Peer Reviewed: Facilitators and Barriers to Implementing a Local Policy to Reduce Sodium Consumption in the County of Los Angeles Government,California, 2009

Introduction

This qualitative study explores facilitators and barriers to a proposed food procurement policy that would require food purchasers, distributors, and vendors of food service in the County of Los Angeles government to meet specified nutrition standards, including limits on sodium content.

Methods

We conducted 30 key informant interviews. Interviewees represented 18 organizations from the County of Los Angeles government departments that purchased, distributed, or sold food; public and private non-County entities that had previously implemented food procurement policies in their organizations; and large organizations that catered food to the County.

Results

Study participants reported 3 key facilitators: their organization''s authority to impose nutrition standards, their organization''s desire to provide nutritious food, and the opportunity to build on existing nutrition policies. Eight key barriers were identified: 1) unique features among food service settings, 2) costs and unavailability of low-sodium foods, 3) complexity of food service arrangements, 4) lack of consumer demand for low-sodium foods, 5) undesirable taste of low-sodium foods, 6) preference for prepackaged products, 7) lack of knowledge and experience in operationalizing sodium standards, and 8) existing multiyear contracts that are difficult to change. Despite perceived barriers, several participants indicated that their organizations have successfully implemented nutritional standards that include limits on sodium.

Conclusion

Developing or changing policies for procuring food represents a potentially feasible strategy for reducing sodium consumption in food service venues controlled by the County of Los Angeles. The facilitators and barriers identified here can inform the formulation, adoption, implementation, and evaluation of sodium reduction policies in other jurisdictions.     

Screening mammography rates and barriers to use: a Los Angeles County survey

The use of screening mammography among women 40 years of age and older in Los Angeles County was assessed through a random digit dial telephone interview. The sample of 802 women represents a large urban population with substantial proportions of blacks, Hispanics, and Asians. The survey obtained information regarding adherence to the ACS/NCI screening mammography guidelines, perceived benefits of early detection and mammography, perceived threat of developing breast cancer, and barriers to utilization. The results showed that 71% of the women had had at least one mammogram, with 49% having received a screening mammogram according to the guidelines for their age. Less than half the respondents knew the screening guidelines for their age, with women ages 40-49 years being less knowledgeable than women greater than or equal to 50 years old (29 vs 58% answering correctly). A logistic regression analysis predicting the likelihood of having obtained a screening mammogram according to the guidelines found the following to be predictive: concern over radiation (negative association), age (negative association), family history, knowledge of guidelines, and cost of a mammogram (negative association). Other demographic factors and beliefs were not significantly related to this dependent variable.     

Developing quality indicators for local health departments: experience in Los Angeles County

OBJECTIVES: To develop public health quality indicators for local health department (LHD) use. METHODS: An indicator development team utilized public health quality measurement concepts, reviewed existing quality measurement-related initiatives, and conducted interviews with LHD staff in order to identify and develop quality indicators for the Los Angeles County Health Department. RESULTS: Sixty-one recommended and 50 acceptable (i.e., scientifically sound but less useful) indicators were developed, with an emphasis on measuring process quality in services delivery. Pre-existing indicators from external sources, when available, were often not well suited to the Health Department's needs. The indicator development process clarified conceptual issues, highlighted strengths and limitations of potential indicators, and revealed implementation barriers. CONCLUSIONS: A limited number of generally available, quantitative indicators of local public health quality exist. Indicators addressing the delivery of LHD services can be locally developed to fill an important gap in public health quality-improvement efforts. However, implementation of quality measurement is difficult due to limited evidence on public health practices, sparse data resources, unclear accountability, and inconsistent organizational motivation.     

Getting Actionable About Community Resilience: The Los Angeles County Community Disaster Resilience Project

Community resilience (CR)—ability to withstand and recover from a disaster—is a national policy expectation that challenges health departments to merge disaster preparedness and community health promotion and to build stronger partnerships with organizations outside government, yet guidance is limited.A baseline survey documented community resilience–building barriers and facilitators for health department and community-based organization (CBO) staff. Questions focused on CBO engagement, government–CBO partnerships, and community education.Most health department staff and CBO members devoted minimal time to community disaster preparedness though many serve populations that would benefit. Respondents observed limited CR activities to activate in a disaster. The findings highlighted opportunities for engaging communities in disaster preparedness and informed the development of a community action plan and toolkit.THE NATIONAL POLICY enthusiasm for re-envisioning the preparedness agenda around community resilience (the ability to prevent, withstand, and mitigate the stress of a disaster) raises questions among local health departments (LHDs) about how to build or strengthen community resilience and how to integrate the “whole of community approach” (a community-integrated model to involve a diverse set of stakeholders) in usual disaster-planning activities.1–6 In the past 3 years, all federal agencies that oversee and fund state and local emergency preparedness and response developed requirements and some guidance to establish more of a focus on inclusion of communities in emergency planning and response activities, and as part of the Public Health Emergency Preparedness Cooperative Agreement, the Centers for Disease Control and Prevention now requires a set of capabilities in the area of community preparedness and resilience.2,4,7,8The purpose of this focus is 2-fold. There is a recognition based on previous disaster experience domestically and internationally (e.g., Hurricane Katrina, Joplin tornado, Hurricane Sandy) that greater partnership between government and a diverse set of nongovernmental organizations (NGOs; both for-profit and nonprofit) is necessary for more effective response and recovery.9–12 Furthermore, there is new acknowledgment that the principles of community engagement used in other aspects of public health promotion, including those employed for daily stressors (e.g., community violence), may serve the best strategy for engaging historically vulnerable populations, leveraging existing community assets, and integrating routine and disaster activities.13 Moreover, the principles of community resilience (e.g., strengthening social connections, finding dual benefit opportunities between routine public health and disaster preparedness) address many of the social and environmental issues that aid communities to withstand and mitigate overlapping disasters.12,14,15This new approach requires very different levels of partnership compared with the traditional top-down disaster response approach that has pervaded the past decade.3,5,9,16–18 Yet, even though all LHDs must address community resilience capabilities as part of their public health emergency preparedness cooperative agreement,7 key questions remain as to how LHDs can operationalize and measure this broader approach, and there are few examples of how to address these expectations. The Los Angeles County Community Disaster Resilience (LACCDR) Project is a comprehensive, community-based approach to answer these questions through both strategy and tactical activities, moving community resilience from conceptual (national policy and associated literature on community resilience) to operational (identifying and testing resilience-building activities in actual communities).The structure of the partnerships, the Los Angeles County Department of Public Health (LACDPH) design strategy, and the community engagement approaches used are described elsewhere in this issue.6,13 This article summarizes findings from a baseline survey of governmental public health and community organizations to document initial capacities and practices regarding community resilience and describes the initial logic model for the LACCDR project. The LACCDR builds on a conceptual framework for community resilience that emphasizes the engagement, education, and interconnection of governmental and NGO partners considered essential to a community’s ability to mitigate vulnerabilities and recover from stress.5,12,19     

The crisis of the Los Angeles County public hospital system: a harbinger for the nation.

The public hospital system in Los Angeles County, California, is in the midst of a major fiscal crisis that has already led to a serious reduction of capacity and could continue to worsen. Given the importance of the public system in a county where 30 percent of the population is uninsured and private hospitals provide very little uncompensated care, what happens in L.A. County is a harbinger for other cities and counties in the United States. This article highlights the issue of the extent to which local taxpayers, as opposed to state or federal taxpayers, are responsible for the continued operation of public hospitals and safety-net facilities in their communities.     

Shifting from in-person to virtual home visiting in Los Angeles County: Impact on programmatic outcomes

Maternal and Child Health Journal - This paper describes the effect that the COVID-19 pandemic, and subsequent shift from in-person to virtual (video-based) home visiting, had on the Los Angeles...     

Risks for abuse against pregnant Hispanic women: Morelos, Mexico and Los Angeles County, California

BACKGROUND: Although violence against women is gaining international attention as a prevention priority, little is known about how risks differ across countries. METHODS: A comparative study of violence against pregnant Mexican women in Morelos, Mexico, and Latina women in Los Angeles County, California, United States. In 1998 and 1999, women in prenatal clinics were interviewed about psychological abuse and sexual and physical violence by their partner, during and the 1 year prior to the index pregnancy. The overall response rate for Morelos was 99%, with a sample size of 914; Los Angeles County had a response rate of 96.9%, with a sample size of 219. RESULTS: Women in Morelos reported a higher prevalence of violence compared to women in the California (14.8% v 11.9%, respectively). A partner aged <20 years was associated with increased violence in both countries, but the association of violence with other socioeconomic factors differed by country. For example, employed women had higher odds of violence in California but lower odds in Morelos. Women who experienced violence during both the year prior to pregnancy and as a child were more than 25 times more likely to be abused during pregnancy than women not reporting this type of abuse. CONCLUSION: The identification of factors associated with violence against women, especially as they differ by culture and ethnicity, will help clinicians to better identify victims and to design and implement culturally appropriate prevention programs.     

Public awareness of and support for infrastructure changes designed to increase walking and biking in Los Angeles County

ObjectivePolicies to promote active transportation are emerging as a best practice to increase physical activity, yet relatively little is known about public opinion on utilizing transportation funds for such investments. This study sought to assess public awareness of and support for investments in walking and biking infrastructure in Los Angeles County.MethodIn the fall of 2013, the Los Angeles County Department of Public Health conducted a telephone survey with a random sample of registered voters in the region. The survey asked respondents to report on the presence and importance of walking and biking infrastructure in their community, travel behaviors and preferences, and demographics.ResultsOne thousand and five interviews were completed (response rate 20%, cooperation rate 54%). The majority of participants reported walking, biking, and bus/rail transportation investments as being important. In addition, participants reported a high level of support for redirecting transportation funds to active transportation investment — the population average was 3.28 (between ‘strongly’ and ‘somewhat’ support) on a 4 point Likert scale.ConclusionVoters see active transportation infrastructure as being very important and support redirecting funding to improve the infrastructure. These findings can inform policy-decisions and planning efforts in the jurisdiction.     

The health care workforce in Los Angeles County and New York City: a comparison and analysis.

New York City and Los Angeles County have the largest health systems in the United States, but they differ significantly in structure. This study compares and analyzes the structural and workforce differences between the two. The health system in New York City is centered around its large hospitals, and as a result New York employs many more health workers than Los Angeles County, where the health system is centered around physician groups. Health care is a significant contributor to the economy of both areas, but a larger contributor to the economy in New York City.     

Applying Community Engagement to Disaster Planning: Developing the Vision and Design for the Los Angeles County Community Disaster Resilience Initiative

Community resilience (CR) is a priority for preparedness, but few models exist. A steering council used community-partnered participatory research to support workgroups in developing CR action plans and hosted forums for input to design a pilot demonstration of implementing CR versus enhanced individual preparedness toolkits. Qualitative data describe how stakeholders viewed CR, how toolkits were developed, and demonstration design evolution.Stakeholders viewed community engagement as facilitating partnerships to implement CR programs when appropriately supported by policy and CR resources. Community engagement exercises clarified motivations and informed action plans (e.g., including vulnerable populations). Community input identified barriers (e.g., trust in government) and CR-building strategies. A CR toolkit and demonstration comparing its implementation with individual preparedness were codeveloped.Community-partnered participatory research was a useful framework to plan a CR initiative through knowledge exchange.

“We want information about how to identify resilience-building tasks and activities that communities can replicate. How can vulnerable communities fit into these activities to make sure they are also more resilient to disasters?”–Workgroup member

Disasters such as wildfires, tropical storms, hurricanes, earthquakes, and epidemics pose temporary and long-term threats to public health.1,2 Underresourced communities are at high risk for adverse outcomes owing to preexisting disparities in health, access to services, and environmental risks.3–5 Large-scale events disrupt physical, social, and communication infrastructures posing challenges to response, and creating “surge burdens” that overwhelm care resources and strain social supports.6 Events such as Hurricane Katrina, the H1N1 epidemic, and the Gulf oil spill have increased public awareness of the impacts of disasters and of gaps in communication, infrastructure, and resources that limit capacities to respond and recover.3,7,8One paradigm that has emerged in response is community resilience (CR).9,10 Based on a community-systems model,11,12 CR refers to community capabilities that buffer it from or support effective responses to disasters.13,14 Such capabilities include effective risk communications, organizational partnerships and networks, and community engagement to improve, prepare for, and respond to disasters. These capabilities may improve outcomes such as access to response and recovery resources, or return to functioning and well-being.15 Yet there are no operational models of how to build CR.16,17One potential model is community-partnered participatory research (CPPR), a manualized form of community-based participatory research18 that emphasizes power sharing and 2-way knowledge exchange following principles of community engagement to support authentic partnerships.19–21 We define a community as persons who work, share recreation, or live in a given area. A CPPR initiative has 3 stages: vision (planning), valley (implementation), and victory (products, dissemination).22–24 Each stage involves organizing, action, and feedback.20 Community-partnered participatory research was used to support post-Katrina mental health recovery in New Orleans24–28 and to address chronic conditions.29–33 Following successful application of CPPR in a postdisaster context, we proposed that it could support development of predisaster CR programs. We describe here the use of CPPR for the planning or vision stage of the Los Angeles County Community Disaster Resilience (LACCDR) initiative.As described elsewhere, LACCDR was initiated in 2010 by the Los Angeles County Department of Public Health (LACDPH) in collaboration with key academic and community partners based on principles from the National Health Security Strategy.10 Representatives of these partners constitute the LACCDR Steering Council. The Council reviewed the policy background for CR34 and developed a logic model35 that emphasizes the importance of community engagement in developing organizational partnerships to build CR. This article focuses on how the Council then used community engagement principles and the CPPR model to develop the project’s CR intervention framework, propose and develop a toolkit containing training and other resources to improve CR, and design a demonstration to compare the effectiveness of implementing the CR toolkit with the enhanced standard approach that emphasizes individual or family preparedness.15,36     

The Break Up: Evaluation of an Anti-Smoking Educational Campaign for Lesbians,Gays, and Bisexuals in Los Angeles County

Lesbian, gay, and bisexual (LGB) adults in the United States have a higher prevalence of smoking than their heterosexual counterparts. In 2013, the Los Angeles County Department of Public Health launched a social marketing and outreach campaign called Break Up to reduce the prevalence of smoking in LGB communities. Break Up was evaluated using cross-sectional, street-intercept surveys before and near the end of campaign. Surveys measured demographics, campaign awareness, and self-reported smoking-related outcomes. Bivariate statistics and logistic regression models were used to identify whether campaign awareness was associated with smoking-related outcomes. Calls by LGB persons to a smokers’ helpline were also measured. Among those interviewed at endline, 32.7% reported Break Up awareness. Awareness was associated with thinking of quitting smoking and ever taking steps to quit but not with smoking cessation (defined as not smoking in the past 30 days among those who had smoked in the past 6 months). There was a 0.7% increase in the percentage of weekly calls by LGB persons to the helpline in the year after the campaign. Break Up reached about a third of its intended audience. The campaign was associated with smoking cessation precursors and may have led to an increase in helpline utilization, but there is no evidence it affected quit attempts. This study adds to the limited literature on tobacco programs for LGB persons and, as far as we know, is one of the first to evaluate tobacco-free social marketing in this important yet understudied population.     

Peer Reviewed: Starting School Healthy and Ready to Learn: Using Social Indicators to Improve School Readiness in Los Angeles County

Background

School readiness is an important public health outcome, determined by a set of interdependent health and developmental trajectories and influenced by a child''s family, school, and community environments. The same factors that influence school readiness also influence educational success and health throughout life.

Context

A California cigarette tax ballot initiative (Proposition 10) created new resources for children aged 0 to 5 years and their families statewide through county-level First 5 commissions, including First 5 LA in Los Angeles County. An opportunity to define and promote school readiness indicators was facilitated by collaborative relationships with a strong emphasis on data among First 5 LA, the Children''s Planning Council, and the Los Angeles County Public Health Department, and other child-serving organizations.

Methods

A workgroup developed school readiness goals and indicators based on recommendations of the National Education Goals Panel and five key domains of child well-being: 1) good health, 2) safety and survival, 3) economic well-being, 4) social and emotional well-being, and 5) education/workforce readiness.

Consequences

The Los Angeles County Board of Supervisors and First 5 LA Commission adopted the school readiness indicators. First 5 LA incorporated the indicators into the results-based accountability framework for its strategic plan and developed a community-oriented report designed to educate and spur school readiness-oriented action. The Los Angeles County Board of Supervisors approved a countywide consensus-building plan designed to engage key stakeholders in the use of the indicators for planning, evaluation, and community-building activities.

Interpretation

School readiness indicators in Los Angeles County represent an important step forward for public health practice, namely, the successful blending of an expanded role for assessment with the ecological model.