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CEHDL’s mission is to contribute to the elimination of health disparities among Latino(a)s through the formation of human resources, community-based research, and culturally appropriate outreach/extension. CEHDL is structured as a consortium led by the University of Connecticut (UConn) in close partnership with the Hispanic Health Council (HHC), a community health agency located in inner-city Hartford, and Hartford Hospital (HH). Demonstrating best practice and culturally skilled, evidence-based outreach, and bringing the best of academic, community, and health institutions to socioeconomically disadvantaged communities, CEHDL fosters scientific-community interactions and supports training of undergraduate, graduate, and medical students. Building capacity in other agencies is one method through which CEDHDL seeks to accomplish its goals. Thus far, CEHDL has made substantial progress demonstrating that interdisciplinary community-academic-hospital partnerships are essential for addressing health inequities in our country.
The Connecticut Center of Excellence for Eliminating Health Disparities among Latinos (CEHDL) is funded by an NIH-National Center on Minority Health and Health Disparities five-year grant of $8.2 million. CEHDL’s mission is to contribute to the elimination of health disparities among Latino(a)s through the formation of human resources, community-based research, and culturally appropriate outreach/extension. CEHDL is structured as a consortium, with formal leadership based at UConn, and leadership of cores and activities, as well as planning and budgets, shared across three institutions representing a true well-functioning partnership. Partnering institutions include the Hispanic Health Council (HHC), a community health agency located in inner-city Hartford, and Hartford Hospital (HH). CEHDL has four cores (Administrative, Research, Education and Training, and Community Connections) and coordinates a type 2 diabetes randomized community trial. The Administrative Core is based within UConn’s Department of Nutritional Sciences. The center director is advised by a state and a national advisory board and works in strong partnership with CEHDL’s steering committee, deputy director, and assistant director.
The following section describes the two institutions, the Hispanic Health Council and Hartford Hospital, that together with UConn form the CEHDL consortium.
HHC is a community-based nonprofit organization located in Hartford, Connecticut. The HHC’s mission is to improve the health and well-being of Latinos and other diverse communities. The agency has a near thirty-year track record of nationally recognized work toward fulfilling this mission through three core strategies: community-based applied research, culturally tailored direct services, and policy advocacy. The HHC is noted for its role in developing, implementing, evaluating, and replicating best practice direct service models designed to address health disparities/inequities.
HHC is based in a four-story building on Main Street in Hartford, strategically located at the meeting point of the heart of the city’s Latino community and its downtown municipal and corporate buildings. The agency employs seventy-five staff representing its multicultural and multidisciplinary approach to its work, and operates over twenty programs based in its Center for Community Nutrition, Center for Women & Children’s Health, Center for Risk Reduction, Latino Policy Institute (LPI), and Center for Community Health Research.
HHC is well known for (1) its close ties to the community it serves based on the trust and credibility it has established with community members; (2) its organizational values of inclusiveness of diversity and respect for all individuals; (3) its social justice perspective on health and socioeconomic issues; and (4) its successful partnerships.
All of HHC’s initiatives involve partnership with some combination of academic, clinical, government, advocacy, and human service organizations. HHC’s strongest and most successful partnership is with CEHDL, the product of long-term partnering with the UConn’s Department of Nutritional Sciences in the development, delivery, evaluation, and dissemination of a comprehensive package of public health approaches to improving the nutritional well-being of Latinos. CEHDL offers the two organizations, along with Hartford Hospital (another long-term partner), the opportunity to bring its impact to a new level through enhanced infrastructure for translational research, and systematic application of research findings to community education and policy advocacy, as well as dissemination of process and results, for maximum impact on the enormous health inequities experienced by Latinos and others.
HH is located in a section of Hartford where a large majority of the Latino population resides, and therefore it is strongly positioned to explore the causes of health disparities between Latinos and the general population and to develop and implement health interventions for the Latino population. As part of its core mission, there is a stated value placed on community, communication, relationships, and diversity. This is evidenced within the hospital by the presence of units and clinics that serve the local community. This includes the Brownstone Clinic with ambulatory as well as inpatient facilities in which a number of innovative culturally tailored programs (diabetes, asthma, AIDS, depression) have developed to serve the special needs of the Latino population. In particular, the Amigos en Salud diabetes program was developed to introduce focused disease management bundles to the underserved (Latino) population of Hartford County. This bundled health care approach focuses on the critical pieces of care that make the most difference in health outcomes. In addition, the Pain Medicine Clinic was introduced at the Brownstone to offer a much-needed service to this community. Over the last eight years, this service has become an integral component of the health care approach to the infirmed. Because of the diversity and success of the Brownstone, the UConn Internal Medicine residency program and Medical School sends approximately forty residents and twenty students per year to the Brownstone for their continuity-based medical education. Other departments within the hospital, such as the Women’s Health Clinic, Cardiac Rehabilitation, and the Anxiety Disorders Center, have developed specialized interventions to serve this population in such areas as breast-feeding, smoking cessation, postpartum depression, and obesity. HH is a nonprofit, 850-bed hospital that annually treats approximately 37,000 inpatients in addition to an outpatient visit volume of 170,000. It is affiliated with the UConn Health Center in undergraduate and graduate medical education. It conducts twenty-eight clinical educational programs for third- and fourth-year medical students and forty programs in graduate medical education at the residency and fellowship levels. In addition, the hospital is also a research institution with research projects that range from resident-, fellow-, and physician-initiated studies to sponsored multisite clinical trials.
During its three years of operation, CEHDL has made major inroads. Achievements by the Community Connections Core include the organization of annual community forums, focus group series, and a health disparity survey, all designed to capture the community perspective and experience with health disparities; development, delivery, and evaluation of community-based culturally appropriate nutrition and health education; publication of a Spanish community health newsletter; and establishment of a plan for strategic coordination between CEHDL and the LPI at HHC in order to maximize resources and systematically identify policy implications of research findings and translate them into policy advocacy through LPI. In the research arena, CEHDL has successfully developed and is testing a culturally appropriate diabetes peer counseling intervention using a randomized controlled trial design. The center supports faculty members and other affiliates with planning grants and pilot studies in the areas of obesity, perceived discrimination and diabetes outcomes, cancer disparities, maternal and child nutrition and health, and mental health. CEHDL fosters major scientific-community interactions through its multi-institutional seminar series, annual conferences, and the organization of symposiums at state, national, and international conferences. In the area of teaching and training, efforts include developing and teaching a Latino Health & Health Care course, establishing a formal partnership with the UConn School of Social Work Vieques field experience, internship funding and placement for twenty-five minority high school and undergraduate students interested in minority health, coordinating UConn’s and HH’s public health and clinical care partnerships with the University of Puerto Rico, and awarding graduate-level fellowships to seven minority master’s and doctoral students. The center offers a much-needed evidence-based cultural skills training program that is now reaching academic, community agency, and health care provider audiences across the state. CEHDL cosponsors seminar series led by other departments addressing health disparities. CEHDL has positioned UConn as a leader in minority health, and has facilitated additional extramural funding and the continuation of funding streams such as the Connecticut Hispanic Family Nutrition Program (funded continuously by USDA-FSNE since 1995). In sum, CEHDL has made substantial progress demonstrating that interdisciplinary community-academic-hospital partnerships are essential for addressing health inequities in this country.
Between 1990 and 2000, the Latino/Hispanic population in Connecticut grew by 50.3 percent, with Latinos becoming the state’s largest minority group. Connecticut Latinos experience the highest poverty rates among all ethnic groups. According to the 2002 Behavioral Risk Factor Surveillance System, Latinos in Connecticut were substantially less likely to have health care coverage compared to whites and blacks. Latinos living in Connecticut are twice as likely as whites to report their health as “fair” or “poor.” In particular, Latinos in Connecticut are heavily affected by type 2 diabetes and its risk factors, including obesity, poor diet, physical inactivity, and smoking (Fitzgerald et al. 2006; Fitzgerald et al. 2008; Pérez-Escamilla and Putnik 2007). Thus, CEHDL’s mission has major public health relevance to Connecticut and beyond.
How did CEHDL happen? With funding from the USDA Food Stamp Nutrition Education Program since 1995, UConn has partnered with HHC and HH to deliver high-quality nutrition and health education to food stamp recipients (Pérez-Escamilla et al. 2002). The Hispanic Family Nutrition Program (HFNP) began with extensive community nutrition needs assessments followed by effective interventions. HFNP’s Programa para Aprender Nutrición y Alimentación (PANA) delivers bilingual and bicultural fun and entertaining diet, health, and food safety puppet shows totaling about ten thousand child nutrition contacts per year to pre-K and elementary school children, and several additional educational activities targeting both adolescent and adult audiences. PANA serves the multicultural nutrition education programmatic needs of a variety of health and community agencies.
HFNP has developed innovative bilingual educational materials such as the Puerto Rican Food Guide Pyramid, the Bilingual Color-Coded Food Label, a coloring book titled From the Farm to the Table, a breast-feeding fotonovela, an infant feeding guide titled The First 12 Months, a prenatal nutrition feeding guide, and a diabetes fotonovela, as well as three nutrition and food safety Jeopardy-style games. HFNP has implemented and evaluated nutrition and food safety award-winning social marketing campaigns delivered through Latino mass media and the mass transit system, reaching approximately two hundred thousand Latinos per year in Connecticut. HFNP has a strong research and evaluation (i.e., evidence-based) orientation documented in peer-reviewed journals. HFNP has trained over forty graduate, medical, undergraduate, and high school students, many of whom have come from socioeconomically disadvantaged communities. HFNP served as the foundation for creating and securing funding for CEHDL, which in turn has now integrated HFNP into its structure.
CEHDL’s Community Connections Core organized diabetes and cancer community forums, developed and evaluated evidence-based culturally appropriate nutrition and health education, provided education through HHC, health fairs, schools, and other community venues, and developed and disseminated its Spanish community health newsletter La Voz de Salud. CEHDL successfully developed, with strong community input, a culturally appropriate diabetes peer counseling model currently being evaluated using a randomized controlled community trial design (Pérez-Escamilla et al. 2008a). Participants are being recruited from the Amigos en Salud diabetes program at HH. The strong collaborative base of this project has already built badly needed research capacity at the hospital and a better understanding of the major health challenges faced by Latinos with diabetes. CEHDL provides and funds experiential learning opportunities internships in community-based research, service, and advocacy at the HHC and HH.
CEHDL has played a central role with the cross-cultural training initiative conducted in partnership with the UConn School of Medicine’s Community Based Education Project; the HHC Health Outreach for Medical Equality project, conducted with the Community Children’s Medical Center; and HHC’s annual community health fair. CEHDL is building capacity in other agencies as exemplified by the major health disparities partnerships with the Connecticut Department of Public Health and is represented in the advisory boards of numerous relevant state public health initiatives, including Connecticut Cancer Partnership Coalition and the Obesity and Diabetes Task Forces.
CEHDL has become a vital component in defining public engagement at the university. The working definitions of “service” that UConn uses include to the university, to a professional organization, or to a community that may not be related to academic expertise. This differs from outreach, where university resources are offered to external constituencies that may lead to impacts. Engagement, as exemplified by CEHDL, includes activities that are mutually beneficial to external and internal communities and lead to measurable impacts. CEHDL aligns with the core values of the institution as reflected in UConn’s mission statement, which identifies outreach and public service as central to the state’s land grant and sea grant flagship public research institution.
The Kellogg Commission report Returning to Our Roots (1999) described the seven-part test of engagement. These seven characteristics nicely apply to how the university can contribute to addressing the complex problems of health disparities in low-income communities. While CEHDL meets a local need, the implications are international in scope. CEHDL demonstrates responsiveness as students learn community interaction skills and model good citizenship working in the community. CEHDL brings together diverse partners on an equitable basis, demonstrating respect for partners. Best practices evolved through CEHDL are strengthening the future of the academy related to the academic neutrality of engagement. Accessibility is paramount to CEHDL’s successful involvement with fairs and forums to educate. Integration of program and research crosses agencies, higher education institutions, and health providers with coordination occurring with USDA and across three UConn campuses. Coalitions around CEHDL reflect resource partnerships that will politically strengthen the institution.
CEHDL reflects the institution’s commitment to translational interdisciplinary work, focused on reciprocity and measured impacts, leading to scholarship. With regard to funding, the initial NIH CEHDL grant was one of the top four grants received by the institution in the last seven years. Funding was awarded with a high degree of confidence in CEHDL’s ability to deliver first-class engaged scholarship as defined by the creation of new knowledge that is peer-reviewed and shared with others for replication or adaptation.
Why does CEHDL fit so well within the university? Not only does the state have a large Latino population, but the Cooperative Extension System, of which CEHDL is a component, has a long history of working with this and other minority communities in the City of Hartford. The Department of Nutritional Sciences, home to the lead PI, has strength in research and extension related to community nutrition that nicely complements CEHDL, which was built upon the foundation established by the Hispanic Family Nutrition Program (USDA-FSNE funded since 1995). This outcome is fully consistent with the philosophy of the College of Agriculture and Natural Resources regarding teamwork across teaching, research, and extension with a train-the-trainer approach.
Institutional impacts from CEHDL include student training in the community that has led to a strengthened community nutrition undergraduate curriculum, increased cross-cultural awareness that could lead to an increase in minority students, and increased expectations of excellence. CEHDL is an evidence-based center that is building a model to better understand food and nutrition problems faced by Latinos. The program demonstrates best practice, culturally skilled, evidence-based outreach, bringing the best of academic, community, and health institutions to socioeconomically disadvantaged communities. For this reason it was designated as a University Center by the University Board of Trustees. Indeed, as previously indicated, CEHDL supports its affiliates with seed grants in diverse communities and health disparity areas. CEHDL fosters major scientific-community interactions through its newsletter La Noticia de Salud, multi-institutional seminar series, annual conferences on the topics of diabetes and cancer, and the organization of symposia at state, national, and international meetings. In the area of teaching and training, CEHDL developed and teaches a Latino Health & Health Care course open to both undergraduate and graduate students; provides funding and placement for experiential learning internships, thus greatly benefiting minority high school, undergraduate, and medical students interested in minority health; coordinates UConn and HH public health and clinical care partnerships with the University of Puerto Rico; and has awarded fellowships to minority master’s and doctoral students. CEHDL cosponsors seminar series led by other departments interested in health disparities. CEHDL has fostered the submission of grant proposals and has already attracted additional extramural funding, and has been instrumental for continuing to secure major funding streams such as the USDA-funded Hispanic Family Nutrition Program.
During more than a decade, UConn, the HHC, and HH have made numerous contributions to the understanding of nutrition problems confronted by Hartford’s Latino community through a number of rigorous assessments and the development and testing of culturally tailored interventions. For example, collaborative breast-feeding peer counseling work has been cited by the Centers for Disease Control and Prevention (CDC) as a best-practices model. At UConn, CEHDL has fostered research collaborations involving faculty, undergraduate, graduate, and medical students belonging to fifteen different academic departments on three different campuses. In recognition of CEHDL and the decade-long work that preceded it, UConn granted its top diversity, excellence in outreach, and scholarship of engagement awards to the center. As CEHDL moves forward, there will be greater integration of engagement across the university, resulting in a strengthened belief in the value of partnerships as this model initiates and develops sustainability.
CEHDL’s success is attributed to being based on the strengths of each partner organization; on a shared vision and shared values, including health as the right of communities experiencing health inequities, and equity in partnerships; on the recognition that the capacity of each organization is increased through its partnership with the other; on equity in planning and implementation, including decisions about budget allocations across institutions; and on key individuals within each institution with the capacity to build and nurture partnerships of this nature.
The center’s steering and advisory committees strongly encouraged CEHDL to start working on the strategy that can lead CEHDL to the five-year renewal that, per NIH guidelines, it will be entitled to in the year 2010. The institutional commitment to CEHDL’s continuing success is clear as all three consortium partners (UConn, HHC, and HH) have institutionalized CEHDL as part of their formal structures and are providing substantial leverage through fiscal and in-kind support, including personnel, equipment, and physical infrastructure. CEHDL has garnered strong political support as expressed in supportive grant letters provided by three key legislators at the federal level. CEHDL’s goal is to continue developing evidence-based cost-effective peer counseling models that can successfully overcome the heath disparities faced by Latino(a)s and other minority groups (Pérez-Escamilla et al. 2008b). CEHDL plans on developing additional models that improve management of diseases such as diabetes and are capable of preventing the disease from starting.
A major emphasis will continue to be the translation of useful knowledge into primary prevention practices (i.e., health promotion) through culturally appropriate and sound nutrition, physical activity, and healthy lifestyles education and interventions. CEHDL’s strong network of community partners will continue to be heavily involved in the decision-making process. CEHDL will seek status as a National Comprehensive Research and Training Center of Excellence so that others in the United States and beyond can replicate its successes. CEHDL-affiliated projects now include funding from NIH, U.S. Department of Agriculture, the Centers for Disease Control and Prevention, and the Patrick & Catherine Weldon Donaghue Medical Research Foundation. In the future, CEHDL will continue expanding and diversifying its funding portfolio, which is critical for its long-term sustainability. These efforts will continue to provide experiential learning opportunities to students throughout the state and beyond, thus strengthening the academy and community partners.
Rafael Pérez-Escamilla, Ph.D., is a Professor of Nutrition and Public Health and Cooperative Extension Nutrition Scientist at the University of Connecticut. He is also the Principal Investigator and Founding Director of the Connecticut NIH EXPORT Center for Eliminating Health Disparities among Latinos (www.cehdl.uconn.edu) and of the Connecticut Hispanic Family Nutrition Program. He is currently leading or co-leading four maternal-child nutrition and food security multi-institutional capacity building projects in the USA, Ghana, and Brazil.
Grace Damio, M.S., C.D.N., is the Director of Maternal and Child Health and Nutrition Centers at the Hispanic Health Council in Hartford, Connecticut. She is also CEHDL’s Deputy Director. Ms. Damio has worked at the Hispanic Health Council since 1986. She has developed and administered service, advocacy and research initiatives in the areas of: maternal and child health, nutrition, breastfeeding, hunger and food security, breast cancer and reproductive health and oral health. Ms. Damio has also written culturally tailored curricula and training manuals, and provided training on diversity skill development at a wide variety of universities, conferences and worksites.
Jeannette DeJesus, M.P.A., M.S.W., is the President of the Hispanic Health Council. Established in 1978 in response to the health care crisis in the Puerto Rican community, the Hispanic Health Council is a community-based, non-profit organization located in Hartford, Connecticut. Sustained over 28 years by the combined efforts of community activists, researchers and dedicated staff, HHC has earned the trust and confidence "confianza" of the community and is a valued institution in the region and nationwide.
Laurine M. Bow, Ph.D. is currently the Vice President for Research at Hartford Hospital. She is also Director of the Transplant Immunology Laboratory at Hartford Hospital, Director of Transplant Immunology at Montefiore Medical Center, Bronx, NY, as well as Assistant Professor of Surgery at the University of Connecticut and Adjunct Assistant Professor of Pharmaceutical Sciences, at the University of Connecticut at Storrs.
Jyoti Chhabra, Ph.D., received her doctorate in Nutrition from The Pennsylvania State University in 1998. She is currently a Senior Scientist in the Research Program at Hartford Hospital and the lead CEHDL investigator of this institution.
Nancy H. Bull, Ph.D., is the Associate Dean for Outreach Education and Public Service, and Associate Director, Cooperative Extension System (CES), University of Connecticut, Storrs. CES is part of a nationwide educational network through the University of Connecticut College of Agriculture and Natural Resources. Associate Dean Bull provides vision and oversight to the CES teams of professionals and trained volunteers who teach the state’s diverse population to make informed choices and decisions affecting their lives and environment.
*Recipient of the 2007 C. Peter Magrath/W.K. Kellogg Foundation Engagement Award–NASULGC North East Region. CEHDL is funded through an EXPORT Center grant from the NIH-National Center on Minority Health and Health Disparities (grant # P20MD001765).
CEHDL Contact Information
Rafael Pérez-Escamilla, Director, NIH EXPORT Center for Eliminating, Health Disparities among Latinos (CEHDL), www.cehdl.uconn.edu, University of Connecticut, 3624 Horsebarn Hill Rd., Storrs CT 06269-4017, voice: (860) 486-5073; fax: (860) 486-3674, Email: firstname.lastname@example.org.
Grace Damio, Centers for Community Nutrition and for Women and Children’s Health, Hispanic Health Council, Hartford CT.
Jeannette De Jesús, Hispanic Health Council, Hartford CT.
Laurine Bow, Hartford Hospital.
Jyoti Chhabra, Hartford Hospital.
Nancy H. Bull, Associate Director, Cooperative Extension System, University of Connecticut, Storrs.