Background

Integrative health equity (IHE) is defined as optimal health for all through a whole person approach that explicitly recognizes cultural, social, and structural determinants of health across the life course. Integrative health equity is a unique, innovative approach to addressing unmet health needs. The UCSF Osher Center for Integrative Health (OCIH) has partnered with numerous community organizations on IHE projects, with support from MZHF. Through community-academic partnerships, we developed and tested strategies for integrative health equity by (1) creating interventions that are socio-culturally tailored for historically marginalized populations and (2) increasing access to integrative healthcare (e.g., acupuncture, mindfulness) in safety-net and community-based settings. These projects have demonstrated positive impacts of integrative healthcare for the management of pain, stress, and chronic conditions in marginalized populations. We see these experiences reflected in the work of colleagues around the country who are working towards IHE through clinical practice and innovative research. 

Community engagement is recognized as a critical element for improving health outcomes in historically marginalized populations and reducing healthcare inequalities (O’Mara-Eves et al., 2015). Our prior community partnerships combined IHE and community engagement strategies to address significant public health needs among vulnerable populations in San Francisco (e.g., diabetes self-management in Cantonese-speaking elders; psychosocial needs of low-income individuals with complex chronic conditions; and undertreated chronic pain in diverse safety-net primary care patients). After nearly three years of the COVID-19 pandemic, the needs of these communities have in many cases been intensified by socio-structural factors including racism, social isolation, and delayed medical care. Despite the success of these projects, sustaining integrative healthcare programs beyond grant funding periods has been challenging, limiting the longer-term impacts of our partnerships. Supporting ongoing partnerships by sustaining and expanding them is critical for advancing health equity beyond incremental progress. Centering MZHF values of Innovation (Hidush), Service (Avodah), and Community Building (Kehilah), we will develop a scalable and sustainable infrastructure that fundamentally shifts the way we partner. by moving away from transactional research-driven projects to a relational, mutual process centering community needs.  

List of Goals 

The overarching goal of our current proposal is to build structures and processes to support sustainable community-academic partnerships for integrative health equity. Throughout the project we aim to foster high levels of community engagement by centering the voices of individuals with lived experience, planning in ways that are community driven, and prioritizing the relationships between collaborators. The proposed project will develop long-term work towards integrative health equity at OCIH on the Mt Zion campus in collaborative partnership with community-based organizations to make integrative healthcare a core element of accessible, culturally responsive care. Our proposal draws on principles of community-based participatory research as well as recommendations from the UCSF study of Accelerating Systematic Stakeholder Patient and Institution Research Engagement (ASPIRE). This proposal is part of a broader Osher Center Integrative Health Equity Initiative, aimed at creating sustainable structural change and being a national model. We aim to support existing community-academic partnerships while creating infrastructure that will demonstrate long-term commitment to this approach.

Specific Aims

Towards this goal, the current proposal aims to: 

(1) Build capacity for three community-academic partnerships to advance integrative health equity in San Francisco. We will do this by embedding integrative health services into existing programming at On Lok and the Shanti Project, providing integrative medicine training to biomedical clinicians (e.g., family medicine residents) through San Francisco Health Network, and providing community-engaged learning to integrative health trainees. 

(2) Create mechanisms for ongoing feedback from and accountability to community partners of the Osher Center. We will establish an Osher Center Community Advisory Board (CAB) that includes staff member and patient representatives from four partner organizations. This CAB will meet quarterly with Osher Center leadership to advise on IHE priorities and projects. CAB activities will also include opportunities for co-learning across the projects described in Aim 1 as well as experiential learning about integrative health. 

(3) Identify and disseminate promising practices for community-academic partnerships focused on integrative health equity. We will conduct a needs assessment of integrative health equity partnerships in San Francisco, followed by an in-depth evaluation of the three partnerships described in Aim 1. We will then disseminate learnings to local and national networks of community-based and academic organizations involved with integrative health equity work. 

Approach/Activities for Aim 1: Build capacity for three community partnerships to advance IHE in SF.

We will continue developing three community-academic partnerships that support the physical and mental health of adults with chronic conditions in San Francisco who are low-income, people of color, LGBTQ+, and/or have limited English proficiency (see attached document “Community Partnership Details” which provides descriptions of each project team, community partner, project goals, and timeline). We selected partnerships that have several commonalities: 

• Share a common motivation to increase access to integrative healthcare and advance health equity
• Serve marginalized communities focusing on adults living with chronic conditions that have been exacerbated by the COVID pandemic and resulting social isolation 
• Offer group-based interventions with high potential for sustaining integrative health services in low-resource settings
• Have received past funding from MZHF and would benefit from capacity-building support to sustain their programs

These partnerships are delivered in distinct settings, address multiple components of integrative health equity, involve multiple OCIH employees, and provide community-engaged learning opportunities for trainees in OCIH fellowship programs. We intentionally chose projects with a history of community partnership at different phases of program development. Collaborating with three separate partners serving distinct populations will allow for testingmultiple strategies for capacity-building, meeting the needs of each organization. This will also allow us to refine and institutionalize key factors common across partnerships to better support integrative health equity (IHE). 

IHE strategies employed by the projects in Aim 1 include providing whole person, culturally responsive care to low-income people living with chronic conditions. Each site has IHE champions who have been involved in the development of this proposal. The focus on capacity-building in three organizations (e.g., train the trainer models) will support IHE sustainability beyond the period of the proposed grant, and facilitate longer-term expansion of access to integrative care. 

1a. Integrative Approaches to Healthy Aging with On Lok.  Asian American elders experienced heightened stress, fear, and anxiety amidst increased anti-Asian hate and violence over the past two years. This project will expand the Integrative Nutritional Counseling (INC) program—which combines Chinese medicinal foods principles with biomedical nutrition advice—to include movement/exercise groups such as tai chi and qi gong adaptable for a range of physical abilities and to provide mental health support.  We will partner with On Lok Program of All-Inclusive Care for the Elderly, whose clientele is 72% Asian and 55% Chinese speaking and experiences a high burden of chronic conditions addressed by INC. We will build sustainability by training On Lok staff to deliver the INC nutrition and movement program as part of existing services. This will address gaps identified by our partners at On Lok, who shared the need for culturally responsive movement programs for elderly people with a range of abilities: “One site is not currently offering any tai chi and another only shows YouTube videos. One concern in offering tai chi classes to seniors is that many of them use walkers and canes when standing, thus practicing standing tai chi may not be easy.” 

1b. Sharing Humanity through Arts, Reflection, and Expression (SHARE) with the Shanti Project. Cultivating social connectedness is critical for addressing isolation and loneliness exacerbated by the COVID-19 pandemic. SHARE provides integrative support to multiple Shanti programs, of whose clientele, 60% receive disability for a diagnosis of primary mental illness, and 37% for an unexplained mind-body syndrome. Monthly in-person group meetings will offer experiential integrative health opportunities such as mind-body skills practice, Ayurveda, East Asian Medicine, and biofeedback. SHARE broadens approaches to integrative health communication by including immersive experiences, the arts, and mind-body awareness. Groups will address topics that impact a large number of Shanti clients—HIV, cancer, and aging—as well as personalize the experience for the participants based on their needs. This aligns with feedback we received from Shanti clients, who spoke to how “People want to know who is going to be there, who is going to be leading it, will they be safe” and want “to access acupuncture, massage, biofeedback in a familiar environment.”

1c. Expanding Integrative Pain Management, with the Tom Waddell Urban Health Clinic and San Francisco Health Network (SFHN). Over 20% of adults suffer from chronic pain and rates are higher among low-income individuals. With the ongoing opioid crisis, providing non-medication approaches for pain is an urgent priority. The Integrative Pain Management Program (IPMP) was established to broaden access to group-based integrative care for racially and ethnically diverse patients in a primary care safety net clinic in the Tenderloin, with the vision to expand access to integrative care for all SFHN patients with chronic pain. This project will provide training on integrative health and group facilitation to SFHN clinicians and clinicians in existing UCSF/SFHN training programs (e.g., addiction medicine fellowship, primary care residencies). We will build capacity by training clinicians to expand integrative pain care to racially and linguistically diverse safety-net patients throughout the city. This responds to patient feedback about the need for integrative pain management in primary care: “IPMP reinforced stuff that I knew I should be doing. But of course, I can’t do acupuncture on myself. I can’t do massage on myself. I’m poor – like really poor – and I can’t afford to go and get that stuff done at some slinky spa somewhere. So, it’s great to have access to it in my primary care clinic.”  

Approach/Activities for Aim 2: Create mechanisms for ongoing feedback from and accountability to community partners of the Osher Center.

We will establish a Community Advisory Board (CAB) to provide a forum for co-learning across integrative health equity partnerships (including those described in Aim 1) and to advise on OCIH’s clinical, research, education, and community programs. This group will meet with OCIH leadership every three months, and participants will receive honorariums for their time and expertise. CAB participants will include a staff member and a client/patient from four community-based organizations (3 established and 1 new partnership), and two OCIH patients who received support through our Community Care Fund. We will regularly elicit feedback and assess the impact of the CAB. This will allow us to promptly respond to feedback with the goal of strengthening engagement of CAB members and developing tools that can be used by other Mount Zion based community partnerships.  

The Osher Center CAB will be aligned with broader UCSF efforts to increase community engagement, such as the Center for Community Engagement and best practices identified by the UCSF ASPIRE study. The CAB will: 

• Foster ongoing relationships focused on developing and sustaining integrative health equity.
• Enhance collective learning to strengthen community-academic partnerships. 
• Provide experiential opportunities for CAB members to familiarize themselves with a range of integrative health practices, strengthening their experience in advising on Osher Center research and education programs. 
• Inform OCIH priorities and practices. 
• Include a mechanism for recruiting appropriate advisors for ongoing individual projects (e.g., a project focused on integrative pediatric care that would benefit from community advisors who are parents or work with children). 

In Year 1, we will identify CAB members and establish group processes, including a practical and experiential orientation to the Osher Center’s work. In years 1-3, the CAB will have quarterly meetings with the OCIH leadership team including the Center Director, Clinic Director, Director of Research, Director of Education, and Associate Director for Health Equity and Diversity. The Integrative Health Equity Program Manager will coordinate the CAB meetings and support CAB members in providing feedback on community-based projects, such as the ones described in Aim 1. OCIH leadership will benefit from consistent guidance from the CAB on how to ensure that Osher programming serves the needs of a diverse range of San Francisco residents. 

Approach/Activities for Aim 3: Identify and disseminate promising practices for community-academic partnerships focused on integrative health equity.

In order to provide data and models that can be employed in San Francisco and beyond, Aim 3 focuses on evaluation and dissemination across projects. In Year 1, we will conduct a citywide scan of integrative health equity partnerships, including but not limited to the community-academic partnerships in Aim 1. Interviews with community-based organization staff and clients as well as their academic collaborators will elicit successes, challenges, and recommendations for strengthening partnerships at an organizational level and towards community impact. We will include ongoing and partnerships between community-based organizations and researchers (e.g., Homeless Prenatal Program, Larkin Street Youth Services, Year Up Bay Area, Sisterweb, Rafiki Coalition, the ARCH/TCM working group, and Mujeres Unidas y Activas). This broad scan will allow us to begin identifying best practices in IHE partnerships.

In Year 2, we will evaluate the three partnerships that are part of Aim 1 using mixed methods instruments developed for community partnerships (Reese et al., 2019). We will use frameworks developed for realist evaluations which focus on answering questions such as what works, for whom, in which circumstances, and why. Using interviews and program implementation data, we will examine factors contributing to sustainability at institutional and programmatic levels (e.g., organizational capacity, program characteristics, funding, staff champions) (Bodkin & Hakimi, 2020). Building on past literature, we will assess how these partnerships have facilitated capacity-building for each of the three partners to offer integrative health services. 

In Year 3, we will focus on dissemination of what we have learned about community-academic partnerships for integrative health equity. We will share preliminary findings with the Community Advisory Board (see Aim 2), then integrate their feedback to create accessible materials summarizing these findings. These materials will be disseminated to community and academic partners locally and nationally through networks conducting integrative health equity work, including the 11 academic centers of the Osher Collaborative for Integrative Health, as well as Integrative Medicine for the Underserved, a national organization. Finally, we will host a daylong event for community-based organizations and researchers focused on IHE partnerships. 

Summary of healthcare-related needs being addressed: Integrative medicine can reduce health disparities and advance health equity through whole person, culturally responsive care for complex conditions that disproportionately impact historically marginalized populations. However, integrative health is not equally accessible for all due to high out-of-pocket expenses and other barriers. The partnerships described in Aim 1 support adults from marginalized communities with a disproportionate burden of chronic conditions, including diabetes, chronic pain, HIV, cancer, and mental health challenges. Aims 2 and 3 will address a broader range of healthcare-related needs across the lifespan, including specific needs emerging from the COVID-19 pandemic (e.g., impacts on mental health, social isolation). The project is designed to strengthen partnerships that respond to current and emerging healthcare needs of vulnerable populations in San Francisco.

MZHF/Jewish values: Based at the Mount Zion Campus, the UCSF Osher Center for Integrative Health will serve as the hub for all proposed project activities. This includes the core academic team (Drs. Chao, Thompson-Lastad, Adler and Chan), the program manager, and OCIH staff involved with the community partnerships. Administrative, fiscal, and programmatic oversight will all be located at the Mount Zion Campus. The community organizations serve populations within the Mount Zion catchment area, focusing on historically marginalized communities. The proposed integrative health equity program embodies MZHF’s core Jewish values: 

• Avodah (service): Community-based organizations in these partnerships serve adults with chronic conditions in multiple ways, including increased access to integrative health services. These efforts are recovering from the COVID-19 pandemic, which increased physical and mental health needs in marginalized communities. The IHE program plans to address this by providing financial and technical support to community-based organizations. 
• Tikkun Olam (social justice): The focus of the IHE program is to address socioeconomic and racial inequities in access to integrative medicine and institutional resources more broadly.
• Kehilah (community building): One of the successes of community partnerships is building relationships among community organizations and university representatives. The COVID-19 pandemic has in some cases worsened silos between organizations and sectors, while creating new partnership opportunities in other cases. Our hope is that the IHE initiative will foster connection and build community among organizations and the people that are part of them. 
• Limud u’Manhigut (education and leadership): This project will support and involve leadership of community organizations and develop collaboration between the UCSF Osher Center and a range of community organizations. It will also contribute to education programs by providing opportunities for community-engaged learning and applied research projects for trainees at UCSF and other institutions.
• Hidush (innovation): The proposal takes an innovative approach to community-academic partnership and increasing access to integrative healthcare, with a focus on capacity-building that will last beyond the period of this grant. 

Information about Partners

Community Project Partners include representation from multiple San Francisco-based organizations:

• Sunny Pak, Associate Medical Director, On Lok, 
• Evelyn Y. Ho, Professor, University of San Francisco
• Tammy Kremer, Public Health Communications Specialist, California Prevention Training Center 
• Liz Stumm, Director of Community Partnerships and Program Evaluation, Shanti Project; 
• Jesse Wennik, Nurse Practitioner, San Francisco Health Network
• Pamela Swedlow, Physician, San Francisco Health Network
• Folashade Wolfe-Modupe, Physician, San Francisco Health Network

Partners from UCSF Osher Center for Integrative Health (OCIH) include

• Maria T. Chao, Associate Director for Health Equity and Diversity
• Ariana Thompson-Lastad, Assistant Professor 
• Shelley Adler, Director
• Selena Chan, Interim Director of Clinical Programs 

Roles of Partners: Partners will jointly foster community engagement by centering the voices of individuals with lived experiences, planning in ways that are community-driven, and prioritizing relationships between collaborators. Community partners will provide an established presence in their respective communities, relevant lived experiences, and informed perspectives on community priorities and feasibility. OCIH partners will provide administrative coordination, technical support for evaluation, and expertise in integrative health. 

Project leadership and background: All partners named above have extensive skill sets and experience with community partnerships, integrative health, and healthcare in marginalized communities. The principal investigators, Drs. Chao and Thompson-Lastad, have led multiple community-academic collaborations on integrative health equity, have 10 years of experience working together, and will ensure that project activities are accomplished. 

Project start date: April 1, 2023, three-year duration.

Estimated total budget: $250k/year; the amount requested from MZHF is $150k/year.