Using Community-based Participatory Research
To Address Disparities In
Obesity And Diabetes Among
American Indians/Alaskan Natives:
A Focus On The Partnership Development Process
Community Campus Partnership for Health
13th Annual International Conference
May 3, 2014
10:30 AM – 12:00 PM
Ramin Naderi, MA
Jan Vasquez , CHES, MPHc
Lisa Goldman Rosas, PhD, MPH
Jill Evans, MPH
Introductions
 Introduce yourselves
 Are you an academic partner, community partner, or
something else?
 Level of experience with CBPR
 Brainstorm challenges with building a successful CBPR
partnership
 Assign a spokesperson to report to larger group
Outline
Background
Forming a CBPR partnership
Evaluating the partnership
Outcomes and future directions
of partnership
Group Exercise
BACKGROUND
American Indian/
Alaskan Native Peoples
• Prior to colonization 10 million AIANs
• By 1860 250,000 remaining
• Health of AI/ANs has been shaped by:
• Warfare and other forms of aggression, diplomatic
manipulation, forced assimilation, legal actions, contagious
diseases to which they had no immunity, and economic
pressure for over 500 years
• IHS responsible for providing health services through treaty
Medicare
$7,631
VA
$5,234
Medicaid
$5,012
Prison
$3,985
IHS
$2,130
Santa Clara County
• 50,000 American Indian/Alaska Natives (including mixed race)
• Diabetes County Wide = 7.9%
• Overweight (37%) and Obese (15%) = 52%
Based on the California Health Interview Survey (CHIS) 2007, Center for Health Statistics, and Department of Finance population estimates.
Indian Health Center:
A Federally Qualified
Health Center (FQHC)
Established in 1976 to support the health and wellness needs
of American Indians in Santa Clara County
IHC
Wellness Center
Fitness center
Health education
Case management and referral
Transportation
Injury prevention
Cultural activities
Wellness Center:
The Setting
Socialization
Group activities
Supportive environment for fitness regardless
of ability
Welcoming
Cultural sensitivity
Celebration
Building community
IHC’s DPP
(Based on NIH/NIDDK DPP study)
National research study on diabetes prevention:
 Conducted 1999 – 2001
 3,000 participants
 All races
Study showed that:
 Losing 7% of body weight, and
 Increasing physical activity to 150 minutes per week
decreased chances of developing diabetes by 58%
(twice as much as medication)
IHC’s
Diabetes Prevention Program (DPP)
(Based on NIH/NIDDK DPP study)
Interactive
Curriculum
After core support
& activities
Practicing a
healthy lifestyle
Goal
Fitness instruction
Nutrition
education
 Lose body weight
and increase
physical activity to
prevent diabetes.
Incentives
Ongoing
celebrations
Healthy cooking
classes
Group support
Fitness
classes
 Connect healing
with fun, recreation,
and fellowship and
to empower.
Lifestyle
coaching
Health
education
Healthy food &
snacks
Multi-disciplinary
Team Approach
As compared to the national sample,
participants at IHC are more likely to be:
Unemployed (42% vs. 19%)
Making less than $15,000 annually (44% vs. 21%)
Have higher rates of co-occurring illnesses (High blood pressure,
depression, arthritis, back pain)
Have higher rates of negative emotional experiences (distress,
posttraumatic stress, anger- especially older males
DPP Holistic Approach
Holistic and based on
American Indian Cultural Practices
We address the 4 aspects of a person:
Physical
Mental
Spiritual
Emotional
Multi-disciplinary
Team Approach
MD
RD/CDE
Kinesiologist
Fitness instructors
Patient advocate
Mental Health Counselor
Health Education Specialist
Registered Nurse
Data coordinator
Volunteers, interns
IHC’s DPP Annual
Conversion Rate to Diabetes
FORMING A
CBPR PARTNERSHIP
Why CBPR?
With so many successes, why the need for CBPR?
To reduce disparities by addressing gaps in the current model
 Address historical trauma through diverse strategies
developed through community engagement
 Increase Lifestyle coaching (case management)
 Add tools that assess and measure historical trauma
Add DPMP
Goals of CBPR
 Sustain and expand DPP program
 Increase funding to enhance DPP to address specific
historical trauma issues related to our community
 Analyze DPP data
 Publish
 Disseminate
 Empower community
CBPR
CBPR
Partnership
Formation
Partnership
formation process
Attended CBPR Summer Institute
at UCSF and UCB
Introduced to Stanford Office of
Community Health (OCH)
Office of Community Health
(OCH) searched within Stanford
for a good match
Program on Prevention Outcomes
and Practices (PPOP)
Embarking on a
Co-Learning Process
IHC Mission
To ensure the survival and healing
of American Indians by providing
health Stanford PPOP Mission
To improve population health
outcomes through research that
fosters evidence-based
prevention interventions
care and wellness services
Stanford PPOP Mission
To improve population health
outcomes through research that
fosters evidence-based
prevention interventions
•
•
Urban American Indian
Alaska Native Community
Stanford OCH Mission
To develop, implement, and
integrate education, research, and
clinical training programs aimed at
building leaders in community
health
Collaborative
Visioning Process
 This is an equal research partnership between IHC and the
Stanford University PPOP to demonstrate effective models
for improving health, reducing disparities, and informing
policy.
 As a partnership, we value meaningful community
engagement, primary prevention and wellness, and rigorous
research methodology
 We are committed to sustainability of the IHC Community
Wellness and Outreach Programs
Partnership Agreement
Development Process
 Collected examples and identified components that reflected
our needs
 Identified common values, short-term goals, long-term goals
 Significant co-learning:



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
Urban AI/AN culture
IHC wellness promotion
Biomedical research model
CBPR
Grant writing
Establish American Indian
Community Action Board
(AiCAB)
 Strategized on how to incorporate diverse segments of
Urban AI/AN community
 Recruited 10 identified leaders
 Conducted digital story-telling workshop
 Obtained seed grant from Stanford OCH
 Conducted 3 four-hour workshops to develop group
cohesion
 Implemented Prevention Institute Training
 Completed CBPR certification
AiCAB Members
2013 Board Members
PARTNERSHIP
EVALUATION
Partnership Evaluation
Adapted tool developed by Schultz
et. al. in 2003 to reflect urban AI/AN
context
OCH staff conducted in-depth
interviews with CAB members, IHC
and PPOP staff
8 of 10 CAB members participated
in in-depth interviews
Partnership interpreted findings
collaboratively
Evaluation Findings
Environmental characteristics shaped group dynamics
Importance of Urban AI/AN history and culture
Previous negative perceptions/experiences with academia/
Stanford University
Diversity and complexity of urban AI/AN community
Community perceptions of diabetes prevention
Evaluation Findings
Group Dynamics
Strong Evidence for:
 Shared leadership
 Open communication
 Development of conflict resolution process
 Cooperative development of goals
 Participatory decision making (consensus)
 Development of mutual trust
 Well-organized project management
Evaluation Findings
Intermediate measures of partnership effectiveness
HIGH
Member involvement and commitment
Group and community empowerment
Benefits of participation
Moderate to high perceived
effectiveness
MODERATE TO HIGH
Lessons Learned
Urban AI/AN culture at core of all activities
Initiation of partnership by community partner is ideal
Sincere and participatory co-learning was critical to process
Overlapping goals contributed to successes
Stanford OCH provided key resources and played critical
facilitation and evaluation role
OUTCOMES
AND FUTURE DIRECTION
OF PARTNERSHIP
Early outcomes
• CBPR process:
R24 unintended consequences
• AiCAB
• Derogatory comments in the review
• Co-learning/training activities
• Collaboration with NIHB & NCUIH
• IRB training
• Similar
experiences among other AIAN groups
•• Raise
Grants:awareness about unfair reviews for AIAN studies
• Submittedfor
R24training
to NIMHD
• Advocated
of reviewers at NIH
• 2 successfully
seed grants in AJPH
• Article
acceptedfunded
for publication
• Successful CDC REACH grant
• Successful PCORI grant
• CHRI grant (pending)
• Kaiser Community Benefit grant (pending)
• Awards
Near Future
Develop local community IRB
Expand programming and research to reach AI/AN adolescents
Increase capacity in addressing historical trauma
Continuously monitor and evaluate partnership development
process
Develop tool kit with strategies for community engagement in
urban AIAN communities
Future
Enhance
DPP
Bring DPMP
to Native
population
Improve
diabetes
outcomes for
AI/AN in
Santa Clara
County
Publish
Disseminate
to other Native
communities
Achieve
policy changes
Group Exercise:
Solutions for Building a Successful
CBPR Partnership
Group Exercise
Brainstorm potential solutions for building a successful
CBPR partnership
Assign a spokesperson to report to larger group
Our Challenges
Developing trust (with each other and AI/AN community)
Our institutions
Aligning goals
Leadership challenges to goal
Slow process
Adequate funding
Overcoming
Challenges
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Having a broker
Good match from the beginning
All team members had years of experience in community
Everyone was invested in making partnership work
Taking time to lay the groundwork
Listening to everyone about direction
Valuing and acting on everyone’s contributions
Establishing co-learning from the start
Consistency (always showing up)
Going through challenges made us a stronger team
Having support from IHS
An extended network of support
Raising awareness throughout the country
Bringing in funding
Having optimism and hope
Thank You
 Urban AI/AN community of Santa Clara Valley
 AiCAB members
 IHC staff
 PPOP staff
 OCH Staff
Contact Us
Ramin Naderi, MA
Community Wellness and Outreach Director
rnaderi@ihcscv.org
Jan Vasquez (Chacon), CHES, MPHc
Associate DPP Director
jvasquez@ihcscv.org
Lisa Goldman-Rosas, PhD, MPH
Research Director, PPOP
lgrosas@stanford.edu
Jill Evans, MPH
Research Program Director, OCH
jille@stanford.edu