Promoting health, from the ground up

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