►
Principles of Partnership: e.g., Reciprocity
►
Bylaws: Organization for a Sustained Effort; Steering Committee
meets monthly; Intervention Work Groups (IWG) more often
►
Conceptual Model: Social Determinants of Health;
Multilevel Influences, Multi-component Interventions
►
Needs Assessment: Qualitative, Quantitative, Priority Setting
►
HCAP Goal: “Should be easier to get help for problems with drugs than
it is to get drugs themselves”.
Harlem Resource Guide
www.harlemresourceguide.org
A web-based resource guide for social
service and health care providers
Brought to you by:
The Community Action Board of the
Harlem Urban Research Center and the
New York Academy of Medicine
Background of Problem Addressed
►
Substance abuse and HIV are major problems in
Harlem.
►
Some have urged the use of pharmacies for HIV
prevention
►
For HIV prevention, New York State enacted public
health legislation permitting pharmacy sales of
syringes requiring no prescription.
Expanded Syringe Access Program (ESAP):
►
State Program started and involved Providers
(pharmacies and health care facilities) registered with the
New York State Department of Health to participate in
ESAP.
►
State mandated an independent evaluation that
assessed pharmacy response, and impact on drug users
and public. [This evaluation, performed by NYAM, was
the official program evaluation for legislature and …
needs assessment for HCAP].
ESAP Program Findings: Widespread Pharmacy
Registration but Utilization in Harlem is Low.

Following early State Health Department-directed educational
efforts, NYAM survey shows that while pharmacies registered and
needle sales began to increase overall in NYC, early findings
identified that:
 utilization lower in black and Hispanic than white IDUs,
 lower in Harlem than other parts of city.
 NYAM partner in HCAP presents these results to HCAP.
►
HCAP reviews information and moves to designate an
Intervention Work Group
Harlem ESAP Evaluation Design
Design :
Pre-Intervention
Communities:
East & Central
Harlem, Brooklyn,
South Bronx
(Intervention & Control)
Intervention
Post-Intervention
East & Central
Harlem
East & Central
Harlem, Brooklyn,
South Bronx
(Intervention
(Intervention & Control)
Levels:
IDU
Survey
Outreach
Survey
Pharmacy
Phone Survey
Outreach
Phone Survey
Community
RDD
Outreach
RDD
ESAP: Rationale for including three
levels
►
IDUs:
 Target for changing behavior.
 Not going to pharmacy: knowledge? Judgmental attitudes of
pharmacists and community?
►
Pharmacists:
 Source for syringes, alcohol pads, cotton, etc.
 See role mostly as public health practitioner or business ?
 IDUs bad for business?
►
Community:
 Would community disapprove and shun a participating
pharmacy?
 Can a community be tolerant (even supportive) of ESAP?
Methods: Pre- Post- Assessments
►
Community residents : RDD telephone survey which
ascertained knowledge and opinions of drug use, HIV,
ESAP and other harm reduction strategies in their
community.
►
Pharmacists: A random sample of ESAP participating
and non-participating pharmacies: random sample
telephone survey which ascertained ESAP knowledge,
attitudes and practices.
►
Injection drug users: respondent driven sampling
methods in Harlem, South Bronx, and Brooklyn, and
underwent a behavioral risk survey.
Community Attitudes and Perceptions of ESAP,
Pre and Post Harlem Intervention
in Harlem (n=980), and South Bronx (n=391)
Aware of ESAP
ESAP is a Good Idea
31
Pre
16
30
Post
14
29
12
28
10
27
8
26
6
25
4
24
2
23
Harlem (p<0.56)
Pre
Post
0
South Bronx (p<0.99)
Harlem (p<0.01)
Increase Spread of HIV
Increase Syringes on Street
80
70
Pre
70
Post
60
Pre
60
Post
50
50
40
40
30
30
20
20
10
10
0
South Bronx (p<0.17)
Harlem (p<0.01)
South Bronx (p<0.01)
0
Harlem (p<0.60)
South Bronx (p<0.01)
Pharmacists’ Attitudes and Perceptions of ESAP,
Pre and Post Harlem Intervention
in Harlem (n=52), Brooklyn, and South Bronx (n=77)
Support ESAP
70
Not Good for
HIV Prevention
Pre
60
Post
50
40
25
Pre
Post
20
15
30
10
20
10
0
5
Harlem (p<0.05)
Brooklyn, Queens, Bronx
(p<0.04)
0
Pre
Post
Harlem (p<0.04)
Brooklyn, Queens, Bronx
(p<0.39)
Brooklyn, Queens, Bronx
(p<0.16)
Increase Drug Use
Increase Syringes on Street
45
40
35
30
25
20
15
10
5
0
Harlem (p<0.04)
45
40
35
30
25
20
15
10
5
0
Pre
Post
Harlem (p<0.12)
Brooklyn, Queens, Bronx
(p<0.22)
IDUs Injection Practices, Pre and Post Harlem
Intervention in Harlem (n=340), South Bronx
(n=377)
Use Pharmacy at Last
Injection
Knowledge of ESAP
60
Pre
16
50
Post
14
10
8
30
6
20
4
10
2
Harlem (p<0.09)
0
South Bronx (p<0.01)
Syringe Disposal-Ground or Bushes
20
18
16
14
12
10
8
6
4
2
0
Post
12
40
0
Pre
Pre
Post
Harlem (p<0.05)
South Bronx (p<0.24)
Syringe Re-Use
12
Pre
10
Post
8
6
4
2
Harlem (p<0.04)
South Bronx (p<0.12)
0
Harlem (p<0.21)
South Bronx (p<0.81)
Discussion
►
Academic side brought key information to HCAP:
 Survey data to present a problem of interest to
partnership.
 Content expertise to help frame design of
intervention
 Content expertise in evaluation
►(sampling, measurement, analysis)
Discussion
►
Community side brought key information to HCAP:
 Definition of community
 Buy in from community
 Community directed intervention: creation and
selection of components (e.g., pharmacy
purchases to identify friendly pharmacies then
built into outreach materials)
 Interpretation of Results
Conclusion
►
Community Academic Partnerships can move beyond
process to accomplish broad scale mobilization efforts.
►
Outcome Effectiveness of mobilization efforts
can be designed, measured and summarized.
►
Such partnerships provide academic challenges as well
as practical public health experience, e.g.,
1. Interdisciplinary Development of Multi-level,
Multi-component Approaches to Intervention;
2. Multi-level Analyses for Program Evaluation.
3. Novel methods: e.g., Improved Sampling
of Hidden Populations.
HCAP members
 Community residents
 Clients
 Community based organizations
(CBOs)
 NYC Department of Health
 Hunter College, City University New
York
 Mount Sinai School of Medicine
 Mailman School of Public Health,
Columbia University
CBOs involved in HCAP activities

Association to Benefit Children (ABC)

Association for Drug Use Prevention and
Treatment (ADAPT)

ACCESS

Boriken Health Center

Central/East Harlem HIV Care Networks

Harlem branch YWCA

Harlem Dowling West Side Center

Harlem East Life Plan

Harlem United Community AIDS Center

Latino Organization for Liver Awareness (LOLA)
CBOs involved in HCAP activities

Little Sisters of the Assumption

Mount Sinai School of Medicine
 Institute for Medicare Practice
 Department of Community Medicine

New York City Department of Health

North General Hospital alcohol Treatment Center

The Riverside Church

Settlement Health Center

Union Settlement

Veritas Therapeutic Community

Women’s Information Network
Funding for CBPR is possible.
This research was supported by:
Robert Wood Johnson Foundation
Centers for Disease Control
National Institute on Drug Abuse
Implications for public
health training
• Faculty development training
in CBPR competencies*
• Post doc training in CBPR
• Coursework in CBPR
*Institutional recognition and support for faculty engaged in CBPR