Okay, Week 7. This is the last of the three lectures. This is the last of our course.

We're still talking about doing things, and in this little module I want to talk about Community Interventions, particularly, Community-based Participatory Research. I'll describe. So CBPR, or Community-based Participatory Research, is a kind of research technique that I think is really important to social epidemiology. The important part here is that researchers work with community members themselves, in a partnership so that the ideas for improving health. Come from both researchers and community members in some kind of dialogue. And they work together to figure out what should be studied, how it should be studied, and of course what improvements can be made. Important idea here is that community members are full partners with the research, researchers in this model. And finally I want to offer that CBPR is really a perspective. It's not a research design, it's not a statistical technique. It's about how we view our research as social epidemiologists. Do we want to go in, and say something like, hi, we're here from the government, here to help you. Or do we want to work with community members sort of hand in hand and try to solve problems together? CBPR is about the latter. Key ideas, we want to get community member buy-in. As most of you probably know, when members are buying in, when the target audience is interested in what you're doing, usually things get done more easily. CBPR in my experience entails lots and lots of meetings, and it takes some patience. You need to work together Its sometimes difficult to discern or figure out what the community members actually want. Remember people like you and me the researchers have thought a lot about these health issues. Many community members have not so it takes some time and some education. And so that's one of the challenges of CBPR.

Finally, its an iterative process its not just let's have one meeting and decide. It goes back and forth, back and forth and again that takes time and huge commitment from the CBPR researchers. Some of the challenges of CBPR are, who is the community member that should represent the community. It's a very difficult question. Sometimes the persons from the community who step forward to partner with the research team, are not the best representatives of the community. There's often not a vote, and it's often difficult to find people who are otherwise busy, working in some fashion perhaps. So one of the key issues of CBPR is, who are the community members we are working with? There can be tensions an difficulties. Researchers might have an agenda, community members might have another agenda. These agendas can clash. We need to have procedures for, working through these obstacles. And there are plenty, an you can look at them, if you wish. It can take an enormous amount of time to build trust. Often researchers from a university are not the most respected members of the community, and you have to rebuild that trust. There's often some history in local communities, and it's important to stay the course, and build the trust, so that everyone's on the same page. Finally though there's some pretty good evidence building its still not yet clear. How much CBPR this approach and technique actually improves the health of community members. So the jury is still out on the great impact of CBPR doesn't mean it doesn't work just means we need more evidence to show that it does. What I want to offer you an examples from, from some of my own work that I did a few years ago. And this of course occurred near my home here at the University of Minnesota and here on this map of course is the great state of Minnesota. Let me zoom in further, and in the great state are the twin cities, or Minneapolis, Saint Paul area. And that's where that arrow is pointing

to, and in that Metropolitan area there is this neighborhood. If you're local here, sometimes it's called the Phillips Powderhorn area, and it's some subset of the city. The idea here was that some large philanthropic organizations literally wanted to improve the health of members at a given geographic area. And by given I mean, they drew a line around a neighborhood and said members inside we're going to try to improve your health. And so the dot is where the headquarters of the organization was and this black line on the map demarcates the boundaries of the target region. You might ask what about people outside the line. Well, they were not the target of this health intervention. But still it's important to know it's not clear that the health intervention what ever turned it turned out to be would work. So it's not as if they were losing anything at the start. So the idea again here is to improve the health of a given, bounded region. Its a very interesting question that doesn't come up enough in social epidemiologic discussions. Here's some pictures for those of you to get a feel of what this place looked like. Its a largely lower middle class working class neighborhood in a middle class city in America. So here are some photos for you. There's some burned out buildings but not too many. There's some reasonable houses, some houses are boarded up, and some basic demographics for you. There's about 45,000 people, 15,000 housing units. There's a large, dynamic population. People are coming in and leaving, moving for jobs and schools and so forth. The demographics are approximately 32% White, 26% African American, and about 22% Hispanic, 7% American Indian, and of course they're some others. 23% are foreign born, 36% lived in the same house five years prior. That's not a large number, 28% of the population are high school graduates, that's a low number, 13% are college graduates. Again a low number greater than 10

percent unemployment when we did this study. So that's pretty high even in the economic recession America was experiencing at the time. 13% of the population live in deep poverty, less than 200% of the poverty line. So that's not a lot of resource, 28% live in poverty and 44 percent are so-called working poor. So this is a challenged area. There's a high proportion in this area of what we called subprime mortgages. Where banks offered, sort of, bad loans that harmed people's chances to keep their home when the market went bad. There's not a lot of crime. There was some homicides, but those rates were dropping. The education of the, students is an important demographic factor. 78% of the students in the area are of color, that is, non-white. 81 and 94% of the high school graduation or had high school graduate, had high school graduation rates at the two primary high schools. That's a pretty good number but it's always a difficult thing to calculate. The math and reading standardized tests were low for the community. 97% of the students that wanted the schools got free or government subsidized lunches. That means they could not afford lunch and so the government steps in to solve that problem. and in the high school the older grades 77% of the students got free lunch. So again this is a lower lower middle class or upper lower class kind of neighborhood. So what about the health status? Well, we did some surveys and 82% of the adults reported being in good health. Now this is an interesting statistic, because when you ask someone their health, it's very predictive of how their health actually will be. So even their subject of assessment, I feel good, is a good indicator of what their health will be today and into the future. 16% of the population was diagnosed with some sort of mental health depression. That's not a large number, but again the key here is diagnosis, and as many of you know, you need to see a doctor in order to get that diagnosis.

Can't see a doctor, can't get the diagnosis. 51% of that population were calculated to be overweight or obese. That's about right for this kind of demographic profile. 13% with high blood pressure, and five percent with one of the two types of diabetes. There's more characteristics. Some of the things I'll just point out, 24% of the population was smoking, that's still a large number. Only 76% always wear seatbelts, 40% did routine moderate physical activity. So none of these numbers should surprise you if you work in this kind of stuff. On the other hand, there are community gardens in this neighborhood, and this was intentionally done by lots of health-advancing persons and groups. And so we want to not only look at health deficits of the area, but health assets. And community gardens are one such asset. In addition, there are hundreds of community based organizations. You cannot see this list but my point is there's a whole long list of organizations trying to improve the health and welfare of their residents. So, the big question the big question for me and my other researcher was. What do we do to improve the health of this neighborhood, given its characteristics. We wanted to work with the community members and we wanted to do something that would be effective. Given the large but still limited amount of funds that we had at our disposal. So what would you do, what would you do if you were asked how do we improve health. Given such and such amount of money. Well, the ideas were simple. Create jobs, give people more jobs and they can have more income and then they can afford better food and better exercise and health care and so forth. So create jobs, is not an unreasonable answer for improving population health. Improve schools, this is one of the things I think most important. We can improve the educational quality of the students, improve their life chance, as they go forward throughout their lives. One of the key areas of improving schools is improving school before kindgergarten. What's called Pre-K School.

This has been shown repeatedly to be a very important investment and critical to health later in life. We can improve prenatal services, make sure moms-to-be have all the health care they need. One suggestion was give every household in the neighborhood $10,000, divide up a big pot of money. But you can ask yourself how far would $10,000 go for a typical household to improve their health. What persons do with their money? Would they buy a gym membership, would they buy a new car, would they throw a party? Its not clear how this would work. You could help persons find health insurance. Lots of people who are eligible for health insurance aren't able to get it because they can't navigate the system. So one thing that can be done, one thing that's interesting from a social epi perspective. Is to actually hire persons to go out in the community and help people get what they're already eligible for, so-called take-up helpers. You could buy or renovate houses. You could add cops to the street. You could have a free clinic. You could increase family services to prevent child abuse. All these things are quite reasonable. So when it comes to improving health, its so common in my experience that researchers will advocate for their own pet their own pet intervention. I work in mental health, so I want to improve mental health services. I work in education I want to improve educational services. I work in heart health, I want to do that. But when you're asked, in general, how do we improve health the best? We have to have this interdisciplinary approach. That's a fascinating idea for social epidemiologists. So you might ask, what was finally accomplished? How did some of these interventions improve population health? Well, one of the struggles with CBPR, or Community-b ased Participator Research is it's very difficult. In the end, it's not clear what was accomplished.

There was some community interventions, things went back and forth, some of the great ideas were found to be too expensive, or not politically attainable. So this is the real world, working in a real society with real people. This goes directly to the idea of policy space that Professor Rossi talked about and I tried to share with you in one of the earlier lectures. So in the end I'm not sure, I'm honestly not sure how health and this target population was improved. But this kind of work in my view is critical for advancing social epidemiology. [SOUND].