The University of North Carolina at Chapel Hill (UNC-CH) has historically played a leadership role in helping to move North Carolina and the region from the periods of slavery and apartheid toward the achievement of equal treatment and equal opportunity. Although constrained by the legal framework, political realities, and mores of the society in which they lived, the University has served as the pulpit for such visionaries as Howard Odum and Frank Porter Graham, who through words and actions challenged segregationist ideology and practices. Less well known are the many activities and initiatives by individual administrators, faculty, and students to bridge the racial divide.

For example, in the 1940's, the President Shephard of North Carolina College in Durham (NCC, the forerunner of North Carolina Central University) and Dean Milton Rosenau of the School of Public Health discussed the creation of a Department of Health Education at NCC. The program begain the following year, with UNC faculty teaching most of the classes. Some of the students in those classes later became faculty at NCCU and at UNC. Meanwhile UNC Department of Public Health Nursing faculty taught public health nursing in the NCC nursing program. Moreover, under the leadership of Dr. Lucy Morgan, chair of the UNC Department of Health Education, joint student activities were conducted to enable students at the two schools to get to know one another. Such activities during the Jim Crow era "was upsetting the hell out of everything. . . . You weren't supposed to do things like that." (John Larsh, quoted in Robert Rodgers Korstad Dreaming of a Time: The School of Public Health, The University of North Carolina at Chapel Hill, 1939-1989, p51).

Although collaboration between UNC-CH and the historically Black universities in North Carolina has not consistently followed that model, in recent years there has been an upsurge of collaborations. These collaborations are part of a longstanding and wide-ranging interest in minority health and minority advancement at UNC-CH. Thus, the Department of Epidemiology launched the first population-based cardiovascular disease cohort study in a biracial county (Evans County, Georgia), which throughout the 1960's and much of the 1970's provided the only population-based data on cardiovascular disease in African Americans. Dr. Sherman James' began his Pitt County Study and developed his concept of John Henryism while a faculty member in the Epidemiology Department. Meanwhile, in the Department of Health Education, John Hatch began his work with the Black Church and with rural African Americans in Chatham County.

Even before the 1985 Secretary's Report on Black and Minority Health greatly stimulated interest in – and funding for – minority health research, the Cecil G. Sheps Center for Health Services Research was already conducting major collaborative research projects, such as a survey and smoking-cessation program with policyholders of the North Carolina Mutual Life Insurance Company, the nation's largest Black-managed life insurance company. In 1989, the Lineberger Comprehensive Cancer Center, in collaboration with the Schools of Public Health and Medicine, created a UNC Minority Cancer Control Research Program (MCCRP) with one of three NCI minority supplement awards. Directed by Dr. Victor Schoenbach, this Program ran for eight years and served as a major stimulus, organizing force, and proving ground for a number of major cancer research projects, including a case-control study of fatty acids and prostate cancer by Dr. Paul Godley, the Save Our Sisters project by Dr. Eugenia Eng, the NC Breast Cancer Screening Program by Drs. Jo Anne Earp and Eugenia Eng, and the PRAISE project (see below).

In 1994, the School created a Minority Health Project with funding from the National Center for Health Statistics/CDC. The Project compiled searchable catalogs for research literature and databases and launched the Annual Summer Public Health Research Institute on Minority Health. A Videoconference component, with over 20 participating sites around the country each year, was added in 1997.

Research programs at UNC-CH have been national leaders in the development, application, and use of innovative methods to reach minority, rural, and low-income populations. These methods include: training natural helpers as lay health advisors; church-based interventions; tailored messages; interactive multimedia messages for low literate adults; and family-based interventions. The methods have been developed and tested with collaborations with hospitals, radiologists, community health agencies, the General Baptist State Convention, the Old North State Medical Society (the African American physicians organization in NC), state agencies, voluntaries, and large groups of primary care practices, public health departments, African American churches, WIC programs, and worksites. Compilation of a full inventory of minority-health related research at UNC-CH would be a research project in itself. Thus, the following examples are meant as illustrative. They are being conducted through various UNC-CH organizations including the CDC-funded UNC Center for Health Promotion/Disease Prevention, and the Lineberger Comprehensive Cancer Center.

• Race, Fatty Acids, and Prostate Cancer Risks – Drs. Paul Godley, Steven Zeisel, and Bahjat Qaqish conducted this NCI-funded case-control study that grew out of Dr. Godley's MCCRP-funded case-control study of the role of lipids in prostate cancer. Both studies used dietary data obtained through questionnaires and adipose tissue biopsies to examine associations between omega-3 and omega-6 fatty acids with prostate cancer risk.
• Carolina Breast Cancer Study – This population-based case-control of breast cancer, part of the Lineberger NCI SPORE (Special Program Of Research Excellence), was launched in 1992 by Dr, Beth Newman and is now led by Dr. Robert Millikan. In collaboration with the NC Central Cancer Registry, the study introduced a rapid case ascertainment system to enroll equal numbers of white and African American women with newly-diagnosed breast cancer and analyzed questionnaire and genetic data.
• Polyp prevention clinical trials – Dr. Robert Sandler directed the UNC-CH component of two clinical trials to test whether calcium carbonate and aspirin/folic acid can inhibit the development of recurrent adenomas. Dr. Sandler also chaired the intergroup national cooperative group clinical trial to examine the relation between aspirin and the reduced incidence of adenomas in patients who have undergone curative resection for colon cancer (New England Journal of Medicine).
• Save Our Sisters – Dr. Eugenia Eng and colleagues have advanced our understanding and use of natural helpers or lay health advisors as effective agents of community behavior change, particularly in vulnerable and underserved populations. With funding from the UNC MCCRP, Eng and colleagues successfully designed and implemented a lay health advisor program promoting breast cancer screening and follow-up among older African-American women in New Hanover County, NC. Dr. Eng presented the keynote address at the 1997 National Meeting of the Society of Public Health Education, and Save Our Sisters was named the Outstanding Public Health Program for North Carolina in 1996.
• NC Breast Cancer Screening Program (NC-BCSP) – Building on the lay health advisor model developed in Save Our Sisters, the physician practice innovations developed in another NCI-funded study, North Carolina Prescribe for Health (NC-PFH), and pilot studies funded by the UNC MCCRP, Dr. Jo Anne Earp and Dr. Eng launched a 10-county study of a multifaceted intervention to increase breast cancer screening among African American women in rural communities. NC-BCSP trained more than 160 African American lay health advisors and 30 nurse-advisors in the five intervention counties and established a cohort of 2,000 women (1,000 Black, 1,000 White) who are being followed over an eight-year period. Drs. Earp and Eng have published extensively on the use of lay health advisors, improving community competence, and their application to increasing breast cancer screening among older, rural African-American women (American Journal of Health Promotion, American Journal of Public Health, Cancer, Evaluation and Program Planning, Health Education Quarterly, Journal of Family and Community Health, Health Education and Behavior, Health Education Research).
• PRAISE (Partnership to Reach African Americans to Increase Smart Eating) – In the third major study to grow out of the MCCRP, Drs. Jan Atwood and Boyd Switzer obtained NCI-funding for a community-based trial to promote adoption of NCI’s dietary. The project is identifying barriers and motivators for dietary change among 1,500 women in 60 African American churches across eight NC counties; developing and using culturally sensitive intervention strategies; and evaluating the effectiveness of these interventions on adherence to NCI dietary guidelines (increased fruit, vegetable, and fiber consumption; reduced fat intake). The proposed interventions include stage-based, tailored messages to individual participants and supportive church-based activities. Culturally sensitive food frequency questionnaires and biomarkers obtained from blood samples (carotenoids, tocopherols, etc) will measure changes in diet.
• Black Churches United for Better Health – Dr. Marci Campbell directed an NCI-funded 5-A-Day community initiative developed with the NC Department of Health. This theory-based, multi-level intervention directed toward 3,700 congregation members from 50 Black churches in 10 rural eastern North Carolina counties significantly increased fruit and vegetable intake, as well as shifted stages of change and other intermediate outcomes (American Journal of Public Health, Health Education and Behavior, Journal of Cancer Education). Dr. Campbell has also evaluated the use of multi-media, tailored communications to reach low-literate, low-income women (Health Education Research, Patient Education and Counseling). Dr. Campbell also directs WATCH (Wellness for African Americans Through Churches), a community-intervention study recently funded by the American Cancer Society (ACS). This study uses a factorial research design to test the effects separately and in combination of innovative interventions to increase fruit and vegetable consumption among rural African American church members. The interventions include stage-based tailored bulletins and videotapes and use of lay health advisors. The US Department of Agriculture (USDA) has recently matched the project’s ACS funding.
• StampSmart and FoodSmart – Dr. Campbell and Dr. Alice Ammerman developed these two studies of tailored interventions including video soap operas, interactive educational infomercials, and printed materials to provide nutrition education for low-income women attending Women and Infant Children (WIC) programs and community health centers. They have recently received funds from the NC General Assembly and the UNC Institute of Nutrition to disseminate the FoodSmart CD-ROM nutrition education program as a cancer prevention/public education program to all health departments in North Carolina.
• Health Works for Women – This CDC-funded study is uses worksite interventions to increase women’s performance of preventive behaviors. Health Works for Women targets women working in small to medium size light manufacturing plans in rural areas and uses a multi-level intervention to promote a number of preventive behaviors: breast and cervical cancer screening; smoking cessation; lower fat/higher fiber diet; and exercise. The multi-level interventions include a printed computer-tailored health magazine and a social network approach using lay health advisors.
• WISEWOMAN – This CDC-funded study is evaluating the impact of supplementing a breast and cervical cancer screening program for older, low income women with a cardiovascular disease intervention. A companion study funded by NIH is investigating a nursing intervention to reduce morbidity and mortality from cancer, stroke, and heart disease in 17 rural North Carolina counties.
• North Carolina Prescribe for Health (NC-PFH) – Drs. Russell Harris, Arnold Kaluzny, Linda Kinsinger, and colleagues conducted this NCI-funded project to increase performance of cancer screening involving 62 medical practices in 21 rural counties. Intervention practices received replicable, office-based systems tailored to their practice needs, and evaluation procedures review of more than 5,000 medical records at two time periods (Journal of General Internal Medicine).
• Making Prevention Work – This follow-up NCI-funded study includes two interactive projects that feature complementary controlled trials of physician and patient activation for preventive services. The research team (Drs. Harris, Kaluzny, Kinsinger, Ransohoff, Bahjat Qaqish, Michael Pignone, and Victor Strecher [now at the University of Michigan]) is examining the effect of small group and in-office support to promote adoption of an effective cancer prevention office system to increase performance of four cancer prevention activities (smoking cessation, screening for breast, cervical, and colon cancer) in 45 primary care practices located in independent practice associations. At the same time, the team is testing the efficacy of sequential vs. simultaneous computer-tailored, stage-based interventions for addressing multiple cancer risk behaviors among 1,000 women patients aged 50 to 75 years from the primary care practices.
• Psycho-educational intervention studies with cancer patients –Dr. Merle Mishel is conducting three NIH (NCI, NINR)-funded studies of interventions in (1) African-American and White men with prostate cancer and their family members, (2) older White, Mexican-American and African-American women with breast cancer, and (3) younger African-American women with breast cancer. All three studies use telephone counseling and supplementary materials to teach patients and/or family members how to manage the uncertainty generated by diagnosis and treatment for cancer by teaching strategies to enhance self-care and self-help behaviors. Phone calls are conducted by nurses, who are matched to participants by race and gender.
• Randomized, controlled trial of an intervention to improve informed decision-making for genetic testing – Dr. Jim Sorenson is conducting this study with funding from the National Center for Human Genome Research. Intervention group women receive a decision balance risk-benefit component (derived from Decision Conflict Theory) in addition to the standard informed consent process for women considering hemophilia A carrier testing. Outcomes are satisfaction with the testing decision; the level of post decisional regret; and stability/change in perceived risks and benefits of testing. Other studies concerning genetic testing are being conducted by Drs. Anita Kinney (a former UNC-CH fellow now at the University of Utah and), Brenda DeVellis, Michael O’Malley, Russell Harris, and others.
• Sexually Transmitted Epidemic Project (STEP) – This study by Drs. James Thomas, Victor Schoenbach, Jo Anne Earp, and Eugenia Eng began as a clinic- and community-based study of repeat sexually transmitted diseases (STD) in a rural NC county with gonorrhea rates among the highest in the state. The renewal (by Drs. Thomas, Eng, and Earp) studied an intervention using lay health advisors to reduce women's risk of acquiring STD.
• Women’s Cardiovascular Health Network Extension: Identifying Environmental, Policy, and Psychosocial Factors Important for Designing Culturally-appropriate Physical Activity Programs for Women (UNC Center for Health Promotion and Disease Prevention) – This study by Dr. Alice Ammerman is identifying environmental, policy, and psychosocial factors that influence women’s activity choices and behaviors among low income Hispanic women in North Carolina. It has convened a North Carolina Women’ s CVH Working Group and Advisory Committee consisting of experts in women’s cardiovascular health and physical activity drawn from the UNC-CH campus, state government, and other North Carolina agencies. The Working Group is: 1) participating in conference calls and meetings with other Prevention Research Centers to develop model, methods and instruments to be used; 2) assisting with the development of a background report on what is currently known about policy and environmental factors that influence adult behavior for physical activity, particularly among female, ethnic/minority, and low socioeconomic populations; 3) refining a conceptual model of the determinants and factors that influence adult decision-making and behavior for physical activity among underserved female ethnic minorities; 4) evaluating the conceptual model using focus groups and structured interviews to determine the multiple factors that influence physical activity in the target population; 5) collating and synthesizing factors that represent perceived mediators or barriers to physical activity and participate in analyzing and organizing data common to all tested participants; 6) collaborating to publish findings and implications for intervention development; 7) participating in all dissemination activities in conjunction with the CDC Prevention Centers-based Women’s Cardiovascular Health Network in efforts to keep all partners, state health departments, and the network well informed.
• A Church-based Intevervention to Improve Diabetic Care (UNC Center for Health Promotion and Disease Prevention) – This two-part study by Drs. Thomas C. Keyserling and Carmen Samuel-Hodge is: 1) expanding and refining an intervention to deliver a community-based diabetes self-management program that builds on physician-directed diabetes care, and emphasizes improvements in dietary and physical activity behaviors of African Americans with type 2 diabetes; and 2) testing this intervention in a randomized controlled trial conducted in African American churches. The goal of Phase 1 is to work with church and community representatives to develop a conceptual model designed to expand and refine a diabetes self-management program for a church setting. The study is conducting an assessment of church characteristics relevant to design and implementation of a diabetes intervention, and a formative evaluation of the intervention through focus groups and structured interviews to ensure cultural relevance and acceptability of program components. The proposed intervention consists of two 6-month components. During the first 6 months (intensive period), a health counselor will assess dietary, physical activity, and other diabetes self-care practices to develop an individually tailored diabetes care plan. A church diabetes advisor (a lay person with diabetes) will provide follow-up (along with feedback from the primary care physician), and facilitate group self-management training. The intervention during the second 6 months (reinforcement period) is delivered primarily by the church diabetes advisor.
  
  Phase 2 involves a randomized controlled trial to determine whether the intervention results in improved: glycemic control; diet and physical activity behavior; and psychosocial outcomes, compared to controls. For this trial, 300 African Americans with diagnosed type 2 diabetes and under the care of a physician, will be enrolled at 24 churches and randomized to either Special Intervention (SI) or Minimal Intervention (MI). During the 6 month intensive intervention, SI participants will receive monthly phone calls from the church diabetes advisor, 4 group sessions in self-management training, and 3 feedback messages from their primary care physician. This intensive period will be followed by 6 months of a church-based reinforcement intervention including 2 additional group sessions and monthly phone calls by the church diabetes advisor. MI participants will be mailed standard American Diabetes Association education. At 6 and 12 months we will assess glycosylated hemoglobin, dietary intake, physical activity, psychosocial outcomes, self-care practices, changes in medication, blood lipids and weight. Acceptability of the intervention to participants, their primary care physicians, the churches, and the broader community will also be assessed.