Multilevel Interventions To Address Health Disparities Show Promise In Improving Population Health

Multilevel interventions are those that affect at least two levels of influence—for example, the patient and the health care provider. They can be experimental designs or natural experiments caused by changes in policy, such as the implementation of the Affordable Care Act or local policies. Measuring the effects of multilevel interventions is challenging, because they allow for interaction among levels, and the impact of each intervention must be assessed and translated into practice. We discuss how two projects from the National Institutes of Health’s Centers for Population Health and Health Disparities used multilevel interventions to reduce health disparities. The interventions, which focused on the uptake of the human papillomavirus vaccine and community-level dietary change, had mixed results. The design and implementation of multilevel interventions are facilitated by input from the community, and more advanced methods and measures are needed to evaluate the impact of the various levels and components of such interventions

Best-fitting prediction equations for basal metabolic rate: informing obesity interventions in diverse populations

Basal Metabolic Rate (BMR) represents the largest component of total energy expenditure and is a major contributor to energy balance. Therefore, accurately estimating BMR is critical for developing rigorous obesity prevention and control strategies. Over the past several decades, numerous BMR formulas have been developed targeted to different population groups. A comprehensive literature search revealed 248 BMR estimation equations developed using diverse ranges of age, gender, race, fat free mass, fat mass, height, waist-to-hip ratio, body mass index, and weight. A subset of 47 studies included enough detail to allow for development of meta-regression equations. Utilizing these studies, meta-equations were developed targeted to twenty specific population groups. This review provides a comprehensive summary of available BMR equations and an estimate of their accuracy. An accompanying online BMR prediction tool (available at http://www.sdl.ise.vt.edu/tutorials.html) was developed to automatically estimate BMR based on the most appropriate equation after user-entry of individual age, race, gender, and weight

One-Year Follow-Up Examination of the Impact of the North Carolina Healthy Food Small Retailer Program on Healthy Food Availability, Purchases, and Consumption

We examined the short-term impact of the North Carolina Healthy Food Small Retailer Program (HFSRP), a legislatively appropriated bill providing funding up to $25,000 to small food retailers for equipment to stock and promote healthier foods, on store-level availability and purchase of healthy foods and beverages, as well as customer dietary patterns, one year post-policy implementation. We evaluated healthy food availability using a validated audit tool, purchases using customer bag-checks, and diet using self-reported questionnaires and skin carotenoid levels, assessed via Veggie Meter™, a non-invasive tool to objectively measure fruit and vegetable consumption. Difference-in-difference analyses were used to examine changes in HFSRP stores versus control stores after 1 year. There were statistically significant improvements in healthy food supply scores (availability), with the Healthy Food Supply HFS score being −0.44 points lower in control stores and 3.13 points higher in HFSRP stores pre/post HFSRP (p = 0.04). However, there were no statistically significant changes in purchases or self-reported consumption or skin carotenoids among customers in HFSRP versus control stores. Additional time or other supports for retailers (e.g., marketing and promotional materials) may be needed for HFSRP implementation to influence purchase and consumption

Religions and Social Progress:Critical Assessments and Creative Partnerships

This chapter engages with three important themes of the larger report: the meaning of progress, its uneven nature, and obstacles to future progress. It also considers a number of political and economic alternatives aimed to overcome these obstacles, emphasizing the need for diverse strategies, open-minded experimentation, and scientific assessment. While it may be impossible to ever reach agreement, the effort to calibrate different interpretations of progress remains an important exercise for political deliberation about how to make the world a better place. The very hope of moving forward implies some agreement on a destination. All of us must take responsibility for the future. Our discussion emphasizes the complexity and multidimensionality of the interpretive debate, but also calls attention to its ideological character. Social actors-individuals, groups, and even academic disciplines-tend to define progress in ways that serve their own interests. In a way, distributional conflict undermines our very efforts to better understand and mediate such conflict. The uneven character of progress is manifest in many different domains. Increases in the global reach of formally democratic institutions have been accompanied by growing concerns about their stability, efficacy, and consistency with democratic ideals

Health Economics in Public Health

BACKGROUND: Economic analysis is an important tool in deciding how to allocate scarce public health resources; however, there is currently a dearth of such analysis by public health researchers. METHODS: Public health researchers and practitioners were surveyed to determine their current use of health economics and to identify barriers to use as well as potential strategies to decrease those barriers in order to allow them to more effectively incorporate economic analyses into their work. Data collected from five focus groups informed survey development. The survey included a demographic section and 14 multi-part questions. Participants were recruited in 2006 from three national public health organizations through e-mail; 294 academicians, practitioners, and community representatives answered the survey. RESULTS: Survey data were analyzed in 2007. Despite an expressed belief in the importance of health economics, more than half of the respondents reported very little or no current use of health economics in their work. Of those using health economics, cost-benefit and cost-effectiveness analysis and determination of public health costs were cited as the measures used most frequently. The most important barriers were lack of expertise, funding, time, tools, and data, as well as discomfort with economic theory. The resource deemed most important to using health economics was collaboration with economists or those with economic training. Respondents indicated a desire to learn more about health economics and tools for performing economic analysis. CONCLUSIONS: Given the importance of incorporating economic analysis into public health interventions, and the desire of survey respondents for more collaboration with health economists, opportunities for such collaborations should be increased

Food policy council case study describing cross-sector collaboration for food system change in a rural setting

Problem: Food Policy Councils (FPCs) are cross-sector collaborations that bring representatives from across the food system together to identify issues, coordinate programs, and inform policy. Little is known about how rural FPCs operate to influence food access in their communities. Purpose: To explore how a rural FPC facilitates cross-sector partnerships and influences food system change through interviews with eight members of the Adam’s County FPC. Results: Connections developed through the FPC helped council members work more effectively in their home organizations. Four themes were discussed: council dynamics and structure; sharing resources, expertise, and information; promoting healthy food access through programs; and food policy opportunities and challenges. Conclusions: This case study illustrates connections between FPC members in a rural county and identifies how FPCs can facilitate food system change in their communities. Improving our understanding of how rural FPCs function can help to advance the potential public health impact of councils

Using implementation mapping to refine strategies to improve implementation of an evidence-based mobile market intervention: a study protocol

Objectives The Veggie Van model is a mobile market model that is efficacious in increasing fruit and vegetable consumption for lower-income participants. The model is currently being evaluated for its effectiveness in a multi-state trial. Preliminary implementation data, collected through process measures surveys and implementation interviews, indicate that there are several barriers to implementation among partner organizations and implementation fidelity to the Veggie Van model was low. Consideration and planning for implementation ought to occur early and often throughout the research process order to ensure Veggie Van model effectiveness. This paper describes the step-by-step process for creating strategies to enhance implementation of Veggie Van model components. Methods Implementation mapping is a systematic process to develop implementation strategies through engagement with key stakeholders. We conducted a series of interviews (n = 31 representatives) with partner organizations (n = 8) to identify facilitators and barriers to Veggie Van model implementation. We then applied interview findings to an Implementation Mapping process to develop theory and practice-driven strategies to be integrated into existing implementation tools and technical assistance. Results We identified implementation outcomes (e.g., staff implement the Veggie Van model component of nutrition education with fidelity) and performance objectives (e.g., offer nutrition education, in the form of food lessons and/or food demonstrations, at least bi-weekly) to achieve them. We conducted a secondary qualitative analysis of the findings from implementation interviews with partner organizations to identify behavioral determinants (e.g., attitudinal beliefs, social support) which were combined with the performance objectives to generate change objectives (e.g., view the Veggie Van model as advantageous to an organization and communities served). To achieve the change objectives, we developed implementation strategies that would be integrated into existing Veggie Van training resources including an online toolkit, webinars and trainings, an annual mobile market conference, and technical assistance. Conclusion The development of theory and practice-driven implementation strategies will enable us to improve our implementation tools, thereby improving fidelity to the Veggie Van model among organizations and increasing the likelihood of its effectiveness. Detailing the design of a multifaceted implementation strategy using Implementation Mapping also provides a model to design similar strategies for other community-based interventions

The role of companionship, esteem, and informational support in explaining physical activity among young women in an online social network intervention

The primary objective of the current study was to examine the relationship between social support and physical activity within the Theory of Planned Behavior (TPB) theoretical framework. This study used data from the Internet Support for Healthy Associations Promoting Exercise randomized controlled trial. A total of 134 female undergraduate students participated in the study, which included baseline and post measures of perceived social support for physical activity (esteem, informational, and companionship), TPB variables related to physical activity (perceived behavioral control, intention, and attitude), and physical activity behavior. Path analysis revealed a significant indirect relationship between change in companionship support and physical activity mediated by change in intention (.13, p<.01) and a significant direct relationship between change in esteem support and change in physical activity (.26, p=.03). The model explained 27% of the variance in physical activity and 59% of the variance in intention. Overall, change in social support exerted a small to medium amount of influence on change in physical activity in this modified TPB model when controlling for traditional model constructs. Encouraging companionship and esteem support should be considered as a strategy for increasing physical activity in this population

Effectiveness of interventions to promote healthy diet in primary care: systematic review and meta-analysis of randomised controlled trials

Background A diet rich in fruit, vegetables and dietary fibre and low in fat is associated with reduced risk of chronic disease. This review aimed to estimate the effectiveness of interventions to promote healthy diet for primary prevention among participants attending primary care.&lt;p&gt;&lt;/p&gt; Methods A systematic review of trials using individual or cluster randomisation of interventions delivered in primary care to promote dietary change over 12 months in healthy participants free from chronic disease or defined high risk states. Outcomes were change in fruit and vegetable intake, consumption of total fat and fibre and changes in serum cholesterol concentration.&lt;p&gt;&lt;/p&gt; Results Ten studies were included with 12,414 participants. The design and delivery of interventions were diverse with respect to grounding in behavioural theory and intervention intensity. A meta-analysis of three studies showed an increase in fruit consumption of 0.25 (0.01 to 0.49) servings per day, with an increase in vegetable consumption of 0.25 (0.06 to 0.44) serving per day. A further three studies that reported on fruit and vegetable consumption together showed a pooled increment of 0.50 (0.13 to 0.87) servings per day. The pooled effect on consumption of dietary fibre, from four studies, was estimated to be 1.97 (0.43 to 3.52) gm fibre per day. Data from five studies showed a mean decrease in total fat intake of 5.2% of total energy (1.5 to 8.8%). Data from three studies showed a mean decrease in serum cholesterol of 0.10 (-0.19 to 0.00) mmol/L.&lt;p&gt;&lt;/p&gt; Conclusion Presently-reported interventions to promote healthy diet for primary prevention in primary care, which illustrate a diverse range of intervention methods, may yield small beneficial changes in consumption of fruit, vegetables, fibre and fat over 12 months. The present results do not exclude the possibility that more effective intervention strategies might be developed.&lt;p&gt;&lt;/p&gt