A Community Academic Partnership to Reduce Healthcare Disparities in Diagnostic Imaging

Description of the Problem:

Patient-, family-, and community-centered care can add value to radiology’s role in the healthcare system by improving healthcare outcomes, improving patient satisfaction, and decreasing healthcare disparities [1,2]. Continued efforts have been made to improve the engagement of community members, including patients, families and local organizations, in radiologic clinical care and operations [3–5]. However, the body of evidence to support integration of community members into the design of programs and research studies to reduce healthcare disparities in diagnostic imaging is limited.

Involving the community in all phases of research from study design to dissemination of results increases both the quality and relevance of research [6]. Further, scientific discoveries are best translated into improvements in individual and population health when community members are involved [7]. Community based participatory research (CBPR) is one strategy to facilitate the translation of scientific knowledge into community benefits by engaging academic and community members to work side by side to identify problems and develop solutions [8]. Community academic partnerships, a component of CBPR approaches, are an effective method to address significant problems in the community, reduce health disparities in the community, and generate scholarship [9–12].

Therefore, we aimed to 1) develop a community academic partnership to facilitate community engaged research and 2) create a model to guide others in establishing community academic partnerships.

What was Done:

Initiating the Partnership:

The academic team first identified a community organization with whom to initiate the community academic partnership. The academic team’s leader, a breast imaging radiologist and health services researcher with interest in early detection of breast cancer and improving utilization of screening mammography, approached the MidSouth Division of the American Cancer Society (ACS) to discuss the possibility of developing a community academic partnership. She approached this organization based on its primary interests in community-based healthcare and eliminating cancer. She met in person with ACS team members to discuss potential common interests and goals. Based on their common interests in improving breast cancer care and early cancer detection, the academic team and the MidSouth Division of the ACS agreed to move forward to establish a community academic partnership.

After this initial meeting, the academic and community partners met again in person to discuss each partner’s potential roles in the partnership and to discuss creating a Give-Get Grid (Table 1) to define what each partner expected to give to the partnership and what each partner expected to get from the partnership [13]. Following this discussion iterations of the Give-Get Grid were exchanged via email until consensus was reached. Establishing clear expectations, including benefits of participation and expected contributions, early in a community academic partnership has been shown to maximize stakeholder investment [14].

Table 1.

Give Get Grid

Partner	Gives	Gets
Academic	Clinical Expertis – Medical understanding of screening mammography – Screening mammography process/history information – Understanding of breast density and other risk factors Research Expertise – Understanding of Patient Preferences in Breast Imaging Health Providers – Access to Preliminary Data of Patient Understanding of Breast Density Reporting Time/Medical Expertise as a Speaker at Local Events Student/Resident Volunteer Time	Relationships with Local Organizations Involved with Mammography Patients Interdisciplinary Experience with Community Stakeholders Research Experience in Improving Utilization of Mammography in the Underserved Populations Ideas for Community/Patient Centered Mammography Research Potential for Interdisciplinary Extramural Funding Improved Grant Writing Skills
Community	Access to Medically Underserved Mammography Populations Access to Local Screening Mammography Organizations Meeting Space	Relationships with Local Organizations Involved with Mammography Patients Voice in Design of Community Centered Mammography Research Proposals Increased Screening of Community’s Medically Underserved Population Potential for Extramural Funding Access to a Screening Mammography Medical Expert Improved Grant Writing Skills

As seen in Table 1, the partners shared expectations of building relationships and improving screening mammography utilization. Each partner also had distinct individual expectations. While the academic partner expected to gain experience in techniques to improve screening mammography utilization, the community partner expected to see an increase in the number of medically underserved women receiving screening in the local community. These distinct expectations helped to shape the goals and outcomes of the partnership.

Defining Partnership Mission and Goals:

Jointly, the partners defined the long-term mission of the partnership, which was to foster relationships among local community stakeholders committed to providing and improving breast health care in the community. The partnership’s mission statement was designed to sustain a lasting relationship between the community and academic partners and encompass a broad range of future projects.

After reaching consensus on the long-term mission statement, the partners defined short-term goals with a more narrow, measurable scope focusing on ways to improve breast health care practices among women in local underserved populations. These goals were to: 1) identify and eliminate barriers to screening mammography, 2) design a program to improve screening mammography uptake, and 3) develop a feasible research study to evaluate program outcomes.

Developing a Community-Centric Strategy:

To achieve these short-term goals, the partners first discussed the potential barriers and facilitators to developing a program that would address under-utilization of screening mammography in the local medically underserved population. Potential barriers identified included, but were not limited to, transportation to clinical care, differences in language and communication styles, distrust in the healthcare system, difficulty recruiting participants, and inability to pay for screening mammography.

The partners next identified the target population. Potential local medically underserved populations included the homeless population, rural populations with limited access to healthcare, and minority populations, such as local Hispanic/Latina and African American women. Of the identified potential target populations, the partners selected the local Hispanic/Latina population. The partners based this selection on the community partner’s long-term experience with the medical needs of this population and on studies showing that Hispanic women have lower odds of utilizing screening mammography than their white counterparts [15].

Once the target population was selected, the partners discussed several strategies to increase screening mammography uptake in the local Hispanic/Latina population. All potential interventions discussed were intended to be culturally sensitive and relevant to the community, while providing benefit to both the community and academic partners.

Ultimately, the partners decided to implement and evaluate a program designed to increase screening mammography uptake in the local Hispanic/Latina population by utilizing the Promotora community health worker model as a framework [16]. In the Promotora model, a culturally appropriate community health worker engages the Hispanic/Latina population in the healthcare system. The academic partner supported this approach based on literature supporting improved cancer outcomes in medically underserved populations in the setting of patient navigators given their ability to effectively educate patients, improve patient comfort with clinical services, and increase patient trust in the health system [17]. In turn, the community partner supported this approach based on the opportunity for cultural tailoring of the processes to reach and engage community members by improving access to and building trust with medically underserved women.

Engaging Additional Community Members:

The partners next engaged community organizations to refine the proposed Promotora screening mammography program. A snowballing approach was used to identify and engage organizations. Initially, the partners identified several community organizations with interest in women’s health and cancer care. Each engaged organization was asked to identify additional community organizations to contact. Engaged organizations and their role within the community can be seen in Table 2. The individual face-to-face stakeholder meetings took place over approximately a one year time period. The academic partner drafted a proposed agenda for meeting which was revised real time as needed.

Table 2.

Community Organizations

Community Organization	Community Organization Role/Mission
MidSouth Division of the American Cancer Society	Organization interested in community-based healthcare and dedicated to eliminating cancer as a major health problem.
Metro Public Health Department of Nashville/Davidson County	Public health department with mission to protect, improve, and sustain the health and well-being of all people in Metropolitan area. Coordinates the TN Breast & Cervical Cancer Screening Program.
Tennessee Cancer Consortium	Non-profit organization with mission to reduce the impact of all cancers on all people in TN through education, research, advocacy, service, collaboration, and networking
Tennessee Breast Cancer Coalition	Grassroots organization dedicated to improving the quality of life for individuals undergoing treatment for breast cancer
Matthew Walker Comprehensive Health Center	Local federally-qualified health center committed to providing quality healthcare services and health education and to promoting wellness to patients regardless of their economic status.
Tennessee Breast and Cervical Screening Program	State and federally funded program that provides breast and cervical cancer screening to eligible women and diagnostic follow up tests for those with suspicious results. Designed to serve lower income uninsured or underinsured women.

Each organization identified possible barriers to implementation of the program, suggested potential solutions to overcome the identified barriers, and suggested facilitators of implementing the program.

To alleviate transportation challenges, community organizations suggested utilizing specific, convenient clinic locations and providing travel/gas giftcards. To overcome language and communication barriers, community organizations suggested clinic locations known to have multilingual providers or translators available, specifically Matthew Walker Comprehensive Health Center, a local federally qualified health center. To overcome recruitment barriers, organizations suggested recruiting at specific community events, by word of mouth, by radio announcement on the local Spanish language radio station, and by targeting specific FaceBook pages. To overcome payment barriers, community organizations suggested exploring the Tennessee Breast and Cervical Screening Program.

The partners incorporated community organization feedback to revise the Promotora screening mammography program. Revisions included refining recruitment strategies, selecting clinic locations convenient to the participants, partnering with community clinics accepting payment through the Tennessee Breast and Cervical Screening Program, and providing translation services.

The partners then presented the revised Promotora screening mammography program at a Community Engagement Studio (CE Studio) for feedback. A CE Studio is a consultative model designed to obtain project-specific community input at any stage of the research process to enhance pre-research activities, design, implementation, translation, and dissemination [18]. The CE Studio can increase the relevance or patient-centeredness of a research project, respond to funder requirements for community input, or address challenges in an active project such as participant recruitment or implementation. It can be a valuable experience for researchers at any stage of their career and suitable for use by a wide range of disciplines. CE Studios have been used to obtain input on a wide range of topics including participant compensation, the culturally appropriateness of recruitment materials, participant retention strategies, simplifying the consent process, survey design, ethical considerations, return of results, and translation of research findings into practice. The researcher does not need experience with community engagement, although an openness to taking advice from non-researchers is essential. The researcher is relieved of the burden of community engagement planning and implementation, and the cost is relatively low compared to the benefits. Many institutions funded by NIH Clinical and Translational Science Awards (CTSA) now use the CE Studio model, which is also a service offered by the Recruitment Innovation Center of the National Center for Advancing Translational Science (NCATS) Trial Innovation Network [19]. The community expert panel convened for our project consisted of 12 Hispanic/Latino community members. Feedback from CE Studio community experts can be seen in Figure 1. The CE Studio provided valuable information for recruitment techniques, defined a necessary skillset for the Promotora, and provided feedback on what could be included in a short education session given by the Promotora.

Figure 1.

Community Engagement Studio (CE Studio) Community Expert Feedback

Following the CE Studio, a group meeting with stakeholders (including Matthew Walker Comprehensive Health Center, the Tennessee Breast and Cervical Screening Program, the Tennessee Cancer Consortium, the Tennessee Breast Cancer Coalition, and the Vanderbilt Ingram Cancer Center Office of Patient and Community Education) and partners was held to gain the community perspective on the Promotora screening mammography program. The needs of the proposed program were discussed at length. The partners and the community agreed that the partnership should be augmented to included two key community organizations, Matthew Walker Comprehensive Health Center and the Tennessee Breast and Cervical Screening Program. These organizations were identified as critical to implementing the program within the local community.

Aligning Outcomes with Partnership Expectations:

Implementation of the Promotora screening mammography program in the local community is expected to benefit both the community and academic partners. The academic partner expects to benefit from the opportunity to observe and measure the outcomes of the program, thereby identifying best practices for reaching this medically underserved population. The community partners expect to benefit from an increase in uptake of screening mammography in the local Hispanic/Latina population.

In order to generate new evidence and test the proposed implementation strategies, the partnership developed a pilot randomized control trial nested within the Promotora screening mammography program (NCT03557801). Outcomes to be assessed include differences in trust, satisfaction with care, and interpersonal processes of care in Hispanic/Latina women with access to the Promotora (in both group and individual settings) and those without access to the Promotora. Evaluation of the implementation strategies will include assessment of feasibility, acceptability, and recruitment methods.

The Promotora screening mammography program meets the community partners’ original expectation to positively impact women in the community: all participants are Hispanic/Latina women not previously engaged in screening mammography and all participants will receive well woman screening (mammography and Papanicolaou testing for cervical cancer screening) at no cost.

Instilling Infrastructure Mechanisms:

The partners developed infrastructure mechanisms to facilitate ongoing research and sustainability of the partnership. Funding and grant writing were targeted as the primary mechanisms to sustain the partnership and promote ongoing development of research projects. The partnership hosted a grant writing workshop led by a local academic expert to explore funding opportunities and develop a grant proposal. This grant writing workshop was held in conjunction with the group stakeholder meeting held after the CE Studio.

Developing the Model:

The partnership developed a graphic model illustrating the key steps taken to establish the community academic partnership (Figure 2).

Figure 2.

Model to Develop a Community Academic Partnership

Outcomes:

Primary outcomes to date include 1) development of a sustainable local community academic partnership and 2) creation of the model to establish a community academic partnership (Figure 2).

Of note, the community academic partnership expanded beyond the original academic team and the ACS to include Matthew Walker Comprehensive Health Center, a local federally qualified health center, to serve as the primary community partner for implementation of the Promotora screening mammography program and the Tennessee Breast and Cervical Screening Program.

Secondary outcomes to date include 1) the design, development, and implementation of the Promotora screening mammography program and 2) obtaining pilot funding to implement and evaluate the program. The pilot study successfully reached its recruitment goal of 100 women within 3 months. We believe our recruitment success is attributable to the incorporation of stakeholder input . Logistical barriers (such as reserving clinic appointments for study patients who were not yet recruited/identified and the burden placed on providers by a sudden influx of study patients for well woman screening) were overcome by regular communication between the academic team and community health center to revise the scheduling template and decrease the number of study patients who could be seen on one day. The partnership is currently performing data analysis and discussing a dissemination plan.

Establishing the community academic partnership, developing the community-centric Promotora screening mammography program, and designing and implementing the pilot research study took approximately two years to accomplish. The detailed timeline of events from initial development of the community academic partnership to implementation of the program can be seen in Figure 3.

Figure 3.

Timeline of Events

Lessons Learned:

While community engaged research can strengthen the design and impact of research, it requires time, resources, and open communication among all involved [6,18]. During the process of establishing the community academic partnership the partners learned several lessons (Table 3). The partners agreed the most important lesson learned was that building a community academic partnership and developing community-centric research proposals takes a significant amount of time and effort. However, the partners concurred that the time and effort spent to develop the partnership and engage community members produced a program stronger than either the academic partner or community partner could have developed alone. Ultimately, the partners agreed that collaboration during the development of the Promotora screening mammography program improved program design, recruitment techniques, selection of locations for clinical services, the plan to provide downstream healthcare services to women, and the plan to analyze and disseminate data.

Table 3.

Lessons Learned

Lesson	Take home message
Priorities	Understand and respect that priorities of the community and academic partners may differ
Time	Allow for adequate time to develop the community academic partnership and build trust
Ethics	Solicit community feedback to inform ethical considerations Identify the Internal Review Board (IRB) of record for community partners and allow for adequate time for each IRB to review and approve study
Communication	Engage in regular, open communication to ensure all partners remain regularly informed of status updates
Budget/Finances	Review the budget regularly and allow for adequate time for flow of funds between academic and community partners
Clinical Services	Understand and respect the differences in how clinical services are provided by different organizations

The partners’ decision to implement and evaluate this community-centric Promotora screening mammography program is supported by previous research demonstrating that strong relationships within the community can improve patient navigation programs [20]. Further, patient navigation reduces screening disparities and there is an established need to evaluate navigation programs in the screening setting [17].

Next Steps:

Once preliminary data is collected, this community academic partnership plans to apply for extramural funding to further expand, evaluate, and sustain the Promotora screening mammography program. Additionally, the partnership plans to develop future interventions to target a broader scope of local medically underserved populations, aiming to narrow the disparity gap in screening mammography.

We believe this model to develop a community academic partnership is an effective tool other institutions can utilize to enhance community engaged research in diagnostic imaging and reduce healthcare disparity.