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.     

Peer Reviewed: Using Social Marketing to Manage Population Health Performance

Population health can be affected by implementing pay-for-performance measures with key players. From a social marketing perspective, people (both consumers and managers) have choices and will do what they perceive enhances their own self-interest. The bottom-up focus of social marketing begins with an understanding of the people whose behaviors are targeted. Desired behavior results when people perceive that they will get more value than the cost of behaving and when the resulting offer is perceived to be better than what is obtainable through alternative choices. Incentives should be offered to consumers; managers should receive motivation for their own behavior and understand how to motivate relevant consumers. Pay can be monetary or nonmonetary, tangible or intangible. Everyone is paid for performance. Some are paid well enough to behave as desired; others are offered a poor rate of pay and choose not to behave.

Organize policy and strategy so that self-interest does what the community requires.Adapted from LeGrand (1)

     

Peer Reviewed: Readiness of US Health Plans to Manage Cardiometabolic Risk

Introduction

American health plans can make a substantial contribution to the control of cardiometabolic risk (CMR), a condition associated with both adverse health outcomes and increased cost of care. Our goal was to determine health plan interest in and ability to provide CMR control services.

Methods

In January 2008, America''s Health Insurance Plans, in collaboration with the HealthPartners Research Foundation, surveyed the chief medical officers of 74 member health insurance plans that offer commercial health maintenance organization, point of service, and preferred provider organization insurance. The response rate was 47%.

Results

The 35 responding chief medical officers reported that their plans identify members with CMR through referral from case or care management (89%), health risk assessment data (86%), claims data (82%), and pharmaceutical use data (79%). Nearly all (97%) plans currently offer interventions for tobacco use, obesity/overweight, and nutrition. Ninety-four percent of plans offer interventions to increase physical activity. All plans offer health risk appraisal or assessment with feedback and education, 91% use Web-based tools, and 85% use health coaching to help plan members lower their risk. Perceived barriers to broader implementation of risk control programs included lack of resources (79%), limited available enrollee data (74%), and lack of reporting systems (79%). Few health plan officers viewed lack of purchaser interest to be a barrier to program implementation.

Conclusion

Health plans appear to be positioned to provide CMR control services that could improve health outcomes, reduce health care costs, and increase workplace productivity in the United States.     

Peer Reviewed: Using Social Media to Communicate Child Health Information to Low-Income Parents

The objective of this study was to determine the value of using social media to communicate child health information to low-income parents. We evaluated qualitative data obtained through focus groups with low-income, predominantly Hispanic parents. Results were mixed; lack of time and credibility were the primary objections parents cited in using social media to obtain information about their children''s health. Social media has value as part of an overall communication strategy, but more work is needed to determine the most effective way to use this channel in low-income populations.     

Peer Reviewed: Learning From the European Experience of Using Targets to Improve Population Health

Health targets have become a widely used instrument to promote population health. We describe the experience in England, where the use of targets has reached the most advanced stage of development, and other European countries. The experience demonstrates that targets may change the behavior of a health system, probably to a larger extent than many other policy instruments, if incentives are aligned correctly and if measures to deal with unintended effects are put in place.     

Peer Reviewed: Use of Peer Groupings to Assess County Public Health Status

Introduction

The Community Health Status Indicators Project was undertaken to produce county-specific reports assessing the status of community health for local jurisdictions throughout the United States. To accomplish this assessment, the Community Health Status Indicators Project team selected peer groupings of counties to monitor and analyze the health of local communities relative to peer communities.

Methods

To identify peer counties, the project team used 5 categorical county demographic variables, a specified order for applying criteria, and a predetermined target for peer grouping size to subdivide counties into homogeneous subgroups called peer groupings.

Results

Eighty-eight peer groupings were developed with 14–58 counties in each. The average size of each peer grouping was 35 counties. All peer groupings included counties representing at least 6 states.

Discussion

Peer groupings are very useful for community health assessment. They convey the range of health status indicator values for similar counties, serve as a basis for expected numbers of reportable diseases, and provide a method for comparing communities with peer and U.S. medians. To maintain their usefulness, peer groupings must be updated periodically.     

Peer Reviewed: Adolescent Obesity and Social Networks

The prevalence of overweight among children worldwide is growing at an alarming rate. Social relationships may contribute to the development of obesity through the interaction of biological, behavioral, and environmental factors. Although there is evidence that early environment influences the expression of obesity, very little research elucidates the social context of obesity among children or adolescents. Social network approaches can contribute to research on the role of social environments in overweight and obesity and strengthen interventions to prevent disease and promote health. By capitalizing on the structure of the network system, a targeted intervention that uses social relationships in families, schools, neighborhoods, and communities may be successful in encouraging healthful behaviors among children and their families.     

Ready or Not: One Home-based Response to the School Readiness Dilemma

This article describes in both theoretical and practical terms a parent-focused, home-based early intervention program known as HIPPY-the Home Instruction Program for Preschool Youngsters. By being explicit about the program's basic philosophy and elaborating on programmatic tensions as it gains a national scope and presence, the article presents the program in some detail and offers an insider's view into a few inherent tensions and issues associated with home visiting programs.     

Peer Reviewed: Simulating and Evaluating Local Interventions to Improve Cardiovascular Health

Numerous local interventions for cardiovascular disease are available, but resources to deliver them are limited. Identifying the most effective interventions is challenging because cardiovascular risks develop through causal pathways and gradual accumulations that defy simple calculation. We created a simulation model for evaluating multiple approaches to preventing and managing cardiovascular risks. The model incorporates data from many sources to represent all US adults who have never had a cardiovascular event. It simulates trajectories for the leading direct and indirect risk factors from 1990 to 2040 and evaluates 19 interventions. The main outcomes are first-time cardiovascular events and consequent deaths, as well as total consequence costs, which combine medical expenditures and productivity costs associated with cardiovascular events and risk factors. We used sensitivity analyses to examine the significance of uncertain parameters. A base case scenario shows that population turnover and aging strongly influence the future trajectories of several risk factors. At least 15 of 19 interventions are potentially cost saving and could reduce deaths from first cardiovascular events by approximately 20% and total consequence costs by 26%. Some interventions act quickly to reduce deaths, while others more gradually reduce costs related to risk factors. Although the model is still evolving, the simulated experiments reported here can inform policy and spending decisions.     

Tailoring outdoor tobacco advertising to minorities in Los Angeles County

This study provides the first longitudinal comparison of the frequency and content characteristics of tobacco ads that appeared along thoroughfares running through four types of Los Angeles ethnic neighborhoods. Tobacco ad density (tobacco billboards per mile), concentration (proportion of billboards with tobacco content), and content were compared from 1990 to 1994 across four neighborhoods at multiple time points. Compared with White neighborhood thoroughfares, African American and Hispanic neighborhoods contained greater tobacco ad density, and all minority neighborhoods contained greater tobacco ad concentration along the roadsides. Initial differences in tobacco ad frequency decreased significantly over time. However, the age, race, and gender of billboard characters remained different among the different ethnic neighborhood thoroughfares, with greater ethnicity-specific content in African American neighborhood thoroughfares than in other neighborhood thoroughfares. These data are consistent with the assertion that tobacco companies target ethnic minorities with higher rates of advertising and ethnically tailored campaigns. This may be used in order to expand the total market of minority consumers.     

Peer Reviewed: Healthy Maine Partnerships: Policy and Environmental Changes

Background

Tobacco settlement funds were used to establish the Healthy Maine Partnerships (HMPs) to reduce tobacco use, increase physical activity, and improve nutrition through local policy and environmental change.

Context

The HMP model is a progressive approach to public health. It provides for coordinated efforts between state and local partners for health promotion and disease prevention. Community coalitions, supported with funding and guidance by the state, are the basis for policy and environmental change.

Methods

The state awarded contracts and provided program guidance to foster policy and environmental change at the local level. The partnerships'' efforts were assessed with a retrospective evaluation that consisted of 2 data collection periods conducted using the same tool. A survey booklet containing lists of possible environmental and policy changes was developed and mailed — once in 2005 and once in 2006 — to all 31 local partnership directors and school health coordinators who completed it. Additional data were collected from the local partnerships in the form of narrative reports required by their funder (Maine Center for Disease Control and Prevention).

Consequences

All local partnerships implemented policy or environmental interventions to address tobacco use, physical activity, and nutrition during the period covered by the surveys (July 2002-June 2005 [fiscal years 2003-2005]). Cumulatively, more than 4,600 policy or environmental changes were reported; tobacco use policies represent most changes implemented. A second round of HMP funding has since been secured.

Interpretation

Although the survey methodology had limitations, results suggest that much work has been accomplished by the local partnerships. Plans are to share success stories among partnerships, provide training, and continue to improve the public health infrastructure in Maine.     

Peer Reviewed: Engaging Employers to Develop Healthy Workplaces: The WorkWell Initiative of Steps to a Healthier Washington in Thurston County

Background

The WorkWell initiative of Thurston County, Washington, established by Steps to a Healthier Washington in Thurston County (Thurston County Steps), focuses on recognizing and supporting local employers who make a commitment to address workforce health issues by implementing programs within their organizations to help adults reach Healthy People 2010 objectives. This article reports on the WorkWell initiative and resulting WorkWell program.

Context

The WorkWell initiative was developed to address the needs of private and public employers in Thurston County, Washington, to reduce the prevalence of chronic diseases through policy, practice, and environmental changes.

Methods

Thurston County Steps recruited local employers to participate in advisory work groups to identify healthy workplace interventions that would be feasible for the employers and initiate a shift in organizational culture. The WorkWell initiative developed 2 distinct approaches — 1 for private sector (designation program) and another for public sector (action planning).

Consequences

Twenty-six employers with approximately 4,700 employees were recognized with WorkWell Healthy Workplace designations for implementing changes that included encouraging stairwell use, providing low- or no-cost healthy meals for employees, and providing healthy foods at meetings. Four public agencies with approximately 4,400 employees have participated in an assessment and action planning process to help government employers focus their efforts and resources to support workforce health promotion.

Interpretation

Unique partnerships between Thurston County Steps and other employers, private and public, demonstrate the important role employers can play in reducing chronic disease to improve a community''s overall health.     

Providers of primary care to homeless women in Los Angeles County

Little is known about the access barriers homeless women face at the sites where they are most likely to receive primary health care. To investigate this issue, we administered a mail survey to administrators and clinicians at clinic sites that were actual or potential providers of primary health care to homeless women in Los Angeles County in 1997. The response rate was 65%. Ninety percent of the homeless women seen by responding sites were seen at only 34% of those sites (designated as "major providers"). Deficiencies were identified in several structural and process characteristics that enhance access to and quality of care for homeless women, including clinician training in care for homeless persons; formal screening for homeless status and associated risk factors; and on-site provision of comprehensive health services, including mental health, substance abuse, reproductive health, and ancillary services. Some, but not all, deficiencies were less severe at major providers. Our results suggest that, although providers of care to homeless women share challenges faced by many safety net providers, there are several policy interventions that could improve access to and quality of care for homeless women.     

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.