Peer Reviewed: Promising Practices in Promotion of Healthy Weight at Small and Medium-Sized US Worksites

Introduction

We developed a new evaluation method to identify promising practices for promoting healthy weight among employees at small and medium-sized worksites.

Methods

We used a structured rating and selection process to select 9 worksites with approximately 100 to 3,000 employees from a pool of worksites with health promotion programs reputed to be exemplary. A site visit over 2 sequential half-days at each site included interviews with senior management, program staff, vendors, and wellness committees; observation guided by a written environmental assessment; and structured review of program data on health outcomes of wellness program participants. The team corroborated findings from interviews, observations, and reviews of aggregate data on health outcomes of participants. Using the site visit reports, the project team and a separate panel of experts identified worksite health promotion practices that were promising, innovative, feasible to implement in a variety of settings, sustainable, and relevant for public health.

Results

Innovative practices included peer coaching, wellness screening coupled with motivational interviewing and follow-up, free access to fitness facilities, and incentives such as days of paid leave for participation in wellness programs. Introduction of incentives was associated with higher participation rates. To build the business case for their programs, staff at several worksites used aggregate data on decreases in high blood pressure, serum cholesterol concentrations, and body weight in longitudinal samples of program participants.

Conclusion

The evaluation method identified promising practices implemented at small and medium-sized worksites to promote healthy weight and related favorable health outcomes.     

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: 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.     

Worksite characteristics and environmental and policy supports for cardiovascular disease prevention in New York state

Introduction

Worksite policy and environmental supports that promote physical activity, healthy eating, stress management, and preventive health screenings can contribute to the prevention of cardiovascular disease and lower employer costs. This study examines the availability of these four categories of supports in a statewide survey of New York State worksites.

Methods

In 2002, we recruited a statewide sample of worksites in New York State with 75 or more employees to participate in a mailed survey assessing worksite policy and environmental supports for wellness and health promotion. The overall response rate was 34.8%. The analysis included data from 832 worksites.

Results

Worksite size was an independent predictor of health promotion supports with small (75–99 employees) and medium-small (100–199 employees) worksites reporting significantly fewer policy and environmental supports in all four categories than worksites with 300 or more employees. Worksites in which most employees were nonwhite reported fewer supports for physical activity, healthy eating, and stress management than worksites in which most employees were white. A wellness committee or wellness coordinator was associated with more health promotion supports, regardless of the size of the worksite or composition of its workforce.

Conclusion

Worksites with fewer than 200 employees have an increased need for assistance in establishing environmental and policy supports promoting cardiovascular health. Worksites that have a wellness committee or coordinator are better able to establish and sustain supports with the potential to improve the health of their workers.     

Cultivating a Cycle of Trust With Diverse Communities in Practice-Based Research: A Report From PRIME Net

PURPOSE

Practice-based research networks (PBRNs) are increasingly seen as important vehicles to translate research into practice, although less is known about the process of engaging diverse communities in PBRN research. The objective of this study was to identify strategies for successfully recruiting and retaining diverse racial/ethnic communities into PBRN research studies.

METHODS

This collaborative, multisite study engaged 5 of the 8 networks of the PRImary care MultiEthnic Network (PRIME Net) consortium that conducts research with traditionally underrepresented/underserved populations. We used a sequential, qualitative research design. We first conducted 1 key informant interview with each of 24 researchers experienced in recruiting research participants from 5 racial/ethnic communities (African American, Arab/Chaldean, Chinese, Hispanic, and Native American). Subsequently, we conducted 18 focus groups with 172 persons from these communities.

RESULTS

Participants’ comments indicated that successful recruitment and retention of underrepresented populations in PBRN studies is linked to the overall research process. This process, which we termed the cycle of trust, entailed developing and sustaining relationships of trust during 4 interrelated stages: before the study, during study recruitment, throughout study conduct, and after study completion. Participants identified a set of flexible strategies within each stage and called for close engagement with clinic and community partners.

CONCLUSIONS

Our participants suggest that approaches to research that lay a foundation of trust, demonstrate respect for community members, and extend beyond the enrollment and data collection phases are essential to enhance the participation of diverse populations in PBRN research. These findings offer the PBRN community a guide toward achieving this important goal.     

Peer Reviewed: The Role of State Health Departments in Supporting Community-based Obesity Prevention

Background

Recent national attention to obesity prevention has highlighted the importance of community-based initiatives. State health departments are in a unique position to offer resources and support for local obesity prevention efforts.

Community Context

In North Carolina, one-third of children are overweight or obese. North Carolina''s Division of Public Health supports community-based obesity prevention by awarding annual grants to local health departments, providing ongoing training and technical assistance, and engaging state-level partners and resources to support local efforts.

Methods

The North Carolina Division of Public Health administered grants to 5 counties to implement the Childhood Obesity Prevention Demonstration Project; counties simultaneously carried out interventions in the community, health care organizations, worksites, schools, child care centers, and faith communities.

Outcome

The North Carolina Division of Public Health worked with 5 local health departments to implement community-wide policy and environmental changes that support healthful eating and physical activity. The state health department supported this effort by working with state partners to provide technical assistance, additional funding, and evaluation.

Interpretation

State health departments are well positioned to coordinate technical assistance and leverage additional support to increase the strength of community-based obesity prevention efforts.     

Peer Reviewed: A Methodology for Evaluating Organizational Change in Community-Based Chronic Disease Interventions

Background

In 2003, the Monterey County Health Department, serving Salinas, California, was awarded one of 12 grants from the Steps to a HealthierUS Program to implement a 5-year, multiple-intervention community approach to reduce diabetes, asthma, and obesity. National adult and youth surveys to assess long-term outcomes are required by all Steps sites; however, site-specific surveys to assess intermediate outcomes are not required.

Context

Salinas is a medically underserved community of primarily Mexican American residents with high obesity rates and other poor health outcomes. The health department''s Steps program has partnered with traditional organizations such as schools, senior centers, clinics, and faith-based organizations as well as novel organizations such as employers of agricultural workers and owners of taquerias.

Methods

The health department and the Stanford Prevention Research Center developed new site-specific, community-focused partner surveys to assess intermediate outcomes to augment the nationally mandated surveys. These site-specific surveys will evaluate changes in organizational practices, policies, or both following the socioecological model, specifically the Spectrum of Prevention.

Consequences

Our site-specific partner surveys helped to 1) identify promising new partners, select initial partners from neighborhoods with the greatest financial need, and identify potentially successful community approaches; and 2) provide data for evaluating intermediate outcomes matched to national long-term outcomes so that policy and organizational level changes could be assessed. These quantitative surveys also provide important context-specific qualitative data, identifying opportunities for strengthening community partnerships.

Interpretation

Developing site-specific partner surveys in multisite intervention studies can provide important data to guide local program efforts and assess progress toward intermediate outcomes matched to long-term outcomes from nationally mandated surveys.     

Peer Reviewed: Feasibility of an Evidence-Based Weight Loss Intervention for a Faith-Based, Rural, African American Population

Background

African Americans and rural residents are disproportionately affected by obesity. Innovative approaches to address obesity that are sensitive to the issues of rural African Americans are needed. Faith-based and community-based participatory approaches show promise for engaging racial/ethnic minorities to change health outcomes, but few faith-based weight loss interventions have used a community-based participatory approach.

Community Context

A faith-based weight loss intervention in the Lower Mississippi Delta arose from a 5-year partnership between academic and community partners representing more than 30 churches and community organizations.

Methods

Community and academic partners translated the 16 core sessions of the Diabetes Prevention Program for rural, church-going African American adults. The feasibility of the lay health advisor–led delivery of the 16-week (January-May 2010), 16-session, adapted intervention was assessed in 26 participants from 3 churches by measuring recruitment, program retention, implementation ease, participant outcomes, and program satisfaction.

Outcome

Twenty-two of 26 participants (85%) provided 16-week follow-up data. Lay health advisors reported that all program components were easy to implement except the self-monitoring component. Participants lost an average of 2.34 kg from baseline to 16-week follow-up, for a mean weight change of −2.7%. Participants reported enjoying the spiritual and group-based aspects of the program and having difficulties with keeping track of foods consumed. The intervention engaged community partners in research, strengthened community-academic partnerships, and built community capacity.

Interpretation

This study demonstrates the feasibility of delivering this adapted intervention by lay leaders through rural churches.     

Systematic review of implementation strategies for risk tables in the prevention of cardiovascular diseases

Background

Cardiovascular disease prevention is guided by so-called risk tables for calculating individual’s risk numbers. However, they are not widely used in routine practice and it is important to understand the conditions for their use.

Objectives

Systematic review of the literature on professionals’ performance regarding cardiovascular risk tables, in order to develop effective implementation strategies.

Selection criteria

Studies were eligible for inclusion if they reported quantitative empirical data on the effect of professional, financial, organizational or regulatory strategies on the implementation of cardiovascular risk tables. Participants were physicians or nurses.

Outcome measure

Primary: professionals’ self-reported performance related to actual use of cardiovascular risk tables. Secondary: patients’ cardiovascular risk reduction.

Data collection and analysis

An extensive strategy was used to search MEDLINE, EMBASE, CINAHL, and PSYCHINFO from database inception to February 2007.

Main results

The review included 9 studies, covering 3 types of implementation strategies (or combinations). Reported effects were moderate, sometimes conflicting and contradictory. Although no clear relation was observed between a particular type of strategy and success or failure of the implementation, promising strategies for patient selection and risk assessment seem to be teamwork, nurse led-clinics and integrated IT support.

Conclusions

Implementation strategies for cardiovascular risk tables have been sparsely studied. Future research on implementation of cardiovascular risk tables needs better embedding in the systematic and problem-based approaches developed in implementation science.     

Disparities in Completion of Substance Abuse Treatment between and within Racial and Ethnic Groups

Objective

To evaluate disparities in substance abuse treatment completion between and within racial and ethnic groups in publicly funded treatment in Los Angeles County, California.

Data Source

The Los Angeles County Participant Reporting System with multicross-sectional annual data (2006–2009) for adult participants (n = 16,637) who received treatment from publicly funded programs (n = 276) for the first time.

Study Design

Retrospective analyses of county discharge and admission data. Hierarchical linear regressions models were used to test the hypotheses.

Data Collection

Client data were collected during personal interviews at admission and discharge for most participants.

Principal Findings

African Americans and Latinos reported lower odds of completing treatment compared with Whites. Within-group analysis revealed significant heterogeneity within racial and ethnic groups, highlighting primary drug problem, days of drug use before admission, and homelessness as significant factors affecting treatment completion. Service factors, such as referral by the criminal justice system, enabled completion among Latinos and Whites only.

Conclusions

These findings have implications for reducing health disparities among members of racial and ethnic minorities by identifying individual and service factors associated with treatment adherence, particularly for first-time clients.     

Peer Reviewed: Design and National Dissemination of the StrongWomen Community Strength Training Program

Background

Physical activity is essential for maintaining health and function with age, especially among women. Strength training exercises combat weakness and frailty and mitigate the development of chronic disease. Community-based programs offer accessible opportunities for strength training.

Program Design

The StrongWomen Program is an evidence-informed, community-based strength training program developed and disseminated to enable women aged 40 or older to maintain their strength, function, and independence. The StrongWomen Workshop and StrongWomen Tool Kit are the training and implementation tools for the StrongWomen Program. Program leaders are trained at the StrongWomen Workshop. They receive the StrongWomen Tool Kit and subsequent support to implement the program in their communities.

Dissemination

Program dissemination began in May 2003 with a three-part approach: recruiting leaders and forming key partnerships, soliciting participant interest and supporting implementation, and promoting growth and sustainability.

Assessment

We conducted site visits during the first year to assess curriculum adherence. We conducted a telephone survey to collect data on program leaders, participants, locations, and logistics. We used a database to track workshop locations and program leaders. As of July 2006, 881 leaders in 43 states were trained; leaders from 35 states had implemented programs.

Conclusion

Evidence-informed strength training programs can be successful when dissemination occurs at the community level using trained leaders. This research demonstrates that hands-on training, a written manual, partnerships with key organizations, and leader support contributed to the successful dissemination of the StrongWomen Program. Results presented provide a model that may aid the dissemination of other community-based exercise programs.     

Peer Reviewed: CAN DO Houston: A Community-Based Approach to Preventing Childhood Obesity

Background

Comprehensive, community-based efforts may reduce rates of childhood obesity.

Community Context

Almost half of the children in Houston are overweight or obese, even though Houston has many available resources that support good nutrition, physical activity, and prevention of weight gain among children.

Methods

We used existing resources to implement a community-based, childhood obesity prevention initiative in 2 low-income neighborhoods in Houston. On the basis of input from community members, we coordinated various activities to promote healthy living, including after-school programs, grocery store tours, wellness seminars, cooking classes, and staff wellness clubs.

Outcome

Preliminary findings indicated that residents in the communities are using additional opportunities to participate in physical activity and nutrition education.

Interpretation

Implementing a successful childhood obesity prevention initiative in an urban setting is feasible with minimal funding through the use of existing resources.     

Peer Reviewed: Establishing Worksite Wellness Programs for North Carolina Government Employees, 2008

Background

State employee health plans sometimes provide worksite wellness programs to reduce the prevalence of chronic diseases among their members, but few offer the comprehensive range of interventions recommended by the Task Force on Community Preventive Services.

Community Context

North Carolina''s State Health Plan for Teachers and State Employees provides health coverage for approximately 665,000 state employees, teachers, retirees, and dependents. Health claims indicate that the prevalence of having at least 1 chronic disease or of being obese is approximately 32% among state employees.

Methods

The State Health Plan created a partnership with North Carolina''s Division of Public Health, Office of State Personnel, and other key state agencies to identify bureaucratic obstacles to providing worksite wellness programs for state employees and to develop a state policy to address them. The Division of Public Health established a model worksite program to guide development of the worksite wellness policy and pilot wellness interventions.

Outcome

The state''s first worksite wellness policy created an employee wellness infrastructure in state government and addressed administrative barriers to allow effective worksite wellness interventions. For example, the policy led to pilot implementation of a subsidized worksite weight management program. Positive results of the program helped generate legislative support to expand the weight management program throughout state government.

Interpretation

Strong interagency partnership is essential to guide worksite wellness policy and program development in state government. State health plans, public health agencies, and personnel agencies each play a role in that partnership.     

Pursuing the Triple Aim: The First 7 Years

Context

In 2008, researchers at the Institute for Healthcare Improvement (IHI) described the Triple Aim as simultaneously “improving the individual experience of care; improving the health of populations; and reducing the per capita costs of care for populations.” IHI and its close colleagues had determined that both individual and societal changes were needed.

Methods

In 2007, IHI began recruiting organizations from around the world to participate in a collaborative to implement what became known as the Triple Aim. The 141 participating organizations included health care systems, hospitals, health care insurance companies, and others closely tied to health care. In addition, key groups outside the health care system were represented, such as public health agencies, social services groups, and community coalitions. This collaborative provided a structure for observational research. By noting the contrasts between the contexts and structures of those sites in the collaborative that progressed and those that did not, we were able to develop an ex post theory of what is needed for an organization or community to successfully pursue the Triple Aim.

Findings

Drawing on our 7 years of experience, we describe the 3 major principles that guided the organizations and communities working on the Triple Aim: creating the right foundation for population management, managing services at scale for the population, and establishing a learning system to drive and sustain the work over time.

Conclusions

The concept of the Triple Aim is now widely used, because of IHI''s work with many organizations and also because of the adoption of the Triple Aim as part of the national strategy for US health care, developed during the implementation of the Patient Protection and Affordable Care Act of 2010. Even those organizations working on the Triple Aim before IHI coined the term found our concept to be useful because it helped them think about all 3 dimensions at once and organize their work around them.     

Peer Reviewed: Effect of a Multifaceted,Church-Based Wellness Program on Metabolic Syndrome in 41 Overweight or Obese Congregants

Introduction

A rise in obesity, poor-quality diets, and low physical activity has led to a dramatic increase in the number of Americans with metabolic syndrome and diabetes. Our objective was to determine the effect of a short-term, multifaceted wellness program carried out in a church setting on weight, metabolic syndrome, and self-reported wellness.

Methods

Forty-one overweight or obese adults in a church congregation provided fasting blood samples and answered a wellness questionnaire before and after completing an 8-week diet and exercise program. We also measured weight, body fat, body mass index, and waist and hip circumference.

Results

The intervention decreased weight, body fat, and central adiposity; improved indexes of metabolic syndrome; and increased self-reported wellness.

Conclusion

A multifaceted wellness intervention that emphasizes diet and exercise can rapidly influence weight, insulin resistance, metabolic syndrome, and self-reported wellness.     

Peer Reviewed: A Comprehensive Worksite Wellness Program in Austin,Texas: Partnership Between Steps to a Healthier Austin and Capital Metropolitan Transportation Authority

Background

In 2003, Steps to a Healthier Austin was funded by the Centers for Disease Control and Prevention to implement chronic disease prevention and health promotion activities. We report Steps to a Healthier Austin''s partnership with Health & Lifestyles Corporate Wellness, Inc (Health & Lifestyles), to provide a worksite wellness program for Capital Metropolitan Transportation Authority (Capital Metro), Austin''s local transit authority.

Context

Capital Metro employs 1,282 people. In 2003, Health & Lifestyles was hired to help promote healthier lifestyles, increase employee morale, and combat rising health care costs and absenteeism rates.

Methods

Health & Lifestyles provided consultations with wellness coaches and personal trainers, a 24-hour company fitness center, personalized health assessments, and preventive screenings. The program expanded to include healthier food options, cash incentives, health newsletters, workshops, dietary counseling, smoking cessation programs, and a second fitness center.

Consequences

Participants in the wellness program reported improvements in physical activity, healthy food consumption, weight loss, and blood pressure. Capital Metro''s total health care costs increased by progressively smaller rates from 2003 to 2006 and then decreased from 2006 to 2007. Absenteeism has decreased by approximately 25% since the implementation of the program, and the overall return on the investment was calculated to be 2.43.

Interpretation

Since the implementation of the wellness program in 2003, Capital Metro has seen a reduction in costs associated with employee health care and absenteeism.     

The Private Partners of Public Health: Public-Private Alliances for Public Good

Objective

We sought to convey lessons learned by the Centers for Disease Control and Prevention''s (CDC''s) Prevention Research Centers (PRCs) about the value and challenges of private-sector alliances resulting in innovative health promotion strategies. Several PRCs based in a variety of workplace and community settings contributed.

Methods

We conducted interviews with principal investigators, a literature review, and a review of case studies of private-sector alliances in a microbusiness model, a macrobusiness model, and as multiparty partnerships supporting public health research, implementation, and human resource services.

Results

Private-sector alliances provide many advantages, particularly access to specialized skills generally beyond the expertise of public health entities. These skills include manufacturing, distribution, marketing, business planning, and development. Alliances also allow ready access to employee populations. Public health entities can offer private-sector partners funding opportunities through special grants, data gathering and analysis skills, and enhanced project credibility and trust. Challenges to successful partnerships include time and resource availability and negotiating the cultural divide between public health and the private sector. Critical to success are knowledge of organizational culture, values, mission, currency, and methods of operation; an understanding of and ability to articulate the benefits of the alliance for each partner; and the ability and time to respond to unexpected changes and opportunities.

Conclusion

Private-public health alliances are challenging, and developing them takes time and resources, but aspects of these alliances can capitalize on partners'' strengths, counteract weaknesses, and build collaborations that produce better outcomes than otherwise possible. Private partners may be necessary for program initiation or success. CDC guidelines and support materials may help nurture these alliances.