Methods: A community based participatory research (CBPR) approach was used to develop, implement and evaluate a culturally tailored intervention strategy to assist women in public housing to quit smoking . A feasibility study (n=10 women) was conducted in one public housing neighborhood, followed by a pilot study (n=103 women) in two public housing neighborhoods. With promising 6 month tobacco abstinence outcomes (39% treatment condition vs. 11.5% control ) and other behavioral and psychosocial measures, funding was received for a larger randomized controlled trial (RCT) in 16 neighborhoods (n=410 women) across two states. In the RCT, the tobacco abstinence outcomes were less promising, with 12 month abstinence rates of 12% in treatment neighborhoods vs. 5% in control neighborhoods. Additional analyses and discussions ensued to better understand the outcomes and lessons learned.
Results: A CBPR approach was used with mutual interest of both the community and academic partners in the initial two neighborhoods. The partnership worked together over 3 years to develop strategies, methods, and materials, which fostered the interest and buy-in of the participating neighborhoods. With the implementation of the RCT in expanded regions in two states, neighborhoods were selected based on inclusion criteria, initial interest, with 2-3 months of time to cultivate relationships and trust. Lessons learned in working with high risk vulnerable populations and implementation of CBPR developed RCT's include: 1) Time to cultivate relationships and interest varies, but the longer positive history, the more likelihood of trust and engagement; 2) Community and organizational readiness vary from neighborhood, residents, and housing authority managers to include goodness of fit, capacity, and operations; 3) Challenges with maintaining intervention fidelity in real world community based interventions with differing readiness levels; and 4) Influence of neighborhood moderators to include social and environmental context and changes in impoverished public housing communities (crime and violence, neighborhood stress, social cohesion) over time.
Conclusion: Outcomes in randomized controlled trials in community-based clusters (i.e., neighborhoods, churches, schools, clinics) will likely vary according to stakeholder engagement, readiness, and social/environmental contexts. Further considerations regarding methods, approaches, and funding sources are needed with the implementation of community-engaged interventions based on these and other factors as we attempt to eliminate disparities in these high-risk vulnerable communities.