Micro-Community-Based Participatory Research Health Science Projects, to Problem-solve and Build Leadership skills in Children at risk of ACES in extreme Urban Poverty: The Orenda Approach

By Robert A. Branch MD FRCP and Michelle L. Steimer , LLC, NCC LPC

The Orenda approach: We describe the foundational base and health and education process to interface science and health learning for vulnerable adolescents, who live in extreme urban poverty in the US, 'the forgotten children', to manage emotional and social barriers at this critical stage of their lives. These children live in neighborhoods concentrated with dysfunctional families many with Adverse Childhood Experiences (ACEs). They are at risk for complications of personal and environmental factors while still adolescents. They lack the opportunity to build resilience and leadership to overcome these challenges. We integrate experiential learning approaches between contemporary physician health and K-12 science learning pedagogy to emphasize the value of science to a community. Our experiences are presented of challenges faced and barriers overcome over 4-years in over 100 adolescents in different extreme neighborhoods of poverty in the rust belt city of Pittsburgh.

Mission: 1. To experience the social skills in an ethical framework for critical thinking and leadership by conducting successful community research in forgotten children. 2. To improve the local culture of health care to reduce health disparities in underserved neighborhoods.

The Orenda Approach, An Iroquois adjective, denotes the goal of developing leadership in adolescents. The approach is by organizing health sciences clubs for at-risk adolescents as an after-school activity with trained mentors. Small teams select and identify locally relevant health disparities micro-Community-Based Participatory Research (mCBPR) projects. Using the 5 steps of mCBPR scientific process. with a mantra of 'learn, decide and do' at each step, they conduct a wide range of practices to extend skills promoted by STEM disciplines by adding arts and science as STREAM learning, The mCBPR projects are used to draw inferences and present recommendations to reduce barriers posed by the local community. Fitted into an academic school year in weekly OST club meetings with an end-of-academic-year, the results are shared in a local community health fair.

Long term objectives: We offer a model for a city-wide network of clubs, targeted to the most underserved neighborhoods, as an approach to improve city-wide health equity. If sustained. This could contribute multiple topics for a cumulative increased awareness to enhance the local culture of health. Without help, these forgotten children are destined to the local cycle of failure; a societal lost opportunity. With help, each year a cohort of students would be trained in problem-solving as an increased societal opportunity as community leaders for the future.

• Language: English
• Publisher: Fulton Books, Inc.
• Release date: Jan 2, 2024
• ISBN: 9781639852970

Book preview

Table of Contents

Title

Copyright

Prologue

Module A1

Module A2

Module A3

Module A4

Module A5

Module A6

Module A7

Module A8

Module B1

Module B2

Module B3

Module B4

Module B5

Module B6

Module B7

Appendices

About the Author

Contents

Micro-Community-Based Participatory Research Health Science Projects, to Problem-solve and Build Leadership skills in Children at risk of ACES in extreme Urban Poverty

The Orenda Approach

Robert A. Branch MD FRCP and Michelle L. Steimer PhD, LLC, NCC LPC

Copyright © 2023 Robert A. Branch MD FRCP and Dr. Michelle L. Steimer PhD, LLC, NCC LPC

All rights reserved

First Edition

Fulton Books

Meadville, PA

Published by Fulton Books 2023

ISBN 978-1-63985-296-3 (paperback)

ISBN 979-8-88731-667-3 (hardcover)

ISBN 978-1-63985-297-0 (digital)

Printed in the United States of America

In acknowledgment to the forgotten girl who inspired this book

Figure 1. A quote from KM: You can be physically fine but be a mental mess.

Prologue

The Convergence of Education and Health in the Metacognitive Science of Learning

This is the story of my (Dr. Bob’s) friends who helped define the convergence of education and health in the metacognitive science of learning.

Personal introduction from Michelle: Accidentally always being in the exact right place

I am a woman of many roles and a compilation of millions of moments that have led me to my path to study mental health, resilience, and trauma. I am also on the luckiest people that I know because I always seem to end up exactly where I am supposed to be despite the sometimes-messy paths that lead me there. Much like Dr. Bob in the role of hitchhiker, I have always found my way to be paved by my desire to learn about and connect with others coupled with my love for learning new things. His work and research inspired me to join in on his ride, a ride that I am still on and thoroughly enjoying.

I was born and raised outside of Pittsburgh, Pennsylvania. My parents were and continue to be hard-working, kind people devoted to helping others. It was from them that I began to learn the meaning of family, community, advocacy, commitment, and leadership. I often joke that most of what I learned about life came from working alongside my father and grandfather at our small family business in Pittsburgh. Although, we lived in a more rural area, my father owned a small gas station within the city.

I had a unique opportunity to live in two worlds, one in which I was the only daughter of devoted middle-class parents who worked to ensure that I had access to education and a close-knit community and the other in which I witnessed the struggles that poverty inflicts on both rural and urban communities. My parents often sacrificed the things that they needed and wanted to ensure that I had access to education and enrichment. We were far from wealthy but always had all that we needed and some of what we wanted. I had a unique seat to view the world as a child and young woman due to our family business being a staple in its local community. We were privileged in the sense that not only were we members of the majority in being White, but my parents were also far enough from the poverty line that they could sacrifice to pay for things like private school. It was a struggle. However, the ability to struggle meant that there were enough resources for education to be a possibility for me. I often saw other children and teens my age whose parents did not have the financial room to sacrifice as there were already not enough resources to go around. I see this now in most of the families that Bob and I have worked with throughout our time together. This idea has profoundly informed my desire to truly see and hear the children and adolescents that we have worked with. Their own research passions came from their life stories and the research that they created the potential for their stories to be both shared and changed, as did the stories of their communities.

I spent my time after school and during summers working with a diverse group of people that had a tremendous impact on how I see the world. I watched my father lean in to helping others with a quiet grace that never commanded attention or thanks. There were times when I knew that we were struggling financially and yet the next day always came, mostly attributed to my father’s unrivaled belief in the good in people, his work ethic, and a refusal to give up no matter what the circumstance. Some of my most powerful memories are of my father lying on cardboard in the snow fixing a car or changing a tire not only to make sure that our family was taken care of, but also because he knew the importance of everyone that worked for him having a job. It is my belief that, when you are a member of the community you serve, that you connect in a unique way that creates this synergy from which individuals and families lift one another up. This is one the reasons that I am so passionate about the concept of Orenda. I have lived Orenda throughout my life, work, and military service.

I think that my time working with my father served as my first example of the power of community in underserved areas and in poor and middle-class families. Once someone has known struggle, they are changed. If someone is born into struggle, they may see no clear way past that struggle. But just as we tell our young people about the concept of Orenda, I believe that one person can change more than just their own life. One person can provide learning, hope, or an example for the possibility of change once they are able to expand their worldview and gain a sense of self. The concept of Orenda provides a beautiful and unique opportunity for adolescents and families to learn, gain hope, and gain efficacy in ways that working in social isolation cannot.

My mother provided such an example for our family and community. She is the definition of strength under pressure always looking to what needs to happen next to have a better next day, next year, or life. She set a tremendous example of how education cannot only raise the person up who is receiving said education, but also how education creates ripples across a family and community. My mother became a nurse in her 40s and graduated with her nursing degree the year before I finished my own undergraduate degree. She applied her success to working with elderly, often marginalized, people. She encouraged others to go back to school as she believed that there was no wrong age to get an education. She also provided me with a mentor of sorts as I looked to her as I pursued my own higher education as a working mother and wife. It was during this time in my life that I learned the true meaning of terms like grit and resilience, as well as humility and gratitude. I learned that if we can provide a safe multiculturally competent space, mentorship, and resources, children, adolescents, and adults alike can work through the discomfort that is created by change, even positive change. I also learned the importance of helping to create lifelong learners that will continue to evolve and shape their own lives as well as those of their family members and community.

These experiences helped lead me to enlist in the Army when I was still a teenager. I felt like I wanted and needed to serve others. I also wanted an adventure. The Army provided me these opportunities as well the opportunity to grow exponentially as a person. From the practical perspective, it also paid for a great deal of my education. My service in the military taught me not only how to be a leader in the pure sense of the word. It taught me to plan, manage, and lead under stress. It also afforded me front row seat to see how stress and trauma impact individuals, families, and communities. On the flip side, it also opened my eyes more to the roles of education, healthcare, community, and resilience in helping yourself and others to move from surviving to living to thriving. Having a family or team approach to growth and change is exponentially more effective than attempting change in a state of social or inner isolation. These are lessons learned that I have been able to apply to my work as a counselor and educator, as well as to my work with Dr. Bob on this endeavor.

I never meant to spend more than twenty years in the military or to get my doctoral degree, but here I sit accidentally and intentionally. I found myself moving back to Pittsburgh after leaving active-duty service in the military where I live next door to my parents and not far from my husband’s family. This place, this beautiful, sometimes trying place to live is home and always will be. As such, I continue to be devoted to using my work and research to not only better my community and to make sure that I work toward scalable projects like the one contained in this book so that the children and families of the readers of this book can do the same. I will be forever grateful to Dr. Bob for allowing me the privilege of working with him and the amazing kids that participated in our program. They have left an indelible mark on my heart not far from own children. I hope to empower the reader to lean into the discomfort of building a program to truly enable empowerment.

Overview

This prologue tells the fifteen-year story—understanding the dilemma of the forgotten children. Defined in this book as adolescents in underserved urban communities who are rendered especially vulnerable to having been exposed to multiple adverse childhood experiences (ACEs) where they suffer the ravages of extreme poverty and racism in the US. This story provides an opportunity to give thanks to the enthusiasts who have helped me along the way to indicate their contribution to the depth of sources of complex concepts that underlie the designation of the forgotten children and a proposed educational recommendation to help build their resilience to snatch them from the jaws of failure to put them on a pass to success. It is by applying what I have called the Orenda approach. Each of the concepts summarized in this prologue is more fully developed in subsequent modules of chapters for fuller discussion. Developing this story has been a slow process of assembly of theoretical basis and a feasible pragmatic approach to address the educational niche that is evolving in high school education. These include in the era of Next Generation Science Standards (NGSS), Common Core State Standards (CCSS) for youth education. It also includes advocacy for experiential learning pedagogy for medical student education in the era of Beyond Flexner Alliance (BFA) where medical students have greater interaction in a community. The two educational systems are both converging to focus on integrated health learning from multiple disciplines within the community.

The contention is that this integration within the community will contribute to healthier communities in underserved neighborhoods. Initial proof-of-principle experiences have shown that the integrated Orenda approach does contribute to the healthy development of poor urban teens at their greatest need. It is proposed that the special professional training requirements and cross-school organizational integration of activities merit a distinctive new organizational construct. It requires its own career tract for the mentors of Orenda. This approach requires a sustainable infrastructure and financial basis to organize and provide local networked health science clubs, analogous to the Teach for America model, to assist underserved schools in providing new educational opportunities.

Teens can conduct research on man: The HSTA experience in rural West Virginia

This book has only been made possible by my interactions with many friends who shared their skills and expertise with me, broadening my perspectives and understanding of how complex the sciences that underlie teenage and young adult learning are evolving. This group of educational enthusiasts have shared the knowledge and skills they’ve gained over many years.

The basic model of health science clubs for underserved high school students developed in this book was initiated in 1984 in West Virginia by Ann Chester, PhD. As the driving organizer, she was assisted ably by Kathy Morton McSwain, EdD, when they started the Health Science and Technology Academy (HSTA) for the most underserved public schools in rural Appalachia.

The goal of HSTA was to provide educational opportunities for teenagers selected by the community (not by the schools) to be exposed to the health sciences, to have fun doing a research project adapted to the annual school cycle, to attend summer camps, and to become competitive for gaining entrance to college. They selected the health sciences as a noncompeting discipline to in-school education disciplines where children want to engage. The program they started has been both successful and sustainable, providing a pipeline of college-enrolled, well-trained students to graduate from college.

Ann is a brilliant organizer. She was able to get state support extended to her graduate students through tuition waivers in higher education not only up to bachelor’s degrees but also to post-graduate and higher education. With these incentives, essentially all the eight hundred students each year who attended four years of the HSTA experience have been enrolled in higher education. This extended support has been justified and sustained because not only did HSTA open doors to successful careers but a greater percentage of HSTA graduates who went to West Virginia colleges and universities completed their degree objectives than non-HSTA graduates from the same communities. Their career advancement was later repaid to the state by higher earnings yielding higher taxes.

Kathy is a master teacher. It was a privilege to learn from her educational ability how to engage and control small and large groups of teens. By 2007, they had eighty clubs for around eight hundred teens across twenty-six counties, each attending weekly science clubs and summer camps.

Ann and I were introduced by Tony Beck, PhD, a dedicated program officer at NIH, for both the SEPA Program (Science Education Partnership Award) from the NIH for science education to schools, which then and now supports HSTA and at that time the GCRC (General Clinical Research Centers at the University of Pittsburgh). I was the director of the University of Pittsburgh GCRC program. Tony is an avid supporter of adolescent science education and helps manage and grow the SEPA Program. His passion and advocacy have been crucial in sustaining this long-term program in which federal health science disciplines support childhood health science education.

At his suggestion, I was invited to help introduce the principles of the community-based participatory research genre to both club mentors and students. Together we confirmed the feasibility of minors conducting bona fide research in their communities. This interaction allowed me to participate in teen education, which was an interesting contrast to medical student and postdoctoral education. I was surprised and encouraged that teenagers were, in general, more altruistic and risk taking, particularly those that came from the poorest background.

Together with my constant companion and invaluable computer-knowledgeable assistant, Stephanie Tomasic, who has supported me throughout these learning experiences, we started an in-depth learning and teaching experience for an established network of mentors and students in the HSTA network.

Health metacognition: The brain processes to change unhealthy behaviors

It was at this time that I learned the meaning of a new word—metacognition. I had to look up its definition, the science of thinking about one’s thinking, from my older cousin Phillip Brimson, PhD. He had spent his career in England conducting adult teaching in a community college and had just received his PhD shortly after retiring about applying neurophysiological principles of adolescent and adult learning to adult teaching.

I was inspired by his perseverance in lifelong learning and sustained enthusiasm. I avidly read the details in his thesis and learned the information available at that time. It resonated as a whole discipline as I had been intuitively practicing it in my career. The advent of newer techniques of brain imaging opening up new insights, also relevant for youth, has been fascinating to follow and has helped build part of the Orenda story conveyed in this book.

Health metacognition (a cumbersome phrase) is, to my mind, a technical description of the brain processes underlying solving health problems needed to change unhealthy behaviors for health that result in health disparities. Understanding and having the insight to these processes actually helps the learning process. The design of weekly health science club meetings optimizes the subconscious ability to assimilate and reorganize prior information with newly acquired information around a complex topic into an acceptable understanding from the integrated sources of the information topic which takes around a week. At that time, reinforcement by active review and further discussion helps maximize clarity and minimize confusion to retain information that can be retrieved and used in the future. It helps students to be aware of the complexity of this process, which can take time but, once acquired, assists in overcoming real challenges in life.

The convergence of learning in high schools and medical schools in the community

The next progression in Orenda learning is the current changing emphasis in health education. A high-level international report from a group of international medical school leaders came out in 2010. This committee was tasked with reviewing the impact of the massive change in physician training following the Flexner Report in 1910. Across the world, this early report emphasized the lost opportunity in training by the separation of medical schools from the sciences that can be applied to better understand illnesses and help guide clinical decisions. The medical student educational system changed from an apprenticeship model in schools outside universities to science-based schools providing rigorous science degrees from within universities.

The Flexnerian model uses science as an essential base for physicians to understand the disease processes and make decisions to guide patient treatment in practice. In the centennial review in 2010, the leaders in health education lauded the advances in science that have produced such substantial changes on how to treat disease and improve health, but they also blasted the system for its tendency to focus on diseases and specializations and for its concentration of resources on major academic medical centers. They pointed out that health disparities both between rich and poor countries or rich and poor communities within a country have failed to provide to all communities what has been learned in not only disease management but also disease prevention and the maintenance of good health. The Flexner 2010 report strongly advocated that more attention during medical education is needed to ensure advances in medical science are distributed to everyone and identified the need to extend medical students’ learning experiences from their ivory towers in hospitals to learning in the community.

Subsequent to the Flexner 2010 report, the Beyond Flexner Alliance (BFA) was formed as consortium of many organizations whose goal is to apply science in order to understand health and to educate the community about health, disease prevention, and wellness (https://www.beyondflexner.org/bfa-allies.html). The BFA initiatives have primarily targeted adult community members, but the approach can equally be applied to adolescents and maybe even more optimally as they are more flexible learners than their elders.

Living in Pittsburgh, where there is considerable inequity with pockets of deep poverty in minority neighborhoods, I wondered if the same principles would help urban poverty as the HSTA model had in rural WV. To better learn the barriers in youth science education in urban poverty, I worked for a year with Gabriela Rose, EdD, to develop an urban model that could be tested on a shoestring budget. Gabriela is from the Allegheny Intermediate Unit 3 (AIU) in Pittsburgh, which is the state-sponsored system for providing advanced professional development for schoolteachers. Gabriela is involved in helping already qualified schoolteachers become up to date in professional development courses in teaching sciences provided to enhance the educational expertise for local science teachers and help them keep up with professional standards in Pennsylvania.

She introduced me to the massive changes being undertaken in adolescent Science, Technology, Engineering and Mathematics (STEM) teaching across the US. The New Generation Science Standards (NGSS) and Common Core State Standards (CCSS) are being mandated in modified form and has become accepted into day-to-day use in Pittsburgh schools. These dramatic interventions are revolutionizing domain content teaching to promote cross-disciplinary education interactions of different science disciplines that use similar practices in a comparable way to the changes in physician training. Together, we explored the potential of extending the STEM concept to STREAM by adding research and arts and then applying STREAM to reduce health disparities, which was my area of interest in these poor neighborhoods.

The addition of research helps in integrating the many disciplines needed to solve a social problem underlying every health disparity. It introduces the experiential process of learning as a deep method for a single problem when the problem is addressed using different skills over a lengthy period of time. This was an evolving, detailed process of integrating educational ideas from two experienced teachers with help artistic talent and organizing support from Stephanie. Our aim was to create a professional development course with a thirty-hour program for potential mentors, recognizing that each mentor had a unique career trajectory as they could have been classically trained teachers not used to experiential learning methods, health-trained professionals such as public health graduates, social workers, counsellors, or health-related PhD scientists untrained in youth education. The syllabus for professional development complementary to this book is available. This course was designed to provide a common orientation so that activities within a local network of clubs could work along the same mission and perspectives. This course was followed by a guide for a year-long curriculum for guiding the student club mentors in the after-school club weekly meetings (Appendix 7).

Once developed, the course and the curriculum were field-tested and refined in a variety of severely underserved neighborhoods over four years. I was accompanied by both Stephanie and a longstanding friend and statistician, Roger Day, PhD, who inspired students with his love of numbers and music (with his beloved but unwieldy tuba). These proof-of-principle experiences were made possible with the enthusiastic support of several school and community organization leaders—in particular, Eddie Wehrer, MBA, the superintendent of Steel Valley School District, and his teachers Yvette Logan and Michelle Maddigan.

Eddie had the challenge of leading one of the poorest school districts in Allegheny County without even the support of a parent-teacher association. He was invited by the school board to rescue and reorganize a failing school system that had just received a major financial cut. The system was run by a businessman who happened to live in the district and loved it but was not trained as a teacher. He was open to outside ideas and nontraditional help.

Yvette and Michelle were heroic in allowing me access to the children. They took risks in building closer relationships on sensitive topics with club members. They had unfailing patience despite the frustrations in the rate of progress and perceived chaos appreciated and ensured that the club meeting was contained in a friendly, safe environment that encouraged student dialogue and feedback. They also prepared and served delicious snacks, which helped retain students if they reached a low point. The weekly sessions and the end-of-year symposia always maintained a high, meaningful, and emotional content. Collectively, we confirmed that the basic model is effective in an urban setting but needed refinement to meet the need of urban poverty.

The essential metacognitive principles applied by including the research process as experiential learning was as effective in this situation as in rural clubs, but it was a challenge for the mentors to adapt to guiding (mentoring) rather than teaching. The community benefitted from both the project participation and the sharing of information among families at the symposia. The conventional school approach of just learn to improve your mind was extended to the learn, decide, and do model, where the research teams had to use what they learned in science about their selected topic and make decisions to actually develop and implement an action plan to promote to others. This involves depth of engagement, understanding, and being responsible for the product of what they had been studying.

Applying a wide variety of skills in a narrow field for a sustained single project over a whole year, ending with a community presentation, can be transformative for the student. The teachers found this format of experiential learning (by finding a solution to a problem that they had not been formally trained to solve) fundamentally different to regular classroom teaching. It required teacher reorientation in professional development, refocusing their attention to mentoring in a university-like style rather than teaching in teacher training style. It was one in which the students introduced them to new topics. In practice, they drew closer to understanding their students’ ways of thinking and gained a better understanding of the social problems they were facing. They were impressed at how much difference this exercise made to growth in critical thinking and social development in students, and they appreciate the personal contribution they were making to that growth.

ACEs explanation for differences in rural and urban barriers for youth

We also found a major difference to rural clubs—it was that the number of students who joined a club were at extremely high risk of mental health problems due to their high Adverse Childhood Experiences (ACEs) scores. Often they had few resources to meet their challenges. Michelle who