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Sidebar:
From medicine to media, a doctor extends his reach
Healthy eating is the linchpin of diabetes prevention and control. At
a March workshop community health advisors got some lessons in preparing
low-fat dishes.
Eggs, says researcher Zubaida Faridi, are a good source of nutrition.
At Griffin Hospital in Derby, she uses an ultrasound to measure the effects
of egg consumption on the ability of blood vessels to dilate, an indicator
of cardiac and vascular health.
At the March workshop Sharon Bradford, above, a member
of a community advisory committee, led the group in line dancing. “People
think that dancing is just fun, but it’s also movement and exercise,”
Bradford says.
At the weekly Bible Study meeting she leads, the Rev.
Audry Tinsley, below, pastor of the Pentecostal Assembly Church of Deliverance
in New Haven, spends a few minutes discussing diabetes. “It affects
people of color disproportionately,” says Tinsley, herself a diabetic.
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Promoting health, from
the ground up
Part of a national effort to create community health partnerships, a
Yale center is working with New Haven churches to prevent diabetes and
with a suburban school to stop teen smoking. The goal? Healthier communities
invested in their own outcomes.
By Jennifer Kaylin
Photographs by Gale Zucker
In 1997, when Veronica Puleo, R.N., became the nurse at Amity High School
in the New Haven suburb of Woodbridge, she was prepared to handle the
fevers, sore throats, headaches, sprained ankles and other ailments that
routinely afflict students, but there was one health problem that confounded
her.
Cigarette smoking was so rampant that school officials imposed a $65 fine
on any student caught smoking in the school. The hard-core smokers chose
to try their luck in “Marlboro Country,” a secluded area behind
the school where students gathered to light up. If caught there, they
faced an after-school detention, with Puleo sometimes presiding.
“For three hours we’d sit and talk,” she says.
“They’d tell me how they were coughing up blood, or that they
felt awful in the morning until they’d had their first cigarette,
or that they couldn’t fall asleep at night until they had a cigarette.
They were almost pleading with me. They were so addicted, but had no way
to stop.”
Puleo knew she had to do something, but with limited resources
and no program geared for adolescents, she was at a loss. “I was
spinning my wheels,” she says. Then she learned about the Yale-Griffin
Prevention Research Center (PRC).
The PRC is a partnership between the Department of Epidemiology
and Public Health at Yale and Griffin Hospital in Derby, where it is headquartered.
It was established in 1998 with a $350,000-a-year grant from the Centers
for Disease Control and Prevention (CDC). That allotment grew to $800,000
annually in the second funding cycle, which began last October. Funding
from other sources brings the PRC budget to between $2 million and $2.5
million each year.
One of 28 such centers nationwide, the Yale-Griffin PRC collaborates
with the community to develop innovative approaches to health promotion
and disease prevention. Collectively, the national PRC network conducts
about 500 research projects a year on such topics as aging, arthritis,
asthma, job safety, nutrition, cardiovascular health, tobacco control,
obesity, diabetes prevention and control, school health and violence prevention.
“The PRC model, which was developed about 20 years ago, grew
out of a productive period in the history of public health,” says
Eduardo J. Simoes, M.D., M.Sc., M.P.H., program director of the CDC’s
prevention research centers. “We had conquered a lot of diseases
through immunizations. We were making progress in the areas of occupational
and environmental health, so the logical next step was to invest in prevention
research at the community level.” Besides funding the PRCs, the
CDC provides oversight and makes periodic site visits.
Michael H. Merson, M.D., the former dean of public health and the
Anna M.R. Lauder Professor of Public Health, is the principal investigator
of the CDC grant. He calls the PRC program “one of the most important
initiatives the CDC has in this country.” Too often, he says, there’s
a divide between academic research and real-world application. “These
centers are really critical in bringing the two together, in taking the
best in public health knowledge and applying it in a field setting.”
Pizza, soda and cigarettes
When Puleo contacted the Yale-Griffin PRC, she was put in touch with the
director, David L. Katz, M.D., M.P.H. ’93, associate clinical professor
of epidemiology and public health, who, along with Merson, founded the
PRC. “He immediately took charge of the situation and helped me
out,” Puleo recalls. Katz introduced her to scientists doing research
on adolescent smoking. He joined her at meetings with students and helped
her write a news bulletin for parents. Eventually, their work became a
research project on the effectiveness of tailored behavioral interventions
and the drug Zyban in fighting adolescent nicotine addiction. Although
Zyban has helped adults quit smoking, Puleo says it proved ineffective
with her study group. Study findings were published in the journal Behavior
Modification last year.
What did work was the eight-week program she and Katz developed.
Each week focused on a different topic—from what cigarette smoking
does to the body and identifying why students smoke to preparing them
for withdrawal. Students received gum, pencils and water bottles to fulfill
the oral fixation that cigarettes satisfy. Puleo and Katz set out to identify
what incentives work best with adolescents. “We gave them a choice:
money or pizza and soda at our weekly meetings,” Puleo says. The
answer provided some insight into why adult treatment models don’t
necessarily work with adolescents. “The money meant nothing; they
just use it to buy more cigarettes,” Puleo says. “The pizza
and soda was front and center. It allowed them to socialize, which is
so important for young people, and gave them something to look forward
to from week to week.” Katz, a nutrition expert, was somewhat reluctant
to go the pizza and soda route. “But I am a practical guy,”
he notes. “I try very hard not to make ‘perfect’ the
enemy of ‘good.’ I figured we could get to dietary detox once
we helped these kids quit smoking.”
There are now about 60 students enrolled in the program. Katz estimates
that between a third and a half either quit smoking or cut back significantly.
The PRC stayed involved with the Amity smoking cessation program for about
four years, until it could run on its own. “This is the kind of
thing we’re hoping to achieve on a larger scale,” Katz says.
“A big part of what our center does is to take the knowledge we
acquire and translate it into a real-world setting until it can become
self-sustaining.”
The Yale-Griffin PRC has generated studies and publications in
the area of smoking cessation for adults, and invented a novel behavior
modification technique Katz terms “impediment profiling,”
which identifies barriers to behavior change. “Then we tailor the
intervention components to correspond,” Katz says. “We’ve
had success with this approach in smoking cessation and physical activity
promotion, and just received notice of our first grant award to develop
the technique for dietary change and weight control as well.”
Another PRC study found positive results with congestive heart
failure patients who received a treadmill and access to a cardiac rehab
nurse to help them use it. “The participants really liked it, which
is proof of principle,” Katz says. “Now we’re looking
for collaborators to help us study whether this could reduce the number
of hospitalizations and mortality.”
A randomized trial just completed by the PRC found that massage
therapy was highly effective for patients with osteoarthritis of the knee.
Katz says the next step is to crunch the financial numbers. “Given
all the press about the dangers of anti-inflammatory medicine, what if
massage is as good, or better? This could lead to a significant policy
change. But to get there requires showing not only that it works, but
that it’s cost-effective.”
Partnering with the community
Beth P. Comerford, M.S., the PRC’s deputy director, says PRCs focus
on different health issues, depending on the needs of the community, but
their basic approach is always the same: partnering with the community.
“Everybody at the table holds an equal place and is involved in
the decisions being made.” This is a time-consuming and, at times,
frustrating process, Comerford concedes, but because the goal is real-world
application, it can also be rewarding.
“With the traditional clinical trial model, you’re
basically saying, ‘You’re the subject, we do things to you.’
Then we leave,” Comerford says. While researchers may develop the
perfect scientific protocol, if it requires test subjects to do something
that makes them uncomfortable, such as take a medication or have blood
drawn, they may refuse to participate. And any scientific results may
not be lasting in real-world settings. “What we do,” Comerford
says, “is go to the community at the start and ask them, ‘What
are your priorities? What would work to address them? What would people
be willing to do?’ This is key for participation and sustainability.”
In 2002, the Yale-Griffin PRC embarked on a long-term project called
predict (Partners Reducing Effects of Diabetes: Initiatives through Collaboration
& Teamwork). While researchers want to determine why information about
diabetes isn’t reaching the at-risk population, they know that for
this project to succeed, there are side issues they may have to tackle
first. “Before you can focus on the health issue, you may need to
work with people on issues related to jobs, child care, housing,”
Comerford says.
While it may seem digressive for public health researchers to address
such social ills as unemployment, Katz says it’s essential. “If
you tell a group of people you want to talk to them about diabetes and
they say they’re more concerned about finding jobs and you say,
‘Yeah, well that’s not our thing,’ they’re going
to show you the door,” he says. He offers an example from his clinical
work: A patient couldn’t quit smoking. The resident physician kept
focusing on smoking cessation, but Katz found out she was homeless, and
the focus shifted to the patient’s more pressing needs. Three months
after she’d moved into a new home, she was ready to quit smoking.
The predict project will evaluate the Community Health Advisor
model for getting people at risk to adopt healthier lifestyles. This method
identifies natural leaders in a community and trains them to serve as
surrogates for health care professionals. “Rather than the traditional
we’re-here-to-help-you model,” Katz says, “members of
the community spread the gospel.” New Haven will be the test community
and Bridgeport will be the delayed control—meaning it won’t
get any intervention until after the study is over. A related pilot study
seeks to improve the patient-doctor relationship by coaching patients
who have been newly diagnosed with diabetes on how to talk to their doctors.
For predict, researchers initially planned to work through the
public schools to disseminate information about diabetes, but an advisory
committee of community members felt it should be a church-based initiative.
“We helped them tweak their structure,” says committee member
Sharon Bradford. “We decided they should work through the religious
community. We felt there was a captive audience in the churches.”
The committee also put researchers in touch with local ministers and helped
select and hire a local outreach coordinator to serve as a liaison between
the community and the PRC.
That outreach worker is Maurice Williams, who also saw that working
through the schools wouldn’t be effective. “When parents go
to a school they’re thinking about how their child is doing in school,
not about health issues,” he says. “Plus, if you work through
the churches the message is flowing from the parent down. The child isn’t
carrying all the weight of bringing the information home.”
Twelve African-American churches in New Haven were chosen for the
study. Two volunteers from each were recruited as community health advisors.
During 10 weeks of training they learned about the causes, symptoms and
treatment options for diabetes. They also learned about nutrition, how
to read food labels, low-fat cooking techniques and different methods
they might use to educate their congregations. Church members were then
given a baseline survey to see how much they know about diabetes. The
next step, which is under way, is for the community health advisors to
go back to their churches and educate their congregations about diabetes.
Church members will then be surveyed again to see whether their understanding
about diabetes has increased.
“Why don’t they serve fruits and vegetables?”
The Rev. Audrey Tinsley, the pastor of the Pentecostal Assembly Church
of Deliverance, signed up as a community health advisor because she has
diabetes. “I wanted to learn ways I could keep my diabetes from
escalating into something worse, and I wanted to help keep other people
from getting the disease,” she says. She spends 15 minutes of every
Bible Study period sharing information about diabetes and passes out diabetes
literature at her church.
Tinsley now talks about diabetes with a convert’s zeal. “It
affects people of color disproportionately,” she says. “It
affects us more because of the food we eat. Fast food, junk food, something
quick. Diet is the number one thing that causes diabetes.”
When the conversation turns to school lunches, Tinsley’s
voice takes on an angry edge. “Pizza, chicken nuggets,” she
says. “There’s nothing nutritional here! Why don’t they
serve fruits and vegetables? Why don’t the kids have decent food?”
Tinsley isn’t alone. At a meeting of community health advisors
in the basement of Bethel AME Church, everyone had stories to tell. Several
people talked about their own experiences with diabetes. Food was a recurring
subject of conversation—low-fat ways to prepare favorite dishes,
the benefits of Mrs. Dash salt substitutes, the merits of cooking collard
greens with smoked turkey instead of pork. At one point, someone suggested
putting together a cookbook of healthy recipes. One health advisor wrote
a skit about diabetes she hoped the group could present at a community
event. It contained three scenes; by the end of the meeting it had grown
to seven.
When the Yale-Griffin PRC began, it served the six towns of the
Lower Naugatuck Valley—Derby, Ansonia, Seymour, Shelton, Oxford
and Beacon Falls. One of its early, major initiatives was the Valley Health
Profile—a collection of data about diseases and causes of death
over a three-year period. “The local data helped us see local patterns
we used to develop our priorities,” Katz says, noting, for example,
that physical activity and fitness levels of Valley schoolchildren were
of concern. This information was disseminated among health care agencies
to be used for setting priorities. The PRC now produces a “Community
Health Profile” every two years, covering not only the Lower Naugatuck
Valley, but also New Haven, Bridgeport and Hartford. In addition, a health
newsletter goes out to approximately 40,000 households twice a year.
As the Yale-Griffin PRC has grown, emphasis has shifted away from
the Valley, but residents who live near Griffin Hospital still participate
in clinical trials. The PRC has about 15 to 20 active projects involving
between 200 and 500 participants, mostly from the Valley communities.
One project is looking into the effects of egg consumption on the
ability of blood vessels to dilate, a reliable indicator of cardiac and
vascular health. The first egg study looked at 50 healthy people from
the Valley who ate two eggs a day. “We found that the blood vessel
response was normal in both the intervention and the control groups,”
says clinical research associate Zubaida Faridi, M.D., M.P.H. This means
egg consumption did not have a negative effect on the endothelium—the
inner lining of the blood vessel—nor did it raise serum cholesterol
levels. Faridi is now replicating the study on test subjects with elevated
cholesterol levels. “We see this study as having practical applications
for a large element of the population,” Faridi says. “Eggs
are a very commonly used food, with an excellent nutrition profile, and
their exclusion from the diet comes at a cost.”
Katz believes the move toward community-based research models represents
a sea change in public health research. “It’s health with
and for communities, rather than the paternalistic, ‘Trust us, we’re
from an academic environment,’” he says. “Gertrude Stein
had it right: ‘A difference, to be a difference, must make a difference.’
For research to make a difference, it must be put to use in the real world.”
While Katz says research universities are slow to deviate from their time-tested
ways, he sees the PRC’s methodology as the wave of the future, from
the standpoint of both public acceptance and financial support.
“I’m hoping we’re tossing a pebble in the pond
and that the ripples go to the far shore.” YM
Jennifer Kaylin is a writer in New Haven.
Gale Zucker is a photographer in Branford, Conn.
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