Community Health & Chronic Disease

We take a patient-centric approach and use our data to help prevent, detect, diagnose, and treat chronic diseases while promoting community health.

Chronic diseases are long-lasting conditions, and people living with chronic diseases (such as cardiovascular disease, diabetes, or depression) must learn to manage daily symptoms that affect their quality of life. According to the Centers for Disease Control and Prevention, chronic disease is the leading cause of death and disability in the United States.

In an effort to mitigate the impacts of chronic diseases, the Primary Care Research Institute (PCRI) promotes community health research and best practices centered around minimizing socioeconomic and environmental risk factors. It is the overarching goal of PCRI researchers to support work at the community level that promotes healthy living, helps to prevent chronic disease, and brings overall health benefits to the greatest number of people in need. By working directly with the community, the PCRI team strives to reduce health gaps caused by social determinants of health, such as differences in race and ethnicity, location, social status, and income.

Associated Faculty

Tirabassi, Jill

Jill Tirabassi, MD, MPH

Clinical Assistant Professor; K12 Research Scholar

UB Gateway Building Department of Family Medicine 77 Goodell Street, Suite 240KK Buffalo, NY 14203

Phone: (716) 816-7228; Fax: (716) 845-6899

Email: jilltira@buffalo.edu

Research Interests

  • Evidence-based Strategies in Nutrition and Lifestyle Medicine
  • Community-clinical Partnerships to Enhance Health Outcomes
  • Implementation Science and Mixed Methods Research
Tumiel Berhalter, Laurene

Laurene Tumiel Berhalter, PhD

Director of Community Translational Research

UB Downtown Gateway Department of Family Medicine 77 Goodell Street, Suite 220N Buffalo, NY 14203

Phone: 716-816-7278; Fax: 716-845-6899

Email: tumiel@buffalo.edu

Research Interests

  • The Patient-Provider Interface
  • Patient Ambassadorship to Address Social Determinants of Health
  • Community Participatory Research Designed to Improve Community Health
Amanda Ziegler, female with brown hair and an orange top.

Amanda M. Ziegler, PhD, MPH, RN

Research Assistant Professor

Department of Family Medicine

77 Goodell Street Suite 220, Buffalo, NY 14203

Phone: 716-816-7267

Email: amz9@buffalo.edu

Research Interests

  • Behavioral Mechanisms of Adolescent Eating Behaviors
  • Community-engaged Approaches to Reduce Health Disparities
  • Environmental and Parental Influences on Adolescent Health

Current Research Projects

  • Advancing Geriatrics Infrastructure & Network Growth (AGING) Initiative
    9/27/23
    Using novel analytic methods with systemwide Health Information Exchange (HIE) data, we will explore new risk factors relevant to Multiple Chronic Conditions (MCCs) in older adults. This pilot study is also using a participatory patient-care partner approach to gain insight on MCC patient experiences and ensure the relevance of risk factors developed for future patient-provider interactions.  
  • An Epidemiological Study on the Health Effects and Coke Oven Emissions from Tonawanda Coke
    9/27/23
    This project will conduct a 10-year cohort study of 38,000 residents of Tonawanda and Grand Island to examine the health effects of industrial environmental pollutants.
  • Center for Ecosystems Data Integration and Pandemic Early Warning (PIPP Phase I)
    5/12/25
    With an interdisciplinary team, including but not limited to biochemists, epidemiologists, mathematicians and computer scientists, we aim to develop and implement a robust system to detect signs of a potential pandemic in our environment and within our populations. Early detection is key to responding to public health crises like the COVID-19 pandemic quickly, effectively, and thoughtfully as a community. This requires true partnership and trust among researchers, public health officials, government and the public. We actively, continuously engage and partner with members of diverse community groups to directly inform each other and provide feedback about what changes in the community should be monitored as part of this predictive system. We consider the unique needs of different communities in the event of a future pandemic to promote community strengths and proactively allocate resources. 
  • Community Health Worker Training Program (CHWTP)
    1/14/25
    As part of this collaborative initiative, led by Dr. Renee Cadzow of D'Youville University, PCRI's role is to create an advanced community health worker (CHW) training for workforce in research and in primary care using a participatory approach. This training will follow guidelines set forth by CoNECT: The Community Health Network of Buffalo and the Patient Voices Network.
  • Developing Appropriate School-based Food Literacy Initiatives for Buffalo Teens and Families
    5/12/25
    The main goal of our seed project is to work with teen leaders and local health professionals to develop and pilot interactive, school-based food literacy sessions that empower teens with the knowledge and skills to be engaged in their food choices and the impact on their health. Since we know that teens seek independence, novelty and are motivated by many factors rather than their future health, we aim to focus on experiential learning and building lasting food skills.
  • Healthy Cattaraugus County: A Drug-Free Community Coalition
    5/12/25
    The primary goal of this grant is to reduce substance use among youth and, over time, reduce substance abuse among adults by addressing the factors in a community that increase the risk of substance abuse and promoting the factors that minimize the risk of substance abuse. We will accomplish this by strengthening collaboration among communities, public and private non-profit agencies, and federal, state, local, and tribal governments to support the efforts of community coalitions working to prevent and reduce substance use among youth.
  • Identifying Determinants of Food Prescription Program Implementation and Usage
    5/12/25
    The current study will capitalize on existing food prescription programs and use a mixed methods implementation science approach to understanding determinants of food prescription program implementation and participation. This research will be guided by the Consolidated Framework for Implementation Research, a determinant framework focused on understanding how characteristics of the intervention and the setting as well as individuals running and participating in the intervention impact implementation.
  • Identifying Determinants of Produce Prescription Implementation and Usage
    1/14/25
    The chief aim of this grant is to evaluate new and ongoing produce prescription programs being offered at Neighborhood Health Center in partnership with the Massachusetts Avenue Project’s Growing Green Mobile market and FreshFix. This research will use focus groups with patients to help determine barriers and facilitators to program usage at both mobile produce markets and a new delivered produce prescription model. These programs have shown significant promise across the country for improving diet and health and reducing health care costs, particularly for those living in food insecurity or with chronic health conditions.
  • Tracking Adolescent Choice Over Eating (TACOE)
    5/14/25
    This project will begin to study how adolescents' eating autonomy might be related to their health (diabetes risk, weight status, and diet quality). We will also look at how parents and others help teens to build these skills. Both teen- and adult-involved community advisory boards will help pinpoint which adolescent eating factors and skills should be prioritized to support teen health.