Sustainability Planning for a Community Network to Increase Participation in Evidence-Based Lifestyle Change Programs: A Mixed-Methods Approach

Community-based chronic disease prevention programs can have long-term, broad public health benefits. Yet, only 40 to 60% of evidence-based health programs are sustained. Using established frameworks and evidence-based tools to characterize sustainability allows programs to develop structures and processes to leverage resources effectively to sustain effective program activities and systems. This study used a mixed-methods, partner-engaged approach to identify barriers and facilitators to sustaining a community network (the Alliance program) aimed to increase participation in evidence-based lifestyle change programs delivered in the community. Surveys and qualitative interviews were conducted with the Alliance partners based on the Program Sustainability Assessment Tool and Consolidated Framework for Implementation Research. Overall, partners felt Alliance had a high capacity for sustainability. Strategic planning, communication, and partnerships were areas partners prioritized to improve the potential for sustaining the program. Results informed the co-development of a sustainability action plan. This paper furthers our understanding of factors critical for the sustainability of community-based programs for chronic disease prevention and health equity and presents a process for developing action plans to build sustainability capacity.

A Communitywide Collaboration to Increase Enrollment, Retention, and Success in Evidence-Based Lifestyle-Change Programs in Racial and Ethnic Minority Populations

PURPOSE AND OBJECTIVES

Chronic diseases (eg, diabetes, hypertension) are the leading causes of death in the US and disproportionally affect racial and ethnic minority populations. This disparity is partially due to the unequal burden of unmet social needs that stem from several factors, including racism.

INTERVENTION APPROACH

The Alliance is a collaboration among health care, public health, and community organizations formed to improve referral, enrollment, and successful completion of evidence-based lifestyle-change programs, particularly among Black people. The Alliance built 1) a system to assess and address social barriers through the screening and referral process and 2) a training center for frontline staff (eg, community health workers).

EVALUATION METHODS

From January 2020 through September 2022, we conducted an evaluation that included both quantitative and qualitative methods. We developed an electronic database to make referrals and track key barriers to participation. Additionally, we conducted a focus group among frontline staff (N = 15) to understand the challenges in making referrals and discussing, documenting, and addressing barriers to participation. We used surveys that collected quantitative and open-ended qualitative responses to evaluate the training center and to understand perceptions of training modules as well as the skills gained.

RESULTS

Frontline staff engaged with 6,036 people, of whom 847 (14%) were referred to a lifestyle-change program from January 2020 through September 2022. Of those referred, 257 (30%) were eligible and enrolled in a program. Food access and unreliable internet were the most common barriers to participation. Thirteen of 15 frontline staff participated in trainings, and, on average, trainees completed 4.2 trainings and gained several skills (eg, ability to monitor personal bias, de-escalate a crisis, educate on mental health, understand community and environmental factors).

IMPLICATIONS FOR PUBLIC HEALTH

The Alliance is an example of how health care, public health, and community partners can work together to increase enrollment in lifestyle-change programs of residents disproportionately affected by chronic diseases. Lessons learned from implementation and evaluation can inform other complex partnerships to improve public health.

Combined Effect of Lead Exposure and Allostatic Load on Cardiovascular Disease Mortality-A Preliminary Study

This study explores the combined effect of lead (Pb) exposure and an index of chronic physiological stress on cardiovascular disease mortality using data from the National Health and Nutrition Examination Survey (NHANES) 1999-2008 linked to 1999-2014 National Death Index data. Chronic physiological stress was measured using the allostatic load (AL) index, which was formed by analyzing markers from the cardiovascular, inflammatory, and metabolic systems, with Pb levels, assessed using blood lead levels (BLL). The dataset was analyzed with statistical techniques to explore (a) the relationship between Pb exposure and AL, and (b) the combined role of Pb and AL on cardiovascular disease mortality. Results indicated that AL was more elevated in those with BLLs above the 50th percentile in the US population and that those with elevated AL were more likely to have high BLL. Finally, the interaction of AL and BLL significantly increased the likelihood of cardiovascular disease mortality. These findings highlight the need for considering the totality of exposures experienced by populations to build holistic programs to prevent Pb exposure and reduce stressors to promote optimal health outcomes and reduce cardiovascular mortality risk.

Development of a measurement tool to assess local public health implementation climate and capacity for equity-oriented practice: Application to obesity prevention in a local public health system

OBJECTIVE

The objective of this study was to develop a measurement tool to capture local public health department (LHD) organizational characteristics that align with implementation of equity-oriented practice, which may be used to gauge progress in building public health structures and functions that address the needs of vulnerable populations and reduce health inequities.

METHODS

We developed and tested a measurement tool, with practitioner input, based on an implementation science framework and informed by previous work defining public health essential services and practice recommendations for health equity. Measures assessed types of vulnerable populations served by the LHD, organizational climate, and four equity-oriented practice areas, including: assessment and planning, monitoring and analysis, leadership support, and obesity prevention. We also assessed opportunities for capacity building by identifying training needs of practitioners. Primary data were collected from Missouri local health department practitioners (n = 92, 80% response rate) via an online questionnaire, with a subset of the sample providing data for test-retest reliability.

RESULTS

Measures of equity-oriented implementation climate indicated areas of variability with respect to strengths and gaps across LHDs. While implementation climate was strong with respect to perceived importance (86%), a substantial proportion of LHDs cited concern over other priorities conflicting with equity-oriented implementation (32%). Likewise, a strong internal push (67%) was often accompanied by limited external political (25%) and community support (40%). Implementation climate measures generally had good to excellent reliability and were significantly associated with areas of equity-oriented practice. Frequently identified (>70%) training needs included improving skills in applying frameworks, assessment methods, and evaluating collaborations around equity.

CONCLUSION

We developed a theory-based, practitioner-informed questionnaire to assess capacity for equity-oriented practice and identify opportunities for capacity building in local public health departments to engage in effective change toward health equity.

Assessing Organizational Supports for Evidence-Based Decision Making in Local Public Health Departments in the United States: Development and Psychometric Properties of a New Measure

CONTEXT

Fostering evidence-based decision making (EBDM) within local public health departments and among local health department (LHD) practitioners is crucial for the successful translation of research into public health practice to prevent and control chronic disease.

OBJECTIVE

The purpose of this study was to identify organizational supports for EBDM within LHDs and determine psychometric properties of a measure of organizational supports for EBDM in LHDs.

DESIGN

Cross-sectional, observation study.

SETTING

Local public health departments in the United States.

PARTICIPANTS

Local health department practitioners (N = 376) across the United States participated in the study.

MAIN OUTCOME MEASURES

Local health department practitioners completed a survey containing 27 items about organizational supports for EBDM. Most items were adapted from previously developed surveys, and input from researchers and practitioners guided survey development. Confirmatory factor analysis was used to test and refine the psychometric properties of the measure.

RESULTS

The final solution included 6 factors of 22 items: awareness of EBDM (3 items), capacity for EBDM (7 items), resources availability (3 items), evaluation capacity (3 items), EBDM climate cultivation (3 items), and partnerships to support EBDM (3 items). This factor solution achieved acceptable fit (eg, Comparative Fit Index = 0.965). Logistic regression models showed positive relationships between the 6 factors and the number of evidence-based interventions delivered.

CONCLUSIONS

This study identified important organizational supports for EBDM within LHDs. Results of this study can be used to understand and enhance organizational processes and structures to support EBDM to improve LHD performance and population health. Strong measures are important for understanding how LHDs support EBDM, evaluating interventions to improve LHD capacity, and to guide programmatic and policy efforts within LHDs.

Abstract B085: Disparities and factors associated with 30-day mortality following surgical treatment for squamous cell head and neck cancer with or without adjuvant therapy

Introduction: Factors such as anatomic complexity and extensive surgical procedures increase the risk of serious, sometimes fatal complications post-surgical treatment for head and neck cancer squamous cell carcinoma (HNSCC). Thirty-day (30-day) mortality is a common quality metric that evaluates short-term survival; however, no study has described disparities associated with 30-day mortality following surgery in HNSCC United States population. The aim of this study was to identify disparities and factors (clinical and nonclinical) associated with 30-day postoperative mortality in patients with HNSCC treated with and without adjuvant therapy.

Methods: In this retrospective study, we utilized a patient cohort of 102,877 confirmed HNSCC cases from the National Cancer Database (2004-2013) who were treated surgically with curative intent for the primary head and neck cancer. The effects of adjuvant therapy and other clinical and nonclinical factors on 30-day postoperative mortality were estimated via multivariate logistic regression with adjustment for time-varying nature of adjuvant therapy. Outcome was defined as any-cause-death within 30 days after definitive surgery of primary cancer. We controlled for several clinical and nonclinical covariates, including age, race, sex, health insurance status, primary tumor site, stage of presentation, and Charlson-Deyo comorbidity score.

Results: There were 859 patients who died within 30 days of definitive surgery for cancer, yielding a 30-day mortality rate of 0.83%. Treatment differences were associated with mortality, and patients who received adjuvant therapy had were significantly more likely to die within 30 days compared with those treated with surgery alone (aOR: 3.51; 95% CI 1.85, 6.66). Increasing number of comorbidities was also associated with greater odds of 30-day mortality (Charlson-Deyo comorbidity scores of 1: aOR: 1.45; 95% CI 1.23, 1.71, and Charlson-Deyo comorbidity scores of 2+ aOR: 2.52; 95% CI 2.05, 3.09). There were also sociodemographic disparities associated with 30-day mortality. Odds of 30-day mortality were significantly increased among patients with Medicaid insurance (aOR: 1.99; 95% CI 1.48, 2.68), as well as those who lived in neighborhoods with little education (≥ 29% missing high school diploma: aOR: 1.43; 95% CI 1.08, 1.88).

Conclusions: Disparities impact short-term mortality in the head and neck cancer population. Patients that were significantly more likely to die within 30 days of surgical treatment were those treated with adjuvant therapy, those with greater burden of comorbidities, those with little education, and those covered by Medicaid. To our knowledge, this is the largest study to document short term (30-day) mortality disparities among patients with head and neck cancer post-surgery in the United States. To improve short-term survival among head and neck cancer patients, it is important to account for these disparities found in this study.

Citation Format: Aleksandr R. Bukatko, Parth Patel, Vindhya Kakarla, Matthew C. Simpson, Eric A. Boakye, Katherine A. Stamatakis, Nosayaba Osazuwa-Peters. Disparities and factors associated with 30-day mortality following surgical treatment for squamous cell head and neck cancer with or without adjuvant therapy [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr B085.

Association between depressive symptoms and poor sleep quality among Han and Manchu ethnicities in a large, rural, Chinese population

Objectives

To estimate the relationship between sleep quality and depression, among Han and Manchu ethnicities, in a rural Chinese population.

Methods

A sample of 8,888 adults was selected using a multistage cluster and random sampling method. Sleep quality was evaluated using the Pittsburgh Sleep Quality Index (PSQI). Depressive symptoms were assessed via the Center for Epidemiological Survey, Depression Scale (CES-D). Logistic regression was conducted to assess associations between sleep quality and depression.

Results

The prevalence of poor sleep quality and depression in the Manchus (20.74% and 22.65%) was significantly lower than that in the Hans (29.57% and 26.25%), respectively. Depressive participants had higher odds ratios of global and all sub PSQI elements than non-depressive participants, both among the Hans and the Manchus. Additive interactions were identified between depressive symptoms and ethnicity with global and four sub-PSQI elements, including subjective sleep quality, sleep disturbance, use of sleep medication and daytime dysfunction.

Conclusions

The findings revealed that the prevalence of poor sleep quality and depression among the Hans was greater than among the Manchus. Depression was associated with higher odds of poor sleep quality.

Developing a Survey Tool to Assess Implementation of Evidence-Based Chronic Disease Prevention in Public Health Settings Across Four Countries

Background: Understanding the contextual factors that influence the dissemination and implementation of evidence-based chronic disease prevention (EBCDP) interventions in public health settings across countries could inform strategies to support the dissemination and implementation of EBCDP interventions globally and more effectively prevent chronic diseases. A survey tool to use across diverse countries is lacking. This study describes the development and reliability testing of a survey tool to assess the stage of dissemination, multi-level contextual factors, and individual and agency characteristics that influence the dissemination and implementation of EBCDP interventions in Australia, Brazil, China, and the United States. Methods: Development of the 26-question survey included, a narrative literature review of extant measures in EBCDP; qualitative interviews with 50 chronic disease prevention practitioners in Australia, Brazil, China, and the United States; review by an expert panel of researchers in EBCDP; and test-retest reliability assessment. Results: A convenience sample of practitioners working in chronic disease prevention in each country completed the survey twice (N = 165). Overall, this tool produced good to moderately reliable responses. Generally, reliability of responses was higher among practitioners from Australia and the United States than China and Brazil. Conclusions: Reliability findings inform the adaptation and further development of this tool. Revisions to four questions are recommended before use in China and revisions to two questions before use in Brazil. This survey tool can contribute toward an improved understanding of the contextual factors that public health practitioners in Australia, Brazil, China, and the United States face in their daily chronic disease prevention work related to the dissemination and implementation of EBCDP interventions. This understanding is necessary for the creation of multi-level strategies and policies that promote evidence-based decision-making and effective prevention of chronic diseases on a more global scale.

Ambient particulate matter air pollution associated with acute respiratory distress syndrome in Guangzhou, China

Limited evidence exists concerning the impact of particulate pollution on acute respiratory distress syndrome (ARDS). We examined the effects of particulate pollution on emergency ambulance dispatches (EAD) for ARDS in Guangzhou, China. Daily air pollution concentrations for PM₁₀, PM_2.5, and PM₁, as well as PM_2.5 chemical compositions, were available from a central air monitoring station. The association between incident ARDS and air pollution on the concurrent and previous 5 days was estimated by an over-dispersed Poisson generalized additive model controlling for meteorological factors, temporal trends, public holidays and day of the week. We identified a total of 17,002 EADs for ARDS during the study period. There were significant associations between concentrations of PM₁₀, PM_2.5, PM_1, and ARDS; corresponding excess risk (ER) for an interquartile range IQR increase in 1-day lagged concentration was 5.45% [95% confidence interval (CI): 1.70%, 9.33%] for PM₁₀ (45.4 μg/m³), 4.71% (95% CI: 1.09%, 8.46%) for PM_2.5 (31.5 μg/m³), and 4.45% (95% CI: 0.81%, 8.23%) for PM₁ (28.8 μg/m³), respectively. For PM_2.5 chemical compositions, we found that OC, EC, sulfate and ammonium were significantly associated with ARDS. The observed effects remained even after adjusting for potentially confounding factors. This study suggests that PM₁₀, PM_2.5, and PM₁, as well as chemical constituents from combustion and secondary aerosols might be important triggers of ARDS in Guangzhou.

Patterns and correlates of use of evidence-based interventions to control diabetes by local health departments across the USA

OBJECTIVE

The nearly 3000 local health departments (LHDs) nationwide are the front line of public health and are positioned to implement evidence-based interventions (EBIs) for diabetes control. Yet little is currently known about use of diabetes-related EBIs among LHDs. This study used a national online survey to determine the patterns and correlates of the Centers for Disease Control and Prevention Community Guide-recommended EBIs for diabetes control in LHDs.

RESEARCH DESIGN AND METHODS

A cross-sectional study was conducted to survey a stratified random sample of LHDs regarding department characteristics, respondent characteristics, evidence-based decision making within the LHD, and delivery of EBIs (directly or in collaboration) within five categories (diabetes-related, nutrition, physical activity, obesity, and tobacco). Associations between delivering EBIs and respondent and LHD characteristics and evidence-based decision making were explored using logistic regression models.

RESULTS

Among 240 LHDs there was considerable variation among the EBIs delivered. Diabetes prevalence in the state was positively associated with offering the Diabetes Prevention Program (OR=1.28 (95% CI 1.02 to 1.62)), diabetes self-management education (OR=1.32 (95% CI 1.04 to 1.67)), and identifying patients and determining treatment (OR=1.27 (95% CI 1.05 to 1.54)). Although all organizational supports for evidence-based decision making factors were related in a positive direction, the only significant association was between evaluation capacity and identifying patients with diabetes and determining effective treatment (OR=1.54 (95% CI 1.08 to 2.19)).

CONCLUSION

Supporting evidence-based decision making and increasing the implementation of these EBIs by more LHDs can help control diabetes nationwide.

Enhancing evidence-based diabetes and chronic disease control among local health departments: a multi-phase dissemination study with a stepped-wedge cluster randomized trial component

BACKGROUND

The rates of diabetes and prediabetes in the USA are growing, significantly impacting the quality and length of life of those diagnosed and financially burdening society. Premature death and disability can be prevented through implementation of evidence-based programs and policies (EBPPs). Local health departments (LHDs) are uniquely positioned to implement diabetes control EBPPs because of their knowledge of, and focus on, community-level needs, contexts, and resources. There is a significant gap, however, between known diabetes control EBPPs and actual diabetes control activities conducted by LHDs. The purpose of this study is to determine how best to support the use of evidence-based public health for diabetes (and related chronic diseases) control among local-level public health practitioners.

METHODS/DESIGN

This paper describes the methods for a two-phase study with a stepped-wedge cluster randomized trial that will evaluate dissemination strategies to increase the uptake of public health knowledge and EBPPs for diabetes control among LHDs. Phase 1 includes development of measures to assess practitioner views on and organizational supports for evidence-based public health, data collection using a national online survey of LHD chronic disease practitioners, and a needs assessment of factors influencing the uptake of diabetes control EBPPs among LHDs within one state in the USA. Phase 2 involves conducting a stepped-wedge cluster randomized trial to assess effectiveness of dissemination strategies with local-level practitioners at LHDs to enhance capacity and organizational support for evidence-based diabetes prevention and control. Twelve LHDs will be selected and randomly assigned to one of the three groups that cross over from usual practice to receive the intervention (dissemination) strategies at 8-month intervals; the intervention duration for groups ranges from 8 to 24 months. Intervention (dissemination) strategies may include multi-day in-person workshops, electronic information exchange methods, technical assistance through a knowledge broker, and organizational changes to support evidence-based public health approaches. Evaluation methods comprise surveys at baseline and the three crossover time points, abstraction of local-level diabetes and chronic disease control program plans and progress reports, and social network analysis to understand the relationships and contextual issues that influence EBPP adoption.

TRIAL REGISTRATION

ClinicalTrial.gov, NCT03211832.

Results from a psychometric assessment of a new tool for measuring evidence-based decision making in public health organizations

BACKGROUND

In order to better understand how to improve evidence-based decision making (EBDM) in state health departments, measurement tools are needed to evaluate changes in EBDM. The purpose of this study was to test the psychometric properties of a new measurement tool to assess EBDM in public health practice settings.

METHODS

A questionnaire was developed, pilot-tested and refined in an iterative process with the input of public health practitioners with the aim of identifying a set of specific measures representing different components of EBDM. Data were collected in a national survey of state health department chronic disease practitioners. The final dataset (n=879) for psychometric testing was comprised of 19 EBDM items that were first examined using exploratory factor analysis, and then confirmatory factor analysis.

RESULTS

The final model from confirmatory factor analysis includes five latent factors representing components of EBDM: capacity for evaluation, expectations and incentives for EBDM, access to evidence and resources for EBDM, participatory decision making, and leadership support and commitment.

CONCLUSIONS

This study addresses the need for empirically tested and theory-aligned measures that may be used to assess the extent to which EBDM is currently implemented, and further, to gauge the success of strategies to improve EBDM, in public health settings. This EBDM measurement tool may help identify needed supports for enhanced capacity and implementation of effective strategies.

Mortality benefits of vigorous air quality improvement interventions during the periods of APEC Blue and Parade Blue in Beijing, China

Vigorous air pollution control measures were implemented during the 2014 Asia-Pacific Economic Cooperation and a large-scale military parade (described here as "APEC Blue" and "Parade Blue" periods) in Beijing, China. A natural experiment was conducted in a health impact assessment framework to estimate the number of deaths attributable to PM_2.5, using concentration-response functions derived from previous studies conducted in Beijing, combined with the differences in PM_2.5 concentrations between intervention and reference periods. Substantial reductions in daily PM_2.5 concentrations were observed during both intervention periods. Using the same dates from the prior year as a reference, daily PM_2.5 concentration decreased from 98.57 μg/m³ to 47.53 μg/m³ during "APEC Blue", and from 59.15 μg/m³ to 17.07 μg/m³ during the "Parade Blue". We estimated that 39-63 all-cause deaths (21-51 cardiovascular, 6-13 respiratory deaths) have been prevented during the APEC period; and 41-65 deaths (22-52 cardiovascular, 6-13 respiratory deaths) have been prevented during the Parade period. This study shows that substantial mortality reductions could be achieved by implementing stringent air pollution mitigation measures.

The role of researchers in disseminating evidence to public health practice settings: a cross-sectional study

BACKGROUND

Evidence-based public health interventions, which research has demonstrated offer the most promise for improving the population's health, are not always utilized in practice settings. The extent to which dissemination from researchers to public health practice settings occurs is not widely understood. This study examines the extent to which public health researchers in the United States are disseminating their research findings to local and state public health departments.

METHODS

In a 2012, nationwide study, an online questionnaire was administered to 266 researchers from the National Institutes of Health, the Centers for Disease Control and Prevention, and universities to determine dissemination practices. Logistic regression analyses were used to examine the association between dissemination to state and/or local health departments and respondent characteristics, facilitators, and barriers to dissemination.

RESULTS

Slightly over half of the respondents (58%) disseminated their findings to local and/or state health departments. After adjusting for other respondent characteristics, respondents were more likely to disseminate their findings to health departments if they worked for a university Prevention Research Center or the Centers for Disease Control and Prevention, or received their degree more than 20 years ago. Those who had ever worked in a practice or policy setting, those who thought dissemination was important to their own research and/or to the work of their unit/department, and those who had expectations set by their employers and/or funding agencies were more likely to disseminate after adjusting for work place, graduate degree and/or fellowship in public health, and the year the highest academic degree was received.

CONCLUSIONS

There is still room for improvement in strengthening dissemination ties between researchers and public health practice settings, and decreasing the barriers researchers face during the dissemination process. Researchers could better utilize national programs or workshops, knowledge brokers, or opportunities provided through academic institutions to become more proficient in dissemination practices.

Importance of scientific resources among local public health practitioners

OBJECTIVES

We examined the perceived importance of scientific resources for decision-making among local health department (LHD) practitioners in the United States.

METHODS

We used data from LHD practitioners (n = 849). Respondents ranked important decision-making resources, methods for learning about public health research, and academic journal use. We calculated descriptive statistics and used logistic regression to measure associations of individual and LHD characteristics with importance of scientific resources.

RESULTS

Systematic reviews of scientific literature (24.7%) were most frequently ranked as important among scientific resources, followed by scientific reports (15.9%), general literature review articles (6.5%), and 1 or a few scientific studies (4.8%). Graduate-level education (adjusted odds ratios [AORs] = 1.7-3.5), larger LHD size (AORs = 2.0-3.5), and leadership support (AOR = 1.6; 95% confidence interval = 1.1, 2.3) were associated with a higher ranking of importance of scientific resources.

CONCLUSIONS

Graduate training, larger LHD size, and leadership that supports a culture of evidence-based decision-making may increase the likelihood of practitioners viewing scientific resources as important. Targeting communication channels that practitioners view as important can also guide research dissemination strategies.

What predicts dissemination efforts among public health researchers in the United States?

OBJECTIVES

We identified factors related to dissemination efforts by researchers to non-research audiences to reduce the gap between research generation and uptake in public health practice.

METHODS

We conducted a cross-sectional study of 266 researchers at universities, the National Institutes of Health (NIH), and CDC. We identified scientists using a search of public health journals and lists from government-sponsored research. The scientists completed a 35-item online survey in 2012. Using multivariable logistic regression, we compared self-rated effort to disseminate findings to non-research audiences (excellent/good vs. poor) across predictor variables in three categories: perceptions or reasons to disseminate, perceived expectation by employer/funders, and professional training and experience.

RESULTS

One-third of researchers rated their dissemination efforts as poor. Many factors were significantly related to whether a researcher rated him/herself as excellent/good, including obligation to disseminate findings (odds ratio [OR] = 2.7, 95% confidence interval [CI] 1.1, 6.8), dissemination important for their department (OR=2.3, 95% CI 1.2, 4.5), dissemination expected by employer (OR=2.0, 95% CI 1.2, 3.2) or by funder (OR=2.1, 95% CI 1.3, 3.2), previous work in a practice/policy setting (OR=4.4, 95% CI 2.1, 9.3), and university researchers with Prevention Research Center affiliation vs. NIH researchers (OR=4.7, 95% CI 1.4, 15.7). With all variables in the model, dissemination expected by funder (OR=2.0, 95% CI 1.2, 3.1) and previous work in a practice/policy setting (OR=3.5, OR 1.7, 7.1) remained significant.

CONCLUSIONS

These findings support the need for structural changes to the system, including funding agency priorities and participation of researchers in practice- and policy-based experiences, which may enhance efforts to disseminate by researchers.

State practitioner insights into local public health challenges and opportunities in obesity prevention: a qualitative study

INTRODUCTION

The extent of obesity prevention activities conducted by local health departments (LHDs) varies widely. The purpose of this qualitative study was to characterize how state obesity prevention program directors perceived the role of LHDs in obesity prevention and factors that impact LHDs' success in obesity prevention.

METHODS

From June 2011 through August 2011, we conducted 28 semistructured interviews with directors of federally funded obesity prevention programs at 22 state and regional health departments. Interviews were transcribed verbatim, coded, and analyzed to identify recurring themes and key quotations.

RESULTS

Main themes focused on the roles of LHDs in local policy and environmental change and on the barriers and facilitators to LHD success. The role LHDs play in obesity prevention varied across states but generally reflected governance structure (decentralized vs centralized). Barriers to local prevention efforts included competing priorities, lack of local capacity, siloed public health structures, and a lack of local engagement in policy and environmental change. Structures and processes that facilitated prevention were having state support (eg, resources, technical assistance), dedicated staff, strong communication networks, and a robust community health assessment and planning process.

CONCLUSIONS

These findings provide insight into successful strategies state and local practitioners are using to implement innovative (and evidence-informed) community-based interventions. The change in the nature of obesity prevention requires a rethinking of the state-local relationship, especially in centralized states.

Understanding administrative evidence-based practices: findings from a survey of local health department leaders

BACKGROUND

There are sparse data showing the extent to which evidence-based public health is occurring among local health departments.

PURPOSE

The purpose of the study was to describe the patterns and predictors of administrative evidence-based practices (structures and activities that are associated with performance measures) in a representative sample of local health departments in the U.S.

METHODS

A cross-sectional study of 517 local health department directors was conducted from October through December 2012 (analysis in January-March 2013). The questions on administrative evidence-based practices included 19 items based on a recent literature review (five broad domains: workforce development, leadership, organizational climate and culture, relationships and partnerships, financial processes).

RESULTS

There was a wide range in performance among the 19 individual administrative evidence-based practices, ranging from 35% for providing access to current information on evidence-based practices to 96% for funding via a variety of sources Among the five domains, values were generally lowest for organizational climate and culture (mean for the domain=49.9%) and highest for relationships and partnerships (mean for the domain=77.1%). Variables associated with attaining the highest tertile of administrative evidence-based practices included having a population jurisdiction of 25,000 or larger (adjusted ORs [aORs] ranging from 4.4 to 7.5) and state governance structure (aOR=3.1).

CONCLUSIONS

This research on the patterns and predictors of administrative evidence-based practices in health departments provides information on gaps and areas for improvement that can be linked with ongoing quality improvement processes.

State legislators' work on public health-related issues: what influences priorities?

CONTEXT

Policies are an effective way to influence population health and prevent disease. Unfortunately, public health research is often not well translated for policy audiences. Furthermore, researchers seeking to influence policy face an incomplete understanding of what influences legislators' decisions regarding which issues will receive their limited time and focus.

OBJECTIVE

The objective of this analysis was to examine various factors that may influence state legislators' decisions about which health issues they address.

DESIGN

Cross-sectional analysis of data collected from a randomized trial.

SETTING

State legislatures.

PARTICIPANTS

State-level legislators.

MAIN OUTCOME MEASURE(S)

Measures included a rating of the influence of various factors on health policy priorities. A 7-point scale was used to measure political ideology on social and fiscal issues. Standard demographic questions were included on age, gender, and level of education.

RESULTS

Seventy-five legislators completed surveys. Sixty-three percent were aged 55 years or older, and 76% male. When they were asked to rate factors according to importance in determining what health issues to work on, the top-rated factor was constituents' needs or opinions followed by evidence of scientific effectiveness. Ratings were also examined by subgroups.

CONCLUSIONS

These findings point to several important applications for public health practitioners and researchers. Because legislators value constituents' opinions, it is critical to inform and educate constituents about public health issues as well as policy options that may be effective in addressing problems. The results also highlight the importance of public health researchers and practitioners improving dissemination efforts to ensure that evidence-based scientific information is shared with policymakers in an effective and timely manner.

Promoting state health department evidence-based cancer and chronic disease prevention: a multi-phase dissemination study with a cluster randomized trial component

Background

Cancer and other chronic diseases reduce quality and length of life and productivity, and represent a significant financial burden to society. Evidence-based public health approaches to prevent cancer and other chronic diseases have been identified in recent decades and have the potential for high impact. Yet, barriers to implement prevention approaches persist as a result of multiple factors including lack of organizational support, limited resources, competing emerging priorities and crises, and limited skill among the public health workforce. The purpose of this study is to learn how best to promote the adoption of evidence based public health practice related to chronic disease prevention.

Methods/design

This paper describes the methods for a multi-phase dissemination study with a cluster randomized trial component that will evaluate the dissemination of public health knowledge about evidence-based prevention of cancer and other chronic diseases. Phase one involves development of measures of practitioner views on and organizational supports for evidence-based public health and data collection using a national online survey involving state health department chronic disease practitioners. In phase two, a cluster randomized trial design will be conducted to test receptivity and usefulness of dissemination strategies directed toward state health department chronic disease practitioners to enhance capacity and organizational support for evidence-based chronic disease prevention. Twelve state health department chronic disease units will be randomly selected and assigned to intervention or control. State health department staff and the university-based study team will jointly identify, refine, and select dissemination strategies within intervention units. Intervention (dissemination) strategies may include multi-day in-person training workshops, electronic information exchange modalities, and remote technical assistance. Evaluation methods include pre-post surveys, structured qualitative phone interviews, and abstraction of state-level chronic disease prevention program plans and progress reports.

Trial registration

clinicaltrials.gov: NCT01978054.

Designing for dissemination among public health researchers: findings from a national survey in the United States

OBJECTIVES

We have described the practice of designing for dissemination among researchers in the United States with the intent of identifying gaps and areas for improvement.

METHODS

In 2012, we conducted a cross-sectional study of 266 researchers using a search of the top 12 public health journals in PubMed and lists available from government-sponsored research. The sample involved scientists at universities, the National Institutes of Health, and the Centers for Disease Control and Prevention in the United States.

RESULTS

In the pooled sample, 73% of respondents estimated they spent less than 10% of their time on dissemination. About half of respondents (53%) had a person or team in their unit dedicated to dissemination. Seventeen percent of all respondents used a framework or theory to plan their dissemination activities. One third of respondents (34%) always or usually involved stakeholders in the research process.

CONCLUSIONS

The current data and the existing literature suggest considerable room for improvement in designing for dissemination.

Association between physical activity and insomnia symptoms in rural communities of southeastern Missouri, Tennessee, and Arkansas

PURPOSE

The purpose of this study is to examine whether physical activity is associated with less insomnia symptoms in the rural communities.

METHODS

This study used cross-sectional data collected from a 2005 telephone survey for evaluation of a community walking trails intervention to promote physical activity in rural communities including 6 communities in the Missouri Ozark region and 6 communities in Arkansas and Tennessee (n = 1,234). The exposure variable is self-reported regular current physical activity. The outcome includes symptoms of insomnia operationalized as having trouble falling asleep, staying asleep, and waking up too early nearly every day. Logistic regression was used to calculate prevalence odds ratios (PORs) and 95% confidence intervals (95% CI).

FINDINGS

The study sample includes mostly white (95%), married (62%), overweight/obese (61%) women with a high school degree and a mean age of 54. Fourteen percent of participants reported having insomnia symptoms. Self-report of currently being physically active regularly was associated with decreased odds of insomnia symptoms (adjusted POR: .37; 95% CI, 0.14-0.99) among participants with under or normal body weight, after controlling for age, gender, education level, marital status, and chronic diseases. There was also a negative linear correlation between the number of days and total minutes of vigorous physical activity and insomnia symptoms.

CONCLUSIONS

In these rural communities, we observed a significant relationship between regular physical activity and decreased insomnia symptoms.

Developing the next generation of dissemination and implementation researchers: insights from initial trainees

BACKGROUND

Dissemination and implementation (D&I) research is a relatively young discipline, underscoring the importance of training and career development in building and sustaining the field. As such, D&I research faces several challenges in designing formal training programs and guidance for career development. A cohort of early-stage investigators (ESI) recently involved in an implementation research training program provided a resource for formative data in identifying needs and solutions around career development.

RESULTS

Responses outlined fellows' perspectives on the perceived usefulness and importance of, as well as barriers to, developing practice linkages, acquiring additional methods training, academic advancement, and identifying institutional supports. Mentorship was a cross-cutting issue and was further discussed in terms of ways it could foster career advancement in the context of D&I research.

CONCLUSIONS

Advancing an emerging field while simultaneously developing an academic career offers a unique challenge to ESIs in D&I research. This article summarizes findings from the formative data that outlines some directions for ESIs and provides linkages to the literature and other resources on key points.

Fostering more-effective public health by identifying administrative evidence-based practices: a review of the literature

CONTEXT

The aim of evidence-based decision-making in public health involves the integration of science-based interventions with community preferences to improve population health. Although considerable literature is available on the development and adoption of evidence-based guidelines and barriers to their implementation, the evidence base specific to public health administration is less developed. This article reviews the literature from public health and related disciplines to identify administrative evidence-based practices (A-EBPs; i.e., agency-level structures and activities that are positively associated with performance measures).

EVIDENCE ACQUISITION

A "review of reviews" was carried out to assess the evidence for the effectiveness of A-EBPs covering the time frame January 2000 through March 2012. The following steps were used: (1) select databases; (2) determine search parameters and conduct the search; (3) screen titles and abstracts; (4) obtain selected documents; (5) perform initial synthesis; (6) abstract data; and (7) synthesize evidence.

EVIDENCE SYNTHESIS

In both the reviews and original empiric studies, the most common outcome reported was performance of the local health department or local public health system. On the basis of a synthesis of data from 20 reviews, a total of 11 high-priority A-EBPs were identified (i.e., practices that local public health systems potentially can modify within a few years). The A-EBPs covered five major domains of workforce development, leadership, organizational climate and culture, relationships and partnerships, and financial processes.

CONCLUSIONS

As the body of practice-based research continues to grow and the ability to measure administrative evidence-based practices improves, this initial list can be further developed and improved.

Where is obesity prevention on the map?: distribution and predictors of local health department prevention activities in relation to county-level obesity prevalence in the United States

CONTEXT

The system of local health departments (LHDs) in the United States has the potential to advance a locally oriented public health response in obesity control and reduce geographic disparities. However, the extent to which obesity prevention programs correspond to local obesity levels is unknown.

OBJECTIVE

This study examines the extent to which LHDs across the United States have responded to local levels of obesity by examining the association between jurisdiction-level obesity prevalence and the existence of obesity prevention programs.

DESIGN

Data on LHD organizational characteristics from the Profile Study of Local Health Departments and county-level estimates of obesity from the Behavioral Risk Factor Surveillance System were analyzed (n = 2300). Since local public health systems are nested within state infrastructure, multilevel models were used to examine the relationship between county-level obesity prevalence and LHD obesity prevention programming and to assess the impact of state-level clustering.

SETTING

Two thousand three hundred local health department jurisdictions defined with respect to county boundaries.

PARTICIPANTS

Practitioners in local health departments who responded to the 2005 Profile Study of Local Health Departments.

MAIN OUTCOME MEASURES

Likelihood of having obesity prevention activities and association with area-level obesity prevalence.

RESULTS

The existence of obesity prevention activities was not associated with the prevalence of obesity in the jurisdiction. A substantial portion of the variance in LHD activities was explained by state-level clustering.

CONCLUSIONS

This article identified a gap in the local public health response to the obesity epidemic and underscores the importance of multilevel modeling in examining predictors of LHD performance.

Measurement properties of a novel survey to assess stages of organizational readiness for evidence-based interventions in community chronic disease prevention settings

BACKGROUND

There is a great deal of variation in the existing capacity of primary prevention programs and policies addressing chronic disease to deliver evidence-based interventions (EBIs). In order to develop and evaluate implementation strategies that are tailored to the appropriate level of capacity, there is a need for an easy-to-administer tool to stage organizational readiness for EBIs.

METHODS

Based on theoretical frameworks, including Rogers' Diffusion of Innovations, we developed a survey instrument to measure four domains representing stages of readiness for EBI: awareness, adoption, implementation, and maintenance. A separate scale representing organizational climate as a potential mediator of readiness for EBIs was also included in the survey. Twenty-three questions comprised the four domains, with four to nine items each, using a seven-point response scale. Representatives from obesity, asthma, diabetes, and tobacco prevention programs serving diverse populations in the United States were surveyed (N=243); test-retest reliability was assessed with 92 respondents.

RESULTS

Confirmatory factor analysis (CFA) was used to test and refine readiness scales. Test-retest reliability of the readiness scales, as measured by intraclass correlation, ranged from 0.47-0.71. CFA found good fit for the five-item adoption and implementation scales and resulted in revisions of the awareness and maintenance scales. The awareness scale was split into two two-item scales, representing community and agency awareness. The maintenance scale was split into five- and four-item scales, representing infrastructural maintenance and evaluation maintenance, respectively. Internal reliability of scales (Cronbach's α) ranged from 0.66-0.78. The model for the final revised scales approached good fit, with most factor loadings >0.6 and all >0.4.

CONCLUSIONS

The lack of adequate measurement tools hinders progress in dissemination and implementation research. These preliminary results help fill this gap by describing the reliability and measurement properties of a theory-based tool; the short, user-friendly instrument may be useful to researchers and practitioners seeking to assess organizational readiness for EBIs across a variety of chronic disease prevention programs and settings.

Systems science methods in public health: dynamics, networks, and agents

Complex systems abound in public health. Complex systems are made up of heterogeneous elements that interact with one another, have emergent properties that are not explained by understanding the individual elements of the system, persist over time, and adapt to changing circumstances. Public health is starting to use results from systems science studies to shape practice and policy, for example in preparing for global pandemics. However, systems science study designs and analytic methods remain underutilized and are not widely featured in public health curricula or training. In this review we present an argument for the utility of systems science methods in public health, introduce three important systems science methods (system dynamics, network analysis, and agent-based modeling), and provide three case studies in which these methods have been used to answer important public health science questions in the areas of infectious disease, tobacco control, and obesity.

The association of sleep duration and depressive symptoms in rural communities of Missouri, Tennessee, and Arkansas

PURPOSE

To determine the association between sleep duration and depressive symptoms in a rural setting.

METHODS

We conducted a cross-sectional study using data from Wave 3 of the Walk the Ozarks to Wellness Project including 12 rural communities in Missouri, Arkansas, and Tennessee (N = 1,204). Sleep duration was defined based on average weeknight and weekend hours per day: short (<7), optimal (7-8), and long (>8). The primary outcome was self-reported elevated depressive symptoms. Multivariable logistic regression was used to estimate adjusted prevalence odds ratios (aPOR) and 95% confidence intervals (95% CI).

FINDINGS

Elevated depressive symptoms were common in this rural population (17%). Depressive symptoms were more prevalent among subjects with short (26.1%) and long (24%) sleep duration compared to those with optimal (11.8%) sleep duration. After adjusting for age, gender, race, education, employment status, income, and BMI, short sleep duration was associated with increased odds of elevated depressive symptoms (aPOR = 2.12, 95% CI: 1.49, 3.01), compared to optimal sleep duration. Conversely, the association between long sleep duration and depressive symptoms was not statistically significant after covariate adjustment. Similar findings were observed when we excluded individuals with insomnia symptoms for analysis.

CONCLUSIONS

This study suggests that short sleep duration (<7 hours per night) and depressive symptoms are common among rural populations. Short sleep duration is positively associated with elevated depressive symptoms. The economic and health care burden of depression may be more overwhelming among rural populations, necessitating the need to target modifiable behaviors such as sleep habits to improve mental health.

Communicating evidence-based information on cancer prevention to state-level policy makers

BACKGROUND

Opportunities exist to disseminate evidence-based cancer control strategies to state-level policy makers in both the legislative and executive branches. We explored factors that influence the likelihood that state-level policy makers will find a policy brief understandable, credible, and useful.

METHODS

A systematic approach was used to develop four types of policy briefs on the topic of mammography screening to reduce breast cancer mortality: data-focused brief with state-level data, data-focused brief with local-level data, story-focused brief with state-level data, and story-focused brief with local-level data. Participants were recruited from three groups of state-level policy makers-legislative staff, legislators, and executive branch administrators- in six states that were randomly chosen after stratifying all 50 states by population size and dominant political party in state legislature. Participants from each of the three policy groups were randomly assigned to receive one of the four types of policy briefs and completed a questionnaire that included a series of Likert scale items. Primary outcomes-whether the brief was understandable, credible, likely to be used, and likely to be shared-were measured by a 5-point Likert scale according to the degree of agreement (1 = strongly disagree, 5 = strongly agree). Data were analyzed with analysis of variance and with classification trees. All statistical tests were two-sided.

RESULTS

Data on response to the policy briefs (n = 291) were collected from February through December 2009 (overall response rate = 35%). All three policy groups found the briefs to be understandable and credible, with mean ratings that ranged from 4.3 to 4.5. The likelihood of using the brief (the dependent variable) differed statistically significantly by study condition for staffers (P = .041) and for legislators (P = .018). Staffers found the story-focused brief containing state-level data most useful, whereas legislators found the data-focused brief containing state-level data most useful. Exploratory classification trees showed distinctive patterns for brief usefulness across the three policy groups.

CONCLUSION

Our results suggest that taking a "one-size-fits-all" approach when delivering information to policy makers may be less effective than communicating information based on the type of policy maker.

Understanding evidence-based public health policy

Public health policy has a profound impact on health status. Missing from the literature is a clear articulation of the definition of evidence-based policy and approaches to move the field forward. Policy-relevant evidence includes both quantitative (e.g., epidemiological) and qualitative information (e.g., narrative accounts). We describe 3 key domains of evidence-based policy: (1) process, to understand approaches to enhance the likelihood of policy adoption; (2) content, to identify specific policy elements that are likely to be effective; and (3) outcomes, to document the potential impact of policy. Actions to further evidence-based policy include preparing and communicating data more effectively, using existing analytic tools more effectively, conducting policy surveillance, and tracking outcomes with different types of evidence.

Effects of sleep fragmentation on glucose metabolism in normal subjects

BACKGROUND

Sleep disorders are increasingly associated with insulin resistance, glucose intolerance, and type 2 diabetes mellitus. Whether the metabolic toll imposed by sleep-related disorders is caused by poor-quality sleep or due to other confounding factors is not known. The objective of this study was to examine whether experimental sleep fragmentation across all sleep stages would alter glucose metabolism, adrenocortical function, and sympathovagal balance.

METHODS

Sleep was experimentally fragmented across all stages in 11 healthy, normal volunteers for two nights using auditory and mechanical stimuli. Primary outcomes included insulin sensitivity (S(I)), glucose effectiveness (S(G)), and insulin secretion, as determined by the intravenous glucose tolerance test. Secondary outcomes included measures of sympathovagal balance and serum levels of inflammatory markers, adipokines, and cortisol.

RESULTS

Following two nights of sleep fragmentation, S(I) decreased from 5.02 to 3.76 (mU/L)(-1)min(-1) (P < .0001). S(G), which is the ability of glucose to mobilize itself independent of an insulin response, also decreased from 2.73 x 10(-2) min(-1) to 2.16 x 10(-2) min(-1) (P < .01). Sleep fragmentation led to an increase in morning cortisol levels and a shift in sympathovagal balance toward an increase in sympathetic nervous system activity. Markers of systemic inflammation and serum adipokines were unchanged with sleep fragmentation.

CONCLUSIONS

Fragmentation of sleep across all stages is associated with a decrease in S(I) and S(G). Increases in sympathetic nervous system and adrenocortical activity likely mediate the adverse metabolic effects of poor sleep quality.

Sleep duration and obesity-related risk factors in the rural Midwest

OBJECTIVE

Habitual short sleep duration is a common practice linked to weight gain and risk of obesity. Our objective was to examine the association between sleep duration with other behaviors, such as physical activity and nutrition, which are important for obesity prevention efforts.

METHODS

We used cross-sectional data from rural communities in Missouri, Tennessee, and Arkansas (N=1203). Controlling for covariates, we assessed the association between short sleep duration (<7 h vs. 7-8 h) and obesity, not meeting vigorous physical activity requirements, low fruit and vegetable consumption, high fat consumption, and frequently eating at fast food restaurants.

RESULTS

The proportion of participants with habitual sleep duration of <7 h, 7-8 h, and > or =9 h was 36.2%, 57.3%, and 6.4%, respectively. After multivariable adjustment, short sleep duration was associated with certain obesity-related behaviors, particularly lower physical activity and lower fruit and vegetable consumption.

CONCLUSIONS

Short sleep duration is associated with risk behaviors that are known to promote weight gain and obesity. Interventions aimed at promoting physical activity and improved nutrition may benefit by considering adequate sleep duration as a potentially modifiable behavior that may impact the effectiveness of efforts to prevent obesity.

Short sleep duration across income, education, and race/ethnic groups: population prevalence and growing disparities during 34 years of follow-up

PURPOSE

Little is known about population determinants of short sleep duration. The authors examined associations between short sleep duration and income, education and race/ethnicity, and assessed changes over time in relative disparities.

METHODS

Questionnaire data from the Alameda County Health and Ways of Living Study (ACS) was obtained at five time-points (1965, 1974, 1983, 1994, and 1999) for short sleep duration (<7 hours sleep per night). Household income, education level, and race/ethnicity were assessed at baseline (n = 6,928). Odds ratios were computed to examine short sleep duration across income, education and race/ethnicity, adjusting for age, sex and time-varying covariates, and to assess changes over time.

RESULTS

Prevalence of short sleep at baseline was 15.2%. The (age-adjusted) odds of short sleep was increased for the lowest household income quintile (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.34-1.94), those with less than high school education (OR, 1.51; 95% CI, 1.30-1.75), and among African Americans (OR, 1.97; 95% CI, 1.68-2.30). Relative disparities increased over time for African-American and Hispanic, compared with white, participants.

CONCLUSIONS

Socioeconomic position is a robust determinant of short sleep duration, even after adjusting for health-related characteristics linked to short sleep duration.

Short sleep duration across income, education, and race/ethnic groups: population prevalence and growing disparities during 34 years of follow-up

PURPOSE

Little is known about population determinants of short sleep duration. The authors examined associations between short sleep duration and income, education and race/ethnicity, and assessed changes over time in relative disparities.

METHODS

Questionnaire data from the Alameda County Health and Ways of Living Study (ACS) was obtained at five time-points (1965, 1974, 1983, 1994, and 1999) for short sleep duration (<7 hours sleep per night). Household income, education level, and race/ethnicity were assessed at baseline (n = 6,928). Odds ratios were computed to examine short sleep duration across income, education and race/ethnicity, adjusting for age, sex and time-varying covariates, and to assess changes over time.

RESULTS

Prevalence of short sleep at baseline was 15.2%. The (age-adjusted) odds of short sleep was increased for the lowest household income quintile (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.34-1.94), those with less than high school education (OR, 1.51; 95% CI, 1.30-1.75), and among African Americans (OR, 1.97; 95% CI, 1.68-2.30). Relative disparities increased over time for African-American and Hispanic, compared with white, participants.

CONCLUSIONS

Socioeconomic position is a robust determinant of short sleep duration, even after adjusting for health-related characteristics linked to short sleep duration.

Self-esteem and mortality: prospective evidence from a population-based study

PURPOSE

Self-esteem is considered to be importantly associated with both psychosocial states such as depression as well as physical health. There are no population-based studies that examine the association between self-esteem and mortality. The objective of this study was to assess whether low self-esteem was prospectively associated with increased risk of death in a population-based sample of Finnish men.

METHODS

A sample of 2682 male residents of Kuopio, Finland were interviewed and followed prospectively as part of the Kuopio Ischemic Heart Disease Risk Factor Study (KIHD). Characteristics of the KIHD sample at baseline included self-esteem, measured by the Rosenberg ten-item scale, socioeconomic factors, behavioral risk factors, other psychosocial characteristics, and prevalent diseases. Mortality was ascertained through linkage to the Finnish national death registry. We assessed the relationship between self-esteem and all-cause mortality using Cox proportional hazards models.

RESULTS

Low self-esteem was associated with a two-fold [hazard ratio (HR)=2.0, 95% confidence interval (CI)=1.3-3.2] increase in age-adjusted mortality. This relationship was partially explained by behavioral and socioeconomic factors, and prevalent diseases, and fully explained by other psychosocial characteristics (hopelessness, depression, cynical hostility, and sullenness). When adjusted for hopelessness alone there was no increased risk associated with low self-esteem (HR=1.3, 95% CI=0.8-2.2).

CONCLUSIONS

This study found no association between self-esteem and all-cause mortality after adjustment for other psychosocial characteristics, primarily hopelessness. Our understanding of the observed relationships between some psychosocial factors and mortality may be improved by simultaneous measurement of multiple psychosocial domains, thus diminishing the potential for residual confounding.

Factors associated with screening for colorectal cancer in a population-based sample

The results of this study shed light on groups of people with shared characteristics that may be at higher risk for colorectal cancer incidence and mortality based on non-compliance with recommended screening tests. The study showed Missouri has a slightly different pattern of colorectal cancer screening prevalence than the US. Public health efforts need to promote colorectal screening to at-risk Missourians, and should consider strategies that encourage jointly screening for various chronic diseases.

Risk factors for exposure to environmental tobacco smoke among ethnically diverse women in the United States

The likelihood of exposure to environmental tobacco smoke (ETS) has been shown to vary across sociodemographic characteristics, health behaviors, and the type of smoking restrictions at work. Women may be particularly at risk. The purpose of our study was to assess differences in the likelihood of exposure to ETS at home and at work among an ethnically diverse sample of women age 40 and older in the United States. We used data from the U.S. Women's Determinants Study and restricted the sample to include only nonsmoking women (n = 2326). Unadjusted and adjusted odds ratios (aOR) for exposure to ETS by sociodemographic characteristics, health risk behaviors, and the type of workplace smoking policy were calculated using logistic regression. Exposure to ETS at home was associated with being American Indian/Alaska Native (aOR 1.5, 95% CI 1.0, 2.6), age 40-44 (aOR 1.6, 95% CI 1.0, 2.6) and 45-54 (aOR 1.8, 95% CI 1.2, 2.6), having eighth grade (aOR 2.1, 95% CI 1.3, 3.6) or high school education (aOR 2.2, 95% CI 1.4, 3.3), inadequate fruit and vegetable consumption (aOR 1.5, 95% CI 1.0, 2.1), and not getting screened for breast cancer (aOR 1.5, 95% CI 1.1, 2.0). Women who did not have regular breast (aOR 1.3, 95% CI 1.9, 1.9) and cervical (aOR 2.0, 95% CI 1.5, 5.3) cancer screening were more likely to be exposed to ETS at work. Exposure to ETS at work was higher among women with some high school education (aOR 2.8, 95% CI 1.5, 5.3) and high school graduates (aOR 3.1, 95% CI 1.9, 5.1) and substantially higher for women who worked where smoking was allowed in some (aOR 15.1, 95% CI 10.2, 22.4) or all (aOR 44.8, 95% CI 19.6, 102.4) work areas. Larger effect sizes were observed for the relationship between selected risk factors and ETS exposure at work than for ETS exposure at home. Among individual risk factors, lower education level was most strongly related to ETS exposure at work. The likelihood of being exposed to ETS at work was highest for women whose workplace smoking policies allowed smoking in some or all work areas.

State youth-access tobacco control policies and youth smoking behavior in the United States

CONTEXT

State policies aimed at controlling youth access to tobacco are an important component of public health efforts to reduce smoking prevalence among youth and prevent subsequent disease.

OBJECTIVES

This study sought to assess the extensiveness of state youth access tobacco control legislation in the United States, describe how state policies changed over a 4-year period, explore how various political and economic characteristics are related to state policies, and determine the relationship of youth smoking behavior to state youth tobacco control policies.

DESIGN

This descriptive and correlational study utilized data from multiple national surveillance, economic, and sociodemographic data sets.

PARTICIPANTS

All 50 states and the District of Columbia provided economic and political data. A standard tobacco-control policy score was developed by an expert panel for each state. Aggregated state-level measures of youth smoking behavior were provided by 79,491 youth in 33 states and the District of Columbia.

MAIN OUTCOME MEASURES

Included were extent of state tobacco control policies and changes over time, relationship between state political and economic characteristics and tobacco control policies, and relationship between state policies and youth smoking behavior.

RESULTS

State policy scores increased in variability and in mean value over the 4-year period, from a mean score of 7.2 in 1993 to 9.0 in 1996. State policy scores were significantly correlated with several state political and economic variables. States with more extensive tobacco control policies had significantly lower youth smoking rates. There was some evidence that a strong state tobacco economy may limit the effectiveness of tobacco control policies on youth smoking rates.

CONCLUSIONS

It is possible to reliably measure the extent to which states are achieving important public health goals in limiting youth access to tobacco products. Comprehensive state tobacco control policies are important for increasing prevention and cessation of smoking among youth.