Background: Numerous reports have demonstrated the disproportionate impact that COVID-19 has had on vulnerable populations. Our purpose is to describe our health care system’s response to this impact.
Methods: We convened a Workgroup with the goal to mitigate the impact of COVID-19 on the most medically vulnerable people in Springfield, Massachusetts, USA, particularly those with significant social needs. We did this through (1) identifying vulnerable patients in high-need geographic areas, (2) developing and implementing a needs assessment/outreach tool tailored to meet cultural, linguistic and religious backgrounds, (3) surveying pharmacies for access to medication delivery, (4) gathering information about sources of food delivery, groceries and/or prepared food, (5) gathering information about means of travel, and (6) assessing need for testing. We then combined these six elements into a patient-oriented branch and a community outreach/engagement branch.
Conclusions: Our highly intentional and methodical approach to patient and community outreach with a strong geographic component has led to fruitful efforts in COVID-19 mitigation. Our patient-level outreach engages our health centers’ clinical teams, particularly community health workers, and is providing the direct benefit of material and service resources for our at-risk patients and their families. Our community efforts leveraged existing relationships and created new partnerships that continue to inform us—healthcare entities, healthcare employees, and clinical teams—so that we can grow and learn in order to authentically build trust and engagement.
Citation: Pirraglia PA, Huebner Torres C, Collins J, Garb J, Kent M, Perez McAdoo S, Oloruntola-Coates M, Smith JM, Thomas A. COVID-19 mitigation for high-risk populations in Springfield Massachusetts USA: a health systems approach. Int J Equity Health. 2021; 20:230. Published 2021 Oct 19. https://doi.org/10.1186/s12939-021-01567-3
COVID-19 vaccine development has advanced at lighting speed. Research that would normally require years has been completed in months. As a result of this unprecedented effort, two vaccine candidates, mRNA-1273 (Moderna, Cambridge, MA) and BNT162b2 (Pfizer, New York, NY), have been found to be safe and more than 90% effective in preventing symptomatic COVID-19 shortly after vaccination. These vaccines are extremely promising and will eventually be distributed widely. Unfortunately, as the science of vaccine development has swiftly progressed, the equally important science of community engagement, which should guide the establishment of mutually beneficial partnerships and promote eventual vaccine uptake, has lagged behind. Research methods focused on the development of effective public health interventions place communities—groups with shared culture, norms, beliefs, or language—at their core and emphasize the primacy of community ownership as essential for uptake and sustainability.1 Yet, communities of color (i.e., Black, Latinx, and Indigenous communities), who remain at highest risk for infection, have been peripheral, not central actors in the pursuit of COVID-19 vaccines. Instead, the tripartite relationship between industry, government, and academia has dominated the research enterprise related to COVID-19.
The peripheral position of community has been evident since early in vaccine development. Notably, initial trial recruitment consisted of short-term community outreach, and more detailed plans for longer-term community engagement to support enrollment and eventual vaccine uptake commenced late in phase III trials. Such a critical oversight may be the Achilles’ heel of this unprecedented effort. Deeply rooted mistrust bred by centuries of well-documented, abusive medical experimentation and ongoing structural racism impedes racially and ethnically diverse individuals’ participation in clinical trials and threatens the uptake of future COVID-19 vaccines, particularly among Black individuals.
This history may be overcome by reimagining how industry, government, and academic institutions partner with marginalized communities. COVID-19 vaccine development offers an opportunity to shift from transient outreach to true investment in communities of color, which may mitigate mistrust, improve vaccine uptake, and have far-reaching effects beyond COVID-19.
Citation: Ojikutu BO, Stephenson KE, Mayer KH, Emmons KM. Building trust in COVID-19 vaccines and beyond through authentic community investment. American Journal of Public Health. 2021; 111:3. Published 2021 Mar 1. https://doi.org/10.2105/AJPH.2020.306087
The National Cancer Institute’s Implementation Science Centers in Cancer Control (ISC3) Network represents a large-scale initiative to create an infrastructure to support and enable the efficient, effective, and equitable translation of approaches and evidence-based treatments to reduce cancer risk and improve outcomes. This Cancer MoonshotSM–funded ISC3 Network consists of 7 P50 Centers that support and advance the rapid development, testing, and refinement of innovative approaches to implement a range of evidence-based cancer control interventions. The Centers were designed to have research-practice partnerships at their core and to create the opportunity for a series of pilot studies that could explore new and sometimes risky ideas and embed in their infrastructure a 2-way engagement and collaboration essential to stimulating lasting change. ISC3 also seeks to enhance capacity of researchers, practitioners, and communities to apply implementation science approaches, methods, and measures. The Organizing Framework that guides the work of ISC3 highlights a collective set of 3 core areas of collaboration within and among Centers, including to 1) assess and incorporate dynamic, multilevel context; 2) develop and conduct rapid and responsive pilot and methods studies; and 3) build capacity for knowledge development and exchange. Core operating principles that undergird the Framework include open collaboration, consideration of the dynamic context, and engagement of multiple implementation partners to advance pragmatic methods and health equity and facilitate leadership and capacity building across implementation science and cancer control.
Citation: Oh A, Emmons KM, Brownson RC, Glasgow RE, Foley KL, Lewis CC, Schnoll R, Huguet N, Caplon A, Chambers DA. Speeding implementation in cancer: The National Cancer Institute’s Implementation Science Centers in Cancer Control. JNCI: Journal of the National Cancer Institute. 2022; 115:2. Published 2022 Oct 31. https://doi.org/10.1093/jnci/djac198
The purpose of this study was to understand challenges that school administrators faced in their approaches to address adolescent vaping in Massachusetts middle and high schools. We analyzed open-ended comments from Massachusetts school administrators who completed a survey between November 2020 and January 2021. Further, we analyzed nine interviews with administrators (e.g., principals, vice principals, school nurses) from Massachusetts school systems (n = 6) and school-based anti-tobacco advocates (n = 3); interviews took place between May and December 2021. We found that challenges to addressing adolescent vaping included school personnel capacity, funding, and lack of mental health and counseling supports. The COVID-19 pandemic was a major barrier to conducting usual in-person vaping programs, but also reduced student vaping at school due to new social distancing practices and bathroom use policies. Successful approaches included peer-led initiatives and parental involvement, and participants discussed the importance of educating adolescents on the harms of vaping. Based on our findings, school-based anti-vaping program practitioners—such as school districts, state departments of education, or local health departments—should leverage peer-led initiatives, alternatives-to-suspension approaches, and parental involvement, to increase the potential impact of adolescent vaping prevention and treatment efforts.
Citation: Liu J, Roberts J, Reynolds MJ, Hanby E, Gundersen DA, Winickoff JP, Rees VW, Emmons KM, Tan ASL. Barriers and facilitators to address vaping in Massachusetts schools: a mixed-methods study of school-based stakeholders. Translational Behavioral Medicine. 2023;13(8):589-600. doi:10.1093/tbm/ibad012
Background: There is little guidance for conducting health equity-focused economic evaluations of evidence-based practices in resource-constrained settings, particularly with respect to staff time use. Investigators must balance the need for low-touch, non-disruptive cost data collection with the need for data on providing services to priority subpopulations.
Methods: This investigation took place within a pilot study examining the implementation of a bundled screening intervention combining screening for social determinants of health and colorectal cancer at four federally qualified health centers (FQHCs) in the Boston metropolitan area. Methods for collecting data on personnel costs for implementation and intervention activities, including passive (automatic) and active (non-automatic, requiring staff time and effort) data collection, as well as three alternate wordings for self-reporting time-use, were evaluated qualitatively using data collected through interviews with FQHC staff (including clinicians, population health staff, and community health workers) and assessments of data completeness.
Conclusion: Passively collected time use data are the least burdensome and should be pursued in research efforts when possible, but should be accompanied by qualitative assessments to ensure the data are an accurate reflection of effort. When workflows are already tracked by active data collection, these are also strong data collection methods. Self-reported time use will be most accurate when questions inquire about “typical” tasks and specific types of patients.
Citation: Levy DE, Singh D, Aschbrenner KA, Davies ME, Pelton-Cairns L, Kruse GR. Challenges and recommendations for measuring time devoted to implementation and intervention activities in health equity-focused, resource-constrained settings: a qualitative analysis. Implementation Science Communications. 2023;4(1). doi:10.1186/s43058-023-00491-7
View the research summary here.
Racial/ethnic minorities have been disproportionately impacted by COVID-19. The effects of COVID-19 on the long-term mental health of minorities remains unclear. To evaluate differences in odds of screening positive for depression and anxiety among various racial and ethnic groups during the latter phase of the COVID-19 pandemic, we performed a cross-sectional analysis of 691,473 participants nested within the prospective smartphone-based COVID Symptom Study in the United States (U.S.) and United Kingdom (U.K). from February 23, 2021 to June 9, 2021. In the U.S. (n=57,187), compared to White participants, the multivariable odds ratios (ORs) for screening positive for depression were 1·16 (95% CI: 1·02 to 1·31) for Black, 1·23 (1·11 to 1·36) for Hispanic, and 1·15 (1·02 to 1·30) for Asian participants, and 1·34 (1·13 to 1·59) for participants reporting more than one race/other even after accounting for personal factors such as prior history of a mental health disorder, COVID-19 infection status, and surrounding lockdown stringency. Rates of screening positive for anxiety were comparable. In the U.K. (n=643,286), racial/ethnic minorities had similarly elevated rates of positive screening for depression and anxiety. These disparities were not fully explained by changes in leisure time activities. Racial/ethnic minorities bore a disproportionate mental health burden during the COVID-19 pandemic. These differences will need to be considered as health care systems transition from prioritizing infection control to mitigating long-term consequences.
Citation: Nguyen LH, Nguyen LH, Anyane-Yeboa A, Klaser K, Merino J, Drew DA, et al. The mental health burden of racial and ethnic minorities during the COVID-19 pandemic. PlosOne. 2022; 17:8. Published 2022 Aug 10. https://doi.org/10.1371/journal.pone.0271661
Background: Dissemination and implementation (D&I) research is a key factor in the uptake and use of evidence-based cancer control interventions. National Cancer Institute (NCI)–designated cancer centers are ideal settings in which to further D&I knowledge. The purpose of this study was to summarize the characteristics of NCI-funded D&I science grants in the nation’s cancer centers to understand the nature, extent, and opportunity for this key type of translational work.
Methods: We used the National Institutes of Health Research Portfolio Online Reporting Tool to identify active NCI-funded grants in D&I science at NCI clinical cancer centers (n = 13) and comprehensive cancer centers (n = 51) as well as their academic affiliates. Active projects were eligible for inclusion if they 1) were awarded directly to an NCI cancer center or an academic or research affiliate, and 2) identified D&I content in the abstract. Portfolio data were collected in February 2021.
Results: We identified 104 active NCI-funded D&I research or training grants across the 64 cancer centers; 57.8% of cancer centers had at least 1 NCI-funded D&I grant. Most awards (71.1%) were for research grants. Training grants constituted 29.1% of D&I-focused grants. Overall, 50.0% of grants (n = 52) concentrated on specific cancers. Almost two-thirds of grants (n = 68, 65.4%) had a stated health equity focus.
Conclusions: More than one-half of NCI-designated cancer centers have active funding in D&I science, reflecting a substantial investment by NCI. There remains considerable room for further development, which would further support NCI’s translational mission.
Citation: Mueller NM, Hsieh A, Ramanadhan S, Lee RM, Emmons KM. The prevalence of dissemination and implementation research and training grants at National Cancer Institute–Designated Cancer Centers. JNCI Cancer Spectru. 2022; 6:1. Published 2021 Dec 15. https://doi.org/10.1093/jncics/pkab092
Background: More than half of cancers could be prevented by employing evidence-based interventions (EBIs), including prevention interventions targeting nutrition, physical activity, and tobacco. Federally qualified health centers (FQHCs) are the primary source of patient care for over 30 million Americans — making them an optimal setting for ensuring evidence-based prevention that advances health equity. The aims of this study are to (1) determine the degree to which primary cancer prevention EBIs are being implemented within Massachusetts FQHCs and (2) describe how these EBIs are implemented internally and via community partnerships.
Methods: We used an explanatory sequential mixed methods design to assess the implementation of cancer prevention EBIs. First, we collected 34 quantitative surveys from staff at 16 FQHCs across Massachusetts to determine the frequency of EBI implementation. We followed up with 12 qualitative one-on-one interviews among a sample of staff to understand how the EBIs selected on the survey were implemented. Exploration of contextual influences on implementation and use of partnerships was guided by the Consolidated Framework for Implementation Research (CFIR). Quantitative data were summarized descriptively, and qualitative analyses used reflexive, thematic approaches, beginning deductively with codes from CFIR, then inductively coding additional categories.
Results: All FQHCs indicated they offered clinic-based tobacco interventions, such as clinician-delivered screening practices and prescription of tobacco cessation medications. Quitline interventions and some diet/physical activity EBIs were available at all FQHCs, but staff perceptions of penetration were low. Only 38% of FQHCs offered group tobacco cessation counseling and 63% referred patients to mobile phone-based cessation interventions. We found multilevel factors influenced implementation across intervention types — including the complexity of intervention trainings, available time and staffing, motivation of clinicians, funding, and external policies and incentives. While partnerships were described as valuable, only one FQHC reported using clinical-community linkages for primary cancer prevention EBIs.
Conclusions: Adoption of primary prevention EBIs in Massachusetts FQHCs is relatively high, but stable staffing and funding are required to successfully reach all eligible patients. FQHC staff are enthusiastic about the potential of community partnerships to foster improved implementation—providing training and support to build these relationships will be key to fulfilling that promise.
Citation: Lee RM, Daly JG, Mallick K, Ramanadhan S, Torres CH, Hayes CR, Manuel A, Nalls R, Emmons KM. Implementation of evidence-based primary cancer prevention interventions in MA community health centers: an explanatory sequential mixed methods study. Implementation Science Communications. 2023;4(1). doi:10.1186/s43058-023-00483-7
Introduction: Access to COVID-19 testing has been inequitable and misaligned with community need. However, community health centers have played a critical role in addressing the COVID-19 testing needs of historically disadvantaged communities. The aim of this paper is to explore the perceptions of COVID-19 testing barriers in six Massachusetts communities that are predominantly low income and describe how these findings were used to build tailored clinical-community strategies to addressing testing inequities.
Methods: Between November 2020 and February 2021, we conducted 84 semi-structured qualitative interviews with 107 community health center staff, community partners, and residents. Resident interviews were conducted in English, Spanish, Vietnamese, and Arabic. We used a 2-phase framework analysis to analyze the data, including deductive coding to facilitate rapid analysis for action and an in-depth thematic analysis applying the Social Ecological Model.
Results: Through the rapid needs assessment, we developed cross-site suggestions to improve testing implementation and communications, as well as community-specific recommendations (e.g., locations for mobile testing sites and local communication channels). Upstream barriers identified in the thematic analysis included accessibility of state-run testing sites, weak social safety nets, and lack of testing supplies and staffing that contributed to long wait times. These factors hindered residents’ abilities to get tested, which was further exacerbated by individual fears surrounding the testing process and limited knowledge on testing availability.
Discussion: Our rapid, qualitative approach created the foundation for implementing strategies that reached underserved populations at the peak of the COVID-19 pandemic in winter 2021. We explored perceptions of testing barriers and created actionable summaries within 1-2 months of data collection. Partnering community health centers in Massachusetts were able to use these data to respond to the local needs of each community. This study underscores the substantial impact of upstream, structural disparities on the individual experience of COVID-19 and demonstrates the utility of shifting from a typical years’ long research translation process to a rapid approach of using data for action.
Citation: Lee RM, Handunge VL, Augenbraun SL, et al. Addressing COVID-19 Testing Inequities Among Underserved Populations in Massachusetts: A Rapid Qualitative Exploration of Health Center Staff, Partner, and Resident Perceptions. Front Public Health. 2022;10:838544. Published 2022 Mar 24. doi:10.3389/fpubh.2022.838544
View the research summary here.
Background: Community Health Centers (CHCs) are a critical source of care for low-income and non-privately insured populations. During the pandemic, CHCs have leveraged their infrastructure and role as a trusted source of care to engage the communities they serve in COVID-19 testing.
Methods: To directly address the impact that COVID-19 has had on historically marginalized populations in Massachusetts, we designed a study of community-engaged COVID-19 testing expansion: (1) leveraging existing partnerships to accelerate COVID-19 testing and rapidly disseminate effective implementation strategies; (2) incorporating efforts to address key barriers to testing participation in communities at increased risk for COVID-19; (3) further developing partnerships between communities and CHCs to address testing access and disparities; (4) grounding the study in the development of a shared ethical framework for advancing equity in situations of scarcity; and (5) developing mechanisms for communication and science translation to support community outreach. We use a controlled interrupted time series design, comparing number of COVID-19 tests overall and among people identified as members of high-risk groups served by intervention CHCs compared with six matched control CHCs in Massachusetts, followed by a stepped wedge design to pilot test strategies for tailored outreach by CHCs.
Conclusions: Here, we describe a community-partnered strategy to accelerate COVID-19 testing in historically marginalized populations that provides ongoing resources to CHCs for addressing testing needs in their communities. The study aligns with principles of community-engaged research including shared leadership, adequate resources for community partners, and the flexibility to respond to changing needs over time.
Citation: Kruse GR, Pelton-Cairns L, Taveras E, Dargon-Hart S, Gundersen G, Lee RM, Bierer BE, Lawlor E, LaRocque R, Marcus JM, Davies ME, Emmons K, the RADx-MA Research Partnership. Implementing expanded COVID-19 testing in Massachusetts community health centers through community partnerships: Protocol for an interrupted time series and stepped wedge study design. Contemporary Clinical Trials. 2022; 118:106783. Published 2022 July. https://doi.org/10.1016/j.cct.2022.106783.