2003 Model Practice Application (Public)

Relationship Model for Accessing and Assessing Underserved Communities

St. Louis City Department of Health

Based on the knowledge that people and communities are unlikely to follow medically sound advice unless they have a trusting relationship with the organization giving it, this model was developed to strengthen relationships with communities, while at the same time collecting valuable qualitative information.

This model was tested in East End Bridgeport, CT, a predominantly African American community of 35,000 to 40,000. By accessing the community through formal and informal community leaders, the health department staff was able to build relationships while assessing awareness, knowledge, attitudes, beliefs, and perceived barriers to care through the Key-Informant Interview process. The ultimate goal was to increase colorectal cancer screening. By developing trusting relationships and sharing assessments with community leaders, staff were able to generate collaborations to increase access to colonoscopy, increase understanding of its importance to detecting cancer and; thus, increase colorectal screening among the people of this community.

The greatest public health problem in the United States today is health disparities. The reason for these disparities is not just lack of access to health care. It is the inability to apply life-saving messages to various disenfranchised communities that often are disproportionately affected by disease. Whether the issue is chronic or infectious diseases, if applied effectively to communities, life-saving messages could significantly reduce disparities.

This relationship model outlines a tested process that allows organizations to access and assess any community where there is a need. This model is unique because it uses community leadership as an effective entry point into the community. This approach is effective because:

• Leaders are often the gatekeepers in the community.
  
  
• Community leaders are often Early Adopters and can be vital in encouraging others in the community to adopt new behaviors.
  
  
• Community leaders have the trust of the community, making it easier for the organization to create change.
  
  
• Community leaders know what the issues are for the community.
  
  
• By dealing directly with community leaders, members of organizations that are unfamiliar or unaccustomed to interacting with various communities, have an increased level of comfort as they attempt to apply their life-saving messages.

This model is also unique in that it uses a modified Key-Informant Interview process not only to collect valuable qualitative data, but also to begin the process of developing a trusting relationship with the community.

The model was developed to improve the ability of the American Cancer Society (ACS), the organization with the lead role, to reach underserved communities in order to increase colorectal cancer screening. Stakeholders were brought to the table to hear the summary of the Key-Informant Interviews. This summary illustrated the profound and compelling lack of awareness and understanding of cancer in general and colorectal cancer in particular, as well as some attitudes, beliefs, and issues that acted as barriers to cancer screening. The interview summary was an eye-opener for the medical community.

Based on the data, the medical community (Greater Bridgeport Medical Group, which is composed of area doctors from the two major hospitals in the Bridgeport area) agreed to provide pro bono colon cancer screenings and other supplies, while the community recruited the patients for screening and provided transportation to and from the hospitals. There was involvement at all levels. The community saw the benefits of people being screened – lives being saved. Doctors increased their clientele, and the community saw the hospitals as caring neighbors.

The cost of this three-year project was $275,000. This paid for the Community Outreach Specialist, clerical support, travel expenses, and program costs (i.e., workshops, presentations, etc.). The funding was provided by the American Cancer Society Foundation.

Unfortunately, at this time, in spite of a demonstrated positive impact, ACS has no plans to continue the project. However, given the demonstrated benefits of the program, the East End Community Council, a community-based organization, is planning fundraising activities, with support from the two area hospitals in the form of matching funds and in-kind services. St. Louis, Missouri, is also currently applying this model in the Healthy Heart Initiative, an outreach project to decrease smoking, improve nutrition, and increase physical activity to ultimately lower heart disease rates. This will be carried out in various targeted areas within zip codes with high prevalence of heart disease.

• Development of trusting relationship, as measured by an increase in the number of community members volunteering to work with ACS to improve cancer outcomes, an increase in the quantity and quality of interactions between community leaders and upper level managers of ACS, an increase in sharing of resources between ACS and the community, and recruitment of community leaders to serve on the ACS Board of Directors.
  
  
• Increase in awareness and knowledge, as measured by increased colorectal cancer screening.
  
  
• Through the development of alliances with local physicians, nurses, hospitals, and ACS, the health department was able to overcome the greatest identified barrier of lack of health insurance. Physicians and nurses volunteered their time and expertise. Hospitals volunteered equipment (coloscopes), supplies and location. ACS and East End Community Council provided transportation.
  
  
• There was an increase in the number of people screened for colorectal cancer. At the first colonoscopy screening there were 16 people screened. Of the 16 screened, seven were found to have polyps and two of the seven were found to be cancerous.

• The community that the program tries to reach often has different goals and priorities such as food on the table and housing. Health is often low on their priority list.
  
  
• Looks can be deceiving. Just because a neighborhood looks dilapidated does not mean that it is not a resilient community.
  
  
• In order for any program to work, there should be community involvement. The program interventions should be community-based and community-driven. Without this, nothing will work.
  
  
• You have to be visible. You cannot do outreach from your desk.
  
  
• People have to trust you in order to open up to you and follow your advice. If they do not trust you, you are wasting your time.

• Outreach staff must have the appropriate sensitivity to meet different people and make them feel comfortable. This staff should be committed to improving the health of the community and have a good working knowledge of the particular health issues they are addressing.
  
  
• The organization must give outreach staff the necessary time and emotional support that it takes to develop relationships with communities where they have not been.
  
  
• The organization must make sure that outreach staff members are qualified to do the job. This means more than being qualified on a resume. The staff members must be sensitive, knowledgeable about the community and willing to find out more, and dedicated to making a positive impact.