baig aade talk 2016 with ask the audience questions baig il cb... · 2016-11-03 · arshiya a....

11/2/2016

1

Using Photovoice to Promote Diabetes Self-Management for Latino Adults

Arshiya A. Baig, MD, MPH, FACPAssistant Professor of Medicine

Associate Director of Chicago Center for Diabetes Translation ResearchUniversity of Chicago

November 2016AADE Illinois

3nd Annual Symposium

Financial Disclosures

National Institute of Diabetes and Digestive and Kidney Diseases Diabetes Research and Training Center (P60 DK20595), Chicago Center for Diabetes Translation Research (P30 DK092949), and a NIDDK Mentored Patient-Oriented Career Development Award (K23 DK087903-01A1).

Walgreens gave us 15% discount on photo development

Bayer supplied us with 6 boxes glucometer strips

Roadmap

Latino Demographics and Diabetes Disparities

Community-based Participatory Research and Photovoice

Using Photovoice in Diabetes Education

11/2/2016

2

My Background and Focus on Latino health

o Training at UCLA

o Bogota, Colombia: U.S. Fulbright Scholar

o University of Chicago

Ask the Audience: What percentage of the U.S. population will be Latino by 2050?

A. 15%

B. 30%

C. 50%

D. 75%

11/2/2016

3

The Hispanic population grew by 49% from 2000 to 2015 in the Midwest per the last U.S. Census.

Currently, Illinois has the fifth largest Hispanic population in the U.S

Relevance to Midwest and Illinois

U.S. Latinos Have Many Barriers to Care

• Socioeconomic: - Average Latino household owns 7 cents for every $1 held by a non-

Hispanic white household (Duke University 2014)

• Barriers in the built environment—violence, limited space for exercise, poor access to fresh food

• Language barriers: 76% of U.S. Latinos speak Spanish at home (2011 Census)

• Access to care

11/2/2016

4

Latino Health Disparities

Ask the Audience: What is the % chance a Latino born in the U.S. will develop diabetes in his/her lifetime?

A. 5%

B. 15%

C. 30%

D. 50%

11/2/2016

5

Estimated lifetime risk of developing diabetes

0

10

20

30

40

50

60

Men Women

Pe

rce

nt

Total Non-Hispanic WhiteNon-Hispanic Black Hispanic

Narayan et al, JAMA, 2003

U.S. Latinos born in 2000 have about a 50% chance of developing diabetes in their lifetime

53%

45%

27%

31%

6.4

12.511.1

12.6 11.9

8.2

0

10

20

Non-Hispanicwhites

Non-Hispanicblacks

Hispanic PuertoRican

Mexican Cuban

% w

ith

dia

be

tes

CDC 2007

Diabetes prevalence is higher among Hispanics and varies by subgroups

53%

11/2/2016

6

Why such high prevalence of diabetes among Hispanics?

• Genetic predisposition towards insulin resistance and beta cell dysfunction but unclear why among Hispanics

• High rate of abdominal obesity and greater amount of visceral fat

• Higher rate of conversion from pre-diabetes to diabetes (15%) than non-Hispanic whites (5-10%)

• Variation in risk may be related to higher proportion of Native American ancestry

Hispanics also suffer from disparities in diabetes outcomes

• Only 1/3 of Latinos with diabetes achieve optimal glycemic control

• Increased risk of complications:- Twice the risk of diabetic retinopathy than non Hispanic

whites- 40% greater risk of nephropathy

• Age-adjusted diabetes death rate is 1.4 times higher than Hispanics than non-Hispanic whites

• Among Hispanics, the diabetes death rate in 2000 was highest among: - Puerto Ricans-- 172 per 100,000- Mexican Americans-- 122 per 100,000- Cuban Americans-- 47 per 100,000

Diabetes in Chicago Latinos

• Chicago: 4th largest Mexican-American population in the U.S. (578,000)

• In Little Village (South Lawndale): 83% Latino, 76% Mexican

• Many risk factors for poor health - 60% below poverty- 40% high school diploma- 46% have insurance- 37 is average BMI

11/2/2016

7

Ask the Audience: Who is familiar with the term community-based participatory research (CBPR)?

A. Yes

B. No

C. Maybe

Traditional vs. Partnered Research

• Traditional approach where researcher largely determines

- Questions asked and tools employed

- Interventions developed

- Kinds of results and outcomes documented and valued

• Difficulty of translating scientific findings into clinical practice

• Many times researchers use communities for research but then never report the findings to them

Meredith Winkler, 2003,”Community-Based Participatory Research for Health”

11/2/2016

8

A Partnered Approach: Community-Based Participatory Research (CBPR)

• 1970’s Paulo Freire, a Brazilian educator

– Communities identify own problems & solutions

– Used with communities to understand and begin to create structural change

• CBPR applies scientifically rigorous methodology in conducting research partnered with a community

• CBPR is not research method itself but an approach

• Findings are “practical and relevant”

• Research findings can be applied directly to develop policy and interventions

Jones, JAMA 2007 Wells, JAMA 2009

Project

Designing and Testing a Church-based Diabetes

Education Program for Latinos Adults

Church-based Diabetes Education

• Diabetes self-care is cornerstone of disease management

• Many Latinos do not participate in self-management education programs

• Churches can provide a familiar, convenient, and trusted setting for diabetes education and support

• Churches are central to many racial/ethnic communities

Our Lady of Tepeyac Church,Chicago

11/2/2016

9

We Learned How to Tailor the Intervention From Patients

• Focus groups

• Participant concerns:- Diabetes affects all aspects of life

- Cost of care

- Psychological impact of having diabetes

- Lack of resources to manage diabetes in community

• Preferences- Interested in group-based education program in church

- Desire diabetes education, support, self-empowerment

- Information on nutrition, exercise, causes, complications

Identify Points of Intervention and Study design

• Formed community advisory board (CAB) for continued input from patients and stakeholders

• Community involvement in designing intervention and in study design

• Using local resources and working with other agencies

• Need to tailor the intervention to the church setting and the community

11/2/2016

10

11/2/2016

11

Ask the Audience: Who is familiar with photovoice?

A. Yes

B. No

C. Maybe

Using Patient Engaged Research Methods: Photovoice

• Uses power of pictures

• People can identify, represent, and analyze their communities by taking photos

• Photos can be accompanied by stories

• As a way to problem solve and give social support

Background on Photovoice

Photovoice is a community-based participatory research methodology that engages community members through the use of photos and storytelling. (Wang, University of Michigan)

33Using Photovoice to Promote Diabetes

Self-Management for Latino Adults

In photovoice, participants take photos of their lives and tell stories about those photos.

Photovoice has traditionally been used for needs assessment.

No studies have assessed the feasibility and acceptability of using photovoice to promote diabetes self-management.

11/2/2016

12

Study Design: Photovoice

• Intervention participants were given disposable cameras and asked to take photographs of their lives with diabetes.

• Photos were developed by the academic team and given to the participants.

• In the weekly classes, participants discussed their photos with the group and shared their challenges and successes in diabetes self-care. These exercise was used to promote problem solving and empower patients to improve their diabetes self care.

• Weekly diabetes self-management classes led by lay leaders trained in motivational interviewing.



Study Design

• The lay health educators were trained by a team of a certified diabetes educator, registered dietitian, and a psychologist with support from a community pharmacist who served as their diabetes experts for information support and education.

• The class leaders guided the group photo discussions and took notes on (1) why the photo was important to the person who took it and (2) what others in the class discussed regarding the photo.

• Using a codebook derived from prevalent themes, two researchers coded the photos and the discussion notes.

• Participants evaluated the photovoice activities at 6-month follow-up.



Educational curriculum

Photovoice

Patient navigation Exercise groups

8‐week church‐based

diabetesself‐

managementintervention

11/2/2016

13

Randomized Study Design

Low intensity High intensity

Receive a 90 min diabetes lecture Picture Good Health8-week church-based diabetes self-

management intervention

Picture Good Health

3 month measures and mailed lab results

Optional monthly group sessions

Patient navigator to establish PCP if neededMailed letter with baseline lab results

6 month measures and mailed lab results

Baseline characteristics

N=100

Age 54 ± 11

% female 81

% 8th grade or less 54

% income less than $30,000 82

% Latino ethnicity 98

% of Latinos reporting Mexican origin 95

% born outside of U.S. 92

% speak “only Spanish” at home 71

% have a source of usual care 93

% insured 49

% in excellent or very good health* 3

% with family history of diabetes 69

*other categories: good, fair, poor

N=100

No. of years with diabetes 8.3 ± 7.9

% with family history of diabetes 69

% with kidney disease 2

% eye disease 25

% hypertension* 56

% high cholesterol 70

% on insulin 25

% on oral meds for diabetes 85

Mean A1c % 8.0 ± 2.0

Mean LDL 108.1 ± 32.0

Mean systolic blood pressure mmHg 119.7 ± 14.4

11/2/2016

14

Change in A1c by Arm (n=76)

Intervention Participants Had More Significant Improvement in Self-Care at 6-months

Within arm Across arms

Usual Caren=41

Interventionn=41

Intervention effect

Following healthful eating plan Average number of days per week following eating plan over last month

Having >=5 servings fruit and vegetables

Having high fat foods

Participating in >=30 min physical activity

Participating in a specific exercise session

Testing blood sugar Testing blood sugar as recommended by healthcare provider

Inspecting the inside of shoes

Checking feet Taking medications as prescribed

Results

Of 50 participants who were invited to the class, 37 attended at least one class and 26 took photographs.

Of the 26 who took photographs, two participants’ photos were not available for analysis.

A total of 503 photos were analyzed.



11/2/2016

15

Ask the Audience: What was the most common theme for the photos?

A. Participant’s workplace

B. People and family

C. Diabetes care (e.g. Medications, syringes, etc.)

D. Religious elements

E. Nutrition and exercise

Subjects and Themes of Photographs



Subjects and Themes N=503 n(%)

People 398 (79%)

People, including family, friends, community members 237 (54%)

Children 69 (14%)

Social events or gatherings 92 (18%)

Nutrition and exercise 236 (47%)

Food 121 (24%)

People exercising or exercise equipment 37 (7%)

Water bottles and people actively drinking water 33 (7%)

Soft drinks 32 (6%)

Neighborhood and built environment 195 (39%)

Neighborhood and surroundings 73 (15%)

Outdoor green spaces including parks and gardens 68 (14%)

Bikes, buses, trains, cars, modes of transportation 37 (7%)

Billboards, window, taxi or bus advertisements 16 (3%)

Subjects and Themes of Photographs



Subjects and ThemesN=503n(%)

Diabetes specific 165 (33%)

Diabetes self-management class 63 (13%)

Diabetes supplies (strips, glucometers, lancets, scales) 34 (7%)

Medications including pills, insulin, and herbal or vitamin supplements

18 (4%)

Home life 124 (25%)

Interior and exterior of home 95 (19%)

Pets or animals 16 (3%)

Religious figures, iconography, or ceremonies 41 (8%)

Participant workplaces (e.g. work desk, cubicle) 3 (0.6%)

11/2/2016

16

Themes of Analysis from Class Discussions (N=65 photos)

46

Theme % photos

Social support

Group advice 36 (55.4%)

Group empathy 14 (21.5%)

Group motivation 7 (10.8%)

Importance of social support 5 (7.7%)

Diabetes self-management

Diet or nutrition or eating 17 (26.2%)

Exercise 8 (12.3%)

Taking medications 6 (9.2%)

Testing sugar at home 3 (4.6%)

Cultural traditions 13 (20%)

Importance of family 12 (18.5%)

Emotional health

Concern for family 11 (16.9%)

Ways to cope with stress 8 (12.3%)

Self-motivation 4 (6.2%)

Faith or religion 4 (6.2%)

Group Advice



Participantexplanation of photograph

To remember that diabetes patients should be careful when using knifes

because they can get injured and that’s very harmful for

them.

Why the photograph is important to the participant

Her mom reminds her to be careful when using knifes

Classroom discussion of photograph

Everyone agrees that they need to be extra careful when using knifes or when they get their nails cut. It is even better to go to a professional to get their nails cut.

Group Empathy



Participantexplanation of photograph

It is a photograph of his daughter who died 3 years ago. His mother gave

him the [statue of ] the Virgin Mary.

Why the photograph is important to

the participant

“I have the picture with me at all times and I just wanted to share it with you.”


Thanks for sharing your pain and your loss. They shared

their own experiences of

losing a loved one.

11/2/2016

17

Group Motivation



Participantexplanation

of photograph

“At a job, I decided to smoke less.”

Why the photograph is important

to the participant

“To remember I decided to start smoking less

because this would help my health.”

Classroom discussion

of photograph

““It is a good way to start smoking less by looking at the

picture. It is good to stop smoking even though it is hard to

quit.”

Importance of Social Support




of photograph

She is part of the class. She receives motivation from her

classmates. She feels that they all speak the same language with the class leader. She is very happy with her

work.


to the participant

Because she receives support and

inspiration from everyone in this

program.


of photograph

Being part of a group helps them to be

stronger. Learning how to improve their life style. Together, they are fighting to have a better life.

Diet, Nutrition, and Eating



Participant explanation of photograph



“Junk food is nothing but fats; it is venom for the

body.”

“I shouldn’t eat junk food because it has a lot of salt and fats.”

“Not only diabetes patients but everyone should take care of their

health.”

11/2/2016

18

Testing Sugar at Home




of photograph

“It is very important to have a blood exam in order to know

our blood sugar level.”


to the participant

“I have to check my blood sugar level twice daily. That way I know if my blood sugar level goes up.”


of photograph

“It is very important to

know our blood sugar level.“

Importance of Family






“Family photo to remind me that I need to take care of

myself for my family since I am the head of household,

they will suffer the consequences.”

“If we don’t take care of ourselves, we will not be in that picture anymore. I would like to

have one in the future with everybody and no one

missing.”

“If we don’t take care of ourselves then there will be no picture with us in it in the future and we will not be able to

achieve our goals.”

Cultural Traditions



Participantexplanation of

photograph

She has an altar with various Saints. She

made it because she used to often dream

of the virgin. The other saints were presents that she

received.

Why the photograph is important to

the participant

She feels that the virgin Mary helps her to keep on going with her diabetes and to

take good care of her health because of her daughter.


Other participants also have altars at

home.

11/2/2016

19

Faith or Religion




of photograph

“For me it represents life, faith, and hope. When I come here, I feel in peace and the best place to meditate because I feel in peace.”


to the participant

“It helps me to maintain my faith and that no matter how life is, there is always hope and a light to follow.”


of photograph

“Thanks to God I found this place, I feel comfortable when I am in Mass and receiving invites for this class.”

Concern for family






Her parents. Her dad lost his left leg and some toes. Both of them have diabetes. Both use a wheelchair but her dad uses it

only when he goes out.

She brought a picture of her parents because God has allowed them to live a long life.

They asked her if her dad uses a walker because some of the participants might have some.

Ways to cope with stress




of photograph

Participant is in the forest where is peaceful and quiet. There, he can exercise and relax from all the stress


to the participant

“It’s very relaxing being in the forest”


of photograph

That is a great picture and is very relaxing to walking in the forest

11/2/2016

20

Self-Motivation




of photograph

“One-way sign. There is only one way and I would like to feel free as a bird not attached

to this illness.”


to the participant

“Because I love myself and that love is motivated by my

family. I need to love myself to be able to

love others.”


of photograph

“We only have one way and it’s the way to health. You have various choices but only one way takes you to a good health and will help us guide

ourselves and to guide our family to

avoid getting diabetes.”

Participant Satisfaction With Photovoice (N=30)



0% 20% 40% 60% 80% 100%

How much fun did you have taking photos forclass?

How much did you enjoy talking about yourphotos in class?

How much did you learn about better managing your diabetes from other

participants’ photos?

How comfortable did you feel sharing yourphotos?

How much confidence did you gain inmanaging your diabetes from talking about

the photos?

How much did the photo discussions help youto better manage your diabetes?

How much did sharing photos make you feelmore connected to the people in the group?

Not at all (%)

A little (%)

Some (%)

A lot (%)

Of 50 participants who were invited to the class, 37 attended at least one class and 30 completed the exit survey.

In Participants’ Words

When asked what they liked about using photos to discuss their lives with diabetes:

o The pictures help us to remind ourselves of what is good and bad for us. It is a great method.

o It teaches us to be better people and continue forward. To be more conscious of our daily lives and remember essential things we had forgotten about. To be able to coordinate our daily lives and see what we have.

o Itʼs a good idea because it helps and you learn more by seeing and talking about it.

When asked what they would change about the photo discussions:

o Nothing, they have great significance in our lives. The pictures speak for themselves. We want more time to express their significance.



11/2/2016

21

Summary of Findings

In a diabetes self-management intervention for Latinos, participants were satisfied with the photovoice exercise and had high rates of participation.



Summary of Findings

Participants’ photos spurred group discussion around diabetes self-management.

Participants gave advice, were empathetic, and motivated the participants who presented their photos to make or sustain healthy behaviors.



Limitations

This study used a convenience sample so results may not be generalizable to all Latinos with diabetes.



We analyzed the class discussion using leader notes which may have not been complete.

We did not record participants' stories regarding the photos.

11/2/2016

22

Conclusion

• Photovoice provided an effective vehicle to receive and provide social support and promote behavior change.

• Future studies should consider using photovoiceas a way to encourage healthy behavior change and facilitate social support in a group setting.



Interpretation of Findings and Dissemination

• Academic publications and presentations

• Town Hall meeting

• CAB continuing to meet

Project

Provider Training

11/2/2016

23

Ask the Audience: What percentage of patients understand everything that their physician has said in a visit?

A. 20-30%

B. 40-50%

C. 60-70%

D. 80-90%

66 68 6857

49

66 6961

5648

0

20

40

60

80

100

Total White Black Hispanic Asian

Felt Doctor Listened to Them Understood Everything Doctor Said

Note: Population includes adults with health care visits in the past two years.

Source: The Commonwealth Fund. Health Care Quality Survey. 2001.

Hispanics are less likely to understand their doctor and less likely to feel their doctor listened to them

Percentage of adults ages 18 to 64 reportingease of communication during doctor visits, 2001

12 10 1319

14

0

20

40

60

80

100

Total White Black Hispanic Asian

Hispanics are twice as likely as whites to leave the doctor’s office with unasked questions.

Percentage of adults ages 18 to 64 reporting they had questionsthat they did not ask on last visit to doctor, 2001

Note: Population includes adults with health care visits in the past two years.

Source: The Commonwealth Fund. Health Care Quality Survey. 2001.

11/2/2016

24

Provider cultural competency

– “...the ability of health care professionals to communicate with and effectively provide high-quality care to patients from diverse sociocultural backgrounds”

– “Understanding the importance of social and cultural influences on patients’ health beliefs and behaviors; considering how these factors interact at multiple levels of the health care delivery system; and, finally, devising interventions that take these issues into account to assure quality health care delivery to diverse patient populations.”

Provider cultural competency: Why is it important?

• To respond to current and projected demographic changes in the United States

• To eliminate long-standing disparities in the health status of people of diverse racial, ethnic and cultural backgrounds.

• To improve the quality of services and primary care outcomes.

• To improve patient-provider communication and improve patient satisfaction

• To meet legislative, regulatory and accreditation mandates.

11/2/2016

25

Provider’s role in patient-centered care

• Few who speak Spanish fluently

• Goes beyond speaking language however.

• Providers who see many Latino patients may not have a good understanding of their patient’s life challenges and cultural beliefs

“Local Patients, Local Stories”

• We learned about patient challenges with provider communication in church-based program

• Developed study aimed to address provider cultural competency and patient centered communication

• Designed training with skill building on patient-centered communication

• Used a video of patient stories and photos to train providers on patient challenges AND successes

• Piloted with 42 local healthcare providers and have noted pre to post-test improvement in cultural sensitivity

Patients Tell Their Stories

11/2/2016

26

Multi-level approach: Work to Date

• Community– How to mobilize community leaders through evaluation of

formation of Community Advisory Board

• Patient– Church‐based education with improvement in self‐care

– Texting messaging in health centers to support diabetes self‐care

– Review of family based interventions for adults with diabetes

• Provider– Cultural competency assessment

– Training with patient stories

• System– Assessment of resources for Latinos in Midwestern health

centers

– Diabetes group visits in community health centers

Summary and What’s Next?

• Latinos suffer from disproportionately high rates of diabetes and have many barriers to care

• We need innovative, multi-pronged interventions to tackle Latino diabetes disparities

• Integrate community partnerships into healthcare systems to gain trust and utilize local resources

• Ultimately want results that are practical and relevant to patients and policy makers

Acknowledgements



• Co‐investigators:

• Marshall Chin

• Deborah Burnet

• Michael Quinn

• Amanda Benitez

• Cara Locklin

• Marla Solomon

• Lisa Sanchez‐Johnsen

• Sang Mee Lee

• Yue Gao

• Erin Staab

• Little Village Community Advisory Board

• NIH NIDDK K23• University of Chicago DRTC• University of Chicago CTSA

• Chicago Center for Diabetes Translation Research

• Taller de José

• Father Don Nevins

• Juan Acevedo

• Maritza Gomez

• Freddy Vazquez

• Denise Salinas

• María Acevedo

• Ana Piña

• Patricia Fernandez

• Jason Espinoza

• Alexis Lopez

• Matthew Stutz.

• Anghela Paredes

• Catherine Castro

• Louis Philipson

• Peggy Hasenauer

• Kovler Diabetes Center

• Walgreens and Bayer

11/2/2016

27

Thank you.

Questions?

Pre and Post Assessment Questions

Choose the incorrect answer.

3. Photovoice is a methodology that:

a. Uses the power of photographs and storytelling to empower patients and communities.

b. Has been traditionally used to conducted community health needs assessments

c. Has been widely used in public health research

d. Incorporates recorded video for use of health promotion

Language

• 12% of US population speaks Spanish.

• Of these 28% report not speaking English well or at all.

• 76% of U.S. Hispanics speak Spanish at home

• Depending on generation as well

11/2/2016

28

Themes and Quotes from Class Discussions (N=65)



Theme % photos Explanation of photograph Why the important Classroom discussion

Diet or nutrition or

eating

17 (26.2%)

“Junk food is nothing but fats; it is venom for the

body.”

“I shouldn’t eat junk food because it has a lot of salt

and fats.”

“Not only diabetes patients but everyone should take care of their

health.”

Importance of family

12 (18.5%)

“Family photo to remind me that I need to take care of

myself for my family since I am the head of household,

they will suffer the consequences.”

“If we don’t take care of ourselves, we will not be in

that picture anymore. I would like to have one in the future with everybody and no one

missing.”

“If we don’t take care of ourselves then there will be no picture with us in it in the future and we will not be able

to achieve our goals.”

Group motivation

7 (10.8%)

“At a job, I decided to smoke less.”

“To remember I decided to start smoking less because this would help my health.”

“It is a good way to start smoking less by looking at the picture. It is good to stop smoking even though it is hard

to quit.”

Faith or religion

4 (6.2%)

“For me it represents life, faith, and hope. When I

come here, I feel in peace and the best place to

meditate because I feel in peace.”

“It helps me to maintain my faith and that no matter how life is, there is always hope

and a light to follow.”

“Thanks to God I found this place, I feel comfortable when I am in Mass and receiving invites for this class.”

Self-motivation

4 (6.2%)

“One-way sign. There is only one way and I would like to

feel free as a bird not attached to this illness.”

“Because I love myself and that love is motivated by my family. I need to love myself to be able to love others.”

“We only have one way and it’s the way to health. You have various

choices but only one way takes you to a good health and will help us guide ourselves and to guide our family to avoid getting diabetes.”

Testing sugar at

home3 (4.6%)

“It is very important to have a blood exam in order to

know our blood sugar level.”

“I have to check my blood sugar level twice daily. That

way I know if my blood sugar level goes up.”

“It is very important to know our blood sugar level.“

Using Photovoice: Some Photos

Main Objective and Aims

We aimed to evaluate the feasibility and acceptability of using photovoice in a diabetes self-care intervention by assessing:



o Participant participation in the photovoice activity o The themes that emerged from the photographso The themes that emerged during class

discussions about the photographso Participants’ satisfaction with the photovoice

exercise

11/2/2016

29

Pilot Intervention Study

• Community-based, randomized pilot intervention: intervention vs. usual care

• 100 participants adults with diabetes recruited from church and community events

• Followed for 6 months

• Results:

– >30% of participants in both arms improved their self-rated health

– Both arms with significant improvement in diabetes self-empowerment

– Patient satisfaction:

• 79% of intervention participants said they learned a lot about diabetes

• 76% said they gained a lot of confidence in their ability to manage their diabetes.

Pre and Post Assessment Questions

1. Which racial/ethnic group has had the largest increase in diabetes risk in the past 10 years?

a. Whites

b. African‐Americans

c. Hispanics

d. All have seen the same increase in diabetes risk

2. The following is the an important concept in community-based participatory research (CBPR):

a. CBPR projects must address racial/ethnic disparities in health.

b. CBPR excludes the use of scientifically rigorous methods like randomized controlled trials.

c. In CBPR, academic and community partners must equally divide grant funds.

d. In CBPR, the academic and community partnership is best when it begins at the inception of the research idea through implementation and dissemination of research findings.

baig aade talk 2016 with ask the audience questions baig il cb... · 2016-11-03 · arshiya a....

Documents