From CBPR to RCT: Lessons Learned Over 10 years with Interventions in Public Housing

Purpose: The purpose of this presentation is to describe the lessons learned after 10 years of community engaged tobacco cessation interventions with women in public housing in the Southeastern US. The original academic-community partnership in one Southeastern US metropolitan region  identified the health area of interest, assessment of need, and developed an overall plan of action, including a multi-level and ecological based intervention at the neighborhood, peer group, and individual level.  Primary outcomes measured were smoking abstinence at 6 and 12 months post intervention.

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.