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"<p>Hello, readers!</p>
<p>I can hardly believe I&#8217;m writing these words, but this is the <em>final</em> installment in my research proposal series.  My time with #CuriousCoLab is coming to a close.  It&#8217;s bittersweet.  I want to thank you all for not only reading these posts of mine, but also for your constructive comments.  It really has been a great experience.</p>
<p>So, without further ado, I present my final research assignment.  Our job this week was to create a concept paper for potential funders.  As always, I appreciate your feedback.</p>
<p>I look forward to catching up with you all sometime in the future.  Stay curious!</p>
<p>&#8211;Samantha</p>
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<p>&nbsp;</p>
<p><strong>Background</strong></p>
<p>The Therapeutic Lifestyle Changes (TLC) in the Homeless Community project is designed to identify barriers to self-management behaviors and healthy lifestyle choices among homeless patients with hypertension. This project grew out of a collaborative effort between academic researchers from Virginia Commonwealth University and partners from local organizations who provide healthcare and social services to the Richmond, Virginia homeless community. The overarching mission of this study and the research partnership is to identify strategies and interventions to reduce health disparities and improve cardiovascular health outcomes among homeless patients. The academic and community partners are committed to employing a community-engaged research approach to identifying addressing the important barriers surrounding self-management and lifestyle behaviors and hypertension.</p>
<p>Approximately one-third of Americans suffer from hypertension, contributing to significant cardiovascular morbidity and mortality in the United States.<sup>1-2 </sup> Homeless and low-income patients are disproportionately affected by cardiovascular disease. Poverty alone has been identified as a significant predictor of cardiovascular mortality, and estimates show that homeless patients are 2-4 times more likely to have high blood pressure, compared to their housed counterparts.<sup>3-4 </sup></p>
<p>Lifestyle changes are one evidence-based approach to improve the management and control of hypertension, and can be implemented alone or in conjunction with appropriate pharmacotherapy<sup>5-6 </sup>Effective TLC approaches include weight reduction, adoption of the Dietary Approaches to Stop Hypertension (DASH) diet, regular physical activity, smoking cessation and stress relief. Unfortunately, many patients struggle to fully implement these changes into their everyday lives. Compared to the general population, homeless and unstably housed patients have a greater number of modifiable risk factors for hypertension (including poor diet and increased use of alcohol and tobacco products), and may be less likely to engage in TLC due to complex competing priorities and unmet basic needs.<sup>7-9 </sup>Food insufficiency is an independent risk factor for hypertension, and limited access to healthy foods due to reliance on shelter and community sponsored meal programs may reduce the feasibility of dietary lifestyle changes.<sup>10-12 </sup>Other barriers to TLC in this population include lack of social support, strict schedules at shelters and rehabilitation centers, inadequate storage options.<sup>13-14</sup> Further, limited access to adequate healthcare further reduces patients’ ability to understand and implement lifestyle changes.<sup>7</sup></p>
<p>In order to address the full spectrum of challenges to TLC, it is essential to first develop a firm understanding of barriers at the individual and community level. There is limited information available about homeless patients’ experiences and beliefs regarding TLC, and barriers to facilitating TLC at the individual and community level have been largely unexplored. A number of healthcare, social service, and community programs in Richmond, Virginia are united by the shared mission of offering support to homeless patients, each organization is able to provide unique insight into the barriers to TLC and help to identify feasible solutions.</p>
<p>Preliminary discussions with healthcare providers, community workers, and patients have indicated that limited resources and difficulty coordinating care across disciplines present challenges for implementing TLC related interventions. Likewise, patients indicated that shelter and community program constraints limited their meal choices and presented barriers to physical activity. This project aims to systematically identify barriers and facilitators to TLC from multiple perspectives, patients, healthcare providers, and community workers. In addition, this project will establish a formal advisory panel of patient and community participations to help guide the development of future interventions to improve hypertension management and overall health for patients experiencing homelessness.</p>
<p><strong>Research Description</strong></p>
<p>This mixed-methods study will be conducted using a community-based participatory research (CBPR) approach, involving community and academic partners in all stages of the project. This approach offers several advantages over traditional research methods, including increased collaboration and a greater focus on community action.<sup>15-16 </sup>The primary objectives of this study are 1.) to identify individual and community level barriers to TLC among homeless patients, and 2.) to establish a formal advisory panel of patient, provider, and community participants to guide future interventions.</p>
<p><em>Community Advisory Panel</em></p>
<p>The advisory panel will consist of members from multiple stakeholder groups, including patients, healthcare providers, social services providers, and community workers from shelters and other supportive services. Participants in the advisory panel will be recruited via flyers and word of mouth. Healthcare workers and social service providers will also be recruited via e-mail list serves where possible. Regular monthly meetings will be established and these participants will serve as the primary guidance board throughout the entire project. Panel members will receive research ethics training, adapted from the Medical University of South Carolina’s Toolkit for Academic-Community Partnerships.<sup>17</sup> All members of the advisory panel will be compensated for their participation.</p>
<p><em>Study Design and Analysis</em></p>
<p>Qualitative data will be collected from a series of focus groups. In order to obtain quality input from the distinct participant groups, three separate focus groups discussions will be conducted using a semi-structured guide. The first group will include only homeless patients, the second will be limited to healthcare providers, and the third will include social service and community workers. Members of the advisory panel will facilitate recruitment of focus group participants, using flyers and word of mouth. Patients will be recruited from local homeless healthcare clinics and shelters, while providers and community workers will be recruited via e-mail. Participants will receive adequate monetary compensation for their participation.</p>
<p>Focus group interview questions will be designed in collaboration with the community advisory panel, and will address barriers to hypertension control, barriers and facilitators to lifestyle changes. Each focus group will be facilitated by both an academic researcher, trained in focus group leadership, as well as a member of the community advisory panel. Discussions will be audio-recorded and transcribed by a member of the research team. Both academic and community partners will schedule weekly meetings to conduct a thematic analysis of the transcripts.</p>
<p>Academic researchers and members of the advisory panel will work together to develop a survey instrument based on the results from this qualitative analysis. Members of the advisory panel will work collaboratively with the research team to develop questions that are culturally appropriate and written at the appropriate literacy level. Two surveys (a patient survey and a provider/community worker survey) will be designed to systematically identify the most common and actionable barriers to TLC. Surveys will also solicit feedback on potential solutions that may be identified in the focus group interviews. Surveys will be pilot tested in the target populations and revised for clarity based on feedback.</p>
<p>Members of the advisory panel will distribute surveys and collect the data, however academic researchers will be available at all times to facilitate the process. A snowball sampling approach will be used to recruit patients and providers, because there is currently no systematic way to identify members of this community. The patient surveys will be distributed to patients at healthcare clinic visits and at local homeless shelters. The provider survey will be distributed via e-mail.  A sample size of 300 is anticipated for the patient survey, and a sample size of 50 is anticipated for the provider survey.</p>
<p>Data analysis will involve a collaborative effort between the academic researchers and members of the community. Academic members of the team will calculate descriptive statistics on survey responses, and a day-long data retreat will be held for members of the advisory panel and interested community participants. Academic researchers will present the results of the survey and solicit feedback from community members regarding the interpretation.</p>
<p>Results from the survey, as well as informative themes from the focus group discussions will be disseminated to healthcare providers and community workers within the homeless care community. Newsletters and a website will be available to provide updates on the status of the project. These communications will also solicit feedback and invite members to participate in the advisory panel and provide feedback and insight regarding future interventions.</p>
<p><em>Conclusions</em></p>
<p>This study is unique in that it incorporates multiple perspectives in order to identify barriers to TLC. Both community level and individual level interventions are necessary to achieve sustainable lifestyle changes, therefore it is essential to examine potential barriers from multiple perspectives. This project will benefit both patients and providers in that it will provide clear insight into the unique barriers faced by homeless patients. With the addition of this knowledge, providers may be able to tailor their conversations and therapeutic plans to help address unique patient needs. The results of the survey and focus groups will also be invaluable as the advisory board plans community based interventions to facilitate lifestyle changes.</p>
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<p>References</p>
<ol>
<li>The Center for Disease Control and Prevention.  Chronic Disease Overview. 2015. Available at <a href=""http://www.cdc.gov/chronicdisease/overview/"">http://www.cdc.gov/chronicdisease/overview/</a> Accessed June 6, 2015.</li>
<li>The American Heart Association. High Blood Pressure Statistical Fact Sheet: 2013 Update. 2013.  Available at <a href=""http://www.heart.org/idc/groups/heart-public/@wcm/@sop/@smd/documents/downloadable/ucm_319587.pdf"">http://www.heart.org/idc/groups/heart-public/@wcm/@sop/@smd/documents/downloadable/ucm_319587.pdf</a>. Accessed June 6, 2015.</li>
<li>Qureshi S, Tyler D, Post P. Hypertension &amp; homelessness: what interferes with treatment. <em>Homeless Health Care Case Report.</em> 2006: 2. Available at <a href=""http://www.nhchc.org/wp-content/uploads/2012/01/CaseReportHTN-1.pdf"">http://www.nhchc.org/wp-content/uploads/2012/01/CaseReportHTN-1.pdf</a>. Accessed June 12, 2015.</li>
<li>Jones CA, Perera A, Chow M, et al Cardiovascular disease risk among the poor and homeless – what we know so far. <em>Current Cardiology Reviews. </em>2009, 5: 69-77.</li>
<li>The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. U.S. Department of Health and Human Services. National Institute of Health. National Heart Lung and Blood Institute. 2003. <a href=""http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf"">nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf</a></li>
<li>James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults. Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). 2014; 311: 507 – 520. <a href=""http://jama.jamanetwork.com/article.aspx?articleid=1791497"">http://jama.jamanetwork.com/article.aspx?articleid=1791497</a></li>
<li>Jones CA, Perera A, Chow M, et al Cardiovascular disease risk among the poor and homeless – what we know so far. <em>Current Cardiology Reviews. </em>2009, 5: 69-77.</li>
<li>Kim DH, Daskalakis C, Plumb JD, et al. Modifiable cardiovascular risk factors among individuals in low socioeconomic communities and homeless shelters. Fam Community Health. 2008; 31:269–280 <a href=""http://www.ncbi.nlm.nih.gov/pubmed/18794634"">http://www.ncbi.nlm.nih.gov/pubmed/18794634</a></li>
<li>Kinchen K, Wright JD. Hypertension management in health care for the homeless clinics: results from a survey. <em>Am J Public Health. </em>1991; 81: 1163 – 1165. <a href=""http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1405639/pdf/amjph00209-0069.pdf"">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1405639/pdf/amjph00209-0069.pdf</a></li>
<li>Dammann KW, Smith C. Factors affecting low-income women’s food choices and the perceived impact of dietary intake and socioeconomic status on their health and weight. <em>J Nutr Educ Behav. </em>2009; 41: 242-254. <a href=""http://www.ncbi.nlm.nih.gov/pubmed/19508929"">http://www.ncbi.nlm.nih.gov/pubmed/19508929</a></li>
<li>Dammann KW, Smith C. Race, homelessness, and other environmental factors associated with the food-purchasing behavior of low-income women. <em>J Am Diet Assoc. </em>2010; 110: 1351-1356. <a href=""http://www.ncbi.nlm.nih.gov/pubmed/20800128"">http://www.ncbi.nlm.nih.gov/pubmed/20800128</a></li>
<li>Vozoris NT, Tarasuc VS. Household food insufficiency is associated with poorer health. <em>J Nutr. </em>2003: 133: 120-126. <a href=""http://www.ncbi.nlm.nih.gov/pubmed/12514278"">http://www.ncbi.nlm.nih.gov/pubmed/12514278</a></li>
<li>Hwang SW, Bugeja AL. Barriers to appropriate diabetes management among homeless patients with diabetes mellitus. <em>Acad Nurse Pract. </em>2002; 14: 372-379. <a href=""http://www.ncbi.nlm.nih.gov/pubmed/?term=hwang%2C+bugeja"">http://www.ncbi.nlm.nih.gov/pubmed/?term=hwang%2C+bugeja</a></li>
<li>Moczygemba LR, Kennedy AK, Marks SA, et al. A qualitative analysis of perceptions and barriers to therapeutic lifestyle changes among homeless hypertensive patients. <em>Res Social Adm Pharm. </em>2013; 9:467-481.</li>
<li>Community-Campus Partnerships for Health. CBPR Curriculum. Available at <a href=""https://ccph.memberclicks.net/cbpr-curriculum-unit-1-section-1-1"">https://ccph.memberclicks.net/cbpr-curriculum-unit-1-section-1-1</a></li>
<li>Sanchez J, Serna CA, de La Rosa M. Project Salud: Using community-based participatory research to culturally adapt an HIV prevention intervention in the Latino migrant worker community. <em>Int Public Health J. </em>2012; 4: 301-308. <a href=""http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3906731/"">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3906731/ </a></li>
<li>Andrews JO, Newman SD, Cox MJ, et al. Are we ready? A Toolkit for Academic-Community Partnerships in Preparation for Community-based Participatory Research (CBPR). 2014.<br />
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<p><em>This post is a part of my ongoing participation in #CuriousCoLab – an online course in community engaged research, sponsored by VCU.  The course is FREE and open to anyone.  You can join us on Twitter with #CuriousCoLab.</em> <em>You can follow me on Twitter: @pharma_sis</em></p>
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