Leveraging a health information exchange for analyses of COVID-19 outcomes including an example application using smoking history and mortality.

Understanding sociodemographic, behavioral, clinical, and laboratory risk factors in patients diagnosed with COVID-19 is critically important, and requires building large and diverse COVID-19 cohorts with both retrospective information and prospective follow-up. A large Health Information Exchange (HIE) in Southeast Texas, which assembles and shares electronic health information among providers to facilitate patient care, was leveraged to identify COVID-19 patients, create a cohort, and identify risk factors for both favorable and unfavorable outcomes. The initial sample consists of 8,874 COVID-19 patients ascertained from the pandemic's onset to June 12th, 2020 and was created for the analyses shown here. We gathered demographic, lifestyle, laboratory, and clinical data from patient's encounters across the healthcare system. Tobacco use history was examined as a potential risk factor for COVID-19 fatality along with age, gender, race/ethnicity, body mass index (BMI), and number of comorbidities. Of the 8,874 patients included in the cohort, 475 died from COVID-19. Of the 5,356 patients who had information on history of tobacco use, over 26% were current or former tobacco users. Multivariable logistic regression showed that the odds of COVID-19 fatality increased among those who were older (odds ratio = 1.07, 95% CI 1.06, 1.08), male (1.91, 95% CI 1.58, 2.31), and had a history of tobacco use (2.45, 95% CI 1.93, 3.11). History of tobacco use remained significantly associated (1.65, 95% CI 1.27, 2.13) with COVID-19 fatality after adjusting for age, gender, and race/ethnicity. This effort demonstrates the impact of having an HIE to rapidly identify a cohort, aggregate sociodemographic, behavioral, clinical and laboratory data across disparate healthcare providers electronic health record (HER) systems, and follow the cohort over time. These HIE capabilities enable clinical specialists and epidemiologists to conduct outcomes analyses during the current COVID-19 pandemic and beyond. Tobacco use appears to be an important risk factor for COVID-19 related death.

Population-Based Estimates of SARS-CoV-2 Seroprevalence in Houston, Texas as of September 2020.

BACKGROUND: In contrast to studies that relied on volunteers or convenience sampling, there are few population-based severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seroprevalence investigations and most were conducted early in the pandemic. The health department of the fourth largest US city recognized that sound estimates of viral impact were needed to inform decision making. METHODS: Adapting standardized disaster research methodology, in September 2020 the city was divided into high and low strata based on reverse-transcriptase polymerase chain reaction (RT-PCR) positivity rates; census block groups within each stratum were randomly selected with probability proportional to size, followed by random selection of households within each group. Using 2 immunoassays, the proportion of infected individuals was estimated for the city, by positivity rate and sociodemographic and other characteristics. The degree of underascertainment of seroprevalence was estimated based on RT-PCR-positive cases. RESULTS: Seroprevalence was estimated to be 14% with near 2-fold difference in areas with high (18%) versus low (10%) RT-PCR positivity rates and was 4 times higher compared to case-based surveillance data. CONCLUSIONS: Seroprevalence was higher than previously reported and greater than estimated from RT-PCR data. Results will be used to inform public health decisions about testing, outreach, and vaccine rollout.

Building and Advancing Coalition Capacity to Promote Health Equity: Insights from the Health Equity Collective's Approach to Addressing Social Determinants of Health.

This article presents the structure and function of the Health Equity Collective in developing a systemic approach to promoting health equity across the Greater Houston area. Grounded in Kania and Kramer's five phases of collective impact for coalition building, The Collective operationalizes its mission through its backbone team, steering committees, and eight workgroups; each has goals that mutually reinforce and advance its vision. To date, Phase I (generating ideas), Phase II (initiating action), and Phase III (organizing for impact) have been completed. Phases IV (implementation) and Phase V (sustainability) are currently underway.

Understanding Associations Between Hurricane Harvey Exposure and Mental Health Symptoms Among Greater Houston-Area Residents.

OBJECTIVE: Hurricane Harvey made landfall on August 25, 2017 and resulted in widespread flooding in Houston and the surrounding areas. This study aimed to explore the associations between exposure to Hurricane Harvey and various mental health symptoms. METHODS: Self-reported demographics, hurricane exposure, and mental health symptomatology were obtained from residents of the greater Houston area through convenience sampling for a pilot study, 5 months after the storm from January 25-29, 2018 (N = 161). RESULTS: Increased hurricane exposure score was significantly associated with increased odds for probable depression, probable anxiety, and probable posttraumatic stress disorder after adjusting for other factors associated with mental health. No significant associations were found between demographic characteristics and risk of mental health difficulties. CONCLUSIONS: Mental health difficulties associated with exposure to Hurricane Harvey were still present 5 months after the storm. Future disaster response programs should focus on providing long-term mental health services to hurricane survivors.

Differences in nativity, age and gender may impact health behavior and perspectives among Asian Indians.

OBJECTIVE: Identify health perspectives among Asian Indians in greater Houston area, to guide a tailored community wide survey. DESIGN: Four focus groups of different ages, gender, and nativity were conducted at which participants were asked for their opinions about specific health topics. Key informant interviews were conducted with ten community leaders to validate focus group responses. Recordings from focus groups and key informant interviews were transcribed and analyzed. RESULTS: Diabetes, cancer, and hypertension were primary health concerns. Common themes were sedentary lifestyle and poor health literacy. Older participants were more accepting of having familial hypertension and high cholesterol. Women were more concerned about health of family members and dietary habits. Perspectives differed on eating habits, physical activity, use of Western medicine, and smoking based on nativity. Responses from key informant interviews validated focus group findings. CONCLUSION: Perspectives on health may differ among Asian Indians depending on gender, age, and nativity.

Chronic Health Conditions, Physical Activity and Dietary Behaviors of Bhutanese Refugees: A Houston-Based Needs Assessment.

Bhutanese refugees resettling in the U.S. face many challenges including several related to health and health care. Limited health literacy and the relatively complicated US health care system may contribute to health disparities as well. A health assessment was conducted on adult refugees in Houston, Texas to provide healthcare providers, community organizations, and stakeholders baseline data to plan programs and interventions. A convenience sample of 100 participants had a mean age of 38.37 years, 56 % where males, and almost 80 % did not have high school level education. High blood pressure (27 %), dizziness (27 %), and arthritis (22 %) were the commonly identified chronic health conditions and trouble concentrating (34 %) and fatigue (37 %) were also reported. Sixty-two percent of the respondents reported that they consume recommended servings of fruits and vegetables and 41 %reported that they were currently getting at least 20-30 min of aerobic exercise per day. The assessment concluded with recommendations on how better provide care and services for the refugees.

Characterizing urban vulnerability to heat stress using a spatially varying coefficient model.

Identifying and characterizing urban vulnerability to heat is a key step in designing intervention strategies to combat negative consequences of extreme heat on human health. This study combines excess non-accidental mortality counts, numerical weather simulations, US Census and parcel data into an assessment of vulnerability to heat in Houston, Texas. Specifically, a hierarchical model with spatially varying coefficients is used to account for differences in vulnerability among census block groups. Socio-economic and demographic variables from census and parcel data are selected via a forward selection algorithm where at each step the remaining variables are orthogonalized with respect to the chosen variables to account for collinearity. Daily minimum temperatures and composite heat indices (e.g. discomfort index) provide a better model fit than other ambient temperature measurements (e.g. maximum temperature, relative humidity). Positive interactions between elderly populations and heat exposure were found suggesting these populations are more responsive to increases in heat.

A1C Testing and its Sociodemographic Predictors: Implications for Diabetes Self-management Programs.

BACKGROUND: One of the Healthy People (2020) goals related to the glycated hemoglobin (HbA1C) test is to increase the percentage of adults (aged 18 years and older) with diabetes who have had an HbA1C test at least twice in the past 12 months from 64.6% percent in 2008 to 71.1% by 2020. However, Texas has historically trailed behind several other states in achieving this goal. Targeted interventions for demographic subgroups of population could be a strategy to increase testing. However, little is known about the sociodemographic predictors of A1C test. METHOD: Texas Behavioral Risk Factor Surveillance System (BRFSS) data (2011 and 2012) were used to identify sociodemographic predictors of having had at least one A1C test in the past 12 months among diabetic patients. The sociodemographic predictors examined included age, sex, race/ethnicity, marital status, educational attainment, insurance status, whether or not the respondents had a primary care physician, and age when diabetes was diagnosed. A logistic model was developed to predict the membership. RESULTS: Multivariate logistic regression indicated that insurance status and educational attainment are predictors of adherence to an annual A1C test. Those with insurance were nearly 3 times more likely than those without insurance to report adherence to annual A1C test (odds ratio [OR] = 2.82, 95% confidence interval [CI], 1.47-5.42, P = .002), when controlled for all other sociodemographic variables. Likewise, those with more than college-level education were also nearly 3 times more likely than those with less than high school level education to report adherence (OR = 2.74, 95% CI, 1.27-5.89, P = .010). CONCLUSION: Population-based diabetes management programs should consider educational attainment level and insurance status of individuals when developing interventions to increase the rate of adherence to A1C testing recommendation among diabetic patients. Targeting interventions toward individuals with less than high school education and ensuring that diabetic individuals have some form of health insurance coverage may be helpful.

Do people become better prepared in the aftermath of a natural disaster? The hurricane Ike experience in Houston, Texas.

OBJECTIVE: Despite large-scale efforts and expensive public education campaigns mounted by the government at all levels in the past decade, the improvements in disaster preparedness among the US Gulf Coast residents have been ineffectual at best. Some factors that contribute to better preparedness are past experience, awareness of what to do in a disaster scenario and availability, and access to informational and supportive resources. We examine whether an experience of a natural disaster brings about changes in preparedness and access to resources. DESIGN: Our study is based on data from 2 cross-sectional random-digit-dialing surveys in 2008 (pre-Ike) and 2009 (post-Ike) with sample sizes of 1001 and 1009, respectively. PARTICIPANTS: Adults living in one of the 85 zip codes in Houston, Texas. MAIN OUTCOME MEASURE: Self-reported preparedness, evacuation plan, available resources (informational, financial and emotional). RESULTS: We found no significant changes in preparedness or evacuation plans in residents of Houston prior to and a year after Hurricane Ike. Hispanics and other minority groups reported a significant increase in access to information and all residents reported an increase in perception of availability of financial support, if needed. Perceived availability of tangible (financial) support has been linked to positive physical and mental health effects and can contribute to resiliency and quicker recovery. The unchanged preparedness levels could be attributed to ceiling effects, that is, the already high levels of preparedness reported by Houston residents. Greater access to information reported by Hispanics and other minorities is encouraging and indicative of success in reaching out. CONCLUSIONS: Our results also indicate a greater need for appropriate targeted strategies to reach out to African Americans in Houston since this group reported poorer access to information. This has implications for planning and preparedness officials and the communication strategies used to reach the community.

Disaster preparedness of linguistically isolated populations: practical issues for planners.

In the absence of culturally and linguistically appropriate disaster preparedness plans, several linguistically isolated and culturally diverse population groups are disproportionately disadvantaged in the United States. The communication gap poses challenges to emergency preparedness planners and response personnel in predisaster communication and postdisaster response efforts. Houston Department of Health and Human Services aimed to develop practical recommendations for local emergency response personnel so as to improve dissemination of emergency information and equitable delivery of services to linguistically isolated communities in the greater Houston area. Sixteen focus group discussions were conducted among linguistically isolated immigrant populations living in the greater Houston metropolitan area who primarily spoke one of the Spanish, Chinese, Vietnamese, and Somali languages. Our questions focused on general knowledge and understanding of disasters and explored experiences during Houston's most recent disaster, Hurricane Ike. We found that (a) understanding of disaster and preparedness is contextual, (b) awareness of preparedness needs and actual plans among LIPs is inadequate, and (c) word of mouth is the preferred information source for linguistically isolated groups. Disaster preparedness plans of a given jurisdiction should reflect the culturally and linguistically appropriate components addressing the needs, concerns, context-based knowledge or awareness, and perceptions of linguistically isolated populations.

Determinants of fruits and vegetables consumption among persons with doctor-diagnosed chronic diseases.

OBJECTIVE: The objective of this study was to examine the factors associated with fruits and vegetables consumption pattern among persons with doctor-diagnosed chronic diseases. METHOD: The authors examined cross-sectional, random-digit-dialed health survey data collected in 2008 in Houston, Texas, a city with a diverse ethnic population. The survey sample, which was designed to represent all households with telephones, was drawn using standard list-assisted random-digit-dialing methodology from telephone exchanges that serve the study area. A total of 1001 households were interviewed, and data obtained were subjected to both bivariate and multivariate analyses. RESULTS: Findings from this study indicate that fruits and vegetables consumption for persons with single chronic disease was significantly predicted (R (2) = 0.83) by the participants' age, educational level, and insurance status. None of the covariates considered in the study were significant predictors of fruits and vegetables consumption pattern among persons who had multiple chronic diseases. But when the subpopulation with any number of chronic diseases was considered, only gender (P < .05) and marital status (P < .001) were noted as the significant predictors of fruits and vegetables (R (2) = 0.34). CONCLUSION: More public health efforts are needed to make individuals with chronic diseases aware of the importance of consumption of fruits and vegetables. Clinicians and health care professionals should be encouraged to emphasize the importance of consumption of fruits and vegetables in their routine practice to the patients with chronic disease(s), especially to those who are unmarried and male.

Prenatal Care Barriers in an Inner-city Neighborhood of Houston, Texas.

The objective of this qualitative pilot study was to explore barriers to prenatal care among women (aged 17 to 30 years) with pregnancy experience who resided in an underserved and predominantly African American neighborhood in Houston, Texas. The authors conducted 5 focus group discussions with, and collected demographic information from, the 32 participants. Discussions were audiotaped, transcribed, and analyzed manually. The data analysis suggested 5 key barriers to prenatal care services among the study populations: unplanned pregnancy, lack of information, lack of support system (eg, lack of emotional and instrumental support from family members), psychosocial challenges (eg, emotions and stress-related to the condition of pregnancy), and economic hardships (eg, lack of money to maintain healthy pregnancy and basic needs). Addressing the causes of unplanned pregnancy, such as low risk perception, behavior-related causes, and attitude toward pregnancy, may be helpful to improve the utilization of prenatal care by underserved women.

Disparities in fruits and vegetables consumption in houston, Texas: implications for health promotion.

BACKGROUND: The consumption of the recommended amount of fruits and vegetables is believed to help prevent nutrient deficiency disorders and lower the risk of several chronic diseases. Information on the disparity of fruit and vegetable consumption may be useful in designing targeted health promotion programs for increasing fruit and vegetable consumption. The objective of this pilot study was to examine disparities in fruit and vegetable consumption among Houston residents based on sociodemographic characteristics. METHODS: The authors conducted bivariate and multivariate analyses to examine the associations between sociodemographic characteristics and fruit and vegetable consumption using a random digit dialing (RDD) health survey data (N = 1001) collected in Houston, Texas. RESULTS: Bivariate analysis showed that there were significant associations between fruit and vegetable consumption and education (P < .01); race/ethnicity (P < .001); marital status (P < .001); and employment status (P < .05). Multivariate analysis indicated that fruit and vegetable consumption pattern could be significantly (P ≤ .05) predicted by gender, race, and marital status. Respondents who were of other race category were less likely than whites to consume fruits and vegetables, while married respondents and women were more likely to consume fruits and vegetables compared to the unmarried and men, respectively. IMPLICATIONS: Health promotion programs aimed at increasing the consumption of fruits and vegetables should consider developing targeted intervention for men, people with less formal education, minority race/ethnicity, people who are unemployed, and those who are unmarried.

Community-based participatory research in disaster preparedness among linguistically isolated populations: a public health perspective.

Working with linguistically isolated immigrants on public health issues poses a set of methodological challenges unique to this population. We used community-based participatory research (CBPR) techniques to investigate the disaster preparedness needs of four linguistically isolated population groups in Houston, Texas (Vietnamese, Chinese, Somali, and Spanish-speaking) in partnership with community-based organizations and community researchers. As a local health department conducting CBPR, we witnessed various challenges, including: engaging and using interpreters versus using community researchers; translating focus group questions from English to other languages; recruiting participants from linguistically isolated populations; and handling issues of community power, data collection, and data reliability. In this article, we discuss these challenges, strategies used, and the outcomes of our approaches in the broader context of CBPR.

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.

Self-reported health, functional status and chronic disease in community dwelling older adults: untangling the role of demographics.

Self-reported health, a widely used measure of general health status in population studies, can be affected by certain demographic variables such as gender, race/ethnicity and education. This cross-sectional assessment of the current health status of older adult residents was conducted in an inner-city Houston neighborhood in May, 2007. A survey instrument, with questions on chronic disease prevalence, health limitations/functional status, self-reported subjective health status in addition to demographic data on households was administered to a systematic random sample of residents. Older adults (>60 years of age) were interviewed (weighted N = 127) at their homes by trained interviewers. The results indicated that these residents, with low literacy levels, low household income and a high prevalence of frequently reported chronic diseases (hypertension, diabetes and arthritis) also reported non-participation in community activities, volunteerism and activities centered on organized religion, thus, potentially placing them at risk for social isolation. Women reported poorer self-reported health and appeared to fare worse in all health limitation indicators and reported greater structural barriers in involvement with their community. Blacks reported worse health outcomes on all indicators than other sub-groups, an indication that skills training in chronic disease self-management and in actively eliciting support from various sources may be beneficial for this group. Therefore, the use of self-reported health with a broad brush as an indicator of "true" population health status is not advisable. Sufficient consideration should be given to the racial/ethnic and gender differences and these should be accounted for.