Telemedicine Implementation for Safety Net Populations: A Systematic Review

Background: Telemedicine systems were rapidly implemented in response to COVID-19. However, little is known about their effectiveness, acceptability, and sustainability for safety net populations. This study systematically reviewed primary care telemedicine implementation and effectiveness in safety net settings. Methods: We searched PubMed for peer-reviewed articles on telemedicine implementation from 2013 to 2021. The search was done between June and December 2021. Included articles focused on health care organizations that primarily serve low-income and/or rural populations in the United States. We screened 244 articles from an initial search of 343 articles and extracted and analyzed data from N = 45 articles. Results: Nine (20%) of 45 articles were randomized controlled trials. N = 22 reported findings for at least one marginalized group (i.e., racial/ethnic minority, 65 years+, limited English proficiency). Only n = 19 (42%) included African American/Black patients in demographics descriptions, n = 14 (31%) LatinX/Hispanic patients, n = 4 (9%) Asian patients, n = 4 (9%) patients aged 65+ years, and n = 4 (9%) patients with limited English proficiency. Results show telemedicine can provide high-quality primary care that is more accessible and affordable. Fifteen studies assessed barriers and facilitators to telemedicine implementation. Common barriers were billing/administrative workflow disruption (n = 9, 20%), broadband access/quality (n = 5, 11%), and patient preference for in-person care (n = 4, 9%). Facilitators included efficiency gains (n = 6, 13%), patient acceptance (n = 3, 7%), and enhanced access (n = 3, 7%). Conclusions: Telemedicine is an acceptable care modality to deliver primary care in safety net settings. Future studies should compare telemedicine and in-person care quality and test strategies to improve telemedicine implementation in safety net settings.

Examining the Role and Strategies of Advocacy Coalitions in California's Statewide Sugar-Sweetened Beverage Tax Debate (2001-2018)

PURPOSE

California's failed attempts to enact a statewide sugary beverage tax presents an opportunity to advance understanding of advocacy coalition behavior. We investigate the participation of advocacy coalitions in California's statewide sugar-sweetened beverage (SSB) tax policy debate.

DESIGN

Document analysis of legislative bills and newspaper articles collected in 2019.

SETTING

California.

METHOD

A total of 11 SSB tax-related bills were introduced in California's legislature between 2001-2018 according to the state's legislative website. Data sources include legislative bill documents (n = 94) and newspaper articles (n = 138). Guided by the Advocacy Coalition Framework (ACF), we identify advocacy coalitions involved in California's SSB tax debate and explore strategies and arguments used to advance each coalitions' position.

RESULTS

Two coalitions (public health, food/beverage industry) were involved in California's statewide SSB tax policy debate. The public health coalition had higher member participation and referred to scientific research evidence while the industry coalition used preemption and financial resources as primary advocacy strategies. The public health coalition frequently presented messaging on the health consequences and financial benefits of SSB taxes. The industry coalition responded by focusing on the potential negative economic impact of a tax.

CONCLUSION

Multiple attempts to enact a statewide SSB tax in California have failed. Our findings add insight into the challenges of enacting an SSB tax considering industry interference. Results can inform future efforts to pass evidence-based nutrition policies.

Nutrition Environment Gaps and Distribution Challenges in Rural Food Pantries During the COVID-19 Pandemic: A Mixed-Methods Study

BACKGROUND

Food insecurity disproportionately affects low-income, racially marginalized, and rural communities. The COVID-19 pandemic led to higher demand for emergency food distribution, potentially impacting food pantry operations and services. Limited research exists assessing consumer nutrition environments of pantries in rural regions.

OBJECTIVES

To assess the consumer nutrition environment of rural food pantries and report challenges and adaptations encountered during the pandemic.

DESIGN

A mixed-methods, cross-sectional survey.

PARTICIPANTS/SETTING

Nineteen food pantry representatives from California's San Joaquin Valley were surveyed between August 2020 and June 2021. Representatives were eligible if their pantry served the general population and was open at least once a week. Nine were church-based pantries, and 10 were from other settings.

MAIN OUTCOME MEASURES

The Nutrition Environment Food Pantry Assessment Tool (NEFPAT) measured the nutrition food environment and scored pantries as bronze (0-15), silver (16-31), or gold (32-47) categories. Eleven items were developed to explore pandemic-related challenges.

STATISTICAL ANALYSES PERFORMED

Independent χ2 tests assessed the relationship between the organization type and NEFPAT scores and food supply sources. Fisher's exact test explored associations between food pantry type, NEFPAT category, and challenges. Nonparametric tests were run on non-normally distributed data. Inductive content analysis was used to examine open-ended pandemic-related questions.

RESULTS

The nutrition environment of most pantries was suboptimal, because no pantry scored in the "gold" category based on total NEFPAT scores (median, 18 of 47). No statistically significant differences were found in the NEFPAT scores by organization type. Most pantries did not provide healthy food nudges or culturally diverse foods. Key COVID-19 challenges encountered consisted of supply- and demand-side issues, including reduced personnel, capacity, and resources, and increased client quantity and demand for food.

CONCLUSIONS

Assessing the nutrition environment of rural food pantries revealed gaps and strategies for improvement, including the use of healthy nudges and increasing the availability of culturally diverse foods.

Implementation of a universal screening and follow-up care system for pediatric developmental and behavioral health in federally qualified health center sites

BACKGROUND

Despite guidelines from the American Academy of Pediatrics (AAP), many pediatric practices still do not have standardized screening processes in place to identify children with developmental delays. From April 2014 to April 2017, six federally qualified health center (FQHC) sites in Northern California implemented an intervention to increase (a) standardized developmental screening at recommended intervals and (b) follow-up care and support for early intervention services.

METHOD

The intervention aimed to optimize each site's screening processes, supported by an automated electronic tablet-based system. To improve follow-up support, social workers were hired to conduct follow-up clinical assessments, provide psychosocial education and treatment, provide referrals and case management support, and collaborate with service partners. We analyze operational and implementation data to characterize site adoption, patient reach, implementation processes, and intervention effectiveness.

RESULTS

During the intervention's final year, when tablet-based screening was adopted, the sites screened an estimated 6,550 children ages 0-18 at 23 intervals in three domains (developmental, autism, and psychosocial/behavioral), compared to a baseline where they screened ages 0-3 at four intervals in one domain. Screening rates increased from 65.3% to 75.5% after automation was extended from the first to the second site, then to 91.8% after automation was expanded to the remaining sites. Follow-up visit rates ranged between 74% and 88%.

CONCLUSIONS

Implementation of a multicomponent developmental and behavioral health screening and follow-up care intervention enabled FQHC sites to meet AAP recommendations and provide follow-up support. Disseminating the intervention may support population-level improvement in early detection and intervention for developmental delays and behavioral health concerns. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Care Redesign to Support Telemedicine Implementation During the COVID-19 Pandemic: Federally Qualified Health Center Personnel Experiences

BACKGROUND

Federally qualified health centers (FQHCs) rapidly adopted and implemented telemedicine during the COVID-19 pandemic. This study analyzes FQHC personnel accounts of care redesign strategies to support telemedicine implementation in 2020 and 2021, and identifies improvement opportunities.

METHODS

We conducted semistructured, in-depth interviews with clinic personnel (n = 15) at 2 FQHCs in Northern California (December 2020-April 2021) to examine telemedicine adoption and use of audio-video and audio-only/phone telemedicine encounters.

RESULTS

FQHC clinicians and staff reported that telemedicine implementation increased access to care and reduced appointment no-show rates. However, a reported reduced ability to develop and foster interpersonal connections negatively impacted clinician-patient relationships. Care redesign strategies included systems to triage appointment types (in-person versus virtual), work-arounds to screen for and address social and nonmedical needs, and new protocols to navigate privacy needs for first time telemedicine users. In addition, increasing remote monitoring capabilities was deemed an important priority for improving telemedicine use for marginalized populations.

CONCLUSIONS

Telemedicine implementation in FQHCs involved care redesign to optimize virtual interactions and care processes. Guidelines and evidence-based practices are needed to improve telemedicine use in FQHCs, including strategies to support interpersonal connections; approaches to virtually screen for and address social needs; and protocols to further mitigate privacy issues. Future research is needed to identify when telemedicine can optimally supplement in-person care to improve patient outcomes and clinic efficiency, particularly in safety net settings.

Telehealth Use, Care Continuity, and Quality: Diabetes and Hypertension Care in Community Health Centers Before and During the COVID-19 Pandemic

BACKGROUND

Community health centers (CHCs) pivoted to using telehealth to deliver chronic care during the coronavirus COVID-19 pandemic. While care continuity can improve care quality and patients' experiences, it is unclear whether telehealth supported this relationship.

OBJECTIVE

We examine the association of care continuity with diabetes and hypertension care quality in CHCs before and during COVID-19 and the mediating effect of telehealth.

RESEARCH DESIGN

This was a cohort study.

PARTICIPANTS

Electronic health record data from 166 CHCs with n=20,792 patients with diabetes and/or hypertension with ≥2 encounters/year during 2019 and 2020.

METHODS

Multivariable logistic regression models estimated the association of care continuity (Modified Modified Continuity Index; MMCI) with telehealth use and care processes. Generalized linear regression models estimated the association of MMCI and intermediate outcomes. Formal mediation analyses assessed whether telehealth mediated the association of MMCI with A1c testing during 2020.

RESULTS

MMCI [2019: odds ratio (OR)=1.98, marginal effect=0.69, z=165.50, P<0.001; 2020: OR=1.50, marginal effect=0.63, z=147.73, P<0.001] and telehealth use (2019: OR=1.50, marginal effect=0.85, z=122.87, P<0.001; 2020: OR=10.00, marginal effect=0.90, z=155.57, P<0.001) were associated with higher odds of A1c testing. MMCI was associated with lower systolic (β=-2.90, P<0.001) and diastolic blood pressure (β=-1.44, P<0.001) in 2020, and lower A1c values (2019: β=-0.57, P=0.007; 2020: β=-0.45, P=0.008) in both years. In 2020, telehealth use mediated 38.7% of the relationship between MMCI and A1c testing.

CONCLUSIONS

Higher care continuity is associated with telehealth use and A1c testing, and lower A1c and blood pressure. Telehealth use mediates the association of care continuity and A1c testing. Care continuity may facilitate telehealth use and resilient performance on process measures.

Impact of the COVID-19 pandemic on infant feeding practices in the United States: Food insecurity, supply shortages and deleterious formula-feeding practices

The coronavirus disease 2019 (COVID-19) pandemic increased food insecurity among US households, however, little is known about how infants, who rely primarily on human milk and/or infant formula, were impacted. We conducted an online survey with US caregivers of infants under 2 years of age (N = 319) to assess how the COVID-19 pandemic impacted breastfeeding, formula-feeding and household ability to obtain infant-feeding supplies and lactation support (68% mothers; 66% White; 8% living in poverty). We found that 31% of families who used infant formula indicated that they experienced various challenges in obtaining infant formula, citing the following top three reasons: the formula was sold out (20%), they had to travel to multiple stores (21%) or formula was too expensive (8%). In response, 33% of families who used formula reported resorting to deleterious formula-feeding practices such as diluting formula with extra water (11%) or cereal (10%), preparing smaller bottles (8%) or saving leftover mixed bottles for later (11%). Of the families who fed infants human milk, 53% reported feeding changes directly as a result of the pandemic, for example, 46% increased their provisioning of human milk due to perceived benefits for the infant's immune system (37%), ability to work remotely/stay home (31%), concerns about money (9%) or formula shortages (8%). Fifteen percent of families who fed human milk reported that they did not receive the lactation support they needed and 4.8% stopped breastfeeding. To protect infant food and nutrition security, our results underscore the need for policies to support breastfeeding and ensure equitable and reliable access to infant formula.

Telemedicine implementation and use in community health centers during COVID-19: Clinic personnel and patient perspectives

In March 2020, federal and state telehealth policy changes catalyzed telemedicine adoption and use in community health centers. There is a dearth of evidence on telemedicine implementation and use in these safety net settings and a lack of information reflecting the perspectives of patients with limited English proficiency. We conducted in-depth interviews with clinic personnel and patients during the pandemic in two federally qualified health centers that primarily serve Chinese and Latino immigrants. Twenty-four interviews (clinic personnel ​= ​15; patients who primarily speak a language other than English ​= ​9) were completed remotely between December 2020 and April 2021. Interview scripts included questions about their telemedicine experiences, technology, resources and needs, barriers, facilitators, language access, and continued use, with a brief socio-demographic survey. Data analyses involved a primarily deductive approach and thematic analysis of transcript content. Both FQHCs adopted telemedicine in a few weeks and transitioned primarily to video and audio-only visits within two months. Findings reveal third-party language interpretation services were challenging to integrate into telemedicine video visits. Bilingual personnel who provided language concordant care were seen as essential for efficient and high-quality patient telemedicine experiences. Audio-only visits were of particular benefit to reach patients of older age, with limited English proficiency, and with limited digital literacy. Continued use of telemedicine is contingent on reimbursement policy decisions and interventions to increase patient digital literacy and technological resources. Results highlight the importance of reimbursing audio-only visits post-pandemic and investing in efforts to improve the quality of language services in telemedicine encounters.

United for health to improve urban food environments across five underserved communities: a cross-sector coalition approach

Background

Cross-sector coalitions can be a powerful vehicle to promote adoption and implementation of evidence-based programs and policies across diverse racial/ethnic communities with a high chronic disease burden. Few studies have examined coalition composition, function, or capacity to promote learning among members.

Methods

We used a mixed methods approach to examine the United for Health coalition’s implementation of multiple food environment interventions across five low-income communities of color in Los Angeles, California (USA). At the coalition-level, key measures included the collaborative environment, membership characteristics, process and structure, communication, resources, strengths, challenges/barriers, and community impact. At the organizational- and individual-levels, we collected data on participation, leadership development, intraorganizational change, perceived benefits, and learning outcomes.

Findings

Overall, the United for Health coalition produced five community gardens, three pop-up produce markets, and one farmers’ market; members also expanded Electronic Benefits Transfer (EBT) access at three existing farmers’ markets. Findings indicate early coalition strengths included having a mutual purpose, which was maintained throughout the study period. Coalition participation and engagement was consistently high, while coalition and inter-organizational communication improved over time. Strengths were membership diversity and the availability of learning opportunities. Benefits included leadership development and strategic alignment across organizations. Members demonstrated an increased awareness of the importance of culturally adapted interventions and knowledge of community health planning topics. Key implementation challenges were a lack of resources and social context barriers.

Conclusions

Examining coalition function and maturation in a real-world context reveals important lessons for scholars and practitioners committed to addressing nutrition-related health disparities in marginalized and historically underserved communities. Future work should investigate the sustainability of externally funded cross-sector coalitions after funding ceases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13245-2.

Assessing sustainment of health worker outcomes beyond program end: Evaluation results from an infant and young child feeding intervention in Bangladesh

Introduction

Alive and Thrive (A&T) implemented infant and young child feeding (IYCF) interventions in Bangladesh. We examine the sustained impacts on health workers' IYCF knowledge, service delivery, job satisfaction, and job readiness three years after the program's conclusion.

Methods

We use data from a cluster-randomized controlled trial design, including repeated cross-sectional surveys with health workers in 2010 (baseline, n = 290), 2014 (endline, n = 511) and 2017 (post-endline, n = 600). Health workers in 10 sub-districts were trained and incentivized to deliver intensified IYCF counseling, and participated in social mobilization activities, while health workers in 10 comparison sub-districts delivered standard counseling activities. Accompanying mass media and policy change activities occurred at the national level. The primary outcome is quality of IYCF service delivery (number of IYCF messages reportedly communicated during counseling); intermediate outcomes are IYCF knowledge, job satisfaction, and job readiness. We also assess the role of hypothesized modifiers of program sustainment, i.e. activities of the program: comprehensiveness of refresher trainings and receipt of financial incentives. Multivariable difference-in-difference linear regression models, including worker characteristic covariates and adjusted for clustering at the survey sampling level, are used to compare differences between groups (intervention vs. comparison areas) and over time (baseline, endline, post-endline).

Results

At endline, health workers in intervention areas discussed significantly more IYCF topics than those in comparison areas (4.9 vs. 4.0 topics, p < 0.001), but levels decreased and the post-endline gap was no longer significant (4.0 vs. 3.3 topics, p = 0.067). Comprehensive refresher trainings were protective against deterioration in service delivery. Between baseline and endline, the intervention increased health workers' knowledge (3.5-point increase in knowledge scores in intervention areas, vs. 1.5-point increase in comparison areas, p < 0.0001); and this improvement persisted to post-endline, suggesting a sustained program effect on knowledge. Job satisfaction and readiness both saw improvements among workers in intervention areas during the project period (baseline to endline) but regressed to a similar level as comparison areas by post-endline.

Discussion

Our study showed sustained impact of IYCF interventions on health workers' knowledge, but not job satisfaction or job readiness-and, critically, no sustained program effect on service delivery. Programs of limited duration may seek to assess the status of and invest in protective factors identified in this study (e.g., refresher trainings) to encourage sustained impact of improved service delivery. Studies should also prioritize collecting post-endline data to empirically test and refine concepts of sustainment.

County-Level Recreational Marijuana Policies and Local Policy Changes in Colorado and Washington State (2012-2019)

Policy Points In 2012, Colorado and Washington were the first states to legalize recreational marijuana through voter-initiated ballots. In these states, counties could restrict or ban local marijuana facilities through a variety of regulatory methods such as ordinances and zoning. County-level recreational marijuana policies in Washington and Colorado vary substantially, with 69.2% of Washington counties and 23.4% of Colorado counties allowing all types of recreational marijuana facilities as of April 1, 2019. After Colorado and Washington legalized recreational marijuana, many counties modified their marijuana policies over time, with shifts in county policy often preceded by advocacy and information-seeking activities.

CONTEXT

In 2012, Colorado and Washington were the first states to legalize recreational marijuana. Both allowed local governments to further regulate the availability of marijuana facilities in their jurisdictions. As early adopters, these states are important quasi-natural experiments to examine local marijuana policy and policy change processes, including key stakeholders and arguments.

METHODS

We conducted a policy scan of county-level recreational marijuana ordinances and regulations in Colorado and Washington. Data collected included policy documents from counties in both states and newspaper articles. We used a mixed-methods approach to describe the types of county-level recreational marijuana policies enacted by April 1, 2019; identify key policy stakeholders involved in local policy debates; and explore arguments used in support or opposition of county policies. We also selected four counties that represent three county policy environments (all marijuana facility types allowed, some marijuana facility types allowed, all marijuana facility types prohibited) and described the policy changes within these counties since recreational marijuana was legalized.

FINDINGS

By April 1, 2019, Colorado counties were less likely than Washington counties to allow marijuana facilities-48.4% of Colorado counties prohibited recreational marijuana facilities in their jurisdiction compared to 23.1% of Washington counties. Since state legalization, several counties in both states have made substantial marijuana facility policy modifications, often preceded by information-seeking activities. Primary stakeholders involved in policy debates included elected officials, law enforcement, individual growers/farmers, marijuana business license applicants, parents, and residents. Proponents referenced local economic gain, reduced crime, and potential health benefits of marijuana as arguments in favor of permitting local facilities, whereas opponents pointed to economic loss, negative health and public health issues, public safety concerns, and existing federal law. Both sides referenced local public opinion data to support their position.

CONCLUSIONS

By early 2019, a patchwork of local marijuana policies was in place in Colorado and Washington. We identify key areas of policy and public health research needed to inform future local marijuana policy decisions, including the impact of legalization on public health outcomes (particularly for youth) and public safety.

Perceptions and determinants of healthy eating for people with HIV in the Dominican Republic who experience food insecurity

OBJECTIVE

The current study aimed to understand how moderate and severe food-insecure people living with HIV (PLHIV) in the Dominican Republic perceive a healthy diet and explore facilitators and barriers to engaging in healthy dietary behaviours as a means of HIV self-management.

DESIGN

We conducted semi-structured interviews with PLHIV. We generated codes on food insecurity among PLHIV and used content analysis to organise codes for constant comparison between and within participants.

SETTING

Two urban HIV clinics in the Dominican Republic.

PARTICIPANTS

Thirty-two PLHIV participated in the interviews.

RESULTS

Factors that contributed to dietary behaviours include individual factors, such as knowledge of nutrition, views and attitudes on healthy dietary behaviours, beliefs about dietary needs for PLHIV and diet functionality. Interpersonal factors, including assistance from family and peers in providing food or funds, were deemed critical along with community and organisational factors, such as food assistance from HIV clinics, accessibility to a variety of food store types and the availability of diverse food options at food stores. Policy-level factors that influenced dietary behaviours were contingent on respondents' participation in the labour market (i.e. whether they were employed) and consistent access to government assistance. Food insecurity influenced these factors through unpredictability and a lack of control.

CONCLUSIONS

PLHIV who experience food insecurity face various barriers to engaging in healthy dietary behaviours. Their diets are influenced at multiple levels of influence ranging from individual to structural, requiring multi-level interventions that can address these factors concurrently.

Taking Care of Yourself and Your Risk for Breast Cancer (CUIDARSE): A Randomized Controlled Trial of a Health Communication Intervention for Latinas

Latinas in the United States are more likely to be diagnosed with late-stage breast cancer (BC) compared to non-Latinas. Literacy-appropriate and culturally sensitive cancer communication interventions can help address existing racial/ethnic BC disparities. We formatively developed a new BC prevention brochure for Spanish-speaking Latinas (≥35 years). Eligible women (n = 240) from a large public hospital in California were randomly assigned to one of three study arms: Group 1 received the new brochure, Group 2 included a community health worker (CHW) who delivered the new brochure's content, and a control group received a standard educational brochure. Participants completed three surveys (baseline, postintervention, 3-month follow-up) with a 100% completion rate for the first two surveys and 80.4% completion after 3 months. We assessed the difference in outcomes for BC risk knowledge, perceived BC susceptibility, and BC information self-efficacy between groups. Participant mean age was 52.3 years, and 82.1% reported low English proficiency. Mean knowledge scores increased and perceived BC susceptibility improved for all groups (p ≤ .05), yet treatment effects were not significant between groups for these outcomes. BC information self-efficacy also increased from baseline to postintervention for all groups to >80%. After 3 months, only Group 2 and the control group retained their increases and treatment effects were significant only for Group 2 compared to other groups in unadjusted and adjusted models. A CHW-delivered intervention may be more effective in improving BC information self-efficacy among Latinas compared to print material alone. More research is needed to examine the efficacy of CHW-delivered interventions.

Church-based interventions to address obesity among African Americans and Latinos in the United States: a systematic review

CONTEXT

Multilevel church-based interventions may help address racial/ethnic disparities in obesity in the United States since churches are often trusted institutions in vulnerable communities. These types of interventions affect at least two levels of socio-ecological influence which could mean an intervention that targets individual congregants as well as the congregation as a whole. However, the extent to which such interventions are developed using a collaborative partnership approach and are effective with diverse racial/ethnic populations is unclear, and these crucial features of well-designed community-based interventions.

OBJECTIVE

The present systematic literature review of church-based interventions was conducted to assess their efficacy for addressing obesity across different racial/ethnic groups (eg, African Americans, Latinos).

DATA SOURCES AND EXTRACTION

In total, 43 relevant articles were identified using systematic review methods developed by the Center for Disease Control and Prevention (CDC)'s Task Force on Community Preventive Services. The extent to which each intervention was developed using community-based participatory research principles, was tailored to the particular community in question, and involved the church in the study development and implementation were also assessed.

DATA ANALYSIS

Although 81% of the studies reported significant results for between- or within-group differences according to the study design, effect sizes were reported or could only be calculated in 56% of cases, and most were small. There was also a lack of diversity among samples (eg, few studies involved Latinos, men, young adults, or children), which limits knowledge about the ability of church-based interventions to reduce the burden of obesity more broadly among vulnerable communities of color. Further, few interventions were multilevel in nature, or incorporated strategies at the church or community level.

CONCLUSIONS

Church-based interventions to address obesity will have greater impact if they consider the diversity among populations burdened by this condition and develop programs that are tailored to these different populations (eg, men of color, Latinos). Programs could also benefit from employing multilevel approaches to move the field away from behavioral modifications at the individual level and into a more systems-based framework. However, effect sizes will likely remain small, especially since individuals only spend a limited amount of time in this particular setting.

Use of research evidence in state health policymaking: Menu labeling policy in California

Addressing the translational gap between research evidence and state health policy requires an understanding of the current use of research evidence in the state policymaking process. In this study, we explore the use of research evidence to inform the legislative debate about restaurant nutrition labeling policy in California. In 2008, California was the first state to enact a mandatory menu calorie labeling policy in the U.S. Using a qualitative approach, we examine data sources and types of evidence used in legislative documents (n = 87) related to six menu labeling bills introduced in California's state legislature between 2003 and 2008. Federal- and state-level government agency reports were the most frequently cited sources of technical knowledge. Advocacy coalition members who were active participants involved in the policy debate were also cited as experts. Five of the six bills included evidence in related legislative documents. While documents included considerable evidence on the magnitude and severity of the obesity problem to justify policy enactment, there were a limited number of statements referring to policy effectiveness and only one statement identified attesting to implementation context and acceptability. Reference to evidence on related policy suggests policy precedence may also play an important role in policy decision making. There is a need to improve the dissemination of obesity policy effectiveness and implementation studies in a politically time sensitive manner to influence state health policy debates. Strategies are discussed to effectively integrate the use of research evidence in the state health policymaking process.

Feasibility and acceptability of a mobile messaging program within a church-based healthy living intervention for African Americans and Latinos

Church-based programs can act on multiple levels to improve dietary and physical activity behaviors among African Americans and Latinos. However, the effectiveness of these interventions may be limited due to challenges in reaching all congregants or influencing behavior outside of the church setting. To increase intervention impact, we sent mobile messages (text and email) in English or Spanish to congregants (n = 131) from predominantly African American or Latino churches participating in a multi-level, church-based program. To assess feasibility and acceptability, we collected feedback throughout the 4-month messaging intervention and conducted a process evaluation using the messaging platform. We found that the intervention was feasible to implement and acceptable to a racially ethnically diverse study sample with high obesity and overweight rates. While the process evaluation had some limitations (e.g. low response rate), we conclude that mobile messaging is a promising, feasible addition to church-based programs aiming to improve dietary and physical activity behaviors.

Eat, Pray, Move: A Pilot Cluster Randomized Controlled Trial of a Multilevel Church-Based Intervention to Address Obesity Among African Americans and Latinos

PURPOSE

To implement a multilevel, church-based intervention with diverse disparity populations using community-based participatory research and evaluate feasibility, acceptability, and preliminary effectiveness in improving obesity-related outcomes.

DESIGN

Cluster randomized controlled trial (pilot).

SETTING

Two midsized (∼200 adults) African American baptist and 2 very large (∼2000) Latino Catholic churches in South Los Angeles, California.

PARTICIPANTS

Adult (18+ years) congregants (n = 268 enrolled at baseline, ranging from 45 to 99 per church).

INTERVENTION

Various components were implemented over 5 months and included 2 sermons by pastor, educational handouts, church vegetable and fruit gardens, cooking and nutrition classes, daily mobile messaging, community mapping of food and physical activity environments, and identification of congregational policy changes to increase healthy meals.

MEASURES

Outcomes included objectively measured body weight, body mass index (BMI), and systolic and diastolic blood pressure (BP), plus self-reported overall healthiness of diet and usual minutes spent in physical activity each week; control variables include sex, age, race-ethnicity, English proficiency, education, household income, and (for physical activity outcome) self-reported health status.

ANALYSIS

Multivariate linear regression models estimated the average effect size of the intervention, controlling for pair fixed effects, a main effect of the intervention, and baseline values of the outcomes.

RESULTS

Among those completing follow-up (68%), the intervention resulted in statistically significantly less weight gain and greater weight loss (-0.05 effect sizes; 95% confidence interval [CI] = -0.06 to -0.04), lower BMI (-0.08; 95% CI = -0.11 to -0.05), and healthier diet (-0.09; 95% CI = -0.17 to -0.00). There was no evidence of an intervention impact on BP or physical activity minutes per week.

CONCLUSION

Implementing a multilevel intervention across diverse congregations resulted in small improvements in obesity outcomes. A longer time line is needed to fully implement and assess effects of community and congregation environmental strategies and to allow for potential larger impacts of the intervention.

Promoting Health from the Pulpit: A Process Evaluation of HIV Sermons to Reduce HIV Stigma and Promote Testing in African American and Latino Churches

Embedding health messages into sermons is a potentially valuable strategy to address HIV and other health disparities in churches that predominantly serve racial and ethnic minorities. This study explores implementation of an HIV sermon as part of a multi-component intervention in three churches (Latino Catholic, Latino Pentecostal, and African American Baptist) in high HIV prevalence areas of Los Angeles County, California. Clergy were given an HIV sermon guide that included local public health data, stigma reduction cues, HIV testing messages, and a sample sermon. Findings are based on a process evaluation (i.e., reach, dose delivered, fidelity, and implementation) and in-depth content analysis to explore HIV frames and messages used by clergy. Sermons were audio-recorded, transcribed verbatim, and coded using an inductive approach. Complementary data were collected through systematic observation. Overall, five clergy delivered nine HIV sermons to majority African American or Latino audiences. On average, 174 congregants were reached per sermon. We found large variation in fidelity to communicating key HIV messages from the sermon guide. While promoting HIV testing from the pulpit seemed viable and acceptable to all the participating clergy, fewer embedded explicit stigma reduction cues. Most spoke about HIV using compassionate and non-judgmental terms, however, issue framing varied across clergy. Structured training of clergy may be necessary to implement the more theoretically driven stigma reduction cues included in the sermon guide. More research is needed on the viability and acceptability of embedding specific health promotion messages into sermons.

Severe food insecurity is associated with overweight and increased body fat among people living with HIV in the Dominican Republic

Food insecurity is an important risk factor for overweight and obesity among low-income populations in high income countries, but has not been well-studied among people living with HIV (PLHIV), particularly in resource-poor settings. To explore the association between food insecurity and overweight and obesity among PLHIV in the Dominican Republic, we conducted a cross-sectional study of 160 HIV-infected adults between March-December 2012 in four geographically-dispersed health centers (Santo Domingo, Puerto Plata, San Juan, and Higuey). We collected information on household food insecurity, anthropometric measurements, and socio-demographic data and ran descriptive and multivariate analyses, controlling for fixed effects of clinics and using robust standard errors. Mean age ± SD of participants was 39.9 ± 10.5 years; 68% were women, and 78% were on antiretroviral therapy (ART). A total of 58% reported severe household food insecurity. After controlling for age, gender, income, having children at home, education, and ART status, severe food insecurity was associated with increased body mass index (BMI) (β = 1.891, p = 0.023) and body fat (β = 4.004, p = 0.007). Age and female gender were also associated with increased body fat (β = 0.259, p < 0.001 and β = 8.568, p < 0.001, respectively) and age and ART status were associated with increased waist circumference (β = 0.279, p = 0.011 and β = 5.768, p = 0.046, respectively). When overweight was examined as a dichotomous variable (BMI ≥ 25.0), severe food insecurity was associated with an increased odds of 3.060 (p = 0.013); no other covariates were independently associated with overweight. The association of severe food insecurity with increased BMI, body fat, and overweight among PLHIV has important implications for clinical care as well as food security and nutrition interventions in resource-poor settings. Integrated programs that combine nutrition education or counseling with sustainable approaches to addressing food insecurity among PLHIV are needed to improve long-term health outcomes of this vulnerable population.

Perceived Barriers and Facilitators to Healthy Eating and School Lunch Meals among Adolescents: A Qualitative Study

OBJECTIVES

We explored how perceived barriers and facilitators influence healthy eating and investigated the acceptability of changes to school lunch meals among adolescents after implementation of the Healthy, Hunger-Free Kids Act of 2010.

METHODS

We conducted 8 focus groups with adolescents (N = 64) at 3 South Los Angeles high schools. Data collection instruments included a semi-structured guide and questionnaire. Two researchers independently coded transcripts.

RESULTS

Most participants believed fruits and vegetables were available in their community and reported high relative cost, poor quality, and lack of motivation as barriers to consumption. Many said school meals were an important source of healthy food and were aware of recent changes to the school lunch program. A primary facilitator to eating school lunches was access to fresh food items (eg, a salad bar). Perceived barriers included long cafeteria lines, time constraints, lack of variety, and limited quantities of preferred items. Adolescents viewed off-campus food establishments near the school as competition to school meals.

CONCLUSIONS

Our findings suggest the need to measure perceived and actual barriers to healthy eating among adolescents and to examine the effect of these barriers on dietary behavior. We provide programmatic and policy recommendations.

Process Evaluation of a Peer-Driven, HIV Stigma Reduction and HIV Testing Intervention in Latino and African American Churches

Purpose: Faith-based organizations may be effective in addressing HIV-related disparities, but few interventions have been implemented across diverse churches. The Facilitating Awareness to Increase Testing for HIV (FAITH) intervention harnessed peer leadership to decrease HIV stigma and promote HIV testing in African American and Latino congregations. A pilot study found more consistent effects among Latino congregations. This process evaluation evaluates implementation of FAITH to better understand the pilot study's findings.

Methods: Data sources included HIV education and peer leader workshop evaluation forms, participant views of the community's perspective of HIV, and peer leader follow-up interviews. Data were triangulated with systematic observation notes and analyzed using process-related themes of recruitment, reach, context, implementation, dose-delivered, and fidelity.

Results: At the Latino churches (compared to the African American church), facilitators spent more time addressing community-based misconceptions about HIV. The peer leader model was well received, especially among Latino participants, and most said that after the workshop they felt comfortable speaking with others about HIV-related topics. Latino peer leaders reported speaking with up to 20 people within their social networks (particularly with family members); African Americans reported up to 4. Implementation challenges at the African American church may have contributed to the limited intervention effects. Nevertheless, we found the peer motivator model feasible and acceptable across diverse faith settings.

Conclusion: Peer-based models within faith settings are promising for addressing HIV. However, differences among groups in HIV knowledge, social network characteristics and norms, and church preferences may influence overall effectiveness.

Factors contributing to food insecurity among women living with HIV in the Dominican Republic: A qualitative study

Background

Food insecurity contributes to poor health outcomes among people living with HIV. In Latin America and the Caribbean, structural factors such as poverty, stigma, and inequality disproportionately affect women and may fuel both the HIV epidemic and food insecurity.

Methods

We examined factors contributing to food insecurity among women living with HIV (WLHIV) in the Dominican Republic (DR). Data collection included in-depth, semi-structured interviews in 2013 with 30 WLHIV with indications of food insecurity who resided in urban or peri-urban areas and were recruited from local HIV clinics. In-person interviews were conducted in Spanish. Transcripts were coded using content analysis methods and an inductive approach to identify principal and emergent themes.

Results

Respondents identified economic instability as the primary driver of food insecurity, precipitated by enacted stigma in the labor and social domains. Women described experiences of HIV-related labor discrimination in formal and informal sectors. Women commonly reported illegal HIV testing by employers, and subsequent dismissal if HIV-positive, especially in tourism and free trade zones. Enacted stigma in the social domain manifested as gossip and rejection by family, friends, and neighbors and physical, verbal, and sexual abuse by intimate partners, distancing women from sources of economic and food support. These experiences with discrimination and abuse contributed to internalized stigma among respondents who, as a result, were fearful and hesitant to disclose their HIV status; some participants reported leaving spouses and/or families, resulting in further isolation from economic resources, food and other support. A minority of participants described social support by friends, spouses, families and support groups, which helped to ameliorate food insecurity and emotional distress.

Conclusions

Addressing food insecurity among WLHIV requires policy and programmatic interventions to enforce existing laws designed to protect the rights of people living with HIV, reduce HIV-related stigma, and improve gender equality.

Catalyzing Implementation of Evidence-Based Interventions in Safety Net Settings: A Clinical-Community Partnership in South Los Angeles

This study is a process evaluation of a clinical-community partnership that implemented evidence-based interventions in clinical safety net settings. Adoption and implementation of evidence-based interventions in these settings can help reduce health disparities by improving the quality of clinical preventive services in health care settings with underserved populations. A clinical-community partnership model is a possible avenue to catalyze adoption and implementation of interventions amid organizational barriers to change. Three Federally Qualified Health Centers in South Los Angeles participated in a partnership led by a local community-based organization (CBO) to implement hypertension interventions. Qualitative research methods were used to evaluate intervention selection and implementation processes between January 2014 and June 2015. Data collection tools included a key participant interview guide, health care provider interview guide, and protocol for taking meeting minutes. This case study demonstrates how a CBO acted as an external facilitator and employed a collaborative partnership model to catalyze implementation of evidence-based interventions in safety net settings. The study phases observed included initiation, planning, and implementation. Three emergent categories of organizational facilitators and barriers were identified (personnel capacity, professional development capacity, and technological capacity). Key participants and health care providers expressed a high level of satisfaction with the collaborative and the interventions, respectively. The CBO's role as a facilitator and catalyst is a replicable model to promote intervention adoption and implementation in safety net settings. Key lessons learned are provided for researchers and practitioners interested in partnering with Federally Qualified Health Centers to implement health promotion interventions.

Advocacy coalitions involved in California's menu labeling policy debate: Exploring coalition structure, policy beliefs, resources, and strategies

Advocacy coalitions often play an important role in the state health policymaking process, yet little is known about their structure, composition, and behavior. In 2008, California became the first state to enact a menu labeling law. Using the advocacy coalition framework, we examine different facets of the coalitions involved in California’s menu labeling policy debate. We use a qualitative research approach to identify coalition members and explore their expressed beliefs and policy arguments, resources, and strategies by analyzing legislative documents (n=87) and newspaper articles (n=78) produced between 1999 and 2009. Between 2003 and 2008, six menu labeling bills were introduced in the state’s legislature. We found the issue received increasing media attention during this period. We identified two advocacy coalitions involved in the debate—a public health (PH) coalition and an industry coalition. State organizations acted as coalition leaders and participated for a longer duration than elected officials. The structure and composition of each coalition varied. PH coalition leadership and membership notably increased compared to the industry coalition. The PH coalition, led by nonprofit PH and health organizations, promoted a clear and consistent message around informed decision making. The industry coalition, led by a state restaurant association, responded with cost and implementation arguments. Each coalition used various resources and strategies to advance desired outcomes. PH coalition leaders were particularly effective at using resources and employing advocacy strategies, which included engaging state legislators as coalition members, using public opinion polls and information, and leveraging media resources to garner support. Policy precedence and a local policy push emerged as important policymaking strategies. Areas for future research on the state health policymaking process are discussed.