Community Action Research Experience
Community Action Research Experience (CARE) is a program designed to train family medicine residents in community action research and equip them with the knowledge, skills and attitudes to adequately engage their community and at the same time care for underserved populations, thereby reducing health disparities in the Dallas County area. It was born out of the concern that current training models may not adequately prepare practicing physicians to partner with, and impact the health of, their communities.
Community action research/community based participatory research (CBPR) is defined as a collaborative approach to research that equally involves all partners in the research process.CBPR has the aim of combining knowledge with action and achieving social change to improve health outcomes and eliminate health disparities.
Goals and Objectives
The overarching goal of the CARE program is to teach family medicine residents community action research skills that will increase their community engagement. The program’s objectives are to:
- Design, pilot, implement and evaluate a residency curriculum in Community Action Research for local use and national dissemination
- Provide in-depth training for residents committed to enter fellowships or practices that focus on underserved care
- Bridge the gap in UT Southwestern’s community training pipeline between our medical students programs and fellowship in Community Action Research.
The CARE program responds to the needs of the underserved Dallas population. If lack of insurance, poverty, unsafe living conditions, environmental contamination or other factors are contributing to illness and disease, then a collaborative effort is needed to remedy these conditions. The community-based action research approach is a collaborative endeavor to grow a model for understanding health and disease determinants and supporting mechanisms to promote healthier lives.
Design
The three-year CARE curriculum in Community Action Research focuses on two levels of resident commitment, namely: an innovative four-week block rotation for PGY2 residents, and an intensive three-year cumulative studies Community Action Research pathway leading to an area of concentration in Community Action Research for two residents per year. In the PGY3 year, CARE pathway residents spend three elective months engaged with a community partner, providing service and completing a community-based research project that is strongly expected to be of publishable and/or fundable quality.
Update
Currently in its third year, CARE has graduated three residents and one fellow. The fellow was also a CARE resident and has proceeded, along with our most recent graduate, to serve in an underserved community. We currently have seven enrolled residents on the program one of who will be graduating in June 2010.
The didactics component of the program has been very rewarding based on the positive feedback we have consistently received from the program participants. The classes included CBPR research methods, statistical tools and dissemination skills. Community engagement has been considerably viable with many of our residents prominent in the planning, organizing, and implementation activities in collaboration with our community partners at health fairs, underserved care, and program development.
Presentations and Publications:
• The CARE program has been presented at several professional meetings including the TAFP 59th Annual session (2008) and 42nd STFM annual conference (2009) where it received an outstanding evaluation. At the latter, all the evaluators thought the program curriculum should be uploaded to STFM's Family Medicine Digital Resource Library (FMDRL). The program has been published as a letter to the editor in the March, 2009 edition of the Family Medicine Journal.
• Results from the Shared Medical Appointment (SMA) study have been presented at several professional conferences (TAFP, NAPCRG etc). The study poster won a first place award at the 2009 TAFP conference in Arlington, Texas. The manuscript is being reviewed for publication.
• The Osteoporosis study has been presented at three professional meetings (TAFP, NAPCRG). The study poster won a second place award at the 2008 TAFP conference. The manuscript has been accepted for publication in the summer 2010 edition of the Journal of Community Health.
• The Health Care Barriers project has been presented at two professional conferences. First as a poster at the 2009 NAPCRG conference in Montreal, Canada; and an oral presentation at the 2009 APHA national conference in Philadelphia, Pennsylvania.
• Abstracts from the three current residents’ projects have been submitted for presentation at upcoming conferences.
• A CARE Program Handbook is currently being compiled for publication as a tool for disseminating the CARE model to other Family Medicine residency programs across the country.
All CARE graduates have expressed a considerably high degree of satisfaction with the content and implementation of the program and have stated that it was worth their time and effort. They have also reported improved research and statistical skills and also have been able to draw a relationship between those skills and the quality of care they give to their patients.
Residents’ Community-Based Research Projects
Resident: Hina Rizvi, MD
Research mentors: Amer Shakil, MD; Nora Gimpel, MD
Title: Awareness of osteoporosis among South Asian women
Status: Completed (2008)
The purpose of this study was to assess the awareness of osteoporosis prevention among peri- and post menopausal women of Southeast Asian (Pakistan, India, Bangladesh) descent attending the community centers in the Dallas Fort Worth Metroplex and to assess the difference between their beliefs/ knowledge/ attitude before and after educational intervention.
Participants showed a significant increase in osteoporosis knowledge post intervention. Intervention completers were better prepared to prevent and manage osteoporosis. Results indicate the efficacy of educational intervention in improving osteoporosis awareness; and point to the potential for knowledge acquisition aimed at developing community-based prevention strategies at the community level.
Resident: Natalia Gutierrez-Chefchis, MD
Research mentor: Nora Gimpel, MD
Title: Clinical Effectiveness of Shared Medical Appointment for Hispanic Diabetic Patients in the Parkland Family Medicine Clinic in Dallas, Texas
Status: Completed (2009)
The overall objectives of the study were : to improve glycemic control; to improve non glycemic goals such as LDL, HDL, triglycerides, blood pressure and BMI; to prevent or slow the development of long term complications, to improve adherence to preventive care measures such as annual retinal exam, monofilament foot examinations, aspirin use, pneumoccocal and influenza vaccinations; to improve diabetes knowledge, quality of life, and satisfaction, and to evaluate acculturation level and its association with the outcomes.
Baseline characteristics were not significantly different between the intervention and control group. When comparing pre- and post- measures, there was approximately a 1 unit decrease in HbA1c for the intervention group and a 0.5 unit decrease in the control group, (p = .02). In the intervention group, the diabetes quality of life and knowledge scores increased by 5 and 1.5 points, respectively (p < .01). There was a significant decrease (p < 0.05) in systolic blood pressure and an increase in adherence to the American Diabetic Association (ADA) guidelines. Patient satisfaction was high among all SMAs (mean = 3.5, 1-4 Likert scale, 4 being the highest).
It was concluded that SMAs were effective in improving HbA1c in a clinic that is a part of a larger medical school and hospital infrastructure. The SMA model promotes discussion among patients and health providers and develops peer support with increased patient and provider productivity and satisfaction. We suggest that health care teams consider this model as an alternative approach or in addition to conventional one-on-one patient interactions.
Resident: Hena Zaki, DO
Research mentors: Nora Gimpel, MD; Amer Shakil, MD
Title: Barriers to health care facing the South Asian Population in Dallas, Texas
Status: Completed (2009)
The objectives were to describe the degree of access to health care South Asians in Dallas receive and determine barriers that affect health care access and experience among this population.
A survey assessing demographic information, socioeconomics, health insurance type and coverage, care utilization and potential barriers to care was collected from South Asian adults attending seven community centers in the Dallas area.
The study population was mostly female (58%). Almost 30% had lived in the US for 11-20 years, 85% reported good or excellent English proficiency and 86% had a college degree or higher education. This population reported high income levels; most were employed and had private health insurance. Furthermore, ~50% reported 1 or 2 doctor visits a year regardless of health insurance status. Our findings indicate that few barriers exist among this population. It is obvious that further research is needed in order to address types of health care utilized by this population.
Resident: Donald Graneto, MD
Research mentor: Nora Gimpel, MD and Barbara Foster, PhD
Title: Physician decision making in the prescription of non-professional post exposure prophylaxis to patients after a possible high risk exposure to HIV.
Status: Ongoing (2010)
This study is being conducted among physicians (residents and attending) at the UTSW Medical Center and affiliated hospitals in order to assess the prescribing of post-exposure prophylaxis (PEP) when exposure is in a non-occupational setting. The objectives are to identify the determining factors and assess the need for educational intervention to improve compliance by physicians.
At the conclusion of this study, we hope to identify trends in physician decision-making for prescribing or not prescribing non-occupational PEP and lead to improved physician awareness of the issues associated with non-occupational PEP including available options and existing regulations. This will set us on a right course of decreasing the spread of HIV among at risk members of society.
Resident: Alex Vilaythong, DO
Research mentors: Nora Gimpel, MD; Lance Rasbridge, PhD; Barbara Foster, PhD
Title: Health care challenges among the Karen-Burmese refugee population in Dallas, Texas
Status: Ongoing (2010)
This is a cross-sectional study being conducted among the Karen-Burmese refugee population in Dallas in order to assess the effect of cultural factors on refugees’ health status; to determine the health care needs of the refugee population; and to ascertain their access to health care. Surveys and in-depth interviews will be used to gather the data.
The study is still in progress and data gathered from the questionnaires and in-depth interviews have the potential of providing insight into refugee health care needs and the impact of cultural factors on the health of refugees. They will also point researchers and agencies in the community towards designing sustainable programs tailored to the health care challenges of the refugee population. The report on the completed study will add to the body of literature in this study area and serve as a reference point for future researchers.
Resident: Guadalupe Reyna, DO
Research mentors: Nora Gimpel, MD; Ellen Elliston, PhD; Barbara Foster, PhD
Title: Knowledge and attitudes towards domestic violence against women in the primary care setting of a large Texas urban city
Status: Ongoing (2010)
This is a non-experimental cross-sectional study being conducted in order to assess the awareness, attitudes, and beliefs of physicians working in a county teaching hospital and community clinics, toward domestic violence.
We expect to find a significant proportion of providers that have not identified an abused person in the past year and do not routinely screen for domestic violence and abuse. Expected results will demonstrate physicians’ perception and confidence level with domestic violence. This project will provide future direction in developing community-based strategies for domestic violence education for physicians. Results may help primary care physicians to develop and apply better screening tools to recognize and prevent domestic violence in the community. Improving awareness may also lead to lowered healthcare costs, better well-being and increased safety of patients.
