Ending Unequal Treatment: Strategies to Achieve Equitable Health Care and Optimal Health for All (2024)

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6 Community-Centered and Community-Engaged Care As informed by the committee’s conceptual framework and discussed in previous chapters, the community has a vital role to play in health and health care because it involves social forces and environmental context. Its embedded structures and processes shape the daily attitudes, beliefs, val- ues, and cultural scripts of people seeking and delivering care. This chapter reviews how the community embedded within the domains of health care law and payment policies, health care service delivery, discovery and evi- dence generation, and accountability can be a determinant of health and produce mechanisms central to developing and maintaining health equity. Recognizing that racial and ethnic differences structure the life opportuni- ties of individuals, this chapter summarizes promising strategies and inter- ventions for mitigating the health care inequities experienced by racially and ethnically minoritized and Indigenous populations, while acknowledg- ing gaps in the literature. As noted in previous chapters, this report uses “inequities” instead of “disparities” in except when citing a publication that explicitly measured disparities. In addition, the committee is aware that health—a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity—and health care—the services provided to individuals, families, and communities for the purpose of promoting, maintaining, or restoring health across settings of care—are different but inextricably linked. Furthermore, this report uses “health care system” (activities related to the delivery of care across the continuum of care) to describe the U.S. health care system as a whole and also individual health care systems. 215 

216 ENDING UNEQUAL TREATMENT COMMUNITY ENVIRONMENTS INFLUENCE HEALTH AND HEALTH CARE Community environments are critical factors influencing health and health care outcomes (NASEM, 2017, 2019). Practices within communi- ties, such as geographical segregation and discriminatory mortgage lend- ing, also have been associated with adverse physical and mental health (Larrabee Sonderlund et al., 2022; Lynch et al., 2021). Similarly, adopting and implementing social policies in different communities influence health and health care inequities. Social policies and rhetoric on such policies can also create hostile community environments for racially and ethnically minoritized individuals that are detrimental to their health. For example, social policies restricting undocumented immigrants’ access to resources and anti-immigrant rhetoric and sentiment adversely impact their health and health care and may even do so differentially, depending on the region (Ornelas et al., 2020). Over the past 20 years, recognition has been increasing of the importance of place, or neighborhood context, on an individual’s health. Neighborhood disadvantage, as measured by social deprivation index, area deprivation index, social vulnerability index, social vulnerability measure, and others, has been associated with health care inequities, such as access to subspecialty care and visits to emergency departments (EDs), and inequitable health outcomes, such as differences in cancer risk, stage of cancer diagnosis, rehospitalization, asthma control, and mortality (Brown et al., 2023; Chang et al., 2021; Edmonds et al., 2021; Saulsberry et al., 2023; Wolfson et al., 2023; Wray and Minaker, 2019). Measures of deprivation are included in some of the new health care payment m ­ odels being developed by the Centers for Medicare & Medicaid Services Center for Medicare and Medicaid Innovation.1 While the evidence from these recent payment demonstrations is nascent, the impact that neighborhood context has on health and health care was demonstrated during the COVID-19 pandemic when individual risks (e.g., presence of chronic disease) were compounded by neighborhood- based risks to disproportionately produce substantial disparities in COVID-19 infection incidence, morbidity, and mortality in racially and ethnically minoritized counties. 1 See https://www.cms.gov/blog/cms-innovation-centers-strategy-support-high-quality-primary- care (accessed April 29, 2024). 

COMMUNITY-CENTERED AND COMMUNITY-ENGAGED CARE 217 COMMUNITY PARTNERSHIPS The recognition of the central role played by communities in health and health care dates to over 80 years ago and was the founding prin- ciple of federally qualified health centers (FQHCs) in the United States.2 FQHCs were originally neighborhood health centers to deliver health and social services to disadvantaged and medically underserved communities.3 Because FQHCs are expected to have more than half of their governing boards of directors from people who represent the community and exhibit the demographics of its population,4 they typically have racially and eth- nically minoritized members with a say in how services are designed and implemented. Consequently, FQHCs can improve health care access and outcomes across racial and ethnic groups, those with lower income, and those with no insurance coverage (NACHC, 2023). FQHCs deliver primary care, gynecologic, behavioral health, and preventive health services, such as vaccinations. For example, FQHCs administered a greater number of COVID-19 vaccines to racially and ethnically minoritized patients (Cole, 2021). FQHCs partner directly with community organizations and build trust within communities which enable them to be a trusted source of care. This trust is partly because clinicians and staff may share the culture and language of the communi- ties they serve. Community members have the institutional knowledge and resources to address many community issues (Baker et al., 2021). Communities can partner with health care systems and policy makers to move toward more integrated models of care to advance health equity. Community members and organizations have firsthand knowledge and lived experience to know what is needed to improve the health and health care of racially and ethni- cally minoritized communities. Partnerships with communities can lead to interventions at multiple places in the care continuum, such as in individual- level patient–provider interactions (e.g., community health worker [CHW] interventions) or in system-level clinical care models (Alegría et al., 2023a). For example, the Care Partners Project involved partnerships between pri- mary care clinics and community-based organizations to improve late-life depression care holistically and seamlessly address patients’ medical and social needs (Wagner et al., 2022). 2 See https://www.nachc.org/community-health-centers/what-is-a-health-center/ (accessed April 29, 2024). 3 See https://www.chcchronicles.org/histories (accessed April 29, 2024). 4 See https://bphc.hrsa.gov/compliance/compliance-manual/chapter20 (accessed April 29, 2024). 

218 ENDING UNEQUAL TREATMENT Community partnerships with health care systems also work upstream to improve population health, such as psychologists partnering with community-based organizations and community members to deliver pre- ventive mental health interventions and increase mental health literacy (Alegría et al., 2023b). Some prevention efforts, such as neighborhood regeneration programs, also lend themselves well to community–policy maker partnerships to shift policy efforts to what matters most to com- munity members and local health and health care needs (Alegría, 2024). These networks can bring awareness of and prioritize the issues impact- ing the health and health care of minoritized communities (Cacari-Stone et al., 2014). Community partnerships with health care systems and policy makers can be mutually beneficial. Knowledge-sharing will often be a central feature of community–health system and community–policy partner- ships; community organizations frequently educate health care systems and policy makers about population health needs. In exchange, health care systems and/or policy partners, for example, may fund community- based organizations or establish grant mechanisms to implement and strengthen projects (Alegría et al., 2022). Community–health care system and community–policy partnerships may be a step toward the ultimate goal of sustainable change because they can establish collaborative opportunities and knowledge-sharing while also increasing the capac- ity of all partners to improve health and health care across sectors and levels (Alegría et al., 2023a). PROMISING INTERVENTIONS A scoping review defined community-centered interventions as “those that take place in a community setting or [are] delivered by the commu- nity and voluntary sector” (Baskin et al., 2021). However, involvement from community members in developing interventions to improve health care access for minoritized communities is relatively rare (Cheng et al., 2020). These interventions are well-positioned to promote community belonging and protective factors and increase the generalizability of find- ings (Mulholland et al., 2021) to populations that tend not to receive care. The evidence demonstrating positive outcomes from community-based and -engaged interventions has grown substantially over the past 20 years. Some successful interventions have been designed and implemented by community-based participatory research (CBPR) approaches, embedding services within communities with active involvement of community mem- bers, and/or codesigning interventions with the community. This section is devoted to highlighting a few examples of promising community-based 

COMMUNITY-CENTERED AND COMMUNITY-ENGAGED CARE 219 and -partnered interventions. It also reviews examples of successful part- nerships built to serve Indigenous communities. Community-Based Participatory Research (CBPR) CBPR is generally defined as an approach in which members of the com- munity targeted in the research project are involved in the process at every step, from conceptualization to dissemination, and share ­decision-making power and ownership with the research team (Baffour and C ­ honody, 2009; Brewer et al., 2021; Jacquez et al., 2019; Panapasa et al., 2012; Rapkin et al., 2017). CBPR has fundamental tenets of co-learning, mutual benefit, and commitment (Wallerstein and Duran, 2006) and recognizes that com- munities have unique knowledge and expertise that can improve health and health care outcomes (Baffour and Chonody, 2009). A recent scoping review identified facilitators of success in CBPR partnerships, which include diverse partners; trust, mutual respect, and transparency between partners; strong and shared leadership; and fair allocation of resources (Brush et al., 2020). Successful use of CBPR interventions to improve health and health care outcomes for minoritized populations has been well-documented for various conditions (Afulani et al., 2021; Geronimus et al., 2020; Stokes and Wilson, 2022; Yonas et al., 2013). CBPR successfully addresses ethical concerns of providing care to historically marginalized populations (Rivers et al., 2019) and other challenges, including recruitment and retention of diverse and representative samples, measurement quality, intervention effec- tiveness, and equity, through meaningful dialogue and culturally grounded approaches (Riffin et al., 2016). Key benefits of CBPR include balancing professional and evidence-based recommendations, addressing specific com- munity needs, and building trust (Wray et al., 2022). A community-based approach can ensure that racially and ethnically minoritized populations are reached and interventions sustained (Nguyen et al., 2021). For example, in HealthLink, a CBPR project for cancer care, researchers worked with community partners to educate them about cancer screening, identify local health care needs and priorities, and implement programs in the community. They later transferred leadership to community members, who implemented programs more independently to ensure long-term sustainability (Rapkin et al., 2017). CBPR approaches can be used in interventions targeting different levels (e.g., individual, clinician, clinic, and community). Box 6-1 provides several examples of CBPR studies that have successfully improved racial and ethnic health care inequities for various conditions, and Chapter 7 includes more discussion about CBPR. 

220 ENDING UNEQUAL TREATMENT BOX 6-1 Examples of Community-Based Participatory Research (CBPR) Studies That Successfully Addressed Racial and Ethnic Health Care Inequities Early Childhood Caries Prevention Study Researchers interviewed local dentists, dental hygienists, public health nurses, mothers/pregnant women, and nonmaternal caregivers to better understand the available resources, barriers, and local values. Community health representatives, community advisory board members, and other community partners, who shared the study’s target popula- tions’ language, ethnicity, and life experiences, served as trusted liaisons for community members and delivered culturally relevant and tailored oral health education in conjunction with Western medical practices, such as fluoride varnish (Camplain et al., 2022). Promoting Informed Prostate Cancer Screening Decision-Making To increase cancer screening decision making among African Ameri- can men, a public health school in St. Louis collaborated with the Empowerment Network to deliver education on prostate cancer in com- munity settings (Wray et al., 2022). Those in the program demonstrated significantly increased knowledge of prostate cancer and screening risks, including those in watchful waiting and active surveillance. Chicas Creando Acceso a la Salud Building dialogue with community partners can be a way to ensure the development of interventions that avoid stigmatizing language, miti- gate structural barriers to care, and consider the intersectional expe- riences of multiple marginalized individuals. Chicas Creando Acceso a la Salud (Girls Creating Access to Health) is a CBPR project with Spanish-speaking interventionists, the majority of whom are transgender or gay, that promotes the uptake of pre-exposure prophylaxis, condoms, and medically supervised hormone therapy for transgender Latinas who speak Spanish (Rhodes et al., 2021). The researchers hypothesized that holding this intervention in safe, convenient locations in the community, particularly in hotel meeting rooms accessible via main highways, would effectively reduce participant distress (Rhodes et al., 2021). As discrimi- nation and stigma often pervade health care systems, community-based settings may provide safer environments for care. TransLife Care TransLife Care is another locally developed community program fol- lowing a patient-centered case management and service delivery model. It facilitates access to housing, employment, and legal and medical services for diverse transgender women to address social and structural 

COMMUNITY-CENTERED AND COMMUNITY-ENGAGED CARE 221 factors contributing to HIV risk. Although the investigators are still evalu- ating the results, this design is a promising method to provide barrier-free services in an affirming environment to decrease distress when access- ing services (Rhodes et al., 2021). Latinos Unidos por la Salud Implementation of a Stress Intervention This study leveraged a long-term, ongoing community–academic research partnership with primarily Spanish-speaking Latino/a immi- grants to design and deliver a stress and coping intervention in Spanish (Jacquez et al., 2019). It significantly improved perceived emotional support, perceived informational support, and stress management. Celebrating Our Magic: Toolkit In a study exploring barriers to care for American Indian and Alaska Native transgender and Two-Spirit youth, CBPR frameworks helped support decolonization and knowledge-sharing. The investigators helped develop a project-specific framework to examine systemic oppression and promote strengths and resilience (Angelino et al., 2020). Healing of the Canoe This project collaborated to develop Holding Up Our Youth, a cultur- ally grounded, 11–session curriculum for substance abuse prevention that centers on tribal traditions and cultural values. The findings showed increased hope/optimism/self-efficacy and decreased substance abuse from baseline to post-intervention and 4-month follow-up among youth receiving the intervention (Donovan et al., 2015). Using Technology to Connect and Share Data Sharing data and information technology systems, traditionally held by health care systems, with communities using CBPR approaches also shows great promise. For example, a CBPR project engaged community groups in using a clinical data database to identify social, economic, and environmental health determinants. This project demonstrated that com- munity groups could use clinical data and data infrastructure to identify better-needed action areas (Salemi et al., 2015). Multilevel Community–Clinical Linkage Intervention Another project used a multilevel community-clinical linkage inter- vention to address diabetes in South Asian Americans, including using electronic health records and health information technology to connect them with community resources (Lim et al., 2021). This proved to be an innovative way to incorporate community health workers and health care technology strategies to enhance community empowerment and capacity to address the social needs of minoritized populations. 

222 ENDING UNEQUAL TREATMENT However, moving successful CBPR models from research into practice is a major challenge. Logistical barriers, such as staff turnover, timespan, and loss of funding, can limit the sustainability and long-term implemen- tation of CBPR interventions (Herbert-Maul et al., 2020). Additionally, Andrews et al. (2016) described difficulties maintaining community engage- ment and participation when scaling from a pilot study to a randomized controlled trial. Integrating Health and Social Care As discussed in Chapter 2, health and health care outcomes are driven by multiple factors beyond the health care system. As discussed in Chapter 5, community-based care models are effective to achieve health care equity and optimal health for all. Patients experiencing negative health impacts from harmful social determinants of health (SDOH) are more likely to enter the health care system with health-related social needs (HRSNs). HRSNs are distinct from SDOH. Harmful SDOH represent the root causes of health inequities affecting entire population segments or communities, while HRSNs are adverse individual conditions that influence individual health outcomes (Green and Zook, 2019). The next section discusses promising interventions in engaging communities to address adverse SDOH and HRSNs. Engaging Communities to Address Adverse Social Determinants of Health (SDOH) Promising mitigation strategies to address adverse SDOH involve engaging communities and leveraging neighborhood-level social factors to improve individual and community health (NASEM, 2017). For example, neighborhoods with high levels of collective efficacy have greater connect- edness and interpersonal trust, which allows residents to advocate for them- selves (e.g., form block clubs to monitor community violence) and reinforce health-promoting behaviors, such as walking and exercise (Fitzpatrick and LaGory, 2013). Researchers found that higher levels of social cohesion in low-income neighborhoods was associated with a lower incidence of dia- betes (Christine et al., 2015). Interventions addressing adverse SDOH and structural determinants of health in community settings have shown promise (Brewer et al., 2021; Camplain et al., 2022; Rhodes et al., 2021; Wu et al., 2022). For example, in a review of 14 interventions to reduce obesity among populations with low socioeconomic status (SES) populations, community-based programs and interventions that addressed social and structural changes in the envi- ronment were effective, whereas those exclusively targeting individual behavioral change were not (Beauchamp et al., 2014). This highlights the 

COMMUNITY-CENTERED AND COMMUNITY-ENGAGED CARE 223 importance of the larger environmental context in moderating the outcomes of individual behaviors. One intervention in Florida provided nutritious meals, started fruit and vegetable gardens, increased opportunities for phys- ical activity (i.e., daily desk-side activity program and structured activities during recess), and implemented an educational curriculum about healthy lifestyles (Hollar et al., 2010). Significant reductions in BMI were reported compared to control groups. Another multilevel, multicomponent intervention, “Live Well, Viva Bien,” provided access to discount and mobile fresh fruit and vegetable markets and nutrition education for low-income and marginalized popula- tions, which improved consumption of fruits and vegetables for low-income adults (Gans et al., 2018). Eight subsidized housing complexes in Provi- dence County, Rhode Island, participated. The intervention included cook- ing demonstrations, access to regular fruit and vegetable markets located at local housing complexes, and prices below local supermarket prices. It also provided informational packets in English or Spanish and nutrition educa- tional campaigns. Seven subsidized housing complex counterparts received a comparison intervention, which included nonnutritional educational cam- paigns on physical activity and stress reduction and a free 6-week YMCA membership. Participants in the intervention increased their daily fruit and vegetable intake by 0.44 cups from baseline to 1 year; in contrast, the con- trol group decreased it by 0.08 cups, particularly at sites that involved older participants (Gans et al., 2018). This multilevel intervention demonstrates a community- and neighborhood-level approach for increasing access to food and reducing food insecurity in conjunction with individual-level educa- tion interventions for hard-to-reach populations, including those with low employment security and minoritized older populations. Approaches used to engage community members can foster the par- ticipation of minoritized populations in identifying resources available to address SDOH, such as food insecurity. One group investigating nutri- tional resources accessible to African American community members in Los Angeles, for example, conducted surveys of market inventories and store conditions and found that the targeted areas were significantly less likely to carry healthy and quality food items (Sloane et al., 2003). The investigators held meetings in the community to discuss their plans to provide education on available nutritional resources, initiate discussions with small local market owners to offer healthier options and convince large chain stores to expand more equitable services into the target areas of the city. In addition, the researchers created an “economic parity” advisory group with community members to develop and execute a mini- grant process. Local organizations were invited to submit applications for funding to supply their local markets’ inventory with healthier options to fill nutritional gaps. 

224 ENDING UNEQUAL TREATMENT Another study improved access to healthy foods for African American communities in Atlanta, Georgia (Rollins et al., 2021). The REACH-HI Healthy Corner Store Initiative created community–research partnerships to develop interventions and policies that work in the community, dis- cuss challenges and opportunities, hire community members as CHWs to ensure cultural and community relevance, and engage community leaders in developing a strategy. The project team developed an intervention based on residents’ needs tailored to their environment. Engaging Communities to Address Health Related Social Needs (HRSNs) Some interventions to address HRSNs in health care systems have been formally evaluated. For example, researchers evaluated CommunityRx, a personalized list of community resources generated from the emergency medi- cal record and tailored to the diagnosed medical problems at the clinic visit, in a pragmatic trial of publicly insured adults aged 45–74 years in Chicago (Lindau et al., 2019). The intervention group reported increased confidence in finding community resources to manage health compared to the control group but no difference in mental or physical health-related quality of life. CommunityRx has been incorporated into interventions for several chronic conditions, including diabetes and dementia (Lindau et al., 2019). Berkowitz and colleagues (2017) evaluated Health Leads. This pro- gram screens patients in primary care clinics for HRSNs and refers those who need it to an advocate to address the need(s). The program showed improvements in cardiometabolic risk factors, as measured by blood pres- sure and lipids. Participants also experienced greater blood pressure control compared to those who did not have HRSNs and therefore did not receive support services. Patients requiring medication to lower their low-density lipoproteins also had larger improvements over those who screened nega- tive and did not receive the support services. In the Individualized Management for Patient-Centered Targets study, Kangovi and colleagues (2018) implemented an RCT comparing a CWH-led social needs intervention to a goal-setting control among patients with mul- tiple chronic conditions, with no or public health insurance, and residing in zip codes with elevated poverty rates in Philadelphia, PA. The intervention consisted of 6 months of CHW-led coaching, social support, advocacy, and navigation to supportive services and identification and activation of other supports (e.g., neighbors, family, church, or a weekly CHW-facilitated sup- port group). The CHWs did not provide clinical services or patient educa- tion on clinical issues. After 6 and 9 months of follow-up, patients in the intervention group had better experiences of high-quality care, fewer days 

COMMUNITY-CENTERED AND COMMUNITY-ENGAGED CARE 225 spent in the hospital, and lower odds of repeat hospitalization, compared to patients in the control group (Kangovi et al., 2018). A 2023 review of 152 studies on social care interventions with multira- cial and multiethnic populations found that only 44 included race or ethnic- ity in the analyses, and only 21 looked for heterogeneous treatment effects among racially and ethnically minoritized populations, which may have differential effectiveness because of structural inequities (e.g., residential segregation) or provider bias. None of the studies were powered to detect racial differences among subgroups, but seven reported such outcomes: four found improved or reduced inequities for racially minoritized groups, and three had mixed results (Cené, 2023). Federal funding has also been leveraged to increase social care in health care services by creating programs involving social services. The Ryan White HIV/AIDS Program, administered by HRSA, provides funding to health care facilities to provide comprehensive support services, including case management and addressing nonmedical social needs, alongside HIV treatment. Weiser and colleagues (2015) compared operational processes and health outcomes for program-funded versus non-program-funded facil- ities. The former were significantly more likely to be CHCs, state or local health departments, and community-based organizations and serve patients who were younger, female, Black or Hispanic, or non-U.S.-born, had less than a high school education, had an income at or below the federal poverty level (FPL), and were uninsured and previously homeless or incarcerated. Patients at program-funded facilities were more likely to receive all pro- vided services (e.g., mental health and substance use care, social services, prevention care) except for dental care. The authors also found that Black and other racially and ethnically minoritized patients were less likely to be prescribed antiretroviral therapy and achieve viral suppression com- pared to White patients. No significant difference occurred in receipt of an anti­retroviral therapy prescription for those at program-funded v­ ersus non-­program-funded facilities, which did not differ when considering inter- actions with race and ethnicity. Among individuals with income at or below the FPL, however, those at program-funded facilities were more likely to reach viral suppression (Weiser et al., 2015). Doshi and colleagues (2017) also found that from 2010 to 2014, among individuals receiving services at a Ryan White HIV/AIDS Program site, the viral suppression rate increased from 69.4 to 81.5 percent. Although inequities in viral suppression outcomes between Black/African American clients and White clients narrowed, they were not eliminated. These studies demonstrate the potential for federally funded programs providing compre- hensive health care and a social services safety net to fill gaps in the care for complex health conditions (Doshi et al., 2017). 

226 ENDING UNEQUAL TREATMENT These examples highlight community-based care that has resulted in demonstrable positive outcomes within the context of rigorous evaluation. The literature clearly supports community-based approaches as efficacious and highlights their importance to health care delivery and equitable care, yet this has not been fully leveraged as part of a national response to eliminate health inequities and remains a critical promising opportunity to advance health equity (Guilamo-Ramos et al., 2023). Interventions Partnering Communities with Traditional Health Care Services These interventions are successful because they use culturally sensitive approaches that address the unique sociocultural factors (e.g., language, acculturation stress, social position) impacting health and health care out- comes (Kabani et al., 2020; Nguyen et al., 2023; Park and Park, 2020). Evi- dence has shown that community-based and culturally relevant interventions promoting cultural identity and connection are most effective (Donovan et al., 2015; Angelino et al., 2020). One common characteristic of many com- munity-based interventions is involving and/or integrating community mem- bers into traditional health care settings, although some send clinicians out into the community. As described in Chapter 5, community-oriented primary care (COPC) is an effective model that focuses care on the individual patient and the community and effectively integrates care within the community and tailors the care to understand and address patient and community needs. Integrating Community Members and Community Health Representatives into Health Care Settings Community members can be integrated into health care settings to bridge the gap between the health care system and the community. Box 6-2 summarizes several ways community members can be included to improve health and health care. Challenges to Moving Care into the Community Several key challenges exist to moving care into the community, orient- ing care to meet community needs, and implementing community-based interventions. The first involves determining who represents the “commu- nity.” Power dynamics may mean that leaders, such as church or commu- nity group leaders, may have more resources to engage, but they may not represent the diversity of the community and/or be most in tune with the specific health needs of its members (Lian et al., 2016). Second, community participation in designing new care models and in participating in research are essential issue (Lian et al., 2016). Failure to enroll and retain interested 

COMMUNITY-CENTERED AND COMMUNITY-ENGAGED CARE 227 BOX 6-2 Integrating Community Members into Health Care Settings Patient navigation: Patient navigation is a common approach involving community mem- bers who help patients access diagnosis and treatment, overcome barriers that disproportionately disadvantage racially and ethnically mi- noritized patients, and move across the cancer care continuum through advocacy, care coordination, trust, and empowerment. It has positively affected areas such as breast cancer disparities (McNeill et al., 2020) and colorectal cancer screening (Lasser et al., 2011). A systematic review of navigator interventions targeting minoritized populations, in- cluding racially and ethnically minoritized, rural, urban low-income, and mixed-ethnic groups, found that they were correlated with positive health outcomes and effectively increased cancer screening knowledge and behaviors in low-income and racially and ethnically minoritized popula- tions (Hou and Roberson, 2015). Lay health educators: A lay health educator intervention, in which native Hmong-speaking and bilingual lay health educators delivered colorectal cancer prevention information to Hmong Americans, was shown to improve cancer screen- ing outcomes among a minoritized population (Jo et al., 2017). This study also found that knowledge was a mediator of the intervention’s effects (Jo et al., 2017), suggesting the potential of lay health education interventions that are culturally and linguistically appropriate to improve cancer screening outcomes for Asian Americans. Community health workers (CHWs) and promotores: CHWs are well positioned to deliver culturally and linguistically tai- lored health education. For example, a CHW-led intervention for control- ling high blood pressure among Korean American older people consisted of weekly group educational sessions delivered by bilingual registered nurses and nutritionists, which included a health literacy component (Kim et al., 2014). At the 12- and 18-month follow-ups, participants in the intervention group had reduced delays in medical treatment and higher adherence to high blood pressure medication. The intervention group experienced significantly steeper decreases in blood pressure at 6 months, and although it increased again at 18 months, it was still lower than the control group’s blood pressure. The Positive Minds—Strong Bodies intervention has two components: Positive Minds is a linguisti- cally and culturally adapted psychosocial intervention delivered by CHWs Continued 

228 ENDING UNEQUAL TREATMENT BOX 6-2 Continued that includes psychoeducation and training in mindfulness and cognitive restructuring, and Strong Bodies is an exercise training program deliv- ered by paraprofessionals to improve physical functioning (Alegría et al., 2019). In a randomized clinical trial evaluating the intervention in racially, ethnically, and linguistically diverse and mostly immigrant older adults, re- searchers found that it improved physical functioning, prevented physical disability, and reduced psychological distress (Alegría et al., 2019). CHW models have been used outside of the United States, and large-scale studies in international settings have demonstrated their effectiveness in improving child health (Alderman et al., 2009), mental health (Fuhr et al., 2019; Rahman et al., 2008), and care-seeking (Acharya et al., 2015). Peer Support The Veterans Health Administration has implemented a peer support intervention, PARTNER-MH, to improve engagement in mental health care among racially and ethnically minoritized veterans (Eliacin et al., 2023). It employs veterans with lived experiences navigating mental health services in a peer support care model to provide patient naviga- tion support and help address and overcome barriers to mental health care. In a sample with mostly Black participants, PARTNER-MH was shown to improve mental health and depression symptoms (Eliacin et al., 2023). Especially when peers are racially or ethnically concordant with the patients they serve, peer support interventions can help specifically target the contextual and cultural barriers to care and increase health literacy and health care use (Hu et al., 2020; Lee et al., 2018). participants has also been seen as a limitation to the generalizability or success of promising interventions. Third, is an essential consideration for scalability and replicability of novel models of care and/or other commu- nity-based interventions because of the differences between participating communities (Chen et al., 2020). A systematic review of community-based health promotion and prevention programs found that large-scale programs did not result in population-wide changes in health outcomes (Nickel and von dem Knesebeck, 2020). The efficacy and potential of an intervention depend on tailoring it to the community’s needs, yet this might create challenges regarding replicability or generalizability. Fourth, resource and logistical constraints are key challenges. Despite being well positioned to reach minoritized populations, community-based organizations often juggle competing needs and dedicate most of their time to their main work. Resources, time, and personnel constraints can pose challenges in CBPR and other health care–related work. 

COMMUNITY-CENTERED AND COMMUNITY-ENGAGED CARE 229 APPROACHES TO ACHIEVE INDIGENOUS HEALTH CARE EQUITY Fundamental to the health and well-being of Indigenous peoples is fully exercising their status as sovereign nations. In the context of health, this is their right to their own practices, traditions, and definitions of health and well-being. Indigenous people experience significant inequities in health and health care outcomes compared to their non-Indigenous counterparts due to many factors, including adverse SDOH, lack of access to health care, lack of culturally centered health care, and lack of data (Jones, 2006). They also experience the continuing effects of colonization, structural racism, and discrimination associated with psychological stress and historical trauma (King et al., 2009). This section presents examples of evidence-based approaches to mitigate health care inequities among U.S. Indigenous populations that illustrate successful community-based interven- tions and partnerships between traditional health care systems and com- munities. It also summarizes a few examples of interventions for Indigenous populations in other high-income countries, including Canada, Australia, and New Zealand. These successful Indigenous models of care demon- strate approaches that can be used more broadly in many Indigenous and non-Indigenous communities to build and maintain relationships between patients, providers, and community members and organizations; center community needs; uplift community voices; and emphasize the central role communities play in achieving health and health care equity. Examples of Models of Care and Approaches to Advance Health Care Equity in Indigenous Populations The Southcentral Foundation Nuka System of Care The Southcentral Foundation in Anchorage created the Nuka model for Alaska Natives living in the southcentral region of Alaska. It has received a great deal of attention for its innovation and success in addressing the numerous health inequities that plague Alaska Natives (Southcentral Foun- dation, 2023). Developing the model was part of the 1998 Indian Self- Determination and Education Assistance Act, which allowed American Indian and Alaska Native (AIAN) tribes to assume control of their own health care rather than rely on the Indian Health Service (IHS).5 The revised model centered Alaska Native people as the “customer-owners” of the health care system, with control over the type of care they wanted, mov- ing away from a bureaucratic system to one focused on overall wellness, 5 See https://www.govinfo.gov/content/pkg/STATUTE-88/pdf/STATUTE-88–Pg2203.pdf#page=4 (accessed April 29, 2024). 

230 ENDING UNEQUAL TREATMENT including physical, mental, emotional, and spiritual wellness. The revised system is based upon the key principle that relationships are central to Alaska Native culture and therefore drive all aspects of the system. Nuka includes primary care, dentistry, outpatient, and residential behavioral health, as well as traditional healing. Health care services are funded based on legislative agreements and funding requirements (Gottlieb, 2013). The Southcentral Foundation operates the Alaska Native Medical Center’s 150-bed hospital, the Anchorage Native Primary Care Center, and the Alaska Native Tribal Health Consortium. Customer-owners are provided a continuum of care between these sites when hospitalization or a high level of care is needed. The foundation clinical teams use state-of- the-art telemedicine and also regularly travel to villages that are accessible only by air or boat, to deliver family medicine, behavioral health, dental, and optometry services. Clinicians establish trusting, accountable and long-term relationships with the customer-owners and, in turn, have an improved understanding of their lived experiences and health care needs. All staff participate in regular ongoing training to support them in understanding how their relational styles impact others and influence customer care. In addition, leaders and owners of the system are from the community and embedded within it so that health care and community are closely woven together. A review of Nuka over 10 years highlighted improvements in various health care indicators, including reducing ED use, hospital days, and staff turnover by 42, 36, and 75 percent, respectively, and increasing childhood vaccinations and patient and client reports of satisfaction in cultural safety by 25 and 94 percent, respectively. Similarly, it has evidence of improved health outcomes (Gottlieb, 2013). The Waianae Coast Comprehensive Health Center (WCCHC) WCCHC is Hawaii’s largest federally qualified health center and a National Health Services Corps site. It is on the rural northwest side of Oahu. Similar to Alaska Natives, Native Hawaiians experience significant and persistent health disparities (Mokuau et al., 2016). WCCHC, a non- profit organization governed by the community, identifies itself as a healing center. It is guided by the belief that the community can thrive physically, spiritually, and economically and enjoy a healthy life, “E ola pono.” This holistic approach is realized through the organization’s commitment to providing accessible, quality, and affordable, comprehensive health care, while preserving Native Hawaiian culture and traditions to achieve com- plete wellness (WCCHC, 2024).WCCHC is a network of six primary care clinics based on an integrative health model, including dental, behavioral health, substance abuse intervention, laboratory, X-ray, pharmacy, and Native Hawaiian healing. It also has three school-based locations. Patients 

COMMUNITY-CENTERED AND COMMUNITY-ENGAGED CARE 231 can choose Western or traditional Hawaiian health care. A council of Native Hawaiian elders who are master practitioners preserve and uphold cultural Hawaiian ways of practice. In addition to providing culturally competent health care, WCCHC has made an institutional commitment to address SDOH, expanding its research infrastructure (Miles et al., 2018), and developing a comprehensive worksite wellness program. It has built a broad network of community partners committed to the common goal of improving residents’ health and wellness and created systems and policy activities to strengthen its and the community’s ability to influence systems changes and policies that reduce health disparities (Okihiro et al., 2014). For example, WCCHC implements the Chronic Care and Obesity Care Models to improve health and health care outcomes by linking primary care best practices and community-based programs (Okihiro et al., 2013). This initiative integrated pediatric services, including nutrition counseling and behavioral health, providing dieticians and psychologists to WCCHC families and resulting in BMI being assessed at 100 percent of child well visits with routine counseling on appropriate growth, BMI, nutrition, and physical activity (Okihiro et al., 2013). In addition, families are supported with the Keiki (child) produce prescription program (KPRx) which provides them with vouchers to purchase fresh fruits and vegetables and directly addresses barriers to healthy foods access (Esquivel et al., 2022). Ke Ku ‘una Na ‘au (KKN) KKN is a Native Hawaiian behavioral health initiative at Queen’s Medical Center (Kim et al., 2019). The program was developed and imple- mented in 2016 to reduce hospital readmissions for socially and economi- cally vulnerable Native Hawaiian adults and improve their health and health care outcomes after hospitalization using Native Hawaiian CHWs, called “navigators,” supported by an advanced practice registered nurse and a social worker. The name translates to “to put one’s mind and heart at ease or to let down gently,” emphasizing the importance of traditional concepts of caregiving and building relationships of trust. Central to the program was developing a bridge to transition patients from the hospital to follow-up medical care. In 2015, Native Hawaiians represented 21 percent of readmissions, with common readmission diagnoses being strongly influ- enced by SDOH (Kim et al., 2019). The navigators’ approach was rooted in traditional Hawaiian values for developing trusting and nonjudgmental relationships. Navigators focused on the importance of overall healing with the patient and connection within the community upon discharge. Naviga- tors met patients during their hospital visit and then remained connected with them for at least 30 days post discharge (Kim et al., 2019). They helped to get follow-up appointments set up, provided health education 

232 ENDING UNEQUAL TREATMENT and medication use support, coordinated transportation and links to other community resources and support services, and aided in access to and coor- dination of insurance. They also prepared for the handover of the patient to community health clinics with a major goal that they would connect or establish a relationship with a primary care provider (PCP). An evaluation of the program found that the baseline readmission rate on two medical units fell from 16.6 percent (of 440 Native Hawaiian patients) in 2015 to 12.6 percent in 2017 (of 445 Native Hawaiian patients, including KKN patients). This decrease suggests that the KKN program has been successful in reducing readmissions for vulnerable patients and, thus, improving care for Native Hawaiians in the health care system generally (Kim et al., 2019). The Choctaw Nation Healthcare System (CHNS) The Choctaw Nation of Oklahoma is the third largest Tribal Nation and owns and operates CNHS, created to provide health care services specifically for Choctaw people and other AIAN people living on or near the Choctaw Nation reservation.6 It includes a hospital and eight outlying clinics that provide quality-focused and holistic services with an emphasis on dignity, cultural values, and SDOH. The Choctaw Nation took over administration of what was originally an IHS hospital and three medical clinics in 1985. This marked the first time in history that a tribe had fully contracted all the health care services and facilities within its service area. It became the first tribe to fund its own hospital, which opened in 1999. CNHS focuses on addressing health-related social needs (HRSNs) in several ways. The tribe provides one-on-one help to members to enroll in all available insurance and federal programs for which they qualify. Families who meet income qualifications are enrolled in food aid programs, such as the Child and Adult Care Food Program, Food Distribution Program on Indian Reservations, and Women, Infants, and Children. CNHS coordinates closely with the tribal affordable housing program for members and elders who meet income limits. Employment is addressed by the Choctaw Nation career devel- opment program that provides financial assistance for training along with a comprehensive array of career guidance services, workforce skills develop- ment, and academic skills enhancement. CNHS patients who report needing employment and training support are connected to this program. Given the high rates of mental health diagnoses, including substance use disorders (SUDs), within the AIAN population, CNHS has several programs for adults and youth focused on these issues. The Celebrating Families pro- gram7 provides access to an array of resources for families struggling with 6 See https://www.choctawnation.com/about/health/ (accessed April 29, 2024). 7 See https://nacoa.org/celebrating-families-main/ (accessed April 29, 2024). 

COMMUNITY-CENTERED AND COMMUNITY-ENGAGED CARE 233 addiction and targets different age groups in individual classes. Families learn skills such as anger management, communication, expressing feelings, problem solving, decision making, and meditation/centering/relaxing. The Chahta Himmitoa Aiahli Tohnochi program seeks to treat SUDs and other mental health conditions by providing behavioral health counseling using techniques that are trauma informed and age appropriate.8 The program strives to improve outcomes for AIAN youth aged 14–24 in specific reserva- tion public schools by increasing student engagement in school, encourag- ing cultural and self-identity exploration, and boosting self-confidence and leadership abilities. In addition, the program improves job and postsecond- ary school readiness, offering support through after-school tutoring, coun- seling and mentors per a leadership training internship camp each summer. The tribe has also invested heavily in restoring cultural and traditional knowledge and practices, an approach shown to improve health among AIAN people (Shea et al., 2019). The Growing Hope program9 supports tra- ditional foods and knowledge through community and household gardens (Thompson et al., 2023). The Chahta Anumpa Aiikhvna, School of Choctaw Language, promotes and supports the preservation of the language, provid- ing both Internet and in-person classes.10 The Cultural Outreach division provides cultural demonstrations on a broad range of Choctaw history and traditional lifeways. Approaches to Addressing Health Care Inequities in Indigenous Populations in Other Countries An estimated 476 million Indigenous people live in other high-income countries. Indigenous peoples are commonly defined as the descendants of those who inhabited a geographical region when people of different cultures or ethnic origins arrived. They include those of the Americas (for example, the Choctaw in the United States and the Maya in Guatemala), the Inuit and Aleutians of the circumpolar region, and the Māori of New Zealand. Due to the diversity of Indigenous peoples, an official definition has not been established, but the United Nations recognizes Indigenous peoples as those population groups who maintain several characteristics, including historical continuity with precolonial and/or presettler societies.11 Box 6-3 summarizes interventions used to advance health care equity for Indigenous populations in high-income countries with economy structures similar to those in the United States. 8 See https://www.choctawnation.com/services/chat/ (accessed April 29, 2024). 9 See https://www.choctawnation.com/services/growing-hope/ (accessed April 29, 2024). 10 See https://www.choctawnation.com/services/language/ (accessed April 29, 2024). 11 See https://www.un.org/esa/socdev/unpfii/documents/5session_factsheet1.pdf (accessed April 29, 2024). 

234 ENDING UNEQUAL TREATMENT BOX 6-3 Selected International Approaches to Achieve Indigenous Health Care Equity Turtle Lodge and Giigewigamig Traditional Healing Center, Sagkeeng First Nation, Manitoba The Giigewigamig12 Traditional Healing Center, in Pine Falls, Manitoba, is a designed to provide culturally appropriate health care services to families in four First Nation communities and the surrounding Métis com- munities: Sagkeeng, Black River, Hollow Water, and Bloodvein. It is con- nected to the Pine Falls Health Complex, run by the Interlake-Eastern Regional Health Authority (RHA) and supporting the RHA and the First Nations groups in working together using a collaborative care model. The partners share facilities and integrate Western and Indigenous programs. However, the center is autonomous from the RHA. The center focuses on healing the whole person, including emotional, spiritual, and physical health, and SDOH within the broader community. It provides traditional Indigenous healing practices, including indoor and outdoor spaces for ceremonies, teachings, sacred fires, and smudging. It has a kitchen facil- ity to prepare traditional foods and medicines and areas for Indigenous approaches to palliative care. The traditional healing practices are con- ducted and overseen by elders from the communities. Although formal evaluations have not been conducted to assess changes in Indigenous health outcomes, early evidence from patient and family interviews shows improved access to culturally safe care and holistic health outcomes (Allen et al., 2020). Supporting Indigenous Community Self-Determination and Sovereignty in Health Research In 2018, the Canadian Institute of Health Research announced the relaunching of the Network Environments for Indigenous Health Re- search (NEIHR) Program to provide supportive research environments for Indigenous health research driven by and grounded in Indigenous communities in Canada.13 The British Columbia Network Environment for Indigenous Health Research (BC NEIHR) is one of nine Indigenous- led networks across Canada that supports research leadership among Indigenous communities, collectives, and organizations (ICCOs). Its goal is to contribute to the improved health, well-being, and strength of Indig- enous peoples by creating strong and respectful research relationships 12 Giigewigamig means “place of healing” in the Anishinaabe language. 13 See https://cihr-irsc.gc.ca/e/51262.html (accessed April 29, 2024). 

COMMUNITY-CENTERED AND COMMUNITY-ENGAGED CARE 235 BOX 6-3 Continued and supporting transformative research (Erb and Stelkia, 2023). It is led by a governing council comprising elders/knowledge holders, community members, and students, ensuring that it is led by Indigenous values and practices. Indigenous health research leaders are represented at the national NEIHR table and can influence Indigenous health research policies and programs (Erb and Stelkia, 2023). The BC NEIHR has de- veloped a set of three best practices to support transformative research: (1) create capacity-bridging initiatives to overcome funding barriers, (2) build relational research relationships with ICCOs: “people on the ground,” and (3) establish a network of partnerships and collaborations to support ICCO self-determination (Erb and Stelkia, 2023). Progress has been made in implementing these practices. As of June 2023, BC NEIHR had over 300 registered members, including Indigenous trainees (37.8 percent), allies (22.4 percent), Indigenous academics/profession- als (21.4 percent), and ICCOs (18.4 percent) (Erb and Stelkia, 2023). It supports research development grants and a knowledge-sharing and mobilization grant for ICCOs. The grants assist ICCOs with research development and dissemination efforts, priorities identified by ICCOs. By administering funds to ICCOs directly, BC NEIHR overcomes the insti- tutional eligibility barriers encountered by many ICCOs. Its approaches advance Indigenous governance and self-determination using Indig- enous and decolonial methodologies and Indigenous research ethics. Indigenous methodologies include the unique ways researchers use Indigenous positionality and perspectives (a distinction-based approach) to conduct research with and within ICCOs (Windchief et al., 2018). Australia’s Closing the Gap Initiative to Achieve Indigenous Health Equity The Australian federal government, prompted by the severe health inequities faced by Indigenous communities (Anderson et al., 2016), initiated the National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes, commonly referred to as the “Closing the Gap” policy.14 Initially set to operate from 2009 to 2013, it was extended to 2018, aiming to close the life expectancy and poor health status gap between Indigenous and non-Indigenous Australians. Recogniz- ing that SDOH contribute significantly to these health inequities, it also focused on education and the ability to gain employment. Each year, performance reports have been issued by the federal government to Continued 14 See https://www.closingthegap.gov.au (accessed April 29, 2024). 

236 ENDING UNEQUAL TREATMENT BOX 6-3 Continued document outcomes. Reports from 2010 to 2017, showed that, although some outcomes did improve, others remained stable or even worsened. A primary outcome was to reduce the gap in life expectancy and reduce mortality rates among Indigenous children under 5. The second target also saw success. During the reporting period, child mortality rates between Indigenous and non-Indigenous people narrowed by 31 per- cent (Commonwealth of Australia, 2017). Programs providing training for health care providers on the topics of respect, awareness, sensitivity, and culturally centered and culturally friendly health services supported by lo- cal Indigenous communities have made a significant difference (Deravin et al., 2018). In March 2019, a formal partnership agreement on Closing the Gap was established between federal, state and territory Australian governments and the Coalition of Aboriginal and Torres Strait Islander Peak Organizations, a more than 50 organizations formed to make substantial progress across the target areas and achieve long-term and sustainable success. The new agreement as developed in partnership between the Australian government and the coalition, and the expertise and experience of the coalition and its membership have been central to the commitments. Interventions Designed by and Serving Indigenous Populations Interventions designed to achieve health and health care equity among U.S.-based Indigenous communities have been implemented in a variety of settings that serve a high population of Indigenous people, including through the IHS, Urban Indian Organizations, and IHS and tribally managed service units.15 Regardless of location, all interventions presented are character- ized by their efforts to provide culturally centered health care and health promotion practices that are focused on the whole person and address the broader SDOH affecting Indigenous populations (Marmot et al., 2008). The importance of cultural traditions and practices is highlighted as a central but underexamined component of health and wellness interventions to achieve Indigenous health equity (Blue Bird Jernigan et al., 2015). Indigenous interventions recognize that health comprises the whole person and the whole community and prioritize community needs and 15 See https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/ factsheets/IHSProfile.pdf (accessed April 29, 2024). 

COMMUNITY-CENTERED AND COMMUNITY-ENGAGED CARE 237 community voices, with communities being involved in every aspect of them, facilitating accountability to the people they serve (Blue Bird Jernigan et al., 2015; Chin et al., 2018). Several characteristics distinguish approaches to improve Indigenous health care from Western models, which are char- acterized by office-based PCPs, specialists, and hospitals; they focus on medical diagnoses, disability, and deficits and use standardized assessments and treatments. Indigenous approaches, in contrast, incorporate or are based entirely on, Indigenous concepts of health and well-being. They value building and maintaining patient–provider relationships; center community needs and community voices; address the historical legacy of colonization and marginalization; are community led, facilitating accountability (Chin et al., 2018); and incorporate interventions to address HRSNs. These examples of Indigenous models of care highlight how best to prioritize building and maintaining relationships between patients, provid- ers, and community members and organizations, center community needs, and uplift community voices. Community-led care and partnering with communities involves culturally centered health care and health promotion practices focused on the whole person and addressing the broader SDOH affecting communities. CHAPTER SUMMARY Since Unequal Treatment, recognition has been growing that the com- munity is central to health and health care. Community-led, -partnered, and -centered health care is essential to mitigating and eliminating inequities. Evidence demonstrating that effective community-based and -engaged inter- ventions improve minoritized populations’ health and health care outcomes has grown substantially. As described in this chapter, community decision making is essential to bringing community engagement, voices, and leader- ship to planning and implementing health care services. Simply including community members in discussions, however, is sometimes not enough to create meaningful and long-lasting connections and partnerships, espe- cially considering the long history and pattern of exploitation in racially and ethnically minoritized communities. Common features of successful community-based, community-partnered models of care and other novel interventions include involving members in developing interventions, as coresearchers, CHWs, PNs, or advisory board members. Through shared lived experiences, cultures, and backgrounds of specific populations being targeted by interventions, community members are well positioned to build lasting and effective relationships with participants and patients that help with participation and retention in interventions and combating social isolation. 

238 ENDING UNEQUAL TREATMENT Based on the materials provided in this chapter, the following conclu- sions are offered: Conclusion 6.1. Community-based interventions can improve health and health care inequities. Involving community members directly in health care settings and partnering with communities to implement new health care models can lead to a better understanding of the specific needs of the populations being served. Conclusion 6.2. Some community-based models have shown to be effective in reducing racial and ethnic inequities in health care, but they have not been widely implemented in large-scale studies. Further, these models have not been implemented and scaled to serve all populations who need the services. Conclusion 6.3. Interventions targeting health-related social needs along with community-level factors show promise to advance health care equity. Conclusion 6.4. Indigenous models of care are successful examples of prioritizing building and maintaining relationships between patients, providers, and community members and organizations, center community needs, uplift community voices, and emphasize sovereignty, Indigenous governance, and self-determination. REFERENCES Afulani, P. A., M. R. Altman, E. Castillo, N. Bernal, L. Jones, T. L. Camara, Z. Carrasco, S. Williams, M. Sudhinaraset, and M. Kuppermann. 2021. Development of the Person- Centered Prenatal Care Scale for people of color. American Journal of Obstetrics & Gynecology 225(4):427. Alderman, H., B. Ndiaye, S. Linnemayr, A. Ka, C. Rokx, K. Dieng, and M. Mulder-Sibanda. 2009. Effectiveness of a community-based intervention to improve nutrition in young children in Senegal: A difference in difference analysis. Public Health Nutrition 12(5):667-673. Alegría, M., W. Frontera, M. Cruz-Gonzalez, S. L. Markle, C. Trinh-Shevrin, Y. Wang, L. Herrera, R. Z. Ishikawa, E. Velazquez, and L. Fuentes. 2019. Effectiveness of a dis- ability preventive intervention for minority and immigrant elders: The Positive Minds– Strong Bodies randomized clinical trial. The American Journal of Geriatric Psychiatry 27(12):1299-1313. Alegría, M., J. Zhen-Duan, I. S. O’Malley, and K. DiMarzio. 2022. A new agenda for optimiz- ing investments in community mental health and reducing disparities. American Journal of Psychiatry 179(6):402-416. Alegría, M., L. Cohen, Z. Lin, M. Cheng, and S. L. Markle. 2023a. Investing in community organizations that serve marginalized populations. Oxford Research Encyclopedia of Global Public Health. Oxford University Press. Alegría, M., I. S. O’Malley, R. Smith, A. Useche Rosania, A. Boyd, F. Cuervo-Torello, D. R. Williams, and D. Acevedo-Garcia. 2023b. Addressing health inequities for children in immigrant families: Psychologists as leaders and links across systems. American Psy- chologist 78(2):173. 

COMMUNITY-CENTERED AND COMMUNITY-ENGAGED CARE 239 Alegría, M. 2024. The need to bring community, policy makers and researchers to the table in prevention programs. World Psychiatry 23(1):94-95. Allen, L., A. Hatala, S. Ijaz, E. D. Courchene, and E. B. Bushie. 2020. Indigenous-led health care partnerships in Canada. Canadian Medical Association Journal 192(9):E208-E216. Anderson, I., B. Robson, M. Connolly, F. Al-Yaman, E. Bjertness, A. King, M. Tynan, R. Madden, A. Bang, and C. E. Coimbra. 2016. Indigenous and Tribal peoples’ health (the Lancet–Low- itja Institute global collaboration): A population study. The Lancet 388(10040):131-157. Andrews, J. O., M. Mueller, M. Dooley, S. D. Newman, G. S. Magwood, and M. S. Tingen. 2016. Effect of a smoking cessation intervention for women in subsidized neighborhoods: A randomized controlled trial. Preventive Medicine 90:170-176. Angelino, A., T. Evans-Campbell, and B. Duran. 2020. Assessing health provider perspectives regarding barriers American Indian/Alaska Native transgender and two-spirit youth face accessing healthcare. Journal of Racial and Ethnic Health Disparities 7:630-642. Acharya, A., T. Lalwani, R. Dutta, J. K. Rajaratnam, J. Ruducha, L. C. Varkey, S. Wunnava, L. Menezes, C. Taylor, and J. Bernson. 2015. Evaluating a large-scale community-based intervention to improve pregnancy and newborn health among the rural poor in India. American Journal of Public Health 105(1):144-152. Baffour, T. D., and J. M. Chonody. 2009. African-American women’s conceptualizations of health disparities: A community-based participatory research approach. American Jour- nal of Community Psychology 44(3–4):374-381. Baker, S. L., K. Z. Black, C. E. Dixon, C. M. Yongue, H. N. Mason, P. McCarter, M. Manning, J. Hessmiller, I. Griesemer, A. Garikipati, E. Eng, D. K. Bullock, C. Bosire, K. M. Alexander, and A. F. Lightfoot. 2021. Expanding the reach of an evidence-based, system-level, racial equity intervention: Translating ACCURE to the maternal healthcare and education sys- tems. Frontiers in Public Health 9:664709. Baskin, C., G. Zijlstra, M. McGrath, C. Lee, F. H. Duncan, E. J. Oliver, D. Osborn, J. Dykxhoorn, E. F. S. Kaner, L. Lafortune, K. R. Walters, J. Kirkbride, and S. Gnani. 2021. Community- centred interventions for improving public mental health among adults from ethnic minor- ity populations in the U.K.: A scoping review. BMJ Open 11(4). Beauchamp, A., K. Backholer, D. Magliano, and A. Peeters. 2014. The effect of obesity pre- vention interventions according to socioeconomic position: A systematic review. Obesity Reviews 15(7):541-554. Berkowitz, S. A., A. C. Hulberg, S. Standish, G. Reznor, and S. J. Atlas. 2017. Addressing unmet basic resource needs as part of chronic cardiometabolic disease management. Journal of the American Medical Association Internal Medicine 177(2):244-252. Blue Bird Jernigan, V., M. Peercy, D. Branam, B. Saunkeah, D. Wharton, M. Winkleby, J. Lowe, A. L. Salvatore, D. Dickerson, A. Belcourt, E. D’Amico, C. A. Patten, M. Parker, B. Duran, R. Harris, and D. Buchwald. 2015. Beyond health equity: Achieving wellness within American Indian and Alaska Native communities. American Journal of Public Health 105(S3), S376-S379. Brewer, L. C., C. Woods, A. Patel, J. Weis, C. Jones, A. Abbenyi, T. A. Brockman, I. G. Sia, E. Berbari, S. Crane, and C. A. Doubeni. 2021. Establishing a SARS-CoV-2 (COVID-19) drive-through collection site: A community-based participatory research partnership with a Federally Qualified Health Center. American Journal of Public Health 111(4):658–662. Brown, L., U. L. França, and M. L. McManus. 2023. Neighborhood poverty and distance to pediatric hospital care. Academic Pediatrics 23(6):1276–1281. Brush, B. L., G. Mentz, M. Jensen, B. Jacobs, K. M. Saylor, Z. Rowe, B. A. Israel, and L. Lachance. 2020. Success in long-standing community-based participatory research (CBPR) partnerships: A scoping literature review. Health Education and Behavior 47(4):556-568. 

240 ENDING UNEQUAL TREATMENT Cacari-Stone, L., N. Wallerstein, A. P. Garcia, and M. Minkler. 2014. The promise of com- munity-based participatory research for health equity: A conceptual model for bridging evidence with policy. American Journal of Public Health 104(9):1615-1623. Camplain, C., C. Kirby, S. D. Barger, H. Thomas, M. Tutt, K. Elwell, S. Young, G. Morrison, S. Hyeoma, and J. A. Baldwin. 2022. Community based participatory research ap- proaches to combat oral health inequities among American Indian and Alaska Native populations. Journal of Public Health Dentistry 82(Suppl 1):79-82. Cené,, C. W., M. Viswanathan, C. Fichtenberg, N. Sathe, S. E. Kennedy, L. M. Gotlieb, Y. Cartier, and M. E. Peek. 2023. Racial health equity and social needs interventions: Rapid review. Washington, DC: Patient-Centered Outcomes Research Institute. Chang, H.-Y., E. Hatef, X. Ma, J. P. Weiner, and H. Kharrazi. 2021. Impact of area deprivation index on the performance of claims-based risk-adjustment models in predicting health care costs and utilization. Population Health Management 24(3):403-411. Chen, E., C. Leos, S. D. Kowitt, and K. E. Moracco. 2020. Enhancing community-based par- ticipatory research through human-centered design strategies. Health Promotion Practice 21(1):37-48. Cheng, C., A. Beauchamp, G. R. Elsworth, and R. H. Osborne. 2020. Applying the electronic health literacy lens: Systematic review of electronic health interventions targeted at so- cially disadvantaged groups. Journal of Medical Internet Research 22(8). Chin, M. H., P. T. King, R. G. Jones, B. Jones, S. N. Ameratunga, N. Muramatsu, and S. Derrett. 2018. Lessons for achieving health equity comparing Aotearoa/New Zealand and the United States. Health Policy 122(8):837-853. Christine, P. J., A. H. Auchincloss, A. G. Bertoni, M. R. Carnethon, B. N. Sánchez, K. Moore, S. D. Adar, T. B. Horwich, K. E. Watson, and A. V. D. Roux. 2015. Longitudinal associations between neighborhood physical and social environments and incident Type 2 diabetes mellitus: The multi-ethnic study of atherosclerosis (MESA). JAMA Internal Medicine 175(8):1311-1320. Commonwealth of Australia. 2017. Closing the Gap Prime Minister’s Report 2017. Canberra, ACT: Department of the Prime Minister and Cabinet. Cole, M. 2021. Federally Qualified Health Centers play a critical role in ensuring equitable Covid-19 vaccine access. Health Services Research 56:9-10. Deravin, L., K. Francis, and J. Anderson. 2018. Closing the gap in Indigenous health inequity— is it making a difference? International Nursing Review 65(4):477-483. Donovan, D. M., L. R. Thomas, R. L. Sigo, L. Price, H. Lonczak, N. Lawrence, K. Ahvakana, L. Austin, A. Lawrence, J. Price, A. Purser, and L. Bagley. 2015. Healing of the Canoe: Preliminary results of a culturally tailored intervention to prevent substance abuse and promote Tribal identity for Native youth in two Pacific Northwest Tribes. American Indian Alaska Native Mental Health Research 22(1):42-76. Doshi, R. K., J. Milberg, T. Jumento, T. Matthews, A. Dempsey, and L. W. Cheever. 2017. For many served by the Ryan White HIV/AIDS program, disparities in viral suppression decreased, 2010–14. Health Affairs 36(1):116-123. Dragomir, R. R., and E. Tadros. 2020. Exploring the impacts of racial disparity within the American juvenile justice system. Juvenile and Family Court Journal 71(2):61-73. Edmonds, A., A. Breskin, S. R. Cole, D. Westreich, C. Ramirez, J. Cocohoba, G. Wingood, M. H. Cohen, E. T. Golub, and S. G. Kassaye. 2021. Poverty, deprivation, and mortality risk among women with HIV in the United States. Epidemiology 32(6):877-885. Eliacin, J., D. Burgess, A. L. Rollins, S. Patterson, T. Damush, M. J. Bair, M. P. Salyers, M. Spoont, M. Chinman, J. E. Slaven, and M. S. Matthias. 2023. Outcomes of a peer-led navigation program, PARTNER-MH, for racially minoritized Veterans receiving mental health services: A pilot randomized controlled trial to assess feasibility and acceptability. Translational Behavioral Medicine 13(9):710-721. 

COMMUNITY-CENTERED AND COMMUNITY-ENGAGED CARE 241 Erb, T., and K. Stelkia. 2023. Best practices to support the self-determination of Indigenous communities, collectives, and organizations in health research through a provincial health research network environment in British Columbia, Canada. International Journal of Environmental Research and Public Health 20(15):6523. Esquivel, M., A. Higa, C. Shelton, and M. Okhiro. 2022. P118 leveraging electronic medical records for produce prescription program referral for improved enrollment and participa- tion. Journal of Nutrition Education and Behavior 54(7):S74. Fitzpatrick, K., and M. LaGory. 2013. Unhealthy cities: Poverty, race, and place in America. Oxfordshire, UK: Routledge. Fuhr, D. C., B. Weobong, A. Lazarus, F. Vanobberghen, H. A. Weiss, D. R. Singla, H. Tabana, E. Afonso, A. De Sa, E. D’Souza, A. Joshi, P. Korgaonkar, R. Krishna, L. N. Price, A. Rahman, and V. Patel. 2019. Delivering the thinking healthy programme for perina- tal depression through peers: An individually randomised controlled trial in India. The Lancet Psychiatry 6(2):115-127. Gans, K. M., P. M. Risica, A. D. Keita, L. Dionne, J. Mello, K. C. Stowers, G. Papandonatos, S. Whittaker, and G. Gorham. 2018. Multilevel approaches to increase fruit and vegetable intake in low-income housing communities: Final results of the “Live Well, Viva Bien” cluster-randomized trial. International Journal of Behavioral Nutrition and Physical Activity 15(1). Geronimus, A. T., J. A. Pearson, E. Linnenbringer, A. K. Eisenberg, C. Stokes, L. D. Hughes, and A. J. Schulz. 2020. Weathering in Detroit: Place, race, ethnicity, and poverty as conceptually fluctuating social constructs shaping variation in allostatic load. Milbank Quarterly 98(4):1171-1218. Gottlieb, K. 2013. The Nuka system of care: Improving health through ownership and rela- tionships. International Journal of Circumpolar Health 72(1):21118. Green, K., and M. Zook. 2019. When talking about social determinants, precision matters. Health Affairs Forefront. Guilamo-Ramos, V., M. Thimm-Kaiser, and A. Benzekri. 2023. Community-engaged mpox vac- cination provides lessons for equitable health care in the United States. Nature Medicine 29(9):2160-2161. Herbert-Maul, A., K. Abu-Omar, A. Frahsa, A. Streber, and A. K. Reimers. 2020. Transferring a community-based participatory research project to promote physical activity among socially disadvantaged women—Experiences from 15 years of big. Frontiers in Public Health 8:571413. Hollar, D., S. E. Messiah, G. Lopez-Mitnik, T. L. Hollar, M. Almon, and A. S. Agatston. 2010. Effect of a two-year obesity prevention intervention on percentile changes in body mass index and academic performance in low-income elementary school children. American Journal of Public Health 100(4):646-653. Hou, S. I., and K. Roberson. 2015. A systematic review on U.S.-based community health navigator (CHN) interventions for cancer screening promotion—Comparing com- munity- versus clinic-based navigator models. Journal of Cancer Education 30(1): 173–186. Hu, J., Y. Wu, F. Ji, X. Fang, and F. Chen. 2020. Peer support as an ideal solution for racial/ ethnic disparities in colorectal cancer screening: Evidence from a systematic review and meta-analysis. Diseases of the Colon and Rectum 63(6):850-858. Jacquez, F., L. M. Vaughn, and G. Suarez-Cano. 2019. Implementation of a stress interven- tion with Latino immigrants in a non-traditional migration city. Journal of Immigrant & Minority Health 21(2):372-382. 

242 ENDING UNEQUAL TREATMENT Jamieson, L., L. Smithers, J. Hedges, E. Parker, H. Mills, K. Kapellas, H. P. Lawrence, J. R. Broughton, and X. Ju. 2018. Dental disease outcomes following a 2-year oral health pro- motion program for Australian aboriginal children and their families: A 2-arm parallel, single-blind, randomised controlled trial. eClinicalMedicine 1:43-50. Jo, A. M., T. T. Nguyen, S. Stewart, M. J. Sung, G. Gildengorin, J. Y. Tsoh, E. K. Tong, P. Lo, C. Cuaresma, and A. Sy. 2017. Lay health educators and print materials for the promo- tion of colorectal cancer screening among Korean Americans: A randomized comparative effectiveness study. Cancer 123(14):2705-2715. Jones, D. S. 2006. The persistence of American Indian health disparities. American Journal of Public Health 96(12):2122-2134. Kaba, F., A. Solimo, J. Graves, S. Glowa-Kollisch, A. Vise, R. MacDonald, A. Waters, Z. Rosner, N. Dickey, S. Angell, and H. Venters. 2015. Disparities in mental health referral and diagnosis in the New York City jail mental health service. American Journal of Public Health 105(9):1911-1916. Kabani, F. A., E. L. Stockbridge, B. Berly Varghese, and A. D. Loethen. 2020. Acculturation and the oral health of a nationally representative sample of Hispanic children in the United States: An analysis of 2011–2012 national survey of children’s health data. BMC Public Health 20(1):111. Kangovi, S., N. Mitra, L. Norton, R. Harte, X. Zhao, T. Carter, D. Grande, and J. A. Long. 2018. Effect of community health worker support on clinical outcomes of low-income patients across primary care facilities: A randomized clinical trial. JAMA Internal Medi- cine 178(12):1635-1643. Kim, K. B., H. R. Han, B. Huh, T. Nguyen, H. Lee, and M. T. Kim. 2014. The effect of a community-based self-help multimodal behavioral intervention in Korean American seniors with high blood pressure. American Journal of Hypertension 27(9):1199-1208. Kim, J. K., L. Garrett, R. Latimer, L. K. i. Nishizaki, J. A. Kimura, D. Taira, and T. Sentell. 2019. Ke ku ‘una na ‘au: A Native Hawaiian behavioral health initiative at the Queen’s Medical Center. Hawai’i Journal of Medicine and Public Health 78(6 Suppl 1):83. King, M., A. Smith, and M. Gracey. 2009. Indigenous health part 2: The underlying causes of the health gap. The Lancet 374(9683):76-85. Larrabee Sonderlund, A., M. Charifson, A. Schoenthaler, T. Carson, and N. J. Williams. 2022. Racialized economic segregation and health outcomes: A systematic review of studies that use the index of concentration at the extremes for race, income, and their interaction. PLoS ONE 17(1):e0262962. Lasser, K. E., J. Murillo, S. Lisboa, A. N. Casimir, L. Valley-Shah, K. M. Emmons, R. H. Fletcher, and J. Z. Ayanian. 2011. Colorectal cancer screening among ethnically di- verse, low-income patients: A randomized controlled trial. Archives of Internal Medicine 171(10):906-912. Lee, S., E. Schorr, N. N. Hadidi, R. Kelley, D. Treat-Jacobson, and R. Lindquist. 2018. Power of peer support to change health behavior to reduce risks for heart disease and stroke for African American men in a faith-based community. Journal of Racial and Ethnic Health Disparities 5(5):1107-1116. Lian, B., C. L. Kohler, and L. Ross. 2016. On some practical considerations regarding com- munity-based participatory research for addressing cancer health disparities. Journal of Cancer Education 31(1):207-211. Lim, S., L. C. Wyatt, S. Mammen, J. M. Zanowiak, S. Mohaimin, A. B. Troxel, S. T. Lindau, H. T. Gold, D. Shelley, C. Trinh-Shevrin, and N. S. Islam. 2021. Implementation of a multi-level community–clinical linkage intervention to improve glycemic control among South Asian patients with uncontrolled diabetes: Study protocol of the Dream Initiative. BMC Endocrine Disorders 21. 

COMMUNITY-CENTERED AND COMMUNITY-ENGAGED CARE 243 Lynch, E. E., L. H. Malcoe, S. E. Laurent, J. Richardson, B. C. Mitchell, and H. C. S. Meier. 2021. The legacy of structural racism: Associations between historic redlining, current mortgage lending, and health. SSM—Population Health 14:100793. Marmot, M., S. Friel, R. Bell, T. A. Houweling, and S. Taylor. 2008. Closing the gap in a gen- eration: Health equity through action on the social determinants of health. The Lancet 372(9650):1661-1669. McNeill, L. H., I. H. C. Wu, D. Cho, Q. Lu, K. Escoto, and C. Harris. 2020. Community outreach and engagement strategies to address breast cancer disparities. Current Breast Cancer Reports 12(4):209-215. Miles, S., P. Burgess, R. K. Enos, G. Kalilihiwa, M. F. M. Oneha, C. H. Titcomb, S. S. Morimoto- Ching, and K. Padilla. 2018. Building the beloved community: Reflections in understanding relationships to food for Native Hawaiians. Progress in Community Health Partnerships: Research, Education, and Action 12(4):483-487. Mokuau, N., P. H. DeLeon, J. K. a. Kaholokula, S. Soares, J. U. Tsark, and C. Haia. 2016. Challenges and promise of health equity for Native Hawaiians. NAM Perspectives. Mulholland, H., J. C. McIntyre, A. Haines-Delmont, R. Whittington, T. Comerford, and R. Corcoran. 2021. Investigation to identify individual socioeconomic and health determi- nants of suicidal ideation using responses to a cross-sectional, community-based public health survey. BMJ Open 11(2):e035252. NACHC (National Association of Community Health Centers). 2023. Community health center chartbook. Bethesda, MD: National Association of Community Health Centers. NASEM (National Academies of Sciences, Engineering, and Medicine). 2017. Communities in action: Pathways to health equity. Washington, DC: The National Academies Press. NASEM. 2019. The promise of adolescence: Realizing opportunity for all youth. Washington, DC: The National Academies Press. Nickel, S., and O. von dem Knesebeck. 2020. Effectiveness of community-based health pro- motion interventions in urban areas: A systematic review. Journal of Community Health 45(2):419-434. Nguyen, T. T., N. Wallerstein, R. Das, M. D. Sabado-Liwag, V. B. B. Jernigan, T. Jacob, T. Cannady, L. S. Martinez, U. J. Ndulue, and A. Ortiz. 2021. Conducting community- based participatory research with minority communities to reduce health disparities. In The Science of Health Disparities Research, edited by I. Dankwa-Mullan, E. J. Pérez-Stable, K. L. Gardner, X. Zhang, and A. M. Rosario. Hoboken, NJ: John Wiley & Sons. Pp. 171-186. Nguyen, K. H., A. D. Rubinsky, M. C. DeRouen, K. E. Kemper, K. Bibbins-Domingo, and C. R. Lyles. 2023. Impacts of individual patient language and neighborhood ethnic enclave on COVID-19 test positivity among Hispanic/Latinx patients in San Francisco. Medical Care 61(2):67-74. Okihiro, M., M. Pillen, C. Ancog, C. Inda, and V. Sehgal. 2013. Implementing the obesity care model at a community health center in Hawaii to address childhood obesity. Journal of Health Care for the Poor and Underserved 24(20):1. Okihiro, M., V. Sehgal, T. Wilkinson, K.-A. Voloch, R. Enos, and J. O’Brien. 2014. Addressing health disparities by building organizational capacity in the community: A case study of the Wai ‘Anae Coast Comprehensive Health Center. Hawai’i Journal of Medicine & Public Health 73(12 Suppl 3):34. Ornelas, I. J., T. J. Yamanis, and R. A. Ruiz. 2020. The health of undocumented Latinx immigrants: What we know and future directions. Annual Review of Public Health 41(1):289-308. 

244 ENDING UNEQUAL TREATMENT Panapasa, S., J. Jackson, C. Caldwell, S. Heeringa, J. McNally, D. Williams, D. Coral, L. Taumoepeau, L. Young, S. Young, and S. Fa’asisila. 2012. Community-based participatory research ap- proach to evidence-based research: Lessons from the Pacific Islander American Health Study. Progress in Community Health Partnerships 6(1):53-58. Park, S. Y., and S. Y. Park. 2020. Immigration and language factors related to depressive symp- toms and suicidal ideation in Asian American adolescents and young adults. Community Mental Health Journal 56(1):139-148. Rahman, A., A. Malik, S. Sikander, C. Roberts, and F. Creed. 2008. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: A cluster-randomised controlled trial. The Lancet 372(9642):902-909. Rapkin, B. D., E. Weiss, D. Lounsbury, T. Michel, A. Gordon, J. Erb-Downward, E. Sabino- Laughlin, A. Carpenter, C. E. Schwartz, L. Bulone, and M. Kemeny. 2017. Reducing disparities in cancer screening and prevention through community-based participatory research partnerships with local libraries: A comprehensive dynamic trial. American Journal of Community Psychology 60(1–2):145-159. Rhodes, S. D., L. M. Kuhns, J. Alexander, J. Alonzo, P. A. Bessler, C. Courtenay-Quirk, D. J. Denson, K. Evans, C. A. Galindo, R. Garofalo, D. J. Gelaude, A. L. Hotton, A. K. Johnson, L. Mann-Jackson, A. Muldoon, R. Ortiz, J. L. Paul, J. Perloff, K. Pleasant, B. A. Reboussin, L. R. Aviles, E. Y. Song, A. E. Tanner, and S. Trent. 2021. Evaluating locally developed in- terventions to promote PrEP among racially/ethnically diverse transgender women in the United States: A unique CDC initiative. AIDS Education and Prevention 33(4):345-360. Riffin, C., C. Kenien, A. Ghesquiere, A. Dorime, C. Villanueva, D. Gardner, J. Callahan, E. Capezuti, and M. C. Reid. 2016. Community-based participatory research: Understand- ing a promising approach to addressing knowledge gaps in palliative care. Annals of Palliative Medicine 5(3):218-224. Rivers, B. M., N. D. Hernandez, D. Rivers, D. L. Cooper, S. J. Enis, C. Belizaire, and R. Matthews. 2019. Utilizing community-based participatory research principles in a safety-net hospital to develop a research partnership. Journal of Health Care for the Poor & Underserved 30(4s):27-35. Rollins, L., T. Carey, A. Proeller, M. Anne Adams, M. Hooker, R. Lyn, O. Taylor, K. Holden, and T. Henry Akintobi. 2021. Community-based participatory approach to increase African Americans’ access to healthy foods in Atlanta, GA. Journal of Community Health 46:41-50. Salemi, J. L., A. A. Salinas-Miranda, R. E. Wilson, and H. M. Salihu. 2015. Transforma- tive use of an improved all-payer hospital discharge data infrastructure for commu- nity-based participatory research: A sustainability pathway. Health Services Research 50(S1):1322-1338. Saulsberry, L., A. Bhargava, S. Zeng, J. B. Gibbons, C. Brannan, D. S. Lauderdale, and R. D. Gibbons. 2023. The social vulnerability metric (SVM) as a new tool for public health. Health Services Research 58(4):873-881. Shea, H., G. S. Mosley-Howard, D. Baldwin, G. Ironstrack, K. Rousmaniere, and J. E. Schroer. 2019. Cultural revitalization as a restorative process to combat racial and cultural trauma and promote living well. Cultural Diversity and Ethnic Minority Psychology 25(4):553. Shea, T., Dotson, S., Tyree, G., Ogbu-Nwobodo, L., Beck, S. and Shtasel, D. 2022. Racial and ethnic inequities in inpatient psychiatric civil commitment. Psychiatric Services 73(12):1322–1329. Sloane, D. C., A. L. Diamant, L. B. Lewis, A. K. Yancey, G. Flynn, L. M. Nascimento, W. J. McCarthy, J. J. Guinyard, and M. R. Cousineau. 2003. Improving the nutritional resource environment for healthy living through community-based participatory research. Journal of General Internal Medicine 18(7):568-575. 

COMMUNITY-CENTERED AND COMMUNITY-ENGAGED CARE 245 Southcentral Foundation. 2023. Awards and Recognition. https://www.­southcentralfoundation. com/about-us/awards-recognition/ (accessed April 29, 2024). Stokes, C., and K. J. Wilson. 2022. Community-based participatory research partnership with faith-based organizations to address obesity and glucose control. Public Health Nursing 39(2):398-404. Thomas, T. E., S. D. Lane, R. M. Elkhatib, J. E. Hamiliton, and T. A. Pigott. 2020. Race, history of abuse, and homelessness are associated with forced medication administration during psychiatric inpatient care. Journal of Psychiatric Practice 26(4):294-304. Thompson, I., J. Putman, M. Madbull, M. Sharp, J. Presley, A. Jauregui-Dusseau, K. Clyma, and V. B. B. Jernigan. 2023. The Choctaw nation’s growing hope program. Health Pro- motion Practice 24(6):1080-1082. Wagner, J., S. Henderson, T. J. Hoeft, M. Gosdin, and L. Hinton. 2022. Moving beyond refer- rals to strengthen late-life depression care: A qualitative examination of primary care clinic and community-based organization partnerships. BMC Health Services Research 22(1):605. Wallerstein, N. B., and B. Duran. 2006. Using community-based participatory research to ad- dress health disparities. Health Promotion Practice 7(3):312-323. WCCHC (Waianaw Coast Comprehensive Healtlh Center). 2024. About Us. https://www. wcchc.com/About (accessed April 29, 2024). Weiser, J., L. Beer, E. L. Frazier, R. Patel, A. Dempsey, H. Hauck, and J. Skarbinski. 2015. Service delivery and patient outcomes in Ryan White HIV/AIDS program–funded and –nonfunded health care facilities in the United States. JAMA Internal Medicine 175(10):1650-1659. Windchief, S., C. Polacek, M. Munson, M. Ulrich, and J. D. Cummins. 2018. In reciprocity: Responses to critiques of Indigenous methodologies. Qualitative Inquiry 24(8):532-542. Wolfson, J. A., S. Bhatia, L. Hageman, E. S. Ross, N. Balas, A. Bosworth, H. S. Te, L. Fran- cisco, E. Funk, and J. Hicks. 2023. Neighborhood disadvantage, health status, and health care utilization after blood or marrow transplant: BMTSS report. Blood Advances 7(3):293-301. Wray, A. J. D., and L. M. Minaker. 2019. Is cancer prevention influenced by the built environ- ment? A multidisciplinary scoping review. Cancer 125(19):3299-3311. Wray, R. J., S. E. Nicks, P. Adsul, M. Elliot, K. Enard, K. Jupka, A. K. Trainer, N. Hansen, M. Shahid, R. Wright-Jones, and S. Siddiqui. 2022. Promoting informed prostate cancer screening decision-making for African American men in a community-based setting. Cancer Causes & Control 33(4):503-514. Wu, T. Y., X. Yang, S. Lally, A. J. Rainville, O. Ford, R. Bessire, and J. Donnelly. 2022. Using community engagement and geographic information systems to address COVID-19 vac- cination disparities. Tropical Medicine and Infectious Disease 7(8). Yonas, M. A., R. Aronson, J. Schaal, E. Eng, C. Hardy, and N. Jones. 2013. Critical incident technique: An innovative participatory approach to examine and document racial dis- parities in breast cancer health care services. Health Education Research 28(5):748-759.