Development and acceptability of an educational video about a smoking cessation quitline for use in adult outpatient mental healthcare.

Tobacco use is a leading preventable cause of early mortality and is prevalent among adults with mental health diagnoses, especially in the southern USA. Increasing cessation resources in outpatient mental health care and targeting individuals most receptive to changing their behavior may improve cessation. Drawing on the transtheoretical model, our goals were to develop an educational video about the Louisiana Tobacco Quitline and evaluate its acceptability. We designed the video with knowledge derived from Louisiana-specific data (2016 Louisiana Adult Tobacco Survey, N = 6,469) and stakeholder feedback. Bivariate associations between demographic/tobacco-use characteristics and participants' stage of quitting (preparation phase vs. nonpreparation phase) were conducted, which informed design elements of the video. Four stakeholder advisory board meetings involving current smokers, mental health clinicians, and public health advocates convened to provide iterative feedback on the intervention. Our stakeholder advisory board (n = 10) and external stakeholders (n = 20) evaluated intervention acceptability. We found that 17.9% of Louisiana adults were current smokers, with 46.9% of them in the preparation phase of quitting. Using insights from data and stakeholders, we succeeded in producing a 2-min video about the Louisiana Tobacco Quitline which incorporated three themes identified as important by stakeholders: positivity, relatability, and approachability. Supporting acceptability, 96.7% of stakeholders rated the video as helpful and engaging. This study demonstrates the acceptability of combining theory, existing data, and iterative stakeholder feedback to develop a quitline educational video. Future research should examine whether the video can be used to reduce tobacco use.

Enterprise Evaluation: A New Opportunity for Public Health Policy.

Standard evaluation practice in public health remains limited to evaluative measures linked to individual projects, even if multiple interrelated projects are working toward a common impact. Enterprise evaluation seeks to fill this policy gap by focusing on cross-sector coordination and ongoing reflection in evaluation. We provide an overview of the enterprise evaluation framework and its 3 stages: collective creation, individual data collection, and collective analysis. We illustrate the application of enterprise evaluation to the Gulf Region Health Outreach Program, 4 integrated projects that aimed to strengthen health care in Louisiana, Mississippi, Alabama, and the Florida Panhandle after the Deepwater Horizon oil spill. Shared commitment to sustainability and strong leadership were critical to Gulf Region Health Outreach Program's success in enterprise evaluation. Enterprise evaluation provides an important opportunity for funding agencies and public health initiatives to evaluate the impact of interrelated projects in a more holistic and multiscalar manner than traditional siloed approaches to evaluation.

Using the emergency department to investigate smoking in young adults.

PURPOSE: Smoking in young adults identifies the population at risk for future tobacco-related disease. We investigated smoking in a young adult population and within high-risk groups using emergency department (ED) data in a metropolitan area. METHODS: Using the electronic health record, we performed a retrospective study of smoking in adults aged 18-30 years presenting to the ED. RESULTS: Smoking status was available for 55,777 subjects (90.9% of the total ED cohort); 60.8% were women, 55.0% were black, 35.3% were white, and 8.1% were Hispanic; 34.4% were uninsured. Most smokers used cigarettes (95.1%). Prevalence of current smoking was 21.7% for women and 42.5% for men. The electronic health record contains data about diagnosis and social history that can be used to investigate smoking status for high-risk populations. Smoking prevalence was highest for substance use disorder (58.0%), psychiatric illness (41.3%) and alcohol use (39.1%), and lowest for pregnancy (13.5%). In multivariable analyses, male gender, white race, lack of health insurance, alcohol use, and illicit drug use were independently associated with smoking. Smoking risk among alcohol and drug users varied by gender, race, and/or age. CONCLUSIONS: The ED provides access to a large, demographically diverse population, and supports investigation of smoking risk in young adults.

Qualitative Methodologies as an Intervention: Beyond Program Planning and Implementation.

The Primary Care Capacity Project (PCCP), implemented by the Louisiana Public Health Institute, systematically and rigorously applied qualitative methodologies beyond simple interviews and focus groups to develop the project areas of focus, evaluate clinical transformation interventions in selected heath centers along the Gulf Coast, and provide data and support to foster ongoing quality improvement approaches. Qualitative methodologies were utilized for formative, implementation, and summative evaluation. During the early formative stages of PCCP, community prioritization meetings were conducted in Louisiana, Mississippi, Alabama, and Florida, in which key stakeholders were asked to brainstorm and prioritize major health issues and recommendations in their communities. Findings from these meetings were then used to inform PCCP clinic funding and other community priorities. During project implementation, dyadic interviews were facilitated around specific PCCP areas of focus. These dyadic interviews were valuable in that they uncovered stories, successes, and challenges of clinical transformation. Moreover, they promoted peer-to-peer learning among diverse health centers. The relationships between interview participants are likely to continue past the grant period and further promote innovation and efficiency. Finally case studies were conducted to inform actionable recommendations tailored to each health center. These data also provided value add back to the health centers as they used the information to guide programming and quality improvement efforts. Qualitative methods are critical tools for public health practitioners to support project planning and improvement as well as community change.

Engagement Strategies to Advance Community-Centered Primary Care.

The Louisiana Public Health Institute designed and implemented the Primary Care Capacity Project (PCCP) with the purpose of expanding access to high-quality, integrated, and sustainable community-based primary care, including linkages to behavioral health services, as well as environmental and occupational health services. With a primary focus to invest in community health centers across 17 Gulf Coast counties and parishes, PCCP engaged stakeholders, including 4 primary care organizations, over 20 federally qualified health centers, public health institutes, health information exchanges, national experts, academic organizations, and health departments along with their relevant community partners. This article examines the strategies PCCP used to engage stakeholders and partners throughout the project in order to strengthen sustainable primary care systems. The PCCP team fostered trusted partnerships with a wide range of stakeholders to not only understand the need of the communities but to also identify ways to complement and not duplicate already existing efforts. Specifically, community prioritization convenings, peer-to-peer learning through the Regional Care Collaborative, and dyadic interviews were instrumental in linking stakeholders and maximizing capacity-building efforts. Health partners across the 4 states are now better positioned to collaborate on future regional opportunities including continued knowledge transfer through special interest groups, ongoing engagement with an annual regional convening, continued efforts to advance emergency management and resiliency, and potential development of group purchasing and other shared services. The PCCP experience suggests that in disaster-prone areas the sustainability of integrated primary care and behavioral health services is enhanced when cross-jurisdiction collaborations are established.

Estimating the costs of supporting safety-net transformation into patient-centered medical homes in post-Katrina New Orleans.

There is a need to understand the costs associated with supporting, implementing, and maintaining the system redesign of small and medium-sized safety-net clinics. The authors aimed to understand the characteristics of clinics that transformed into patient-centered medical homes and the incremental cost for transformation.The sample was 74 clinics in Greater New Orleans that received funds from the Primary Care Access and Stabilization Grant program between 2007 and 2010 to support their transformation. The study period was divided into baseline (September 21, 2007-March 21, 2008), transformation (March 22, 2008-March 21, 2009), and maintenance (March 22, 2009-September 20, 2010) periods, and data were collected at 6-month intervals. Baseline characteristics for the clinics that transformed were compared to those that did not. Fixed-effect models were conducted for cost estimation, controlling for baseline differences, using propensity score weights.Half of the 74 primary care clinics achieved transformation by the end of the study period. The clinics that transformed had higher total cost, more clinic visits, and a larger female patient proportion at baseline. The estimated incremental cost for clinics that underwent transformation was $37.61 per visit per 6 months, and overall it cost $24.86 per visit per 6 months in grant funds to support a clinic's transformation.Larger-sized clinics and those with a higher female proportion were more likely to transform. The Primary Care Access and Stabilization Grant program provided approximately $24.86 per visit over the 2 and 1/2 years. This estimated incremental cost could be used to guide policy recommendations to support primary care transformation in the United States.

Developing a Community-Based Participatory Research Curriculum to Support Environmental Health Research Partnerships: An Initiative of the GROWH Community Outreach and Dissemination Core.

BACKGROUND: The Transdisciplinary Research Consortium for Gulf Resilience on Women's Health (GROWH) addresses reproductive health disparities in the Gulf Coast by linking communities and scientists through community-engaged research. Funded by the National Institutes of Environmental Health Sciences, GROWH's Community Outreach and Dissemination Core (CODC) seeks to utilize community-based participatory research (CBPR) and other community-centered outreach strategies to strengthen resilience in vulnerable Gulf Coast populations. The CODC is an academic-community partnership comprised of Tulane University, Mary Queen of Vietnam Community Development Corporation, Bayou Interfaith Shared Community Organizing, and the Louisiana Public Health Institute (LPHI). METHODS: Alongside its CODC partners, LPHI collaboratively developed, piloted and evaluated an innovative CBPR curriculum. In addition to helping with curriculum design, the CODC's community and academic partners participated in the pilot. The curriculum was designed to impart applied, practical knowledge to community-based organizations and academic researchers on the successful formulation, execution and sustaining of CBPR projects and partnerships within the context of environmental health research. RESULTS: The curriculum resulted in increased knowledge about CBPR methods among both community and academic partners as well as improved relationships within the GROWH CODC partnership. CONCLUSION: The efforts of the GROWH partnership and curriculum were successful. This curriculum may serve as an anchor for future GROWH efforts including: competency development, translation of the curriculum into education and training products, community development of a CBPR curriculum for academic partners, community practice of CBPR, and future environmental health work.

Texting for Health: An Evaluation of a Population Approach to Type 2 Diabetes Risk Reduction With a Personalized Message.

txt4health is an innovative, 14-week, interactive, population-based mobile health program for individuals at risk of type 2 diabetes, developed under the Beacon Community Program in the Greater New Orleans, La., area. A comprehensive social marketing campaign sought to enroll hard-to-reach, at-risk populations using a combination of mass media and face-to-face engagement in faith-based and retail environments. Little is known about the effectiveness of social marketing for mobile technology application in the general population. A systematic evaluation of the campaign identified successes and barriers to implementing a population-based mobile health program. Face-to-face engagement helped increase program enrollment after the initial launch; otherwise, enrollment leveled off over time. Results show positive trends in reaching target populations and in the use of mobile phones to record personal health information and set goals for reducing the risk of type 2 diabetes. The lessons from the txt4health campaign can help inform the development and programmatic strategies to provide a person-level intervention using a population-level approach for individuals at risk for diabetes as well as aid in chronic disease management.

Can school choice improve more than just academic achievement? An analysis of post-Katrina New Orleans.

BACKGROUND: Recent evaluations of school choice school reforms have focused on improving academic achievement but have ignored associations with adolescent health and the risk of interpersonal violence. The innovative school choice model implemented in post-Katrina New Orleans provides a unique opportunity to examine these effects. METHODS: Using a sample of approximately 1700 students from the 2009 School Health Connection Survey, the relationships between the type of school attended and depression, suicide planning, absences attributable to fears for personal safety, and threats of violence at school are examined. Multivariate regression analysis adjusting for self-selection into the type of school attended-a city-run high-performing school, a state-run failing school, or an independent charter school-estimates the effects of school type on student health. RESULTS: Relative to students at state-run schools, students who choose to attend city-run schools are less likely to plan for suicide or to miss school because they are afraid of becoming victims of violence. These beneficial effects tend to be larger for students traveling from higher violence neighborhoods. The effects for charter schools are similar but less robust. CONCLUSIONS: Local school jurisdictions that implement reforms allowing adolescents and their families greater freedom in school choice may also improve adolescent health.

How a Beacon Community Program in New Orleans Helped Create a Better Health Care System by Building Relationships before Technology.

INTRODUCTION: In the aftermath of Hurricane Katrina, much of New Orleans' healthcare infrastructure was destroyed. Initial federal funding after the storm expanded primary care services and helped set up medical homes for New Orleans' large uninsured and underinsured population. Following that, the Beacon Community in New Orleans, charged with improving health care through the use of technology, decided the best way to accomplish those goals was to build community partnerships and introduce technology improvements based on their input and on their terms. The purpose of this paper is to describe how those partnerships were wrought, including the innovative use of a conceptual framework, and how they are being sustained; how different technologies were and are being introduced; and what the results have been so far. METHODS: Past successful community experiences, as well as a proven conceptual framework, were used to help establish community partnerships and governance structures, as well as to demonstrate their linkages. This paper represents a compilation of reports and information from key Beacon leaders, staff and providers and their firsthand experiences in setting up those structures, as well as their conclusions. RESULTS: The community partnerships proved extremely successful in not only devising successful ways to introduce new technology into healthcare settings, but in sustaining those changes by creating a governance structure that has enough fluidity to adapt to changing circumstances. CONCLUSIONS: Building and developing community partnerships takes time and effort; however, these relationships are necessary and essential to introducing and sustaining new technologies in a healthcare setting and should be a first step for any organization looking to accomplish such goals.

Evaluating the Reliability of EHR-Generated Clinical Outcomes Reports: A Case Study.

INTRODUCTION: Quality incentive programs, such as Meaningful Use, operate under the assumption that clinical quality measures can be reliably extracted from EHRs. Safety Net providers, particularly Federally Qualified Health Centers and Look-Alikes, tend to be high adopters of EHRs; however, recent reports have shown that only about 9% of FQHCs and Look-Alikes were demonstrating meaningful use as of 2013. Our experience working with the Crescent City Beacon Community (CCBC) found that many health centers relied on chart audits to report quality measures as opposed to electronically generating reports directly from their EHRs due to distrust in the data. This paper describes a step-by-step process for improving the reliability of data extracted from EHRs to increase reliability of quality measure reports, to support quality improvement, and to achieve alignment with national clinical quality reporting requirements. BACKGROUND: Lack of standardization in data capture and reporting within EHRs drives distrust in EHR-reported data. Practices or communities attempting to achieve standardization may look to CCBC's experience for guidance on where to start and the level of resources required in order to execute a data standardization project. During the time of this data standardization project, CCBC was launching an HIE. Lack of trust in EHR data was a driver for distrust in the HIE data. METHODS: We present a case study where a five-step process was used to harmonize measures, reduce data errors, and increase trust in EHR clinical outcomes reports among a community of Safety Net providers using a common EHR. Primary outcomes were the incidence of reporting errors and the potential effect of error types on quality measure percentages. The activities and level of resources required to achieve these results were also documented by the CCBC program. FINDINGS: Implementation of a community-wide data reporting project resulted in measure harmonization, reduced reporting burden, and error reduction in EHR-generated clinical outcomes reporting across participating clinics over a nine-month period. Increased accuracy of clinical outcomes reports provided physicians and clinical care teams with better information to guide their decision-making around quality improvement planning. DISCUSSION: A number of challenges exist to achieving reliable population level quality reporting from EHRs at the practice, vendor, and community levels. Our experience demonstrates that quality measure reporting from EHRs is not a straightforward process, and it requires time and close collaboration between clinics and vendors to improve reliability of reports. Our experience found that practices valued the opportunity and step-wise process to validate their data locally (out of their EHRs) prior to reporting out of the HIE. CONCLUSION AND NEXT STEPS: Communities can achieve higher levels of confidence in quality measure reporting at the population level by establishing collaborative user groups that work with EHR vendors as partners and use technical assistance to build relationships and trust in EHR-generated reports. While this paper describes the first phase of our work around improving standardization and reliability of EHR reports, vendors should continue to explore modifications for improving data capture (at the front-end) via standardized data entry templates.

Workplace exposure to secondhand smoke among non-smoking hospitality employees.

INTRODUCTION: This article examines salivary cotinine concentrations to characterize secondhand smoke (SHS) exposure among non-smoking hospitality employees (bar and casino employees and musicians who perform in bars) who are exposed to SHS in the workplace. METHODS: A pre-post test study design was implemented to assess SHS exposure in the workplace. The convenience sample of 41 non-smoking hospitality employees included 10 controls (non-smoking hospitality employees not exposed to SHS in the workplace). RESULTS: The findings demonstrate that post-shift saliva cotinine levels of hospitality employees who are exposed to SHS in the workplace are significantly higher than controls who work in smoke-free venues. Findings also suggested a statistically significant increase between pre- and post-shift saliva cotinine levels of hospitality employees who are exposed in the workplace. No statistically significant difference was noted across labor categories, suggesting that all exposed employees are at increased risk. CONCLUSION: The study results indicate that non-smoking hospitality employees exposed to SHS in the workplace have significantly higher cotinine concentration levels compared with their counterparts who work in smoke-free venues. Findings from other studies suggest that these increased cotinine levels are harmful to health. Given the potential impact on the health of exposed employees, this study further supports the efforts of tobacco prevention and control programs in advocating for comprehensive smoke-free air policies to protect bar and casino employees.

Sexual risk behaviors among youth heads of household in Gikongoro, south province of Rwanda.

BACKGROUND: As a result of the 1994 genocide and AIDS, Rwanda has a crisis of orphans. In 2005, the Ministry of Local Governance and Social Affairs of Rwanda has reported one million vulnerable children. Many of these are not only orphans but also youth heads of households (YHH). The purpose of this study was to: (a) identify risk behaviors that expose YHH to HIV infection, (b) determine gender-specific high risk profiles and, (c) determine predictors of sexual onset. METHODS: A household survey was conducted among 692 YHH, aged 12-24, all beneficiaries of a World Vision basic needs program in Gikongoro, Rwanda, from January to March 2004. Participants were interviewed using a structured questionnaire. Data was collected on socio-demographic variables, HIV/AIDS prevention knowledge and sexual risk behaviors. Bivariate analyses of the study variables were performed to examine differences between males and females. A logistic regression analysis was conducted to analyze factors that were independently associated with the debut of having sex. RESULTS: Forty-one percent of respondents reported sexual onset before age 15. Males were more likely to start earlier than females (50.4% versus 26.7%) but females reported more sexual onset with an older partner. Fifty-eight percent of females had their first intercourse with a partner who was four or more years older than themselves. While sexual activity was low (1.75 mean lifetime sexual partner, 0.45 mean sexual partner last twelve months), sexual experience was related to less social connectedness and use of drugs. Having a close friend also appeared to be protective for sexual debut. The analysis also found that although YHH were aware of some prevention measures against HIV/AIDS, there was low (19.8%) knowledge of the "ABC" prevention program promoted by the government. In addition, despite 85% of respondents knowing someone who had died of AIDS, only 31% perceived themselves at risk of HIV infection, and there was very low (13.2%) condom use among the sexually experienced. CONCLUSIONS: Results suggest the urgent need of HIV prevention programs tailored to YHH that provide knowledge, enhance negotiations skills, and increase the perception of HIV infection risk among YHH in Rwanda.

Disaster and youth violence: the experience of school-attending youth in New Orleans.

PURPOSE: Although disaster exposure has been linked with increased child aggression by previous reports, population-level trends are unknown. Pre- to post-Katrina changes in violence-related behaviors among New Orleans high school youth (ages: 12-18 years) were assessed. METHODS: Data from the 2003 (pre-Katrina), 2005 (pre-Katrina), and 2007 (post-Katrina) New Orleans Youth Risk Behavior Survey (n = 5,267) were used. Crude comparisons across years of population characteristics and violence behavior prevalence were made with χ(2) analyses. Changes in violence-related behaviors over time were assessed with logistic regression models including indicators for survey years and controls for compositional changes. RESULTS: Age, gender, and race/ethnicity of school-attending youth were stable across years. In models controlling for demographics, most behaviors were stable over time. Some changes were observed for all groups; dating violence and forced sex increased before the storm, whereas weapon-carrying and missing school as a result of feeling unsafe decreased after the storm. Among African American adolescents only, being threatened at school increased before Katrina. CONCLUSIONS: Results do not support significant population-level increases in violent behavior post-Katrina among school-attending youth in New Orleans. Factors that buffered New Orleans students from post-Katrina violence increases, such as population composition changes or increased supportive services, may explain these findings.

The influence of orphan care and other household shocks on health status over time: a longitudinal study of children's caregivers in rural Malawi.

In the context of rising rates of orphanhood in AIDS-affected settings, very little is understood about implications for caregiver well-being given increasing and intensifying responsibilities for the care of orphaned children. Emotional distress and self-reported health status as well as shifts in household orphan care, wealth, food security and recent illness and death among household members were measured among a panel of 1219 caregivers in rural Malawi between 2007 and 2009. Logistic regression was used to identify predictors of improved and diminished caregiver health and emotional distress. Results suggest that becoming an orphan caregiver is associated with a shift from good to poor health status (adjusted odds ratio [AOR]=2.29, 95% confidence interval [CI]=1.16-4.54), and that elevated levels of distress and poor health both persist over time in comparison with care for non-orphans only. Once engaged in orphan care, taking on additional orphans is associated with increased emotional distress in relation to not caring for orphans (AOR=3.16, 95% CI=1.30-7.73) as well as in relation to maintaining the same number of orphans in care over time (AOR=2.84, 95% CI=1.04-7.70). In addition, findings illustrate the strong influence of household wealth and food security on caregiver well-being. Food insecurity and poverty that persist or develop over time are associated with increasing distress. Conversely, maintenance or improvement in food security and household wealth are associated with decreases in distress. Providing all aspects of household maintenance and care for children, primary caregivers are key to the extended family solution for orphaned and vulnerable children. Bolstering the foundation of rural African families to ensure care and protection of these children involves targeting support to orphan caregivers but must also include addressing the issues of poverty and food insecurity that pose a wider threat to caregiving capacity.

Improving the lives of vulnerable children: implications of Horizons research among orphans and other children affected by AIDS.

From 1997 through 2007, the Horizons program conducted research to inform the care and support of children who had been orphaned and rendered vulnerable by acquired immunodeficiency syndrome in sub-Saharan Africa. Horizons conducted studies in Kenya, Malawi, Rwanda, South Africa, Uganda, Zambia, and Zimbabwe. Research included both diagnostic studies exploring the circumstances of families and communities affected by human immunodeficiency virus (HIV) and evaluations of pioneering intervention strategies. Interventions found to be supportive of families included succession planning for families with an HIV-positive parent, training and supporting youth as caregivers, and youth mentorship for child-headed households. Horizons researchers developed tools to assess the psychosocial well-being of children affected by HIV and outlined key ethical guidelines for conducting research among children. The design, implementation, and evaluation of community-based interventions for orphans and vulnerable children continue to be a key gap in the evidence base.

Reducing HIV-related stigma: lessons learned from Horizons research and programs.

Since the early years of the human immunodeficiency virus (HIV) epidemic, stigma has been understood to be a major barrier to successful HIV prevention, care, and treatment. This article highlights findings from more than 10 studies in Asia, Africa, and Latin America-conducted from 1997 through 2007 as part of the Horizons program-that have contributed to clarifying the relationship between stigma and HIV, determining how best to measure stigma among varied populations, and designing and evaluating the impact of stigma reduction-focused program strategies. Studies showed significant associations between HIV-related stigma and less use of voluntary counseling and testing, less willingness to disclose test results, and incorrect knowledge about transmission. Programmatic lessons learned included how to assist institutions with recognizing stigma, the importance of confronting both fears of contagion and negative social judgments, and how best to engage people living with HIV in programs. The portfolio of work reveals the potential and importance of directly addressing stigma reduction in HIV programs.

A longitudinal quality-of-life study of HIV-infected persons in South India: the case for comprehensive clinical care and support services.

This study longitudinally assesses the quality of life (QOL) of HIV-infected individuals in a resource-limited setting prior to the extensive generic roll-out of highly active antiretroviral therapy. Data was collected on 136 individuals receiving clinical care at Y.R. Gaitonde Centre for AIDS Research and Education YRG CARE, a large community-based HIV tertiary care referral center in Chennai, South India. The QOL questionnaire was administered to participants at baseline, 6-months follow-up, and 12-month follow-up, and analysis of variance was used to assess for significant differences in mean QOL scores for each of these visits. Study findings showed that QOL scores significantly improved in all five domains of the questionnaire between participants' baseline visit, second interview, and third interviews (p < 0.01). We conclude that a multidisciplinary approach to managing HIV infection can enhance patients' QOL, independent of antiretroviral therapy.