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Power between evaluator and community: research relationships within New Mexico's healthier communities.

The relationship between evaluators and communities has been changing in the last two decades to a model of research 'with' the community, instead of research 'on' the community. This shift has paralleled increasing community demands for accountability and authority as community participation rhetoric has given way to words such as partnership, collaboration and community empowerment. Despite the rhetoric, there has been little reflection on the problematic and contradictory relationships between communities and researchers, specifically as related to their differing positions of power. This article provides a reflective examination of the contested power dynamics of the research relationship within a participatory evaluation process of the Healthier Communities initiative in New Mexico. An in-depth literature review of the philosophical principles and the complex realities of evaluations based on participatory, community-driven and post-modern inquiry precedes the case study. Without ongoing consideration of power issues, the article argues that evaluation design, implementation and utilization of findings will be compromised.

Community Health Planning↗

Making the links between community structure and individual well-being: community quality of life in Riverdale, Toronto, Canada.

An inquiry into community quality of life was carried out within a framework that recognizes the complex relationship between community structures and individual well-being. Through use of focus groups and key informant interviews, community members, service providers, and elected representatives in a Toronto community considered aspects of their community that affected quality of life. Community members identified strengths of access to amenities, caring and concerned people, community agencies, low-cost housing, and public transportation. Service providers and elected representatives recognized diversity, community agencies and resources, and presence of culturally relevant food stores and services as strengths. At one level, findings were consistent with emerging concepts of social capital. At another level, threats to the community were considered in relation to the hypothesized role neo-liberalism plays in weakening the welfare state.

Community Networks↗

Involving communities in community assessment.

Focus groups provide an effective means of incorporating the perspectives of "hidden" populations in assessments of community health needs and assets. A series of focus groups was conducted with specifically targeted segments of a community to develop a comprehensive picture of community health. The authors describe the focus group process, major findings, and the use of focus group results in a highly multicultural community. Despite differences in age, length of residence, and ethnicity, the focus groups were remarkably similar in the issues raised. The majority of participants viewed the multicultural nature of the community as an asset but voiced some of the difficulties of living in a multiethnic and multilanguage environment. Similar areas of concern in the community arose from all of the focus groups, including housing and other environmental issues and problems of access to health care. Focus group findings have been used to initiate activity addressing identified community problems. Focus group participation had the added benefit of increasing community members' participation in other community endeavors.

Adolescent↗

Moving from medical student placement to a community-academic partnership with a rural community.

This article explains a partnership-based community education model, which uses as an example a partnership between the Center for Healthy Communities in the Department of Family and Community Medicine at the Medical College of Wisconsin (MCW) and the rural Marion area of central Wisconsin. MCW is similar to other medical schools in that it has a strong history and philosophy of placing students in communities for educational purposes. This article describes how the Center for Healthy Communities is moving beyond student placement to true partnership building. The center followed four stages of development as it built a partnership with this rural Wisconsin community: (1) establish and build relationships, (2) develop common goals, (3) develop and implement programs and (4) maintain and expand progress. The center also applied a set of principles in developing the partnership. By following the stages and applying the principles, the center found that two elements were key to building a partnership for medical student education and community health improvement: long-term commitment and ability and willingness to spend time in the community. As a result, a meaningful, ongoing partnership developed that benefits both the community and MCW.

Clinical Clerkship↗

Communities defining environmental health: examples from the Colorado (U.S.A.) Healthy Communities Initiative.

Communities are increasingly defining 'health' for themselves, then becoming the main actors in actions to improve their health and well being. These community members work from a broad and inclusive definition of 'health' that often incorporates environmental health as a key aspect. They also assume an ecological, or systems, viewpoint that integrates many aspects of the community that affect health and well being, including housing, health, economy, education, transportation, youth and family issues, as well as health and illness care. This paper describes a program that involves 28 large and small, urban and rural communities in the United States state of Colorado that undertook this type of community-based health improvement project. The Colorado Healthy Communities Initiative (CHCI) was designed to bring together citizens in Colorado to work collaboratively to make their communities healthier. This paper describes the program's background, including its principles, processes, and participants, then focuses on the particular aspects of environmental health that communities included in their definitions of a 'healthy community'.

Colorado↗

Involvement of family and community medicine professionals in community projects.

OBJECTIVE: Medical schools are being challenged to continue their excellence in education, research, and patient care while responding to the health needs of the public. The objective of our study was to determine the nature and type of community involvement of professionals in departments of family and community medicine. STUDY DESIGN: We mailed a 24-item structured survey to a random national sample of family medicine professionals. POPULATION: Survey recipients included 770 full-time physician and nonphysician active members of the Society of Teachers of Family Medicine. OUTCOMES MEASURED: Our survey assessed community activities, challenges and incentives to those activities, and desired resources for working in the community. RESULTS: A total of 446 usable surveys were returned (58% response rate). Ninety-five percent of respondents had participated in a community activity within the previous year. More male respondents precepted medical students or residents and educated faculty on topics regarding community education; more older respondents participated by sitting on community health boards or councils. Insufficient release time and lack of funding were the 2 most frequently cited barriers to community-based activities. CONCLUSIONS: Most faculty are involved in community-related teaching and service. Reasons for low levels of research and subgroup differences, especially among women and young faculty, merit further research.

Academic Medical Centers↗

Community health orientation, community-based quality improvement, and health promotion services in hospitals.

The objective of the study presented in this article was to examine the relationship between hospital community orientation and the provision of health promotion services. The study used data from the 2000 American Hospital Association survey and the 2000 Area Resource File to examine acute care hospitals throughout the United States. The study was a cross-sectional multiple regression analysis. Hospital community orientation was measured by two independent variables: (1) community health orientation and (2) community-based quality orientation. Health promotion services were represented by two dependent variables: (1) hospital-based health promotion services and (2) collaborative health promotion services. Organizational control variables included bed-size code, not-for-profit ownership, network participation, and joint venture/alliance membership. Environmental control variables included the proportion of population over age 65, the percentage of population below the poverty level, the square root of the proportion of Medicaid inpatient revenue, the presence of state community benefit laws/guidelines, a Herfindahl-Hirschman Index of level of competition, and an index of managed care influence. Results of regression analyses showed that community health and community-based quality orientations were positively and significantly related to both the direct provision of health promotion services by hospitals and the collaborative provision of health promotion services through systems, joint ventures, and networks. The study concludes that a community health orientation and a community-based quality orientation lead to greater provision of health promotion services.

Community-Institutional Relations↗

Reducing diabetes health disparities through community-based participatory action research: the Chicago Southeast Diabetes Community Action Coalition.

To address disproportionately high rates of diabetes morbidity and mortality in some of Chicago's medically underserved minority neighborhoods, a group of community residents, medical and social service providers, and a local university founded the Chicago Southeast Diabetes Community Action Coalition, a Centers for Disease Control and Prevention REACH 2010 Initiative. A community-based participatory action research model guided coalition activities from conceptualization through implementation. Capacity building activities included training on: diabetes, coalition building, research methods, and action planning. Other activities sought to increase coalition members' understanding of the social causes and potential solutions for health disparities related to diabetes. Trained coalition members conducted epidemiologic analyses, focus groups, a telephone survey, and a community inventory. All coalition members participated in decisions. The participatory process led to increased awareness of the complexities of diabetes in the community and to a state of readiness for social action. Data documented disparities in diabetes. The participatory action research approach (a) encouraged key stakeholders outside of the health care sector to participate (e.g., business sector, church groups); (b) permitted an examination of the sociopolitical context affecting the health of the community; (c) provided an opportunity to focus on preventing the onset of diabetes and its complications; (d) increased understanding of the importance of community research in catalyzing social action aimed at community and systems change and change among change agents.

Chicago↗

Community partnerships: the cornerstone of community health research.

Community partnerships have been recognized as the cornerstone of community research. The recent Institute of Medicine report, Unequal Treatment, puts forth the idea of creating community partnerships as a strategy to address racial and ethnic disparities in health care. Community-based research is frequently reported in the literature as a study conducted in the community versus with the community. The objective of this review is to examine models of community partnerships, to consider their implications for community-based research, and to identify directions for future nursing research.

Community Health Nursing↗

Characteristics of bacteremia between community-acquired and nosocomial Klebsiella pneumoniae infection: risk factor for mortality and the impact of capsular serotypes as a herald for community-acquired infection.

BACKGROUND: Although several epidemiological surveys of Klebsiella clinical isolates have been performed, few studies have correlated the clinical isolate with disease. OBJECTIVE: To compare the clinical and bacteriological characteristics of Klebsiella pneumoniae bacteremia acquired as community or nosocomial infections. METHODS: We prospectively enrolled 158 consecutively hospitalized patients with K pneumoniae bacteremia. Clinical data were reviewed. Antimicrobial susceptibility testing and capsular serotyping were performed. We used the chi(2) test, the Fisher exact test, or the t test for statistic analysis. RESULTS: Underlying diabetes mellitus was more common in community-acquired than in nosocomial infection (46/94 [49%] vs. 8/64 [12%]; P<.001). On the other hand, neoplastic disease (34/64 [53%] vs. 13/94 [14%]; P<.001) and antibiotic resistance (P<.01) were more frequent in patients with nosocomial compared with community-acquired infections. Klebsiella pneumoniae liver abscesses, which were all community acquired, accounted for the source of 22 (23%) of 94 community-acquired K pneumoniae infections. No attributable source of infection was found for 37 (58%) of the 64 nosocomial infections vs. 15 (16%) of the 94 community-acquired infections. Only 58 isolates (36.7%) could be serotyped; of these, capsular serotypes K1, K2, and K28 accounted for 37 (23.4%), 8 (5.1%), and 6 (3.8%), respectively, of all strains. However, typeable isolates were significantly more common among community-acquired than nosocomial isolates (42/94 [45%] vs. 16/64 [25%]; P =.01), especially for serotype K1 (28/94 [30%] vs. 9/64 [14%]; P =.02). Significant risk factors for mortality included nosocomial infection, lung infection, thrombocytopenia, leukopenia, ceftazidime resistance, inappropriate antimicrobial therapy, and septic shock. CONCLUSIONS: Significant differences were identified between community-acquired and nosocomial K pneumoniae bacteremia. Ceftazidime resistance in nosocomial K pneumoniae bacteremia carried a high risk for mortality, and serotype K1 in K pneumoniae was more prevalent in community-acquired infection, suggesting more virulence.

Bacteremia↗

Community-based HIV/AIDS research--whither community participation? Unsolved problems in a research programme in rural Uganda.

Involvement of the study community in research on HIV/AIDS has presented the MRC/UVRI programme in rural Uganda with a multi-layered challenge. A typology developed in agricultural research which defines different levels of community participation in research is described where participation may be at 'contract', 'consultative', 'collaborative' and 'collegiate' level (each level indicating an increasing degree of community participation). Community involvement in the MRC/UVRI Programme is then outlined and the typology applied. It is shown that the majority of community participation in the Programme is at the contract level since the nature of the research programme as a 'foreign imposition' with 'foreign goals' has precluded the involvement of the community in much of the policy development and research planning. However, it is noted that as the Programme becomes more established in the area community influence grows and signs of community impact on policy and increased research inputs are beginning to be seen. The question is raised as to whether it is realistic to expect that externally imposed health research, particularly on sensitive topics, can ever be truly community participatory research.

Acquired Immunodeficiency Syndrome↗

Community-directed treatment with ivermectin in two Nigerian communities: an analysis of first year start-up processes, costs and consequences.

OBJECTIVES: To determine the start-up processes, costs and consequences of community-directed treatment with ivermectin (CDTI) in two onchocerciasis endemic rural towns of Southeast Nigeria; namely Achi and Nike. The other objectives were to discover the community-financing mechanisms, local ivermectin distribution strategies and communities' organisational capacity to handle the programme. METHODS: Structured questionnaires, informal interviews, observations, discussions with community members at general village assemblies and community outreach lectures were used at different stages of the study. RESULT: The towns had the organisational capacity to implement the programme. Coverage with ivermectin was between 31-73% in Achi (mean = 58.6%), and 36.6-72% in Nike (mean = 61.95%). The unit financial costs were $0.17 in Nike and $0.13 in Achi, but the unit aggregate cost was $0.37 in Nike and $0.39 in Achi. When research costs were removed, the unit aggregate cost was $0.22 in Achi and $0.20 in Nike. Provider's financial costs and communities' non-financial costs were the biggest contributors to the aggregate cost. The cost would decrease in subsequent years since the research cost and parts of the mobilisation and training costs would not be incurred after the first year. CONCLUSION: Governments and sponsors of CDTI should find means of continuously strengthening the programme and providing technical support to the communities. As both CDTI and communities are dynamic entities, continuous health education campaigns are needed to keep reminding the people of the benefit of long-term ivermectin distribution, together with the need for community ownership of the programme.

Anthelmintics↗

[Community activities in primary care in Spain. An analysis based on the network of the Program of Community Activities (PACAP)].

OBJECTIVE: To describe, analyse and discuss the activities in the Network of Community Activities of the Programme of Community Activities in Primary Care of the Spanish Society of Family and Community Medicine. DESIGN: Description of the activities within this Network.Setting. Network of Community Activities of the Spanish Society of Family and Community Medicine. MAIN MEASUREMENTS: Specifications of the variables of geography, target population and experience descriptives were obtained from the qualitative analysis of the activity summary composed by its authors. The measurements are frequency tables expressed in graphs and analysis of the summaries contributed by the groups on objectives, kinds of programme, methodologies, evaluation and conclusions reached. The community orientation activities undertaken by the health centres registered on the Network came mostly (54%) from the autonomous communities of Madrid and Andalusia. A great many of them were aimed at the adult population, tackling problems of chronic diseases, and particularly at women, in this case tackling gender themes such as menopause and pregnancy, etc. CONCLUSIONS: There was uneven distribution between autonomous communities of the experiences included on the web. Central to community orientation are the replies to questions such as: inside or out of the health centre?, the importance of transferring leadership to society, and adaptation to the needs and demands of the population cared for.

Adult↗

Validity and community-health-nursing sensitivity of six outcomes for community health nursing with older clients.

A survey research design was used to assess the importance, sensitivity to nursing interventions, and content validity of six client outcomes from the Nursing Outcomes Classification (NOC)). Outcomes relevant for elderly community residents and caregivers were included in a questionnaire mailed to American Nurses Credentialing Center-certified expert community health nurses. Two hundred thirty-nine experts rated specific indicators of the six outcomes for their importance in determining the outcomes and the contribution of nursing to their achievement. Outcomes also were rated for their importance for community health nursing clients and responsiveness to community health nursing intervention. Results strongly support the content validity and nursing sensitivity of outcomes and specific indicators. Experts judged all six outcomes to be important and 90% of indicators as important in determining the outcome. All outcomes and 78% of indicators were judged to be responsive to community health nursing intervention. Recommendations include the testing of NOC outcomes in community health nursing clinical practice and inclusion in community health nursing curricula. Areas for further research include development and validation of community-level outcomes, validation of outcomes with rural and home health nursing experts, and exploration of the community health nursing-sensitivity of one study outcome.

Activities of Daily Living↗

Wounds that echo: community perceptions of the socio-structural determinants of community violence in post-apartheid South Africa in the context of COVID-19.

The COVID-19 pandemic and its associated public health measures significantly altered the social, economic, and psychological landscape of communities worldwide. In South Africa, the post-COVID-19 period has been marked by a notable surge in homicide rates and interpersonal and community violence. Using a combined structural and social disorganisation framework, this qualitative study critically explores community members' perceptions of the socio-structural factors contributing to community violence, in the context of COVID-19. Utilising data from in-depth interviews and focus group discussions, this study examines the lived experiences of residents in a marginalised high-risk South African community, unpacking the interplay between structural inequities, social disintegration, and community violence. Community violence emerged not as periodic or individual, but as structurally generated, geographically concentrated, and socially normalised. The findings demonstrate that community violence is perceived as being embedded in cycles of survival, where long-standing systemic inequality, economic precarity, spatial disadvantage, and institutional neglect and inequity generate contexts in which community violence becomes normalised and self-reinforcing. The study findings advocate for interventions that not only address immediate catalysts of violence but also the deeper historical and structural determinants of violence in the post-pandemic era, while ensuring preparedness for effective violence prevention during future pandemics.

Humans↗

Knowledge, skills and experiences for community health nursing practice: the perceptions of community nurses, administrators and educators.

Nursing in Canada is committed to preparing all new graduates at the baccalaureate level for entry to nursing practice by the year 2000. This goal has major implications for community health nursing education and practice. Health care reform is also expected to move care out of the hospital and into the community. It was against this backdrop that the researchers mounted a study on the educational preparation needed for graduates to begin to practice community health nursing. In this paper, the knowledge, professional and personal skills, and experiences that graduates need to begin community practice are reported. The study was carried out within an action-research framework. All major groups of stakeholders involved in community health nursing throughout the study province were involved in the project. This included nurses and administrators from two public health agencies (provincial and municipal), home care nurses, home health nurses (i.e. non-governmental visiting nurses), community health centres, provincial health care and nursing consultants, and faculty from two universities. In addition to the generation of relevant research findings for use by the educational institutions, the study was initiated to set the stage for future and ongoing interactions between the researchers and community experts to implement the findings from the project. Data were collected from 118 participants by means of 27 focus groups of community nurses, administrators and educators. Interviews were tape-recorded, transcribed and analysed using latent content analysis and constant comparison techniques. Findings indicated that qualified nurses from university programmes need a wide range of knowledge, skills and experiences to begin to practice community health nursing. Detailed accounts of these requirements are outlined and the implications for practice and education put forward.

Attitude of Health Personnel↗

Promoting prenatal care: what do community leaders know and believe about it? (community leader beliefs about promotion).

Community leaders directly affect prenatal services in their local communities. Twenty-nine leaders in an urban community and 47 in a rural community in Wisconsin were interviewed to determine their knowledge and beliefs about and intent to promote prenatal care for low-income women in their communities. The findings showed that leaders generally assigned high importance to prenatal care for low-income women and intended to promote it during the next six months; and they demonstrated good general knowledge about prenatal care and perceived broad-based community support for their decision to promote it. Disturbingly, many community leaders did not know what percentage of local pregnant women entered prenatal care late or how many medical care providers were available to their constituents on Medicaid, cost was cited as a disadvantage to promoting prenatal care for low-income women, and several leaders in both communities believed that promoting prenatal care would result in low-income women wanting to have more babies or increasing their dependence on free programs. Public health nurses can use the findings of this study in their work with community leaders to ensure prenatal services for low-income populations.

Community Participation↗

Community tenure of people with serious mental illness in assertive community treatment in Canada.

OBJECTIVE: This study followed consumers after admission to an assertive community treatment program to determine when the first hospital admission was more likely to occur, which variables predicted community tenure, and, more specifically, whether the availability of within-program hospital beds predicted community tenure. METHODS: Data were gathered from three assertive community treatment programs in southeastern Ontario--the psychosocial rehabilitation program, the community integration program, and the assertive community treatment team program. Only the psychosocial rehabilitation program provided within-program beds. Hospital records of consumers who entered a program between July 1, 1990, and December 1, 1999, were examined prospectively until January 1, 2000, in order to record time to the first admission. Survival analysis based on the life-tables method was used to estimate the probability of remaining out of the hospital at 90-day intervals. Factors associated with time to admission were identified by using the Cox proportional hazards model. RESULTS: A total of 333 consumers were followed: 117 consumers in the psychosocial rehabilitation program, 105 in the community integration program, and 111 in the assertive community treatment team program. Findings indicated that consumers were most likely to be admitted to a hospital in the nine months after entering an assertive community treatment program. A diagnosis of substance use disorder, higher past hospital use, and the availability of within-program beds were associated with an increased risk of admission. CONCLUSIONS: Studies have shown that hospitalization remains a reality for many consumers and therefore warrants further study. The survival model proved advantageous by allowing a more complete and comparable description of consumers' hospitalization patterns that cannot be achieved with previously used methods, and it offered the power of regression analysis.

Acute Disease↗