Comprando Rico y Sano: Increasing Latino Nutrition Knowledge, Healthful Diets, and Food Access Through a National Community-Based Intervention.

PURPOSE: Evaluation findings from Comprando Rico y Sano (CRS), a culturally relevant, community-based intervention addressing nutrition knowledge and food access are presented. DESIGN: No-control quasi-experimental intervention with pre, post, and follow-up assessments. SETTING: CRS was promotores-led through UnidosUS's Affiliate Network of community-based partners. SAMPLE: Low-income Latino adults (N = 966) receiving services at 25 partner sites. INTERVENTION: CRS was a six-hour intervention focused on nutrition knowledge and consumption of fruits, vegetables, and home-prepared meals. It also provided guidance for health-conscious grocery shopping, Supplemental Nutrition Assistance Program (SNAP) information, and enrollment assistance. MEASURES: Self-report surveys assessed nutrition knowledge; intention to change; and frequency of fruit, vegetable, and home-prepared meal consumption. Sites reported monthly SNAP enrollment data. ANALYSIS: Paired-samples t-tests and repeated-measures ANOVAs assessed changes in knowledge, intentions, and behavior from pre-to-post (n = 960) and pre-to-follow-up (n = 115). RESULTS: Pre-to-follow-up increases in nutrition knowledge (P < .001) were observed. Intention to consume more vegetables (P = .027) and home-prepared meals (P < .001) also improved between pre- and follow-up. Increases from pre-to-follow-up were observed for frequency of consuming fruits (P = .007), vegetables (P = .001), and home-prepared meals (P < .001). Across 16 months, 24,359 Latinos enrolled for SNAP. CONCLUSION: Large-scale community collaborations to deliver culturally relevant nutrition education and SNAP enrollment assistance can increase food access, health literacy, and promote healthful diets for Latinos.

Adding folic acid to corn Masa flour: Partnering to improve pregnancy outcomes and reduce health disparities.

Although strides have been made in preventing neural tube defects (NTDs), Hispanic women remain more likely to have a baby born with an NTD and less likely to know the benefits of, or consume, folic acid than women of other race/ethnic groups. In 1998, the U.S. Food and Drug Administration (FDA) mandated that all enriched cereal grain products be fortified with folic acid; however, corn masa flour (CMF), used to make many corn products that are a diet staple of many Hispanic groups, was not included under this regulation. In 2006, a Working Group began a collaboration to address this disparity by pursuing a petition to FDA to allow folic acid to be added voluntarily to CMF. The petition process was a monumental effort that required collaboration and commitment by partners representing the affected population, manufacturers, scientists, and others. The petition was approved in 2016 and folic acid is now added to CMF products, with expected results of more women achieving the recommended daily folic acid intake, more infants born per year without an NTD, and millions of dollars in direct medical expenditures averted. This 10-year public-private partnership brought together diverse groups that traditionally have different goals. The Working Group continues to work toward ensuring that fortified CMF products are available to the consumer, with the end goal of achieving a reduction in NTD-affected pregnancies.

Race, ethnicity, and language data collection by health plans: findings from 2010 AHIPF-RWJF survey.

BACKGROUND: Previous national surveys have documented the increase in collection of race, ethnicity, and language (REL) data by health plans. The latest 2010 survey created an opportunity to examine recent trends and to determine whether the Patient Protection and Affordable Care Act (ACA) had an effect on plans' practices. METHODS: A 51-item survey was sent to all health plans included in a national listing of plans (N = 250). RESULTS: The majority of responding plans collect data on members' REL. The frequency of race and ethnicity data collection was only slightly greater in 2010 than in 2008, 78.7% and 75% respectively. By 2010, 89.3% of health plans were collecting language data of their members, up from 74% in 2008 and 57.3% in 2003. CONCLUSIONS: Since 2008, collection and use of REL data continues gradually to increase among health plans, demonstrating the industry's commitment to address racial/ethnic gaps in care.

Collection of data on race/ethnicity and language proficiency of providers.

OBJECTIVES: To determine the extent to which health plans were collecting and using data on the race, ethnicity, and language proficiency of network physicians and other network providers. STUDY DESIGN: Survey of health plans conducted in 2010, with results compared with data from similar surveys conducted in 2006 and 2008. METHODS: Surveys were sent by e-mail to representatives of 250 health plans identified through the Atlantic Information Service's Directory of Health Plans: 2010. Basic descriptive statistics were used to characterize response patterns to individual items in the 2010 survey and to compare responses to matching items in the 2006 and 2008 surveys. RESULTS: Approximately half of responding plans reported collecting data on race/ethnicity of providers. This proportion was not significantly different from that of previous years' surveys, and several plans that had been collecting data on providers' race/ethnicity in 2006 had discontinued the practice by 2010. Nearly all plans reported collecting data about languages spoken for 1 or more types of employees or providers. Plans were more likely in 2010 than in 2006 to verify language proficiency of staff and share this information with plan members. CONCLUSIONS: Even though health plans and other healthcare organizations were more likely in 2010 than in the past to collect data on member/patient race, ethnicity, and language preferences, collection and use of data on providers' race/ethnicity have not expanded in scope since 2006. Collection and use of data on providers' proficiency in languages other than English were more common.

Exploring health plan perspectives in collecting and using data on race, ethnicity, and language.

OBJECTIVES: To explore why health plans collect or forgo data collection efforts on race, ethnicity, and language (REL), and the challenges encountered in collecting and using data for quality improvement. STUDY DESIGN: In-depth interviews with 15 health plans were conducted between June and August 2009. METHODS: Fifteen health plans participated and were divided into 2 groups: Plans that collect and use REL data (n = 10), and plans that do not collect REL data (n = 5). A structured interview guide was developed that included questions about REL data collection efforts, leadership support, collaboration with external partners, and challenges and opportunities in the collection and use of REL information. For plans not collecting REL data, questions were also asked regarding reasons to forgo data collection and existing health equity efforts. A summary report, based on audiotapes, interview notes, and input from the research team, was developed and analyzed. RESULTS: The interviews highlight the need for new partnerships and coordinated efforts to improve healthcare equity through disseminating best practices and tools that help expand such activities. Barriers noted include the costs associated with adapting information technology systems to accommodate new functions, such as new data fields, appropriate software and analytical tools, and the lack of standard codes for race and ethnicity. CONCLUSIONS: Health plans are eager to collaborate with new partners and share strategies to collect REL data as a foundation to reduce disparities. Opportunities exist to collaborate with employers and purchasers to improve the extent and quality of REL data and can ultimately lead to designing and implementing culturally appropriate programs in the workforce.

Collection of race and ethnicity data by health plans has grown substantially, but opportunities remain to expand efforts.

In 2003 the Institute of Medicine called on health plans to collect data on their members' race and ethnicity as a foundation for improving the quality of care and reducing disparities. We describe the progress made toward collecting these data, the most commonly used data collection methods, and the challenges plans have encountered. We found that from 2003 through 2008, the proportion of plans that collected members' data on race and ethnicity doubled in the commercial market to 60 percent. It increased even more sharply to 94 percent and 83 percent, respectively, for plans covering Medicaid and Medicare Advantage enrollees. However, the scope of data collection varied greatly across plans, and data collection was an organizationwide initiative in a minority of plans. To fulfill the goals of recent legislation, including the Affordable Care Act, health plans will need to expand their efforts. Among other steps, plans and other key stakeholders should agree on uniform race and ethnicity categories, modify information systems to capture these data, and increase members' trust so that self-reported data-the most accurate data on race and ethnicity-can be gathered.

Collection of language data and services provided by health plans.

OBJECTIVES: Key stakeholders agree better data on patients' language are needed to effectively address language-related barriers to timely, highquality healthcare. Our objective was to describe health plan efforts to collect language data from its members, provide language services, and improve the provision of culturally and linguistically appropriate services (CLAS). STUDY DESIGN: National surveys in 2003, 2006, and 2008. METHODS: Surveys were administered to health plans offering commercial, Medicaid, and/or Medicare Advantage products. RESULTS: 123 health plans responded to the 2008 survey (50% response rate), including 65 commercial (50%), 46 Medicaid (53%), and 12 Medicare plans (44%), representing a total enrollment of 133.8 million Americans. In 2008, 74.0% of health plans collected language data (commercial 60.0%, Medicaid 89.1%, Medicare 91.7%), which is an increase for each plan type since 2003. Health plans used direct and indirect collection methods. Nearly all health plans reported offering language services, the most common being telephonic interpreting, multilingual member materials, and access to bilingual providers. A variety of strategies for improving CLAS were cited by health plans, including improving health plan communication materials, health literacy initiatives for members, and targeted training for providers and staff. CONCLUSIONS: Health plans have made substantial progress in the collection of language data and many are offering options for language services. With the rapid growth in Medicaid participation and newly insured individuals anticipated under the Affordable Care Act, health plans may be uniquely positioned to implement and test interventions that aim to improve appropriate utilization of language services by providers and patients.

The development of a health literacy assessment tool for health plans.

Despite growing information on the magnitude and consequences of low health literacy, there is little information about the role health plans are playing and the activities they undertake to address this problem. Our goal was to develop a health literacy organizational assessment tool for health plans that could be used as a benchmark and encourage further work. The existing tool consists of six evaluation areas: (1) information for members/navigation; (2) member services/communication; (3) web navigation; (4) forms; (5) nurse call line; and (6) nurse case/disease management. During May and June, 2009, a pilot was conducted with eight diverse health plans, including national, regional, and local plans serving commercial, Medicare, and/or Medicaid members. After incorporating feedback from the pilot, the full assessment was launched in June 2009. Feedback from the participating plans has been very positive about using this tool as a benchmark and using the results to help strengthen health literacy efforts within their health plans. The variety of health plans that have utilized this assessment tool suggests that widespread use is possible. Evaluation of health literacy efforts using this comprehensive tool can help bring attention to areas in need of improvement and help plans better engage consumers in their own health.

Readiness of US health plans to manage cardiometabolic risk.

INTRODUCTION: American health plans can make a substantial contribution to the control of cardiometabolic risk (CMR), a condition associated with both adverse health outcomes and increased cost of care. Our goal was to determine health plan interest in and ability to provide CMR control services. METHODS: In January 2008, America's Health Insurance Plans, in collaboration with the HealthPartners Research Foundation, surveyed the chief medical officers of 74 member health insurance plans that offer commercial health maintenance organization, point of service, and preferred provider organization insurance. The response rate was 47%. RESULTS: The 35 responding chief medical officers reported that their plans identify members with CMR through referral from case or care management (89%), health risk assessment data (86%), claims data (82%), and pharmaceutical use data (79%). Nearly all (97%) plans currently offer interventions for tobacco use, obesity/overweight, and nutrition. Ninety-four percent of plans offer interventions to increase physical activity. All plans offer health risk appraisal or assessment with feedback and education, 91% use Web-based tools, and 85% use health coaching to help plan members lower their risk. Perceived barriers to broader implementation of risk control programs included lack of resources (79%), limited available enrollee data (74%), and lack of reporting systems (79%). Few health plan officers viewed lack of purchaser interest to be a barrier to program implementation. CONCLUSION: Health plans appear to be positioned to provide CMR control services that could improve health outcomes, reduce health care costs, and increase workplace productivity in the United States.

Preventing and managing cardiometabolic risk: the logic for intervention.

Cardiometabolic risk (CMR), also known as metabolic syndrome or insulin resistance syndrome, comprises obesity (particularly central or abdominal obesity), high triglycerides, low HDL, elevated blood pressure, and elevated plasma glucose. Leading to death from diabetes, heart disease, and stroke, the root cause of CMR is inadequate physical activity, a Western diet identified primarily by low intake of fruits, vegetables, and whole grains, and high in saturated fat, as well as a number of yet-to-be-identified genetic factors. While the pathophysiological pathways related to CMR are complex, the universal need for adequate physical activity and a diet that emphasizes fruits and vegetables and whole grains, while minimizing food high in added sugars and saturated fat suggests that these behaviors are the appropriate focus of intervention.

Addressing tobacco in managed care: results of the 2003 survey.

INTRODUCTION: Although tobacco control activity in the United States during the past several years has increased dramatically, tobacco use continues to have devastating consequences among all age cohorts. METHODS: In November 2003, a survey of tobacco control practices and policies in health insurance plans was conducted by America's Health Insurance Plans' national technical assistance office. The survey was the fourth and final survey conducted as part of the Addressing Tobacco in Managed Care program. Of the 215 plans in the sample, 160 (74%) completed the survey. Collectively, these plans represent more than 60 million members of health maintenance organizations. RESULTS: From 1997 to 2003, health insurance plans have demonstrated increasing use of evidence-based programs and clinical guidelines to address tobacco use. The number of plans providing full coverage for any type of pharmacotherapy for tobacco cessation has more than tripled since 1997. Plans have also shown substantial improvement in their ability to identify all or some of their members who smoke. Similarly, a greater percentage of plans are using strategies to address smoking cessation during treatment for other chronic diseases and after acute events such as a myocardial infarction. CONCLUSION: Despite improvements, important opportunities remain for health insurance plans and other stakeholders to expand their tobacco control activities and transfer the lessons learned to other health problems.

Addressing tobacco in managed care: results of the 2002 survey.

INTRODUCTION: In the United States, tobacco use is the leading preventable cause of death and disease. The health and cost consequences of tobacco dependence have made treatment and prevention of tobacco use a key priority among multiple stakeholders, including health plans, insurers, providers, employers, and policymakers. In 2002, the third survey of tobacco control practices and policies in health plans was conducted by America's Health Insurance Plans' technical assistance office as part of the Addressing Tobacco in Managed Care (ATMC) program. METHODS: The ATMC survey was conducted in the spring of 2002 via mail, e-mail, and fax. A 19-item survey instrument was developed and pilot-tested. Of the 19 items, 12 were the same as in previous years, four were modified to collect more detailed data on areas of key interest, and three were added to gain information about strategies to promote smoking cessation. The sample for the survey was drawn from the 687 plans listed in the national directory of member and nonmember health plans in America's Health Insurance Plans. RESULTS: Of the 246 plans in the sample, 152 plans (62%) representing more than 43.5 million health maintenance organization members completed the survey. Results show that health plans are using evidence-based programs and clinical guidelines to address tobacco use. Compared to ATMC survey data collected in 1997 and 2000, the 2002 ATMC survey results indicate that more health plans are providing full coverage for first-line pharmacotherapies and telephone counseling for smoking cessation. Plans have also shown improvement in their ability to identify at least some members who smoke. Similarly, a greater percentage of plans are employing strategies to address smoking cessation during the postpartum period to prevent smoking relapse and during pediatric visits to reduce or eliminate children's exposure to environmental tobacco smoke. CONCLUSION: The results of the 2002 ATMC survey reflect both tremendous accomplishments and important opportunities for health plans to collaborate in tobacco control efforts. With appropriate support, analytical tools, and resources, it is likely that health plans, clinicians, providers, and consumers will continue to evolve in their efforts to reduce the negative consequences of tobacco use.