Incorporating Lifestyle Medicine Into Primary Care Practice: Perceptions and Practices of Family Physicians.

Introduction: Lifestyle medicine (LM) uses therapeutic lifestyle behavior change to address the root causes of chronic diseases. The purpose of this study was to assess family physicians' perceptions and utilization of LM principles in their primary care practices, as well as identify reported barriers to implementation. Methods: A survey was administered to 5770 family physicians registered with the American Academy of Family Physicians (AAFP). The survey questions assessed the gap between perception and practice of LM core competencies and the 6 domains of LM. Results: The responses from 447 family physicians were included in the study. Respondents' perceived importance and reported practice was higher for clinical skills compared to the community partnerships and advocacy. There was a substantial gap in the reported comfort with and practice of certain LM domains, such as sleep (47%) and relationships (39.4%). However, LM board-certified physicians had a significantly higher frequency of practice in these domains. The majority of participants identified both difficulty with changing patient behavior (89%) and having limited time (81%) as major barriers to incorporate LM into their practice. Conclusion: Lifestyle medicine concepts resonate strongly with family physicians although gaps exist surrounding engaging in community partnerships, advocacy, and certain domains of LM. This study assesses family physicians' perceptions and utilization of LM principles in their primary care practices, and identifies reported barriers to implementation.

Age-Adjusted All-Cause Mortality in Counties Served by PHAB-Accredited Local Health Departments Compared With Counties Served by Nonaccredited Local Health Departments: 1999 to 2020.

OBJECTIVES: To analyze trends in the age-adjusted all-cause mortality rate (AAMR) from 1999 to 2020 between counties served by a Public Health Accreditation Board (PHAB)-accredited local health department and a nonaccredited local health department to determine whether accreditation impacted the AAMR and whether there were differences in the AAMR preceding the first health departments being accredited in 2013. DESIGN: Descriptive time trends and difference-in-differences analysis was used to explore differences in the AAMR between accredited counties and nonaccredited counties. Propensity score matching was used to develop a control group matched on county characteristics to address confounding. SETTING: A national observational study using data obtained from the Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research, the American Community Survey, and a PHAB data set on accreditation status. PARTICIPANTS: All US counties with data on the AAMR and county characteristics. INTERVENTION: Accreditation by the PHAB. MAIN OUTCOME MEASURE: The AAMR. RESULTS: Difference-in-differences in the AAMR between accredited and nonaccredited counties were stable following the launch of the accreditation program in 2013, except for an improvement in 2020 in the total sample (32.2 deaths per 100 000 people, 95% confidence interval: 3.8-60.6, P = .03). Age-adjusted all-cause mortality rates were lower in accredited counties across the 22-year period. This was statistically significant every year in the total sample but only statistically significant in 2020 in the matched sample ( P < .05). Prior to accreditation, the AAMR improved by 24.7 deaths per 100 000 people ( P = .05) and 18.0 deaths per 100 000 people ( P = .24) more among accredited counties between 1999 and 2008, among the total and matched samples, respectively. CONCLUSION: Currently, PHAB accreditation has not had a substantial impact on the AAMR, and the AAMR was higher among nonaccredited counties preceding the first health departments being accredited in 2013.

Co-creating opportunities to incorporate cessation for electronic nicotine delivery systems in family medicine - a qualitative program evaluation.

BACKGROUND: The number of Americans who use tobacco has decreased in the twenty-first century, but electronic nicotine delivery systems (ENDS) have increased the complexity of treating tobacco dependence. The experiences of 18 family medicine practices were explored and opportunities to improve ENDS cessation were co-created in this study. METHODS: Eighteen family medicine practices were enrolled into an implementation project to incorporate ENDS cessation into their practice. The participants' experiences were explored throughout the project using an iterative qualitative approach. The research team provided technical assistance. Semi-structured group interviews and focus groups were held with participants at the beginning, middle, and end of the project to explore participants' experiences. The collective knowledge and experiences of participants, expert consultants and the research team were fused together to co-create opportunities to improve ENDS cessation. RESULTS: Nine opportunities to improve ENDS cessation were identified in three larger categories. The first category was leading change. This included: creating a vision for change to establish buy-in from key stakeholders and educate health care professionals to improve their confidence to address ENDS. The second category was creating processes. This included: establishing criteria for screening and quality improvement for ENDS cessation; being specific when asking about ENDS; creating electronic health record systems to support incorporating ENDS cessation; using chart audits if electronic health records cannot support incorporating ENDS into tobacco cessation; and assigning roles and responsibilities to members of the clinical care team. The third category was assisting patients who use ENDS. This included: educating patients and their parents/caregivers about ENDS and their potential harms, avoiding dual use, and developing a plan to quit. CONCLUSIONS: This study highlights challenges and opportunities for incorporating ENDS cessation into family medicine. The opportunities outlined here provide a practical approach which is rooted in the experiences of family physicians and their clinical care teams working to improve how they address ENDS and based on peer reviewed literature and expert input. Improving how ENDS are addressed in family medicine will require more than clinical expertise. It will also require leadership skills and the ability to create process improvements. TRIAL REGISTRATION: Not applicable.

An Analysis of How Characteristics of Local Health Department Jurisdictions Influence Involvement in PHAB Accreditation: Implications for Health Equity.

OBJECTIVE: To explore how characteristics of local health department (LHD) jurisdictions impact involvement in Public Health Accreditation Board (PHAB) accreditation and to characterize the implications for health equity. METHODS: Data from the 2016 National Profile of LHDs survey were linked with data from the American Community Survey, National Center for Health Statistics, Behavioral Risk Factor Surveillance System, and the 2016 presidential election. Outcome measures included LHDs that were formally engaged in PHAB accreditation and LHDs that planned to apply for PHAB accreditation but were not formally engaged. Logistic regression was used to assess for the impact LHD jurisdictions' socioeconomic position, demographics, population health status, political ideology, and LHD organizational characteristics have on PHAB accreditation. RESULTS: Approximately 37% of the participants were formally engaged (n = 297) and planned to apply (n = 337) for PHAB accreditation. Involvement in PHAB accreditation was equal among LHDs based on poverty and income inequality, but median household income was negatively associated. Diverse jurisdictions were more likely to be involved in PHAB accreditation but less likely to be involved after controlling for covariates. Jurisdictions with worse population health status were either as likely or more likely to be involved in PHAB accreditation. Jurisdictions with a greater conservative political ideology were less likely to be involved. CONCLUSION: LHD involvement in PHAB accreditation varies by their jurisdiction's characteristics. This has implications for health equity based on socioeconomic, racial, and population health status. Policies and practices are needed to improve the uptake of PHAB accreditation in LHD jurisdictions impacted most by health inequities.

How Engaged Are Family Physicians in Addressing the Social Determinants of Health? A Survey Supporting the American Academy of Family Physician's Health Equity Environmental Scan.

Purpose: Public health leaders have advocated for clinical and population-based interventions to address the social determinants of health (SDoH). The American Academy of Family Physicians has worked to support family physicians with addressing the SDoH. However, the extent that family physicians are engaged and the factors that influence this are unknown. Methods: A survey was used to identify actions family physicians had taken to address the SDoH and perceived barriers. Physician and community characteristics were linked. Ordinal logistic regression was used to identify factors associated with engagement in clinical and population-based actions, separately. Results: There were 434 (8.7%) responses. Among respondents, 81.1% were engaged in at least one clinical action, and 43.3% were engaged in at least one population-based action. Time (80.0%) and staffing (64.5%) were the most common barriers. Physician experience was associated with higher levels of clinical engagement, lower median household income was associated with higher levels of population-based engagement, and working for a federally qualified health center (FQHC) was associated with both. Conclusions: The study provides preliminary information suggesting that family physicians are engaged in addressing the SDoH through clinical and population-based actions. Newer family physicians and those working in FQHCs may be good targets for piloting clinical actions to address SDoH and family physician advocates may be more likely to come from an FQHC or in a lower socioeconomic neighborhood. The study also raises questions about the value family physicians serving disadvantaged communities place on clinical interventions to address the SDoH.

Informing the American Academy of family Physician's Health Equity strategy - an environmental scan using the Delphi technique.

BACKGROUND: Many organizations have prioritized health equity and the social determinants of health (SDoH). These organizations need information to inform their planning, but, relatively few quantifiable measures exist. This study was conducted as an environmental scan to inform the American Academy of Family Physician's (AAFP's) health equity strategy. The objectives of the study were to identify and prioritize a comprehensive list of strategies in four focus areas: health equity leadership, policy, research, and diversity. METHODS: A Delphi study was used to identify and prioritize the most important strategies for reducing health inequities among the four aforementioned focus areas. Health equity experts were purposefully sampled. Data were collected in three rounds for each focus area separately. A comprehensive list of strategy statements was identified for each focus area in round one. The strategy statements were prioritized in round two and reprioritized in a final third round. Quantitative and qualitative data were integrated for the final analysis. RESULTS: Fifty strategies were identified across the four focus areas. Commitment to health equity, knowledge of health inequities, and knowledge of effective strategies to address the drivers of health inequities were ranked the highest for leadership. Universal access to health care and health in all policies were ranked highest for policy. Multi-level interventions, the effect of policy, governance, and politics, and translating and disseminating health equity interventions into practice were ranked the highest for research. Providing financial support to students from minority or low-socioeconomic backgrounds, commitment from undergraduate and medical school leadership for educational equity, providing opportunities for students from minority or low-socioeconomic backgrounds to prepare for standardized tests, and equitable primary and secondary school funding were ranked highest for diversity. CONCLUSIONS: The AAFP and other medical specialty societies have an important opportunity to advance health equity. They should develop a health equity policy agenda, equip physicians and other stakeholders, use their connections with practice-based research networks to identify and translate practical solutions to address the SDoH, and advocate for a more diverse medical workforce. TRIAL REGISTRATION: Not applicable.

Perceived Benefits of Collaboration Between Local Health Departments and Schools and Programs of Public Health: A Mixed-Methods Study.

OBJECTIVES: Collaboration between local health departments (LHDs) and schools and programs of public health (SPPH) may be a way to improve practice, education, and research. However, little is known about why LHDs and SPPH collaborate. This mixed-methods study addressed this issue by exploring what LHDs and SPPH perceive to be beneficial about their collaboration. METHODS: A mixed-methods study using quantitative and qualitative data was conducted. A survey of 2000 LHDs that completed the 2013 National Profile of LHDs measured how important and effective LHDs perceived 30 indicators of the 10 essential public health services to be for collaboration with SPPH. Focus groups were held with LHD officials and the faculty from SPPH to further explore their perceptions of the mutual benefits of their collaboration. RESULTS: This study showed that LHD officials and the faculty from SPPH valued their collaborative work because it can improve education and training, support public health accreditation, enhance LHD credibility, enhance LHD technological capabilities, and improve research and evidence-based practice. Benefits increased with an increase in the degree of collaboration. This also showed that LHD officials would like to collaborate more closely with SPPH. CONCLUSION: Collaboration between LHDs and SPPH is mutually beneficial, and close collaboration can help transform public health practice, education, and research. In light of this, more attention should be paid to developing goals and objectives for a collaborative agenda. Attention should be paid not only to the immediate needs of the organizations and individuals involved but also to their long-term goals and underlying desires. Funding opportunities to support the development of partnerships between LHDs and SPPH are needed to provide tangible tasks and opportunities for taking a more long-term and strategic view for collaborative relationships.